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
Print “July
2016 ISMP Updates TALLman Lettering List”
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
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
Print “July
2016 New Simple Test for Delirium”
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:
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:
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
Print “July
2016 Holy Moly, My Patient has a FOLEY!”
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:
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:
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
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
Print “July
2016 NQF/CDC Guideline on Antibiotic Stewardship”
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2016 What's New in the Patient Safety World (full
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2016 ISMP Updates TALLman Lettering List”
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2016 New Simple Test for Delirium”
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2016 Holy Moly, My Patient has a FOLEY!”
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2016 NQF/CDC Guideline on Antibiotic Stewardship”
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