What’s New in the Patient Safety World
September 2016
· More on Preventing HAI’s
· Too Much of a Good Thing?
· American College of Surgeons Statement on Operating Room Attire
· Adverse Events in Rehab Facilities
More on Preventing
HAI’s
Two recent studies done on specialized patient populations identified combinations of interventions that were able to reduce hospital-acquired infections (HAI’s) by over 50%. The first study utilized a bundle of evidence-based interventions in patients undergoing spine surgery (discectomy, decompression, spinal augmentation or spinal fusion) and found surgical site infections declined by 50% after implementation (. Components of the “bundle” were:
- screening for Staphylococcus aureus nasal colonization and
decolonization with mupirocin
- self-preparation bath with chlorhexidine gluconate
- self-preparation with chlorhexidine gluconate wipes
- storage optimization of operating room supplies
- preoperative antibiotic administration algorithm
- staff training on betadine scrub and paint
- intrawound vancomycin in instrumented cases
- postoperative early patient mobilization
- wound checks at 2 and 6 weeks postoperatively
The number needed to
treat (NNT) to prevent one infection was 47 patients. In addition to the 50
percent decline in SSIs there was an $866 cost reduction per case.
The second study involved ventilator patients in patients in neurointensive care units and found an HAI reduction of 53% over an 18 month period. The two main interventions were (1) reducing the number of intrahospital transports and (2) reducing the number of urinary catheters. The primary way intrahospital transports was reduced was by the introduction of a mobile CT scanner so that patient needing frequent brain imaging could have the imaging done in the neuro ICU rather than being transported to the CT suite. Reduction in urinary catheters was accomplished by daily assessment of the continued need for such catheters, plus staff re-education on insertion and maintenance techniques plus introducing a new Foley kit that simplified and standardized the sterile insertion process Ventilator-associated events decreased 48 %, Foley use decreased 46 %, CAUTIs decreased from 11 per 1000 catheter days to 6.2.
Given our multiple
columns on adverse events occurring in the Radiology suite (see full list below
but in particular see our October 22, 2013 Patient Safety Tip of the Week “How
Safe Is Your Radiology Suite?”) we would be interested to see if the
reduction in transports to Radiology also resulted in fewer overall adverse
events of other types. That may well have been the case since they also found
overall complication rate decreased 55 %, ICU length of stay decreased an
average of 1.5 days, and risk-adjusted mortality decreased 11%.
Lastly, back to one of the most important interventions to reduce HAI’s: good hand hygiene. We often have difficulty convincing our healthcare workers (particularly our physicians) that better compliance with hand hygiene actually translates to fewer HAI’s. That is especially a problem where levels of compliance with hand hygiene are already relatively high. Well, a recent study in CDC’s Emerging Infectious Diseases journal should bolster your argument. Researchers from UNC Chapel Hill
Some of our prior columns on patient safety issues in the radiology suite:
- October 16, 2007 “Radiology as a Site at High-Risk for Medication Errors”
- February 19, 2008 “MRI
Safety”
- September 16, 2008 “More on Radiology as a High Risk Area”
- October 7, 2008 “Lessons
from Falls....from Rehab Medicine”
- October 2008 “Preventing Infection in MRI”
- March 17, 2009 “More on MRI Safety”
- March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”
- August 11, 2009 “The Radiology Suite…Again!”
- January 2010 “Falls
in the Radiology Suite”
- August 2010 “Sedation
Costs for Pediatric MRI”
- January 25, 2011 “Procedural
Sedation in Children”
- February 1, 2011 “MRI Safety Audit”
- October 25, 2011 “Renewed Focus on MRI Safety”
- March 13, 2012 “Medical Emergency Team Calls to Radiology”
- August 2012 “Newest
MRI Hazard: Ingested Magnets”
- October 22, 2013 “How
Safe Is Your Radiology Suite?”
- February 25, 2014 “Joint
Commission Revised Diagnostic Imaging Requirements”
- July 2014 “New
MRI Risks: for Staff!”
- July 1, 2014 “Interruptions
and Radiologists”
- November 2014 “More
Radiologist Interruptions”
- October 21, 2014 “The
Fire Department and Your Hospital”
- August 25, 2015 “Checklist
for Intrahospital Transport”
- March 22, 2016 “Radiology
Communication Errors May Surprise You”
- August 2016 “Guideline
Update for Pediatric Sedation”
Our other columns on urinary catheter-associated UTI’s:
- May 8, 2007 Tip of the Week “Doctor, when do I get this red rubber hose removed?”
- January 8, 2008 Tip of the Week “Urinary Catheter-Associated Infections”
- April 2008 What’s New in the
Patient Safety World column “More
on Nosocomial UTI’s”
- June 24, 2008 Tip of the Week “Urinary Catheter-Related UTI’s: Bladder Bundles”
- April 21, 2009 Tip of the Week “Still Futzing with Foleys?”
- June 9, 2009 Tip of the Week “CDC Update to the Guideline for Prevention of CAUTI”
- March 2010 “IDSA
CAUTI Guidelines”
- February 2011 What’s New in the Patient Safety World column “Catheters Not Needed in C-Sections?”
- January 2012 “CAUTI’s
Still Get No Respect”
- May 2012 “Foley
Catheter Hazards”
- November 2012 “CAUTI
Conundrum”
- December 18, 2012 “Unintended
Consequences of the CAUTI Measure?”
- January 2013 “Silver-Coated
Urinary Catheters Don’t Reduce CAUTI’s”
- June 2013 “Barriers
to CAUTI Prevention”
- November 2013 “Further
Reducing Urinary Catheter Use”
- June 2014 “Updated
HAI Prevention Guidelines from SHEA/IDSA”
- June 30, 2015 “What
Are Appropriate Indications for Urinary Catheters?”
- December 2015 “CAUTI
Prevention Tools”
- July 2016 “Holy
Moly, My Patient has a FOLEY!”
Some of our other columns on handwashing and hand hygiene:
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!”
September 2015 “APIC’s
New Guide to Hand Hygiene Programs”
November 2015 “Hand
Hygiene: Paradoxical Solution?”
April 2016 “Nudge:
An Example for Hand Hygiene”
August 2016 “Hand
Hygiene: Who’s Watching? Does it Matter?”
References:
Implementation of an Infection Prevention Bundle to Reduce Surgical Site Infections and Cost Following Spine Surgery. JAMA Surgery 2016; Online First July 20, 2016
http://archsurg.jamanetwork.com/article.aspx?articleid=2534130
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2016 More on Preventing HAI’s”
Too Much of a Good
Thing?
We all assume that ICU’s are good things and that you’ll receive better and safer care in an ICU almost regardless of what your medical problem is. But a new study challenges that assumption. Researchers from the University of Michigan (Valley 2016) analyzed data from Medicare’s Hospital Compare database and found that hospitals with high ICU use for patients with acute MI or CHF exacerbation often had higher mortality rates and lower rates of using evidence-based testing and treatments. For example, MI patients in high ICU use hospitals were less likely to receive aspirin on arrival. MI patients treated in high-ICU hospitals were 6 percent more likely to die within 30 days than patients admitted to low-ICU hospitals, and the difference was about 8 percent for heart failure patients. Hospitals treating smaller numbers of MI and CHF patients and for-profit hospitals tended to have higher use of ICU beds. Patients from lower income zip codes also tend to be overrepresented in the high-ICU hospitals.
Some of the same researchers last year identified similar findings in patients with pneumonia (Sjoding 2015). Hospitals with the highest rates of ICU admission for Medicare patients with pneumonia were less likely to deliver pneumonia processes of care (such as appropriate initial antibiotics and pneumococcal vaccination) and had worse outcomes (higher 30-day mortality and higher readmission rates) for Medicare patients with pneumonia. Hospital spending for pneumonia patients was also higher in high-ICU hospitals.
Somewhat difficult to reconcile with the latter study was another one by many of the same researchers (Valley 2015). They found in Medicare patients with pneumonia that patients with “discretionary” admission to ICU’s had a significantly lower adjusted 30-day mortality. That means that patients who were “borderline” for ICU admission actually had a mortality benefit over those with similar features who were admitted to general wards. That was the opposite of what the researchers expected to find. It is not really clear why these findings differed from those in the Sjoding 2015 study.
Another new study looked at the associations between hospital-level ICU utilization rates and risk-adjusted hospital mortality, use of invasive procedures, and hospital costs (Chang 2016). For each of the 4 medical conditions studied (DKA, PE, UGIB, and CHF) hospital-level ICU utilization rate was not associated with hospital mortality. But use of invasive procedures and costs of hospitalization were greater in institutions with higher ICU utilization for all 4 conditions. They also found that hospitals had similar ICU utilization patterns across the 4 medical conditions studied, suggesting that systematic institutional factors may influence decisions to potentially overutilize ICU care.
Fortunately, in a timely release, the Society for Critical Care Medicine has just updated its guidelines for admission to and discharge from critical care units (Nates 2016). The guidelines also have recommendations for prioritization and triage of potential ICU patients based upon factors such as severity of illness, functional impairment, comorbidities, prognosis for recovery and quality of life, patient preferences with regard to life-sustaining treatment, etc. Chronological age should not be a primary determinant in the elderly. One important recommendation under discharge guidelines is to avoid “after hours” discharge (see our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare” regarding huddles with bed coordinators to avoid such after hours transfers from the ICU). The guidelines also discuss potential sites to which discharge from the ICU can occur, including general wards, step down units, post-acute care facilities, etc. They also discuss use of outreach programs to supplement ICU care, such as rapid response teams and ICU consult teams on wards.
Hospitals need to take a close look at their ICU utilization. We still see hospitals that lack formal criteria for ICU admission and discharge or have them but don’t adhere to them. Yes, ICU’s provide patients with levels of nursing care and monitoring that should be advantageous but they also expose patients to a variety of potential hazards (nosocomial infections, invasive procedures, etc.). And provision of services that don’t result in better patient outcomes may be detrimental to the fiscal health of the hospital.
References:
Valley TS, Sjoding MW, Goldberger ZD, Cooke CR. Intensive care use and quality of care for patients with myocardial infarction and heart failure. Chest 2016; In Press Accepted Manuscript, Available online 15 June 2016
http://journal.publications.chestnet.org/article.aspx?articleid=2530383
Sjoding MW, Prescott HC, Wunsch H, Iwashyna TJ, Cooke CR. Hospitals with the highest intensive care utilization provide lower quality pneumonia care to the elderly. Crit Care Med 2015; 43(6): 1178-1186
Valley TS, Sjoding MW, Ryan AM, Iwashyna TJ, Cooke CR. Association of Intensive Care Unit Admission With Mortality Among Older Patients With Pneumonia. JAMA 2015; 314(12): 1272-1279
http://jama.jamanetwork.com/article.aspx?articleid=2442938
Chang DW, Shapiro MF. Association Between Intensive Care Unit Utilization During Hospitalization and Costs, Use of Invasive Procedures, and Mortality. JAMA Intern Med 2016; Published online August 08, 2016
http://archinte.jamanetwork.com/article.aspx?articleid=2542419
Nates JL, Nunnally M, Kleinpell R, et al. ICU Admission, Discharge, and Triage Guidelines. A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research. Crit Care Med 2016; 44(8): 1553-1602
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2016 Too Much of a Good Thing?”
American College of
Surgeons Statement on Operating Room Attire
Tired of seeing your surgeons and OR personnel traipsing through your hospital cafeteria dressed in their scrubs (with all the contaminants you don’t want to even think about)? Well, get them all to comply with the new recommendations in a statement from the American College of Surgeons (ACS) on operating room attire (ACS 2016). And, while you are at it, make sure everyone in your cath labs or GI labs or other procedure areas also comply with the new recommendations.
The ACS bases its
guidelines for appropriate attire on “professionalism, common sense, decorum,
and the available evidence”. They are as follows:
- Soiled scrubs and/or hats should be changed as soon as feasible and
certainly prior to speaking with family members after a surgical
procedure.
- Scrubs and hats worn during dirty or contaminated cases should be
changed prior to subsequent cases even if not visibly soiled.
- Masks should not be worn dangling at any time.
- Operating room (OR) scrubs should not be worn in the hospital
facility outside of the OR area without a clean lab coat or appropriate
cover up over them.
- OR scrubs should not be worn at any time outside of the hospital
perimeter.
- OR scrubs should be changed at least daily.
- During invasive procedures, the mouth, nose, and hair (skull and
face) should be covered to avoid potential wound contamination. Large
sideburns and ponytails should be covered or contained. There is no
evidence that leaving ears, a limited amount of hair on the nape of the
neck or a modest sideburn uncovered contributes to wound infections.
- Earrings and jewelry worn on the head or neck where they might fall
into or contaminate the sterile field should all be removed or
appropriately covered during procedures
- The ACS encourages clean appropriate professional attire (not
scrubs) to be worn during all patient encounters outside of the OR.
The ACS strongly
suggests that scrubs should not be worn outside the perimeter of the hospital by
any health care provider. To facilitate enforcement of this guideline for
OR personnel, the ACS suggests the adoption of distinctive, colored scrub suits
for the operating room personnel.
But not everyone is
on board with the ACS statement. In particular, AORN (Association of periOperative Registered Nurses) has issued its own
statement (AORN
2016) noting that several of the ACS recommendations are not
evidence-based. The AORN statement comments on the ACS recommendations item-by-item
but especially differs on several points. Whereas the ACS statement recommends
that “Scrubs and hats worn during dirty or contaminated cases should be changed
prior to subsequent cases even if not visibly soiled.” AORN notes that OSHA
requires "attire that has been penetrated by blood, body fluids, or other infectious
materials be removed immediately or as soon as possible and be replaced with
clean attire." AORN also questions the recommendation about wearing a lab
coat over scrubs, noting evidence that lab coats are often contaminated by
large numbers of pathogenic organisms. AORN also discusses issues regarding
head coverings and how difficult it would be for facilities to enforce vague
terminology like “modest sideburn” or “limited amount of hair”. Read the AORN
statement in full for other details. AORN also has its own guidelines
on surgical attire.
The ACS plans to
publish its statement in the October 2016 issue of Bulletin of the American
College of Surgeons. One would hope that ACS and AORN would get together with
the ASA (American Society of Anesthesiologists) and organizations representing
all other OR healthcare workers to agree on standards that apply to all.
References:
ACS (American College of Surgeons). Statement on Operating Room Attire. Online August 4, 2016
https://www.facs.org/about-acs/statements/87-surgical-attire
AORN (Association of periOperative
Registered Nurses). AORN Responds to ACS Statement on Surgical Attire. Periop Insider Newsletter 2016; August 16, 2016
AORN (Association of periOperative
Registered Nurses). Clinical FAQ’s. Surgical Attire.
https://www.aorn.org/guidelines/clinical-resources/clinical-faqs/attire
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2016 American College of Surgeons Statement on Operating Room Attire”
Adverse Events in
Rehab Facilities
A recent report by the Office of the Inspector General (Levinson 2016) found that 29% of Medicare patients admitted to a post-acute rehabilitation facility (rehab units in acute care hospitals were excluded) experienced either an adverse event or temporary harm event. Almost half (46%) of these were deemed to be likely preventable. About a quarter of the events led to acute care hospitalizations, which were estimated to cost Medicare $92 million annually.
The results were based upon a sample of 417 Medicare patients discharged from such units in March 2012. This event rate is really quite similar to rates the OIG has found for Medicare patients in acute hospitals (27%) and SNF’s (33%). 10% of the patients had an adverse event, which implied harm came to the patient. An additional 18% had events that led to temporary harm. 1.7% of patients had “cascade” events (where multiple related adverse events or temporary harm events occurred in succession). But only 0.7% had events that caused or contributed to their death.
We don’t think the OIG’s report is meant to single out rehab facilities. Rather, it simply demonstrates that all the factors which contribute to adverse events in hospitals are not unique to general hospitals but also occur in almost all healthcare settings.
References:
Levinson DR (Office of the Inspector General. Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. July 2016
https://oig.hhs.gov/oei/reports/oei-06-14-00110.asp
https://oig.hhs.gov/oei/reports/oei-06-14-00110.pdf
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2016 Adverse Events in Rehab Facilities”
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2016 What's New in the Patient Safety World (full
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2016 More on Preventing HAI’s”
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2016 Too Much of a Good Thing?”
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2016 American College of Surgeons Statement on Operating Room Attire”
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2016 Adverse Events in Rehab Facilities”
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