June 2007
Dear Colleague:
Two stories this month highlight factors that improve patient outcomes in intensive care units (ICUs) – appropriate nurse staffing of adult ICUs and greater experience in treating low birth weight infants in neonatal ICUs.
Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- Higher RN staffing linked to lower risk of healthcare-associated conditions
- Regulators agree – Alcohol foam hand rubs dispensed in healthcare hallways as safe as gel
- Tubing misconnections, sharps disposal, hand hygiene among safety solutions from WHO
- A combination of paper and computer-based safety reporting systems provides lessons for improving event reporting
- Decreased infant mortality linked to high-level, high-volume neonatal intensive care units
- Patient lift devices, bariatric issues planned for 2010 AIA Guidelines – public invited to comment
- Premier seeks entries for 16th annual Cares Award for innovative programs to improve the health of the medically underserved
Safety tools
- AHRQ DVD – Training for respiratory care/vents in disasters
- Monitor news daily - Premier’s free Media Monitoring e-mail newsletter
- AORN Patient Hand-Off toolkit – Free Web-based surgical patient transfer
- AHRQ toolkit – "Mistake-proofing" healthcare process design
- OSHA – Complete HCW pandemic flu preparedness guidance
- AHRQ – Sample healthcare quality report cards
Higher RN staffing linked to lower risk of healthcare-associated conditions
A recent study examined the effects of hospital working conditions for nurses on elderly patient safety outcomes in intensive care units (ICUs). The study included 15,846 patients in 51 adult intensive care units in 31 hospitals; 1,095 nurses were surveyed. Patient outcome data were collected using CDC’s National Nosocomial Infection Surveillance System (NNIS) protocols and Medicare files. Hospital organizational climate was measured using nurse surveys, staffing patterns, and payroll data for overtime and wages.
The study, "Nurse Working Conditions and Patient Safety Outcomes," published in the June 2007 issue of Medical Care, found that units with higher staffing levels (the average was 17 registered nurse hours per patient day) had lower incidence of certain healthcare-associated conditions. Higher staffed units were found to have lower incidences of central line-associated bloodstream infections (CL-BSI), ventilator-associated pneumonia (VAP), 30-day mortality, and pressure ulcers. Increased overtime hours were associated with higher rates of catheter-associated urinary tract infections and pressure ulcers, while less overtime was associated was associated with a lower incidence of CL-BSI. Wages were not found to be associated with any of the outcomes under review. This is the first study to link NNIS infection surveillance data and other patient outcomes to nurse working conditions. Authors conclude that improving nurse working conditions will improve patient safety. Although they suggest that hospitals may be able to improve their ICU staffing by increasing the availability of qualified float nurses, they stress that this should be explored further.
Illinois introduces legislation for nurse staffing
based on acuity
States are recognizing the importance of nurse staffing and acuity and are enacting legislation that focuses on the issue and involves nurses in the decision making process. On May 29, the state of Illinois successfully passed Senate Bill 0867, "Nurse Staffing by Patient Acuity," which requires each hospital to implement a written staffing plan aligning patient care needs with registered nurse expertise. In addition to the baseline written staffing plan, each hospital must implement a patient acuity tool that helps guide the need for additional staff due to changing patient care acuity. The Illinois Nurses Association (INA) rejected a statewide mandated fixed staffing ratio plan because staffing by a specifically required ratio does not take into consideration the nursing staff expertise or patient acuity. SB 0867 requires that direct care staff nurses participate in determining both the written staffing plan and in identifying the patient acuity tool. The Illinois Hospital Association (IHA) has maintained that the bill reinforces an evidence-based approach to nurse-patient staffing and complements the hospitals’ current policies and practices. When signed, the bill will take effect in January 2008.
Staffing and Safety Outcomes (.doc) (29 KB)
For more information on SB 0867, go to:
http://www.ihatoday.org/advocacy/state/sb867.html
Regulators agree – Alcohol foam hand rubs dispensed in healthcare hallways as safe as gel
The latest revision to the International Fire Code (IFC) is the final change needed to simplify healthcare personnel's access to all types of alcohol-based hand rubs (ABHR) in corridors. This revision by the International Code Commission now (ICC) permits foam as well as gel dispensers in corridors, making all regulations equivalent and improving opportunities for hand hygiene. Approved on May 25, 2007, the revised code is now similar to the codes currently enforced by the Centers for Medicare and Medicaid Services (CMS) and is consistent with Joint Commission requirements. Details on the revisions and their implications for healthcare have been summarized in an advisory by the American Society for Healthcare Engineering (ASHE).
Background
The 2006 edition of the IFC permitted the use of liquid ABHR but not aerosol formulations (e.g., foam) based on ASHE’s "Alcohol-Based Hand Rub Solution Fire Modeling Analysis Report." This modeling research study demonstrated the safety of liquid ABHRs. However, because the report did not address aerosol type ABHRs, the ICC prohibited its use in corridors. The final evidence on the safety of aerosol products came from a study by the Consumer Specialty Products Association (CSPA) titled, "Alcohol Based Hand Sanitizer - Level 1 Aerosol Products."
Unified acceptance of aerosol/foam ABHR
This recent action by the ICC represents the last step in an ongoing controversy and a series of approvals needed to allow ABHRs to be installed in corridors of hospitals and nursing homes that began in 2002 when the Centers for Disease Control and Prevention (CDC) released the "Guideline for Hand Hygiene in Health-Care Settings," which recommended the use of ABHR. Through the collaborative efforts of a national stakeholder panel continuing over five years, there is now agreement among all the key agencies, including the ICC, CMS, National Fire Protection Administration (NFPA) and the Joint Commission.
Recommendations
Before installing or relocating ABHR dispensers, healthcare organizations should review the current advisory, as well as the March 21, 2007 advisory on dispenser placement, "CMS and The Joint Commission Define Installation Criteria of Alcohol-Based Hand Rub Dispensers" (March 21, 2007). This information should be discussed with infection control professionals, safety committees and with the appropriate state and local fire authority and building code departments before taking any action.
IFC and ABHR aerosol approval (May 28, 2007)
CMS and The Joint Commission Define Installation Criteria of Alcohol-Based Hand Rub Dispensers (March 21, 2007)
For more information on the Life Safety Code, Joint Commission, and CMS, go to:
http://www.ashe.org/ashe/codes/handrub/
Tubing misconnections, sharps disposal, hand hygiene among safety solutions from WHO
Catheter and tubing misconnections, sharps safety disposal and hand hygiene practices are among the nine solutions recommended by the World Health Organization’s (WHO) Collaborating Centre for Patient Safety Solutions to prevent healthcare errors as part of their efforts to promote patient safety among member states.
The Patient Safety Solutions were developed with the assistance of an international steering committee of patient safety experts and patient representatives, as well as regional advisory councils in Europe, the Middle East, and the Asia-Pacific region. The Joint Commission will be pilot-testing five of the nine solutions in seven countries to see how they could be applied in the field. The Premier Safety Institute provides resources for a number of these issues. The goal is to develop standard operating protocols for each of the five solutions. The Patient Safety Solutions recommendations include:
- Look-alike, sound-alike medication names: Using protocols to decrease risks, ensuring prescription legibility, and using preprinted orders or electronic prescribing.
- Correct patient identification: Emphasis on methods for verifying patient identity, including patient involvement, standardizing identification methods across hospitals in a healthcare system, and using protocols for distinguishing the identity of patients with the same name.
- Communication during patient hand-offs: Improving patient hand-offs such as using protocols for communicating critical information, providing opportunities to ask and resolve questions, and involving patients and families.
- Correct procedure at the correct body site: Using a preoperative verification process, marking the operative site by the practitioner who will do the procedure, and having the team involved in the procedure take a "time out" immediately before starting the procedure to confirm patient identity, procedure, and operative site.
- Control of concentrated electrolyte solutions: Standardizing dosages, units of measure and terminology, and preventing mix-ups of specific concentrated electrolyte solutions.
- Medication accuracy: Having a complete and accurate list of a patient's current medications, comparing the list against the admission, transfer and/or discharge orders when writing medication orders, and communicating the list to the next provider of care whenever the patient is transferred or discharged.
- Catheter and tubing mis-connections: Ensuring the correct route of medication and feeding administration, and using the correct connections and tubing when connecting a patient.
- Needle reuse and injection device safety: Banning the reuse of needles, periodic training of practitioners and other healthcare professionals in infection prevention and control principles, educating patients and families regarding transmission of blood borne pathogens, and safe needle disposal practices.
- Hand hygiene: Emphasis on implementing strategies that make alcohol-based hand-rubs readily available at points of patient care, access to a safe, continuous water supply at all taps/faucets, staff education on correct hand hygiene techniques, use of hand hygiene reminders in the workplace, and measurement of hand hygiene compliance through observational monitoring and other techniques.
Safety Institute resources
For more information on the Patient Safety Solutions, go to:
www.jointcommissioninternational.org/solutions
A combination of paper and computer-based safety reporting systems provides lessons for improving event reporting
Adding paper-based patient safety reporting to existing online reporting doubled the rate of reporting and provided lessons to improve the quality of data and the online reporting tool, including a simple and brief tool with peer protection and regular feedback.
A study published in the April 2007 edition of Critical Care Medicine conducted at Barnes-Jewish Hospital, part of BJC HealthCare, evaluated a new voluntary and anonymous card-based patient safety event reporting system in three intensive care units.
During the 14-month study period, 714 patient safety events were reported with the new card-based reporting system, reflecting a significant increase in reporting compared to the pre-intervention Web-based reporting system (an increase from 20.4 events to 41.7 events per 1,000 patient days). Physicians experienced the greatest increase in reporting among their group, a 43-fold increase, compared to nurses with a 1.7-fold increase.
Before the introduction of the card-based system, there were two online event reporting systems. One system was an online risk management system accessible to all employees but used primarily by nurses. Most physicians were not hospital employees, did not know how to use the system, and so often asked nurses to report specific errors. These online reports are not anonymous. The other system was an online medication and adverse event drug reaction system that was used only by pharmacists. Both systems remained in use during the use of the new card-based system.
The lessons learned from the implementation of the card-based reporting program were used to develop a new and improved Web-based reporting system. A number of barriers to reporting were identified and addressed to improve voluntary reporting, including the development of a simple and brief reporting tool, anonymity, privacy and convenience in reporting, equal access and encouragement to report for all healthcare workers, and regular feedback about reported events.
Patient safety event reporting (.doc) (29 KB)
More resources on incident reporting from the Safety Institute’s Patient Safety Web site.
Decreased infant mortality linked to high-level, high-volume neonatal intensive care units
Very low birth weight infants weigh less than 1,500 grams, about 3.3 pounds, at birth and are highly vulnerable to medical complications. They account for 1.4 percent of U.S. births but 51 percent of infant deaths. Previous studies in both adults and neonates have found lower mortality rates in hospitals with higher volumes of patients.
The May 24, 2007, issue of the New England Journal of Medicine reported the results of a study on mortality rates among 48,237 very low birth weight infants born in California hospitals between 1991 and 2000. Very low birth weight infants (below 1,500 grams) were found to be significantly more likely to survive when delivered in hospitals with high-level neonatal intensive care units (NICUs) that care for more than 100 of these patients annually than are those delivered in comparable facilities that provide care to fewer than 100 of these patients every year.
Less than a quarter of very low birth weight infants were found to be born in hospitals that have NICUs with both high levels of care and high volumes, and this percentage is declining over time, decreasing from 35.6 percent in 1991 to 21.5 percent in 2000. This decline is offset by an increase in deliveries cared for in NICUs with higher levels of care and treating 26-50 very low birth weight infants. The researchers suggest that increased regionalization and the merging of existing smaller NICUs to create units that deliver higher levels of care and high volumes may have the potential for preventing 21 percent of the deaths among very low birth weight infants.
NICU Mortality Abstract (.doc) (29 KB)
Patient lift devices, bariatric issues planned for 2010 AIA Guidelines – public invited to comment
Patient lift devices, bariatric issues, designs to improve infection control and safety concerns are under discussion already to improve the 2010 edition of the AIA/FGI "2006 Guidelines for Design and Construction of Health Care Facilities." The guideline is used by architects, engineers, and healthcare professionals to regulate the design and construction of healthcare facilities. The time period for the public to submit changes recently opened and will end September 30, 2007. After this date, the public will be able to comment on proposed changes only.
The Health Guidelines Revision Committee (HGRC), with the support of the Facility Guidelines Institute (FGI) and the American Institute of Architects (AIA), seek proposals from the public for the development of the "2010 Guidelines for Design and Construction of Health Care Facilities."
The guidelines recommend minimum program, space, and equipment needs for clinical and support areas of hospitals, ambulatory care facilities, rehabilitation facilities, and nursing and other long-term care facilities. The document also addresses minimum engineering design criteria for plumbing, electrical, and heating, ventilation, and air conditioning (HVAC) systems.
The HGRC is addressing patient- and staff-related building design and construction issues such as:
- Use of patient lift devices;
- Imaging technologies used in operating rooms;
- Bariatric accommodations;
- Sound design and vibration in healthcare environments;
- Single-bed rooms beyond medical/surgical and obstetric facilities;
- Environment of care;
- Infection control; and
- Healthcare facility engineering.
Chapters on small hospitals and sections on imaging, emergency, obstetric, and psychiatric facilities in both the hospital and ambulatory care parts of the book will be updated. As follow-up to the expansion of the outpatient facility material in the 2006 edition, chapters on freestanding urgent care, office surgical, renal dialysis, and endoscopy facilities, among others, will be carefully reviewed.
To propose a change to the current edition – the "2006 Guidelines for Design and Construction of Health Care Facilities," – go to "Changes to Guidelines" on the FGI Guidelines Web site.
Changes to guidelines, go to:
http://www.fgi-guidelines.org
Excerpts on the 2006 AIA guidelines numerous resources on safe design and construction are available from the Safety Institute's Construction Web site.
Premier seeks entries for 16th annual Cares Award for innovative programs to improve the health of the medically underserved
Through its 16th annual Monroe E. Trout Premier Cares Award competition, Premier is searching for programs that are providing exemplary, innovative services to improve the health of the medically underserved in communities all across the country.
Since 1992, Premier has presented cash awards to community agencies and health organizations that support people excluded from or underserved by the mainstream health delivery system. These include farm workers, homeless children, pregnant teens, low-income mothers and infants, and individuals who don't have the strength or means to reach a clinic or hospital. Primary funding for the award is provided by Premier and its owner healthcare organizations.
The award provides a cash prize of $70,000 to the winning organization or program and an additional $120,000 distributed among five runners up. Entries must be not-for-profit entities in the public or private sector, be able to show measurable results/outcomes for a full two-year period prior to July 31, 2007, and be replicable. The deadline to submit entries is Tuesday, July 31. Entry forms and additional information about the award and past recipients are available.
Premier's Safety Institute provides safety news, resources and tools to promote a safe healthcare delivery environment for patients, workers, and their communities Also provided on this site are the latest news, resources, and cost-saving success stories in green purchasing and healthcare practices.
Entry forms and award information:
www.premierinc.com/caresaward
Safety Institute's resources:
www.premierinc.com/safety
Safety tools
AHRQ DVD – Training for respiratory care/vents in disasters
The Department of Health & Human Services' (HHS) Agency for Healthcare Research and Quality (AHRQ) has released a DVD titled, "Cross Training Respiratory Extenders for Medical Emergencies (Project XTREME)," that trains healthcare professionals who are not respiratory care specialists to provide basic respiratory care and ventilator management to adult patients in any mass casualty event. The DVD includes six training modules with interactive quizzes to test viewers' knowledge. Meant for physicians, physician assistants, nurses and others, the modules cover topics such as infection control, respiratory care terms and definitions, manual ventilation (using hand-held bags), mechanical ventilation (using the two types of ventilators included in the federal government's Strategic National Stockpile of medicines and medical supplies for emergencies), airway maintenance, and airway suctioning. A free, single copy of the DVD and a CD-ROM with the report may be ordered by calling 800.358.9295 or by sending an e-mail to ahrqpubs@ahrq.hhs.gov.
Monitor news daily - Premier’s free Media Monitoring e-mail newsletter
Premier offers a free, daily Media Monitoring e-mail newsletter that you will find valuable. Every day, Premier's Communications team scans hundreds of publications and media outlets to bring you the latest round-up of healthcare news in a quick, easy-to-digest format.
Media Monitoring helps you stay up to date and "in the know" on what's being reported on a variety of subjects, such as safety, quality, hospital news, legislative/regulatory issues and more. Subscribing is free and easy. To subscribe, send a blank e-mail to:
join-media-monitoring@lyris.premierinc.com.
AORN Patient Hand-Off toolkit – Free Web-based surgical patient transfer
The Association of periOperative Registered Nurses (AORN) and the U.S. Department of Defense Patient Safety Program have collaboratively developed a new Web-based toolkit that provides the resources to help streamline and standardize communications for safe transfer of surgical patients within perioperative units. The toolkit is based on the Department of Defense patient safety program, TeamSTEPPS™. The AORN "Patient Hand-Off Toolkit" helps caregivers effectively communicate key information such as the patient’s current and past condition, ongoing treatments, and possible changes or complications that should be monitored closely. The kit includes sample checklists and forms, slide presentations on standardizing communication and information exchanges, and a guide to additional resources. The toolkit can be downloaded free of charge at:
http://www.aorn.org/PracticeResources/ToolKits/
AHRQ toolkit – "Mistake-proofing" healthcare process design
A new guide available from the Agency for Healthcare Research and Quality (AHRQ) titled "Mistake-Proofing the Design of Health Care Processes" describes simple, low-cost interventions that organizations can undertake to improve patient safety. The toolkit (.pdf) (1.5 MB) includes more than 150 real world examples of process or design features that have been implemented as a result of root-cause analyses and other interventions to help ensure that processes help prevent errors or the negative impact of an error.
OSHA – Complete HCW pandemic flu preparedness guidance
The Occupational Safety and Health Administration (OSHA) has released a pandemic flu preparedness guidance for healthcare workers and employers. The new guidance focuses specifically on healthcare workers and their employers. The diversity among the providers of healthcare, from emergency departments to ambulances to temporary patient care facilities, makes preparing for a pandemic influenza challenging. This guidance document is consistent with all previous pandemic preparedness guidance issued by OSHA, the Centers for Disease Control and Prevention (CDC), and Department of Health and Human Services (HHS), according to OSHA. The 104-page document is organized in four major sections: clinical background information on influenza, infection control, pandemic influenza preparedness planning, and OSHA standards of special importance. It addresses flu diagnosis and treatment, healthcare worker vaccination, and personal protective equipment. The appendices include additional resources for healthcare institutions, such as communication tools for promoting employee infection control practices, strategies for planning respiratory protections programs, triage algorithms, supply and pandemic planning checklists, and even a crisis communication guide for handling questions from the media.
AHRQ – Sample healthcare quality report cards
The Agency for Healthcare Research and Quality (AHRQ) has developed a new Web tool demonstrating a variety of approaches for health quality report cards. The new Health Care Report Card Compendium is a searchable directory of more than 200 samples of report cards produced by a variety of organizations. The samples show formats and approaches for providing comparative information on the quality of health plans, hospitals, medical groups, individual physicians, nursing homes, and other providers of care. The purpose of the AHRQ Report Card Compendium is to inform and support the various organizations that develop healthcare quality reports, to provide easy access to examples of different approaches to content and presentation, and to meet the needs of health services researchers.
Visit: http://www.talkingquality.gov/compendium/
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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
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.
You may forward this newsletter to your colleagues. If you would like to reprint any of these stories, please cite the "Safety Share newsletter, Premier, Inc." as your source and send an email to safety_institute@premierinc.com and alert us. Thank you.
