In our April 2015 What’s
New in the Patient Safety World column “Pediatric
Dosing Unit Recommendations” we discussed the American Academy of
Pediatrics new Policy Statement on “Metric Units and the Preferred Dosing of Orally
Administered Liquid Medications” (AAP
2015). That new policy statement recommends switching to sole use of metric dosing, i.e.
strictly using milliliters for dosing of orally administered liquid medications
in children and infants. Use of measures such as “teaspoon” and “tablespoon”
should no longer be used. Moreover, it emphasizes that the correct abbreviation for milliliters is “mL” (rather than “ml”, “ML”, or “cc”). Dispensing devices are also critical. The statement recommends that
pharmacies, hospitals, and healthcare centers distribute appropriate-volume
milliliter-based dosing devices such as syringes. Another important point is
that the syringe (or other dosing device) should not be significantly larger
than the dose prescribed. It also recommends that manufacturers avoid labeling,
instructions or dosing devices that contain units other than metric units.
Several other organizations have concurred with these
recommendation and it should not just apply to pediatric patients.
Now a new national
alert has been issued that recommends hospitals replace medication dosage
cups that use units other than mL (NAN 2015). This
follows reporting of a fatal event to
the ISMP National Medication Errors Reporting Program in which a nurse confused
two dosing scales that appear on a plastic oral liquid dosing cup. In that
event drams were confused with mL, resulting in a fatal overdose of morphine.
Unfortunately, such cups are still available and it’s
possible they will be found in your healthcare facility. The alert recommends
that in their place you use available oral syringes that measure only in mL whenever
possible. If a dosing cup must be used, ideally it should allow measurement in
mL only.
References:
AAP (American Academy of Pediatrics). Committee on Drugs.
Policy Statement. Metric Units and the Preferred Dosing of Orally Administered
Liquid Medications. Pediatrics 2015; 135(4): 784-787; originally published
online March 30, 2015
http://pediatrics.aappublications.org/content/early/2015/03/25/peds.2015-0072.full.pdf
NAN (National Alert Network). Move toward full use of metric
dosing: Eliminate dosage cups that measure liquids in fluid drams. Use cups
that measure mL. NAN 2015; June 30, 2015
http://www.ismp.org/NAN/files/NAN-20150630.pdf
Print “September
2015 Alert: Use Only Medication Dosing Cups with mL Measurements”
It’s human nature to
think we are doing better at something than we really are when we don’t know
the data. A number of years ago we asked caregivers at a community hospital how
well they provided care for patients with acute MI. They weren’t really sure
because they sent most of their acute MI patients to a tertiary hospital. But
they thought most of their patients would have received percutaneous coronary
angioplasty within the prescribed timeframes. When they finally got around to requesting
the data from the tertiary hospital it turned out that almost none of the
patients got the angioplasty within the recommended timeframe, mainly because
of transport delays and delays on arrival. Their patient population would have
been much better off receiving thrombolytic therapy at the community hospital
before being transported to a tertiary hospital. Once the hospital recognized
this problem they began initiating thrombolytic therapy on-site and did a good
job achieving this therapy within the prescribed timeframes for most acute MI
patients. The problem was clearly one of lack of data availability and lack of
timely feedback on performance.
The same applies to
acute stroke care. A recent study from hospitals participating in the American
Heart Association’s “Get With The Guidelines” (GWTG)
program found that hospitals often overestimate their ability to deliver timely
tPA to patients treated with tPA
(Lin 2015).
Less than one third of all hospitals responding to a survey accurately identified
their door-to-needle (DTN) time performance. Respondents from hospitals in
middle- and low-performing hospitals in particular overestimated their DTN
performance.
The key message is
that to improve care you need to provide comparative provider performance data
routinely to caregivers.
There are many
factors that go into running successful stroke programs. We’ve discussed those
in the several prior columns listed at the end of today’s column. But there are
a few new considerations.
One important factor
is coming to a correct diagnosis of stroke. Prior to administering tPA we need to exclude certain
stroke “look-alikes” or “mimics” (eg. migraine,
post-ictal Todd’s paralysis, etc.). However, we may also fail to diagnosis
acute strokes in some patients. A recent study (Richoz 2015)
looked at acute stroke “chameleons” presenting to a university hospital
emergency department. They found that 2.1% of strokes were missed initially.
These were either misdiagnosed as other neurologic diseases (42%) or non-neurologic
diseases (17%) or as unexplained decreased level of consciousness (21%) or as
concomitantly present disease (19%). These strokes tended to be either very
mild or very severe. At 12 months patients with these “chameleons” tended to
have less favorable outcomes and higher mortality.
Another problem in
thrombolytic therapy for acute stroke was recently noted by Bordoehl
and colleagues (Brodoehl
2015). Because of the short
half-life of tPA, it should
be administered as a bolus followed by an immediate infusion. However, they
note that in clinical practice there are sometimes delays between the
application of the bolus and the start of the infusion. In addition,
interruptions of the infusion may occur. They found that even 1-minute delays
before the infusion is begun or interruptions of the infusion for more than
1-minute may affect serum tPA
concentrations. Their results strongly suggest avoiding bolus-infusion delays
by giving the bolus only when the infusion is ready. They went on to estimate the
dosing of a potential second bolus depending on the duration of the
delay/interruption to allow for the achievement of appropriate serum tPA concentrations. However, they
stress that clinical safety data are needed to recommend the application of a
second bolus.
Sustaining improvement is often difficult and another recent study illustrates the
difficulties encountered in sustaining some components of good stroke care. Perhaps
just as important as getting thrombolytic therapy to those eligible acute
stroke patients is prevention of complications of stroke, such as UTI’s,
pneumonia, and DVT. Williams and colleagues (Williams
2015) conducted a cluster-randomized
quality improvement trial, randomizing hospitals to quality improvement
training plus indicator feedback versus indicator feedback alone to improve
deep vein thrombosis (DVT) prophylaxis and dysphagia screening. DVT prophylaxis
improved more during the intervention period in the active intervention group
but this improvement was not sustained afterward. For improving dysphagia
screening quality improvement training was no better than feedback alone.
So, while we
encourage you to make the major changes noted in our columns below, we also use
the above examples to remind you that some of the other issues in stroke care
also impact the outcomes for your patients.
Some of our previous columns on improving stroke care:
November 6,
2012 “Using
LEAN to Improve Stroke Care”
March 18, 2014 “Systems
Approach Improving Stroke Care”
September 23, 2014 “Stroke
Thrombolysis: Need to Focus on Imaging-to-Needle Time”
January 27, 2015 “The
Golden Hour for Stroke Thrombolysis”
May 12, 2015 “More
on Delays for In-Hospital Stroke”
June 2015 “Too
Much of a Good Thing? Very Early Mobilization in Stroke”
References:
Lin CB, Cox M, Olson DM, et al. Perception versus actual
performance in timely tissue plasminogen activation administration in the management
of acute ischemic stroke. Journal of the American Heart Association 2015; DOI:
10.1161/JAHA.114.001298
http://jaha.ahajournals.org/content/4/7/e001298.abstract
Richoz B, Hugli O, Dami F, et al. Acute stroke chameleons in a university
hospital: Risk factors, circumstances, and outcomes. Neurology 2015; 85:
505-511; published ahead of print July 15, 2015
http://www.neurology.org/content/85/6/505.abstract?etoc
Brodoehl S, Günther
A, Witte OW, Klingner CM. How to Manage Thrombolysis
Interruptions in Acute Stroke? Clinical Neuropharmacology 2015; 38(3): 85-88
Williams L, Daggett V, Slaven JE,
et al. A cluster-randomised quality improvement study
to improve two inpatient stroke quality indicators. BMJ Qual Saf 2015;
published online 24 August 2015 doi:10.1136/bmjqs-2015-004188
http://qualitysafety.bmj.com/content/early/2015/08/24/bmjqs-2015-004188.short?g=w_qs_ahead_tab
Print “September
2015 Stroke: Doing Less Well Than You Think?”
We’ve done numerous columns discussing the role of fatigue
in healthcare. We’ve also done numerous columns discussing the conflicting
studies on the impact of resident work hour restrictions on patient outcomes,
noting that overall there does not seem to be an impact of such restrictions in
either direction. We’ve always suspected that any improvement due to reduction
of resident fatigue is offset by the increased number of handoffs and reduction
of continuity of care.
But most of the literature has focused on residents and
training programs rather than attending physicians. Therefore, a new study from
Ontario, Canada sheds important light on the impact on patient outcomes when
their attending surgeon has performed late night surgery the previous night. The
Canadian researchers (Govindarajan 2015)
were able to use administrative (billing) data to identify cases in which a
surgeon likely performed one or more procedures after midnight and then performed
another surgery the next day. They then created a control group matched for the
same surgeon and type of procedure and adjusted for other clinical variables.
They essentially found no significant difference in outcomes between the two
groups for the primary outcome (a composite of death, complications, and
readmission within 30 days) or a number of secondary measures.
The study is limited in that the researchers did not know
whether surgeons may have cancelled some cases voluntarily if they felt fatigued
after a late night surgery or had lightened their elective schedule in
anticipation of night call. They also had no measure of the actual hours of
sleep a surgeon may have had the prior day/night. It also is limited by the use
of administrative billing data to identify time of surgery. Nevertheless, the
study included almost 39,000 patients operated on by 1448 attending surgeons
and included data from 12 of the most commonly performed surgical procedures.
We think their conclusion that the risks of adverse outcomes for elective
daytime procedures were similar whether the surgeon had provided medical
services the previous night is likely valid.
Note that this is a very different question from one we have
addressed on numerous occasions. Several of our columns have questioned whether
surgery should be done “after hours”, particularly for procedures that may not
be true emergency ones (see our What’s
New in the Patient Safety World columns for September 2009 “After-Hours
Surgery – Is There a Downside?”, October
2014 “What
Time of Day Do You Want Your Surgery?”, December 2014 “Another
Procedure to Avoid Late in the Day or on Weekends” and January 2015 “Emergency
Surgery Also Very Costly”).
In those columns we
have pointed out that such surgeries and procedures involve considerations far
beyond just the surgeon. Why should “after hours” surgery be more prone to
adverse outcomes than regularly scheduled elective surgery? There are many
reasons aside from the fact that patients needing emergency and after hours
surgery are generally sicker. You are operating with a team that is likely
different from your daytime team. All members of that team (physicians, nurses,
anesthesiologists, techs, etc.) may not have the same level of expertise as
your regular daytime team and the team dynamics between members is likely to be
different. The post-surgery recovery unit is likely to be staffed much
differently after-hours as well. The staff may be more likely to be unfamiliar
with things like location of equipment. And some of the other hospital support
services (eg. radiology, laboratory) may have lesser
staffing after-hours. Just as importantly, many or all of the “on-call” staff
that make up the after-hours surgical team have likely worked a full daytime
shift that day so fatigue enters as a potential contributory factor. And there
are always time pressures after hours as well. In addition, one of the most
compelling reasons surgery is done at night rather than deferred to the next
morning is the schedule of the surgeon or other physician for that next morning
(either in surgery or the cath lab or his/her
office). Because the surgeon does not want to disrupt that next day schedule,
he/she often prefers to go ahead with the current case at night. Similarly,
many hospitals run very tight OR schedules and adding a case from the previous
night can disrupt the schedule of many other cases.
The current Canadian
study is reassuring in that outcomes for the “next day” case do not seem to be
adversely impacted by the surgeon’s previous night procedures. But it does not
address outcomes of the cases done the previous night.
We highly recommend
hospitals take a hard look at surgical cases done “after hours”. In particular,
you need to determine which cases truly needed to be done after hours and,
perhaps more importantly, which ones could have and should have been done
during “regular hours”. If the latter are significant, you need to consider
system changes such as reserving some “regular hours” for such cases to be done
the following morning. You may have to alter the scheduling of cases for
individual surgeons as well. For example, perhaps the surgeon on-call tonight
should not have elective cases scheduled tomorrow morning. That way, if a case
comes in tonight that should be done tomorrow morning you will have both a
“free” OR room and a “free” surgeon. And you would need to develop a list of
criteria to help you triage cases into “regular” or “after-hours” time slots.
Some of our previous
columns on the “weekend effect”
or “after-hours effect”:
·
February 26, 2008 “Nightmares….The
Hospital at Night”
·
December 15, 2009 “The
Weekend Effect”
·
July 20, 2010 “More
on the Weekend Effect/After-Hours Effect”
·
October 2008 “Hospital
at Night Project”
·
September 2009 “After-Hours
Surgery – Is There a Downside?”
·
December
21, 2010 “More
Bad News About Off-Hours Care”
·
June
2011 “Another
Study on Dangers of Weekend Admissions”
·
September
2011 “Add
COPD to Perilous Weekends”
·
August
2012 “More
on the Weekend Effect”
·
June
2013 “Oh
No! Not Fridays Too!”
·
November
2013 “The
Weekend Effect: Not One Simple Answer”
·
August
2014 “The
Weekend Effect in Pediatric Surgery”
·
October
2014 “What
Time of Day Do You Want Your Surgery?”
·
December
2014 “Another
Procedure to Avoid Late in the Day or on Weekends”
·
January
2015 “Emergency
Surgery Also Very Costly”
·
May 2015
“HAC’s
and the Weekend Effect”
·
August
2015 “More
Stats on the Weekend Effect”
Some of our other columns on the role of fatigue in
Patient Safety:
November 9, 2010 “12-Hour
Nursing Shifts and Patient Safety”
April 26, 2011 “Sleeping
Air Traffic Controllers: What About Healthcare?”
February 2011 “Update
on 12-hour Nursing Shifts”
September 2011 “Shiftwork
and Patient Safety
November 2011 “Restricted
Housestaff Work Hours and Patient Handoffs”
January 2010 “Joint
Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety
January 3, 2012 “Unintended
Consequences of Restricted Housestaff Hours”
June 2012 “June
2012 Surgeon Fatigue”
November 2012 “The
Mid-Day Nap”
November 13, 2012 “The
12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The
12-Hour Nursing Shift: Debate Continues”
October 2014 “Another
Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA
Position Statement on Nurse Fatigue”
August 2015 “Surgical
Resident Duty Reform and Postoperative Outcomes”
Some of our other columns on housestaff
workhour restrictions:
December 2008 “IOM
Report on Resident Work Hours”
February 26, 2008 “Nightmares:
The Hospital at Night”
January 2010 “Joint
Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety
January 2011 “No
Improvement in Patient Safety: Why Not?”
November 2011 “Restricted
Housestaff Work Hours and Patient Handoffs”
January 3, 2012 “Unintended
Consequences of Restricted Housestaff Hours”
June 2012 “Surgeon
Fatigue”
November 2012 “The
Mid-Day Nap”
December 10, 2013 “Better
Handoffs, Better Results”
April 22, 2014 “Impact
of Resident Workhour Restrictions”
January 2015 “More
Data on Effect of Resident Workhour Restrictions”
August 2015 “Surgical
Resident Duty Reform and Postoperative Outcomes”
References:
Govindarajan A, Urbach DR, Kumar M, et al. Outcomes of Daytime Procedures
Performed by Attending Surgeons after Night Work. N Engl
J Med 2015; 373: 845-853
http://www.nejm.org/doi/full/10.1056/NEJMsa1415994
Print “September
2015 Surgery Previous Night Does Not Impact Attending Surgeon Next Day”
APIC (Association for Professionals in Infection Control and
Epidemiology) has published its updated guide to hand hygiene (APIC
2015). The guide begins with an overview summarizing the scientific
evidence for hand hygiene in infection control. It also lists hand hygiene
elements required by regulatory and accrediting bodies. It has a good section
on hand hygiene products, including details about both ingredients and
formulations and also delivery systems. The section on monitoring hand hygiene
compliance covers direct observation, measuring product usage, and newer
electronic or hi-tech methods but also notes the importance of timing of the
monitoring to actually impact compliance. But the best sections are those on
implementing multimodal hand hygiene programs and changing culture. These
include elements regarding access to hand hygiene products, workflow
considerations, supply chain issues, role of management, leadership, integration
with organizational goals, educational and training issues, and more. A whole section
is dedicated to strategies for behavior change. The APIC guide is well
referenced and includes links to many valuable resources and tools.
Sharp Healthcare has a new video on hand hygiene that is quite
good. Links to some hand hygiene videos we’ve used in the past can be found in
our May 24, 2011 Patient Safety Tip of
the Week “Hand
Hygiene Resources”.
But our favorite video on HAI’s and hand washing is still the
one done by the Penn State Hershey Medical
Center Infection Control Team. This also sends a powerful message
that is likely to be remembered. Its semi-animated format also introduces a bit
of levity that makes this one an ideal video to be shown to patients and
families as well.
Some of our other
columns on handwashing:
January 5, 2010
“How’s
Your Hand Hygiene?”
December 28, 2010 “HAI’s:
Looking In All The Wrong Places”
May 24, 2011 “Hand
Hygiene Resources”
October 2011 “Another
Unintended Consequence of Hand Hygiene Device?”
March 2012 “Smile…You’re
on Candid Camera”
August 2012 “Anesthesiology
and Surgical Infections”
October 2013 “HAI’s:
Costs, WHO Hand Hygiene, etc.”
November 18, 2014 “Handwashing
Fades at End of Shift, ?Smartwatch to the Rescue”
January 20, 2015 “He
Didn’t Wash His Hands After What!”
References:
APIC (Association for Professionals in Infection Control and
Epidemiology). Guide to Hand Hygiene Programs for Infection Prevention (2015).
http://www.apic.org/Professional-Practice/Implementation-guides#HandHygiene
Sharp HealthCare. "It's OK to Ask" (video)
Penn State Hershey Medical Center Infection Control Team/McGuckinMethodsIntl.
Healthcare Worker Hand Hygiene Educational Training Video.
http://www.youtube.com/watch?v=LvRP3c5n3P8
Print “September
2015 APIC’s New Guide to Hand Hygiene Programs”
Print “September
2015 What's New in the Patient Safety World (full
column)”
Print “September
2015 Alert: Use Only Medication Dosing Cups with mL Measurements”
Print “September
2015 Stroke: Doing Less Well Than You Think?”
Print “September
2015 Surgery Previous Night Does Not Impact Attending Surgeon Next Day”
Print “September
2015 APIC’s New Guide to Hand Hygiene Programs”
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