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Hospitals Can Improve Their Infection Prevention Strategies, Study Finds

By Jay Kumar

A new review of 144 studies found that healthcare-associated infections (HAI) can be reduced by as much as 55% through the implementation of evidence-based infection prevention and control strategies. Published in the Society for Healthcare Epidemiology of America’s (SHEA) journal Infection Control & Hospital Epidemiology, the study points out that hospitals can do much more to reduce infections.

“Healthcare-associated infections come at a considerable expense to patients and families, but also cost the U.S. healthcare system an estimated $9.8 billion each year,” said Keith Kaye, MD, MPH, president of SHEA, in a release. “There have been tremendous advancements in developing strategies to prevent and control HAIs. This study demonstrates a need to remain vigilant in identifying and maintaining key infection control processes to ensure they can be optimally used to prevent infections, which in some cases are life-threatening.”

The review was conducted by researchers from University Hospital Zurich and Swissnoso, the Swiss National Center for Infection Control, who examined 144 studies published worldwide (including 56 done in the U.S.) between 2005 and 2016 to determine the proportion of HAIs prevented through infection control interventions in different economic settings. The papers reviewed studied efforts designed to prevent at least one of the five most common HAIs using a combination of two or more interventions, including education and surveillance or preoperative skin decolonization and preoperative changes in the skin disinfection protocol.

The interventions produced a 35% to 55% reduction in new infections, the researchers found. The largest effect was for prevention of central line-associated bloodstream infections; other infections studied included catheter-associated urinary tract infections, surgical site infections, ventilator-associated pneumonia, and healthcare-associated pneumonia.

The study’s lead author, Peter W. Schreiber, MD, a researcher from the Division of Infectious Diseases and Hospital Epidemiology at the University Hospital of Zurich, said the review’s results show that hospitals are not doing enough to fight infections. “Our analysis shows that even in high-income countries and in institutions that supposedly have implemented the standard-of-care infection prevention and control measures, improvements may still be possible,” he noted. “Healthcare institutions have a responsibility to improve quality of patient care and reduce infection rates by effectively implementing customized multifaceted strategies and improv[ing] patient outcomes.”

Patient Outcomes No Better For Joint Commission–Accredited Hospitals Than Peers

By John Commins

Hospitals that earn certification by independent accreditors, such as The Joint Commission, have no better outcomes than hospitals reviewed by a state survey agency, according to a new report in the BMJ.

“Furthermore, we found that accreditation by The Joint Commission, which is the most common form of hospital accreditation, was not associated with better patient outcomes than other lesser known, independent accrediting agencies,” the study concluded.

Researchers at Harvard T.H. Chan School of Public Health compared 4,400 hospitals across the United States, of which 3,337 were accredited, including 2,847 by The Joint Commission, and 1,063 hospitals that underwent state-based reviews between 2014 and 2017.

The study reviewed more than 4.2 million Medicare inpatient records for people ages 65 and older who were admitted for 15 common medical and six common surgical conditions, and respondents to the Hospital Consumer Assessment of Healthcare Provider and Systems survey.

“Hospital accreditation by independent organizations is not associated with lower mortality, and is only slightly associated with reduced readmission rates for the 15 common medical conditions selected in this study,” the study said.

Among the findings:

  • Thirty-day readmissions for The Joint Commission-accredited hospitals were 0.4% lower than those at hospitals that were reviewed by state survey agencies, which the researchers called “not statistically significant lower rates.”
  • Mortality rates for the six surgical conditions were “nearly identical,” and “no statistically significant differences were seen in 30-day mortality or readmission rates (for both the medical or surgical conditions) between The Joint Commission-accredited hospitals, and hospitals rated by other independent accreditors.
  • Readmissions for the 15 medical conditions “were significantly lower at accredited hospitals than at state survey hospitals (22.4% v 23.2%, 0.8% (0.4% to 1.3%), but did not differ for the surgical conditions (15.9% v 15.6%, 0.3% (−1.2% to 1.6%), the study found.
  • Patient experience scores were modestly better at state survey hospitals than at accredited hospitals. Among accredited hospitals, The Joint Commission did not have significantly different patient experience scores compared to other independent organizations.

While not the only hospital accrediting entity in the United States, the study authors note that private, not-for-profit The Joint Commission plays an outsized role, and controls more than 80% of the accreditation market as the accrediting agency of choice for nearly all major hospital systems.

“There was no evidence in this study to indicate that patients choosing a hospital accredited by The Joint Commission confer any healthcare benefits over choosing a hospital accredited by another independent accrediting organization,” the study concluded.

The Joint Commission could not immediately be reached Friday morning for comment.

Joint Commission Unveils New Emergency Management Checklist

On October 10, Hurricane Michael made landfall in Florida, damaging at least two hospitals so badly they were forced to evacuate. On the same day, The Joint Commission (TJC) published a new Emergency Management Health Care Environment Checklist on its website, which helps healthcare organizations reopening their facilities after a disaster.

While the timing of these two events were coincidental, providers should to take time to go over the checklist and their emergency plans in general.

A TJC workgroup developed the checklist at the request of the U.S. Department of Health & Human Services’ Office of the Assistant Secretary for Preparedness and Response. It aligns with the accreditor’s Emergency Management standards, covers both clinical and environmental issues, and addresses crucial post-disaster elements that need addressing before reopening. It should be noted that the checklist isn’t hurricane-specific.

Jim Kendig, TJC’s field director of Life Safety Code surveyors, says it’s critical that hospitals customize the checklist for their needs by examining the relationships they establish in the community, and at the regional and state levels.

“For example, in Florida, a county Office of Emergency Management met with utilities and other emergency support functions to determine hospitals and PSAPS [public safety answering points] are the first to receive power restoration,” he says. “Establishing an unidentified victims process is also a good start, as it the ability to share that information within an hour of a disaster event.”

“The Joint Commission’s Emergency Management Committee continues meeting with organizations after disaster events to glean important information to share with the field through our Environment of Care News and ongoing communications,” he adds. “This also give us the opportunity to ensure that our standards and elements of performance are effective and contemporary.”

Revisions deeming EPs

Starting January 1, five revisions to The Joint Commission’s Elements of Performance (EP) will go into effect. The revisions deal with the deeming in hospitals and critical access hospitals. The changes are a result of CMS’ review of The Joint Commission’s EP Review Project for the Leadership (LD) chapter.

Some of the changes include specifying that if hospitals provide emergency services that they comply with 42 CFR 482.55 and  that operating rooms have available a communications system that can summon staff outside the OR.

The affected EPs are:

• EC.02.03.01 EP 9

• LD.01.03.01 EP 13 (hospitals only)

• LD.04.03.01 EP 2

• LS.01.01.01 EP 1

• PC.02.02.03 EP 7 (critical access hospitals only)

• PC.03.01.01 EPs 5 and 8

You can read the prepublication changes to hospital and critical access hospitals here.

Accreditation Book Survey 2019

We’re working on books for 2019 and like to hear from you. Please take this short survey and let us know what safety topics or updates you’d like us to write about! https://www.surveymonkey.com/r/QTRWX8H

Last Flu Season Led to 80,000 Deaths

Federal public health officials are urging everyone six months and older to get vaccinated against influenza in the wake of last winter’s severe flu season, which resulted in a record high of 900,000 hospitalizations and more than 80,000 deaths.

“Last season illustrated what every public health official knows—influenza can be serious in people of all ages, even in the healthiest children and adults,” said U.S. Surgeon General Jerome M. Adams, MD, MPH, at a news conference Thursday. “It is critical that we focus national attention on the importance of influenza vaccination to protect as many people as possible every season.”

The press conference was held to highlight what officials see as disappointing flu vaccination coverage estimates in recent years. Over the last several flu seasons, coverage among children aged six months to 17 years has remained steady but fallen short of national public health goals, which are 80%. During the 2017-2018 season, coverage dropped by 1.1 percentage points overall, with young children aged six months to four years with a decline in vaccination coverage of 2.2 percentage points. Even with the drop, vaccination coverage was highest in this age group (67.8%) and lowest among children aged 13 to 17 years (47.4%).

The CDC estimates that 78.4% of healthcare personnel were vaccinated during the 2017-2018 season, up 15% since the 2010-2011 season. Vaccination coverage was highest (91.9%) among healthcare workers in hospital settings and lowest (67.4%) among those working in long-term care settings. The CDC’s FluVaxView site has a more in-depth breakdown of these statistics.

Joint Commission Revises Scoring for IC Standard

The Joint Commission (TJC) announced scoring changes for its IC.02.02.01 standard, which requires facilities to reduce infection risk associated with medical equipment, devices, and supplies. The standard was included on TJC’s list of most-cited standards.

In the latest post in its 4-1-1 on Survey Enhancements series, TJC focused on high-level disinfection and sterilization. Effective as of September 1, the revisions are meant to hone in on the process steps that pose the highest risk to patients. TJC plans to monitor the revisions over the next several months to ensure scoring is consistent.

For example, IC.02.02.01 was previously scored on the finding of visible bioburden and dried blood of instruments. Now surveyors will cite hospitals if the wiping or flushing of soiled instruments isn’t observed during a case in the operating or procedure room and it’s clinically appropriate, or if an item that’s ready to be used on a patient is visibly soiled.

Standard findings recorded before September 1 will not be removed. Hospitals that are in the clarification window or preparing an Evidence of Standards Compliance report should document their compliance with the revised scoring guidelines.

FDA warning on surgical fires

This summer, FDA issued an alert reminding healthcare professionals and facility staff of “factors that increase the risk of surgical fires on or near a patient.” The agency also recommended practices to reduce the occurrence of surgical fires, including “the safe use of medical devices and products commonly used during surgical procedures.”

The alert is targeted at healthcare professionals involved in surgical procedures—such as surgeons, surgical technicians, anesthesiologists, anesthesiologist assistants, certified registered nurse anesthetists, physician assistants, and nurses—and staff responsible for patient safety and risk management.

“Although surgical fires are preventable, the FDA continues to receive reports about these events,” read the alert. “Surgical fires can result in patient burns and other serious injuries, disfigurement, and death. Deaths are less common and are typically associated with fires occurring in a patient’s airway.”

This report comes 13 months after the FDA warned that certain lithium battery–powered medical carts had been overheating, igniting, smoking, burning, or exploding. In some cases, firefighters have had to bury medical carts to put out the flames.

When fires break out

ECRI Institute estimates that, based off the nonprofit research organization’s reporting data from Pennsylvania that has been scaled to encapsulate the entire country, there are between 90 and 100 surgical fires in the U.S. every year, down from 550–650 in 2007. ECRI Institute estimates that about 10%–15% of these surgical fires are major, leading to serious injuries or disfiguration.

In 2016, a man in Florida was getting a cyst removed from his forehead when a surgical tool caught cloth on fire during surgery, causing third-degree burns on his face, according to a news report. Another news report out of Chicago said that in 2012, a man having a catheter implanted in his chest suffered surgical fire burns so painful that he “prayed to God to just let me die.”

In rare cases, as the FDA noted, surgical fires can be fatal. For example, a 65-year-old woman undergoing surgery at an Illinois hospital in 2009 died six days after being burned during a “flash fire” in the OR.

It’s not just patients who can be harmed. Healthcare workers are also at danger of being injured when surgical fires occur. Plus, medical equipment and devices are at risk of damage, too.

Fire starters

“A surgical fire can occur when all elements of the fire triangle are present,” Scott Lucas, PhD, PE, director of ECRI Institute’s Accident and Forensic Investigation team, explained via email. Those three elements, he wrote, are a fuel, such as drapes, gauze, breathing tubes, or prepping agents; an oxidizer, such as oxygen or nitrous oxide; and an ignition source, such as a laser or electro-surgical pencil.

“Procedures involving the face, head, neck and upper chest (above the xiphoid) are of the greatest risk, particularly in the presence of supplement oxygen,” Lucas wrote in the email.

Lucas also noted that more than 70% of surgical fires involve oxygen enrichment, which OSHA defines as any atmosphere that contains more than 22% oxygen. He added that “alcohol-based prepping agents also pose a high risk of fire if the agent has not dried prior to beginning the procedure.” The recommended drying time for prepping agents should be listed in product instructions, Lucas wrote.

In its alert, the FDA wrote that it “reviews product labeling for drugs and devices that are components of the fire triangle to ensure the appropriate warnings about the risk of fire are included.”

Increased oversight means more pressure on AOs

Expect CMS to continue to put pressure on The Joint Commission (TJC) and other accrediting organizations (AO) to find more of the serious fire safety and infection control issues the federal agency says they are still missing during surveys.

Also, you may find CMS surveyors showing up soon with your AO team. But they won’t be there to watch you. They’re going to be watching the watchers, as a part of a pilot program that could potentially end the 60-day validation survey process.

In a new report to Congress, CMS says the disparity rate between serious problems identified by the AOs and those found by CMS surveyors within 60 days of survey was 46% in fiscal year 2016, up from 38% and 39%, respectively, in the two preceding fiscal years.

Most of those disparities were in infection control and physical environment, which includes fire safety violations.

Fiscal year 2016 began on October 1, 2015, and ended September 30, 2016, about a month before CMS began enforcing compliance with the 2012 editions of the NFPA 101 Life Safety Code® (LSC)  and NFPA 99 Health Care Facilities Code on November 1, 2016.

Both fire codes were adopted by CMS in June 2016 after more than a decade of requiring hospitals to adhere to the 2000 version of the LSC. Although long warned that the change was coming, many hospitals scrambled to play catch-up to the new requirements, as did AOs that had to update standards.

CMS is required by regulation to evaluate how its approved AOs do their jobs and must report to Congress every year. After last year’s report was highly critical of AO performance, TJC and other AOs stepped up their efforts to find problems and are likely to do so again, say consultants.

In addition, the Senate Energy and Commerce committee earlier this year announced it was seeking answers from each of the hospital AOs about patient safety.

CMS evaluates AOs based on their ability to meet certain quality measures, including providing information back to CMS on problems found at hospitals in a timely fashion, and by conducting what it calls validation surveys in which CMS inspectors conduct a second survey within 60 days of an AO survey.

In those validation surveys, CMS state survey agency inspectors look for any problems in which a hospital fails to meet federal Conditions of Participation, which allows the facilities to bill Medicare. CMS assumes those condition-level problems were present during the AOs survey, and that is marked against the AO as a missed deficiency.

Consultants and others have noted that the practice of doing validation surveys as long as 60 days after an AO visit is unfair because the condition-level problem identified later might not have existed when AO teams were on site.

On October 4, CMS announced several changes it says will make hospital patient safety and accountability more transparent for the public, including posting deficiency reports online for hospitals where it identifies condition-level problems.

Executive Briefings: Joint Commission Surveyor Focus Remains on EC, LSC, Ligature Risks

Highlight the zip codes where employees live so you can have a handy reference of where staff is available in emergencies, keep policies consistent and updated with the most relevant references, and focus suicide prevention efforts on making your physical environment ligature-resistant.

Those were some of the top takeaways for environment of care and other healthcare and quality professionals attending The Joint Commission’s (TJC) annual Hospital Executive Briefings held September 14 in New York City. The state of healthcare “is not good,” said Ana Pujols McKee, MD, TJC’s chief medical officer, rattling off uncomfortable facts such as the U.S.’s rising maternal mortality rate and that medical errors are the third leading cause of death. She urged attendees to accept nothing less than achieving zero harm in their hospitals and facilities.

Attendee Brian Pitt, safety director of SUNY Downstate Medical Center said his biggest takeaway from the briefings was that there are a lot of opportunities to make changes and improve. That was particularly true for the areas of environment of care and infection control, which never seem to get full administrative support, he noted. Among other things, the briefing taught him the need for consistency in what organizations — such as the CDC or the Association for the Advancement of Medical Instrumentation — you reference in your hospital policies.

“These policies can be used against us if you don’t keep it consistent and follow a consistent national standard,” said Pitt.

Here are some brief highlights from the day’s topics:

1. Suicide Prevention and Ligature Risk

Emily Wells, CSW, MSW, TJC’s project director, surveyor management and development, said that the accreditor has realized that no environment can be “ligature free,” so it’s changed the terminology to “ligature resistant.” That said, you still need to do risk assessments and have protocols to keep patient safe including removing as many ligature risks from a patient room as reasonably possible.  Facilities should pay extra attention to standard EC.02.06.01 EP 1 which was the most cited standard related to Immediate Threat. The standard requires hospitals to maintain a safe environment and EP 1 RFI include self harm risks like door hinges, beds, and drop ceilings.

Kathryn Petrovic, MSN, RN-BC, TJC field director of surveyor management and development, stressed was the need to test ligature resistant products to ensure they’re properly installed. Buying special anti-pinch point doorknobs doesn’t matter if they’re put in the wrong way, seize up and create a ligature risk, she says.  Surveyors test to see if your products work, not that you have them. And improperly installed equipment can result in a patient hurting themselves on something you thought was safe.

2. Emergency Management

Jim Kendig, MS, CHSP, CHCM, CHEM, LHRM, field director of surveyor management and development, recommends facilities run zip code tests to determine where most of their employees live. Most staff won’t come to work in during an emergency if their homes and family are in the affected area. Doing a zip code test can tell you ahead of time if you’ll need to call in help from other facilities.

Kendig also said security staff should work with local law enforcement on what to do in the event a hospital becomes a crime scene. There have been cases where a crime was committed in a hospital and police prevented hospital staff from re-entering the facility or move between rooms. That’s a possibility that needs to be dealt with before it happens, he said.

3. Physical Environment 

Kenneth A. Monroe, PE, CHC, PMP, TJC director of engineering, started off the physical environment and environment of care section with a look at Legionella. There have been multiple cases of the bacteria in hospitals, he said, and facilities need to be vigilant to protect their patients.

He also noted that 98% of all surveyed hospitals had at least one finding in the EC chapter, with ligature risks as the leading driver of Immediate Threat findings. However, the most common EP finding in the red category was EC.02.02.01 EP 5 — hazardous material handling and storage.

Ninety-seven percent-of hospitals had a finding in the Life Safety chapter, with LS.02.01.35 (sprinklers) being the most cited. Facilities don’t clean their sprinklers, test them, or put things that block the spray. Easy ways to get a finding. That said, only about 12% of LS findings were in the moderate or high risk range, with LS.01.02.01 EP 1 (No ILSM policy) being the most common high risk finding.