Author Archive for: Brian Ward

CMS updates its surveyor’s manual for first time in more than a year

January 13th, 2020 Email This Post Print This Post

Just in time for the holidays, CMS is offering the gift of a newly revised State Operations Manual (SOM), one of the first significant overhauls in more than a year, especially for hospitals. Expect updated standards from accrediting organizations (AOs) to follow.

The updated interpretive guidelines for CMS surveyors includes most—but not all—of the new or revised Conditions of Participation (CoP) for discharge planning and burden reduction outlined in two final rules published in September.

There are revisions for the SOM appendices to the interpretive CoP guidelines are for hospitals, psychiatric hospitals, home health agencies,  portable x-ray units, rural health clinics and federally qualified health centers (RHC/FQHC), end stage renal disease facilities (ERSD), comprehensive outpatient rehabilitation facilities, ambulatory surgical centers, hospice care,  religious nonmedical healthcare institutions, critical access hospitals (CAH), organ transplant programs and emergency preparedness.

The updates were published December 20, in a 608-page memo from CMS Quality, Safety & Oversight Group to CMS’ state regional offices and state survey agencies, as well as AOs. The memo can be found here:

While the two final rules were for the most part effective on November 29, 2019, the memo does note that changes regarding antibiotic stewardship programs for hospitals and CAHs, are not effective until March 30, 2020, and regulations quality assessment and performance improvement programs (QAPI) are not effective until March 30, 2021.

The revised interpretive guidelines for antibiotic stewardship and QAPI are expected in the spring, says CMS.

The final rules were “Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction” (CMS 3346-F) and “Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies” (CMS 3317-F).

Other changes in this SOM release, as outlined in the Dec. 20 memo, include:

“• CAH- Revisions to Appendix W also include renumbering the C-Tags; inserting regulations §485.601, §485.603, §485.604, and §485.606; and inserting the CAH Distinct

Part Unit and Emergency Medical Treatment and Labor Act (EMTALA) C-Tags for reference. The changes also include updates to the Life Safety Code (LSC).

• Hospital/CAH/RHC/FQHC- Detailed requirements of United States Pharmacopeia (USP) have been removed from Appendices A, G, and W accordingly, as CMS requires compliance with applicable Federal and State law and adherence to accepted general standards of practice or guidelines for pharmaceutical services and medication administration issued by nationally recognized professional organizations.

• Psych Hospitals- The Special Conditions of Participation (CoPs) for the regulations §482.60 through §482.62(g)(2) psychiatric hospitals have been moved from the SOM Appendix AA to the SOM Appendix A. Appendix AA is being deleted as surveyors will now refer to Appendix A.

• Transplant Programs – Requirements at §482.82 that state that transplant centers must meet all data submission, clinical experience, and outcome requirements for Medicare reapproval have been removed. In addition, the special procedures for re-approval at §488.61 (f) through (h) is revised to remove the requirements with respect to the reapproval process for transplant centers. The change corresponds to the remove of the provisions at §482.82.

• ESRD Facilities: Appendix H updates the regulatory text based on requirements set forth in the 2008 Conditions for Coverage for ESRD Facilities and also includes revisions based on recent Federal regulation changes set forth in “Fire Safety Requirements for Certain Dialysis Facilities (CMS–3334–P).

• RHC/FQHC – Revisions to Appendix G include updates to regulatory text and interpretative guidance for both §491.9(b)(4) and §491.11(a) changing the requirement for an annual review to a biennial review.”

CMS officials say they are also developing online training for its surveyors on the revisions.

Sections of the main SOM have been revised over the last months and years, as have the individual appendices for each organization type that must adhere to the CoPs. The appendix for hospitals, for instance, was last updated online in October 2018. However, the appendix for ambulatory surgical centers has not been updated online since 2014.

Other sections have been added, such as Appendix Z on emergency preparedness, while the appendix for swing beds was deleted and folded into requirements for hospitals and CAHs.

The opening sections of the manual can be found online here:

The appendices can be found here:

Indiana Hospital: Sterilization Issue Put 1,200 Patients at Risk of Infection

December 2nd, 2019 Email This Post Print This Post

Patients who underwent surgery at Goshen (Indiana) Hospital between April 1 and September 30 may have been exposed to dangerous diseases after a breakdown in the facility’s surgical instrument sterilization process.

The Goshen News reported this week that the hospital sent a letter to affected patients earlier this month, announcing that one of the hospital’s seven surgical instrument sterilization technicians failed to complete one of the steps required in the sterilization process with certain instruments. This potentially exposed surgical patients to a variety of infections, including hepatitis C, hepatitis B, and HIV.

“The surgical instruments in question were still treated with our usual chemical disinfection and machine sterilization processes which include a wide margin of safety; however, such instruments may or may not have been completely sterile,” according to the letter, which was quoted by the paper. “While we believe the risk is extremely low, out of the utmost caution, we want to notify you that it is possible that this action may have exposed you to infections. To be very conservative, we want to offer patients free lab testing services to verify the absence or presence of any of these viruses.”

A hospital official told the newspaper that a total of 1,182 surgical patients may have been exposed to disease, but did not say whether any have tested positive for any diseases.

Goshen Hospital Chief Operating Officer Daniel Nafziger told the paper that the hospital took quick action to address the issue.

“As with any patient safety concern, we rigorously investigated all aspects around the incident,” Nafziger said. “We have put strict policies and additional safety measures in place to ensure it does not happen again. We also want to express our concern for each of these patients.”

Proper sharps management in senior living helps reduce risk for needle stick injuries

November 12th, 2019 Email This Post Print This Post

The following article is an excerpt from HCPro’s book Disaster Planning, Infection Control, and OSHA Compliance: A Toolkit for Senior Living, written by Karen T. Stratoti, RN, BSN, LNHA, CALA

In the senior living environment, many of the residents come in with their own ways of handling their needles and syringes. It is not uncommon to find medical waste sharps in empty tin coffee cans, used needles placed in large baggies, and used needles and syringes stored in laundry detergent containers. Many times, residents do not come into the facility with a proper disposal system. Facility administrators must make sure that the residents get the proper container for needle and syringe disposal, and that residents are given an inservice on how to use these containers to avoid staff getting a needle stick injury.

How should sharps containers be handled?

Each sharps container must either be labeled with the universal biohazard symbol and the word biohazard, or be color-coded red. Sharps containers must be maintained upright throughout use, replaced routinely, and not be allowed to overfill. Also, the containers must be:

  • Closed immediately prior to removal or replacement, to prevent spillage or protrusion of contents during handling, storage, transport, or shipping;
  • Placed in a secondary container if leakage is possible.

The second container must be:

  • Closable,
  • Constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping; and
  • Labeled or color-coded according to the standard.

Reusable containers must not be opened, emptied, or cleaned manually or in any other manner that would expose employees to the risk of percutaneous injury.

Upon closure, duct tape may be used to secure the lid of a sharps container, as long as the tape does not serve as the lid itself.

Where should sharps containers be located?

Sharps containers must be easily accessible to employees and located as close as feasible to the immediate area where sharps are used (e.g., resident care areas, resident apartments). If a mobile cart is used in these areas, an alternative would be to lock the sharps container in the cart.

What type of container should be purchased to dispose of sharps?

Sharps containers are made from a variety of products, from cardboard to plastic. As long as they meet the definition of a sharps container (i.e., containers must be closable, puncture resistant, leak proof on sides and bottom, and labeled or color-coded), OSHA would consider them to be of an acceptable composition.

For tools and interactive training activities to improve safety and satisfaction in your facility, click here.

This story originally ran in Post-Acute Advisor, a free, weekly e-newsletter focused on delivering information, education, and guidance on complex topics such as MDS and care planning to help long-term care administrators and managers, reimbursement professionals, and clinical staff members break down confusing regulations into easy-to-understand processes and procedures.

LeapFrog Releases Biannual Hospital Safety Grades

November 7th, 2019 Email This Post Print This Post

By John Commins

One third of the 2,600 general, acute care hospitals across the nation rated in The Leapfrog Group’s fall 2019 Hospital Safety Grades got an ‘A,’ grade, while 1% flunked, the patient safety monitors said.

Leapfrog grades are based upon process and structural measures such as hand hygiene, risk mitigation, and discharge communication, as well as outcome measures such as falls, pressure ulcers, and infections.

The safety ratings’ release coincides with the 20th anniversary of the Institute of Medicine’s shocking report, To Err Is Human, which showed that nearly 100,000 people die every year due to preventable medical errors. Other research has shown that number could be twice as high.

“The findings of the IOM report, published two decades ago, laid the foundation of what The Leapfrog Group stands for today,” said Leah Binder, president and CEO of The Leapfrog Group. “In stark contrast to 20 years ago, we’re now able to pinpoint where the problems are, and that allows us to grade hospitals.”

“It also allows us to better track progress. Encouragingly, we are seeing fewer deaths from the preventable errors we monitor in our grading process,” she said.

Among the findings:

  • More than 2,600 hospitals graded with the breakdown as follows: 33% earned an “A,” 25% earned a “B,” 34% earned a “C,” 8% a “D” and just under 1% an “F.”
  • The five states with the highest percentages of “A” hospitals are: Maine (59%), Utah (56%), Virginia (56%), Oregon (48%) and North Carolina (47%).
  • There are no “A” hospitals in three states: Wyoming, Alaska and North Dakota.
  • Notably, 36 hospitals nationwide have achieved an “A” in every grading update since the launch of the Safety Grade in spring 2012.

Earlier this year, Leapfrog commissioned the Johns Hopkins Armstrong Institute for Patient Safety and Quality to update its estimate of deaths due to errors, accidents, injuries and infections at “A”, “B”, “C”, “D” and “F” hospitals.

The study estimated that 160,000 lives are lost each year from the avoidable medical errors identified in the Leapfrog Hospital Safety Grade, down from 205,000 avoidable deaths in 2016.

The Johns Hopkins analysis found that “D” and “F” hospitals have nearly twice the risk of mortality of “A” hospitals, and that more than 50,000 lives could be saved if all hospitals performed at the level of “A” graded hospitals.

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

Wildfire Preparation Tips for Your Organization

October 28th, 2019 Email This Post Print This Post

By Christopher Douyard, EHS Daily Advisor

Wildfires can happen at any time, though changes in land use combined with the steady and continuing rise of global temperatures over the past decades have helped create the perfect environmental conditions for them to thrive. To compound the problem, more and more people are living and working in communities where the risks posed by wildfire are most severe. It’s imperative that your facility takes every precaution to ensure that it doesn’t become another casualty of these increasingly common natural disasters.

The good news is that despite a great cause for concern, there are steps that you can take to assess and protect your buildings in advance. Here are some tips to help you prepare in the event that a wildfire threatens your organization.

Assess Your Facility’s Current Risk

There are several factors to consider when determining the potential risk for wildfire damage at your facility’s site. Foremost, it is important to understand the conditions at your facility, including weather patterns, types of local vegetation, and topography. Some regions are more fire prone than others, though there are a few key factors that apply, regardless. During your initial visual assessment, take note of the following:

  • The presence of wild vegetation, including wild grasses, brush, and timber, as these can be highly combustible. However, vegetation used in landscaping can be equally combustible.
  • Plants with a higher probability of combustion:
    • Contain volatile oils or resins. These are typically aromatic;
    • Have long and/or narrow leaves or needles;
    • Have leaves that are fuzzy or waxy;
    • Have loose or paper-like bark; and
    • Will have dead plant material accumulating beneath them.

Keep in mind that wildfires move both horizontally and vertically. Some of the most devastating fires start on the ground and then travel to bushes and shrubs, where they can then move into treetops or to a roofline. Take note of tall shrubs or overhanging tree branches near your facility or its outbuildings.

Also, recognize that these factors work in reverse. A fire that starts inside your facility can easily spread from your building by jumping to nearby vegetation, from which it can spread outward into the community.

Create a Defensible Space

Once you’ve assessed the vertical and horizontal risks posed by the vegetation and outbuildings adjacent to your building(s), you must create a defensible space around them. This space should consist of three nested zones, each with a unique set of requirements.

Zone 1: within 30 feet (ft) of facility

  • Remove all combustible materials, such as fire-prone vegetation, firewood, furniture (such as picnic tables), and/or lumber decking.
  • Remove combustible litter from the roof and/or gutters.
  • Trim branches that overhang your facility.

Traditionally, the landscaping closest to a building helps keep the facility attractive and inviting to workers, clients, and the community, but it should also be as fire-resistant as possible. For example, plant drought-resistant native plants that are low maintenance instead of ornamental species, and any lawn needs to be well-irrigated. Hardscapes are also good in Zone 1, and features like stone, gravel, or otherwise paved walkways can serve as firebreaks across the property. Using crushed stone rather than mulch for beds that are placed up against the building will also help mitigate the risk of fire reaching the building.

Zone 2: between 30 and 100 ft from facility

  • Incorporate hardscape features into your property to act as firebreaks.
  • Plant fire-resistant vegetation, and limit trees to individuals or small clusters.
    • Prune dead or dying branches regularly, and be sure to remove them.

In addition, any outbuildings located on the property should be placed in Zone 2 and should be a minimum of 50 ft from your facility if they are used to store combustible materials. Double-check your state and local building codes to make sure any fuel tanks are properly located at the minimum required distance (if not farther) from the building. If they are required to be above ground, make sure they are placed on a noncombustible pad.

Zone 3: more than 100 ft from facility

The health of the vegetation should be the maintenance focus in Zone 3. Though the trees may be more densely packed, especially if your facility is in a relatively unpopulated area, you should still prune and remove any dead or dying branches. Be sure to prune both horizontally and vertically to help minimize the potential for fire to spread.

While you don’t need to “rake the forest,” remove any larger concentrations of dead materials from the ground.

Other Steps to Consider

If you have any questions or concerns about how a wildfire event would impact your facility, first and foremost, you should reach out to your local fire department, state fire agency, or a qualified fire management specialist for an on-site consultation. Any of them can help you assess your facility’s risk and help prepare a plan for addressing issues. You could also reach out to your local planning and zoning office if you’re unsure about requirements in your area.

It’s also important to keep in mind that any codes or requirements represent the minimum effort that you should incorporate into your facility. If your building(s) are located in an area with an elevated wildfire risk, it doesn’t hurt to spend a little more on design, materials, and maintenance that could be the difference between keeping your facility safe or having to make a very expensive insurance claim.

Top 10 Medical Technology Hazards for 2020 Announced

October 24th, 2019 Email This Post Print This Post

By Christopher Cheney, HealthLeaders Media

Surgical staplers are the top medical technology hazard for 2020, according to the ECRI Institute.

Twenty years after publication of the Institute of Medicine’s landmark report To Err is Human: Building a Safer Health System, patient safety remains a significant concern for the healthcare sector. The Institute of Medicine report estimated 98,000 Americans were dying annually due to medical errors. Estimates of annual patient deaths due to medical errors have since risen steadily to 440,000 lives, which make medical errors the country’s third-leading cause of death.

Earlier this year, the U.S. Food and Drug Administration published an analysis of more than 109,000 adverse stapler incidents from 2011 to 2018, including 412 deaths and 11,181 serious injuries.

“Injuries and deaths from the misuse of surgical staplers are substantial and preventable. We want hospitals and other medical institutions to be in a better position to take necessary actions to protect patients from harm,” Marcus Schabacker, MD, PhD, president and CEO of the Plymouth Meeting, Pennsylvania-based ECRI Institute said this week in a prepared statement.

The following is the ECRI Institute’s Top 10 list of medical technology hazards for 2020.

1. Surgical staplers:  

“Consequences of a staple line failing or staples being misapplied can be fatal. Patients have experienced intraoperative hemorrhaging, tissue damage, unexpected postoperative bleeding, failed anastomoses, and other forms of harm,” an ECRI Institute executive report released this week says.

Most surgical stapler adverse incidents are linked to human error such as picking an incorrect staple size and clamping on tissue that is too thick or too thin, the executive report says. ECRI Institute’s recommendations for safe use of surgical staplers include hands-on practice with specific staplers that are used in healthcare settings.

2. Point-of-care ultrasound:

“A lack of oversight regarding the use of point-of-care ultrasound (POCUS)—including when to use it and how to use it—may place patients at risk and facilities in jeopardy,” the executive report says.

Although POCUS has been established as a valuable technology for diagnosis and guiding interventional procedures, safeguards are insufficient at many healthcare facilities, the executive report says. “Safeguards for ensuring that POCUS users have the requisite training, experience, and skill have not kept pace with the speed of adoption.”

Recommendations for POCUS safety include user training and credentialing, exam documentation, and data archiving.

3. Infection risks from sterile processing:

“Insufficient attention to sterilization processes in medical offices, dental offices, and some other ambulatory care settings can expose patients to contaminated instruments, implants, or other critical items,” the executive report says.

Physician practice offices and dental offices are high-risk locations because they often do not have the sterilization resources found in hospitals, the executive report says. Recommendations to improve sterile processing in these settings include designating a qualified staff member to support infection prevention and control practices.

4. Hemodialysis risks with central venous catheters in the home health setting:

“Many hemodialysis patients receive treatment through a central venous catheter (CVC) well beyond the period when transition to another form of vascular access is recommended. And the U.S. federal government recently announced a push to increase the use of home treatment for kidney disease patients,” the executive report says.

CVCs are often placed through the jugular vein and can result in severe adverse events such as infection, clotting, and disastrous blood loss if there is a disconnection. “Family members or other caregivers may be ill-equipped to manage the risks or to respond when a CVC problem occurs. The possibility that an increasing number of patients with CVCs might receive hemodialysis in the home raises concerns,” the executive report says.

5. Surgical robotic procedures:

“While the use of surgical robots in innovative ways or for new procedures can help advance clinical practice, such uses can also lead to injury or unexpected complications and the potential for poorer long-term outcomes,” the executive report says.

Although robots have benefits during surgical procedures such as improved dexterity and tremor reduction, they have drawbacks, including limited tactile feedback for forces exerted on tissue, the executive report says. Recommendations for safe use of surgical robots in new procedures include training, credentialing, and privileging operating room staff in the new applications.

6. Alarm, alert, and notification overload:

“More than ever before, clinicians have to divide their attention between direct patient care tasks and responding to prompts from medical devices and health IT systems. As the number of devices that generate alarms, alerts, and other notifications increases, so too does the risk that the clinician will become overwhelmed, creating the potential for a clinically significant event to go unaddressed,” the executive report says.

Recommendations to address alert overload include decreasing overall notification burden and helping clinical staff to develop critical thinking skills to ease cognitive overload.

7. Cybersecurity risks in the home health setting:

“Remote patient monitoring technologies are increasingly being used for at-home monitoring to help clinicians identify deteriorating patients before they require hospitalization. As network-connected medical technologies such as these move into the home, cybersecurity policies and practices that address the unique challenges involved must be instituted,” the executive report says.

8. Missing implant data for MRI scan patients:

“Patients presenting for magnetic resonance imaging (MRI) studies must be screened for implanted devices to avoid harm. Some implants can heat, move, or malfunction when exposed to an MRI system’s magnetic field. Thus, MRI staff must identify and follow any contraindications or conditions for safe scanning prescribed by the implant manufacturer,” the executive report says.

Recommendations include creating implant lists in patients’ electronic medical records.

9. Medication errors from dose timing discrepancies in electronic medical records:

“Missed or delayed medication doses can result from discrepancies between the dose administration time intended by the prescriber and the time specified within the automatically generated worklist viewed by the nurse,” the executive report says.

10. Loose nuts and bolts in medical devices:

“The nuts, bolts, and screws that hold together medical device components can loosen over time with routine use. Failure to repair or replace loose or missing mechanical fasteners can lead to severe consequences: Devices can tip, fall, collapse, or shift during use—any of which could lead to patient, staff, or bystander injury or death,” the executive report says.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.

Crisis communication: 10 tips for hospitals to prepare for a disaste

October 21st, 2019 Email This Post Print This Post

By Jody Moore, PSQH

Hurricanes, floods, fires, and other natural and manmade incidents can strike anytime, anywhere. Faced with such disasters, hospitals must not only respond to the emergency but also maintain continuity of patient care under the most trying circumstances imaginable.

What can your hospital do to be better prepared when the next crisis hits? How can you minimize the physical, psychological, and emotional stresses that can overwhelm staff and patients? What strategies, resources, and practices can you deploy when a natural disaster cripples the technological systems needed for essential functions?

Several hospital leaders with firsthand experience in crisis management shared insights on how to address communication issues—a core element of emergency preparedness—in a discussion I moderated at the annual Voalte User Experience conference (VUE18). The panelists included:

  • Scott McCarty, unified communications manager at Tampa General Hospital, who is a member of its Emergency Preparedness/Disaster Planning committee and helped the hospital prepare for Hurricane Irma in 2017
  • Roberta Romeo Shannon, project manager of strategic projects and clinical systems at UConn Health in suburban Hartford, which recently opened a new hospital tower that gave staff the experience of evacuating inpatients similar to what would happen during an emergency
  • Keith Turner, manager of clinical enterprise systems at Texas Children’s Hospital in Houston, who was on-site in 2017 when the Category 4 storm Hurricane Harvey made multiple landfalls and caused massive flooding and $125 billion in damage statewide

The following are 10 practical tips from this discussion that can help hospitals be better prepared to communicate during a crisis:

1. Understand and comply with CMS regulations on crisis communication preparation

Hospitals, along with multiple other provider types, must comply with CMS’ Emergency Preparedness rule to participate in the Medicare or Medicaid program. Developing and executing a communication plan is one of the rule’s four core elements, and the plan should include:

  • Compliance with federal and state laws
  • A comprehensive method to contact staff, including patients’ physicians and other necessary persons
  • Well-coordinated communication within the facility, across healthcare providers, and with state and local public health departments and emergency management agencies

2. Establish one available and secure endpoint to simplify emergency communication

When developing an emergency plan, it’s important to consider all the hospital’s systems and endpoints that people use and how those systems are integrated. Also keep in mind that nurses and staff could be working anywhere in the hospital and may not have access to their desk phones.

According to McCarty, “We’re getting away from pagers by using an SMTP setup that gives us a bridge to funnel communications to our Voalte smartphone platform endpoint. This means that one operator can then quickly send an emergency code without logging in to multiple systems.”

3. Prepare to be home alone

Flooding, power outages, and impassable roads can cut off connections to the outside world. When Hurricane Irma was bearing down in 2017 on the island where Tampa General is located, the hospital faced the possibility of being physically isolated from the rest of the city.

Since it couldn’t rely on the internet, Tampa built redundancies into its core on-premise Wi-Fi network, including data recovery servers. It has backup generators on the island and diesel fuel for four days, with more available if needed. Core switches are located on higher floors in case of flooding. These redundancies ensure that Tampa can continue running its Voalte communication platform if it is ever cut off from the mainland.

4. Use mobile technologies to track and connect patients

Federal regulations require that hospitals’ emergency preparedness programs include systems to track the location of on-duty staff and sheltered patients in the hospital’s care during an emergency. Hospitals must be able to quickly reunite families with their loved ones, which can be especially challenging on sprawling campuses with millions of square feet of space.

One solution is to use apps that enable physicians, nurses, and staff to take pictures using a smartphone linked to a secure communication platform. These pictures can be stored temporarily on hospital servers and prevented from being uploaded or sent to anyone without access to the platform.

5. Be flexible and redundant, and don’t forget low-tech and old-tech alternatives

The urgency and frequency of alarms, messages, and other patient communications don’t abate just because a network shuts down. Hospitals need backup communication solutions to ensure the continuity of patient services.

“If there’s a system outage, we’ll employ different communications, such as a ticker on our intranet page,” said Turner. “We also keep a directory of phone numbers that can be used for ‘phone tree’ communications and can still pull out walkie talkies if needed.”

At Tampa General, McCarty became interested in ham radio as a result of Irma. The hospital now has a ham radio in its command center with an antenna on its roof as well as three iridium satellite phones—two at the hospital and the other at a large outpatient facility that has a freestanding ED and a helipad.

6. Build muscle memory with training drills

When a crisis happens, chaos and confusion supplant the natural order of everyday routines. To ensure that hospital staff are prepared to function in these high-stress situations, CMS requires facilities to demonstrate completion of two emergency exercises per rolling 12-month interval. Regulations also currently require hospitals to update their training and testing methods at least once a year.

The panelists emphasized that routinely conducting these drills several times a year builds much-needed “muscle memory” that enables the staff to react reflexively in high-stress situations. At Tampa General, each unit has its own downtime plan and downtime boxes that are routinely updated.

Four more tips

  • Ensure IT and communication leaders are included on disaster planning committees
  • Align communication policies with current technologies, clinician and patient needs, and various disaster scenarios, including active shooter events
  • Keep an extra supply of smartphones on hand and strategically place them in certain units for use only in an emergency
  • Don’t put all your eggs in one basket; always have a plan B, C, and D

Final word

Ultimately, crisis communication is all about meeting the needs of staff, patients, and their caregivers. As Shannon pointed out, “Our priority during any emergency is to support and connect the people who are doing the most important work. We may find ourselves swirling around trying to get everything right, but our focus should always be helping all those who are caring for patients.”

Jody Moore is co-founder and principal partner of Crisis Focus, an emergency management consulting company for healthcare providers.

In-hospital delirium predictive of readmission, discharge to postacute facilities, ER visits

October 18th, 2019 Email This Post Print This Post

By Christopher Cheney, HealthLeaders Media

In-hospital delirium is a predictor of readmission, emergency department visits, and discharge to a location other than home, recent research shows.

The development of delirium in the hospital setting impacts about 12.5% of general medical admissions and as many as 81% of intensive care unit patients. Earlier research has shown delirium among hospitalized patients is predictive of prolonged hospital length stay, lengthened mechanical ventilation, and mortality.

The recent research in the Journal of Hospital Medicine featured data collected from more than 700 delirious patients and nearly 8,000 non-delirious patients. The researchers found delirious patients had increased odds for 30-day readmissions, ED visits, and discharge to postacute care facilities.

“These results suggest that patients with delirium are particularly vulnerable in the posthospitalization period and are a key group to focusing on reducing readmission rates and post-discharge healthcare utilization,” the researchers wrote.

Link between in-hospital delirium and readmissions

The Journal of Hospital Medicine research builds on earlier studies about in-hospital delirium, the lead author of the research told HealthLeaders.

“Prior studies have shown that delirium is associated with functional decline at discharge, so these patients may be particularly vulnerable in the days and weeks following hospital discharge. Our work helps to confirm this as we show that patients who become delirious in the hospital are far more likely to be readmitted within 30 days of discharge, compared with patients who do not develop delirium,” said Sara LaHue, MD, a resident physician at the Department of Neurology, School of Medicine, University of California San Francisco.

The new research indicates that hospital-based interventions should be targeted at delirious patients to reduce readmissions, she said. “Hospital-based interventions that reduce the development of delirium may then reduce the complications of delirium, such as readmission.”

Reducing delirium-associated postacute care service utilization

To avoid hospital readmissions linked to delirium, clinicians should focus on preventing patients from becoming delirious in the hospital, LaHue said.

“This may include systems for identifying patients at high risk of becoming delirious, screening for active delirium, and enacting interventions that target the underlying cause in order to reduce the severity or duration of delirium. While such a program can take a bit of work to get off the ground, the benefits for patients, their families, and the hospital system can be significant.”

One team member who is often overlooked is the caregiver at home, she said.

“Educating caregivers about delirium risk factors can be very helpful—he or she can bring glasses or hearing aids from home, engage the patient in meaningful conversation to help with orientation, and encourage regulation of sleep-wake cycles. If a patient does become delirious, the caregiver can continue to help with these interventions.”

Caregivers at home are an essential component of postacute care, LaHue said.

“We know that delirium is associated with functional decline at discharge, so coordinating safe discharge plans with the caregiver, especially to identify need for resources—physical therapy, occupational therapy, home health, and nursing—can potentially help reduce post-discharge complications.”

Follow-up care is another crucial factor, she said. “Ensuring expedited follow-up with a primary care provider, who can assess for any additional needs, is also important.”

Multidrug-resistant infections can cost $4,600 per hospital stay

October 16th, 2019 Email This Post Print This Post

By Christopher Cheney, HealthLeaders Media

Infections linked to multidrug-resistant organisms (MDROs) cause a significant cost burden for U.S. healthcare, recent research shows.

The development of antibiotic-resistant infections is one of the most severe public health problems in the country, according to the Centers for Disease Control and Prevention. About 23,000 Americans die annually from an antibiotic-resistant infection, the CDC says.

The national price tag for treating infections linked to MDROs in the hospital setting is at least $2.39 billion, according to the recent research, which was published in the journal Health Services Research.

The researchers also tallied the treatment cost per inpatient hospital stay for methicillin-resistant Staphylococcus aureus (MRSA)Clostridium difficile (C. difficile), and other MDROs.

  • Treatment of infection with MRSA cost about $1,700
  • Infection with C. difficile cost about $4,600
  • Infection with another MDRO cost about $2,300
  • Infection with multiple MDROs cost about $3,500

“We find the highest incremental and total costs for C. difficile and the lowest incremental costs for MRSA, consistent with estimates from previous reports. The higher costs appear to be driven largely by a higher average length of stay, but may also be due to additional testing and increased risk for ICU admission with C. difficile,” the researchers wrote.

In 2014, the President’s Council of Advisors on Science and Technology made several recommendations to combat antibiotic resistance, including surveillance of MDROs in healthcare settings and the community, anti-microbial stewardship campaigns, precautions to limit exposure, and education of patients and physicians about the dangers of overprescribing antibiotics.

Calculating superbug economics

The lead author of the Health Services Research article, Kenton Johnston, PhD, MPH, told HealthLeaders that determining the cost effectiveness of efforts to reduce MDRO infections is challenging.

“Essentially, you are comparing the costs of MDRO-reduction efforts to the savings generated by those efforts. The costs of MDRO-reduction efforts would be the programmatic costs of interventions. This is tricky because the interventions are wide-ranging throughout society such as hand-washing campaigns. The savings part is also tricky because the savings also accrue throughout society,” said Johnston, an assistant professor at the College for Public Health & Social Justice, St. Louis University.

Johnston’s research team only examined hospital costs of efforts to combat MDRO infections.

“A systematic review of the literature on just the cost side of this equation found that the cost of measures to combat and eradicate MDROs ranges from $331 to $66,772 per MDRO-positive patient. This is obviously an unacceptably huge range for calculating the cost side of the equation alone. As a result, more research needs to be done,” he said.

7-Part EMS screening tool boosts early sepsis treatment

October 16th, 2019 Email This Post Print This Post

By Chris Cheney, HealthLeaders Media

Emergency medical service screening for sepsis speeds administration of the Surviving Sepsis Campaign 3-hour bundle of treatment, new research shows.

On an annual basis, sepsis affects about 1.7 million American adults and the infection is linked to more than 250,000 deaths. Timely application of the 3-hour bundle has been associated with reduced mortality.

In the new research, EMS crews conducted sepsis screening of patients before emergency department arrival, a co-author of the study told HealthLeaders.

“We implemented a standard operating procedure for sepsis screening—seven questions for the emergency department RN to ask EMS in any adult patients excluding trauma. When sepsis was suspected, the radio RN would notify the charge nurse to help get them into a room. The key takeaways are that implementing a sepsis screening tool for EMS to use is feasible and it helps to expedite care in these patients,” said Megan Rech, PharmD, MS, an emergency medicine clinical pharmacist and adjunct assistant professor, Department of Emergency Medicine, Stritch School of Medicine, Loyola University, Chicago.

In the primary finding of the research, 3-hour bundle compliance was significantly higher using the EMS sepsis screening tool compared to a control group, 80.0% vs. 44.2%, respectively.

The bundle has four main components: measurement of serum lactate concentration, fluid resuscitation, blood cultures prior to antimicrobials, and broad-spectrum antibiotics for suspected or documented infection.

The EMS sepsis screening tool had seven elements:

  1. Respiratory rate: N20 breaths per minute
  2. Heart rate: N90 beats per minute
  3. Systolic blood pressure: b90 mm Hg
  4. Documented fever or history of temperature: N100.9 °F or b96.8 °F
  5. Onset of mental status change
  6. Oxygen saturation: b90%
  7. Suspected infection

“There is great potential in the pre-hospital setting for earlier recognition of sepsis in patients arriving to the ED via EMS. Early recognition of sepsis will allow medical personnel to initiate sepsis protocol and decrease an important variable in sepsis mortality: time. We demonstrated that the use of a pre-hospital sepsis screening tool was associated with significant improvement in 3-hour bundle compliance, likely due to improved recognition of sepsis,” Rech and her co-authors wrote.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.

The chronic issue of cybersecurity

October 14th, 2019 Email This Post Print This Post

By Suzanne Widup

Healthcare institutions large and small can be left black and blue by a cyberattack. Larger institutions have more patients and thus have more user health records that attackers can compromise. Smaller institutions, on the other hand, may not have the financial resources to protect themselves against an attack or respond to one when it occurs.

In the event of an incident or breach, repairing a security system can take a massive toll on a healthcare institution, costing time, money, and staffing support to remedy. This severely affects the number of patients seen for however long it takes to address and fix the damage, which in turn causes the institution’s finances and reputation to suffer.

Healthcare institutions are vulnerable cyber targets, with thousands of patient records to protect and a federal requirement to comply with HIPAA and HITECH. These institutions lack the staffing (and sometimes the awareness) to prevent personal health data from being accessed and held by threat actors. With the constant demand to see and treat patients, cybersecurity hasn’t always been a top priority for these institutions. But it should be.

The call is coming from inside…

According to Verizon’s 2019 Data Breach Investigations Report, for the second consecutive year, the majority of healthcare cybersecurity breaches in 2018 were attributed to internal (rather than external) threat actors—a skew unique to the healthcare industry. These internal threat actors are typically employees working within healthcare institutions (doctors, nurses, etc.). Though these employees are not always acting out of malice, the major concern here is that they have been granted access to systems to carry out their jobs; thus, they do not need to break into those systems to retrieve or expose classified information.

Across sectors, including the healthcare industry, misdelivery (sending data to the wrong recipient) is the most common error type that leads to data breaches. Typically, these errors involve mailing patient paperwork to the incorrect address, or issuing discharge papers or other private records to the wrong person.

The healthcare sector also suffers from the widespread problem of social attacks. Like many industries, healthcare institutions are under the constant threat of phishing emails that bait unsuspecting recipients to enter personal information, such as email credentials, onto fake sites. The stolen login information is then used to access the user’s cloud-based email account, thus compromising any patient data in the user’s inbox, outbox, or other folders.

Required to report

Unlike other sectors, the healthcare industry is required by law to report ransomware attacks as though they were confirmed breaches due to U.S. regulatory requirements. These attacks tend to make headlines as they disrupt an organization’s ability to carry out its primary function—patient care. While some organizations have resorted to paying the ransom demand, this is no guarantee that the criminals behind the attack will provide a valid key to restore an organization’s data—they may just take the money and run.

So how can healthcare institutions immunize themselves from cyberattacks and breaches? There is no magic pill, but there are precautions that industry leaders can put in place to better protect themselves against inside and outside threats.

Prescriptions for protecting your network

  • Locate the problem areas: Practice good security hygiene by examining the current health of the network. Healthcare institution leaders and administrators should know where their major data stores are, limit necessary access for their employees and staff, and keep track of access attempts to pinpoint weak spots. Certain staff may not need complete access to files and records to perform their jobs, and practitioners can enact low-cost process controls to prevent miscellaneous errors that can erode the cybersecurity of an institution.
  • Make it easier for employees to report issues: Minor errors like phishing can be infectious. Industry leaders should make it easy for their staff to report phishing when it occurs (regardless of whether the staff took the bait) so they can nip issues in the bud and prevent an influx of employees from potentially compromising the network. Leaders can incentivize the process by implementing reward-based motivations for employees to report incidents quickly, thereby limiting the people and information affected.
  • Institute checks and checkups: Have a game plan that focuses on mitigating or preventing incidents and breaches, rather than nursing a security system back to health after an attack has occurred. Institutional leaders need to know which processes deliver, dispose of, or publish personal data and put up checks to ensure that a minor mistake made by an employee does not escalate into a breach. By enacting a plan and conducting regular checkups of mobile and network security, healthcare institution leaders will have a standard by which they can regularly measure the pulse of their performance.

As healthcare institutions become increasingly interconnected, leaders need a plan to address the state of mobile and network security before an attack occurs. Reframe cybersecurity as a matter of patient care: Medical devices can be hacked, a breach can cause a misdiagnosis, and personal health information stored on computers can be stolen. Not to mention, the downtime during a breach can put patients in critical danger.

Protect before you have to treat. Industry leaders must take all of the necessary measures to assess and stabilize their institutions’ cybersecurity and better thwart attacks—especially “from the inside.” By putting up safeguards for employees, including doctors and nurses, to protect themselves from accidentally compromising their network, these institutions can lessen or prevent the threat of an incident or breach.

Or you can always seek a second opinion.

Suzanne Widup, senior analyst at Verizon Enterprise Solutions, is a co-author of the Verizon Data Breach Investigations Report, and lead author for the Verizon PHI Data Breach Report. She spends quality time hunting for publicly disclosed data breaches for the VERIS Community Database ( She has 20 years of IT experience, including Unix system administration, information security engineering, and digital forensics in large enterprise environments. She holds a BS in computer information systems and an MS in information assurance. Widup is the author of Computer Forensics and Digital Investigation With EnCase Forensic v.7,published by McGraw-Hill.

Doing more harm than good? Study finds healthcare workers often provide care while ill

October 11th, 2019 Email This Post Print This Post

Many healthcare workers may be putting patients at risk by continuing to work when they have symptoms of cold, flu, or other respiratory illnesses, according to a new study published in Infection Control & Hospital Epidemiology.

The study found that 95% of healthcare workers have worked while sick, most often because the symptoms were mild or began during their work shift.

“We found that physicians and people working in areas that required the most intensive contact with patients were less likely than other workers to stay home or to leave work if symptoms progressed after the start of the day,” said Brenda Coleman, PhD, clinical scientist in the Infectious Disease Epidemiology Research Unit at Mount Sinai Hospital, Toronto, and lead author of the study, in a release. “Managers and senior staff need to both model and insist on workers staying home when symptomatic as it protects both patients and coworkers from infection.”

The study, published in the journal for the Society for Healthcare Epidemiology of  America, found that 92% of healthcare workers report to work while symptomatic for an acute respiratory viral illness. Hospital-acquired respiratory viral infections cause significant illness and death, in addition to increased healthcare costs. The Centers for Disease Control and Prevention recommends that healthcare workers with fever and respiratory symptoms consider temporary reassignment or exclusion from work while they are symptomatic.

Researchers conducted a four-season prospective cohort study of influenza and other respiratory illnesses in nine Canadian hospitals in Toronto, Hamilton, and Halifax. Healthcare workers in hospitals who worked more than 20 hours per week filled out daily online illness diaries whenever they developed symptoms; these included information about symptoms, possible exposure, attendance at work, reason for work or absence, and medical consultations.

In all, 10,156 illness diaries were completed by 2,728 participants. Diaries of workers who were not scheduled to work were excluded, which left 5,281 diaries for analysis. Sixty-nine percent of participants said they worked during an illness because their symptoms were mild and they felt well enough to work, 11% said they had things to finish at work, 8% said they felt obligated to work, and 3% responded that they couldn’t afford to take the time off. Half of the participants said they had episodes of acute respiratory viral illness during influenza season, with 95% of those working one or more days of their illness. Of the study participants, 79% said they were entitled to paid sick leave.

Coleman said the study illustrates the need to educate healthcare workers, managers, workplace health/safety/infection control staff, and administrators about the transmission risk associated with respiratory viral infection. Organizations should also clarify what symptoms require exclusion from work and develop and roll out policies for working while symptomatic, she added.

Subscribe - Get blog updates via e-mail

  • test
  • HCPro Broadcast Events Calendar