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Restrictions on visiting patients may be due to legitimate reasons (eg. a COVID-19 outbreak or other contagious disease outbreak). But often we end up restricting visitors for reasons that are inappropriate or even selfish. We often just dont want to be interrupted by questions from visitors. Weve even seen physicians who round early in the morning to avoid having to speak with relatives or other patient visitors!
But visitors can also be helpful. They can assist the hospital staff with things like feeding patients. We often recommend that relatives or close friends sit in the room with patients who have delirium. And they can often serve to ensure that a patient understands instructions when the patient might be otherwise distracted or cognitively impaired.
So, are visitors good or bad? Researchers at the Pennsylvania Patient Safety Authority actually looked at this. Sanchez et al. culled information from patient safety reports from 92 hospitals in Pennsylvania (Sanchez 2022). Not surprisingly, they found visitor behavior might have good or bad influence on patient risks.
They found evidence of helpful visitor behavior. For example, visitors often helped reposition patients, helped them ambulate, helped them gain balance, and even escorted patients within the hospital in some cases. They identified instances where visitor behaviors prevented events such as falls, administration of incorrect medication, or allergic reactions from occurring.
But some other behaviors might be good or bad. For example, they might give a patient something potentially harmful or they might take such an item away from a patient. Or they might alert staff to a potential safety situation or they might distract staff from other responsibilities.
And some behaviors may always be detrimental, such as powering on or off devices or equipment, disconnecting equipment, or changing placement of equipment. The equipment or devices most frequently manipulated by visitors were bed or chair alarms and intravenous (IV) catheters.
Some specific detrimental actions they found included:
Of course, the classic detrimental action by a visitor is manipulating a PCA (patient-controlled analgesia) pump (see our many columns on PCA safety listed below).
Sanchez et al. suggest some potential safety strategies targeting visitor behaviors:
They note that development and display of warning and instructional signs require minimal effort and could be designed to impact numerous behaviors and event types. The article has a nice table with design recommendations for effective signage.
Overall, this is an excellent contribution to a topic we dont pay enough attention to.
Other Patient Safety Tips of the Week pertaining PCA safety:
Sanchez CE, Taylor MA, Jones R. Visitor Behaviors Can Influence the Risk of Patient Harm: An Analysis of Patient Safety Reports From 92 Hospitals. Patient Safety 2022; 4(2): 70-79
The COVID-19 pandemic has had a significant impact on hospital infections. In our October 2021 What's New in the Patient Safety World column HAIs Increase During COVID-19 Pandemic we noted that during the pandemic there were significant national increases in CLABSIs (central lineassociated bloodstream infections), CAUTIs (catheter-associated urinary tract infections), VAEs (ventilator-associated events), and MRSA infections.
In addition, there has been a substantial increase in antimicrobial resistance since the pandemic began. CDC (CDC 2022) reports that resistant hospital-onset infections and deaths both increased at least 15% from 2019 to 2020 among seven pathogens:
Antifungal-resistant threats rose in 2020, too, including Candida auris (60% increase) and other Candida species (26% increase) in infections in hospitals.
During the first year of the pandemic, more than 29,400 people died from antimicrobial-resistant infections commonly associated with healthcare. Of these, nearly 40% of the people got the infection while they were in the hospital.
CDC notes that hospitals treated sicker patients who required more frequent and longer use of medical devices like catheters and ventilators. Hospitals also experienced personal protective equipment supply challenges, staffing shortages, and longer patient visits.
CDC hopes that the trend is temporary but notes we must invest in the prevention-focused public health actions that we know work, such as accurate laboratory detection, rapid response and containment, effective infection prevention and control, and expansion of innovative strategies to combat antimicrobial resistance. Those strategies include alternatives to antibiotics and antifungals, new vaccines to combat infections that can develop antimicrobial resistance, and novel decolonizing agents to stop the spread of antimicrobial-resistant germs by people who may not know they are carriers.
Some of our prior columns on antibiotic stewardship:
See also our other columns related to COVID-19:
CDC (Centers for Disease Control and Prevention). COVID-19. U.S. Impact on Antimicrobial Resistance. 2022 Special Report. CDC 2022
Good organizations are not satisfied with good practices. They strive for great practices. Intermountain Healthcare is one of those organizations.
Clinical decision rules have been quite successful for some conditions in reducing unnecessary imaging studies without jeopardizing patient safety. One such condition is minor head trauma. Our multiple columns listed below describe several different clinical decision rules that have been used to help guide clinicians in their decisions about CT scanning in adults with minor head trauma. There are also clinical decision rules for ordering CT scans in pediatric patients with minor head trauma. Intermountain Healthcare (Knighton 2022) was using a clinical pathway based on the PECARN (Pediatric Emergency Care Applied Research Network) risk stratification criteria for clinically important traumatic brain injury. Their Primary Childrens Hospital, which had participated in the development of those criteria, had pretty good compliance with the pathway but compliance at general EDs in their 21 other system hospitals was not as good.
They initially deployed an intranet-based lookup tool, a care pathway, and a mobile flashcard application across general EDs. But emergency physicians perceived the retrieval of guideline information as cumbersome and it did not fit well with their workflows.
So, they developed a clinical decision support system to accompany the clinical pathway. Part of it included automated feedback and education (both at the site level and individual physician level). But the major intervention was embedding an easy-to-understand, information-rich graphic pop-up alert providing current PECARN risk stratification criteria and supporting evidence, along with a risk assessment prompt linked to a head CT scan order or an observation order. (The article has nice screen shots of the pop-up alert for children less than 2 years old and those older than 2 years.)
They observed 4% lower odds of ordering a CT scan during the intervention months versus the control months. The CT scan rate remained significantly below the control
Months during the sustainment months (35.4% in the sustainment months versus 38.6% in the control months). As youd expect a higher percentage yield of abnormalities by doing CT scans only in those children at higher risk, they found CT positivity rates increased from 6.0% during the control months to 9.3% during the sustainment months. CT scans with clinically important findings increased from 9.2% during the control months to 33.3% during the sustainment months. And no 72-hour readmissions with confirmed clinically important traumatic brain injury were identified.
The authors do acknowledge that the alert was only evoked in about half the eligible encounters and they discuss the issue of alert fatigue. However, they surmise that the educational value of seeing the alert led to later improved compliance with the criteria even when the clinicians did not subsequently see the alert.
The pop-up alert is a pretty simple tool and this study showed it can have a positive impact on care.
Some of our previous columns on CT scans in minor head trauma:
April 16, 2007 Falls With Injury
July 17, 2007 Falls in Patients on Coumadin or Heparin or Other Anticoagulants
November 23, 2010 Focus on Cumulative Radiation Exposure
June 5, 2012 Minor Head Trauma in the Anticoagulated Patient.
July 8, 2014 Update: Minor Head Trauma in the Anticoagulated Patient
January 2017 Still Too Many CT Scans for Pediatric Appendicitis
March 2017 Update on CT Scanning after Minor Head Trauma
September 2017 Clinical Decision Rule Success
August 21, 2018 Delayed CT Scan in the Anticoagulated Patient
September 21, 2021 Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective
December 14, 2021 Delayed Hemorrhage After Head Trauma in Anticoagulated Patients
Knighton AJ, Wolfe D, Hunt A, et al. Improving Head CT Scan Decisions for Pediatric Minor Head Trauma in General Emergency Departments: A Pragmatic Implementation Study. Annals of Emergency Medicine 2022; Published June 23, 2022
Most of the literature on checklists focuses on their use prior to surgery or other procedures. But how about using checklists after a procedure? A recent study (Siewert 2022) looked at the impact of a post-procedure close-out checklist during image-guided procedures. The authors found that the post-procedure close-out checklist improved patient outcomes by decreasing the number of adverse events that occur from inadequate safety processes at the conclusion of an image-guided procedure by 43%, the need for repeat procedures by 80%, and the severity of impact of an error.
Overall compliance with the postprocedure closeout checklist was in the high 90% range but compliance was lower in the group of patients with procedural errors reported (60%). In reviewing those incidents where the checklist was not used, the authors felt that most adverse events would have been prevented by use of the checklist.
Preventable errors were mostly related to obtaining and handling of specimens and retained foreign objects such as guidewires.
They did note some new error types after implementation of the checklist and plan to revise the checklist further. They anticipate that, with further modification of the checklist, 70% of incidents would have been preventable.
Some of our prior columns on checklists:
· July 16, 2019 Avoiding PICCs in CKD
· June 2020 Are Two Checklists Better Than One?
· March 2021 Medical Crisis Checklists in the ED
· June 21, 2022 Preventing Post-op Pneumonia
Siewert B, Brook OR, Swedeen S, et al. Impact of a post-procedure close-out checklist on the incidence of preventable adverse events during interventional radiology procedures: an initiative to improve outcomes. Journal of Vascular and Interventional Radiology 2022; Published July 04, 2022
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