New Clinical Measures in CMS Final Rule for Fiscal Year 2010
NQF: Measures to Improve Medication Safety and Quality
The National Quality Forum (NQF) has endorsed 18 new measures to improve medication safrey and quality. These are aimed primarily at improving adherence to medications in patients with chronic conditions such as diabetes, hypercholesterolemia, coronary artery disease, COPD, psychiatric conditions, and chronic kidney disease and on the elderly in general. But they also focus on medication reconciliation and on monitoring of patients on high-risk medications such as warfarin.
National Quality Forum. National Quality Forum Endorses Measures to Improve Medication Safety and Quality. 18 Endorsed Measures Address Use and Management of Medication. August 17, 2009
After-Hours Surgery – Is There a Downside?
This month’s Journal of Bone and Joint Surgery has a very interesting article on adverse outcomes associated with doing certain types of orthopedic surgery after hours (Ricci 2009). We think the issues raised are significant to almost every type of surgery, not just orthopedic surgery.
The study was a prospective multicenter study, though not randomized. They looked at outcomes for surgery with intramedullary nail fixation for femoral and tibial shaft fractures. They sorted the patients into 2 groups: those done during “regular” hours (6 AM to 4 PM) and those done “after hours” (4 PM to 6 AM). Though there were no significant differences in fracture healing, infectious complications, or radiation exposure, the “after hours” group was associated with an increased need for reoperations for removal of painful fracture hardware. They note that this type of complication is more likely related to surgical technique than to characteristics of the fracture. They go on to discuss some of the potential factors that might be contributory.
We have previously seen increased mortality rates for cardiac surgery done after hours (unpublished data). We know you are thinking “obviously those cases that have to be done after hours are sicker so you’d expect a higher mortality”. That, of course, is true in many cases. However, we were very surprised to see how many cases that could have been delayed until “regular hours” were done “after hours” and the mortality rates in those cases were higher.
When you think about it, it makes sense. You are operating with a team that is likely different from your daytime team. All members of that team (physicians, nurses, anesthesiologists, techs, etc.) may not have the same level of expertise as your regular daytime team and the team dynamics between members is likely to be different. The post-surgery recovery unit is likely to be staffed much differently after-hours as well. The staff may be more likely to be unfamiliar with things like location of equipment. And some of the other hospital support services (eg. radiology) may have lesser staffing after-hours. Just as importantly, many or all of the “on-call” staff that make up the after-hours surgical team have likely worked a full daytime shift that day so fatigue enters as a potential contributory factor. And there are always time pressures after hours as well. Our February 26, 2008 Patient Safety Tip of the Week “” discussed other adverse events occurring after hours in hospitals as well as in other industries and talked about the many potential contributory factors.
We highly recommend hospitals take a hard look at surgical cases done “after hours”. In particular, you need to determine which cases truly needed to be done after hours and, perhaps more importantly, which ones could have and should have been done during “regular hours”. If the latter are significant, you need to consider system changes such as reserving some “regular hours” for such cases to be done the following morning. You may have to alter the scheduling of cases for individual surgeons as well. For example, perhaps the surgeon on-call tonight should not have elective cases scheduled tomorrow morning. That way, if a case comes in tonight that should be done tomorrow morning you will have both a “free” OR room and a “free” surgeon. And you would need to develop a list of criteria to help you triage cases into “regular” or “after-hours” time slots.
The Ricci paper has done a great service in raising this issue. It’s one of those issues that “everyone knows about” but most have assumed that nothing can be done about. We hope that other researchers will take the lead and do similar studies for other types of surgery (and help develop the criteria for which cases could be delayed to daytime hours) but it’s time to be proactive at each of our hospitals and review both our historical data and our systems and capabilities. Lacking randomized controlled trials that demonstrate improved outcomes by deferring such cases to the next morning means we can’t apply a solid evidence-based approach at this time. But sometimes common sense needs to be applied while waiting for such studies to be done. At least take a look at the experience at your own hospital. We bet you’ll be surprised by the findings.
Ricci WM, Gallagher B, Brandt A, Schwappach J, Tucker M, Leighton R. Is After-Hours Orthopaedic Surgery Associated with Adverse Outcomes? A Prospective Comparative Study. J Bone Joint Surg Am. 2009;91: 2067-2072
AHRQ’s New Health Care-Associated Infections Resource Page
AHRQ has launched a new web page with tools and links to resources on health care-associated infections (HAI’s). It contains links to the key infection control organizations, links to resources like the Hopkins’ central line insertion checklist, the Michigan Keystone ICU project, and IHI’s HAI tools. Nice to have one site from which to get multiple resources.
AHRQ. Health Care-Associated Infections
New Clinical Measures in CMS Final Rule for Fiscal Year 2010
CMS’s final rule for hospital payment for Fiscal Year 2010 adds four new clinical measures that must be submitted. Two of these measures are additions to the existing Surgical Care Improvement Project measure set (SCIP–Infection-9 Postoperative Urinary Catheter Removal on Postoperative Day 1 or 2 and SCIP-Infection-10: Perioperative Temperature Management). The other two new measures are participation in a systematic clinical database registry for stroke care and participation in a systematic clinical database registry for nursing sensitive care.
We applaud the addition of SCIP-Infection-9. It should help you get your surgeons to buy into standardized order sets that contain Foley catheter indication criteria and protocols for early removal, such as nurse-directed protocols. See our June 9, 2009 Patient Safety Tip of the Week “CDC Update to the Guideline for Prevention of CAUTI” for a discussion on perioperative Foley catheter issues.
Participating in a program such as the Get With The Guidelines® (GWTG) program from the American Heart Association and the American Stroke Association would fulfill the stroke registry participation requirement.
CMS Final Rule FY 2010 Home Page
American Heart Association. Get With The Guidelines® (GWTG).