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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.

Nurses Report Gaps in Quality and Safety Competencies Based on Education

By Jennifer Thew- 

While quality and safety measures are key to delivering excellent nursing care, new graduate nurses are not always adequately prepared in these areas, reports a new study by researchers at NYU Rory Meyers College of Nursing.

Educational preparation appears to be tied quality and safety competencies. The study found there is a growing gap in preparedness in quality and safety competencies between new nurses with associate and bachelor’s degrees. Nurses with BSN degrees report they are “very prepared” in more quality and safety measures than their ADN peers.

“Understanding the mechanisms influencing the association between educational level of nurses and patient outcomes is important because it provides an opportunity to intervene through changes in accreditation, licensing, and curriculum,” Maja Djukic, PhD, RN, associate professor at NYU Meyers and the study’s lead author, says in a news release.

Nurses With BSNs More Prepared

For the study, the researchers examined quality and safety preparedness in two groups of new nurses who graduated with either associate or bachelor’s degrees in 2007 to 2008 and 2014 to 2015. They surveyed more than a thousand new nurses (324 graduated between 2007 to 2008 and 803 graduated between 2014 to 2015).

The nurses were asked how prepared they felt about different quality improvement and safety topics. The responses of nurses with ADNs and BSNs were analyzed for differences.

There were significant improvements across key quality and safety competencies for new nurses from 2007 to 2015, however, the number of preparedness gaps between BSN and ADN graduates more than doubled during this time.

In the 2007 to 2008 cohort, nurses with BSNs reported being significantly better prepared than those with ADNs five of 16 topics:

  • Evidence-based practice
  • Data analysis
  • Use of quality improvement data analysis and project monitoring tools
  • Measuring resulting changes from implemented improvements
  • Repeating four quality improvement steps until the desired outcome is achieved

Of the 2014 to 2015 graduates, those with BSNs reported being significantly better prepared than those with ADNs in 12 of 16 topics:

  • The same five topics as the earlier cohort
  • Data collection
  • Flowcharting
  • Project implementation
  • Measuring current performance
  • Assessing gaps in current practice
  • Applying tools and methods to improve performance
  • Monitoring sustainability of changes

How to Affect Change

“The evidence linking better outcomes to a higher percentage of baccalaureate-prepared nurses has been growing. However, our data reveal a potential underlying mechanism—the quality and safety education gap—which might be influencing the relationship between more education and better care,” Djukic, says.

Laws and organizational policies encouraging or requiring bachelor’s degrees for all nurses could close quality and safety education gaps, note the researchers.

New York was recently the first state to pass a law, often called the BSN in 10, requiring new nurses to obtain their bachelor’s degree within 10 years of initial licensure.

Additionally, nurse leaders and employers can affect change by:

  • Preferentially hiring nurses with BSNs
  • Requiring a percentage of the nurse workforce to have BSNs
  • Requiring nurses with ADNs to obtain a bachelor’s degree within a certain timeframe as a condition of maintaining employment

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.”

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.

FDA warning on surgical fires

This summer, FDA issued an alert reminding healthcare professionals and facility staff of “factors that increase the risk of surgical fires on or near a patient.” The agency also recommended practices to reduce the occurrence of surgical fires, including “the safe use of medical devices and products commonly used during surgical procedures.”

The alert is targeted at healthcare professionals involved in surgical procedures—such as surgeons, surgical technicians, anesthesiologists, anesthesiologist assistants, certified registered nurse anesthetists, physician assistants, and nurses—and staff responsible for patient safety and risk management.

“Although surgical fires are preventable, the FDA continues to receive reports about these events,” read the alert. “Surgical fires can result in patient burns and other serious injuries, disfigurement, and death. Deaths are less common and are typically associated with fires occurring in a patient’s airway.”

This report comes 13 months after the FDA warned that certain lithium battery–powered medical carts had been overheating, igniting, smoking, burning, or exploding. In some cases, firefighters have had to bury medical carts to put out the flames.

When fires break out

ECRI Institute estimates that, based off the nonprofit research organization’s reporting data from Pennsylvania that has been scaled to encapsulate the entire country, there are between 90 and 100 surgical fires in the U.S. every year, down from 550–650 in 2007. ECRI Institute estimates that about 10%–15% of these surgical fires are major, leading to serious injuries or disfiguration.

In 2016, a man in Florida was getting a cyst removed from his forehead when a surgical tool caught cloth on fire during surgery, causing third-degree burns on his face, according to a news report. Another news report out of Chicago said that in 2012, a man having a catheter implanted in his chest suffered surgical fire burns so painful that he “prayed to God to just let me die.”

In rare cases, as the FDA noted, surgical fires can be fatal. For example, a 65-year-old woman undergoing surgery at an Illinois hospital in 2009 died six days after being burned during a “flash fire” in the OR.

It’s not just patients who can be harmed. Healthcare workers are also at danger of being injured when surgical fires occur. Plus, medical equipment and devices are at risk of damage, too.

Fire starters

“A surgical fire can occur when all elements of the fire triangle are present,” Scott Lucas, PhD, PE, director of ECRI Institute’s Accident and Forensic Investigation team, explained via email. Those three elements, he wrote, are a fuel, such as drapes, gauze, breathing tubes, or prepping agents; an oxidizer, such as oxygen or nitrous oxide; and an ignition source, such as a laser or electro-surgical pencil.

“Procedures involving the face, head, neck and upper chest (above the xiphoid) are of the greatest risk, particularly in the presence of supplement oxygen,” Lucas wrote in the email.

Lucas also noted that more than 70% of surgical fires involve oxygen enrichment, which OSHA defines as any atmosphere that contains more than 22% oxygen. He added that “alcohol-based prepping agents also pose a high risk of fire if the agent has not dried prior to beginning the procedure.” The recommended drying time for prepping agents should be listed in product instructions, Lucas wrote.

In its alert, the FDA wrote that it “reviews product labeling for drugs and devices that are components of the fire triangle to ensure the appropriate warnings about the risk of fire are included.”

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

HFAP ligature risk updates

To keep themselves as closely aligned with CMS as possible, HFAP has updated their Acute Care Manual with new prepublication requirements on removing ligature (hanging) risks in rooms meant for suicidal patients. Several standards have been affected:

04.01.01 – Staff Training – Identification of Patients at Risk for Harm

11.01.01 – Periodic Monitoring for Safety Issues

11.01.02 – Building Safety

11.01.08 – Review of Safety Policies and Procedures

11.02.01 – Building Security

13.00.01 – Life Safety Code Compliance

13.01.06 – Exit Discharge

13.05.09 – Utility Systems

15.01.17 – Privacy and Safety: Safe Setting

15.01.19 – Privacy and Safety: Identify Patients at Risk

15.01.20 – Privacy and Safety: Environmental Risk Assessment

27.03.01 – Privacy and Safety: Identify Patients at Risk

27.03.02 – Privacy and Safety: Environmental Risk Assessment

To see the changes to the standards, visit the HFAP website. And for more analysis of the changes read Briefings on Accreditation and Quality. 

Editor’s note: HFAP announced these standards won’t be revised again due to the July CMS memo on ligature risks. 

Catheters Pose More Risks Than Just CAUTIs

Catheter-associated urinary tract infections are a well-known issue related to urinary catheters. However, a new study in JAMA Internal Medicine finds the devices can cause more issues that previously thought. In fact, UTIs are five times less common than non-infectious problems caused by indwelling urinary catheters.

In-depth interviews and chart reviews from more than 2,000 patients found more than half of catheterized hospital patients experienced a complication of some kind.

The issues ranged from pain, bloody urine and activity restrictions while the catheter was in, to problems with urination and sexual function after it was removed.

“Our findings underscore the importance of avoiding an indwelling urinary catheter unless it is absolutely necessary, and removing it as soon as possible,” says the study’s lead author Sanjay Saint, MD, MPH, chief of medicine at the VA Ann Arbor Healthcare System, George Dock professor of internal medicine at the University of Michigan and director of the U-M/VA Patient Safety Enhancement Program.

A wide array of issues

For the study, Saint and his colleagues from U-M, VAAAHS, and two Texas hospitals analyzed data from 2,076 patients who had recently had a catheter placed for short-term use. Most catheters were placed because the patients were having surgery. Researchers followed-up with patients two weeks after catheter placement and again one month after their catheter placement to ask about their catheter-related experience.

Nearly three quarters of the patients were male, and the catheter was removed within three days of the insertion for 76% of patients. Among the study’s findings:

  • Just over 10% of patients reported infections
  • 55% of patients reported at least one complication of a non-infectious kind
  • 31% of patients whose catheters had been removed at the time of the first interview said it hurt or caused bleeding coming out.
  • More than half of those interviewed while the catheter was still in place said it was causing them pain or discomfort.
  • One in four patients reported the catheter had caused bladder spasms or a sense of urgency about urinating.
  • 10% said the catheter led to blood in their urine.
  • Nearly 40% of patients interviewed while a catheter was still in place, said it restricted their daily activities
  • About 20% who had their catheters removed said they experienced urine leakage, or difficulty starting or stopping urination.

“While there has been appropriate attention paid to the infectious harms of indwelling urethral catheters over the past several decades, recently we have better appreciated the extent of non-infectious harms that are caused by these devices,” says Saint.

Story first appeared in PSQH.

CMS Reverses Plan to Cut Reporting of HAIs

The Centers for Medicare & Medicaid Services (CMS) has decided not to carry out a proposal to remove public reporting of hospital-acquired infections (HAI), medical errors, and injuries. Instead, CMS will publish the information on the Hospital Compare site and in a database.

After the plan was announced in June, there were complaints from patient safety advocates. A new rule, published last week, restores reporting of data through the Inpatient Quality Reporting Program, including infection rates of Clostridium difficile, Methicillin-resistant Staphylococcus aureus, and post-surgery sepsis.

The Trump administration had initially agreed to remove the reporting measures at the request of the American Hospital Association, which argued that they unfairly penalize hospitals for safety problems.