February  24, 2011
Premier Safety Institute - Safety Share Newsletter
From the Premier Safety Institute®

Patient SafetyThis issue features disclosure, empowerment, and education of patients as key to safety.

Gina Pugliese, editor


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Should sleep deprivation among surgeons be disclosed to patients?

Evidence cited in a recent Perspective in the New England Journal of Medicine shows that sleep deprivation adversely affects clinical performance to the same degree as alcohol intoxication. One study found that in surgery, there is an 83 percent increase in the risk of complications (massive hemorrhage, organ injury, or wound failure) in situations where the surgeon is sleep-deprived. Sleep deprivation was defined in that study as an attending surgeon who had less than six hours of sleep between the prior on-call night and the following daytime elective surgery. The commentary noted that those who are sleep-deprived are not able to recognize their impairments and suggests that patients should be informed when their surgeons may be sleep-deprived and be given the opportunity to select another provider or reschedule elective procedures.

Studies show that patients want to know if their physicians were sleep-deprived and a majority would choose a different provider if they knew. Based on evidence of risk, the authors of the commentary suggest that healthcare organizations adopt policies to address this issue that consider options, such as not scheduling surgeons or anesthesiologists for elective surgery after an on-call night, or requiring disclosure of sleep deprivation to patients with informed consent.

Patients and their families should also be encouraged to ask if their practitioners have had adequate sleep prior to their procedures, although this approach can place undue responsibility on patients and families.

The American College of Surgeons took issue with these recommendations in a letter to the editor in the same issue of the New England Journal of Medicine, stating that surgeons, as professionals, should be able to determine their ability to perform surgeries, and that a call for mandatory disclosure essentially eliminates the necessary judgmental latitude surgeons should possess to determine their fitness for providing optimal patient care.


Spikes in pertussis in three states; booster vaccine rates extremely low among adults

Pertussis has resurged with the reported cases steadily increasing since the 1980s. Three states have had unusually high rates of pertussis, prompting the need to reassess immunization status for everyone. The resurgence is thought to be due to the consequence of immunity waning after childhood vaccination, leaving adolescents and adults only partially protected.

Pertussis (whooping cough), caused by Bordetella pertussis, is a highly contagious bacterial illness spread by coughs and sneezes. It starts like the common cold, with runny nose or congestion, sneezing, and mild cough or fever. After one to two weeks, severe coughing begins and can last for months. Infants and children with the disease cough violently and rapidly, over and over, until the air is gone from their lungs and they're forced to inhale with a loud "whooping" sound. Pertussis is most severe for infants, with more than half of infants under 1 needing to be hospitalized. Adults and adolescents typically have a milder form of pertussis that is often misdiagnosed as bronchitis or asthma. However, they can still easily spread the infection to others, including infants and young children.

High rates in Michigan, California and Ohio Unusually high rates of pertussis have been reported in Michigan, California and Ohio. In Michigan, there were 1,519 cases in 2010, up sharply from the previous year's 902 cases. California reported 8,383 cases in 2010. And Columbus, OH, and surrounding Franklin County areas reported 966 cases in 2010, the region's highest in 25 years.

Vaccination best defense Vaccination is the best defense against pertussis. Infants and young children should receive their complete tetanus, diphtheria, and pertussis (Tdap) vaccination series, and adolescent and adults should receive boosters, even if they received all their recommended vaccines. It is estimated that 97 percent of eligible adults have not been vaccinated against tetanus, diphtheria, and pertussis.

Healthcare workers are at risk of pertussis Healthcare-associated outbreaks of pertussis also have been increasingly recognized and reported from a diverse range of healthcare facilities, putting healthcare workers at increased risk for infection. One study estimates that there is a 1.7-fold increased risk for healthcare workers compared with the general population. Pertussis now ranks among the most frequent infectious disease exposures that require evaluation by occupational health services in hospitals.

Report suspect cases and assess pertussis immunization status Suspect cases of pertussis need to be isolated in Droplet precautions, preferably in a single room, and reported to the local health department to assist in preventing additional cases. Every patient encounter should be used to assess pertussis vaccination status and vaccinate with Tdap or DTaP vaccine, as age appropriate. Vaccination is particularly important for all close contacts of infants, as well as all healthcare workers.


One in 20 elderly seeks medical care for adverse drug events in clinics, ERs

Each year, outpatient settings, offices, clinics and emergency rooms, see more than 4.3 million people seeking care for an adverse drug event (ADE). A study analysis of an 11-year period for all age groups report people 65 and older had the greatest proportion of ADE visits and a quarter of ADE-related hospital admissions. Comparisons of ADE visits over two periods (1995-2000 and 2001-2005) also show that ADE visits in the past five years are nearly doubling in this group (as high as one in 20), along with associated high morbidity and healthcare costs.

Multiple medications are common
The proportion of patients taking three or more medications increased over the five-year study period and medication classes with the highest ADE visit rates included hormones and synthetic substitutes, antimicrobial agents and cardiovascular agents.

Focus is critical - now. The study highlights the magnitude and impact of ADEs on healthcare systems in a way not possible in studying ADEs only in hospitalized patients. Clearly the incidence of ADEs requiring medical treatment has substantially increased between 1995 and 2005, particularly in older patients – a  major concern since ADEs in this group are associated with substantial morbidity, with a quarter of patients requiring admission. This impact will become more critical for cost of care as well. For example, this study shows the largest payer for clinic or ED care is the government, and under current and future reimbursement plans, the aim is to reduce hospital readmissions by 40 percent. It also points to important areas of focus to reduce readmission rates, namely improved identification of preventable ADEs in these populations, monitoring and instituting related interventions.  


Empowering patients to "ask caregiver to wash their hands" improves compliance

Patient empowerment is one of the strategies to improve hand hygiene in the 2009 Guidelines on Hand Hygiene in Health Care, developed and tested by the World Health Organization. A recent review article by McGuckin and colleagues described four components as fundamental to the process of patient empowerment that needed to be addressed in developing any program.

  • Patient participation – understanding and acceptance of the opportunity to become involved one's care. Key patient characteristics that will affect success when engaging patients include age, culture and level of intelligence.

  • Patient knowledge – acquiring sufficient knowledge to engage in conversation with healthcare workers. Patients prefer information that is specific, provided by the healthcare worker, and printed to use as a prompt.

  • Patient skills – including health literacy and self-efficacy. This would include strategies to encourage the patient, such as reminders, motivational messages in the form of badges or stickers worn by the patient or healthcare worker (e.g., patient sticker that says "thank you for washing your hands").

  • Development of a facilitating environment – encouraging patients to engage in open communication about their care in an environment free of barriers. A positive safety culture of the organization can support this type of environment that includes senior staff serving as role models in performing hand hygiene.

A template for a five-step process for successful hand hygiene promotion is provided in the 2009 WHO guidelines, and describes the final step needed – an evaluation of the process that might include patient satisfaction surveys or patient observations of practices. The full template is part of the WHO Guidelines on Hand Hygiene in Health Care.

CDC video – Hand hygiene saves lives A recent study evaluated the success of a video to educate patients and families about hand hygiene and empower them to ask their caregiver to wash their hands. The video, Hand Hygiene Saves Lives, developed by the Centers for Disease Control (CDC), was evaluated in 17 Catholic Healthcare Partner hospitals in collaboration with CDC and Premier. The results showed that the after watching the video, caregivers were twice as likely to ask their caregivers to wash their hands.

The video, CDC's Guideline for Hand Hygiene in Health-Care Settings, the 2009 WHO Guidelines on Hand Hygiene in Health Care and other hand hygiene resources are available on the Premier Safety Institute's Hand Hygiene website.


Passive safety device features 10 times more effective in preventing needlesticks

Passive safety engineered devices (SEDs) that automatically or semi-automatically activate the safety feature were found to be 10 times more effective in preventing needlestick injuries (NSI), compared to fully manual devices requiring active engagement of the safety feature, according to a recent study conducted in 61 French hospitals. This is one of the largest multi-center studies comparing one sharps safety device to another. Knowledge of the most effective designs is important, both to guide the choice for users among available devices and to guide manufacturers in developing new safety technology.

NSI rates vary with the type of safety feature NSI rates differed according to the type of safety feature. Among the active devices, the semiautomatic (e.g., push button or plunger devices) were found to be safer than those with hinged recap/toppling shield, which in turn were safer than manually activated devices such as those with sliding sleeve protection. Passive devices, e.g., self retracting lancets and IV catheters that automatically shield the needle during use, were the most effective in preventing NSIs.

User acceptance of a device may influence efficacy More than one-fourth of all the NSIs in this study were from non-activation or incomplete activation and could have been avoided. Factors contributing user acceptance of SEDs, which may also influence the efficacy of SEDs, include the design of the device, training provided before and after introduction of the device, ease of use, changes in technique, the perceived risk of occupational infection, and patient safety issues. For example, healthcare workers' concerns for patient safety or comfort may reduce the efficacy of such SEDs, because users may delay activation or rate the device as being more difficult to use. Passive devices, which do not rely on user activation, may address some of these issues.  

A study conducted by the Premier Safety Institute® confirms the authors' suggestion that user preference varies and might influence device activation. In the Premier study, 875 clinicians in 30 hospitals assessed the performance considerations of 10 different types of syringe and phlebotomy (34,075) devices. The top 10 performance considerations identified by study participants follow. It was noted that for syringes, the ability of the device to deliver an accurate dose was identified as more important than the safety feature.

Top 10 performance considerations of phlebotomy devices

1. Reliable safety feature
2. Ease of use
3. Easily disposed in sharps container
4. Does not interfere with blood draw
5. No risk of spray or drip
6. Satisfactory for standard procedures
7. One-handed
8. Permits procedure visualization
9. Range of sizes available
10. Use on heavy, thin, fragile veins

Top 10 performance considerations of syringes

1. Accuracy of dose
2. Reliable safety feature
3. Hands remain behind needle
4. Visibility of medicine
5. Exposed sharp covered after use
6. One-handed
7. Does not interfere with procedure
8. Simple and self-evident
9. Range of syringe and gauge size
10. Does not take more time to activate

This French study provides evidence that passive SEDs that require no input from the user are more effective than active SEDs for NSI prevention. The authors note that further studies are needed to determine whether their higher cost may be offset by savings related to fewer NSIs and to a reduced need for user training.



TJC - Hand hygiene solution chart

Joint Commission-accredited hospitals have access to an interactive tool that simplifies processes for solving healthcare quality and safety problems that exist in healthcare systems. The Targeted Solutions Tool™ (TST), launched in fall 2010, encapsulates the work of the Joint Commission Center for Transforming Healthcare and provides step-by-step processes to measure performance, identify barriers to excellent performance, and implement proven solutions. The first set of targeted solutions, created by eight of the country's leading hospitals and healthcare systems that worked with the center, focuses on improving hand hygiene. The Transforming Healthcare site provides links to various issues, as well as resources such as the Hand Hygiene Factors and Solutions.


ACOG - Endorses flu vaccination during pregnancy

Nearly a dozen professional organizations, including the American College of Obstetricians and Gynecologists, urge pregnant women to seek vaccination in a letter that may be useful when safety questions related to seasonal influenza vaccination surface. Download.

Commonwealth Fund - "Why Not the Best?"

WhyNotTheBest.org website was created and is maintained by The Commonwealth Fund, a private foundation working toward a high performance health system. This free resource for healthcare professionals helps track and compare performance on various measures of healthcare quality and enables organizations to benchmark measures of evidence-based care, patient experience, readmission and mortality rates, and costs. Case studies and improvement tools spotlight successful improvement strategies of the nation's top performers. Currently the site includes measures of hospital quality that are publicly reported on the Centers for Medicare & Medicaid Services website, Hospital Compare. This new site also includes data on the incidence of central line associated bloodstream infections, from some 900 U.S. hospitals. For information on the particular measures, see Methodology.


TJC - Enforces design and construction guideline

Effective January 1, 2011, the Joint Commission updated its standard (EC.02.06.05) addressing the design and construction of healthcare facilities. The EC standard formerly referred users to the "2001 Guidelines for Design and Construction of Hospitals and Health Care Facilities" for design criteria for new construction as well as for renovations. The Joint Commission announced in the December 2010 issue of its publication Environment of Care® News that the requirement refers to the more current Facility Guidelines Institute 2010 edition of the guidelines. Organizations are required to use either state rules and regulations or the guidelines in their design and construction efforts. The Joint Commission stressed that the changes to EC.02.06.05 do not constitute a revision in policy regarding alternatives, but only updates the 2001 guidelines. Since the guidelines are not retroactive, only new designs initiated after January 2011 are affected by the change to 2010 guidelines.


CDC, IDSA, SHEA - Online antimicrobial resistance CME

The Centers for Disease Control and Prevention, in partnership with the Infectious Diseases Society of America, The Society for Healthcare Epidemiology of America and Medscape, offer a free continuing education (CME and CE) activity titled "Antimicrobial Resistance Across the Continuum of Care: Winning the War One Battle at a Time." The CME and CE offer includes a roundtable discussion with antimicrobial resistance and stewardship experts and is intended for clinicians who regularly prescribe antibiotics.

The goal is to raise awareness of the potential public health crisis created by inappropriate antibiotic prescribing and antibiotic resistance in the United States in an effort to motivate clinicians to change the prescribing practices that created the problem. At the completion of the 45-minute program, clinicians should be able to identify the most important contributing factors for development of antimicrobial resistance; recognize patient and provider pressures for prescribing antibiotics; and identify ways to optimize antimicrobial therapy through stewardship initiatives. Participate in this free CME activity.


NIOSH - HCW slips, trips, falls prevention

A workbook, "Slip, Trip, and Fall (STF) Prevention for Healthcare Workers," has recently been released by CDC/NIOSH to address work-related slip, trip and fall incidents that frequently result in serious disabling injuries that impact a healthcare employee's ability to do his or her job, often resulting in lost workdays, reduced productivity, expensive worker compensation claims, and diminished ability to care for patients. The STF workbook is intended for healthcare facility administrators, safety and health professionals, facility managers, housekeeping managers, food service managers, and workers who are responsible for safety. It also identifies the top 10 STF hazards specific to healthcare facilities. For each hazard, this workbook will:

  • Explain how the hazard contributes to STFs,

  • Identify where the hazard is likely to occur, and

  • Provide recommendations to reduce or eliminate the hazard.

Editorial team:
Gina Pugliese, R.N., M.S., editor
Judene Bartley, M.S., M.P.H., associate editor
Cathie Gosnell, R.N., M.S., M.B.A., contributor

Laura Botwinick, M.S., contributor
John Hall, B.S.J., contributor
David Huntley, B.A., Web master

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