July 2006
Dear Colleague:
Delete this email! 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, sharps safety, Clostridium difficile, construction, and more?
Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- Shortage of critical care specialists impacts on ICU patient care
- Private rooms are the standard for new construction to reduce medical errors and
infection risks - Restricting duty hours improves quality of life for surgical residents; attending surgeons concerned with continuity of care
- Regionalize ER services: IOM recommendation to relieve fragmented care
- Provide influenza vaccination to healthcare workers, children ages 2 to 4 and offer to patients; CDC recommends
- Strategic National Stockpile expands respirator, mask supplies
- Surgery with non sharp devices and techniques is feasible
- Disruptive behavior in operating rooms linked to adverse events
- Medical students and residents call for disclosure and more open discussions of errors
Safety tools
- APIC – New consumer-oriented infection prevention Web site
- SCIP – Surgical care improvement tools
- AMA – Guidelines for improving patient communications
- HIPAA privacy tool for emergency planners
- IHI – Perinatal SBAR toolkit
- New York City pandemic influenza plan
Shortage of critical care specialists impacts on ICU patient care
A new report from the Department of Health and Human Services (HHS) indicates that as many as two thirds of patients needing critical care services may be receiving suboptimal care because the demand for critical services may surpass the supply of critical care specialists needed to provide optimal care.
The HHS report titled, The Critical Care Workforce: A Study of the Supply and Demand for Critical Care Physicians, was released to Congress in May 2006 and estimates a 35 percent shortage of intensivists by 2020. The report reinforces findings that the use of intensivists improves outcomes for critically ill patients and suggests there is an imminent need to bolster the intensivist workforce. With an estimated 360,000 deaths occurring each year in intensive care units (ICU) not managed by intensivists, increasing the intensivist supply may help save up to 54,000 lives annually. Further, if the current one third of ICU patients cared for by an intensivist were to increase to the more optimal level of two thirds, the demand for intensivists would likely increase by 63 percent.
The report also references findings from reports published by the Critical Care Workforce Partnership, a collaboration of the nation's top critical care societies, including the American College of Chest Physicians (ACCP), American Thoracic Society (ATS), Society of Critical Care Medicine (SCCM), and the American Association of Critical-Care Nurses (AACN). The societies previously reported that the demand for critical care services would increase rapidly due to the aging population, while the intensivist supply would not be able to care for a greater proportion of critically ill patients.
The Critical Care Workforce Partnership is working to develop solutions to ease the burden created by the workforce shortage. Recommended solutions to the critical care workforce issues include:
- Increasing the efficiency of the current critical care workforce by developing incentives to better distribute critical care providers and supporting alternative delivery models, such as improving the current distribution of critical care resources.
- Increasing the utilization of technology.
- Increasing the effective supply of critical care providers through cross training.
- Increasing the supply of critical care professionals by expanding opportunities for U.S.-trained international medical graduates to practice in the United States, and increasing medical and nursing school capacity to train critical care providers.
- Increasing support for critical care research in the elderly population and exploring alternative care pathways for elderly patients with high mortality conditions.
A study of the supply and demand for critical care physicians (.pdf) (212 KB)
Private rooms are the standard for new construction to reduce medical errors and infection risks
With mounting evidence that shared hospital rooms may contribute to medical errors, higher infection rates, privacy violations, and harmful stress for patients, the updated Guidelines for Design and Construction of Health Care Facilities calls for single-patient rooms in medical/surgical and postpartum units to become standard for all newly constructed hospitals. This is the first such recommendation since these guidelines were originally published by the federal government in 1947. Updated every four years by the Facility Guidelines Institute (FGI) and published by The American Institute of Architects (AIA), the guidelines are currently used by more than 40 state governments to regulate hospital licensing and construction.
Highlights of the 2006 Guidelines for Design and Construction of Health Care Facilities:
- Private rooms for acute medical/surgical and postpartum patients in new hospital construction.
- New sections on intermediate care units, observation units in emergency departments, and skilled nursing units in general hospitals.
- Strengthened information on the infection control risk assessment process.
- New chapters on urgent care facilities, gastrointestinal endoscopy facilities, psychiatric outpatient centers, renal dialysis centers, office surgical facilities, and small primary care hospitals.
- New language on assisted living facilities, hospice facilities, and adult day health care facilities.
- New appendix language on green architecture and surge capacity in emergency departments.
Order the 2006 Guidelines for Design and Construction of Health Care Facilities online in the AIA bookstore or call 800.242.3837 (choose option 1).
Order the 2006 Guideline online at AIA bookstore
Restricting duty hours improves quality of life for surgical residents; attending surgeons concerned with continuity of care
A recent study found that the Accreditation Council of Graduate medical Education (ACGME) mandated restriction of resident duty hours has no measurable impact on the quality of care and led to better quality of life of surgical residents. Attending surgeons were concerned with continuity of care and loss of critical information during handoffs.
To assess the impact of the ACGME 80-hour resident workweek restrictions on surgical residents and attending surgeons, a series of studies were conducted at a single academic surgical program with data collected both before the ACGME necessary workforce restructuring and one year after, using Web-based surveys and structured one-on-one interviews. After the work-hour changes, surgical residents reported decreased "burnout" scores, significantly less "emotional exhaustion" and better quality of life both in and out of the hospital. Residents also said they felt they got more sleep, and had a lighter workload and increased motivation to work. There was no measurable, statistically significant difference in the quality of patient care using data from National Surgical Quality Improvement Program (NSQIP) data.
Attending surgeons had concerns about the professional development of future surgeons, including a change toward a shift-worker mentality that is not patient-focused, less continuity of care with a loss of critical information with each handoff, and a decrease in the patient/doctor relationship.
ACGME work hour restrictions
The ACGME has mandated nationwide restrictions on resident work-hours since July 1, 2003. The new requirements include: an 80-hour weekly limit averaged over four weeks; at least 10 hours of rest between duty periods; a 24-hour limit to continuous duty with no more than six additional hours for continuity of care and education; one in seven days free from patient care; and in-house call no more than once every three nights averaged over four weeks.
Abstract, Hutter et al. 2006 (.doc) (20 KB)
Regionalize ER services: IOM recommendation to relieve fragmented care
A three-part Institute of Medicine report titled "Future of Emergency Care" recommends action to address the challenge of increased demand and inadequate capacity in the nation's emergency care system, calling the current system overburdened, under-funded and highly fragmented. The report makes a number of recommendations, including:
- Calling on Congress to appropriate $50 million for hospitals with significant uncompensated emergency and trauma care.
- Recommending states regionalize the delivery of emergency and trauma services to ensure that patients get to the right hospital and that on-call specialists are available to treat them.
- Having the Centers for Medicare & Medicaid Services (CMS) convene a working group to develop standards and incentives to end ambulance diversion and boarding of patients in the emergency department.
- Having hospitals streamline patient flow by adopting operations management techniques and modern information technologies.
There are three books in the Future of Emergency Care series. Emergency Care Services at the Crossroads presents an in-depth analysis of the current organization, delivery, and financing of these types of services and systems. Emergency Care for Children: Growing Pains examines the challenges associated with the provision of emergency services to children and families. The third book, Hospital-Based Emergency Care: At the Breaking Point, addresses the difficulty of balancing the roles of hospital-based emergency and trauma care, safety net care for uninsured patients, public health surveillance, disaster preparation, and adjunct care in the face of increasing patient volume and limited resources.
Pre-publication copies of The Future of Emergency Care series, which includes Emergency Care Services at the Crossroads, Emergency Care for Children: Growing Pains, and Hospital-Based Emergency Care: At the Breaking Point, are available from the National Academies Press by calling 202.334.3313 or 800.624.6242, or visiting http://www.nap.edu.
Provide influenza vaccination to healthcare workers, children ages 2 to 4 and offer to patients; CDC recommends
The CDC issued the guidelines, Prevention and Control of Influenza, in an early release article in the June 28, 2006, issue of the Morbidity and Mortality Weekly Report. This report updates the 2005 recommendations from the Advisory Committee on Immunization Practices (ACIP) regarding the use of influenza vaccine and antiviral agents. Highlights of the guidelines follow.
Vaccinate healthcare workers and others who can transmit influenza to high-risk persons
Persons who are clinically or asymptomatically infected can transmit influenza virus to persons at high risk for complications from influenza. Decreasing transmission of influenza from caregivers and household contacts to persons at high risk might reduce influenza-related deaths among persons at high risk. Vaccination levels for healthcare workers are typically less than 40 percent. Studies have shown that vaccination of healthcare workers has been associated with decreased deaths among nursing home patients, and hospital-based influenza outbreaks frequently occur where unvaccinated healthcare workers are employed.
All healthcare workers should be vaccinated against influenza annually. Facilities that employ healthcare workers are strongly encouraged to provide vaccine to workers by using approaches that maximize vaccination levels. Influenza vaccination levels among healthcare workers should be regularly measured and reported. Physicians, nurses, and other workers in both hospital and outpatient care settings, including medical emergency-response workers (e.g., paramedics and emergency medical technicians), should be vaccinated, as should employees of nursing home and chronic-care facilities who have contact with patients or residents. In addition to healthcare workers, other groups that can transmit influenza to persons at high risk and that should be vaccinated include the following:
- Employees of assisted living and other residences for persons in groups at high risk;
- Persons who provide home care to persons in groups at high risk; and
- Household contacts (including children) of persons in groups at high risk.
Vaccination of children
These guidelines incorporate the ACIP recommendation, proposed earlier this year, that all toddlers ages 2 through 4 receive annual influenza immunization. Since 2004, the CDC has recommended that children ages 6 months to 2 years receive annual influenza immunizations, but recent reports indicate that children ages 2 though 4 are almost as likely to be treated for the flu as the children in the younger age group. The CDC also highlights the importance of administering two doses of influenza vaccine to previously unvaccinated children ages 6 months to less than 9 years.
Outreach efforts
The recent guidelines also advise healthcare providers, those planning organized campaigns, and state and local public health agencies to a) develop plans for expanding outreach and infrastructure to vaccinate more persons than the previous year, and b) develop contingency plans for the timing and prioritization of administering influenza vaccine, if the supply of vaccine is delayed and/or reduced.
Annual influenza immunization is recommended for the following groups:
- Children and adolescents (6 months through 18 years) who are receiving long-term aspirin therapy;
- Women who will be pregnant during the flu season;
- Adults and children who have asthma, other chronic respiratory or cardiovascular conditions, or any condition that can impair respiratory function;
- Adults and children under treatment for chronic metabolic disorders, kidney problems, hemoglobinopathies, or immunodeficiency;
- Residents of nursing homes and other chronic-care facilities;
- People age 50 and older;
- Healthcare workers; and
- Household contacts and caregivers of children up to 59 months and people at high risk for severe flu complications.
Antiviral medications
CDC recommends that neither amantadine nor rimantatine be used for the treatment or chemoprophylaxis of influenza A in the United States until evidence of susceptibility to these antiviral medications has been re-established among circulating influenza A viruses.
CDC: Prevention and Control of Influenza, June 28, 2006 (.pdf) (630 KB)
More Influenza resources – Premier Safety Institute Web site
Strategic National Stockpile expands respirator, mask supplies
HHS Secretary Michael Leavitt released a pandemic planning update on June 29, addressing five priorities for pandemic preparedness:
- Monitoring and status of cases in humans and birds;
- Developing vaccines and production capacity;
- Strategic National Stockpiles increases in antivirals, protective equipment and supplies;
- Coordination and surveillance of state and local preparedness; and
- Progress on HHS risk communication training sessions.
After reviewing the number of cases of H5N1 influenza through June 24, 2006 (a cumulative 225 cases in 53 countries), Leavitt noted that the virus has not yet arrived in North America as anticipated, concluding that its spread through Asia, Europe and Africa was caused in part by international trade in poultry. Other pandemic preparedness areas also were updated.
Vaccine: More than $1 billion has been invested in the advanced development of cell-based vaccine technology, representing a shift from egg-based technology.
Antivirals: HHS expects to purchase 44 million treatment courses of flu antiviral drugs for the Strategic National Stockpile in fiscal years 2006 and 2007, and to allocate at least 20 million of those courses to states in proportion to their population. To assist in this goal, HHS is working with Roche Laboratories and GlaxoSmithKline to provide up to 31 million treatment courses of the flu antiviral treatment Tamiflu to states and territories at a federally subsidized price. States are required to develop distribution plans and HHS is working with the Healthcare Distribution Management Association in developing a model distribution plan to help the states with their planning. Leavitt said the ultimate goal is to stockpile enough antiviral drugs to treat 25 percent of the U.S. population. The Strategic National Stockpile now contains sufficient antivirals to treat more than 7 million people. An additional 19 million courses of Tamiflu and Relenza are on order, and HHS expects the SNS to contain 26 million courses by the end of 2006.
Supplies: HHS also continues to stockpile N95 respirators and surgical masks. Planned purchases in 2006 include:
- 6,000 ventilators;
- 100 million N95 respirators;
- 50 million surgical masks, as well as face shields, gowns and gloves.
To date, 20.2 million respirators have been stockpiled, with another 87.2 million on order through September 2007, and 12.3 million surgical masks are on hand, with another 39.2 million on order through September 2006.
Communication: HHS has conducted summits in 48 states and has scheduled summits in the remaining two. Many states already are taking their planning to the regional and community level. Some states have held cross-state pandemic planning meetings to coordinate their strategic plans with neighboring states.
HHS Pandemic Planning Update II (.pdf) (3 MB)
Surgery with non sharp devices and techniques is feasible
A report in the June 2006 World Journal of Surgery concludes that selected common general surgery procedures can be performed entirely without sharps, eliminating the risk of intraoperative percutaneous injuries to surgical personnel. In "Sharpless Surgery: A Prospective Study of the Feasibility of Performing Operations using Non-sharp Techniques in an Urban, University-based Surgical Practice," researchers from Johns Hopkins University evaluated 358 procedures in which to implement sharpless techniques abstract.
Sharpless techniques used included skin adhesive, electrocautery, tissue stapling, and minimally invasive instrumentation. Conventional scalpels and suture needles were readily available and used when necessary. Ninety-one procedures were identified preoperatively as appropriate for sharpless surgery; 87 percent of these were completed without the use of sharps, including open laparotomy procedures (59.1 percent), laparoscopic procedures (90.9 percent), and soft tissue procedures (97.8 percent). Sharps were needed in 12 cases.
Abstract, Makary. World Journal of Surgery (.doc) (20 KB)
Disruptive behavior in operating rooms linked to adverse events
Disruptive behavior among surgeons, nurses, and anesthesiologists happens often in the perioperative setting and can have a significant impact on team dynamics and patient outcomes, according to a recent study in a large metropolitan academic center.
The study reported that 94 percent of respondents said disruptive behavior needlessly contributes to adverse events, medical errors, compromises patient safety and quality, and can affect patient mortality. Nineteen percent said they knew of an adverse event that occurred as a direct result of disruptive behavior.
The comments section of the survey yielded some potentially serious issues. These included a listing of disruptive attitudes, actions and events that led to unwillingness to confront physicians for fear of receiving an antagonistic response. The researchers include a list of 11 recommended protocols to implement in order to address disruptive behaviors. Key recommendations include organizational commitment, recognition and awareness, implementation of behavior policies and procedures providing team-training programs to discuss contributing factors, and tools to build effective communication and team collaboration skills.
Abstract, Rosenstein et al. Am Coll Surg 2006 (.doc) (20 KB)
Medical students and residents call for disclosure and more open discussions of errors
An analysis of 59 structured telephone interviews with medical students and residents categorized the factors and areas of tension that influenced their learning from errors. The study, "Factors that Influence How Students and Residents Learn from Medical Errors," revealed intense emotional responses by medical students and residents to the idea of committing errors in patient care. They noted variation, conflict, and confusion in institutional recommendations and individual actions, whether and how to initiate discussion after errors occurred, and reporting errors to those individuals responsible for their evaluation. Students wanted more faculty disclosure and open discussion of actual errors. Students also reported that they learned the most when actual harm was caused, rather than from a near miss.
Researchers concluded that facilities could help by addressing variability in faculty response and local culture by disseminating clear, accessible algorithms to guide behavior when errors occur. Criteria should be developed that integrates actual cases and faculty disclosure. The survey also revealed the need for a teaching and learning focus on emotionally charged situations, learning from errors and near misses and a balance between individual and systems responsibility.
Abstract, Learning from medical errors. J Gen Intern Med 2006 (.doc) (20 KB)
Safety tools
APIC – New consumer-oriented infection prevention Web site
The Association for Professionals in Infection Control and Epidemiology (APIC) and Tyco Healthcare/Kendall have launched www.Preventinfection.org, a new Web site to educate healthcare professionals and consumers about preventing infections. The Web site offers research findings, statistics, and articles on preventing infections.
SCIP – Surgical care improvement tools
The Surgical Care Improvement Project (SCIP) Web site has added practical tools for the four SCIP areas: cardiac, infections, venous thromboembolism, and respiratory. Tools include help with antibiotic timing, glucose management, and prevention of deep vein thrombosis. Visitors can download a DVT order set, an antibiotic recommendations chart, and a glucose management protocol order set.
One tool is a pocket card organized by surgery type and recommended antibiotics for fast reference and easy reading. Antibiotic recommendations (.pdf) (310 KB) are current as of March 2006. Additional tools are available at www.medqic.org/scip. To find the tools on the SCIP Web site, go to the "Hospitals" tab and click on "Tools."
AMA – Guidelines for improving patient communications
A new consensus report (.pdf) (624 KB) from the American Medical Association Ethical Force Program offers guidelines to help healthcare organizations ensure effective, patient-centered communications with patients of diverse backgrounds. This report lists a number of specific, measurable expectations for performance that organizations can use as a framework for evaluating performance, as well as a guide for improving communication quality. An organizational self-assessment toolkit based on the report is being field-tested.
HIPAA privacy tool for emergency planners
A Web-based interactive decision tool designed to assist emergency preparedness and recovery planners is available from the Department of Health and Human Services. The new tool helps determine how to access and use health information about various populations such as the elderly and those with disabilities, and is consistent with the Health Insurance Portability and Accountability Act's privacy rule in emergency preparedness situations. The tool should help planners organize their activities, and provide useful information to a range of potential programs. To access the "HIPAA Privacy Rule: Disclosures for Emergency Preparedness - A Decision Tool," go to: http://www.hhs.gov/ocr/hipaa/decisiontool/.
IHI – Perinatal SBAR toolkit
A toolkit containing five SBAR (Situation-Background-Assessment-Recommendation) tools adapted for improving communication in labor and delivery is available from the Institute for Healthcare Improvement (IHI). The SBAR technique provides a framework for communication between members of the healthcare team about a patient's condition. SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician's immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety.
- SBAR Nurse Survey (.pdf) (528 KB)
- SBAR Survey Physician (.pdf) (527 KB)
- SBAR Perinatal Report (.pdf) (556 KB)
- SBAR Fetal heart rate tracing (.pdf) (512 KB)
- SBAR Physician, critical situation (.pdf) (514 KB)
For more information, visit the site at
http://www.ihi.org/IHI/Topics/PerinatalCare/
PerinatalCareGeneral/EmergingContent/
PerinatalSBARTools.htm.
New York City pandemic influenza plan
New York City has released a pandemic flu preparedness and response plan (.pdf) (2.3 MB). The plan is a blueprint for identifying an outbreak, containing its spread and distributing scarce resources like ventilators and antiviral medications. It also emphasizes that the city must rely on itself, not Washington, to plan for and react to potential disasters. The plan describes the importance of early detection to help contain the spread of the illness and includes disease monitoring, laboratory capacity, vaccine and medicine delivery, hospital preparedness, mental health and communications.
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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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