What’s New in the Patient Safety World
May 2016
·
More Debate on Contact Precautions
·
Guidelines for Perioperative Geriatric Care
·
Name Confusion in the Pharmacy
·
ECRI Institute’s Top 10 Patient Safety Concerns
for 2016
More Debate on
Contact Precautions
We’ve done multiple columns on the unintended consequences
of contact isolation precautions (see the list at the end of today’s column). Patients
in contact isolation have less contact by healthcare workers (and visitors) and
this may lead to errors and omissions in care and other unintended consequences
like decubiti, delirium, falls, and fluid/electrolyte disorders among other
preventable adverse events.
Morgan and
colleagues, who have done much of the work we’ve previously cited on adverse
consequences of contact isolation, have reconsidered contact precautions for endemic
VRE and MRSA (Morgan 2015).
They did a literature review, a survey
of the SHEA Research Network members on use of contact precautions, and a
detailed examination of the experience of a convenience sample of hospitals not
using contact precautions for MRSA or VRE. They found that there is no high
quality data to support or reject use of contact precautions for endemic MRSA
or VRE and that hospital practices are widely varied. They concluded that higher
quality research on the benefits and harms of contact precautions in the
control of endemic MRSA and VRE is needed and that until more definitive data
are available, practices in acute care hospitals should be guided by local
needs and resources.
Most guidelines for contact precautions have been aimed at
healthcare workers. But what about
visitors? Last year SHEA (Society for Healthcare Epidemiology of America) reviewed
the evidence, which is scant, and developed a consensus statement to deal with
the issue in visitors (Stokowski
2016). The guidelines take into account several scenarios and recognize
that visitors are unlikely to transmit pathogens in certain circumstances and
they take into account practical considerations as well. Important
considerations are the specific pathogen, the underlying infectious condition,
and the endemicity of the organism in the hospital
and the community. Therefore, recommendations really need to be on a case by
case basis.
The guideline, of course, stresses the importance of hand
hygiene and recommends all visitors should perform hand hygiene before entering
and immediately after leaving a patient room. They note that hand washing with
soap and water and proper use of an alcohol-based hand rub are acceptable. They
stress the importance of ensuring that sinks and alcohol-based hand rub
stations are easily accessible to visitors. Note our April 2016 What's New in the Patient Safety World column “Nudge:
An Example for Hand Hygiene”
cited an article (Hobbs
2016) which demonstrated that when the hand sanitizers were placed in the
middle of the lobby (with limited
landmarks or barriers) visitors were 5.28 times more likely to use them.
The SHEA guideline says that visitors should be educated on
the importance of frequent hand hygiene in the hospital setting and on the
available options and proper techniques for performing hand hygiene. But they
note that such education must be repeated often, particularly since conditions
may change during a hospitalization. While most hospitals use signage to help
visitors understand proper hand hygiene, few use oral/verbal education for
visitors.
Perhaps somewhat surprising to some is that contact precautions
might not always be needed for visitors in areas where MRSA or VRE are endemic.
But if the visitor is likely to interact with multiple patients or if the patient
is immunocompromised or if the visitors cannot perform good hand hygiene then
contact precautions (gowns, gloves, etc.) should be used just as healthcare
workers would use. In some cases hospitals might further limit or preclude
visitation. But with some pathogens,
like Clostridium difficile and Norovirus
or extensively drug-resistant gram-negative organisms, full contact precautions
would be recommended. Exceptions might be family members or other close
contacts who would have likely already been exposed to those from a symptomatic
patient.
For patient rooms under droplet precautions visitors would
be expected to wear appropriate masks though, again, exceptions might be family
members or other close contacts who would have likely already been exposed to those
from a symptomatic patient. However, if the latter are symptomatic (eg. cough, fever) they would not likely to be allowed to
visit anyone in the hospital. Incubation periods of the specific organism and
virulence of the organism might also need to be taken into account in any
recommendations. For patients on airborne restrictions (eg.
TB or SARS) surgical masks would be used and visitors may require fit testing
for recommended masks.
For known outbreaks or suspected infection with serious
organisms (eg. Ebola) visitors would likely be
restricted.
For visitors to patients with extended stays, isolation
precautions are probably not practical and even wearing personal protective
equipment (PPE) may be of unclear benefit but would be recommended when
assisting in care delivery and contact with blood, body fluids, or non-intact
skin is anticipated.
They have special considerations for family and household
contacts of neonatal/pediatric patients, again noting a paucity of evidence to
inform guidelines. They note how isolation precautions can interfere with
bonding, breastfeeding, and family-centered care. But they also note the
importance of distinguishing family and household visitors from non-household
visitors.
The guidelines further note that “hospitals should only
consider writing policies regarding visitors when they can be realistically
enforced and regularly evaluated for compliance”. The Stokowski article notes
that 77% of hospitals do not have active programs for monitoring visitor
compliance with recommendations.
The guidelines are
available from SHEA in pocket card format (SHEA
2015). They are also available on the SHEA apps for iOS and Android
devices.
Decisions about who and when to use contact precautions
should be made considering the potential benefits and potential harms, the
clinical scenarios and epidemiology. Such decisions should be made on a
case-by-case basis in most circumstances and you need to consider both
healthcare workers and visitors. If you do implement contact precautions, make
sure that your care plans include appropriate interventions and monitoring to
ensure that patients on contact precautions get all their medical and
psychological needs met.
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”
Some of our other
columns on handwashing and hand hygiene:
January 5, 2010
“How’s
Your Hand Hygiene?”
December 28, 2010 “HAI’s:
Looking In All The Wrong Places”
May 24, 2011 “Hand
Hygiene Resources”
October 2011 “Another
Unintended Consequence of Hand Hygiene Device?”
March 2012 “Smile…You’re
on Candid Camera”
August 2012 “Anesthesiology
and Surgical Infections”
October 2013 “HAI’s:
Costs, WHO Hand Hygiene, etc.”
November 18, 2014 “Handwashing
Fades at End of Shift, ?Smartwatch to the Rescue”
January 20, 2015 “He
Didn’t Wash His Hands After What!”
September 2015 “APIC’s
New Guide to Hand Hygiene Programs”
November 2015 “Hand
Hygiene: Paradoxical Solution?”
April 2016 “Nudge:
An Example for Hand Hygiene”
References:
Morgan DJ, Murthy R, Munoz-Price LS, et al.
Reconsidering Contact Precautions for Endemic Methicillin-Resistant
Staphylococcus aureus and Vancomycin-Resistant Enterococcus. Infect Control Hosp Epidemiol 2015; 36(10):
1163-1172
Stokowski LA, reviewed
by Munoz-Price LS. Hospital Visitors and Isolation Precautions: Clearing
Up the Confusion. SHEA (Society for Healthcare Epidemiology of America). In Medscape
April 29, 2016
http://www.medscape.com/features/slideshow/hospital-visitors?src=wnl_edit_tpal&uac=14695HV#page=1
Hobbs MA, Robinson S, Neyens DM,
Steed C. Visitor characteristics and alcohol-based hand sanitizer dispenser
locations at the hospital entrance: Effect on visitor use rates.
Am J Infection Contol 2016;
44(3): 258-262
http://www.ajicjournal.org/article/S0196-6553%2815%2901158-X/abstract
SHEA (Society for Healthcare Epidemiology of America). Expert Guidance: Isolation Precautions for
Visitors. Published: 4/10/2015
Print “May
2016 More Debate on Contact Precautions”
Guidelines for
Perioperative Geriatric Care
A best practices guideline “Optimal Perioperative Management
of the Geriatric Patient” jointly developed by the American College of Surgeons
and the American Geriatrics Society was recently published (Mohanty
2016).
As you’d expect, there is a preoperative emphasis on
establishing goals, expectations and preferences for the patient. That also
includes ensuring that there is an advance directive in place and that a health
care proxy has been identified. And, where appropriate, consideration should be
given to obtaining a palliative care consultation.
Preoperative care should also include a shortened liquid
fasting period (clear liquids up to two hours before surgery). Discontinuing
non-essential medications but ensuring that the patient is compliant with
essential medications is important. Best practices for DVT prevention and
antibiotic prophylaxis are also discussed.
Intraoperative management includes attention to fluid and
hemodynamic status but also stresses use of regional anesthesia techniques and
multimodal opioid-sparing analgesia techniques and reducing postoperative
nausea. Prevention of decubiti or nerve damage are important and preventing postoperative
pulmonary complications are stressed. Patients should also continue indicated
cardiac medications. Avoiding hypothermia is another important consideration.
The postoperative section contains a good discussion on preventing
and managing delirium and fall prevention and prevention of UTI’s, topics we’ve
discussed in numerous columns. A section on nutritional needs is very good. The
postoperative section even includes a postoperative rounding checklist. There
are also very good discussions on functional decline and care transition
planning.
Overall, this is a concise yet focused document with
excellent recommendations. It is also very well referenced with links to the
cited documents.
References:
Mohanty S, Rosenthal RA, Russell
MM, et al. Optimal Perioperative Management of the Geriatric Patient: A Best
Practices Guideline from the ACS NSQIP/American Geriatrics Society. J Amer Coll Surg
2016; Published online: January 4 2016
http://www.journalacs.org/article/S1072-7515%2815%2901822-0/fulltext
Print “May
2016 Guidelines for Perioperative Geriatric Care”
Name Confusion in
the Pharmacy
We’ve done numerous columns on wrong patient errors and
confusion over patient names. However, a recent article in Pharmacy Times (Ross
2016) shows how such errors can occur outside the hospital and be
propagated to the hospital.
A pharmacy dispensed
a medication intended for a patient named Florence Frost instead to an elderly
patient named Margaret Forrest. That medication was the oral
hypoglycemic agent gliclazide and it apparently led to hypoglycemic brain
injury and other complications in Margaret Forrest. She was found unconscious
and admitted to a hospital. At the hospital, the staff thought she was patient Frost
because a paramedic had grabbed a box of medication from the apartment that had
Frost’s name on it.
The pharmacy, as do
most pharmacies, keeps patient medications on shelves in alphabetical order. So
it is not surprising that a pharmacist or pharmacy technician might
accidentally pick up a medication intended for another patient and dispense it.
In our discussions on patient safety with lay people we emphasize the need for
them to identify they have the right medication at the pharmacy and that it is
intended for them (verifying their name is on the prescription). But one can
easily see how someone with impaired vision or cognition may fail to verify
that.
And even after
hospitals recognize wrong medications and stop them we’ve all seen wrong
medications get propagated in medication lists in our copy-and-paste world (see
our April 5, 2016 Patient Safety Tip of the Week “Workarounds
Overriding Safety”).
Patient
identification errors remain frequent and this year were ranked number 2 on
ECRI Institute’s Top 10 Patient Safety Concerns for 2016 (see our May 2016 What's
New in the Patient Safety World column “ECRI
Institute’s Top 10 Patient Safety Concerns for 2016”).
References:
Ross M. Woman Dies from Alleged Dispensing Error. Pharmacy
Times 2016; Published Online: Thursday, March 24, 2016
Print “May
2016 Name Confusion in the Pharmacy”
ECRI Institute’s
Top 10 Patient Safety Concerns for 2016
Every year ECRI Insitute publishes its Top 10 list of patient safety
concerns. Here is their Top 10 list for 2016:
- Health IT configurations and organizational workflow that do not
support each other
- Patient identification errors
- Inadequate management of behavioral health issues in
non-behavioral-health settings
- Inadequate cleaning and disinfection of flexible endoscopes
- Inadequate test-result reporting and follow-up
- Inadequate monitoring for respiratory depression in patients
prescribed opioids
- Medication errors related to pounds and kilograms
- Unintentionally retained objects despite correct count
- Inadequate antimicrobial stewardship
- Failure to embrace a culture of safety
The first two are no
surprise, given our frequent columns on issues related to healthcare IT and
wrong patient issues. Also, the issue of inadequate management of behavioral
health problems in non-behavioral health settings has been a frequent topic for
us (many columns on suicide on general hospital units, wandering and elopement,
and violence in healthcare).
We’ll let you go to
the full ECRI list for details. Click here
to go to the ECRI Institute site where you can download the list.
References:
ECRI Insitute. Top 10 Patient Safety Concerns for
Healthcare Organizations 2016.
Print “May
2016 ECRI Institute’s Top 10 Patient Safety Concerns for 2016”
Print “May
2016 What's New in the Patient Safety World (full
column)”
Print “May
2016 More Debate on Contact Precautions”
Print “May
2016 Guidelines for Perioperative Geriatric Care”
Print “May
2016 Name Confusion in the Pharmacy”
Print “May
2016 ECRI Institute’s Top 10 Patient Safety Concerns for 2016”
Print “PDF
version”
http://www.patientsafetysolutions.com/