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Patient Safety Monitor Journal

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.

  • CDC launches campaign to catch sepsis early

    The Centers for Disease Control and Prevention (CDC) has launched a campaign to help bring attention to the dangers of sepsis, a condition that is fast becoming the number one cause of death in U.S. hospitals.

    Called “Get Ahead of Sepsis,” the program was launched last August as an educational initiative to protect Americans from the devastating effects of sepsis, including emphasizing the importance of early recognition and rapid treatment, as well as the importance of preventing infections that could lead to sepsis.

    Sepsis is the body’s extreme response to an infection. It is life-threatening, and without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death. Each year in the U.S., more than 1.5 million people develop sepsis, and at least 250,000 Americans die as a result.

    Research shows that mortality rates increase quickly—even within a matter of hours—if sepsis goes untreated. A study released by the CDC found that seven in 10 patients with sepsis had recently used healthcare services or had a chronic disease requiring frequent medical care, indicating that there are opportunities to detect the infection before it’s too late.

    To make matters worse, the treatment and screening for sepsis could lead to an increase in other common and pesky healthcare infections, including Clostridium difficile (C. diff), according to a new report published in the American Journal of Infection Control.

    In that study, titled Impact of an electronic sepsis initiative on antibiotic use and health care facility–onset Clostridium difficile infection rates, researchers from the Icahn School of Medicine at Mount Sinai in New York City used data collected from four patient wards between June 2011 and July 2014 to analyze the unintended consequences of sepsis screening and treatment protocols, which generally involves large amounts of antibiotics.

    “We found that the implementation of an integrated sepsis initiative coincided with changes in use of broad-spectrum antibiotics and [healthcare facility–onset] CDI rates in adult patients admitted to medical wards,” the authors of the study wrote. “Because these protocols are increasingly used, further study of their unintended consequences is warranted.”

    According to the CDC, public education is critical to save lives since, for many patients, sepsis develops from an infection that begins outside the hospital, and treatment goes on from there once admitted.

    However, many patients still aren’t aware of what sepsis is or how to identify warning signs. A 2016 survey by the Sepsis Alliance found that only 55% of Americans have heard of sepsis.

  • Hurting silently: Assessing pain in nonverbal patients

    How patients assess their own pain is a key component to how hospitals are expected to manage pain medications. But what about patients who can’t communicate their level of pain?

  • USP deadline on hazardous drug handling postponed until 2019

    The U.S. Pharmacopeial Convention (USP) has announced it intends to push back the compliance deadline for USP Chapter <800> “Hazardous Drugs; Handling in Healthcare Settings” from July 1, 2018, to December 1, 2019.

  • Patient handoffs: The gap where mistakes are made

    A patient handoff (also known as transitioning) is both the act of passing a patient between caregivers and the information exchanged between the sender (the provider giving away the patient) and the receiver (the provider taking the patient).

    These transfers can be as dramatic as airlifting a patient to a specialty hospital and telling the EMTs that the patient thinks she can fly and will try to jump out of the helicopter, or as mundane as a nurse ending her shift and telling her replacement the patient has been taken off a certain medicine.

    This exchange is a huge weak point in healthcare; each handoff runs the risk of having key treatment information being garbled, forgotten, or not passed on. On September 12, The Joint Commission published Sentinel Event Alert 58 on inadequate handoff communications and their effect on patient care.

    “Potential for patient harm—from the minor to the severe—is introduced when the receiver gets information that is inaccurate, incomplete, not timely, misinterpreted, or otherwise not what is needed,” The Joint Commission wrote. “When hand-off communication fails, many factors are involved, such as healthcare provider training and expectations, language barriers, cultural or ethnic considerations, and inadequate, incomplete or nonexistent documentation, to name just a few.”

    Christopher Landrigan, MD, MPH, research director of inpatient pediatrics at Boston Children’s Hospital and the principal investigator of the I-PASS study on patient handoffs, says that just by looking at the data on the role communication plays in medical errors, one can see how huge an impact handoff can have.

    “Our best estimates are that 150,000-250,000 patients are killed each year in the U.S. as a consequence of adverse events, which are injuries due to medical care,” he says. “In data that’s been gathered by The Joint Commission, Department of Defense, and other agencies, communication is a leading cause of sentinel events, which are the most serious adverse events. All told, communication failures contribute to somewhere between 50% to 80% of sentinel events. So it’s the number one cause of the most serious events in hospitals which in turn are a leading cause of death in the U.S.”

    Nan Tomsky, MN, RN, CPHRM, a principal consultant at Compass Clinical Consulting, explains that the information provided during a handoff is key in ensuring a seamless transition of patient care.

    “Failure to properly transfer knowledge about the patient can result in serious outcomes when the receiving caregiver is ignorant of critical information,” she says. “Needed medications may be omitted, key symptoms/indications of patient changes can be missed, and patients can fall and suffer serious injuries among other outcomes.”

    Part of the problem, she says, is that handoff procedures can vary widely within and between facilities, if they are done at all. While there are several good models and formats for healthcare organizations to adapt and develop, like SBAR and I-PASS, it’s up to facilities to adopt and tailor them for their needs.

  • The route to eliminating hospital-acquired conditions

    Editor’s note: This article was written by Janet Spiegel, MS, a Lean-certified management consultant in Portland, Maine, who has advised and coached several payer and provider organizations. For questions or comments, she can be contacted at jmitchellspiegel@gmail.com.

    The newly released hospital safety report from the Agency for Healthcare Research and Quality tells an encouraging story: Hospital-acquired conditions (HAC) are on a double-digit decline. The study showed that these conditions decreased 21% since 2010. While that progress should certainly be commended, we shouldn't celebrate just yet. Research reminds us that patient outcomes overall are still favorable at hospitals that perform well on quality. And as the most common quality grade received by the scored facilities was a C, we know that opportunity to improve remains. 

    Include RCA in corrective action plans
    One of the graded measures is number of methicillin-resistant Staphylococcus aureus (MRSA) events. As CMS notes, length of stay can contribute to the occurrence of MRSA events, and of course MRSA events themselves can impact length of stay. If there is an opportunity for improvement in any of the measures at your facility, it’s important not only to have a corrective action plan (CAP) in place for audit readiness and future safety surveys, but to ensure that the CAP is based on a root cause analysis (RCA).

    For example, consider a hospital that experiences a spike in MRSA events. The hospital may put a CAP in place that focuses its interventions around improving wound care or changing sterilization processes. While these may be wise in theory, without a focused RCA, the facility cannot know for sure that these interventions will reduce these specific MRSA occurrences.

    Recently a hospital group shared that it was incentivizing its providers to discharge patients by noon every day. It was a clear directive that providers bought into: "Let’s move our patients back to their homes as soon as they are ready to reduce the possibility of infection or other conditions and to turn over beds for those who need care."

    The positive impact to patient satisfaction, patient outcome, process, and revenue was undisputable. What unfortunately resulted was that when providers came too close to the noon deadline, they would hold their patients an extra night to meet their metric the next day.
    At times, our metrics can incent unhelpful behaviors. Through an RCA, teams may uncover what MRSA patients have in common—whether the infections are due to delayed discharges, inadequate wound care, ineffective sterilization processes, or something else the teams hadn’t considered. This will ensure they are solving for the right problem.

    Use the Plan-Do-Study-Adjust cycle in your CAP
    Continuous improvement is an experimental cycle, commonly known as Plan-Do-Study-Adjust. Once the problem has been defined and the RCA with data or observation has been performed, only then should teams move into intervention mode where a solution, hypothesis, and action plan are proposed.

    The intervention portion of the cycle is where the experimentation happens. Try the proposed solutions documented in the CAP, and study the results as frequently as possible. It can take a while to gather data on large-scale problems such as MRSA, but it is recommended that teams be vigilant in their quest to improve. Ask what can be done in a week, a month, six months, etc. Test against hypotheses within short time frames rather than waiting for large amounts of data. Through this method, teams will be able to test small ideas, adjust, then cycle back around to learn whether the problem has been solved.

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