RSSAll Entries in the "Patient Safety" Category

Three Ways to Limit Overprescribing Antibiotics in the Urgent Care Setting

By Christopher Cheney

Antibiotics stewardship at urgent care centers is in the spotlight after the release of a pair of recent studies.

Appropriate prescribing of antibiotics by healthcare providers is essential to help avoid the development of antibiotic-resistant infections, which the Centers for Disease Control and Prevention calls one of the most severe public health problems in the country. About 23,000 Americans die annually from an antibiotic-resistant infection, the CDC says.

In July, CDC researchers published a study in JAMA Internal Medicine that found inappropriate prescribing of antibiotics for respiratory conditions was highest in the urgent care setting at 45.7% of patient visits. Emergency departments were the second highest at 24.6% of patient visits. The research was based on 2014 data.

“Antibiotic stewardship interventions could help reduce unnecessary antibiotic prescriptions in all ambulatory care settings, and efforts targeting urgent care centers are urgently needed,” the CDC researchers wrote.

This fall, DocuTAP, an urgent care electronic health record company, released an antibiotics stewardship report based on 2017 and 2018 data. The DocuTAP research found inappropriate prescribing of antibiotics for respiratory conditions in urgent care centers at 32.4% of patient visits.

“While we all have work to do when it comes to antibiotic prescribing, this data con?rms that the rate at which urgent cares are inappropriately prescribing antibiotics is in line with other segments of the healthcare market,” the DocuTAP report says.

Laurel Stoimenoff, PT, CEO of the Warrenville, Illinois-based Urgent Care Association, says there are three primary ways that urgent care providers can improve antibiotics stewardship.

[more]

Financial Penalties in Hospital Readmissions Linked to Higher Mortality

By John Commins

Using financial penalties to reduce hospital readmissions has been linked to a significant rise in post-discharge mortality for patients with heart failure and pneumonia, a new, large-scale study shows.

In an article published last week in JAMA, researchers at Beth Israel Deaconess Medical Center examined the unintended consequences of the Hospital Readmissions Reduction Program, a component of the Affordable Care Act that began in 2012.

Under the HRRP, hospitals have faced financial penalties for higher-than-expected 30-day readmissions for heart failure, pneumonia, and heart attack. Nearly $2 billion in penalties have been imposed on hospitals by the HRRP since 2012.

“Policy makers had observed that hospital readmissions for these conditions were high and that many of these readmissions were potentially avoidable,” study first author Rishi Wadhera, MD, said in comments accompanying the study.

To one extent, HRRP worked. Hospitals made changes to avoid readmissions rates among Medicare beneficiaries and readmissions rates for those three conditions fell. However, a growing chorus of researchers and physicians have raised concerns that the drop in readmissions has led to increased mortality.

“Some policy makers have declared the HRRP a success because they believe that reductions in readmissions solely reflect improvements in quality of care,” Wadhera said. “But the financial penalties imposed by HRRP may have also inadvertently pushed some physicians to avoid readmitting patients who needed hospital care, or potentially diverted hospital resources and efforts away from other quality improvement initiatives.”

The researchers examined more than 8 million Medicare fee-for-service hospitalizations from 2005 to 2015. They evaluated mortality among Medicare patients who were hospitalized for heart failure, a heart attack or pneumonia before the establishment of HRRP in 2012.

Then, they compared those trends to determine if there was a significant change in mortality after the HRRP was announced in 2010 and then after the policy was implemented in 2012.

“Even though 30-day post-discharge mortality was increasing among patients hospitalized for heart failure in the years before HRRP was established, we found that the rise accelerated after the policy was implemented,” said co-corresponding author Changyu Shen, PhD, senior biostatistician in the Smith Center for Outcomes Research in Cardiology at BIDMC.

The team also found mortality rates among patients with pneumonia were stable prior to HRRP, but began increasing after the HRRP. “Whether the HRRP is responsible for this increase in mortality requires further research, but if it is, our data suggest that the policy may have resulted in an additional 10,000 deaths among patients with heart failure and pneumonia during the five-year period after the HRRP announcement,” Shen said.

Readmissions has become a controversial topic among physicians and researchers, with some studies indicating that it leads to a rise in mortality, and other studies indicating that HRRP has improved care delivery.

study published last month in the American Journal of Medicine showed that HRRP is having a positive impact beyond Medicare beneficiaries and beyond the medical conditions targeted in the initiative.

The primary implication of the research is that health systems and hospitals have made broad improvements to quality of care rather than changes aimed only at Medicare beneficiaries treated for the conditions targeted by HRRP.

EPA announces final rule to set new standards on hazardous waste pharmaceuticals

By A.J. Plunkett

Get the word out to everyone in your organization who handles hazardous waste pharmaceuticals that soon, flushing or rinsing those drugs down a drain into the sewers will be specifically prohibited by the EPA.

That’s harder. On the easier end, you can tell your nurses that the packaging for a patient’s nicotine patch, gum, or lozenge might soon go straight into the regular trash—as long as it is FDA-approved as an over-the-counter nicotine replacement therapy and your state signs off on the exemption of the packaging as hazardous waste under the federal Resource Conservation and Recovery Act (RCRA).

Those are just some of the changes you can expect in handling hazardous waste pharmaceuticals at your facility or business now that the Environmental Protection Agency has finalized its long-awaited “Management Standards for Hazardous Waste Pharmaceuticals and Amendment to the P075 Listing for Nicotine.”

The rule creates a new subpart P under RCRA that manages hazardous waste pharmaceuticals across a wide array of industries, including hospitals, physician offices, ambulatory care, and other providers who “distribute, sell, or dispense pharmaceuticals, including over-the-counter pharmaceuticals, dietary supplements, homeopathic drugs, or prescription pharmaceuticals,” according to the EPA.

The rule has benefits

Under the provision, in general, the EPA says hospitals

  • will no longer have to count hazardous waste pharmaceuticals in calculating generator status (those drugs often sent facilities into large-quantity generator, or LQG, status);
  • can collect and manage hazardous waste pharmaceuticals from satellite facilities as long as they are under the same business umbrella;
  • can accumulate the drugs on site without a RCRA permit for up to 365 days, an increase of 275 days over current regulations;
  • but will have specific basic training requirements associated with those managing hazardous waste pharmaceuticals.

Experts in hazardous waste management in healthcare hailed the ruling as a breakthrough in finally putting a regulatory focus on the need to better control the amount of pharmaceuticals going into the environment while easing up on confusing and often unnecessary restrictions that cost both money and cause aggravation in the healthcare sector.

Another big plus for hospitals in the final rule is that drugs considered controlled substances are no longer considered hazardous waste, erasing concerns about competing regulations between the EPA and the Drug Enforcement Agency.

The rule’s provisions will become effective within six months of its publication in the Federal Register. While the rule has been signed and is expected to be published in the Federal Register before the end of December, there is still the question of when states with their own RCRA-authorized programs will adopt the new regulations.

TJC anticoagulant NPSG updated

The Joint Commission (TJC) announced revisions to its anticoagulant therapy National Patient Safety Goal (NPSG) on December 7. NPSG 03.05.01 has eight new Elements of Performance (EPs).

All the changes are listed in R3 Report 19 and will take effect on July 1, 2019. The update applies to all TJC accredited hospitals, critical access hospitals, nursing care centers, and medical centers accredited under the ambulatory health care program.

The update requires impacted facilities too:

  • Have evidence-based protocols for starting, continuing, reversing, and testing anticoagulant treatment.
  • Establish processes for responding to adverse drug events
  • Educate patients and their families on anticoagulant treatment
  • Use programmable IV pumps when administering heparin
  • Use pre-measured products to limit dosing errors

More on this topic will be in future editions of Briefings on Accreditation and Quality

Suicides and drugs cut U.S. life expectancy

U.S. life expectancy dropped to 78.6 years in 2017, according to the CDC, with the main culprits of the decline being drug overdoses and suicides. The research shows that a baby born in 2017 had 1.2 months shaved off its life expectancy compared to one born 12 months earlier.  This is the third year in a row where life expectancy has declined.

“Life expectancy gives us a snapshot of the nation’s overall health and these sobering statistics are a wakeup call that we are losing too many Americans, too early and too often, to conditions that are preventable,” CDC director Robert Redfield, MD said in a public statement.

The CDC release three reports on November 28—one on suicide mortality, one on drug overdose deaths, and one on mortality overall. And while healthcare organizations have been working hard to treat, prevent, and respond to these issues, the CDC’s numbers show that more work is to be done.

In 2017 there was a grand total of 2.8 million deaths— 69,000 more than the prior year and the most deaths in one year since the government started recording over a century ago. Of those deaths 70,237 were due to drug overdoses and 47,000 were suicides.

Drug overdoses

The spike in drug addiction and deaths was rapid and devastating for many. Drug overdose deaths have increased 16% per year since 2014 says the CDC. And between 2016 and 2017 that number grew 9.6% to 21.7 deaths per 100,000. So far 20 states and the District of Columbia have overdose death rates higher than the national average, and eight have rates comparable to the national average.

Drug Overdoses Statistics

  • The rate of drug overdose deaths in 2017 was 21.7 per 100,000. That’s 3.6 times what it was in 1999 (6.1).
  • While drug use increased in all age groups, overdose rates were much higher for those aged 25–34 (38.4 per 100,000), 35–44 (39.0), and 45–54 (37.7)
  • Men are more likely to die of an overdose than women
  • The number of drug overdoses caused by synthetic opioids increased 45% between 2016 and 2017.

Suicide

As we’ve written about before, suicide has been the 10th leading cause of death since 2008, with suicide rates on the rise. There’s no single identifiable cause for the increase, though some suggest better reporting, a lack of accessible mental healthcare, economic stresses, and social isolation have played a role.

CMS and other healthcare organizations have made efforts in recent years to reduce ligature risks and patient suicides—new ligature regulations, resources and training, etc. Just on November 28, The Joint Commission released a new R3 report on improving suicide care.

Additional research has shown that many suicide victims visit a healthcare provider in the months leading up to the act. And screening programs, ligature risk checklists for patient rooms, and safety planning for after discharge have been shown to be effective.

Suicide Statistics

  • The CDC report says that between 1999 and 2017 the age-adjusted suicide rate rose 33%, up to 14 deaths per 100,000 from 10.5
  • In 2017 47,000 people died by suicide and 1.3 million made a suicide attempt
  • The number of suicides committed by women (9.7 per 100,000) is lower than for men (22.4). However, suicide rates for women have been growing rapidly and is up 53% since 1999
  • Suicide rates increased for men of every age except those aged 75 and older. However, men in this age group still commit suicide far more often than any other (39.7)
  • Suicides are more common in rural counties (20) than in urban ones (11.1). Between 1999 and 2017, suicide rates for rural areas increase 53%. Meanwhile the rate only grew 16% for urban areas.

 

Use TRAIN matrix to triage patients in mass evacuation

By  A.J. Plunkett (aplunkett@h3.group)

Modify the Triage by Resource Allocation for IN-patient (TRAIN) matrix to suit your facility’s needs in case of a mass evacuation.

Developed by the Lucile Packard Children’s Hospital at Stanford in Palo Alto, California, the matrix is combined with the hospital’s electronic medical records system to allow quick assessment of patients and the types of transportation needed to evacuate them to safety. The matrix is also available in PDF form online (see Resources).

“Caregivers have prompt access to a fully automated report that categorizes patients in terms of their specific needs, such as what types of intravenous medication they receive, whether they’re on ventilators or whether they need an intensive care unit bed,” according to the Stanford Medicine News Center in announcing the program in 2015.

Hospitals across California and other areas, including the Sharp Healthcare system in San Diego, have modified the matrix for use as part of their all-hazards preparation for emergencies, including wildfires (see p. 1).

According to a toolkit by Lucile Packard, the matrix allows a hospital to:

Be able to quickly assess and accurately request the right resources from the emergency operations center.

  • Streamline communication with a common code.
  • Implement a standardized and automated inpatient hospital evacuation triage system with minimal impact to workflow.
  • Increase awareness and disaster preparedness across the institution.

System is color-coded

“TRAIN helps determine what vehicles and equipment are necessary for continuous patient care during a crisis event and simplifies communicating patients’ needs to other hospitals or command centers coordinating transfers. For instance, TRAIN helps the hospital decide whether cars or vans are needed, how many ambulances or specialty transports are required and even how many IVs and ICU beds should be in place at the receiving facility,” according to the news center article.

“Under TRAIN, patients are assigned a color, with red designated for patients in critical condition. These patients need specialized transport, such as an ambulance or military vehicle, in addition to life-support equipment, such as ventilators and multiple intravenous drips for medication. TRAIN allows care teams to communicate the medical needs of this patient, as well as the severity of his or her condition, with a single word: red,” according to the news center. “In comparison, patients marked with blue tags are considered stable and can be transported in a car or bus, without any specialized equipment.”

The toolkit is available through HHS Assistant Secretary for Preparedness and Response’ Technical Resources, Assistance Center, and Information Exchange (ASPR-TRACIE) collection of evidence- and experience-based resources for emergency management. It is part of the Healthcare Facility Evacuation/Sheltering collection of resources.

Resources

Before the Plane Crash

In January 2009, all eyes were focused on the Hudson River after a plane flying out of New York’s LaGuardia Airport struck a flock of geese and crash landed in the river. Thanks to fast acting by the pilots, all 155 passengers survived, with few major injuries, in the disaster dubbed “the Miracle on the Hudson.” However, trouble emerged in the aftermath when people tried to find out which hospital their loved ones had been sent to.

“Some of the patients went to New York and some went to New Jersey. And because of HIPAA laws, it was very difficult for airline authorities to get the names of who was where,” says Sharon Carlson, RN, director of Emergency Preparedness at Sharp HealthCare in San Diego, CA. “As a family member you can imagine your terror knowing that your loved one was in a plane crash and not knowing where they are. That’s a big issue we always have, reunifying people after a disaster.”

“Because of [the Miracle on the Hudson] we decided in San Diego that we needed to make relationships before an event happens,” she adds. “Get to know each other, work together, know each other by first name, know each other’s number.”

Using the lessons learned from the Hudson, Carlson and her health system joined a disaster partnership with their local airport, San Diego International (SAN.) The airport has been growing steadily over the past decade, with over 22 million people flying in and out of it in 2017. The airport partnership was started originally in 2010 by UC San Diego Health system.

The transportation administration requires SAN to conduct major disaster drills periodically. As part of the partnership, Sharp Healthcare is included in those drills, Carlson says. They practice their communication process once a year to ensure everybody is on the same page and that there’s been no changes in the contact information.

“We have a partnership with the airports, so they know who to contact at our hospitals,” she says. “And we’ve sent it through our compliance and legal departments, they know what kind of information we can give them.”

In the event of a plane crash or disaster, airport staff have a list of hospital contacts so they can reach out, then read names off the plane’s manifest and the hospital will be able to tell them which people on the list are there or not.

“We don’t give out conditions, injuries, or illnesses,” she says. “We just say if they’re here or not. Because the airline is wanting to tell the family members ‘ok, go over here, your loved one is at this hospital.’”

Tapping Patient Engagement to Reduce Diagnostic Errors

By Christopher Cheney at HealthLeaders Media

Drawing information from patients can help boost understanding of why diagnostic errors happen and reduce the risk of future errors, research published this week says.

Diagnostic errors are a serious patient safety problem, impacting about 12 million adult outpatients each year and causing as many as 17% of adverse events for hospitalized patients.

“Health systems should develop and implement formal programs to collect patients’ experiences with the diagnostic process and use these data to promote an organizational culture that strives to reduce harm from diagnostic error,” researchers wrote in an article published today in the journal Health Affairs.

The research features an examination of 184 narratives from patients or family members about diagnostic errors collected in a new database maintained by the Empowered Patient Coalition.

The data provide unique and valuable insight into diagnostic errors, the researchers wrote.

“Patients’ reports of their experiences of diagnostic errors can provide information that traditional measurement mechanisms often fail to capture. Given the absence of diagnosis-specific experiences in most surveys and patient-reported outcomes, the only current way to capture patients’ experiences of diagnostic error is via patient complaints. However, complaints are often viewed as satisfaction matters rather than safety signals,” the researchers wrote.

Pain points

The Empowered Patient Coalition narratives identified four areas where poor clinician-patient relations contributed to diagnostic errors.

  • Patient knowledge was ignored in 92 of the narratives. Patients or family members said that clinicians ignored or disregarded reports of clinical indications such as symptoms and changes in patient status.
  • Disrespect of patients was considered a possible contributing factor in several diagnostic errors. Clinician disrespect of patients was reported in several forms such as belittling, mocking, and stereotyping.
  • Failure to communicate was another theme in the narratives, with clinician failings ranging from ineffective communication styles to refusal to talk with patients and family members. Examples of poor communication included unanswered phone calls and unresponsiveness to questions.
  • Manipulation or deception was reported in 15 of the narratives. This behavior fell into two categories: Clinicians using fear to influence care decisions or patients who were misled or misinformed.

Addressing the problem

To help reduce diagnostic errors, the Health Affairs researchers propose five methods to collect patient experience data and encourage better communication between clinicians and patients.

  • Creating new requirements for clinicians to conduct lifelong communication training. These requirements could include training to manage patient expectations through discourse.
  • Including communication skills, professionalism, and safety knowledge in certification and continuing medical education programs.
  • Health systems and providers should encourage patient engagement in safety through active and systematic collection of patient observations of clinician behaviors. These patient engagement efforts should be incorporated in mechanisms that are designed to change clinician behaviors.
  • Patient reports identifying clinician behaviors that pose a risk of diagnostic errors should result in interventions to foster patient-centered communication. These reports should be corroborated through the medical record or some other form of independent analysis.
  • Hospitals and health systems should include patient reports of diagnostic errors into training and patient safety programs.

A multi-pronged approach is needed to address aberrant clinician behaviors that lead to diagnostic errors, Traber Giardina, PhD, lead author of the Health Affairs research, told HealthLeaders today.

“We recommend health systems use a systematic method to collect patient reports of these types of behaviors. This would allow for these behaviors to be identified and monitored. A safety culture that encourages not just patients but also clinicians and staff to report these behaviors is needed. Additionally, we suggest reforms in medical education that highlight patient safety,” she said.

These efforts require walking a fine, said Giardina, a patient safety researcher at the Michael E. DeBakey VA Medical Center and assistant professor of medicine at Baylor College of Medicine, both in Houston.

“Fostering clinician accountability for the unprofessional behaviors experienced by the patients who reported diagnostic errors is sure to be challenging and will need to be balanced by the need to address pressures on clinicians that lead to burnout, which may even contribute to these behaviors. These at-risk behaviors that compromise patient safety must be addressed though. More policy priority to nurture the patient-physician relationship is long overdue.”

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

This simple tool predicts readmission risk for heart attack patients

By Christopher Cheney, HealthLeaders Media

A new risk model provides a simple and inexpensive way to determine whether acute myocardial infarction (AMI) patients are at high risk for hospital readmission.

The risk model, which is detailed in a recent study published in the Journal of the American Heart Association (JAHA), features seven variables that can be scored in as little as five minutes during a patient’s first day of hospital admission. With a simple calculation at the bedside or in an electronic health record, physicians can determine whether a heart attack patient is at high risk for readmission and can then order interventions to help the patient avoid a return to the hospital after discharge.

Research published by the Healthcare Cost and Utilization Project shows that about one in six AMI patients are readmitted to a hospital within 30 days of discharge, with annual healthcare costs estimated at $1 billion. Targeting AMI patients who are at high risk of readmission also helps hospitals avoid financial penalties under the federal Hospital Readmissions Reduction Program and promotes cost-effective interventions, the JAHA researchers wrote.

“Although federal readmission penalties have incentivized readmissions reduction intervention strategies (known as transitional care interventions), these interventions are resource intensive, are most effective when implemented well before discharge, and have been only modestly successful when applied indiscriminately to all inpatients,” the researchers wrote. “The acute myocardial infarction READMITS score (renal function, elevated brain natriuretic peptide, age, diabetes mellitus, nonmale sex, intervention with timely percutaneous coronary intervention, and low systolic blood pressure) is the best at identifying patients at high risk for 30?day hospital readmission; is easy to implement in clinical settings; and provides actionable data in real time.”

The AMI READMITS risk model is superior to other models, they wrote. “The few currently available AMI readmission risk prediction models have poor-to-modest predictive ability and are not readily actionable in real time.”

Key findings 

The JAHA research, which examined health outcomes for 826 AMI patients at six hospitals in north Texas, has several key findings:

  • The AMI READMITS score accurately predicts which heart attack patients are at high risk or low risk of readmission. In the JAHA research, about one third of AMI patients that were deemed at high risk through the AMI READMITS score had a 30-day readmission. Only 2% of patients considered at low risk experienced a readmission.
  • The AMI READMITS score can accurately predict readmission risk during the first 24 hours of a hospital inpatient admission, which gives clinicians the ability to make timely interventions.
  • Clinical severity metrics such as shock, heart strain or failure, and renal dysfunction, as well as timely percutaneous coronary intervention, were strongly associated with readmission risk.

Why this model matters

Assessing the readmission risk of AMI patients during the first day of hospital admission is crucial, says Oahn Nguyen, MD, MAS, the lead author of the JAHA research and an assistant professor at UT Southwestern Medical Center in Dallas. “[The model] gives you more time to intervene and try to prevent someone from having to come back to the hospital. It gives you more time to optimize someone’s path to recovery,” she said.

She said development of the AMI READMITS risk model is the first step toward significantly reducing readmissions for AMI patients. “Studies of interventions to reduce readmissions for other conditions suggest that the earlier you can intervene, the better. One caveat is those interventions have yet to be assessed in acute myocardial infarction.”

The current primary strategy to prevent readmissions for heart attack patients is transitional care intervention, and the AMI READMITS score helps physicians target patients for this intervention, she said.

“Transitional care intervention is a bundle of care to promote a safe transition from hospital to home. One way I like to think of it is deploying a medical SWAT team in the hospital to make sure that everything you can do for a patient is being done to ensure the transition from the hospital to the community is as smooth as possible,” Nguyen said.

A “SWAT team” approach to care is often costly, so the capability of the AMI READMITS score to target patients who are at high risk of readmission improves the cost-effectiveness of care.

There are several primary elements to transitional care intervention:

  • Medication counseling to make sure AMI patients know how to take their medications
  • Making sure patients get their medications when they leave the hospital
  • Connecting patients with the most appropriate outpatient care, such as setting up clinic appointments
  • Conducting phone calls to patients’ homes to check on their health status after discharge

Major strengths of the AMI READMITS score include the risk model’s simplicity and low cost, said Nguyen. “Our goal in creating this model was creating something that was simple and pragmatic; so, it’s parsimonious because there are only seven variables that go into it. The seven variables are also information that is commonly and routinely collected during most hospitalizations.”

The AMI READMITS risk model does not require sophisticated support systems, Nguyen said. “In an age when there is a lot of hype about machine learning and big data, we were able to distill the big data of an electronic health record down to small, simple, parsimonious data that is easily applied at the bedside by clinicians.”

Plus, the time expense for the AMI READMITS risk model is minimal.

“It’s low cost because a clinician could look at our [research], then see how many of the seven factors a patient has in the hospital. You can literally spend less than five minutes summing up the points in the model scale, add them up, and determine whether a patient is at high risk or not. It does not take a fancy new IT infrastructure to implement,” Nguyen said.