Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

January 2023

· Oxygen During Surgery

· A Nudge in Time

· Never Assume

· Hearback Is More Than Just Hearing Back

Oxygen During Surgery

Appropriate use of oxygen therapy is important. Several of our prior columns on use of oxygen in non-hypoxemic patients have shown the potential for untoward side effects.

A new study (McIlroy 2022) analyzed data on over 250,000 adult patients undergoing surgical procedures ≥120 minutes’ duration with general anesthesia and endotracheal intubation at 42 medical centers across the United States. These medical centers were participating in the Multicenter Perioperative Outcomes Group data registry. Excess use of oxygen was defined as oxygen concentrations greater than 21% for any period during which oxygen saturation was greater than 92%.

After accounting for baseline covariates and other potential confounding variables, increased oxygen exposure was associated with a higher risk of acute kidney injury, myocardial injury, and lung injury.

Patients at the 75th centile for the area under the curve of the fraction of inspired oxygen had 26% greater odds of acute kidney injury, 12% greater odds of myocardial injury, and 14% greater odds of lung injury compared with patients at the 25th centile.

Secondary outcomes included 30-day mortality, hospital length of stay, and stroke. Increased supraphysiological oxygen administration was associated with stroke (p<0.001) and 30-day mortality (p=0.03), independent of all factors included as covariates. Patients at the 75th centile compared to those at the 25th centile of excess oxygen exposure had 9% greater odds of stroke and 6% greater odds of 30-day mortality.

Increased supraphysiological oxygen administration was associated with decreased hospital length of stay (p<0.001). Patients at the 75^th centile had a 0.20 day shorter length of stay compared to those at the 25th centile (even after excluding those patients who died prior to discharge). The authors did not comment on potential reasons for this. It’s a bit unexpected. Usually, we see an increase in LOS when there is an increase in complications. Since kidney and myocardial damage were identified by lab values, perhaps these were not clinically significant enough to impact LOS.

The researchers conclude that a large clinical trial to detect small but clinically significant effects on organ injury and patient centered outcomes is needed to guide oxygen administration during surgery.

Just one more example that you can have “too much of a good thing”. We need to use sound judgement when we use supplemental oxygen in any setting.

Some of our prior columns on potential harmful effects of oxygen and other oxygen issues:

April 8, 2008 “Oxygen as a Medication”

January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!”

April 2009 “Nursing Companion to the BTS Oxygen Therapy Guidelines”

October 6, 2009 “Oxygen Safety: More Lessons from the UK”

July 2010 “Cochrane Review: Oxygen in MI”

December 6, 2011 “Why You Need to Beware of Oxygen Therapy”

February 2012 “More Evidence of Harm from Oxygen”

March 2014 “Another Strike Against Hyperoxia”

June 17, 2014 “SO2S Confirms Routine O2 of No Benefit in Stroke”

December 2014 “Oxygen Should Be AVOIDed”

August 11, 2015 “New Oxygen Guidelines: Thoracic Society of Australia and NZ”

November 2016 “Oxygen Tank Monitoring”

November 2016 “More on Safer Use of Oxygen”

October 2017 “End of the Oxygen in MI and Stroke Debate?”

February 2018 “Oxygen Cylinders Back in the News”

June 2018 “Too Much Oxygen”

July 2021 “Unique Way to Rapidly Identify Oxygen Flow”

References:

McIlroy D R, Shotwell M S, Lopez M G, Vaughn M T, Olsen J S, Hennessy C et al. Oxygen administration during surgery and postoperative organ injury: observational cohort study BMJ 2022; 379: e070941

https://www.bmj.com/content/379/bmj-2022-070941

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A Nudge in Time

Nudges, when provided correctly, can often be an effective means to help achieve desirable outcomes. We’ve given several examples in the columns noted below.

Researchers at Penn Medicine recently demonstrated successful use of EHR-delivered nudges to improve prescribing statins to patients where statin therapy was indicated. Because statins are often underutilized in patients who may benefit from them, Adusumalli and colleagues (Adusumalli 2022) performed a cluster randomized clinical trial of 4131 patients from 28 primary care practices affiliated with Penn Medicine who met criteria for statin use in guidelines. Nudges were provided to primary care clinicians, patients, or both and results were compared with groups having no nudges. The clinician nudge combined an active choice prompt in the electronic health record during the patient visit and monthly feedback on prescribing patterns compared with peers. The patient nudge was an interactive text message delivered 4 days before the visit. The combined nudge included the clinician and patient nudges.

During the intervention, statins were prescribed to 7.3% of patients in the usual care group, 8.5%, in the patient nudge group, 13.0% in the clinician nudge arm, and 15.5% in the combined group. So, the clinician nudge improved statin prescribing and the combined nudge (clinician and patient) was even more successful. But the patient nudge alone did not improve statin prescribing. Prescribing rates improved in the clinician-only and clinician -plus-patient nudge groups compared with usual care, by 5.55 and 7.2 absolute percentage points, respectively.

But success was likely due to more than just the targets of the nudges. The timing and content were important. Rather than presenting the nudge when the clinician logged on to the EHR, the nudge appeared when the clinician went to the ordering page of an eligible patient. And it was presented with a calculation of the patient’s risk and a chart with statin dosing options. That made it easier for the clinician to order a statin without an interruption in workflow. The timing of the patient nudge may also have been important. It was delivered via text message starting 4 days before their appointment, reminding them of the upcoming appointment and informing them of an important message about their heart health. Patients had to reply to confirm their willingness to communicate by text, and if so, they were told that “guidelines indicate you should be taking a statin to reduce the chance of a heart attack” and about the benefits of lowering cholesterol and the rare adverse effects that go away upon stopping the medication. Patients were told that “at Penn Medicine, it is standard of care to prescribe a statin to patients like you.” Patients were asked to reply “Y” if they were interested in taking a statin or reply “?” if they were unsure or had questions for the physician. Patients replying “Y” were told to remember to discuss the statin during their visit and sent a link to a shared decision-making tool on statin therapy. While nudging the patient alone did not improve statin prescribing, it probably set the stage for appropriate discussion with those clinicians who also were nudged.

One other likely success factor was that the active choice prompt in the EHR to clinicians was codesigned by leadership and frontline clinicians in the health system.

We like this nudge. Although the improvements might seem modest, the accompanying editorial (Ahmad 2022) notes that this occurred against a background high baseline prescription rate of statins in the statin-eligible population (approximately 70%) and the majority of untreated patients were candidates for primary, not secondary, prevention, making this group of patients particularly challenging for seeing large effect sizes of interventions.

See some of our other columns dealing with “nudges”:

July 7, 2009 “Nudge: Small Changes, Big Impact”
February 18, 2018 “Nudged, But Who Nudged Who?”
June 19, 2018 “More EHR-Related Problems”
April 30, 2019 “Reducing Unnecessary Urine Cultures”
July 23, 2019 “Order Sets Can Nudge the Right Way or the Wrong Way”
February 18, 2020 “More Nudges”

References:

Adusumalli S, Kanter GP, Small DS, et al. Effect of Nudges to Clinicians, Patients, or Both to Increase Statin Prescribing: A Cluster Randomized Clinical Trial. JAMA Cardiol 2022; Published online November 30, 2022

https://jamanetwork.com/journals/jamacardiology/fullarticle/2798971

Ahmad FS, Persell SD. Nudging to Improve Cardiovascular Care—Clinicians, Patients, or Both. JAMA Cardiol 2022; Published online November 30, 2022

https://jamanetwork.com/journals/jamacardiology/article-abstract/2798974

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Never Assume

For many years, when we would do our patient safety orientation to our incoming residents, we had one slide that said “Never Assume – It will make an “Ass” out of “U” and “Me”. We came across a recent sad story of how an assumption probably led to a premature death of a patient.

A woman in her 80’s was hospitalized in Japan in December 2017 with a femur fracture and underwent a CT scan (Mainichi 2022). A doctor in the diagnostic radiology department noticed the suspicion of lung cancer and compiled an examination report. However, the attending orthopedic surgeon reportedly did not read the report because the woman's fracture surgery had already been completed. In December 2021, the woman was hospitalized again for a lumbar compression fracture. The same radiologist prepared a report acknowledging the suspicion of lung cancer, but mistakenly assumed that her cancer treatment had already begun and failed to alert her attending physician, a different orthopedic surgeon from 2017. The surgeon reportedly only looked at the CT of the lumbar spine and failed to check the report. In May 2022, the woman was again transported to a hospital for suspected heart failure. Because of fluid in her lungs, a respiratory physician checked the two previous reports and found the description of suspected lung cancer. However, it was too late and the patient died. The hospital director apologized, saying, "If she had started treatment earlier, she might have survived."

Such assumptions are a sure way to court similar disasters. In our numerous columns on communicating significant results to avoid patients “falling through the cracks”, we have emphasized the need for multiple people to have systems in place to ensure the message does not get lost. Every radiology department must have in place a system that ensures the message about the suspicious imaging finding was received by the ordering clinician (or clinician who will be providing ongoing care).

See also our other columns on communicating significant results:

May 1, 2007 “The Missed Cancer”
February 12, 2008 “More on Tracking Test Results”
October 13, 2009 “Slipping Through the Cracks”
July 2009 “Failure to Inform Patients of Clinically Significant Outpatient Test Results”
March 9, 2010 “Communication of Urgent or Unexpected Radiology Findings”
March 1, 2011 “Tests Pending at Discharge”
August 21, 2012 “More on Missed Followup of Tests in Hospital”
October 2, 2012 “Test Results: Everyone’s Worst Nightmare”
March 12, 2013 “More on Communicating Test Results”
October 2013 “New AHRQ Toolkit: Improving Your Office Testing Process”
January 2014 “Email Alerts for Pending Test Results”
July 2015 “Technology to Avoid Delays in Follow-up of Significant Results”
November 17, 2015 “Patient Perspectives on Communication of Test Results”
December 20, 2016 “End-of-Rotation Transitions and Mortality”
September 2018 “ECRI Institute Partnership: Closing the Loop”
September 24, 2019 “EHR-related Malpractice Claims”
November 26, 2019 “Pennsylvania Law on Notifying Patients of Test Results”
January 2020 “The Joint Commission on Closing the Loop”
September 8, 2020 “Follow Up on Tests Pending at Discharge”
April 13, 2021 “Incidental Findings – What’s Your Strategy?”
May 25, 2021 “Yes, Radiologists Have Handoffs, Too”
February 2022 “Managing Incidental Findings”
April 5, 2022 “Follow-up on Incidental Findings”

References:

Patient dies after info-sharing error at Japan hospital delays cancer diagnosis for 4.5 yrs. The Mainichi 2022; November 25, 2022

https://mainichi.jp/english/articles/20221125/p2a/00m/0na/011000c

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Hearback Is More Than Just Hearing Back

We often talk about the importance of “hearback” in aviation or in the OR or other medical situations. But hearback is also important in our communications with our patients. Hearback is much more than simply having someone repeat back what you said to them. It is ensuring that the intent of the communication was understood.

We’ve given examples where aviation accidents have occurred because a person issuing a warning failed to make sure that the target of that communication understood the gravity of the situation. We’ve noted that our use of some medical terminology may be confusing in the OR, particularly in multicultural settings. But, if we can confuse other clinicians with our medical jargon, what do we expect when we use it with patients?

A recent study looked at patient understanding of medical terms we use (Gotlieb 2022). Gotlieb et al. surveyed 215 adults about some common medical phrases may lead to confusion among patients affecting health outcomes.

A 13-question survey with a mix of open-ended and multiple-choice questions assessing jargon understanding of common phrases used in medicine was administered. The full survey and contextual comments can be found in the supplementary materials to the Gotlieb article. Note that some of the questions had been used in previous studies demonstrating that patients may have difficulty understanding some medical jargon. Some questions were “dual” in that one was in jargon, the other in non-jargon. Respondents were asked to indicate if they felt these statements indicated good news, bad news, or they were unsure.

Some examples of the questions are:

“We are halfway through your chemotherapy treatment and your tumor is progressing.”

“Your urine tests are back and there were bugs in your urine.”

“You will need to be NPO at 8 am.”

“You are to have nothing by mouth after 4 pm.”

“Your nodes are positive.”

“The findings on the X-ray were quite impressive.”

“I am concerned the patient has an occult infection.”

“Have you been febrile?”

Most respondents (96%) knew that negative cancer screening results meant they did not have cancer. However, fewer respondents knew that “your tumor is progressing” was bad news (79%) or that positive nodes meant their cancer had spread (67%).

Significantly more respondents correctly interpreted the phrase nothing by mouth compared with the use of the acronym NPO (75% vs 11%), respectively. The authors suggest we should actually be using the phrase “You should not have anything to eat or drink”, which is more in keeping with everyday language where “by mouth” is not commonly used.

98% correctly understood “blood test shows no infection”, but only 87% understood the jargon phrase “your blood culture was negative”.

Interestingly, only 41% of respondents correctly interpreted “neuro exam is grossly intact” as good news. The authors speculated this might have been because the word “gross” more often means “unpleasant” than “in general” in common usage.

Few respondents accurately understood the questions that required a free-text response. Only 29% correctly interpreted “bugs in the urine” as intending to convey a urinary tract infection, 9% knew what febrile meant, and 2% of respondents understood the phrase “occult infection”.

The authors did look at factors like age, gender, and educational level but did not come to any firm conclusions about the impact of these on understanding of many of the jargon terms.

The bottom line is that we need to be very careful with the medical terminology we use with our patients and avoid medical jargon where possible. More importantly, we need to make sure our patients clearly understand what we are saying. Asking them, in a non-condescending manner, what they understood from our communication is both appropriate and necessary. The problem is even more serious and complicated when we communicate with them regarding medications and dosages, as highlighted in many of our columns on “numeracy”.

Some of our other columns on health literacy and numeracy:

June 2012 “Parents' Math Ability Matters”

May 7, 2013 “Drug Errors in the Home”

November 2014 “Out-of-Hospital Pediatric Medication Errors”

January 13, 2015 “More on Numeracy”

August 2017 “More on Pediatric Dosing Errors”

References:

Gotlieb R, Praska C, Hendrickson MA, et al. Accuracy in Patient Understanding of Common Medical Phrases. JAMA Netw Open 2022; 5(11): e2242972

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2799079?utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_term=113022

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