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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.

  • Saving blood: The relatively simple task of blood management

    Want to save your bosses some money and improve patient safety? Improve your blood transfusion practices. A study published in the August 2017 issue of The Joint Commission Journal on Quality and Patient Safety found that by eliminating unnecessary red blood cell (RBC) transfusions, researchers were able to save their hospital over $1 million per year.

    "[Fifty percent] or more of RBC transfusions may be unnecessary," the authors wrote in their conclusion. "And the rate of RBC transfusion in other developed countries, including Canada, the United Kingdom, and the Netherlands, is more than 25% lower than in the United States."

    RBC transfusions have increased 134% between 1997 to 2011 to become the most frequently performed hospital procedure in America. And while they are a vital tool for treating patients, they come with potential risks like allergic reactions, fever, and infection.

    The Joint Commission, the AABB, and the U.S. Department of Health and Human Services have flagged excessive transfusions as an improvement priority. So have six professional organizations, including obstetric, hematology, critical care, and anesthesiology societies, and the Society of Hospital Medicine.

    “The cost and risks of RBC transfusions, along with evidence of overuse, suggest that improving transfusion practices is a key opportunity for health systems to improve both the quality and value of patient care,” the study’s authors wrote.

    Ian Jenkins, MD, SFHM, lead author of the study, is a clinical professor and chair of the Patient Safety Committee at the University of California San Diego Health (UCSD). In the study, Jenkins and his co-authors used educational tools, new protocols in their computerized order entry system, and guidance at the point of care to improve their blood management. By the end of the 32-month study, they reported a 47% reduction in hemoglobin transfusions and a 67% reduction in multi-unit transfusions. The overall rate of RBC transfusions dropped 19%, bringing a savings of over $1 million. However, Jenkins points out that the savings for other hospitals would depend on their volume and current performance.

    So far, no hospital has reached out to UCSD about its blood management practices, says Jenkins. However, UCSD is trying to set up a collaborative where hospitals can go through this process together and learn from each other’s experiences.

    "We’re hoping to see more interested people because as far as quality improvement projects go, this one was relatively easy to implement," he says. "There're well-defined best practices, relatively simple order set design, straightforward education, and data was easy to collect on the EHR [electronic health record]."

  • Harvey, Irma, and Maria: Questions hospitals need to answer before a hurricane hits

    While the deadline to meet CMS's new emergency preparedness Conditions of Participation (CoP) is November 15, hurricanes this August and September have shown why these rules are needed in the first place.

    In a mere six days, Hurricane Harvey dropped 27 trillion gallons of water on Texas and Louisiana, destroyed over 30,000 homes, displaced over 1 million people, and killed at least 82. Mercifully though, John Hellerstedt, commissioner of the Texas Department of State Health Services, told reporters on September 14 that “mass casualties have absolutely not happened.”

    Then, before Harvey's floodwaters were drained, Hurricane Irma mowed through the Caribbean and into Florida. Irma broke several records and has already been named one of the strongest hurricanes to hit the U.S. mainland. The hurricane caused the entire island of Barbuda to evacuate, left nearly 2 million homes and businesses without power, and killed at least 31 in the U.S.

    A mere 10 days later, Hurricane Maria struck Puerto Rico and left over 3.4 million Americans without power. As of October 1, only nine out of 69 Puerto Rican hospitals are back on regular power, with the rest either closed or operating on generator power. Meanwhile, half the island is without drinking water, and only 11% of cell towers and 5% of the electric grid are operational. Early estimates say it’ll take more than six months to restore the power grid.

    Hospitals throughout the Gulf Coast had to react quickly to these storms. Some facilities became isolated or inundated with floodwaters, while others faced a surge in patient population.

    With lots of shore-hugging cities and towns, Gulf Coast and East Coast states are extremely vulnerable to hurricanes and other large storms. And while these storms tend to hit the Southeast the hardest, they can still cause devastation up north, as seen with Hurricane Sandy in 2012.

    Medical facilities that sit in hurricane-prone regions know to remain prepared before, during, and after the regular storm season, which extends from June 1 to December 1. But Harvey and Irma struck with surprising speed and strength, leaving many facilities with one question: How can a hospital possibly prepare for an event of such magnitude?

    While it’s a bit too early to offer many critical lessons learned from these storms, the main advice is to pay attention now so you can plan for similar scenarios, says one disaster planning expert.

  • How to prevent maternal mortality

    Maternal mortality is a measure of how many mothers die from pregnancy-related complications while carrying or within 42 days after birth. And in most of the developed world, this number has fallen to historic lows.

    But not in the U.S., where the maternal mortality rate (MMR) has grown 2.7% between 2000 and 2015. Annually, there are 700–900 maternity deaths, 60% of which are preventable. An additional 65,000 people nearly die due to pregnancy complications.

    For perspective, the U.S. MMR is 26.4 deaths per 100,000 live births. In Kazakhstan, the MMR is 26.5 per 100,000. But unlike America, Kazakhstan’s MMR has fallen 5.6% over the past 15 years.

    America’s maternity deaths are even worse when compared to other developed nations. The United Kingdom has an MMR of 9.2, down 2.5% since 2000. In fact, a British man is “more likely to die while his partner is pregnant than she is.” And the UK’s MMR is higher than that of Sweden (4.4), Norway (3.8), Ireland (4.7), Italy (4.2), and many others. 

    While this is bleak news for providers and patients, there are signs of hope out west. In the past decade, California has been the only state to buck the national trend and reduce MMR, down to seven deaths per 100,000. California hospitals have adopted a number of guidelines and best practices around maternal care, blood loss, C-sections, pre-conception planning, and other topics.

    While these tools and guidelines haven’t been implemented nationwide yet, they have great promise in reversing this disturbing health trend in American hospitals and clinics.

    Maternal mortality complications
    Michelle Genova, RNC, MSN, executive director of women’s services at St. Joseph’s Hospital in Orange, California, says the rise in maternal mortality is linked to the rise in chronic health conditions in women, such as high blood pressure, obesity, diabetes, hyper-tension, blood clots, etc. St. Joseph’s is the second largest obstetrics hospital in southern California and conducts 5,000 deliveries and 3,500 outpatient preg-nancy-related visits each year.

    These chronic conditions can be extremely detrimental to pregnancies if not properly managed, Genova says. There are also new concerns over the impact congenital anomalies have on maternal mortality.

    “Specifically cardiac anomalies and some others [in people] that are surviving into womanhood and having children of their own,” she says. “Those kinds of situations are new to this generation of people and something we have to take into consideration.”

    Randy Fiorentino, MD, an obstetrics/gynecology physician at St. Joseph’s, says age is a large determinant in maternal mortality rates, and many women in the U.S. are getting pregnant at older ages.

    “When they’re starting their families and childbearing in their 20s and their early 30s, they have much less chronic health conditions,” Fiorentino says. “When women start their families over the age of 35 and 40, there’s a lot of other chronic health conditions that affect pregnancy.”

  • Study says hospital room floors may need more attention in infection control

    Want to improve your infection control? Consider your hospital floors.

    A study published in the March issue of the American Journal of Infection Control (AJIC) found that hospital room floors may be an overlooked source of infection.

    “In a survey of five hospitals, we found that floors in patient rooms were frequently contaminated with pathogens and high-touch objects such as blood pressure cuffs and call buttons were often in contact with the floor,” wrote the authors of the study. “Contact with objects on floors frequently resulted in transfer of pathogens to hands.”

    Here are a few takeaways from the authors:

    • Educate on the dangers. Since floors are frequently quite dirty and thus contaminated, hospitals should educate staff and visitors about the importance of not placing high-touch objects and equipment on the floor if possible.
    • Conduct better floor cleaning. It’s probably a good idea for hospitals to reexamine how they clean their floors. The study authors noted that sporicidal disinfectants used to clean rooms and kill germs such as C. difficile are not typically used on floors. “In particular, because C. difficile spores were frequently recovered from floors in CDI [C.diff infection] and non-CDI rooms, there is a need to identify approaches that are effective in reducing the burden of spores on floors,” the authors wrote.

  • Service animals in the ER

    At a Roaring 20s party this summer, I saw a flapper in a sparkly dress dance with her service dog, a husky in a red vest. The woman was having a great time, though the dog seemed confused by the whole situation.

    While it was funny to watch then, what if the next day she and her service dog went to your hospital or clinic? Do you know if the dog can ride with her in an ambulance? Is the dog allowed in every area of the hospital? Who takes care of it if the patient becomes incapacitated during care?

    Odds are you’ve probably seen service animals working in a variety of places: grocery stores, state fairs, restaurants, airports, offices, hotels, museums, etc. And in (most) situations, these animals don’t pose a problem. However, when anyone brings an animal into a healthcare setting, it’s reasonable to consider if its presence might pose a risk.

    While fleas, ticks, mites, and more could undermine a facility’s pest and infection control efforts, facilities must also respect the rights of patients and visitors with disabilities to have service animals. Both The Joint Commission and Medicare Conditions of Participation require that hospitals respect and protect the rights of patients.

    That said, balancing the need to keep medical settings safe and clean against the rights of patients with disabilities to bring service animals with them isn’t always easy. Applying the law correctly and consistently requires a significant amount of pre-work and communication, both within the organization and with the public.

    The Americans with Disabilities Act
    Generally speaking, government bodies, businesses, and nonprofit organizations that serve the public are required under the Americans with Disabilities Act (ADA) to permit service animals in their facilities.

    The ADA supersedes any and all breed-specific bans and prohibits facilities from requesting documentation to prove that the animal is a service animal. But there are limited circumstances in which covered entities can exclude such animals, according to the Disability Rights Section of the U.S. Department of Justice (DOJ), Civil Rights Division.

    “For example, in a hospital it would be inappropriate to exclude a service animal from areas such as patient rooms, clinics, cafeterias, or examination rooms,” the DOJ explained in a summary of the ADA’s provisions. “However, it may be appropriate to exclude a service animal from operating rooms or burn units where the animal’s presence may compromise a sterile environment.”

    The ADA has a service animal fact sheet and an FAQ page on the topic.

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