In this edition
Premier Safety Web site
Gina Pugliese, Editor
After listening to concerns from providers, the Leapfrog Group recently modified three controversial patient-safety standards. Hospitals should now have an easier time demonstrating progress toward meeting the criteria: computerized prescribing, use of intensivists in critical care and handling minimum volumes of certain high-risk procedures.
Hospitals have until 2005 to begin using prescription-ordering information systems that alert physicians and other clinicians to drug interactions or allergies. The business coalition will give partial credit for systems implemented for computerized prescribing in at least one area of the hospital, as opposed to requiring full implementation. Leapfrog board member Arnold Milstein, medical director of the Pacific Business Group on Health, said that industry feedback convinced the group that computerized prescribing systems cannot be implemented quickly. They recognized that such a high-dollar investment requires board approval and that significant time is required for physician acceptance. Leapfrog also broadened its definition of intensivist to include physicians who have a long record of full-time experience in intensive care but who might not be board-certified in the specialty. Finally, the group deleted a volume-based measure of proficiency for one high-risk procedure, carotid endarterectomy, after new research countered previous findings of better outcomes at higher-volume hospitals.
More information on The Leapfrog Group at: http://www.leapfroggroup.org
OSHA affirmed that the recommendations supporting the use of alcohol-based hand rubs in the Centers for Disease Control and Prevention’s, “Guideline for Hand Hygiene in Health-care Settings,” is consistent with handwashing requirements in OSHA’s Bloodborne Pathogen Standard. An official letter of interpretation, “Acceptable use of antiseptic-hand cleansers for bloodborne pathogen decontamination and as an appropriate handwashing practice,” was posted on its Web site April 8, 2003.
Last month’s Safety Share newsletter featured concerns raised by some who questioned the consistency of the two documents. OSHA notes that many of CDC's hand hygiene guidelines are for infection control and patient safety, which OSHA standards do not specifically address. OSHA's Bloodborne Pathogen Standard, designed to protect workers from exposure to blood or other potentially infectious materials (OPIM), requires that when a worker removes gloves and had contact with blood or OPIM, hands must be washed with an appropriate soap and running water. If a sink is not readily accessible, such as when workers are in the field, and there has been occupational exposure, hands may be decontaminated with a hand cleanser or towelette. Soap and running water, however, must be used "as soon as feasible." According to OSHA, substituting antiseptic hand cleansers is an appropriate handwashing practice if there has been no occupational exposure to blood or OPIM.
The Agency for Healthcare Research and Quality (AHRQ) now offers an array of decision-making and research tools, including quality and patient safety indicators that use hospital inpatient administrative data for measuring quality and identifying potential adverse events occurring during hospitalization. The AHRQ quality indicators (QIs) are organized into three "modules," each of which measures quality associated with processes of care that occur in an outpatient or an inpatient setting. All three modules rely solely on the following hospital inpatient administrative data:
- Inpatient mortality for medical conditions;
- Inpatient mortality for procedures;
- Utilization of procedures for which there are questions of overuse, underused, or misuse; and
- Volume of procedures for which there is evidence that a higher volume of procedures is associated with lower mortality.
The PSIs are a new tool to help health system leaders identify potential adverse events occurring during hospitalization. They are a set of indicators providing information on potential in-hospital complications and adverse events following surgeries, procedures, and childbirth. The PSIs were developed after a comprehensive literature review, analysis of ICD-9-CM codes, review by a clinician panel, implementation of risk adjustment, and empirical analyses. PSIs include Hospital-Level Patient Safety Indicators and Area-Level Patient Safety Indicators.
The Centers for Disease Control and Prevention (CDC) recently issued infection control guidelines for people exposed to patients suspected of having Severe Acute Respiratory Syndrome (SARS). The March 29, 2003, CDC guidelines recommend SARS patients limit their interactions outside the home and avoid work, out-of-home day care, or other public areas for 10 days after respiratory symptoms and fever are gone.
People living with SARS patients should wash their hands frequently or use alcohol-based rubs, and wear disposable gloves for contact with the patient's body fluids. Patients with suspected SARS should wear surgical masks during close contact with uninfected household members. If patients are unable to wear a mask, CDC recommends household members wear a surgical mask during close contact.
Inpatient setting guidelines
If a suspect SARS patient is admitted to the hospital, the CDC advises infection control personnel to be notified immediately. Infection control measures for inpatients should include the following:
According to the CDC, patients should be placed in a private room if airborne precautions cannot be fully implemented, and all persons entering the room should wear N-95 respirators. Where possible, a qualitative fit test should be conducted for N-95 respirators.
Early identification and isolation of suspect patients continues to be the most important method of prevention and control of SARS. Although concern remains about the possibility of airborne transmission, the CDC believes that the virus primarily spreads by droplets when an infected person coughs or sneezes, and therefore the use of eye protection, hand hygiene, and environmental cleaning remain the key control measures.
SARS symptoms include fever (100.5 ° F. or higher) and respiratory difficulties such as coughing, shortness of breath or other difficulty breathing, developing on or after February 1, 2003, in persons who recently traveled to countries in Asia where the illness has been transmitted in community settings. Those who have had close contact with ill persons who recently traveled to those countries should also be on alert. Individuals who experience respiratory symptoms, fever, and have either of these kinds of exposures should call their doctor.
At this writing, the CDC reported a total of 196 suspected cases of SARS in U.S. residents. The World Health Organization (WHO) reported a total of 3,169 probable SARS cases and 144 deaths worldwide.
The healthcare industry needs to follow a universally accepted published reference to help avoid errors resulting from misread or misinterpreted abbreviations, according to the Institute for Safe Medication Practices (ISMP). Michael R. Cohen, ISMP president, made his remarks at a recent discussion around the issue of hospitals developing in-house (revised) approved abbreviations policies -- which would address safety issues identified by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the ISMP. Standardizing the abbreviations, acronyms, and symbols used throughout an organization, including a list of abbreviations, acronyms, and symbols not to use, is one of the recommendations in the JCAHO’s National Patient Safety Goals for 2003.
Cohen said in-house approved abbreviations lists are not worth the effort, adding that hospitals tend to spend a great deal of time developing these abbreviation lists only to find them impossible to administer. New abbreviations not on the list keep being developed so that its value as a reference increasingly diminishes, he noted. Moreover, Cohen believes it is more important to have a list of dangerous abbreviations that should never be used at all. For example, abbreviations for discharge (“D/C”), subcutaneous (“S/C,” or “S/Q”) and the Latin abbreviation for every day (“Q.D.”), are classified as unacceptable and dangerous abbreviations by the JCAHO, ISMP, and other organizations.
Cohen stressed that such abbreviations - which could be confined to the 10 most dangerous abbreviations and dose designations - should be included in any reference book used by healthcare practitioners, if such a reference is all that is being used.
Both the JCAHO and ISMP urged a cooperative industry effort be undertaken to develop a universally accepted reference list.
The Centers for Disease Control and Prevention (CDC) backs an advisory panel’s recommendation to exempt persons with heart disease or other cardiac risk factors from pre-event vaccinations for smallpox. The decision came on the heels of several deaths among vaccinated people who may have had underlying cardiac disease. No direct link was made, however, between those deaths and the smallpox vaccine.
On March 31, the CDC informed states that the agency accepted the Advisory Committee on Immunization Practices’ (ACIP) recommendations to exclude persons from pre-event vaccination if they have underlying heart disease – with or without symptoms – or if they have three or more major cardiac risk factors. The voluntary vaccination program will continue, and CDC is distributing revised pre-vaccination clinic education materials reflecting the new exclusion criteria.
ACIP made recommendations to the CDC after widely reported cases of adverse cardiac events following smallpox vaccination. The agency recommends that programs exclude volunteers with three or more known major cardiac risk factors – hypertension, diabetes, hypercholesterolemia (high cholesterol) and smoking, in addition to people with known heart disease – as it gathers more information on those cases of cardiac adverse events following vaccination. The CDC did not recommend special medical follow-up for vaccinated people with cardiovascular risk factors, but said vaccinees should seek a healthcare provider right away if they develop shortness of breath, chest pain, or other symptoms of cardiac disease.
These recommendations update prior CDC recommendations that people diagnosed with heart disease be temporarily deferred from receiving the smallpox vaccine while it investigates reports of heart problems. The CDC previously received reports suggesting the smallpox vaccine may be playing a causal role in several cases of myopericarditis – inflammation in or around the heart – reported in vaccinated healthcare and military personnel. The agency said 10 cases of myopericarditis have been reported among 350,000 military vaccinees, as well as one 55-year-old individual who died of a heart attack five days after receiving a smallpox shot. An autopsy showed the man had underlying coronary artery disease, leading medical authorities to believe that his death was unlikely to have been related to the vaccination. Those cases are in addition to two civilian and seven healthcare worker cases. Three of the healthcare worker vaccinees experienced heart attacks; among them, two have died. All seven of the cases experienced symptoms four to 18 days post vaccination.
A recently released Institute of Medicine (IOM) report states the government should re-evaluate the costs, risks, and goals of the vaccination program and determine whether some states had already inoculated enough health workers to cope with a bioterror attack. The IOM report urges communities to measure their preparedness to handle a smallpox outbreak by examining how effectively their public health and medical personnel and other emergency responders are coordinated, not solely by the number of workers who have been vaccinated. The IOM report also noted that many health workers are refusing to volunteer for the vaccine because the government has no program to compensate them if they are harmed or lose time at work because of side effects. Congress continues to negotiate over legislation to address compensation for adverse effects of smallpox vaccination.
As providers struggle to find a uniform set of criteria to measure high quality healthcare, Premier demonstrated at the recent National Patient Safety Foundation’s (NPSF) Safety Congress that quality is measurable and that high quality is not necessarily tied to high costs. In fact, Premier has demonstrated through its national comparative database Perspective that high quality can improve a hospital’s financial health. By using a new set of definitions suggested by the federal government and other quality watchdog organizations, Premier demonstrated to Congress attendees that quality and safety improvements to clinical processes offer financial benefits. This is a critical point, as not-for-profit health systems struggle to meet community demands for core and cutting edge services while insurance reimbursement declines.
A focus on healthcare quality offers a double benefit: improved outcomes and lowered costs. Put differently, cutting operational costs or reducing staff is not the only answer to staying financially healthy. When a hospital converts ”good” healthcare to ”great” delivery, the process helps trim costs because complications are reduced, fewer products are used, and the length of stay is decreased.
The federal Agency for Healthcare Research and Quality recently established Patient Safety Indicators (PSI), which are benchmarks that help hospitals identify when errors are likely to occur. Using Premier’s proprietary clinical comparative database, Perspective Online researchers compared the potential outcomes if patients were tracked using these indicators against those who were not. Some of the examples included:
More than 500 hospitals subscribe to the Web-based Perspective Online to compare their performance to peers and top performers, find opportunities to make improvements, and track their progress.
On March 13, the Occupational Safety and Health Administration (OSHA) issued a voluntary ergonomics guideline for the nursing home industry. The guidelines focus on practical recommendations for employers to reduce the number and severity of workplace injuries by using methods found to be successful in the nursing home environment. To develop the guidelines, OSHA reviewed existing ergonomics practices and programs, state OSHA programs, as well as available scientific information. The guidelines are divided into five sections: developing a process for protecting workers; identifying problems and implementing solutions for resident lifting and repositioning; identifying problems and implementing solutions for activities other than resident lifting and repositioning; training; and additional sources of information.
OSHA emphasized that specific measures or guideline implementations may differ from site to site. Still, the agency recommends that all facilities minimize manual lifting of residents in all cases, and eliminate such lifting when feasible. In addition, OSHA encouraged employers to implement a basic ergonomic process that provides management support while involving workers, identifying problems and implementing solutions, addressing reports of injuries, providing training and evaluating ergonomics efforts.
In April 2002, OSHA announced its strategy to reduce ergonomic injuries. The four-pronged approach includes guidelines, enforcement, research, and outreach and assistance. In addition to nursing homes, the agency is preparing industry-specific guidelines for the retail grocery store and poultry processing industries.
The Premier Safety Institute offers an Internet-based clearinghouse of tools and resources designed to help prevent back injuries in patient care.
Three of the leading healthcare supply chain organizations have released proposed medical/surgical supply lists or formularies materials managers can use for disaster readiness planning and coordination. (Editor link to DR module, product section) Developed jointly by the Association for Healthcare Resource and Materials Management (AHRMM), the Health Industry Distributors Association (HIDA), and the Healthcare Supply Chain Association (HSCA), the formularies are based on information from numerous hospitals and healthcare systems. These supply lists are intended only as starting points for preparedness and should be modified to fit each hospital based on individual hospital needs, internal and regional supply chain activities, and need for self reliance until arrival of federal aid. Working with suppliers for pre-event orders and collaboration with local and community agencies is also essential to ensure coordination of the flow of supplies.
The Premier Safety Institute provides additional resources to help material managers develop an emergency preparedness supply inventory.
The Centers for Disease Control and Prevention (CDC) has developed a clinician's registry to provide real-time information to help prepare for and respond to terrorism and emergency situations. As participants, physicians will receive regular updates on terrorism and emergency response issues targeted to clinicians.
To participate, go to http://www.bt.cdc.gov/,
click on "Clinician Registry for E-mail Updates on Terrorism and Emergency Response" under “Featured Links,”
follow the instructions for entering an e-mail address.
Subscribers will not be asked to enter a name or other personal information.
A special discount is being offered to Premier Safety Share subscribers for the P4PS videos, “First, Do No Harm.” The P4PS video, “First, Do No Harm Part 1,” is an 18-minute case study available only in VHS format. “First, Do No Harm Part 2” is a complete training package, available in DVD or VHS formats. It includes a 19-minute case study, a facilitator’s guide, and over 35 minutes of commentary by safety experts on the issues raised by the case. The discounted videos are only available until June 30, 2003. Use the form to order your copy of these films at the reduced price of $149 for Part 1 (a $40 savings) and $595 for Part 2 (a $100 savings).
The Agency for Healthcare Research and Quality (AHRQ) recently launched its Web-based National Quality Measures Clearinghouse™ (NQMC). The site is designed to be a one-stop shop for physicians, hospitals, health plans, and others interested in quality, and contains the most current evidence-based measures available to evaluate and improve healthcare delivery. Users can search the NQMC for measures targeting a particular disease/condition, treatment/intervention, age range, gender, vulnerable population, setting of care, or contributing organization. The site enables searching for measures by specific disease, treatment, age range, gender, and a variety of other topics. The clearinghouse also permits side-by-side comparative measurements that identify which will best work for a given organization.
To locate NQMC go to http://www.qualitymeasures.ahrq.gov.
This report, “Cleaning for Health: Products and Practices for a Safer Indoor Environment,” is a one-stop guide to environmentally preferable cleaning products and methods that have been effectively used in office buildings, schools, hospitals and other facilities in the United States and Canada. It describes pioneering product evaluation programs and lists the brands that were chosen based on environmental and performance criteria. It also provides a model specification, as well as manufacturer contacts and other resources for those who want to develop a safer cleaning program for their buildings. Copies of the report can be downloaded in its entirety or by chapter.
On-line version available at http://www.informinc.org/cleanforhealth.php,
or download the Cleaning for Health guide (416 KB).
A number of enhancements have recently been made to Premier’s Web sites to improve access and ease-of-use. Premier’s Safety Institute now offers rapid access to the full array of safety resources as well as to hot topics and archived Health Alert Network bulletins sent out by the Centers for Disease Control and Prevention (CDC). The two new additions recently added include:
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
Premier, Inc. is a national strategic alliance of leading hospitals and healthcare systems representing more than 200 not-for-profit owners that own, operate, or are affiliated with approximately 1,600 facilities. Premier members have access to a wealth of resources that support them as they evolve into integrated delivery systems and improve community health across the continuum of care. Premier maintains corporate offices in San Diego, CA; Charlotte, NC; Chicago, IL; and Washington, DC. For information, visit www.premierinc.com.