July 2007
Dear Colleague:
Reducing risk to both the patient and the staff from procedures involving needles and injections are highlighted in two stories this month, the newly released CDC guidelines on isolation and an article on risks in surgery from needlestick injuries.
Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- Respiratory hygiene added to standard precautions in 2007 CDC isolation guidelines
- Tubing misconnections – Better technology needed to eliminate risk
- Surgical "time-out" expanding as a performance improvement tool
- Nearly all surgical residents sustain needlestick injuries; culture change recommended to improve reporting
- Increased transparency of healthcare quality and cost improves care and empowers patients
- Upcoming 2007 Quality Colloquium focuses on developing a safety action plan
Safety tools
- AHRQ 2007 tool – Small hospital benchmarking tool for AHRQ hospital survey
- CDC – New meningococcal vaccine information available in Spanish and English
- Comprehensive hospital checklist – pandemic influenza preparation
- ACR – Updated guidance on magnetic resonance safety
Respiratory hygiene added to standard precautions in 2007 CDC isolation guidelines
Respiratory hygiene/cough etiquette and safe injection practices are new additions to the "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June 2007," released by the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee (HICPAC). The new guideline is intended for use by infection control professionals, healthcare epidemiologists, administrators, nurses and other healthcare professionals in developing, implementing, and evaluating infection control programs in healthcare settings across the continuum of care.
Organization Part I of the guidelines includes the literature review of the scientific data regarding transmission of infectious agents in healthcare settings. Parts II and III address the fundamental elements needed to prevent transmission, as well as HICPAC's precautions to prevent transmission of infectious agents, followed by Part IV, the official recommendations. Appendix A maintains the popular table for quick location of recommendations by alphabetical listing of infectious agents. Other appendices include a guide for the recommended sequence for applying and removing personal protective equipment used for isolation precautions to optimize safety and prevent self-contamination during removal.
New information The literature review addressing fundamentals in preventing transmission of infections includes updates on hand hygiene, barrier precautions, safe work practices, and isolation practices. Given increased attention to healthcare-associated infection (HAI) in the media, it is noteworthy that the guidelines include information for administrators emphasizing the importance of appropriate infection control staffing, nursing levels, and needed numbers of appropriately trained ICU nurses for the prevention of healthcare-associated infections (HAIs). The surveillance of healthcare associated infections is a new addition to this guideline as well.
Terminology and changes The term "nosocomial infections" is replaced by "healthcare-associated infections" (HAIs) to reflect the changing patterns in healthcare delivery and difficulty in determining the geographic site of exposure to an infectious agent and/or acquisition of infection. Although "Transmission-Based Precautions" have not changed from the 1996 guideline, the successful experience with Standard Precautions, first recommended in the 1996 guideline, has led to a reaffirmation of this approach as the foundation for preventing transmission of infectious agents in all healthcare settings. New additions to the recommendations for Standard Precautions are respiratory hygiene/cough etiquette and safe injection practices, including the use of a mask when performing certain high-risk, prolonged procedures involving spinal canal punctures (e.g., myelography, epidural anesthesia).
Safe injection practices A new section of this guideline addresses safe injection practices, including recommendations for single-dose vials for parenteral medications when possible and sterile-technique for all injection practices for patient safety.
Download the 2007 isolation guidelines
More CDC guidelines are available from the Safety Institute's Web site on Guidelines
Tubing misconnections – Better technology needed to eliminate risk
Government, professional, trade and healthcare organizations are working with medical device manufacturers and the media to raise awareness of and develop solutions to reduce the risk of medical tubing misconnection errors that can cause life-threatening complications.
A patient may be connected to several devices used to administer fluids through a vein; deliver feedings via a tube to the stomach; monitor blood pressure; and administer oxygen via mask or cannula. This collection of devices, all of which may interconnect, poses a risk of tubing misconnection, especially in a busy clinical environment where stress, fatigue and distractions are common. For example, a tubing misconnection that may lead to severe illness or death occurs when a liquid feeding or formula intended for a feeding tube leading to the stomach is connected in error to an intravenous (IV) line, delivering oral liquid feeding into the bloodstream.
Noting that tubing errors are generally underreported, The Joint Commission in a Sentinel Event Alert issued April 2006 directed hospitals to raise staff members' awareness of tubing misconnection errors and called on manufacturers to redesign products to prevent misconnections.
According to a recent article about tubing misconnections in The Wall Street Journal, the not-for-profit group U.S. Pharmacopeia, which collects inpatient safety data, noted that more than 300 tubing misconnections occurred from 1999 to 2004 and an additional 1,000 cases likely have occurred in subsequent years. The article also reported that to prevent such errors, the FDA recently enlisted the Beaumont Technology Usability Center, part of William Beaumont Hospital in Michigan, to develop educational resources for hospitals. The resulting tools will be available on the FDA's Medical Product Surveillance Network and will address common tubing error scenarios to raise awareness of those safety issues.
The Wisconsin State Journal ran a five-part series on patient safety in June 2007 that included a special feature on tubing misconnections and highlighted the death of a 15-year-old Wisconsin hospital patient who was given an epidural anesthetic (intended for her spine) mistakenly into her IV line.
Safety Institute resources
Premier’s Safety Institute has developed a special Web site on tubing misconnections to educate hospital staff about this problem. The site contains resources from a number of organizations, including guidelines from ECRI and a selected list of products that reduce risk. The Safety Institute, in collaboration with Premier’s group purchasing and food and nutrition teams, has been educating a number of device manufacturers over the past three years and has encouraged them to redesign their devices to reduce risk. Premier’s Web site has a case study describing how device maker Viasys Healthcare took Premier's challenge and designed a pediatric feeding tube system that has unique tubing connections that are incompatible with intravenous lines and packaged it with a specially designed oral syringe from Baxa Corporation.
Experts agree that the best solution to prevent tubing misconnections is to change the design of the connectors so only appropriate and compatible devices can be connected. This design incompatibility would make it easy to make the correct connection and difficult or impossible to make the "wrong" connection or a tubing misconnection. Many devices are able to reduce risk; few eliminate risk.
Joint Commission Sentinel Event Alert (.doc) (44 KB)
The Wall Street Journal, Landro June 27, 2007,"Tackling tubing misconnections."
Wisconsin State Journal; "Medical Misconnections: Patient safety problems and solutions." Go to: http://www.madison.com/wsj/projects/safety/
Surgical "time-out" expanding as a performance improvement tool
The surgical time-out (STO) is an opportunity before a surgical procedure for all operating room team members to review the patient case. The time-out provides an opportunity to identify inconsistencies and prevent errors in the operating room. By improving overall communication, it also helps empower members of the team to continue the dialogue during the operation if things do not seem to be going according to plan. The two main objectives during the STO are patient identification and verification of the operative site.
In the April 2007 issue of the Journal of the American College of Surgeons, researchers at the University of Louisville hospital wanted to demonstrate that the use of a surgical time-out not only would decrease the chance of a wrong-site operation, but also would improve other aspects related to the surgical procedure. Once an STO is implemented, the surgical team believed it would be relatively easy to add a small list of other quality-safety surgical measures that are part of the CMS Surgical Care Improvement Project.
Real-time data collection on 299 procedures in 2006 showed that 99 percent of STOs were performed properly. In addition, there were measurable improvements in five recorded surgical quality process measures: antimicrobial prophylaxis, venous thrombo-embolism prophylaxis, intraoperative patient temperature maintenance, blood glucose control, and beta-blocker use when indicated.
Planning and implementing the STO as a reflective pause or a preoperative briefing involved the entire surgical team, including surgeons, anesthesiologists, nurse anesthetists, and quality control specialists and administration. A key component was the collection of real-time data on these measures tracked with regular feedback to all the surgical team.
The authors concluded that the use of STO is a useful surgical safety and quality improvement tool and suggested that each hospital add their own safety and quality measures.
JACS Abstract Time-Out (.doc) (29 KB)
The Safety Institute's Web site on SCIP measures
Nearly all surgical residents sustain needlestick injuries; culture change recommended to improve reporting
A recent survey of 578 surgeons in 17 medical centers found that nearly all (99 percent) surgical residents sustained a needlestick injury by their final year of training. Fifty-one percent of the needlesticks overall and 16 percent of those involving high-risk patients, however, were never reported to employee health service.
The risk of underreporting, and thus delaying or forgoing treatment, is significant. If there has been an exposure to HIV, HBV or HCV, there are implications for personal relationships, future employment, and insurance coverage. Reporting also allows medical evaluation and prompt post-exposure prophylaxis for HIV and HBV and early treatment if HCV infection develops to reduce risk for chronicity.
A history of a greater number of injuries was associated with a lower likelihood of reporting the injury, leading surveyors to conclude that trainees are desensitized by or embarrassed to report each event. Surveyors found that a report was more likely to be made if another person knew about the injury. Needlestick injuries involving patients not considered to be at high risk were less likely to be reported.
Strategies to reduce risk include the use of "sharp-less" methods for passing of instruments and needles, such as a safe zone in the operative field, or sharp-less surgery with the use of blunt tip needles. Double gloving has also been shown to reduce risk of blood contamination by a factor of seven to eight, yet a recent study of members of two surgical societies reported that only about 12 percent of surgeons engage in this practice.
Data analysis of the most recent injury reported in this survey revealed that more than half of the injuries occurred during suturing. The most common perceived cause of the injury was rushing (57 percent) and fatigue (15 percent). Lack of time was the most common reason for not reporting injuries (42 percent).
The authors, Makary and colleagues of "Needlestick injuries among surgeons in training." suggest some system level changes that may increase reporting, including a timely reporting mechanism (e.g., hotlines), routine prompts (e.g., postoperative checklists that include a question about whether an injury has occurred) and peer education to create a culture that encourages open communication. Download the new Needlestick prevention brochure from the Safety Institute on devices and work practices for prevention and medical follow-up that can be used for staff training across the continuum of care.
Surgeons, surgical residents and other members of surgical team sustaining needlestick injuries also pose a potential risk to the patient. If any of the team is infected with a bloodborne pathogen, the blood from the needlestick may contact the patient. Thus all devices, strategies, and work practices designed to reduce the risk of needlesticks and other injuries from sharps in the surgical setting will reduce the risk of infection to both the surgical team and the patient.
Makary NEJM Needlestick injuries abstract (.doc) (28 KB)
New Needlestick prevention brochure
(.pdf) (925 KB)
from the Safety Institute on devices, work practices and medical follow-up for staff training across the continuum of care.
For more information on sharps injuries, visit the Safety Institute's Web site on Sharps injury prevention.
Increased transparency of healthcare quality and cost improves care and empowers patients
On June 21, 2007, the Centers for Medicare and Medicaid Services (CMS) posted the broad comparison of the death rates for heart attack and heart failure on its Web site, Hospital Compare, consistent with the trend toward greater transparency in the healthcare industry.
The risk adjusted mortality data places more than 4,477 hospitals in one of three categories: better than the national rate, no different than the national rate, or worse than the national rate in preventing heart failure and heart attack deaths. Seventeen of 4,477 hospitals had heart attack death rates that were better than the national rate, and 38 of 4,804 hospitals had heart failure death rates that were better than the national rate. CMS announced that it will be reporting data but not taking corrective action at this time. However, the agency said it would provide hospitals with a report that includes their mortality rates with patient coded information so they may review patient records and look for patterns as part of their performance improvement activities.
Hospitals also publicly report their compliance with 21 specific quality measures on the Hospital Compare Web site. The reporting of these measures is linked to full annual updates for inpatient Medicare payments and is proposed to increase to 32 measures by October 2008.
Hospital pricing information
A number of recent state and federal actions have provided consumers with more useful and comparative information about hospital pricing and performance.
States have taken the lead in requiring hospitals to report pricing data. Thirty-two states have adopted laws requiring hospitals to post charges online and make such information available to anyone on request. Last August, an executive order directed federal agencies sponsoring health coverage to post information on prices paid to providers for episodes of care and chronic diseases and to share data on the quality of services provided by hospitals, doctors, and other providers. In addition, CMS is currently posting payment and volume data on its Web site for common elective hospital inpatient procedures and ambulatory surgical centers.
CMS Hospital Compare data on heart failure and heart attack 30-day mortality rates.
See CMS for hospital inpatient procedures and ambulatory surgical centers.
Upcoming 2007 Quality Colloquium focuses on developing a safety action plan
Healthcare clinical and administrative leaders who want to champion their safety and quality efforts should plan on attending the Sixth Quality Colloquium being held August 19-22, 2007, at Harvard University and the Inn at Harvard in Cambridge, MA. Premier's Safety Institute joins the Agency for Healthcare Research and Quality (AHRQ), the Institute for Safe Medication Practices (ISMP), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Quality Forum (NQF) and others in sponsoring this conference.
This executive education course will explore such issues as:
-
Patient safety;
- Healthcare quality enhancement and medical error reduction;
- Teams and transitions of care;
- Six Sigma, Lean and beyond;
- Value-driven healthcare, transparency, financial incentives and pay for performance;
- The role of patient stories and storytelling;
- Health information technology and electronic health records; and
- Advanced initiatives in patient safety.
More than 100 featured faculty include:
- AHRQ Director Carolyn Clancy, M.D.
- Harvard Professor David Cutler, Ph.D.
- Leapfrog Group CEO Suzanne Delbanco, Ph.D.
- Baldrige National Quality Program Director Harry Hertz, Ph.D.
- Premier's Leslie Schultz, Ph.D., CPHQ, Director of Performance Improvement
This year The Quality Colloquium is offering a Patient Safety Certificate Program in the form of an optional course. The purpose of the Patient Safety Certificate Program is to give participants the understanding and tools necessary to conduct state-of-the-art clinical practice improvement projects around key patient safety issues. The course is designed for patient safety officers, front-line practitioners, risk managers, administrators, researchers, and medical educators. Those who successfully complete the course will receive a certificate of completion of the Quality Colloquium Patient Safety Certificate Program.
Visit the conference Web site for complete faculty listing, detailed agenda, and registration at: http://www.qualitycolloquium.com/.
Safety tools
AHRQ 2007 tool – Small hospital benchmarking tool for AHRQ hospital survey
The Agency for Healthcare Research and Quality (AHRQ) released the Hospital Survey on Patient Safety Culture (HSOPSC) in 2004 as a tool to help hospitals evaluate how well they had established a culture of safety in their institutions. The HSOPSC 2007 Comparative Database Report provides data for benchmarking for comparison to other, similar hospitals or hospital units. Hospitals can use the results in the 2007 report as one basis for comparison in their efforts to establish, improve, and maintain a culture of patient safety in their institutions.
Now AHRQ is providing a new tool developed for small and critical access hospitals to benchmark and compare their results from the AHRQ Hospital Survey on Patient Safety Culture. However, the tool can be used by any size hospital because it allows the addition of any benchmarking data. The tool is from Statis Health and the Oklahoma Foundation for Medical Quality and the Hospital Interventions Quality Improvement Organization Support Center (HIQIOSC) and is adapted with permission for a benchmarking tool developed by the Nebraska Center for Rural Health Research. Download the benchmark tool (.xls) (197 KB) .
CDC – New meningococcal vaccine information available in Spanish and English
One young man's experience with meningococcal meningitis and his subsequent recovery is available in both English (.doc) ( KB) and Spanish (.doc) (59 KB) to be shared with patients and staff (.doc) (1.9 MB). His story emphasizes the importance of receiving the available vaccine. Current Advisory Committee on Immunization Practices (ACIP) guidelines (.doc) (1.2 MB) state that although routine vaccination is not recommended for children under 11 years old, a single dose of a tetravalent meningococcal polysaccharide-protein conjugate vaccine (MCV4) is recommended for children in the general population at 11-12 years old or at high school entry. Vaccination for adults over age 19 in the general population is not recommended, but for college freshmen, particularly those living in dormitories or residence halls, a single dose of MCV4 is recommended. These and other resources are available from http://www.ips-usa.com/vaccine_resources.htm.
Comprehensive hospital checklist – pandemic influenza preparation
Premier's Safety Institute is now offering a checklist to save on your computer and complete or update at your own pace.
The Word document (.doc) (463 KB) retains the HTML format and features developed by the Centers for Disease Control and Prevention (CDC), with input from other federal partners. It is intended to help hospitals assess and improve their preparedness for responding to pandemic influenza. Because of differences among hospitals (e.g., characteristics of the patient population, size of the hospital/community and scope of services), each hospital will need to adapt this checklist to meet its unique needs and circumstances. HHS also offers this as an Adobe® PDF (2 MB) or online at:
http://www.pandemicflu.gov/plan/healthcare/
hospitalchecklist.html.
ACR – Updated guidance on magnetic resonance safety
An update of the American College of Radiology’s (ACR) white paper on magnetic resonance (MR) safety is now available. The white paper titled "ACR Guidance Document for Safe MR Practices"
(.pdf) (335 KB) details MR safety, from the design of the MR suite and the qualifications of personnel to screening patients and what to do in an emergency.
See also:
http://www.acr.org/SecondaryMainMenuCategories/
quality_safety/MRSafety.aspx
The guidance is for both those who work in or near a magnetic resonance facility and for non-radiology personnel who prepare patients for MR procedures (e.g., managing the potential risks of aneurysm clips, pacemakers, dermal drug delivery patches and gadolinium-based contrast agents). The paper can be found in the June 2007 issue of the American Journal of Roentgenology.
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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 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 © 2007 Premier, Inc.
You may forward this newsletter to your colleagues. If you would like to reprint any of these stories, please cite the "Safety Share newsletter, Premier, Inc." as your source and send an email to safety_institute@premierinc.com and alert us. Thank you.
