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Survey: 36% of facilities struggle to meet TJC MRI standards

new survey found that 36% of medical resonance imaging (MRI) providers do not comply with The Joint Commission’s (TJC) standards for diagnostic imaging services, which were released in 2015.

The standards, which are in effect for hospital and ambulatory care programs, require that MRI facilities should collect data on incidents where ferromagnetic objects unintentionally entered the MRI scanner room and injuries resulting from the presence of ferromagnetic objects in the scanner room. Ferromagnetic objects, which include oxygen tanks and wheelchairs, can become dangerous when brought into an MRI room; the MRI’s strong magnetic field can pull objects at high speed toward the machine, which can lead to injuries and occasionally deaths.

Conducted by MRI safety firm Metrasens, the survey of 162 MRI professionals highlights ongoing issues with safety in those facilities. “The Joint Commission’s Revised Requirements for Diagnostic Imaging Services state that hospitals must manage safety risks in the MRI environment, but these survey results suggest that there is still room for improvement,” said Tobias Gilk, a Metrasens consultant, in a release.

TJC’s standards also cover equipment testing and maintenance, annual education for staff, minimum qualifications for medical physicists, and managing MRI safety risks.

CMS Revises Memo on Requirements to Reduce Risk of Legionella Infection

Be prepared for renewed interest in your water management program and especially how it is designed to prevent the spread of Legionella infection. CMS just updated its memo from last year on requirements to reduce the risk of Legionnaire’s disease, in part to clarify expectations for hospitals and nursing homes (NH).

While there are no new expectations for hospitals or critical access hospitals (CAH), be aware it does add a specific statement that “facilities must have water management plans” as well as a new note that testing for waterborne pathogens is left “to the discretion of the provider,” according to the letter to CMS’ Quality, Safety and Oversight (QSO) group, formerly the Survey & Certification (S&C) group.

“The terms ‘plans’ and ‘policies’ are sometimes confusing to hospitals,” warns Kurt Patton, the former director of accreditation services for The Joint Commission (TJC) and founder of Patton Healthcare Consulting, now in Naperville, Ill.

“TJC already requires a utilities management plan and water is a component of that. The unknown will be if CMS surveyors say they don’t want to look at a utilities plan, they want to look at a water management plan,” explains Patton. “At a minimum, I would suggest accredited hospitals have a table of contents and a subject header for ‘Water Management Plan’ inside their overall utilities plan.”

The memo, QSO 17-30-Hospitals/CAHs/NHs, was published July 6 and supersedes the former S&C 17-30-Hospitals/CAHs/NHs, issued in June 2017, and it adds more specific expectations for long-term care (LTC) facilities. [more]

New CMS guidance on ligature risk says Joint Commission recommendations set the bar

Expect CMS surveyors to be referring to recommendations set out by The Joint Commission last fall when looking for ligature risk and other environmental hazards in the push to make hospitals and psychiatric units safer for patients at-risk of self-harm.

For now, assess your hospital’s environmental compliance against those Joint Commission recommendations, regardless of what organization you might use for accreditation, and be prepared to provide one-to-one observation of at-risk patients if you cannot provide a ligature-resistant environment, says one safety consultant.

In a new memo to its state survey agencies, CMS said it would use those Joint Commission recommendations — drawn from a task force convened by the accreditor that included several CMS experts in suicide prevention — as the federal agency goes forward with clarifying and updating interpretive guidelines for its surveyors.

The memo QSO: 18-21-All Hospitals, “CMS clarification of Psychiatric Environmental Risks,” from the Quality, Safety & Oversight Group (QSO), formerly known as the Survey and Certification Group, is dated July 20, although it was not posted online until Aug. 1.

CMS says Joint Commission panel good enough

In earlier communications, CMS had indicated it would convene its own group of experts to update its guidance to increase focus on ligature as well as other physical risks covered under the Condition of Participation (CoP) for patient rights to care in a safe setting.

However, since participating in the The Joint Commission panel, CMS officials now think its own panel would be redundant. “CMS felt that to repeat the work of TJC Suicide Panel (in which CMS participated) would not provide any substantive additional gains and would not be a productive use of the time and expertise of the participants,” according to the newest memo.

CMS is still working to revise the interpretive guidelines for its surveyors but referred regional offices for now to expectations set out in its Dec. 8 memo on clarifying ligature risk, S&C 18-06-Hospitals (ECL 1/1/18). That memo carried extensive guidance, including an initial update to parts of the interpretive guidelines found in Medicare’s State Operations Manual, Appendix A (SOMA).

Expect more changes in the future, though. In the most recent memo, CMS said it would continue to work on updates to Appendix A as well as Appendix AA, guidelines for surveyors at Psychiatric Hospitals, “which will incorporate the standards that were recommended via the collaborative work of the The Joint Commission Suicide Panel Special Report: Suicide Prevention in Health Care Settings.” The memo provided an online link to the November The Joint Commission recommendations.

Written by A.J. Plunkett

Human Trafficking and Healthcare

This June, The Joint Commission released Quick Safety Issue 42 on identifying human trafficking victims. The Health and Human Services Department estimates that 88% of trafficking victims visit a healthcare provider at least once during their captivity and aren’t recognized as victims. Misconceptions and a lack of awareness have caused many providers to inadvertently send victims back to their captors.

“Human trafficking is modern-day slavery and a public health issue that impacts individuals, families and communities,” The Joint Commission wrote in a news release. “The alert provides health care professionals with tips to recognize the signs of human trafficking, including a patient’s poor mental and physical health, abnormal behavior, and inability to speak for himself/herself due to a third party insisting on being present and/or interpreting.”

Human trafficking is the fastest growing criminal enterprise in America, worth $32 billion a year (for comparison, Starbucks’ annual revenue is $19 billion.) It’s difficult to gauge how many victims there are in the U.S. However, in the past 10 years there has been over 40,000 human trafficking cases reported to the National Human Trafficking Hotline. 

There are many challenges to identifying trafficking victims. Injuries and ailments are attributed to other causes; drug addiction, accidents, sexual promiscuity, etc. The victims themselves are often afraid to speak up because they or a family member is being threatened.

There are many entities working to create standardized human trafficking tools for providers, similar to suicide screening tools, to identify potential victims. The National Association of Pediatric Nurse Practitioners launched a national human trafficking initiative last fall and has come out with a new training module, Human Trafficking 101, which is available online for $15.

Sending Sepsis Patients Home May Not Harm Them

Researchers at Intermountain Healthcare are challenging the conventional wisdom for sepsis treatment in emergency departments.

“Based on our data, we are trying to document something that was previously unrecognized in the literature—a significant fraction of patients with clinical sepsis are not admitted to the hospital after presenting to the ED,” says Ithan Peltan, MD, MSc, an attending physician at Intermountain and a leader of the research effort.

Peltan and his research team studied 8,239 adult ED sepsis patients at two tertiary hospitals and two community hospitals in Utah. The researchers found that 1,607 of the patients—19.5% of the total—were discharged rather than admitted to the hospital.

“The conventional wisdom assumes that all sepsis patients coming to the emergency department are being admitted, but our data shows some are being discharged. … We need a reconceptualization of who these patients are and how our care guidelines are being formulated,” Peltan says.

Peltan’s team presented the research last month at an American Thoracic Society conference in San Diego. Although the findings are preliminary, the researchers found that it is probably appropriate for some sepsis patients to be discharged from an ED into outpatient care.

“There was no significant difference in 30-day mortality for discharged versus admitted sepsis patients,” the researchers wrote in the abstract they presented in San Diego.

Discharge safety uncertain

The researchers have shown that ED physicians are sending some patients home, and the next step is to characterize which sepsis patients are appropriate for ED discharge, Peltan says.

“We are not at the point where we can recommend routine discharge of any sepsis patients for outpatient management in the community.”

He says there likely are several factors that determine whether a sepsis patient in the ED is a good candidate for discharge:

  • Patients who are not gravely ill and are not in need of intensive care intervention
  • Patients who are not at high risk of deterioration
  • Patients who can get the care they need as outpatients such as compliance with prescribed medications
  • Patients who can set and attend follow-up visits

A major element of safely discharging sepsis patients from EDs is developing a risk stratification methodology for sepsis similar to risk tools created for pneumonia, Peltan says. “We need that kind of risk-stratification tool for sepsis.”

Risk stratification will help ED physicians sort out the best care path for sepsis patients, he says. “Who are the patients who need to be admitted? Who are the patients we might miss but need to be admitted? Which patients can be managed as outpatients?”

Physician decision-making varies

Peltan’s team found significant variation in ED physician decision-making on whether to admit or discharge sepsis patients.

“We looked at physician-level behaviors and found some physicians did not discharge any of their sepsis patients and some physicians discharged nearly 40% of their sepsis patients,” he says.

The decision-making variation is a valuable data point, Peltan says.

“Somewhere in the middle, there probably is a happy medium within that range of variation.”

The final version of the Peltan team’s research is slated for publication in 2019.

First published in HealthLeaders Media

Hawaii Hospital Investigates Possible Legionella Outbreak

Hawaii health officials are investigating a possible Legionella outbreak at Queen’s Medical Center in Honolulu after one patient died and three others were hospitalized with Legionnaire’s disease, according to KHON-TV.

The patient died in May after being admitted with pneumonia-like symptoms and may have had an underlying medical condition. Doctors believe the deceased patient and another who has been released acquired Legionella outside the hospital. But the state Department of Health stepped in after learning two other patients developed symptoms after already being hospitalized, making it possible they contracted Legionnaire’s in the hospital, according to KHON.

Officials took water samples at the hospital earlier this week. Legionella has an incubation period of two to 10 days and is spread through water that has been aerosolized. People with weak immune systems are susceptible.

KHON reported that Queen’s is not allowing high-risk patients with weak immune systems to take showers or flush the toilet. They are restricted to drinking bottled water and the hospital is replacing all of its faucets.

First published on PSQH

CMS Delays Hospital Star Ratings Update, Again

Citing “stakeholder concerns,” the Centers for Medicare & Medicaid Services has once again postponed an update to its Overall Hospital Quality Star Ratings.

“When changes are made to the underlying measures it is vital to take the time needed to understand the impact of those changes and ensure we are giving consumers the most useful information,” CMS said Tuesday in a posted notice.

“As part of this process, CMS will seek feedback from a multi-disciplinary Technical Expert Panel, a Provider Leadership Workgroup, and a public comment period,” CMS said.

No date was given for when CMS anticipates activating the ratings updates. Typically, the updates are issued every July and December. However, CMS has a history of delaying the updates, most recently in May. And the ratings themselves have been bitterly contensted ever since they were proposed, with many questioning CMS’ methods. 

News of the pushback was well-received by hospital stakeholders.

“CMS made the right call,” said Tom Nickels, executive vice president of the American Hospital Association.

“We appreciate the agency allowing more time for a fuller analysis of its methodology and measures and to hear from stakeholders, including hospitals and health systems, about concerns found in many preview reports,” Nickels said.

Bruce Siegel, MD, president and CEO of America’s Essential Hospitals, welcomed the delay and said that stakeholder reviews of the proposed July updates showed “large shifts in overall hospital star ratings from December 2017 to July 2018.”

“These changes have created confusion and raised new questions about the reliability and validity of the methodology used to calculate these ratings,” he said.

“We remain deeply concerned the star ratings could do more harm than good in their current form. We look forward to working with CMS to ensure patients and their families can make care decisions based on accurate and meaningful data,” he said.

CMS said it will update these metrics on July 25:

Outcome measures for 30-day mortality, 30-day readmissions, and CMS Patient Safety Indicators, including:

  • Outpatient imaging efficiency;
  • Payment and value of care;
  • Timely and effective care;
  • Healthcare-associated infections;
  • HCAHPS surveys.

CMS will add three new measures to Hospital Compare:

  • Hospital return days for pneumonia patients (EDAC-30-PN);
  • Percentage of patients who received appropriate care for severe sepsis and septic shock (SEP-1);
  • Average time patients spent in the emergency department before being sent home (OP-18c), which will only be reported on data.medicare.gov

CMS is no longer reporting the Pain Management composite 4 on Hospital Compare or in the downloadable databases. This composite measure is also being excluded from the calculation of the HCAHPS Summary Star Rating for the July Hospital Compare release.

In addition, CMS said it:

  • Will not publish the Overall Hospital Star Rating from the July Preview Reports on Hospital Compare.
  • Will Post the SAS Pack with the next Star Ratings refresh on Hospital Compare.
  • Will keep Star Ratings released in December 2017 on the Hospital Compare until the next update.

Written by John Commons, HealthLeaders Media

See our previous coverage on the CMS star ratings below.

AHRQ Data Shows Drop in Hospital-Acquired Conditions

new report from the Agency for Healthcare Research and Quality (AHRQ) found that hospital-acquired conditions (HAC) dropped between 2014 and 2016, preventing an estimated 8,000 deaths and saving $2.9 billion.

The AHRQ National Scorecard on Hospital-Acquired Conditions estimated that 350,000 HACs, including adverse drug events and injuries from falls, were avoided and the rate was reduced by 8% from 2014 to 2016.

CMS has set a goal of reducing HACs by 20% from 2014 through 2019. Using Hospital Improvement Innovation Networks (HIIN), CMS has worked to spread best practices in harm reduction in more than 4,000 hospitals. Once the 20% reduction goal is met, AHRQ projects that during 2015 through 2019, there would be 1.8 million fewer patients with HACs, which would result in 53,000 fewer deaths and $19.1 billion in hospital cost savings.

AHRQ’s new estimates are based on an expanded population set of hospital patients and were calculated despite recent changes in medical coding. Data in the new scorecard showed that overall harms decreased in several categories, such as infections and adverse drug events, which dropped 15% from 2014 to 2016. On the other hand, pressure ulcers increased during that time.

The new numbers echo earlier advances. HACs overall dropped 17% from 2010 to 2014, saving nearly $20 billion in healthcare costs and preventing 87,000 deaths. Preliminary data for 2017 are expected within the next year.

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. 

AORN Expects to Revise its Guideline for OR Headwear

After participating with other healthcare heavy-hitters in February in a task force that met to discuss recommendations for OR attire, specifically ear and hair covering, The Association of periOperative Registered Nurses (AORN) expects to make changes to its Guideline for Surgical Attire.

Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, AORN’s director of evidence-based perioperative practice, tells OSHA Healthcare Advisor that AORN will still recommend complete hair coverage in that revised guideline, but “there’s not going to be a recommendation on which head covering.”

As for the coverage of ears, AORN is “probably going to come out in our new guideline and say the ears don’t need to be covered” because the task force feels the research focusing on its necessity has been inconclusive. “However,” she says, “our guideline stands as is until it’s revised.”

It is significant that AORN will be changing its official guideline. While the organization is the world’s largest professional association for perioperative nurses, it has been a tone-setter for issues that affect all healthcare workers who enter the OR. CMS and subsequently The Joint Commission followed AORN’s lead on headwear and has cited healthcare organizations accordingly.

AORN decided to reconsider its stance on headwear after a study led by Troy Markel, MD, assistant professor of surgery at Indiana University, examined the effectiveness of disposable bouffant hats and skull caps as well as newly-laundered cloth skull caps in preventing airborne contamination.

Not only did Markel and his peers observe no significant differences between the disposable bouffant hats and disposable skull caps “with regard to particle or actively sampled microbial contamination,” they also determined that the disposable bouffant hats had greater permeability, penetration, and greater microbial shed compared to both disposable and cloth skull caps.

Therefore, the researchers wrote in conclusion that disposable bouffant hats “should not be considered superior to skull caps in preventing airborne contamination in the operating room.”

The Markel study made the strongest case to date in the contentious debateover OR headwear, which started several years ago when AORN began, depending on who you ask, either promoting the use of bouffant hats among surgical staff or advocating for skull caps to be banned. AORN encouraged full coverage of the ears in the OR, one of the reasons why it favored bouffant hats.

Spruce says the study “just sparked everybody’s interest and opened up this discussion.” AORN and others felt the evidence was enough to revisit the controversy and, according to Spruce, the American College of Surgeons assembled the task force. That group met in February and recently released a joint statement that “covering the ears is not practical for surgeons and anesthesiologists” and also that “available scientific evidence does not demonstrate any association between the type of hat or extent of hair coverage and [surgical site infection] rates.”

Spruce says AORN had already decided “that it was time to revise that guideline” but “it was valuable” to hear the thoughts among that multi-disciplinary group. She adds, “The perioperative setting has always been a team environment and we’ve always promoted that, so we want the teams to come together and agree on issues that are important to patient safety.”

AORN’s Guideline for Surgical Attire will be reviewed by AORN’s advisory board, which includes representatives from organizations that formed the task force and others. That revised guideline will be available for public comment early next year and will be ready for publication in April.

First published in OSHA Healthcare Advisor