What’s New in the Patient Safety World

January 2017



·         Joint Commission Thinks Twice About Texting Orders

·         More on Inappropriate ICU Use

·         Still Too Many CT Scans for Pediatric Appendicitis

·         Nursing Skill Mix and Patient Safety




Joint Commission Thinks Twice About Texting Orders



Thank goodness The Joint Commission listens. In our May 24, 2016 Patient Safety Tip of the Week “Texting Orders – Is It Really Safe?” we decried The Joint Commission’s proposed rescinding of its ban on texted orders.


The Joint Commission had announced its intent to rescind the ban on texting orders in April 2016 (TJC 2016a, TJC 2016b). But shortly thereafter TJC put a temporary hold on that rescinding, therein keeping the ban on texting orders while it gathered more input and information (TJC 2016c).


In our May 24, 2016 Patient Safety Tip of the Week “Texting Orders – Is It Really Safe?” we identified the following areas of concern regarding texted orders:

See that previous column for details on each of those concerns.


Now The Joint Commission, in conjunction with CMS (Centers for Medicare & Medicaid Services), has clarified position on texting orders, reaffirming that sending orders via a secure text messaging is not permitted at this time (TJC 2016d). It highlighted several factors influencing its decision. For example, compared to verbal orders which allow for a real-time two-way discussion that allows for clarification of orders, texted orders would not allow such synchronous real-time discussion. And it would likely add to the burden on nurses (in our May 24, 2016 Patient Safety Tip of the Week “Texting Orders – Is It Really Safe?” we noted that nurses would have additional burdens due to more telephone tag and to physicians taking the shortcut and avoiding having to input orders via CPOE). It also noted that clinical decision support tools would not be directly available to the ordering physician and that nurses entering the orders would need to track down the ordering physician if clinical decision support messages popped up when they were inputting orders. TJC reaffirms that CPOE is the preferred method for order entry.


The Joint Commission, in its clarification, recognizes that “CPOE is increasingly available through secure, encrypted applications for smartphones and tablets, which will make following this recommendation less burdensome.” It then notes that when access to CPOE is not directly available verbal orders would be an acceptable alternative, keeping in mind that verbal orders must meet all Joint Commission requirements for verbal orders. We also encourage you to look back at the recommendations in our January 10, 2012 Patient Safety Tip of the Week “Verbal Orders”. Keep in mind that some of the security issues (pro and con) related to texting apply even more so to verbal orders. In particular, you should have a mechanism in place to ensure the identity of the person phoning in a verbal order. You’d be surprised how often staff at hospitals tell us they identify the caller “because we know his/her voice”.


It’s been reported that vendors and patient advocates have criticized this continuation of the ban following new Joint Commission and CMS clarification of secure texting rules (Sutner 2016). It’s pretty clear why vendors of secure texting applications would oppose continuation of the ban. But we don’t understand how patient advocates would oppose keeping in place something that can prevent significant patient safety risks.


We remain staunch advocates for use of advanced technology to improve healthcare. Secure text messaging has numerous ways to improve communication in healthcare and we advocate its use (for example, it can be extremely useful in helping to prevent alarm fatigue). But texting orders should not be allowed. We commend the Joint Commission’s decision to keep the ban on texting orders in place.







TJC (The Joint Commission). Orders – Texting. What is The Joint Commission's position on texting orders? The Joint Commission 2016




TJC (The Joint Commission). Update: Texting Orders. Joint Commission Perspectives 2016; 36(5): 15




TJC (The Joint Commission). Joint Commission Online. June 8, 2016




TJC (The Joint Commission). Clarification: Use of Secure Text Messaging for Patient Care Orders Is Not Acceptable. Joint Commission Perspectives 2016;

36(12): 9 December 2016




Sutner S. Joint Commission bans CPOE secure texting for physicians. Vendors and patient advocates criticize computerized physician order entry ban following new Joint Commission and CMS clarification of secure texting rules. SearchHealthIT 2016; December 28, 2016







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More on Inappropriate ICU Use



In our September 2016 What's New in the Patient Safety World column “Too Much of a Good Thing” we noted some studies that suggested that some quality of care measures and even mortality might be lower at hospitals having high ICU utilization rates.


In that column we noted that the Society for Critical Care Medicine has just updated its guidelines for admission to and discharge from critical care units (Nates 2016). The guidelines also have recommendations for prioritization and triage of potential ICU patients based upon factors such as severity of illness, functional impairment, comorbidities, prognosis for recovery and quality of life, patient preferences with regard to life-sustaining treatment, etc. Chronological age should not be a primary determinant in the elderly. One important recommendation under discharge guidelines is to avoid “after hours” discharge (see our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare” regarding huddles with bed coordinators to avoid such after hours transfers from the ICU). The guidelines also discuss potential sites to which discharge from the ICU can occur, including general wards, step down units, post-acute care facilities, etc. They also discuss use of outreach programs to supplement ICU care, such as rapid response teams and ICU consult teams on wards.


Using those SCCM guidelines, Chang and colleagues (Chang 2016) retrospectively analyzed a year’s worth of ICU admissions at Harbor-UCLA Medical Center to determine appropriateness for ICU use. The levels were priority1 (critically ill and needing intensive treatment and monitoring that cannot be provided outside an ICU), priority 2 (not critically ill, but requiring close monitoring or potential immediate intervention), priority 3 (critically ill but with reduced likelihood of recovery because of underlying diseases or severity of acute illness), and priority 4 (not appropriate for ICU, similar outcomes can be achieved in non-ICU settings), and a fifth priority category they added for patients awaiting transfer out of the ICU.


Not surprisingly, only 46.9% were determined to be priority 1 so just over 50% were deemed to potentially have received adequate care in non-ICU settings. And 65% of total ICU bed days were “allocated to care that was considered discretionary monitoring (priority 2), low likelihood of benefit despite critical illness (priority 3), or manageable in non-ICU settings (priority 4 or 5).”


Of the priority 3 patients (those critically ill but having an underlying disease that led to a limited likelihood of recovery), 26% had advance malignant neoplasms and 27% had advanced dementia.


We’re not surprised by the findings. For years we (medical director and director of nursing) would periodically do “ICU Bed Rounds” where we similarly assessed appropriateness for ICU level care, albeit with criteria that were less well-established than those in the SCCM guidelines. We also routinely found that about half the patients could be receiving care in alternative sites.


We recognized several factors that contributed to putting patients in an ICU who could have received adequate care elsewhere. Sometimes it was pressure from families to “do everything possible”. Other times it was pressure from housestaff to move “sicker” patients to a different service. Occasionally, it was unavailability of “downstream” beds. But there were other less obvious factors. Most prominent was the disconnect between a physician’s concern that a patient needs a higher level of nursing care when what the patient needed primarily was monitoring. For example, patients who were stable but had conditions that could conceivably have fatal outcomes were often put in the ICU for monitoring even though they actually needed very little nursing intervention (roughly equivalent to priority 2 in the SCCM guidelines). Second, Roemer’s Law (if you have beds someone will fill them) applies. While Roemer’s Law was intended to apply to a region’s supply of hospital beds, the same concept applies to ICU beds within a hospital. A third, and usually unmentionable, factor has to do with reimbursement. While hospital reimbursement may or may not be impacted by the level of care utilized by patients, there may be physician reimbursement issues (for daily care and for procedures) that serve as barriers to moving patients to other levels of care. You’d be surprised how ICU utilization can be reduced if your intensivists are paid in a manner that removes such financial incentives “to do more”. As long as hospitals are on a DRG (or other fixed payment) methodology and physicians on a fee-for-service methodology you will always have conflicts of interest that impact both total hospital utilization and ICU utilization.


Chang and colleagues also point out that there are other important factors, such as the level of availability of monitoring and care in the non-ICU areas. You’ll recall that we have even recommended ICU care for some high-risk patients (such as a patient with sleep apnea receiving opioids) if continuous physiological monitoring and capnography are not available on a med-surg floor or step-down unit.


Our previous column concluded that hospitals need to take a close look at their ICU utilization. We still see hospitals that lack formal criteria for ICU admission and discharge or have them but don’t adhere to them. Yes, ICU’s provide patients with levels of nursing care and monitoring that should be advantageous but they also expose patients to a variety of potential hazards (nosocomial infections, invasive procedures, etc.). And provision of services that don’t result in better patient outcomes may be detrimental to the fiscal health of the hospital.







Nates JL, Nunnally M, Kleinpell R, et al. ICU Admission, Discharge, and Triage Guidelines. A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research. Crit Care Med 2016; 44(8): 1553-1602




Chang DW, Dacosta D, Shapiro MF. Priority Levels in Medical Intensive Care at an Academic Public Hospital. JAMA Intern Med 2016; Published online December 27, 2016









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Still Too Many CT Scans for Pediatric Appendicitis



It’s been a while since we last discussed efforts to reduce patient exposure to ionizing radiation. We’ve previously discussed the Imaging Gently® and Imaging Wisely® campaigns, which are attempts to reduce the inappropriate use of imaging with ionizing radiation when safer alternatives are available (see our multiple columns on radiation safety and the Imaging Gently® and Imaging Wisely® campaigns listed below).


One particular area in which efforts have been focused is minimizing use of CT scanning for pediatric appendicitis, instead using modalities that avoid ionizing radiation like ultrasound or, to a lesser degree, MRI.


A retrospective study looked at imaging performed in children prior to appendectomy for acute appendicitis at a metropolitan hospital system that had one children’s hospital and eight non-children’s hospitals (Anderson 2016). They found that children's hospital patients had fewer computed tomography scans (23% vs 70%) and more ultrasonography (75% vs 20%). At non–children's hospitals, older age (age >10) and higher patient weight (>45 kg) predicted computed tomography use. Another recent retrospective study compared imaging for suspected pediatric appendicitis between definitive care hospitals and the hospitals referring to those centers (Glass 2016). About a third of patients had an attempt at imaging before transfer to the definitive care hospitals. The overall odds of an initial attempt at ultrasound prior to CT was 11.1 times greater and the odds of receiving any ultrasound was 6.25-times greater at definitive care hospitals compared to referral hospitals. A 2015 study of over 2500 Washington State appendectomy patients 18 years old and under (Kotagal 2015) found that 52.7% had a CT scan as their first imaging study. Evaluation at a non-children’s hospital was associated with higher odds of CT use (OR 7.9). Similar to the Anderson study, children age >10 and obesity were associated with higher rates of CT scanning.


Russell and colleagues developed a clinical practice guideline that focused on examination, early surgeon involvement, and utilization of ultrasound as the initial imaging modality for evaluation of abdominal pain concerning for appendicitis in a children’s hospital emergency department (Russell 2013). After implementation of that guideline for evaluation of abdominal pain concerning for appendicitis they saw a 41% decrease in CT use for patients undergoing appendectomy without an increase in the negative appendectomy rate or missed appendicitis. Even more striking, in the subset of patients undergoing appendectomy without imaging from an outside hospital, CT scan utilization decreased from 82% to 20%, a 76% reduction.


Ultrasound is the modality used most often as an alternative to CT scanning for suspected appendicitis. What about MRI scanning? A 2015 study found that MRI had excellent diagnostic accuracy and was associated with good outcomes in cases of suspected appendicitis (Kulaylat 2015). Those findings, in conjunction with avoiding ionizing radiation, led to the authors’ suggestion that MRI may supplant the role of CT scans in pediatric appendicitis imaging. We don’t have any statistics on how often MRI scanning is being used for pediatric appendicitis. However, a recent presentation at the 2016 RSNA meeting showed that use of overall MRI scanning in pediatric patients has been increasing at a major New York City hospital (Hulkower 2016). In a discussion of that presentation (Forrest 2016) it was noted that the rates for “trunk” exams were steady until the final year of the study (2015) “when there was an uptick, likely due to an emphasis on performing more MRIs than CTs for appendicitis workups”. We don’t have a position on the role of MRI in suspected pediatric appendicitis. We expect, however, to be doing another column in the future on issues of safety in pediatric patients undergoing MRI.


There likely are multiple factors, aside from lack of awareness, contributing to the continued performance of CT scans for suspected pediatric appendicitis that seems prevalent in non-children’s hospitals. One is that the early surgical consultation, as emphasized in the Russell study, may not be readily available in the non-children’s hospitals (since such patients are often transferred to children’s hospitals if they need surgery). Another and perhaps more likely factor is that it’s often easier to find a CT technician than a pediatric ultrasound technician at non-children’s hospitals.


Bottom line: there continue to be too many CT scans for suspected appendicitis in children seen at non-children’s hospitals. This makes for an opportunity to do community-wide collaboratives that identify and track the rates of such CT use at all area hospitals, look for root causes, and perhaps set up programs where pediatric surgeons would be available via telemedicine for early evaluation of such patients and discussion as to whether imaging without ionizing radiation is possible or whether the patient should be transferred to the children’s hospital for such studies.



Some of our previous columns on the issue of radiation risk:







Imaging Gently®




Imaging Wisely®




Anderson KT, Putnam LR, Caldwell KM, et al. Imaging gently? Higher rates of computed tomography imaging for pediatric appendicitis in non–children's hospitals

Presented at the 11th Annual Academic Surgical Congress in Jacksonville, FL, February 2–4, 2016. Surgery 2016; Articles in Press December 2, 2016




Glass CC, Saito JM, Sidhwa F, et al, Diagnostic imaging practices for children with suspected appendicitis evaluated at definitive care hospitals and their associated referral centers. J Pediatr Surg 2016; 51: 912-916




Kotagal M, Richards MK, Flum DR, et al. Use and accuracy of diagnostic imaging in the evaluation of pediatric appendicitis. J Pediatr Surg 2015; 50: 642-646




Russell WS, Schuh AM, Hill JG, et al, Clinical practice guidelines for pediatric appendicitis evaluation can decrease computed tomography utilization while maintaining diagnostic accuracy. Pediatr Emerg Care 2013; 29: 568-573




Kulaylat AN, Moore MM, Engbrecht BW, et al. An implemented MRI program to eliminate radiation from the evaluation of pediatric appendicitis. J Pediatr Surg 2015; 50: 1359-1363




Hulkower M, Taragin B, Davoudzadeh R, et al. Pediatric MRI in the Emergency Department Over Five Years: An Analysis of Usage and Trends. Program SSQ17-06. Radiological Society of North America 2016 Scientific Assembly and Annual Meeting, November 27 - December 2, 2016, Chicago IL


as discussed in:

Forrest W. Why are pediatric MRI scans on the rise in the ED? AuntMinnie.com 2016; December 27, 2016







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Nursing Skill Mix and Patient Safety



Studies have generally shown that higher nurse:patient ratios are associated with better quality of care and lower mortality rates. But the number of nurses is not the only important factor. Nursing skill mix is another consideration.


A recent study from European hospitals participating in the RN4CAST Consortium looked at the relationship between hospital nursing skill mix and quality of care, mortality, and patient ratings (Aiken 2016). They found that every 10-point increase in the percentage of professional nurses among all nursing personnel was associated with lower odds of mortality (OR=0.89), lower odds of low hospital ratings from patients (OR=0.90) and lower odds of reports of poor quality (OR=0.89), poor safety grades (OR=0.85) and other poor outcomes (0.80<OR<0.93), after adjusting for patient and hospital factors. Each 10 percentage point reduction in the proportion of professional nurses is associated with an 11% increase in the odds of death.


In a commentary (Needleman 2016) on the Aiken study, Needleman notes that previous studies from Canada and the US have also shown lower nursing skill mix to be associated with higher rates of adverse events and longer lengths of stay. Needleman in a previous study (Needleman 2006) had shown that greater use of RNs in preference to LPNs appears to reduce in-hospital patient deaths and pay for itself.


These studies, of course, fly in the face of recent trends to replace RN’s with less skilled levels of nursing care in attempt to reduce hospital costs. Such reductions in higher level nursing staff may paradoxically (because of increased adverse events and longer lengths of stay) increase hospital costs.


A 2015 review of the literature on nursing case mix (Jacob 2015) found that economic savings from substituting registered nurses with other health professionals may be offset by increased patient length of stay in hospital and increased patient mortality.


Some studies have suggested that differences in the importance of skill mix may differ between medical and surgical admissions. Li and colleagues, using data on both nursing staffing and nurse skill mix at the unit, rather than hospital, level (Li 2011) found that for medical admissions, a business case could be made for improving nurse staffing by increasing the proportion of RN hours while holding total nursing hours unchanged.


Ironically, almost the same day that the Aiken study was published a news article was published on the development of a nurse robot through collaboration between Duke’s School of Engineering and School of Nursing (Bridges 2016). But don’t worry- it’s not intended to replace nurses! Rather it is being developed to assist nurses and other healthcare workers in certain environments. The example given in the article is assisting in the care of an Ebola patient.


We’d like to add one other consideration. In our multiple columns on the “weekend” or “after hours” effect we’ve pointed out the numerous non-nursing tasks that nurses end up doing. The roles of clerical staff, housekeeping staff, transport staff, etc. are not accounted for in the nursing skill mix formulas in studies done to date. We think that in addition to maintaining good nurse:patient ratios and high levels of nursing skill mix you need to ensure that nurses have time to attend to clinical tasks and not be burdened by non-clinical tasks.






Aiken LH, Sloane D, Griffiths P, et al. Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care

BMJ Qual Saf 2016; Published Online First 15 November 2016




Needleman J. Nursing skill mix and patient outcomes (Editorial). BMJ Qual Saf 2016; December 30, 2016




Needleman J, Buerhaus PI, Stewart M, et al. Nurse staffing in hospitals: is there a business case for quality? Health Aff (Millwood) 2006; 25: 204-211




Jacob ER, McKenna L, D'Amore A. The changing skill mix in nursing: considerations for and against different levels of nurse. J Nurs Manag 2015; 23: 421-426




Li Y-F, Wong ES, Sales AE, et al. Nurse staffing and patient care costs in acute inpatient nursing units. Med Care 2011; 49: 708-715




Bridges V. Duke officials test, refine robot-nurse. The News & Observer (North Carolina) 2016; November 16, 2016







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