A Johns Hopkins-led collaborative project involving 56 ICUs at 38 hospitals in Maryland and Pennsylvania from October 2012 to March 2015 successfully reduced rates of ventilator-associated events (Rawat 2017). The quarterly mean ventilator-associated event rate significantly decreased from 7.34 to 4.58 cases per 1,000 ventilator-days after 24 months of implementation, a 38% reduction. Infection-related ventilator-associated complications decreased from 3.15 to 1.56 per 1,000 ventilator-days. Even more impressive was the reduction in rates of possible and probable ventilator-associated pneumonia, which decreased from 1.41 to 0.31 cases per 1,000 ventilator-days, a 78% reduction.
Like many of the collaborative projects led by Johns Hopkins clinicians and researchers, training related to unit teamwork and safety culture was a key. Principles of CUSP (Comprehensive Unit-based Safety Program) are a core element (see our March 2011 What's New in the Patient Safety World column Michigan ICU Collaborative Wins Big for comments about CUSP and links to resources).
The training emphasized evidence-based practices:
The above collaborative was sponsored by AHRQ, NIH and several other organizations. Another collaborative of hospitals in the Hospital Innovation and Improvement Network (HIIN) project led by the Centers for Medicare & Medicaid Services (CMS) and the Partnership for Patients (PFP) used the HRET Preventing Ventilator-Associated Events Change Package (HRET 2017). That describes how the elements of the ABCDEF Bundle (see our September 20, 2016 Patient Safety Tip of the Week ) can be implemented and reduce the rate of ventilator-associated events.
Collaboratives which promote adherence to evidence-based interventions have usually demonstrated successful outcomes. However, the core elements of CUSP and culture training are critical to the success of such collaboratives. We always tell hospitals that patient safety projects are much more likely to be successful when implemented at the unit level than across entire institutions.
Rawat N, Yang T, Ali, KJ, et al. Two-State Collaborative Study of a Multifaceted Intervention to Decrease Ventilator-Associated Events. Critical Care Medicine 2017; Published Ahead of Print Post Author Corrections: April 26, 2017
HRET (Health Research & Educational Trust). Preventing Ventilator-Associated Events Change Package. Update 2017
Multi-component non-pharmacological interventions such as HELP, the Hospital Elder Life Program (see our October 21, 2008 Patient Safety Tip of the Week Preventing Delirium and our September 2011 What's New in the Patient Safety World column Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery) or tools like the ABCDEF Bundle (see our September 20, 2016 Patient Safety Tip of the Week ) have been used to reduce the rate or impact of delirium in hospitalized patients.
In our March 21, 2017 Patient Safety Tip of the Week we noted that a delirium prevention bundle (DPB) in ICU patients reduced the odds of delirium were reduced by 78% despite considerable barriers to implementation of the bundle (Smith and Grami 2017).
Similar success with the modified Hospital Elder Life Program (mHELP) was recently demonstrated in a cluster randomized clinical trial in Taiwan of patients age 65 and older who underwent major abdominal surgery (Chen 2017). The intervention consisted of 3 protocols administered daily: orienting communication, oral and nutritional assistance, and early mobilization. The odds of delirium were reduced by 56% and LOS was reduced by 2 days in the group receiving mHELP compared to the control group.
The success of non-pharmacologic interventions to prevent delirium is particularly important given the relative lack of success of pharmacologic interventions in preventing it. Since our last column on delirium there have been two more unsuccessful attempts at preventing delirium with agents that had shown promise.
A randomized clinical trial of intraoperative infusion of dexmedetomidine for prevention of postoperative delirium and cognitive dysfunction in elderly patients undergoing major elective noncardiac surgery found that ntraoperative dexmedetomidine does not prevent postoperative delirium (Deiner 2017). And the Prevention of Delirium and Complications Associated with Surgical Treatments (PODCAST) study found that a single subanaesthetic dose of ketamine did not decrease delirium in older adults after major surgery, and might cause harm by inducing negative experiences (Avidan 2017).
So, while the search is likely to continue for pharmacologic agents that might reduce the rate of delirium in several populations of hospitalized patients, hospitals should be implementing multi-component interventions like mHELP. Given the substantial financial savings that a 2-day reduction in LOS for such patients, you should have no difficulty convincing your CFO to support the resources necessary to implement an effective mHELP or similar program.
One of the components of almost all multi-component programs for delirium is promoting more natural sleep and trying to simulate more natural sleep/waking cycles. It turns out that not only is sleep disruption in the hospital an important contributing factor to delirium but sleep disruption at home prior to hospitalization is also a risk factor for delirium. Todd and colleagues (Todd 2017) used the Pittsburgh Sleep Quality Index and actigraphy to objectively measure sleep disruption in the hospital before and after elective surgery in patients age 65 and older. They found that those patients with sleep disruption at home were 3.26 times as likely to develop postoperative delirium as those without it. So that is another risk factor to add to your pre-op assessments.
Wed also be remiss if we did not take the opportunity to direct our readers to the recent excellent review of hypoactive delirium by Hosker and Ward in the British Medical Journal (Hosker 2017). Hypoactive delirium, of course, is both more common and more difficult to recognize than its counterpart of the agitated, hyperactive type of delirium. But its impact on patient outcomes and use of healthcare resources is just as or even more significant than that for hyperactive delirium. Multi-component interventions like HELP remain the mainstays for all types of delirium.
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
· 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
· February 2013 The ABCDE Bundle in Action
· 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
· June 16, 2015 Updates on Delirium
· October 2015 Predicting Delirium
· April 2016
· April 2016
· July 2016
· September 20, 2016
· January 24, 2017
· March 21, 2017
Hospital Elder Life Program (HELP) for Prevention of Delirium.
Smith CD, Grami P. Feasibility and Effectiveness of a Delirium Prevention Bundle in Critically Ill Patients. Am J Crit Care 2017; 26(1): 19-27
Chen CC-H, Li H-C, Liang J-T, et al. Effect of a Modified Hospital Elder Life Program on Delirium and Length of Hospital Stay in Patients Undergoing Abdominal Surgery. A Cluster Randomized Clinical Trial. JAMA Surg 2017; Published online May 24, 201
Deiner S, Luo X, Lin H-M, et al and the Dexlirium Writing Group. Intraoperative Infusion of Dexmedetomidine for Prevention of Postoperative Delirium and Cognitive Dysfunction in Elderly Patients Undergoing Major Elective Noncardiac Surgery. A Randomized Clinical Trial. JAMA Surg 2017; Published online June 7, 2017
Avidan MS, Maybrier HR, Abdallah AB, et al. Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. The Lancet 2017; Published 30 May 2017
Todd OM, Gelrich L, MacLullich AM, et al. Sleep Disruption at Home As an Independent Risk Factor for Postoperative Delirium. J Am Geriatr Soc 2017; 65(5): 949-957
Hosker C, Ward D. Hypoactive delirium. BMJ 2017; 357: j2047 (Published 25 May 2017)
In our November 2015 What's New in the Patient Safety World column Medications Most Likely to Harm the Elderly Are we cited a study from New Zealand that found medications to be the number one cause of harm to ambulatory patients age 65 and older and antibiotics the most common offenders (Wallis 2015). The antibiotic category accounted for 51% of all medication injuries and 39% of serious or sentinel injuries.
That was on the outpatient side. Now a new study on almost 1500 patients hospitalized on four general medicine services at Johns Hopkins Hospital (Tamma 2017) found that 20% of hospitalized patients experienced at least 1 antibiotic-associated ADE (adverse drug event). For nonclinically indicated antibiotic regimens, 20% were also associated with an ADE, including several cases of C difficile infection. Every additional 10 days of antibiotic therapy conferred a 3% increased risk of an ADE. The most common ADEs were gastrointestinal, renal, and hematologic abnormalities, accounting for 42%, 24%, and 15% of 30-day ADEs, respectively.
Importantly, this study followed patients not only through hospital discharge but also following discharge. 27% of the antibiotic related ADEs occurred after hospital discharge. So they recorded ADEs as either 30-day or 90-day ADEs. Many of the antibiotic-related ADEs occurred later. 43% of all the ADEs were found in their 90-day follow up period. 39% of those were C. diff infections and 61% were multiple drug resistant organism infections. The median time to development of a 90-day ADE was 15 days.
The most frequently prescribed antibiotics were thirdgeneration cephalosporins, parenteral vancomycin, and cefepime and 79% of patients received more than one antibiotic. Notable differences were identified in the incidence and types of ADEs associated with specific antibiotics. For example, aminoglycosides, parenteral vancomycin, and trimethoprim-sulfamethoxazole were associated with the highest rates
of nephrotoxic effects, QTc prolongation occurred with azithromycin and ciprofloxacin,
and neurotoxic effects, including encephalopathy or seizures, occurred with cefepime.
Perhaps the most striking finding is that these rates were seen at Johns Hopkins Hospital, which already has a very robust antibiotic stewardship program. One would anticipate the rates to be even higher at hospitals not having such robust programs.
Avoidability was defined as occurring when antibiotic therapy was considered to be not indicated after review by infectious disease expert reviewers. The rate of potentially avoidable ADEs may have been even higher, since they did not include excessively prolonged durations of antibiotic therapy or inappropriately broad antibiotic use in their calculation of avoidable antibiotic associated ADEs.
In our November 2015 What's New in the Patient Safety World column Medications Most Likely to Harm the Elderly Are we also noted a US study (Shebab 2008) that found an estimated 142,505 visits annually were made to US EDs for drug-related adverse events attributable to systemic antibiotics. Antibiotics were implicated in 19.3% of all ED visits for drug-related adverse events. Allergic reactions accounted for 78.7% of visits. Those authors suggested that minimizing unnecessary antibiotic use by even a small percentage could significantly reduce the immediate and direct risks of drug-related adverse events in individual patients.
And, of course, inappropriate antibiotics are not limited to ambulatory and acute care settings. Up to 75% of nursing home patients are also inappropriately given antibiotics (CDC 2015a) and CDC has recommended that all nursing homes implement its Core Elements of Antibiotic Stewardship for Nursing Homes (CDC 2015b).
Antibiotic related ADEs can lead to prolongation of hospital stays and, given that some of the ADEs occur later, can also lead to rehospitalizations or emergency room visits. Hence, not only are antibiotic related ADEs harmful to patients but they also can add considerable cost to our healthcare system. This provides increased emphasis on the need for effective antibiotic stewardship programs.
Some of our prior columns on antibiotic stewardship:
Wallis KA. Learning From No-Fault Treatment Injury Claims to Improve the Safety of Older Patients. Ann Fam Med 2015; 13(5): 472-474
Tamma PD, Avdic E, Li DX, et al Association of Adverse Events With Antibiotic Use in Hospitalized Patients. JAMA Intern Med 2017; Published online June 12, 2017
Shehab N, Patel PR, Srinivasan A, Budnitz DS. Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis 2008; 47(6): 735-743
CDC. CDC Recommends All Nursing Homes Implement Core Elements to Improve Antibiotic Use. September 15, 2015
CDC. The Core Elements of Antibiotic Stewardship for Nursing Homes. 2015
From our earliest columns on falls weve pointed out that we always have two goals that may seem to be somewhat contradictory: (1) preventing injuries related to falls and (2) promoting mobility and its positive consequences. Notice that we put the emphasis not on preventing falls but rather preventing injuries that occur related to falls. Perhaps because of our background in neurology weve been sensitive to the need to encourage mobility in many of our patients who have neurologic impairments.
A recent Viewpoint in JAMA Internal Medicine (Growdon 2017) eloquently expresses this tension between promoting mobility and preventing falls in the hospital. The authors emphasize some of the problems engendered by immobility, including contribution to the post-hospital syndrome (see our February 17, 2015 Patient Safety Tip of the Week Functional Impairment and Hospital Readmission, Surgical Outcomes). They note that, in our zeal to prevent falls, we do things that restrict mobility (eg. bed and chair alarms, etc.). They also discuss that many fall prevention interventions have failed to impact fall-related injury rates.
They go on to point out that strategies that promote mobility may actually help prevent falls. Note that in another of this months What's New in the Patient Safety World columns we discussed the Hospital Elder Life Program (HELP program). While one of the primary goals of HELP is prevention of delirium and its consequences, it has also been shown that the HELP program actually prevents falls. A meta-analysis of multicomponent nonpharmacological interventions for delirium prevention (Hshieh 2015) confirmed that multicomponent nonpharmacological interventions are effective in decreasing delirium incidence and preventing falls. It estimated that potential savings in the US from such programs might be more than $16 billion annually. The meta-analysis included over 4000 patients from 14 studies. Most used HELP or a modified HELP program. Some used volunteers, family, or nurses in their interventions. Overall, the odds of delirium were 53% lower in patients receiving these interventions and the NNT (number needed to treat) was 14.3. In addition, the odds of falling were 62% lower among patients with such interventions (delirium is a risk factor for falls). While there were trends favoring those in the intervention group for length of stay, institutionalization, and changes in functional or cognitive status, these trends did not reach statistical significance.
Growdon and colleagues attribute the limitation on promoting mobility, in part, to the risk of lawsuits and to institutional cultures driven to avoid any financial penalties. Specifically, they note that hospitals are penalized financially only for falls that result in
injuries, so they do not always collect data that can prospectively separate injurious from noninjurious falls.
Weve always advocated use of ambulation teams that can help promote mobility in a safe manner and relieve some of the pressure on nursing staff. Growdon et al. also advocate transforming fall prevention teams into mobility teams. Further they suggest we need to add measures of mobility promotion to our measures of quality and safety. They suggest that, rather than using bed and chair alarms, we should be using accelerometers to assess how many steps our patients are actually taking and use these as measures of progress during hospital stays. They note that the dichotomy between fall prevention and mobility promotion is really a false one.
Further, they call for adjustment of current fall prevention metrics to reflect the counterbalancing benefits of increased mobility. We wholeheartedly agree.
Some of our prior columns related to falls:
Some of our previous columns on falls after correction of vision:
June 2010 Seeing Clearly a Common Sense Intervention
June 2014 New Glasses and Fall Risk
August 2014 Cataract Surgery and Falls
Growdon ME, Shorr RI, Inouye SK. The Tension Between Promoting Mobility and Preventing Falls in the Hospital. JAMA Intern Med 2017; 177(6): 759-760
Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med 2015; 175(4): 512-520
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