July 2009

Who has time to cover their cough? Where is my tissue?

CDC's guidance for preventing the spread of novel (A H1N1) influenza includes covering your nose and mouth with a tissue when you cough or sneeze, throwing the issue in the trash after you use it and then washing your hands with soap and water or alcohol-based hand cleaners. For one example see CDC's guidance to workers. But, who really has a tissue handy when you feel you are about to cough or sneeze? What should you do?

We know that influenza virus (seasonal and novel H1N1) may be spread to others when a person coughs on their hands and then touches nearby surfaces, which are soon after touched by someone else who may pick up the virus on their hands and touch their own mucous membranes.

Who has tissue?
Look around. Who really has a tissue handy for a cough or sneeze? People are sneezing on their hands all the time.

We also know that seasonal flu and novel H1N1 can be most easily transmitted before the onset of symptoms and during the first few days of illness, with infectivity tapering off after that. Therefore, coughing into our hands before we feel ill enables us to transmit the flu virus without realizing it.

What should we do? Cough into your sleeve!
CDC's Division of Healthcare Quality Promotion has published "Respiratory Hygiene-Cough Etiquette" that includes directions to cough or sneeze in your sleeve if you don’t have a tissue to prevent the transmission of all respiratory infectious agents, including seasonal flu virus. CDC also suggests that this practice be part of the standard precautions that should be used on all patients. CDC even provides signs that show you how to "COVER YOUR COUGH" so you can also send the message graphically as you tell everyone about it. The signs describe how to cover your cough and sneeze either with a tissue, if handy, or cough into your sleeve.

Why not use the same cough etiquette all the time and everywhere – in the hospital, in the airports, in the home, at parties, at work, in an elevator, in the grocery store?

"Cover Your Cough" message is missing from CDC's guidance on the prevention of novel H1N1
This practical message to "Cover your Cough" is absent from many public health messages specifically addressing the prevention of novel H1N1, messages that focus only on using a tissue for coughs and sneezes. So, unfortunately, many aren't aware of the "Cover your Cough" technique.

Let’s tell everyone!
Let’s do our part and reduce the risk of seasonal and novel H1N1 flu transmission. Spread the word – not flu – and tell your friends, family, co-workers how to "Cover Your Cough" and sneeze either into a tissue (if handy), or cough into their sleeve. See cartoon at link below as well as more information and signs from CDC.

What to do in the healthcare setting

• Post signs about "Cover Your Cough". CDC recommends posting signs about "Cough Etiquette" at entrances to outpatient facilities, such as emergency departments, physician offices, and outpatient clinics. Cough Etiquette includes covering coughs and sneezes either with a tissue, if handy, or coughing into a sleeve.
• Educate patients and family about "Cover Your Cough". Patients and persons who accompany them should be told to inform healthcare personnel of symptoms of a respiratory infection when they first register for care. They should also be taught Cough Etiquette. Healthcare facilities (and other public places where people congregate) should provide tissues, waste receptacles for used tissue disposal, handwashing supplies and/or conveniently located dispensers of alcohol hand rubs.

Downloads and links

• Guidance for the workplace http://www.cdc.gov/h1n1flu/guidance/workplace.htm
• Respiratory Hygiene/Cough Etiquette Signs from CDC http://www.cdc.gov/flu/protect/covercough.htm
• More information and materials are available from the Premier Safety Institute's Influenza-Seasonal Web site

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Health and wellness should be centerpiece of reform, assert Gerberding and Gawande at Premier’s annual Breakthroughs Conference

Keeping the focus on the health and not treating illness should be the focus of the current healthcare reform debate, says Julie Gerberding, M.D., former head of the Centers for Disease Control and Prevention. Atul Gawande, M.D., points out the need not only for a greater focus on prevention and improvement of quality of care, but also accountable-care organizations where doctors can collaborate to make this happen.

Gerberding's perspective
"I think one of the most important things we need to do is to introduce health as the overarching purpose for any of the changes that we're considering in our health system, and that we use health as the driver of those decisions as well as the determinant of whether or not we’re successful." Dr. Gerberding made these points at Premier's Breakthroughs Conference June 16-19 in Anaheim, CA. Noting that the emphasis in the current debate is currently on cost and access to healthcare coverage and funding, she added, "We have a serious national health deficit and that deficit is not going to be repaired only by improving access to affordable healthcare insurance but on prevention of disease."

Gawande points out accountability
Dr. Gawande who also spoke at Premier's conference, discussed his compelling article in The New Yorker (June 2009) titled, "The Cost Conundrum - What a Texas town can teach us about health care." In the article, Gawande compared the Texas communities of McAllen and El Paso – the former in one of the most expensive healthcare markets in the country and the latter 800 miles away. Though it has similar demographics, El Paso spends half as much on healthcare. He found overuse of medical care was really the problem in McAllen, where patients generally received more of everything – from diagnostic testing and hospital treatment to surgery and home care. He explored the reasons behind this discrepancy and identifies lessons that are applicable to today’s healthcare reform debate. Gawande concludes that what is needed is accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering, and the need for a revised payment system to promote desired models of health delivery that provide incentives for quality of care and efficiency.

Healthcare reform developments
Although reform bills are being debated, it is possible that healthcare legislation may not emerge before the August 8 recess given the current debates over coverage and financing. In spite of impending delays, the President still could sign health reform legislation this year. For current information on the status of health reform initiatives, see "Washington Outlook" on Premier’s Advocacy Web pages.

Downloads and links

• The Cost Conundrum” Gawande, New Yorker, June 2009
• Premier's health reform summaries
• "Washington Outlook"

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Powder-free latex gloves reduce worker claims for latex-related illness

A significant decrease in workers' compensation claims for latex-related illness in a major medical center followed a switch to powder-free latex gloves.  Between 1997 and 2001,Geisinger Medical Center, Danville, PA, experienced a growing number of claims related to healthcare personnel (HCP) reactions to latex gloves and latex-related illness. In an effort to reduce latex-related illness, Geisinger in October 2001 transitioned to powder-free latex gloves. Geisinger's dermatology department recently compared an analysis of HCP claims from the 1997-2001 period with claims from 2002-2005, years in which the claims gradually declined. The average yearly incidence of claims was 3.16 times higher before the transition to powder-free gloves than after the intervention (2.92 vs. 0.92: 95% CI, 1.87-5.34; p = .001).

Adverse reactions to natural rubber latex gloves such as dermatitis are an important cause of concern related to HCP and patient safety. Natural rubber latex gloves are traditionally powdered with cornstarch powder in order to ease the process of putting on the gloves. However, the powder is associated with a higher frequency of positive test results for latex sensitization, compared with those who use powder-free gloves. In an article published in Dermatitis-, 2008 describing the study, the authors also noted that the increased cost of powder-free gloves was partially offset by direct savings in operating room materials and decreased workers' compensation claims.

Downloads and links

• Latex gloves Geisinger abstract
• For more information, see Premier Safety Institute's Web site on Latex Allergy Prevention

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Leapfrog safe practice survey measures do not correlate with inpatient mortality, researchers claim

A recent study (link to PDF) of Leapfrog's Safe Practices Score (SPS) found that 2006 SPS scores were not significantly associated with risk-adjusted inpatient mortality, an outcome measure that has been reported on the Hospital Compare Web site since 2007.

Leapfrog
The Leapfrog Group is a voluntary program aimed at mobilizing employer purchasing power based on a premise that "big leaps in healthcare safety, quality and customer value" will be recognized and rewarded. The initial three "leaps," or measures, had grown to 27, but recently were cut back to 13. Aggregate results of Leapfrog’s Safe Practices Survey (SPS) are reported on the Internet and available to the public. However, it is not clear that higher scores on the survey correlate with better actual outcomes of interest to policy makers and the public, such as mortality. Authors of this study looked at the relationship between survey scores and risk-adjusted inpatient mortality and found that higher scores were not associated with reduced mortality.

Researchers' findings
The researchers compared the SPS for hospitals completing the 2006 Safe Practices survey to mortality data obtained from the most recent version of the Nationwide Inpatient Sample (NIS). Almost 1,100 urban hospitals completed the 2006 Safe Practices Survey and 155 were identifiable in the National Inpatient Sample. The authors believe this nearly 15 percent sample is generalizable to the larger population. Using logistical analysis, they determined the relationship between quartiles of SPS and risk-adjusted inpatient mortality, after adjusting for hospital discharge volume and teaching status. Researchers found no relationship between quartiles of scores and inpatient mortality, regardless of adjusting for expected mortality risk and certain hospital characteristics. In 2008, the Leapfrog survey was reduced from 27 to 13 safe practices. The authors performed a similar analysis using only those 13 safe practices and found a similar lack of association with mortality.

Conclusions, future direction
The researchers conclude that the Safe Practices Survey may not be measuring what needs to be measured. In its current form, the survey gives hospitals credit for each individual step taken to achieve full implementation, even if the safe practice is not routinely followed. They go on to note that too many items may be included. Steps have already been taken to address this by reducing the survey to 13 practices, but the study results suggest that this alone is unlikely to improve the survey’s ability to correlate with inpatient mortality. However, they do not conclude that the safe practices are unimportant or that they cannot be measured in an informative and valid way. Researchers said they are hopeful that future work will be directed at establishing valid methods for assessing adherence to the safe practices and at determining how performance on the SPS may correlate with other outcomes beyond mortality such as complication rates.

In its response to the article on its Web site, the Leapfrog Group agrees that the study provides useful information, and states that it will address the questions raised by the study while other issues for consideration are pursued.

Downloads and links

• Leapfrog Safe Practices Scores
• Leapfrog http://www.leapfroggroup.org/home
• Leapfrog response http://www.leapfroggroup.org/media/file/Leapfrog%27s_Response_to_JAMA_study.pdf

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Nearly 50,000 elderly treated in EDs for falls related to walkers and canes

More than 47,000 Americans 65 or older are treated each year in emergency departments for fall injuries involving walkers and canes, according to a new study by the Centers for Disease Control and Prevention (CDC), reinforcing The Joint Commission's National Patient Safety Goal Safety Goal #9 [NPSG 09.02.01], "Reduce the risk of [patient] harm resulting from falls."

Fractures most common injury
Most of the injuries involve walkers (87 percent); fractures are the most common injury and women are more likely to be injured than men. The study (Journal of the American Geriatrics Society) is based on 2001-2006 data from CDC's National Electronic Injury Surveillance System All Injury Program. Strategies to prevent falls – whether in the home or healthcare setting and related to walking aids – include:

• Spending more time with clients (or patients) fitting walking aids.
• Educating people how to use walkers and canes safely.

Recommendations
To help reduce the risk of falling, CDC′s Injury Center recommends that adults 65 and older begin a regular exercise program, have their doctors review their medications, have their vision checked, and make their home surroundings safer.

The authors recommend additional research to understand the physical and cognitive demands that walking aids place on users. Additional studies also are needed to better understand fall risk factors for older adults who use walkers and canes, as well as to identify potential design problems and improve the design of walkers.

Pertinent to NPSG #9, the study highlights the importance of a fall reduction program that includes educating patients who have been fitted with walkers and canes about safe use of these devices.

Downloads and links

• CDC press release
• Fall injuries
• More information – See Premier's Safety Institute Web site on Fall Prevention

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Safe in-hospital transport of the patient often overlooked

There are no formal guidelines for the intra-hospital transport of the non-intensive care unit (ICU) patient, frequently involving personnel lacking the clinical qualifications or experience to safely monitor patients. New transport team protocols for the non-intensive care patient are now available

Identification of risks
Guidelines exist for the intra- and inter-hospital transport of critically ill patients, but not for the non-ICU patient. A recent review of incidents and serious events related to patient transport by the Pennsylvania Patient Safety Authority identified serious patient safety problems in more than 10 percent of 2,390 reports. Noted problems related to: patient identification; disconnection of pumps, lines and tubes; transporters making adjustments that were beyond their scope of practice; and lack of or failure of monitoring devices. More than 40 percent of the problems related to the need for improved communication between healthcare providers.

Risk reduction strategies
The study's results and recommendations (Pennsylvania Patient Safety Advisory, March 2009) include the development or use of communication standards, coordinated teamwork, defined roles and responsibilities of the team members, and appropriate equipment for safe and effective transport of patients. Risk reduction strategies were suggested for the safe transport of non-ICU patients; selected recommendations follow:

• Develop a transport team model of care with a clear outline of the specific responsibilities and expectations for each team member. Identify who should be on the transport team, what training they should have, required supplies, standardized handoff protocols, and a defined basic level of monitoring during transport.
• Coordinate pre-transport assessments and communication between the transporter, nurse, and destination areas. Determine what criteria are to be used to determine patient stability, patient risk, and level of monitoring during transport, as well as accountabilities and monitoring compliance.
• Provide a robust educational and competency program for unlicensed hospital transport personnel. Transport personnel should know how to activate the rapid response team or code blue, how to make contact with the care nurse, and also meet a list of competencies for unlicensed transport personnel such as CPR certification.
• Ensure that essential patient equipment is functional by making sure all equipment is fully charged, filled, and in good repair.
• Provide cardiac monitoring, if warranted, by qualified clinical personnel.
• Follow-up on incidents or serious events that occur during intra-hospital transport of non-ICU patients and learn from these events to improve patient safety within the organization.

Downloads and links

• PA PS transport

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AHRQ releases culture survey tools for nursing homes, medical offices

New toolkit materials to support users of the Nursing Home Survey on Patient Safety Culture (Nursing Home SOPS) and the Medical Office Survey on Patient Safety Culture (Medical Office SOPS) were released earlier this year by the Agency for Healthcare Research and Quality (AHRQ). AHRQ released the SOPS in fall 2008 and early 2009. These surveys are administered to managers, providers, and staff to assess the culture of patient safety and healthcare quality. The culture surveys assess some of the same patient safety culture dimensions included in the hospital survey released five years ago, but also include new dimensions that are specific to long-term care and medical office settings.

The toolkits include:

• Survey forms;
• Survey items and dimensions;
• Survey user’s guides that provide guidance on survey administration and reporting of results;
• Survey feedback report PowerPoint templates that can be customized to display survey results for presentation purposes;
• Preliminary comparative results for the items and patient safety culture dimensions; and
• Data entry and analysis tool.

AHRQ has also released the presentation materials and a newsletter developed from the first SOPS User Group Meeting held in December 2008. More than 60 presentations from the expert speakers are available on the AHRQ Web site. Two speakers providing presentations related to interpreting survey results and action planning are featured:

• "Tips on how to increase the number of physicians taking the culture survey," Barry Kitch, M.D., MPH, Institute for Health Policy, Massachusetts General Hospital; and
• "Unsafe Acts Algorithm – Determining Your Hospital’s Response to Individual Errors," which was adapted from the work of James Reason (slide 23) and Katherine Jones, Ph.D., University of Nebraska Medical Center.

Downloads and links

• Nursing Home and Medical Office Culture Survey Toolkit
  http://www.ahrq.gov/qual/patientsafetyculture
• Materials from Patient Experience & Patient Safety Culture
  https://www.cahps.ahrq.gov/content/community/events/comm_events_UGM11.asp
• Newsletter: “Surveys on Patient Safety Culture”
• Tips on how to increase physician participants
• Unsafe Acts Algorithm
  https://www.cahps.ahrq.gov/content/community/events/files/T-5-S_Jones-Final_fwp.pdf
• Full set of patient safety materials – Katherine Jones, Ph.D.,
  http://www.unmc.edu/rural/patient-safety/
• More information is available from the Premier Safety Institute's Culture of Safety Web site

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WHO launches worldwide campaign to promote “five moments” for hand hygiene

WHO Alliance
The World Health Organization's (WHO) Alliance for Patient Safety officially kicked off its "Save Lives: Clean Your Hands" initiative in May to encourage hospitals and healthcare facilities worldwide to raise awareness of hand hygiene to reduce often preventable healthcare-associated infections. The WHO Alliance released a set of tools for system change, training and education, evaluation and feedback, workplace reminders, and institutional safety climate. The tools emphasize that healthcare providers and workers at all levels of experience should be familiar with the importance of hand washing and hand hygiene. The tools, along with a guide to implementation, can be downloaded free on the WHO site. (link to 1st link below) There also is a 270-page guideline (link to 2nd link below)designed for hospital administrators and healthcare workers that reviews current evidence addressing hand hygiene in healthcare.

Premier alliance
The Premier healthcare alliance has been promoting the WHO initiative to hospitals participating in its QUEST performance and quality improvement collaborative. "We want to piggyback on these efforts and say there is no tolerance. "Not washing your hands is a never event," says Leslie Schultz, R.N., Ph.D., Premier's director of knowledge transfer in Charlotte, NC. Schultz said Premier, which also promotes hand hygiene through its Safety Institute, has witnessed "a lot of activity and a lot of education" in light of the recent experience with H1N1 virus. In certain conditions, surgical masks may be appropriate, "but the foundation and most basic thing is wash your hands, people," Schultz said. Two-thirds (67 percent) of Americans report that they or someone in their household has washed their hands or used hand sanitizer more frequently in response to reports about H1N1 flu.

The WHO initiative emphasizes the "five moments for hand hygiene" approach that defines the key moments when healthcare workers should perform hand hygiene. This approach recommends workers clean their hands: before touching a patient, before performing clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings.

The July issue of the newsletter, "WHO Saves Lives: Clean Your Hands," discusses new tools to advance the campaign. Several tools are provided on the WHO Web site that support the implementation of system change in healthcare organizations. Template letters and other communication tools (link to 5th link) are also provided for getting the word out to providers, staff and patients about the importance of hand washing.

Launched on May 5, 2009, the new WHO initiative, "Save Lives: Clean Your Hands," is an extension of the First Global Challenge launched by WHO in 2005 called Clean Care is Safer Care" and takes the Global Challenge work to the patient's bedside by further translating hand hygiene theory into practice.

Downloads and links

• WHO site resources
  http://www.who.int/gpsc/en/
• WHO tools for system change
  http://www.who.int/gpsc/5may/tools/system_change/en/index.html
• Premier in the news: "WHO initiates worldwide campaign to promote hand hygiene"; HealthLeaders Media; 5/6/09 https://premierinc.com/about/news/inthenews/index.jsp
• "My 5 Moments for Hand Hygiene"
  http://www.who.int/gpsc/5may/background/5moments/en/index.html
• WHO template letters and other communication tools
  http://www.who.int/gpsc/5may/tools/safety_climate/en/index.html
• See Premier's Safety Institute Web site on Hand Hygiene

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