Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

July 2016

· ISMP Updates TALLman Lettering List

· New Simple Test for Delirium

· Holy Moly, My Patient has a FOLEY!

· NQF/CDC Guideline on Antibiotic Stewardship

ISMP Updates TALLman Lettering List

In our December 1, 2015 Patient Safety Tip of the Week “TALLman Lettering: Does It Work?” we noted some recent publications that had questioned the effectiveness of TALLman lettering in preventing LASA drug pair errors. We’ve long been fans of TALLman lettering and we’ve recommended its use (eg. HYDROmorphone) in our numerous columns on the dangers of Dilaudid. In fact, we’ve even sometimes suggested our own TALLman lettering schemes for certain LASA drug pairs (see our prior columns “Ophthalmology: Blue Dye Mixup” and “Another Blue Dye Eye Mixup”). So we weren’t about to conclude that TALLman lettering should be abandoned. But the two publications noted in our December column (Zhong 2015, ISMP Canada 2015) suggested that we need a systematic review of the impact of TALLman lettering in multiple other venues. While we doubt TALLman lettering causes harm, it makes sense we find out which drug pairs benefit the most from TALLman lettering and whether there have been any unintended consequences noted. Therefore, we recommended that, while waiting for such future studies, it is probably wisest to reserve your TALLman lettering conventions for those LASA drug pairs with the most potential to have serious patient safety consequences in your organizations.

ISMP (US) has now responded to the issues raised, reported results of a survey it has done with multiple hospitals, and updated its List of Drug Names with Tall Man Letters (ISMP 2016).

The new ISMP survey found that the vast majority of responding hospitals use TALLman lettering in some fashion and almost all find it useful. Some recalled specific examples where TALLman lettering helped avoid dangerous errors.

Interestingly, the survey also found some problems with implementation of TALLman lettering conventions, particularly integrating it into some electronic medical records and/or CPOE systems. For example, some such systems listed drugs in all capital letters and did not allow case changes. Others do not allow mixing of upper and lower case letters in names and many do not allow part of a name to be bolded (remember: part of the format for TALLman names suggested by ISMP is bolding or use of a different color or contrast as a further way to visually highlight part of the name and alert users that there might be a potential LASA issue).

ISMP also asked for potential new drug pair additions from survey respondents and 16 such pairs were recommended. Of those 16, ISMP opted to add 13 to its List of Drug Names with Tall Man Letters.

Though ISMP has added to its list, it acknowledges the ISMP Canada observation that overuse of tall man lettering may reduce effectiveness since names no longer appear novel. ISMP took into consideration keeping the list short enough to avoid diluting the effectiveness of the list.

The ISMP article also has nice descriptions from survey respondents as to how TALLman lettering really works as an alert system. It visually captures the attention of the user and makes them refocus or slow down and ensure they are ordering the correct drug.

The same June 2, 2016 special issue of ISMP Medication Safety Alert! Acute Care Edition also has a companion article with a review of the evidence for tall man lettering.

You can access the FDA and ISMP Lists of Look-Alike Drug Name Sets with Recommended Tall Man Letters with the updates at the ISMP website at the following address: http://www.ismp.org/tools/tallmanletters.pdf.

Should you be considering using tall man lettering for a drug pair you have identified as risky at your own institution, the ISMP article also recommends following the “CD3 rule” as a methodology for capitalizing and promoting consistency and standardization. See the ISMP article for details.

References:

Zhong W, Feinstein JA, Patel NS, et al. Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years. BMJ Qual Saf 2015; published online first November 3, 2015

http://qualitysafety.bmj.com/content/early/2015/11/03/bmjqs-2015-004562.short?rss=1

ISMP Canada. Application of TALLman Lettering for Selected High-Alert Drugs in Canada. ISMP Canada Safety Bulletin 2015; 15(10): 1-3 October 30, 2015

http://www.ismp-canada.org/download/safetyBulletins/2015/ISMPCSB2015-10_TALLman.pdf

ISMP (Institute for Safe Medication Practices). Special Edition: Tall Man Lettering. ISMP updates its list of drug names with tall man letters. ISMP Medication Safety Alert! Acute Care Edition 2016; June 2, 2016

http://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=1140

ISMP (Institute for Safe Medication Practices). FDA and ISMP Lists of Look-Alike Drug Name Sets with Recommended Tall Man Letters. 2016

http://www.ismp.org/tools/tallmanletters.pdf

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New Simple Test for Delirium

The race is on for a simple test to diagnose delirium. In our August 2014 What’s New in the Patient Safety World column “A New Rapid Screen for Delirium in the Elderly” we discussed the importance of recognizing delirium but that delirium goes unrecognized or undiagnosed in up to 72% of cases in hospitalized patients (Collins 2010). One of the reasons may be that commonly used screening tests for delirium may not be brief enough or may require specific training for administration. We noted a new screening tool, the 4 ‘A’s’ Test (4AT) to help improve screening for delirium and its validation in a population other than that in which it was developed (Bellelli 2014).

Then in our November 2014 What's New in the Patient Safety World column “The 3D-CAM for Delirium” we discussed another brief diagnostic tool for delirium, the 3D-CAM, that had been derived and validated (Marcantonio 2014). The assessment takes only about 3 minutes to administer and can be administered by a wide variety of healthcare workers. It takes less than an hour to train someone to administer the tool.

In the validation study, the 3D-CAM had a sensitivity of 95% and specificity of 94% and performed almost equally well in patients with and without dementia (specificity in patients with dementia was slightly less at 86% but sensitivity was 96%). Importantly, the vast majority of patients identified as having delirium had either the hypoactive variety or normal psychomotor activity. That is the population in which delirium is often undiagnosed, compared to those with the hyperactive variety.

Then in late 2015 yet another simple screening tool for delirium was introduced by the team that had developed the 3D-CAM (Fick 2015). Fick and colleagues used subsets of the 3D-CAM to develop an ultrabrief two-item bedside test for delirium. They found that the best 2-item screen was the combination of “months of the year backwards” and “what is the day of the week?” Those two items had a sensitivity of 93% and specificity of 64%. Even the single item “months of the year backwards” had a sensitivity of 83% and specificity of 69% for diagnosing delirium. The median time it took to administer the screening was 36.5 seconds. The authors emphasize that this should not be considered a diagnostic test but rather a screening tool. When positive, it could be followed with a more comprehensive test like the 3D-CAM. This 2-item tool still needs validation in other populations.

And now an even newer test, the Stanford Proxy Test for Delirium (S-PTD), is being touted as a rapid, simple screening test for delirium that may have the additional desirable feature of not requiring direct patient participation (Maldonado 2016). This test also took less than a minute for nurses to complete. It would completed it at the end of each shift and it is based purely on nursing observations. The researchers found the S-PTD had a sensitivity of 79% for identifying delirium, specificity 91%, positive predictive value 70%, and negative predictive value 94%.

And, finally, another study noted that delirium assessments that can be reliably and quickly performed by nonphysicians are lacking in the emergency department setting (Han 2016). The authors evaluated the diagnostic performance of the modified Brief Confusion Assessment Method (modified bCAM) in ED patients 65 years or older. The original bCAM was a brief (<2 minutes) delirium assessment that assessed for inattention by asking the patient to recite the months backward from December to July. It was modified by adding the Vigilance A (“squeeze my hand when you hear the letter ‘A’”) to the inattention assessment. The elements of the modified bCAM were performed by a research assistant (RA) and emergency physician. Delirium was found in 12% of the 406 patients enrolled in their study. The modified bCAM had a sensitivity of 82.0% and specificity of 96.1% when performed by the RA. The emergency physician's modified bCAM exhibited similar diagnostic performance. Use of the modified bCAM needs to be validated in other sites and settings but nevertheless is promising as a screening tool that can be easily administered.

While traditional validated tools like the CAM and CAM-ICU remain key components of any programs addressing delirium, we wholeheartedly support the exploration of tools that can be administered briefly and by those without extensive training. We agree that such tools will likely greatly increase the detection of delirium so that appropriate management strategies can be put in place.

Some of our prior columns on delirium assessment and management:

· October 21, 2008 “Preventing Delirium”

· October 14, 2008 “Managing Delirium”

· February 10, 2009 “Sedation in the ICU: The Dexmedetomidine Study”

· March 31, 2009 “Screening Patients for Risk of Delirium”

· June 23, 2009 “More on Delirium in the ICU”

· January 26, 2010 “Preventing Postoperative Delirium”

· August 31, 2010 “Postoperative Delirium”

· September 2011 “Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery”

· December 2010 “The ABCDE Bundle”

· February 28, 2012 “AACN Practice Alert on Delirium in Critical Care”

· April 3, 2012 “New Risk for Postoperative Delirium: Obstructive Sleep Apnea”

· August 7, 2012 “Cognition, Post-Op Delirium, and Post-Op Outcomes”

· September 2013 “Disappointing Results in Delirium”

· October 29, 2013 “PAD: The Pain, Agitation, and Delirium Care Bundle”

· February 2014 “New Studies on Delirium”

· March 25, 2014 “Melatonin and Delirium”

· May 2014 “New Delirium Severity Score”

· August 2014 “A New Rapid Screen for Delirium in the Elderly”

· August 2014 “Delirium in Pediatrics”

· November 2014 “The 3D-CAM for Delirium”

· December 2014 “American Geriatrics Society Guideline on Postoperative Delirium in Older Adults”

· June 16, 2015 “Updates on Delirium”

· October 2015 “Predicting Delirium”

· April 2016 “Dexmedetomidine and Delirium”

· April 2016 “Can Antibiotics Lead to Delirium?”

References:

Collins N, Blanchard MR, Tookman A, Sampson EL. Detection of delirium in the acute hospital. Age Ageing 2010; 39 (1): 131-135

http://ageing.oxfordjournals.org/content/39/1/131.full.pdf+html

The 4 ‘A’s Test: screening instrument for delirium and cognitive impairment

http://www.the4at.com/

Bellelli G, Morandi A, Davis DHJ, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing 2014; 43(4): 496-502

http://ageing.oxfordjournals.org/content/43/4/496.full.pdf+html

Marcantonio ER, Ngo LH, O'Connor M, et al. 3D-CAM: Derivation and Validation of a 3-Minute Diagnostic Interview for CAM-Defined Delirium: A Cross-sectional Diagnostic Test Study. Ann Intern Med 2014; 161(8): 554-561

http://annals.org/article.aspx?articleid=1916821

3D-CAM (3 minute diagnostic assessment). The Hospital Elder Life Program 2014.

http://www.hospitalelderlifeprogram.org/delirium-instruments/3dcam/

Fick DM, Inouye SK, Guess J, et al. Preliminary development of an ultrabrief two-item bedside test for delirium. Journal of Hospital Medicine 2015; 10(10): 645-650

http://onlinelibrary.wiley.com/doi/10.1002/jhm.2418/abstract

Maldonado JR. The Proxy Test for Delirium (PTD): A New Tool for the Screening of Delirium Based on DSM-5 and ICD-10 Criteria. American Psychiatric Association (APA) 2016 Annual Meeting. SCR-Measurements and Scales, no. 3. Presented May 17, 2016

As discussed in Brooks M. New Delirium Test May Be Simpler, More Accurate. Medscape Medical News 2016; May 25, 2016

http://www.medscape.com/viewarticle/863826

Han JH, Wilson A, Graves AJ, et al. A quick and easy delirium assessment for nonphysician research personnel. Am J Emerg Med 2016; 34(6): 1031-1036

http://www.ajemjournal.com/article/S0735-6757%2816%2900176-5/abstract

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Holy Moly, My Patient has a FOLEY!

In our many columns on avoiding unnecessary use of Foley catheters we’ve often noted that posters or screensavers are helpful tools in achieving reduction of Foley catheter use. At the recent American Geriatrics Society (AGS) 2016 Annual Scientific Meeting one of the poster presentations highlighted a program on a Canadian acute geriatrics unit that successfully reduced urinary catheter use by almost half (Sinha 2016). One of the keys to success was use of a poster that had the headline “Holy Moly, My Patient has a Foley!”. Way back in our May 8, 2007 Patient Safety Tip of the Week “Doctor, when do I get this red rubber hose removed?” (and our many other columns on avoiding CAUTI’s) we’ve talked about how often physicians are surprised to find that their patient had a Foley catheter in place.

Variations of that phrase have been used elsewhere, such as “Holy Moley, Take Out That Foley!” (Ghanem 2015) or “Holey Moley, What About That Foley?” (Steinmann 2012). But what was unique in the Canadian program was that they apparently placed the posters in bathroom stalls “where all staff had ample time to review indications for catheters, associated risks, and ways they could take action to remove them”. What a great concept! We’ve seen that with posters elsewhere or computer screensavers staff tend to block them out after they’ve seen a few. But we like the idea of using the bathroom stall where you have a “captive audience”!

It’s creative programs like this that every healthcare organization can learn from. There are many evidence-based interventions and best practices that we try to disseminate in our organizations. But dissemination of some are more successful than others. It’s often in the way you communicate. And use of a catchy phrase and an even catchier place to put it might really help spread the message. Kudos to Sinha and colleagues for this program!

We’d, of course, be remiss if we failed to mention the results of a recently published, AHRQ-sponsored national project to reduce unnecessary urinary catheter use and CAUTI’s (Saint 2016). Led by Sanjay Saint, whose work on CAUTI reduction we’ve noted in many of our prior columns on CAUTI prevention such as the Michigan Health and Hospital Association (MHA) Keystone Center’s Bladder Bundle Initiative, the national Comprehensive Unit-based Safety Program included dissemination of information to sponsor organizations and hospitals, data collection, and guidance on key technical and socioadaptive factors in the prevention of catheter-associated UTI. Principles from CUSP (Comprehensive Unit-Based Safety Program) programs were utilized in understanding some of those socioadaptive factors (we discussed CUSP principles in our March 2011 What's New in the Patient Safety World column “Michigan ICU Collaborative Wins Big”).

Data were obtained between March 2011 and November 2013 from over 900 units before and after implementation and again at 12 months to assess sustainability. Adjusted CAUTI rates overall fell 14%. For non-ICU units CAUTI rates fell 32%. Catheter use decreased 7% in non-ICU units. Results of both were sustainable over the 12 months of data collection.

Interestingly, neither catheter use nor CAUTI rates fell in ICU’s. The reason for the lack of improvement in ICU’s is not clear, though the authors speculate the need for monitoring urinary output may justify more use of urinary catheters in the ICU setting and several other factors in ICU patients may lead to higher CAUTI rates.

Our December 2015 What's New in the Patient Safety World column “CAUTI Prevention Tools” discussed AHRQ’s “Toolkit for Reducing CAUTI in Hospitals” (AHRQ 2015). The toolkit was developed as part of a multi-hospital project in which CUSP (Comprehensive Unit-based Safety Program) principles were used along with evidence-based CAUTI prevention measures. The toolkit includes multiple tools, including:

Ways to assess physicians and executives for leadership/champion roles
Sample catheter appropriateness policies
Sample bladder scanning policies
Posters, pocket cards, algorithms, fact sheets
Sample nurse-driven protocol for catheter removal
And many others

It also has links to a host of prior AHRQ webinars on preventing CAUTI’s and using CUSP principles. It also has multiple resources for sustaining change and improvement.

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

May 8, 2007 Tip of the Week “Doctor, when do I get this red rubber hose removed?”
January 8, 2008 Tip of the Week “Urinary Catheter-Associated Infections”
April 2008 What’s New in the Patient Safety World column “More on Nosocomial UTI’s”
June 24, 2008 Tip of the Week “Urinary Catheter-Related UTI’s: Bladder Bundles”
April 21, 2009 Tip of the Week “Still Futzing with Foleys?”
June 9, 2009 Tip of the Week “CDC Update to the Guideline for Prevention of CAUTI”
March 2010 “IDSA CAUTI Guidelines”
February 2011 What’s New in the Patient Safety World column “Catheters Not Needed in C-Sections?”
January 2012 “CAUTI’s Still Get No Respect”
May 2012 “Foley Catheter Hazards”
November 2012 “CAUTI Conundrum”
December 18, 2012 “Unintended Consequences of the CAUTI Measure?”
January 2013 “Silver-Coated Urinary Catheters Don’t Reduce CAUTI’s”
June 2013 “Barriers to CAUTI Prevention”
November 2013 “Further Reducing Urinary Catheter Use”
June 2014 “Updated HAI Prevention Guidelines from SHEA/IDSA”
June 30, 2015 “What Are Appropriate Indications for Urinary Catheters?”
December 2015 “CAUTI Prevention Tools”

References:

Sinha S, et al. American Geriatrics Society (AGS) 2016 Annual Scientific Meeting: Abstract P2. Presented May 19, 2016

As presented by Harrison L. Geriatrics Unit Reduces Catheter Use, Reports Fewer Deaths. Medscape Medical News 2016; May 25, 2016

http://www.medscape.com/viewarticle/863837#vp_2

Ghanem A, Artime C, Moser M, et al. Holy Moley! Take out that Foley! Measuring Compliance with a Nurse Driven Protocol for Foley Catheter Removal to Decrease Utilization. Amer J Infect Control 2015; 43(6): Supplement, Page S51

http://www.ajicjournal.org/article/S0196-6553%2815%2900371-5/abstract

Steinmann K. Holey Moley! What About That Foley?! PowerPoint presentation. Hennepin County Medical Center. September 7, 2012

http://www.mnreducinghais.org/documents/Foley_Steinmann_HCMC.ppt

Saint S, Greene MT, Krein SL, et al. A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care. N Engl J Med 2016; 374: 2111-2119

http://www.nejm.org/doi/full/10.1056/NEJMoa1504906

AHRQ (Agency for Healthcare Research and Quality). Toolkit for Reducing CAUTI in Hospitals. 2015

http://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/cauti-hospitals/index.html?utm_source=PressRelease56&utm_medium=PressRelease&utm_term=Toolkit&utm_content=56&utm_campaign=CUSP4CAUTI2015

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NQF/CDC Guideline on Antibiotic Stewardship

With the continued emergence of pathogens resistant to multiple antibiotics there is a renewed urgency to optimize use of antibiotics. The latest CDC report notes that 20-50 percent of antibiotics prescribed in hospitals are unnecessary or inappropriate (CDC 2016). Antibiotic stewardship programs have proven to be successful in hospitals at reducing antibiotic resistance (see or October 14, 2014 Patient Safety Tip of the Week “Antibiotic Stewardship”). And we also discussed antibiotic stewardship in ambulatory and long-term care settings in our November 2015 What's New in the Patient Safety World column “Medications Most Likely to Harm the Elderly Are…”.

Despite the push to get antibiotic stewardship programs functioning at high levels, a recent study found that among 4,184 U.S. hospitals, 39% reported having an antibiotic stewardship program that met all seven CDC-defined core elements (Pollack 2016). 59% of hospitals with greater than 200 beds had such programs but only 25% of hospitals with less than 50 beds reported achieving all seven CDC-defined core elements of a comprehensive ASP.

In our November 2015 What's New in the Patient Safety World column “Medications Most Likely to Harm the Elderly Are…” we mentioned that the National Quality Forum had recently announced a new initiative on antibiotic stewardship. That resource is now available. Antibiotic Stewardship in Acute Care: A Practical Playbook is produced by the NQF and numerous partner organizations, including the CDC (NQF 2016).

For each of the CDC core elements the Playbook includes a brief rationale and overview, examples for implementation, potential barriers and suggested solutions, and suggested tools and resources. The seven CDC-defined core elements (CDC 2016) of a comprehensive antibiotic stewardship program are:

Leadership Commitment: Dedicate necessary human, financial, and information technology resources.
Accountability: Appoint a single leader responsible for program outcomes who is accountable to an executive-level or patient quality-focused hospital committee. Experience with successful programs shows that a physician leader is effective.
Drug Expertise: Appoint a single pharmacist leader responsible for working to improve antibiotic use.
Action: Implement at least one recommended action, such as systemic evaluation of ongoing treatment need after a set period of initial treatment (i.e., “antibiotic time out” after 48 hours).
Tracking: Monitor process measures (e.g., adherence to facility-specific guidelines, time to initiation or de-escalation), impact on patients (e.g., Clostridium difficile infections, antibiotic-related adverse effects and toxicity), antibiotic use, and resistance.
Reporting: Report the above information regularly to doctors, nurses, and relevant staff.
Education: Educate clinicians about disease state management, resistance, and optimal prescribing.

The Playbook does a very good job of identifying potential barriers and suggesting solutions. For each core element it also provides links to resources available to help with that element. Such resources include not only those pertinent to patient safety but also those involved in making the business case for a good antibiotic stewardship program. It also provides examples of potential interventions (system interventions, patient-specific interventions, and diagnosis- and infection-specific interventions). It offers suggestions on tracking both process and outcome measures and antibiotic use.

You’ll find the Playbook a very valuable tool, both for getting your antibiotic stewardship program up to snuff (meeting the 7 CDC-defined elements) and taking it to the next level. It will also help you get ready to meet The Joint Commission’s proposed new standards on antibiotic stewardship (TJC 2015).

Other excellent resources on antibiotic stewardship are available for free from the Pennsylvania Patient Safety Authority (Adkins 2015, Bradley 2015), The Joint Commission, the CDC, and Johns Hopkins Hospital. The CDC core elements document has a nice checklist for you to see if your organization is meeting the core elements of a good antibiotic stewardship program.

And, as we were getting ready to publish this column, CMS has announced that hospitals will be required to have antibiotic stewardship programs and demonstrate that they have reduced inappropriate antibiotic usage (CMS 2016).

Some of our prior columns on antibiotic stewardship:

October 14, 2014 “Antibiotic Stewardship”
November 2015 “Medications Most Likely to Harm the Elderly Are…”
July 2016 “NQF/CDC Guideline on Antibiotic Stewardship”

References:

CDC (Centers for Disease Control and Prevention). Core Elements of Hospital Antibiotic Stewardship Programs. Page last updated: May 25, 2016

http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

Pollack LA, van Santen KL, Weiner LM, et al. Antibiotic stewardship programs in U.S. acute care hospitals: findings from the 2014 National Healthcare Safety Network (NHSN) Annual Hospital Survey. Clin Infect Dis 2016; First published online: May 19, 2016

http://cid.oxfordjournals.org/content/early/2016/05/18/cid.ciw323.abstract

NQF (National Quality Forum) National Quality Partners Antibiotic Stewardship Action Team. Antibiotic Stewardship in Acute Care: A Practical Playbook. May 2016

http://www.qualityforum.org/Publications/2016/05/Antibiotic_Stewardship_Playbook.aspx?utm_source=external&utm_medium=link&utm_term=ABX&utm_content=Playbook&utm_campaign=ABX

TJC (The Joint Commission). Proposed Standard for Antimicrobial Stewardship in AHC, CAH, HAP, NCC, and OBS. The Joint Commission 2015; November 2015

https://jointcommission.az1.qualtrics.com/CP/File.php?F=F_5tDHGzIVDMHenDn

Adkins J, Bradley S, Finley E. Strategies to Turn the Tide against Inappropriate Antibiotic Utilization. Pa Patient Saf Advis 2015; 12(4):149-157

http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2015/Dec;12%284%29/Pages/149.aspx

Bradley S. Antibiotic Stewardship in Hospitals and Long-Term Care Facilities: Building an Effective Program. Pa Patient Saf Advis 2015; 12(2): 71-78

http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2015/Jun;12%282%29/Pages/71.aspx

CDC (Centers for Disease Control and Prevention). Get smart for healthcare website. Page last updated: January 13, 2016

http://www.cdc.gov/getsmart/healthcare/

The Joint Commission. Antimicrobial Stewardship Toolkit.

http://www.jointcommission.org/topics/hai_antimicrobial_stewardship.aspx

Johns Hopkins Medicine. JHH Antibiotic Management Guidelines (updated annually).

http://www.hopkinsmedicine.org/AMP

CMS (Centers for Medicare & Medicaid Services). CMS Issues Proposed Rule that Prohibits Discrimination, Reduces Hospital-Acquired Conditions, and Promotes Antibiotic Stewardship in Hospitals. June 13, 2016

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-06-13.html