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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:
References:
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
Print August 2022 Visitors Good or Bad?
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:
References:
CDC (Centers for Disease Control and Prevention). COVID-19.
U.S. Impact on Antimicrobial Resistance. 2022 Special Report. CDC 2022
https://www.cdc.gov/drugresistance/covid19.html
Print August 2022 Resistant Infections Up During
COVID-19 Pandemic
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.
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
March 2010 CATCH: New Clinical Decision Rule for CT in
Pediatric Head Trauma
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
References:
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
https://www.annemergmed.com/article/S0196-0644(22)00279-7/fulltext
Print August 2022 CDSS Success for Pediatric Head
CT
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:
· May 2019 WHO
Surgical Safety Checklist Cut Mortality 37% in Scotland
·
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
References:
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
https://www.jvir.org/article/S1051-0443(22)01052-1/pdf
Print August 2022 Postprocedure
Closeout Checklist Reduces Adverse Events
Print August
2022 What's New in the Patient Safety World (full column)
Print August 2022 Visitors Good or Bad?
Print August 2022 Resistant Infections Up During
COVID-19 Pandemic
Print August 2022 CDSS Success for Pediatric Head
CT
Print August 2022 Postprocedure
Closeout Checklist Reduces Adverse Events
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