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Study: ED intervention reduces suicide attempts by 30%

How much of a role can emergency departments (ED) play in preventing suicide attempts? The world’s largest study of 1,376 suicidal patients gave the answer.

By implementing interventions at the ED, hospitals were able to lower the of risk patients attempting suicide again by 20% compared to if they are treated as usual (TAU). Researchers also found that “there were no meaningful differences in risk reduction between the TAU and screening phases.”

The study, called the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE), was the largest suicide intervention trial to date, covering patients from eight EDs and seven states.

“Results indicated that the provision of universal screening, while successful in identifying more participants, did not significantly affect subsequent suicidal behavior compared with that experienced by participants in the TAU phase,” they wrote. “By contrast, those participants who received the intervention had lower rates of suicide attempts and behaviors and fewer total suicide attempts over a 52-week period.”

With around 42,000 deaths annually, suicide is the seventh leading cause of death for American men, the 14th for American women, and the 10th overall. Annually, there are 460,000 ED visits that occur following cases of self-harm and a single ED visit due to self-harm increases future suicide risk by almost sixfold, according to the study.

The study compared a control group of patients who were given TAU, a group that was just screened, and one group that was screened along with interventions.

Intervention efforts included additional suicide screening, suicide prevention info, and a personalized safety plan for dealing with future suicide ideation, and periodic telephone follow-ups. Those who got these interventions made 30% fewer total suicide attempt than others.

“We were happy that we were able to find these results,” said lead author Ivan Miller, PhD, professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University, in a statement. “We would like to have had an even stronger effect, but the fact that we were able to impact attempts with this population and with a relatively limited intervention is encouraging.”

Overall, 21% of those studied made at least one suicide attempt within 12 months. Those in the TAU group had a 22.9% suicide attempt rate, while in the screening group it was 21.5%. The intervention group only had a rate of 18.3%. Of all patients studied, there were five fatal suicide attempts.

Study: Single step reduces readmissions by 25%

A new study published in the Journal of the American Geriatrics Society has found that integrating informal, unpaid caregivers into the discharge process can cut readmission rates by a quarter. The study found that by using these caregivers when discharging elderly patients, they were able to reduce readmissions 25% over 90 days.  The study reviewed 4,361 patient cases and 10,715 scientific publications to come up with its results. The study found that:

•    66% of the caregivers were female
•    61% were a spouse or partner
•    35% were adult children

The study also found that informal caregivers significantly reduced time-to-readmission, rehospitalization lengths, and costs of post-discharge care.

“Due to medical advances, shorter hospital stays, and the expansion of home care technology, caregivers are taking on considerable care responsibilities for patients,” said lead author Juleen Rodakowski, OTD, MS, OTR/L, assistant professor in the Department of Occupational Therapy in the University of Pittsburgh’s School of Health and Rehabilitation Sciences, in a statement.

“This includes increasingly complex treatment, such as wound care, managing medications, and operating specialized medical equipment. With proper training and support, caregivers are more likely to be able to fulfill these responsibilities and keep their loved ones from having to return to the hospital.”

“While integrating informal caregivers into the patient discharge process may require additional efforts to identify and educate a patient’s family member, it is likely to pay dividends through improved patient outcomes and helping providers avoid economic penalties for patient readmissions,” said senior author A. Everette James, JD, MBA, director of the University of Pittsburgh’s Health Policy Institute, in a statement.

Caregiver statistics aggregated from the AARP, the Family Caregiver Alliance (FCA), the Institute of Medicine (IOM), and the National Alliance for Caregiving (NAC) reveal that:

•    More than 34 million unpaid caregivers provide care to someone age 18 and older who is ill or has a disability (AARP, 2008)
•    Unpaid caregivers provide an estimated 90% of the long-term care (IOM, 2008)
•    The majority (83%) are family caregivers—unpaid persons such as family members, friends, and neighbors of all ages who are providing care for a relative (FCA, 2005)
•    The typical caregiver is a 46-year-old woman with some college experience and provides more than 20 hours of care each week to her mother (NAC, 2004)

See the full article at HealthLeaders Media and read previous Accreditation Insiderarticles for more on readmissions:

Throwback Thursday: Hospital near-death ­experience: An organization’s fight for survival after CMS decertification

Editor’s Note: The following is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

After reading this article, you will be able to:

  • Describe where an organization’s goals can be counterintuitive to quality
  • Discuss leadership’s role in decertification
  • Identify ways nursing staff are key to recertification
  • Discuss physician involvement in rescuing the facility after CMS decertification

 Closed Sign

The threat of loss of accreditation is one that keeps survey coordinators and hospital leaders awake at night, but for most hospitals, it’s more of a bogeyman than an actual threat-there are many stages an organization must go through and fail before their accrediting bodies slam the hammer down. However, a recent case of decertification and recertification by Medicare stands as a cautionary tale for hospitals across the country to never lose sight of the goals of quality and safety.

Compass Clinical Consulting, an independent consulting group, recently had the experience of helping one hospital recover from the rare event of decertification from CMS. (For the privacy of the organization, the hospital’s name has been omitted from this article.)

“How we got here is pretty straightforward,” says Kate Fenner, RN, PhD, managing director of Compass Clinical. “It was an organization with a very strong leader, and they were focused on entrepreneurship and building the base of the organization.”

The organization had been fairly aggressive in acquisition and reservice, and its board of trustees was on board with this concept. An unintentional downside to this approach, however, was the neglect of day-to-day clinical operations, says Fenner.

“They got very involved with growth-it became their mantra,” she says. “But making certain that their core business was well served did not hit high on the radar. Board meetings were dominated by financial discussions, acquisition discussions, real estate, and building, with little to no discussion about clinical quality or issues going on at the hospital.”

This lack of attention to clinical operations did not go unnoticed. Physicians became concerned-so much so that one physician submitted a complaint to CMS, bringing the state survey office in. The physician’s fears turned out to be legitimate, and the organization received an immediate jeopardy finding.

Too little too late

CMS wanted an action plan on how the deficiencies it found would be addressed. Amazingly, the board did not even know about the immediate jeopardy finding, says Fenner. Instead, the CEO-that same leader who had led the charge toward acquisition and growth-delegated addressing the CMS finding to the chief nursing officer (CNO), who was an interim CNO at the time.

“She did her best,” says Fenner. But despite the CNO’s efforts, CMS came back in and found the facility still out of compliance.

“The second immediate jeopardy had a tight timeline on it,” says Fenner. “Their CEO chose to say, ‘You can’t do that to us.’ Well, they can! CMS is like the IRS-they have a lot of power. And this was a legitimate clinical concern.”

Despite this, the state government gave the facility another opportunity to save itself-the surveyors even chose to stay in the area over a weekend, coming back on Sunday night, to give the organization one more chance to clean up and comply.

It failed.

“At this point they received notice of decertification,” says Fenner, whose organization was brought in to help. “I wish they’d called us a week or two earlier.”

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CDC updates SSI prevention guidelines

For the first time in 18 years, the Centers for Disease Control and Prevention (CDC) has updated its surgical site infection (SSI) prevention guidelines. In its previous iteration, the guidelines were based on expert opinion rather than evidence-based practices on preventing SSIs.

“Unfortunately, in many cases the authors make no recommendation with respect to support or harm if the level of the evidence was low or very low or if they were unable to judge tradeoffs between harms and benefits of the proposed intervention because of lack of outcomes,” wrote Pamela A. Lipsett, MD, MHPE, MCCM, in the accompanying editorial. 

The CDC said it was heeding the call of healthcare professionals who said that guidelines needed to be based on evidence rather than opinions from 1999. The agency condensed thousands of studies into 170 high-quality trials to issue the following recommendations:

  • Patients should shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before surgery.
  • Antimicrobial prophylaxis should be administered only when indicated and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made.
  • Skin prep in the OR should be done with an alcohol-based agent unless contraindicated.
  • For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the OR, even when a drain is being used.
  • Topical antimicrobial agents should not be applied to the surgical incision.
  • During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL.
  • Normothermia (i.e., normal body temperature) should be maintained in all patients.
  • For patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation, increased fraction of inspired oxygen should be administered during surgery and immediately after extubation in post-op.
  • Blood transfusions should not be withheld from surgical patients as a means to prevent SSIs.

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.

Throwback Thursday: Assisting the impaired clinician

Editor’s Note: The following is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

How to overcome barriers to recognition

By the time the general public hears about an impaired clinician, whether it’s a nurse, technician, or physician, it is often too late to head an incident involving that clinician off at the pass-whether that incident is a medical error, diversion of medication, or something even worse, like the technician recently accused of inadvertently exposing thousands of patients to hepatitis C.

But the healthcare industry is well aware that ­impaired clinicians exist, and it has methods for addressing, confronting, and helping these medical professionals. Where are the industry’s gaps to success in ­preventing this far too common occurrence? BOAQ recently sat down with Jill Pollock, RN, LMFT, administrator of Loma Linda University Behavioral Medicine Center and ­frequent lecturer on chemical dependency recognition and intervention, to discuss this topic.

It takes a case as shocking as the hepatitis C outbreak in New Hampshire to bring a topic like this to light, she says.

“I think it’s difficult for people in healthcare to wrap their heads around it,” says Pollock. “What do you think one of our biggest barriers is to recognition of addiction and confronting it? If I can get people to talk just a little bit, we start hearing how there is a fear that confronting someone’s addiction could ruin someone’s life.”

For many healthcare professionals, the thinking is backward, she says–they’re focused on saving a coworker’s career. But we have a professional responsibility to our patients, our loved ones, and the public in general.

“What happens if someone drives impaired and kills someone in a car crash? Would you worry about their professional life?” says Pollock. “Or if your facility has an outbreak of hepatitis C?”

After talking with audiences about the possible outcomes of not confronting versus trying to help the impaired professional, she has found that the best tactic is to bring in personal, relatable example scenarios. “If someone is diverting drugs, then that patient, that ­mother or father, son or daughter, husband or wife, is not getting their pain medications,” she says. “Or, ­alternately, is being cared for by an impaired nurse. I try to bring it home to something we can all relate to.”

Who would you want taking care of your loved one? Pollock asks. Would you be comfortable with a caregiver who is impaired or thinking about where to find his or her next fix?

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Transparency and Termination Notices; CMS proposes changes for Accreditation Orgs.

Early this April, CMS sent out a memo with big proposals for accreditation. If passed, the proposed rule would require accrediting organizations (AO) to make their survey reports publicly available and publish termination notices somewhere other than in local newspapers.

Currently, AOs like The Joint Commission and DNV aren’t required to make their survey reports or plans of corrections available to the public. Under the proposed rule, AOs would have to post these on their websites. CMS Logo

The agency does acknowledge that this information is already available on CMS regional office and state agency websites. However, the new rule is intended to make this information easier for patients to find.

“Access to survey reports and PoCs will enable health care consumers, in addition to Medicare beneficiaries, to make a more informed decision regarding where to receive health care thus encouraging health care providers to improve the quality of care and services they provide,” the memo states.

That interest in transparency leads into the second half of the proposed rule on termination notices. Previously, when an ambulatory surgical center, federally qualified health center, rural health clinic, or organ procurement organization receives a Medicare termination notice, it has to be published in a local newspaper. Acknowledging approximately 23% of the general public continues to read print newspapers, CMS has come up with a list of additional posting options.

If you want to read and comment on the proposed rule, you can find a copy of the memo and commenting instructions here. CMS will accept comments until June 13, 2017.

Proposed seven-day limit to opioid bill enters Congress

A new Senate bill would limit the amount of opioids a patient can initially receive for acute pain. If passed, physicians could only prescribe seven days’ worth of opioids when first treating a patient’s condition.

The bill was put forward by Senators John McCain (R-Ariz.) and Kirsten Gillibrand (D-N.Y.) as a way to prevent opioid addiction. The limit is backed up by medical literature and is there are nine states with similar opioid laws in place.

“Our legislation builds on the important steps taken by Arizona Governor Doug Ducey last fall to tackle a root cause of this epidemic by limiting the supply of an initial opioid prescription for acute pain to seven days. We have a long way to go to end the scourge of drugs across our communities, but this legislation is an important step forward in preventing people from getting hooked on these deadly drugs,” said McCain in a press release.

“Too many lives have been destroyed, too many families have been torn apart, and too many communities all over New York are suffering because of this tragic epidemic. I am proud to join with Senator McCain in this urgent fight against the overprescription of opioids, and I look forward to seeing it pass through the Senate as quickly as possible,” said Gillibrand in a press release.

New CMS requirements for fire door inspection

The American Society for Healthcare Engineering (ASHE) recently published answers involving CMS’ new fire safety regulations. The new Conditions of Participation require fire doors be routinely inspected by “qualified persons.”

ASHE clarified to members that there isn’t any class or certification to qualify for door inspection. Anyone who’s familiar with the code requirements for fire doors will meet the “qualified” standard.

For more details, see the ASHE brief on the topic.

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