Print “PDF version”
Clinicians spend an awful lot of time on the electronic
medical record (EMR) and this has been an important
factor contributing to burnout. See our
What's New in the Patient Safety World columns for April 2017 “How Much Time Do We Actually
Spend on the EMR?” and May
2019 “Too Much Time on the EMR”.
Many of the studies
have looked at time spent on the EMR in the hospital setting. But a few have
looked at EMR use in the ambulatory setting. A time-motion study of physicians
in ambulatory practices (Sinsky
2016) found that, during
the office day, physicians spent 27.0% of their total time on direct clinical
face time with patients and 49.2% of their time on EHR and desk work. While in
the examination room with patients, physicians spent 52.9% of the time on
direct clinical face time and 37.0% on EHR and desk work. In addition, outside
of office hours, physicians spend another 1 to 2 hours of personal time each
night doing additional computer and other clerical work. Thus, for every hour
physicians provide direct clinical face time to patients, they spent nearly 2
additional hours on EHR and desk work within the clinic day. Of the time spent
on EHR and desk work, 38.5% was spent on documentation and review tasks, 6.3%
on test results, 2.4% on medication orders, and 2.0% on other orders. They
spent 1.1% of their time on administrative tasks (0.6% involved
insurance-related tasks and 0.5% involved scheduling).
(Rotenstein 2021). Those researchers found that m
A second recent study (Eschenroeder
2021) confirmed the impact of after-hours EMR activity on burnout.
The researchers found that physicians reporting ≤ 5 hours weekly of
after-hours charting were twice as likely to report lower burnout scores
compared to those charting ≥6 hours (aOR 2.43).
Kutney-Lee
2021) found that nurses who worked in hospitals with poorer EHR (electronic
health record) usability had significantly higher odds of burnout (odds ratio 1.41),
job dissatisfaction (OR 1.61) and
intention to leave (OR 1.31) compared with nurses working in hospitals with
better usability.
Not only did poor EHR usability impact nurse burnout, it also impacted patient safety and outcomes. Surgical
patients treated in hospitals with poorer EHR usability had significantly
higher odds of inpatient mortality (OR 1.21) and 30-day readmission (OR 1.06)
compared with patients in hospitals with better usability.
See some of our other
Patient Safety Tip of the Week columns dealing with unintended consequences of
technology and other healthcare IT issues:
Some of our prior
columns on “burnout”:
References:
Sinsky C, Colligan L, Li L, et al.
Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in
4 Specialties. Ann Intern Med 2016; 165: 753-760
https://www.acpjournals.org/doi/10.7326/M16-0961
Rotenstein LS, Holmgren AJ,
Downing NL, Bates DW. Differences in Total and After-hours Electronic Health
Record Time Across Ambulatory Specialties. JAMA Intern Med 2021; Published
online March 22, 2021
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2777845
Kutney-Lee A, Brooks Carthon M, Sloane DM, Bowles KH, McHugh MD, Aiken LH.
Electronic Health Record Usability: Associations With
Nurse and Patient Outcomes in Hospitals. Med Care 2021; Apr 1, 2021
Eschenroeder E, Manzione LC, Adler-Milstein J, et al. Associations of
physician burnout with organizational electronic health record support and
after-hours charting, Journal of the American Medical Informatics Association
2021; 28(5): 960-966
https://academic.oup.com/jamia/article/28/5/960/6242740
Print “May 2021 More on Time Spent on the EMR”
Several studies have found an increase in CLABSI’s (Central
Line-Associated Bloodstream Infections) during the COVID-19 pandemic. Patel et
al. (Patel
2021) used data reported to the Centers for Disease Control and Prevention’s
National Healthcare Safety Network (NHSN) in almost 3000 acute care
hospitals. They compared standard
infection ratios of CLABSI’s from April, May and June
of 2019 to the same period of 2020. They
found the rate of CLABSI’s increased from 0.68 in 2019 to 0.87 in 2020, an
increase of 28%. Critical care units experienced the highest increase at 39% (from
0.75 to 1.04), followed by ward locations at 13%.
Fakih et al. (Fakih 2021) also
used NHSN data to do a retrospective evaluation of CLABSI and CAUTI outcomes in
78 hospitals from a single healthcare system over 2 periods: before the
COVID-19 pandemic (March 2019–February 2020; 12 months) and during the COVID-19
pandemic (March–August 2020; 6 months). CLABSI rates increased by 51.0% during
the pandemic period from 0.56 to 0.85 per 1,000 line
days and by 62.9% from 1.00 to 1.64 per 10,000 patient days. Hospitals with
monthly COVID-19 patients representing >10% of admissions had a National
Health Safety Network (NHSN) device standardized infection ratio for CLABSI
that was 2.38 times higher than hospitals with <5% prevalence during the pandemic
period. In contrast, no significant changes were identified for CAUTI’s (0.86
vs 0.77 per 1,000 catheter days).
A number of factors have been
hypothesized as contributors to this increase in CLABSI rates. The frequency of
contact with patients may have changed during the pandemic in attempt to reduce
healthcare worker exposure to patients and to preserve personal protective
equipment. Patients admitted during the pandemic were more likely to require
critical care support and to need it for a longer period of
time, potentially putting them at greater risk for CLABSI. The
proportion of COVID-19 patients with CLABSI events was 5 times greater than for
non–COVID-19 patients during the pandemic period. The average time from
COVID-19 diagnosis to developing CLABSI was ∼18 days, indicating that the
CLABSI events occurred in COVID-19 patients with prolonged hospitalization.
Qualitative feedback from their infection prevention teams
reported changes to routine CLABSI prevention practices in ICUs, such as less
universal decolonization (eg, mupirocin
administration and chlorhexidine bathing), alterations in line care due to
intravenous pumps placed in hallways (eg, extension
tubing used and less bedside checks on lines), line and dressing integrity gaps
related to prone positioning of patients, opportunities in scrub-the-hub
compliance, and increases in line draws for blood cultures.
In addition, staffing changes responding to increased
patient volume on the units, such as the help of traveling clinicians not as
familiar with standard unit prevention practices, may have contributed.
They also noted that “line rounds”, which had been a routine
practice prior to the COVID-19 pandemic, often stopped during the COVID-19
pandemic period due to competing priorities. Those rounds had helped ensure
proper device selection, utilization, and bedside practices were being followed.
Line rounds are
something we advocate be performed on a daily basis to
reduce CLABSI’s (we also advocate “Foley rounds” daily to reduce CAUTI’s). During
those rounds we consider the continued “appropriateness” of such devices.
The above studies do not separate CLABSI’s due to traditional central
lines vs. peripherally inserted central lines (PICC’s). An important
milestone in reducing CLABSI’s was publication of the Michigan Appropriateness
Guide for Intravenous Catheters (MAGIC) (Chopra 2015), which provides evidence-based criteria for multiple types of
vascular access devices but especially focused on peripherally inserted central
catheter (PICC) use. Chopra and colleagues recently looked at whether
implementing MAGIC reduces complications (Chopra 2021). They used data from 52 Michigan hospitals. During the preintervention
period, the mean frequency of appropriate PICC use was 31.9% and the mean
frequency of complications was 14.7%. Following the intervention, PICC appropriateness
increased to 49.0% while complications decreased to 10.7%. Compared with patients
with inappropriate PICC placement, appropriate PICC use was associated with a
significantly lower odds of complications (OR 0.29), including a decrease in
CLABSI’s (OR 0.61). There were also decreases in occlusion (OR 0.25) and VTE
(OR 0.40).
Some of our other columns
on IV access, central venous catheters and PICC lines:
January 21, 2014 “The PICC Myth”
December 2014 “Surprise Central Lines”
July 2015 “Reducing Central Venous Catheter Use”
October 2015 “Michigan Appropriateness Guide for
Intravenous Catheters”
March 27, 2018 “PICC
Use Persists”
February 26, 2019 “Vascular
Access Device Dislodgements”
July 16, 2019 “Avoiding PICC’s in CKD”
March 2, 2021 “Barriers to Timely Catheter
Removal”
References:
Patel P, Weiner-Lastinger L, Dudeck M, et a;. Impact of
COVID-19 Pandemic on Central Line-Associated Bloodstream Infections During the
Early Months of 2020, National Healthcare Safety Network. Infection Control &
Hospital Epidemiology 2021; 1-8 Published online by Cambridge University
Press: 15 March 2021
Fakih MG, Bufalino A, Sturm L, et
al. Coronavirus disease 2019 (COVID-19) pandemic, central-line-associated
bloodstream infection (CLABSI), and catheter-associated urinary tract infection
(CAUTI): The urgent need to refocus on hardwiring prevention efforts. Infect
Control Hosp Epidemiol 2021; Published online 2021 Feb 19
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8007950/
Chopra V, Flanders SA, Saint S, et al. The Michigan
Appropriateness Guide for Intravenous Catheters (MAGIC): Results from a
Multispecialty Panel Using the RAND/UCLA Appropriateness Method. Ann Intern Med
2015; 163(6_Supplement): S1-S40
https://www.acpjournals.org/doi/10.7326/M15-0744?articleid=2436759&atab=7
Chopra V, O'Malley M, Horowitz J, et al. Improving
peripherally inserted central catheter appropriateness and reducing
device-related complications: a quasiexperimental
study in 52 Michigan hospitals. BMJ Quality & Safety 2021; Published Online
First: 29 March 2021
https://qualitysafety.bmj.com/content/early/2021/03/28/bmjqs-2021-013015
Print “May 2021 CLABSI’s Up in the COVID-19 Era”
Some solutions sound intuitive. But common sense doesn’t always pan out. When it comes to hand
hygiene, it is logical that transmission of infectious agents should be reduced
if you don’t have to touch various surfaces. But, is that borne out in practice?
Electronic faucets
are one such example. The idea is great. You don’t
have to touch the faucet to turn it on. It simply turns on when it senses the
presence of your hands beneath the faucet. In our May 2011 What's New in the
Patient Safety World column “The Best Laid Plans,,,Electronic
Water Faucet Paradox” we
noted that researchers at Johns Hopkins demonstrated 50% of electronic water
faucets grew Legionella species, compared to 15% of manual faucets. They felt
that the complex valve structure of the electronic faucets predisposed to
growth of Legionella. While some wanted more studies to confirm this finding,
Hopkins was so concerned that they removed 20 electronic faucets in patient
care areas and cancelled planned installation of about 1000 such faucets in a
new clinical building.
Now a new study questions use of high speed air dryers (Moura
2021). These are devices that blow warm or hot air over your hands to dry
them off after you wash them. Theoretically, if you don’t
have to touch the device, you would be less likely to get contamination
compared to touching a paper towel dispenser. Moura et al. used a bacteriophage
as a surrogate for bacterial pathogens and compared bacteriophage counts on
volunteers’ hands dried via high speed air dryers vs.
those dried by paper towels. The volunteers first cleansed their hands or
gloved hands in 70% alcohol gel, then immersed their hands in the study
solution containing the bacteriophage. The researchers then measured
bacteriophage levels not only on the volunteers’ hands, but also on their
clothing and on surfaces they might touch (eg.
stethoscope, arms of a chair, and several other surfaces).
Both the jet air dryer and the paper towel methods significantly
reduced bacteriophage contamination of the hands. But,
apron (simulated trunk or clothing) contamination by bacteriophage during hand
drying was significantly higher after jet air dryer use. The bacteriophage
levels detected on the volunteers’ hands at the end of the experiments
suggested gross persistence of bacteriophage contamination throughout the
sampling period.
Moreover, all 8 surfaces investigated following jet air
dryer use had bacteriophage contamination above the limit of detection, whereas
this occurred for only 5 surfaces after paper towel use. For all samples, there
was a significantly higher level of surface contamination following hand drying
with the jet air dryer than with paper towels. Samples obtained from smaller
surface areas, namely elevator and ward access buttons, showed lower
bacteriophage contamination. Interestingly, simulated use of a hospital phone
for 10 seconds resulted in detectable contamination only following jet air
dryer use. The average surface contamination following hand contact was
>10-fold higher after jet air dryer use than after paper towel use (4.1 log10
copies/µL versus 2.9 log10 copies/µL, respectively).
This, of course, is not the first study to warn of potential
contamination from high speed air dryers. Best et al.
(Best
2018) compared bacterial contamination levels in washrooms with hand-drying
by either paper towels (PT) or jet air dryer (JAD). Bacterial contamination was
lower in PT versus JAD washrooms. Total bacterial recovery was significantly
greater from JAD versus PT dispenser surfaces and significantly more bacteria
were recovered from JAD washroom floors. Multiple examples of significant
differences in surface bacterial contamination, including by fecal and antibiotic-resistant
bacteria, were observed, with higher levels in JAD versus PT washrooms. The
authors concluded that hand-drying method affects the risk of (airborne)
dissemination of bacteria in real-world settings.
The findings of these studies certainly question the use of
hand drying with jet air dryers in a hospital setting.
References:
Moura I, Ewin D, Wilcox M. From the hospital toilet to the
ward: A pilot study on microbe dispersal to multiple hospital surfaces
following hand drying using a jet air dryer versus paper towels. Infection
Control & Hospital Epidemiology 2021; 1-4
Published online 17 March 2021
Best E, Parnell P, Couturier J, et al. Environmental
contamination by bacteria in hospital washrooms according to hand-drying
method: a multicentre study. J Hosp Infect 2018; 100:
469-475
https://www.sciencedirect.com/science/article/pii/S0195670118303669
Print “May 2021 Another Hands-Free Unintended
Consequence”
We’ve done multiple columns on
problems created by use of fax in healthcare. But, it
just won’t go away! A recent opinion column in the Toronto Star (Singh
2021) serves as a reminder that fax machine use in healthcare just won’t
die!
The problem really is one of interoperability, or rather,
lack of interoperability. Singh notes that millions of medical records are
faxed in Ontario every month. He points out that doctors’ offices and hospitals
use various electronic medical record systems to document patients’ medical information,
but if they want to send a patient to a specialist or a prescription to a
pharmacy, they often need to print out the paperwork and fax it.
He compares that to the equivalent of drafting an email,
printing it out, and then mailing it to the recipient.
Moreover, Singh notes that about 20% of faxes sent on
traditional fax machines fail daily. That leads to many hours of unnecessary
work and inefficiency. That leads to errors, lost patient information, and slows
down the process of getting patients connected to the health care they need.
Beth Gerritsen, who did a Masters
thesis on fax usage in Ontario, notes that the COVID-19 pandemic has
exacerbated problems related to use of fax in healthcare (Gerritsen
2021). She notes that, before the pandemic, the healthcare system’s
reliance on the fax was embarrassing, but now it’s a
critical failure point for the entire system. Her work on fax usage in Ontario showed
that:
Gerritsen notes that, during the pandemic, clinicians
stepped up with a quick shift to virtual care in order to support patients but quality virtual care needs proper support from
digital infrastructure. She notes that a fax failure of a prescription or lab
order after a virtual visit critically impacts a patient and nobody should
experience a delay in a referral for specialty care because of a misdirected or
a failed fax transmission.
She goes on to discuss the steps Ontario needs to take to
move away from use of fax in healthcare.
Though both Singh and Gerritsen are discussing use of fax in
Ontario, the situation in the US is not much better. Yes, we are making strides
in improving interoperability but every hospital and physician’s office in the
US still relies on fax at least to some degree. Our January 16, 2018 Patient
Safety Tip of the Week “Just
the Fax, Ma’am” discussed a podcast on faxing in US doctors’ offices by Sarah
Kliff and colleagues on Vox’s “The Impact” series (Kliff 2017). And, even where hospitals and physician’s offices have
joined in regional healthcare information exchanges, other third parties that must
receive healthcare information (eg. insurers, home
care agencies, etc.) may not be included.
Our Patient Safety Tips of the Week for June 19, 2012 “More
Problems with Faxed Orders” and January 16, 2018 “Just
the Fax, Ma’am” outline many patient safety issues associated with use of
faxes.
It’s worth repeating
some of the caveats we raised in our June 19, 2012 Patient Safety Tip of the
Week “More
Problems with Faxed Orders” and other columns. The problem we have
mentioned most often is the missed
decimal point (where lines or smudge during fax transmission and printing
obscures a decimal point) and the patient receives a 10x overdose of the
medication. (In our September 9, 2008 Patient Safety Tip of the Week “Less
is More….and Do You Really Need that Decimal?” we cautioned against even
using a decimal point when the fraction following the decimal point is
clinically irrelevant because that decimal point may be overlooked, especially
in faxed orders.) The opposite, of course, may also occur where a smudge on the
fax looks like a decimal point (the
phantom decimal point) so the patient receives one-tenth the intended
amount.
But we’ve also mentioned the case where 2 sheets put into a fax machine stick
together and thus only one sheet gets transmitted (see our January 18, 2011
Patient Safety Tip of the Week “More
on Medication Errors in Long-Term Care” where we cited such an example from
ISMP 2010).
Unless you have a cover fax sheet that says “3 pages (cover sheet plus 2
others)” the receiving party may not realize that they are missing a page.
We’ve also seen cases where faxes on multiple patients are sent out at the same time and the
receiving party does not recognize that the second sheet is actually for a
different patient (see our January 18, 2011 Patient Safety Tip of the Week “More
on Medication Errors in Long-Term Care”).
Just as with handwritten orders, on a faxed order with a drug ending in the letter “L” if there
is insufficient space between the “L” and the next number, the receiver may
think the “L” is actually a “1” (one) and give a dose
10 times too high. And dangerous
abbreviations may show up even more frequently on faxed orders than orders
written on-site because the provider is more likely to have access to the “do
not use” abbreviation list when on-site.
Another mistake is when a person faxes documents that have
information on both sides and does not realize that only one side of each page is being faxed.
And remember when you are sending a fax that some elements (eg.
text in a different color) may fail to be seen when transmitted. Or that highlighted items (eg.
items you tied to stress with a yellow highlighter) may appear blacked out on the received fax! (Reminds
me of the time in college when I asked a friend to send me his notes from a class I had missed so I could study for a test the next day.
He faxed them and all the important stuff, which he had highlighted with a
highlighting marker, was blacked out on the fax!!!).
And one of the most egregious errors of all – faxing to the
wrong phone number (the misdirected fax).
Ever get a call from the local supermarket that you faxed them a sheet with PHI
on it? Your HIPAA compliance officer and risk manager will turn gray when that
call comes in! We’ve seen faxes sent to old fax
numbers after a physician has moved to a new office and even faxes sent to
physicians who have been deceased for four years! And hospital computer systems
often have the wrong physician listed as primary care physician, often leading
to faxes being sent to the wrong PCP.
ISMP Canada (ISMP
Canada 2012) came up with a new fax error – the truncation error. They provide a great example of a faxed order
for “dalteparin” where the “da” gets cut off in the
fax and the “lt” looks like an “H” on the fax,
resulting in what clearly looks like an order for “Heparin”. Click on the link
above and you’ll see both the faxed prescription and
the original.
Note that prescription has lots of other bad errors on it.
It uses the do-not-use abbreviation “U” (for units) as well as 2 other
abbreviations that should be avoided (“SQ” for subcutaneous and “QD” for once
daily). It has a different dose written above and crossed out. And it does not
have listed the indication for the drug. It also has an illegible word
following the “QD” (is it nitely? or is it a
provider’s signature?). And there is nothing on the prescription to indicate
the duration of therapy, amount to be dispensed, whether it should be refilled,
etc. Who would have thought one prescription could be used as a primer for
medication errors!
ISMP Canada notes the importance of reviewing copies of the
fax you send or the one you receive. For instance, in the case given one might
have noticed that the name of the hospital was also truncated, which might have
been a clue that the medication name was truncated. They also note in the example
given that the dosing frequency would have been unusual for heparin (it is
usually given twice daily or three times daily rather than once daily), perhaps
being another clue to the receiver that there was an error. They also note that
including both the generic and brand names on the prescription would have
provided another clue to the error. They note the importance of engaging the
patient to be on the lookout for errors as well.
We refer you back to our Patient Safety Tips of the Week for
June 19, 2012 “More
Problems with Faxed Orders” and January 16, 2018 “Just
the Fax, Ma’am” for our multiple recommendations on faxing issues.
Our January 2019 What's New in the Patient Safety World
column “Still
Faxing?” noted initiatives in the UK and the US to eliminate use of fax in
healthcare. But we are still not there. Both Singh and Gerritsen use the catchy
phrase “Axe the Fax”. It seems that, in politics, catchy 3-word phrases go a
long way. Maybe it’s time we all adopt “Axe the Fax”!
See our prior columns on problems related to use of fax in
healthcare:
June 19, 2012 “More
Problems with Faxed Orders”
January 16, 2018 “Just
the Fax, Ma’am”
September 2018 “ECRI
Institute Partnership: Closing the Loop”
January 2019 “Still
Faxing?”
References:
Singh P, Aggarwal S. We need to axe the fax in health care —
now. Toronto Star 2021; March 24, 2021
Gerritsen B. Axe the fax: A primer on fax tech in the 21st
century, an Ontario’s healthcare system perspective. Canadian Healthcare
Network. The Medical Post 2021
Kliff S, Pinkerton B, Weinberger
J, Drozdowska A. It’s 2017.
Why does medicine still run on fax machines? Vox “The
Impact” (podcast) 2017; October 30, 2017
https://www.vox.com/2017/10/30/16387306/american-medicine-healthcare-fax-machine
ISMP (Institute for Safe Medication Practices). Order
scanning systems (and fax machines) may pull multiple pages through the scanner
at the same time, leading to drug omissions. ISMP Medication Safety Alert
(Nurse Advise-ERR) 2010; 8(11): 1-2
http://www.ismp.org/newsletters/nursing/default.asp
ISMP Canada. ALERT:
Medication Mix-up with a Faxed Prescription. ISMP Canada Safety Bulletin 2012;
12(6): 1-3 June 5, 2012
Print “May 2021 Axe the Fax”
Print “May
2021 What's New in the Patient Safety World (full column)”
Print “May 2021 More on Time Spent on the EMR”
Print “May 2021 CLABSI’s Up in the COVID-19 Era”
Print “May 2021 Another Hands-Free Unintended
Consequence”
Print “May 2021 Axe the Fax”
Print “PDF
version”
http://www.patientsafetysolutions.com/
What’s New in
the Patient Safety World Archive