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This newsletter includes several tools and resources and provides easy access to downloadable news-related documents and resources. We hope you will find the information to be timely and beneficial. Also, visit our Safety Web site for more safety resources.
Gina Pugliese, Editor
Tools and resources
President Bush signed the Nurse Reinvestment Act (HR. 3847) August 1st, 2002, following the compromise achieved by House and Senate negotiators. Major provisions of the act include nurse recruitment through public service announcements and expansion of the National Nurse Service Corps, nurse retention through internships, residency programs and career ladders, improved retention by enhancing collaboration with other professionals, programs to increase geriatric education, nurse faculty loan programs, and "magnet facility" patient safety grants to support greater provider and care activity coordination.
On July 24, members of the House and Senate, along with Secretary of Health and Human Services Tommy Thompson and Secretary of Labor Elaine Chao, praised the legislation. Representative Lois Capps (D-CA), one of its lead proponents, noted that any resulting positive effects would be directly linked to the ability to secure appropriations for the authorized programs.
According to the Centers for Disease Control and Prevention (CDC), hospital-acquired infections are adverse patient events that affect approximately two million people each year. This issue has been highlighted in recent news reports, which also addressed challenges related to calculating accurate rates of infection because of incomplete reporting. Although most agree that these reports have increased public awareness of a serious issue, critics say they focused on past problems without sufficiently recognizing current efforts to control infection. The American Hospital Association has noted that the process of controlling infection requires constant attention and new technologies. For example, waterless hand cleaning agents, which many hospitals have adopted, have been shown to improve hand hygiene practices because of their ease of use and accessibility. As a result, they help reduce infections spread by hand contact.
In a related issue, the importance of monitoring hospital-associated infections as critical adverse events is underscored by the CDC’s plan (download plan below) to expand its current infection surveillance system for identifying and reporting infections. The CDC’s Division of Healthcare Quality Promotion (DHQP) has monitored infection for more than 25 years using the National Nosocomial Infections Surveillance System (NNIS). NNIS has standardized definitions and reporting processes that permit comparisons and measurement of improvements. NNIS is undergoing expansion and will become an Internet-based knowledge system network, called the National Healthcare Safety Network (NHSN). It will monitor the reporting of adverse events, including healthcare-associated infections and disseminate information on prevention. When NHSN has been implemented, any healthcare facility will be eligible to participate.
An outbreak of twelve cases of Legionnaire’s disease in Pennsylvania has investigators puzzled. The outbreak occurred in a nursing home that has been open less than a year with a modern water system. Since the first report in early June 2002, two residents have died from the disease. Nine residents, ranging in age from 85 to 101, and one staff member have recovered or are improving. The source of the pathogen has not yet been identified, but some have suggested a specific water pipeline. According to the Montgomery County health director, this conclusion was based on the presence of Legionella bacteria cultured from showerheads and faucets. The initiating event remains speculative, and the source may never be positively identified. The nursing home, which houses 324 people, has had its entire water system disinfected several times, with special attention given to the plumbing (showerheads) in the wing where the outbreak occurred. The home resumed normal operations once tests indicated decontamination efforts had been successful.
Legionnaires’ disease, a serious form of pneumonia, is transmitted through contaminated airborne water droplets. It is not transmitted from person to person. Symptoms include fatigue, headache, fever, chills, coughing up blood, and chest and abdominal pain. The first case of legionellosis was identified at the nursing home when a male resident was hospitalized because he did not respond to pneumonia treatment.
Strategies for disinfecting Legionella in potable water distribution systems have had varying degrees of efficacy. They include superheating, auto-chlorination, ultraviolet irradiation, and copper-silver ionization. Although initial treatments may be successful, the contamination may return. One treatment recently approved by the U.S Environmental Protection Agency (EPA) uses chlorine dioxide, which is effective in treating both hot and cold drinking water and offers some hope for sustained success over time. [See abstract below from Society for Healthcare Epidemiology of America (SHEA), 2002.]
On June 11, 2002, the Accreditation Council for Graduate Medical Education (ACGME) (download report below) issued new rules that limit the number of hours that medical residents may work and establish minimum break periods between shifts. As the body responsible for accrediting some 7,800 medical residency programs nationwide, the ACGME took action in response to "concerns about patient safety and information about the effect of excessively long hours on cognitive performance and functioning."
Under the new rules, residents:
The ACGME has also adopted new requirements for institutions sponsoring graduate medical education to promote patient safety. Requirements include duty hour assignments, monitoring the effect of "moonlighting" and the demands of home call on residents’ performance, and making scheduling adjustments as needed.
The new rules are slated to take effect July 1, 2003. During the graduate medical academic year that began July 1, 2002, residency review committees are expected to provide constructive feedback about duty hours without taking any adverse accreditation action. ACGME will step up its enforcement of the new requirements by collecting data on residents’ duty hours during accreditation site visits and by addressing violations more rapidly.
An article (download abstract below) in the American Journal of Infection Control reviews the issues behind these changes, relating work hours and fatigue to patient outcomes. (Lundstrom, Pugliese, Bartley, Cox and Guither. Am J Infect Control 2002;30:93-106)
Hospitals in at least one part of the country recently found inspectors at their front doors checking for compliance with the bloodborne pathogens standard. The Occupational Safety and Health Administration's (OSHA) Region 8 office (which covers Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming) began what is known as a "local emphasis program" that looks at how hospitals stay in line with the requirements of the bloodborne standard (29 CFR 1910.1030).
Inspections will focus on key provisions of the Needlestick Safety and Prevention Act, (download below) including recordkeeping — a key requirement of the bloodborne pathogens standard —the hospital's exposure control plan, and the organization’s needlestick injury log.
In addition, OSHA’s national emphasis program will continue to focus its outreach efforts and inspections on other specific hazards, such as ergonomics (primarily related to nursing home resident handling), exposure to blood and other infectious materials, exposure to tuberculosis, and slips and falls. Nursing and personal care facilities with 14 or more injuries or illnesses resulting in lost workdays or restricted activity for every 100 full-time workers will be among the approximately 1,000 facilities inspected. These facilities have rates about two and half times that of all other general industries.
In a recent letter, the U.S. Environmental Protection Agency (EPA) expressed concern over the potential use of sanitizers and/or disinfectant products and other types of antimicrobial products to treat the surfaces of heating, ventilation, and air conditioning (HVAC) or air handling systems. These systems are typically considered as part of air duct cleaning.
Although the directions for these products permit their use on hard, non-porous surfaces, they may not specifically include the use of the product in air handling systems. The EPA has not assessed the potential exposure and risks to people inside buildings or to those doing the actual cleaning, from the use of these products on these surfaces, under these conditions. Users cannot assume that EPA registration of these products reflects any conclusions about their safety or effectiveness when used in air handling systems.
Even when product labels do list potential use in HVAC systems, the EPA is concerned that it has not received and reviewed adequate data to fully evaluate potential risks. The EPA emphasizes that disinfectants, sanitizers, or other antimicrobial products should not be used to treat HVAC systems if the product does not include specific directions for HVAC use. The fact that some products are labeled "antimicrobial pesticide products" further complicates proper usage and increases potential risk of exposure. The EPA provides an excellent Web resource, Antimicrobial Pesticide Products, (see link below) for related guidance, including descriptions, uses, type and regulations concerning antimicrobial pesticides. The site also provides a link to a practical primer on similar products, Household Antimicrobial Products, from the Virginia Cooperative Extension (download primer below).
go to http://www.epa.gov/pesticides/citizens/antimic.htm
The six patient safety goals developed from reported sentinel events have been finalized by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The JCAHO Board of Commissioners approved the six National Patient Safety Goals, representing 11 recommendations for improving the safety of patient care, for implementation effective January 1, 2003. The recommendations were developed by the Sentinel Event Alert Advisory Group through an intensive review process of all past Alert recommendations published by JCAHO. The 2003 National Patient Safety Goals are to:
The recommendations for each goal are provided in the full document below. As mentioned recently in Premier Safety Share (July, 2002), the recommendations associated with the JCAHO 2003 National Patient Safety Goals will be subject to survey beginning January 1, 2003. Organizations may implement alternatives to the recommendations if they are determined, upon review by the Sentinel Event Alert Advisory Group, to be at least as effective as the published recommendations. Organizations that fail to implement the recommendations or acceptable alternatives will receive a single special Type I recommendation related to the particular patient safety goal. The process for reviewing alternative recommendations will be communicated to accredited organizations in a future issue of Joint Commission Perspectives and will be posted on JCAHO's Web site.
Special flexible endoscopes are designed for use in sinus, nose, and throat examinations. Following a recent news report that revealed possible contamination of examination instruments from carrying cases, Olympus America issued a statement reminding healthcare workers of the instructions regarding the use of carrying cases for transport of endoscopes (download statement below).
The instructions are clear and have not changed. New endoscopes are shipped in a dedicated carrying case that is designed to protect a new or reprocessed instrument during transport. The case may be kept for use when there is a need to return a clean and reprocessed instrument for repair or when a clean and reprocessed instrument is taken out of the hospital. Endoscope cases are not intended for use as storage or for transport within the hospital. If a clean and reprocessed endoscope is transported in a carrying case, that endoscope must again be cleaned and reprocessed before its next use.
Storing an endoscope in the carrying case presents a possible infection control risk because it is a humid, non-ventilated environment. Placing a contaminated endoscope in a carrying case contaminates the case itself. Since the case cannot be cleaned or disinfected, it must be discarded.
The Food and Drug Administration’s (FDA) Center for Devices and Radiological Health (CDRH) recently notified healthcare professionals of a possible association between cochlear implants and the occurrence of bacterial meningitis. At least 25 cases of meningitis have been diagnosed worldwide in children and adults ranging in age from 21 months to 63 years who have undergone cochlear implantation for severe to profound deafness. A total of nine known deaths resulted from these cases. Surveys of cochlear implant centers currently underway suggest there are additional unreported cases of meningitis in the cochlear implant population.
In October 2002, the Institute for Healthcare Improvement (IHI) is launching a new Breakthrough Series Collaborative on Improving Patient Safety. The collaborative is part of a new IMPACT network, change-oriented healthcare organizations ready to join the improvement movement at a new level of intensity. Openings exist for organizations that are not currently IMPACT network members. Participating organizations will work to create a system of safety, including changing organizational culture and attitudes of leadership and front line staff, improving critical core processes, encouraging appropriate use of technology, and establishing an effective system for measuring harm.
The Center for Devices and Radiological Health (CDRH) has developed a two-CD set (An Overview of the Regulatory Requirements for Reprocessing of Single-Use Devices by Hospitals) that covers the regulatory requirements that a hospital must meet if it reprocesses single-use devices (SUDs). Topics include basics, such as registration and listing, premarket review, labeling, corrections and removals, medical device tracking and reporting, and the quality system regulation. The FDA deadline for active enforcement of premarket notification submission requirements for class II SUDs begins August 14, 2002.
The National Academies’ Institute of Medicine (IOM) has released a report providing a set of measurement tools and a process for evaluating the extent to which communities have implemented the disaster preparedness plans required by the Department of Health and Human Services’ Metropolitan Medical Response System program. The report identifies 23 essential capabilities that form the basis for preparedness and provides a set of indicators for judging community preparedness in each area. The 332-page report Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program can be ordered from the National Academy Press.
The Radiation Emergency Assistance Center/Training Site (REAC/TS) provides an excellent resource for radiation information and training. In addition to a radiation accident registry, the Center offers courses in handling radiation accidents and guidelines for radiation accident management. The REAC/TS Web site offers free online information on radiation basics, detection, measurement, safety around radiation sources, types of radiation exposure, and managing radiation emergencies.
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.