Print “PDF version”
What’s New in the
Patient Safety World
October 2022
· Physician Burnout and Patient Safety
· Preventing Unrecognized Esophageal Intubation
· How Safe Are Wheelchairs?
· Portable Oxygen and Ambulance Fire
Physician Burnout
and Patient Safety
Burnout has become a major problem among all healthcare professionals. And burnout is a patient safety issue because several studies have shown burnout is associated with more frequent patient safety events and other quality of care issues. And the prevalence of burnout has accelerated significantly in the COVID-19 era. A survey of US physicians found that 62.8% of physicians had at least one manifestation of burnout in 2021 compared with 38.2% in 2020 (Shanafelt 2022). This trend was consistent across nearly all specialties, though there was substantial variability by specialty. Satisfaction with work-life integration declined from 46.1% in 2020 to 30.2% in 2021. Mean scores for depression increased a modest 6.1%, suggesting to the authors that the increase in physician distress was overwhelmingly work-related.
In our August 2018
What's New in the Patient Safety World column “Burnout
and Medical Errors” we noted a
study published in the Mayo Clinic Proceedings (Tawfik
2018) showed that physicians
reporting symptoms of burnout were more than twice as likely to have reported a
major medical error in the prior 3 months. Now a systematic review and
meta-analysis (Hodkinson
2022) also found that physician burnout doubled patient safety incidents compared
with no patient safety incidents. Hodkinson et al. found that burnout in
physicians was associated with an almost four times decrease in job
satisfaction compared with increased job satisfaction (odds ratio 3.79) and
that turnover intention also increased by more than threefold compared with
retention (odds ratio 3.10). Burnout and patient safety incidents were greatest
in physicians aged 20-30 years, and people working in emergency medicine.
The editorial accompanying the Hodkinson study (Weigl 2022) notes that work design and organization level interventions are often neglected but are the key to meaningful progress on burnout.
Another survey of over 1300 US physicians (Menon 2020) found that each standard deviation-unit increase in burnout was associated with an increase in self-reported medical errors (OR, 1.48).
Of course, burnout and its relationship to medical errors is not limited to physicians. Melnyk et al. (Melnyk 2021), in a survey of critical care nurses, found that nurses in poor physical and mental health reported significantly more medical errors than nurses in better health. Nurses who perceived that their worksite was very supportive of their well-being were twice as likely to have better physical health. Their findings suggest that the worksite environment impacts burnout and can lead to more medical errors.
Some of our prior columns on “burnout”:
- August 2018 “Burnout
and Medical Errors”
- October 16, 2018 “Burnout”
- February 9, 2021 “Nursing Burnout”
- May 2021 “More on Time Spent on
the EMR”
References:
Shanafelt TD, West CP, Dyrbye LN, et al. Changes in Burnout and Satisfaction With Work-Life Integration in Physicians Over the First 2 Years of the COVID-19 Pandemic. Mayo Clinic Proceedings 2022; September 13, 2022
https://www.mayoclinicproceedings.org/article/S0025-6196(22)00515-8/fulltext#articleInformation
Tawfik DS, Profit J, Morgenthaler TI, et al. Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors. Mayo Clinic Proceedings 2018; 93(11): 1571-1580 Published online: July 9, 2018
https://www.mayoclinicproceedings.org/article/S0025-6196(18)30372-0/fulltext
Hodkinson A, Zhou, A, Johnson J, Geraghty K, Riley R, Zhou A et al. Associations of physician burnout with career engagement and quality of patient care: systematic review and meta-analysis. BMJ 2022; 378: e070442
https://www.bmj.com/content/378/bmj-2022-070442
Weigl M. Physician burnout undermines safe healthcare. BMJ 2022; 378: o2157
https://www.bmj.com/content/378/bmj.o2157
Menon NK, Shanafelt TD, Sinsky CA, et al. Association of Physician Burnout With Suicidal Ideation and Medical Errors. JAMA Netw Open 2020; 3(12): e2028780
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2773831
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2773777
Melnyk BM, Tan A, Hsieh AP, et al. Critical Care Nurses’ Physical and Mental Health, Worksite Wellness Support, and Medical Errors. Am J Crit Care 2021; 30 (3): 176-184
Print “October 2022 Physician Burnout and Patient
Safety”
Preventing
Unrecognized Esophageal Intubation
Because preventable mortality and serious morbidity from
unrecognized esophageal intubation continue to occur worldwide, a group of
medical specialty societies came together to publish a new guideline.
Unrecognized esophageal intubation
results in profound hypoxemia, brain injury and death. Such events occur in the
hands of both inexperienced and experienced practitioners. The new guideline (Chrimes
2022) focuses on both prevention of
esophageal intubation and prompt recognition and correction when it does occur.
“The detection of ‘sustained exhaled carbon dioxide’ using waveform capnography is the mainstay for excluding esophageal placement of an intended tracheal tube. Tube removal should be the default response when sustained exhaled carbon dioxide cannot be detected.”
The guideline also focuses on strategies to address cognitive biases and the deterioration of individual and team performance in stressful situations, to which all practitioners are vulnerable.
Key recommendations in the guideline:
· Exhaled carbon dioxide monitoring and pulse oximetry should be available and used for all episodes of airway management.
· Routine use of a videolaryngoscope is recommended whenever feasible.
· At each attempt at laryngoscopy, the airway operator is encouraged to verbalize the view obtained.
· The airway operator and assistant should each verbalize whether ‘sustained exhaled carbon dioxide’ and adequate oxygen saturation are present.
· Inability to detect sustained exhaled carbon dioxide requires esophageal intubation to be actively excluded.
· The default response to the failure to satisfy the criteria for sustained exhaled carbon dioxide should be to remove the tube and attempt ventilation using a facemask or supraglottic airway.
· If immediate tube removal is not undertaken, actively exclude esophageal intubation: repeat laryngoscopy, flexible bronchoscopy, ultrasound and use of an esophageal detector device are valid techniques.
· Clinical examination should not be used to exclude esophageal intubation.
· Tube removal should be undertaken if any of the following are true:
o Esophageal placement cannot be excluded
o Sustained exhaled carbon dioxide cannot be restored
o Oxygen saturation deteriorates at any point before restoring sustained exhaled carbon dioxide
· Actions should be taken to standardize and improve the distinctiveness of variables on monitor displays.
· Interprofessional education programs addressing the technical and team aspects of task performance should be undertaken to implement these guidelines.
References:
Chrimes N, Higgs A, Hagberg .A, et al. Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies*. Anaesthesia 2022; First published: 17 August 2022
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15817
Print “October 2022 Preventing Unrecognized
Esophageal Intubation”
How Safe Are
Wheelchairs?
Here’s an issue we haven’t even thought about before – how safe are wheelchairs? The Pennsylvania Patient Safety Authority has issued a safety alert about wheelchairs (PPSA Alert 2022). While we all probably recognize that patients may fall when getting into or out of wheelchairs, PPSA found that other injuries can result from wheelchairs being unfolded. These can affect patients, visitors, volunteers, or staff.
The alert describes the injuries as:
· Cuts
· Loss of nails
· Broken bones
· Crushing injuries
· Loss of fingers
In an article accompanying the PPSA alert (Quesenberry 2022), Molly Quesenberry notes “it is imperative that staff using this equipment, or any other type of equipment, receive education and training on it prior to patient use.” She cautions that, at the time of purchase, it is important to obtain instructions for the produce and users should read the instruction manual before using the wheelchair. While we do this for what we perceive as more complicated pieces of medical equipment, it is just as important we do this for wheelchairs.
She also cautions that folding wheelchairs should not be kept in unsupervised public areas, such as commonly done in hospital entrances. Instead, only non-folding rigid-frame wheelchairs should be kept there.
PPSA has also an excellent 4-minute YouTube video on “The Hidden Risks of Wheelchair Use”. It notes that some wheelchairs come with tags warning about the risks of these chairs and recommends these tags be kept on the wheelchairs.
References:
Pennsylvania Patient Safety Authority. Safety Alert. Wheelchair-Related Harm. 2022
https://patientsafetyj.com/index.php/patientsaf/article/view/wheelchair-risks/safety-alert
Quesenberry ML. The Hidden Risk of Wheelchair Use. Patient Safety 2022; 4(3): 6-9
https://patientsafetyj.com/index.php/patientsaf/article/view/wheelchair-risks
Pennsylvania Patient Safety Authority. The Hidden Risks of Wheelchair Use. YouTube video 2022
https://www.youtube.com/watch?v=od1ECM5pWA4
Print “October 2022 How Safe Are Wheelchairs?”
Portable Oxygen
and Ambulance Fire
(Adams 2022a). Though the investigation into the accident is still ongoing, preliminary reports suggest that a spark allowed the fire to spread in an oxygen-rich environment. Photos and videos of the event show flames coming from inside the ambulance cabin rather than near the ambulance’s engine (Jedra 2022).
An official said the fire likely started when the patient's source of oxygen was switched to a portable oxygen cylinder (Adams 2022b). It was reported that "there was a sound described as a pop followed by a bright flash of light, with the back of the ambulance was filling with smoke and fire." In the ambulance, prior to the blaze, the patient was using a CPAP device connected to oxygen supplied via the main oxygen tank on the ambulance. The patient was switched to a portable oxygen tank as the ambulance approached the hospital, which is apparently “standard practice”.
Quite frankly, we’re surprised such fires have not occurred more frequently. In the ambulance you often have an oxygen-rich environment confined to a relatively small, closed space. Most patients are not intubated and the oxygen is often administered via face mask, so that oxygen typically leaks into the air. Almost anything that can cause a spark, including defibrillator paddles, could trigger a fire in an oxygen-rich environment.
It turns out that, maybe such ambulance fires are more common than we knew. The Jedra article cites news reports of ambulance fires in recent years in many places, including North Carolina, Massachusetts, Maryland, Mississippi, New York, New Jersey, Texas, Virginia, and more than once in California. Officials have cited engine trouble, electrical issues and other mishaps in those cases. In most of these the cause of the fire was not determined but, in several, oxygen cylinders were said to explode.
In the New York incident, an ambulance that had been idling by a maintenance bay had caught fire, and then tanks of compressed oxygen inside the burning ambulance blew up, sending shrapnel hurtling through the air in a 100-foot radius.
We’ll never know what actually caused the fire in the Hawaii incident. But perhaps the “standard practice” of switching from the ambulance’s oxygen source to a portable oxygen cylinder might need to be reviewed. Maybe the oxygen cylinder would be better accessed outside the ambulance. However, the Hawaii incident should lead to all organizations operating ambulances (including air ambulances) to assess their risks and vulnerabilities with regard to oxygen and oxygen cylinders.
References:
Adams A. Patient Dies, Paramedic Seriously Hurt After Ambulance Mysteriously Catches Fire in Hospital Driveway. At a Wednesday night press conference, an official said the ambulance "possibly" exploded. People 2022; Published on August 25, 2022
Jedra C. Oxygen Tanks May Have Caused Honolulu Ambulance Fire to Spread Faster, Experts Say. Honolulu Civil Beat 2022; September 2, 2022
Adams A. Portable Oxygen Tank Likely Caused Ambulance Fire Outside Hospital That Killed Patient. Yahoo News 2022; September 16, 2022
https://www.yahoo.com/entertainment/portable-oxygen-tank-likely-caused-213339274.html
Print “October 2022 Portable Oxygen and Ambulance
Fire”
Print “October
2022 What's New in the Patient Safety World (full column)”
Print “October 2022 Physician Burnout and Patient
Safety”
Print “October 2022 Preventing Unrecognized
Esophageal Intubation”
Print “October 2022 How Safe Are Wheelchairs?”
Print “October 2022 Portable Oxygen and Ambulance
Fire”
Print “PDF
version”
http://www.patientsafetysolutions.com/
What’s New in
the Patient Safety World Archive