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:
- Bypassing clinical decision support tools
- Taking the easy way and avoiding CPOE as a shortut
- Ordering in a vacuum (without important clinical information in the
chart that might impact orders)
- Promoting telephone tag
- Failure to allow the recipient to ask appropriate questions
- AutoText/AutoCorrect issues
- Security issues
- HIPAA issues
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.
References:
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
http://www.jointcommission.org/assets/1/6/Update_Texting_Orders.pdf
TJC (The Joint Commission). Joint Commission Online. June 8,
2016
https://www.jointcommission.org/assets/1/23/JC_Online_June_8.pdf
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
https://www.jointcommission.org/assets/1/6/Clarification_Use_of_Secure_Text_Messaging.pdf
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
Print “January
2017 Joint Commission Thinks Twice About Texting Orders”
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.
References:
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
http://www.learnicu.org/SiteCollectionDocuments/ICU-Admission-Discharge-Triage-Guidelines.pdf
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
http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2594281
Print “January
2017 More on Inappropriate ICU Use”
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:
- February 2, 2010 “The
Hazards of Radiation”
- November 23, 2010 “Focus
on Cumulative Radiation Exposure”
- March 2010 “More
on Radiation Safety”
- June 2011 “Progress
in Reducing Radiation from CT Scans”
- April 2013 “Radiation
Risk of CT Scans: Debate Continues”
- June 4, 2013 “Reducing
Unnecessary CT Scans”
- July 2013 “More
on the CT/Cancer Debate”
References:
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
http://www.surgjournal.com/article/S0039-6060(16)30644-4/abstract
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
http://www.jpedsurg.org/article/S0022-3468(16)00143-3/fulltext
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
http://www.jpedsurg.org/article/S0022-3468(14)00650-2/pdf
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
http://www.jpedsurg.org/article/S0022-3468(14)00847-1/pdf
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
http://archive.rsna.org/2016/16005757.html
as discussed in:
Forrest W. Why are pediatric MRI scans on the rise in the
ED? AuntMinnie.com 2016; December 27, 2016
http://www.auntminnie.com/index.aspx?sec=sup&sub=mri&pag=dis&ItemID=116204
Print “January
2017 Still Too Many CT Scans for Pediatric Appendicitis”
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.
References:
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
http://qualitysafety.bmj.com/content/early/2016/11/03/bmjqs-2016-005567
Needleman J. Nursing skill mix and patient outcomes
(Editorial). BMJ Qual Saf
2016; December 30, 2016
http://qualitysafety.bmj.com/content/early/2016/12/30/bmjqs-2016-006197.full
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
http://www.newsobserver.com/news/local/community/durham-news/article114543668.html
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2017 Nursing Skill Mix and Patient Safety”
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2017 What's New in the Patient Safety World (full
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2017 Joint Commission Thinks Twice About Texting Orders”
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2017 More on Inappropriate ICU Use”
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2017 Still Too Many CT Scans for Pediatric Appendicitis”
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2017 Nursing Skill Mix and Patient Safety”
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