March 2010

·More on Radiation Safety

·CATCH: New Clinical Decision Rule for CT in Pediatric Head Trauma

·IDSA CAUTI Guidelines

·If Sedation Vacations Work, Why Not Eliminate Sedation All Together?

·Focusing on Compliance to Prevent VAP

More on Radiation Safety

A lot has happened since the NY Times publication of its eye-opening 2-part series (Bogdanich 2010a and 2010b) on the hazards of radiation (see our February 2, 2010 Patient Safety Tip of the Week “The Hazards of Radiation”). Both Congress and the FDA have opened investigations into radiation safety issues. NIH is requiring imaging vendors to include dose-tracking technology in scanners purchased by NIH so that doses can be catalogued in a central database or EMR and be provided to patient’s personal medical records. The manufacturers of imaging equipment (MITA or the Medical Imaging and Technology Allicance) have issued new principles on radiation safety and begun an initiative to establish radiation dose safeguards. These include comparing the dose of radiation for a planned scan against a dosage threshold established by the hospital, above which an alert will be generated. Others include development of a national dose registry for tracking dose levels of patients across the US and integration of dosing information into EMR’s. And others apply to accreditation, training and education of all workers in imaging and better reporting of radiation-related incidents.

All this occurs as a CDC report showed the rates in the US of office visits or hospital outpatient clinic visits in which MRI, PET or CT scans were ordered or performed tripled between 1996 and 2007. And the number of advanced imaging studies ordered by or performed in emergency departments increased four-fold during the same time period.

Largely in response to the series of radiation overdoses during CT scanning that had occurred at Cedars Sinai and other hospitals, the FDA unveiled its “Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging”. The FDA has planned a public meeting on March 30-31, 2010 to discuss reduction of unnecessary radiation exposure to patients during CT scanning, nuclear imaging, and fluoroscopy. It issued a white paper that outlines some planned recommendations. One will be establishment of requirements for manufacturers to incorporate safeguards into their equipment design, labeling and user training. This might include recording and displaying radiation dose with alerts for users when dose exceeds usual levels. The second major element of the initiative will be to partner with accrediting organizations to develop standards that ensure appropriate quality improvement and patient safety programs are utilized by all facilities using these diagnostic imaging modalities. Thirdly they will collaborate to develop diagnostic reference levels and a national radiation dose registry. Similarly, they recommend development of patient registry tools, coupled to electronic medical records, that would provide cumulative dosages of radiation to be made available when a practitioner is considering ordering another imaging study. They recommend continued efforts by multiple organizations to develop appropriateness criteria for various imaging studies. And, lastly, they plan to increase patient awareness of the issues involved in radiation and imaging and recommend development of tools that patients themselves can use to track their personal radiation imaging history.

Meanwhile, further instances of radiation-induced injury have continued to appear. A recent report from a Missouri hospital noted that 76 patients had been overradiated during procedures involving their brain stereotactic system. Most striking is the fact that the cases spanned the time period 2004 to 2009. An original programming error using an incorrectly calibrated measurement apparently led to the overdoses. But the problem was not identified until 5 years later when a second radiation physicist was undergoing training on the system. The hospital system is in the process of notifying all the patients affected. But the case highlights the fact that many hospitals lack quality improvement systems for monitoring doses of radiation actually delivered.

While most of the recent flurry of activity has related primarily to CT scanning and radiation therapy, a new article highlighted the hazards of fluoroscopy (Balter et al 2010). The article notes that current guidelines on fluoroscopy-related skin injuries are over 16 years old and that we have seen expanded use of fluoroscopy as interventional procedures have grown. A key point is that the radiation-induced skin changes may not occur for a month after the procedure and that both patient and physician often don’t make the connection back to the fluoroscopic procedure. Patients often get unnecessary (even dangerous) skin biopsies and inappropriate treatments. Two important points are informing patients they have received high doses of radiation and actually making followup contact with them in the future. Ensuring appropriate training and privileging of physicians performing fluoroscopy is key. You may be surprised to find out all the physicians in your organization who may be peforming fluoroscopy. While you anticipate it will mainly be radiologists and cath lab personnel, we have been surprised at the number of emergency room physicians, orthopedic surgeons, anesthesiologists and others who have done fluoroscopy. Many of the latter have never had appropriate radiation safety training. And remember that in those circumstances, not only are patients at risk but staff may be inadvertently exposed to radiation.

Prior to the NY Times series on injuries from radiation therapy, an outstanding article appeared in the journal Radiotherapy & Oncology (Scorsetti et al 2010). Italian researchers performed a FMEA (failure mode and effects analysis) of their entire process of radiation therapy. A multidisciplinary team mapped out all the steps in the workflow of performing radiation therapy (including going out and observing to identify some steps that may have been overlooked during brainstorming), then identified things that could go wrong and weighted scores by the likelihood they could go wrong. They then focused on improving processes in those areas considered most vulnerable. It is well worth your while to read this comprehensive work and use it as a model for performing a FMEA of your own.

In our January 12, 2010 Patient Safety Tip of the Week “Patient Photos in Patient Safety” we said we couldn’t find any unintended consequences of patient photographs in the medical literature. Well, the Scorsetti group did find one! During their focus on potential misidentification of patients they noted that a photo of each patient had been added to the medical record. However, these photos were often not representative of the patient’s appearance at the time of treatment so staff tended not to rely on the photographs.

References:

Bogdanich W. The Radiation Boom. Radiation Offers New Cures, and Ways to Do Harm. New York Times. January 24, 2010

http://www.nytimes.com/2010/01/24/health/24radiation.html

Bogdanich W. The Radiation Boom. As Technology Surges, Radiation Safeguards Lag.

The New York Times. January 26, 2010

http://www.nytimes.com/2010/01/27/us/27radiation.html

ACR Press Release. NIH Takes Step to Assess Any Possible Risk Associated With Low-Dose Radiation Exposure. February 1, 2010

http://www.jacr.org/webfiles/images/journals/jacr/NIH_Takes_First_Step_Bluemke.doc

MITA. Medical Imaging Manufacturers Unveil Eight Key Principles to Reduce Unnecessary Radiation Exposure and Medical Errors. Plan addresses CT and radiation therapy. February 12, 2010

http://www.medicalimaging.org/news/20100212b.cfm

CDC. National Center for Health Statistics. Health,United States, 2009 with Special Feature on Medical Technology.

http://www.cdc.gov/nchs/data/hus/hus09.pdf#executivesummary

FDA. Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging.

http://www.fda.gov/Radiation-EmittingProducts/RadiationSafety/RadiationDoseReduction/ucm199904.htm

FDA. White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging.

http://www.fda.gov/Radiation-EmittingProducts/RadiationSafety/RadiationDoseReduction/ucm199994.htm

76 patients overradiated at Missouri hospital. HealthImaging.com. February 25, 2010.

http://www.healthimaging.com/index.php?option=com_articles&view=article&id=20886:76-patients-overradiated-at-missouri-hospital

Balter S, Hopewell JW, Miller DL, Wagner LK, Zelefsky MJ.

Fluoroscopically Guided Interventional Procedures: A Review of Radiation Effects on Patients’ Skin and Hair

Radiology 2010; 254: 326-341

http://radiology.rsna.org/content/254/2/326.abstract

Scorsetti M, Signori C, Lattuada P, Urso G, Bignardi M, Navarria P, Castiglioni S, Mancosu P, Trucco P. Applying failure mode effects and criticality analysis in radiotherapy: Lessons learned and perspectives of enhancement.

Radiother Oncol. 2010  Jan 27. [Epub ahead of print]

http://www.ncbi.nlm.nih.gov/pubmed/20116118?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=1

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CATCH: New Clinical Decision Rule for CT in Pediatric Head Trauma

In our November 10, 2009 Patient Safety Tip of the Week “Conserving Resources…But Maintaining Patient Safety” we extolled the virtues of clinical “rules” that help guide the decisions whether to pursue imaging or not in patients seen in the emergency department. For years, we have used the Ottawa knee and ankle rules in our ED’s and seen the number of knee and ankle x-rays diminish without adversely affecting patient care. The Canadian C-spine rule has recently been shown to reduce utilization of cervical spine imaging without compromising patient safety or outcomes. Use of such rules not only saves costs but it also streamlines ED throughput and helps avoid lengthy waits by patients.

Similarly, there are several “rules” that aid the decision about performing CT scans of the head in patients with minor head trauma. The Canadian CT Head Rule (Stiell 2001) for adults with minor head trauma has been around for about 10 years. The New Orleans Criteria (Haydel 2000) have been around for about the same period and the CHIP Prediction Rule (Smits 2007) is slightly newer. A recent cost-effectiveness analysis for use of these rules in minor head injury (Smits 2010) showed that use of these rules can produce substantial cost savings.

All the above rules were developed and validated in adult populations. There has been no widely-accepted clinical decision rule for CT scanning in children with minor head trauma. Given recent concerns about the dosages of ionizing radiation given to children by CT scans, any rule that would identify which children could safely avoid CT scanning would be very useful. Now a new rule, CATCH (the Canadian Assessment of Tomography for Childhood Head Injury), has been developed as a clinical decision support rule to help identify which children with minor head injury need CT scanning done (Osmond et al 2010). The study derived the CATCH rule from a population of children, aged 0 to 16 years, who presented to the emergency department after minor head trauma with a Glasgow Coma Scale score of 13-15 and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. The rule now requires validation in other pediatric cohorts If so validated, it holds great potential to help manage pediatric patients with minor head trauma in the ER in a cost-effective way without jeopardizing patient safety.

References:

Stiell IG, Wells GA,Vandemheen K, et al for the CCC Study Group. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001; 357: 1391–96

http://www.mcgill.ca/files/emergency/CCHR.pdf

Haydel MJ, Preston CA, Mills TJ, et al. Indications for Computed Tomography in Patients with Minor Head Injury. N Engl J Med 2000; 343: 100-5

http://content.nejm.org/cgi/reprint/343/2/100.pdf

Smits M, Dippel DWJ, Steyerberg EW, et al.Predicting Intracranial Traumatic Findings on Computed Tomography in Patients with Minor Head Injury: The CHIP Prediction Rule. Ann Intern Med. 2007; 146: 397-405

http://www.annals.org/content/146/6/397.full.pdf+html

Smits M, Dippel DWJ, Nederkoorn PJ. Minor Head Injury: CT-based Strategies for Management—A Cost-effectiveness Analysis. Radiology 2010; 254: 532-540

http://radiology.rsna.org/content/254/2/532.abstract

Osmond MH, Klassen TP, Wells GA, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. Can. Med. Assoc. J., Feb 2010; early release published February 8, 2010 doi:10.1503/cmaj.091421

http://www.cmaj.ca/cgi/rapidpdf/cmaj.091421v1?maxtoshow=&hits=10&RESULTFORMAT=1&author1=osmond+mh&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=date&resourcetype=HWCIT,HWELTR

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ISDA CAUTI Guidelines

The Infectious Diseases Society of America has released its newest guidelines on CAUTI’s “Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America” (Hooton 2010). The guidelines were developed in collaboration with multiple other specialty societies. The recommendations are presented in the first few pages, then reiterated with summaries of the evidence for each recommendation in the rest of the document.

These guidelines reinforce most of the important concepts that have been put forward in 2 other recent guidelines on CAUTI: (1) CDC HICPAC’s “Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009” (Gould 2009) and (2) “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals” (Lo 2008) that is part of the Hospital Acquired Infections Compendium in the supplement to October 2008 issue of Infection Control & Hospital Epidemiology.

As in all the guidelines, the IDSA CAUTI guideline stresses that the most effective way to reduce the occurrence of CAUTI is to reduce the use of urinary catheterization, both by restricting catheterization to appropriate indications and by limiting duration of catheterization to the minimum time needed. Each facility should develop a list of appropriate indications, educate all healthcare workers on those indications, require a physician’s order for catheterization, and monitor closely compliance with these indications. Particularly for post-operative patients facilities should consider use of portable bladder ultrasound scanners to determine whether catheterization is necessary. Their list of acceptable indications:

• Acute urinary retention
• Need for accurate measurements of urinary output in critically ill patients
• Cases where patient is unable or unwilling to collect urine (eg. during prolonged surgical procedures with general or spinal anesthesia, selected urological and gynecological procedures in the postoperative period)

Most importantly, the guideline stresses that indwelling urethral catheters should not be used for management of incontinence except under very unique circumstances, such as for comfort in terminally ill patients in whom less invasive measures are inadequate.

To minimize duration of urinary catheterization in those cases with legitimate indications, facilities should consider nurse-based discontinuation protocols or electronic physician reminder systems or automatic stop-orders.

In our April 21, 2009 Patient Safety Tip of the Week “Still Futzing with Foleys?” we again offered the following suggestion: treat the Foley catheter like a drug! Have it ordered through your CPOE or medication ordering system. That column lists out some of the potential benefits of using such a system such as:

• Do automatic stop orders
• Barcode them (useful for inventory as well as bedside verification)
• Put them in automated medication dispensing machines
• Require information about reason for use when the order is placed
• Display prompts about the alternatives to indwelling catheters
• Program rules-based alerts and reminders to ensure prompt removal of Foleys
• Force you to “reconcile” them at each transfer of care (internal or external)
• Track catheter usage and catheter days electronically
• And probably others we haven’t even thought about!

In our April 21 column we also noted that one of the problems with failure to remove indwelling urethral catheters postoperatively may be that the OR IT systems are often poorly integrated with the other hospital IT systems. The other problem is that multiple handoffs occur in the perioperative patient. They typically go from a med/surg floor (or pre-op intake area) to the OR, then to the PACU or recovery room, then back to a med/surg floor or ICU. We strongly recommend that your structured handoff tools include a specific item related to indwelling urethral catheters.

The IDSA CAUTI guideline also stresses that screening for asymptomatic bacteruria in the catheterized patients should not be done, except in certain selected clinical situations such as pregnant women. Testing becomes indicated when patients have signs or symptoms suggestive of urinary tract infection.

They have good sections on proper techniques for urinary catheter insertion and maintenance of catheter drainage systems and on alternatives to indwelling urethral catheter use (such as intermittent catheterization and suprapubic catheterization). They also have good recommendations of interventions that should not be routinely used.

And don’t forget our other columns on urinary catheter-associated UTI’s:

• May 8, 2007 Tip of the Week “Doctor, when do I get this red rubber hose removed?”
• January 8, 2008 Tip of the Week “Urinary Catheter-Associated Infections”
• April 2008 What’s New in the Patient Safety World column “More on Nosocomial UTI’s”
• June 24, 2008 Tip of the Week “Urinary Catheter-Related UTI’s: Bladder Bundles”
• April 21, 2009 Tip of the Week “Still Futzing with Foleys?”
• June 9, 2009 Tip of the Week “CDC Update to the Guideline for Prevention of CAUTI”

References:

Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical Infectious Diseases 2010; 50: 625-663

http://www.journals.uchicago.edu/doi/pdf/10.1086/650482

Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. CDC.

http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf

Lo E, Nicolle L, Classen D, et al. Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals. Infect Control Hosp Epidemiol 2008; 29:S41–S50

http://www.journals.uchicago.edu/doi/abs/10.1086/591066

Hospital Acquired Infections Compendium. In supplement to October issue of Infection Control & Hospital Epidemiology 2008; 29: 901-994

http://www.journals.uchicago.edu/toc/iche/2008/29/s1

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If Sedation Vacations Work, Why Not Eliminate Sedation All Together?

Daily sedation “vacations” are a key component of the IHI VAP Bundle and other bundles designed to prevent ventilator-associated pneumonia. Minimizing sedation also helps reduce the incidence of delirium in the intubated, mechanically-ventilated patient. We all recognize there is a tendency to oversedate ICU patients on ventilators. But what about trying no sedation at all?

A group of Danish clinical researchers did just that (Strem 2010). They did a randomized controlled trial in which ICU patients on mechanical ventilation were randomized to receive either no sedation or daily interrupted sedation. They found that patients who received no sedation had significantly fewer days on ventilators, shorter ICU stays, and shorter total hospital LOS. There was no difference in accidental extubations or VAP, though more patients in the no sedation group had agitated delirium.

These results are actually quite encouraging and the practice of eliminating sedation all together may become more widely accepted if these results can be replicated in other settings.

References:

Strem T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. The Lancet 2010; 375: 475 - 480

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)62072-9/abstract

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Focusing on Compliance to Prevent VAP

Most strategies to prevent HAI’s (healthcare-associated infections) require multifaceted interventions or “bundles” of individual interventions. Use of such bundles has been demonstrated to reduce the risk of various HAI’s, though there is often controversy over which of the individual components of the bundle is most important. One of the problems in implementing bundles, however, is that compliance with all the individual components tends to be highly variable. Having a good auditing tool, such as the one used with IHI’s VAP Bundle, is very important.

Last month, a group from France (Bouadma 2010) demonstrated how they significantly reduced their VAP rates by focusing on improving compliance with 8 targeted measures for VAP prevention. The criteria for the measures they chose were that were (1) based on well-recognized published guidelines, (2) easily and precisely defined acts, and (3) directly concerned healthcare workers’ bedside behavior. Compliance with hand hygiene and glove-and-gown use was high at the start and remained high throughout. But compliance with all other measures was low at the start and showed continuous and sustained improvement throughout. These included backrest elevation, tracheal cuff pressure maintenance, orogastric tube use, avoidance of gastric overdistention, good oral hygiene, and elimination of non-essential tracheal suctioning. Their multidisciplinary team focused on an educational program for staff with written materials (including a mandatory 3-hour slide presentation with interactive discussion) and reminders displayed on screensavers and prominently placed posters and feedback. Compliance improved progressively and produced a sustained improvement with 51% reduction in VAP prevalence.

There were a couple other lessons learned. To help improve compliance with the backrest elevation, they equipped all ICU beds with a simple color-coded visual reminder at the head of the bed to help the healthcare workers determine the optimal position. Maintaining that proper position is one of the most difficult interventions in our experience so this “pearl” is one many organizations can take home. A second intervention they did was to monitor tracheal cuff pressure continuously and use an alarm to warn healthcare workers when the pressure was too low.

The concept here is remarkably simple and similar to Peter Pronovost’s approach when the central line “checklist” was developed: (1) determine what the literature says works (2) look to see whether we comply with those recommendations (3) provide tools to help improve compliance and (4) audit or measure compliance with those interventions. And both are examples of incredibly effective interventions.

References:

Bouadma L, Mourvillier B, Deiler V, et al. A multifaceted program to prevent ventilator-associated pneumonia: Impact on compliance with preventive measures. Critical Care Medicine 2010; 38(3): 789-796

http://journals.lww.com/ccmjournal/Abstract/2010/03000/A_multifaceted_program_to_prevent.8.aspx

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