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Get ready for Patient Safety Awareness Week

Next week marks Patient Safety Awareness Week, presented by the National Patient Safety Foundation’s (NPSF) United for Patient Safety Campaign. The week will kick off a yearlong effort to highlight methods of reducing patient harm, while engaging healthcare organizations with related discussions and events.

Events start on Sunday, March 13 and continue through Saturday, March 19.

As part of events, The Joint Commission will unveil a new Web page dedicated to patient safety resources, including a new issue of its Quick Safety newsletter about the Patient Safety Systems chapter of the hospital manual. The page is being launched on Monday, March 14 and will be on the Joint Commission home page. 

The NPSF will conduct a Twitter chat on safety in all types of healthcare settings at 2 p.m. EST on March 15. Those interested in joining the discussion are asked to use #PSAW16chat when tweeting.

The organization will also host a free webcast, “Patient Safety is a Public Health Issue,” on March 17.

Drug-resistant bacteria on the rise

First, the good news. Between 2008 and 2014 there was a 50% and 9% drop in central line-associated bloodstream infections at short-term care (STC) facilities and long-term acute care (LTAC) facilities, respectively. Surgical site infection rates are also down by 17% in STC facilities, while LTAC facilities saw a 11% decline in catheter-associated urinary tract infections.

Now the bad news. Even as hospitals reduce hospital-acquired infections (HAI), there have been more cases of antibiotic-resistant (AR) bacteria. A new Vital Signs report released by the Centers for Disease Control and Prevention (CDC) found that one in seven HAIs at a STC facility is caused by an AR infection. At LTAC facilities, there’s a one in four chance that an HAI is caused by a AR infection.

“The good news is that we are preventing healthcare-acquired infections, which has saved thousands of lives,” said Patrick Conway, MD, CMS deputy administrator and chief medical officer said in a statement. “The challenge ahead is how we help to prevent antibiotic resistance, as well as infections. We are using incentives, changes in care delivery, and transparency to improve safety and quality for patients.”

Two million Americans contract AR infections annually, with 23,000 dying because of their infections. There are six bacteria causing the most concern, with a significant percentage of each becoming drug-resistant:

  1. 6% of Acinetobacter species are multidrug-resistant
  2. 9% of Staphylococcus aureus isolates are methicillin-resistant
  3. 5% of Enterococci are vancomycin-resistant
  4. 8% of Enterobacteriaceae are extended-spectrum β-lactamase-producing.
  5. 9% of Pseudomonas aeruginosa are multidrug-resistant
  6. 6% of Enterobacteriaceae are carbapenem-resistant

“For clinicians, prevention means isolating patients when necessary,” said report author Clifford McDonald, MD, in the release. “It also means being aware of antibiotic resistance patterns in your facilities, following recommendations for preventing infections that can occur after surgery or from central lines and catheters placed in the body, and prescribing antibiotics correctly.”

The CDC encourages the healthcare community to continue to focus on preventing HAIs by stronger adherence to existing best practices.  The agency has also come up with a new web app that allows users can make customizable, interactive maps and tables with regional, state and national on HAIs caused by AR bacteria.


Iowa system reports four wrong-site surgeries in 40 days

Wrong-patient, wrong-site, or wrong-procedure surgeries were the second most common sentinel event of 2015, with 111 cases reported to the Joint Commission.

One Iowa health system took this to new level, with four wrong-site surgeries happening with 40 days at its hospitals. The Genesis Health System reported that the incidents happened late last year, resulting in no deaths or amputations.

The first incident involved a surgeon cutting into a patient’s left hip to treat a fracture on the right hip.  Two weeks later, another physician removed the left half of a patient’s thyroid even though the patient had been sent in for a suspicious mass on the right side of his thyroid.  The mistake wasn’t discovered until after the surgery, and patient was operated on again to remove the remainder of the thyroid. The hospital noted that the right half turned out to be cancerous, meaning the entire thyroid would have been removed regardless.

Details on the other two wrong-side surgeries have not been released.

Genesis Health leadership blamed the failure on lax attitudes toward patient safety in the operating room. In a memo sent to staff, hospital administration said that, “Doctors were not fully participating in timeouts” and “At times there were distractions such as music playing in the background and that markings on a patient were covered up.”

After a follow-up survey in February, state inspectors announced that new safety protocols were being followed.

Physicians spend $15.4 billion reporting quality metrics

A study published in Health Affairs found that the time lost reporting on quality measures costs medical practices around $15.4 billion annually. The time spent reporting on quality costs practices around $40,069 per physician each year, with 80% of practices saying that time spent on quality reporting has increased over the last three years.

Hundred Dollar Bills

Reporting on quality costs around $40,069 per physician annually

The study compared 1,000 practices across four specialties: cardiology, orthopedics, primary care, and multispecialty. Researchers found that a single physician generates about 15.1 hours’ worth of quality data per week. Physicians typically spent 2.6 hours doing quality measure reporting, with the rest falling to staff. A majority of the work was data entry. How much time a physician personally spent each week on quality measures varied between primary care physicians (3.9 hours), multispecialty physicians (3.0 hours), cardiologists (1.7 hours), and orthopedists (1.1 hours).

“There is much to gain from quality measurement, but the current system is far from being efficient and contributes to negative physician attitudes toward quality measures,” the authors wrote.

Most healthcare insurers have their own unique quality measure sets and reporting methods. However, this is expected to change with the recent CMS announcement of new nationally accepted core quality measures, which are currently being phased in by CMS and 70% of private insurers.

CDC releases new antibiotic stewardship app

On March 7, the Centers for Disease Control and Prevention (CDC) the release of a new web app; Antibiotic Resistance Patient Safety Atlas (AR Atlas).

With the AR Atlas app, users can make customizable, interactive maps and tables with regional, state and national on healthcare-associated infections (HAI) caused by antibiotic resistant (AR) bacteria.

With the AR Atlas app, users can make customizable, interactive maps and tables with regional, state and national on healthcare-associated infections (HAI) caused by antibiotic resistant (AR) bacteria. Users will be able to see and study antibiotic resistance patterns in HAIs by filtering the data by geographical area, time period, event type, and patient age. The app includes resistance data on 31 different AR strains, including:

• Methicillin-resistant Staphylococcus aureus (MRSA)
• Carbapenem-resistant Enterobacteriaceae (CRE)
• Multidrug-resistant Pseudomonas aeruginosa

The AR Atlas includes information from 2011-2014 and data collated from 3,676 acute care hospitals, 506 long-term acute care hospitals and 221 inpatient rehabilitation facilities. Click here to learn more about the app and its uses.

Teaching hospitals struggle with C. diff; infection rates higher than national average

Despite strong efforts to reduce hospital acquired infections, some of the best teaching hospitals in the U.S. have seen a rapid rise in Clostridium difficile (C. diff) infections. In 2014 alone, 101,074 patients contracted C. diff at a hospital, a 4% increase from the previous year. C. diff infects 450,000 people annually and plays a role in 29,000 deaths.

A Consumer Reports study examined C. diff rates in 3,200 American hospitals and found that at least a third of them had C. diff rates higher than the national average. Some of the worst performers included 24 of the nation’s largest teaching hospitals, including:

  • Baylor University Medical Center, TX
  • Brigham and Women’s Hospital, MA
  • Cleveland Clinic, OH
  • John Hopkins Hospital, MD
  • Massachusetts General, MA
  • Mount Sinai Hospital, NY
  • VCU Medical Center, VA
  • Yale-New Haven Hospital, CT

“Teaching hospitals are supposed to be places where we identify the best practices and put them to work,” Lisa McGiffert, director of Consumer Reports’ Safe Patient Project, said in a news release. “But even they seem to be struggling against this infection.”

All 24 teaching hospitals have at least 500 beds and over 200,000 patient days a year. Representatives from several of the larger hospitals in question have said that the higher infection rates might be because they treat a higher ratio of sicker patients than non-teaching hospitals or that they may be better at detecting and testing for C. diff.

The report suggests better hygiene and antimicrobial stewardship is needed to fight C. diff infections. Antibiotics can kill off the “good” bacteria in a patient’s stomach that normally keep C. diff at bay, and antibiotic misuse is thought to be one of the main causes in growing C. diff rates. The bacteria is also able to live outside the body for weeks, making hand hygiene and sanitation a high priority.

Only 28% of hospitals received top scores in C. diff prevention, four of which were large teaching hospitals; Mount Sinai St. Luke’s, Maimonides Medical Center, Maine Medical Center, Harris Health System.

Click here to see the Consumer Reports interactive map to see how your local hospital did on the report. 

Easy to read guide of the new Sepsis definition

In February, the definition of sepsis and septic shock was updated to eliminate nonspecific and misleading criteria previously used for diagnosing.

The updated definitions no longer require two or more systemic inflammatory response syndrome (SIRS) criteria as part of a sepsis diagnosis.

2016 Sepsis redefintion

Sepsis Definitions: Old vs. 3.0 —- @FOAMpodcast

“The SIRS criteria do not necessarily indicate a dysregulated, life-threatening response,” the task force wrote. “SIRS criteria are present in many hospitalized patients, including those who never develop infection and never incur adverse outcomes.”

The new sepsis definition includes evidence for infection, plus life-threatening organ dysfunction. Septic shock is now defined to include sepsis with fluid-unresponsive hypotension, serum lactate level greater than 2 mmol/L, and the need for vasopressors to maintain mean arterial pressure of 65 mm Hg or greater.

You can read more about the sepsis update at HealthLeaders Media.

And thanks to FOAMcast for proving us with this chart!

Joint Commission releases 2015 sentinel event stats

On March 2, The Joint Commission released its sentinel event statistics from 2015. Of the 936 sentinel events reported last year, the most common were unintended retention of a foreign body (116), wrong-site/wrong-side/wrong procedure surgery (111), falls (95), and suicides (95).

The most common root causes of sentinel events last year were human factors (e.g., staff supervision issues), leadership (e.g., organizational planning), and communication with either administration or patients.

The Joint Commission has been compiling sentinel event data since 2004. Of the 9,884 patient cases reported, more than 55% of patients died due to a sentinel event and 8.7% suffered from permanent loss of function.

To see the full chart, click here. 

Duodenoscope saga continues: Olympus to pay $646 million settlement

On March 1, the Department of Justice (DOJ) charged Olympus Corp. with paying millions of dollars in kickbacks to hospitals and doctors to buy its products. The company, which owns 85% of the U.S. endoscope market, has agreed to pay $646 million total to resolve the criminal charges and civil charges brought against it. The Department of Justice says that Olympus’ U.S. division made more than $600 million in sales and $230 million in profits with the kickback scheme.

$22.8 million of the sum is being paid by Olympus’s Latin American division to resolve a separate criminal charge after paying providers at government-owned facilities to buy Olympus products.

“For years, Olympus Corporation of the Americas and Olympus Latin America dropped the compliance ball and failed to have in place policies and practices that would have prevented the substantial kickbacks and bribes they paid,” said U.S. Attorney Paul Fishman in a statement. “It is appropriate that they be punished for that. At the same time, the deferred prosecution agreement takes into account the companies’ cooperation and commitment to fully functional corporate compliance.”

Olympus has previously come under fire for concealing flaws in its duodenoscopes that resulted in dozens of infection outbreaks. 



Following heart attack protocol key to saving lives

Every year, 735,000 Americans have a heart attack, with 389,550 of those heart attacks happening inside a hospital. As such, tHeart Attack Rates, 2011-2013reating in-house cardiac arrests (IHCA) is a major priority for healthcare facilities.

Despite this, how often and how strictly healthcare personnel adhere to these guidelines varies from hospital to hospital. A new study in The Journal of the American Medical Association has found that compliance with IHCA protocols ranges from 82.6% to 94.8%, with a median score of 89.7% compliance.

Every 10% increase in a hospital’s process composite performance was associated with a 22% higher chance of survival.  Higher performing hospitals also had more IHCA patients discharged with a favorable neurologic status, with 19.9% better outcomes compared with 17.7% at the lowest performing facilities.

Click here to see the Advanced Cardiac Life Support Training Center’s algorithm for basic life support, and advanced cardiac life support.