The editorial team of the Premier Safety Share newsletter would like to wish you and your family a happy holiday!
Gina Pugliese, RN, MS, editor
Judene Bartley, MS, MPH, CIC, associate editor
John Hall, BSJ, contributor
Judith Luca, RN, BSN, contributor
Derek Kleckner, BA, Web master
Jena Abernathy, executive sponsor
- Emphasis on healthcare worker influenza vaccination shifts to patient safety; mandatory versus voluntary
- Success noted in adoption of sharps injury prevention devices; but gaps remain
- Clinical Decision Support - paper, electronic support systems supplement education to reduce inappropriate antimicrobial prescribing in outpatient settings
- Rural physicians prefer print to online sources for evidence-based medicine, study finds
- Poor communication a major contributor to medication reconciliation errors: USP
- VA policy - Directive on disclosure of adverse events
- FDA - Use of personal protective equipment during influenza outbreak
- IHI newsletter - Updates on 100,000 Lives Campaign
- NIOSH pocket guide - Chemical hazards
Emphasis on healthcare worker influenza vaccination shifts to patient safety; mandatory versus voluntary
Poor access to influenza vaccines and perceptions of low risk among healthcare workers (HCW) are major reasons cited for the poor performance of voluntary vaccination campaigns. Less than 50 percent of HCW have been vaccinated through such programs. In response, infection prevention professional associations have taken a dramatic step to recommend that HCW be required to receive influenza vaccination as the emphasis shifts from worker to patient safety.
The Association for Professionals in Infection Control and Epidemiology (APIC) published a 2004 position paper on improving influenza vaccination rates among HCW and just released a follow up statement in a press release endorsing mandatory influenza vaccination for HCW who have direct contact with patients. In November 2005, the Society for Healthcare Epidemiology of America (SHEA) also published a position paper recommending that all HCW receive annual influenza vaccinations and sign a declination form if they actively refuse vaccination after participating in an educational program.
The position papers of APIC and SHEA are consistent with the U.S. Public Health Service recommendations for influenza vaccination, but also provide specific suggestions to achieve success. Among those suggestions is increasing access with the use of mobile vaccination carts.
Experts predict that the shift in requiring vaccination with an emphasis on patient safety may lead to regulatory requirements for influenza vaccinations. One of the challenges in measuring improvement is to develop simple methods to capture information on workers who have been vaccinated in non-work locations.
APIC press release (.pdf) (33 KB)
APIC position (.pdf) (88 KB)
SHEA position (.pdf) (139 KB)
Influenza resources from the Premier Safety Institute:
The Needlestick Safety and Prevention Act of 2000 obliged OSHA to clarify the Bloodborne Pathogen Standard and require the evaluation and use of sharps safety devices and the involvement of non-managerial front line workers in device selection. This clarification and subsequent revisions to OSHA's enforcement procedures, as well as the emergence of new technology, have led to successful adoption and increased use of sharps safety devices. An article in the November issue of Materials Management in Healthcare summarizes data showing increasing percentages of four key sharps safety devices (peripheral IV catheters, disposable scalpels and blades, syringes, and blood collection devices) being used in acute and alternate sites (doctors' offices, outpatient clinics, surgical centers) in 2002 through 2005. Data for these conversion rates were compiled by BD Company from medical/surgical supply market data supplied by Healthcare Products Information Services (HPIS).
For peripheral IV safety catheters, conversions have increased in acute care from 88 percent of catheters in 2002 to 95 percent of catheters in 2005 and among alternate sites from 60 percent in 2002 to 82 percent in 2005. The data show that peripheral IV catheters have the greatest conversion rates in acute care settings among the four devices. Although conversion rates for needleless IV systems were not included in this article, prior reports have indicated conversion rates of more than 95 percent.
For hypodermics (e.g., syringes and needles), conversions have increased in acute care from 46 percent in 2002 to 79 percent in 2005, and among alternate sites from 35 percent in 2002 to 45 percent in 2005. It is important to note that safety syringes are required by OSHA only when there is a risk of exposure to bloodborne pathogens; therefore, syringes used for sterile procedures such as admixtures in pharmacy or use without the needle for irrigation may account for some of the conventional, non-safety, syringes in use.
For blood collection devices, conversions have increased in acute care from 74 percent in 2002 to 83 percent in 2005 and among alternate sites from 44 percent in 2002 to 57 percent in 2005. A special bulletin from OSHA clarifying its position against reuse of phlebotomy tube holders likely helped to boost conversion rates because of the attention it cast on the risks and need for safer blood collection.
For disposable scalpels and blades, overall conversion rates were lower than other safety devices, but represent the greatest progress in acute care over the past four years -a three-fold increase in usage from 22 percent in 2002 to 59 percent in 2005. Among alternate sites, conversion has been a bit slower, increasing from 10 percent in 2002 to 25 percent in 2005. These data represents only disposable scalpels and blades; reusable stainless steel handles with safety blades are not included in the data and represent only about 5 percent of this category of scalpels and blades.
Surgeons have resisted using safety scalpels, blades, and other safety devices such as blunt suture
needles despite the risks of accidental injury. U.S. EPINet data (2003) from the International Healthcare
Worker Safety Center at the University of Virginia indicate that the highest rate of injuries is occurring
in the operating room (33.3 percent) compared to patient rooms (27 percent); intensive care units
(5.4 percent); and procedure rooms (5.2 percent).
An article in the December 2005 issue of OR Manager discusses the challenges of complying with OSHA requirements for use of sharps safety devices. Some surgeons explained in the article that first and second generation technology was just not "good" and when new "easier to use" technology in safety scalpels emerges, surgeons will adopt them more readily.
The article describes OSHA requirements to avoid a citation and fine, such as an exposure control plan that documents the annual review and evaluation of available technology and rationale for any exceptions to the use of sharps safety devices. Download a copy of the article to review strategies for increasing adoption of safety devices and compliance with OSHA. This issue is also addressed in Premier Safety Institute's Sharps FAQs.
Hogan A. "Gaps and Successes of Safety Device Market Conversion" Materials Management in Health Care, November 2005
"OSHA is pressing ORs to adopt safety scalpels but surgeons resist." OR Manager, December 2005 (.pdf) (275 KB)
Clinical Decision Support - paper, electronic support systems supplement education to reduce inappropriate antimicrobial prescribing in outpatient settings
Overuse of antimicrobial agents fosters the emergence and spread of antimicrobial-resistant organisms. Despite recent trends that demonstrate reduced outpatient use of antimicrobial agents, prescribing continues to exceed prudent levels. At least half of the courses of antimicrobial drugs in the outpatient setting are prescribed for patients with viral infections and therefore are not clinically indicated.
A number of studies have shown some improvement in antimicrobial prescribing by addressing two major drives of antimicrobial overuse - academic outreach to clinicians and educational programs for patients. Two studies published in the November 9, 2005, issue of the Journal of the American Medical Association (JAMA) address prescribing of antimicrobial drugs. One article documents continued overuse for patients with sore throats and a second demonstrates the efficacy of a clinical decision support system in improving antimicrobial selection in a rural setting.
"Antibiotics for Children with Sore Throat." Linder and colleagues report that physicians prescribed antibiotics for children with a sore throat in 53 percent of an estimated 7.3 million annual visits in settings that included physician's offices and hospital outpatient and emergency departments. This represents an excess of the maximum expected prevalence of Group A beta-hemolytic streptococci (GABHS), estimated to be 15 to 36 percent of children with sore throats having GABHS. The data also showed a decrease in the proportion of children receiving antibiotics - from 66 percent in 1995 to 54 percent in 2003. However, GABHS testing was underutilized.
"Clinical Decision Support to Improve Antimicrobial Prescribing Practices." Samore and colleagues reported on a randomized trial that evaluated the impact of a clinical decision support system (CDSS) in reducing inappropriate prescribing of antimicrobials for acute respiratory tract infections in rural ambulatory settings in Utah and Idaho. One group received only a community intervention that consisted of educational efforts to include meetings with community leaders, news releases, articles in local newspapers, and distribution of educational materials (posters, brochures, flip charts, self care guides, and refrigerator magnets) to pharmacists, physicians, and patients. The second group received the community intervention and the clinical decision support system (CDSS), which was a direct clinician intervention that incorporated a stand-alone decision support tool on paper or a handheld personal digital assistant (PDA) for management of acute respiratory tract infection at the point of care. The antimicrobial prescribing rate decreased from 84.1 to 75.3 per 100 person-years in the CDSS group, compared with a slight increase in the prescribing rate (84 to 85 per 100 person-years) in the non-CDSS group. The relative decrease in antimicrobial prescribing in the "antibiotics never indicated" category was 32 percent in the CDSS group and only 5 percent in the other group. Use of macrolides was also found to decrease significantly in the CDSS group but not the non-CDSS group.
This study on CDSS demonstrates the feasibility and benefits of stand-alone, portable CDSS tools for improving antimicrobial agent selection in rural primary care settings where there is limited access to consultation and subspecialty services.
Join the "Author in the room" teleconference. Join Dr. Matthew Samore, author of the JAMA article on clinical decision support systems, on Wednesday, December 21, 2005, from 2 to 3 p.m. (EST) for an interactive conference call aimed at closing the gap between knowledge and action, and how much of this knowledge can be put into actual practice. The teleconference is sponsored by JAMA and the Institute for Healthcare Improvement (IHI), with support from the Robert Wood Johnson Foundation. For more information, visit the IHI Web site.
Download Linder antibiotics abstract (.doc) (30 KB)
Download Samore clinical decision support abstract
(.doc) (27 KB)
For more information, visit http://www.ihi.org/authorintheroom
Having current, evidence-based information available to answer clinical questions that occur during patient care is critical to providing high quality care, according to a study published in the April 2005 issue of the Journal of the Medical Library Association. The study also found that physicians in a rural primary care practice-based research network (PBRN) report a greater use of print media and interpersonal sources of evidence-based information, compared to online resources.
Information overload. One of the key problems with accessing knowledge for decision-making purposes is simply information overload, study authors noted. This problem is being addressed through evidence-based medicine (EBM) methods. But EBM literature queries are hampered by lengthy search times. Sixty percent of responding physicians rarely or never get evidence-based medicine information from online sources, such as the Cochrane Library. Physicians ranked their top barriers to accessing health information as lack of time (76 percent of respondents), cost (33 percent), format of information sources (22 percent), and information-seeking skills (25 percent of respondents).
Of the 59 survey respondents, 58 percent indicated that they sought information to support patient care several times a week. Another 18 percent said they do so daily, 22 percent rarely, and 2 percent never. Moreover, 68 percent of respondents said they sought information while the patient was waiting. Forty percent of practitioners said they never or almost never perform literature searches from online sources such as MEDLINE, while 44 percent reported that they did so only a few times a month.
Solutions. Two groups of information seekers presented during this study - those who sought information from more sources and more frequently and those who sought information less frequently, regardless of the source. The authors concluded that innovative approaches to enhancing access to information resources will be needed to change behavior, including individualized training sessions to develop information-seeking skills and access to a standardized interface to reduce the need for special search skills.
Information-seeking behaviors of practitioners (.pdf) (127 KB)
Poor communication of medical information at transition points of care is a major contributor to medication errors, according to the October issue of USP's Patient Safety CAPSLink™ newsletter. The review of MEDMARX® data on medication errors involving reconciliation failures shows that as much as 46 percent of medication errors occur during a patient's admission or discharge from the hospital or a unit. Medication reconciliation definitions may differ slightly, but in this review, medication reconciliation is defined as a process for obtaining and documenting a complete and accurate list of a patient's current medications upon admission and comparing this list to the physician's admission, transfer, and/or discharge orders to identify and resolve discrepancies.
From September 2004 through July 2005, 2,022 medication errors involving a reconciliation issue were reported to MEDMARX®. According to the review, 23 percent of reconciliation errors occurred during admission, 67 percent during the patient's transition or transfer to another level of care, and 12 percent at discharge. Greater than 50 percent of the "admission" and "transition" errors were intercepted before reaching the patient and 28 percent of discharge reconciliation errors were intercepted. Analysis of the causes of the errors suggests that errors due to performance deficit, transcription, documentation, and communication were the most frequently associated with reconciliation failures. Suggestions for improving medication reconciliation include:
- Developing a formal and systematic approach to reconcile a patient's medications across the continuum of care with multidisciplinary input.
- Creating policies and procedures that outline the roles, tasks, and steps in the reconciliation process.
- Adopting a standardized form for reconciling medications and placing the form in a consistent, highly visible location within the patient's chart.
- Assigning responsibility for resolving variances in medication orders to someone with sufficient expertise.
- Establishing specified time frames for reconciling medications.
- Providing clinicians readily available, as-needed access to drug information and a pharmacist consult.
- Improving access to complete medication lists at the point of admission; improving outreach and contact information for community pharmacies, physician offices, ambulatory clinics, nursing homes, home health care agencies, assisted living centers, and hospitals.
Download Medication Reconciliation (.doc) (116 KB)
A recent directive from the U.S. Veterans Health Administration provides background information on the disclosure of adverse events related to clinical care to patients or their representatives. VA Directive 2005-049 (.pdf) (163 KB), "Disclosure of Adverse Events to Patients," is consistent with the Joint Commission on Accreditation of Healthcare Organizations requirements, and includes key definitions and a policy statement on disclosure for all VA hospitals.
The U.S. Food and Drug Administration (FDA) has published "Questions and Answers about Using Personal Protective Equipment (PPE) during Influenza Outbreaks, including Bird Flu (Avian Influenza)"(.doc) (50 KB). Consistent with the Centers for Disease Control and Prevention (CDC), the document discusses PPE, how the use of PPE prevents the spread of infection, and how PPE for healthcare workers is different from those in other industries. The document shows how to search for items cleared by the FDA. Premier's Influenza resources Web site has a new fact fheet that also describes available personal protective attire.
The Institute for Healthcare Improvement (IHI) publishes a free monthly e-newsletter to share updates on the 100,000 Lives Campaign. Topics in the current issue include a guide to the campaign Web site, tips for rural hospitals, campaign information, and resources for patients and families. The newsletter features an interview with IHI's Don Berwick, who reflects on his career, values and excitement about the 100,000 Lives Campaign. It also includes articles about two Campaign interventions: medication reconciliation and rapid response teams. Free registration, subscription required. To subscribe, visit http://www.ihi.org.
The Centers for Disease Control and Prevention's (CDC) National Institute for Occupational Safety and
Health (NIOSH) has released its 2005 NIOSH Pocket Guide to Chemical Hazards. Key general industrial hygiene
information is included on several hundred chemicals and substances groups such as cyanides, fluorides, and
manganese compounds. The information includes a physical description, exposure limits, substances with which
the chemical is incompatible or will react, and recommended personal protection equipment. The booklet also
provides information on sanitation measures, first aid procedures, respirator recommendations, exposure
routes and symptoms, target organs, and cancer sites. Download at:
- Gina Pugliese, RN, MS editor
- Judene Bartley, MS, MPH, CIC, associate editor
- John Hall, BSJ, contributor
- Judith Luca, RN, BSN, contributor
- Derek Kleckner, BA, Web master
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.