RSSAll Entries in the "Patient Safety" Category

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.

Survey: 36% of facilities struggle to meet TJC MRI standards

new survey found that 36% of medical resonance imaging (MRI) providers do not comply with The Joint Commission’s (TJC) standards for diagnostic imaging services, which were released in 2015.

The standards, which are in effect for hospital and ambulatory care programs, require that MRI facilities should collect data on incidents where ferromagnetic objects unintentionally entered the MRI scanner room and injuries resulting from the presence of ferromagnetic objects in the scanner room. Ferromagnetic objects, which include oxygen tanks and wheelchairs, can become dangerous when brought into an MRI room; the MRI’s strong magnetic field can pull objects at high speed toward the machine, which can lead to injuries and occasionally deaths.

Conducted by MRI safety firm Metrasens, the survey of 162 MRI professionals highlights ongoing issues with safety in those facilities. “The Joint Commission’s Revised Requirements for Diagnostic Imaging Services state that hospitals must manage safety risks in the MRI environment, but these survey results suggest that there is still room for improvement,” said Tobias Gilk, a Metrasens consultant, in a release.

TJC’s standards also cover equipment testing and maintenance, annual education for staff, minimum qualifications for medical physicists, and managing MRI safety risks.

New CMS guidance on ligature risk says Joint Commission recommendations set the bar

Expect CMS surveyors to be referring to recommendations set out by The Joint Commission last fall when looking for ligature risk and other environmental hazards in the push to make hospitals and psychiatric units safer for patients at-risk of self-harm.

For now, assess your hospital’s environmental compliance against those Joint Commission recommendations, regardless of what organization you might use for accreditation, and be prepared to provide one-to-one observation of at-risk patients if you cannot provide a ligature-resistant environment, says one safety consultant.

In a new memo to its state survey agencies, CMS said it would use those Joint Commission recommendations — drawn from a task force convened by the accreditor that included several CMS experts in suicide prevention — as the federal agency goes forward with clarifying and updating interpretive guidelines for its surveyors.

The memo QSO: 18-21-All Hospitals, “CMS clarification of Psychiatric Environmental Risks,” from the Quality, Safety & Oversight Group (QSO), formerly known as the Survey and Certification Group, is dated July 20, although it was not posted online until Aug. 1.

CMS says Joint Commission panel good enough

In earlier communications, CMS had indicated it would convene its own group of experts to update its guidance to increase focus on ligature as well as other physical risks covered under the Condition of Participation (CoP) for patient rights to care in a safe setting.

However, since participating in the The Joint Commission panel, CMS officials now think its own panel would be redundant. “CMS felt that to repeat the work of TJC Suicide Panel (in which CMS participated) would not provide any substantive additional gains and would not be a productive use of the time and expertise of the participants,” according to the newest memo.

CMS is still working to revise the interpretive guidelines for its surveyors but referred regional offices for now to expectations set out in its Dec. 8 memo on clarifying ligature risk, S&C 18-06-Hospitals (ECL 1/1/18). That memo carried extensive guidance, including an initial update to parts of the interpretive guidelines found in Medicare’s State Operations Manual, Appendix A (SOMA).

Expect more changes in the future, though. In the most recent memo, CMS said it would continue to work on updates to Appendix A as well as Appendix AA, guidelines for surveyors at Psychiatric Hospitals, “which will incorporate the standards that were recommended via the collaborative work of the The Joint Commission Suicide Panel Special Report: Suicide Prevention in Health Care Settings.” The memo provided an online link to the November The Joint Commission recommendations.

Written by A.J. Plunkett

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.