January 2007
Dear Colleague:
Delete this email! Every issue, every story, and every tool in Safety Share for the past five years is archived. And, have you visited our Safety Web site and the special A to Z safety topics? See emergency preparedness, fall prevention, "bundling," construction, hand hygiene and more – all sites are regularly updated.
Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- CMS issues letter supporting use of alcohol-based surgical skin preps
- Administrative data improves risk-adjusted mortality rates by adding POA, lab data
- Prior falls and gait/balance assessment are key predictor of falls
- Michigan ICUs reduce catheter-related bloodstream infections to zero for 18 months
- Technology, nurse-staffing ratio associated with high quality performance
- Bush signs law requiring study on payment for 'never event'
- WHO global initiative focuses on specific patient safety problems
Safety tools
- CEO assessment tool for leadership
- HAI reporting resource – First mandatory risk-adjusted infection data released
- CMS – New hospital mortality reporting data requirements
- FDA – Updates on hospital bed safety guidance
CMS issues letter supporting use of alcohol-based surgical skin preps
On January 12, 2007, CMS published guidance to all state surveyors, supporting the use of alcohol-based skin preps in all surgical settings, based on NFPA fire prevention strategies. The letter published on the CMS Web site removes the risk of individual states banning their use, following such action in two states.
The risk reduction techniques incorporate those outlined in the NFPA 99 amendment approved in August 2005. With the passage of the amendment, the National Fire Protection Agency (NFPA) lifted a six-month-long ban on the use of alcohol-based surgical prep solutions during laser and electrocautery procedures providing specific fire prevention precautions were followed. However, this was not enough to prevent hospital citations by state authorities, since CMS had not yet officially adopted the amendment. In late 2006, after Pennsylvania issued a ban on the use of alcohol-based skin preps, CMS stepped up its process and issued a letter to all state surveyors, stating:
"A review of recommendations produced by various expert organizations concerning use of alcohol based skin preparations in anesthetizing locations indicates there is general consensus that the following fire risk reduction measures are appropriate:
- Using skin prep solutions that are: 1) packaged to ensure controlled delivery to the patient in unit dose applicators, swabs, or other similar applicators; and 2) provide clear and explicit manufacturer/supplier instructions and warnings. These instructions for use should be carefully followed.
- Ensuring that the alcohol-based skin prep solution does not soak into the patient's hair or linens. Sterile towels should be placed to absorb drips and runs during application and should then be removed from the anesthetizing location prior to draping the patient.
- Ensuring that the alcohol-based skin prep solution is completely dry prior to draping. This may take a few minutes or more, depending on the amount and location of the solution. The prepped area should be inspected to confirm it is dry prior to draping.
- Verifying that all of the above has occurred prior to initiating the surgical procedure. This can be done, for example, as part of a standardized pre-operative "time out" used to verify other essential information to minimize the risk of medical errors during the procedure.
Hospitals that employ alcohol-based skin preparations in anesthetizing locations should establish appropriate policies and procedures to reduce the associated risk of fire. They should also document the implementation of these policies and procedures in the patient's medical record."
The full CMS letter and the NFPA amendment may be downloaded. See Premier's Safety Share for background information.
CMS letter to surveyors (1/12/07) (.pdf) (47 KB)
NFPA amendment (.pdf) (26 KB)
Premier Safety Share, August 2005
Administrative data improves risk-adjusted mortality rates by adding POA, lab data
Risk-adjusted hospital mortality rates are often used in public reporting and for pay-for-performance programs. A recent study supports the value of adding "present on admission" (POA) codes and numerical laboratory data to administrative claims data to determine risk-adjusted hospital mortality rates. The authors of "Enhancement of Claims Data to Improve Risk Adjustment of Hospital Mortality" (Journal of the American Medical Association, January 3, 2007) reviewed the practice using current administrative claims data from payers that typically cannot distinguish between conditions present on admission and complications occurring during a hospital admission. Several states (California and New York) implemented POA codes to test their effectiveness as reported by the Agency for Healthcare Research and Quality(AHRQ). The nationwide adoption of a present on admission (POA) modifier is included with revised ICD-9-CM coding modifications for hospital claims data to be implemented in March 2007.
Researchers in this study compared risk-adjustment equations for inpatient mortality by sequentially adding clinical data to an administrative database. The population studied included patients hospitalized for acute myocardial infarction, congestive heart failure, acute cerebrovascular accident, gastrointestinal tract hemorrhage, pneumonia, or who underwent an abdominal aortic aneurysm repair, coronary artery bypass graft surgery, or craniotomy.
The first model used standard claims data, the second model included POA data, the third model used POA codes and added numerical laboratory data from the first day of admission, and the fourth model added patient vital signs and other clinical data not previously included.
Statistical measures found increased predictive value by adding POA codes and numerical laboratory data to administrative claims data to determine risk-adjusted hospital mortality rates. Improvements were found with the addition of more complex clinical data but added little to the predictive power of risk-adjustment equations.
These study findings, though applicable only to mortality rates, highlight the importance of the soon-to-be implemented POA codes for other performance measures such as healthcare-associated infections.
JAMA 07 abstract (.doc) (23 KB)
AHRQ HCUP POA study (.pdf) (246 KB)
For more on challenges of administrative data see the July 2005 Safety Share article article, "Pennsylvania first to disclose hospital-acquired infections."
Prior falls and gait/balance assessment are key predictor of falls
Screening patients for their risk of falling during a clinical examination should begin with determining if the patient has fallen in the past. According to a recent study in the Journal of the American Medical Association (JAMA), patients who have fallen or who have a gait or balance problem are at higher risk of future falls. These findings highlight a comprehensive approach to analyzing current data on patient falls published in "Will My Patient Fall" in JAMA, January 2007.
The purpose of this meta-analysis was to review risk factors for future falls in order to identify older patients who might benefit from diagnostic testing and multifactorial interventions. Effective multifactorial interventions can reduce the frequent falling rate of older patients by 30 to 40 percent. However, clinical consensus suggests reserving these interventions for high-risk patients. Limiting fall prevention programs to high-risk patients implies that clinicians must recognize features that predict future falls.
The study was based on a search of MEDLINE (1966-September 2004), CINAHL (1982-September 2004), and authors' own files to identify prospective cohort studies of risk factors for falls that performed a multivariate analysis of such factors. Two reviewers independently determined inclusion of articles and assessed study quality. Clinically identifiable risk factors were identified across six domains:
- Orthostatic hypotension,
- Visual impairment,
- Impairment of gait or balance,
- Medication use,
- Limitations in basic or instrumental activities of daily living, and
- Cognitive impairment.
Findings Eighteen studies met inclusion criteria and provided a multivariate analysis, including at least one of the risk factor domains. The estimated pretest probability of falling at least once in any given year for individuals 65 years and older was 27 percent (95 percent confidence interval, 19 percent-36 percent). Patients who have fallen in the past year are more likely to fall again (likelihood ratio range of 2.3-2.8). The most consistent predictors of future falls are clinically detected abnormalities of gait or balance (likelihood ratio range of 1.7-2.4). Visual impairment, medication variables, decreased activities of daily living, and impaired cognition did not consistently predict falls across studies. Orthostatic hypotension did not predict falls after controlling for other factors.
Conclusions Screening patients for their risk of falling during a clinical examination should begin with determining if the patient has fallen in the past year. For patients who have not previously fallen, screening consists of an assessment of gait and balance. Patients who have fallen or who have a gait or balance problems are at higher risk of future falls.
The lead author, David Ganz, M.D., will be discussing this study in the February 21, 2007 webcast "Author in the rooms" sponsored by JAMA and the Institute for Healthcare Improvement.
"Will my patient fall" JAMA abstract (.doc) (27 KB)
Tool kits and other fall prevention resources are available from the Premier's Falls module
To register for Author in the Room, please visit http://www.ihi.org/authorintheroom
Michigan ICUs reduce catheter-related bloodstream infections to zero for 18 months
The New England Journal of Medicine (NEJM) reported that 103 Michigan intensive care units (ICUs) reduced catheter-related bloodstream infections (CRBSI) to zero at three months from the study baseline. Up to 66 percent sustained the zero rates during the 18-month study period. NEJM reported that the median rate of CRBSI per 1,000 catheter-days decreased from 2.7 infections at baseline to zero at three months.
A statewide patient safety initiative in Michigan ICUs, known as the Michigan Health and Hospital Association (MHA)'s "Keystone Center for Patient Safety and Quality Keystone ICU project," focused on reducing CRBSIs. The structure of the intervention included a daily commitment to a culture of safety, ongoing surveillance by trained infection control personnel, and a supportive education program. Interventions included:
- Handwashing;
- Use of full barrier precautions with central line placement;
- Cleaning/prepping the insertion site with chlorhexidine;
- Avoiding the use of femoral catheters if possible; and
- Removing all unnecessary catheters.
In the study, "An intervention to decrease catheter-related bloodstream infections in the ICU," Peter Pronovost M.D. and colleagues analyzed data from 103 intensive care units (ICUs), including 1,981 ICU-months of data and 375,757 catheter-days. Rates of infection per 1,000 catheter-days were measured at three-month intervals, according to the guidelines of the National Nosocomial Infections Surveillance System (NNIS) now known as the National Healthcare Safety Network (NHSN). This study also demonstrated that a large-scale project focused on reducing the incidence of CRBSI can be done and can have important health consequences.
In an editorial in the same NEJM issue, Richard Wenzel, M.D., and Michael Edmond, M.D., suggest that since the five interventions used in the Pronovost study required very little additional cost or effort, they should be widely adopted. All five interventions called the "central line bundle" are considered category IA by the CDC classification system, meaning they are "strongly recommended for implementation and strongly supported by well designed experimental, clinical or epidemiological studies." The focus of the MHA Keystone ICU collaborative remains the prevention and reduction of all healthcare associated infections (HAIs), including CRBSIs. A new MHA Keystone: Hospital-Associated Infection (K-HAI) initiative has begun focusing on hand hygiene as well as device bundles (central line bundle, urinary catheter and ventilator bundle). This preventive approach is aimed at eliminating all hospital infections, whether caused by drug-resistant or susceptible organisms.
Pronovost study abstract – Catheter-related bloodstream infections (doc.) (20 KB)
More on Keystone and evidence-based 'bundles'
Technology, nurse-staffing ratio associated with high quality performance
A study in the Archives of Internal Medicine
(December, 2006), "Quality of care for the treatment of acute medical conditions in US hospitals," reports that patients are more likely to receive high quality care in hospitals that invest in technology, have a high registered nurse staffing ratio, are not-for-profit, has a federal or military designation, and are Joint Commission (JCAHO) accredited.
Researchers from Harvard Medical School (HMS) reviewed 2004 data on 4,059 facilities' characteristics and performance on acute myocardial infarction, congestive heart failure, and pneumonia care measures. They linked the performance data to American Hospital Association (AHA) data on hospital characteristics. Composite scales for each disease were developed and the relationship between hospital characteristics and quality were examined.
In general, patients with these conditions received recommended care 75.9 percent of the time. Analysis determined that for-profit hospitals consistently underperformed not-for-profit hospitals for each condition. Major teaching hospitals had better performance on the treatment and diagnosis composite but scored lower on the counseling and prevention composite. Hospitals with more registered nurses performed better on all quality measures,
Federal and military hospitals had the highest performance. Bruce Landon, MD, MBA, associate professor of healthcare policy at HMS, noted that a large portion of federal and military hospitals are part of the Veterans Health Administration, and recommended additional study of lessons learned from their decade-long experience in quality improvement. Landon also suggested that the information technology and computerized reporting systems at the VA contributed to their high performance.
Researchers concluded that quality improvement interventions should cross multiple care areas and that widespread efforts are likely to have more impact than narrowly defined initiatives. Hospitals should also evaluate the effect of alternative payment approaches on quality, the study authors added.
Quality of care abstract (.doc) (23 KB)
More information on high performing hospitals
Bush signs law requiring study on payment
for 'never event'
Changes in the "Tax Relief and Health Care Act of 2006" (PL 109-432) include the provision that the Office of the Inspector General (OIG) conduct a study and submit a report to Congress on the incidence of "never events" for Medicare beneficiaries.
The study would include the extent to which Medicare paid, denied or recouped payment for services furnished in connection with such events, and the process for detecting such events and denying payment for connected services. The requirement is included in this Act signed by President Bush in December 2006 under the Medicare provisions.
An updated list of "Serious Reportable Events in Healthcare" known as "never events" was released in November 2006 by the National Quality Forum (NQF). A "never event" is a serious or costly error in the provision of healthcare that should never happen. Common examples are: surgery on the wrong body part, mismatched blood transfusion, and a foreign body left in a patient after surgery. Congress has earmarked $3 million for the study and will include auditing a sample of claims and medical records of Medicare beneficiaries. The statute requires the Inspector General to submit a report to Congress in two years that details the results of the study.
Many consumers and companies support a "do-not-pay-for-errors" approach, especially given the momentum in Washington and state governments to demand that medical-care providers adhere to basic quality standards. Only a few states require hospitals to report serious errors, but the Joint Commission does require hospitals to analyze, document investigations into the causes and action taken for prevention. Many hospitals already have policies of disclosure and do not bill for the original treatment or absorb the cost of follow-up care related to any of the 28 never events. For detail on this issue, see December 2006 Safety Share.
Summary of Medicare Provisions in PL109-432 (HR 6111) (.pdf) (24 KB)
Premier Safety Share newsletter, December 2006, "Never event policy calls for apologizing to patients"
WHO global initiative focuses on specific patient safety problems
"Action on Patient Safety" (also called "High 5s"), a seven-country collaborative project that will focus on five patient safety solutions, was recently announced by the World Health Organization (WHO) Collaborating Center on Patient Safety Solutions, the World Alliance for Patient Safety, and the Commonwealth Fund.
The "Action on Patient Safety" project will be coordinated by the WHO Collaborating Centre, which is led by the Joint Commission (JCAHO) and its affiliate Joint Commission International. The seven countries include Australia, Canada, Germany, New Zealand, Netherlands, United Kingdom, and United States. The goal is to reduce or eliminate five highly prevalent patient safety problems in selected hospitals in each country over a five-year period ("High 5s").
The patient safety problems selected for the "High 5s" initiative include:
- Prevention of patient care hand-over errors;
- Prevention of wrong site/wrong procedure/wrong person surgical errors;
- Prevention of continuity of medication errors;
- Prevention of high concentration drug errors; and
- Promotion of effective hand hygiene practices.
Each country is expected to produce draft solutions that include standardized operating protocols. A lead agency in each country is to serve as coordinator and 10 or more hospitals from each country will be enrolled. These hospitals will select up to five safety solutions from among those identified for the project. Results will be measured using a package of tools that will include patient safety indicators as developed by the U.S. Agency for Healthcare Research and Quality (AHRQ), root cause analyses of indicator events and other adverse events, periodic organization culture assessments, and economic impact indices.
The World Health Organization's Collaborating Center for Patient Safety is also asking for comments on nine proposed solutions for improving patient safety. The proposed "Patient Safety Solutions" address the issues of: look-alike, sound-alike medications; correct patient identification; hand-over communications; wrong site, wrong patient surgery; use of concentrated electrolyte solutions; medication reconciliation; catheter and tubing misconnections; needle reuse and injection safety; and hand hygiene.
The electronic Patient Safety Solution survey will be available online until February 16, 2007
http://www.jcipatientsafety.org/survey
Additional information on the World Alliance for Patient Safety
http://www.who.int/patientsafety/worldalliance/en/
Additional information on the World Health Organization (WHO) Collaborating Centre on Patient Safety Solutions
http://www.who.int/patientsafety/newsalert/issue2/en/
Safety tools
CEO assessment tool for leadership
The Center for Healthcare Governance has provided the first tool in a series of Collaborative Leadership Tools. "Collaborative Leadership: A New Model for Developing Truly Effective Relationships Between CEOs and Trustees" explores the board/CEO relationship in the context of governance reform, which calls for boards in all sectors to raise the bar on their performance and accountability. This CEO resource discusses what governance reform means in terms of how boards and CEOs work together to lead their healthcare organizations. It also provides an assessment tool and process that CEOs can use to take the lead in diagnosing their current relationship with their board, and to work together with board leaders to re-energize and strengthen the relationship to achieve maximum effectiveness and value. If completed online, all responses are confidential.
http://www.americangovernance.com/americangovernance/
ctool/welcome.html
HAI reporting resource – First mandatory risk-adjusted infection data released
Healthcare-associated infections (HAIs) are a major health problem in the United States. They can be very serious, even life threatening, and may increase the cost and length of hospital stay. In Missouri, hospitals and ambulatory surgery centers (ASCs) are required by law to report selected HAI data to the Missouri Department of Health and Senior Services. The "Missouri Nosocomial Infection Reporting Act of 2004" was established to decrease the incidence of infections within healthcare facilities in Missouri. The reported infection data are available, by facility, on http://www.dhss.mo.gov/HAI.
At this time only one category of HAIs – central line-associated bloodstream (CLAB) infections data – is available for review. In the future, the site will contain information on surgical site infections (SSI). The site helps consumers understand HAIs, be informed about hospital and ambulatory surgery center infection rates in Missouri, and learn what they can do to lower their risk of a HAI. It includes a question-and-answer section, common definitions, and details on the Missouri state law and regulation that made this reporting mandatory.
CMS – New hospital mortality reporting data requirements
Beginning in June 2007, all hospitals, including Critical Access Hospitals (CAH), will have 30-day (risk adjusted) mortality rates for acute myocardial infarction (AMI) and heart failure (HF) published on the Hospital Compare Web site (http://www.hospitalcompare.hhs.gov/) through an initiative led by the Hospital Quality Alliance (HQA) (.pdf) (28 KB). The data reported in June will cover the period July 1, 2005, to June 30, 2006; reported data will also soon include pneumonia patients.
So that hospitals may become familiar with the background of the measures and their own mortality rates, Centers for Medicare and Medicaid Services (CMS) will provide a mock report based on 2003 Medicare claims. The rates contained in these initial reports will not be posted publicly on the Hospital Compare Web site. Information and updates about this initiative will be posted periodically to http://www.qualitynet.org/ under the "Hospitals" section. The CMS timeline (.pdf) (27 KB) from November 2006 contains additional information, including the important dates for public reporting. More information is available at QNet exchange.
FDA – Updates on hospital bed safety guidance
The FDA Hospital Bed Safety Workgroup's (HBSW), final guidance on hospital bed design, "Guidance for Industry and FDA Staff; Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment" (.pdf) (860 KB), identifies special issues associated with hospital bed systems and provides design recommendations for manufacturers of new hospital beds and suggestions for healthcare facilities on ways to assess existing beds. First available in March 2006, the HBSW guidance characterizes the body parts at risk for entrapment, identifies the locations of hospital bed openings that are potential entrapment areas, recommends dimensional criteria for new hospital bed systems, provides information about reporting entrapment adverse events, and includes a description of recommended test methods for assessing gaps in hospital bed systems. "A Guide for Modifying Bed Systems and Using Accessories to Reduce the Risk of Entrapment" (.pdf) (500 KB), released by the HBSW in June 2006, focuses on modifying bed systems and using add-on or replacement equipment and accessories to reduce the entrapment risks posed by openings in existing bed systems. The HBSW also has a Bed Safety Entrapment Kit containing information and tools that can be used to assess the risk of entrapment in hospital beds http://www.fda.gov/cdrh/beds/entrapmentkit.html.
Although these documents are useful, the American Society for Healthcare Engineering (ASHE) notes that an initial patient risk assessment remains a key initial step. See ASHE Advisory (.pdf)( 72 KB).
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Editorial team
- Gina Pugliese, RN, MS editor
- Judene Bartley, MS, MPH, CIC, associate editor
- John Hall, BSJ, contributor
- Judith Luca, RN, BSN, contributor
- Derek Kleckner, CUA, Web master
- Jena Abernathy, Executive sponsor
About Premier
Premier, Inc. is a healthcare alliance entirely owned by 200 of the nations leading not-for-profit hospital and healthcare systems. These systems operate or are affiliated with 1,500 hospital facilities and hundreds of other healthcare sites. Premier provides an array of resources supporting health services delivery, including clinical and operational comparative data applications for quality/safety performance improvement, group purchasing and supply chain services, and insurance programs. The Centers for Medicare and Medicaid Services (CMS) has recently partnered with Premier for a three-year quality incentive demonstration project. Participating hospitals using Premier’s Perspective Online ™ database can receive recognition and additional Medicare payment when they meet or exceed specific quality measures.
Safety Share © 2006 Premier, Inc.
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