Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

July 2021

· Adverse Effects of Contact Isolation in the COVID-19 Era

· Mid-Shift Huddles

· EPIC Sepsis Prediction Tool Falls Short

· Unique Way to Rapidly Identify Oxygen Flow

Adverse Effects of Contact Isolation in the COVID-19 Era

Contact isolation is an important infection control tool to prevent spread of infections. But patients in contact isolation experience more unintended consequences and adverse events than patients not in isolation. Our multiple columns on the unintended consequences of isolation are listed at the end of today’s column.

Since our last column, there has been one other good review of such consequences. Jiménez-Pericás et al. (Jiménez-Pericás 2020) compared adverse events (AE’s) in isolated patients to those in non-isolated patients in a large public hospital in Spain. The incidence of AE’s among isolated patients was 18.5% compared with 11% for non-isolated patients. (The incidence of isolated patients with AE’s was 16.5% compared with 9.5% non-isolated). The incidence “density” of patients with AE’s (per 1000 days/patient) among isolated patients was 11.8 compared with 4.3 among non-isolated patients. Most AE’s corresponded to healthcare-associated infections (HAI’s) for both isolated and non-isolated patients (48.6% vs 45.4%). Notably, there were significant differences with respect to the preventability of AE’s (67.6% among isolated patients compared with 52.6% among non-isolated patients). The authors concluded that AE’s were significantly higher in isolated patients compared with non-isolated patients, more than half being preventable and with HAI’s as the primary cause. The authors conclude it is essential to improve training and the safety culture of healthcare professionals relating to the care provided to this type of patient.

Note that this study preceded the COVID-19 pandemic. Unfortunately, the COVID-19 pandemic has filled our hospitals with many patients who require contact isolation. And many have experienced adverse events while in contact isolation.

There are a number of factors we’d expect to result in increased rates of adverse events in isolated patients in the COVID-19 era. First and foremost is the overloaded work burden on our healthcare workers, which meant less time was available for care of such patients. A second major factor was the paucity of PPE (Personal Protective Equipment). That undoubtedly led to fewer face-to-face contacts with patients in isolation. And, as noted by Taylor et al. (Taylor 2021) below, delays due to the need to put on PPE led to some staff not being able to prevent falls in some cases. And the ubiquitous presence of masks can impair communication, not only with patients but with other staff.

A new study (Taylor 2021) from the Pennsylvania Patient Safety Reporting System (PA-PSRS) database looked at adverse events in isolated patients in the COVID-19 pandemic. They identified 484 events from January 1, 2020 to September 30, 2020. Patient safety events in COVID-19 patients in isolation began in March 2020 and peaked in April and May 2020, where there was an average of 4.2 safety events per day impacting patients in isolation.

Falls accounted for 27% of the events. Both prevention and timely detection of falls can be impeded by various conditions associated with an isolation environment. Many of the falls occurred despite strategies to prevent falls being in place. Categories of associated factors most frequently identified in fall events were patient mental status (50%) and staff’s time to don PPE (37%). Notably, in 26% of the fall events the patient had not yet fallen when staff arrived at the entrance to the isolation room, but staff were unable to prevent the fall due to time required to don PPE.

Even detecting falls in patients in isolation can be problematic. In 20% of cases the patient was simply found unexpectedly on the floor. In 10% staff heard either a patient calling or heard a crash. 4% were alerted via a triggered heart or oxygen monitor, 4% by a video monitor or telesitter, 3% via a call bell, and 2% were from patient communication post-fall.

Medication-related adverse events accounted for 16% of reported events. 38% of those involved a dose omission, half of which involved an inhaled respiratory medication. Problems with equipment and supplies were common contributing factors. 9 events were related to use of an infusion pump, 4 of which involved broken tubing that was run from a pump outside the isolation room, under an active door, and to the patient inside the room. In another the infusion pump inside the isolation room was inaudible. Four events were related to not having a computer or scanner in the isolation room.

Issues related to skin integrity were actually the most frequently reported events (29%).\ but Taylor et al. did not describe the details of those. We encourage you to go to the Taylor article for details of all the other adverse events reported.

But we find the text comments in the reports to the Pennsylvania Patient Safety Reporting System (PA-PSRS) database, especially those about contributing factors, to be even more important than the statistics. Problems visualizing the patient often had to do with closed doors, lack of windows or poorly placed windows, and lack of video monitoring or poor quality of video monitoring.

Auditory issues were also frequent. Inability to hear alarms was often due to closed doors, competing noise on the unit, and alarms either not set high enough to be audible outside the room or not designed to produce adequate decibel levels.

Taylor et al. noted a number of ways in which communication was impaired. Yes, masks or other devices covering the face did impair communication. In other cases, staff were at the door or hallway trying to communicate with the patient. And inability to visualize the staff’s face or name badge was also noted.

We already mentioned some of the equipment/supply issues, such as unavailability of PPE, lack of computers or barcode scanners in the isolation room, infusion pump tubing that was broken because it was running under doors, etc. Sometimes an inadequate wireless signal prevented quality video monitoring.

PPE-related issues included not only unavailability but also inadequate training on use of PPE and the prolonged time it took to don PPE.

The relative newness of several treatments and protocols led to unfamiliarity of the effects and potential reactions by some staff.

Mental status of patients was often impaired, making communication difficult but also likely contributing to certain types of adverse events (like falls, self-extubation, removal of catheters, etc.). Moreover, because family and friends were excluded from isolation rooms, staff were less likely to be alerted about patient behavior that might be risky.

Lastly, staff issues may have been contributing factors in some cases. This includes not only staff fatigue and burnout, but also the need to use staff on units they were unfamiliar with or involve them in procedures with which they were unfamiliar.

The Taylor article also provides many practical recommendations to address all these contributing factors. This is an article well worth your time reading. Its utility extends well beyond just those patients in isolation during the COVID-19 era, but to almost any patient in contact isolation.

Some of our prior columns on the unintended consequences of contact isolation:

January 17, 2012 “Delirium and Contact Isolation”
March 25, 2008 “More on MRSA”
January 2013 “More on the Downside of Contact Isolation”
April 29, 2014 “More on the Unintended Consequences of Contact Isolation”
May 2016 “More Debate on Contact Precautions”
October 18, 2016 “Yet More Questions on Contact Precautions”
March 2018 “Duration of Contact Precautions”
July 2018 “Contact Precautions Conundrum”
March 3, 2020 “Opportunities to Reduce Unnecessary Contact Precautions”

References:

Jiménez-Pericás F, Gea Velázquez de Castro MT, Pastor-Valero M, et al

Higher incidence of adverse events in isolated patients compared with non-isolated patients: a cohort study. BMJ Open 2020; 10: e035238

https://bmjopen.bmj.com/content/10/10/e035238

Taylor MA, Reynolds CM, Jones R. Challenges and Potential Solutions for Patient Safety in an Infectious-Agent-Isolation Environment: A Study of 484 COVID-19-Related Event Reports Across 94 Hospitals. Patient Safety 2021; 3(2): 45-62

https://patientsafetyj.com/index.php/patientsaf/article/view/covid-isolation-safety

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Mid-Shift Huddles

We’ve long been advocates of huddles in healthcare. Not just pre-op huddles and post-op debriefings, but also huddles in a variety of healthcare settings. For example, we advocate a huddle at the beginning of a clinic or office session. That helps plan the day’s activities and allow for contingencies. Similarly, we like a huddle at the end of the day to take a look at tomorrow’s clinic or office schedule. See our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare” for examples of various huddle opportunities in healthcare.

But the mid-shift huddle is a new one for us. Yet it makes a whole lot of sense. A recent article in Health Leaders (Davis 2021) discussed how mid-shift huddles at University of Wisconsin Health improved care for fall-risk patients and provided other benefits.

At University of Wisconsin Health the mid-shift huddles occur three times per day (once per shift) at 10:30 AM, 5 PM, and 3 AM. The care team leader leads these huddles and they are attended by the staff working that shift. While the initial focus was on patient safety, they subsequently added informational content.

The article discusses how the mid-shift huddles differ from the more typical change-of-shift huddles. The change-of-shift huddles provide a high-level overview of what staff need to know to successfully start their shift, such as unit status (census, open beds, admits/discharges), staffing, and safety concerns (code status, high fall-risk patients/recent falls, patients of concern). They also cover cover quick unit or organizational updates that don't need much discussion but are helpful to know, such as updates to the visitor policy, PPE changes, or workflow updates related to COVID.

The mid-shift huddles go into more detail regarding unit status, include more detail on high fall-risk patients, and check in with each staff member to redistribute resources if anyone needs help. These huddles last closer to 15 minutes and cover topics that need more in-depth discussion, such as a practice changes, lessons learned from recent healthcare-associated infections events on the unit, or educational content. In addition to including educational content, they sometimes add fun activities to the mid-shift huddles.

The article also notes positive experience with mid-shift huddles at Johns Hopkins Bayview (Buckingham 2018). The team on a surgical unit added mid-shift huddles to their existing use of the “huddle board”, a way of visually presenting data on ongoing projects. The mid-shift huddles were added as a way of reviewing each shift in real-time, looking backward and forward. But they quickly realized these huddles were great team building exercises. All staff attend the huddle, led by members of the management team, and other members of the interdisciplinary care teams are invited as well. They share not only clinical details and census data, but also staffing updates, announcements, and congratulations. They found these mid-shift huddles helped them improve fall rates, hand hygiene compliance, staff responsiveness (on the HCAHPS report), staff engagement, and improvements in both the Safety Climate and Teamwork domains.

Another very logical venue for mid-shift huddles would be the emergency department. Rather than waiting for end-of-shift to prepare handoffs to incoming staff, it makes sense to plan well ahead of time for change of shift. For example, a mid-shift huddle could help expedite moving an admission to an actual inpatient bed rather than leaving that task to incoming staff. That mid-shift huddle can also alert staff to incoming patients (either transfers from other facilities or in-transit ambulance patients).

The biggest challenge for mid-shift huddles, according to Sara Schoen, nurse manager at University of Wisconsin Health, is balancing the time to attend huddles against any time being taken away from patient care. Our own take on this balancing act is that any mid-shift refocusing of resources can likely minimize any care left undone and be beneficial in the long run. The added benefit on team building and staff morale is a real bonus whose value you simply can’t measure.

See our prior columns on huddles, briefings, and debriefings:

April 9, 2007 “Make Your Surgical Timeouts More Useful”
May 22, 2007 “More on TeamSTEPPS™”
December 9, 2008 “Huddles in Healthcare”
March 10, 2009 “Prolonged Surgical Duration and Time Awareness”
January 11, 2011 “NPSA (UK) ‘How to Guide’: Five Steps to Safer Surgery”
March 2009 “Surgical Team Training”
April 2012 “Operating Room Briefings and Debriefings”
July 31, 2012 “Surgical Case Duration and Miscommunications”
January 2014 “A Tool to Assess Pre-op Briefings”
July 22, 2014 “More on Operating Room Briefings and Debriefings”
March 17, 2015“Distractions in the OR”

References:

Davis C. Huddle Up! Nursing Mid-Shift Meetings Create Better Outcomes. HealthLeaders 2021; June 21, 2021

https://www.healthleadersmedia.com/nursing/huddle-nursing-mid-shift-meetings-create-better-outcomes

Buckingham B. Huddling for Healthcare. In 2017-2018 Johns Hopkins Bayview Nursing Annual Report. Creating a Highly Reliable Organization. Johns Hopkins Medicine 2018

https://www.hopkinsmedicine.org/johns_hopkins_bayview/_docs/about/nurse/2018_nursing_annual_report.pdf

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EPIC Sepsis Prediction Tool Falls Short

Early recognition and treatment of sepsis is essential to reduce mortality from sepsis. Everyone agrees that it would be helpful to have help in recognizing early signs of sepsis and the of data in the EMR (electronic medical record) is a logical potential source for early warning signs. We’ve discussed some early warning tools for sepsis in our Patient Safety Tips of the Week for March 15, 2011 “Early Warnings for Sepsis” and September 8, 2015 “TREWScore for Early Recognition of Sepsis” and our October 2015 What's New in the Patient Safety World column “Even Earlier Recognition of Severe Sepsis”.

But perhaps the most widely used tool for predicting sepsis is a proprietary tool that is part of the EPIC electronic health record, one of the most widely used EMR’s in the US.

Wong et al. (Wong 2021) recently published results of an external validation of the Epic Sepsis Model (ESM). Its performance was less than stellar. In the analysis of over 38,000 hospitalizations at the University of Michigan, they found the ESM had a sensitivity of 33%, specificity of 83%, positive predictive value of 12%, and negative predictive value of 95%. The ESM generated alerts on 18% of all patients but did not detect sepsis in 67% of patients who actually had sepsis.

Basically, the ESM identified only 7% of patients with sepsis who were missed by a clinician (based on timely administration of antibiotics). And it failed to identify 67% of patients with sepsis despite generating alerts on 18% of all hospitalized patients, thus creating a large burden of potential alert fatigue.

The researchers used an ESM score threshold of 6, within the recommended range by EPIC. If the ESM were to generate an alert only once per patient when the score threshold first exceeded 6—a strategy to minimize alerts—then clinicians would still need to evaluate 15 patients to identify a single patient with eventual sepsis. And, if clinicians were willing to reevaluate patients each time the ESM score exceeded 6 to find patients developing sepsis in the next 4 hours, they would need to evaluate 109 patients to find a single patient with sepsis.

The authors conclude that “the increase and growth in deployment of proprietary models has led to an underbelly of confidential, non–peer-reviewed model performance documents that may not accurately reflect real-world model performance.”

In the accompanying editorial, Habib et al. (Habib 2021) emphasize not only the importance of external validation of such tools but also the need to avoid “black box” type proprietary tools and always use open-access models so external validation is possible. They also highlight the importance of having the appropriate staff to evaluate performance in each hospital’s own clinical setting.

Some of our other columns on sepsis:

March 15, 2011 “Early Warnings for Sepsis”
April 1, 2014 “Expensive Aspects of Sepsis Protocol Debunked”
September 8, 2015 “TREWScore for Early Recognition of Sepsis”
October 2015 “Even Earlier Recognition of Severe Sepsis”
February 2, 2016 “Success Against Sepsis”
March 2016 “Finally…A More Rationale Definition for Sepsis”
February 2017 “Yes, the New Sepsis Criteria Fit the Bill”
June 6, 2017 “NYS Mandate for Sepsis Protocol Works”

References:

Wong A, Otles E, Donnelly JP, et al. External Validation of a Widely Implemented Proprietary Sepsis Prediction Model in Hospitalized Patients. JAMA Intern Med 2021; Published online June 21, 2021

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2781307

Habib AR, Lin AL, Grant RW. The Epic Sepsis Model Falls Short—The Importance of External Validation. JAMA Intern Med 2021; Published online June 21, 2021

https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2781313

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Unique Way to Rapidly Identify Oxygen Flow

In our October 6, 2009 Patient Safety Tip of the Week “Oxygen Safety: More Lessons from the UK” we reported on a UK National Patient Safety Agency (NPSA) Rapid Response Report on Oxygen Safety in Hospitals. The NPSA alert followed reports of 281 incidents involving oxygen over a 5-year period, 9 of which caused patient deaths and another 35 of which may have contributed to patient deaths.

103 of the incidents involved equipment, including empty oxygen cylinders, missing or faulty equipment, inaccessibility of equipment, or user errors. A large number of these incidents occurred during patient transports or transfers. We’ve previously noted that some studies have shown over 50% of all inhospital transports have been complicated by oxygen supplies running out and encouraged use of tools such as “Ticket to Ride” to help avoid such events.

In 54 of the incidents, oxygen was not appropriately administered. This included cases where compressed air was mistakenly given to patients, cases where oxygen sources were disconnected, and cases where oxygen was given at incorrect flow rates. Again, some of these occurred during transport of patients within the hospital, often by nonclinical personnel.

Then, in our February 2018 What's New in the Patient Safety World column “Oxygen Cylinders Back in the News” we discussed a 2018 UK National Health Service report on over 400 incidents involving incorrect operation of oxygen cylinder controls, including 6 patient deaths (NHS 2019). Incidents involved portable oxygen cylinders of all sizes on trolleys, wheelchairs, resuscitation trolleys and neonatal resuscitaires, and larger cylinders in hospital areas without piped oxygen. The problem was related to the design of portable oxygen cylinder controls. “Staff appeared to assume the same single step to start piped oxygen flowing (turning the flowmeter dial) also applies to cylinders. They also appeared confused by aspects of the cylinder’s design: no clear indicator on the valve showing the open and closed positions, and the plastic cap hiding controls. The green indicator showing a full cylinder appeared to be misinterpreted as an indicator of active flow. When the flow rate dial is operated on cylinders that have previously been used, but not vented before next use, a ‘hiss’ of flowing oxygen can be heard for a few seconds even with the valve closed. This can reinforce a member of staff’s belief that they have turned the flow on. Reinforcement of the need for oxygen to be considered a prescribed medication seemed in some cases to have been misinterpreted as meaning only clinical professionals could check or prepare cylinders for use.”

We’ve also noted our own experiences with lack of oxygen flow. We previously described a near-miss (see our March 5, 2007 Patient Safety Tip of the Week “Disabled Alarms”) in which an oxygen blender alarm on a ventilator failed to alert staff to disconnection of the oxygen source because a piece of tape had been placed over the blender alarm (probably during maintenance). Problems with a pulse oximeter also failed to alert staff to the lack of oxygen flow in that case.

So, wouldn’t it be useful to have a way to rapidly identify lack of oxygen flow? An Australian anesthesiologist came up with a practical solution to the problem. Dr. Matthew Matusik came up with the solution after a near-miss in which a patient being transported from the OR to the PACU temporarily had no oxygen flow because of a problem related to the oxygen cylinder system being used. He developed a face mask with a flow indicator that provides a clear visual cue that oxygen is flowing to a patient. If oxygen is flowing to the patient, a bright orange indicator is visible (see the St. Vincent’s Hospital video 2020).

This system obviously can be very practical in patients being transported on portable oxygen. But it would also be useful for rapid identification of cases where oxygen hoses get disconnected from their sources for any reason.

It has another potential use as well. In our many columns on surgical fires, we’ve pointed out that almost all cases occur when a heat source, such as electrocautery, is used in the presence of active oxygen flow. To prevent such fires, it is essential that the anesthesiologist and surgeon coordinate to ensure that oxygen flow has been stopped prior to use of electrocautery (or any other heat source). Being able to visibly confirm there is no oxygen flow could be a very valuable patient safety tool in that setting.

Great concept!

Some of our prior columns on issues related to oxygen:

April 8, 2008 “Oxygen as a Medication”

January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!”

April 2009 “Nursing Companion to the BTS Oxygen Therapy Guidelines”

October 6, 2009 “Oxygen Safety: More Lessons from the UK”

July 2010 “Cochrane Review: Oxygen in MI”

December 6, 2011 “Why You Need to Beware of Oxygen Therapy”

February 2012 “More Evidence of Harm from Oxygen”

March 2014 “Another Strike Against Hyperoxia”

June 17, 2014 “SO2S Confirms Routine O2 of No Benefit in Stroke”

December 2014 “Oxygen Should Be AVOIDed”

August 11, 2015 “New Oxygen Guidelines: Thoracic Society of Australia and NZ”

November 2016 “Oxygen Tank Monitoring”

November 2016 “More on Safer Use of Oxygen”

October 2017 “End of the Oxygen in MI and Stroke Debate?”

February 2018 “Oxygen Cylinders Back in the News”

June 2018 “Too Much Oxygen”

References:

NHS (UK National Health Service). Patient Safety Alert: Risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders. January 9, 2018, updated December 9, 2019

https://www.england.nhs.uk/publication/failure-to-obtain-and-continue-flow-from-oxygen-cylinders/

St. Vincent’s Hospital (Melbourne, Australia) 2020; Video clip June 22, 2020

https://www.facebook.com/StVincentsHospitalMelb/posts/1389302017936768

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