All Entries in the "HAI" Category
CAUTIs still a problem
Bit of a plug, but I think my visitors will find HCPro’s webcast on CAUTIs (catheter-associated urinary tract infections) extremely relevant, especially as CAUTIs cause 35% of all hospital-acquired infections every year, with 38,000 patient infections, and costing hospitals $400 million a year, according to an October 2011 National Quality Forum’s Partnership for Patients/ National Priorities Partnership webinar.
And don’t forget that The Joint Commission named CAUTIs a National Patient Safety Goal to be fully implemented by 2013. The Partnership for Patients also aims to reduce preventable CAUTIs by 50% by 2013.
So join nurse practitioner Mikel Gray, PhD, PNP, FNP, CUNP CCCN, FAANP, FAAN, and chief of infection prevention and 2012 APIC conference speaker Brian Koll, MD, FACP, FIDSA, for a live presentation of proven methods on CAUTI reduction, including how Beth Israel Medical Center reduced the number of CAUTIs by 83% using proven organization-wide catheter best practices such as evidence-based practice, staff education, daily need assessments, multidisciplinary teamwork, monitoring, and root-cause analysis. You’ll also get best practices to educate and train your entire staff.
Just a note that now, you can buy the live audio and download the on demand version free.
Patient safety in 140 characters
In honor of patient safety week, the National Patient Safety Foundation hosted a tweet chat, in which participants all follow the same hashtag (#keyword) to have a large conversation. If you missed it, you can read the conversation by searching twitter for “#PSAW2012.” I suggest checking it out (you don’t even have to have Twitter to conduct a search) for the resourceful links alone. Comment below or tweet @PSeditor if you joined and what you liked about it.
Here are some of the topics and facts brought up in conversation:
- Health literacy:
Twelve percent of adults have good health literacy
E-literature might help follow up with patients post-visit
MDs tend to interrupt patients after 18 seconds of speaking
- PSAW:
Getting PSAW recognized by more of the general public to spread awareness beyond the healthcare setting
Why PSAW is observed, recognized, but not celebrated
Next PSAW is March 3 –9, 2013!
Here are some resources brought up in conversation:
NSPF’s new “Ask Me” video
AHRQ’s “Questions are the Answer” video
IMSP has new tools and resources
Health Literacy: Reducing the Burden of a Complex Healthcare System
Patient Safety Week 2012: Informing the Journey, Not Changing the Destination
Checklists that patients and doctors follow can improve hospital care
Dreaming the dream (by Peter Provonost)
Navigating the Health Care System: Advice Columns from Dr. Carolyn Clancy
Do Electronic Medical Records Save Money?
What’s in a Name? Safer care, for one.
20 Tips to Help Prevent Medical Errors: Patient Fact Sheet
Bloodstream infections in pediatric ICUs
A Consumers Report study has found that many pediatric ICUs have high rates of bloodstream infections, often higher than adult ICUs—on average, 20% higher.
As you may recall, Josie King, whose unfortunate story has been made famous by her mother who now advocates for better patient safety, had complications after a central-line bloodstream infection.
Hospitals may want to look at the strategy of 2010 Baldrige-award winner Children’s Hospital at Providence in Anchorage, AK. Children’s cut catheter-related bloodstream infections in the neonatal ICU. Though they didn’t focus on central lines, the strategies might be of interest. They resisted the typical “see one, do one, teach one” method and instead implementing standard teaching methods. The hospital also ensured peace and quiet upon insertion by moving the patient into a quiet room during the procedure. Read more about this in Patient Safety Monitor Journal.
Still, there’s a problem a bit more concerning than the infections: a lot of pediatric ICUs aren’t reporting the data publicly, according to the report::
Of the 423 pediatric intensive-care units in the U.S., information on bloodstream infection rates is publicly available for less than half.
The investigation was left to focus on the 92 pediatric intensive-care units in 31 states plus Washington, D.C. that did report rates.
What can be done? What’s missing? Why aren’t we reporting rates? How can hospitals emulate others that have low rates if we can’t identify which ones they are?
Top 10 most read blogs posts from 2011
The new year is upon us. I thought before we dive into what’s to come for patient safety and quality in 2012, we might want to look back at 2011 and see what grabbed the attention of the patient safety world.I calculated the top ten by how many times each post was viewed. They are:
10. Joint Commission and FDA to focus on alarm fatigue
The Joint Commission (TJC) told The Boston Globe that it would work with the Food and Drug Administration (FDA) to make alarm fatigue—a worrisome problem in most hospitals—a priority.
9. Disruptive behavior, negligence, endangered patients, and millions of dollars
In August, settlements for old patient safety incidents in Boston and recent investigations in Dallas found more recent patient safety infarctions.
8. Rewarding near-miss reporting
This post discusses the importance–and challenge–of getting staff to report near misses, highlighting an example in one surgical suite in Johns Hopkins Hospital in Baltimore that implemented its Good Catch Awards.
7. Joint Commission issues Sentinel Event Alert about workplace violence
The Joint Commission issued an alert on workplace violence in July 2010, but workplace violence was a hot enough topic to remain at the top in 2011.
My personal story of a patient and family whose anger and frustration grew as they faced an elusive plan of care and a care team who seemed uncommunicative.
5. New York Times article exposes radiation therapy errors
Another post that was published in 2010, but the issue of radiation errors and over-radiation remained hot in 2011. This post highlights one of the first articles in a series The New York Times ran from 2010 and into 2011 on radiation concerns.
4. Medication error prompts lawsuit for Massachusetts General Hospital
A medication error that resulted in a death and a lawsuit was met with a communicative response from hospital representatives, who said systematic improvements implemented since the error now help staff to avoid making similar errors.
3. Boston hospital admits three spinal surgery errors in two months
Published at the very end of 2010, this is yet another post on a hospital admitting to errors—this time surgical site errors—that did not need to happen. Beth Israel Deaconess Medical Center in Boston is in the spotlight after its surgeons made errors in three separate spinal operations in two months.
This post explaining how a resident failed to carry out an order on her mobile device after she was interrupted by a personal text messaged grabbed the attention of Patient Safety Blog readers. With this anecdote as proof, social media concerns have leaped from HIPAA violations to immediate threats to patient safety.
1. Can a video really help curb infections?
Perhaps videos are just more fun to watch. This post embedded the winning video of the APIC Infection Prevention Film Festival, which lays blame on frontline providers who fail to do everything they can to “do no harm—” in this case, failing to wash their hands.
What do you think? Any of your favorites missing? Let me know.
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Can a video really help curb infections?
For quite some time now, hospitals have been creating and posting videos to create awareness about proper infection control protocol for patient caregivers (most focus on hand washing or vaccination).
The Association of Peri-operative Nurses (AORN) and 3M had a contest for nurses to submit videos on hand hygiene. The World Health Organization (WHO) posted a video on hand hygiene, and even the Department of Health and Human Services (HHS) had a contest for people to submit a public service announcement video for preventing flu. And of course, hospitals have created videos on their own to help raise awareness and educate.
Videos are fun—they have the power to get staff out of their daily routine, dancing in sterile hospital hallways and awkwardly singing their newly-crafted lyrics over popular hits (think “I’m Gonna Wash My Hands” or “Pump It”). I also assume that while the video is being made, hospital staff are more focused on proper patient safety protocol. But do videos actually make a lasting effect on ensuring staff wash their hands or get vaccinated?
After watching the APIC Infection Prevention Film Festival winner’s video, I think some might. About forty entries were submitted, but the winner takes a less gimmicky approach and “depicts the tragedy and irony of healthcare-associated infections, transforming the statistics into a story of a patient who gets an infection,” according to the APIC press release. In my opinion, the video directly connects the simple–and sometimes annoying–act of hand washing to the safety of the patient, leaving the responsibility square on the shoulders of healthcare professionals. In fact, I would go as far as to say that the fun, light-hearted videos may be downplaying the danger. But that’s just what I think; I’d love to hear what you think of the video posted below. Over dramatic? Right on target? Play movie critic and share your thoughts below.
When quality data reaches the public
Most of you who read this blog are likely aware of common adverse events that occur in hospitals, but what about the average Joe? “Never events” and “HACs” are terms the public is becoming more and more aware of. News stories are focusing on such events, mostly due to The Centers for Medicare & Medicaid Services (CMS) March 31, 2011 release of Medicare data on certain measures, such as patient falls and central line infections. Before, only measures concerning heart attack and pneumonia patients were made public.
One thing you learn as a reporter is that all news is local—in other words, what’s happening in your own community usually takes precedent. It’s one thing to have the federal data on Hospital Compare, a site that is a bit cumbersome for average people to explore and find information that is meaningful to them, even if they know of the site in the first place; it’s another to read it in your local newspaper.
For example, if you live in Louiseville, KY, an article in yesterday’s paper explains which “never events” are occurring in your hospitals. The Post Crescent reports that hospitals in Fox Cities, Wisconsin suffer from a higher rate of pressure ulcers. Connecticut residents read last month that collectively, the state’s hospital had a higher level of objects left after surgery than the national average. In April, The Chicago Tribune reported on the newly available data and in Georgia, a state that does not publicly post such data, the Atlantic-Journal Constitution headline announces that Georgia residents have been kept in the dark on hospital infections. A simple Google news search shows many more city newspapers are reporting on the new data.
Of course, this is what transparency is all about. However, not all reports explain that the AHA is against the release of such raw data, and why. (The AHA is concerned the data are too raw and do not account for sickliness of patients. The organization has other concerns, including the fact that the measures have not been reviewed by an organization such as the National Quality Forum.)
What do you think? Is this ultimately good? Will this lead to more quality efforts in healthcare? Will it lead to more funding, more public awareness? Will more news coverage lead consumers to use Hospital Compare more regularly? Have you seen your hospital in the news? Has the media had an effect on your quality efforts?
A new proposed rule would allow more Medicare data to be available, as I posted last week. The new link to the proposed rule can be found here.
New CMS final and proposed rules address HACs, transparency
Last week, The Centers for Medicare & Medicaid Services (CMS) issued the final rule on reducing or prohibiting payments to providers for hospital-acquired conditions (HAC). The new rule will better align Medicare and Medicaid payment policy and give states flexibility to add to the federal list of HACs. This rule specifically prohibits states from making payments to providers under the Medicaid program for HACs, using the current list of HACs under the no-payment Medicare rule already in place.
The final rule is effective July 1, 2011 and gives states the option to implement its effective date July 1, 2012.
View the press release and the list of reduce or no-pay HACs.
In other CMS news, a new proposed rule would allow Medicare and private sector claims data to be used to produce public reports that evaluate the performance of physicians, other healthcare providers, and suppliers. Organizations seeking such Medicare information would have to undergo an application process and be continually monitored by CMS.
To prevent mistakes, the proposed rule requires that any reports generated from the Medicare data be shared confidentially with providers and suppliers before being released to the public. Publicly released reports would contain aggregated information only, meaning that no individual patient/beneficiary data.
“Performance reports that include Medicare data will result in higher quality and more cost effective care,” CMS administrator Donald M. Berwick, MD, said in a statement.
For more analysis, visit HealthLeaders Media.
The proposed rule will be published in the Federal Register on June 8, and the CMS will accept public comments for 60 days. Until June 8 the proposed rule is available here.
HHS recognizes hospitals’ patient safety successes
The U.S. Department of Health and Human Services (HHS) recognized 37 hospital and healthcare facilities for their efforts to prevent – and eventually eliminate – healthcare-associated infections (HAIs), a leading cause of death in the United States.
The organizations are the first to be honored as part of a new national awards program to highlight successful and sustained efforts to prevent healthcare-associated infections, specifically infections in critical care settings. This initial set of awards recognizes critical care professionals and healthcare institutions for their efforts to reduce, and eventually eliminate, ventilator-associated pneumonia and bloodstream infections associated with central intravenous lines.
Awards were conferred on two levels, according to specific criteria tied to national standards. The “Outstanding Leadership Award” went to teams and organizations that sustained success in reaching their targets for 25 months or more. The “Sustained Improvement Award” recognizes teams that demonstrated consistent and sustained progress over an 18- to 24-month period.
Organizational issues for prevention of HAIs and the systemic nature of the problem
Healthcare-associated infections are no doubt a focal point of every patient safety professional. This month’s column by Catherine Hinz in Patient Safety Monitor Journal explores how organizations might lower their rates.
The following is an excerpt of a Patient Safety Monitor Journal column that explores patient safety from the perspective of a newcomer to the patient safety field. Columnist Catherine Hinz, MHA, currently works at PatientSafe Solutions, Inc. Previously, she was the patient safety lead at HealthEast Care System in St. Paul, MN, worked for seven years as an ED health unit coordinator, and has completed a patient safety internship with the Agency for Healthcare Research and Quality.
You can’t read anything about patient safety and quality or health reform without running into the topic of healthcare-associated infections (HAI). The issue tops a list of priorities for many health-related government institutions (e.g., Agency for Healthcare Research & Quality, CMS), nonprofit organizations (e.g., IHI, National Patient Safety Foundation), current research and publications, and patient advocacy groups. Popular media has recently been ¬shining a light on the problem as well as the use of tools, such as checklists, as part of the solution for prevention.
Intense process improvement and research efforts in Michigan ICUs have gained a lot of ¬attention for demonstrating significant reductions (and subsequent sustainability of those reductions) of HAIs. The work of Peter Pronovost, Atul Gawande, and others is quickly gaining traction. One of the troubling aspects of HAIs is the systemic nature of how they occur, the complex contributing factors, and the organizational issues of detecting and preventing them (not to mention their breadth of type and severity). HAIs are a problem wrought with cost and reimbursement pressures, challenges in allocating organizational resources, and care team performance factors.
To read Catherine’s full column on HAIs, see the May issue of Patient Safety Monitor Journal (a part of your Patient Safety Monitor subscription for those blog readers out there who are also subscribers.)
