What’s New in the
Patient Safety World
December 2017
· A Fix for OR Foot Traffic?
· Speech Recognition Still Not Up to Snuff
· Study Confirms Safety of Restrictive Transfusion Policy
· ECRI’s Top 10 Health Technology Hazards for 2018
A Fix for OR Foot
Traffic?
In several of our
columns we’ve warned that long surgical duration has the potential to increase
surgery-related infections and that excessive OR traffic and opening of OR
doors is likely a major factor. In our March 10, 2009 Patient Safety Tip of the
Week “Prolonged
Surgical Duration and Time Awareness” we noted a study (Lynch 2009) that
suggested increased foot traffic may be factor related to prolonged procedures
that increases the likelihood of surgical site infections. Then in our
January 2010 What's New in the Patient Safety World column “Operative
Duration and Infection” we discussed another study (Proctor
et al 2010) that looked at a large database of general surgical procedures
and demonstrated a linear relationship between duration of surgery and
infectious complications. This relationship persisted even after adjustment for
a variety of other risk factors for perioperative infections. The unadjusted
infectious complication rate increased by 2.5% per half hour. Hospital length
of stay (LOS) also increased geometrically by 6% per half hour. We again
speculated that increased foot traffic may be another factor related to
prolonged procedures that increases the likelihood of surgical site infections
as suggested by Lynch et al. And our December 30, 2014 Patient Safety Tip of
the Week “Data
Accumulates on Impact of Long Surgical Duration” cited several other
studies in which surgical infections were one of several complications related
to prolonged surgery.
Then in our November 24, 2015 Patient Safety Tip of the Week “Door Opening and Foot Traffic in the OR” we discussed a study from Johns Hopkins that formally studied how often OR doors are opened during joint arthroplasty surgeries and the impact on OR air flow (Mears 2015). The researchers measured how often and for how long OR doors were opened during 191 hip and knee arthroplasty procedures. They also measured air pressures in the OR and adjacent corridors. They found that, on average, OR doors were open 9.5 minutes per case and the average time between door openings was 2.5 minutes. As you’d expect the number and duration of door openings correlated with the length of surgery. In 77 of the 191 cases positive pressure within the OR was defeated. The implications are obvious. While they found only one surgical infection in the 191 cases, the effects of the door opening on OR pressure and air flow theoretically would predispose to surgical infections. OR’s have positive pressure to avoid flow of air and airborne pathogens from nonsterile adjacent areas.
Finally, our July
26, 2016 Patient Safety Tip of the Week “Confirmed:
Keep Your OR Doors Closed”
highlighted a study that actually demonstrated that a program to reduce
unnecessary door openings may reduce surgery-related infections (Camus
2016). A Canadian hospital did a manual
count of door openings during total joint replacement operations and revision
procedures. They counted between 42 and 70 door openings per operation from
incision time to joint capsule closure time. Operations averaged 75 minutes.
Reasons for entering and exiting the OR during operations included retrieving
charts, instruments, or equipment, and taking a break. Next their CUSP
(Comprehensive Unit-Based Program) team brainstormed and came up with key
changes, including stopping all traffic in and out of the OR between total
joint capsule opening and closure, communicating by phone, and increasing the
use of templates to identify implant size prior to each operation. They also
put a sign on the OR door reminding staff to minimize traffic and asking them
to record why they are entering the OR during an operation. Subsequent traffic
audits taken every six months indicated an amazing reduction in OR traffic from
between 42 and 70 door openings to 3.2 door openings per case. They felt this
intervention may have contributed to a decrease in orthopedic SSIs from 2.8
percent to 2.1 percent.
Now yet another
study looked at the impact of an audible alarm on reducing OR foot traffic
during total joint arthroplasties (Eskildsen
2017). Researchers placed an
audible alarm on the substerile operating room door that sounded continuously
when the door was ajar. This resulted in a significant difference in the
overall mean door openings per minute between the period with no alarm and with
an alarm. Prior to the door alarm, the substerile door was opened a mean of
88.12 times per case, or 0.53 times per minute. After
the door alarm was installed, door openings decreased to a mean of 69.46 times
per surgery, or 0.42 times per minute. However, this effect slowly
decreased over the time of the intervention.
The percentage of
time the door was left ajar per case also decreased significantly with the
alarm. Prior to the intervention the door remained open for a mean of 14.45
minutes per case, or 8.65% of overall surgical time. After the door alarm was
installed the mean duration of time that the door remained open decreased to
10.81 minutes per surgery, or 6.63% of the overall surgical time.
Unfortunately, the
study was not large enough to determine whether the reduced door opening had an
impact on surgical infection rates. But the findings certainly suggest that
this may be one way to reduce such infections.
So while the idea of
using an alarm or our prior suggestion of using an “On the Air” sign similar to
that used in television or radio studios may help alert staff to the fact that
excess foot traffic into and out of the OR are undesirable, neither is a
forcing function. Forcing functions are much better interventions. One
quasi-forcing function we’ve suggested is keeping a log where staff are
required to log in every time they leave and enter the OR for each case,
similar to what was done in the Canadian study (Camus
2016). Of course, there will be blowback from many of
your staff that this might be time consuming. It need not be. How many of you
have an electronic device like an Amazon Echo or a Google Home Assistant and
say something like “Alexa, add paper towels to my grocery list.”? Alexa creates
a grocery list and adds paper towels to it. You could do the same with such a
device in your substerile OR area and, when the OR door alarm sounds, require
the person entering the OR to say something like “Alexa, this is surgical tech
Yvonne Jones entering the OR with new equipment” and Alexa could add the name
of the staff member and the reason to the log created when the case began.
Voila! It took years before we learned about barcoding from our supermarkets
and applied it to healthcare. It’s time we take a lesson from our hi-tech
kitchens!
And, of course, the
potential benefit of such a system is not just on surgical infections. We’d
anticipate that the number of distractions and interruptions would likely
decrease with decreased movement in and out of the OR. And analysis of the log
entries should help identify ways to improve OR efficiency. For example, the
log entries might identify the need for a certain supply or piece of equipment
to be present prior to the cases. So we’d suggest you make review of the log
part of your postop debriefing. You are doing debriefings after every case,
aren’t you?
Our prior columns focusing on surgical OR foot traffic and door opening:
- March 10, 2009 “Prolonged
Surgical Duration and Time Awareness”
- January 2010 “Operative
Duration and Infection”
- August 26, 2014 “Surgeons’
Perception of Intraoperative Time”
- December 30, 2014 “Data
Accumulates on Impact of Long Surgical Duration”
- November 24, 2015 “Door Opening and Foot Traffic in the OR”
- July 26, 2016 “Confirmed:
Keep Your OR Doors Closed”
References:
Lynch RJ, Englesbe MJ, Sturm L, et al. Measurement of Foot Traffic in the Operating Room: Implications for Infection Control. American Journal of Medical Quality 2009; 24: 45-52
http://journals.sagepub.com/doi/abs/10.1177/1062860608326419
Procter LD, Davenport DL, Bernard AC, Zwischenberger JB. General Surgical Operative Duration Is Associated with Increased Risk-Adjusted Infectious Complication Rates and Length of Hospital Stay, Journal of the Amercican College of Surgeons 2010; 210: 60-65
http://www.journalacs.org/article/S1072-7515%2809%2901411-2/abstract
Mears SC, Blanding R, Belkoff SM. Door Opening Affects Operating Room Pressure During Joint Arthroplasty. Orthopedics 2015; 38(11): e991-e994
Camus S. Operating Room Traffic Monitoring Improves Patient Safety. Abstract session presentation at the 2016 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) Conference. July 18, 2016 as reported in ACS (American College of Surgeons). Minimizing Operating Room Traffic May Improve Patient Safety by Lowering Rates of Surgical Site Infections. ACS Press Release July 18, 2016
https://www.facs.org/media/press-releases/2016/nsqip-ssi-071816
Eskildsen SM, Moskal PT, Laux J, Del Gaizo DJ. The Effect of
a Door Alarm on Operating Room Traffic During Total Joint Arthroplasty. Orthopedics 2017; 40(6): e1081-e1085
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2017 A Fix for OR Foot Traffic?”
Speech Recognition
Still Not Up to Snuff
It’s been quite a
while since we discussed errors related to speech recognition (see our October
4, 2011 Patient Safety Tip of the Week “Radiology
Report Errors and Speech Recognition Software”). We certainly thought by
now the technology had improved considerably and that errors related to speech
recognition software would have diminished.
But a new study (Hodgson 2017) compared the efficiency and safety of using speech recognition assisted clinical documentation within an electronic health record (EHR) system with use of keyboard and mouse in an emergency department setting. 35 ED clinicians were randomly allocated to clinical documentation tasks using speech recognition or keyboard and mouse on a commercial EHR system
The researchers found that mean task completion times were 18.11% slower overall when using speech recognition compared to keyboard and mouse. For simple tasks speech recognition was 16.95% slower and for complex tasks 18.40% slower. Increased errors were observed with use of speech recognition (138 vs. 32 total errors, 75 vs. 9 errors for simple tasks, and 63 vs. 23 errors for complex tasks). Interestingly, interruptions did not significantly affect task completion times or error rates for either modality.
The authors felt that some of the observed increase in errors may be due to suboptimal speech recognition to EHR integration and workflow. They concluded that improving system integration and workflow, as well as speech recognition accuracy and user-focused error correction strategies, may improve SR performance.
Bottom line: we still have a long way to go before speech recognition software can improve both efficiency and patient safety. Lots of promise but still too many glitches.
References:
Hodgson T, Magrabi F, Coiera E. Efficiency and safety of speech recognition for documentation in the electronic health record. Journal of the American Medical Informatics Association 2017; 24960; 1127-1133
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2017 Speech Recognition Still Not Up to Snuff”
Study Confirms
Safety of Restrictive Transfusion Policy
We’ve done numerous columns on the benefits and safety of more restrictive transfusion policies. Most studies comparing restrictive vs. liberal transfusion policies have been conducted in patients undergoing non-cardiac surgery. The question has been unanswered in patients undergoing cardiac surgery. Until now, that is. The recently completed Transfusion Requirements in Cardiac Surgery (TRICS) III trial demonstrated that even for those patients undergoing cardiac surgery who are at moderate-to-high risk for death a restrictive transfusion strategy is noninferior to a liberal strategy with respect to the composite outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis (Mazer 2017).
Patients were
randomized to either a restrictive red-cell transfusion threshold (transfuse if
hemoglobin level was <7.5 g per deciliter, starting from induction of
anesthesia) or a liberal red-cell transfusion threshold (transfuse if hemoglobin
level was <9.5 g per deciliter in the operating room or intensive care unit
[ICU] or was <8.5 g per deciliter in the non-ICU ward).
Red-cell transfusion
occurred in 52.3% of the patients in the restrictive-threshold group, as
compared with 72.6% of those in the liberal-threshold group Mortality was 3.0%
in the restrictive-threshold group and 3.6% in the liberal-threshold group. The
percentage of patients who had a primary composite outcome event was 11.4% in
the restrictive-threshold group, as compared with 12.5% in the
liberal-threshold group.
So the restricted
transfusion strategy was as good as a more liberal one from a patient safety
perspective and resulted in far fewer transfusions. This should answer that
last unanswered question. It is clear that a restrictive transfusion strategy
is safe and effective in all types of surgical patients, even those undergoing
cardiac surgery.
Also timely in this regard are recommendations from researchers at Johns Hopkins for a patient blood management program to promote high-value care and reduce unnecessary transfusions (Sadana 2017). They note that 3 recommendations summarize evidence-based RBC transfusion practices, derived from the AABB clinical practice guidelines and Choosing Wisely aims:
- RBC transfusion is not indicated in hemodynamically stable adult hospitalized patients with a Hb level of 7 g/dl or more. This population includes critically ill patients.
- RBC transfusion is not indicated in patients undergoing orthopedic or cardiac surgery or in patients with underlying cardiovascular disease with a Hb level of 8 g/dl or more.
- Single-unit RBC transfusions followed by reassessment should be the standard of care for patients who are hemodynamically stable and not actively bleeding.
They offer the following blueprint for a patient blood management program:
Step 1: Organization and Support
Step 2: Transfusion Guidelines
Step 3: Education and Clinical Decision Support
Step 4: Data Dashboards, Audits, and Reports
Step 5: Other Blood Conservation Methods
They note the importance of multidisciplinary representation from multiple departments (medicine, surgery, pediatrics, blood bank/transfusion medicine, anesthesiology, critical care, nursing, pharmacy, quality/safety, and IT) for developing buy-in and ensuring compliance. The initiative should be adequately funded, with the savings from blood resource utilization justifying the funding. The guidelines can include blood products other than just RBC’s (eg. plasma, platelets, etc.). Education should be targeted but supplemented by clinical decision support (CDS) in the EMR. The CDS alerts should include reasons for bypassing alerts (eg. active bleeding). Data with feedback should include peer-to-peer comparisons. Each clinical service should have a champion or leader who reviews the reports and provides feedback to service members. Other blood conservation methods include treating anemia before surgery, using antifibrinolytic medications, autologous blood salvage, preoperative autologous blood donation, avoiding excessive phlebotomy, etc.
While transfusions may be lifesaving, they also have several potential harms and downsides. An effective blood transfusion management program is essential for patient safety and will likely produce considerable financial savings for every hospital or ambulatory surgery center.
Prior columns on potential detrimental effects related to red blood cell transfusions:
- March 2011 “Downside of Transfusions in Surgery”
- August 2011 “CPOE
Alerts Reduce Blood Transfusions in Children”
- January 2012 “Need
for New Transfusion Criteria?”
- April 2012 “New
Transfusion Guidelines from the AABB”
- February 2013 “More
Evidence Favoring Restriction of Transfusions”
- June 2013 “Hopkins
Blood Ordering Initiative”
- May 2014 “Blood
Transfusion and Infection Risk”
- June 2015 “Economics
and Blood Transfusion”
- November 2016 “AABB
Updates Transfusion Guidelines Again”
References:
Mazer CD, Whitlock RP, Fergusson DA, et al. for the TRICS Investigators and Perioperative Anesthesia Clinical Trials Group. Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery. NEJM 2017; November 12, 2017
http://www.nejm.org/doi/full/10.1056/NEJMoa1711818?query=featured_home
Sadana D, Pratzer A, Scher LJ, et al. Promoting High-Value Practice by Reducing Unnecessary Transfusions With a Patient Blood Management Program. JAMA Intern Med 2017; Published online November 20, 2017
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2663855
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2017 Study Confirms Safety of Restrictive Transfusion Policy”
ECRI’s Top 10
Health Technology Hazards for 2018
ECRI Institute has
released its annual Top 10 list for health technology hazards for 2018 (ECRI 2017). They are:
- Cybersecurity threats in health care delivery and patient
endangerment
- Endoscope reprocessing
- Bed and stretcher mattress contamination
- Secondary alarm notification systems
- Medical device cleaning methods
- Electrosurgical electrode pencil handling
- Digital imaging tools to control radiation
- Bar-coded medication system workarounds
- Networked medical devices and information systems
- Enteral feeding tubing erroneously connected to patient lines
Most of these have
been on ECRI’s lists at some time in the past. But the cybersecurity
issue really vaulted to the top of the list this year after hospital systems
ground to a halt after ransomware attacks. HealthLeaders Media (Pecci
2017) noted six points for leadership to consider
from Juuso Leinonen, senior project engineer for ECRI Institute's Health
Devices Group:
- Define organization-specific goals to improve security and develop a
practical plan.
- Prioritize resource allocation, including money and people power.
- Conduct real-life exercises and drills that consider overall
organizational response and what the clinical workflow would be in the
case of an attack (including the chance of reverting to a paper workflow).
- Create a complete and detailed inventory of assets that are
connected to the hospital networks.
- Involve everyone in the organization, which can be as small as
reminding everyone not to click on suspicious emails.
- Institute a plan for identifying when software updates are
available, confirming whether a device can be safely updated, and applying
the updates in a timely manner.
Again on this year’s
list is the one regarding secondary alarm notification systems. You’ll
recall in our February 9, 2016 Patient Safety Tip of the Week “It
was just a matter of time…”
we described a case in which the alarm notification went out to a healthcare
worker who was not assigned to that patient rather than to the correct person.
Electrosurgical electrode pencil handling also made this year’s list. Proper use of
safety holsters for active-electrode pencils is critical to avoid inadvertent
activation of ESU pencils. We’ve done numerous columns on the role of
electrocautery devices causing both surgical fires and iatrogenic burns. Our September
5, 2017 Patient Safety Tip of the Week “Another
Iatrogenic Burn” discussed
in detail issues related to electrocautery devices.
We’ll let you read about these and all the others in the ECRI document itself. You can download ECRI Institute’s Top 10 Health Technology Hazards for 2018 for free at the ECRI site.
References:
ECRI Institute. Top 10 Health Technology Hazards for 2018. ECRI Institute. November 2017
https://www.ecri.org/Pages/2018-Hazards.aspx
Pecci AW. 6 Things Healthcare Execs Should Do to Prepare for Cyber Threats. HealthLeaders Media 2017; November 21, 2017
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2017 ECRI’s Top 10 Health Technology Hazards for 2018”
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2017 What's New in the Patient Safety World (full column)”
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2017 A Fix for OR Foot Traffic?”
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2017 Study Confirms Safety of Restrictive Transfusion Policy”
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2017 Speech Recognition Still Not Up to Snuff”
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2017 ECRI’s Top 10 Health Technology Hazards for 2018”
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