Patient Safety Focus

Medicare Encouraging Patient Safety through Financial Disincentives -- by Lisa Hayden Espenschade

On October 1, 2008, Medicare placed new financial responsibilities on hospitals for certain “reasonably preventable” hospital acquired conditions.  In addition to Medicare’s new policy, covered here in more detail previously, private insurers are following suit.

 

Catheter insertion is associated with two conditions on the list: vascular and urinary tract infections. Medicare is also targeting surgical site infections after coronary artery bypass and some other orthopedic and bariatric procedures.

 

These three types of infections accounted for 42,096 cases in fiscal year 2007, according to the Centers for Medicare and Medicaid Services. Vascular catheter-associated infections are the worst offender on Medicare’s list--affecting 29,536 patients in 2007. Bladder catheterization is linked to another 12,185 infections.

 

Economic incentives, such as no longer elevating payments to cover the costs of preventable complications are likely to motivate improvement, but to improve, hospitals need effective systems designed to prevent the medical errors in the first place.

 

Many prevention principles – particularly hand hygiene – apply to both these types of catheter-related bloodstream infection (CR-BSI).  This is where Hospital Video Auditing (HVA) can help:  it gives 24/7/365 monitoring for adherence to safety practices and protocols and encourages health care workers to both improve and sustain their performance. 

 

Previous posts on CR-BSIs include:

Hygiene. A study at Huguley Memorial Medical Center in Fort Worth, TX, looked at simple measures for limiting infection: practicing hand hygiene, avoiding femoral lines because of proximity to the groin, using gloves and other physical barriers, and monitoring the appearance of lines.

Checklists. Atul Gawande’s December 10, 2007, article in The New Yorker detailed infection prevention research from Peter Pronovost, a critical-care specialist at Johns Hopkins Hospital. Pronovost found providers often skipped crucial steps during line insertion. Our post excerpting Gawande’s article includes information on hospital culture and successes using checklists.

Studies, Statistics & Safety. Robin Walters, RN, BSN, notes studies about costs of CR-BSIs plus strategies and guidelines for prevention. Among them: the Central Line Bundle from the Institute for Healthcare Improvement and participation in infection prevention collaboratives like the 5 Million Lives Campaign and the National Healthcare Safety Network.

Lisa Hayden Espenschade is a freelance writer based in Scarborough Maine who has written on genomics, gene therapy, stem cells, and other drug discovery topics, as well as other biotechnology issues.

 

Interested in submitting content to PatientSafetyFocus.com? Please go here to learn more.

New Compendium of Strategies to Prevent Healthcare-Associated Infections

Today, the Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals was released in Infection Control and Hospital Epidemiology.  The Compendium contains practical strategies for preventing the six most significant hospital-acquired infections in acute-care hospitals.  The strategies include recommendations for first- and second-tier infection control practices – ones which should be adopted by all acute-care hospitals in all cases, such as hand hygiene, and others that might need to be employed in the event of certain outbreaks.  The six hospital-acquired infections that are the focus on the Compendium are:

 

• Methicillin-resistant staphylococcus aureus (MRSA)
• Clostridium difficile infections (C-diff)
• Central-line associated bloodstream infections
• Ventilator-associated pneumonia
• Catheter-associated urinary tract infections
• Surgical-site infections

The report was sponsored by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).  Partners in the work were the Association for Professionals in Infection Control (APIC), the Joint Commission, and the American Hospital Association.  The Joint Commission also announced that it would be considering adoption of the strategies into its accreditation standards and patient safety goals.

Could Your Clothes Make Someone Sick? -- by Lisa Hayden Espendschade

A recent article in The New York Times discussed one of the unsolved mysteries of infection prevention: are pathogens on providers’ clothing capable of infecting anyone?

 

Tara Parker-Pope’s article - "The Doctor's Hands Are Germ-Free.  The Scrubs Too?" – cites evidence showing clothing can carry pathogens, including methicillin-resistant staphylococcus aureus (MRSA).

 

One study, conducted in 2004 at New York Hospital Queens,showed doctors’ neckties are particularly hospitable to bacteria. Parker-Pope also mentions European efforts to limit the potential for providers’ apparel to gather germs: the British National Health Service banned neckties and long sleeves, and some European hospitals require clothing changes before and after work.

 

Even without solid proof that clothing-borne pathogens cause illness, researchers are working on antibacterial fabrics. Scientists in South Dakota, for example, are creating antibacterial Kevlar cloth. Until such materials become available, here are simple ways health care workers can reduce risks of harboring pathogens on clothes:

• Follow rules against wearing scrubs, lab coats, or other “work” clothes outside the office or hospital.

• Adopt the British National Health Service’s ban on ties, long sleeves, and jewelry.

• Clean your name tag or lanyard regularly. Researchers at the Monash Medical Center in Melbourne, Australia, found pathogens, including seven instances of MRSA, on 45 lanyards or badges worn by 71 doctor and nurses.

• Adhere to isolation precaution guidelines from the Centers for Disease Control: don and remove gowns and other protective clothing properly.

• Commit to observing strict hand hygiene procedures: hand washing is one of the most effective methods for preventing infection.

Lisa Hayden Espenschade is a freelance writer based in Scarborough Maine who has written on genomics, gene therapy, stem cells, and other drug discovery topics, as well as other biotechnology issues.

 

There is additional information on MRSA and hand hygiene on Patient Safety Focus.

 

Interested in submitting content to PatientSafetyFocus.com? Please go here to learn more.

Discussions about Hospital Video Auditing Ramp Up -- by Suzanne Delbanco, Ph.D.

This has been an exciting week at Arrowsight Medical.  News of my appointment as President of Arrowsight’s Health Care Division has sparked conversations in the blogosphere about using Hospital Video Auditing (HVA) to improve hand hygiene and other quality and safety practices.  We welcome it and encourage you to join the conversation here at Patient Safety Focus where you can find more information on HVA and Arrowsight. 

 

Here are a few reports from the blogosphere to peruse:

 

• The Wall Street Journal’s health blog, by Laura Landro
• The U.S. News and World Report blog on health care quality, by Avery Comarow
• Wachter’s World, hosted by Robert Wachter, M.D., a hospitalist at the University of California at San Francisco

In addition, Modern Healthcare covered the news. Let us know what you think.  We also welcome posts on other patient safety topics from guest bloggers. Interested in submitting content to PatientSafetyFocus.com? Please go here to learn more.

Leapfrog Group 2008 Top Hospitals Announced

Today, The Leapfrog Group announced its 2008 Top Hospitals, with 26 adult and 7 children’s hospitals making the cut.  To make this list, hospitals must demonstrate high performance on a variety of quality and safety measures that are part of the Leapfrog Hospital Survey.  Meant to provide national recognition for the hospitals on the list, Leapfrog has released the list for the last several years.  The requirements for making the list have gotten more stringent each year, with this year’s criteria requiring:

• Fully meeting Leapfrog standards for computer physician order entry(CPOE) systems, as well as testing CPOE systems with Leapfrog’s CPOE evaluation tool;
• Fully meetings standards for a complex, high-risk procedure on Leapfrog’s list for evidence-based hospital referral;
• Fully meeting the standard for physician staffing in the ICU; and, 
• Fully meeting or demonstrating significant progress on 13 other patient safety practices, including hand hygiene practices.

More details on the methodology and the complete list of the 2008 Leapfrog Top Hospitals is available on The Leapfrog Group web site.

Arrowsight Announces Appointment of Suzanne Delbanco as President of Health Care Division

                  

Arrowsight, Inc. today announced the appointment of Suzanne Delbanco, Ph.D. as president of its newly formed health care division. Delbanco will oversee Arrowsight Medical, which focuses on helping hospitals improve the quality and safety of their care by using video to measure adherence to protocols and provide feedback on performance to hospital staff.

 

Prior to joining Arrowsight, Delbanco was CEO of The Leapfrog Group, a Washington, D.C.-based organization driven by major employers and other health care purchasers working to initiate breakthrough improvements in the safety, quality and affordability of care.  Among other accomplishments during her tenure there from 2000-2007, the proportion of hospital ICUs staffed by intensivists - doctors with special training in critical care - grew from 10% to almost 30%, saving an estimated 20,000 lives annually in the U.S.

 

Commenting on the appointment, Arrowsight CEO Adam Aronson, who supported The Leapfrog Group as a partner member and award sponsor said, “Suzanne Delbanco has a proven track record in pioneering efforts designed to create change.  We are excited to have her on our team as we continue rolling out a groundbreaking strategy to help hospitals and other health care settings improve the delivery of patient care.”

 

Across multiple safety-sensitive business sectors such as food processing, food services and manufacturing, Arrowsight has helped improve practices, compliance and employee morale with long-lasting effects.  In its first health care pilot, launched in January of 2007, Arrowsight’s hospital video auditing service (HVA) improved hand-hygiene compliance from 38 to 90 percent within three months, and kept it above 90 percent for twelve months running.

 

“It is extremely gratifying, after a long and rigorous search, to find another opportunity to have an impact on the quality and safety of health care,” said Delbanco.  “While there is much activity in this arena, I found nothing as compelling as Arrowsight’s approach.  Arrowsight helps not just with improvement, but also with sustaining it.  I’m thrilled to have the chance to make a measurable difference for patients, this time by giving hospitals new tools that help them get to the top of their game.” 

As part of its service, Arrowsight sends automated intra-shift emails to nurse managers and attending physicians that rank current shift performance metrics room by room.  Additionally, Arrowsight automates the delivery of aggregate team metrics to LED boards at the work site, which are updated every ten minutes 24/7/365.

 

Aronson also noted “As hospitals work to reduce the incidence of hospital acquired conditions, or so-called never events, Arrowsight can provide methodologies to improve hand hygiene, adherence to protocols for central line insertions, and other practices that reduce the incidence of some of the other preventable conditions for which Medicare and many other health care payers are no longer willing to absorb added costs.”

 

Along with developing Arrowsight Medical, Delbanco will edit this Arrowsight-sponsored blog (www.patientsafetyfocus.com) for health care workers, hospital administrators and insurers seeking new ways to improve patient safety.  Patient Safety Focus welcomes contributions from experts in the field.

 

In addition to her duties at Arrowsight, Delbanco is on the Advisory Committee to the Director and the National Biosurveillance Advisory Subcommittee of the Centers for Disease Control and Prevention (CDC), the boards of Bridges to Excellence and Prometheus Payment, Inc., the SafeMed, Inc. Advisory Council, and in the Healthcare Executives Leadership Network.  Modern Healthcare has regularly listed Delbanco as one of the 100 most powerful people in health care.  She speaks frequently at conferences and has published several peer-reviewed articles on hospital quality and safety as well as consumer access to care.

 

Study Shows CMV Reactivation Linked to Longer Hospital Stays -- by Lisa Hayden Espenschade

  

CMV – cytomegalovirus – is so common the Centers for Disease Control and Prevention (CDC) estimate 50-80 percent of U.S. adults carry it by age 40. Few show symptoms. CMV can, however, reactivate in patients with normal immune function during intensive care unit (ICU) stays, according to a paper published in the July 23-30, 2008, JAMA, the Journal of the American Medical Association.

 

Researchers from University of Washington and the Fred Hutchinson Cancer Research Center, led by Ajit Limaye, associate professor of medicine and laboratory science at UW, studied CMV in 120 CMV-seropositive ICU patients, looking for incidences of reactivation during a 30-day period. Around 30 percent showed active CMV infection, and researchers found correlations between reactivation and longer hospital and ICU stays, and death.

 

Patients with normal immune systems are seldom tested for CMV during hospitalization. The paper’s conclusions suggest “a controlled trial of CMV prophylaxis in this setting is warranted.” Further research may investigate whether antivirals can reduce CMV reactivation and/or hospital stays. Ganciclovir and valganciclovir are used in immunocompromised CMV patients, according to the CDC.

 

Typical CMV symptoms among healthy individuals include fever, sore throat, fatigue, and swollen glands, says the CDC, so they may be attributed to other factors. Primary infections in immunocompromised patients can cause death, pneumonia, or gastrointestinal disease. Congenital CMV infection may cause temporary symptoms including liver and lung problems, permanent symptoms like hearing or vision loss, and even death.

 

Although CDC notes that CMV is not highly contagious, it may spread in households or day care centers. Sexual contact, body fluids, organ transplants, and blood transfusions can transmit CMV. Washing hands with soap and water removes the virus.

 

Lisa Hayden Espenschade is a freelance writer based in Scarborough Maine who has written on genomics, gene therapy, stem cells, and other drug discovery topics, as well as other biotechnology issues.

 

Interested in submitting content to PatientSafetyFocus.com? Please go here to learn more.

Summit Attendees Get Called to Reduce HAIs and Spark Systematic Change in the Health Care System

Along with PatientSafetyFocus.com, over 400 people (about three-quarters of whom represent hospitals) attended Cardinal Health's first Chasing Zero Summit in Washington DC today.  According to their spokesperson, Cardinal's mission is to help improve health care and reduce costs.  Their aim for the Summit is to bring leaders together to share actionable steps to reduce hospital acquired infections (HAIs).

Pushing for systematic health care change

Director of the Engelberg Center for Health Care Reform at the Brookings Institution and past administrator of the Centers for Medicare & Medicaid Services (CMS), Dr. Mark McClellan opened the 2-day event with a strong call to action:  Now is the time for providers and other health care leaders to lead the effort to move away from a system of runaway costs and use of health care resources, to one based on value - where quality and cost are no longer independent variables.  After stating that hospitals are making money from hospital-acquired infections, McClellan talked about CMS actions over the past few years to stop paying for certain "never events," or serious and costly errors in the provision of health care services that should never happen.  The list of no-pay events has grown to include 11 hospital acquired conditions today, including HAIs.  "Expect that list ot get longer," he intoned.  But, it's not enough simply to keep adding to the list.  McClellan drove home the point that we need to focus on a systematic effort to make our health care system sustainable.  "We're in a vicious cycle of delivering care that isn't high value."  Providers must work with patients to achieve the best care at the best cost for each individual. 

He turned last to three trends beginning to drive systematic health care change.  The first is the growth of activity on the measurement scene - from measuring health care outcomes, to cost and patient satisfaction.  Payment reform is the second trend:  from pay for reporting and pay for performance, to a shared savings model in which physicians are eligible for payments derived from savings from care management that's designed to anticipate patient needs, prevent chronic disease complications and avoidable hospitalizations, and improve quality.  The third trend is changes in benefit design such as tiering, where for instance, hospitals that demonstrate the best quality and cost are put into the top tier of hospitals.  Patients choosing these providers may get zero out-of-pocket expenses.

The Road to Eliminating Device-Related Infections -- by Rabih O. Darouiche, M.D.

Hospital-acquired infections (HAIs) are infections resulting from treatment in a hospital or a health care service unit that are not related to the patient's original condition for which they entered the hospital.  While HAIs can come from a variety of sources, including contaminated bed sheets and dirty hands, it is critical to note that more than half of HAIs are attributed to medical devices such as central venous catheters (CVCs), bladder catheters, endotracheal tubes, tracheostomy devices and surgical implants.

To advance the fight against these infections, the Multidisciplinary Alliance Against Device-Related Infections(MADRI) conference was founded as a platform for various institutions to gather under one goal - medical device infection prevention.  Governmental agencies, health care providers, medical societies and drug- and device-manufacturing companies meet annually to provide education and promote discussion around medical interventions, surgical advances and regulatory perspectives on device-related infections.

However, one of the common difficulties for medical professionals when discussing prevention methods is how to reduce the incidence rates of infections without reducing the number of indwelling devices used.  Removing the device altogether is not always a feasible strategy, as some indwelling devices are critical to a patient's care and well-being.  With this in mind, MADRI focuses on multidisciplinary approaches for the prevention and treatment of infections associated with various types of medical devices that include a two-pronged strategy of:

1. Adhering to strict hand washing and hygiene protocols
2. Using scientifically validated, evidence-based, proven medical device innovations

Studies Shed Light on Isolation Precaution Practices -- by Robin Walters, R.N., B.S.N.

Robin Walters, R.N., B.S.N., has been privileged to provide care in hospitals, clinics, schools and physician offices, at sites ranging from large urban to remote rural. Be sure to also read Robin's other contributions on bloodstream infections, hand washing compliance, and culture of safety.

Timely and consistent use of isolation measures can prevent untold thousands of hospital-acquired infections each year.  Depending on the infectious agent, required precautions may include:  a private room, dedicated patient-care equipment, room air pressure and ventilation measures, and/or the appropriate use of personal protective equipment such as masks, gowns and gloves.  The following studies highlight strengths and weaknesses in compliance at three major medical centers and may assist other facilities in focusing their improvement efforts.

At the University of North Carolina Hospitals in Chapel Hill, infection control personnel observed staff and visitors in 2004 and 2005, finding the overall rate of compliance by type of isolation ranged from 60-75%.  For contact isolation, which is designed to prevent infections transmitted by direct or indirect contact with a patient or a patient's environment, researchers assessed gown and glove use.  In the ICUs, compliance ranged from 92-100% for both staff and visitors.  But on the adult floors, perhaps as expected, visitor gown (50%) and glove (33%) use was much lower than staff gown (81%) and glove (81%) use.  On the pediatric floors, rates of gown and glove use varied even more between visitors (23% and 5%) and staff (87% and 93%).

Over the same time period, observers at St. John's Mercy Medical Center Hospital in St. Louis, MO documented adherence by health care workers (HCWs) and non-HCW visitors to the facility's modified contact precautions, which include donning gown and gloves before entering a patient's room regardless of whether direct contact is anticipated.  Among HCWs, females and those working in the ICUs complied best.  Visitors in the ICUs complied better than those on the general floors (91% vs. 51%).