April 22, 2009

Faucet and sink design contribute to splashing, ICU outbreak with resistant organism and 12 deaths

A multi-drug resistant organism (MDRO) causing an ICU outbreak and at least 12 deaths was associated with poor placement of handwashing sinks and environmental contamination.

A recent study from the University of Toronto illustrates the importance of room design, particularly the location and design of sinks, and how sink drains were identified as the reservoir of pathogens in a major outbreak.

From December 2004 through March 2006, 36 patients located in an intensive care or transplant unit of a tertiary care hospital were infected with a similar resistant strain of P. aeruginosa. Infections caused by the outbreak organism contributed to or directly caused the death of 12 (71 percent) of these patients. The source of the outbreak was determined to be the sink drain. Organisms from drain biofilm (pipe slime) were viable and matched patient Pseudomonas strains. Drain contents were found to splash up and at least 1 meter or 3.28 feet from the sinks when they were used for hand washing. This was likely due to high-pressure water flowing through high gooseneck spouts into shallow sinks and directed right into the drain. Visualization techniques using fluorescent markers helped identify how transmission occurred and the distance the splashing water traveled to contaminate material and supplies.

The outbreak continued until the sinks were renovated with a number of changes to prevent splashing onto surrounding areas, the most critical being installation of new faucet spouts that did not flow directly into the drain, along with decreased water flow pressure. These measures resulted in elimination of splashing without replacing the shallow sinks. Other important steps included providing a barrier between the sinks and adjacent preparatory areas, as well as moving patient care materials more than 3.28 feet from sinks. Fluorescent marker testing for splash of drain contents was repeated and revealed no splash onto the adjacent counter or patient bed.

Related resources from the Safety Institute

Audioconference: Dr. Arjun Srinivasan, lead epidemiologist from the Centers for Disease Control and Prevention (CDC) in a Premier program on "Preventing Transmission of Resistant Organisms" discusses how environmental contamination, including water sources, are potential source of MDROs in the hospital and transmission results when infection prevention measures are not followed, such as lack of hand hygiene. Audiofile and slides

Audioconference: Dr. Robert A. Weinstein from Stroger (Cook County) Hospital, in a recent Premier’s program on "Eliminating Bad Bugs" reviewed relevant research confirming infection control practices that reduce the risk of transmission of drug-resistant organisms and healthcare-associated infections, including improved hand hygiene, environmental cleaning, appropriate physician antibiotic prescribing practices, and use of chlorhexidine gluconate (CHG) cleansing cloths. Audiofile and slides

Review abstract: Cervia JS, Ortolano GA, Canonica, FP. Hospital Tap Water A Reservoir of Risk for Health Care-Associated Infection. Infect Dis Clin Pract 2008;16: 349-353 An additional resource is a review in Infectious Diseases and Clinical Practice that addresses the efforts healthcare systems are making in the control of waterborne pathogens.

Downloads and links

• ICU design ICHE abstract
• Antibiotic resistance Srinivasan
• Elimination of MDRO Weinstein
• Hospital Tap Water IDCP abstract

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Visual cues may prevent tubing misconnections

In absence of designs to completely prevent tubing misconnections, visual images and cues are being used to raise awareness of risks and potential for serious injury and death.

Graphic depictions of tubing misconnections and related case studies are downloadable individually or as a calendar from the FDA. Each month describes misconnection cases that have occurred, along with recommendations on error prevention.

Experts agree that the best solution to prevent tubing misconnections is to change the design of the connectors so only devices that should be connected can be connected and those devices that should not be connected are incompatible. (See Premier Safety Institute’s Tubing misconnection Web site) Design incompatibility would make it easy to make the correct connection and difficult or impossible to make the "wrong" tubing misconnection. An international standard, related to small-bore connectors for liquids and medical gases, is currently under development by a working group of the Association for the Advancement of Medical Instrumentation (AAMI). It has an anticipated publication date of January 2010.

Downloads and links

• Medical device case studies-luer; Graphics calendar
• More information is available from the Premier Tubing Misconnection Web site
• International standard

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Incidence of MRSA bloodstream infections decline 50 percent over past decade

The Centers for Disease Control and Prevention (CDC) reported. that the incidence of methicillin-resistant Staphylococcus aureus (MRSA) causing central line-associated bloodstream infections (BSI) in all major adult intensive care units (ICUs) decreased by nearly 50 percent from 1997 to 2007.

There have also been significant declines in the incidence of methicillin-sensitive S. aureus (MSSA) and total central line-associated BSI in all major adult ICUs suggesting that BSI prevention efforts have been successful. These prevention efforts include the adoption of a central line-association BSI "bundle" of measures, including hand hygiene, disinfection of catheter insertion sites, consistent use of gowns, gloves and masks, and draping patients during catheter insertion. When 103 ICUs in Michigan hospitals participating in the Michigan Keystone project began to follow a checklist of precautionary measures or "central line-associated BSI bundles" during insertion of central lines in ICU patients, all central line-associated BSIs were eliminated within three months and nearly 66 percent sustained zero infections during an 18-month follow-up study period. See story below on "Michigan Success with central line-associated-BSI."

The CDC notes that a careful analysis of temporal trends in the incidence of healthcare associated MRSA disease in the United States is crucial to formulate prevention strategies and tracking success. An analysis of just the percent of MRSA (i.e., pooled mean percent resistance) as the only metric to monitor the MRSA problem is misleading - as the CDC data suggest a steady worsening of MRSA central line-associated-BSIs over the analysis period. The percent MRSA only tells us the likelihood that S. aureus will be MRSA and not the absolute risk of MRSA disease.

In comparison, MRSA incidence data indicate a reversal of the direction of MRSA central line-associated BSI problem starting in 2001 with a dramatic decline resulting in a rate in 2007 significantly lower than it was in 1997.

CDC urges caution in interpreting studies that report increasing percent MRSA among any healthcare-associated infections without providing corresponding trend data for the incidence of MRSA infections. The percent MRSA, however, is a vital metric for guiding empiric antimicrobial therapy when S. aureus HAIs are identified, because you want to know what organism causes HAIs the greatest percent of the time. Percent MRSA may also be useful for monitoring drug resistance.

The Chicago Tribune reported recent information from the Illinois Hospital Association (IHA) indicating that although MRSA infections may be more prevalent than initially thought, the majority of the patients with these infections were infected with MRSA before they were admitted, that is, community-acquired MRSA. Although approximately 19,000 MRSA cases were reported as required by state law, only 5.3 percent of infected patients contracted MRSA during their hospital stay, according to nine months of 2008 data. That is much lower than the national 23 percent figure reported by the Association for Professionals in Infection Control (APIC) in 2007. Reasons for this disparity are not clear but the findings highlight the prevalence of MRSA in the community.

Downloads and links

• MRSA JAMA abst.doc
• Michigan Keystone and CLA-BSI available at: Premier Safety Institute's Bundling Web site
• "Good news, bad news." Go to: ChicagoTribune.com or search on Chicago Tribune for February 18, 2009

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Oral care found to reduce risk of ventilator-associated pneumonia

A recent study conducted by researchers at Barnes-Jewish Hospital in St. Louis found that implementation of a simple, low-cost oral care protocol in the surgical intensive care unit (SICU) led to a reduction in risk of ventilator-associated pneumonia (VAP), confirming results of other studies. Researchers introduced an oral care protocol to assist in prevention of bacterial growth of plaque by cleaning the patients' teeth with stock toothpaste (sodium monoflurophosphate 0.7 percent paste) and brush, rinsing with tap water, and subsequent application of a 0.12 percent chlorhexidine gluconate (CHG) chemical solution done twice daily at 12-hour intervals.

This pre-post intervention study involved infection preventionist (IPs) to identify and track VAP cases using the National Healthcare Safety Network or NHSN criteria to define VAP. The study results indicated that a strict regimen of brushing the patients' teeth twice a day reduced the risk of VAP by 46 percent. The incidence of VAP dropped from 5.2 percent (24 cases) in 2003 to 2.4 percent (10 cases) in 2004 with the VAP rate remaining at 2.4 percent or lower since continuing this regimen. Staff compliance with the oral care protocol was monitored during the 12-month study period and averaged 81 percent. The oral care protocol saved $140,000 to $560,000 in combined hospital costs in 2004; the total cost of the protocol was $2,187.

A recent randomized control study (Journal of Neuroscience Nursing) published similar findings in October 2008, although it did not include the addition of CHG. Summa Health System (Akron, OH) found that increased oral care, specifically toothbrushing, contributed to the prevention of ventilator-associated pneumonia (VAP) in the ICU. Oral care is not currently a part of the Institute of Healthcare Improvement's (IHI) VAP bundle, which includes for example, practicing good hand hygiene, elevating the head of the bed of ventilated patients to 30 percent, administering gastric acid histamine2 blockers, initiating early mobilization, and performing daily sedation interruption to evaluate neurologic status. Patients were randomized into either a control group that performed usual oral care or an intervention group that required brushing teeth every eight hours. Results showed that the VAP rate decreased significantly. At one point in 2005, the neuro ICU had a VAP rate of 6.49 percent per 1,000 ventilator days; after the study began, the VAP rate was observed in June 2007 to be 0.62 percent. The cost of regular tooth brushing is inexpensive compared to the estimated $40,000 extra cost for every case of VAP. Review of these two studies does continue to point to the value of oral care in preventing pneumonia.

Downloads and links

• VAP oral Jan 09 abstract
• VAP dental Oct 08 abstract
• More information on VAP bundles is available at: Premier Safety Institute's Bundling and Evidence-based Practices Web site

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Michigan's success in preventing infections and saving 1,800 lives in 120 ICUs is expanded to 10 states

Michigan's Hospital Association's successful Keystone: ICU program, in collaboration with the Johns Hopkins University (JHU) Quality and Safety Research Group, has achieved significant, measurable patient safety improvements – saving lives and reducing healthcare costs in 120 intensive care units (ICU) in 76 hospitals. In a four-year period since its initiation in March 2004, MHA Keystone: ICU found that nearly 1,800 lives were saved, 129,000 excess hospital days avoided and $247 million in healthcare dollars saved. The lessons learned in reducing central line associated bloodstream infections (CLA-BSI) to zero, including tools and checklists, and how to foster development of a safety culture are now being used to assist 10 more states to achieve similar successes. In fact, it was noted after a congressional hearing that "If all state hospital associations were to implement the MHA/JHU program and achieve the same results, more than 15,000 lives and over $1 billion dollars could be saved annually." (United States House of Representatives Committee on Oversight and Government Reform Staff Report, September 2008)

The Keystone-ICU program is a comprehensive unit-based safety program aimed at preventing infections related to the use of central line catheters. The program includes tools to help healthcare professionals identify opportunities to reduce potential HAI, a checklist to ensure compliance with safety practices, staff education on evidence-based practices to reduce CLA-BSI, and education of staff on team training. The program also assists hospitals in implementing policies to make care safer. Two-year results were published in the New England Journal of Medicine in December 2006, reporting that 103 Michigan intensive care units (ICUs) reduced CLA-BSI to zero at three months, with up to 66 percent sustaining the zero rates during the 18-month study period.

The 10-state project is aimed at similarly reducing the average rate of CLA-BSI in hospital ICUs by 80 percent. Participants in the 10 states' hospitals will similarly implement the Keystone tools, educate and provide feedback on infection rates to care units, and hold monthly team meetings to assess progress. The expansion is funded through the Agency for Healthcare Research and Quality's (AHRQ) Accelerating Change and Transformation in Organizations and Networks (ACTION) initiative, and supports actions outlined in HHS’ Action Plan for preventing healthcare-associated infections (HAI). The program expansion includes hospital associations in California, Colorado, Florida, Massachusetts, Nebraska, North Carolina, Ohio, Pennsylvania, Texas, and Washington. Participation will also involve the California Hospital Patient Safety Organization, the North Carolina Center for Hospital Quality and Patient Safety and the Ohio Patient Safety Institute.

Downloads and links

• AHRQ announcement BSI project: www.ahrq.gov/news/press/pr2009/clabsipr.htm
• For additional information see Premier Safety Institute’s module Bundling - Evidence-based practices

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Joint Commission standards no longer required to include CMS language

On March 26, the Joint Commission (TJC) removed overly prescriptive language from its 2009 standards that the Centers for Medicare and Medicaid Services (CMS) had previously required TJC to add effective January, 2009.

The changes are a result of TJC's negotiations with CMS over its deeming authority. The January 5, 2009 language had required specific requirements for certain standards such as Infection Prevention and Control, Environment of Care, based on CMS conditions of participation (COP). The COP prescriptive language had been absent from TJC standards for 15 years and is now removed from the March 26 document. TJC states that these requirements are already covered in existing elements of performance or addressed in the survey process.

A cross-walk provides a side-by-side comparison. For more information see Premier's Safety Institute's SafetyShare January 2009.

Downloads and links

• TJC cross-walk
• For more information on TJC and Deeming authority go to Premier Safety Institute's SafetyShare January 2009
• For complete information on CMS and deemed status see Premier Safety Institute's Web site CMS guidelines
• Joint Commission standards http://www.jointcommission.org/standards

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Coordinated discharge instructions ensured follow-up care and reduced readmission rates

A package of discharge services detailing patients after-hospital care instructions, including how to take their medicines and when to make follow-up appointments, reduced hospital utilization within 30 days of discharge, according to a new study in the Annals of Internal Medicine (February 2009).

The Re-Engineered Hospital Discharge Program, or RED, was introduced and tested through a randomized controlled trial. The RED used specially trained nurses to help one group of patients arrange follow-up appointments, confirm medication reconciliation, and conduct patient education with an individualized instruction booklet that was sent to their primary care provider.

A pharmacist contacted patients between two and four days after hospital discharge to reinforce the medication plan and answer any questions. The study did note that reviewing medications with patients did not necessarily prevent medication problems, but provided opportunity for follow-up corrective action. Sixty-five percent of patients in the RED program who completed the medication review with the pharmacist had at least one problem with their medications. In half of those cases, the pharmacist needed to take action, such as contacting the patient's doctor. Outcomes measured included emergency department visits and hospitalizations within 30 days of discharge. Self-reported readiness for discharge and frequency of primary care providers' follow-up within 30 days of discharge were also measured.

Key among the findings was that patients who were given the packaged discharge services were 30 percent less likely to be readmitted or visit the emergency department than patients who lacked this information. Ninety-four percent of the patients who participated in the RED program had follow-up appointments with their primary care physicians when they left the hospital, compared to only 35 percent for patients who did not participate. Almost all participants (91 percent) had their discharge information sent to their primary care physician within 24 hours of leaving the hospital.

The AHRQ-funded study found that total costs (a combination of actual hospitalization costs and estimated outpatient costs) were an average of $412 lower for the patients who received complete information than for patients who did not. One barrier to the implementation of such a discharge program is the lack of financial incentives. Authors stated that the increasing importance to hospitals of demonstrating their quality performance could increase interest in this type of program. The current attention by the Centers for Medicare and Medicaid to readmission rates for potential savings may increase attention to programs such as RED.

Downloads and links

• Bundling discharge instructions abstract

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NPSF 2009 Patient Safety Congress - May 21-22

The National Patient Safety Foundation (NPSF) will host its Annual Patient Safety Congress on May 21-22, 2009 at the Gaylord National, Washington, DC area. Early-bird registration ends on April 2, 2009.

The theme of this year's Congress is "Now More Than Ever, a Critical Need: Patient Safety in Challenging Times," which emphasizes the need for real-world strategies and tools, new thinking, and vigilance across healthcare. From adversity comes the spark of innovation and renewed commitment, a mindset at the heart of this years’ Congress, offering highly focused programs designed to speak directly to today’s critical patient safety imperatives. Premier, Inc. is pleased to be a sponsor of this year’s NPSF Patient Safety Congress. Pre-conference sessions on May 20 will include "Community Engagement from the Patient and Family Perspective" and "Leadership Day & Patient Safety 101." To register, visit the conference Web site where you will find information on hotel accommodations, sponsorship opportunities and the program.

The education tracks selected address today’s critical issues and deliver the information, tools, and tactics participants need to drive meaningful change. The tracks include:

• Safe and Reliable Care: A Focus on Staff;
• Patient and Family Engagement: Untapped Resilience;
• Pre-Hospital, Ambulatory and Emergency Care: New Challenges and Opportunities;
• Making the Business Case for Safety;
• Medication Safety: A Prescription for Performance Improvement;
• Yes We Can: Improving Patient Safety through Public Policy; and
• Tools for Transformation and Efficiency.

Downloads and linkss

• NPSF program brochure
• NPSF Web site: http://www.npsf.org.

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