December 2007
Dear Colleague:
Delete this email! Every issue, every story, and every tool is archived. Healthcare-associated infections are featured in a number of stories this month.
Happy Holidays from the Safety Share team!
Gina Pugliese
Judene Bartley
Cathie Gosnell
John Hall
David Huntley
Judy Luca
News
- Infection control guidelines released for CMS surveys
- USP issues pharmacy sterile compounding standards; ventilation requirements costly
- AHRQ report – 10-year steady decline in inpatient mortality
- Olympic theme song reminds staff to turn patients, prevent pressure ulcers
- Decreased ICU nurse staffing increases healthcare-associated infections
- Premier – Healthcare-associated infection presentations available online
Safety tools
- FDA guidance – Equipment cleaning hazards
- Safety Institute – Guide for patient safety tools
- Premier webcast – Implementing a pharmacy waste management system
- IHI assessment tool – Patient- and family-centered care
- AHRQ DVD – Free resource on patient safety
- CDC - "Happy Health Singing Holiday" Card
Infection control guidelines released for CMS surveys
The Centers for Medicare and Medicaid Services (CMS) updated guidelines used by CMS surveyors to interpret hospital infection prevention and control standards that are part of their Conditions of Participation (CoP) regulations- Infection Control. CMS develops CoPs that are the minimum health and safety standards that providers must meet in order to be Medicare- and Medicaid-certified and receive reimbursement. CMS has not changed the standards, but revised the guidelines used by state regulators for interpreting the standards, to better reflect current conditions within hospitals as well as contemporary infection control standards of practice.
The infection control interpretive guidelines (IC IG) received major input from professional organizations and a working draft has been available for state surveyors to use since June 2006. However, the final guidelines and survey procedures have been reorganized and in a letter to surveyors, those final guidelines became effective November 21, 2007.
Housewide surveillance not required. The IC IG includes all aspects of a comprehensive infection prevention and control program. The addition of the term "prevention" in itself is noteworthy, as is the explicit statement that "house-wide surveillance is not required.” CMS stipulates that there must be some reliable mechanism in place to permit identifying and monitoring infections and communicable diseases occurring throughout the hospital. The IC IG contains discussion and examples of practices that hospitals are encouraged to adopt, but which are not necessarily required by the regulation. One welcome addition to prevention interventions is the promotion of hand hygiene, including the use of alcohol-based hand rubs.
Infection control staffing ratio not specified. Although CMS does not prescribe the number of infection control professionals or hospital epidemiologists that a hospital must have, it does require hospitals to assure that "resources be adequate to accomplish the tasks required for the infection prevention and control program," and that “a prudent hospital would consider patient census, characteristics of the patient population, and complexity of the healthcare services it offers in determining the size and scope of the resources it commits to infection control. The CDC’s HICPAC, as well as professional infection control organizations such as the APIC and the SHEA, publish studies and recommendations on resource allocation that hospitals may find useful.”
Infection log required but may be electronic. Until now, one contentious issue among hospitals related to rule language requiring maintenance of a "log" or list of infections. CMS recognizes the change from manual to electronic documentation systems. In the list of items CMS states should be identified in an infection prevention program and reported in a log, CMS supports flexibility even as it protects staff confidentiality. CMS states that the log "may be a paper log or in electronic format, but regardless of the format, the information must at all times be safe/secure from unauthorized access, up-to-date, and accessible and readily retrievable by authorized personnel."
Hospital leaders responsible for linking IC with QAPI. The CEO, medical staff and director of nursing (DON) are jointly responsible for linking the infection prevention and control program with the hospital’s Quality Assurance/Performance Improvement (QAPI) and training programs. Hospital leaders are held accountable for addressing problems identified by the infection prevention and control program, implementing successful corrective action plans by monitoring adherence to corrective action plans, assessing the effectiveness of actions taken, and implementation of revised corrective actions as needed.
- Download CMS IC rules 42.CFR 484.42 (pdf) (28 kb)
- Download CMS Interpretive guidelines (doc) (103 kb)
- Download CMS letter to states (doc) (178 kb)
- More CMS standards
USP issues pharmacy sterile compounding standards; ventilation requirements costly
U.S. Pharmacopeia (USP) has published the final standards – Pharmaceutical Compounding – Sterile Preparations, effective June 2008. The standards will be included in the March 2008 Pharmacists’ Pharmacopeia and are applicable to all healthcare pharmacies. Enforcement of this standard varies by state, depending on whether the state pharmacy boards adopt sections, specific text or the entire chapter. The Joint Commission views this chapter as representing "best practice" and requires documentation of its review, though organizations may choose an alternative approach to a specific USP guideline based on review of literature or organizational studies.
Some ventilation requirements costly to implement
Ventilation requirements for the room where compounding is done is required at a level similar to "clean room" standards found in the pharmaceutical industry. Experts agree with the laminar air flow workbench (LAFW) requirements but disagree with the level of ventilation required surrounding the LAFW and the added cost required to achieve those levels, believing they are not necessary to reduce risk of contamination.
Environmental sampling, cleaning and disinfection consistent with CDC guidelines
Improvements have been made in the overall environmental quality control program, which now better align with the
CDC guidelines on environmental infection control. Environmental air sampling is to be guided by specific rationale and is not done on arbitrary frequencies and time schedules. The appendices summarize the many recommendations and checklists and include a table of disinfectants for consideration, developed and modified by CDC experts.
- Download USP 797 (pdf) (11.87 mb)
- CDC Environmental Infection Control Guidelines (pdf) (1.5 mb)
- Safety Institute - Infection Prevention and Safety Guidelines
AHRQ report – 10-year steady decline seen in inpatient mortality
A statistical brief titled "Trends in Hospital Risk-Adjusted Mortality," published recently by the Agency for Healthcare Research and Quality (AHRQ), reported a decline in risk-adjusted inpatient mortality rates for 12 common diagnoses and surgical procedures from 1994 to 2004.
Medical diagnoses A steady decline between 18 percent and 46 percent was observed from 1994 to 2004. The mortality rate for heart attack fell from 125 to 82 per 1,000 admissions over the period, while the mortality rate for congestive heart failure, pneumonia and stroke each fell by about 30 per 1,000 admissions. Other declines include the mortality rate for heart bypass surgery (20 per 1,000 admissions); abdominal aortic aneurysm repair (29 per 1,000 admissions); gastrointestinal hemorrhage (21 per 1,000 admissions) and hip fracture (16 per 1,000 admissions).
Overall, among the six diagnostic conditions examined in the brief (acute myocardial infarction, congestive heart failure, gastrointestinal hemorrhage, hip fracture, pneumonia, and stroke), an estimated 136,000 fewer inpatient deaths occurred (over 1994 mortality levels). Acute myocardial infarction had the largest reduction.
Surgical procedures Among the six selected surgical procedures reviewed in the report, abdominal aortic aneurysm (AAA) repair had the largest reduction in deaths per 1,000 admissions. Mortality rates declined for all six procedures, including abdominal aortic aneurysm repair, carotid endarterectomy, coronary artery bypass graft, craniotomy, hip replacement, and percutaneous transluminal coronary angioplasty.
In summary, the analysis determined an estimated 13,000 fewer inpatient deaths occurred for patients receiving these six procedures over 1994 mortality levels.
Olympic theme song reminds staff to turn patients, prevent pressure ulcers
While technology and treatment in healthcare may be constantly changing, basic bedside care has not. As patients become sicker and staffing becomes shorter, this basic care becomes especially important in the area of skin care. Almost 1 million patients develop a pressure ulcer each year. A recent case-study, "Best-practice protocols: Reducing harm from pressure ulcers," described how OSF Saint Francis Medical Center (OSF SFMC) played the Olympic theme song every two hours on the overhead paging system to remind staff to turn patients. This was among the strategies that resulted in a 50 percent reduction in pressure ulcers. OSF SFMC used Six Sigma methodologies and a proven, evidence-based skin breakdown prevention protocol to reduce its incidence of pressure ulcers.
OSF SFMC’s skin breakdown prevention protocol incorporates guidance from the Agency for Healthcare Research and Quality (AHRQ) and the Wound, Ostomy, and Continence Nurses Society (WOCN). To ensure compliance with the protocol, performance audits are conducted on individual units to determine if the four indicators have been met. Indicators call for staff to:
- Initiate prevention protocols,
- Provide patient and family education
- Turn or tilt patients every two hours
- Place signage on door for at-risk patients
To streamline the process and encourage compliance, OSF SFMC suggests making the prevention protocol easy to follow, using a pressure-reducing mattress on all adult patients, turning and repositioning on the even hours with a musical cue as a reminder, publishing the results of successes, and having unit champions to provide expertise and support.
Another available resource, given increasing attention to pressure ulcers, is the recent definition of pressure ulcer stages from the National Pressure Ulcer Advisory Panel, published in February 2007.
- Griffin B Nursing Management, September 2007 abstract (doc) (29 kb)
- Pressure Ulcer scale - National Pressure Ulcer Advisory Panel (pdf) (98 KB)
Decreased ICU nurse staffing increases healthcare-associated infection
A number of studies have shown that insufficient nursing staff has been associated with an increase in mortality and adverse outcomes, including infections. A recent study confirms that staffing does have a significant impact on healthcare-associated infections. Researchers used a variety of statistical methodologies to confirm this in an intensive care unit, including a case-crossover design, a case-time-control design, and a cohort design to evaluate the effect of nurse staffing level on the risk of healthcare-associated infection infections.
The study looked at 366 patients who stayed in the intensive care unit in the University of Geneva Hospital, Switzerland, for more than seven days between 1999 and 2002. Regardless of the study design, the results remained the same: Lower nurse staffing was associated with an approximately 50 percent increased risk of nosocomial infections.
- Hugonnet, Villaveces, and Pittet, Am J Epid, June 2007 abst. (doc) (78.5kb)
Premier – Healthcare-associated infection presentations available online
Presentations are available from a Premier-sponsored conference on "Healthcare-associated infections (HAI) – What everyone needs to know." Topics addressed by nationally known experts included HAI surveillance, costs and public reporting, as well as prevention and intervention strategies. All presentations are available online for download. Specific topics include:
HAI Surveillance
- Developing a hospital-wide approach to healthcare-associated infections;
- Surveillance and reporting of healthcare-associated infections
- Improving the rate of HAI: will, ideas, and execution.
Public reporting and business case
- Public reporting of healthcare-associated infections
- Reducing the cost and impact of infectious disease;
- The business case for infection control; and
- Antibiotic utilization – engaging the practitioners.
HAI prevention
- HAI prevention and intervention strategies; and
- Infection prevention: the Keystone experience.
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 Health Care; Premier's Dan Peterson, M.D, M.P.H.; Premier’s Gina Pugliese, R.N., M.S.; and Premier’s Scott Pope, Pharm.D.
All presentations are available online for download.
- Download Presentations from Premier's Safety Institute
- See related story: Business case, Perencevich, Safety Share, September 2007
Safety tools
FDA guidance – Electronic equipment cleaning hazards
The Food and Drug Administration joined with the CDC, the EPA and OSHA in releasing guidelines on how to prevent hazards due to inappropriate use of cleaners and disinfectants on electronic medical equipment. Such solutions can cause the equipment to malfunction. Many stakeholders, including AHA, APIC, and ASHE, provided input to the guidelines for handling and cleaning of electronic medical devices. Minimizing the potential for cross contamination and patient and worker injuries is critical, but of equal importance is the emphasis on the process of proper cleaning and disinfecting in accordance with manufacturers’ guidelines in the interest of safety.
Safety Institute – Guide for patient safety tools
Each issue of the Premier Safety Institute's Safety Share contains four to five popular and frequently used safety tools and resources on patient, worker and environmental safety. A safety tool archive is available and organizes all the safety tools and resources from January 2002 to the present for easy location and access. Topics range from adverse medical events to bar coding, hazardous materials, patient safety and sharps injury prevention. Select a topic to see a list of related tools or download an Excel spreadsheet listing each tool by category.
Premier webcast – Implementing a pharmaceutical waste management system
Audio files and slides are available from a recent Premier webcast that describes how hospitals can bring their organizations into compliance with current EPA hazardous waste regulations and Joint Commission requirements while preparing for future disposal restrictions. Increasing national interest in a sustainable environment has accelerated the healthcare industry's attention to waste management and recycling practices. Among those challenges in waste management and recycling is safe disposal of leftover medications, antibiotics, and other chemicals that may find their way into our drinking water and food chain. Premier hosted a public webcast titled “Implementing a pharmacy waste management system” to understand the problem of pharmaceutical waste and suggest solutions and tips on how to separate, label and dispose of common chemicals and drugs. Charlotte Smith, president of PharmEcology Associates, LLC, presented the topic, noting that managing pharmaceutical waste is becoming a nationwide issue, and highlighted the impact on the ecosystem from disposal of leftover drugs through flushing and landfilling. See also: Premier contracted supplier-Pharmaceutical waste
IHI assessment tool – Patient- and family-centered care
The Institute for Healthcare Improvement (IHI) recently released a report titled “Advancing the Practice of Patient- and Family-Centered Care” that includes assessment tools to help hospitals determine the degree to which patient- and family-centered approaches exist in their current organizational culture; IHI also released a tool that helps gather information about the perceptions and attitudes of staff and administrative leaders. The report describes how hospitals can get started with understanding how quality and safety are advanced by bringing patients and families directly into the planning, delivery and evaluation processes. This 25-page report provides rationale for a patient- and family-centered approach to care and defines its core concepts and outlines steps that a hospital can take to create partnerships with patients and families. This report from the Institute for Family-Centered Care was published in IHI’s October 2007 Continuous Improvement newsletter.
AHRQ free DVD – Patient safety
A new free DVD addressing patient safety consists of eight modules involving one to five separate lessons, and provides processes and tools that can be used to develop a systems-based approach to patient safety. The modules include the investigation of medical errors and their root causes; identification, implementation and evaluation of system-level interventions to address patient safety concerns; and steps necessary to promote a culture of safety within a hospital or other healthcare facility. The DVD was developed by the Agency for Healthcare Research and Quality and the Department of Veterans Affairs National Center for Patient Safety to be a self-paced, modular approach to training individuals involved in patient safety activities at the institutional level. Order the DVD at http://www.ahrq.gov/qual/psicdvd.htm.
CDC – “Happy Healthy Singing Holiday” Card
Enjoy a special holiday message from the CDC you might like to use and share! Click here (with speakers on) and listen to a singing message about healthy habits for the holidays: http://www.cdc.gov/women/owh/holiday/12waysSong.htm or go to CDC’s Web page: http://www.cdc.gov/women/hlthobs.htm#dec.
Editorial team
- Gina Pugliese, RN, MS editor
- Judene Bartley, MS, MPH, CIC, associate editor
- John Hall, BSJ, contributor
- Judith Luca, RN, BSN, contributor
- David Huntley, BA, Web master
About Premier Inc., 2006 Baldrige Quality Award recipient
Serving 1,700 not-for-profit hospitals and more than 49,000 other healthcare sites, Premier is the largest healthcare alliance in the United States dedicated to improving patient outcomes while safely reducing the cost of care. Premier provides an array of resources to improve the quality and safety of patient care, including clinical and operational comparative data applications, group purchasing and supply chain services and its publicly accessible Safety Institute. The Centers for Medicare and Medicaid Services (CMS) has a partnership with Premier for a pay-for-performance demonstration project.
Safety Share © 2007 Premier, Inc.
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