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Brian Ward

Brian Ward is an Associate Editor at HCPro working on accreditation news.

Sending Sepsis Patients Home May Not Harm Them

Researchers at Intermountain Healthcare are challenging the conventional wisdom for sepsis treatment in emergency departments.

“Based on our data, we are trying to document something that was previously unrecognized in the literature—a significant fraction of patients with clinical sepsis are not admitted to the hospital after presenting to the ED,” says Ithan Peltan, MD, MSc, an attending physician at Intermountain and a leader of the research effort.

Peltan and his research team studied 8,239 adult ED sepsis patients at two tertiary hospitals and two community hospitals in Utah. The researchers found that 1,607 of the patients—19.5% of the total—were discharged rather than admitted to the hospital.

“The conventional wisdom assumes that all sepsis patients coming to the emergency department are being admitted, but our data shows some are being discharged. … We need a reconceptualization of who these patients are and how our care guidelines are being formulated,” Peltan says.

Peltan’s team presented the research last month at an American Thoracic Society conference in San Diego. Although the findings are preliminary, the researchers found that it is probably appropriate for some sepsis patients to be discharged from an ED into outpatient care.

“There was no significant difference in 30-day mortality for discharged versus admitted sepsis patients,” the researchers wrote in the abstract they presented in San Diego.

Discharge safety uncertain

The researchers have shown that ED physicians are sending some patients home, and the next step is to characterize which sepsis patients are appropriate for ED discharge, Peltan says.

“We are not at the point where we can recommend routine discharge of any sepsis patients for outpatient management in the community.”

He says there likely are several factors that determine whether a sepsis patient in the ED is a good candidate for discharge:

  • Patients who are not gravely ill and are not in need of intensive care intervention
  • Patients who are not at high risk of deterioration
  • Patients who can get the care they need as outpatients such as compliance with prescribed medications
  • Patients who can set and attend follow-up visits

A major element of safely discharging sepsis patients from EDs is developing a risk stratification methodology for sepsis similar to risk tools created for pneumonia, Peltan says. “We need that kind of risk-stratification tool for sepsis.”

Risk stratification will help ED physicians sort out the best care path for sepsis patients, he says. “Who are the patients who need to be admitted? Who are the patients we might miss but need to be admitted? Which patients can be managed as outpatients?”

Physician decision-making varies

Peltan’s team found significant variation in ED physician decision-making on whether to admit or discharge sepsis patients.

“We looked at physician-level behaviors and found some physicians did not discharge any of their sepsis patients and some physicians discharged nearly 40% of their sepsis patients,” he says.

The decision-making variation is a valuable data point, Peltan says.

“Somewhere in the middle, there probably is a happy medium within that range of variation.”

The final version of the Peltan team’s research is slated for publication in 2019.

First published in HealthLeaders Media

Hawaii Hospital Investigates Possible Legionella Outbreak

Hawaii health officials are investigating a possible Legionella outbreak at Queen’s Medical Center in Honolulu after one patient died and three others were hospitalized with Legionnaire’s disease, according to KHON-TV.

The patient died in May after being admitted with pneumonia-like symptoms and may have had an underlying medical condition. Doctors believe the deceased patient and another who has been released acquired Legionella outside the hospital. But the state Department of Health stepped in after learning two other patients developed symptoms after already being hospitalized, making it possible they contracted Legionnaire’s in the hospital, according to KHON.

Officials took water samples at the hospital earlier this week. Legionella has an incubation period of two to 10 days and is spread through water that has been aerosolized. People with weak immune systems are susceptible.

KHON reported that Queen’s is not allowing high-risk patients with weak immune systems to take showers or flush the toilet. They are restricted to drinking bottled water and the hospital is replacing all of its faucets.

First published on PSQH

CMS Delays Hospital Star Ratings Update, Again

Citing “stakeholder concerns,” the Centers for Medicare & Medicaid Services has once again postponed an update to its Overall Hospital Quality Star Ratings.

“When changes are made to the underlying measures it is vital to take the time needed to understand the impact of those changes and ensure we are giving consumers the most useful information,” CMS said Tuesday in a posted notice.

“As part of this process, CMS will seek feedback from a multi-disciplinary Technical Expert Panel, a Provider Leadership Workgroup, and a public comment period,” CMS said.

No date was given for when CMS anticipates activating the ratings updates. Typically, the updates are issued every July and December. However, CMS has a history of delaying the updates, most recently in May. And the ratings themselves have been bitterly contensted ever since they were proposed, with many questioning CMS’ methods. 

News of the pushback was well-received by hospital stakeholders.

“CMS made the right call,” said Tom Nickels, executive vice president of the American Hospital Association.

“We appreciate the agency allowing more time for a fuller analysis of its methodology and measures and to hear from stakeholders, including hospitals and health systems, about concerns found in many preview reports,” Nickels said.

Bruce Siegel, MD, president and CEO of America’s Essential Hospitals, welcomed the delay and said that stakeholder reviews of the proposed July updates showed “large shifts in overall hospital star ratings from December 2017 to July 2018.”

“These changes have created confusion and raised new questions about the reliability and validity of the methodology used to calculate these ratings,” he said.

“We remain deeply concerned the star ratings could do more harm than good in their current form. We look forward to working with CMS to ensure patients and their families can make care decisions based on accurate and meaningful data,” he said.

CMS said it will update these metrics on July 25:

Outcome measures for 30-day mortality, 30-day readmissions, and CMS Patient Safety Indicators, including:

  • Outpatient imaging efficiency;
  • Payment and value of care;
  • Timely and effective care;
  • Healthcare-associated infections;
  • HCAHPS surveys.

CMS will add three new measures to Hospital Compare:

  • Hospital return days for pneumonia patients (EDAC-30-PN);
  • Percentage of patients who received appropriate care for severe sepsis and septic shock (SEP-1);
  • Average time patients spent in the emergency department before being sent home (OP-18c), which will only be reported on data.medicare.gov

CMS is no longer reporting the Pain Management composite 4 on Hospital Compare or in the downloadable databases. This composite measure is also being excluded from the calculation of the HCAHPS Summary Star Rating for the July Hospital Compare release.

In addition, CMS said it:

  • Will not publish the Overall Hospital Star Rating from the July Preview Reports on Hospital Compare.
  • Will Post the SAS Pack with the next Star Ratings refresh on Hospital Compare.
  • Will keep Star Ratings released in December 2017 on the Hospital Compare until the next update.

Written by John Commons, HealthLeaders Media

See our previous coverage on the CMS star ratings below.

AHRQ Data Shows Drop in Hospital-Acquired Conditions

new report from the Agency for Healthcare Research and Quality (AHRQ) found that hospital-acquired conditions (HAC) dropped between 2014 and 2016, preventing an estimated 8,000 deaths and saving $2.9 billion.

The AHRQ National Scorecard on Hospital-Acquired Conditions estimated that 350,000 HACs, including adverse drug events and injuries from falls, were avoided and the rate was reduced by 8% from 2014 to 2016.

CMS has set a goal of reducing HACs by 20% from 2014 through 2019. Using Hospital Improvement Innovation Networks (HIIN), CMS has worked to spread best practices in harm reduction in more than 4,000 hospitals. Once the 20% reduction goal is met, AHRQ projects that during 2015 through 2019, there would be 1.8 million fewer patients with HACs, which would result in 53,000 fewer deaths and $19.1 billion in hospital cost savings.

AHRQ’s new estimates are based on an expanded population set of hospital patients and were calculated despite recent changes in medical coding. Data in the new scorecard showed that overall harms decreased in several categories, such as infections and adverse drug events, which dropped 15% from 2014 to 2016. On the other hand, pressure ulcers increased during that time.

The new numbers echo earlier advances. HACs overall dropped 17% from 2010 to 2014, saving nearly $20 billion in healthcare costs and preventing 87,000 deaths. Preliminary data for 2017 are expected within the next year.

Report: Medication Errors Led to Patient Death at Boston Children’s Hospital

Boston Children’s Hospital was threatened with termination from Medicare last year after three patients suffered from serious medication errors. An inspection report revealed that one of the patients waited 14 hours for an antibiotic and later died, while two others suffered overdoses of a powerful anesthetic, according to the Boston Globe.

The errors took place between January and November 2017, involving two medications and leading CMS surveyors to threaten Boston Children’s with potential termination from the Medicare program. The patient who died had been prescribed Zosyn, an antibiotic, at noon, but the drug was not administered until 14 hours later, the Globe reported. Two days later, the patient died after developing a sepsis infection.

The other two medication errors involved patients receiving overdoses of Propofol, an anesthetic. The first overdose occurred in January 2017 and was followed by a recommendation from leadership for an improved procedure for measuring Propofol doses. But the recommendations were never developed and 10 months later, another patient was given an overdose of the drug by a doctor using the same procedure. The inspection report said both patients eventually recovered, although the second patient had to be resuscitated.

Boston Children’s was able to avoid disciplinary measures this spring by adding improvement plans to treat sepsis patients immediately and for proper Propofol administration. The inspection report said the hospital failed to properly analyze the errors and correct the conditions that led to them.

The Globe reported that in 2016, Massachusetts hospitals reported 47 medication errors that killed or injured patients.

First published in PSQH. 

AORN Expects to Revise its Guideline for OR Headwear

After participating with other healthcare heavy-hitters in February in a task force that met to discuss recommendations for OR attire, specifically ear and hair covering, The Association of periOperative Registered Nurses (AORN) expects to make changes to its Guideline for Surgical Attire.

Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, AORN’s director of evidence-based perioperative practice, tells OSHA Healthcare Advisor that AORN will still recommend complete hair coverage in that revised guideline, but “there’s not going to be a recommendation on which head covering.”

As for the coverage of ears, AORN is “probably going to come out in our new guideline and say the ears don’t need to be covered” because the task force feels the research focusing on its necessity has been inconclusive. “However,” she says, “our guideline stands as is until it’s revised.”

It is significant that AORN will be changing its official guideline. While the organization is the world’s largest professional association for perioperative nurses, it has been a tone-setter for issues that affect all healthcare workers who enter the OR. CMS and subsequently The Joint Commission followed AORN’s lead on headwear and has cited healthcare organizations accordingly.

AORN decided to reconsider its stance on headwear after a study led by Troy Markel, MD, assistant professor of surgery at Indiana University, examined the effectiveness of disposable bouffant hats and skull caps as well as newly-laundered cloth skull caps in preventing airborne contamination.

Not only did Markel and his peers observe no significant differences between the disposable bouffant hats and disposable skull caps “with regard to particle or actively sampled microbial contamination,” they also determined that the disposable bouffant hats had greater permeability, penetration, and greater microbial shed compared to both disposable and cloth skull caps.

Therefore, the researchers wrote in conclusion that disposable bouffant hats “should not be considered superior to skull caps in preventing airborne contamination in the operating room.”

The Markel study made the strongest case to date in the contentious debateover OR headwear, which started several years ago when AORN began, depending on who you ask, either promoting the use of bouffant hats among surgical staff or advocating for skull caps to be banned. AORN encouraged full coverage of the ears in the OR, one of the reasons why it favored bouffant hats.

Spruce says the study “just sparked everybody’s interest and opened up this discussion.” AORN and others felt the evidence was enough to revisit the controversy and, according to Spruce, the American College of Surgeons assembled the task force. That group met in February and recently released a joint statement that “covering the ears is not practical for surgeons and anesthesiologists” and also that “available scientific evidence does not demonstrate any association between the type of hat or extent of hair coverage and [surgical site infection] rates.”

Spruce says AORN had already decided “that it was time to revise that guideline” but “it was valuable” to hear the thoughts among that multi-disciplinary group. She adds, “The perioperative setting has always been a team environment and we’ve always promoted that, so we want the teams to come together and agree on issues that are important to patient safety.”

AORN’s Guideline for Surgical Attire will be reviewed by AORN’s advisory board, which includes representatives from organizations that formed the task force and others. That revised guideline will be available for public comment early next year and will be ready for publication in April.

First published in OSHA Healthcare Advisor

National Guidelines, Quality Measures Clearinghouses Shutting Down

If you or anyone at your hospital use the National Guidelines Clearinghouse or National Quality Measures Clearinghouse operated under the auspices of the Agency for Healthcare Research and Quality (AHRQ), download the information you need soon.

Both online clearinghouses will go dark after July 16 as federal funding runs out. Neither site is accepting new guidelines or quality measure sets in anticipation of shutting the databases down.

Announcements on each website note that that AHRQ has received “expressions of interest from stakeholders” that want to takeover maintenance of the databases, but AHRQ officials have declined to identify who those stakeholders are for now.

The clearinghouses were set up more than two decades ago as central sites to help hospitals, clinicians and others in health care find evidence-based information on which to set policy, create clinical treatment plans and objectively measure quality outcomes.

The guidelines and measures are submitted by various professional or academic health organization and must meet detailed criteria to be included in each database. As guidelines or measures are updated or become outdated, the information is removed.

AHRQ evaluating options

“AHRQ recognizes the importance of this resource and is evaluating potential options, including the participation of stakeholders who may wish to operate the Clearinghouse in the future,” stated Alison Hunt, MPH, with AHRQ’s Office of Communications, Media Division.

If public or private stakeholders are found to take over the clearinghouses, ARHQ still has not decided what role it will continue to play, Hunt said.

While the federal sites may go away, the information will still be available from each of the professional society, academy or other healthcare group that originated the material, notes Karen Schoelles MD, SM, FACP, director of ECRI Institute’s Penn Medicine Evidence-based Practice Center (EPC) and project director for both clearinghouses.

ECRI was the original contractor hired by AHRQ to set up and run the guidelines clearinghouse in 1987.

Besides having information in one place, one of the advantages in having each of the clearinghouses is that users could have some assurance that the information had been professionally vetted and was up-to-date.

Having evidence-based information to back a policy or best practice is one of the key mantras of both The Joint Commission and CMS.

Hospital leaders or others who need information about the validity of a particular set of guidelines or best practice can still seek out help from any of the Evidence-based Practice Centers (EPC) set up through AHRQ, says Schoelles. ECRI-Penn Medicine is one of 12 EPCs across North America.

EPC programs offer help

The EPCs develop evidence reports and technology assessments to assist public- and private-sector organizations, and “provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies and strategies,” according to a AHRQ research white paper released in December. Schoelles was a work group leader on the paper, A Framework for Conceptualizing Evidence Needs of Health Systems.

The paper sets out to determine the evidence needs of health systems to both guide future EPC programs and ultimately help organizations as they seek “evidence to inform decisions about acquiring new or emerging medical technologies; implementation or expansion of service offerings; and selection of governance, finance or delivery system models,” notes a summary.

As part of the group’s research it looked at information requests made at four large health institutions;  Kaiser Permanente Southern California, the Veterans Health Administration’s Evidence Synthesis Program, ECRI Institute’s Health Technology Assessment Information Service, and Penn Medicine Center for Evidence-based Practice.

“A wide range of clinical and administrative decision-makers requested evidence reviews, and the topics were similarly broad—ranging from evidence to guide clinical care; purchasing of medications and devices; procedural and non-procedural interventions; and processes of care,” according to the paper.

Highlighted throughout the requests was a need for trustworthiness of information, notes Schoelles.

If you are seeking to verify or evaluate information and are part of a larger health system, Schoelles suggests starting with the larger organization to see what help it can offer. Often health systems will evaluate a guidelines or best practice and then establish a policy or guidelines based on that information, or can share the evaluation throughout the system’s smaller organizations, she said.

ECRI, for instance, offers a variety of evaluation services. Some ECRI services are free to members, others are fee-based. ECRI Institute also is currently exploring ways to maintain a guideline repository, notes Schoelles.

Resources

This article was originally published in Inside The Joint Commission.

Study Questions Effectiveness of Performance Measures

study published in the New England Journal of Medicine asserts that the U.S. healthcare system does a poor job of measuring quality. The study’s researchers led by lead author Catherine McLean, MD, PHD, chief value medical officer, Hospital for Special Surgery, recommend that organizations should stop using performance measures until they can be assessed and revised.

The study notes that a recent survey found that 63% of physicians said that current performance measures do not capture the quality of the care physicians provide. The Performance Measurement Committee (PMC) of the American College of Physicians (ACP) had developed criteria to assess the validity of performance measures. McLean and researchers applied the ACP criteria to the measures included in the Medicare Merit-based Incentive Payment System (MIPS)/ Quality Payment Program (QPP), hypothesized that if most of the MIPS/QPP measures assessed were deemed valid using this process, physicians would have more confidence in using them to improve patient outcomes.

In this study, the researchers identified and rated the validity of 86 measures on the 2017 QPP list that were considered relevant to ambulatory general internal medicine. Of those, 32 (37%) were rated as valid by this method, 30 (35%) were found to be not valid, and 24 (28%) were of uncertain validity. For each measure, the committee rated validity using five domains: importance, appropriateness, clinical evidence, specifications, and feasibility and applicability.

“We believe that the next generation of performance measurement should not be limited by the use of easy-to-obtain (e.g., administrative) data or function as a stand-alone, retrospective exercise,” the researchers wrote. “Instead, it should be fully integrated into care delivery, where it would effectively and efficiently address the most pressing performance gaps and direct quality improvement. For now, we need a time-out during which to assess and revise our approach to physician performance measurement.”

CMS’ severe sepsis bundle ISN’T a Joint Commission requirement

The April 17 issue of Annals of Internal Medicine (AIM) incorrectly stated The Joint Commission was considering creating a requirement for hospitals to implement CMS’ Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) to receive accreditation. This information is incorrect and AIM has published a correction.

Study: Improvement in Errors, Accidents, Infections

The Leapfrog Group this week released its spring 2018 Hospital Safety Grades, which found that hospitals have stepped up their game when it comes to reducing avoidable deaths from errors and infections. Leapfrog issues the report cards twice a year, grading hospitals on an “A through F” scale based on their patient safety efforts.

“The national numbers on death and harm in hospitals have alarmed us for decades. What we see in the new round of Safety Grades are signs of many hospitals making significant improvements in their patient safety record,” said Leah Binder, Leapfrog’s president and CEO, in a release. “Leapfrog Hospital Safety Grades have definitely spurred these improvement efforts. But the hospitals achieving new milestones are doing the hard work, and we salute them as the leaders, researchers and organizations fighting every year for patient safety.”

Leapfrog listed improvements including:

  • Five hospitals achieving “A” grades for the first time once had received “F”s
  • Since the report cards started six years ago, 46 hospitals have received an A for the first time
  • 89 hospitals receiving an A had at one point received a D or F
  • Strong performance from hospitals in states that once were ranked poorly, including Rhode Island, Hawaii, Wisconsin, and Idaho

Of the approximately 2,500 hospitals graded by Leapfrog, 30% earned an A, 28% received a B, 35% were given a C, 6% got a D, and 1% received an F. The states with the highest percentage of A-graded hospitals are Hawaii, Idaho, Rhode Island, Massachusetts, and Virginia. Hospitals with F grades are located in California, Washington, DC., Florida, Iowa, Illinois, Maryland, Michigan, Mississippi, New Jersey, and New York.

The Leapfrog Hospital Safety Grades are calculated by top patient safety experts, peer-reviewed, transparent, and free to the public. The report card is released each spring and fall.

Story first published in PSQH