April 2006
Dear Colleague:
Looking for a tool to help with JCAHO's National Patient Safety Goal on hand hygiene compliance? See the tool developed by CDC in collaboration with IHI, APIC, SHEA and other groups.
Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- CDC, IHI release new tool to increase hand hygiene compliance
- Antimicrobial skin bathing reduces colonization from resistant organisms
- Study: Hospital safety culture is local and influenced by department-specific safety policies
- Private patient rooms – a new building requirement promotes safety
- JCAHO urges local best practice over prescriptive approach to USP 797 standard for sterile medication prep
- AHRQ seeks safety culture survey data - new benchmarking initiative
- CMS updates Hospital Compare quality data
- Premier earns fourth consecutive environmental leadership award
Safety tools
- Preparedness planning – pediatric needs
- Influenza pandemic – home health checklists
- NIOSH – patient handling
- Harvard report – disclosure of adverse events
CDC, IHI release new tool to increase hand hygiene compliance
A program to boost hand hygiene compliance to 100 percent using behavior-modification techniques, "best practice" guidelines, and rigorous program compliance was launched in early April by the Centers for Disease Control and Prevention (CDC) in collaboration with the nonprofit Institute for Healthcare Improvement (IHI) and two leading infection-control professional societies – the Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America (SHEA).
Major studies still report lagging compliance rates averaging 50 percent, in spite of the CDC's 4-year-old hand hygiene guidelines aimed at stemming the spread of bacteria on contaminated hands, and improving access to alcohol-based hand rub dispensers in healthcare facilities. The IHI program, meanwhile, recommends a far more active approach and holds organization administrators and staffers accountable for failure.
The new tool details a "hand hygiene intervention package," which reviews a group of best practices to use individually or together to improve care. The document also gives a "how-to" for beginning improvement in healthcare organizations through the institution of a multidisciplinary team approach. It addresses barriers to implementing a program, provides checklists for hand hygiene materials and a questionnaire for surveying clinical staff of their knowledge of hand hygiene.
The IHI suggests that for their part, healthcare organizations take such steps as ensuring staff wash their hands after removing gloves to remove any bacteria that may have been transferred from the gloves to the hands, asking staff members to help make hand-hygiene rules easy to comply with, and verifying that alcohol-rub dispensers are conveniently placed and fully functional. This means organizations must be vigilant in maintaining hand cleanser dispensers, many of which are not conveniently located or refilled.
More hand hygiene resources are available from the Premier Safety Institutes' Web site.
Hand hygiene tool (.pdf) (230 KB)
Developed by CDC in collaboration with IHI, APIC and SHEA
IHI Web site:
www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Tools
More information on Hand Hygiene
Antimicrobial skin bathing reduces colonization from resistant organisms
A method to interrupt pathogen transmission using "source control" (e.g., patient skin decontamination) may be added to recommended infection control practices in the future if additional studies can confirm a recently published study's apparent safety and efficacy. The study by Vernon et al. found that when patients were cleansed with chlorhexidine gluconate-saturated (CHG) washcloths, there was a significant decrease in the incidence of vancomycin-resistant enterococci (VRE) acquisition among patients, a decrease of VRE on the hands of caregivers and decreased VRE environmental contamination.
Patient skin cleansing study The purpose of the study was to evaluate patient skin decontamination as a means of lowering the overall microbial load in a medical ICU, and also decrease the level of environmental contamination and transmission within the unit. During a period between October 2002 and December 2003, 1,787 patients were bathed or cleansed and assessed periodically for VRE acquisition. In the three study periods each lasting four to five months, patients were bathed daily using 1) soap and water; 2) single-use, no-rinse disposable cloths saturated with 2 percent CHG; or 3) non-medicated disposable cloths identical in appearance to the CHG cloths. Staff hands were also assessed for VRE throughout the study. The results were dramatic. Use of soap and water was comparable to plain disposable cloths. But use of the CHG-impregnated cloth resulted in a greater than 50 percent reduction in skin colonization with VRE, a significant decrease in VRE contamination in the environment and on nurses' hands and most importantly, a significant decrease in the incidence of VRE acquisition among patients (26 colonizations per 1,000 patient-days to 9 per 1,000 patient-days).
There appeared to be no adverse events, though future studies are needed to reinforce the apparent safety and efficacy of this application, especially to determine its application to other resistant organisms such as MRSA. However, these results suggest this simple method may be an important adjunctive approach to the control of VRE. Cleansing patients with CHG-saturated cloths is a simple, effective strategy to reduce VRE contamination of patients' skin, the environment, and healthcare workers' hands, as well as decreasing patient acquisition of VRE.
Patient skin cleaning prior to surgery A related study on the use of chlorhexidine-gluconate bathing to reduce skin contamination prior to surgery was presented in an abstract by Maki et al. during the Society for Healthcare Epidemiologists of America (SHEA) conference in Chicago, March 19, 2006. The poster "Prospective evaluation of six preoperative cutaneous antiseptic regimens for prevention of surgical site infection" summarized the effects of bathing with CHG prior to surgery. Proper application and skin cleansing with CHG-impregnated washcloths appeared to have a remarkable effect on reducing all skin contaminants (colonization), regardless of the type of surgical site prep used just prior to incision.
Although neither study measures outcomes in terms of reduced infections, each study is encouraging and point to potential methods to better reduce skin colonization and control transmission of resistant organisms in healthcare facilities.
"Effectiveness of Source Control" abstract – Archive of Internal Medicine. 2006; 166: 306-312. (.doc) (25 KB)
"Prospective Evaluation of six Preoperative Cutaneous Antisepsis" – Maki abstract. (.doc) (30 KB)
Study: Hospital safety culture is local and influenced by department-specific safety policies
Hospitals' attempt to improve safety culture and increase error reporting often focus on hospital-wide formal error reporting processes. A recent study in Medical Care assessed how the safety culture of individual departments of a hospital affected the reporting of treatment errors.
A questionnaire was used in three hospitals among three medical departments: internal medicine, surgery, and intensive care. The questionnaire attempted to assess: how the three departments perceived existing safety procedures; how safety information flowed within the department; and the priorities given to safety within the department. Risk management records were used to collect information on the number of reported errors. In general, the study found that the clinicians were more willing to report treatment errors when they were instructed on safety procedures as they relate to their daily work and working conditions. Overall, staff also felt more secure in reporting errors when they perceived that safety and safety training information was readily available. However, there was also variation between departments. For example, internal medicine and surgical staff were significantly more likely and willing to report errors than those in intensive care units because they more readily perceived the suitability of safety procedures to their culture.
The authors concluded that hospitals must realize the importance of taking into account employee perceptions regarding safety procedures and related information and understand that these perceptions – and employee willingness to report treatment errors – can vary significantly among departments.
This article adds to the body of growing knowledge that culture is local and highlights the need to further understand the unique characteristics of each department type. Additional issues that should be explored for individual departments include their task characteristics, technology, level of discretion needed to perform work, and level of required interaction with other departments.
Abstract: "Readiness to Report Medical Treatment Errors" (.doc) (28 KB)
Premier's Culture of Safety Web site
Private patient rooms – a new building requirement promotes safety
The adoption of single-bed (private) rooms as a standard for new hospital construction will become a new minimum requirement for new hospital construction with the publication of the 2006 edition of "Guidelines for Design and Construction of Hospital and Health Care Facilities." The guidelines are scheduled for release by June 2006. In studies commissioned by the Facilities Guidelines Institute (FGI) and the American Institute of Architects' Academy of Architecture for Health (AIA/AAH), private rooms appear to reduce the risk of disease transmission, lower the risk of medical errors, and decrease the risks of falls. In fact, those studies suggest that hospitals may benefit economically from having all private rooms. A private room typically costs more than a semi-private room, and insurance normally does not cover the difference. If all of the rooms were private, Medicare, Medicaid, and private insurers would be required to pay one standard rate, study authors argued.
Most observers note, however, that not all hospitals will be able to build all private rooms, given space constraints that may exist in some urban areas. Hospitals must also consider "surge capacity" – the ability to add beds in an emergency or disease outbreak. Facilities do have an opportunity to make modifications as needed in conjunction with state authorities. The approved language in the new guidelines state that:
"In new construction, the maximum number of beds per room shall be one unless the functional program demonstrates the necessity of a two-bed arrangement. Approval of a two-bed arrangement shall be obtained from the licensing authority. Where renovation work is undertaken and the present capacity is more than one patient, maximum room capacity shall be no more than the present capacity, with a maximum of four patients."
New material in the 2006 document includes updated sections and new chapters on small inpatient primary care hospitals, as well as concerns with "green" architecture, and therapeutic, safe patient environments. The new rules also include safety recommendations for better ventilation systems to optimize conditions to reduce transmission of airborne microorganisms and also support placement of dispensers for alcohol-based hand sanitizers when space does not permit required sinks.
The guidelines are published every four years by the AIA/FGI and are used by more than 40 state governments to set regulations, approve construction plans and license hospitals. The FGI also provides a formal interpretation process between editions with support from the American Society for Healthcare Engineering (ASHE) to address guidelines questions, including concerns about private rooms. The final interpretation of the Guidelines is the responsibility of the state or federal authority having jurisdiction.
For additional information and downloads on construction, ICRA, single rooms and more, see the Premier Safety Institute's Construction – Infection control risk assessment module at: http://www.premierinc.com/quality-safety/tools-services/safety/topics/construction/
For information on how to request a formal interpretation, visit http://www.aia.org/aah_gd_hospcons
JCAHO urges local best practice over prescriptive approach to USP 797 standard for sterile medication prep
Hospitals have struggled to develop capital budgets to upgrade existing pharmacy sterile medication preparation rooms in anticipation of meeting a proposed pharmacy standard revision. JCAHO had announced its intent to enforce a USP-797 draft standard once finalized but has recently published a clarification in its April 2006 Perspectives newsletter that permits different ways to meet the still-pending USP-797 "Compounding Sterile Preparations" standard.
JCAHO position The Joint Commission says it evaluates compliance with its standards – not compliance with the details of USP-797. The JCAHO permits organizations to determine how they can best comply with USP 797 if it is not mandated by state regulations, and within a reasonable time frame. (There are only 16 states in which state pharmacy boards mandate compliance with USP-797.) An organization may choose an alternate approach to a specific USP guideline based on their review of literature. JCAHO considers USP-797 a valuable guideline that describes a best practice for establishing safe processes in compounding sterile medications. This guideline can help organizations comply with JCAHO standards, specifically Medication Management standard MM.8.10, which requires organizations to evaluate literature for new technologies and successful practices relevant to improving their medication management systems.
Recommended action JCAHO recommends that the new standard be reviewed carefully for all applications. By inference, this includes ventilation design, hand hygiene, and sampling of products for quality control. JCAHO also recommends documentation demonstrating that the organization has read and considered USP-797and then made decisions in light of this standard as one source of "best practice." Organizations must document their review of other sources of "best practices," such as the CDC's Guidelines for Environmental Infection Control and Guidelines for Hand Hygiene.
American Journal of Health-System Pharmacy (AJHP) Another excellent resource to consider is an AJHP study (November 2005): "I.V. admixture contamination rates: Traditional practice site versus a class 1000 cleanroom," which describes the contamination rates associated with the preparation of admixtures in a traditional practice site compared to a class 1000 cleanroom. USP-797 procedures were followed and aseptic technique used. Results of this study indicated no significant difference in the contamination rates between the traditional practice site and the cleanroom environment. The researchers concluded that the most important variable affecting microbial contamination was the aseptic technique of the personnel, not the environment in which the drugs were compounded. They further concluded that the assumption that a cleanroom will eliminate medication contamination is not a safe one and continuous quality monitoring of personnel's aseptic technique is mandatory. An American Society of Healthcare Engineering (ASHE) Regulatory Advisory provides additional perspective on this issue.
The Joint Commission Perspectives article can be obtained at:
http://www.ingentaconnect.com/content/jcaho/jcp/
2006/00000026/00000004/art00006
CDC Environmental Control Guidelines
Abstract, "I.V. admixture contamination rates: Traditional practice site versus a class 1000 cleanroom" (.doc) (23 KB)
Full text of the American Journal of Health-System Pharmacy can be obtained at:
http://www.ajhp.org/cgi/content/full/62/22/2386
ASHE Advisory (.pdf) (38 KB)
AHRQ seeks safety culture survey data - new benchmarking initiative
AHRQ is establishing a new benchmarking database on the AHRQ Survey on Patient Safety Culture. The database will be an important resource for hospitals wishing to compare their survey results with other hospitals. Any U.S. hospital that has completed the AHRQ survey by May 31, 2006, is eligible to participate and must submit their results to AHRQ by June 30, 2006. The database is expected to be published by October 2006. A second annual database is already planned for 2007 for data submitted between June 1, 2006, and May 31, 2007.
Aggregate hospital-level data will be available free to the public on the AHRQ Web site. Participating hospitals will have access to additional analyses using multiple hospital characteristics. Individual hospital data will be broken down by bed size, teaching status, and other hospital characteristics but will only be available to participating hospitals and health systems. Information on eligibility, registration, and data submission is available on the AHRQ Web site at http://www.ahrq.gov/qual/hospculture.
AHRQ has provided preliminary benchmarks for the safety culture survey to allow hospitals to compare their survey results against the results from 20 hospitals that participated in a 2003 pilot test of the survey.
Premier's Culture of Safety Web site – Benchmarking update (link to this site)
Pilot benchmarking (.pdf) (58 KB)
AHRQ information: http://www.ahrq.gov/qual/hospculture
CMS updates Hospital Compare quality data
CMS recently updated its Hospital Compare Web site with latest 2005 data from the Hospital Quality Alliance hospitals. The site enables patients and families to compare the performance of the nation's acute care hospitals on 20 quality measures for care provided to adult patients since 2004, including heart attack, heart failure, pneumonia and prevention of surgical infections.
The majority of acute care hospitals voluntarily provided data on measures identified by the Hospital Quality Alliance (HQA). Approximately 4,200 hospitals provided information on 18 measures for heart attack, heart failure and pneumonia. These measures included the 10 forming the "starter set" in October 2003 plus measures added in April, 2005. Data provided by 1,349 hospitals on two measures for surgical infection prevention were added to the site in September 2005. The "starter set" remains the only set of indicators currently tied to CMS's full market basket reimbursement as noted in the summary table of quality indicators.
Later this year, HQA participants will begin collecting data from a new national survey on patients' perceptions of hospital care, known as H-CAHPS, or the CAHPS Hospital Survey (Consumer Assessment of Healthcare Providers and Systems), with the first public reporting of results slated for late 2007. HQA partners include CMS, the American Hospital Association and other hospital groups, the AFL-CIO, AARP, and others.
Access the Hospital Compare Web site at: http://www.hospitalcompare.hhs.gov/
AHRQ information on H-CAHPS: https://www.cahps.ahrq.gov/default.asp
HQA summary table of scheduled quality indicators
(.pdf) (85 KB)
Premier earns fourth consecutive environmental leadership award
Article text.
Premier and 28 of its members have received awards from Hospitals for a Healthy Environment (H2E) for achievements in environmentally preferable purchasing (EPP), pollution prevention, elimination of harmful mercury, and reductions in waste and toxicity. Premier received the 2006 Champions for Change Award H2E for its leadership role in helping hospitals enhance workplace safety and promoting environmentally friendly purchasing and practices through its Environmentally Preferable Purchasing (EPP) program.
Premier's environmentally preferable purchasing program assists members in enhancing the safety and health of patients and healthcare workers, and supports the healthcare industry's efforts to reduce or eliminate products deemed harmful to the environment. Initiated in 2001, the EPP program, a collaborative effort of the Premier Safety Institute and Premier's Group Purchasing Services, offers products, resources, and information about environmentally friendly alternatives. EPP encompasses products and packaging that prevent pollution and are less toxic, more energy efficient, and safer and healthier for patients, workers and the environment, compared to competing products and services.
The Premier Safety Institute provides a wealth of related information through its comprehensive, publicly available Web-based tools and other resources available at the Safety Institute Web site at www.premierinc.com/safety. These include a newly launched Green Link newsletter on green purchasing and healthcare practices, a CEO Scorecard for environmental assessments and resources on mercury pollution prevention, latex allergies, reuse of single-use devices, DEHP, PVC, green cleaners, pharmaceutical waste, and computer "e-waste." In addition, Premier offers the only publicly available list of mercury-containing pharmaceuticals to help hospitals identify, manage, and dispose of these potentially hazardous drugs.
EPP related Web-based tools and resources
Safety Institute: http://www.premierinc.com/safety
Safety tools
Preparedness planning – pediatric needs
The Agency for Healthcare Research and Quality (AHRQ) has released "The Decontamination of Children: Preparedness and Response for Hospital Emergency Departments." The 27-minute training video teaches hospital personnel how to decontaminate children after being exposed to hazardous chemicals during a bioterrorist attack or other type of disaster. It reviews strategies, tools and key preparedness planning issues. The training video is intended for hospitals and emergency and pediatric professionals because it explains the unique needs of children versus adults during public health emergencies. The video also covers three main areas: a step-by-step presentation of the decontamination process; a real-time demonstration of the decontamination of children from infancy to adolescence, and; a section for administrators that outlines the steps involved in establishing and maintaining a pediatric decontamination facility in any emergency department. The video is available in DVD and VHS format. To obtain a free single copy, contact the AHRQ Publications Clearinghouse at 800.358.9295, or via email at ahrqpubs@ahrq.gov. The Clearinghouse can also provide multiple copies for a charge.
Influenza pandemic – home health checklists
The Department of Health and Human Services (HHS) has developed a checklist to help home healthcare providers care for the sick during an influenza pandemic. The checklist will help organizations assess their readiness to respond by identifying strengths and weaknesses. It also explains that building community contacts will provide a strategic advantage if a pandemic influenza strikes. The checklist was designed with a pandemic influenza in mind, although it may be used in other types of emergencies. Some of the suggestions include:
- Creating a planning committee to specifically address pandemic influenza preparedness;
- Identifying points of contact at local and state health departments, emergency management srvice providers, and other community healthcare providers;
- Ensuring your plan complements local response plans;
- Planning for an increase in patients who require home healthcare services during a pandemic;
- Planning for an increased demand on supplies, such as masks, hand hygiene materials, food, medications and other necessities;
- Developing a system for evaluating symptomatic personnel before they report for duty;
- Identifying the minimum number and categories for nursing staff and other professional personnel necessary to sustain home care services for a given number of patients; and
- Developing a contingency staffing plan.
Download a copy of the English (.pdf) (200 KB) or Spanish (.pdf) (291 KB) "Home Healthcare Services Pandemic Influenza Planning Checklist." More information can be found at http://www.pandemicflu.gov/plan/tab6.html.
NIOSH – patient handling
The National Institute for Occupational Safety and Health (NIOSH) has a draft, "Evaluation of Safe Patient Handling and Movement Principles", available for comment until May 30, 2006. The presentation was developed for use in nursing schools to improve work practices for patient care workers. It covers the definition of ergonomics, risk factors for musculoskeletal injury during patient handling and movement, recognizing high-risk patient care activities and conditions that result in high-risk patient-care environments, and identifying the best solutions for patient handling. The draft may be viewed and information obtained on how to submit comments at:
http://www.cdc.gov/niosh/review/public/safe-patient/.
Harvard report – disclosure of adverse events
A working group of risk managers and clinicians from several Harvard teaching hospitals, the School of Public Health, and the Risk Management Foundation (Malpractice Captive for the Harvard Teaching Institutions) have released a consensus statement titled "When Things Go Wrong: Responding to Adverse Events" (.pdf) (196 KB). The consensus statement is intended to provide a deeper understanding of preventable adverse events, their impact on patients, families, and providers, and how to manage such events. The report provides detailed guidelines based on the premise that all care should be safe and patient-centered and proposes a full disclosure when adverse events or medical errors occur, including an apology to the patient. The report is divided into three major sections: the patient and family experience, the caregiver experience, and the management of the event. Each section contains a summary of the expert consensus of the issue, including the reasoning and evidence behind the consensus, and recommendations. The report also offers appendices that include recommendations, a case study on communicating with patients and families, elements of emotional support of caregivers, and a bibliography on medical disclosure.
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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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