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Tip of the Week Archive Oct-Dec 2008
Tips, Tools, Techniques, and Resources You Can Use in Your Patient Safety and Quality Improvement Initiatives
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October 7, 2008
Lessons from Falls....from Rehab Medicine
Now that CMS is no longer paying for certain “never events”, it’s appropriate that our first Patient Safety Tip of the Week for October is on falls. We can learn some valuable lessons on falls from our colleagues in rehab medicine.
The nature of the medical conditions giving rise to the need for rehabilitation medicine services results in differences in the likelihood of falling compared to other typical acute care hospital services. Both the risk of falls and the risk of injury are higher on inpatient rehab units than on other acute care units. But the lessons learned are very applicable to all areas of the hospital. Lee and Stokic (Lee 2008) recently published a paper on the risk factors for falls during inpatient rehabilitation. They found that 9.5% of such patients fell at least once. Most falls occurred during the daytime (85%) and most occurred in the patient’s room (90%). But falls varied substantially by the type of diagnosis a patient was admitted with. A multivariate model showed high risk of falls with the following factors: diagnosis of stroke or amputation, age between 41 and 50, lower cognitive FIM scores, and large number of medical comorbidities. Most falls are also unwitnessed. In the Lee study, 74% of the falls were not observed.
The Lee paper also notes how the rate of falls is very dependent on the nature of the patient population and varies considerably among the different diagnostic groups. Patients with stroke and amputation were more likely to fall than those with spinal cord injury. Similarly, in an acute hospital population there is likely a considerable difference in fall rates between a hospital that does lots of obstetrics, pediatrics and behavioral health and one that does lots of trauma and orthopedic care. So it is very difficult to benchmark fall rates across hospitals without knowing details about the patient population. It is much more important to measure (and display for feedback) the fall rates on individual units of a hospital so that they can compare their own experience and trends from month to month.
One of the most interesting findings was that the risk of falls was greatest for the age range 41-50 years. Most studies on fall risk have found that the risk increases with age. However, if one uses appropriate multivariate logistical models, age often disappears as an independent predictor of falls. Rather, other risk factors that often appear with increasing age (eg. impaired mobility, impaired cognition) are the true underlying risk factors for falls. In fact, data actually suggests that increasing age may have a preventive effect on falls (Hendrich 2003) when considered as an independent risk factor.
The FIM (functional independence measure) score on admission to rehab may turn out to be valuable in predicting which patients are at risk for falls. The FIM scores in the Lee study showed that patients requiring moderate assistance with motor activities (those who could do 50-75% of activities on their own) may be at greatest risk for falls. Further research is needed to clarify the exact role of the FIM score as a predictor of falls.
In the Lee paper, the risk for falls among the more dependent patients actually increased as they gained more motor activities. On rehab, we are usually encouraging patients to do more for themselves and this may lead to an increased fall risk.
The Lee paper also notes that many of the unobserved falls that occurred in the patients’ rooms were related to the patient attempting to use the bathroom. It is well known that over half the falls which occur in hospitals are related to toileting activities. The Hendrich II Fall Risk Score includes male sex as a risk factor. We’ve never been quite sure whether that risk factor is due to macho vs. modesty. Particularly relating to the risk of falls during toileting, many males may have a “can do” attitude that increases their risk. Alternatively, since the nursing profession is still predominantly female, it may be that modesty keeps male patients from asking for assistance with toileting. At any rate, it is imperative to recognize which patients are at increased risk for falls and ensure that staff are available to assist those patients in toileting activities. Use of timed or scheduled toileting is a very useful tool. Hi-tech systems, such as alarms that trigger when a patient attempts to get out of bed, may be useful. However, see our June 19, 2007 Patient Safety Tip of the Week “Unintended Consequences of Technological Solutions” for an example where a hospital had to swap the nurse call button for the new alarm button and a patient fell when he tried to get out of bed after no one responded when he pushed the nurse call button!
All areas of hospital must understand fall risk and be able to identify which patients are at risk for falls. We’ve had several columns about the risk of adverse events in the radiology suite. That is an area where falls often happen. Patients are often on a gurney or a table or in a wheelchair and may fall when they attempt to get up to use the bathroom. They may be tethered to IV poles or other equipment that become obstacles to trip over. And they may have received benzodiazepines or other sedating medications for the radiology procedure, further increasing their fall risk. So it is critical that the fall risk of a patient is accurately conveyed to all staff when a patient is sent to radiology. This is another example of the hazards of handoffs (see last week’s tip of the week on handoffs). One way to facilitate this handoff would be to include information on fall risk in a structured communication tool for transports like the “ticket to ride” we described in our April 8, 2008 column. A new paper on use of the “ticket to ride” type checklist as a handoff tool (Pesanka 2008) also just appeared in the Journal of Nursing Quality. Also, as per this month’s “What’s New in the Patient Safety World” column, the movement toward color-coded wristbands is gaining momentum. The yellow wristband is the one that signifies the patient is at risk for falls in that system. However, do not use that color-coding convention unless all the hospitals in your area or state have agreed to that convention. And be wary that the yellow wristband does not get confused with the Lance Armstrong wristband commonly worn outside the hospital.
Don’t forget the importance of updating the fall risk. Most hospitals are very good at performing a fall risk assessment on admission. However, lots of things change during a hospitalization that may increase the fall risk (medications are the most obvious change that impacts the fall risk) and hospitals are not as good at recognizing those things. A good fall prevention program has fall risk assessments done on each nursing shift. And a good CPOE system has clinical decision support that may remind the physician about fall risk at the time of order entry (or has a rule that alerts nursing when a medication is added that may increase the fall risk).
We’ve previously discussed fall risk (see April 16, 2007 Patient Safety Tip of the Week “Falls with Injury”) and pointed out that the risk of injury is probably more important than the simple risk of falling, though a fall for a rehab patient may result in a fear of falling that could interfere with the rehab process.
See our January 1, 2008 Patient Safety Tip of the Week “Fall Prevention” for other tips on fall prevention. We’ve also addressed some aspects of falls in our April 16, 2007 and July 17, 2007 Patient Safety Tip of the Week columns and also in our December 18, 2007 discussion about bed rails.
References:
Lee JE, Stokic, DS. Risk Factors for Falls During Inpatient Rehabilitation. American Journal of Physical Medicine & Rehabilitation. 1988; 87(5):341-353
Hendrich AL, Bender PS, Nyhuis A.Validation of the Hendrich II Fall Risk Model: A Large Concurrent Case/Control Study of Hospitalized Patients. Applied Nursing Research 2003; 16: 9-21 http://www.ahincorp.com/hfrm/ARTICLE.PDF
Hendrich II Fall Risk Model
Pesanka DA, Greenhouse PK, Rack LL, Delucia GA, Perret RW, Scholle CC, Johnson MS, Janov CL. Ticket to Ride: Reducing Handoff Risk During Hospital Patient Transport. J Nurs Care Qual. 2008 Aug 26. [Epub ahead of print]
Print “Lessons from Falls....from Rehab Medicine”
Now that CMS is no longer paying for certain “never events”, it’s appropriate that our first Patient Safety Tip of the Week for October is on falls. We can learn some valuable lessons on falls from our colleagues in rehab medicine.
The nature of the medical conditions giving rise to the need for rehabilitation medicine services results in differences in the likelihood of falling compared to other typical acute care hospital services. Both the risk of falls and the risk of injury are higher on inpatient rehab units than on other acute care units. But the lessons learned are very applicable to all areas of the hospital. Lee and Stokic (Lee 2008) recently published a paper on the risk factors for falls during inpatient rehabilitation. They found that 9.5% of such patients fell at least once. Most falls occurred during the daytime (85%) and most occurred in the patient’s room (90%). But falls varied substantially by the type of diagnosis a patient was admitted with. A multivariate model showed high risk of falls with the following factors: diagnosis of stroke or amputation, age between 41 and 50, lower cognitive FIM scores, and large number of medical comorbidities. Most falls are also unwitnessed. In the Lee study, 74% of the falls were not observed.
The Lee paper also notes how the rate of falls is very dependent on the nature of the patient population and varies considerably among the different diagnostic groups. Patients with stroke and amputation were more likely to fall than those with spinal cord injury. Similarly, in an acute hospital population there is likely a considerable difference in fall rates between a hospital that does lots of obstetrics, pediatrics and behavioral health and one that does lots of trauma and orthopedic care. So it is very difficult to benchmark fall rates across hospitals without knowing details about the patient population. It is much more important to measure (and display for feedback) the fall rates on individual units of a hospital so that they can compare their own experience and trends from month to month.
One of the most interesting findings was that the risk of falls was greatest for the age range 41-50 years. Most studies on fall risk have found that the risk increases with age. However, if one uses appropriate multivariate logistical models, age often disappears as an independent predictor of falls. Rather, other risk factors that often appear with increasing age (eg. impaired mobility, impaired cognition) are the true underlying risk factors for falls. In fact, data actually suggests that increasing age may have a preventive effect on falls (Hendrich 2003) when considered as an independent risk factor.
The FIM (functional independence measure) score on admission to rehab may turn out to be valuable in predicting which patients are at risk for falls. The FIM scores in the Lee study showed that patients requiring moderate assistance with motor activities (those who could do 50-75% of activities on their own) may be at greatest risk for falls. Further research is needed to clarify the exact role of the FIM score as a predictor of falls.
In the Lee paper, the risk for falls among the more dependent patients actually increased as they gained more motor activities. On rehab, we are usually encouraging patients to do more for themselves and this may lead to an increased fall risk.
The Lee paper also notes that many of the unobserved falls that occurred in the patients’ rooms were related to the patient attempting to use the bathroom. It is well known that over half the falls which occur in hospitals are related to toileting activities. The Hendrich II Fall Risk Score includes male sex as a risk factor. We’ve never been quite sure whether that risk factor is due to macho vs. modesty. Particularly relating to the risk of falls during toileting, many males may have a “can do” attitude that increases their risk. Alternatively, since the nursing profession is still predominantly female, it may be that modesty keeps male patients from asking for assistance with toileting. At any rate, it is imperative to recognize which patients are at increased risk for falls and ensure that staff are available to assist those patients in toileting activities. Use of timed or scheduled toileting is a very useful tool. Hi-tech systems, such as alarms that trigger when a patient attempts to get out of bed, may be useful. However, see our June 19, 2007 Patient Safety Tip of the Week “Unintended Consequences of Technological Solutions” for an example where a hospital had to swap the nurse call button for the new alarm button and a patient fell when he tried to get out of bed after no one responded when he pushed the nurse call button!
All areas of hospital must understand fall risk and be able to identify which patients are at risk for falls. We’ve had several columns about the risk of adverse events in the radiology suite. That is an area where falls often happen. Patients are often on a gurney or a table or in a wheelchair and may fall when they attempt to get up to use the bathroom. They may be tethered to IV poles or other equipment that become obstacles to trip over. And they may have received benzodiazepines or other sedating medications for the radiology procedure, further increasing their fall risk. So it is critical that the fall risk of a patient is accurately conveyed to all staff when a patient is sent to radiology. This is another example of the hazards of handoffs (see last week’s tip of the week on handoffs). One way to facilitate this handoff would be to include information on fall risk in a structured communication tool for transports like the “ticket to ride” we described in our April 8, 2008 column. A new paper on use of the “ticket to ride” type checklist as a handoff tool (Pesanka 2008) also just appeared in the Journal of Nursing Quality. Also, as per this month’s “What’s New in the Patient Safety World” column, the movement toward color-coded wristbands is gaining momentum. The yellow wristband is the one that signifies the patient is at risk for falls in that system. However, do not use that color-coding convention unless all the hospitals in your area or state have agreed to that convention. And be wary that the yellow wristband does not get confused with the Lance Armstrong wristband commonly worn outside the hospital.
Don’t forget the importance of updating the fall risk. Most hospitals are very good at performing a fall risk assessment on admission. However, lots of things change during a hospitalization that may increase the fall risk (medications are the most obvious change that impacts the fall risk) and hospitals are not as good at recognizing those things. A good fall prevention program has fall risk assessments done on each nursing shift. And a good CPOE system has clinical decision support that may remind the physician about fall risk at the time of order entry (or has a rule that alerts nursing when a medication is added that may increase the fall risk).
We’ve previously discussed fall risk (see April 16, 2007 Patient Safety Tip of the Week “Falls with Injury”) and pointed out that the risk of injury is probably more important than the simple risk of falling, though a fall for a rehab patient may result in a fear of falling that could interfere with the rehab process.
See our January 1, 2008 Patient Safety Tip of the Week “Fall Prevention” for other tips on fall prevention. We’ve also addressed some aspects of falls in our April 16, 2007 and July 17, 2007 Patient Safety Tip of the Week columns and also in our December 18, 2007 discussion about bed rails.
References:
Lee JE, Stokic, DS. Risk Factors for Falls During Inpatient Rehabilitation. American Journal of Physical Medicine & Rehabilitation. 1988; 87(5):341-353
Hendrich AL, Bender PS, Nyhuis A.Validation of the Hendrich II Fall Risk Model: A Large Concurrent Case/Control Study of Hospitalized Patients. Applied Nursing Research 2003; 16: 9-21 http://www.ahincorp.com/hfrm/ARTICLE.PDF
Hendrich II Fall Risk Model
Pesanka DA, Greenhouse PK, Rack LL, Delucia GA, Perret RW, Scholle CC, Johnson MS, Janov CL. Ticket to Ride: Reducing Handoff Risk During Hospital Patient Transport. J Nurs Care Qual. 2008 Aug 26. [Epub ahead of print]
Print “Lessons from Falls....from Rehab Medicine”
October 14, 2008
Managing Delirium
As we anticipated, delirium did not make the final cut on the CMS list of conditions (“never events”) for which payment will be withheld (see our April 22, 2008 Patient Safety Tip of the Week “CMS Expanding List of No-Pay Hospital-Acquired Conditions”). But that doesn’t mean that managing delirium is not important for your bottom line. Quite frankly, it is very important for both your patients and your bottom line and you need to have a systematic approach to both recognizing delirium and managing it.
Numerous studies have shown that patients with delirium have excess morbidity and mortality, excess hospital resource consumption, and are more likely to suffer cognitive and functional decline, institutionalization and death in the year following hospitalization. Leslie et al (Leslie et al. 2008) showed that delirium is associated with prolonged lengths of stay and excess costs. Average costs per day survived among patients with delirium were more than 2 times the costs among patients without delirium and total healthcare cost estimates attributable to delirium ranged from $16,303 to $64,421 per patient in the year following delirium.
There are some excellent delirium resources available for free on the Internet. National guidelines “Clinical Practice Guidelines For The Management Of Delirium In Older People” published in Australia in late 2006 provide some excellent recommendations on identification, prevention, and management of delirium. Vanderbilt University’s ICU Delirium and Cognitive Impairment Study Group website is also an excellent resource for information on delirium. And the National Guideline Clearinghouse has several resources available for delirium, including “Delirium: prevention, early recognition, and treatment. In: Evidence-based geriatric nursing protocols for best practice.”
For those interested in the pathophysiology of delirium, we refer you to the discussion in the Girard (Girard 2008) and Fricchione (Fricchione 2008) papers. There has been much speculation about the role of inflammatory processes in the etiology of delirium, particularly since the time course of post-operative delirium (typically occurring 2-7 days post-op) tends to parallel the inflammatory response seen after surgery.
Delirium has long been underrecognized in hospital settings. One of the problems is that the agitated or hyperactive subtype of delirium is more easily recognized than the more common hypoactive subtype. A number of structured clinical tools have been developed and validated to aid in identifying delirium in patients in several different hospital settings. These include the Confusion Assessment Method (CAM), Confusion Assessment Method for the ICU (CAM-ICU), the Intensive Care Delirium Screening Checklist (ICDSC), the Delirium Detection Score (DDS), and the Nursing Delirium Screening Scale (Nu-DESC). We also previously noted that if the Hazards of Hospitalization Questionnaire tool (Fernandez 2008) can be validated in several settings or populations, it has tremendous potential to help us prevent complications such as delirium.
Delirium is commonly precipitated by acute intercurrent illnesses such as infections, metabolic derangements, surgery and medications. Post-operative delirium is very common and especially likely to occur after major orthopedic or vascular or cardiovascular surgery or major abdominal or head/neck surgery. Risk factors for delirium include advanced age, smoking, hypertension, pre-existing dementia, depression, prior history of delirium, visual impairment, hyponatremia, alcohol-related illness, indwelling urinary catheters, use of physical restraints, and sleep deprivation.
A series of articles out of Vanderbilt University recently have looked at the prevalence and risk factors associated with delirium in the ICU setting. Girard and colleagues (Girard 2008) noted that delirium may be present in up to 80% of ICU patients. Pandharipande et al (Pandharipande 2008), using the Richmond Agitation Sedation Scale (RASS) and the CAM-ICU tools, found 73% of surgical ICU patients and 67% of trauma ICU patients had delirium. While many of the traditional risk factors for delirium that apply to all hospitalized patients also occur in ICU’s, certain risk factors are much more prevalent in ICU’s. Sleep deprivation is very frequent in the ICU setting and use of sedatives and analgesics is very high in ICU patients. Midazolam and lorazepam, but probably benzodiazepines as a class, have been implicated as strong risk factors for delirium in the ICU setting as well as other settings. Such drugs are used almost universally in patients being mechanically ventilated in ICU’s.
Benzodiazepines are a treatment of choice in alcohol withdrawal. However, alcohol withdrawal may often be inappropriately diagnosed in patients with delirium of other cause. Hecksel and colleagues (Hecksel 2008) at the Mayo Clinic looked at use of a widely utilized symptom-directed protocol for managing alcohol withdrawal. However, when they looked at its use on med-surg units, they found it was administered inappropriately in a substantial proportion (over 50%) of patients, many of whom suffered adverse events related to the treatment. Many of the patients had causes of delirium unrelated to alcohol withdrawal. This was particularly so in post-operative cases. These findings stress the importance of a thorough search for etiology and precipitants in patients who develop delirium in the hospital.
Opiates have also been implicated as risk factors for development of delirium. Just about every opiate preparation, administered via a variety of routes, has been implicated in one study or another. Meperidine especially seems to be related to development of delirium. However, inadequately treated pain is also a risk factor for delirium. So judicious use of opiates may be necessary but alternative analgesics should be considered if they provide adequate pain relief.
Drugs on Beer’s list (see our January 15, 2008 Patient Safety Tip of the Week “Managing Dangerous Medications in the Elderly ” and June 2008 What’s New in the Patient Safety World “Potentially Inappropriate Medication Use in Elderly Hospitalized Patients”) should generally be avoided.
Important to remember is the risk of falls and injury is much higher in patients with altered cognition and this is especially the case in patients with delirium. One of the benefits of a delirium management protocol may be a reduction in the rate of falls (Kratz 2008).
So what strategies can be used to prevent delirium? Environmental modifications may be helpful. Using lighting appropriate to the time of day, noise reduction, providing familiar clues from the home environment, avoiding room changes, adequate hydration, good bowel/bladder care, early mobilization, use of vision and hearing aids, involvement of family and friends, avoiding catheters and restraints are some of the interventions commonly used. Careful review of all medications is critical and where possible benzodiazepines and drugs on Beer’s list should be avoided. There is no good evidence that use of specific drug therapy can prevent delirium, though there is some evidence that use of haloperidol may reduce the duration and severity of delirium.
Several 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. An evidence-based nursing protocol (Kratz 2008) focusing on orientation, nonpharmacologic sleep and early mobilization resulted in significant reductions in falls, restraint use, medication use, and sitter usage.
For those patients with delirium severe enough to merit pharmacologic intervention, we refer the reader to the paper by Fricchione et al (Fricchione 2008). Though the evidence base for any pharmacologic intervention is scant at best, haloperidol (particularly by the IV route) appears to be the mainstay of treatment and is in the APA guidelines. The Fricchione paper also discusses the potential hazards of haloperidol use, including the risks of hypotension, extrapyramidal syndromes, and Q-T interval prolongation and torsade de pointes. They also discuss the use of other pharmacologic therapies and future strategies.
We strongly encourage organizations to develop policies and protocols for identification, prevention and management of delirium. Most of the interventions have little cost involved and the cost savings can be substantial.
Update (10/15/08):
Since we originally posted this Tip we’ve come across another incredibly useful resource. The Hartford Institute for Geriatric Nursing at ConsultGeriRN.org, a site that we often recommend for useful resources, does a great job of demonstrating how to use the CAM tool. These include an article with a case study to show how CAM is used and a well-done video showing techniques that can be used in different scenarios.
See the second part in our series on delirium in our Patient Safety Tip of the Week for October 21, 2008 “Preventing Delirium” and see also our February 10, 2009 Patient Safety Tip of the Week “Sedation in the ICU: The Dexmedetomidine Study”.
References:
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
Clinical Epidemiology and Health Service Evaluation Unit, Melbourne
Health in collaboration with the Delirium Clinical Guidelines Expert Working Group. Clinical Practice Guidelines For The Management Of Delirium In Older People.
Victorian Government Department of Human Services: Melbourne, Victoria,
Australia October 2006
http://www.health.vic.gov.au/acute-agedcare/delirium-cpg.pdf
National Guideline Clearinghouse. Delirium: prevention, early recognition, and treatment. In: Evidence-based geriatric nursing protocols for best practice. Updated Jan. 2008
http://www.guideline.gov/summary/summary.aspx?doc_id=12261&nbr=006345&string=delirium
Girard TD. Pandharipande PP. Ely EW. Delirium in the intensive care unit. [Review] [69 refs] Critical Care (London, England) 2008; 12 Suppl 3:S3 http://ccforum.com/content/12/S3/S3
Fricchione GL. Nejad SH. Esses JA. Cummings TJ Jr. Querques J. Cassem NH. Murray GB. Postoperative delirium. American Journal of Psychiatry 2008; 165(7):803-12
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
Pandharipande P. Cotton BA. Shintani A. Thompson J. Pun BT. Morris JA Jr. Dittus R. Ely EW. Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients. Journal of Trauma-Injury Infection & Critical Care 2008; 65(1):34-41 http://www.jtrauma.com/pt/re/jtrauma/abstract.00005373-200807000-00006.htm;jsessionid=L0GJH75CtGJ553LJLJnN9gh7Jg5NrMnwnfZCSxd9xV951X3skKQ0!-1763103798!181195628!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search
Hecksel KA, Bostwick JM, Jaeger TM, Cha, SS. Inappropriate Use of Symptom-Triggered Therapy for Alcohol Withdrawal in the General Hospital. Mayo Clinic Proceedings 2008; 83(3):274-279 http://www.mayoclinicproceedings.com/inside.asp?AID=4611&UID
Kratz A. Use of the Acute Confusion Protocol: A Research Utilization Project. Journal of Nursing Care Quality2008; 23(4):331-337 http://www.jncqjournal.com/pt/re/jncq/abstract.00001786-200810000-00008.htm;jsessionid=L0gPLp4fCkkb2Z391xs1Nzq2y2vLh1JKcKHy9rk2zhtsbHZQV5Dy!-1763103798!181195628!8091!-1
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)
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)
Print “Managing Delirium”
October 21, 2008
Preventing Delirium
This is the second part of our series on delirium in the hospital setting. Many of you who read last week’s Patient Safety Tip of the Week “Managing Delirium” probably said to yourselves “Sounds like the best way to manage delirium is to prevent it in the first place…”. So did we! It’s interesting to see how we have evolved in our thinking in medicine over the years. We went back and looked at a chapter on neurological problems we had written in a geriatric textbook almost 20 years ago (Truax 1989). It was a short segment about diagnosing and treating delirium and acute confusional states in the geriatric population. Not much has actually changed about the diagnostic or therapeutic approach once delirium occurs but we didn’t even mention prevention! Obviously what has to change is our approach to identifying patients at risk for delirium before they develop it so that we can prevent it all together.
Much of what we know about delirium today comes from the work of Sharon Inouye and her colleagues at Yale and their Hospital Elder Life Program (HELP). Two comprehensive reviews of delirium in older people (Inouye 2006; Young and Inouye 2008) provide good statistical data about delirium as well as clinical and practical management recommendations. Both cite $2500 additional cost per patient and an annual total impact for Medicare of $6.9 billion resulting from delirium. Delirium affects 20% of all hospitalized patients over the age of 65 and care of such patients accounts for 49% of all hospital days. Some studies show even higher costs in certain settings. Milbrandt et al (Mildbrandt 2004) looked at the financial impact of delirium in ICU patients and found that it increased ICU costs by about $9000 and total hospital costs by about $14,500.
How much time and resources have you seen wasted in the “preoperative workup”? Inordinate amounts of resources are wasted getting laboratory and imaging studies that never impact upon a patient’s hospitalization. The same applies to the preoperative “medical clearance”. The evidence base for a shotgun approach to preoperative testing and clearance is thin at best. What makes more sense is a very targeted approach, basing any preoperative evaluation on known medical problems and risk factors and problems likely to occur during the surgery or other reason for hospitalization. But identifying risk factors for delirium should be a very productive endeavor, given the high human and financial costs that accompany delirium and the number of strategies that are available to prevent deilirum.
The strongest risk factor for delirium is pre-existing dementia. Also, of those patients suffering delirium during a hospitalization, a substantial number show cognitive decline in the subsequent year. So there is a complex but clearcut relationship between dementia and delirium. In addition, we’ve mentioned that most cases of delirium are multifactorial in etiology. In patients with pre-existing dementia, fewer other risk factors and/or triggers are necessary to cause delirium whereas several such factors usually must be present to cause delirium in patients lacking dementia. So it makes sense that identifying dementia would be a logical step in predicting a patient is at risk for delirium.
The simplest evaluation that can be done is the standard Mini-Mental Status Examination (MMSE) or one of the shorter derivative tests. Even though there are several more compehensive screening tools that have been used to predict delirium risk, almost all use the MMSE or similar tool as part of their protocol and the additional tools usually just add to the sensitivity and specificity of the MMSE.
A number of tools or instruments have been touted as being predictive of postoperative delirium. The DEAR (Delirium Elderly At-Risk) instrument uses 5 parameters (age > 80, hearing aid/poor vision, activities of daily living, the MMSE, and use of alcohol/benzodiazepines). Use of the DEAR tool preoperatively predicted delirium in 100 hip fracture patients (Freter 2005) with a sensitivity of 71% and specificity of 48%. Surprisingly, the MMSE alone (using a cutoff score of 23) actually had better sensitivity and specificity for postoperative delirium. The same group (Freter 2005b) used the DEAR instrument in 132 patients having elective arthroplasty of the hip or knee and found that having 2 or more risk factors increased the risk of postoperative delirium eight-fold.
Priner et al (Priner 2008) used the short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) in patients 60 and older who were admitted for elective hip and knee arthroplasty and found a score of >50 was predictive of postoperative delirium with an odds ratio of 12.7.
Kalisvaart et al (Kalisvaart 2006) used a medical risk factor model combining 4 risk factors for delirium (MMSE <24, APACHE II score > 16, visual acuity by Snellen chart worse than 20/70, and dehydration as assessed by a BUN/creatinine ratio >18) and were able to stratify elderly hip surgery patients into low-, intermediate-, and high-risk categories. The MMSE and APACHE II scores were independent predictors of postoperative delirium. They also noted that adding age and type of admission (emergency vs. elective) might further strengthen the predictive power of their model but the model needs validation with these risk factors added.
A systematic review (Dasgupta 2006) of preoperative risk assessment for delirium after noncardiac surgery found 25 articles that validated 2 scales, a clinical prediction rule, and a delirium classification system but concluded that further research is needed to better identify patients at risk for postoperative delirium.
And just this week at the American Society of Anesthesiologists annual meeting a new study from Duke by Mork et al was released identifying risk factors to flag patients at risk for postoperative delirium. That study of 100 patients found a 16% incidence of postoperative delirium in patients over 65 who underwent noncardiac surgery. They used 2 tools as potential screening tools to predict postoperative delirium – the Geriatric Depression Scale (short form) and the Trail Making Test. The results are promising.
We recommend that any patient over the age of 65 have a delirium risk assessment prior to admission. If the patient does not have a primary care physician or geriatrician who routinely does such screening, you should have a preoperative program staffed by a nurse or physician extender. That program should include a screening for delirium risk factors in addition to looking for risk factors for other conditions that may complicate a hospitalization. Doing the MMSE (or shorter versions) would be the minimum assessment we’d recommend until future studies validate more complex instruments but it is certainly logical to look for other delirium risk factors noted above as well.
The presence of delirium as patients emerge from anesthesia or in the recovery room is also a good predictor of postoperative delirium occurring later. Sharma et al (Sharma 2005) noted a prevalence of delirium in the recovery room of 45% and prevalence of later postoperative delirium of 36% of elderly hip fracture patients. All patients who later developed postoperative delirium had delirium in the recovery room as well so the sensitivity of recovery room delirium as a predictor of postoperative delirium was 100%.
Once you have identified a patient at risk of delirium, regular screening for delirium with a tool such as the CAM should be done as described in last week’s Tip of the Week.
So what preventive steps do you need to take when you identify a patient as being at risk for delirium and do they work? Inouye et al (Inouye 1999) 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.
Last week we also mentioned several studies that 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) and other hospital outcomes (Kratz 2008). Those strategies include patient orientation, early mobilization, nonpharmacologic sleep, appropriate pain management, good hydration, avoiding a variety of drugs (but especially benzodiazepines and other sedatives), and avoiding physical restraints and urinary catheters or other unnecessary intrusive devices.
Delirium is a common problem in elderly hospitalized patients, with potentially devastating consequences to the patient, their families, the hospital, and society. Delirium’s occurrence should be anticipated. Patients at risk should be identified as soon as possible, preferably even before admission so that appropriate preventive interventions and surveillance can be put in place.
References:
Truax BT: Selected Neurological Problems in the Nursing Home, in Katz P and Calkins E (eds.): The Principles and Practice of Nursing Home Care. Springer Publishing Co.: New York (1989); Ch. 18: pp. 349-374
Inouye SK. Delirium in Older Persons. NEJM 2006; 354: 1157-1165 http://content.nejm.org/cgi/content/extract/354/11/1157
Young J, Inouye SK. Delirium in Older People. BMJ 2007; 334: 842-846 http://www.bmj.com/cgi/reprint/334/7598/842?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&author1=inouye&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT
Milbrandt EB. Deppen S. Harrison PL. Shintani AK. Speroff T. Stiles RA. Truman B. Bernard GR. Dittus RS. Ely EW. Costs associated with delirium in mechanically ventilated patients.[see comment]. Critical Care Medicine 2004; 32(4):955-962 http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200404000-00009.htm;jsessionid=L9PTcBQypPVSwgPpR7SJWnTyLTrkpzk3vyVTvSN7RKGwCpS222wg!949623904!181195628!8091!-1?index=11&database=ppvovft&results=1&count=10&searchid=1&nav=search
Freter SH, George J, Dunbar MJ, Morrison M, MacKnight C, Rockwood K. Prediction of delirium in fractured neck of femur as part of routine preoperative nursing care. Age Ageing 2005; 34: 387-388 http://ageing.oxfordjournals.org/cgi/reprint/34/4/387
Freter SH, Dunbar MJ, McLeod H, Morrison M, MacKnight C, Rockwood K. Predicting postoperative delirium in elective orthopaedic patients: the Delirium Elderly At-Risk (DEAR) instrument. Age Ageing 2005; 34: 169-171 http://ageing.oxfordjournals.org/cgi/reprint/34/2/169
Priner M. Jourdain M. Bouche G. Merlet-Chicoine I. Chaumier JA. Paccalin M. Usefulness of the short IQCODE for predicting postoperative delirium in elderly patients undergoing hip and knee replacement surgery. Gerontology 2008; 54(2):116-119 http://content.karger.com/produktedb/produkte.asp?typ=fulltext&file=000117574
Kalisvaart KJ, Vreeswijk R, de Honghe JFM, van der Ploeg T, van Gool WA, Eikelenboom P. Risk Factors and Prediction of Postoperative Delirium in Elderly Hip-Surgery Patients: Implementation and Validation of a Medical Risk Factor Model. J Am Geriatr Soc 2006; 54: 817-822 http://www3.interscience.wiley.com/journal/118579278/abstract
Dasgupta M. Dumbrell AC. Preoperative risk assessment for delirium after noncardiac surgery: a systematic review. [Review] [51 refs] Journal of the American Geriatrics Society 2006: 54(10):1578-89 http://www3.interscience.wiley.com/journal/118579032/abstract
Mork TG et al. Duke study on preventing postoperative delirium (presentation at 2008 annual meeting of the American Society of Anesthesiologists).
http://www.newswise.com/articles/view/545148/
Sharma PT, Sieber FE, Zakriya KJ, et al. Recovery Room Deliriium Predicts Postoperative Delirium After Hip-Fracture Repair. Anesth Analg 2005; 101: 1215-1220 http://www.anesthesia-analgesia.org/cgi/reprint/101/4/1215
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 http://content.nejm.org/cgi/reprint/340/9/669.pdf
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)
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)
Kratz A. Use of the Acute Confusion Protocol: A Research Utilization Project. Journal of Nursing Care Quality2008; 23(4):331-337 http://www.jncqjournal.com/pt/re/jncq/abstract.00001786-200810000-00008.htm;jsessionid=L0gPLp4fCkkb2Z391xs1Nzq2y2vLh1JKcKHy9rk2zhtsbHZQV5Dy!-1763103798!181195628!8091!-1
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October 28, 2008
More on Computerized Trigger Tools
We’ve done several columns on use of trigger tools in patient safety. Our October 30, 2007 Patient Safety Tip of the Week “Using IHI’s Global Trigger Tool” is a good starting point to learn about what trigger tools can do for your organization. Trigger tools have consistently demonstrated an ability to identify far more adverse events than are identified by typical voluntary hospital reporting systems and formal incident reporting systems. However, we talked about the real potential of using hi-tech tools to enhance the trigger tool concept in our April 15, 2008 Patient Safety Tip of the Week “Computerizing Trigger Tools”.
Two excellent articles on computerized trigger tools have been published recently by the group at Duke University. Ferranti and colleagues (Ferranti 2008a) reported on their dual systems for reporting adverse drug events in adult inpatients, one a voluntary reporting system and the other a trigger-tool based computerized system. The authors feel that Duke’s non-punative culture of safety makes voluntary reporting likely to be utilized. Yet the adverse drug event rate detected by the computerized trigger tool detected substantially higher rates than did the voluntary reporting system (6.93 ADE’s per 1000 patient days vs. 1.96 ADE’s per 1000 patient days). The overlap between the computerized surveillance system and the voluntary reporting system was only 5.6%. Yet both systems contributed significantly to the overall patient safety program at Duke. The voluntary system provided insight into the system nature of medication errors and also identified a wider spectrum of events. The latter, of course, provide the opportunity to develop new rules to add to the computerized trigger system. Also, some types of events (such as drug omissions) may be picked up in the voluntary system but are not detected by the computerized system. The computerized system probably provides a better overall estimate of the frequency of ADE’s and is probably more accurate for trending ADE’s over time. The computerized system also detected some ADE’s that had occurred prior to admission. None of those were captured in the voluntary system. Overall, the dual approach to ADE detection appears to be very useful. Their study also pointed out the need for standardizing taxonomy in all systems.
The second paper (Ferranti 2008b) looked at the two systems in the pediatric population. The ADE rate was 1.8 per 1000 patient days in the voluntary reporting system and 1.6 ADE’s per 1000 patient days in the computerized system. Note that the computerized surveillance system did not perform as well in the pediatric population as in the adult inpatient population. The authors suggest the need for development of more rules specifically-tailored to the pediatric population. Nevertheless, the two systems were complementary. The voluntary system was better at identifying system failures and failures in the medication administration processes, the computerized system appeared better at identifying events related to high-risk medications.
These two articles provide great insight into the potential capabilities of computerized systems for ADE surveillance. Their description of some of the rules in the trigger system and their system for severity scoring are also well worth reading about. Yet they underscore the importance of using more than one method for detecting ADE’s and highlight the strengths and weaknesses of each, while demonstrating synergy.
And there are also two recent articles by David Classen, an original architect of the trigger tool concept. Classen and colleagues (Classen 2008) have refined the IHI Global Trigger methodology. They have used a methodology based on the old Harvard Medical Practice Study for chart review and used a 2-stage approach in which 4 clinical reviewers perform and initial review and then 2 physician reviewers perform a second review, followed by a consensus review. All reviewers reviewed a set of 15 training records, then a set of 50 test records. They were able to demonstrate substantial improvement in interrater agreement after training, both for the presence of an adverse event and also for the classification of the severity of the adverse event. They did limit the individual chart reviews to a maximum of 20 minutes, as commonly recommended by IHI.
Griffin and Classen (Griffin 2008) summarized the results of IHI’s Perioperative Safety Collaboborative. At the 11 hospitals participating, surgical adverse events were identified in 14.6% of patients and the rate of surgical adverse events was 16 per 100 patients. Almost half the events resulted in increased length of stay and 8.7% resulted in harm or required life-saving intervention. As in most other studies using trigger tools to identify adverse events, many more were identified than had been reported in voluntary incident reporting systems.
Trigger tools are here to stay. They provide great ways to identify and trend a whole variety of patient safety events and undoubtedly will be expanded as we develop new rules for triggers. Their potential to also identify events at a stage where intervention may prevent harm to patients is exciting. But they’ll never be the sole tools you’ll use in your patient safety programs. They will, however, nicely complement many of your more conventional patient safety and quality activities.
References:
Ferranti J, Horvath M, Cozart H, Whitehurst J, Eckstrand J, Pietrobon R, Rajgor D, Ahmad A. A Multifaceted Approach to Safety: The Synergistic Detection of Adverse Drug Events in Adult Inpatients. Journal of Patient Safety. 2008; 4(3):184-190
Ferranti J. Horvath MM. Cozart H. Whitehurst J. Eckstrand J. Reevaluating the safety profile of pediatrics: a comparison of computerized adverse drug event surveillance and voluntary reporting in the pediatric environment. Pediatrics 2008; 121(5):e1201-e1207 http://pediatrics.aappublications.org/cgi/reprint/121/5/e1201
Classen, David C. MD, MS *; Lloyd, Robert C. PhD +; Provost, Lloyd PhD +; Griffin, Frances A. RRT, MPA +; Resar, Roger MD + Development and Evaluation of the Institute for Healthcare Improvement Global Trigger Tool. Journal of Patient Safety. 4(3):169-177, September 2008
[My paper]Griffin FA, Classen DC. Detection of adverse events in surgical patients using the Trigger Tool approach. Qual Saf Health Care. 2008; 17 (4):253-258 http://qshc.bmj.com/cgi/content/abstract/17/4/253?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=classen&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT
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November 4, 2008
Beta Blockers Take More Hits
It was almost a year ago that we discussed the findings of the POISE trial (see November 20, 2007 Patient Safety Tip of the Week “New Evidence Questions Perioperative Beta Blocker Use”). The POISE trial showed that, though preoperative beta blockers prevented 15 MI’s for every 1000 patients treated, there was an increased risk of stroke and an excess of 8 deaths per 1000 patients treated. Many hospitals have been slow to change their perioperative beta blocker policies despite those significant findings.
Now a new study (Kaafarani 2008) adds additional concerns about the use of beta blockers in patients undergoing noncardiac surgery. However, it raises more questions than it answers.
The study, conducted at a VA medical center, identified all patients in one year who were taking beta blockers during noncardiac surgery. The authors then matched these patients with a control group from the same population undergoing noncardiac surgery. They found that the patients on beta blockers had higher rates of 30-day MI (2.94% vs, 0.74%) and 30-day mortality (2.52% vs. 0.25%). Differences for both rates were statistically significant.
In addition, within the beta blocker group the mean pre-op heart rate was higher in those patients who died compared to those who survived. Note that all the deaths were in patients considered intermediate or low cardiac risk and no patients in the high risk group died. Thus, this study particularly raises the possibility that beta blockers may be detrimental in low-risk or intermediate-risk patients. It also raises the possibility that inadequate beta blockade (as determined by pre-op heart rate) may play a role in the higher risk for mortality and that titration of beta blockers to an acceptable heart rate before surgery may be important. They suggest the heart rate of 50-60 per minute recommended in the AHA/ACC guidelines might be the most appropriate target.
The Kaafarani study adds weight to the POISE trial in that it reaches the similar conclusion that beta blockers increase mortality after surgery. It differs from the POISE trial in that most of the patients were already on beta blockers well before their surgery (in POISE the beta blockers were begun immediately before surgery). Yet it still leaves open a possibility raised by critics of POISE: that slow titration of beta blockers to achieve a target heart rate might result in a beneficial effect of beta blockers in the perioperative period.
But there are problems with this study. It was not a randomized controlled trial. Rather the “control” group was constructed to look like the patients in the beta blocker group in most respects. Todd Rasmussen, author of the invited critique of the Kaafarani paper, suggests it is possible, if not likely, that the beta blocker patients were at higher risk than the control group in view of the fact that their physicians began them on beta blockers. Also, the reasons for beta blocker use were not specified in the Kaafarani paper. That is important because another recent paper (Bangalore 2008), a systematic review, showed that use of beta blockers for hypertension increased the risks for MI, stroke and mortality. In fact, in hypertensive patients on beta blockers, the risks increased in proportion to the degree of heart rate slowing achieved. The latter fact certainly makes the controversy over target heart rate even more muddled.
So does the Kaafarani study add any practical advice? It certainly does suggest that perioperative beta blockers should not be started without really good indications. Even though the AHA/ACC guidelines suggest a benefit for perioperative beta blockers in high-risk patients, their use had in practice extended to intermediate- and low-risk patients as well. That was the group that did particularly poorly in the Kaafarani study. High-risk patients would be, for example, patients who had demonstrated myocardial ischemia on preoperative cardiac testing. Also, most would also argue that sudden withdrawal of beta blockers is probably not appropriate in the perioperative period so discontinuing them immediately before surgey would not appear to be wise.
What is clearly needed is a randomized controlled trial, similar to POISE, in which patients are clearly stratified by cardiac risk and beta blockade is achieved by slower titration and to target heart rates. Until then the impact of perioperative beta blockers will remain speculative.
Update (11/13/08): Today’s online edition of The Lancet contains a new meta-analysis of 33 studies on perioperative beta blockers in patients having non-cardiac surgery (Bangalore 2008b). This paper concludes that evidence does not support the use of beta blocker therapy for the prevention of perioperative clinical outcomes in patients undergoing non-cardiac surgery. It does acknowledge that the “anti” trials are heavily weighted by the POISE trial results, whereas the “pro” trials are heavily weighted by the early trials in mainly higher risk patients. Their conclusion is that beta blockers should not be used routinely for the perioperative treatment of patients undergoing non-cardiac surgery unless patients are already taking them for other clinically indicated reasons (MI, CAD, CHF). They do acknowledge there are issues still unresolved about types of beta blockers, dosages, protocols, etc. and suggest those issues need to be evaluated in appropriate randomized controlled trials. An accompanying editorial (Boersma 2008) by the investigators of previous pro-beta-blocker trials again raises the issues of the importance of hemodynamic factors related to dose, duration and timing of the perioperative beta blockers.
References:
Kaafarani HMA, Atluri PV, Thornby J, Itani KMF. β-Blockade in Noncardiac Surgery: Outcome at All Levels of Cardiac Risk. Arch Surg. 2008;143(10):940-944
http://archsurg.ama-assn.org/cgi/content/abstract/143/10/940
Rasmussen TE. β-Blockade in Noncardiac Surgery—Invited Critique. Arch Surg. 2008;143(10):944
http://archsurg.ama-assn.org/cgi/content/extract/143/10/944
Bangalore S, Sawhney S, Messerli FH. Relation of Beta-Blocker–Induced Heart Rate Lowering and Cardioprotection in Hypertension. J Am Coll Cardiol 2008 52: 1482-1489
http://content.onlinejacc.org/cgi/content/abstract/52/18/1482
Bangalore S, Wetterslev J, Pranesh S, Sawhney S, Gluud C, Messerli FH. Perioperative β blockers in patients having non-cardiac surgery: a meta-analysis. The Lancet, Early Online Publication, 12 November 2008
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61560-3/fulltext
Boersma E, Poldermans D. β blockers in non-cardiac surgery: haemodynamic data needed. The Lancet, Early Online Publication, 12 November 2008
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61623-2/fulltext
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November 11, 2008
Probiotics and VAP Prevention
A new article that generated a lot of press coverage investigated the possible role of a novel therapy in the prevention of ventilator-associated pneumonia (VAP). Klarin and colleagues published this study on use of probiotics in intubated ICU patients in the online journal Critical Care.
This was a randomized controlled trial in intubated, mechanically ventilated patients. Half received oral application of the probiotic lactobacillus Lp299 and the other half (control group) received chlorhexidine oral decontamination. Subsequent bacteriologic cultures of oropharyngeal or tracheal specimens failed to show any difference in potentially pathogenic bacteria between the probiotic group and the chlorhexidine group. No adverse effects were seen in the probiotic group.
Note that this was a pilot study, intended to determine the power needed to study possible use of such probiotic therapy to prevent VAP.
Though oral decontamination with chlorhexidine (CHX) has been shown to prevent VAP (Chlebick 2007), it does not reduce the time on the ventilator, the length of stay (LOS) in the ICU or rates of mortality (Chan 2007). You’ll recall in our September 2, 2008 Patient Safety Tip of the Week “Updates on VAP Prevention” we criticized the studies touting use of silver-coated endotracheal tubes for the same reason (i.e. they did not duration of intubation, ICU or hospital length of stay, or mortality).
The concept is based on the empiric observation that probiotics reduced pathogenic bacteria on biofilms in patients with vocal prostheses. It makes a lot of sense to consider the probiotic intervention but it is far too early to jump on the probiotic bandwagon. All this study did was demonstrate that probiotics did reduce colonization by pathogenic bacteria. The next step is to see whether that not only reduces the incidence of VAP but also reduces the more important clinical outcomes like mortality, time on the ventilator, ICU and hospital LOS, and costs. Stay tuned.
But what should you be doing in the meantime? In this month’s What’s New in the Patient Safety World we directed you to a great new free resource: the supplement to the October issue of Infection Control & Hospital Epidemiology “A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals”. In that compendium is an article on recommendations for prevention of VAP. Those recommendations include the most important ones from the IHI VAP Bundle, i.e. use of the semirecumbent position and daily assessment of readiness to extubate, plus many others. They recommend many practical general measures (surveillance, handwashing, education, etc.) but one of the most important general measures is assessment of the need to intubate at all. The emergence of noninvasive ventilation techniques in the last decade has made it possible to avoid intubation in a substantial number of patients. Avoiding unplanned extubation and reintubation is also important (see our back-to-back articles “Managing Delirium” and “Preventing Delirium” in October 2008). They recommend use of a cuffed endotracheal tube with in-line or subglottic suctioning and maintenance of an endotracheal cuff pressure of at least 20 cm. H2O. To reduce bacterial colonization, orotracheal intubation is preferred over nasotracheal intubation. As we have mentioned previously, the practice of gastric acid suppression with proton pump inhibitors or H2-blockers, as had originally been recommended in some VAP bundles is very controversial because there is some evidence that such actually increases the likelihood of colonization with pathogenic bacteria (and may also be a risk factor for C. diff). So the current guideline recommends avoiding these drugs unless the patient is at high risk for stress ulcer or stress gastritis. They do recommend oral care, using an antiseptic solution, but note that the ideal frequency of oral care has not been determined. And they provide recommendation regarding the care and cleaning of the ventilator circuits and equipment. As part of the surveillance for VAP, they also strongly recommend surveillance for compliance with the preventive measures noted above. Most of you familiar with the IHI VAP Bundle also use the IHI ventilator bundle checklist. Those of you who are regular readers of this column know we are big advocates of simple checklists, which can be some of our most valuable (and cost-effective!) patient safety tools.
Ventilator-associated pneumonia remains a serious cause of morbidity, mortality and cost in our ICU’s. Preventing VAP must be a serious patient safety goal for all organizations. Though VAP did not make Medicare’s list of “never events” yet, it has clearly been on their radar for a long time and you can bet it will someday make that list. Lack of agreement on how to best diagnose VAP may have been the only thing keeping it off the final list for 2009. So make sure you have good VAP prevention programs in place now – it will help your patients and you will save money while doing that.
Update (11/13/08): This month’s issue of CHEST contains the results of a randomized controlled trial of CASS (continuous aspiration of subglottic secretions) (Bouza 2008) which confirms previous studies demonstrating that CASS is effective in preventing VAP. CASS not only significantly reduced the incidence of VAP, but also significantly reduced the duration of ventilation, reduced ICU LOS, reduced antibiotic usage, and produced significant cost savings. So, unlike the probiotic and silver-coated ETT studies, CASS has documented significant improvement in clinically relevant outcomes. As noted above, subglottic suctioning is already recommended by most VAP prevention guidelines. The current study emphasizes the clinical and business case for use of CASS.
References:
Klarin B, Goran Molin G, Jeppsson B, Larsson A. Use of the probiotic Lactobacillus plantarum 299 to reduce pathogenic bacteria in the oropharynx of intubated patients: a randomised controlled open pilot study. Critical Care 2008, 12:R136 (6 November 2008)
http://ccforum.com/content/pdf/cc7109.pdf
Chlebick MP, Safdar N: Topical chlorhexidine for prevention of ventilator-associated
pneumonia: A meta-analysis. Crit Care Med 2007, 35:595–602 http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200702000-00037.htm;jsessionid=JYzZFqbp77jdqFqLrhwhZ1cbDLbnBwLvyYMRxvhTwWK48kjGpw9B!-1031399950!181195629!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=2&nav=search
Chan EY, Ruest A, O Meade M and Cook DJ: Oral decontamination for prevention of
systematic review and meta-analysis pneumonia in mechanically ventilated adults.
BMJ 2007, 334:889 http://www.bmj.com/cgi/reprint/334/7599/889?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=ruest&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
Coffin SE, Klompas M, Classen D, Arias KM, et al. Supplement Article: SHEA/IDSA Practice Recommendation. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals. Infect Control Hosp Epidemiol 2008; 29: S31–S40
http://www.journals.uchicago.edu/doi/pdf/10.1086/591062
Bouza E, Pérez MJ, Muñoz P, Rincón C, Barrio JM, Hortal J. Continuous Aspiration of Subglottic Secretions in the Prevention of Ventilator-Associated Pneumonia in the Postoperative Period of Major Heart Surgery. Chest 2008: 938–946
http://www.chestjournal.org/cgi/content/abstract/134/5/938
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November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
In September we talked about the hazards of handoffs (September 30, 2008 Patient Safety Tip of the Week Hot Topic: Handoffs) and our September 16, 2008 Patient Safety Tip of the Week “More on Radiology as a High Risk Area” spoke about many of the hazards of transporting patients to the diagnostic imaging suite. One way to facilitate such handoffs would be to include information on various risks in a structured communication tool for transports like the “ticket to ride” we described in our April 8, 2008 column “Oxygen as a Medication”. Some excellent tools have been developed to improve the handoff processes that take place during such transports.
One of the most interesting papers we’ve seen on ICU transports (Esmail 2006) focuses on development of a standardized decision/communication tool. Though the paper does not report any outcome data, it provides some incredible insights into issues associated with development of such tools. It describes the efforts of a Canadian collaborative project to improve ICU transport safety that arose after 2 incidents of cardiopulmonary arrest that occurred in ICU patients that had been transported to diagnostic imaging areas. It goes through all the steps involved in development of a decision “scorecard” to determine the stability of the patient for such transport and the resources necessary if such transport does take place. They used multiple PDSA cycles to test and revise the tool. Their multidisciplinary performance improvement team began by flowcharting all the steps involved in transporting an ICU patient to diagnostic imaging and back to the ICU. They found 29 steps in all (those steps are all included in a figure in the paper). They scanned the literature to find other guidelines and tools for such transports and utilized these to develop their own tool.
One of the most important lessons from this collaborative was the involvement of a human factors expert and their focus on how humans interact with reading and filling out forms. They collected about 80 forms through their iterative processes and found that many of the forms were too complex and not user-friendly. As a result they progressively simplified the form and sought to include only “show stoppers” as their clear decision points. Originally using the traffic signal metaphor, they had green-yellow-red columns for various levels of safety for transport. But in the final analysis, they moved to a geen-red or go/no-go type format. (Red means that the ICU physician must determine whether the potential benefits of the transport outweigh the risks and, if so, the physician should accompany the patient during the transport). But they note that effective forms accommodate two-way flow of information: instruction to the person filling out the form and collection of information from that person. They cite research that shows form fillers read less than 50% of relevant information such as instructions. And they make the very important distinction between “directed forms” and simple “checklists” Directed forms require a yes/no type of response for each item, forcing a decsion and forcing the form filler to read carefully before coming to that decision. They caution that checklists, on the other hand, often lead to the form filler scanning the list for relevant items and often skipping critical information they might perceive to be irrelevant. (Important: note that most of the Peter Pronovost-type checklists you’ve heard us advocate really fit the “directed forms” format defined in this paper).
Particularly enlightening is their discussion of instructions for form use. They note that instructions are often placed on a face sheet or introductory page and, if they are even read, are often forgotten by the time the form filler gets to the area of the form they apply to. So a good form includes the instructions visually at the point where they are relevant.
The second lesson was their insight that the tool needed to be designed so that a “novice” staff member could use it.
A third lesson had to do with some of the resistance to the form that was encountered at one participating site. That particular site had its diagnostic imaging area located adjacent to the ICU and staff there did not perceive the same pressing needs for such a transport decision tool. We strongly agree with the conclusion of the authors that such proximity likely gives rise to a false sense of security and that adverse events are a danger related to even short transports.
A new paper on use of the “ticket to ride” type checklist as a handoff tool (Pesanka 2008) also just appeared in the Journal of Nursing Quality. Analysis of events occurring during off-unit transports had identified a number of issues, so Pesanka and colleagues at UPMC put together a team to develop a standardized handoff communication tool to be utilized during in-hospital transports. The form they developed utilizes an SBAR format and includes most of the key elements you need to consider during patient transports, with appropriate checkboxes and places for sign-off (initials) by everyone involved in the transport (sending team, transport team, receiving team) at all destinations. Importantly, the UPMC Ticket to Ride includes the patient himself as a key stakeholder and participant in the transport. The tool also does a good job of addressing the issue of adequacy of oxygen therapy during transports and stays off the unit (remember our original discussion of the ticket to ride concept arose because of the frequent problem with oxygen during such trips). Though the tool was originally intended for use during transports to diagnostic imaging, it is now being rolled out as a tool for all sorts of transports system-wide in the UPMC system.
Summarizing from the two papers, there are several keys to developing a “ticket to ride” form:
- Keep it simple
- Put instructions visually where they are needed
- Use a structure (such as SBAR)
- Verify each of the key elements at each handoff
- Consider how even the least experienced staff member would use it
- Involve the patient in the process
- Tie outcomes collection to the tool
The Esmail paper and the Pesanka paper provide good examples that you might use for ICU transport decisions and actual transports, respectively. However, rather than just adopting such tools we strongly encourage you to read the articles for the wealth of information they contain about the development of such tools. You will use many of the lessons learned for development of a variety of tools in your organization.
References:
Esmail R, Banack D, Cummings C, Duffett-Martin J, Shultz J, Thurber T, Rimmer K, Hulme T. Is Your Patient Ready for Transport? Developing an ICU Patient Transport Decision Scorecard. Healthcare Quarterly, 9(Sp) 2006: 80-86
http://www.longwoods.com/view.php?aid=18376&cat=452
Pesanka DA, Greenhouse PK, Rack LL, Delucia GA, Perret RW, Scholle CC, Johnson MS, Janov CL. Ticket to Ride: Reducing Handoff Risk During Hospital Patient Transport. J Nurs Care Qual. 2008 Aug 26. [Epub ahead of print]
Print “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
A new article that generated a lot of press coverage investigated the possible role of a novel therapy in the prevention of ventilator-associated pneumonia (VAP). Klarin and colleagues published this study on use of probiotics in intubated ICU patients in the online journal Critical Care.
This was a randomized controlled trial in intubated, mechanically ventilated patients. Half received oral application of the probiotic lactobacillus Lp299 and the other half (control group) received chlorhexidine oral decontamination. Subsequent bacteriologic cultures of oropharyngeal or tracheal specimens failed to show any difference in potentially pathogenic bacteria between the probiotic group and the chlorhexidine group. No adverse effects were seen in the probiotic group.
Note that this was a pilot study, intended to determine the power needed to study possible use of such probiotic therapy to prevent VAP.
Though oral decontamination with chlorhexidine (CHX) has been shown to prevent VAP (Chlebick 2007), it does not reduce the time on the ventilator, the length of stay (LOS) in the ICU or rates of mortality (Chan 2007). You’ll recall in our September 2, 2008 Patient Safety Tip of the Week “Updates on VAP Prevention” we criticized the studies touting use of silver-coated endotracheal tubes for the same reason (i.e. they did not duration of intubation, ICU or hospital length of stay, or mortality).
The concept is based on the empiric observation that probiotics reduced pathogenic bacteria on biofilms in patients with vocal prostheses. It makes a lot of sense to consider the probiotic intervention but it is far too early to jump on the probiotic bandwagon. All this study did was demonstrate that probiotics did reduce colonization by pathogenic bacteria. The next step is to see whether that not only reduces the incidence of VAP but also reduces the more important clinical outcomes like mortality, time on the ventilator, ICU and hospital LOS, and costs. Stay tuned.
But what should you be doing in the meantime? In this month’s What’s New in the Patient Safety World we directed you to a great new free resource: the supplement to the October issue of Infection Control & Hospital Epidemiology “A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals”. In that compendium is an article on recommendations for prevention of VAP. Those recommendations include the most important ones from the IHI VAP Bundle, i.e. use of the semirecumbent position and daily assessment of readiness to extubate, plus many others. They recommend many practical general measures (surveillance, handwashing, education, etc.) but one of the most important general measures is assessment of the need to intubate at all. The emergence of noninvasive ventilation techniques in the last decade has made it possible to avoid intubation in a substantial number of patients. Avoiding unplanned extubation and reintubation is also important (see our back-to-back articles “Managing Delirium” and “Preventing Delirium” in October 2008). They recommend use of a cuffed endotracheal tube with in-line or subglottic suctioning and maintenance of an endotracheal cuff pressure of at least 20 cm. H2O. To reduce bacterial colonization, orotracheal intubation is preferred over nasotracheal intubation. As we have mentioned previously, the practice of gastric acid suppression with proton pump inhibitors or H2-blockers, as had originally been recommended in some VAP bundles is very controversial because there is some evidence that such actually increases the likelihood of colonization with pathogenic bacteria (and may also be a risk factor for C. diff). So the current guideline recommends avoiding these drugs unless the patient is at high risk for stress ulcer or stress gastritis. They do recommend oral care, using an antiseptic solution, but note that the ideal frequency of oral care has not been determined. And they provide recommendation regarding the care and cleaning of the ventilator circuits and equipment. As part of the surveillance for VAP, they also strongly recommend surveillance for compliance with the preventive measures noted above. Most of you familiar with the IHI VAP Bundle also use the IHI ventilator bundle checklist. Those of you who are regular readers of this column know we are big advocates of simple checklists, which can be some of our most valuable (and cost-effective!) patient safety tools.
Ventilator-associated pneumonia remains a serious cause of morbidity, mortality and cost in our ICU’s. Preventing VAP must be a serious patient safety goal for all organizations. Though VAP did not make Medicare’s list of “never events” yet, it has clearly been on their radar for a long time and you can bet it will someday make that list. Lack of agreement on how to best diagnose VAP may have been the only thing keeping it off the final list for 2009. So make sure you have good VAP prevention programs in place now – it will help your patients and you will save money while doing that.
Update (11/13/08): This month’s issue of CHEST contains the results of a randomized controlled trial of CASS (continuous aspiration of subglottic secretions) (Bouza 2008) which confirms previous studies demonstrating that CASS is effective in preventing VAP. CASS not only significantly reduced the incidence of VAP, but also significantly reduced the duration of ventilation, reduced ICU LOS, reduced antibiotic usage, and produced significant cost savings. So, unlike the probiotic and silver-coated ETT studies, CASS has documented significant improvement in clinically relevant outcomes. As noted above, subglottic suctioning is already recommended by most VAP prevention guidelines. The current study emphasizes the clinical and business case for use of CASS.
References:
Klarin B, Goran Molin G, Jeppsson B, Larsson A. Use of the probiotic Lactobacillus plantarum 299 to reduce pathogenic bacteria in the oropharynx of intubated patients: a randomised controlled open pilot study. Critical Care 2008, 12:R136 (6 November 2008)
http://ccforum.com/content/pdf/cc7109.pdf
Chlebick MP, Safdar N: Topical chlorhexidine for prevention of ventilator-associated
pneumonia: A meta-analysis. Crit Care Med 2007, 35:595–602 http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200702000-00037.htm;jsessionid=JYzZFqbp77jdqFqLrhwhZ1cbDLbnBwLvyYMRxvhTwWK48kjGpw9B!-1031399950!181195629!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=2&nav=search
Chan EY, Ruest A, O Meade M and Cook DJ: Oral decontamination for prevention of
systematic review and meta-analysis pneumonia in mechanically ventilated adults.
BMJ 2007, 334:889 http://www.bmj.com/cgi/reprint/334/7599/889?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=ruest&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
Coffin SE, Klompas M, Classen D, Arias KM, et al. Supplement Article: SHEA/IDSA Practice Recommendation. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals. Infect Control Hosp Epidemiol 2008; 29: S31–S40
http://www.journals.uchicago.edu/doi/pdf/10.1086/591062
Bouza E, Pérez MJ, Muñoz P, Rincón C, Barrio JM, Hortal J. Continuous Aspiration of Subglottic Secretions in the Prevention of Ventilator-Associated Pneumonia in the Postoperative Period of Major Heart Surgery. Chest 2008: 938–946
http://www.chestjournal.org/cgi/content/abstract/134/5/938
Print “Probiotics and VAP Prevention”
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
In September we talked about the hazards of handoffs (September 30, 2008 Patient Safety Tip of the Week Hot Topic: Handoffs) and our September 16, 2008 Patient Safety Tip of the Week “More on Radiology as a High Risk Area” spoke about many of the hazards of transporting patients to the diagnostic imaging suite. One way to facilitate such handoffs would be to include information on various risks in a structured communication tool for transports like the “ticket to ride” we described in our April 8, 2008 column “Oxygen as a Medication”. Some excellent tools have been developed to improve the handoff processes that take place during such transports.
One of the most interesting papers we’ve seen on ICU transports (Esmail 2006) focuses on development of a standardized decision/communication tool. Though the paper does not report any outcome data, it provides some incredible insights into issues associated with development of such tools. It describes the efforts of a Canadian collaborative project to improve ICU transport safety that arose after 2 incidents of cardiopulmonary arrest that occurred in ICU patients that had been transported to diagnostic imaging areas. It goes through all the steps involved in development of a decision “scorecard” to determine the stability of the patient for such transport and the resources necessary if such transport does take place. They used multiple PDSA cycles to test and revise the tool. Their multidisciplinary performance improvement team began by flowcharting all the steps involved in transporting an ICU patient to diagnostic imaging and back to the ICU. They found 29 steps in all (those steps are all included in a figure in the paper). They scanned the literature to find other guidelines and tools for such transports and utilized these to develop their own tool.
One of the most important lessons from this collaborative was the involvement of a human factors expert and their focus on how humans interact with reading and filling out forms. They collected about 80 forms through their iterative processes and found that many of the forms were too complex and not user-friendly. As a result they progressively simplified the form and sought to include only “show stoppers” as their clear decision points. Originally using the traffic signal metaphor, they had green-yellow-red columns for various levels of safety for transport. But in the final analysis, they moved to a geen-red or go/no-go type format. (Red means that the ICU physician must determine whether the potential benefits of the transport outweigh the risks and, if so, the physician should accompany the patient during the transport). But they note that effective forms accommodate two-way flow of information: instruction to the person filling out the form and collection of information from that person. They cite research that shows form fillers read less than 50% of relevant information such as instructions. And they make the very important distinction between “directed forms” and simple “checklists” Directed forms require a yes/no type of response for each item, forcing a decsion and forcing the form filler to read carefully before coming to that decision. They caution that checklists, on the other hand, often lead to the form filler scanning the list for relevant items and often skipping critical information they might perceive to be irrelevant. (Important: note that most of the Peter Pronovost-type checklists you’ve heard us advocate really fit the “directed forms” format defined in this paper).
Particularly enlightening is their discussion of instructions for form use. They note that instructions are often placed on a face sheet or introductory page and, if they are even read, are often forgotten by the time the form filler gets to the area of the form they apply to. So a good form includes the instructions visually at the point where they are relevant.
The second lesson was their insight that the tool needed to be designed so that a “novice” staff member could use it.
A third lesson had to do with some of the resistance to the form that was encountered at one participating site. That particular site had its diagnostic imaging area located adjacent to the ICU and staff there did not perceive the same pressing needs for such a transport decision tool. We strongly agree with the conclusion of the authors that such proximity likely gives rise to a false sense of security and that adverse events are a danger related to even short transports.
A new paper on use of the “ticket to ride” type checklist as a handoff tool (Pesanka 2008) also just appeared in the Journal of Nursing Quality. Analysis of events occurring during off-unit transports had identified a number of issues, so Pesanka and colleagues at UPMC put together a team to develop a standardized handoff communication tool to be utilized during in-hospital transports. The form they developed utilizes an SBAR format and includes most of the key elements you need to consider during patient transports, with appropriate checkboxes and places for sign-off (initials) by everyone involved in the transport (sending team, transport team, receiving team) at all destinations. Importantly, the UPMC Ticket to Ride includes the patient himself as a key stakeholder and participant in the transport. The tool also does a good job of addressing the issue of adequacy of oxygen therapy during transports and stays off the unit (remember our original discussion of the ticket to ride concept arose because of the frequent problem with oxygen during such trips). Though the tool was originally intended for use during transports to diagnostic imaging, it is now being rolled out as a tool for all sorts of transports system-wide in the UPMC system.
Summarizing from the two papers, there are several keys to developing a “ticket to ride” form:
- Keep it simple
- Put instructions visually where they are needed
- Use a structure (such as SBAR)
- Verify each of the key elements at each handoff
- Consider how even the least experienced staff member would use it
- Involve the patient in the process
- Tie outcomes collection to the tool
The Esmail paper and the Pesanka paper provide good examples that you might use for ICU transport decisions and actual transports, respectively. However, rather than just adopting such tools we strongly encourage you to read the articles for the wealth of information they contain about the development of such tools. You will use many of the lessons learned for development of a variety of tools in your organization.
References:
Esmail R, Banack D, Cummings C, Duffett-Martin J, Shultz J, Thurber T, Rimmer K, Hulme T. Is Your Patient Ready for Transport? Developing an ICU Patient Transport Decision Scorecard. Healthcare Quarterly, 9(Sp) 2006: 80-86
http://www.longwoods.com/view.php?aid=18376&cat=452
Pesanka DA, Greenhouse PK, Rack LL, Delucia GA, Perret RW, Scholle CC, Johnson MS, Janov CL. Ticket to Ride: Reducing Handoff Risk During Hospital Patient Transport. J Nurs Care Qual. 2008 Aug 26. [Epub ahead of print]
Print “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
November 25, 2008
Wrong-Site Neurosurgery
The National Patient Safety Agency (UK) has just released a new guidance for neurosurgical teams to avoid wrong side burr holes. This includes the formal guidance and the supporting information. This release comes after identification of at least 15 instances of wrong-sided burr holes or craniotomies in less than a 3-year period. Most of you, of course, remember the press last year about three wrong-site surgeries that occurred at Rhode Island Hospital within a one year period.
So is this a problem that neurosurgery is especially prone to? And is this an increase in occurrence rate?
Well, it is probably not an increase. A national audit in the UK published in 2005 noted that at least 17 cases of wrong-site neurosurgery had been identified in the previous 2 years (Winbush 2005). And an anonymous survey of Canadian neurosurgeons in 2004 estimated the incidence of wrong-site surgery for lumbar spine surgery, cervical discectomies, and craniotomies to be 4.5, 6.8, and 2.2 occurrences per 10,000 operations respectively (Jhawar 2007) and they found those rates were likely stable over a 5-year period. The percentage of wrong-site surgery cases in the Joint Commission Sentinel Event database for neurosurgery was 12-13% from 1995 to 2005 (Croteau 2007), though it dropped in subsequent years.
The anonymous survey by Jhawar et al noted that 25% of all neurosurgeons responding admitted to having cut skin on the wrong side of the head at one point in their careers. Contributing factors for wrong-side craniotomies were emergency nature of the case, after-hours surgery, fatigue, and unusual time pressure to start of complete the case. Other factors included mental distraction, neurological false localizing signs (eg. the dilated pupil being on the “wrong” side), unusual positioning of the patient (either in the OR or in the CT scanner), unusual OR setup, incorrect placement of the images on the viewbox, and others. In 11% of the cases the appropriate imaging studies were not available in the OR.
The neurosurgeons in the Jhawar study noted that standard protocol was breached in 40% of the wrong-side craniotomies and 21% of the wrong-level spinal surgeries.
For wrong-level spinal surgery, contributing factors were more likely related to lack of intraoperative imaging capabilities, poor quality of images, and unusual patient anatomy.
The Jhawar group also noted that wrong-site surgeries actually tended to occur more often with experienced surgeons, a finding similar to that noted for hand surgeons.
The UK NPSA guidance noted the following challenges as contributing to wrong-side burr holes or craniotomies: need for midline incisions, reliance on imaging, difficulty marking below the hairline, and inability of patients to confirm the appropriate site. But they also found numerous breaches of best practice: lack of site listing on various documents, failure to mark the side of surgery, lack of compliance with pre-operative assessment or final verification, and lack of being challenged or questioned by other operating room staff.
There are a few risk factors relatively unique to neurosurgical patients that may further contribute to wrong-site neurosurgery. By virtue of their pathological condition they may be obtunded or comatose or confused or aphasic so they may be unable to participate in their site verification in a meaningful way. Also, the crossed nature of many of the neurological deficits (eg. right hemisphere-left hemiparesis) may be confusing not only to patients but to staff as well.
The Rhode Island incidents add some other dimensions to the discussion. Rhode Island Hospital had an incident during the summer of 2007 in which a neurosurgeon operated initially on the wrong side of the head in a patient with a subdural hematoma. Apparently in that case a nurse did raise questions about site verification but the surgeon felt he was sure which side the subdural was on (AP/MSNBC.com 2007). The hospital had been undergoing corrective action in conjunction with the Rhode Island Health Department when, in November 2007, another case where surgery began on the wrong side of the head occurred. The latter case involved a procedure for a subdural hematoma that was being performed by the neurosurgery chief resident at the bedside in a neurosurgery ICU. No formal preprocedure site verification had taken place and the nurse attending the procedure was a “travel nurse” who had not been trained on the hospital policy and procedure for preprocedure site verification. The hospital’s corrective efforts after the July 2007 case had been focused on procedures being performed within the operating room and apparently had not yet focused on invasive procedures elsewhere.
The third case had occurred in January 2007 and involved a neurosurgery resident placing a drain on the wrong side of a patient’s head. That procedure also had occurred at the bedside. Though the hospital apparently had a procedure for invasive procedures performed outside the operating room and a form to be completed prior to such procedures, the resident was quoted as saying “he knew about the policy but he had never seen the form or seen anyone use it” (Mello 2007).
The three Rhode Island cases show several of the commonest circumstances or factors predisposing to wrong-site surgery: incomplete availability of all records and images, emergency procedures, not ensuring that all staff understand the safe-surgery verification procedures, and a hierarchical authority gradient.
That a case is being performed on an emergency basis is, of course, no excuse for not performing an appropriate “timeout” and final site verification before commencing with surgery. The 2-3 minutes that would have been spent doing such verification are far less than the time wasted in beginning the cases on the wrong side.
The Rhode Island cases also highlight a very important fact: wrong-site surgery is very common outside the operating room. (In New York we have seen wrong-site incidents with a variety of procedures, most notably bedside procedures such as chest tube insertions). So it is incumbent upon all organizations to give as much attention to safety of procedures out of the OR as in the OR.
The issue of training is critical. All your staff must understand the safe surgery policies and procedures. Many hospitals have a continuous influx of new nurses and residents rotating through various services. Sometimes you have an agency nurse or a “float” resident covering a service for just one or a few nights. It is incumbent upon all hospitals to ensure that they get appropriate orientation and are not unwittingly put in the position where they might do a wrong-site procedure.
The hierarchical/authority gradient issue is one that rears its ugly head in many, if, not most, cases of wrong-site surgery. Undoubtedly, there are some of you reading this and thinking “its that neurosurgeon’s personality!”. We don’t think so. We know lots of neurosurgeons who are meticulous safety-conscious empathetic physicians and such a generalization would be demeaning and unfair. Wrong-site surgery occurs in all specialties. However, the cluster of cases within a department at Rhode Island Hospital does raise another important point. Just as there are “microclimates” in meteorological environments, there are different “cultures of safety” within organizations. Even within an operating room, you have teams that function as units and their culture may be different from that of other OR teams. That is the reason we are not advocates of formal culture of safety assessments. There are several good instruments and tools out there for assessing culture of safety. But applying them organization-wide can provide very misleading results. More often what we see is that a hospital overall may do well on such assessment but there are individual units or departments or other “pockets” in which the culture of safety is less than desirable. And we feel you can learn much more about those “pockets” during your patient safety walkrounds by looking around and asking around.
Our September 23, 2008 Patient Safety Tip of the Week “Checklists and Wrong Site Surgery” stressed the importance not just of developing policies, procedures and checklists but of auditing the use and success of such procedures and checklists. In that column we noted that all hospitals have policies compatible with the Joint Commission Universal Protocol but very few actually monitor how those policies are used on a day-to-day basis. You can have all the policies in the world but if you do not have a culture of safety the intent of those policies is never guaranteed. So monitor how your actual performance is on both operating room procedures and those done outside the operating room.
The UK NPSA guidance recommends that the side of intended cranial surgery be marked by the surgeon on the side of the forhead (or back of the neck below the hairline for posterior approaches). Such marking ideally is done outside the OR at a time when imaging studies, notes, and the patient consent are available and when the patient or caregiver is able to participate in confirmation of the site marking. The final verification/timeout should take place in the OR immediately prior to anticipated incision. Note that these recommendations follow in general the WHO Safe Surgery Checklist (see our July 1, 2008 Patient Safety Tip of the Week “WHO’s New Surgical Safety Checklist”.) The Jhawar paper also stresses that during the timeout immediately prior to the first incision, the other members of the team verify the patient and the surgical site by reviewing the case booking information on the OR schedule, the consent form, and any site marking and the surgeon reviews the imaging studies.
Our comment on imaging studies: It is critical that imaging studies on the patient be available both before and during the surgery. But that is not enough. You need to ensure that the X-ray folder does not contain individual images of other patients. And when the images are placed on the view box, it is critical that attention be paid to ensure that the image is not placed backwards or in other manner that might lead to right-left confusion. We also stress that you need to make sure that the OR does not contain images for any other patients or cases. The practice of bringing images for “all the cases of the day” into the OR is one that will lead you to do wrong site surgery at some point in your career.
See our Patient Safety Tools and Resources page for links to many other great safe site protocols and tools, including the great work that has been done on the topic by organizations like the Pennsylvania Patient Safety Authority and the Joint Commission.
References:
National Patient Safety Agency (UK). New guidance for neurosurgical teams to avoid wrong side burr holes. November 2008
actual guidance
http://www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=19158
supporting information
http://www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=19160
AP/MSNBC.com. Trail of errors led to 3 wrong brain surgeries. Surgeons' ego at R.I. hospital may have led to carelessness, study says. December 14, 2007
http://www.msnbc.msn.com/id/22263412/
S, Wimbush; S, Shinde; J, Carter National Audit of "Wrong-Site" Neurosurgery. Journal of Neurosurgical Anesthesiology. 2005; 17(3):160-161
Jhawar BS, Mitsis D, Duggal N. Wrong-sided and wrong-level neurosurgery: a national survey. J Neurosurg Spine 2007; 7: 467-472
http://thejns.org/doi/pdf/10.3171/SPI-07/11/467?cookieSet=1
Croteau R. Wrong-Site Surgery – the Evidence Base. Presentation at NYSDOH Patient Safety Conference 2007
Freyer FJ. Hospital fined in wrong-site surgery. Projo.com (Providence Journal online) Nov. 27, 2007 http://www.projo.com/news/content/WRONG_Site_11-27-07_PB818Q7_v12.2704b40.html#
Mello F. Wrong-site surgery case leads to probe. 2d case of error at R.I. hospital this year
Boston.com (Boston Globe online) August 4, 2007
http://www.boston.com/news/local/articles/2007/08/04/wrong_site_surgery_case_leads_to_probe/
Print “Wrong-Site Neurosurgery”
December 2, 2008
Playing without the ball....the art of communication in healthcare
Sports fans, how often have you heard the accolade for an athlete in a team sport “he’s really good at playing without the ball (or puck)”? This might mean a wide receiver in football making a downfield block for one of his teammates or a basketball player setting a pick for one of his teammates to go to the basket. Or it might mean a lacrosse player or hockey player moving or slowing down or even stopping to get into a position away from a defender so he can get a pass from a teammate and be in position to shoot on goal.
Medicine, of course, is the consummate team sport and lots of the key teamwork takes place away from the patient and the bedside. Much of the critical communication between healthcare workers takes place behind the scenes and it is important to ensure effective communication systems are in place. Just as the athlete needs to get in the best position to score, the effective clinician needs to get into the best position to influence a positive, safe outcome for the patient.
Let’s start by looking at the inpatient consultation. It is striking how often consultants’ recommendations are never implemented. Though there is considerable variation by both the consulting service and the service requesting the consult, many studies show only about half of all recommendations by some consulting services ever get implemented.
Unfortunately, most of the literature on consultations dates back to the 1980’s and a lot has changed since that time. Goldman et al (Goldman 1983) wrote “the ten commandments for effective consultations”:
- Determine the question being asked
- Establish the urgency
- Gather primary data
- Communicate as briefly as appropriate
- Make specific recommendations
- Provide contingency plans
- Understand one’s own role in the process
- Offer educational recommendations
- Communicate recommendations directly to the referring physician
- Provide appropriate followup
According to Wachter et al (Wachter 2005), citing some of the above work, consultants’ recommendations are more likely to be followed if:
- the consultant has direct contact with the referring physician
- makes a limited number of recommendations
- identifies high priority recommendations
- continues to see the patient after the original consultations
- makes specific recommendations about drug dosage, route and duration
But Salerno et al (Salerno 2007) almost 25 years later reviewed the literature on consultation guidelines and updated those guidelines based upon results of a survey they performed. They addressed an important issue that many hospitals still struggle with: “can consultants write orders?”. The old school of thought has been that the primary service should write all orders since that best ensures continuity and coordination of care. However, Salerno et al found somewhat differing views based upon the service requesting consultation. Only 37% of surgeons preferred to retain order writing authority, compared to 59% of primary care physicians. Also, whereas 69% of nonsurgeons wanted the consultant to have a narrow focus, only 37% of surgeons wanted the consultant to have such a narrow focus. And while most (75%) of physicians desired direct communication with the consultant, the value of educational references was not perceived as important as it had been in the 1980’s studies. In their discussion, they note how the changing practice of medicine may have changed needs. Economic pressures may have caused surgeons to spend more time in the OR at the same time when the increasing age and complexity and comorbidities of patients necessitates more time in nonsurgical aspects of care. Even things like contracted housestaff work hours may interfere with desirable direct communication. They recommend the “ten commandments” be rewritten to allow for more of a comanagement relationship between surgeons and nonsurgical consultants and the decision about order writing should be a mutual decision.
Lo et al (Lo 2004), looking at adherence to recommendations by infectious disease consultants, found an overall adherence rate of about 80%. However, they did not find any relationship between adherence and the number of recommendations, severity of illness, or presence of followup notes. Though adherence was less when notes were of poor legibility or disorganized, notes of these qualities were very rare. They did find that adherence was much better for therapeutic recommendations than for diagnostic ones. Calling the primary service increased adherence at a private hospital but not at a public hospital (but they speculate this may have been due to fewer resources available at the public hospital to comply).
(Our own comment on the observation that diagnostic recommendations are less likely to be followed: it is very clear that specialists in the US are much more likely to order diagnostic studies than primary care physicians in general. In some cases that may be appropriate, in others not. So it should not be at all surprising that the primary service is less likely to comply with all the consultant’s recommendations for diagnostic studies.)
Weiner et al (Weiner 2006) looked at implementation of recommendations made by geriatrics consultants. They found their recommendations implemented completely in only 52% of cases. They did find higher rates of implementation when verbal rather than written communication took place and for those recommendations that facilitated things like discharge planning.
We are fans of the direct communication approach. That has a value not only in the current consultation but helps instill a trust and understanding about consultations in the future as well. Back to the sports analogy: the better you get to know your teammate, the more you will anticipate how he will be able to help achieve your goals and your patient’s goals.
Nevertheless, we have entered a different age of communication. Just look at your kids “texting” each other (or multiple others). Email allows us to communicate back and forth with our colleagues effectively rather than play frustrating telephone tag. And, given the comments in the Salerno paper about some physicians’ limited availability because of time and economic constraints, these forms of asynchronous but effective communication are here to stay.
Enter the computer age and some potential solutions to these dilemmas. Were et al (Were 2008) at the Regenstrief Institute have developed an innovative approach using CPOE to improve implementation of recommendations by consultants. They identified a low rate of compliance with recommendations (about 50%) and put together an interdisciplinary quality improvement team to come up with suggested improvements. Focus groups including both referring and consulting physicians agreed that use of CPOE could provide a good solution. So they developed a tool with which consultants could create “consultant-recommended orders (CRO’s). These are orders input by the consultant using the typical CPOE entry tools they would use to write orders on their own patients. However, they are stored separately from other orders and do not become actual orders until they are activated by the primary (referring) physician. When the primary physician logs on to the system, the CRO’s are flagged and he/she can review, edit and turn those CRO’s into actual approved orders.
Using a before/after study design, the Were team demonstrated a 30% improvement in compliance with consultant recommendations and demonstrated satisfaction by both the referring and consulting physicians with the CPOE CRO tool. You’re going to see a lot more of useful tools like this.
The Were article contradicts the prior finding that suggested a larger number of consultatnt recommendations reduces the likelihood of implementation of those recommendations since they found no such correlation.
Also, remember that the consultation is a two-way process. Just as when diagnostic imaging studies are ordered, an order for a consult should clearly convey what question is being asked. CPOE can also facilitate this. A good CPOE order entry tool for consults would allow the referring physician to click on a drop-down list of the most common reasons for consulting the specialty being consulted and a text box to enter specific information or questions being asked. The standardized items in the drop down list are useful because you can tie alerts to them. For instance, if a particular consulting service always wants a specific study done for a specific condition, an alert could convey that to the referring service so the result of that study could be available by the time the consultant sees the patient. Another alert might actually suggest that consultation for a specific reason might be better done as an outpatient.
It is amazing how hi-tech tools can overcome some of the limitations in our complex medical systems. So use them judiciously. But don’t forget the value of face-to-face communication with your colleagues even when you are using these hi-tech tools.
References:
Goldman L, Lee T, Rudd P. Ten Commandments for Effective Consultations. Arch Intern Med. 1983; 143(9):1753-5
http://www.psychresidentonline.com/Ten Commandments of Effective Consultations.html
Wachter RM, Goldman L, Hollander H. Ch. 28 Medical Consultation. in Hospital Medicine. 2nd Edition. Philadelphia: Lippincott Williams & Wilkins 2005
Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of Effective Consultation: An Update for the 21st-Century Consultant. Archives of Internal Medicine 2007; 167(3):271-275
Lo E. Rezai K. Evans AT. Madariaga MG. Phillips M. Brobbey W. Schwartz DN. Wang Y. Weinstein RA. Trenholme GM. Why don't they listen? Adherence to recommendations of infectious disease consultations.[see comment]. Clinical Infectious Diseases 2004; 38(9):1212-8
http://www.journals.uchicago.edu/doi/pdf/10.1086/383315
Weiner M, Lamar V, Munger S, Perkins A, Fultz B, Wheeler M, Counsell S, Sennour Y, Callahan C. Variation In Implementation Of Recommendations Of Inpatient Geriatrics Consultation. J Am Geriatr Soc 2006; 54 (S4): S94-95 (abstract)
http://www3.interscience.wiley.com/cgi-bin/fulltext/118579459/PDFSTART
Were MC, Abernathy G, Hui SL, Kempf C, Weiner M. Using Computerized Provider Order Entry and Clinical Decision Support to Improve Referring Physicians’ Implementation of Consultants’ Medical Recommendations. First published October 24, 2008 as JAMIA PrePrint; doi:10.1197/jamia.M2932http://www.jamia.org/cgi/content/abstract/M2932v1
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December 9, 2008
Huddles in Healthcare
Seems we’ve been doing a lot of sports analogies lately! Actually, since we’ve recently been spending time on ways to improve communication in healthcare (handoffs, briefings, debriefings, checklists, etc.), it is logical that we look at the tools other “teams” use to promote teamwork. The football “huddle” is one of the most obvious.
What is the purpose of the huddle? It is to get all the players on the same page. They all develop a mental image of what the play should look like and what their role in that play is. They all need to understand what count the ball will be snapped on. They develop an understanding of the goal of the play (“we’re trying to get 7 yards for the first down” or “we’re going to fake it and go for the bomb”). They discuss contingencies (“here’s what we will do instead if the defense is in a specific formation”) and how the quarterback will let them know to change the play at the line of scrimmage (the “audible”). And sometimes they even discuss a second play they may run without a second huddle. Though one person, the quarterback, usually leads the huddle, a good leader takes feedback from other team members (eg. one of the lineman says the defense is likely to do something that may interfere with the play called, or the wide receiver says “I think I can beat the safety on a post pattern”). And they even discuss safety issues (“if I can’t see a receiver open by the time I count 3, I’ll just throw the ball out of bounds because we can’t risk a quarterback sack here”). And body language plays a role in huddles – like when you see fear in the eyes of your 180-lb. running back who just realized he has to block the 320-lb. defensive end by himself! There are huddles on defense, too. They discuss what type of defensive pattern to be in, whether they will blitz the quarterback, what they will do if the offense comes out in a certain formation, etc. The defensive captain also goes through his own mental checklist, which includes counting the number of men his team has on the field.
The huddle is not unique to sports. Pilots do a “huddle” before every flight, facilitated by a checklist. The executive team of a business usually does a huddle before presenting at a shareholders’ meeting (unless you are automotive executives presenting to Congress!). Even a rock band does huddles between songs (“let’s play this, and we need to pick up the tempo a little, and a little less volume on that bass guitar”)!
Huddles are also practiced over and over again. That practice and repetition helps everyone understand how their teammates are likely to act in certain situations, so that when there is no time for a huddle (the “2-minute drill” in football), the team members can use visual or quick verbal signals to help coordinate what they do.
And sometimes you need to huddle after a play is over (“why didn’t that play work?”, “what should we do differently next time?”, etc.).
So why not huddles in healthcare? They already are used. Sometimes they go by different names, eg. the pre-op “briefing”, the “timeout”, the post-incident “debriefing”, etc.
The surgical timeout is a prime example of a huddle. Though the timeout is best recognized for its function for final verification of patient and site of surgery, the timeout has many more potential uses. Nundy and colleagues at Johns Hopkins (Nundy 2008) used a very simple format for pre-operative briefings that led to a 31% reduction in unexpected delays in the OR and a 19% reduction in communication breakdowns that lead to delays. The tool they used was simple and consisted of 5 key items:
- Names and roles of team players
- Correct patient/procedure/site (“timeout”)
- Prophylactic antibiotics given?
- What are the critical steps of the procedure?
- What are the potential problems in the case?
We’ve long been advocates of using the surgical timeouts for far more than originally intended. In our April 9, 2007 Patient Safety Tip of the Week “Make Your Surgical Timeouts More Useful” we advocated using either the pre-surgical timeout and/or the final verification timeout to also focus on some of the more common complications you wish to avoid. For example, use the timeout to ask questions such as following:
- Is this patient getting prophylactic antibiotics? Who is giving them? When?
- Is this patient a candidate for perioperative beta blockers (though fewer patients are candidates after publication of the POISE trial)? Did he get them?
- Is this patient a candidate for DVT prophylaxis? If it will be a long procedure, will we need to begin this intraoperatively?
- Will this patient need repositioning to avoid nerve compression or decubitus? If so, when? And who will remind us?
- If the potential for a surgical fire is high (eg. certain ENT surgeries), what are the roles of the anesthesiologist, nurse and surgeon if a fire were to occur?
- Do we anticipate any changes in OR personnel during this procedure? If so, how will the incoming staff be brought up to date?
But one of the unsaid messages in the Nundy paper is the KISS (“Keep It Simple, Stupid”) principle. Anticipate things and try to discuss the most serious things that might happen, but don’t make the process so complex and long that team members lose their attention.
Using a checklist to facilitate the huddle makes a lot of sense. There’s nothing wrong with using a checklist to help you remember things to do. Even the best quarterbacks in football keep a list of plays on a plastic wristband to help them remember during a game. In our discussion on handoffs, we noted Lingard et al (Lingard 2008) used a checklist to structure short team briefings and documented both reduction in the number of communication failures and other utility of the intervention. And remember, the 2009 Joint Commission National Patient Safety Goals now include a requirement for use of a checklist in the preprocedure verification process. That checklist should include elements such as the H&P, anesthesia assessment, completed informed consent, appropriate diagnostic and imaging reports or images, and any required implants, devices, special equipment or blood products that will be needed. Note that such a checklist would also be expected to reduce unnecessary delays.
So what are you other opportunities to “huddle up”? The following list names just a few:
- At the start of a clinic session or office hours
- With the ICU team and the bed coordinator late in the afternoon (to plan for bed availability during the night and avoid dangerous night shift transfers)
- The AM bed huddle (IHI)
- After a case with a less than desirable outcome
- After a case with a good outcome
- Maybe after any case!
- A patient transport (internal or external)
- A busy ER at any time during a shift
You’ve heard us rave about the free TeamSTEPPS™ program as a great resource on communication and teamwork developed by the Department of Defense (DoD) in collaboration with the Agency for Healthcare Research and Quality (AHRQ). It covers huddles as a specific topic. The TeamSTEPPS™ resources include presentation modules, great videos of bad and good team interactions and communications, implementation and action planning tools, evaluation tools, a pocket guide and posters. Many of the resources are available online and others are provided on CD/DVD’s. Topics covered include developing teams, use of briefs, brief checklists, huddles, debriefing, situation monitoring, cross monitoring, SBAR, handoffs, and others.
The huddle is a simple concept and can take place in just a few minutes. Like the checklist, simple but powerful.
References:
Nundy S, Mukherjee A, Sexton JB, Pronovost PJ, Andrew Knight A, Rowen LC, Duncan M, Syin D, Makary MA. Impact of Preoperative Briefings on Operating Room Delays: A Preliminary Report. Arch Surg 2008; 143(11):1068-1072
http://archsurg.ama-assn.org/cgi/content/abstract/143/11/1068
Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, Espin S, Bohnen J, Whyte S. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg, Jan 2008; 143: 12-17
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December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
Joint Commission released is most recent Sentinel Event Alert last week, pointing out the many patient safety dangers actually resulting from technologies introduced to improve patient safety. The report comes just as President-elect Obama is about to make a big push for healthcare IT in his new economic stimulus package and as CMS makes a big push the get all physicians to use e-prescribing.
We, of course, are strong backers of the use of information technology in patient safety. But regular readers of this column have seen us frequently talk about the unintended consequences of many of the information technology strategies and tools.
Lessons from other industries have provided ample warning and examples that introduction of new technologies introduces opportunities for new types of errors and other unintended consequences. Charles Perrow in his classic book “Normal Accidents” (Perrow 1999) talks about how new technologies often simply push the envelope, citing as an example how the introduction of maritime radar simply encouraged boats to travel faster and did little to reduce the occurrence of maritime accidents.
Medicine is no different. Our June 19, 2007 Patient Safety Tip of the Week “Unintended Consequences of Technological Solutions” gave several examples of new healthcare technologies leading to unexpected consequences that harmed patients. We gave examples of a new dual-power source ventilator failing to alert staff that it was using battery power, a telemetry transceiver transposition, a case where a new bed alarm displaced the nurse call button, and cases of unintended consequences of CPOE (including a well-known case where neuromuscular blocking agents ordered remotely by CPOE on a patient not on a ventilator led to a patient’s death).
The latter case led to our first discussion on unintended consequences of healthcare IT - CPOE Unintended Consequences – Are Wrong Patient Errors More Common? In that discussion we noted multiple factors that may make it easier to order on the wrong patient using CPOE rather than paper. In June 2008 “Technology Workarounds Defeat Safety Intent” we focused on barcoding system workarounds and discussed Ross Koppel’s article identifying the multiple types of workarounds in barcode systems and their underlying causes. They identified 15 types of workarounds and 31 types of causes for the workarounds in barcoding medication administration systems. In August 2008 (Pattern Recognition and CPOE) we talked about how CPOE often removes the pattern recognition that nurses and pharmacists and physicians utilize when they look at a set of orders in toto and how that might lead to new types of unexpected consequences. And in September 2008 (Less is More….and Do You Really Need that Decimal?) we discussed misprogramming infusion pumps.
The new Joint Commission Sentinel Event Alert was written by multiple health information technology experts with diverse clinical backgrounds. The Alert begins with some statistics about adverse events arising from factors related to information technologies, some coming from prior Joint Commission sentinel events and others coming from the MEDMARX® data base. It then discusses some of the factors contributing to adverse outcomes and provides practical guidelines in the planning and implementation of new technologies.
It places a real emphasis on the human-technology interface and clinical workflows. Actual or perceived roles often change substantially after introduction of a technology like CPOE or barcoding bedside medication verification (BMV). Frustration and even resentment at these changes is common. It discusses the tensions that often arise between physicians and nursing staff, the perceived loss of autonomy by physicians, “alert fatigue”, and problems with the technology itself.
It provides a good list of guidelines that organizations should follow in implementing new technology. That includes involving all end-users in the planning process, examining workflows, assessing technology and hardware needs, training/education, extensive testing, continuous monitoring and ongoing maintenance, communication and oversight, judicious use of standardized order sets and alerts/reminders, minimizing distractions during use of the technology, and ongoing surveillance and error detection.
One interesting phenomenon we have seen regarding the frustration around these new technologies is that the frustration is on the “upfront” end of the processes. That is, for both CPOE and BMV there is usually actually an increase in time and work done early in the process. It is counterbalanced by considerable time savings on the “back end”, i.e. fewer phone calls for verification of orders, etc. That is why it is extremely important to capture the true time, effort and workflow involved in a whole “episode” of care. It is the whole episode that usually becomes more efficient and more reliable.
We often find that healthcare organizations fail to include an adequate measurement strategy in their decision-making and planning for new technologies. And even when they do, they tend to focus too heavily on measures of the technology itself rather than on the more important clinical outcomes. And every such measurement strategy must include surveillance for unintended consequences. And, since many or most of those unintended consequences may be unexpected, the only way to measure them is to go out and look for them. That means direct observation of the various processes and interviewing staff using the technologies on patient safety walkrounds. And sometimes you have to resort to low-tech methods for your measurements. For example, determining how long it takes a physician to do order entry may not be accurately captured electronically. You may have to go out and use a stopwatch to capture the true time required for order entry and other processes that are part of the workflow not only for physicians, but also nurses and pharmacists.
A good measurement system looks at the impact of the technology from multiple different perspectives. It does need to include measures of the technology itself (eg. system availability, downtime, mean order entry time, % of alerts approved, etc.). But it also needs measures of end-user satisfaction (physicians, nurses, pharmacists, clerical staff, etc.), measures of hospital and staff efficiency (eg. lab/rad/pharm turn-around times, # of phone calls for clarification of orders, etc.), measures of clinical outcomes (eg. CMS core measures, Joint Commission standards, P4P measures, SCIP measures, impact on nosocomial infection rates, etc.), unexpected consequences (see above), and financial impact. All too often the set of measures is determined only after the fact. Any good project develops its measures during the planning/decision phase. After all, the three fundamental questions of performance improvement are (in order): Where do I want to be? How will I know that I’ve gotten there? How will I get there? When making decisions about technology-related projects it’s easy to jump to the last question. However, if you take the time and effort to answer the second question and set up the measures by which you will assess success, you may realize that there are other (low-tech) methods to achieve some of those goals.
The authors of the Joint Commission Sentinel Event Alert are a group that are strong advocates for use of technology to improve patient safety. The main theme here is to remind all that any solution (whether technological or instituting a new approach, etc.) may give rise to unintended consequences. Sometimes they can be anticipated, other times they cannot. Either way, careful vigilance for unintended consequences is necessary. Good planning and thoughtful implementation are important but even the best-laid plans often produce unexpected results.
Refeences:
Joint Commission. Sentinel Event Alert. Safely implementing health information and converging technologies. Issue 42, December 11, 2008
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm
Perrow C. Normal Accidents: Living with high-risk technologies. Princeton, New Jersey: Princeton University Press, 1999
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December 23, 2008
Why Safety Alerts Often Fail
We have seen over and over again occurrence of incidents with adverse patient outcomes similar to incidents that had been the subject of safety alerts at other facilities. The story of neonatal heparin overdoses due to heparin flushing has been repeated multiple times on this website and many others. The lethal administration of concentrated KCl occurred at multiple hospitals before all eventually removed it from floor stock. Implantable devices get implanted into patients after a recall has been issued on those devices.
So how does your organization disseminate safety alerts? How do you ensure they get to the people who most need to see and understand them? How do you ensure that people who need to make changes are aware of the alerts and have taken appropriate steps to ensure those changes have been made?
Nursing Times (UK) reported this month (Patient safety alerts: Failing to reach the frontline) on interesting research done on implementation of patient safety alerts issued in the UK by the National Health Service. They found that alerts, though reliably reaching middle managers in the NHS system, were often not acted upon or were implemented suboptimally by frontline staff because of problems in how the alerts were distributed to or interpreted by frontline staff. They noted that two-thirds of the liaison officers they interviewed did not have clinical backgrounds and may not have understood the relevance of the alert. They also commented on the role of the title of the alerts. As an example, an alert including “needle-free intravascular connectors” in its title was often ignored by nurses who recognized these devices instead as “bioconnectors” or “bungs”.
We have, of course, seen the same thing here in the United States. Many organizations have no systematic approach to findng and identifying safety alerts. And in many organizations, the individual who may receive the safety alert has no clinical background and may not understand the significance or relevance of the alert nor rout it to all the appropriate individuals who need to see it.
In addition, the “Dear CEO” letter is often problematic. Most CEO’s do not have a clinical background. Logically, you would think they would discuss any such letters with their clinical leadership (Medical Director, Director of Nursing, Pharmacy Director, etc.). But, in reality, the CEO’s often rely on their administrative assistants to rout the letters to other individuals and the end result is often suboptimal. The “Dear CEO” letter that begins “you will be fined if…” usually gets their attention and improves routing to the appropriate individuals but very few letters include such threats.
Safety alerts may come from a variety of different sources, including:
- Drug recalls
- Device recalls
- FDA safety alerts
- ISMP safety alerts
- Joint Commission Sentinel Event Alerts
- Alerts from your state health department
- Lessons from the literature
We have long advocated that a standing agenda item at your organization’s monthly quality improvement committee meeting be “Alerts and Recalls”. Someone in the organization needs to be assigned the task of assembling these items, discussing their importance and targeted audiences with relevant organizational leaders (eg. medical director, director of nursing, director of pharmacy, director of environmental services, etc.), and ensuring they are sent to the appropriate people for action. Each month you need not only to note the new alerts you’ve identified but also to do a followup on the alerts you disseminated the previous month(s) and update the organization on the status of implemented changes. The quality improvement committee often has suggestions as to who else in the organization needs to be made aware of the alerts. You’d be surprised how often we hear comments like “oh yeah, unit X also keeps its own stock of Y…”.
The Nursing Times article noted above also mentions use of nursing “champions” to help improve awareness of certain alerts. They cite as an example use of nursing champions to improve awareness about a latex allergy alert that had been issued.
Jennifer Snyder and Laura Lindberg from Press Ganey Associates and Kim Judd from University Medical Center in Lubbock, Texas described a unique “safety coach” program in the September 2008 issue of Health & Hospital Networks. That program promotes two-way communication within the health system regarding safety issues. All units and departments have representatives in the program and they meet as a group monthly. Each safety coach is responsible for educating members of their unit or department on safety issues. In addition, they identify safety issues in their respective areas and report them back to the bigger group as part of a true “no-blame” safety culture. Reading this article is well worth your while because it is a great way to involve all your frontline staff in promoting patient safety. Use of such a system would be a good way to help you ensure that patient safety alerts get down to the people most likely to be involved in implementing change.
We didn’t mean above to exonerate the C-suite of its obligations in patient safety. Brief discussion of the status of such safety alerts should be part of the Executive Team’s daily or weekly meetings. Boards of Directors are surprisingly good at raising issues about alerts. Perhaps because they are usually mostly laypersons rather than clinical professionals, they often innocently say at a Board meeting “I read about X happening at a hospital. Could that happen here?”. It’s pretty embarrassing if you can’t tell them that you are already aware of that incident and your hospital has already addressed the issues involved.
You really want everyone in your organization to be aware of adverse events occurring elsewhere in healthcare and ask the question “I wonder if that could happen here?.
Alerts are most likely to be successful when they are:
- Simple
- Easy to read
- Focused on a single problem
- Specifically actionable
Compare the Joint Commission Sentinel Event Alert we discussed last week Issue 42 - December 11, 2008: Safely implementing health information and converging technologies with an earlier Sentinel Event Alert Issue 33 - December 20, 2004: Patient controlled analgesia by proxy. The recent alert is loaded with great information and a host of important findings and recommendations. However, it is far too complicated to flow down to frontline staff and result in immediate changes. On the other hand, Alert #33 is far simpler. It is easy to read, straight to the point, focused on a single problem, and has several specific actions to take. Which of the two do you think is more likely to result in action being taken?
But we also need to be careful about the recommendations in alerts. All too often in recent years we have jumped on the bandwagon for actions felt likely to address a specific serious problem, only to find out later that our “solution” produced some unintended consequences that themselves resulted in patient harm. We’ll be discussing some examples in this column in the new year.
References:
Patient safety alerts: Failing to reach the frontline. Nursing Times 2008; December 2, 2008
Developing a Safety Culture with Front-line Staff
By Laura Lindberg, Kim Judd, R.N., and Jennifer Snyder
Health & Hospital Networks. September 2008
Joint Commission. Sentinel Event Alert. Issue 33 - December 20, 2004: Patient controlled analgesia by proxy
Joint Commission. Sentinel Event Alert. Issue 42 - December 11, 2008: Safely implementing health information and converging technologies
Print “Why Safety Alerts Often Fail”
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
When it comes to patient safety ideas, we need to constantly assess whether the impact we predicted has been achieved in practice and whether any consequences that we did not anticipate have cropped up. In the past year, we have discussed multiple examples of good ideas that have not lived up to their potential. Use of perioperative beta blockers has lost its luster and rather than being something to be used almost universally in surgery, we are now looking for subpopulations in which they might work. GI prophylaxis was included as part of IHI’s bundle to prevent ventilator-associated pneumonia but now is suspected of increasing susceptibility to C. diff infections. Rapid response teams have not yet demonstrated improvement in key clinical outcomes such as mortality or ICU days and numerous questions persist regarding but the most appropriate targets, the triggers, the makeup of teams, the mode of response, the logistics, and the best outcome measures. Yet numerous hospitals have rushed to develop RRT’s. And 2 weeks ago we discussed the newest Joint Commission Sentinel Event Alert about unintended consequences of healthcare information technology, a topic we’ve often talked about in the column over the past 2 years.
So it’s a pretty safe New Year’s prediction for 2009 that we will see another patient safety intervention become associated with some unintended consequences. Our prediction: medication reconciliation.
Medication reconciliation is a good idea. We have all witnessed bad patient outcomes from failure to reconcile medications at all transitions of care. We’ve seen the patient who develops an addisonian crisis because steroids he was on at home were overlooked and not ordered on admission. We’ve seen the patient who gets a withdrawal syndrome because no one knew about opiates or benzodiazepines he was taking at home. Or the patient who develops seizures in the hospital because the dose of anticonvulsants prescribed was lower than the patient had been taking at home. And the patient who gets excessive operative bleeding because no one asked about the OTC drugs he was taking. At discharge we all too often see the patient “sentenced” to perhaps lifelong PPI therapy because no one discontinued the PPI’s that were only for prophylaxis while he was an acutely ill ICU patient. And on in-hospital transitions we’ve seen the patient who gets a C. diff infection because his intended short course antibiotics were mistakenly continued on transfer to another service. There is ample evidence that medication errors occurring at transitions of care often lead to adverse patient outcomes, many or most of which are preventable (Commonwealth Fund 2008). So it was no surprise when IHI included medication reconciliation as part of its 100,000 Lives Campaign and 5 Million Lives Campaign and when Joint Commission added it as a new national patient safety goal. A good business case has been made for medication reconciliation and there are numerous spreadsheets available where you can calculate the potential savings for your organization by avoiding preventable medication errors with medication reconciliation.
But unless you are one of those very rare integrated health systems that has an enterprise electronic medical record encompassing care at all levels and among all providers, you are probably struggling with medication reconciliation. Most hospitals are struggling with it. Even though physicians have the ultimate responsibility for reconciling medications, we’ve often seen considerable resistance and resentment at the time required to do it correctly. Many physicians have remained skeptical that the outcomes of medication reconciliation will justify the time invested. And the cost and challenges of implementation may be substantial (Schenkel 2008). We’ve also seen battles between nursing and physician staffs as to who should begin building the “best possible medication history”.
Those organizations that have implemented medication reconciliation and successfully reduced ADE’s have usually used a model in which a specific individual or group of individuals have been charged with building the “best possible medication history”. In some cases those individuals have been nurses, in others pharmacists. But not all CFO’s and CEO’s have been convinced to invest considerable resources up front to realize both clinical and financial benefits on the back end.
Our October 23, 2007 Patient Safety Tip of the Week “Medication Reconciliation Tools” provided a good discussion of medication reconciliation and links to good tools and resources for medication reconciliation. We have advocated use of electronically downloaded medication lists from sources such as third-party payors, PBM’s, RHIO’s and other sources. But we have emphasized the need to use data from multiple sources in developing best possible medication histories and for diligent cross-checking of items on those lists.
But that is exactly where the potential for unintended consequences is arising. Those electronically downloaded lists may include drugs that a patient is not or never has been taking. Such medications can get on those lists for several reasons. In some cases, fraudulent activity is involved (eg. the medication is for a friend or relative) or there is medical identity theft involved. In most cases, though, it is simply due to honest mistakes taking place in the billing process. Remember, those lists are largely generated for the purpose of fulfilling the payment transaction between the pharmacy and the third-party payor. How many of you have ever had an item that you never purchased show up on your credit card statement? Probably most of you. Usually a harmless error that you can easily rectify via a phone call. Though we don’t know the frequency of such ID errors in healthcare, your ID number at the pharmacy often differs from that of one of your family members by only one digit so we would not be surprised at all if such errors are more frequent than in the credit card industry. And if such an error leads to appearance on your best possible medication history of a drug you have never taken, that can lead to problems. Shouldn’t that discrepancy be resolved when your physician goes over that list with you on admission? Certainly. But what if you are obtunded or comatose or otherwise not able to communicate on admission? You may well be started on a medication you have never taken. And you could ultimately also be discharged on that medication and have it continued indefinitely.
Also, from our experience with healthcare IT in general, we have learned that some of the unintended consequences may arise from excessive reliance on the computer (caregivers trust the computer to always be correct) and short cuts/workarounds may be seen (i.e. the physician under time constraints may not diligently question you about the medications on that list).
Additionally, confidentiality laws in many states often prohibit release of HIV-related medication or behavioral health medication information on such electronically downloaded lists. That may include medications whose cessation could lead to withdrawal syndromes. And other drugs, such as samples dispensed in a physician’s office, OTC drugs, or drugs administered in a physician office (such as biological agents) do not appear on the electronically downloaded lists in most cases.
The bottom line is that your organization must be diligent in truly reconciling the medications that appear on electronically downloaded medication lists. Especially in those patients who are unable to participate themselves in medication reconciliation on admission, you must have systems in place to prompt someone to repeat reconciliation once the patient has improved enough to communicate. And, of course, reconciliation via the patient’s outside physicians and family become even more important in the poorly communicative patient.
Medication reconciliation is an extremely important patient safety improvement process. There has not been much written about the downside of medication reconciliation. But you can bet that as we better utilize technological solutions to improve the medication reconciliation process, we are also likely to encounter unintended consequences. Do it diligently…but keep your eyes and ears open!
References:
Institute for Healthcare Improvement. 5 Million Lives Campaign.
http://www.ihi.org/IHI/Programs/Campaign/Campaign.htm?TabId=1
Joint Commission. 2009 National Patient Safety Goals.
Commonwealth Fund. Case Study: Preventing Adverse Drug Events at OSF HealthCare. September 30, 2008
http://www.commonwealthfund.org/innovations/innovations_show.htm?doc_id=708142
Northwestern Memorial Hospital. Making the Case for Medication Reconciliation.
http://www.medrec.nmh.org/nmh/medrec/makingthecase.htm
American Society of Health-System Pharmacists. ROI Worksheet for medication reconciliation..
http://www.ashp.org/s_ashp/docs/files/PS_ROI Worksheet.xls
Schenkel S. The unexpected challenges of accurate medication reconciliation.[comment]. Annals of Emergency Medicine. 2008: 52(5):493-5
http://www.annemergmed.com/article/S0196-0644(08)01513-8/fulltext
Print “Unintended Consequences: Is Medication Reconciliation Next?”
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August 31, 2010
August 24, 2010
The BP Oil Spill – Analogies in Healthcare
August 17, 2010
Preoperative Consultation – Time to Change
August 10, 2010
It’s Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMR’s Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HIT’s Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCA’s: Everyone Learns from Them
March 23, 2010
ISMP’s Guidelines for Standard Order Sets
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
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesn’t End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
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
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
August 4, 2009
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
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
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
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
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ball…the art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More….and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopman’s “How Doctors Think”
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHO’s New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTI’s: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May 27, 2008
If You Do RCA’s or Design Healthcare Processes…Read Gary Klein’s Work
May 20, 2008
CPOE Unintended Consequences – Are Wrong Patient Errors More Common?
May 13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSA’s FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares….The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
Communication…Communication…Communication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHI’s Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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