In 2016 there was a substantial reduction in hospital-acquired infections compared to 2015. According to the CDC () 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 () had shown patients’ risk of having a health care–associated infection was 16% lower in 2015 than in 2011.
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 (), leadership rounds ( ), a vascular access midlines program ( ), hospital staffing ( ), and the U.S. Department of Health and Human Services (HHS) Partnership for Patients (PfP) initiative, which was started in 2011 ( ). (Azar 2018) 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 () 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 () 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 “( ” 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 ). 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).
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 () provides a variety of toolkits and resources to help healthcare organizations reduce the various hospital-acquired conditions. And
Some of our prior columns on HAI’s (hospital-acquired infections):
December 28, 2010 “ ”
October 2013 “ ”
February 2015 “ ”
April 2016 “”
September 2016 “”
November 2018 “”
Some of our other columns on central venous catheters and PICC lines:
January 21, 2014 “ ”
December 2014 “ ”
July 2015 “ ”
October 2015 “ ”
March 27, 2018 “”
Our other columns on urinary catheter-associated UTI’s:
Some of our other columns on handwashing and hand hygiene:
January 5, 2010 “ ”
December 28, 2010 “ ”
May 24, 2011 “ ”
October 2011 “ ”
March 2012 “ ”
August 2012 “ ”
October 2013 “ ”
November 18, 2014 “ ”
January 20, 2015 “ ”
September 2015 “ ”
November 2015 “”
April 2016 “”
August 2016 “”
September 2016 “”
July 18, 2017 “”
Some of our prior columns on antibiotic stewardship:
CDC (Centers for Disease Control and Prevention). Healthcare-Associated Infection (HAI) Data for Various Healthcare Settings. CDC 2018
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
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
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
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
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
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
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
IBM Watson Health. Hospital-Acquired Conditions lead to avoidable cost and excess deaths. IBM Watson Health 2018
Anand P, Kranker K, Chen AY. Estimating the hospital costs of inpatient harms. Health Serv Res 2018; Early View published online Oct 11, 2018
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
Dalton C. Dangerous Infection Tied To Hospitals Now Becoming Common Outside Them. NPR Vermont Public Radio 2018; November 25, 2018
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
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 “”, October 2014 “ ”, and August 16, 2016 “ ”).
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 ( ( , ). 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.) 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
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 “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 ( ” we cited a study ). 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:
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
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
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
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
The Joint Commission recently released its Ambulatory NPSG’s (National Patient Safety Goals) for 2019 ( ). 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)
· 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 ().
The Joint Commission . Ambulatory Health Care National Patient Safety Goals. October 16, 2018
The Joint Commission . Ambulatory Health Care National Patient Safety Goals (chapter with elements of performance detailed). October 16, 2018
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 () 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 () 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 Week “ and December 2014 “ ” and the ” and our What’s New in the Patient Safety World columns for June 2012 “ ”. 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 “ ”
May 22, 2007 “ ”
August 28, 2007 “ ”
December 11, 2007 “ ”
February 26, 2008 “ ”
September 30, 2008 “ ”
November 18, 2008 “ ”
December 2008 “ ”.
June 30, 2009 “”
April 25, 2009 “ ”
April 13, 2010 “ ”
July 12, 2011 “”
July 19, 2011 “ ”
November 2011 “ ”
December 2011 “ ”
February 14, 2012 “ ”
March 2012 “ ”
June 2012 “ ”
August 2012 “ ”
August 2012 “ ”
January 29, 2013 “ ”
December 10, 2013 “ ”
February 11, 2014 “ ”
March 2014 “ ”
September 9, 2014 “ ”
December 2014 “ ”
January 6, 2015 “ ”
March 2017 “”
August 22, 2017 “”
October 2017 “”
October 30, 2018 “”
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
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
I-PASS Study website.
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