Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

November 2016

· Oxygen Tank Monitoring

· More on Safer Use of Oxygen

· AABB Updates Transfusion Guidelines Again

· C. Diff and Your Predecessor’s Room

Oxygen Tank Monitoring

We don’t endorse vendors or products in our columns. But we recently happened to come across an article written by a company COO that highlighted a type of product sorely needed.

In our September 1, 2015 Patient Safety Tip of the Week “Smarter Checklists” we were describing how we would develop a smart checklist for intrahospital transports. In that we included the following statement: “Conceivably, the amount of oxygen remaining in the oxygen cylinder might be populated in the checklist automatically via Bluetooth or other wireless technology.” That is because oxygen runs out in a substantial number of intrahospital transports (not just the transport but also the stay in the area to which the transport occurred, such as radiology). Because manually checking the gauge on the oxygen canister is often a forgotten step before transporting patients, it would be useful to have a technological tool that flags inadequate oxygen supplies.

Also, in our August 11, 2015 Patient Safety Tip of the Week “New Oxygen Guidelines: Thoracic Society of Australia and NZ” we noted that one of the items we often check on Patient Safety Walk Rounds is the status of oxygen cylinders wherever they may be stored. You’d be surprised how often we find used (empty or partially empty) oxygen cylinders interspersed with full ones. Obviously, that is a serious patient safety vulnerability since one can readily see how in an emergency someone might grab an empty cylinder thinking it is full of oxygen.

The article we recently came across (McSheffrey 2016) describes use of electronic notification technology to deliver real-time alerts about oxygen cylinder status. We have not done a search to see what other similar products might be out there. But it is nice to see that such potential safeguards are now available.

Nevertheless, we do have a couple caveats about use of such potential electronic notification technologies. One is that most rely on battery power (or at least battery backup) and batteries may run low (see our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?” for examples of problems that might arise when batteries run low). Another potential problem is that methods of electronic communication (Bluetooth, Wi-Fi, etc.) may not work in all locations. And, most importantly, complacency may become an issue in that staff may presume the oxygen cylinder is full because they have not received a notification that it is not.

But the capability of electronically conveying the status of oxygen cylinders is potentially very useful for patient safety purposes.

References:

McSheffrey M. Simplifying oxygen tank monitoring. Long Term Living Magazine. 2016; October 3, 2016

http://www.ltlmagazine.com/article/rehabtherapy/simplifying-oxygen-tank-monitoring

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More on Safer Use of Oxygen

We’ve long been advocates of using oxygen therapy wisely, using it only in patients with documented hypoxemia and titrating it to appropriate oxygenation targets without producing hyperoxemia. We’ve detailed in multiple columns the potential downsides of hyperoxemia (see list at the end of today’s column).

A new study (Girardis 2016) randomized ICU patients to “conventional” care (where oxygen therapy was used to achieve SpO2 levels 97-100%) or “conservative” oxygen therapy (where oxygen therapy was titrated to target SpO2 levels of 94-98%). ICU mortality in the conservative group was 11.6% compared to 20.2% in the conventional group, a relative risk reduction of 57% and absolute risk reduction of 8.6%! Total hospital mortality was also significantly lower in the conservative group. Patients in the conservative group also had fewer episodes of shock, liver failure, and bacteremia.

Sounds great, doesn’t it? While the reported results showed a lower ICU mortality for patients in the conservative group, various aspects of the study raise many questions, appropriately brought out in the accompanying editorial (Ferguson 2016). First of all, there were differences in the illness severity of patients at baseline, favoring the conservative group so some of the lower mortality in that group may have been due to lower severity of illness. Secondly, the trial was terminated early, purportedly because of difficulty recruiting patients and because the interim results so strongly favored the conservative group. Clinical trials that are terminated early tend to overestimate the treatment effect. Thirdly, the modified intention-to-treat analysis used excluded patients who were randomized but did not remain in the ICU for at least 72 hours and those who did not have at least one ABG analysis per day. And, though differences in deaths were statistically significant, the total number of deaths was small. And this was a single center study so generalization may not be appropriate.

Botom line: these results need to be validated in another (preferably multicenter) trial of sufficient size with appropriate randomization. But while we are waiting for such a study, we concur with the editorialist that careful titration of oxygen therapy to achieve physiologically normal levels and avoid hyperoxia makes sense.

Some of our prior columns on potential harmful effects of oxygen:

April 8, 2008 “Oxygen as a Medication”

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

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

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

July 2010 “Cochrane Review: Oxygen in MI”

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

February 2012 “More Evidence of Harm from Oxygen”

March 2014 “Another Strike Against Hyperoxia”

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

December 2014 “Oxygen Should Be AVOIDed”

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

References:

Girardis M, Busani S, Damiani E, et al. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care UnitThe Oxygen-ICU Randomized Clinical Trial. JAMA 2016; Online First October 5, 2016

http://jama.jamanetwork.com/article.aspx?articleid=2565306

Ferguson ND. Oxygen in the ICU. Too Much of a Good Thing? JAMA 2016; Published online October 05, 2016

http://jama.jamanetwork.com/article.aspx?articleid=2565302

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AABB Updates Transfusion Guidelines Again

We’ve done numerous columns over the years about the increasing evidence that more restrictive criteria for transfusions do not lead to worse outcomes for many or even most patient conditions and that transfusions may be associated with a variety of potential adverse effects. The AABB (American Association of Blood Banks) updated its guidelines on transfusion in 2012 (see our April 2012 What's New in the Patient Safety World column “New Transfusion Guidelines from the AABB”) to reflect the trending literature. Now the AABB has once again updated its transfusion guidelines after reviewing the updated literature for randomized controlled trials (RCT’s) dealing with transfusion criteria (Carson 2016).

The updated AABB guideline recommends two tiers of hemoglobin level transfusion triggers:

7 g/dL for hemodynamically stable adults, even those in critical care
8 g/dL for patients with preexisting cardiovascular disease or those undergoing cardiac or orthopedic surgery

The guidelines do not include any recommendations regarding patients with acute coronary syndromes, severe thrombocytopenia, or chronic transfusion–dependent anemia.

Interestingly, one point brought out in the discussion is that "standard practice should be to initiate a transfusion with 1 unit of blood rather than 2 units. This would have potentially important implications for the use of blood transfusions and minimize the risks of infectious and noninfectious complications”. That is of interest because one of the triggers historically used by transfusion committees to review cases for appropriateness was the use of a single unit of packed RBC’s rather than at least two units.

The other new recommendation has to do with the freshness of the RBC’s. It states that patients, including neonates, should receive RBC units selected at any point within their licensed dating period rather than limiting patients to transfusion of only fresh (storage length: <10 days) RBC units.

The Carson article also includes the evidence summary and has a nice table summarizing the odds of the various adverse effects of RBC transfusions.

In an accompanying editorial (Yazer 2016) Yazer and Triulzi remind us that good clinical practice dictates that the decision to transfuse should not be solely based on the hemoglobin level. They suggest that future studies look at inclusion of some sort of measure of tissue oxygenation to aid in the clinical decision about transfusion.

The Carson article includes the following Good Clinical Practice Statement: “When deciding to transfuse an individual patient, it is good practice to consider not only the hemoglobin level, but the overall clinical context and alternative therapies to transfusion. Variables to take into consideration include the rate of decline in hemoglobin level, intravascular volume status, shortness of breath, exercise tolerance, lightheadedness, chest pain thought to be cardiac in origin, hypotension or tachycardia unresponsive to fluid challenge, and patient preferences. This practice guideline is not intended as an absolute standard and will not apply to all individual transfusion decisions.”

Prior columns on potential detrimental effects related to red blood cell transfusions:

March 2011 “Downside of Transfusions in Surgery”
February 2012 “More Bad News on Transfusions”
January 2012 “Need for New Transfusion Criteria?”
April 2012 “New Transfusion Guidelines from the AABB”
February 2013 “More Evidence Favoring Restriction of Transfusions”
June 2013 “Hopkins Blood Ordering Initiative”
May 2014 “Blood Transfusion and Infection Risk”
June 2015 “Economics and Blood Transfusion”

References:

Carson JL, Guyatt G, Heddle NM, et al. Clinical Practice Guidelines from the AABB. Red Blood Cell Transfusion Thresholds and Storage. JAMA 2016; Published online October 12, 2016

http://jamanetwork.com/journals/jama/article-abstract/2569055

Yazer MH, Triulzi DJ. AABB Red Blood Cell Transfusion Guidelines. Something for Almost Everyone. JAMA 2016; Published online October 12, 2016

http://jamanetwork.com/journals/jama/fullarticle/2569053

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C. Diff and Your Predecessor’s Room

A recent study demonstrated that C. diff infections can occur even in patients who have not received antibiotics if the patient occupying their room previously had received antibiotics (Freedberg 2016). The authors found that subsequent patients were 22 percent more likely to develop C. diff infections if the patient who previously occupied their hospital bed had received antibiotics. It is likely that in patients colonized with C. diff, antibiotic use may increase proliferation of the bacterium, increasing the number of C. diff spores that make into the environment.

So what does this study mean in practical terms? Clearly, a patient is not going to be able to ask whether the previous occupant of that room received antibiotics (in fact, answering such question could probably be considered a HIPAA violation even if the name of that patient were not revealed in the answer!). And, while it could be considered an indictment of our inability to rid the environment of C. diff spores, the real implication is that we need more focus on antibiotic stewardship. See the list below of our prior columns on antibiotic stewardship.

Medscape recently had a succinct review by John Bartlett on both the evidence base for antibiotic stewardship practices and appropriate antibiotic prescribing practices for common outpatient conditions (Bartlett 2016). He cited the recent guidelines from the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America (Barlam 2016) which showed that of 23 antibiotic stewardship interventions reviewed only 5 should be considered endorsed recommendations with adequate supporting evidence:

Preauthorization and/or prospective audit with feedback;
Implementation of interventions designed to reduce the use of antibiotics with a high risk for Clostridium difficile infection;
Interventions to reduce antibiotic therapy to the shortest effective duration;
Implementation of pharmacokinetic monitoring with dose adjustment for aminoglycosides; and
Promotion of switching from intravenous to oral administration when clinically feasible.

Hopefully, the recent focus on antibiotic stewardship by CDC and CMS and The Joint Commission will begin to have an impact not only on C. diff infections but a whole host of adverse consequences of inappropriate antibiotic use.

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”
August 2016 “Some Reassurance on Antibiotic Stewardship”

References:

Freedberg DE, Salmasian H, Cohen B, et al. Receipt of Antibiotics in Hospitalized Patients and Risk for Clostridium difficile Infection in Subsequent Patients Who Occupy the Same Bed. JAMA Intern Med 2016; Published online October 10, 2016

http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2565687

Bartlett JG. Antibiotic Stewardship Priorities: Follow the Evidence. Medscape Infectious Disease 2016; October 12, 2016

http://www.medscape.com/viewarticle/870002?src=wnl_edit_tpal&uac=14695HV

Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America. Clin Infect Dis 2016; 62: e51-e77

http://cid.oxfordjournals.org/content/62/10/e51.full?sid=88b5b2fa-989f-4b15-9d02-8101b2760c30

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