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Joint Commission updates diagnostic equipment SEA

The Joint Commission has announced additions to Sentinel Event Alert (SEA) 47, which was first issued in 2011 and focuses on the radiation risks of diagnostic equipment. While most of the language in the alert remains the same, The following changes were made:

  1. Hospitals must comply with the Image Gently Alliance’s guidelines when using imaging radiation or fluoroscopy on pediatric patients..
  2. The alert contains a link to SEA 57, The essential role of leadership in developing a safety culture, replacing the previous link to SEA 43. Both alerts talk about leadership’s role in creating a safety culture, but SEA 57 is more recent. 
  3. The list of references has been updated to show which ones had been recently accessed.

Throwback Thursday: Boston Medical Center reduces alarm fatigue by recalibrating alarm limits

Siren

Editor’s Note: The following is a free Patient Safety Monitor Journal article from yesteryear! If you like it, check out more of our work covering quality and patient safety!

If you walk onto the medical-surgical units in Boston Medical Center (BMC), you may notice something strange: silence.

On a unit that is typically a cacophony of beeping emanating from cardiac monitors, silence is a strange occurrence. But thanks to BMC’s pilot study that began in August 2012, the unit is significantly quieter, the nurses are noticeably happier, and the hospital has positioned itself as a national model for reducing alarm fatigue-a recent hot topic in the patient safety world.

What began as a pilot study on one unit transformed into a hospitalwide initiative that reduced alarms on all medical-surgical units from 1 million to 400,000 per week.

“Our nurses threatened us that if we ever went back to the old settings; they never wanted us to end the pilot program,” says Deborah Whalen, MSN, APRN, ANP-BC, clinical service manager and cardiology nurse practitioner at BMC, and one of the coauthors of the study published in the Journal of Cardiovascular Nursing. “Initially they were terrified that there would be all these crisis alarms, but in fact, we made the changes and did it on a Monday at noon, changed the order sets on the pilot unit and educated staff, and then we stood there and there were no alarms.

“As a matter of fact I called Jim, our clinical engineer, at 2 a.m. to say the system was broken.”

The proof was in the pilot

The overwhelming success of the pilot study on one unit prompted BMC to expand the program to every medical-surgical unit and the hospital quickly became identified as a national leader in alarm management, during a time of heightened awareness and a new National Patient Safety Goal from The Joint Commission. Over the past several months The Boston Globe, NPR, and two local news channels have done stories about the hospital’s program. In May 2013, BMC’s work was featured in a Joint Commission webinar, exemplifying the steps hospitals could implement to better manage alarms and improve patient safety.

The results of the pilot program were published online in December in the Journal of Cardiovascular Nursing, which showed a reduction of 89% in total mean weekly audible alarms by dropping averages from 12,546 per day to 1,424. Weekly alarms averaged 87,823 but dropped to 9,967 during the pilot. The most significant decrease came from changes for bradycardia, tachycardia, and heart rate parameter limits, which started at 62,793 per week and dropped to 3,970 per week.

Perhaps the most telling statistic: The decibel level on the floor dropped from 90 decibels before the pilot to 72 decibels, the equivalent of noise levels generated by heavy traffic to normal conversation.

“It’s not silent by any stretch of the imagination, but it’s quiet and there aren’t these alarms constantly going off in the background,” Whalen says.

What made the study particularly appealing to other hospitals searching for ways to better manage alarms in their own facility was the fact that there were no adverse events related to missed cardiac events, and the pilot study required no additional resources or technology.

“While some hospitals are looking to add technology to combat this issue, BMC’s approach demonstrates the opportunity for clinicians to interact with current alarm systems more effectively to decrease clinical alarm fatigue while simultaneously capturing and displaying all important alarms,” James Piepenbrink, BSBME, director of clinical engineering at BMC and a study coauthor, said in a press release.

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Joint Commission deletes standards during third phase of EP review

On April 25, The Joint Commission announced it had completed the third phase of its Element of Performance (EP) review project. Phase three looked at standards from seven Joint Commission programs, deleting those deemed duplicative or have become standard operating procedure.

It should be noted that what was deleted varies based on each program. For example, an EP deleted for the hospital program might still exist for home care. Chapters affected include Environment of Care and Infection Prevention and Control.

Below are links to the various prepublication standards, which are effective July 1, 2017.

Family-centered ICUs improve outcomes

To improve medical outcomes in intensive care units, some hospitals are attempting to make units more accessible for patients’ family and caregivers. Allowing patients to have more access to their families have been shown to reduce hospital stays, improve satisfaction, and help prepare patients for post-discharge, according to Giora Netzer, MD, a critical care specialist at the University of Maryland Medical Center (UMMC) in an interview with The Baltimore Sun.

“It’s not just more humane care, it ends up being better healthcare,” Netzer said.

Netzer also helped develop guidelines for the Society of Critical Care Medicinethat give providers strategies to better include family members in patient care. This includes having an “open or flexible” place by the patient’s bed, having a place for family members to sleep, and educating the family as part of clinical care. It also includes giving patients’ family’s mental, emotional, and spiritual support to reduce anxiety, stress, depression, or risk for post-traumatic stress disorder in certain instances.

The UMMC has implemented the guideline recommendations and now offers larger rooms to accommodate family members. The facility eliminated visiting hours and makes social workers available to work with relatives on the discharge instructions. UMMC is also has a pilot program where family members attend medical rounds.

Last Chance: “How Parkland Health & Hospital System Successfully Implemented a Suicide Risk Screening Program Webinar”

Date: Tuesday, February 7

1:00-2:30 p.m. ESTHCPro Webcast Icon

Presented by:
Kimberly Roaten, PhD, CRC
Celeste Johnson, DNP, APRN, PMH CNS

Level of Program: Intermediate

Suicides were the third most common sentinel event of 2015. Universal screening is the best strategy to identify patients in general healthcare settings whose suicide risk would otherwise go undetected. This webinar will take a case study approach to bring to light proven methods to reduce patient suicide.

Join Parkland Health and Hospital System expert speakers Kimberly Roaten, PhD, CRC, and Celeste Johnson, DNP, APRN, PMH CNS, as they explain how Parkland became the first in the nation to establish a universal suicide screening program in all its departments. Parkland was recognized in Sentinel Event Alert 56 for making significant progress in suicide prevention. Roaten and Johnson will discuss processes for implementation, strategies to obtain support, universal screening data, and lessons learned from implementation.

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

  • Discuss the process for implementation of a hospitalwide suicide screening protocol
  • Describe strategies for obtaining nursing and physician stakeholder support for universal suicide screening
  • Describe the prevalence data collected from the first two years of a universal screening program
  • Apply lessons learned from the implementation of the program in a large hospital system

Sign up today! 

 

Study: Quality isn’t affected by physician employment

A new study published in the Annals of Internal Medicine found that between 2003 and 2012, the number of hospitals hiring physicians jumped up by 13%. Despite this, the authors caution that the glut in physicians will have little impact on care quality.

Forty-two percent of hospitals were employing physicians in 2012, the majority of which were teaching hospitals, nonprofits, and larger facilities. The study’s authors then looked at key quality metrics between 803 hospitals that switched to the employment model vs. 2,085 hospitals that didn’t. They wanted to see if there was a noticeable difference in length of stay, patient satisfaction, mortality, and 30-day readmissions when hospitals changed their employment style. What the researchers found was that hiring physicians had almost no impact on any of these metrics. Mortality rates, for example, were only 0.1% better in hospitals that switched compared to those that didn’t. The only exception was for pneumonia (secret and public) which saw a 0.6% improvement in switched hospitals.

“Our study, which used contemporary national data, suggests that a fundamental improvement in care delivery will require more than mere changes in hospital-physician integration, and if physician employment is a key ingredient, it must be linked to other key goals, such as hospital prioritization of quality, to be successful,” the authors wrote.
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Boston Scientific issues immediate recall of device guidewires

The Boston Scientific Corp. issued an urgent medical device recall of its RotaWire “Elite” core wires and wireClip Torquer guidewires on November 27. The company said the guidewires may crack and detach from the Rotablator Rotational Atherectomy System (RRAS). The RRAS is used to open narrow arteries and cut away at plaque, improving blood flow to the heart. When the guidewires crack, the pieces can be left inside the artery causing tamponade or heart attacks. Boston Medical has learned of three incidents of guidewires cracking so far, with one case resulting in a patient’s death.

The recall comes in the wake of a FDA safety communication on intravascular devices. Since 2014, the FDA has received 500 medical device reports on peeling hydrophilic and/or hydrophobic coatings on intravascular devices, with the majority of reports submitted for vascular guidewires.

The FDA encourages healthcare professionals and patients to report adverse events or side effects related to the use of these products to the FDA’s MedWatch Safety Information and Adverse Event Reporting Program. Facilities still using these guidewires are told to stop using them immediately. All affected products should be returned to Boston Scientific and distributors should notify any customer who may have received the product.

Reducing the length of stay: Not yours, but somebody who visits but once in a three-year cycle…

Editor’s note: This post, written by my colleague Steve MacArthur, originally appeared on Mac’s Safety Space.

One of the most interesting parts of my job is helping folks through the actual Joint Commission survey process. Even as a somewhat distant observer, I can’t help but think that the average survey (in my experience) is about a day longer than it needs to be. Now, I recognize that some of that on-site time is dedicated to entering findings into the computer, so I get that. But there are certain parts of the process, like, oh I don’t know, the EC/EM interview session, that could be significantly reduced, if not dispensed with entirely. Seriously, once you’ve completed the survey of the actual environment, how much more information might you need to determine whether an organization has its act together?

At any rate, I suppose this rant is apropos of not very much, but the thought does occur to me from time to time. So I ask you: is there anybody out there who feels the length of the survey was just right or, heaven forbid, not long enough? As I’ve always maintained, TJC (or, for that matter any regulatory survey type—including consultants) tend to look their best when you see them in the rear view mirror as you drive off into the future. I know the process is intended to be helpful on some level, but somehow, the disruption never seems to result in a payoff worth the experience. But hey, that may just be me…

Any thoughts you’d like to share would be most appreciated.

Reduce clinical alarm fatigue with new HCPro webcast

The problem of clinical alarm fatigue is so pervasive in hospitals that The Joint Commission created a new National Patient Safety Goal to address it. With so many device alarms going off, staff may tune them out and miss important warnings that can lead to adverse patient events.

In this webcast scheduled for Wednesday, October 14 at 1 p.m. Eastern, Deborah Whalen and Jim Piepenbrink of Boston Medical Center will explain how their facility successfully reduced alarm fatigue through process management, collaboration, and governance. Register today for “Clinical Alarm Management: Reduce Alarm Fatigue and Meet The Joint Commission’s National Patient Safety Goal” and get the knowledge you need to improve alarm management in your facility.

Visit here for more information.

Try not to breathe

Editor’s note: This post, written by my colleague Steve MacArthur, originally appeared on Mac’s Safety Space

I know that we’ve visited (and revisited) this topic once or twice over the last little while, but it continues to be (at least in my mind’s eye), the most significant vulnerability for every healthcare organization that uses The Joint Commission (TJC) for accreditation services: the management of temperature, humidity, and air pressure relationships (THAPR—How’s that for an acronym? It’s pronounced “thapper” or, if you’re from Boston, “thappah”) in the care environment. Folks continue to be cited for issues in this regard; other folks are jumping on board (a little late, but better than never) but are in the closing section of their survey window; and others still have not quite grasped the importance of having a stranglehold (if you will) on those areas for which there are THAPR requirements. Those of you who’ve accompanied me in the blogosphere for a while know that I do not do a lot of product marketing (even my own product), but I will encourage you once again: if you do not have a copy of ASHRAE 170—2008 Standard for Ventilation of Health Care Facilities, you are not in possession of what may be (at least at the moment) the single most important slab of information in the physical environment pantheon (yes, we will always have a place in our hearts for the 2000 edition of NFPA 101 Life Safety Code®; probably for too long, based on the ever-so-slow-to-adopt new things track for the 2012 edition).

While I’m not suggesting that you memorize ASHRAE 170 (it is fairly brief and those of you with eidetic memories probably won’t be able to keep yourselves from doing so), I am suggesting that you need to go to the table on pages 9-11 and start identifying the areas in your organization that have specific requirements and start figuring out where you stand in relation to those requirements, and perhaps more importantly, come to some sort of sense as to how reliably your systems can support those requirements. And you really need to go through the entire table; TJC certainly is. Just last week, I heard of pressurization issues in lab and pharmacy areas (labs are to be under negative pressure; pharmacies under positive) that added up to condition-level survey results.

Make sure you know where you have sterile storage in your organization; sterile storage areas are to be under positive pressure and should be monitored for temperature and humidity. But the reality of the situation is that you have sterile supplies in locations throughout your organization, so you have to define what does and what does not represent sterile storage (my best advice is to coordinate with your infection control and surgical folks on this one—it’s beginning to look a lot like a risk assessment—everywhere you go!). That way, you have a solid foundation for determining what needs to be managed from an environmental standpoint; it’s the only thing that will keep you out of the hottest water during survey.

Two final thoughts before signing off for this week; make sure that routine bronchoscopies are being performed under negative pressure (urgent or emergency bronchoscopies may not have quick enough access to the appropriate environment, so make sure that folks know what protective measures need to be considered to protect themselves and the patient when they’re aerosolizing potential bugs). There are still instances in which this is being cited during survey, so I think my best advice is to go and check with your respiratory therapy folks, as well as the folks in surgery, critical care, infection control, etc., and ask the question: Are bronchoscopy procedures being performed, and if so, where are they being performed? Then you can start walking it back to a point where you can be assured that they are being done in an appropriate environment.

The last thing is a brief reminder that the process for the survey of the physical environment (again, as it is currently being administered) involves all of the survey team – when it comes down to this are of concern, there is no more “clinical” versus “non-clinical”; everything that occurs within the four walls of your organization are patient care activities, direct or indirect (you may have noticed TJC has been splitting its performance elements using that very same language). Coordination of the various hospital services, etc., has never been more heavily scrutinized and never been found more wanting during survey. There is a paradigm shift afoot, my friends, and we need to get on the good foot.