What’s New in the Patient Safety World

December 2018

 

·       HAI Rates Drop

·       Cost Savings from Eliminating Unnecessary Telemetry

·       Joint Commission Ambulatory NPSG’s for 2019

·       Handoffs Don’t Predict Everything

 

 

HAI Rates Drop

 

 

In 2016 there was a substantial reduction in hospital-acquired infections compared to 2015. According to the CDC (CDC 2018) the following reductions took place in US hospitals between 2015 and 2016:

·       CLABSI’s decreased 11%

·       CAUTI’s decreased 7%

·       MRSA bacteremia decreased 6%

·       C. diff events decreased 8%

·       Ventilator-associated events decreased 2%

·       SSI’s for abdominal hysterectomy decreased 13%

·       SSI’s for colon surgery decreased 7%

 

Another recently published study on a sample of hospitals in 10 states (Magill 2018) had shown patients’ risk of having a health care–associated infection was 16% lower in 2015 than in 2011.

 

And, according to AHRQ (AHRQ 2018a), data for 2014 through 2016 continue to show a downward trend in hospital-acquired conditions (which include much more than hospital-acquired infections) previously reported for 2010 to 2014. From 2010 through 2014, the rate of hospital-acquired conditions (HACs) decreased 17 percent. New data for 2014 to 2016 show an 8 percent decrease.

 

Various programs in hospitals have had positive roles in reducing infections, including LEAN Six Sigma (Improta 2017), leadership rounds (Knobloch 2017), a vascular access midlines program (Pathak 2018), hospital staffing (Mitchell 2018), and the U.S. Department of Health and Human Services (HHS) Partnership for Patients (PfP) initiative, which was started in 2011 (AHRQ 2016). Researchers at Regenstrief Institute and Indiana University School of Medicine (Azar 2018) borrowed a tool from software development, called “agile implementation”, to reduce CLABSI’s by 30% and also reduce C. diff infections and SSI’s. A change in culture that occurred during the implementation process was considered a key factor in its success.

 

IBM Watson Health (IBM Watson Health 2018) looked at HAC’s (hospital acquired conditions) in 2016 to assess both the human and financial costs of HAC’s. Keep in mind that hospital-associated infections are only are part of the overall spectrum of HAC’s. They found that there were over 48,000 HAC’s in 2016 and that these resulted in over 3000 potentially avoidable deaths. Moreover, this was associated with more than $2 billion in excess hospital costs. That calculates out to an average excess hospital cost of $41,917 per HAC patient. These HAC’s added, on average, 8.17 days per patient to average length of stay. They increased mortality risk per patient by 72.32%.

 

Another study (Anand 2018) looking at cost aspects of various inpatient harms found that surgical site infections were associated with about $30,000 additional costs per case. Hospital‐associated urinary tract infections added $6000 to $13,000 per case. Patients with preventable hospital-acquired conditions were also more likely to be readmitted within 90 days.

 

Some may be surprised by the cost of CAUTI’s in the Anand study. We’ve previously noted wide variation in the “attributable” costs of CAUTI’s (attributable costs are costs that would not have been incurred had the CAUTI not occurred). In our April 3, 2018 Patient Safety Tip of the Week “Cost of a CAUTI” we highlighted a systematic review which showed the attributable costs of CAUTI’s are very dependent upon the nature of the patient population and location of services (Hollenbeak 2018). From that review the authors note the attributable costs of a CAUTI were: $876 (inpatient cost to the hospital for additional diagnostic tests and medications); $1,764 (inpatient cost to Medicare for non-intensive care unit [ICU] patients); $7,670 (inpatient and outpatient costs to Medicare); $8,398 (inpatient cost to the hospital for pediatric patients); and $10,197 (inpatient cost to Medicare for ICU patients).

 

One of the studies mentioned above (Magill 2018) noted there is still a need for further efforts to reduce C. diff related events. While the reduction in C. diff related events in 2016 (CDC 2018) is encouraging, there has also been evidence that C. diff related events are becoming more prevalent outside the hospital (Dalton 2018, Khanna 2012).

 

In addition to the numerous resources on preventing HAI’s in our multiple columns below, there a couple resources we’ve not previously mentioned. AHRQ (AHRQ 2018b) provides a variety of toolkits and resources to help healthcare organizations reduce the various hospital-acquired conditions. And APIC (Association for Professionals in Infection Control and Epidemiology) provides “Quick Infection Prevention Observation Tools”.

 

 

 

Some of our prior columns on HAI’s (hospital-acquired infections):

 

December 28, 2010     HAI’s: Looking In All The Wrong Places

October 2013              HAI’s: Costs, WHO Hand Hygiene, etc.

February 2015             17% Fewer HAC’s: Progress or Propaganda?

April 2016                   HAI’s: Gaming the System?

September 2016          More on Preventing HAI’s

November 2018          Privacy Curtains Shared Rooms and HAI’s

 

 

Some of our other columns on central venous catheters and PICC lines:

 

January 21, 2014         The PICC Myth

December 2014           Surprise Central Lines

July 2015                    Reducing Central Venous Catheter Use

October 2015              Michigan Appropriateness Guide for Intravenous Catheters

March 27, 2018           PICC Use Persists

 

 

Our other columns on urinary catheter-associated UTI’s:

 

 

 

Some of our other columns on handwashing and hand hygiene:

 

 

January 5, 2010           How’s Your Hand Hygiene?

December 28, 2010     HAI’s: Looking In All The Wrong Places

May 24, 2011              Hand Hygiene Resources

October 2011              Another Unintended Consequence of Hand Hygiene Device?

March 2012                 Smile…You’re on Candid Camera

August 2012               Anesthesiology and Surgical Infections

October 2013              HAI’s: Costs, WHO Hand Hygiene, etc.

November 18, 2014    Handwashing Fades at End of Shift, ?Smartwatch to the Rescue

January 20, 2015         He Didn’t Wash His Hands After What!

September 2015          APIC’s New Guide to Hand Hygiene Programs

November 2015          Hand Hygiene: Paradoxical Solution?

April 2016                   Nudge: An Example for Hand Hygiene

August 2016               Hand Hygiene: Who’s Watching? Does it Matter?

September 2016          More on Preventing bookmark’s

July 18, 2017              Another Hazard from Alcohol-Based Hand Gels

 

 

Some of our prior columns on antibiotic stewardship:

 

 

References:

 

 

CDC (Centers for Disease Control and Prevention). Healthcare-Associated Infection (HAI) Data for Various Healthcare Settings. CDC 2018

https://gis.cdc.gov/grasp/PSA/HAIreport.html

 

 

Magill SS, O’Leary E, Janelle SJ, et al. Changes in Prevalence of Health Care–Associated Infections in U.S. Hospitals. N Engl J Med 2018; 379: 1732-1744

https://www.nejm.org/doi/full/10.1056/NEJMoa1801550

 

 

AHRQ (Agency for Healthcare Research and Quality). AHRQ National Scorecard on Hospital-Acquired Conditions. Updated Baseline Rates and Preliminary Results 2014–2016. AHRQ 2018; June 2018

https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf

 

 

Improta G, Cesarelli M, Montuori P, et al. Reducing the risk of healthcare‐associated infections through Lean Six Sigma: The case of the medicine areas at the Federico II University Hospital in Naples (Italy). Journal of Evaluation in Clinical Practice 2017; 24(2): 338-346 First published: 03 November 2017

https://onlinelibrary.wiley.com/doi/full/10.1111/jep.12844

 

 

Knobloch MJ, Chewning B, Musuuza J, et al. Leadership rounds to reduce health care–associated infections. American Journal of Infection Control 2018; 46(3): 303-310 Published online: November 2, 2017

https://www.ajicjournal.org/article/S0196-6553(17)31053-2/fulltext

 

 

Pathak R, Gangina S, Jairam F, Hinton K.  A vascular access and midlines program can decrease hospital-acquired central line-associated bloodstream infections and cost to a community-based hospital. Therapeutics and Clinical Risk Management 2018: 14: 1453-1456

https://www.dovepress.com/a-vascular-access-and-midlines-program-can-decrease-hospital-acquired--peer-reviewed-article-TCRM

 

 

Mitchell BG, Gardner A, Stone PW, at al. Hospital Staffing and Health Care–Associated Infections: A Systematic Review of the Literature. Joint Commission Journal on Quality and Patient Safety 2018; 44(10): 613-622

https://www.jointcommissionjournal.com/article/S1553-7250(17)30538-X/fulltext

 

 

AHRQ (Agency for Healthcare Research and Quality). National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data from National Efforts to Make Health Care Safer. AHRQ 2016

http://www.ahrq.gov/professionals/quality-patient-safety/pfp/2015-interim.html?utm_source=AHRQ&utm_medium=PR&utm_term=&utm_content=6&utm_campaign=AHRQ_NSOHAC_2016

 

 

Azar J, Kelley K, Dunscomb J, et al. Using the Agile Implementation Model to Reduce Central Line-associated Blood Stream Infections. Am J Infect Control 2018; Published online September 7, 2018

https://www.ajicjournal.org/article/S0196-6553(18)30751-X/fulltext

 

 

IBM Watson Health. Hospital-Acquired Conditions lead to avoidable cost and excess deaths. IBM Watson Health 2018

https://www-01.ibm.com/common/ssi/cgi-bin/ssialias?htmlfid=51020151USEN&

 

 

Anand P, Kranker K, Chen AY. Estimating the hospital costs of inpatient harms. Health Serv Res 2018; Early View published online  Oct 11, 2018

https://onlinelibrary.wiley.com/doi/abs/10.1111/1475-6773.13066

 

 

Hollenbeak CS, Schilling AL. The attributable cost of catheter-associated urinary tract infections in the United States: A systematic review. Am J Infect Control 2018; Published online: February 22, 2018

http://www.ajicjournal.org/article/S0196-6553(18)30036-1/fulltext

 

 

Dalton C. Dangerous Infection Tied To Hospitals Now Becoming Common Outside Them. NPR Vermont Public Radio 2018; November 25, 2018

https://www.npr.org/sections/health-shots/2018/11/25/657861409/dangerous-infection-tied-to-hospitals-now-becoming-common-outside-them

 

Khanna S, Pardi DS, Aronson SL, et al. The epidemiology of community-acquired Clostridium difficile infection: a population-based study. Am J Gastroenterol 2012; 107(1): 89-95. Epub 2011 Nov 22

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3273904/

 

 

AHRQ (Agency for Healthcare Research and Quality). AHRQ's Healthcare-Associated Infections Program. Accessed October 15, 2018

https://www.ahrq.gov/professionals/quality-patient-safety/hais/index.html?utm_source=AHRQ&utm_medium=psls&utm_term=&utm_content=3&utm_campaign=AHRQ_ipw_2018

 

 

APIC (Association for Professionals in Infection Control and Epidemiology). Quick Infection Prevention Observation Tools. APIC 2018

http://ipcobservationtools.site.apic.org/observation-tools-library/

 

 

 

 

 

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Cost Savings from Eliminating Unnecessary Telemetry

 

 

In our numerous columns on alarm fatigue and alarm management, we’ve emphasized that the first place to look to reduce unnecessary alarms is usually telemetry (see our columns for July 2, 2013 “Issues in Alarm Management”, October 2014 “Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring”, and August 16, 2016 “How Is Your Alarm Management Initiative Going?”).

 

In addition to the beneficial patient safety aspect of reducing unnecessary alarms that might contribute to alarm fatigue, there is also a potential for cost savings. A new study (Chong-Yik 2018) demonstrates the considerable cost savings when you limit use of telemetry to those patients meeting the AHA/ACA guidelines for telemetry. The researchers reviewed 250 consecutive patients admitted to telemetry capable beds on the general medical-surgical, noncritical care units at a tertiary care hospital. Only 24% of telemetry days were deemed appropriate based on the American Heart Association Practice Standards for Electrocardiographic Monitoring in Hospital Settings  (Drew 2004, Sandau 2017). The cost of telemetry was calculated as $34.28 more per day than a nontelemetry hospital day. They calculated that elimination of inappropriate telemetry days would result in a minimum estimated savings of $37,007 in these 250 patients, and an annual savings of $528,241 overall. Importantly, no cardiac code call occurred on a “nontelemetry” day (codes on patients not meeting the criteria were for respiratory events rather than cardiac events). Of 16 significant arrhythmias detected by telemetry, all were on appropriate telemetry days. Of 19 significant clinical decisions were prompted by telemetry, only one was on a “nontelemetry” day.

 

Many hospitals have never developed local guidelines to help identify which patients should be monitored by telemetry (and which should not). Moreover, criteria for continued monitoring are extremely important because all too often a physician orders telemetry and it gets continued indefinitely. Getting your physician staff involved early in developing your telemetry criteria is the key.

 

In our October 2014 What's New in the Patient Safety World column “Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring” we cited a study at Christiana Care Health System that successfully implemented a system that significantly reduced unnecessary non-ICU telemetry and achieved substantial financial savings while not adversely impacting patient safety (Dressler 2014). A multidisciplinary team designed the program and ensured appropriate training of impacted departments. The key component was hardwiring the AHA guidelines into their electronic ordering system. Providers were now required to choose an indication from a list, each of which included a duration based upon the AHA guidelines. In addition, they removed telemetry orders from order sets for conditions where monitoring was not supported by the AHA guidelines. Also, guidelines were established for automatic discontinuation of telemetry monitoring.

 

Focusing on unnecessary telemetry monitoring can lead to significant financial savings without sacrificing patient safety and likely reducing alarm fatigue.

 

 

 

Prior Patient Safety Tips of the Week pertaining to alarm-related issues:

 

 

 

 

 

References:

 

 

Chong-Yik R, Bennett AL, Milani RV, Morin DP. Cost-Saving Opportunities with Appropriate Utilization of Cardiac Telemetry. Am J Cardiol 2018; 122, Issue 9, Pages 1570–1573

https://www.ajconline.org/article/S0002-9149(18)31488-7/fulltext

 

 

Drew BJ, Califf RM, Funk M, Kaufman ES, Krucoff MW, Laks MM, Macfarlane PW, Sommargren C, Swiryn S, Van Hare GF, American Heart Association, Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young. Practice standards for electrocardiographic monitoring in hospital settings: an American Heart Association scientific statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young [published correction appears in Circulation. 2005;111:378]. Circulation 2004; 110: 2721-2746

https://www.ahajournals.org/doi/pdf/10.1161/01.CIR.0000145144.56673.59

 

 

Sandau KE, Funk M, Auerbach A, et al. AHA Scientific Statement. Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association. Circulation 2017; 136: e273-e344 Originally published October 3, 2017

http://circ.ahajournals.org/content/136/19/e273

 

 

Dressler R, Dryer MM, Coletti C, et al. Altering Overuse of Cardiac Telemetry in Non–Intensive Care Unit Settings by Hardwiring the Use of American Heart Association Guidelines. (Research Letter). JAMA Intern Med 2014; published online first September 22, 2014

http://archinte.jamanetwork.com/article.aspx?articleid=1906998

 

 

 

 

 

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Joint Commission Ambulatory NPSG’s for 2019

 

 

The Joint Commission recently released its Ambulatory NPSG’s (National Patient Safety Goals) for 2019 (TJC 2018a). These become effective January 1, 2019. They are listed below:

 

Identify Patients Correctly

·       Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment. (NPSG.01.01.01)

·       Make sure that the correct patient gets the correct blood when they get a blood transfusion. (NPSG.01.03.01)

 

Use medicines safely

·       Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up. (NPSG.03.04.01)

·       Take extra care with patients who take medicines to thin their blood. (NPSG.03.05.01)

·       Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor. (NPSG.03.06.01)

 

Prevent infection

·       Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning. (NPSG.07.01.01)

·       Use proven guidelines to prevent infection after surgery. (NPSG.07.05.01)

 

Prevent mistakes in surgery

·       Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body. (UP.01.01.01)

·       Mark the correct place on the patient’s body where the surgery is to be done. (UP.01.02.01)

·       Pause before the surgery to make sure that a mistake is not being made. (UP.01.03.01)

 

 

Details with the elements of performance are included in the full chapter (TJC 2018b).

 

 

References:

 

 

The Joint Commission . Ambulatory Health Care National Patient Safety Goals. October 16, 2018

https://www.jointcommission.org/assets/1/6/2019_AHC_NPSGs_final.pdf

 

 

The Joint Commission . Ambulatory Health Care National Patient Safety Goals (chapter with elements of performance detailed). October 16, 2018

https://www.jointcommission.org/assets/1/6/NPSG_Chapter_AHC_Jan2019.pdf

 

 

 

 

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Handoffs Don’t Predict Everything

 

 

Arguably, the most important feature of the “signout” or handoff is the ability to anticipate events that might potentially occur on the next shift. But how good are we at anticipating actual events? A new study in an ICU setting provides some insight.

 

Dutra and colleagues in Brazil (Dutra 2018) analyzed 44 day-to-night handovers between intensivists in an ICU. They surveyed clinicians immediately after a handover and identified clinical events through chart abstractions and interviews with clinicians the next morning.

 

Nighttime clinicians correctly identified only 53% of diagnoses and 40% of goals shortly after the handoff. The positive predictive value of both daytime and nighttime clinicians for anticipating clinical events at night was low (13% vs 17%). Daytime clinicians were more sensitive (65% vs 46%) but less specific (82% vs 91%) than nighttime clinicians in anticipating clinical events at night. Handovers among staff intensivists showed more gaps in the identification of diagnostic uncertainty and for neurologic diagnoses.

 

The authors conclude that the expectation that anticipatory guidance can inform handovers needs to be balanced against information overload. Furthermore, they suggest that handovers could benefit from communication strategies such as cognitive checklists, prioritizing discussion of neurologic patients, and brief combined clinical examination at handover.

 

A previous study of pediatric resident handoffs (Borowitz 2008) showed similar problems in anticipating events. 31% of surveyed resident physicians indicated something happened while they were on call for which they were not adequately prepared. And in 82% of those instances, they indicated there was information they did not receive during sign-out that would have been helpful to them in caring for a patient overnight, And, of those, they indicated the situation should have been anticipated and discussed during sign-out in 82.5% of cases. Perhaps surprisingly, residents were no more likely to report events they were unprepared for when they were “cross-covering” at night than when they were members of the general pediatric ward team or if they had cared for the child previously.

 

Note that the Borowitz study was in the era before I-PASS became popular and successful as a format for handoffs. The I-PASS format stands for:

I: Illness Severity

P: Patient Summary

A: Action List

S: Situation Awareness and Contingency Planning

S: Synthesis by Receiver

 

The “S” for “situation awareness and contingency planning” obviously emphasizes the importance of anticipating things that might go wrong or events that might appear and stresses planning for contingencies.

 

Details on the format of I-PASS and reasons for its development can be found in our February 14, 2012 Patient Safety Tip of the WeekHandoffs – More Than Battle of the Mnemonics” and our What’s New in the Patient Safety World columns for June 2012 “I-PASS Results and Resources Now Available  and December 2014  I-PASS Passes the Testand the I-PASS website. I-PASS is really much more than a handoff format. It really is part of a culture of patient safety.

 

 

Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:

 

May 15, 2007              Communication, Hearback and Other Lessons from Aviation

May 22, 2007              More on TeamSTEPPS

August 28, 2007         Lessons Learned from Transportation Accidents

December 11, 2007     Communication…Communication…Communication

February 26, 2008       Nightmares….The Hospital at Night

September 30, 2008     Hot Topic: Handoffs

November 18, 2008     Ticket to Ride: Checklist, Form, or Decision Scorecard?

December 2008            Another Good Paper on Handoffs”.

June 30, 2009               iSoBAR: Australian Clinical Handoffs/Handovers

April 25, 2009             Interruptions, Distractions, Inattention…Oops!

April 13, 2010             Update on Handoffs

July 12, 2011              Psst! Pass it on…How a kid’s game can mold good handoffs

July 19, 2011              Communication Across Professions

November 2011           Restricted Housestaff Work Hours and Patient Handoffs

December 2011            AORN Perioperative Handoff Toolkit

February 14, 2012       Handoffs – More Than Battle of the Mnemonics

March 2012                 More on Perioperative Handoffs

June 2012                    I-PASS Results and Resources Now Available

August 2012               New Joint Commission Tools for Improving Handoffs

August 2012                Review of Postoperative Handoffs

January 29, 2013         A Flurry of Activity on Handoffs

December 10, 2013     Better Handoffs, Better Results

February 11, 2014       Another Perioperative Handoff Tool: SWITCH

March 2014                  The “Reverse” Perioperative Handoff: ICU to OR

September 9, 2014      The Handback

December 2014            I-PASS Passes the Test

January 6, 2015            Yet Another Handoff: The Intraoperative Handoff

March 2017                 Adding Structure to Multidisciplinary Rounds

August 22, 2017         OR to ICU Handoff Success

October 2017              Joint Commission Sentinel Event Alert on Handoffs

October 30, 2018        Interhospital Transfers

 

 

References:

 

 

Dutra M, Monteiro MV, Ribeiro KB, et al. A Study of Information Loss and Clinical Accuracy to Anticipate Events. Crit Care Med 2018; 46(11): 1717-1721

https://journals.lww.com/ccmjournal/Abstract/2018/11000/Handovers_Among_Staff_Intensivists___A_Study_of.1.aspx

 

 

Borowitz SM, Waggoner-Fountain LA, Bass EJ, et al: Adequacy of information transferred at resident sign-out (in-hospital handover of care): A prospective survey. Qual Saf Health Care 2008; 17: 6-10

https://qualitysafety.bmj.com/content/17/1/6.long

 

 

I-PASS Study website.

http://www.ipasshandoffstudy.com/home

 

 

 

 

 

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Print “December 2018 What's New in the Patient Safety World (full column)

Print “December 2018 HAI Rates Drop

Print “December 2018 Cost Savings from Eliminating Unnecessary Telemetry

Print “December 2018 Joint Commission Ambulatory NPSG's for 2019

Print “December 2018 Handoffs Don’t Predict Everything

 

 

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