February 2007
Dear Colleague:
We have a number of stories and tools this month that address healthcare-associated infections, including a story on improving hand hygiene, ICU staffing and risk of infection; AHRQ's report on evidence for infection prevention; and a new CDC guidance tool for public reporting of infection.
Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- New Green Guide launched with tools to build healing healthcare environments
- ISMP targets anticoagulation safety with FMEA tool
- Newer cell phone devices are safer; distance from critical devices is key
- Hand hygiene and glove use improves with convenient dispenser location, interactive education and poster campaign featuring senior staff
- Study confirms that safety culture varies across ICUs in a single hospital
- Hospital acoustic design impacts patients and healthcare workers
- Low ICU nurse staffing increases risk of patient infections
- National Patient Safety Initiative launched to provide free electronic prescribing to physicians
Safety tools
- AHA – Leadership monographs
- Inform eDesign – Healthcare design implications
- FEMA – Implementing the National Incident Management System (NIMS)
- AHRQ patient safety and information technology conference materials
- New Hampshire – Health forms in multiple languages
- CDC – Tools for reporting healthcare-associated infections
- AHRQ – Report on strategies to prevent healthcare-associated infections
New Green Guide launched with tools to build healing healthcare environments
The Green Guide for Health Care Version 2.2, just released in January 2007 is the primary green building guide for the healthcare industry. It provides a toolkit of measurable best practices to guide and evaluate the progress toward high performance healing and "green" environments.
The guide is a voluntary, self-certifying system modeled with permission after the U.S. Green Building Council's LEED® rating system, with 96 design and construction points and 72 operations points. The Green Guide considers health issues an explicit component of each credit and incorporates design elements that enhance the healing process. It is specifically customized for buildings that are predominately institutional occupancies as defined by the local building code, such as acute care hospitals, where regulatory requirements have created unique needs. The guide applies to new freestanding facilities; additions to existing facilities coupled with renovation, and extensive rehabilitation/adaptive reuse projects.
Healthcare focused sustainable design tools were built on the Green Healthcare Construction Guidance Statement published by the American Society for Healthcare Engineering (ASHE) in January 2002, representing the first sustainable design guidance document to emphasize a health-based approach. At the time, the green building movement was gaining significant traction in the United States and abroad, and demand was growing for a design tool specifically tailored to optimize the health and sustainability of healthcare facilities.
The Green Guide for Health Care development initiative is a professionally and geographically diverse group of green healthcare industry leaders. The Green Guide for Health Care Version 2.2 is free and available for download on the Web site. The Green Guide Pilot program is mostly new construction (50 percent based on construction type) and acute care facilities (60 percent based on facility type). There is tremendous enthusiasm in the healthcare industry for the Green Guide for Health Care. Since the Pilot Version 2.0 was released in November 2004, more than 4,000 people from more than 30 countries have registered on the Web site and a growing number of hospitals are using the Green Guide during its pilot phase and participating in the peer-to-peer Green Guide Forum.
Green Healthcare Construction Guidance Statement
(.pdf) (41 KB)
Green Guide for Healthcare Web site: http://www.gghc.org/
For more, see Premier Safety Institute's Construction Web site
ISMP targets anticoagulation safety with FMEA tool
Anticoagulant medication errors can cause life-threatening or fatal bleeding or thrombosis. The Institute for Safe Medication Practices (ISMP) targeted anticoagulants as its first "high-alert medication" feature, including tools to support the proposed 2008 JCAHO safety goal related to anticoagulation therapy. The ISMP focused on anticoagulants, unfractionated heparin, low-molecular weight heparin, and warfarin, in the January 11, 2007, ISMP Medication Safety Alert-Acute Care. ISMP has a current high-alert medication list, as well as a sample failure modes and effects analysis (FMEA) that help identify sources of failure with anticoagulants and key improvements for reducing the risk of harmful errors.
As a 2008 National Patient Safety Goal, the Joint Commission has proposed the addition of a requirement to Goal 3: Improve the safety of using medications, i.e., "reducing the likelihood of patient harm associated with the use of anticoagulation therapy."
The Institute for Healthcare Improvement (IHI) has also included the prevention of harm from high-alert medications, starting with a focus on anticoagulants, sedatives, narcotics, and insulin anticoagulants in its recently launched 5 Million Lives Campaign.
For "High-alert medication list" and FMEA tool, go to http://www.ismp.org/
ISMP Medication Safety Alert – Acute Care home page http://www.ismp.org/Newsletters/acutecare/
JCAHO 2008 NPSG (.pdf) (59 KB)
IHI 5 Million Lives: http://www.ihi.org/IHI/Programs/Campaign/
Newer cell phone devices are safer; distance from critical devices is key
Recent data have shown that newer cell phone technology has reduced the risk of electromagnetic interference (EMI) when used beyond approximately 3 feet (one meter) from critical medical equipment. Several sources updating current information and guidance on cell phones and electromagnetic interference indicate that although risks are reduced, they are not eliminated. Following is a recap of some current reports and findings:
ECRI Health Devices (December 2006) The publication provides guidance on cell phones and electromagnetic interference. Hospital policies nationwide vary from no cell phone use to virtually unlimited use. Balanced against potential risks, hospitals are rethinking the use of cell phones because of improvements in cell phone technology, the benefits of using a cell phone for quicker communication among caregivers, and improvements made to the electromagnetic compatibility of newer medical devices. ECRI maintains that although evidence indicates risks may have diminished, cell phones continue to demonstrate a risk that EMI will affect medical devices. Consequently, ECRI advocates against the complete lifting of cell phone restrictions.
Journal of Critical Care This 2006 study concludes that the majority of studies indicate that medical device malfunction is extremely rare if the distance from the transmitting device is greater than 1 meter or 39.37 inches.
Mayo Clinic One study conducted at the Mayo Clinic observed decreases in EMI events, most significantly in "clinically important" events, yet these events were not eliminated. Researchers reported on testing 15 devices with six cell phones and found a "clinically important interference" of 1.2 percent. Authors of this study conclude that the use of the newer technology must be closer to medical devices before any interference is noticed and suggest that cell phones be periodically tested to determine their effects on medical equipment.
Abstract Anesth cell phone 2006 (.doc) (25 KB)
Abstract JCC cell 2006 (.doc) (27 KB)
Abstract Mayo cell 2005 (.doc) (28 KB)
Issues of Health Devices are available for member access only online at www.ecri.org; for reprints of articles or complete issues of Health Devices, contact ECRI's Membership Services Department at 610.825.6000, Ext. 5891.
Safety Institute - Safety topics A-Z: Cell phones and EMC
Hand hygiene and glove use improves with convenient dispenser location, interactive education and poster campaign featuring senior staff
A recent three-year study found that hand hygiene and glove use increased and the incidence of antimicrobial resistance decreased with a multi-modal intervention program that included: 1) readily accessible alcohol-based hand rub dispensers (wall mounted at entrance to room); 2) interactive infection control educational sessions with content guided by a needs assessment survey at intervention hospitals; and 3) a hospital-wide poster campaign featuring photos of high profile administrative and clinical staff. This study by Trick and colleagues published in the January 2007 issue of Infection Control and Hospital Epidemiology included observation of 6,948 hand hygiene opportunities during all work shifts.
The interventions were implemented at three study hospitals that included an acute and long-term care hospital, community hospital, and public teaching hospital. At a fourth "control" hospital, a university teaching hospital, researchers only increased the availability of alcohol-based hand rubs.
Results indicated that workers preferred using an alcohol-based hand rub to soap and water at the three intervention hospitals, compared with the control hospital. As healthcare workers became more knowledgeable about hand hygiene, they wanted alcohol-based hand rubs more accessible. The frequency of hand hygiene performance or glove use significantly increased during the study period at the intervention hospitals but not at the control hospital the maximum quarterly frequency of hand hygiene performance or glove use at the intervention hospitals (74 percent, 80 percent, and 77 percent) was higher than at the control hospital (59 percent).
The researchers also demonstrated a significant reduction in the incidence of antimicrobial resistance among isolates from clinical cultures at one of the intervention hospitals, which had the greatest increase in the frequency of hand hygiene performance.
The authors concluded that multimodal intervention contributed to the increased adherence to hand hygiene recommendations and use of alcohol-based hand rubs.
Location of alcohol-based hand rub dispensers
Convenient placement of alcohol-based hand rub dispensers has been identified as a key strategy to increase the frequency of hand hygiene. Trick and colleagues placed the wall-mounted dispensers at or near the entrance to each patient room. In a letter to the editor from Somner and colleagues from the Royal Infirmary of Edinburgh (England) in the same issue, alcohol-based hand rub dispensers that were located at the foot of the bed and within easy reach of the patient were used more frequently than dispensers next to a sink in an adjacent room.
WE Trick. Multicenter intervention program abstract
(.doc) (24 KB)
Safety Institute - Safety topics A-Z: Hand hygiene guideline
Study confirms that safety culture varies across ICUs in a single hospital
A recently released study in Critical Care Medicine (CCM), "Perceptions of safety culture vary across the intensive care units of a single institution," confirmed that safety culture, staff attitude, and job satisfaction varied significantly across ICUs in a single hospital. In addition, staff often did not recognize their stress. The study describes how workplace safety culture varies across the intensive care units (ICUs) of a single hospital, how it differs among nurses and physicians, and describes ICU nursing directors' perceptions of their personnel's attitudes. Previous studies have demonstrated that intensive care units with high levels of teamwork and coordination measured better patient outcomes. These data support the critical need to maintain a safety culture that supports teamwork and communication. Researchers in this study used a cross-sectional survey to assess safety culture in six areas (factors): teamwork climate, perceptions of management, safety climate, stress recognition, job satisfaction, and work environment.
Results show that except for stress recognition, ICU personnel attitudes were significantly different across the various units. Job satisfaction and working conditions were the most significantly different across ICUs. Nurses reported lower scores related to working conditions and perceptions of management than physicians. Their scores also trended lower than physicians in job satisfaction and teamwork. ICU nursing directors overestimated their personnel's attitudes especially for teamwork and working conditions. Survey respondents were asked to describe patient safety recommendations. The top four recommendations were to improve staffing, education, teamwork, and equipment. The researchers suggest further studies of this type but indicate that these results suggest safety culture should be assessed at the ICU level rather than at the hospital level or by relying on director opinions.
Huang safety culture abstract (.doc) (26 KB)
Safety Institute - Safety topics A-Z: Culture – Patient safety
Hospital acoustic design impacts patients and healthcare workers
The Center for Health Design (CHD) has released an Issues Paper, "Sound Control for Improved Outcomes in Healthcare Settings," that provides solutions for the design of acoustic environments to produce a positive impact in the healthcare setting through noise reduction, speech privacy and intelligibility, and music therapy. Hospitals frequently exceed recommended guidelines for noise levels and high noise levels affect both patients and staff. Patients can experience sleep loss, elevated blood pressure, delayed wound healing, and a higher incidence of re-hospitalization, and staff may experience emotional exhaustion, increased fatigue and burnout. High noise levels may also compromise patient confidentiality if private information exchanges between healthcare worker and patient or between healthcare workers can be overheard by unintended listeners.
The issue paper by Anjali Joseph, Ph.D., and Roger Ulrich, Ph.D., describes how to effectively decrease noise levels in hospitals. Several solutions include: providing single-patient bedrooms, installing high-performance sound-absorbing acoustical ceiling tiles, and removing or reducing loud noise sources on hospital units and staff conversations. Another solution for promoting patient privacy is to provide private discussion areas in the admitting area as well as on patient units for private conversations. The paper includes a discussion of the research demonstrating that music therapy can effectively reduce anxiety and distress among patients in many different types of healthcare settings.
CHD Issue Paper Sound 4 (.pdf) (367 KB)
The Center for Health Design (CHD) http://www.healthdesign.org/
Safety Institute - Safety topics A-Z: Construction – ICRA
Low ICU nurse staffing increases risk of patient infections
A recent study of patients admitted to intensive care units (ICU) reported that low nurse staffing is associated with an increased infection risk. Researchers from the University of Geneva Hospitals in Geneva, Switzerland, studied whether low staffing levels increased the infection risk in a medical intensive care unit. The study, "The effect of workload on infection risk in critically ill patients," reported in Critical Care Medicine (CCM), indicates that staffing is a key factor in healthcare-associated infections (HAI) in critically ill patients. All patients admitted during a four-year period were observed in a prospective cohort study to determine the effect of staffing on risk of HAI.
The overall HAI rate was 64.5 per 100 patient days; this rate was twice as high in patients staying 7 days or longer. Close to half (45.8 percent) of the infections were in the lower respiratory tract, 11.8 percent catheter exit-site, 11.1 percent eyes, nose, and throat, 7.4 percent primary bloodstream, and 7.1 percent urinary tract. The ICU mortality rate was more than double among infected patients than non-infected patients. Median length of hospital stay among infected patients was 28 days versus 16 days among non-infected patients. The researchers analysis of staffing levels indicated that low nurse staffing is associated with an increased infection risk and that having a higher staffing level could prevent a large number of infections in the ICU. The ICU healthcare-associated infections were found to occur only a few days after exposure to high workload suggesting that with an increased workload, healthcare workers may not comply with infection control measures.
CCM ICU infections abstract (.doc) (23 KB)
More on preventing ICU HAI - Safety Institute - Safety topics A-Z: Evidence –based practices and bundling interventions
National Patient Safety Initiative launched to provide free electronic prescribing to physicians
A coalition of U.S. technology companies, health benefit companies and healthcare providers has launched an initiative to improve patient safety and reduce harmful medication errors by increasing the adoption and utilization of electronic prescribing. The National ePrescribing Patient Safety Initiative (NEPSI) will provide free electronic prescribing to every physician in the United States. Providing Allscripts' safe and secure Web-based electronic prescribing software free, is NEPSI's way of addressing the cost barriers to e-prescribing systems.
The software, Allscripts eRx NOWTM, is simple and easy to use; 15 to 30 minutes of training is required, addressing physicians' concerns that the technology requires too much time to learn and install. Allscripts is a Chicago provider of clinical software, information and connectivity solutions. Allscripts eRx NOWTM software requires no download and no new hardware. Physicians can register and begin using the software by going to the e-prescribing link. The eRx NOWTM software can quickly generate secure electronic prescriptions that can be sent computer-to-computer or by fax to more than 95 percent of all retail pharmacies. The prescriptions are instantly checked for potentially harmful interactions with a patient's other medications using a real-time complete medication database, as well as real-time notification of insurance formulary status from leading payers, plans and pharmacy benefit managers. The eRx NOWTM software also allows physicians to search and find targeted health-related information using a custom search engine from Google.
Regional supporters will encourage physicians in adopting and implementing e-Tuesday, February 20, 2007 11:00 AM-11:30 AM (GMT-05:00) Eastern Time (US & Canada)prescribing by offering training, incentives and local support. Premier members are among those regional supporters of the NEPSI initiative. The NEPSI initiative is also is supported by a growing number of academic medical centers, integrated delivery networks and physician groups across the country. Additional information is available at the NEPSI Web site.
NEPSI QA (.pdf) (64 KB)
Register at the NEPSI Web site: http://www.nationaleRx.com
Safety tools
AHA – Leadership monographs
The American Hospital Association's resource for governance information, tools and counsel to promote excellence in healthcare governance, The Center for Healthcare Governance,
http://www.americangovernance.com/
americangovernance_app/, has two new monographs for hospital trustees. The first monograph, "Are You Rolling the Dice on CEO Succession?" is designed to help trustees navigate the CEO selection process. The monograph contains a Leadership Continuity Risk Management Model to help trustees understand how to effectively define the requirements for a new CEO, assess candidates and approach the final selection process. The second, "The Board's Fiduciary Role: Legal Responsibilities of Health Care Governing Boards," describes the basic legal duties and obligations of the boards of not-for-profit hospitals. This guidance can be used to support trustee recruitment and orientation, and as a reference tool for existing board members. To order any of the monographs, contact the Center at 888.540.6111 or e-mail at:
info@americangovernance.com.
Inform eDesign – Healthcare design implications
Created by the University of Minnesota, InformeDesign®
www.informedesign.umn.edu brings research and practice aspects of the design professions together. Designers face a multitude of complex challenges that are environmental, behavioral, and design in nature. This Web site focuses on providing the design community with reputable research sources that address those challenges. A monthly publication,
Implications, addresses the issues facing practitioners and researchers
who focus on design and human behavior. Under the links, "SPACE," then
"Healthcare," there is a wide variety of healthcare related articles and
research summaries on topics from ambulatory care to wellness centers.
http://www.informedesign.umn.edu/Rs.aspx?s=space&tId=664
FEMA – Implementing the National Incident Management System (NIMS)
Two courses designed to help hospital personnel implement the National Incident Management System (NIMS) are available from the Federal Emergency Management Agency (FEMA). NIMS was developed so responders from different jurisdictions and disciplines can better collaborate to respond to natural disasters and other emergencies. Course IS-100. HC, "Introduction to the Incident Command System for Healthcare/Hospitals,"
http://www.training.fema.gov/
EMIWeb/IS/is100HC.asp describes the history, features, principles and organizational structure of ICS. FEMA notes that the course is for hospital personnel who would have a direct role in emergency preparedness, incident management, and/or emergency preparedness. Course IS-200. HC, "Applying ICS to Healthcare Organizations,"
http://www.training.fema.gov/EMIWeb/IS/
is200HC.asp is designed to enable healthcare personnel to operate efficiently during an incident or event within the ICS and is for personnel whose primary responsibility is emergency management. FEMA's Web site has additional information on NIMS implementation activities for hospitals. Other professional groups such as the American Society for Healthcare Engineering also offer similar training courses for ICS.
http://www.fema.gov/emergency/nims/
compliance/assist_non_govt.shtm.
AHRQ patient safety and information technology conference materials
The second Patient Safety and Health Information Technology (Health IT) Annual Conference was held from June 4-6, 2006, and hosted by the Agency for Healthcare Research and Quality (AHRQ). Conference presenters, including researchers, officials, and healthcare providers, reviewed how the patient safety and information technology are working together as well as examined future opportunities to improve health. The conference, "AHRQ 2006 Annual Patient Safety and Health Information Technology Conference: Strengthening the Connections," included panel discussions, keynote addresses, plenary sessions, town hall meetings, poster displays and learning sessions over nine tracks (.doc) (596 KB), which included:
- Patient Safety and Health IT Across Settings and Populations;
- Implementation Issues in Patient Safety and Health IT;
- Improving the Health of Communities through Regional Health Information Exchange (HIE);
- Assessing Value and Evaluating Project Impact;
- Achieving and Sustaining Improvements;
- Using Reporting Systems for Safety and Quality Improvement;
- Working Conditions Challenges in Patient Safety;
- Patient and Family-Centered Health IT and Safety; and
- Emerging Approaches to Drive Change in Healthcare.
Access the full agenda, speakers, presentations and meeting materials at the conference Web site.
New Hampshire – Health forms in multiple languages
An online tool created by the Foundation for Healthy Communities in New Hampshire has a directory that enables healthcare workers working with culturally and linguistically diverse communities to easily find translated health forms and documents. The directory provides access to documents created and translated by New Hampshire health agencies and organizations. The documents are intended for use by any healthcare organization. Translated documents include consent forms, patient bills of rights, financial assistance applications, and information about cholesterol, asthma and child immunizations. Part of the Foundation's Cultural Effectiveness and Quality Health Care Project, the tool will be updated with documents and language translations. Access the tool on the Foundation Web site.
http://www.healthynh.com/fhc/resources/
translateddocuments.php
CDC – Tools for reporting healthcare-associated infections
A new toolkit designed to provide guidance on issues that should be considered when designing measures for public reporting of healthcare-associated infections (HAI) is available from the Centers for Disease Control and Prevention (CDC). The kit was designed in conjunction with the Association of Professionals in Infection Control and Epidemiology (APIC), the Society for Healthcare Epidemiology of America (SHEA) and other professional groups. Many states are considering making HAI reporting mandatory. "Essentials of Public Reporting of Healthcare-Associated Infections: A Tool Kit" (.pdf) (199 KB) details recommended steps, including the identification or creation of a responsible agency at the state level, personnel for data collection and quality improvement, strategies to prevent unintended consequences of public reporting, and recommended outcome measures. Access the CDC Web site for the Public Reporting of Healthcare-Associated Infections (http://www.cdc.gov/ncidod/dhqp/PublicReportingHAIs.html) for the toolkit, as well as the February 2005 American Journal of Infection Control article, Guidance on Public Reporting of Healthcare-Associated Infections (.pdf) (150 KB).
AHRQ – Report on strategies to prevent healthcare-associated infections
AHRQ released a new Evidence Report/Technology Assessment (Number 9), which concludes that several approaches and practices implemented to prevent healthcare-associated infections (HAI) are promising and warrant additional research. The objective of the report was to determine the effects of quality improvement strategies on HAI and on HAI rates. The selected infections (.pdf) (785 KB) included surgical site infections (SSI), central line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infections (CAUTI) The AHRQ Evidence Report concludes that there is insufficient evidence to recommend quality improvement strategies that will improve adherence to preventive interventions for healthcare-associated infections. The evidence is generally of suboptimal quality, consisting primarily of single-center, simple before-after studies of limited internal and external validity. Results from the limited data suggest that certain strategies require additional study and potential wider implementation. Those strategies include reducing unnecessary catheter use by using "stop orders" (which require that a catheter be removed after a certain period of time if it is no longer needed), reminders to improve surgical antibiotic prophylaxis, the use of checklists to improve adherence to central line insertion practices, and improving the use of proper infection control practices for ventilator-associated pneumonia through education and tutorials.
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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 © 2007 Premier, Inc.
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