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Patient Safety Monitor Journal answers your most important patient safety questions and offers field-tested compliance strategies to ensure your patient safety efforts measure up to The Joint Commission.

  • Study: Seasonal spikes in antibiotic misuse

    This March, a team of experts working with the Centers for Disease Control and Prevention (CDC) published a study on antibiotic prescription habits in outpatient facilities. The study, which appeared in the Infection Control & Hospital Epidemiology journal, showed that there are seasonal trends in prescriptions, with most antibiotics prescribed during winter months.

    The study also found that antibiotic misuse continues to be a problem, writing, “The lack of any apparent change in utilization over the course of this study may support the findings of other studies suggesting that professional guidelines may not be the most effective form of influencing provider actions.”

    The study authors say their findings suggest that "current initiatives to improve the use of antibiotics in outpatient settings may not be enough to change clinicians’ prescribing practices." And they feel clinicians must be better equipped "with the tools and knowledge to know when antibiotics are needed."

    "It is one of the most important steps towards reducing antibiotic-resistant bacteria, as well as adverse events associated with these powerful drugs,” the study's lead author, Michael Durkin, MD, MPH, assistant professor of medicine at Washington University School of Medicine, said in a statement released by the Society for Healthcare Epidemiology of America. “There has been progress in reducing antibiotic prescriptions in hospitals, but there needs to be more research and attention on how to address this issue in the outpatient setting.”

    Unchanged rates
    Durkin and co. conducted a retrospective analysis of 98 million outpatient antibiotic prescriptions from administrative claims data from 2013–2015, using a sample from Express Scripts Holding Company’s database of insured members. They tracked monthly prescription rates for all antibiotics, in addition to the five most commonly prescribed antibiotics:

    • Azithromycin
    • Amoxicillin
    • Amoxicillin/clavulanate
    • Ciprofloxacin
    • Cephalexin

    Despite new professional guidelines, the study authors wrote there wasn’t any apparent change in the annual prescription rates. They added that their most conservative estimate found that 30% of those medications were inappropriately prescribed.

    “If quality improvement guidelines were sufficient to improve antibiotic prescribing practices, then we would have expected to see an overall decrease in antibiotic prescribing rates over time. However, standalone educational materials are rarely successful for changing clinician behavior,” wrote Durkin. “A more rigorous framework and greater investment of resources is needed to substantially improve outpatient antibiotic prescribing rates, helping to combat antibiotic resistance and improve patient safety.”

  • Use checklist to reduce self-harm risks in the ER

    There’s a case where a World War II POW committed suicide by hitting himself in the head with an empty metal canteen after days without water. While that happened in the hold of a Japanese prison boat, not a hospital, it highlights how resourceful a suicidal person can be when it comes to finding ways to self-harm. Earbud cords, compact mirrors, trash bags, bed frames, IV tubing, socks, and much more can be used to attempt suicide in a hospital setting.

    With the renewed focus on ligature and self-harm, facilities need to undergo a complete reassessment of the physical environment where patients with behavioral or mental health problems are cared for.

    That goes especially for emergency departments. Annually, 460,000 emergency department visits occur following cases of self-harm, and those patients are six times more likely to make another suicide attempt in the future. To prevent patients from further harming themselves, staff should start each shift by reviewing emergency department rooms designated for treatment of behavioral health patients to remove any items patients could use in a suicide attempt.

    You may want to use a checklist to ensure no items are overlooked. In rooms that can’t be completely cleared of ligatures or other instruments for self-harm, facilities should have trained one-on-one observers available to keep patients safe.

    “As healthcare organizations and accrediting bodies intensify efforts to make the healthcare environment safer, it is critical to use available data and expert opinion to have clear guidelines on what constitutes serious environmental hazards that must be corrected and what mitigation strategies are acceptable in those situations when all potential hazards cannot be removed,” wrote The Joint Commission in a special report on suicide prevention.

    Boarded patients a concern
    When evaluating physical risks in emergency departments, remember that behavioral health patients awaiting transfer to a psychiatric unit or facility may be in the ER for hours, if not days, says Ernest E. Allen, a former Joint Commission life safety surveyor and current patient safety account executive with The Doctors Company in Columbus, Ohio. The company is a medical malpractice insurer.

    Minimizing self-harm opportunities in the physical environment is not only a patient safety issue, but also vital to the hospital’s bottom line, says Allen, who presented an HCPro webinar last November on evaluating the environment of care for suicide risk.

    That’s because patient suicides can not only result in investigations by CMS and your accrediting organization, but also a visit from your local or state department of health and possible fines. Lawsuits from family members can draw unwanted media attention.

    Incidents of self-harm by patients also create poor morale among staff, notes Allen. He recommends you consider designating a room or rooms in your ER area to specifically house psychiatric patients if necessary.

  • Case study: Harborview Medical Center's automated sepsis alert system

    Sepsis mortality rates increase quickly when left untreated, even if it’s only for a few hours. The difficulty facing providers is that there isn’t a simple test for sepsis. Instead, they have to watch for patterns and symptoms that could indicate sepsis. As a result, it’s common to have misdiagnoses or delays in diagnosis.

    Sepsis is also the most fatal complication for burn victims, accounting for 50%–60% of burn injury deaths. That last issue is a particular concern for places like Harborview Medical Center in Seattle. The facility is the only designated Level I trauma and burn center in Washington state and is the regional trauma and burn referral center for Alaska, Montana, and Idaho. The 413-bed facility has around 17,000 admissions, 259,000 clinic visits, and 59,000 emergency department visits annually.

    Rosemary Grant, BSN, RN, CPHQ, is the sepsis coordinator at Harborview. She says her facility chose to focus their attention on sepsis detection because the condition is “prevalent, expensive, and deadly.”

    “When we looked at data from our hospital and others, we saw that patients who develop sepsis in the hospital have a much higher mortality than patients who arrive in the emergency department with sepsis,” says Grant. “So, we knew we needed to focus on faster identification of sepsis in our inpatient population.”

    The evidence backs up her concerns. A 2017 study found that while sepsis is only present in 6% of hospitalizations, it accounts for 15% of in-hospital deaths. In 2014 alone, there were 1.7 million sepsis hospitalizations and 270,000 sepsis deaths in the U.S. It’s also one of the most expensive medical conditions, costing tens of billions of dollars annually. And sadly, despite increased awareness of the condition, mortality rates are rising.

    In 2011, the Harborview team decided to fight sepsis by changing the way they detected it. Working in-house, they developed an automated flagging system for their electronic health record (EHR).

    After a patient is admitted to Harborview, his or her vitals are plugged into the EHR several times each day. The system searches for patterns, trends, and symptoms that might indicate sepsis. If found, a red box appears around the patient’s name and the nurse is assigned a task in the EHR to screen the patient for infection.

    The nurse then assesses the patient for non-sepsis causes for the readings. If the nurse thinks the patient could have sepsis, then the physician is alerted. The system is designed so it won’t sound more than once every 12 hours, she says, so nurses won’t get more than one alert per patient per shift.

    “I think the most important component of our system is that it incorporates the bedside nurses’ clinical judgment,” says Grant. “The alert is just a computer algorithm, and if it paged the provider every time, they would become tired of it very quickly. Instead, it asks the nurse who is spending his/her shift with a patient whether infection is suspected based on abnormal vitals and the patient’s overall clinical picture. It’s only if and when the nurse suspects infection that the provider is notified.”

  • Case study: Hospitalwide huddles curb catheter infections at Saint Anthony

    This February, Saint Anthony Hospital in Chicago won the Illinois Health and Hospital Association’s (IHA) “Innovation Challenge: Partners in Progress Award.” In just two years, the facility cut its hospital-acquired infection (HAI) rate by 90% and saved itself $498,000. 

    How did the facility make such tremendous strides in infection control? Short answer: daily interdisciplinary safety huddles (DISH).

    While most hospitals conduct safety huddles, what makes DISH different is that participation is hospitalwide. Representatives from all departments (security, nursing, emergency services, infection control, etc.) meet every morning for a 15-minute daily briefing.

    Alfredo Mena Lora, MD, is the medical director of infection control (IC) at Saint Anthony. DISH is just one aspect of their HAI reduction program, he says, but it’s a unique part of it.

    “We know that huddles have been proven to improve outcomes and reduce certain variables, whether it’s in surgery or catheter placement,” he says. “But a hospitalwide huddle is what I think is novel.”

    At DISH, nurse managers report on which patients have indwelling catheters (urinary or central venous). Then it’s decided which patients still need their catheters. If not, the device is expected to be removed within 24 hours. The reason this matters is because the longer a patient has a catheter, the more likely he or she is to develop an infection.

    After one year of DISH meetings, Lora became curious. He felt the meeting was making a difference—after all, he saw the catheters being removed. But he wanted to prove it.

    “Everything we do, every small quality improvement initiative, as the IC person here I always try to study it to see if there are empirical ways to assess the before and after,” he says. “I knew the meeting was being effective; my objective was to look at the before and after.”

    In the summer of 2016, he made a chart of his findings and submitted it to the IHA’s innovations competition. While he’s glad to be recognized, he says winning the award wasn’t the point.

    “Our goal wasn’t to win any specific award, but rather our day-to-day quality improvement objectives here in the hospital,” he says.

    For an improvement program, DISH is pretty simple and cheap to set up. Saint Anthony started doing DISH meetings in late 2014. While it took a few months to get rolling, Lora says they saw results almost immediately.

    They tracked their progress by tracking their device usage rate (DUR). While the definition of HAIs have changed over time, DUR has remained a constant variable for measuring the effects of medical intervention.

    “When we reviewed this retrospective, we saw a downtrend after we were assessing the needs of catheters on a daily basis and forcing their removal,” he says. “I do think it promotes quick removal and is pretty cost-efficient and easy to do.”

    There are always small challenges in trying a new improvement project, he says. But DISH is very sustainable and it helps correct any kind of challenges they have.

    Right now, he’s working on a way to better assess why certain catheters remain. For example, was there a rise in the DUR because there were more sick patients? Because a new physician didn’t know the catheter policies? Or something else?

    “Because I’m the infection control physician here, I know why some catheters remain—because some patients are sick and so forth,” he says. “As part of optimizing DISH, I’m looking for better ways to obtain that data moving forward and report it at DISH in a more efficient way.”

  • Expect more scrutiny on hand hygiene

    Surveyors didn’t always punish healthcare organizations (HCO) if one of their employees was caught not following proper hand hygiene rules. So long as the organization had an otherwise compliant hand hygiene program, they were let off with a (pardon the pun) slap on the wrist. 

    That’s not how things work anymore, thanks to a January rule change. Now, if a Joint Commission surveyor sees anyone who directly cares for patients fail to perform required hand hygiene, the HCO will get a Requirement for Improvement (RFI).

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