March 2007
Dear Colleague:
Every issue, every story, and every tool in Safety Share is archived back to 2001. And, have you visited our Safety Web site and the special A to Z safety topics such as fall prevention, back injury prevention, culture of safety, tubing misconnections, Clostridium difficile, construction, and more?
Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- Premier, CMS extend P4P demonstration project; three-year extension includes new incentive models to improve quality
- HHS offers severity index for pandemic flu planning to address home isolation, school closings, work schedules
- MRSA elimination – only one solution?
- Nearly half of adverse event reported in Minnesota involved surgery - retained objects and wrong-site surgery
- Mayo study finds cell phones in hospitals safe; but CD players and anti-theft devices may pose certain risks
- Nursing home resident safety culture scores indicate less developed safety culture - high RN staffing levels associated with higher culture scores
- Patient discharge summaries not available for outpatient physicians two thirds of the time
Safety tools
- Minnesota manual – Methods for temporary negative pressure isolation
- AHRQ – Audio newscast series
- Premier – New Performance Suite™
- WHO – Testing hand hygiene guidelines
- FDA – Avoiding burns from electrodes and cables during MRI exams
- APIC – A business case for preventing healthcare-associated infections
Premier, CMS extend P4P demonstration project; three-year extension includes new incentive models to improve quality
The Centers for Medicare and Medicaid Services (CMS) has approved a three-year extension of the CMS/Premier Hospital Quality Incentive Demonstration (HQID), a national effort involving more than 250 hospitals. The project provides Medicare incentive payments to participating hospitals that deliver the highest quality of care, providing a testing ground to measure quality incentive models.
Congress has required CMS to deliver a Medicare hospital "value-based purchasing" (VBP) plan later this year for its consideration. The HQID project provides important direction for VBP plans since it has already shown dramatic impact for patients and now will continue for three more years to determine if financial incentives do improve quality.
Model During the first three years of the project, only top-performing hospitals have been eligible for Medicare incentive payments. The three-year extension also will test the effectiveness of the following two new models:
- Hospitals achieving a defined level of quality, or quality threshold; and
- Hospitals making the most improvement in quality that also achieve the quality threshold.
The extension will continue to track hospital performance in the clinical areas of pneumonia, heart bypass, heart attack (acute myocardial infarction), heart failure, and hip and knee replacement.
CMS has built into the extension the flexibility to add quality measures and clinical conditions in the fifth and sixth years. New mortality and patient safety measures are among those that may be included in the extension of the HQID project.
Extension While testing new payment models and additional quality measures and clinical conditions for potentially greater improvements, an extension of the HQID will build upon the successes of the initial years of the project.
According to official Year 2 results released in January, participating hospitals raised overall quality by 11.8 percent in two years in the five clinical areas studied. That meant better care and outcomes for more than 800,000 patients.
Improvements in quality of care in participating hospitals over the first two years in the CMS/Premier demonstration project saved 1,284 acute myocardial infarction (heart attack) patients and resulted in approximately 150,000 additional recommended evidence-based treatments, such as smoking cessation, detailed discharge instructions and pneumococcal vaccination.
CMS/Premier Hospital Quality Incentive Demonstration project: www.qualitydemo.com
HHS offers severity index for pandemic flu planning to address home isolation, school closings, work schedules
Recent pandemic influenza guidance released by Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) offers a new pandemic severity index to guide plans for isolating patients in their homes, closing schools, canceling public gatherings, and changing work schedules to help slow the spread of a pandemic.
The guidance, "Interim Pre-pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the United States," introduces the Pandemic Severity Index (PSI), which utilizes five pandemic severity levels. Similar to hurricane classifications, the index ranks pandemics based on case fatality ratios and projected number of deaths.
Community strategies become especially important during the first six months of a pandemic, when a vaccine is most likely to be unavailable. Communities will be challenged to implement the plan and will need to involve their public health workers as well as businesses, local organizations, and individual members of their community. Extra attention is recommended for efforts to support at risk members of the community such as low income and non-English speaking residents. School closings and the isolation of individuals will have a large impact on businesses of all sizes.
Businesses are encouraged to become knowledgeable with social distancing methods, including discouraging handshakes, limiting face-to-face meetings, limiting shared workstations, and offering work alternatives such as working from home, more flexible unscheduled leave policies, and staggered shifts. Continued business operations may even include reconfiguring the work environment to minimize contact between employees and customers.
OSHA business resource The HHS guidance also recommends that employers review the Occupational Safety and Health Administration (OSHA) and HHS' guidance document, released in early February 2007, which helps businesses understand what they need to do to prepare for a pandemic influenza. This guidance specifically addresses the risks and gives advice for various work place settings. The "Guidance on Preparing Workplaces for an Influenza Pandemic" portrays a four-level pyramid that stratifies workplaces by pandemic influenza risk zones and links the zones with preventive steps. It also contains information on stockpiling supplies, providing employees with sources of information, what businesses should include in their plan, and how to maintain operations during a pandemic.
For additional pandemic influenza guidance documents and information, go to the Safety Institute's Influenza Resources web site.
MRSA elimination – only one solution?
Will some of the proposed new laws mandating universal testing of all hospital admissions, and isolating patients with methicillin-resistant Staphylococcus aureus (MRSA) eliminate MRSA infection? Experts agree that the solution is not one single strategy but multiple strategies selected according to an organizational risk assessment of prevalence, patients and programs – the most important being control of antibiotic use.
Proposed state legislation mandates the testing of all hospital admissions for MRSA, with subsequent isolation of culture-positive patients – whether or not the patients have infections. In response, leading infection prevention experts, the Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America (SHEA) recently published a joint position paper titled, "Legislative Mandates for Use of Active Surveillance Cultures to Screen for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci: Position Statement from the Joint SHEA and APIC Task Force." The paper clearly opposes any requirement for "universal screening" (also called "active surveillance cultures," or ASC). While the joint position agrees with the goal to reduce MRSA, it does stress that what appears to be a simple solution is highly complex.
The big picture – prevention and control of multidrug-resistant organisms (MDRO)
MRSA is but one of many organisms resistant to multiple antibiotics treatment; vancomycin-resistant enterococcus (VRE) is another. Infection prevention professionals believe that programs focusing on one organism or one antimicrobial agent are less successful in controlling other critical MDROs, and risk the "ballooning" of other organisms. For example, a well-known proponent of "universal screening," Betsy McCaughey, points to other countries (such as the Netherlands) that successfully reduced MRSA using this "search and destroy" approach. What is less well known by supporters of this approach is that these same countries are not planning to apply the same approach to VRE in their hospitals. Endemic rates of their community-acquired VRE are approaching 4 percent, making this approach impractical and unlikely to succeed according to published studies.
CDC's approach to MDRO Last fall, the CDC released its guidelines, "Management of multidrug-resistant organisms in healthcare settings, 2006," in which it recommends preventing transmission in multiple care settings using a two-tiered strategy. Tier 1 requires a risk assessment based on the facility's data to determine which organism may need to be 'targeted' for reduction efforts. An intensified intervention (Tier 2) is undertaken only after data demonstrate that Tier 1 interventions (standard precautions) are not reducing rates of the MDRO and compliance with Tier 1 recommendations are high. If the incidence or prevalence of the targeted organism is not decreasing, a facility would go to Tier 2, utilizing ASC, among other control efforts. This comprehensive approach ensures continued attention to all MDROs.
IHI MRSA bundle The Institute for Healthcare Improvement has proposed many initiatives with great success using "bundles" to reduce adverse events such as bloodstream infections or pneumonia. However, in its latest "Protecting 5 Million Lives from Harm" campaign, IHI adds a "Reduce MRSA" intervention. The "MRSA bundle" includes ASC primarily for high-risk patients. Although ASC is not recommended for all admissions, it does not include CDC's MDRO Tier 1 process.
MHA-Keystone The Michigan Hospital Association's Keystone Center also has had considerable success using bundled interventions to reduce healthcare-associated infections (HAI). This statewide initiative has focused on the elimination of HAIs ("no infection, no resistance, no problem") and has achieved and sustained zero bloodstream infection rates for over 18 months in well over 100 ICUs without using ASC. This approach using bundling of evidence-based practices was described in a recent issue of the New England Journal of Medicine. In a letter to all hospital CEOs in Michigan, the Keystone Center said its approach supports the IHI campaign with one important difference: The Keystone-HAI initiative incorporates the CDC MDRO Tier 1. Moreover, it notes that the initiative "has already built in steps to measure such compliance, e.g., hand hygiene. Immediate institution of ASC without data on adherence to Tier 1 is a reactive and more costly approach that requires the culturing of each patient and the isolation of that patient until either culture results or rapid test results are available. In the consideration of how best to expend limited resources, the MHA Keystone Center has chosen not to recommend the use of ASC as a routine part of Keystone: HAI. Rather, Keystone: HAI continues to focus on the use of evidence-based, best-practice interventions that have been demonstrated to be effective in preventing infections."
SHEA and APIC The position paper noted earlier states that although there is considerable evidence supporting the use of active surveillance cultures as a clinically effective and cost-effective method for combating the transmission of MDRO in specific circumstances, to mandate the strategy as the single infection control intervention to be applied in all circumstances would preclude local risk assessment and the implementation of a broad range of interventions. Both organizations stress that while they support ongoing and additional research, such research must not only employ the most appropriate methodology, but also specifically anticipate and address the many uncertainties and potential unintended consequences of such a strategy.
SHEA-APIC Position paper, Legislative Mandates for Use of Active Surveillance Cultures to Screen for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci: Position Statement from the Joint SHEA and APIC Task Force.
The Safety Institute's Evidence-based practices and "bundling interventions" web site
New England Journal of Medicine bloodstream infection reduction article abstract. Go to Additional resources: "Pronovost study abstract-Catheter-related blood stream infections."
Nearly half of adverse event reported in Minnesota involved surgery - retained objects and wrong-site surgery
Data from Minnesota's "Adverse Health Events Third Annual Report" indicate that nearly half of the 154 reported adverse events were surgery related. These included 42 retained objects and 23 wrong-site surgeries. Minnesota has been collecting data from hospitals, ambulatory surgical centers and regional treatment centers on 27 preventable adverse events, such as wrong-site surgeries, pressure ulcers, retained objects after surgery, death or serious disability from a medication error or death from a fall. These events based on the National Quality Forum list are now required reporting in Minnesota with the purpose to help hospitals focus on learning what went wrong – not whom to blame.
The "Adverse Health Events in Minnesota: Third Annual Public Report" summarizes the number and types of events that occurred between October 7, 2005, and October 6, 2006. According to the report, during that period, 154 adverse events were reported by 49 facilities, and 24 deaths and seven serious disabilities resulted from the events.
Actions taken The report describes the steps being taken by facilities to prevent these adverse health events following the hospitals' findings from root cause analyses of the events. This year's report also includes a new consumer guide and an interactive Web site. The consumer guide provides information about the adverse events reporting system and tips for working with healthcare providers to ensure safe care. The interactive Web site allows consumers to select specific hospitals and surgical centers to see what, if any, adverse events have been reported by that facility.
Types of events The most frequently reported event was stage three or four pressure ulcers (serious bed sores) (48); the next most frequently reported event was a foreign object left in a patient after surgery (42). Of the 24 reported deaths, 12 were due to falls.
Preventive strategies Some of the strategies that will be used to prevent these errors include establishing multidisciplinary skin care teams to identify and prevent pressure ulcers before they become serious, improving how patients are assessed for the risk of developing a serious pressure ulcer, developing new ways to track sponges and other objects used in surgical procedures, ensuring that procedures for counting those objects are thorough and consistent throughout a facility, clarifying policies both inside and outside the operating room to ensure correct site surgery, and improving how patients are assessed for the risk of falling.
These strategies are developed from results of the root cause analyses performed by the individual facilities. The top four root causes of the adverse events included communication; environment and equipment; training; and policies and procedures. Many facilities reported more than one contributing factor and while the individual events may be different, researchers identified some common contributing causes. The report urges consumers and patients to use its information to increase their awareness of patient safety issues and to let their healthcare providers know that patient safety and adverse event prevention are among their priorities.
Adverse events report (.pdf) (975 KB)
The Minnesota Department of Health (MDH) Adverse Health Events Web page can
be accessed at:
http://www.health.state.mn.us/patientsafety.
For more information on error reporting, go to the Safety Institute's Patient safety web site, Part II – A framework for safety culture and reporting.
Mayo study finds cell phones in hospitals safe; but CD players and anti-theft devices may pose certain risks
The Mayo Clinic has updated earlier studies on cell phone safety with more recent data that supports their safe use in hospitals. However, other electronic equipment such as stores' anti-theft devices may cause implanted heart devices to malfunction unless safe distances are maintained.
Premier's February 2007 Safety Share cited a 2005 Mayo clinic study that noted decreases in EMI events, most significantly in "clinically important" events, yet these events were not eliminated. At that time researchers reported on testing 15 devices with six cell phones and found a "clinically important interference" of only 1.2 percent. The authors concluded then that the use of the newer technology must be close to medical devices before any interference is noticed.
Cell phones - 2007 David Hayes, M.D., and colleagues reported in the "Mayo Clinic Proceedings" (March 12, 2007) that no phone problems were found during 300 tests run from February through June 2006. The cell or mobile phones were tested using two different technologies from different carriers, switching them on near 192 medical devices in 75 patient rooms. The incidence of clinically important interferences was 0 percent.
Other electronic devices The Mayo Proceedings also noted in two other articles that a CD player affected an electrocardiogram (ECG) reading and identified problems of malfunctioning devices in individuals with implanted heart devices (pacemakers or cardiac defibrillators) when in stores using an anti-theft device. These incidents would be prevented, however, by simply moving some distance from devices using magnetic fields, researchers noted.
February 2007 Safety Share article
Mayo Clinic Proc abstract 2007
More information on cell phones and EMC is available at the Safety Institute's Cell phone web site.
Nursing home resident safety culture scores indicate less developed safety culture - high RN staffing levels associated with higher culture scores
Patient safety culture has been the subject of many studies done in hospitals settings, but few studies have examined safety culture in nursing homes. A recent survey of 2,840 nursing home administrators examined resident safety culture using the AHRQ's Hospital Survey on Patient Safety Culture (HSOPSC) survey tool. Findings of the study, "Nursing home administrators' opinions of the resident safety culture in nursing homes," were published in "Health Care Management Review" (January-March, 2007).
Results indicated that most of the HSOPSC subscale scores from the nursing home sample were considerably lower than the hospital scores. However, for team work across units, the average scores for nursing homes (55 percent) were higher than those for hospitals (53 percent). A regression analysis found staffing was significantly associated with higher resident safety scores -- the highest resident safety scores being associated with RN staffing. A number of studies have found an association between RN staffing levels and quality indicators implying that adequate staff is needed to provide care. The authors caution the interpretation of this finding because it represents the opinion of nursing home administrators and not actual practice. However, they note that it is possible that the resident safety culture is more highly influenced by RNs because they are in leadership positions and thus influence the interactional and organizational norms in a facility.
An analysis of facility characteristics found that membership in a chain and higher average private pay occupancy were also significantly associated with high resident safety scores. The authors note that certain facility characteristics such as RN staffing, chain membership and higher private pay resident occupancy have also been associated with higher quality and therefore resident safety culture may be a proxy for quality of care. It is believed that chain membership provides some degree of economies of scale and free resources for members to pursue resident care initiatives and a higher percentage of private pay residents provide more funding for safety initiatives.
"Nursing home administrators' opinions of the resident safety culture in nursing homes" (.doc) (36 KB)
For additional information on safety culture and use of HSOPSC tool, see the Safety Institute's Culture – Patient safety web site.
Patient discharge summaries not available for outpatient physicians two thirds of the time
Poor communication and information transfer between inpatient and outpatient physicians at discharge adversely affects patient care. A recent analysis of 73 published studies published in the Journal of the American Medical Association, "Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians - Implications for Patient Safety and Continuity of Care," (February 28, 2007) describes significant deficits in timeliness, content, and format of discharge communications between inpatient (hospital physicians) and outpatient (primary care physicians).
Direct communication between primary hospital physicians and primary care physicians was rare, with only 3 percent of primary care physicians directly involved in the discharge process, and only 17-20 percent reporting always being notified of discharges.
Discharge summaries were available from only 12-34 percent of the first post-discharge visits; discharge summary availability remained low at four weeks from 51-77 percent, and 25 percent of summaries never arrived. Where information was available, it frequently lacked important data such as test results, hospital course and medication. For example, discharge summaries often lacked important information about diagnostic test results, hospital treatment, discharge medications, test results pending at discharge, patient or family counseling, and follow-up plans. Researchers stated that this lack of information negatively influenced care quality in one-quarter of follow-up visits and led to primary care physician dissatisfaction with communication processes.
Interventions that expedited the exchange of discharge information between hospital-based physicians and primary care physicians included computer-generated discharge summaries and using patients as couriers. The authors provide a standardized format to show that the most pertinent information improved the perceived quality of documents.
With the rapid growth in hospitalists, it has become increasingly important for hospital-based physicians to communicate relevant patient information with the primary care physician at hospital discharge. The authors conclude that the current methods of transferring discharge information are inadequate and adversely affect patient care. Interventions could include use of health information technology and most importantly, a timely and standard format for sharing pertinent information.
JAMA Communications abstract (.doc) (29 KB)
The Safety Institute's Patient safety web site
Safety tools
Minnesota manual – Methods for temporary negative pressure isolation
This manual was written to assist hospitals in developing strategies for temporary negative pressure isolation and provides instruction on the use of equipment used for airborne infectious disease management. In addition to graphic "how to" portrayals, the guide includes tools such as preventative maintenance schedules and a sample log for measuring particle counts for performance improvement planning. Additional information, including education/training slides, are located at the Web site below. Download
the manual from the Safety Institute's
Construction, ICRA,
risk assessment web site, or go to:
http://www.health.state.mn.us/oep/training/
bhpp/isolation.html
AHRQ – Audio newscast series
This site provides the agency's latest healthcare research findings, news, and information. This site enables viewers to also hear the newscasts through a computer or permit a download to a portable digital player such as an iPod.
Go to: http://www.healthcare411.org/
This link is also available from the Safety Institute's Patient safety web site under "Resources."
Premier – New Performance Suite™
The Premier Performance Suite is a comprehensive offering of hospital performance tools to integrate quality and safety, labor management, and supply chain channels for a global approach to improving overall quality and cost. The Performance Suite provides Web-based performance measurement and benchmarking, real time surveillance, and best practices to allow hospitals to make better decisions. For more information on the Premier Performance Suite, visit the home page at: https://premierinc.com/quality-safety/tools-services/performance-suite/.
WHO – Testing hand hygiene guidelines
The World Health Organization's (WHO) first global patient safety challenge, "Clean Care is Safer Care," acknowledges the importance of addressing the global challenge of healthcare-associated infections (.pdf) ( 2 MB). Low-cost WHO strategies that help reduce infection risks in areas such as blood products and their use, injection practices and immunization, safe water, basic sanitation and waste management, and clinical procedures, particularly in first-level emergency care, are already available. These strategies are combined with efforts to implement the WHO Guidelines on Hand Hygiene in Healthcare (Advanced Draft). The draft is available for download at: http://www.who.int/gpsc/resources/newsalert/jan2007/en/
More information available in the January 2007 edition of the "Clean Care is Safer Care NewsAlert" explains how to enroll your healthcare facility in testing the advanced draft version of the WHO Guidelines on Hand Hygiene in Healthcare. Additional information on the "First Global Patient Safety Challenge" can be found at http://www.who.int/gpsc/en/.
FDA – Avoiding burns from electrodes and cables during MRI exams
Patients undergoing MRI exams while wearing ECG electrodes and cables have experienced second and third degree burns sometimes requiring plastic surgery to repair. After a FDA investigation into reports received regarding these burns, precautions that can be taken to prevent these types of burns were released. The problem is the radiofrequency fields created during an MRI exam can heat ECG cables and electrodes, seriously burning the underlying skin. In a Nursing 2006 article (.doc) (29 KB), the FDA promoted the precautions for reducing the risk of such burns. These include:
- Remove any electrodes and cables that are no longer being actively used for monitoring.
- If the patient needs ECG monitoring during the MRI procedure, check beforehand with the MRI staff to be sure that the cables and electrodes have been cleared for use in the MRI environment. If still in doubt, check with the manufacturer of these devices.
- Be sure that there is complete contact between the electrode surface and the patient's skin; poor contact can result in a serious burn even if you are using electrodes and cables that are approved for MRI.
- Avoid looping and crossing the cables, because this can create excessive heat from resistance in the cable, which can burn the patient. Keep cables off the patient's skin.
- After completing the MRI study, examine the patient for possible burns or reddening of the skin under the electrodes. This is especially important for patients who can't express themselves, or those who have impaired sensation. If the patient has a burn, administer appropriate treatment.
APIC – A business case for preventing healthcare-associated infections
The Association for Professional in Infection Control and Epidemiology (APIC) has released a white paper on healthcare associated infections (HAI) titled "Dispelling the Myths: The True Cost of Healthcare-Associated Infections." Featured in the March issue of Healthcare Financial Management magazine, the white paper presents the business case for reducing HAIs from the perspective of the healthcare executive. Case studies of cost saving are detailed, along with a methodology for determining the cost of different categories of HAIs. APIC's goal with the white paper is to help healthcare executives understand the costs involved with these infections, evaluate HAIs in their own institutions and take a more aggressive approach to infection prevention.
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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.
Premier offices:
San Diego, CA
12225 El Camino Real
San Diego, CA 92130
Charlotte, NC
2320 Cascade Pointe Blvd.
Charlotte, NC 28208
Washington, DC
444 N. Capitol Street, NW Suite 625
Washington, DC 20001
Safety Share © 2007 Premier, Inc.
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