Patient Safety Focus

Comparative Effectiveness Research Discussions Begin in Earnest

The American Recovery and Reinvestment Act devotes $1.1 billion to support comparative effectiveness research.  The U.S. Department of Health and Human Services will split the funds between the Office of the Secretary, the Agency for Healthcare Research and Quality and the National Institutes of Health.  The working definition for comparative effectiveness research is "is the conduct and synthesis of systematic research comparing different interventions and strategies to prevent, diagnose, treat and monitor health conditions."

How each agency focuses its use of the funds is being determined by a Federal Coordinating Council for Comparative Effectiveness Research, which released Monday its recommendations for the Office of the Secretary suggesting that it focus investing in the data infrastructure and patient registries that can support comparative effectiveness research. 

Today, the Institute of Medicine released its recommendations for for the top 100 priority areas for comparative effectiveness research.  Their suggestions are as far ranging as comparing effectiveness of treatments for hearing loss in adults and children to strategies for reducing health care-associated infections and unintended pregnancies.

There is no doubt that the health care system, and most stakeholders participating in it, could benefit from rigorous examinations of how we spend our money and choose to seek and deliver care.  That there will be politics and debates surrounding how this money is spent is just as certain.

Hospitals Wise to Cut Spending on Infection Control? -- by Suzanne Delbanco, Ph.D.

Does it make sense to cut spending on infection control when certain hospital-associated infections are on the rise and pressure is mounting to curb such infections?  Logical or not, a new study released today by the Association for Professionals in Infection Control suggests that hospitals are cutting staff, resources and educational efforts.

Almost 2,000 infection preventionists responded to the 2009 APIC Economic Survey.  Of those, 41 percent said that their budgets had been cut in the last year and half, due primarily to the economic downturn.  Among those who experienced cuts, three-quarters lost training money, and half had cuts for infection prevention resources like technology, staff, and equipment.  One in three of the survey respondents say that cuts in resources and staffing have restricted their capacity to focus on infection prevention.  On a related note, one quarter say they have cut back on surveillance activities to detect, track and manage hospital-associated infections. 

While infection prevention is not a source of revenue, APIC points out it can help reduce costs significantly.  The U.S. Agency for Healthcare Research and Quality estimates based on its Health Cost and Utilization Project (HCUP) data that acquiring an infection with methicillin-resistant Staphylococcus aureus (MRSA) during a hospital stay can double a patient's length of stay and almost double the cost of the stay (from $7,600 to $14,000).  Perhaps hospitals will get a chance to see the return on investment for infection prevention more clearly when they reduce the investment and need to live with the financial consequences.

Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.

IOM Vision for Reducing Medical Errors Not Yet Realized

Has the U.S. made any progress on patient safety since the Institute of Medicine (IOM) released To Err is Human in 1999?  According to Consumers Union, few of the IOM’s recommendations have been implemented.  In a recently released report, Consumers Union's Safe Patient Project highlight’s the following areas as falling short of the IOM’s recommendations for tackling preventable medical mistakes:

 

Prevention of medication errors:  Only a minority of hospitals has implemented computer physician order entry systems, the Food and Drug Administration has not reviewed and changed enough confusing and sound alike drug names, and there is not yet a system for reporting medication errors by facility.

Transparency:  There are still 24 states that do not require public disclosure of infections or other quality and safety data.

 

Measurement: the Agency for Healthcare Research and Quality estimates that patient safety has actually declined year after year, but still has too little data to make accurate assessments.

 

Standards for Competency: Efforts to boost the competency of health care providers have been scattered and criticized.

Leapfrog Hospital Survey Results Released

The results of the 2008 Leapfrog Hospital Survey, released this week, suggest that hospitals still have tremendous work to do to be safe for patients. 

For example, sixty-five percent yet to put in place all of the recommended policies to prevent hospital-acquired infections (though this is an improvement from 87% in 2007).  Similarly, seventy-five percent do not fully meet the standards for thirteen critical safety practices from hand washing to the competency of the nursing staff.  Just 30% of hospitals are fully meeting the standards for preventing hospital-acquired pressure ulcers and only 25% are meeting standards for preventing certain injuries in the hospitals. 

The Leapfrog Group's Survey included 1,276 hospitals in 37 major metropolitan areas.

New Monograph on Hand Hygiene May Push Us Forward -- by Suzanne Delbanco, Ph.D.

The Joint Commission, along with several partners, has just released a new framework for determining "when, why and how to measure compliance with hand hygiene."  The monograph, entitled Measuring Hand Hygiene Adherence: Overcoming the Challenges, is the result of a two-year collaboration among the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), the Centers for Disease Control and Prevention (CDC), the Society for Healthcare Epidemiology of America (SHEA), the World Health Organization (WHO) World Alliance for Patient Safety, the Institute for Healthcare Improvement (IHI) and the National Foundation for Infectious Diseases (NFID).

What's the big deal?  There has yet to be agreement about how to measure compliance with hand hygiene protocols. Without some standardization, it is very difficult to measure the comparative effectiveness of different interventions to improve and sustain hand hygiene practices.  And depending on the measurement method, hospitals may produce for themselves a false sense of security that their hand hygiene practices are sufficient when they are not.  My suspicion is that the more rigorously we measure hand hygiene practices, the more disappointed we will be with performance - that is, until we also implement successful interventions to drive and maintain improvement.

The monograph does not create a single international standard for measurement of hand hygiene practices, though it draws from examples from several countries.  It moves us closer, however.  So let's cross fingers and get to the hard work ahead.

At Arrowsight, we offer a powerful methodology for implementing many of the features and elements of measurement the monograph outlines.  Arrowsight's deep experience in video monitoring and feedback in other industries allowed us to jump start our efforts in health care.  Our work is too new to have been cited in the monograph, though we have recently briefed many of its authors.  With 24/7 video monitoring, a very large and continuous sampling process, rigorous quality assurance and near-real-time feedback to front-line staff, we are excited for our Hospital Video Auditing approach to be part of the solution going forward. 

As a side note, it may not be a surprise to readers that the project was underwritten by GOJO Industries, the makers of Purell hand sanitizer.

New Poll Suggests 18% of Americans Affected by Hospital Infections

Consumers Union conducted a poll during mid-March of more than 2,000 Americans to learn about their experiences with health care-associated infections, preventable medical errors and preventive care.  Almost one in five (18%) say they or an immediate family member have experienced a dangerous infection following a medical procedure. 

• Sixty nine percent of these respondents said they had to be admitted to a hospital or extend their stay because of these infections.

One-third of the Americans surveyed report that medical errors are common in everyday medical procedures.

• Thirteen percent have had their medical records lost or misplaced.
• Nine percent have been given the wrong medicine by a pharmacist when filling their doctor's prescriptions.

The results of the poll were released at a Congressional briefing on reforming the health care delivery system with the American Cancer Society, the American Diabetes Association, and the American Heart Association, who together also released a joint statement.

Patient Sharing Among Hospitals Could Impact Spread of Infectious Diseases

Twenty-two percent of people who are discharged from acute-care hospitals are readmitted at different hospitals within one year, according to a study released today by the University of California, Irvine School of Medicine.  This has big implications for the spread of infectious diseases, as hospitals typically only track direct transfers of patients from one hospital to another.  Patients can carry organisms like MRSA for long periods of time, even if they aren't actively experiencing symptoms of infection.  As a result, they can bring these organisms with them from one facility to another, even with gaps between admissions.

The study was conducted by Susan S. Huang, MD, MPH, assistant professor and hospital epidemiologist and colleagues, and funded by both UC Irvine and the National Institutes of Health's Models of Infectious Disease Agent Study (MIDAS).  The study analyzed nearly 240,000 patient admissions at 31 acute care hospitals in Orange County, CA using a retrospective evaluation of 2005 California Hospital Discharge Data.

2009 Safe Practices Released by National Quality Forum

The National Quality Forum has released the 2009 Safe Practices for Better Healthcare.  These 34 evidence-based practices build on six years of development, and represent practices that should be implemented in every hospital.

The 2009 report adds new practices in areas such as pediatric imaging, glycemic control, organ donation, catheter-associated urinary tract infection, and multi-drug resistant organisms. The report updates other previously endorsed practices based on new evidence, including the pharmacist’s role in medication management and pressure ulcers, and an entire chapter on healthcare-associated infections.  Some of the Safe Practices remain the same, such as hand hygiene and management of patients in ICUs by doctors with special training in critical care.

The Texas Medical Institute of Technology funded the project.  The National Quality Forum will be holding webinars throughout the year to review implementation strategies for the Practices.

Diagnotic Errors Warrant Attention Too

In a commentary released earlier this week in the Journal of the American Medical Association, Drs. David Newman-Toker and Peter Pronovost of Johns Hopkins suggest that far too little attention has been paid to diagnostic errors and the harm they cause.   In comparison to wrong-site surgeries, medication errors and hospital acquired-infections, they argue, diagnostic mistakes may account for a greater number of medical problems and preventable deaths.

While the patient safety movement has highlighted the need for "systems" approaches to reducing medical mistakes, as opposed to better training of individual physicians, for example, it has not focused on the need to improve systems for diagnosis.  Instead, the emphasis has been on the individual physician's ability to diagnose early and correctly.

Newman-Toker and Pronovost suggest that computerized decision support tools and and checklists can help physicians check for critical diagnoses and each patient's level of risk for certain diseases.

Saying Sorry - by Suzanne Delbanco, Ph.D.

If our health care system were highly reliable, the debate whether to say sorry to patients harmed by preventable medical mistakes would occur far less frequently.  However, until we have the processes and systems in place to reduce the incidence of preventable errors drastically, everyone from individual clinicians to patients' families to CEOs of major health care systems will have to discuss what's right to do when mistakes happen.

In an on-line commentary posted yesterday to the BBC Web site, Sir Liam Donaldson, Chief Medical Officer for England, argues that the National Health Service (NHS) needs to apologize more, and to mean it.

NHS clinical staff have a range of attitudes about apologizing, with some favoring being open in the face of errors, and others saying "over my dead body."  Being fully or partly responsible for harming a patient can be just as painful emotionally for the clinician as for the patient or patient's family.  And while saying sorry may be the start of emotional healing for all parties, Donaldson suggests that an apology is not meaningful until it becomes the start of a process to learn from the mistake so that future patients are spared similar harm.

This is remarkable leadership from the head of a closely-watched health care system.  We have much more to learn about this issue and far to go in evolving "apology" policies that work for both health care professionals and patients.  Many have studied the connection between apologies and lawsuits, finding that saying sorry can reduce the likelihood of a patient bringing suit to seek compensation for injuries from medical care.  Liability concerns raise the costs of care through rising malpractice insurance premiums.  Such concerns may also lead to the delivery of defensive medicine, during which clinicians may, for example, order extra but unnecessary tests to avoid accusations of not being thorough.

Reducing the likelihood of medical mistakes through methods like Hospital Video Auditing from Arrowsight, Inc., as well as others, is a critical aspect of moving forward.  But let's figure out how to work in "saying sorry."  It's the right thing to do and the benefits will likely have a beneficial ripple effect for all involved.

Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.