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Why Auditing Catheter Dislodgement is a Patient Safety Must

By Christopher Cheney

Dislodgement of venous access devices such as catheters is widespread and underreported, a survey of 1,500 clinicians shows.

There are several negative impacts from dislodgement of peripheral and central catheters including interrupted treatment, supply waste with catheter replacement, phlebitis, and infection.

Dislodgement is a significant source of wasteful spending at health systems and hospitals, the author of the survey, Nancy Morneau, RN, PhD, of Hartwell Georgia-based PICC Excellence Inc., told HealthLeaders last week.

“Accidental dislodgement may be a much bigger problem than central line associated blood stream infections. It contributes to the increasing cost of healthcare. When we look at the estimates of dislodged catheters, there are more than five million incidents. If you put dollars and cents to that, it’s more than a billion dollars that is lost every year,” she said.

The survey found high rates of catheter dislodgement.

 

  • 68% of clinicians surveyed said accidental dislodgement occurred often, daily, or multiple times daily
  • 96% said peripheral intravenous catheters were the most commonly dislodged vascular access device
  • The top three reasons for dislodgement were confused patient (80%), patients removing catheters (74%), and loose IV catheter tape or securement (65%)

Audits essential step

Auditing incidences of catheter dislodgement and other vascular access device failures is crucial to managing care, Morneau said.

“With value-based purchasing and pay-for-performance, everyone is on alert to reduce complications with these devices whether they are peripheral or central. By auditing complications—specifically dislodgement—we can identify causes and incidents. Then you can look to the solutions.”

Documentation is a key element of auditing.

The electronic medical record should account for discontinuation of vascular access devices for a patient including dislodgement, Morneau said.

“The EMR should have appropriate choices that include dislodgement and whether it was associated with securement, the dressing, or a patient dislodgement or a staff dislodgement. Looking at the reasons helps us to reach what the solutions may be.”

Health systems and hospitals also should encourage reporting of catheter dislodgements, she said.

“Hospitals can stress compliance with documentation and work on electronic medical record documentation in order to provide clear choices that are consistent with the reasons for catheter failure with dislodgement. Making a more accurate notation is one of the best ways hospitals can move forward with managing dislodgement.”

Auditing is foundational to improving vascular access device care, Morneau said. “Audit can help you achieve two key results: increasing education and helping to recognize where there are safety issues.”

Patient Safety Movement announces progress towards Zero Harm goal

By Jay Kumar

Patient Safety Movement (PSM) has made major progress toward its goal of zero preventable deaths worldwide by 2020, even though it likely won’t achieve that goal, PSM founder and CEO Joe Kiani told attendees Friday at the group’s 7th annual World Patient Safety, Science & Technology Summit in Huntington Beach, California.

That said, PSM plans to continue to aggressively pursue its efforts to reduce and eliminate medical errors through aligning with healthcare leaders, doctors and nurses, patients and families, politicians and medical technology companies.

“Our goal of zero preventable deaths by 2020 is daunting,” Kiani said. “If we’re not going to get to zero, we at least have to give it our all. I’m going to give it my all. We have to…Don’t let your miracle of healing get hijacked by some medical error.”

Kiani announced that he is stepping down as PSM’s leader, with David Mayer, MD, vice president of quality and safety for MedStar Health and executive director of the MedStar Institute for Quality and Safety, taking over as CEO effective immediately. In addition, Michael A.E. Ramsay, chairman of the Department of Anesthesiology and Pain Management at Baylor University, will be the incoming chairman of the PSM Foundation board. Kiani, who is found and CEO of medical technology firm Masimo Corporation, said he will remain active in the group by serving on the board.

“I’m not quitting, I’m not leaving,” he said. “This is about the mission. I’m going to help you like the two of you helped me.”

Ramsay lauded Kiani’s efforts and urged attendees to keep moving forward. “For every life that’s lost, there’s probably 1,000 patients that have avoided harm,” he said. While PSM has been successful in raising awareness and spreading education, “we have a lot more to do.”

Asked if there will be a new goal after 2020, Ramsay noted that PSM initially began as a U.S.-focused effort, and now it has gone global. Kiani said the goal could be revised to zero deaths by 2025 or 2030, but nothing official was announced.

Mayer noted that PSM has created urgency in the healthcare industry to improve processes. Another big step forward was bringing patients and families into the effort. “It’s about the transparency,” he said. “It’s about learning from the event.”

“We’ve got to make our hospitals safe,” Ramsay added. “Families want to get to the safe place, and that’s home, not the hospital.”

What’s also necessary is to improve education in medical and nursing schools, Mayer said.

One of PSM’s major efforts is to create a series of 18 Actionable Patient Safety Solutions (APSS) that it has encouraged healthcare organizations to implement as they work to reduce preventable patient harm.

“We need to treat every death as a plane crash that you learn from instead of a car crash, where you say that happens,” Kiani said.

Even as he discussed the progress made by PSM over the last several years, Kiani voiced frustration at the apathy he still finds in the healthcare industry when it comes to making radical changes to reach the group’s goal of zero preventable deaths.

“One life is one too many that we lose, and we’re losing millions a year,” he said. “How can anyone not be willing to do anything and everything to stop reckless care?”

Three Ways to Limit Overprescribing Antibiotics in the Urgent Care Setting

By Christopher Cheney

Antibiotics stewardship at urgent care centers is in the spotlight after the release of a pair of recent studies.

Appropriate prescribing of antibiotics by healthcare providers is essential to help avoid the development of antibiotic-resistant infections, which the Centers for Disease Control and Prevention calls one of the most severe public health problems in the country. About 23,000 Americans die annually from an antibiotic-resistant infection, the CDC says.

In July, CDC researchers published a study in JAMA Internal Medicine that found inappropriate prescribing of antibiotics for respiratory conditions was highest in the urgent care setting at 45.7% of patient visits. Emergency departments were the second highest at 24.6% of patient visits. The research was based on 2014 data.

“Antibiotic stewardship interventions could help reduce unnecessary antibiotic prescriptions in all ambulatory care settings, and efforts targeting urgent care centers are urgently needed,” the CDC researchers wrote.

This fall, DocuTAP, an urgent care electronic health record company, released an antibiotics stewardship report based on 2017 and 2018 data. The DocuTAP research found inappropriate prescribing of antibiotics for respiratory conditions in urgent care centers at 32.4% of patient visits.

“While we all have work to do when it comes to antibiotic prescribing, this data con?rms that the rate at which urgent cares are inappropriately prescribing antibiotics is in line with other segments of the healthcare market,” the DocuTAP report says.

Laurel Stoimenoff, PT, CEO of the Warrenville, Illinois-based Urgent Care Association, says there are three primary ways that urgent care providers can improve antibiotics stewardship.

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Financial Penalties in Hospital Readmissions Linked to Higher Mortality

By John Commins

Using financial penalties to reduce hospital readmissions has been linked to a significant rise in post-discharge mortality for patients with heart failure and pneumonia, a new, large-scale study shows.

In an article published last week in JAMA, researchers at Beth Israel Deaconess Medical Center examined the unintended consequences of the Hospital Readmissions Reduction Program, a component of the Affordable Care Act that began in 2012.

Under the HRRP, hospitals have faced financial penalties for higher-than-expected 30-day readmissions for heart failure, pneumonia, and heart attack. Nearly $2 billion in penalties have been imposed on hospitals by the HRRP since 2012.

“Policy makers had observed that hospital readmissions for these conditions were high and that many of these readmissions were potentially avoidable,” study first author Rishi Wadhera, MD, said in comments accompanying the study.

To one extent, HRRP worked. Hospitals made changes to avoid readmissions rates among Medicare beneficiaries and readmissions rates for those three conditions fell. However, a growing chorus of researchers and physicians have raised concerns that the drop in readmissions has led to increased mortality.

“Some policy makers have declared the HRRP a success because they believe that reductions in readmissions solely reflect improvements in quality of care,” Wadhera said. “But the financial penalties imposed by HRRP may have also inadvertently pushed some physicians to avoid readmitting patients who needed hospital care, or potentially diverted hospital resources and efforts away from other quality improvement initiatives.”

The researchers examined more than 8 million Medicare fee-for-service hospitalizations from 2005 to 2015. They evaluated mortality among Medicare patients who were hospitalized for heart failure, a heart attack or pneumonia before the establishment of HRRP in 2012.

Then, they compared those trends to determine if there was a significant change in mortality after the HRRP was announced in 2010 and then after the policy was implemented in 2012.

“Even though 30-day post-discharge mortality was increasing among patients hospitalized for heart failure in the years before HRRP was established, we found that the rise accelerated after the policy was implemented,” said co-corresponding author Changyu Shen, PhD, senior biostatistician in the Smith Center for Outcomes Research in Cardiology at BIDMC.

The team also found mortality rates among patients with pneumonia were stable prior to HRRP, but began increasing after the HRRP. “Whether the HRRP is responsible for this increase in mortality requires further research, but if it is, our data suggest that the policy may have resulted in an additional 10,000 deaths among patients with heart failure and pneumonia during the five-year period after the HRRP announcement,” Shen said.

Readmissions has become a controversial topic among physicians and researchers, with some studies indicating that it leads to a rise in mortality, and other studies indicating that HRRP has improved care delivery.

study published last month in the American Journal of Medicine showed that HRRP is having a positive impact beyond Medicare beneficiaries and beyond the medical conditions targeted in the initiative.

The primary implication of the research is that health systems and hospitals have made broad improvements to quality of care rather than changes aimed only at Medicare beneficiaries treated for the conditions targeted by HRRP.

EPA announces final rule to set new standards on hazardous waste pharmaceuticals

By A.J. Plunkett

Get the word out to everyone in your organization who handles hazardous waste pharmaceuticals that soon, flushing or rinsing those drugs down a drain into the sewers will be specifically prohibited by the EPA.

That’s harder. On the easier end, you can tell your nurses that the packaging for a patient’s nicotine patch, gum, or lozenge might soon go straight into the regular trash—as long as it is FDA-approved as an over-the-counter nicotine replacement therapy and your state signs off on the exemption of the packaging as hazardous waste under the federal Resource Conservation and Recovery Act (RCRA).

Those are just some of the changes you can expect in handling hazardous waste pharmaceuticals at your facility or business now that the Environmental Protection Agency has finalized its long-awaited “Management Standards for Hazardous Waste Pharmaceuticals and Amendment to the P075 Listing for Nicotine.”

The rule creates a new subpart P under RCRA that manages hazardous waste pharmaceuticals across a wide array of industries, including hospitals, physician offices, ambulatory care, and other providers who “distribute, sell, or dispense pharmaceuticals, including over-the-counter pharmaceuticals, dietary supplements, homeopathic drugs, or prescription pharmaceuticals,” according to the EPA.

The rule has benefits

Under the provision, in general, the EPA says hospitals

  • will no longer have to count hazardous waste pharmaceuticals in calculating generator status (those drugs often sent facilities into large-quantity generator, or LQG, status);
  • can collect and manage hazardous waste pharmaceuticals from satellite facilities as long as they are under the same business umbrella;
  • can accumulate the drugs on site without a RCRA permit for up to 365 days, an increase of 275 days over current regulations;
  • but will have specific basic training requirements associated with those managing hazardous waste pharmaceuticals.

Experts in hazardous waste management in healthcare hailed the ruling as a breakthrough in finally putting a regulatory focus on the need to better control the amount of pharmaceuticals going into the environment while easing up on confusing and often unnecessary restrictions that cost both money and cause aggravation in the healthcare sector.

Another big plus for hospitals in the final rule is that drugs considered controlled substances are no longer considered hazardous waste, erasing concerns about competing regulations between the EPA and the Drug Enforcement Agency.

The rule’s provisions will become effective within six months of its publication in the Federal Register. While the rule has been signed and is expected to be published in the Federal Register before the end of December, there is still the question of when states with their own RCRA-authorized programs will adopt the new regulations.

CMS examines possible Conflicts of Interests in Accreditation Organizations

By John Commons 

Federal regulators are asking for public comment and cite ‘disparity rates’ between state audits and AO reviews of healthcare facilities.

The Centers for Medicare & Medicaid Services is asking questions about potential conflicts of interest between Medicare accrediting organizations and the healthcare facilities they monitor.

“We are concerned that the practice of offering both accrediting and consulting services–and the financial relationships involved in this work–may undermine the integrity of accrediting organizations and erode the public’s trust,” CMS Administrator Seema Verma said in a media release.

“Our data shows that state-level audits of healthcare facilities are uncovering serious issues that AOs have missed, leading to high ‘disparity rates’ between the two reviews,” Verma said.

“We are taking action across-the-board to ensure the quality and safety of patient care through strengthened CMS oversight of AOs, and today’s RFI is a critical component of that effort.”

The query likely will include an examination of The Joint Commission, the nation’s largest hospital accrediting organization. In a media statement, The Joint Commission said it is reviewing CMS’s requests for comment, but said it is confident in the integrity of the “firewall” between its consulting and accrediting divisions.

“The Joint Commission recognizes the importance of assuring the integrity of the accreditation process, which we accomplish by prohibiting any sharing of information about consulting services for individual organizations with anyone involved in accreditation,” the statement read.

“The Joint Commission as an accrediting organization and Joint Commission Resources, Inc. as a provider of education and consulting services are two separate organizations. The Joint Commission enterprise has long-standing firewall policies, practices and procedures in place that assure that this goal is achieved,” the statement read.

TJC anticoagulant NPSG updated

The Joint Commission (TJC) announced revisions to its anticoagulant therapy National Patient Safety Goal (NPSG) on December 7. NPSG 03.05.01 has eight new Elements of Performance (EPs).

All the changes are listed in R3 Report 19 and will take effect on July 1, 2019. The update applies to all TJC accredited hospitals, critical access hospitals, nursing care centers, and medical centers accredited under the ambulatory health care program.

The update requires impacted facilities too:

  • Have evidence-based protocols for starting, continuing, reversing, and testing anticoagulant treatment.
  • Establish processes for responding to adverse drug events
  • Educate patients and their families on anticoagulant treatment
  • Use programmable IV pumps when administering heparin
  • Use pre-measured products to limit dosing errors

More on this topic will be in future editions of Briefings on Accreditation and Quality

Joint Commission Revises Suicide Prevention National Patient Safety Goal

The Joint Commission (TJC) this week announced revisions to its suicide prevention National Patient Safety Goal (NPSG) to improve quality and safety of care for patients treated for behavioral health conditions and who are identified as high-risk for suicide.

Effective July 1, 2019, NPSG.15.01.01 (Reduce the risk for suicide) is applicable to all Joint Commission-accredited hospitals and behavioral healthcare organizations. The revised requirements are based on more than a year of research, public field review, and analysis with multiple panels convened by TJC and representing provider organizations, suicide prevention experts, behavioral facility design experts, and other key stakeholders.

The requirements are detailed in a new R3 Report published by TJC. The NPSG encompasses seven elements of performance (EP) that TJC will use to review hospitals and behavioral healthcare organizations during accreditation surveys. This is an increase over the three EPs in the current version of NPSG.15.01.01 (Identify individuals at risk for suicide).

“The science of suicide prevention has really advanced over the past few years, including better tools for screening, assessment of suicidal ideation, identification of environmental hazards in health care facilities, and methods to prevent suicide after discharge,” said David W. Baker, MD, MPH, FACP, executive vice president, TJC’s Division of Health Care Quality Evaluation, in a release. “We had not updated the NPSG since its original release in 2007. This revised version and the accompanying resource compendium will more robustly support health care organizations in preventing suicide among patients in their care.”

The new and revised requirements cover:

  • Environmental risk assessment and action to minimize suicide risk
  • Use of a validated screening tool to assess at-risk patients
  • Evidence-based process for conducting suicide risk assessments of patients screened positive for suicidal ideation
  • Documentation of patients’ risk and the plan to mitigate
  • Written policies and procedures addressing care of at-risk patients and evidence staff are following them
  • Policies and procedures for counseling and follow-up care for at-risk patients at discharge
  • Monitoring of implementation and effectiveness, with action taken as needed to improve compliance

Suicides and drugs cut U.S. life expectancy

U.S. life expectancy dropped to 78.6 years in 2017, according to the CDC, with the main culprits of the decline being drug overdoses and suicides. The research shows that a baby born in 2017 had 1.2 months shaved off its life expectancy compared to one born 12 months earlier.  This is the third year in a row where life expectancy has declined.

“Life expectancy gives us a snapshot of the nation’s overall health and these sobering statistics are a wakeup call that we are losing too many Americans, too early and too often, to conditions that are preventable,” CDC director Robert Redfield, MD said in a public statement.

The CDC release three reports on November 28—one on suicide mortality, one on drug overdose deaths, and one on mortality overall. And while healthcare organizations have been working hard to treat, prevent, and respond to these issues, the CDC’s numbers show that more work is to be done.

In 2017 there was a grand total of 2.8 million deaths— 69,000 more than the prior year and the most deaths in one year since the government started recording over a century ago. Of those deaths 70,237 were due to drug overdoses and 47,000 were suicides.

Drug overdoses

The spike in drug addiction and deaths was rapid and devastating for many. Drug overdose deaths have increased 16% per year since 2014 says the CDC. And between 2016 and 2017 that number grew 9.6% to 21.7 deaths per 100,000. So far 20 states and the District of Columbia have overdose death rates higher than the national average, and eight have rates comparable to the national average.

Drug Overdoses Statistics

  • The rate of drug overdose deaths in 2017 was 21.7 per 100,000. That’s 3.6 times what it was in 1999 (6.1).
  • While drug use increased in all age groups, overdose rates were much higher for those aged 25–34 (38.4 per 100,000), 35–44 (39.0), and 45–54 (37.7)
  • Men are more likely to die of an overdose than women
  • The number of drug overdoses caused by synthetic opioids increased 45% between 2016 and 2017.

Suicide

As we’ve written about before, suicide has been the 10th leading cause of death since 2008, with suicide rates on the rise. There’s no single identifiable cause for the increase, though some suggest better reporting, a lack of accessible mental healthcare, economic stresses, and social isolation have played a role.

CMS and other healthcare organizations have made efforts in recent years to reduce ligature risks and patient suicides—new ligature regulations, resources and training, etc. Just on November 28, The Joint Commission released a new R3 report on improving suicide care.

Additional research has shown that many suicide victims visit a healthcare provider in the months leading up to the act. And screening programs, ligature risk checklists for patient rooms, and safety planning for after discharge have been shown to be effective.

Suicide Statistics

  • The CDC report says that between 1999 and 2017 the age-adjusted suicide rate rose 33%, up to 14 deaths per 100,000 from 10.5
  • In 2017 47,000 people died by suicide and 1.3 million made a suicide attempt
  • The number of suicides committed by women (9.7 per 100,000) is lower than for men (22.4). However, suicide rates for women have been growing rapidly and is up 53% since 1999
  • Suicide rates increased for men of every age except those aged 75 and older. However, men in this age group still commit suicide far more often than any other (39.7)
  • Suicides are more common in rural counties (20) than in urban ones (11.1). Between 1999 and 2017, suicide rates for rural areas increase 53%. Meanwhile the rate only grew 16% for urban areas.

 

Use TRAIN matrix to triage patients in mass evacuation

By  A.J. Plunkett (aplunkett@h3.group)

Modify the Triage by Resource Allocation for IN-patient (TRAIN) matrix to suit your facility’s needs in case of a mass evacuation.

Developed by the Lucile Packard Children’s Hospital at Stanford in Palo Alto, California, the matrix is combined with the hospital’s electronic medical records system to allow quick assessment of patients and the types of transportation needed to evacuate them to safety. The matrix is also available in PDF form online (see Resources).

“Caregivers have prompt access to a fully automated report that categorizes patients in terms of their specific needs, such as what types of intravenous medication they receive, whether they’re on ventilators or whether they need an intensive care unit bed,” according to the Stanford Medicine News Center in announcing the program in 2015.

Hospitals across California and other areas, including the Sharp Healthcare system in San Diego, have modified the matrix for use as part of their all-hazards preparation for emergencies, including wildfires (see p. 1).

According to a toolkit by Lucile Packard, the matrix allows a hospital to:

Be able to quickly assess and accurately request the right resources from the emergency operations center.

  • Streamline communication with a common code.
  • Implement a standardized and automated inpatient hospital evacuation triage system with minimal impact to workflow.
  • Increase awareness and disaster preparedness across the institution.

System is color-coded

“TRAIN helps determine what vehicles and equipment are necessary for continuous patient care during a crisis event and simplifies communicating patients’ needs to other hospitals or command centers coordinating transfers. For instance, TRAIN helps the hospital decide whether cars or vans are needed, how many ambulances or specialty transports are required and even how many IVs and ICU beds should be in place at the receiving facility,” according to the news center article.

“Under TRAIN, patients are assigned a color, with red designated for patients in critical condition. These patients need specialized transport, such as an ambulance or military vehicle, in addition to life-support equipment, such as ventilators and multiple intravenous drips for medication. TRAIN allows care teams to communicate the medical needs of this patient, as well as the severity of his or her condition, with a single word: red,” according to the news center. “In comparison, patients marked with blue tags are considered stable and can be transported in a car or bus, without any specialized equipment.”

The toolkit is available through HHS Assistant Secretary for Preparedness and Response’ Technical Resources, Assistance Center, and Information Exchange (ASPR-TRACIE) collection of evidence- and experience-based resources for emergency management. It is part of the Healthcare Facility Evacuation/Sheltering collection of resources.

Resources