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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.

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. 

National Guidelines, Quality Measures Clearinghouses Shutting Down

If you or anyone at your hospital use the National Guidelines Clearinghouse or National Quality Measures Clearinghouse operated under the auspices of the Agency for Healthcare Research and Quality (AHRQ), download the information you need soon.

Both online clearinghouses will go dark after July 16 as federal funding runs out. Neither site is accepting new guidelines or quality measure sets in anticipation of shutting the databases down.

Announcements on each website note that that AHRQ has received “expressions of interest from stakeholders” that want to takeover maintenance of the databases, but AHRQ officials have declined to identify who those stakeholders are for now.

The clearinghouses were set up more than two decades ago as central sites to help hospitals, clinicians and others in health care find evidence-based information on which to set policy, create clinical treatment plans and objectively measure quality outcomes.

The guidelines and measures are submitted by various professional or academic health organization and must meet detailed criteria to be included in each database. As guidelines or measures are updated or become outdated, the information is removed.

AHRQ evaluating options

“AHRQ recognizes the importance of this resource and is evaluating potential options, including the participation of stakeholders who may wish to operate the Clearinghouse in the future,” stated Alison Hunt, MPH, with AHRQ’s Office of Communications, Media Division.

If public or private stakeholders are found to take over the clearinghouses, ARHQ still has not decided what role it will continue to play, Hunt said.

While the federal sites may go away, the information will still be available from each of the professional society, academy or other healthcare group that originated the material, notes Karen Schoelles MD, SM, FACP, director of ECRI Institute’s Penn Medicine Evidence-based Practice Center (EPC) and project director for both clearinghouses.

ECRI was the original contractor hired by AHRQ to set up and run the guidelines clearinghouse in 1987.

Besides having information in one place, one of the advantages in having each of the clearinghouses is that users could have some assurance that the information had been professionally vetted and was up-to-date.

Having evidence-based information to back a policy or best practice is one of the key mantras of both The Joint Commission and CMS.

Hospital leaders or others who need information about the validity of a particular set of guidelines or best practice can still seek out help from any of the Evidence-based Practice Centers (EPC) set up through AHRQ, says Schoelles. ECRI-Penn Medicine is one of 12 EPCs across North America.

EPC programs offer help

The EPCs develop evidence reports and technology assessments to assist public- and private-sector organizations, and “provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies and strategies,” according to a AHRQ research white paper released in December. Schoelles was a work group leader on the paper, A Framework for Conceptualizing Evidence Needs of Health Systems.

The paper sets out to determine the evidence needs of health systems to both guide future EPC programs and ultimately help organizations as they seek “evidence to inform decisions about acquiring new or emerging medical technologies; implementation or expansion of service offerings; and selection of governance, finance or delivery system models,” notes a summary.

As part of the group’s research it looked at information requests made at four large health institutions;  Kaiser Permanente Southern California, the Veterans Health Administration’s Evidence Synthesis Program, ECRI Institute’s Health Technology Assessment Information Service, and Penn Medicine Center for Evidence-based Practice.

“A wide range of clinical and administrative decision-makers requested evidence reviews, and the topics were similarly broad—ranging from evidence to guide clinical care; purchasing of medications and devices; procedural and non-procedural interventions; and processes of care,” according to the paper.

Highlighted throughout the requests was a need for trustworthiness of information, notes Schoelles.

If you are seeking to verify or evaluate information and are part of a larger health system, Schoelles suggests starting with the larger organization to see what help it can offer. Often health systems will evaluate a guidelines or best practice and then establish a policy or guidelines based on that information, or can share the evaluation throughout the system’s smaller organizations, she said.

ECRI, for instance, offers a variety of evaluation services. Some ECRI services are free to members, others are fee-based. ECRI Institute also is currently exploring ways to maintain a guideline repository, notes Schoelles.

Resources

This article was originally published in Inside The Joint Commission.

Study Questions Effectiveness of Performance Measures

study published in the New England Journal of Medicine asserts that the U.S. healthcare system does a poor job of measuring quality. The study’s researchers led by lead author Catherine McLean, MD, PHD, chief value medical officer, Hospital for Special Surgery, recommend that organizations should stop using performance measures until they can be assessed and revised.

The study notes that a recent survey found that 63% of physicians said that current performance measures do not capture the quality of the care physicians provide. The Performance Measurement Committee (PMC) of the American College of Physicians (ACP) had developed criteria to assess the validity of performance measures. McLean and researchers applied the ACP criteria to the measures included in the Medicare Merit-based Incentive Payment System (MIPS)/ Quality Payment Program (QPP), hypothesized that if most of the MIPS/QPP measures assessed were deemed valid using this process, physicians would have more confidence in using them to improve patient outcomes.

In this study, the researchers identified and rated the validity of 86 measures on the 2017 QPP list that were considered relevant to ambulatory general internal medicine. Of those, 32 (37%) were rated as valid by this method, 30 (35%) were found to be not valid, and 24 (28%) were of uncertain validity. For each measure, the committee rated validity using five domains: importance, appropriateness, clinical evidence, specifications, and feasibility and applicability.

“We believe that the next generation of performance measurement should not be limited by the use of easy-to-obtain (e.g., administrative) data or function as a stand-alone, retrospective exercise,” the researchers wrote. “Instead, it should be fully integrated into care delivery, where it would effectively and efficiently address the most pressing performance gaps and direct quality improvement. For now, we need a time-out during which to assess and revise our approach to physician performance measurement.”

Joint Commission Urges Hospitals to Protect Workers from Abuse

This story originally ran on HCPro’s OSHA Healthcare Advisor.

The Joint Commission is the latest healthcare heavy-hitter to call for better protection of healthcare workers, announcing on Tuesday the creation of Sentinel Event Alert 59, which addresses violence—physical and verbal—against healthcare workers.

About 75% of workplace assaults occur in healthcare and social service sector each year, and violence-related injuries are four times more likely to cause healthcare workers to take time off from work than other kinds of injuries.

The purpose of the new alert is to help hospitals and other healthcare organizations better recognize workplace violence directed by patients and visitors toward healthcare workers and better prepare healthcare staff to address workplace violence, both in real time and afterward, The Joint Commission wrote in this latest Sentinel Event Alert publication.

Sentinel Event Alert 59 has some overlap with Alerts 40 and 57—which were released in 2008 and 2017, respectively, and focused on the development and maintenance of safety culture—and therefore were not addressed in this alert.

Per the Occupational Safety and Health Administration (OSHA), about 75% of workplace assaults annually occurred in the healthcare and social service sector. Violence-related injuries are four times more likely to cause healthcare workers to take time off from work than other kinds of injuries, according to the Bureau of Labor Statistics (BLS).

The Joint Commission cites both of those facts in this Sentinel Event Alert publication and adds that Joint Commission data show 68 incidents of homicide, rape, or assault of hospital staff members over the past eight years—and that’s mostly only what hospitals voluntarily reported.

The Joint Commission is calling for each incident of violence or credible threat of violence to be reported to leadership, internal security, and—if necessary—law enforcement, and it also wants an incident report to be created. Under its Sentinel Event policy, The Joint Commission says that any rape, any assault that leads to death or harm, or any homicide of a patient, visitor, employee, licensed independent practitioner, or vendor on hospital property should be considered a sentinel event and requires a comprehensive systematic analysis.

Additionally, The accreditor says it’s up to the healthcare organization to specifically define unacceptable behavior and determine what is severe enough to warrant an investigation.

This Sentinel Event Alert, which you can download here along with other resources, comes on the heels of an emergency preparedness rule from CMS that recently went into effect and efforts from the National Fire Protection Association to fast-track its new standard for active shooter events and other violent incidents. OSHA is also considering a standard to help protect healthcare and social workers from violence.

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!

Avoid Eyewash-Related Regulatory Compliance Issues

Eyewash stations continue to confuse and confound healthcare organizations (HCO). Not only can they pose infection control and safety issues for workers, they can be a point of contention between HCOs and surveyors, who often seem to work by different sets of rules.

During this 90-minute webinar on May 31, former hospital administrator and accreditation expert John R. Rosing, MHA, FACHE, will explain what regulators like CMS, The Joint Commission, and OSHA expect from an HCO’s eyewash stations. He will provide the steps personnel can take to keep staff safe and the organization in compliance with rules and regulations. Attendees will learn how to avoid eyewash-related regulatory compliance issues, how to perform a risk assessment to determine when an eyewash station is necessary, and what type of eyewash station they need.

At the conclusion of this program, participants will be able to:

  • Avoid eyewash-related regulatory compliance issues
  • Perform a risk assessment to determine when an eyewash station is needed
  • Identify what type of eyewash station is needed
  • Properly maintain eyewash stations

Presented on:
Thursday, May 31, 2018
1:00-2:30 p.m. ET

Presented by:
John R. Rosing, MHA, FACHE

Level of Program:

Intermediate

To register or get more information, please visit the event page at HCMarketplace.com.

Healthcare and Law Enforcement: Working Together Instead of Against Each Other

A working relationship with law enforcement is key to the safety, efficacy, and well-being of everyone in the hospital. That said, hospitals and law enforcement have different goals, and while the two usually work well together, they can find themselves at odds.

During this 90-minute webinar on May 22, industry expert Lisa Terry, CHPA, CPP, will review the hospital’s role in successfully partnering with law enforcement. She will discuss how to balance best practices for ensuring the safety of patients as well as the hospital staff. Participants will also learn how they should communicate with law enforcement, as well as how to plan and implement “crucial conversations” between hospitals and law enforcement.

At the conclusion of this program, participants will be able to:

  • Access and use the best resources on how hospitals who are treating patients “under arrest” should interact with the police
  • Plan and implement “crucial conversations” between the hospital/healthcare executive team and local law enforcement leadership
  • Use the tenets and teachings of “Verbal Judo” to benefit both clinicians and law enforcement first responders
  • Understand how hospitals can support and help facilitate law enforcement’s “guardians of the peace” mentality as they partner with hospitals
  • Apply enterprise security risk management (ESRM) to situations that may arise

Presented on:
Tuesday, May 22, 2018
1:00-2:30 p.m. Eastern

Presented by:
Lisa Terry, CHPA, CPP

Level of Program:
Intermediate

To register or get more information, please visit the event page at HCMarketplace.com.

3 Ways to Knock C. diff Rates Down to Zero

For Necia Kimber, RN, CIC, MHA, infection control practitioner at Stillwater (Oklahoma) Medical Center, “one infection is too many.” Fortunately, when it comes to C. diff, Kimber has infection rates at the healthcare organization at just the right number: zero.

Thanks to a multifaceted approach, the 177-bed hospital with average daily census of 60 patients, has not seen a hospital-acquired case of C. diff since October 2017.

While the organization’s rates were not above the national average, Kimber still wanted to reduce the bioburden—particularly of C. diff, MRSA, VRE, and CRE—within the hospital.

“We didn’t have a high rate that made me say, ‘Oh, my goodness!’ It was just wanting to do overall good and making sure we were doing the best we could,” she says. “This is the hospital I’m going to bring my family to and I want to provide the best care for anybody who walks through that door.”

Here are three ways Kimber achieved lower infection rates at Stillwater Medical Center:

1. Education
Kimber spearheaded an antimicrobial stewardship program at the facility in 2017. There was also assessment of and education regarding ordering of C. diff testing.

“[As healthcare professionals], when you have a patient and you can’t find anything with normal testing, we tend to expound our testing,” she says. “Sometimes it would end up hurting us with pay-for-performance—if [the patient] tested positive for [C. diff, it] didn’t mean they were actually infected with it. They can just be colonized with it.”

The infection control team provided education on national standards for ordering C. diff testing, including testing only when patients were symptomatic of the infection. The IC team provided nurses and physicians with education on when to implement C. diff precautions with the intent that earlier intervention would prevent transmission.

2. Hand hygiene and cleanliness
Hand hygiene was a focus area for preventing the spread of infections at Stillwater.

“We do a program that’s a commitment to excellence,” she says. “Last year we did a huge push on hand hygiene.”

Each month, “secret shoppers” do direct observation on the units to assess issues regarding hand hygiene.

“What we check for is hand hygiene upon entering the room and upon leaving the room,” Kimber says.

To increase patients’ sense of safety, Kimber says she has reinforced hand hygiene practices with clinicians so that even if nurses or physicians have just cleaned their hands with alcohol foam or gel after exiting a room, they need to reapply it if they are going directly into a new room, even if they have not touched anything between rooms.

In addition, Stillwater Medical Center is using a bleach-based product to clean all rooms and equipment after a patient is discharged.

“We used to only [use bleach] on positive C. diff rooms,” Kimber explains. “Now we use it on all rooms because there are so many people who are carriers and not showing signs [of infection] until after they’ve been discharged.”

Kimber also educates environmental services staff on the “why” behind cleaning techniques.

“What we honed-in on is the actual cleaning of the area—friction and leaving the products on for the allotted time to disrupt the replication of cells and bacteria,” she says. “We’ve done a ton of education on how to clean, when to clean, and why to clean.”

3. Robots
While the campaign took place over a year, Kimber says it was the addition of pulsed xenon ultra-violet robots that drove C. diff rates down to zero.

“What we saw with our use of the UV robots, which we started in October 2017, was that for the last quarter of the year, our C. diff hospital onset cases have been zero,” she says. “I’ve been an infection control nurse for almost 18 years and I’d never seen a drop as dramatically as I had in C. diff after implementation of the UV robots.”

While the robots are not cheap, Kimber estimates that each machine costs about $100,000. Stillwater purchased six robots.

“You always worry about surgical-site infections, and you always worry about those infections that patients get in the hospital such as C. diff, MRSA, CRE, and VRE,” she says. “By national standards one C. diff infection is about $30,000 when you look at morbidity and length of stay. For surgical-site infection, if it’s a hip or a knee, you’re getting into the hundreds of thousands. So, for example, with surgical-site infections if you could just save one surgical-site infection—say a hip or a knee—you’ve already saved $100,000, so your ROI will be pretty quick in knocking your infection rates down.”

Kimber says she encourages infection control practitioners to talk with their colleagues about effective solutions for decreasing infections—whether it’s using education, technology, or something else.

“I recommend people do their own research and find out what’s best for their facility and what their actual needs are,” she says. “Infection control nurses have a pretty tight network, so talk to your colleagues and see what they’re doing in their hospitals. Talk to the ones that are the same size as you and bigger than you and see how you can glean information from that.”

Kimber says, “There were tons of things that went into [reducing hospital onset infections]. Having that rate down to zero for three months has been a huge accomplishment.”

Orignially published in HealthLeaders Media

Webinar: How Vanderbilt University Medical Center Established a Hand Hygiene Program

Presented on: March 22, 2018, 1:00-2:30 p.m. EST
Presented by: Thomas R. Talbot, MD, MPH
Level of Program: Intermediate
Registration:  http://hcmarketplace.com/hand-hygiene-program

HCPro Webcast Icon

Summary: 
Hand hygiene is the top way to prevent the spread of healthcare-associated infections. It has also become a major focus of Joint Commission and CMS surveyors, so hospitals need to ensure their healthcare workers are complying with hand washing guidelines.

During this 90-minute webinar, Thomas R. Talbot, MD, MPH, will explain how he led a successful effort to establish a hand hygiene compliance program at Vanderbilt University Medical Center. Dr. Talbot will help attendees overcome barriers to hand hygiene compliance, set up a compliance program in their facility, and create a culture of safety that encourages increased accountability.


Who Should Listen?

  • Infection preventionists
  • Quality improvement personnel
  • Operational quality leaders
  • Safety directors
  • Patient safety professionals
  • Risk managers