December 2006
Dear Colleague:
Premier wins Baldrige award. We are pleased to announce that Premier has achieved the 2006 Malcolm Baldrige National Quality Award, the nation's highest presidential honor awarded to organizations for performance excellence.
Safety Share is brought to you by the Safety Institute, Premier Inc., as part of our social responsibility and goals to serve our communities.
The Safety Share team wishes you a healthy and happy holiday season!
Gina Pugliese, RN, MS editor
Judene Bartley, MS, MPH, CIC, associate editor
John Hall, BSJ, contributor
Judith Luca, RN, BSN, contributor
Cathie Gosnell, RN, MS, MBA, contributor
Derek Kleckner, CUA, Webmaster
Jena Abernathy, Executive sponsor
News
- IHI announces new "5 Million Lives Campaign"- goals include engagement of the Board of Directors
- Syringe reuse in nuclear pharmacy source of Hepatitis C outbreak
- Automated sprinklers to improve fire safety tied to proposed nursing home rules
- Empowered ED staff activating cath lab, on-site cardiologists among strategies to reduce AMI door-to-balloon time
- HHS increases stockpile of vaccine, antivirals, and respiratory protection
- NQF updates lists of "safe practices" and "never events" prompting call for hospitals to adopt policy of apologizing to injured patients
- Falls are leading cause of fatal injury among seniors
Safety tools
- SCIP – New surgical, VTE tools
- Medication safety guide – Ambulatory care
- IHI – Patient safety trigger tools
- H2E – New environmental compliance and improvement guide
- AHRQ emergency planning – Mass casualty care guide
- Prevent Influenza Now! - New Web site provides influenza vaccination updates
IHI announces new "5 Million Lives Campaign"- goals include engagement of the Board of Directors
At the recent Institute for Healthcare Improvement (IHI) Nineteenth Annual Forum on Quality Improvement in Health Care, IHI president Donald Berwick announced the new "5 Million Lives Campaign" and its goal of protecting patients from 5 million incidents of medical harm over the next two years (December 2006 to December 2008).
IHI estimates that 15 million incidents of medical harm occur in U.S. hospitals each year, based on studies of injury rates in hospitals that have shown that between 40 to 50 incidents of harm occur for every 100 hospital admissions. With 37 million admissions in the United States each year, this equates to approximately 15 million harm events annually – or 40,000 incidents of harm in U.S. hospitals every day.
"Medical harm" is defined as unintended physical injury that results from, or is contributed to by, medical care (including the absence of indicated medical treatment) and also requires additional monitoring, treatment or hospitalization, or results in death. Such injury, IHI explains, is considered harm whether or not it is considered preventable, resulted from a medical error, or occurred within a hospital.
"IHI and its 3,100 partner organizations in the first campaign of 100,000 Lives saved an estimated 122,000 lives in 18 months prompting the beginning of new standards of care and it is now time to establish another bold and seemingly impossible goal for U.S. healthcare," Berwick explained.
The "5 Million Lives Campaign" is intended to focus on tackling medically-induced injuries in healthcare and will promote the adoption of up to 12 improvements in care that can both save lives and reduce patient injuries. It will also continue to promote and fight needless deaths as part of the continuation of efforts from the "100,000 Lives Campaign." How-to-guides are available from IHI for all 12 interventions.
Six of the 12 improvements are a continuation of the "100,000 Lives Campaign" and include:
- Deploy rapid response teams;
- Deliver reliable, evidence-based care for acute myocardial infarction;
- Prevent adverse drug events;
- Prevent central line infections;
- Prevent surgical site infections; and
- Prevent ventilator-associated pneumonia.
Six new recommended interventions are targeted at harm and include:
- Prevent harm from high-alert medications, starting with a focus on anticoagulants, sedatives, narcotics, and insulin;
- Reduce surgical complications…by reliably implementing all of the changes recommended in the Surgical Care Improvement Project (SCIP);
- Prevent pressure ulcers…by reliably using science-based guidelines for their prevention;
- Reduce methicillin-resistant Staphylococcus aureus (MRSA) infection by reliably implementing infection control practices;
- Deliver reliable, evidence-based care for congestive heart failure...to avoid readmissions; and
- Get Boards on board…by defining and spreading the best known leveraged processes for hospital boards of directors, so they can become more effective in accelerating organization progress towards safe care.
Hospitals are involved in many other patient safety initiatives to align with the specific campaign objectives and interventions. There is no cost for hospitals to join the "5 Million Lives Campaign," though there is an obligation to adopt at least one intervention and an expectation of regularly reporting hospital profile and mortality data throughout the campaign.
Goals for the Board of Directors
The new initiative includes a goal for the Boards of Trustees in all hospitals to spend more than 25 percent of their time, at a minimum, on quality and safety issues and to conduct, as a full board, a conversation with at least one patient, or family member of a patient, who sustained serious harm at their institution within the last year. A "how-to" guide is provided by IHI that includes recommendations for core leadership activities, such as establishing the mission, vision and strategy as a "relentless drumbeat" for communicating the direction of the organization to the stakeholders.
Free informational calls - The first two in a series of free information calls will be held on:
Wednesday, December 20 (1-2 p.m. EST) and
Monday, January 8 (4-5 p.m. EST).
For more information about the campaign, toolkits, and schedule of information calls, visit:
http://www.ihi.org/ihi/programs/campaign.
Syringe reuse in nuclear pharmacy source of Hepatitis C outbreak
Reuse of needles and syringes were practices that likely led to a HCV contaminated vial affecting 15 patients receiving injections from the single contaminated vial prepared in a nuclear pharmacy. The potential source was a patient positive for HCV and human immunodeficiency virus (HIV) since the HCV markers from this index case were nearly identical to the 15 subsequent HCV cases.
Researchers found that 16 patients testing positive for HCV had received injections for myocardial perfusion studies. According to an article in the October 2006 issue of the Journal of the American Medical Association, the patients were from three different clinics but all received a radiopharmaceutical injection drawn from the same contaminated vial. An additional 59 tested patients who received doses from six other vials prepared at the same pharmacy did not test positive for acute HCV infection. The HCV/HIV index case had blood processed at the pharmacy for a radio-labeled white blood cell study 12 hours before the contaminated vial was prepared. The HCV markers from the index case were nearly identical to those from other cases.
Although a specific contamination point was not found, pharmacy practices that could have led to blood cross-contamination of the radiopharmaceutical include:
- Reuse of needles and syringes during dilutions;
- Sharing of saline vials between sterile preparations; and
- Use of common flow hoods for some steps in the preparation of sterile and blood-derived products.
Researchers noted that this is the first known report of HCV transmission from contaminated nuclear medicine products. Authors of the study concluded that nuclear pharmacies that handle biological products should follow appropriate aseptic technique to prevent contamination of sterile radiopharmaceuticals. Moreover, researchers recommended that nuclear pharmacies adhere to the standards set by the U.S. Pharmacopeia and have established policies that provide sterile equipment, a sterile environment, standardized compounding procedures, and training of employees on aseptic technique.
JAMA abstract HCV contamination (.doc) (22 KB)
Automated sprinklers to improve fire safety tied to proposed nursing home rules
A new proposed rule from the Centers for Medicare and Medicaid Services (CMS) would require all long-term care facilities to install automatic sprinkler systems throughout their facilities in order to receive Medicare or Medicaid payments.
Since 2000, only new long-term care facilities and those undergoing renovations have been required to install sprinkler systems. After more than 30 resident deaths from fires in long-term care facilities in 2005, CMS required the placement of battery operated smoke alarms in patient rooms and in public areas. The proposed regulation would expand on this requirement to include the requirement that all long-term care facilities install and maintain approved, supervised, automatic sprinkler systems. CMS is asking for public and industry recommendations on an appropriate implementation timeframe, permitting older facilities time to retrofit.
Experts estimate that the proposed rule would cost $47.8 million to $69.9 million annually with a 10-year phase-in; $73.5 million to $107.5 million annually with a seven-year phase-in; and $107.7 million to $157.6 million annually with a five-year phase-in. The proposed rule was published in the October 27, 2006, Federal Register. Comments may be submitted to CMS through December 26, 2006.
Review the proposed rule at:
http://a257.g.akamaitech.net/7/257/2422/01jan20061800/
edocket.access.gpo.gov/2006/E6-17911.htm
Empowered ED staff activating cath lab, on-site cardiologists among strategies to reduce AMI door-to-balloon time
Current national guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) recommend that the interval between arrival at the hospital and intracoronary balloon inflation (door-to-balloon or D2B time) during primary percutaneous coronary intervention (PCI) should be 90 minutes or less. Many hospitals are not in compliance with this recommendation, which is one of the core quality measures collected and reported by the Center for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). In a study titled "Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction" and published by the New England Journal of Medicine, authors provided specific hospital strategies that are associated with a significant reduction in the door-to-balloon time in the management of myocardial infarction with ST-segment elevation.
Strategies that work
Six identified strategies were significantly associated with a faster door-to-balloon time and improved patient outcomes. Most of the six strategies don't cost any extra money and just require implementation plans. These strategies include:
- Emergency department (ED) physicians activate the catheterization laboratory (mean reduction in door-to-balloon time: 8.2 minutes);
- A single call to a central page operator to activate the catheterization lab (13.8 minutes);
- ED staff activate the catheterization laboratory while the patient is en route to the hospital (15.4 minutes);
- Staff arrive in the catheterization laboratory within 20 minutes as opposed to greater than 30 minutes after being paged (19.3 minutes);
- A cardiologist always on-site (14.6 minutes); and
- Staff in the ED and the catheterization laboratory using real-time data feedback (8.6 minutes).
Hospitals that implemented just two of the six strategies had an 88-minute average door-to-balloon time, and the routine implementation of four of the six strategies cut 11 minutes off door-to-balloon time.
American College of Cardiology's "D2B: An Alliance for Quality"
The study findings coincide with the launch of a national quality improvement campaign by the ACC aimed at cutting D2B to shorter than 90 minutes. The "D2B: An Alliance for Quality" focuses on lowering D2B time to 90 minutes or less for 75 percent of the ST-segment elevation myocardial infarction (STEMI) patients presenting at facilities capable of performing primary PCI. The program will focus on the best-practice guidelines highlighted in the New England Journal of Medicine study, as well as previous research from the ACC. The plan is to include a Web-based component that will allow successful hospitals to share best-practice tips, policies and procedures.
Premier is a sponsor of this initiative, and actively promotes "Guidelines Applied in Practice-D2B" "or GAP-D2B." There are no fees for participating in GAP-D2B. Tools and educational materials will be available online for participating hospitals at http://www.d2balliance.com.
NEJM Abstract Door to Balloon (.doc) (26 KB)
HHS increases stockpile of vaccine, antivirals, and respiratory protection
In the third in a series of reports on pandemic planning released November 13, 2006, HHS Secretary Mike Leavitt provides an update on current federal activities related to funding, monitoring and surveillance, research, vaccines, antivirals, state and local preparedness and communications.
Vaccine
The government has stockpiled enough vaccine to inoculate about 3 million Americans against bird flu, and expects to stockpile another 5 million treatment courses in 2007.
Antiviral drugs
The report also indicates that two antiviral drugs are effective against H5N1 virus in lab testing, Tamiflu, manufactured by Roche Laboratories and Relenza, manufactured by GlaxoSmithKline. The government's goal is to have 26 million courses of antivirals in the Strategic National Stockpile by the end of 2006 and a total of 50 million courses by the end of 2008. The federal stockpile, in addition to the subsidized state purchases of an additional 31 million courses will ensure that there are enough antivirals for 25 percent of the population.
Personal protective equipment
Personal protective equipment has been increased as well, with 73.1 million N-95 respirators already purchased for the national stockpile, with another 31.8 million on order, and 37.4 million surgical masks stored, with another 14.1 million on order. Face shields, gloves and gowns are included in the stockpile.
Ventilators
While studies are being conducted to determine the most appropriate types of ventilators to stockpile for a response to a pandemic influenza event, HHS has allocated $25 million for ventilator purchases. Strategic National Stockpile (SNS) ventilator purchases are projected to occur in 2007-2008.
The Pandemic Planning Update III report noted that every state has at least drafted a pandemic plan. Many states have held pandemic flu exercises, and the National Governors Association, with HHS funding, will assist states with additional issues such as public health preparedness, continuity of government, and maintaining the central functions of society during a pandemic. Moreover, in early 2007 a team of pandemic flu experts will hold an exercise that will test how the media and the experts will respond should an actual pandemic occur. This exercise will help work through the challenges of getting and reporting timely and accurate information in a pandemic.
Pandemic Planning Update III (.pdf) (2 MB)
Safety Institute's Pandemic Influenza resources module:
https://premierinc.com/quality-safety/tools-services/safety/topics/influenza/
HHS activities for all updates:
http://www.pandemicflu.gov/plan/federal/
NQF updates lists of "safe practices" and "never events" prompting call for hospitals to adopt policy of apologizing to injured patients
A list of "safe practices" that should be universally followed in healthcare settings to reduce the risk of harm, and a list of "serious reportable events" in healthcare, sometimes called "never events" were recently updated by the National Quality Forum (NQF). As part of a "never events" policy, The Leapfrog Group and others are calling for hospitals to adopt policies to apologize to the injured patients.
Safe practices
The list of 30 "safe practices" that should be universally utilized in applicable healthcare settings to reduce the risk of harm resulting from processes, systems, or environments of care was updated and released by NQF in October 2006. The
revised list includes three new practices and 23 changes to practices on the original 2003 list. Four of the original practices remain unchanged.
Details of the revised NQF Safe Practices are available.
Serious reportable ("never events")
An updated list of serious reportable events in healthcare, sometimes called "never events," was released by the National Quality Forum (NQF) on November 15, 2006. The original NQF endorsed list, released in 2002, contained 27 adverse events that are serious, mostly preventable, and of concern to both the public and healthcare providers. These events are increasingly used for public reporting as they are easily identified and measured. One new event was added and six from the original list were changed, while the remaining 21 events were unchanged.
The new event is artificial insemination with the wrong donor sperm or donor egg. The changed six events are:
- Unintended retention of a foreign object in a patient after surgery or other procedure;
- Patient death or serious disability associated with patient disappearance;
- Medication error;
- Hemolytic reaction due to the administration of incompatible blood or blood products;
- Electric shock or elective cardioversion while being cared for in a healthcare facility; and
- Fall while being cared for in a healthcare facility.
Never event policy
In conjunction with the release by the NQF, the Leapfrog Group has asked hospitals to commit to its new Never Events policy, which includes apologizing to injured patients. The Centers for Medicare and Medicaid Services (CMS) is working with Congress, hospitals and healthcare organizations and discussing a value-based approach to care during which a never event occurs, as well as providing the public with more information about these events.
Leapfrog wants to give hospitals public recognition for agreeing that certain steps should be taken whenever a serious reportable adverse event occurs in their facility. The Leapfrog proposal includes hospitals either not billing for the original treatment or absorbing the cost of follow-up care related to any of the 28 never events. Hospitals would also agree to apologize to the patient and/or family affected by a never event, report the event to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or a state agency, and perform root cause analysis to mitigate future risks.
2006 NQF safe practices summary (.doc) (37 KB)
2006 NQF Safe Practices (.pdf) (346 KB)
Updated Never Event list (.pdf) (113 KB)
Specific information on the National Quality Forum serious reportable events can be found at:
http://www.qualityforum.org.
Falls are leading cause of fatal injury among seniors
Unintentional falls affect approximately 30 percent of persons older than 65 each year, according to the Centers for Disease Control and Prevention (CDC). CDC reported in the November 17, 2006, Morbidity and Mortality Weekly Report (MMWR) that falls have become the leading cause of injury deaths for seniors. The CDC analyzed U.S. rates of: fatalities from falls (1993-2003); hospitalizations for hip fractures (1993-2003); and nonfatal injuries resulting from falls in persons treated in emergency departments (2001-2005).
Mortality and injury rates
Falling is the fourteenth leading cause of death among the elderly, with fatal falls having increased by 55 percent from 1993 to 2003 among Americans 65 and older. The fatality rate rose by about 45 percent for men and 60 percent for women in that time. The rate of non-fatal falls was 48 percent higher for women than men over the 10-year period, while men were more likely to die from falls than women. Nearly 1.8 million seniors were treated in the emergency department for nonfatal injuries from falls in 2003, and more than 460,000 were hospitalized. An epidemiologist in the CDC's Injury Center stated that fall death rates have increased faster than fall injury rates, likely because this group includes people living longer with chronic conditions such as cancer and heart disease and becoming frailer.
The report also noted that women's hip fracture injury rates have dropped, most likely due to osteoporosis screenings and bone-building treatments. In 1998, the Medicare program began reimbursing doctors to do bone density screenings on elderly people.
Prevention
Interventions to reduce falls are discussed in the MMWR report and include:
- Exercising regularly;
- Asking the doctor or pharmacist to review medicines – both prescription and over-the-counter – to reduce side effects and interactions;
- Having eyes checked by an eye doctor at least once a year; and
- Making homes safer by eliminating fall hazards and improving lighting.
The CDC also offers free fall prevention posters and brochures, including "A Home Fall Prevention Checklist for Older Adults," which offers a room-by-room list of hazards to look for in the home that can increase the risk of falling and tips for reducing these hazards.
The Safety Institute regularly updates an extensive Web site on fall prevention and includes links to the CDC brochures and posters in the "Sample procedures and tools." Two new items have recently been added:
- An online calculator to determine a return on investment for safe lifting programs; and
- Tool kit links to an interactive video, a comprehensive training program on the use of the Morse Instrument and Fall Scale made available through Hill-Rom.
2006 Morbidity and Mortality Weekly Report (MMWR)
Fatalities and Injuries from Falls Among Older Adults,
United States, 1993-2003 and 2001-2005
http://www.cdc.gov/mmwr/preview/
mmwrhtml/mm5545a1.htm
For additional resources, go to the Safety Institute's
Fall prevention module.
CDC fall prevention brochures at:
http://www.cdc.gov/ncipc/duip/fallsmaterial.htm
Safety tools
SCIP – New surgical, VTE tools
Several new tools have recently been added to the Surgical Care Improvement Project (SCIP) Web site. The first, "Preventive Antibiotics in Colon and Rectal Surgery: Discontinuation Within 24 Hours After Operation," is a presentation that discusses the importance of giving recommended antibiotics in colorectal surgery with the equally important factor of discontinuing the antibiotics within 24 hours. The information includes the audio recording of the conference, the slides used as handouts for the conference, and the bibliography of references cited in the handouts. Other tools related to venous thromboembolism include:
- Deep Vein Thrombosis Prophylaxis Risk Factor Assessment – This is venous thromboembolism risk form that allows the user to calculate a risk score and provide recommended interventions for prophylaxis. It also contains a physician order at the bottom for appropriate pharmacological therapies;
- Thrombosis Screen and Prophylaxis Recommendations – This risk assessment tool can be completed on admission via computerized assessment. If the screening is greater than the acceptable level, an order sheet for prophylaxis automatically prints out. The physician can check which intervention is preferred and signs the order. Access these tools from the SCIP Web site at http://www.medqic.org/scip.
- VTE guidelines are available from the Premier Safety Institute Infection Prevention and Safety Module under "Other guidelines, selected resources."
Medication safety guide – Ambulatory care
Creighton University Medical Center, Omaha, NE, provides a tool to guide considerations of resource requirements when evaluating the ambulatory care environment for medication safety. The guide is titled "Medication Safety Best Practices Guide for Ambulatory Care Use" (.pdf) (159 KB). The guide proceeds through the medication use process, the office environment, error management, workplace conditions, safety education, safety perceptions and patients.
IHI – Patient safety trigger tools
The Institute for Healthcare Improvement (IHI) has developed a series of Trigger Tools. "Triggers," or clues to identify adverse events (AEs), are an easy method for accurately identifying AEs and tracking the rate over time as one useful way to detect whether or not changes are improving the safety of the care processes.
The first tool is a "Global Trigger Tool" designed to help get started in the approach; the other tools focus on specific areas such as measuring adverse drug events, perioperative care, neonatal intensive care, and adverse events in outpatient settings. Access IHI Trigger Tools at:
http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/
Tools/IntrotoTriggerToolsforIdentifyingAEs.htm.
H2E – New environmental compliance and improvement guide
Hospitals for a Healthy Environment (H2E) has developed an "Environmental Compliance and Improvement Guide"
(http://www.h2e-online.org/
regsandstandards/jcahointro.html)
that matches each JCAHO Element of Performance to specific federal regulations. This guide helps facilities identify how to be in compliance with both. The guide also suggests steps that facilities can take to encourage environmental performance improvements. A comprehensive environmental program, including waste minimization and pollution prevention initiatives, not only ensures compliance, but can also help reduce the costs of compliance. The guide provides links, tips and tools that enumerate specific management practices, materials, regulatory requirements, and facility infrastructure relevant to the specific JCAHO Element of Performance (EP).
AHRQ emergency planning – Mass casualty care guide
"Providing Mass Medical Care with Scarce Resources: A Community Planning Guide" (.pdf) (1.1 MB) is the product of a collaborative effort between AHRQ and the Office of Public Health Emergency Preparedness. Experts in the areas of mass casualty care, including pre-hospital care, hospital and acute care, alternative care sites, palliative care, ethical issues, and legal considerations, contributed to this guide. It describes shortages (such as of hospital beds and ambulances) healthcare workers may face and gives planners specific recommendations, such as providing off-site care and using taxis, buses, and private cars to transport sick or injured patients. The report provides planning checklists and tips for making wise use of limited medical resources. Additional information includes:
- Circumstances that communities are likely to face in a MCE;
- Key constructs, principles, and structures to be incorporated into the planning for a MCE;
- Approaches and strategies that could be used to provide the most appropriate standards of care possible under the circumstances;
- Examples of tools and resources to help states and communities in their planning process; and
- Illustrative examples of how specific health systems, communities, or states have approached various issues in their MCE-related planning efforts.
Prevent Influenza Now! - New Web site provides influenza vaccination updates
A Web site sponsored by the National Influenza Vaccine Summit called "Prevent Influenza Now!" provides information updates on the current influenza vaccination season. The site contains vaccine information for the public about influenza, the benefits of vaccination, who should be vaccinated, how to find a clinic, media such as public service announcements and press releases issued for this season's influenza vaccination campaign, clinic procedures, patient materials, and other useful tools to help prevent influenza. Information for healthcare professionals includes a section on the vaccination of healthcare workers. This section has many resources on how to increase healthcare worker vaccination, including many toolkits that can be used to implement or expand healthcare worker immunization programs. For more, go to:
http://www.preventinfluenza.org.
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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
- Cathie Gosnell, RN, MS, MBA, contributor
- Derek Kleckner, CUA, Webmaster
- 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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