Two recent studies done on specialized patient populations identified combinations of interventions that were able to reduce hospital-acquired infections (HAI’s) by over 50%. The first study utilized a bundle of evidence-based interventions in patients undergoing spine surgery (discectomy, decompression, spinal augmentation or spinal fusion) and found surgical site infections declined by 50% after implementation (. Components of the “bundle” were:
The number needed to treat (NNT) to prevent one infection was 47 patients. In addition to the 50 percent decline in SSIs there was an $866 cost reduction per case.
The second study involved ventilator patients in patients in neurointensive care units and found an HAI reduction of 53% over an 18 month period. The two main interventions were (1) reducing the number of intrahospital transports and (2) reducing the number of urinary catheters. The primary way intrahospital transports was reduced was by the introduction of a mobile CT scanner so that patient needing frequent brain imaging could have the imaging done in the neuro ICU rather than being transported to the CT suite. Reduction in urinary catheters was accomplished by daily assessment of the continued need for such catheters, plus staff re-education on insertion and maintenance techniques plus introducing a new Foley kit that simplified and standardized the sterile insertion process Ventilator-associated events decreased 48 %, Foley use decreased 46 %, CAUTIs decreased from 11 per 1000 catheter days to 6.2.
Given our multiple columns on adverse events occurring in the Radiology suite (see full list below but in particular see our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite?”) we would be interested to see if the reduction in transports to Radiology also resulted in fewer overall adverse events of other types. That may well have been the case since they also found overall complication rate decreased 55 %, ICU length of stay decreased an average of 1.5 days, and risk-adjusted mortality decreased 11%.
Lastly, back to one of the most important interventions to reduce HAI’s: good hand hygiene. We often have difficulty convincing our healthcare workers (particularly our physicians) that better compliance with hand hygiene actually translates to fewer HAI’s. That is especially a problem where levels of compliance with hand hygiene are already relatively high. Well, a recent study in CDC’s Emerging Infectious Diseases journal should bolster your argument. Researchers from UNC Chapel Hill
Some of our prior columns on patient safety issues in the radiology suite:
Our other columns on urinary catheter-associated UTI’s:
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 “”
April 2016 “”
August 2016 “”
Implementation of an Infection Prevention Bundle to Reduce Surgical Site Infections and Cost Following Spine Surgery. JAMA Surgery 2016; Online First July 20, 2016
We all assume that ICU’s are good things and that you’ll receive better and safer care in an ICU almost regardless of what your medical problem is. But a new study challenges that assumption. Researchers from the University of Michigan (Valley 2016) analyzed data from Medicare’s Hospital Compare database and found that hospitals with high ICU use for patients with acute MI or CHF exacerbation often had higher mortality rates and lower rates of using evidence-based testing and treatments. For example, MI patients in high ICU use hospitals were less likely to receive aspirin on arrival. MI patients treated in high-ICU hospitals were 6 percent more likely to die within 30 days than patients admitted to low-ICU hospitals, and the difference was about 8 percent for heart failure patients. Hospitals treating smaller numbers of MI and CHF patients and for-profit hospitals tended to have higher use of ICU beds. Patients from lower income zip codes also tend to be overrepresented in the high-ICU hospitals.
Some of the same researchers last year identified similar findings in patients with pneumonia (Sjoding 2015). Hospitals with the highest rates of ICU admission for Medicare patients with pneumonia were less likely to deliver pneumonia processes of care (such as appropriate initial antibiotics and pneumococcal vaccination) and had worse outcomes (higher 30-day mortality and higher readmission rates) for Medicare patients with pneumonia. Hospital spending for pneumonia patients was also higher in high-ICU hospitals.
Somewhat difficult to reconcile with the latter study was another one by many of the same researchers (Valley 2015). They found in Medicare patients with pneumonia that patients with “discretionary” admission to ICU’s had a significantly lower adjusted 30-day mortality. That means that patients who were “borderline” for ICU admission actually had a mortality benefit over those with similar features who were admitted to general wards. That was the opposite of what the researchers expected to find. It is not really clear why these findings differed from those in the Sjoding 2015 study.
Another new study looked at the associations between hospital-level ICU utilization rates and risk-adjusted hospital mortality, use of invasive procedures, and hospital costs (Chang 2016). For each of the 4 medical conditions studied (DKA, PE, UGIB, and CHF) hospital-level ICU utilization rate was not associated with hospital mortality. But use of invasive procedures and costs of hospitalization were greater in institutions with higher ICU utilization for all 4 conditions. They also found that hospitals had similar ICU utilization patterns across the 4 medical conditions studied, suggesting that systematic institutional factors may influence decisions to potentially overutilize ICU care.
Fortunately, in a timely release, the Society for Critical Care Medicine has just updated its guidelines for admission to and discharge from critical care units (Nates 2016). The guidelines also have recommendations for prioritization and triage of potential ICU patients based upon factors such as severity of illness, functional impairment, comorbidities, prognosis for recovery and quality of life, patient preferences with regard to life-sustaining treatment, etc. Chronological age should not be a primary determinant in the elderly. One important recommendation under discharge guidelines is to avoid “after hours” discharge (see our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare” regarding huddles with bed coordinators to avoid such after hours transfers from the ICU). The guidelines also discuss potential sites to which discharge from the ICU can occur, including general wards, step down units, post-acute care facilities, etc. They also discuss use of outreach programs to supplement ICU care, such as rapid response teams and ICU consult teams on wards.
Hospitals need to take a close look at their ICU utilization. We still see hospitals that lack formal criteria for ICU admission and discharge or have them but don’t adhere to them. Yes, ICU’s provide patients with levels of nursing care and monitoring that should be advantageous but they also expose patients to a variety of potential hazards (nosocomial infections, invasive procedures, etc.). And provision of services that don’t result in better patient outcomes may be detrimental to the fiscal health of the hospital.
Valley TS, Sjoding MW, Goldberger ZD, Cooke CR. Intensive care use and quality of care for patients with myocardial infarction and heart failure. Chest 2016; In Press Accepted Manuscript, Available online 15 June 2016
Sjoding MW, Prescott HC, Wunsch H, Iwashyna TJ, Cooke CR. Hospitals with the highest intensive care utilization provide lower quality pneumonia care to the elderly. Crit Care Med 2015; 43(6): 1178-1186
Valley TS, Sjoding MW, Ryan AM, Iwashyna TJ, Cooke CR. Association of Intensive Care Unit Admission With Mortality Among Older Patients With Pneumonia. JAMA 2015; 314(12): 1272-1279
Chang DW, Shapiro MF. Association Between Intensive Care Unit Utilization During Hospitalization and Costs, Use of Invasive Procedures, and Mortality. JAMA Intern Med 2016; Published online August 08, 2016
Nates JL, Nunnally M, Kleinpell R, et al. ICU Admission, Discharge, and Triage Guidelines. A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research. Crit Care Med 2016; 44(8): 1553-1602
Tired of seeing your surgeons and OR personnel traipsing through your hospital cafeteria dressed in their scrubs (with all the contaminants you don’t want to even think about)? Well, get them all to comply with the new recommendations in a statement from the American College of Surgeons (ACS) on operating room attire (ACS 2016). And, while you are at it, make sure everyone in your cath labs or GI labs or other procedure areas also comply with the new recommendations.
The ACS bases its guidelines for appropriate attire on “professionalism, common sense, decorum, and the available evidence”. They are as follows:
The ACS strongly suggests that scrubs should not be worn outside the perimeter of the hospital by any health care provider. To facilitate enforcement of this guideline for OR personnel, the ACS suggests the adoption of distinctive, colored scrub suits for the operating room personnel.
But not everyone is on board with the ACS statement. In particular, AORN (Association of periOperative Registered Nurses) has issued its own statement (AORN 2016) noting that several of the ACS recommendations are not evidence-based. The AORN statement comments on the ACS recommendations item-by-item but especially differs on several points. Whereas the ACS statement recommends that “Scrubs and hats worn during dirty or contaminated cases should be changed prior to subsequent cases even if not visibly soiled.” AORN notes that OSHA requires "attire that has been penetrated by blood, body fluids, or other infectious materials be removed immediately or as soon as possible and be replaced with clean attire." AORN also questions the recommendation about wearing a lab coat over scrubs, noting evidence that lab coats are often contaminated by large numbers of pathogenic organisms. AORN also discusses issues regarding head coverings and how difficult it would be for facilities to enforce vague terminology like “modest sideburn” or “limited amount of hair”. Read the AORN statement in full for other details. AORN also has its own guidelines on surgical attire.
The ACS plans to publish its statement in the October 2016 issue of Bulletin of the American College of Surgeons. One would hope that ACS and AORN would get together with the ASA (American Society of Anesthesiologists) and organizations representing all other OR healthcare workers to agree on standards that apply to all.
ACS (American College of Surgeons). Statement on Operating Room Attire. Online August 4, 2016
AORN (Association of periOperative Registered Nurses). AORN Responds to ACS Statement on Surgical Attire. Periop Insider Newsletter 2016; August 16, 2016
AORN (Association of periOperative Registered Nurses). Clinical FAQ’s. Surgical Attire.
A recent report by the Office of the Inspector General (Levinson 2016) found that 29% of Medicare patients admitted to a post-acute rehabilitation facility (rehab units in acute care hospitals were excluded) experienced either an adverse event or temporary harm event. Almost half (46%) of these were deemed to be likely preventable. About a quarter of the events led to acute care hospitalizations, which were estimated to cost Medicare $92 million annually.
The results were based upon a sample of 417 Medicare patients discharged from such units in March 2012. This event rate is really quite similar to rates the OIG has found for Medicare patients in acute hospitals (27%) and SNF’s (33%). 10% of the patients had an adverse event, which implied harm came to the patient. An additional 18% had events that led to temporary harm. 1.7% of patients had “cascade” events (where multiple related adverse events or temporary harm events occurred in succession). But only 0.7% had events that caused or contributed to their death.
We don’t think the OIG’s report is meant to single out rehab facilities. Rather, it simply demonstrates that all the factors which contribute to adverse events in hospitals are not unique to general hospitals but also occur in almost all healthcare settings.
Levinson DR (Office of the Inspector General. Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. July 2016
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