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Check your State for deadlines on new hazardous waste pharmaceuticals rule

By A.J. Plunkett

Let your pharmacists and anyone else in your organization who handles hazardous waste pharmaceuticals know that flushing those drugs down a drain or toilet will be specifically prohibited as of August 2019. That is provided the EPA’s new final rule on the management of hazardous waste pharmaceuticals is published as planned on February 22 in the Federal Register.

The ban on sewering hazardous waste pharmaceuticals is “long overdue,” said Kristin Fitzgerald, with the EPA Office of Resource Conservation and Recovery on February 14 during the first of what could be several informational webinars the agency plans on the long-awaited rule.

Sewering “is a common practice in many healthcare facilities and it needs to stop,” said Fitzgerald, noting that the while the new prohibition applies only to hazardous waste drugs and only to those organizations covered under the new rule, the EPA strongly discourages the flushing of any pharmaceuticals by anyone anywhere.

While the final rule creating a new Subpart P to the federal Resource Conservation and Recovery Act (RCRA) does exempt controlled substances that are under the Drug Enforcement Administration’s jurisdiction from the new hazardous waste regulations, even those controlled drugs still are banned under the no-flushing rule. [more]

Hospital-Acquired Conditions drop 13%

By John Commins

Hospital-acquired conditions dropped 13% from 2014 to 2017; from 99 per 1,000 acute care discharges to 86 per 1,000, according to newly released federal data.

That reduction translates into 910,000 fewer HACs, including adverse drug events and healthcare-associated infections, which helped prevent 20,500 hospital deaths and saved $7.7 billion over the three-year span, according to a new analysis from the Agency for Healthcare Research and Quality.

AHRQ’s review quantifies trends for several HACs, including adverse drug events, catheter-associated urinary tract infections, central-line associated bloodstream infections, Clostridioides difficile infections, pressure ulcers, and surgical site infections.

The report showed marked declines in several categories, such as adverse drug events, which dropped 28%, and C. diff. infections, which fell 37% from 2014 to 2017.

“The updated estimates are a testament to the successes we’ve seen in continuing to reduce hospital-acquired conditions,” AHRQ Director Gopal Khanna said.

It was not all good news, however. HACs involving pressure ulcers increased by 6%, and the number of surgical site infections didn’t budge over the three years.

“There’s no question that challenges still remain in addressing the problem of hospital-acquired conditions, such as pressure ulcers,” Khanna said. “But the gains highlighted today were made thanks to the persistent work of many stakeholders’ ongoing efforts to improve care for all patients.

The Centers for Medicare & Medicaid Services wants to reduce HACs by 20% between 2014 and 2019, which would result in 1.8 million fewer HACs over the five-year period, potentially saving 53,000 lives and saving $19.1 billion in hospital costs.

CMS Administrator Seema Verma said Tuesday that the work around reducing HACs is ongoing, as her agency develops new patient-centered measures that place outcomes over processes.

“While I am so proud of this accomplishment, we are working to get to a smaller set of dynamic measures that patients can use to identify high-value providers,” Verma told the CMS Quality Conference.

Why Auditing Catheter Dislodgement is a Patient Safety Must

By Christopher Cheney

Dislodgement of venous access devices such as catheters is widespread and underreported, a survey of 1,500 clinicians shows.

There are several negative impacts from dislodgement of peripheral and central catheters including interrupted treatment, supply waste with catheter replacement, phlebitis, and infection.

Dislodgement is a significant source of wasteful spending at health systems and hospitals, the author of the survey, Nancy Morneau, RN, PhD, of Hartwell Georgia-based PICC Excellence Inc., told HealthLeaders last week.

“Accidental dislodgement may be a much bigger problem than central line associated blood stream infections. It contributes to the increasing cost of healthcare. When we look at the estimates of dislodged catheters, there are more than five million incidents. If you put dollars and cents to that, it’s more than a billion dollars that is lost every year,” she said.

The survey found high rates of catheter dislodgement.

 

  • 68% of clinicians surveyed said accidental dislodgement occurred often, daily, or multiple times daily
  • 96% said peripheral intravenous catheters were the most commonly dislodged vascular access device
  • The top three reasons for dislodgement were confused patient (80%), patients removing catheters (74%), and loose IV catheter tape or securement (65%)

Audits essential step

Auditing incidences of catheter dislodgement and other vascular access device failures is crucial to managing care, Morneau said.

“With value-based purchasing and pay-for-performance, everyone is on alert to reduce complications with these devices whether they are peripheral or central. By auditing complications—specifically dislodgement—we can identify causes and incidents. Then you can look to the solutions.”

Documentation is a key element of auditing.

The electronic medical record should account for discontinuation of vascular access devices for a patient including dislodgement, Morneau said.

“The EMR should have appropriate choices that include dislodgement and whether it was associated with securement, the dressing, or a patient dislodgement or a staff dislodgement. Looking at the reasons helps us to reach what the solutions may be.”

Health systems and hospitals also should encourage reporting of catheter dislodgements, she said.

“Hospitals can stress compliance with documentation and work on electronic medical record documentation in order to provide clear choices that are consistent with the reasons for catheter failure with dislodgement. Making a more accurate notation is one of the best ways hospitals can move forward with managing dislodgement.”

Auditing is foundational to improving vascular access device care, Morneau said. “Audit can help you achieve two key results: increasing education and helping to recognize where there are safety issues.”

CMS Report: AOs missing fire safety and IC deficiencies during survey

Expect CMS to continue pressuring The Joint Commission (TJC) and other accrediting organizations (AO) to find more of the serious life safety, environment of care, and infection control issues the federal agency says they are still missing during surveys.

In the newest report to Congress assessing AO performance, CMS says the overall disparity rate between serious problems identified by the AOs at hospitals and those found by CMS surveyors within 60 days of survey was 46% in fiscal year 2016, up from 38% and 39%, respectively, in the two preceding fiscal years.

Most of those disparities were in infection control and physical environment, says the report. CMS is particularly concerned that AOs are missing key Life Safety Code® (LSC) deficiencies, with fire and smoke barriers, sprinkler systems, electrical systems, hazardous areas, and means of egress taking the top five categories for missed problems in fire safety at hospitals.

Hospitals already face funding challenges to meet fire code requirements after CMS finally adopted the 2012 LSC, and it will get even worse as survey scrutiny increases, predicts Ernest E. Allen, a former TJC surveyor and current consultant and patient safety executive with The Doctor’s Company in Columbus, Ohio.

This is on top of TJC’s response to criticism in the report released last year. TJC began pushing its own surveyors to cite every life safety deficiency, no matter how small, Allen says.

More on this topic can be found on

Hospitals Can Improve Their Infection Prevention Strategies, Study Finds

By Jay Kumar

A new review of 144 studies found that healthcare-associated infections (HAI) can be reduced by as much as 55% through the implementation of evidence-based infection prevention and control strategies. Published in the Society for Healthcare Epidemiology of America’s (SHEA) journal Infection Control & Hospital Epidemiology, the study points out that hospitals can do much more to reduce infections.

“Healthcare-associated infections come at a considerable expense to patients and families, but also cost the U.S. healthcare system an estimated $9.8 billion each year,” said Keith Kaye, MD, MPH, president of SHEA, in a release. “There have been tremendous advancements in developing strategies to prevent and control HAIs. This study demonstrates a need to remain vigilant in identifying and maintaining key infection control processes to ensure they can be optimally used to prevent infections, which in some cases are life-threatening.”

The review was conducted by researchers from University Hospital Zurich and Swissnoso, the Swiss National Center for Infection Control, who examined 144 studies published worldwide (including 56 done in the U.S.) between 2005 and 2016 to determine the proportion of HAIs prevented through infection control interventions in different economic settings. The papers reviewed studied efforts designed to prevent at least one of the five most common HAIs using a combination of two or more interventions, including education and surveillance or preoperative skin decolonization and preoperative changes in the skin disinfection protocol.

The interventions produced a 35% to 55% reduction in new infections, the researchers found. The largest effect was for prevention of central line-associated bloodstream infections; other infections studied included catheter-associated urinary tract infections, surgical site infections, ventilator-associated pneumonia, and healthcare-associated pneumonia.

The study’s lead author, Peter W. Schreiber, MD, a researcher from the Division of Infectious Diseases and Hospital Epidemiology at the University Hospital of Zurich, said the review’s results show that hospitals are not doing enough to fight infections. “Our analysis shows that even in high-income countries and in institutions that supposedly have implemented the standard-of-care infection prevention and control measures, improvements may still be possible,” he noted. “Healthcare institutions have a responsibility to improve quality of patient care and reduce infection rates by effectively implementing customized multifaceted strategies and improv[ing] patient outcomes.”

Last Flu Season Led to 80,000 Deaths

Federal public health officials are urging everyone six months and older to get vaccinated against influenza in the wake of last winter’s severe flu season, which resulted in a record high of 900,000 hospitalizations and more than 80,000 deaths.

“Last season illustrated what every public health official knows—influenza can be serious in people of all ages, even in the healthiest children and adults,” said U.S. Surgeon General Jerome M. Adams, MD, MPH, at a news conference Thursday. “It is critical that we focus national attention on the importance of influenza vaccination to protect as many people as possible every season.”

The press conference was held to highlight what officials see as disappointing flu vaccination coverage estimates in recent years. Over the last several flu seasons, coverage among children aged six months to 17 years has remained steady but fallen short of national public health goals, which are 80%. During the 2017-2018 season, coverage dropped by 1.1 percentage points overall, with young children aged six months to four years with a decline in vaccination coverage of 2.2 percentage points. Even with the drop, vaccination coverage was highest in this age group (67.8%) and lowest among children aged 13 to 17 years (47.4%).

The CDC estimates that 78.4% of healthcare personnel were vaccinated during the 2017-2018 season, up 15% since the 2010-2011 season. Vaccination coverage was highest (91.9%) among healthcare workers in hospital settings and lowest (67.4%) among those working in long-term care settings. The CDC’s FluVaxView site has a more in-depth breakdown of these statistics.

Joint Commission Revises Scoring for IC Standard

The Joint Commission (TJC) announced scoring changes for its IC.02.02.01 standard, which requires facilities to reduce infection risk associated with medical equipment, devices, and supplies. The standard was included on TJC’s list of most-cited standards.

In the latest post in its 4-1-1 on Survey Enhancements series, TJC focused on high-level disinfection and sterilization. Effective as of September 1, the revisions are meant to hone in on the process steps that pose the highest risk to patients. TJC plans to monitor the revisions over the next several months to ensure scoring is consistent.

For example, IC.02.02.01 was previously scored on the finding of visible bioburden and dried blood of instruments. Now surveyors will cite hospitals if the wiping or flushing of soiled instruments isn’t observed during a case in the operating or procedure room and it’s clinically appropriate, or if an item that’s ready to be used on a patient is visibly soiled.

Standard findings recorded before September 1 will not be removed. Hospitals that are in the clarification window or preparing an Evidence of Standards Compliance report should document their compliance with the revised scoring guidelines.

Be ready for surveyor focus on dialysis

Surveyors from CMS and The Joint Commission are taking an interest in dialysis compliance. Which means you should, too. Each year, 468,000 patients receive dialysis as treatment for end-stage renal disease (ESRD). A single procedure takes about several hours, during which a patient’s blood is filtered and cleaned inside their body (peritoneal dialysis) or outside of it (hemodialysis). There are many possible points of failure in a dialysis treatment, and infections are a major risk. That’s why surveyors are being extra stringent about compliance, say Jennifer Cowel, RN, MHSA, president of Patton Healthcare Consulting in Naperville, Illinois, and Kathleen Good, MSN, RN, an associate of the company. Both are Joint Commission alumni.

The Joint Commission isn’t delicate when telling people what surveyors are looking for, nor when citing them. Three focus areas have come up repeatedly at Joint Commission presentations: sterile compounding, pain standards, and dialysis. And there’s been a corresponding uptick in scoring for all of these areas in 2018.

“When The Joint Commission indicated that dialysis is going to be a focus area, the field should be prepared for more detailed surveys than we have seen in the past,” Cowel says. “Take this as a heads-up notice. We have seen an uptick in dialysis scoring; in fact, we have seen scoring in dialysis in more than half of the survey reports we have seen in recent months.”

There are plenty of examples that hospitals can focus on, Good notes.

“Note that hospitals that are providing inpatient hemodialysis or contracting for the service need to pay attention to the room where dialysis is being provided, particularly if [it’s] not in the patient’s room,” Good says. “I have seen rusty air conditioning units, soil around the unit, blood spots on the floor, tiles missing behind the dialysis machine, wet towels on the floor, [and] sinks designated solely for hand hygiene being used for emptying bottles of concentrate that were used for patient dialysis.”

Cowel and Good have seen numerous findings in dialysis in recent months, including the calibration of the pH/conductivity meter not being tested per the manufacturer instructions for use (IFU). Other common findings they’ve seen include:

  • Not having an eyewash station when bleaching of a portable dialysis machine is done in a patient room.
  • Not conducting a special check of a patient’s catheter that was locked with high-concentration anticoagulant, in clear violation of the hospital’s policy on high-risk medications.
  • Improper management of medicines administered during or before dialysis treatment. For example, a dialysis nurse transporting multidose vials of heparin, despite the fact they should be considered single-dose vials.
  • Not documenting vascular site assessment (e.g., redness, warmth, tenderness, swelling) before and after dialysis, per hospital policy.
  • Not recording that consent was received from a new dialysis patient or that a conversation about risks and benefits occurred.
  • Not verifying that the amount of fluids or medications administered to a patient match the medical order. For example, if a nurse administers 100cc normal saline (NS) instead of 200cc NS per the protocol order set for hypotension during dialysis.

More on dialysis compliance will be in the upcoming edition of Briefings on Accreditation and Quality