August 2007
Dear Colleague:
Staff safety, health, and training are featured in stories this month on reducing noise levels, needlestick injuries and online video training.
Also, download or order a free printed copy of Premier Safety Institute’s brochure, Preventing Needlestick Injuries for staff training. Go to: www.premierinc.com/needlestick.
Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- Hospitals aim to reduce noise levels to improve healing, patient satisfaction and reduce error and worker stress
- One-third of ED communications are interruptions, contributing to medical error
- Checklist added to pandemic planning resources from HHS, WHO
- Needlestick injury rate linked to working conditions and frequency of needle use
- Fall prevention success linked to standardized assessment with customized prevention strategies key
- Electronic health record cost effective in ambulatory care
- C. difficile infection rates in hospitalized patients rise; current prevention and control strategies still apply
- Staffing levels linked to increase in VAP rates in ICU
- Online video training increases compliance with sterile practices during central venous catheter insertion
Safety tools
- Premier – Healthcare associated infection presentations available online
- AHA/HRET – Comprehensive tool for HIV testing in ED
- Premier – "Green" programs: Catholic Healthcare West; West Penn Allegheny
- AHRQ – Emergency prep guide to locate healthcare sites during disaster
- OSHA – New healthcare "Quick Start" compliance tool
Hospitals aim to reduce noise levels to improve healing, patient satisfaction and reduce error and worker stress
When noise levels were found to be patients’ chief complaint on a New York hospital's satisfaction survey, the hospital staff implemented a program designed to reduce noise. According to a recent article in the New York Times (July 6, 2007), "Hospitals turn the volume down," Montefiore Medical Center's fifth floor has become a quiet zone after instituting Silent Hospitals Help Healing (SHHH), a noise awareness program. SHHH signs alert workers, patients, and visitors to keep the noise down; medication carts with squeaky wheels have been repaired and the hospital has installed sound-absorbing ceiling tiles and curtains to reduce hallway commotion.
Other noise reduction measures taken include workers wearing soft-soled shoes, keeping hallway conversation to a minimum, and switching pagers to vibrate mode. Additionally, the hospital lowered its intercom’s volume and gives patients the option of wearing headphones while watching television. Since implementing the changes, the floor’s noise level has been reduced from as high as 90 decibels – roughly equivalent to the din of a busy city street – to about 65 decibels, which is comparable to the noise level in a library. The program has also been shown to reduce worker stress and enabled patients to sleep more soundly – benefits that have prompted some other hospital floors to adopt the program’s noise-reducing strategies.
Similarly, in late 2006, Mercy Health Center in Oklahoma City initiated a "Yacker Trackers" system that alerted the maternity unit when chatter escalates to a dangerous level. A traffic light-shaped sound level meter’s steady green glow turns yellow for caution as noise levels rise, and red when the unit becomes too loud. Mercy sets the decibel level between 50 and 60, about that of a library. The devices are used intermittently and their location is changed every couple of weeks.
Noise levels in hospitals have been studied by a number of groups and suggest that the library level of 50-60 decibels, though an improvement, may not be low enough. Acoustical engineers from Johns Hopkins University demonstrated that excessive noise in hospitals leads to over-stressed workers raises the risk of errors because instructions aren't properly heard, and can even interfere with healing and recovery. Their 2005 report indicated hospital noise levels rose from 57 decibels during the day in 1960 to 72 decibels; at night, the levels jumped from 42 decibels to 60 decibels. In 1995, the World Health Organization issued noise guidelines that put the preferable noise levels in patients' rooms at 35 decibels. The EPA-recommended guideline values for continuous background noise are 35 decibels during the day and 40 decibels at night in patient rooms. The Center for Health Design has summarized design changes that may assist in controlling sound in its Issues paper #4, published in January 2007.
"Hospitals turn the volume down" New York Times. Register and search "July 6, 2007."
"New moms need privacy" USA Today. December 2006
"Rise in hospital noise poses problems for patients and staff" Johns Hopkins University, 2005
Download CHD study, "Sound control" Construction safer, greener:design. (.pdf) (367 KB)
One-third of ED communications are interruptions, contributing to medical error
A case study designed to observe, record, and determine the context of activities and interruptions experienced by physicians and registered nurses working in a Level One Trauma Center at a tertiary teaching hospital is described in the June 2007 International Journal of Medical Informatics. Brixey and colleagues selected the emergency department for the study because of its frequent interruptions, recognizing the fact that these interruptions may contribute to medical errors.
The study describes that many of the interruptions experienced by physicians and RNs are due to synchronous communication events, face-to-face meetings, telephone calls, and pages, and at least one-third of all communication events in the ED are classified as interruptions. This breaks down to about 11 interruptions an hour by a communication event initiated by a colleague.
Physicians were interrupted slightly more than 10 times per hour with RNs interrupted almost 12 times per hour.
Resumption of the original activity was done in the majority of the situations after performing only one interrupting activity, although data showed as many as eight activities in some instances. No data was collected on the consequences of activities that were not resumed because of the interruptions.
People were found to interrupt more frequently than technology. However, the researchers conclude that future studies of interruptions should look at how new technologies, such as the increasing use of mobile phones, may introduce interruptions or reduce need for an interruption. For example, physicians in this study stopped to answer ringing landline phones with a voice mail feature less frequently than answering their mobile phones without a voicemail function.
Brixey JJ. Int J Med Inform. July, 2007 abstract (.doc) (29 KB)
Checklist added to pandemic planning resources from HHS, WHO
Premier's Safety Institute's recently launched Web site on pandemic influenza includes resources such as the latest progress reports, plans and strategies from the World Health Organization (WHO), the White House Homeland Security council, Health and Human Services (HHS), Centers for Disease Control and Prevention (CDC), OSHA, and a comprehensive hospital checklist developed from HHS/CDC pandemic influenza resources.
The Web site includes a section for healthcare professionals and provides the latest infection control guidance from WHO (June 2007), as well from CDC/HHS respiratory hygiene, personal protective attire and educational material. Links to the latest information on vaccine research and development are provided, as well as additional resources such as the just-published lessons learned from strategies used during the 1918 pandemic.
Easy links are provided to the Safety Institute's seasonal influenza Web site, with similar types of usable resources, as well as links to emergency preparedness information.
White House National Strategy one-year report.
Premier hospital checklist – pandemic influenza
Merkel JAMA August, 2007 abstract.
Visit the Premier Safety Institute's pandemic influenza resources and seasonal influenza web sites
Premier Safety Institute's Web site on emergency preparedness
Needlestick injury rate linked to working conditions and frequency of needle use
Nearly 16 percent of nurses reported a history of needlestick injuries in the past year with risk of injury associated with the number of needles used and extended hours worked.
These findings were identified in a three-wave longitudinal survey conducted of 2,624 registered nurses from two states between November 2002 and April 2004. Respondents who had worked as a nurse during the past year, prior to wave one of the survey, were included in the analysis. Workplaces of the respondents included hospitals, nursing homes, skilled nursing facilities, ambulatory care settings, home health, assisted living, government, schools and business.
The cumulative incidence of needlestick injuries for nurses by the third wave of the study was 16.3 percent. The risk of sustaining a needlestick injury was significantly associated with the number of needles used per day, hours worked per day, weekends worked per month, working other than day shifts, and working 13 or more hours per day at least once a week.
Because of a higher estimated daily use of needles, groups reporting a greater percentage of needlestick injuries in the past year included staff nurses and hospital nurses; those with specialties in emergency, adult critical care, operating rooms, oncology, transplantation, acquired immunodeficiency syndrome, catheterization labs, diagnostics, and hemodialysis.
Eighty-one percent of nurses who sustained a needlestick from a contaminated or possibly contaminated needle reported their injuries, compared to only 14 percent of those injured by an uncontaminated needle. Nurses sustaining injury from a contaminated needle were also more likely to see a healthcare provider. One-third of the reported injuries resulted from needles that had a safety design such as self-sheathing, self-blunting, or retractable; however, it is not clear if the safety mechanisms on these devices were activated.
Trinkoff and colleagues conclude that despite advances in protecting workers from needlestick injuries, extended work schedules and their related physical demands are still contributing to the occurrence of injuries and illnesses to nurses. They suggest that if working conditions were modified, further reductions in needlestick injuries might be possible.
New educational brochure from Safety Institute –
Prevent Needlestick Injuries
The Premier Safety Institute has just published a brochure to caregivers in any setting across the continuum of care about the serious risks of needlestick injuries and strategies and devices to reduce risks. This 12-page brochure summarizes the risks of needlestick injuries, work practice prevention strategies, safety devices, device evaluation, post-exposure follow up, and sharps disposal. Visit the
Safety Institute Web site to download a copy of the brochure, order copies, or find other tools and resources on sharps safety.
Trinkoff. ICHE. February 2007 abstract (.doc) (28 KB)
Prevent Needlestick Injuries brochure
www.premierinc.com/needlestick
Additional downloadable tools and resources are available on the Safety Institute's sharps safety web site.
Fall prevention success linked to standardized assessment with customized prevention strategies key
In 2002, Ascension Health articulated a call for action to provide 100 percent access to safe, effective care with a goal of no preventable injuries or deaths by July 2008. Preventing falls was one of the goals adopted. Eight hospitals in this system served as the alpha site with recommendations for four key strategies that extended to all Ascension Health facilities and resulted in a 9.9 percent systemwide reduction in acute care fall rates from January to October 2006 and a reduction in serious injuries.
According to Lancaster and colleagues, methods for implementing the four key strategies varied among the hospitals, with the exception of the first strategy for assessment and reassessment of patient risk factors. All electronic medical records incorporated the Hendrich II Fall risk Model to assess the patient's risk factors for falling on admission with a reassessment of risk when there is a change in caregiver or a change in patient condition. A second strategy was visual identification of the patient that included, for example, ruby red slippers, special socks, armbands, door signs, or special signs on door like "Falling Star." The third strategy, communication of patient fall risk status, included verbal reports at change of shift or caregiver and computer notification to other departments of fall risk status. One hospital published tips to reduce falls, such as toileting rounds every hour on the 11 p.m. to 7 a.m. shift to offer bathroom assistance and recording usual waking times to ensure availability of assistance. The fourth strategy involved education of patients, families and physicians with special education, such as the use of a white board in the room with a stop sign to remind patients to call the nurse.
In addition, special beds were ordered to address both the prevention of pressure ulcers and falls with built-in alarms to alert staff when patients get out of bed, pressure redistribution surfaces, and capable of being lowered within 8-10 inches of the floor.
Lancaster AD. Jt Comm J Quality Pt Safety. 2007 abstract (.doc) (28 KB)
For additional information on fall prevention, including comprehensive prevention programs, go to the Safety Institute's fall prevention web site.
Electronic health record cost effective in ambulatory care
Electronic health records (EHR) have been found to be a valuable tool for improving patient safety and quality of care, as well as improved access to patient information. However, adoption rates for EHR have been slow with cost frequently being cited as an obstacle. A recent analysis of the return on investment for implementing EHR in five ambulatory care practices found that that the initial costs were recaptured within 16 months, with nearly $10,000 annual savings per provider.
A study was conducted by Greiger et al. at the University of Rochester Medical Center in five ambulatory care offices with 28 providers. The total costs (capital and operating costs) for the first year were $509,539 ($18,182 per provider) and ongoing annual costs were $114,016 ($4,072 per provider).
Measurements of key financial indicators included cost savings associated with improved efficiencies or increased revenue associated with chart pulls, new chart creation, filing time, support staff salary, and transcription time. In addition, patient cycle time, evaluation and management codes billed, and days in accounts receivable were evaluated to assess the impact on office efficiency and billing. The savings realized were compared with the costs of the first two years of EHR to determine return on investment.
The total annual savings were $393,662 ($14,055 per provider). Based on these cost savings, the initial expense was recaptured in 16 months. In addition, once the ongoing annual operating expense was accounted for, there was a net annual savings of $9,983 per provider.
The authors concluded that an EHR could rapidly demonstrate a positive return on investment when implemented in ambulatory offices. Plans are underway to roll out this system over all ambulatory offices within the medical system, and completed by early 2008.
Greiger DL. J Am Coll Surg. July 2007 abstract (.doc) (28 KB)
For more information, see the Safety Institute's CPOE web site.
C. difficile infection rates in hospitalized patients rise; current prevention and control strategies still apply
A recent analysis of infections from Clostridium difficile for the 10-year period between 1993 and 2003 showing a doubling of rates from patients discharged from U.S. hospitals in that decade. Ricciardia and colleagues conducted a population-based sample of patients (National Inpatient Sample) to determine the prevalence and severity of Clostridium difficile colitis (C diff) in hospitalized patients in the United States. Of those patients, almost 300,000 had a diagnosis of C. difficile colitis, a rate of 383 cases per 100,000 discharged patients. C. diff cases increased from 261 per 100,000 discharged patients in 1993 to 546 per 100,000 patients in 2003.
C. diff infections generally result as a side effect of antibiotic use, especially among hospital patients and nursing-home residents. Clostridium difficile is a bacterium normally kept in check by the other bacteria that live in the colon. Antibiotics damage the protective bacteria in the colon, allowing C. diff to flourish. One to 3 percent of people carry C. diff in their colons. Among those taking antibiotics, however, the percentage increases to 20 percent. A more severe strain of C. diff causing severe diarrhea, colon damage (often resulting in surgical removal of the colon), and death was noted in 2004 in the United States and Canada. The study showed that the prevalence and severity of the infection grew worse each year. The rate of C. diff-associated colectomy (surgical removal of the colon) nearly tripled from 1.2 per 100,000 patients in 1993 to 3.4 per 100,000 patients in 2003, while the death rate among the patients rose from 20.3 per 100,000 patients in 1993 to 50.2 per 100,000 patients in 2003.
Because results of toxin assays were not available in this data set, researchers could not verify actual cases, preventing them from determining a cause even though the data indicated the changing nature of C. diff in hospitalized patients.
Toxin determination is important since the most marked increases in the incidence and severity of Clostridium difficile associated disease (CDAD) began in 2001 and have been attributed to the emergence of a hypervirulent strain of C. difficile that produces increased levels of toxins A and B, as well as an extra toxin known as "binary toxin," according to Blossom and McDonald. This previously uncommon strain has become epidemic, coincident with its development of increased resistance to fluoroquinolones, the use of which is increasingly associated with CDAD outbreaks. Recent recommendations for C. diff surveillance by McDonald and colleagues also identify the complexity of distinguishing healthcare-associated versus community-associated disease.
Regardless of setting, these findings corroborate the critical need for appropriate antibiotic usage – the number one prevention and control strategy. Environmental prevention and control methods in healthcare facilities are well defined by the CDC. They include use of "contact precautions" for patients with known or suspected CDAD in private rooms and vigilant adherence to hand hygiene. Recommendations and more background on the disease, prevention and control are available on the Safety Institute's special C. difficile Web site.
Ricciardi. Arch Surgery. July 2007 abstract (.doc) (40 KB)
Blossom DB. CID. July 2007 (.pdf) (118 KB)
McDonald L. ICHE. February 2007 - CDAD Surveillance guidelines (.doc) (33 KB)
Additional information and resources from the Safety Institute's Clostridium difficile web site.
Staffing levels linked to increase in VAP rates in ICU
A recent study asking whether low nurse-to-patient ratio increases the risk for ventilator-associated pneumonia (VAP), and whether this effect is similar for early-onset and late-onset VAP, found that decreasing the number of nurses on duty in an intensive care unit (ICU) increases the risk for late-onset VAP. The study by Hugonnet et al. published in the open access journal Critical Care, July 2007, is a prospective, observational, single-center cohort study conducted in the medical intensive care unit (ICU) of the University of Geneva Hospitals and followed 2,470 patients admitted from January 1999 to December 2002.
VAP affected 22.3 percent of the 936 patients who received mechanical ventilation. Late-onset VAP accounted for 61 percent of all episodes, with a VAP rate of 37.6 episodes per 1,000 days at risk. Patients who developed VAP were compared to the number of nurses on duty for each patient in the preceding days. Among the patients on mechanical ventilation, the risk of late-onset pneumonia (occurring six days or more after intubation) was 58 percent lower when there were two or more nurses for each patient than when nurse-patient ratios were lower. No association was observed with early-onset VAP. The nurses' training level had no effect on infection rates. This research supports the case for increasing RN staffing in hospitals and limiting the number of patients assigned to a nurse.
VAP is caused by bacteria entering the lungs as a consequence of the ventilator tubing and is one of the most common preventable problem affecting critically ill hospital patients. It can cause a stay of about an average of 10 extra days in hospital at a cost of $10,000 to $40,000. The authors state that an increased workload results in noncompliance with basic hygiene measures and infection control recommendations, and that time constraints can increase the probability of error by creating a busy, stressful environment with distractions and interruptions, leading to low compliance with hand hygiene recommendations and isolation procedures, or inadequate care for the ventilated patient.
Hugonnet S. CC. July 2007 (.pdf) (151 KB)
For more information on VAP prevention, see the Safety Institute's bundling – evidence-based practices web site.
Online video training increases compliance with sterile practices during central venous catheter insertion
A recent study by Xiao and colleagues found that residents trained with a video were more likely to comply with sterile practices during central venous catheter (CVC) insertion, compared to residents being trained by a paper method or in the control group. The online training course contained short video clips from actual patient care demonstrating common noncompliance behavior and breaks regarding recommended sterile practices. The paper training had similar content to the video program.
The primary outcome measure was compliance with recommended sterile practices in 11 aspects covering three areas: skin preparation (friction scrubbing, aseptic techniques in skin preparation, maintaining sterile field, and adequate drying time), operator preparation (use of cap, mask, sterile gown, and sterile gloves, with gown tied), and draping (use of a full-body drape and maintenance of sterile field during draping). Compliance was assessed by reviewing video records of CVC insertion and marking score sheets for occurrence of infractions. Full compliance was defined as being devoid of infractions in all 11 aspects.
Fifty residents inserted 73 elective central venous catheters. The overall compliance with proper operator preparation, skin preparation, and draping was 49 percent (36 of 73 procedures). The training had no effect on selection of site and skin preparation agent. The video group was significantly more likely than the other two groups to fully comply with sterile practices (74 percent compared to 33 percent) even after controlling for the number of years in residency training, specialty, number of central venous catheters inserted, and central venous catheter site chosen.
Interactive educational tools using compelling media has been shown to be able to deliver cognitive content as well as motivate students to comply with recommended practices and behavior. Online training is becoming prevalent because of its flexibility in scheduling and location – valuable characteristics for residents who work long and unpredictable hours. Online training can also track individual use of training material and can be tailored to individual users. Although gains in knowledge achieved by residents through online training have been measured for a wide variety of topics, this is the first study that shows evidence of its impact on compliance with sterile-practice procedures.
XIAO. Crit Care Med. May 2007 (.doc) (27 KB)
For more information on central line evidence based practice, see the Safety Institute's bundling – evidence-based practices web site.../topics/bundling/national.jsp
Safety tools
Premier – Healthcare associated infection presentations available online
Nine presentations from Premier's conference on "Healthcare-associated infections – What everyone needs to know," held June 19, 2007, in Orlando, FL, are available online for download. Featured faculty include: Graeme Forrest, M.D., University Maryland Medical Center; Peter Gross, M.D., Hackensack University Medical Center; Carol Haraden, Ph.D., IHI; Eli Perencevich, M.D., M.S., VA Maryland Healthcare System; Chesley Richards, M.D., M.P.H, FACP, CDC/DHQP; Richard Van Enk, Ph.D., Bronson Methodist Hospital; Daniel Varga, M.D., SSM Healthcare; and Premier's Dan Peterson, M.D, M.P.H.; Gina Pugliese, R.N., M.S.; and Scott Pope, Pharm.D. Download from https://premierinc.com/advisorlive/.
AHA/HRET – Comprehensive tool for HIV testing in ED
The Health Research and Educational Trust (HRET) has developed a comprehensive guide for clinicians and administrators to help incorporate routine HIV testing in their emergency departments (EDs). This practical guide describes different approaches, considerations, and resources for making HIV testing routine in ED care. It is based on findings from site visits and interviews with leadership and staff in EDs and health departments that implemented it. The guide can be used to assist with program design and resource allocation decisions, as well as to inform policies and operational approaches to HIV testing in your ED. Access the guide at http://www.edhivtestguide.org.
Premier – "Green" programs: Catholic Healthcare West; West Penn Allegheny
Listen to leaders discuss their "green" programs: Catholic Healthcare West’s Ecological Initiatives and West Penn Allegheny Medical Center greening the waste stream from Premier’s 2007 Governance conference. Download the audio file and slides or order the CD in the Safety Institute Store.
AHRQ – Emergency prep guide to locate healthcare sites during disaster
The Agency for Healthcare Research and Quality (AHRQ) has released an atlas to help disaster planners locate hospitals and nursing homes that could assist in an emergency http://www.ahrq.gov/prep/nursinghomes/atlas.htm. The Emergency Preparedness Atlas includes maps showing the location of hospitals and nursing homes in each state, and case studies for six states that show bed capacity and the emergency management and bioterrorism preparedness regions for each facility. The Atlas is intended to help nursing homes plan how they may be used to handle a surge of patients in response to emergency situations; it is not a review of the quality or adequacy of preparedness efforts in any area. The Atlas can help explain the state-specific regulatory environment of nursing homes with respect to surge capacity and illustrate nursing home geographic distribution in the United States. A separate report, "Nursing Homes in Public Health Emergencies – Special Needs and Potential Roles," addresses the role that nursing homes could play in regional preparedness, and is based on focus groups with nursing homes in the case study states.
OSHA – New healthcare "Quick Start" compliance tool
The new Healthcare Industry Quick Start module is directed primarily to small employers in the healthcare field. The module is designed to help users find free resources on the OSHA Web site related to the healthcare industry. The eight-step module includes information on OSHA requirements that apply to many healthcare employers; developing a comprehensive safety and health program; training employees; and record keeping, reporting and posting requirements. Compliance Assistance Quick Start provides step-by-step guidance on how to identify OSHA requirements and guidance materials that may apply to specific workplaces. In addition to the new Healthcare module, Quick Start includes modules for General Industry, Construction, and Hispanic Outreach.
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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 partnered with Premier for a pay-for-performance demonstration project to determine if financial incentives are effective at improving the quality of inpatient hospital care. Participating hospitals are using Premier's Perspective™ clinical database.
Safety Share © 2007 Premier, Inc.
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