All Entries Tagged With: "Infection control"
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.
Transparency… are we there yet?
Apparently not. Public reporting of surgical site infections is required in only eight states. That fact was brought to light by a new Johns Hopkins University report, which calls for more reporting. Lead author of the report, Martin Makary, MD, notes that patients still have little information when choosing hospitals.
Personally, I think the bigger issue is that public reporting gives hospitals, from the top down, a real push to do better. I think Makary does too:
“Nothing motivates hospitals to improve quality and listen to their front line staff like public reporting,” he says. “In order for the consumer to interpret publicly reported SSI rates, it is imperative that the data be collected and reported in a standardized manner,” he and his co-authors wrote.
I would have to agree. Surgical site infections not only result in 8,000 deaths a year in the U.S., they occur in 4% to 25% of patients who undergo major surgical procedures, and their cost to the healthcare system is about $10 billion annually (these stats are mentioned in the report and come from other studies).
Makary calls out state hospital associations for not supporting public reporting. What do you think? Is public reporting the way to change hospital culture?
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.
It always boils down to communication
A recent incident in which three people, including one child, was infected with hepatitis C through transplanted tissue just highlights, yet again, the importance of communication to achieve patient safety, no matter whether it’s between colleagues who work together every day or organizations hundreds of miles apart that never (usually) have a reason to communicate.
The tissue was implanted in the child after it was discovered the organ donor had infected another person. Eight days after.
Two days after the implantation, the CDC was notified.
I think the lesson here is communicate early, communicate often, and when in doubt, communicate some more. Providers are busy, and often move communication to a lower priority than it should be. Communication makes the world go round, gets work done, and gets it done right. Even the pathways of how each participant plans to communicate (e-mail, phone, etc.) should be decided ahead of time when it’s really important—and in healthcare, it’s often really important.
Adverse events always remind me of an activity we used to do at camp when I was a child. As part of “outdoor adventure,” we’d often take hikes, go canoeing, and enjoy nature. It also provided team building and safety education. One of the activities that promoted these teachings was the Trust Fall:
A person stands on top of a platform above everyone else, who form a “net” with their arms and hands by facing each other in two parallel lines and linking arms, forearms up. The faller stands on the platform, at the edge, back toward everyone else, arms crossed over chest. The idea is that this person will fall backward into the net, trusting that everyone will catch him or her. The activity shows that if you are careful and follow proper protocol, you can trust your team to keep you safe, even when facing the unknown or scary. (As you might imagine, it’s very difficult to allow yourself to simply fall backward.)
The protocol of communication begins once everyone is in place:
Faller: Falling!
Catchers: Fall away!
Only until this communication occurs does the faller fall.
This type of communication, of course also used in many other industries, needs to be far more common in healthcare, among colleagues and among hospitals across the nation.
The hospital about to use the tissue could have checked one more time (“Falling!”) with the transplant center (“Fall away!” or, in this case, “Stop!”). A method for that kind of check needs to be implemented. A real-time online database that can be updated directly by transplant centers and checked immediately before surgery at the recipient’s hospital should exist. I think many patients already assume it does.
Patients should be able trust the healthcare system and its protocol, even when facing the unknown or scary.
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Is it time to stop duplicating reporting efforts?
Interesting turn of events this week. The Cleveland Clinic, Henry Ford Hospital in Detroit, and Parkview Health in Fort Wayne, IN, have all ceased to report hospital-acquired infections to the Leapfrog Group, a nonprofit organization in Washington, D.C.
According to Consumer Reports, the three health systems fall in different spots for bloodstream infections—something Consumer Reports previously analyzed. One did better than average, one about average, on under average.
The hospitals’ reason for the end to Leapfrog reporting was that they now report to CMS on the same or similar measures, and must end duplicate efforts to reduce waste of resources.
What do you think? Do you think the private nonprofit reporting group will soon be a thing of the past?
Surgical standardization a takeaway from AHA Leadership Summit
HealthLeaders Media reporter Cheryl Clark attended the American Hospital Association’s Leadership summit and found seven interesting points of focus. One in particular was that surgical prep is becoming more standardized.
The Cleveland Clinic now has nurses doing the surgical prep, who are all trained to do it the same way, using the same materials, to help reduce infection and confusion. Guido Bergomi, director of Project Management of the Quality and Patient Safety Institute of the Cleveland Clinic said he found surgeons were not standardized enough in their prep.
What do you think? Should nurses, formally trained, perform this task? Comment below.
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.
