We often talk about how patient compliance and failure to keep office visits impact negatively on the health of our patients. Yet when one looks at interactions with the healthcare system, it is clear that most such patients indeed have interacted with someone in the healthcare system and that many opportunities to intervene are missed. We often see patients who never get their preventive health measures (eg. immunizations) but were seen in an emergency department or other non-PCP setting at a time in which that preventive measure could have been delivered.
Now a new study (Meeker 2011) of patient visits to emergency departments shows an even bigger opportunity to intervene is being overlooked. They looked at patients presenting to the ED who were discharged from the ED without admission and found that 2% of all patients were taking warfarin for one reason or another. Over 70% of those patients had an INR drawn, almost half of which showed the patient was not in the therapeutic range. The ED providers addressed the undesired state of anticoagulation only 21% of the time. They were more likely to intervene when INR was in the supratherapeutic range but only 41% of those with an INR below the therapeutic range had either anticoagulant-related discharge instructions (34%) or an intervention (9%). Many of those patients with non-therapeutic INR’s were taking other medications potentially interacting with warfarin.
So this is another good example of how our fragmented healthcare system fails to provide optimal overall medical care. This is a prime example of how various players in the healthcare system have limited ability to communicate with each other and especially limited ability to agree on responsibility for managing important clinical problems.
Meeker E, Dennehy CE, Weber EJ, Kayser SR. Emergency Department Management of Patients on Warfarin Therapy. Ann Emerg Med 2011; 58: 192-199
In our August 9, 2011 Patient Safety Tip of the Week “Frailty and the Surgical Patient” we discussed the significant risks of surgery in the elderly and fact that outcomes in this population, particularly the frail elderly, are often not good. We also discussed the value of tools such as the frailty index in predicting outcomes in that group. But we also lamented the fact that predictive tools are just that – they often are good at predicting outcomes but don’t allow you to intervene in a fashion that improves outcomes.
However, in many of our prior columns on delirium we have mentioned multimodality intervention programs that were promising in reducing the incidence or severity of delirium in hospitalized patients (see our Patient Safety Tips of the Week for October 21, 2008 “Preventing Delirium”, October 14, 2009 “Managing Delirium”, February 10, 2009 “Sedation in the ICU: The Dexmedetomidine Study”, March 31, 2009 “Screening Patients for Risk of Delirium” and January 26, 2010 “Preventing Postoperative Delirium”).
One of those interventions was HELP, the Hospital Elder Life Program (see our October 21, 2008 Patient Safety Tip of the Week “”). Inouye et al () had shown in a landmark study of 852 medical patients aged 70 and older that management of 6 risk factors was able to reduce the incidence of delirium from 15% to 9.9%. The number of days with delirium and the number of episodes of delirium was also reduced by the intervention. The intervention targeted cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. This was strong evidence that a multicomponent intervention could be of benefit in reducing delirium.
Recently, investigators (Chen 2011) studied the effect of a modified HELP protocol on outcomes of elderly patients undergoing abdominal surgery. They focoused on three key elements of HELP (early ambulation, nutritional management, and cognitive activities). A trained HELP nurse oversaw early ambulation (or active ROM exercises) 3 times daily, oral care, nutritional screening and dietary counseling, feeding assistance, orienting communication and cognitively stimulating activities. Compared to a historical control group, those receiving the HELP intervention had significantly less functional decline and less delirium, less decline in cognitive function, and less depression. Though there was no difference in average length of hospital stay, the above outcomes were clinically meaningful. And the cost of implementing this program was modest. One HELP nurse could manage 4-5 patients, doing 3 visits daily.
The authors note that some of the HELP interventions are also part of the approach taken in fast-track (also know as Enhanced Recovery After Surgery or ERAS) surgery that has become popular for colon surgery and other procedures (Kehlet 2008). That approach, which utilizes early mobilization, early feeding, and analgesic techniques that avoid use of opiates has been shown to significantly reduce morbidity and LOS in patients undergoing colon surgery.
Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients. NEJM 1999; 340: 669-676
Chen C C-H, Lin M-T, Tien Y-W, Yen C-J, Huang G-H, Inouye SK. Modified Hospital Elder Life Program: Effects on Abdominal Surgery Patients. J Amer Coll Surg 2011; 213(2): 245-252
Kehlet H, Wilmore DW. Evidence-Based Surgical Care and the Evolution of Fast-Track Surgery. Annals of Surgery 2008; 248(2): 189-198
In our November 17, 2009 Patient Safety Tip of the Week “Switched Babies” we did a fairly extensive review of the problem of the wrong babies being given to the wrong mothers. The exact incidence of this problem is unknown but in doing our research we found an article in the news about such switches occurring somewhere almost every year. Now another episode has occurred in Australia (Cooper 2011).
In the recent Australian case, the two switched babies spent about 8 hours with the wrong mothers. Both were breastfed during the period with the wrong mothers so testing for potentially transmissible pathogens must be done. Details of the hospital’s investigation are sparse but apparently there was failure to verify identities on the bracelets.
We’ve done FMEA’s (Failure Mode and Effects Analysis) on this potential issue in the past and no matter how safe you think your present system is your FMEA will likely uncover potential vulnerabilities.
See our November 17, 2009 Patient Safety Tip of the Week “Switched Babies” for an extensive discussion of the risk factors and contributory factors to incidents of both switched babies and breastmilk mixups.
Cooper A. Switch shock as newborns go to wrong families. Sydney Morning Herald. July 18, 2011
We’ve done multiple columns on the fact that there are dangers on weekends in most hospitals that go above and beyond those present on weekdays or even weekday nights.
Yet another study (Barba 2011) demonstrates increased mortality for patients admitted on weekends - this time for patients with COPD exacerbations. The authors looked at survival of COPD patients admitted to Spanish hospitals. Case fatality rates were significantly higher for those COPD patients admitted on weekends (12.9% vs. 12.1%) and when they analyzed deaths within 48 hours and 24 hours of admission, those admitted on weekends had a 17% and 39% higher risk, respectively.
In our June 2011 What’s New in the Patient Safety World “Another Study on Dangers of Weekend Admissions” we noted a study (Ricciardi 2011) that came to similar conclusions about mortality for a variety of conditions. The authors studied nonelective hospital admissions in a large all-payor database and analyzed data by day of the week admitted. They found that mortality rates were higher for 15 of 26 major diagnostic categories when patients were admitted on weekends. Even after adjustment for comorbidities and a variety of other clinical and demographic characteristics there remained a significant increase in mortality, on the order of 10% higher for those admitted on weekends. The major diagnostic category of “respiratory” in that study did also show higher weekend mortality rates.
We’ve discussed the numerous factors that may contribute to the “weekend effect” in our previous columns:
Barba R, Zapatero A, Losa JE, et al. The impact of weekends on outcome for Acute Exacerbations of COPD. Eur Respir J erj00132-2011; published ahead of print 2011
Ricciardi R, Roberts PL, Read TE, et al. Mortality Rate After Nonelective Hospital Admission. Arch Surg. 2011; 146(5): 545-551
The August issue of “The Hospitalist” has some good resources about scheduling hospitalists’ workshifts. Of course, the advice probably applies equally well to scheduling shift work of any healthcare worker.
An audio interview (Henkel 2011a) with Christopher P. Landrigan, director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital has some really good points about the effects of shiftwork on mistakes and patient safety. He stresses that you don’t want to schedule someone to work too many nights in a row, citing literature from multiple industries that shows error rates go up with consecutive nights worked. Our November 9, 2010 Patient Safety Tip of the Week “study on shift workers in fields other than healthcare ( ”cited a Folkard 2003) which showed that the risk of incidents increased each consecutive day worked. For example, on average for night shifts risk was 6% higher on the second night, 17% higher on the third night, and 36% higher on the fourth night (for morning/day shifts the corresponding risks were 2%, 7% and 17%).
So Landrigan says that it is probably better to schedule hospitalists for only 3-4 days of night shifts rather than the more popular 7days on/7 days off pattern.
He also discusses the biology of circadian rhythms and notes the importance of taking a 1.5-2.0 hour nap on the afternoon prior to working the first night shift and that working a day shift immediately after a night shift is not a good idea. He discusses how working consecutive night shifts adds to the burden of sleep deprivation, which ultimately has a role in the occurrence of mistakes and errors. When asked about “nocturnists”, he does note that some people have been able to alter their circadian rhythms to accommodate chronic night shift work. But he cautions that when such people take vacations their bodies return to a “day” circadian rhythm and there may be problems when they return to the night shift pattern.
Not only are too many consecutive night shifts potentially dangerous to patients, they are dangerous to the healthcare workers themselves. In the second article (Henkel 2011b) Landrigan notes “We know that if hospitalists are driving home after night shifts, particularly multiple night shifts, that they’re at risk for motor vehicle crashes and at risk of sticking themselves with needles and scalpels toward the tail end of their shifts. None of us want that.”
The latter article also has good advice from John Krisa, medical director of an Albany, NY-based hospitalist group. He avoids 50-50 parceling out of night and day shifts for his hospitalists and uses per diem hospitalists and moonlighters to cover some of the night shifts. That leaves a core of regular hospitalists to provide continuity during the day shifts. Such continuity is likely to garner increased scrutiny after the recent publication of an article (Kuo 2011) showing that patients cared for by hospitalists have shorter lengths of stay but more readmissions and, ultimately, higher overall costs than patients followed in hospital by their primary care physician.
These are some good bits of wisdom. The whole field of managing the biology of shiftwork is just beginning to focus on healthcare.
Henkel G. ONLINE EXCLUSIVE: How to minimize the adverse affects of working night shifts. The Hospitalist. August 2011
Henkel G. ONLINE EXCLUSIVE: Scheduling Rules of Thumb. Safety, equality should factor into HM groups’ coverage plans. The Hospitalist. August 2011
Folkard S, Tucker P. Shift work, safety and productivity. Occupational Medicine 2003; 53: 95-101
Kuo Y-F, Goodwin JS. Association of Hospitalist Care With Medical Utilization After Discharge: Evidence of Cost Shift From a Cohort Study. Ann Intern Med 2011; 155: 152-159
Our September 9, 2008 Patient Safety Tip of the Week “Less is More….and Do You Really Need that Decimal?” we raised the issue of decimal points leading to excessive doses and whether you really need decimal points at all. When do you really need them? You all know you should never use a “trailing zero”, i.e. a zero following a decimal point, because if the decimal point is not seen there is a risk of a 10-fold (or higher) overdose. But what about other numbers following a decimal point? They are important in certain circumstances (eg. a dose of 0.3 mg or 2.7 mg). However, at higher doses they become much less relevant. For example, let’s say you performed a calculation and the result was a recommended dose of a drug is 72.2 mg. Is there really a difference if the patient gets 72 mg. or 72.2 mg of most drugs? Yet ordering the latter dosage increases the risk that the decimal point may not be seen or not input into a computer or missed in a faxed order and the patient gets a 10x overdose. So we strongly recommend that in writing medication orders one specifically decides whether such fractional doses are important or merely place the patient at increased risk of an error.
A related issue is rounding of medication doses. In many cases it is appropriate to “round” the dose to the closest reasonable amount. For example, it might round to the nearest whole number or the nearest first decimal point. But the tolerance for rounding depends on multiple factors and needs to be individualized to specific drugs. Johnson et al (Johnson 2011) convened a group of pediatric experts to review over 100 medications that comprised >95% of all commonly prescribed pediatric medications. They categorized the drugs as fitting one of three categories:
1) medications for which rounding is judiciously used to retain the intended effect
2) medications that are rounded with attention to potential unintended effects
3) medications that are rarely rounded because of the potential for toxicity
They reviewed the literature on each of the drugs and used a Delphi technique to arrive at consensus for categorization of the drugs and the degree of tolerance for rounding. For instance, in the third category drugs having a narrow therapeutic index (eg. digoxin) are rounded with only a 0-2% tolerance. In the second category, drugs like antibiotics or steroids having dose-dependent unintended consequences might have a tolerance of 5-15% and be rounded down to a dose that can be easily administered. Drugs in the first category have dose-dependent intended effects (eg. furosemide) and can be rounded up or down in increments of 10% or so. They derived a list of over 100 drugs with recommended tolerances for rounding that might be adopted in other pediatric organizations.
Johnson KB, Lee CKK, Spooner SA, et al. Automated Dose-Rounding Recommendations for Pediatric Medications . Pediatrics 2011; 128: 2 e422-e428; published ahead of print July 25, 2011, doi:10.1542/peds.2011-0760