Tips, Tools, Techniques, and Resources You Can Use in Your Patient Safety and Quality Improvement Initiatives

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April 1, 2008

Pennsylvania PSA's FMEA on Telemetry Alarm Interventions

When we look at our root cause analyses, we usually come up with “the big three”: (1) communication problems (2) failure to buck the authority gradient and (3) problems related to alarms. And when we are asked where to focus FMEA (Failure Mode and Effects Analysis) activities, we always mention situations where alarms are in use.

This month, the Pennsylvania Patient Safety Authority addresses both in a patient safety advisory supplement “Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode and Effects Analysis”. They analyzed data on alarm-related incidents from the Pennsylvania Patient Safety Reporting System, then narrowed their focus to responses to alarm interventions related to telemetry so that they could reasonably perform a FMEA. They utilized the FMEA format recommended by Joint Commission.

Their multidisciplinary FMEA team did a great job flowcharting the alarm intervention process and identified 29 steps involved in the telemetry monitoring process. They then brainstormed to identify as many possible failure modes they could think of, prioritized the identified failure modes, and identified root causes for each of those failure modes. They then developed mitigation strategies for each and sought to redesign the processes where feasible. Because they are not a healthcare facility, they could not complete the FMEA process, which would require analyzing, testing, implementing and monitoring the redesigned process. That, of course, is extremely important because, no matter how meticulously we consider the possibility of unintended consequences, surprises often “bite back”.

Their risk priority rating scale assigned numerical equivalents for probability of occurrence, detectability, and severity and they multiplied these these 3 scores for each identified failure mode to establish priorities for developing mitigation strategies. An arbitrary cut-off score was established but they were careful to point out that not all potential failure modes nicely fit a numerical rating scheme so they allowed for circumstances where clinical and technical staff identified other practical considerations based on their experience.

We don’t want to distract you from actually going to their site and actually reading this thorough and thoughtfully done FMEA so we won’t give you all their recommendations here. However, they provide excellent recommendations regarding patient identification, optimal display location, ensuring the power source of the telemetry receivers, protocols for when monitoring is temporarily suspended or on standby (eg. during transport or while electrodes are being manipulated), protocols for alarm volume levels, electrode placements and inspection and maintenance, making alarm parameters appropriate to both the individual patient and the setting, and protocols for responding to all alarms (whether low- or high-priority alarms) including establishment of a tiered backup response system. They also point out a very important question easily overlooked in a FMEA “is telemetry monitoring indicated in this patient at all?”.

We are hard pressed to add much to their solid recommendations but do have one important recommendation. Our July 19, 2007 Patient Safety Tip of the Week “Unintended Consequences of Technological Solutons” noted an adverse outcome related to transposition of telemetry receivers that were placed on two patients at about the same time. When the telemetry alarm-related incidents from the Pennsylvania Patient Safety Reporting System were analyzed, patient misidentification was one of the root causes seen fairly frequently, though it was not clear if any replicated the circumstances in the case above. We think it is extremely important that a forcing function or constraint be put in place that would preclude a nurse or technician from signing out two remote telemetry receivers at the same time. That forcing function or constraint should require that the appropriate communication and hookup to the telemetry unit occur for the first patient before the same nurse/technician could sign out a second receiver. Would that forcing function/constraint likely produce unintended consequences? For instance, what if there are two patients who emergently need telemetry monitoring? In such circumstance, both those patients would deserve one-to-one nursing care so each should have one nurse sign out one unit. And an alternative strategy would be to have a bar coding system in place whereby the patient identification is electronically communicated to the telemetry system.

As usual, the Pennsylvania Patient Safety Authority has done another excellent job of not only addressing and important, practical problem-prone area but also providing a model that healthcare organizations may look to in doing their own FMEA on any patient safety problem area.

References:

Pennsylvania Patient Safety Authority. Patient Safety Advisory supplement “Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode and Effects Analysis”. March 2008

http://www.psa.state.pa.us/psa/lib/psa/advisories/v5n1march_2008/mar_2008_medical_telemetry_fmea_supplementary_review.pdf

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April 8, 2008

Oxygen as a Medication

In our December 2007 “What’s New in the Patient Safety World” column we speculated that one of the contributing factors to the occurrence of 1000-fold heparin overdoses may be that “heparin flush” is often not looked upon as a medication. The same can be said for another substance that should be considered a medication – oxygen.

Think about it – it’s a chemical given for specific indications, in a specific dose, via a specific route, for an intended duration. Its use needs to be monitored using clinical and laboratory parameters. Its effects are influenced by existing comorbidities affecting specific organ systems. It has both beneficial effects and potentially harmful effects. Sure sounds like a drug to us!

But oxygen therapy seldom gets the same degree of respect that therapy with other medications gets. Numerous surveys or audits (eg. Boyle 2006) in acute hospitals have revealed that there is often no formal prescription for oxygen therapy and, when there is, the prescription is often inadequate or inappropriate.

While oxygen is obviously very helpful or lifesaving in many circumstances, it does have potential adverse effects as well. Several of our previous columns have focused on nonclinical adverse consequences such as surgical fires or neonatal nursery fires and the role of oxygen in fires. And we’ve talked about oxygen canisters becoming potentially lethal projectiles in MRI suites. And oxygen has been involved in various ways in cases of tubing misconnections. But there are also potential clinical physiological adverse consequences of oxygen therapy. Obviously in the newborn, hyperoxygenation is associated with the risk of retinopathy of prematurity and potential pulmonary complications. And in the patient with COPD, precipitation of hypercapnia and respiratory depression is a well-known potential complication of oxygen therapy.

Perhaps the most important consideration in oxygen therapy is the order for it. Much like our discussion on inappropriate use of Foley catheters, oxygen therapy seems to have a way of simply “popping up” on patients in the hospital. It often gets started in the ER, or the post-op recovery room, or other location without adequate documentation of the reasons for its use. It is thus critical that an appropriate order for oxygen always be written (or otherwise entered entered into a CPOE system). That order should include an indication for the oxygen therapy. Each hospital should go through the exercise of establishing a list of the indications for oxygen use. This is not just of practical value – it may have educational value as well. For years, those of us who are neurologists commonly began stroke patients routinely on oxygen therapy. In fact, a stroke by itself is not an appropriate indication for oxygen therapy. A study (Pancioli 2002) looked at oxygen utilization on an inpatient stroke population and found that only 45.6% of days of oxygen use were justified by evidence-based criteria they developed.

The order should also include the desired oxygen concentration or flow rate, method of delivery (eg. mask, nasal prongs, etc.), duration of therapy, and the method of monitoring the effectiveness or potential adverse effects of therapy (such as pulse oximetry or arterial blood gases). Because the order may be somewhat complex, some organizations (see Dodd 2000) have developed an “oxygen prescription chart” or other formal preprinted order set. All the complexities of the oxygen therapy order can also be captured more completely by using a CPOE system.

Compliance with orders for oxygen therapy should also be assessed. How many times have you gone into a patient room and seen the nasal prongs hanging down on his/her neck or being worn on his/her forehead like a sweatband or bandana!

Monitoring the effectiveness of oxygen therapy is usually accomplished noninvasively by pulse oximetry. However, remember that this only measures oxygen saturation and does not provide any assessment of the CO2 and pH status. You’d be surprised how often COPD patients who even have a history of hypercapnia fail to be adequately monitored for hypercapnia. Though hypercapnia may be looked for in other ways (eg. capnography), most often we still look to arterial blood gases before and after initiation of oxygen therapy as the best measure of CO2 status.

The duration of oxygen therapy is often difficult to predict or estimate. Just as each facility should establish criteria for use of oxygen, each facility should develop criteria for cessation of oxygen therapy.

Problems maintaining adequate oxygenation are particularly a problem during transport of patients (within or outside of facilities). The Pennsylvania Patient Safety Authority highlighted this issue in a Patient Safety Advisory in 2005 “Continuity of Oxygen Therapy During Intrahospital Transport”. They reviewed numerous reports to the Pennsylvania Patient Safety Reporting System (PA-PSRS) and looked at failure modes in the many steps involved in maintaining adequate oxygen therapy during transport. They noted that oxygen therapy has been reported to be interrupted in as many as 55% of transports. Failure modes indentified included: failure to treat with oxygen when ordered, failure to initiate flow from the oxygen source, failure to connect the oxygen tubing to the source, failure to place the oxygen delivery device on the patient, and failure to anticipate the oxygen demand and provide an adequate supply throughout the transport.

They suggested standardization of procedures for transport, a formalized hand-off, and clarification of responsibilities for individuals involved. They provided examples from two facilities that addressed these issues. One facility developed a formal communication tool that included details such as the oxygen delivery device, flow rate, PSI, and minutes of oxygen available in the cylinder. The latter is especially important because the sorts of delays that are common when patients are transported away from their rooms (eg. to physical therapy or radiology) make running out of oxygen in the cylinder particularly likely. The above advisory includes a nice table for estimating the amount of oxygen left in the cylinder. They also stress, however, the need to maintain stores of strategically placed oxygen sources throughout the facility and a procedure to ensure that those sources are full and functional. Appropriate education and training of all personnel involved in transports is obviously important.

They include the mnemonic “START” from Harborview Medical Center in Seattle to help staff remember important steps involved:

            Supply adequate oxygen for the trip

            Turn on the oxygen cylinder

            Apply the cannula or mask to the patient

            Rate as ordered and verified

            Trace the connections from the patient to the oxygen source

Mark Daly at the McGill University Health Centre led a project called “O2 Ticket to Ride” that included a two-sided form to be utilized for all transports to ensure adequacy of oxygen therapy. One side had places for documentation of key items such as noted above. The other side had a chart for estimating how long the oxygen should last.

We like the concept of a structured hand-off with a formal communication tool for transport. Many of the same issues that arise for oxygen therapy may apply to other modalities during transport (eg. IV fluids, other medications) and could be addressed in such a tool.

As you implement a plan for management of oxygen therapy, be sure to consider potential unintended consequences. Untreated or undertreated hypoxemia is likely to be a much more frequent cause of patient harm than some of the rarer adverse effects due to oxygen therapy itself.

Implement a good strategy for managing the drug “oxygen” and you will also make your CFO happy. The Pancioli study noted above identified potentially substantial financial savings if oxygen were only used for those stroke patients meeting appropriate criteria for use.

(For discussion of other oxygen cylinder-related adverse events see Gosbee 2002 and medical gas mix-ups see the FDA Patient Safety News 2002.)

Update: See also our June 10, 2008 Patient Safety Tip of the Week “Monitoring the Postoperative COPD Patient” and our January 27, 2009 Patient Safety Tip of the Week “Oxygen Therapy: Everything You Wanted to Know and More!”.

References:

Boyle M, Wong J. Prescribing oxygen therapy. An audit of oxygen prescribing practices on medical wards at North Shore Hospital, Auckland, New Zealand.

Journal of the New Zealand Medical Association 2006; 119: http://www.nzma.org.nz/journal/119-1238/2080/

Pancioli AM, Bullard MJ, Grulee ME, Jauch EC, Perkis DF.  Supplemental Oxygen Use in Ischemic Stroke Patients. Does Utilization Correspond to Need for Oxygen Therapy?

Arch Intern Med. 2002;162:49-52. http://archinte.ama-assn.org/cgi/content/full/162/1/49

Dodd ME, Kellet F, Davis A, Simpson JCG, Webb AK, Haworth CS, Niven R McL. Audit of oxygen prescribing before and after the introduction of a prescription chart. BMJ 2000;321:864-865 http://www.bmj.com/cgi/content/full/321/7265/864?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=dodd&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

Pennsylvania Patient Safety Authority. Patient Safety Advisory.

Continuity of Oxygen Therapy During Intrahospital Transport. September 2005.

http://www.psa.state.pa.us/psa/lib/psa/advisories/v2n3september2005/vol_2-3-sept-05-article_c-continuity_of_oxygen.pdf

Canadian Patient Safety Institute. McGill University Health Centre project: O2 Ticket to Ride. http://www.patientsafetyinstitute.ca/Canadian_Profiles/Mark_Daly.html

Gosbee J, DeRosier JM. Oxygen (Compressed Gas) Cylinder Hazard Summary. VA National Center for Patient Safety. July 2002. http://www.va.gov/ncps/SafetyTopics/O2Cylinder.html

FDA Patient Safety News. Preventing Deaths and Serious Injuries From Medical Gas Mix-Ups. February 2002. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/printer.cfm?id=114

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April 15, 2008

Computerizing Trigger Tools

This month’s issue of the journal Pediatrics has an article (Takata 2008) on adverse drug events in pediatric patients that has received considerable media attention. It demonstrated that adverse drug events occur much more frequently in this patient population than previously published. It also was one factor that led Joint Commission to publish a new Sentinel Event Alert on pediatric medication errors. Takata and colleagues modified the IHI Trigger Tool for Measuring ADE’s to apply to the pediatric population. They then studied its use in 12 children’s hospitals and found a rate of 11.1 ADE’s per 100 patients, a frequency about 5 times higher than typically reported in studies using other methods of detection in the pediatric population. They found that 22% of the identified ADE’s were potentially preventable, 17.8% could have been identified earlier, and 16.8% could have been mitigated more effectively.

The trigger tool they developed was obviously very effective in identifying ADE’s. Less than 4% of the ADE’s they identified by use of the trigger tool had been identified through the usual occurrence reporting systems at the participating hospitals.

We previously discussed trigger tools in our October 30, 2007 Patient Safety Tip of the Week “Using IHI’s Global Trigger Tool” and in our February 5, 2008 Patient Safety Tip of the Week “Reducing Errors in Obstetrical Care”. The beauty of trigger tools is that they identify patients in whom there is a high probability that an adverse event will have occurred. Thus, time-intensive and labor-intensive chart review can be focused on high-yield cases. The results can help identify system problems that need to be addressed in attempt to reduce adverse events in the future. Also, using sampling methodology allows rates to be identified in a more cost-effective manner and the rates can be compared over time to identify trends. Voluntary incident reporting systems and even mandatory ones vastly underestimate the occurrence of adverse events, medical errors and iatrogenic events. Virtually all studies reported have shown that trigger tools substantially improve on the detection and identification of adverse events. Hopefully, this leads to a better understanding of the systems issues and root causes underlying these events.

We do endorse the use of trigger tools as part of your quality improvent/patient safety programs but we need to move our thinking to another level. Does it really help us to know that 17.8% of the ADE’s consisted of pruritis after exposure to a drug to which the patient had no previously known allergy? Not likely. (It could help if the drug given was one to which the patient had a previously known allergy or if the drug had been given without an appropriate indication. Also it would be useful be sure that the patient’s allergy list was immediately updated so that the patient does not get the offending drug a second time.) But the chance that quality improvement will occur after follow up on many such cases is small and it still takes at least 20 minutes on most of the chart reviews. So the real focus needs to be on preventable ADE’s.

The real value of the Takata paper on use of a trigger tool for identifying adverse drug events is the potential for developing real-time triggers that help us identify such ADE’s before harm actually comes to the patient or at least early enough so that immediate interventions can at least mitigate any harm. That’s where we should be focusing our energies.

Trigger tools typically rely on flags developed from information coming from pharmacy or laboratory data sources. Many of the triggers in the IHI trigger tools can be used to identify things that potentially need intervention in real time. For example, a rising serum creatinine should both raise the alert that a potential nephrotoxic agent may need to be stopped or that dosage regimens for renally-excreted drugs may need to be adjusted. It’s easy to think of multiple potential possible actions in response to changes in serum sodium, potassium, glucose, hemoglobin, white blood count, platelet count, PT, PTT, INR, etc. Prescription of an anti-diarrheal agent could alert staff to consider the possibility a patient may have developed a C. difficile infection. Prescription of a hi-alert medication (eg. narcotic) or a rescue medication (eg. flumazenil) might also identify patients needing closer attention.

We are all wary as we develop and refine our CPOE (computerized physician order entry) systems that bombarding physicians with too many alerts can be counterproductive. But many of the alerts can be directed to other staff (pharmacy, nursing, etc.). Would it not be more productive to have a QI staff nurse spending 20 minutes identifying a potential preventable complication or mitigating it early rather than doing retrospective chart review? Of course, we can’t answer those questions conclusively until we have developed and validated a set of “real-time” triggers but it sure makes sense to move as much of the process to real time as possible.

We previously mentioned the study done at Northwestern (Szekendi 2006) that utilized such an active electronic trigger tool to identify potential adverse events early (while patients were still hospitalized). They developed such a system using certain abnormal laboratory results and pharmacy data as triggers and demonstrated such a system can identify many adverse events that might have otherwise gone unreported. In addition, it has the more important feature of being able to identify issues in real-time or near-real-time. They gave some specific examples of how the system actually led to interventions that prevented or mitigated harm.

A further advantage of a real-time surveillance system noted in the Szekendi study is that the investigators had the opportunity to speak directly to caregivers who were often able to provide critical information or context about the the case that would not ordinarily be available during retrospective chart review.

Triggers are generally positive results, events or occurrences. But equally important are the negative ones, i.e. the absence of something that is expected. For instance, the lack of a digoxin level within a certain time frame after a change in digoxin dosing, particularly in a patient with renal impairment, should serve as a red flag. And obviously, the lack of an evidence-based intervention (eg. no beta blocker in a patient with a recent MI) should be flagged for intervention or at least investigation.

While the lack of full integration of electronic data systems currently limits trigger tools and active surveillance systems to a limited set of potential adverse events, future advances will likely expand our ability to identify early a larger number of potential adverse events. Hospitals should prioritize events based on their quality improvement/patient safety initiatives and goals, regulatory considerations, and even financial considerations (since almost every adverse event in a hospitalized patient has financial as well as human consequences). It could be a great tool for improving your hi-alert medication program (eg. anticoagulants, narcotics, sedating agents, insulin, neuromuscular blocking agents, etc.). One group (Hartis 2005) demonstrated use of specific triggers to detect and improve warfarin-related adverse events. Itcould also be used to identify potential look-alike/sound-alike (LASA) medication errors. It could be used to flag circumstances where a patient’s fall risk or DVT risk or even decubitus risk has increased because of events occurring subsequent to admission. It should be noted that such systems are also clearly of potential utility in meeting goals in various pay-for-performance programs.

More and more hospital IT systems are now incorporating electronic medical records and many are including test-based reports (radiology reports, EKG reports, etc.). Some are even mandating that all history & physicals, admission and discharge summaries, consults, and progress notes be entered electronically. The capability of performing text searches and use of techniques such as fuzzy logic have the potential to dramatically expand the data sources that could be used in trigger tools and real-time electronic surveillance systems.

Trigger tools have a place today in your patient safety programs but clearly the wave of the future will be in electronic trigger tools or real-time electronic surveillance programs that integrate rules-based alerts and reminders into your CPOE systems.

By the way, that recent Joint Commission Sentinel Event Alert on pediatric medication errors discusses many of the reasons children and infants may be more prone to medication errors and has many excellent recommendations on things your organization can and should be doing to prevent adverse events related to medication errors. And for those interested in another pediatric trigger tool, see some of the fine work done on the Canadian Paediatric Trigger Tool (Matlow 2005 and Matlow 2007).

References:

Takata, GS, et al:  Development, Testing, and Findings of a Pediatric-Focused Trigger Tool to Identify Medication-Related Harm in US Children’s Hospitals. Pediatrics 2008; 121:e927-3935. http://pediatrics.aappublications.org/cgi/content/full/121/4/e927

Joint Commission. Sentinel Event Alert. Preventing pediatric medication errors. Issue 39, April 11, 2008 http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_39.htm

Institute for Healthcare Improvement. Trigger Tool for Measuring Adverse Drug Events.

http://www.ihi.org/NR/rdonlyres/8D970CE4-BF8C-4F35-9BC1-51358FC8B43F/2222/TriggerToolforMeasuringAdverseDrugEventsCorrected1.pdf

Szekendi, M K; Sullivan, C; Bobb, A; Feinglass, J; Rooney, D; Barnard, C; Noskin, G A Active surveillance using electronic triggers to detect adverse events in hospitalized patients. Quality & Safety in Health Care 2006; 15(3):184-190 http://qshc.bmj.com/cgi/content/abstract/15/3/184?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=Szekendi&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

Hartis C, Gum MO.; Lederer JW. Use of specific indicators to detect warfarin-related adverse events. American Journal of Health-System Pharmacy 2005; 62(16):1683-1688 http://pt.wkhealth.com/pt/re/ajhp/abstract.00043627-200508150-00010.htm;jsessionid=LDRKjc1KwHJgChNhsvd0LlVyhPhlVsQTth1Yw5cJnwknPTGQr6Vg!509222201!181195629!8091!-1

Matlow A, Flintoft V, Orrbine E, Brady-Fryer B, Cronin CMG, Nijssen-Jordan C, Fleming M, Hiltz MA, Lahey M, Zimmerman M, Baker GR. The Development of the Canadian Paediatric Trigger Tool for Identifying Potential Adverse Events. Healthcare Quarterly 2005; 8(Sp): 90-93 http://www.longwoods.com/product.php?printable=Y&productid=17671

Matlow A, Cronin G for the CAPHC Paediatric Trigger Tool Research Group.

Reducing Harm in Paediatric Care: Learning about Adverse Events using a Validated Canadian Paediatric Trigger Tool. Presentation at the CAPHC annual conference. Montreal, October 14, 2007

http://www.caphc.org/documents_annual/2007/conference_ppts/14_10_2007/patient_safety/matlow_cronin.pdf

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April 22, 2008

CMS Expanding List of No-Pay Hospital-Acquired Conditions

Beginning October 1, 2008, Medicare will no longer pay the hospital at a higher rate for eight conditions originally announced in a final rule last year or any conditions added to the list, if they were acquired during the hospital stay. The first eight hospital-acquired conditions (HAC’s) were:

• Objects inadvertently left in after surgery
• Air embolism
• Blood incompatibility
• Catheter-associated urinary tract infection
• Pressure ulcer (decubitus ulcer)
• Vascular catheter associated infection
• Surgical site infection- Mediastinitis after coronary artery bypass graft surgery
• Certain types of falls and trauma

CMS is proposing to expand the list of conditions to include:

• Surgical site infections following certain elective procedures (total knee replacement, laparoscopic gastric bypass and gastroenterostomy, and ligation and stripping of varicose veins)
• Legionnaires’ disease
• Extreme blood sugar derangement (diabetic ketoacidosis, non-ketotic hyperosmolar coma, diabetic coma, and hypoglycemic coma)
• Iatrogenic pneumothorax
• Delirium
• Ventilator-associated pneumonia (VAP)
• Deep vein thrombosis/Pulmonary Embolism
• Staphylococcus aureus septicemia
• Clostridium difficile associated disease

Comments on the proposed rule will be accepted by CMS through June 13, 2008 a final rule is expected on or before August 1, 2008.

The proposed changes are contained in a 1205-page document CMS-1390-P that is not easy reading! However, it does contain useful information about the conditions selected. CMS does utilize specific criteria in the process of selecting candidates as hospital acquired conditions to be included on the list. They must be of either high cost or high volume or both. They must have an ICD-9-CM diagnosis code that clearly identifies them. And there must be evidence in the literature that the complication is reasonably preventable through application of evidence-based guidelines. The document includes tables that provide links to at least some of the evidence base for preventability of each of the proposed conditions.

We anticipate that at least 7 of the proposed 9 additional HAC’s will be in that final rule. We suspect that the comments submitted may likely lead to removal of delirium and Legionnaire’s disease from the list.

The problem with delirium is not that it’s not important to maintain surveillance for delirum but rather in what the evidence base says about interventions. We discussed delirium briefly in our March 4, 2008 Patient Safety Tip of the Week “Housestaff Awareness of Risks for Hazards of Hospitalization”. We noted that if the Hazards of Hospitalization Questionnaire tool developed by the authors (Fernandez 2008) can be validated in several settings or populations, it has tremendous potential to help us prevent complications such as delirium. Not only is delirium associated with increased morbidity and mortality, but it is also associated with prolonged lengths of stay and excess costs (Leslie et al. 2008). At least 2 studies have demonstrated that multifactorial interventions targeted at elderly inpatients at risk for delirium may shorten hospital length of stay, reduce duration of delirium, and reduce mortality (Lundstrom et al. 2005; Naughton et al 2005). The Lundstrom study showed that a multifactorial intervention program reduces the duration of delirium, length of hospital stay, and mortality in delirious patients. The Naughton study showed that a multifactorial intervention designed to reduce delirium in older adults was associated with improved psychotropic medication use, less delirium, and hospital savings. So there does appear to be some evidence that such programs make sense from quality, patient safety, and financial perspectives. However, the interventions are not likely to significantly reduce the number of patients identified with delirium. In fact, a good tool might actually increase the number identified. There are also many factors that are truly not under control of the hospital and staff that may precipitate delirium. So our feeling is that hospitals should not be penalized unfairly for the occurrence of delirium.

The issue with Legionnaire’s disease is the problem of attribution to the hospital or the community. A clearcut outbreak in a hospital that can be traced to problems with a pipe system, etc. certainly should merit no pay. The problem is more likely to arise with isolated cases of Legionnaire’s, which will probably be more common in the long run. In those cases, it may be very difficult to determine whether the patient was exposed prior to or after admission to the hospital. We think that CMS and the hospitals would have a difficult time adjudicating such cases.

So what should hospitals be doing in the interim? Our November 2007 “What’s New in the Patient Safety World” column pointed out an excellent paper by ECRI Institute on how to get ready for the CMS final rule on Hospital-Acquired conditions. It gives good recommendations on putting together a multidisciplinary team to get ready for this. There is also a video and podcast available. Now, more than ever, hospitals need to prevent costly complications because they will bear the full burden for most of those excess costs. And for the newly added conditions, you’ll want to make sure you have programs such as the IHI VAP Bundle, and the Peter Pronovost-like checklists to help prevent central-line associated infections, and the Surgical Care Improvement Project (SCIP) bundle, a good system for determining DVT risk and implementing appropriate prophylaxis, fall and decubitus risk assessments, a Foley catheter use reduction program, and a good overall infection control plan. Make good use of standard order sets, trigger tools, and CPOE with clinical decision support. We also expect to see more “proceduralists” working at hospitals to reduce complications such as pneumothoraces.

References:

CMS Office of Public Affairs. CMS PROPOSES TO EXPAND QUALITY PROGRAM FOR HOSPITAL INPATIENT SERVICES IN FY 2009.Monday, April 14, 2008. http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3041&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&srchOpt=0&srchData=&keywordType=All&chkNewsType=1,+2,+3,+4,+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date

Centers for Medicare & Medicaid Services. [CMS-1390-P]. Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed Changes to Disclosure of Physician Ownership in Hospitals and Physician Self-Referral Rules; Proposed Collection of Information Regarding Financial Relationships Between Hospitals and Physicians. http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1390-P.pdf

Fernandez HM, Callahan KE, Likourezos A, Leipzig RM. House Staff Member Awareness of Older Inpatients' Risks for Hazards of Hospitalization. Arch Intern Med. 2008;168(4):390-396 http://archinte.ama-assn.org/cgi/content/abstract/168/4/390

Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK. One-Year Health Care Costs Associated With Delirium in the Elderly Population. Arch Intern Med 2008; 168(1): 27-32. http://archinte.ama-assn.org/cgi/content/abstract/168/1/27

Naughton BJ, Saltzman S, Ramadan F, Chadha N, Priore R, Mylotte JM. A multifactorial intervention to reduce prevalence of delirium and shorten hospital length of stay. J Am Geriatr Soc. 2005; 53(1):18–23 http://www.blackwell-synergy.com/doi/abs/10.1111/j.1532-5415.2005.53005.x?prevSearch=allfield:(naughton)

Lundström M, Edlund A, Karlsson S, Brännström B, Bucht G, Gustafson Y. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. J Am Geriatr Soc. 2005; 53(4): 622–628 http://www.blackwell-synergy.com/doi/abs/10.1111/j.1532-5415.2005.53210.x?prevSearch=allfield:(Lundstrom)

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June 10, 2008

Monitoring the Postoperative COPD Patient

June 17, 2008

Technology Workarounds Defeat Safety Intent

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March 16, 2010

A Patient Safety Scavenger Hunt

March 9, 2010

Communication of Urgent or Unexpected Radiology Findings

March 2, 2010

Alarm Sensitivity: Early Detection vs. Alarm Fatigue

February 23, 2010

Alarm Issues in the News Again

February 16, 2010

Spin/Hype…Knowing It When You See It

February 9, 2010

More on Preventing Inpatient Suicides

February 2, 2010

The Hazards of Radiation

January 26, 2010

Preventing Postoperative Delirium

January 19, 2010

Timeouts and Safe Surgery

January 12, 2010

Patient Photos in Patient Safety

January 5, 2010

How’s Your Hand Hygiene?

December 29, 2009

Recognizing Deteriorating Patients

December 22, 2009

Falls on Toileting Activities

December 15, 2009

The Weekend Effect

December 8, 2009

Prescribing Errors

December 1, 2009

Patient Safety Doesn’t End at Discharge

November 24, 2009

Another Rough Month for Healthcare IT

November 17, 2009

Switched Babies

November 10, 2009

Conserving Resources…But Maintaining Patient Safety

November 3, 2009

Medication Safety: Frontline to the Rescue Again!

October 27, 2009

Co-Managing Patients: The Good, The Bad, and The Ugly

October 20, 2009

Radiology Again…But This Time It’s Really Radiology!

October 13, 2009

Slipping Through the Cracks

October 6, 2009

Oxygen Safety: More Lessons from the UK

September 29, 2009

Perioperative Peripheral Nerve Injuries

September 22, 2009

Psychotropic Drugs and Falls in the SNF

September 15, 2009

ETTO’s: Efficiency-Thoroughness Trade-Offs

September 8, 2009

Barriers to Medication Reconciliation

September 1, 2009

The Real Root Causes of Medical Helicopter Crashes

August 25, 2009

Interruptions, Distractions, Inattention…Oops!

August 18, 2009

Obstructive Sleep Apnea in the Perioperative Period

August 11, 2009

The Radiology Suite…Again!

August 4, 2009

Faulty Fall Risk Assessments?

July 28, 2009

Wandering, Elopements, and Missing Patients

July 21, 2009

Medication Errors in Long Term-Care

July 14, 2009

Is Your “Do Not Use” Abbreviations List Adequate?

July 7, 2009

Nudge: Small Changes, Big Impacts

June 30, 2009

iSoBAR: Australian Clinical Handoffs/Handovers

June 23, 2009

More on Delirium in the ICU

June 16, 2009

Disclosing Errors That Affect Multiple Patients

June 9, 2009

CDC Update to the Guideline for Prevention of CAUTI

June 2, 2009

Why Hospitals Should Fly…John Nance Nails It!

May 26, 2009

Learning from Tragedies. Part II

May 19, 2009

Learning from Tragedies

May 12, 2009

Errors With PCA Pumps

May 5, 2009

Adverse Drug Events in the ICU

April 28, 2009

Ticket Home and Other Tools to Facilitate Discharge

April 21, 2009

Still Futzing with Foleys?

April 14, 2009

More on Rehospitalization After Discharge

April 7, 2009

Project RED

March 31, 2009

Screening Patients for Risk of Delirium

March 24, 2009

Medication Errors in the OR

March 17, 2009

More on MRI Safety

March 10, 2009

Prolonged Surgical Duration and Time Awareness

March 3, 2009

Overriding Alerts…Like Surfin’ the Web

February 24, 2009

Discharge Planning: Finally Something That Works!

February 17, 2009

Reducing Risk of Overdose with Midazolam Injection

February 10, 2009

Sedation in the ICU: The Dexmedetomidine Study

February 3, 2009

NTSB Medical Helicopter Crash Reports: Missing the Big Picture

January 27, 2009

Oxygen Therapy: Everything You Wanted to Know and More!

January 20, 2009

The WHO Surgical Safety Checklist Delivers the Outcomes

January 13, 2009

Lab Errors in the News

January 6, 2009

Preventing Inpatient Suicides

December 30, 2008

Unintended Consequences: Is Medication Reconciliation Next?

December 23, 2008

Why Safety Alerts Often Fail

December 16, 2008

Joint Commission Sentinel Event Alert on Hazards of Healthcare IT

December 9, 2008

Huddles in Healthcare