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Human Trafficking and Healthcare

This June, The Joint Commission released Quick Safety Issue 42 on identifying human trafficking victims. The Health and Human Services Department estimates that 88% of trafficking victims visit a healthcare provider at least once during their captivity and aren’t recognized as victims. Misconceptions and a lack of awareness have caused many providers to inadvertently send victims back to their captors.

“Human trafficking is modern-day slavery and a public health issue that impacts individuals, families and communities,” The Joint Commission wrote in a news release. “The alert provides health care professionals with tips to recognize the signs of human trafficking, including a patient’s poor mental and physical health, abnormal behavior, and inability to speak for himself/herself due to a third party insisting on being present and/or interpreting.”

Human trafficking is the fastest growing criminal enterprise in America, worth $32 billion a year (for comparison, Starbucks’ annual revenue is $19 billion.) It’s difficult to gauge how many victims there are in the U.S. However, in the past 10 years there has been over 40,000 human trafficking cases reported to the National Human Trafficking Hotline. 

There are many challenges to identifying trafficking victims. Injuries and ailments are attributed to other causes; drug addiction, accidents, sexual promiscuity, etc. The victims themselves are often afraid to speak up because they or a family member is being threatened.

There are many entities working to create standardized human trafficking tools for providers, similar to suicide screening tools, to identify potential victims. The National Association of Pediatric Nurse Practitioners launched a national human trafficking initiative last fall and has come out with a new training module, Human Trafficking 101, which is available online for $15.

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

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

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

Patient Safety Strategies: Building a Fall Prevention Toolkit

When: May 30, 1-4 p.m. EST

Speakers: Virginia Hall, DNP, MSN/Ed. RN, CNE

Carole Eldridge, DNP, RN, CNE, NEA-BC

Registration: http://hcmarketplace.com/patient-fall-prevention

Patient falls are a fixture in The Joint Commission’s list of top 10 sentinel events; in fact, they were the third highest sentinel event reported to the accreditor in 2016. Causes of falls can include inadequate assessments, side effects from medications or diseases, and environmental hazards, as well as a lack of leadership or staff orientation.

During this three-hour virtual workshop, Carole Eldridge, DNP, RN, CNE, NEA-BC, and Virginia Hall, DNP, MSN/Ed. RN, CNE, will provide a step-by-step guide to setting up a successful and sustainable evidence-based multidisciplinary fall prevention program in your facility.

Learn more about the workshop here.

Study: Link between infection control and antibiotic stewardship

Healthcare facilities must ensure that infection prevention and control (IPC) and antibiotic stewardship (AS) programs work together, according to a joint position paper released last week by the Association for Professionals in Infection Control and Epidemiology (APIC), the Society for Healthcare Epidemiology of America (SHEA), and the Society of Infectious Disease Pharmacists (SIDP).

An update to a 2012 paper that examined the roles of infection preventionists and healthcare epidemiologists in the use of antimicrobials, the new paper was published in the American Journal of Infection Control and Infection Control and Hospital Epidemiology. The new paper focuses on the synergy between IPC and AS programs, with emphasis on the importance of an effective IPC program as part of a strong AS strategy.

?The issues surrounding the prevention and control of infections are intrinsically linked with the issues associated with the use of antimicrobial agents and the proliferation and spread of multidrug-resistant organisms,? said lead author of the new paper Mary Lou Manning, PhD, CRNP, CIC, FSHEA, FAPIC, in an APIC press release. ?The vital work of IPC and AS programs cannot be performed independently. They require interdependent and coordinated action across multiple and overlapping disciplines and clinical settings to achieve the larger purpose of keeping patients safe from infection and ensuring that effective antibiotic therapy is available for future generations.?

AS programs strive to emphasize the appropriate use of antimicrobials to minimize overuse, improve patient outcomes, reduce microbial resistance, decrease infection spread, and preserve antibiotic efficacy, according to the release. AS programs are more effective when rolled out alongside IPC programs than they are on their own, the paper states.

A study recently released in the Joint Commission Journal on Quality and Patient Safety found that antimicrobial-resistant organisms lead to more than 2 million infections and 23,000 deaths each year in the U.S. The use of AS programs can reduce inappropriate antimicrobial use, length of stay, rates of antimicrobial-resistant infections, and cost, the researchers found.

This story originally ran in PSQH. 

CDC Warns of New Wave of Antibiotic-Resistant Germs in U.S.

A new Centers for Disease Control and Prevention (CDC) Vital Signs report released this week said health departments found more than 220 cases of germs with “unusual antibiotic resistance genes” in the United States last year. These germs include those that cannot be killed by all or most antibiotics, are not common to a geographic area or the U.S., or have specific genes that enable them to spread their resistance to other germs, according to a CDC release.

The CDC’s Antibiotic Resistance (AR) Lab worked with local health departments to deploy a containment strategy to stop the spread of antibiotic resistance. The first step is rapid identification of new or rare threats; after a germ with unusual resistance is detected, facilities must quickly isolate patients and begin aggressive infection control and screening actions, according to the release.

“CDC’s study found several dangerous pathogens, hiding in plain sight, that can cause infections that are difficult or impossible to treat,” said Anne Schuchat, MD, CDC’s principal deputy director, in the release. “It’s reassuring to see that state and local experts, using our containment strategy, identified and stopped these resistant bacteria before they had the opportunity to spread.”

After rapid identification of antibiotic resistance, the CDC strategy calls for infection control assessments, testing patients without symptoms who may carry and spread the germ, and continued assessments until the spread is stopped. It requires coordinated response among healthcare facilities, labs, health departments, and the CDC through the AR Lab Network.

The CDC study also found that about one in 10 screening tests of patients without symptoms found a hard-to-treat germ that spreads easily, which means the germ could have spread undetected in that facility. For carbapenem-resistant Enterobacteriaceae (CRE), the report estimates that the containment strategy would prevent as many as 1,600 new infections in three years in a single state, which would be a 76% reduction.

Story originally published by our friends at PSQH!