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A recent study in the Journal of the American Medical Association (JAMA) found that using mandatory physician specialists (called intensivists) in intensive care units (ICUs) could reduce mortality rates and lower lengths of stay. Intensivists may either consult in the ICU or direct all ICU care.
According to the article, staffing the nation’s ICUs with intensivists could reduce death rates by 30 percent and save as many as 162,000 lives each year. The report compared 27 alternative staffing strategies for ICU-attending physicians. The authors then related the strategies to outcomes of hospital and ICU mortality rates and length of stay (LOS).
The data show that lower hospital and ICU mortality is associated with mandatory intensivist involvement versus ICUs without intensivists or with elective intensivist consultation. Reduced hospital and ICU (case-mix adjusted) LOS was also considered a result of high-intensivist staffing., In addition, the authors say that intensivists "can help reduce inappropriate ICU admissions, prevent complications...and recognize opportunities for prompt discharge," thus conserving hospital resources.
The authors note that only 10 percent of U.S. hospitals currently employ intensivists, and they call for a standardized organization and staffing model for the nation’s 6,000 ICUs. This concept has also been a key element in the Leapfrog Group’s requirements for healthcare plans.
As the Bush Administration considers the logistics of administering the smallpox vaccine, Congress passed the Homeland Security Act of 2002 (HR. 5710), on November 19, 2002. The bill, a compromise between the White House and several long-standing holdouts in the Senate, contains language exempting healthcare workers and facilities from liability related to delivery of the smallpox vaccine. However, government officials remain divided on when Americans should start receiving the vaccine.
Specifically, the provision exempts:
The provision authorizes the Secretary of the U.S. Department of Health and Human Services (HHS) to issue a declaration "concluding that an actual or potential bioterrorist incident or other actual or potential public health emergency makes advisable the administration of a covered countermeasure to a category or categories of individuals." The duration of such a declaration would be left to the secretary’s discretion. Liability and litigious defense for any post-vaccine lawsuits filed would rest with the federal government, and any resultant awards would be limited to compensatory damages (punitive damages would not be permitted).
In related news, the "Health Agencies Update" in the November 20, 2002, Journal of the American Medical Society (JAMA) reported that 6,000 officers of the U.S. Public Health Service Commissioned Corps were asked to volunteer for smallpox vaccine inoculation to help increase the nation’s supply of vaccinia immunoglobulin (VIG). VIG is used to counteract adverse effects of smallpox vaccination. Plasma is collected from volunteers seven to ten days after immunization.
The office of the U.S. Surgeon General sent a letter to all officers requesting additional help in late October, stating that our national security may require a large-scale smallpox vaccination program resulting in some adverse reactions among recipients. The letter added that VIG can help treat these adverse reactions. The Centers for Disease Control and Prevention (CDC) began the immunoglobulins collection program earlier this fall, and by late October had collected antibodies from about 1,000 employees. For more information, go to the JAMA Web site.
In ongoing efforts to develop innovative products for the healthcare marketplace, manufacturers are offering a variety of colored latex and non-latex gloves. No standards, guidelines, or regulations currently exist on color-coding exam or surgeon’s gloves used in healthcare settings. However, non-latex (nitrile) gloves have traditionally been offered in bright colors like purple and green, allowing for quick identification. While they have some initial appeal, there is a growing concern that these new products may cause problems for workers and patients with latex allergies who have relied on color to distinguish between latex and non-latex.
The concern expressed by many healthcare facilities is that workers with latex allergies may reach for a glove they believe is latex-free because it is brightly colored. If the glove is really made of latex, a serious and potentially life-threatening adverse reaction may occur.
Although U.S. Food and Drug Administration (FDA) requires labeling of medical products containing latex, there are several scenarios that confound even this safety measure. For example, healthcare workers are now offered a variety of gloves from companies that vary in shades of color for latex and non-latex. Clinical staff may also use gloves that have been removed from the original box and placed in a dispenser, or gloves in a dispenser that covers up the labeling on the glove box. In these instances, the worker is unaware that the colored glove is made of latex and at increased risk. And just as important is the serious risk for patients with latex allergies if a clinician mistakenly uses latex gloves during the care of the latex-allergic patient.
The Premier Safety Institute has provided additional guidance on considerations for selection of latex and non-latex gloves. A recent discussion of the issue may be found in the November 2002 Materials Management in Health Care.
Hospitals and healthcare systems must prepare vigilantly for major natural or man-made disasters, especially in the wake of September 11, 2001. Hospitals should plan collaboratively with local emergency response committees, local and state public health departments, and other area facilities to determine the supplies, equipment, and resources they will need. "Preparedness" means having basic and specialized supplies, equipment and resources available.
Premier has prepared a list of products and equipment that supplement a hospital’s emergency supply inventory. The Premier Safety Institute’s Disaster readiness module has a number of additional resources to assist with selection of products and equipment for emergency preparedness, including:
Hospital and industry groups agree that the medical supply chain is critical to supporting an adequate emergency response to a disaster. They believe that relying on existing supply chain channels for emergency preparedness is a better solution than facility-level stockpiling.
"Hospitals have their fingers on the pulse of preparedness, but the necessary resources must be available and appropriately tapped," said Bill Atkinson, Ph.D., president and CEO of New Hanover Regional Medical Center, in a recent report on Premier’s Advocacy Web site. Atkinson noted that for decades, state and federal authorities largely neglected the public health infrastructure, taking its fitness for granted. "We’re looking not at ‘unpreparedness,’ but rather ‘under-preparedness,’ because even adequately equipped and trained facilities, and ultimately, patients, will suffer if coordination and communication with the public health system are faulty," Atkinson said.
In June 2002, President Bush signed the Public Health Security and Bioterrorism Preparedness Response Act (H.R. 3448), which provides $520 million for enhancing hospital preparedness for nuclear, biological, and chemical attacks. A provision in the agreement allows for additional funding if significant changes in circumstances warrant it. From 2004 to 2006, the law provides funding for hospital-based preparedness activities as well as grants to the states. Hospital funding will support an environment of collaboration with local and/or state entities responsible for disaster preparedness.
In addition, the U.S. Department of Health and Human Services (HHS) approved plans to strengthen public health and bioterrorism preparedness, paving the way for states to receive the remaining 80 percent of the $1.1 billion appropriated in 2002. The Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) will channel funding intended to improve public health infrastructure, enhance disease surveillance, and better equip hospitals.
A new report to Congressional committees released by the U.S. General Accounting Office (GAO) addresses concerns of critics about the Medicare payment differential for endoscopic procedures. Payment differentials, known as "site-of-service payment differentials," have been phased in since 1999. Critics suggest that the differential gives physicians incentives to perform endoscopic procedures in the physician’s office — a setting that is less safe than a hospital.
Medicare provides higher payments for medical procedures performed in physician offices than those performed in hospitals or ambulatory surgical centers. This difference is related to the relative resources used in the delivery of the service at each setting. Physicians who conduct procedures in their offices are responsible for providing clinical staff, supplies and equipment. In a hospital or ambulatory surgical center, the facilities provide those services.
The GAO review found no evidence to suggest any difference in the safety procedures in physician offices or healthcare facilities. Despite the site of service payment differential, the report also found that the proportion of endoscopic procedures performed in physician offices for Medicare patients has not increased since 1996.
A study published in the November 11, 2002 issue of the Archives of Internal Medicine indicates that less than five percent of patients aged 65 and older are vaccinated against pneumonia and influenza during hospital stays despite recommendations from the government’s Advisory Committee on Immunization Practices (ACIP) that both vaccines be administered to adults during hospitalization. Adults not receiving inoculations are at risk for contracting influenza and secondary infections such as pneumonia and meningitis.
To comply with recommendations some hospitals, such as the Mayo Clinic, vaccinate every adult inpatient who consents and is not already inoculated. One hospital expert estimates that vaccinating all patients over 65 could reduce death rates from related causes by half, since influenza can leave patients open to other potentially deadly illnesses. The study’s lead author recommends that hospitals incorporate vaccination into routine inpatient treatment.
In related research, an earlier study in the September 23, 2002, Archives of Internal Medicine reported that the emergency departments of inner-city hospitals could vaccinate the greatest number of at-risk patients, and do so less expensively than inpatient units or general medicine clinics.
To encourage influenza vaccinations during hospital stays, the Centers for Medicare and Medicaid Services (CMS) modified its Conditions of Participation, no longer requiring physicians to write individual orders for each influenza and pneumococcal vaccination. The federal rule, which went into effect October 2, 2002, states that, where allowed by state law, appropriate non-physician personnel can provide these vaccinations to Medicare and Medicaid patients under a facility-approved standing order protocol.
CMS has provided a guide for providers that answers questions about reimbursement issues as well. It includes information on vaccination benefits, immunization guidelines, coverage policy, payment policy, mass immunization, centralized billing, and managed care. CMS also provides step-by-step instructions and a video explaining how to bill Medicare (via roster or provider) for these vaccinations.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has informed its surveyors that they may not provide private accreditation-readiness consulting on the side once a revamped accreditation process takes effect on January 1, 2004.
To remain on the 2004 survey force, all surveyors must submit a letter of intent to abide by the prohibition by March 31, 2003. Surveyors also will be prohibited from providing consulting services through Joint Commission Resources, a not-for-profit subsidiary that has a "preferred provider" relationship with JCAHO for educational and consulting services to accredited organizations.
The ban on readiness consulting stems in part from JCAHO’s intent to help hospitals shift their focus from preparation for the accreditation visit to continuous operational improvement.
In October 2001, the film "First, Do No Harm," a collaborative effort between the Risk Management Foundation (RMF) and the Partnership for Patient Safety (p4ps), premiered at the Partnership Symposium on Patient Safety in Dallas, Texas. Based on actual events drawn from RMF medical liability claims files, the film tells the story of Ariana Romanov, a healthy, pregnant woman, and the healthcare workers who treat her and her newborn child. This film has helped thousands of organizations better understand a systems approach to patient safety by dramatically illustrating how small medical failures build on each other.
In October 2002, a follow-up video, "First, Do No Harm Part 2: Taking the Lead," takes the dialog within the patient safety movement to new levels. The video was a feature of the p4ps Symposium held in Washington, D. C. Continuing the story 48 hours later, the film illustrates how one hospital might respond to the adverse outcome that Ariana experienced. The dramatized case study focuses on the interaction among executive and clinical leaders and board of director members in deciding what to do next. "First, Do No Harm Part 2: Taking the Lead" is not intended to depict best practices. Its goal is to stimulate dialog about how a healthcare community might handle similar circumstances.
A variety of resources are available from the Centers for Disease Control and Prevention’s (CDC’s) bioterrorism Web site to answer basic questions about smallpox and vaccination. These resources include up-to-date news and media coverage of all pertinent smallpox-related issues. The newest module includes detailed descriptions of smallpox vaccination processes and adverse event training for healthcare professionals. This comprehensive module addresses the vaccine, methods of inoculation, prevention of contact transmission, laboratory testing and use of vaccinia immunoglobulins (VIGs). Colored photos of vaccination sites showing normal and adverse reactions are an added value to the Web site.
The American Hospital Association (AHA) has published the
proceedings of the February 15, 2002 National Symposium on Hospital
Disaster Readiness. More than 70 metropolitan hospital executives heard
how hospitals near "Ground Zero" in lower Manhattan and the
Pentagon responded to the immediate tragedies of September 11, 2001, as
well as strategies related to ongoing disaster readiness preparations
against possible future biological, and chemical, and natural disasters.
Featured hospitals included St. Vincent’s and Jamaica Hospitals (New
York), Inova Health (Virginia) and New Hanover (North Carolina).
The Agency for Healthcare Research and Quality (AHRQ) and an editorial team at the University of California - San Francisco are creating the nation’s first peer-reviewed, Web-based medical journal to showcase patient safety lessons drawn from actual cases of medical errors. Called AHRQ WebM&M (Morbidity and Mortality Rounds on the Web), the site is designed to educate healthcare providers about medical errors in an engaging and blame-free context. The site will launch in February 2003, but is now open for case submissions. Authors of cases chosen for posting will receive an honorarium while retaining their anonymity.
Every month, five cases of medical errors and patient safety problems (one each in medicine, surgery/anesthesiology, obstetrics-gynecology, pediatrics, and psychiatry) will be posted as well as commentaries from distinguished experts. The site will also include a forum for reader comments. Each month, one of the cases will be expanded into an interactive learning module ("Spotlight Case") featuring reader polls, quizzes, and other multimedia elements. Spotlight Cases will offer continuing medical education credits.
An October 2002 report released by ECRI rates more than two dozen general-purpose infusion pumps. In addition to standard performance and human-factors design issues, the report addresses patient safety, reflecting some exciting advancements in infusion pump technology. The results of testing reveal that most pumps perform reliably and accurately when properly used. However, not all models offer the same level of protection against free-flow and other events that can lead to intravenous medication errors.
A new report by the California HealthCare Foundation states that companies have started to "make inroads" to reduce costs and errors associated with physician drug e-prescribing. The report analyzed 19 companies that offer a range of basic to comprehensive e-prescribing products. It organizes the technology into four categories based on function: (1) electronic drug references, (2) e-prescribing solutions, (3) integrated drug references and formulary tools, and (4) integrated electronic medical records and e-prescribing systems. Each category was rated on efficiency, ability to lower costs, potential to improve patient safety, ease of implementation, affordability, and stability and use in the market. The study used a "low, moderate, high" rating scale. The results provide potential buyers with an easy way to see both the range of options and implementation considerations. Most of the products rely on the use of a personal digital assistant (PDA) to provide the physicians with needed information. However, only 30 percent of the 1,200 physicians surveyed own a PDA.
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.