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November 2003

Dear Colleague:

Please review our worker safety tools and resources on back injury prevention, influenza, latex allergies, sharps injury prevention, and more.

Encourage your colleagues to subscribe to Safety Share so they don't miss any issues. Search our archives for topics featured in past issues.

Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute

News

Safety tools

 

JCAHO publishes medication abbreviation list

New and updated frequently asked questions for National Patient Safety Goal (NPSG) #2 are now available on the JCAHO Web site. These FAQs reflect the new requirements for a JCAHO-approved minimum list of "do not use" abbreviations, acronyms and symbols. JCAHO also notes that these apply to all clinical terms, not just medication-related terms.

Effective April 1, 2004, each organization must identify and apply a minimum of three additional "do not use" abbreviations, acronyms or symbols of its own choosing. This requirement applies to those organizations without additional do not use items in place. JCAHO lists another seven sets in the FAQs updated November 4, 2003, and also recommends selection from the Institute for Safe Medical Practices (ISMP) list.

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Obesity epidemic poses new challenges for providers

The crisis

Approximately nine million U.S. adults are considered extremely obese with a body mass index (BMI) of over 40, representing a 130 percent increase in the last ten years. This segment of the population has a significantly increased risk for illness and premature death creating new challenges for treatment therapies as well as risks of occupationally related back injuries among providers. (More information on preventing back injuries, BMI measurement and equipment, is available from Premier Safety Institutes Web resources.)

Many obese patients avoid receiving medical care for reasons ranging from the practical CAT scanners that are too small and exam tables that tip over to the more subjective embarrassment they feel about their weight. Compounding the problem is evidence that clinicians harbor negative feelings about obese patients and feel frustrated when treating obese patients because the patients size prevents them from practicing the best medicine. The potent combination of patient feelings and clinician frustration has led to a care crisis in which obese patients often are forced to forego necessary treatments or diagnostic scans for common ailments like diabetes, hypertension, heart disease, and cancer. Worse, many obese patients are not seeking adequate preventive care, despite needing this care more than other patient populations. A 1994 study in the Archives of Family Medicine demonstrated that the higher a womans BMI, the more likely she is to delay or cancel a visit to the physician. In acknowledgement of such problems and the growing obesity epidemic in the U.S., some providers are working to accommodate severely overweight patients. A handbook issued by the NIH provides guidance to physicians on how to sensitively treat and diagnose obese patients and improve office accommodations by adding armless seats and scales with wide bases in private areas.

Bariatric surgery one alternative

An increasing alternative treatment for obesity is bariatric surgery. U.S. hospitals and insurers are trying to accommodate the growing demand among Americans eligible for bariatric surgery, a number increasing by an estimated 10 percent to 12 percent annually. Its no surprise that spending on bariatrics is nearing $3 billion per year. Bariatric surgery costs an average of $25,000, a figure that can skyrocket to as much as $100,000 for follow-up costs that often are not covered by insurance. Medicaid programs in many states have been reluctant to pay for the procedures. As a result, poor patients, among whom obesity is an especially acute concern, are often forced to wait. At the University of California-Davis, for example, Medi-Cal patients face a 12-year wait for bariatric surgery, which Medi-Cal reimburses at less than 33 percent of cost.

Body mass index criteria for coverage?

Currently, 10 million Americans meet eligibility requirements for bariatric surgery, and there is increasing pressure on payers to lower the body mass index-threshold for payment. To qualify for bariatric surgery, a patient must be at least 100 pounds overweight or have a BMI of 40 or higher, putting them in the high-risk category of the morbidly obese. Physicians may also consider patients with a BMI above 35 who have other life-threatening health problems such as heart disease that could be helped by weight loss. In order for patients to meet the standards, physicians must consider the risk of being overweight to be greater than the risk of the surgery, which has about a 1 percent mortality rate from complications and requires life-long dietary supplements and follow-up care.

Pediatric surgery and obesity specialists will soon release the first-ever guidelines on gastric bypass surgery for adolescents in an effort to help physicians identify the best candidates for the procedure. According to the guidelines, adolescents will qualify for bariatric surgery if they have a body mass index of 40 (a BMI of 30 is considered obese) and a serious obesity-related medical condition. Those with a BMI of 50 can qualify for the surgery if they have less serious obesity-related problems, such as being maliciously teased, according to the NIH guidelines. The guidelines also recommend that surgeons not operate on teens until they nearly reach their full height potential age 13 for girls and 15 for boys because the procedure limits the absorption of nutrients.

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IOM Report: Limit nursing hours and enhance culture to improve safety

In a report released by the Institute of Medicine, a panel recommends work hour limits and other changes to the work environment for nurses to strengthen patient safety. In the press release for the report, titled “Keeping Patients Safe: Transforming the Work Environment of Nurses,” the IOM proposes limiting nurses' working hours to fewer than 60 hours per week and 12 hours in any 24-hour period. It also recommends that healthcare organizations reduce their use of temporary nursing staff, invest more in training and continuing education for nurses, and increase nurses' role in management and decision-making. The panel also noted that regulators and healthcare leaders should work to reduce workplace inefficiencies, such as excessive paperwork and documentation, which reduce the time nurses have to spend with patients. Significantly, the report also recommends that Congress pass laws to extend peer-review protections to data collected internally by hospitals or shared with outside agencies for the purpose of improving safety and quality. "[The report] highlights some important areas that we've already begun to address,” noted Pamela Thompson, CEO of the American Organization of Nurse Executives (AONE). “Hospital and nurse leaders are working to redesign the work environment -- through technology, training and retention efforts -- to better support nurses as they work to deliver quality care to patients." AONE is the AHA's nursing affiliate.

The panel's recommendations are made in a climate of high turnover rates among nursing staffs, as well as an ever-worsening nursing shortage. Implementation of the recommended changes in nurses' work environments would likely help healthcare organizations recruit and retain nurses, the report asserts. "It may be tempting to think that these recommendations can wait for increases in the supply of nurses, but evidence on nursing retention indicates just the reverse is true,” said Donald M. Steinwachs, chair of the committee that wrote the report, and chair, department of health policy and management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore. "Because the supply of nurses is unfortunately stretched thin right now, they must be supported by work processes, work spaces, hours, staffing practices, and a culture that better defends against errors and readily detects and mitigates errors when they occur. Nurses will be more likely to stay in health care organizations that implement the management and work-design practices recommended in this report." Access the IOM press release, or the executive summary below; the full report may also be purchased on-line.

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e-Prescribing and remote ICU monitoring can improve quality and lower costs

Seven advanced technologies that have demonstrated the ability to simultaneously reduce costs and improve quality are detailed in a new report, “Advanced Technologies to Lower the Cost of Health Care and Improve Quality,” jointly produced by the Massachusetts Technology Collaborative and the New England Healthcare Institute. Those with the greatest savings include computerized physician order entry (CPOE), electronic prescribing, electronic patient-physician communication, and remote ICU monitoring. Technologies with the potential to yield dramatic administrative savings but no direct clinical benefit, are not addressed by the report. There are a host of non-information-based technologies that also have dramatic effects. The seven selected information-based technologies with the estimated savings, discussed in more detail in the report, include:
 

Electronic patient-physician communication $167.8 million
e-Prescribing $140.7 million
Ambulatory CPOE $290.3 million
Inpatient CPOE $966.0 million
Disease management $710.0 million
Regional data sharing $23.8 million
E-ICU (e.g., remote ICU monitoring) $177.4 million
Total $2.48 billion

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Greater surgical risks seen in physicians offices

During the 1980s, many surgical procedures previously performed in hospitals began to be performed in ambulatory surgery centers (ASCs) or outpatient clinics. By the 1990s, more than 50 percent of all surgeries took place in ASCs, and more surgeries moved to the physician office setting. According to a new study, death and injury is 10 times more likely to occur during a surgical procedure done in an office setting than an outpatient clinic. The September 2003 issue of The Archives of Surgery published the study comparing outcomes to determine whether patient safety is similar in Florida ambulatory surgery centers and offices.

Hector Vila Jr., MD, of the H. Lee Moffitt Cancer Center and Research Institute in Tampa, FL, and colleagues compared surgical outcomes for patients who underwent surgeries in ASCs with those whose procedures were performed in physician offices in Florida. The researchers reviewed all adverse incidents reported to the Florida Board of Medicine for procedures performed between April 1, 2000, and April 1, 2002. They concluded that 66 adverse events occurred per 100,000 procedures performed in offices and 5.3 adverse events occurred per 100,000 procedures performed in ASCs. The death rate per 100,000 procedures was 9.2 in offices and 0.78 in ASCs.

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CDC releases draft SARS preparedness plan

Hospitals should consider initiating a "universal respiratory etiquette" to decrease transmission of severe acute respiratory syndrome (SARS) and more-common respiratory ailments such as the flu, the Centers for Disease Control and Prevention (CDC) stated in a draft SARS preparedness plan. The draft plan outlines the concepts and strategies that would guide the U.S. response in the event of another outbreak of SARS. The document is intended to assist local and state public health and health care officials in their preparations for a possible reemergence of SARS during the approaching respiratory disease season. The agency's recommendations include installing plexiglass barriers at triage or registration stations to protect healthcare workers from respiratory droplets, and segregating patients with respiratory symptoms by at least three feet in waiting areas. In a SARS outbreak in Toronto last year, 77 percent of patients in the outbreak's first phase were infected in the hospital; half of all SARS cases in Toronto were healthcare workers.

The CDC is directing all U.S. hospitals to equip for a limited number of SARS patients as part of routine operations, and a large number of patients in the case of an outbreak. Hospitals should develop a written preparedness and response plan that includes procedures for surveillance and triage, patient placement, exposure reporting, and staffing needs. Currently, many patient management decisions must be made before SARS is officially diagnosed, because no specific clinical or laboratory finding can reliably distinguish SARS from other respiratory illnesses early on. The CDC plan can be found at the CDC SARS Web site. The American Hospital Association issued an advisory November 3, urging hospitals to review and forward comments on the draft to the CDC.

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Care at teaching hospitals associated with higher complication rates

A retrospective analysis of nearly 4,000 acute care hospitals in the U.S. reveals that there is a higher rate of certain complications if care is received in a teaching hospital instead of a non-teaching hospital. Recent data analyzed at Georgetown University in Washington from the Healthcare Cost and Utilization Project (HCUP) and the American Hospital Association's annual Survey of Hospitals indicates that there is a higher rate of certain complications if care is received in a teaching hospital instead of a non-teaching hospital. Researchers conducted a retrospective analysis of 3,818 U.S. acute care hospitals included in the National Inpatient Sample from 1990 through 1996 and presented the results at the American Academy of Family Physicians’ 2003 Scientific Assembly October 1-5, 2003, in New Orleans, LA.

Researchers looked at the rates of postoperative deep vein thrombosis (DVT) or pulmonary embolism (PE); postoperative pulmonary compromise; postoperative urinary tract infections (UTIs); and postoperative pneumonia. Hospitals were divided into three groups: major teaching hospitals, other teaching hospitals, and non-teaching hospitals. The incidence of postoperative DVT, PE, and pulmonary compromise were highest in the teaching hospitals and lowest in the non-teaching hospitals. Postoperative UTIs were more frequent in non-teaching hospitals than in teaching hospitals. The Georgetown researchers cited the structure of the teaching hospital, with its multiple levels of care and the typically long work hours, as contributing factors. "There are constant changes in shifts and no continuity of care in teaching hospitals," Amar Duggirala, MD said. The number of nurses also has a positive effect on postoperative adverse events. The number of patients cared for during an average shift was higher for nurses in teaching hospitals than for nurses in non-teaching hospitals.

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Safety tools

 

Resource guide: Families end-of-life wishes

Last Acts, a national coalition to improve end-of-life care, has published a resource guide designed to help the elderly and their children start discussions about end-of-life wishes before an unexpected illness arises. The guide, "Conversations Before the Crisis," includes conversation "triggers," such as using television programs and family gatherings to start talking, and includes sample language as guidance. The booklet is geared toward the elderly and children of the aging, and includes a resources list with helpful books and Web sites.

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CDC healthcare worker guide: Recognizing chemical agent exposure

The Centers for Disease Control and Prevention (CDC) has issued a guide intended to help health care providers recognize exposure to chemical agents in the event of a covert chemical release. The agency said symptoms of exposure to some chemical agents might be similar to those of common diseases, making them difficult to identify. Immediate symptoms from certain chemical exposures may be mild or nonexistent, despite the risk for long-term effects, while exposure to contaminated food, water or consumer products may result in reports of illness over a long period and in various locations.

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NIOSH web resource: Indoor air quality

Indoor air quality problems are preventable and solvable. The National Institute for Occupational Safety and Health (NIOSH) has announced an online resource that aids employers in addressing air quality concerns. The Indoor Environmental Quality topic page provides links to a variety of air quality topics, including how to identify, correct, and prevent indoor air problems; how to implement an effective air quality plan; and resources on mold, asbestos, asthma and allergies, and chemical safety.

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OSHA tools: Fire threats and mold control

The Occupational Safety and Health Administration (OSHA) announced the online availability of two new resources that may be of interest to environmental health, safety, and security managers. One, a matrix tool, provides information on how facilities can reduce vulnerability to and consequences of a terrorist attack that involves fire or an explosive device.

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AHA tools: Communication with patients

The American Hospital Association (AHA) has created a new resource folder, Strategies for Leadership: Improving Communications with Patients and Families, which is designed to help hospitals communicate with patients and families. The centerpiece of the folder is a brochure titled, The Patient Care Partnership: Understanding Expectations, Rights and Responsibilities,  which replaces the AHA's A Patient's Bill of Rights. Other resources include a workbook highlighting case studies from hospitals using innovative programs, and a "quick assessment" tool to determine where improvements could be made. Each of the resources, including five foreign language translations of The Patient Care Partnership, is available at http://www.aha.org under "Communicating with Patients."

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Editorial team

Gina Pugliese, RN, MS editor
Judene Bartley, MS, MPH, associate editor
Donna Bernstein, MPH, marketing consultant
John Hall, BSJ, contributor
Derek Kleckner, BA, Web master
Judith Luca, RN, BSN, contributor

About Premier

Premier, Inc. is a healthcare alliance entirely owned by 200 of the nation's 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 Premiers Perspective Online database can receive recognition and additional Medicare payment when they meet or exceed specific quality measures.

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