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July 26, 2022
More Risks in the Radiology Suite
You’ve seen our multiple columns describing the radiology suite as being high-risk for patient safety events. In our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite” and the other columns listed below we’ve discussed the multitude of safety issues seen in radiology suites that have little to do with radiology per se. That’s because sick patients with multiple medical problems and vulnerabilities are being taken to the radiology suite and staying there, sometimes for prolonged periods. The events include things like falls, medication errors, patient mixups, IV connection errors, running out of oxygen, conscious sedation incidents, suicides, and others.
But sometimes factors related to the imaging procedure may also contribute to patient safety events. Sanchez et al. (Sanchez 2022) recently discussed cases of 2 patients given IV sedation to facilitate MRI scans. In one, a 43-year-old woman with acute neurological symptoms and signs was given lorazepam 2 mg intravenously (IV) as premedication to reduce agitation after a first attempt at doing the MRI was unsuccessful. The MRI was again unsuccessful, despite anxiolysis. After returning to the medical unit, flumazenil 0.2 mg was given due to somnolence, with subsequent improvement in mental status.
In the second case, a 71-year-old man with a possible epidural abscess following a bout of sepsis was sent for an MRI scan. He was unable to tolerate the scan due to back pain, so hydromorphone 0.5 mg IV was administered. Because of continued restlessness, additional doses of lorazepam 1 mg IV and hydromorphone 0.4 mg IV were ordered. After the patient received a 3rd dose of lorazepam 1mg IV, he became obtunded, hypotensive, and developed respiratory depression with oxygen saturation around 60%. The rapid response team was called, and naloxone and flumazenil were administered. The patient was placed on bilevel positive airway pressure (BiPAP) and given a fluid bolus before being transported to the intensive care unit (ICU), where he was emergently intubated. The patient remained intubated for several days due to severe acute respiratory distress syndrome (ARDS), which was attributed to aspiration while in the MRI machine.
Sanchez et al. provide a nice discussion of the risks of minimal-to-moderate sedation for imaging procedures, especially in high-risk patients, when multiple medication doses are required, and when monitoring is limited or inadequate (e.g., inside an MRI machine). They highlight the need for risk assessment prior to administering such drugs and consideration of patient-specific risk factors for respiratory depression. They stress such risk factors for oversedation as obesity, hepatic, renal, and lung disease; substance use disorder, and obstructive sleep apnea. They recommend looking for higher American Society of Anesthesia (ASA) physical status classification and checking a STOP-BANG score to help identify patients who might have unrecognized obstructive sleep apnea. In addition, they note that lower BMI values are associated with higher plasma concentrations of fentanyl or midazolam, two commonly used medications for diagnostic imaging sedation. They also suggest assessing the patient for potential aspiration risk and considering NPO (nothing by mouth) orders prior to diagnostic imaging procedures with sedation.
They caution against “dose-stacking” of medications (administering medications multiple times and/or from various routes before each dose reaches its peak therapeutic effect).
Monitoring is very important. Because of variability and risk for oversedation, patients must be assessed before and after each dose or medication administration. They note that consistent sedation assessments are important throughout the duration of action of the medication(s) administered. They emphasize “Continuous electronic monitoring is indicated for moderate levels of sedation or higher and should be considered for high-risk patients receiving opioids and/or benzodiazepines.”
They also stress an important point that is often overlooked – sedation might be avoided all together in many patients. They discuss non-pharmacologic techniques that can be used to minimize anxiety, agitation, and claustrophobia prior to such imaging studies. These include positioning issues, use of movie goggles, mirrors, 2-way communications, call buttons, and even fragrance administration.
Nice, practical discussion of a problem we continue to see all too often in patients undergoing imaging studies.
Some of our prior columns on patient safety issues in the radiology suite:
Some of our prior columns on patient safety issues related to MRI:
References:
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. AHRQ PSNet Web M&M July 8, 2022
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
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What's New in the Patient Safety World
Restrictions on visiting patients may be due to legitimate reasons (eg. a COVID-19 outbreak or other contagious disease outbreak). But often we end up restricting visitors for reasons that are inappropriate or even selfish. We often just don’t want to be interrupted by questions from visitors. We’ve even seen physicians who round early in the morning to avoid having to speak with relatives or other patient visitors!
But visitors can also be helpful. They can assist the hospital staff with things like feeding patients. We often recommend that relatives or close friends sit in the room with patients who have delirium. And they can often serve to ensure that a patient understands instructions when the patient might be otherwise distracted or cognitively impaired.
So, are visitors good or bad? Researchers at the Pennsylvania Patient Safety Authority actually looked at this. Sanchez et al. culled information from patient safety reports from 92 hospitals in Pennsylvania (Sanchez 2022). Not surprisingly, they found visitor behavior might have good or bad influence on patient risks.
They found evidence of helpful visitor behavior. For example, visitors often helped reposition patients, helped them ambulate, helped them gain balance, and even escorted patients within the hospital in some cases. They identified instances where visitor behaviors prevented events such as falls, administration of incorrect medication, or allergic reactions from occurring.
But some other behaviors might be good or bad. For example, they might give a patient something potentially harmful or they might take such an item away from a patient. Or they might alert staff to a potential safety situation or they might distract staff from other responsibilities.
And some behaviors may always be detrimental, such as powering on or off devices or equipment, disconnecting equipment, or changing placement of equipment. The equipment or devices most frequently manipulated by visitors were bed or chair alarms and intravenous (IV) catheters.
Some specific detrimental actions they found included:
Of course, the classic detrimental action by a visitor is manipulating a PCA (patient-controlled analgesia) pump (see our many columns on PCA safety listed below).
Sanchez et al. suggest some potential safety strategies targeting visitor behaviors:
They note that development and display of warning and instructional signs require minimal effort and could be designed to impact numerous behaviors and event types. The article has a nice table with design recommendations for effective signage.
Overall, this is an excellent contribution to a topic we don’t pay enough attention to.
Other Patient Safety Tips of the Week pertaining PCA safety:
References:
Sanchez CE, Taylor MA, Jones R. Visitor Behaviors Can Influence the Risk of Patient Harm: An Analysis of Patient Safety Reports From 92 Hospitals. Patient Safety 2022; 4(2): 70-79
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The COVID-19 pandemic has had a significant impact on hospital infections. In our October 2021 What's New in the Patient Safety World column “HAI’s Increase During COVID-19 Pandemic” we noted that during the pandemic there were significant national increases in CLABSI’s (central line–associated bloodstream infections), CAUTI’s (catheter-associated urinary tract infections), VAE’s (ventilator-associated events), and MRSA infections.
In addition, there has been a substantial increase in antimicrobial resistance since the pandemic began. CDC (CDC 2022) reports that resistant hospital-onset infections and deaths both increased at least 15% from 2019 to 2020 among seven pathogens:
Antifungal-resistant threats rose in 2020, too, including Candida auris (60% increase) and other Candida species (26% increase) in infections in hospitals.
During the first year of the pandemic, more than 29,400 people died from antimicrobial-resistant infections commonly associated with healthcare. Of these, nearly 40% of the people got the infection while they were in the hospital.
CDC notes that hospitals treated sicker patients who required more frequent and longer use of medical devices like catheters and ventilators. Hospitals also experienced personal protective equipment supply challenges, staffing shortages, and longer patient visits.
CDC hopes that the trend is temporary but notes we must invest in the prevention-focused public health actions that we know work, such as accurate laboratory detection, rapid response and containment, effective infection prevention and control, and expansion of innovative strategies to combat antimicrobial resistance. Those strategies include alternatives to antibiotics and antifungals, new vaccines to combat infections that can develop antimicrobial resistance, and novel decolonizing agents to stop the spread of antimicrobial-resistant germs by people who may not know they are carriers.
Some of our prior columns on antibiotic stewardship:
See also our other columns related to COVID-19:
References:
CDC (Centers for Disease Control and Prevention). COVID-19. U.S. Impact on Antimicrobial Resistance. 2022 Special Report. CDC 2022
https://www.cdc.gov/drugresistance/covid19.html
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Good organizations are not satisfied with good practices. They strive for great practices. Intermountain Healthcare is one of those organizations.
Clinical decision rules have been quite successful for some conditions in reducing unnecessary imaging studies without jeopardizing patient safety. One such condition is minor head trauma. Our multiple columns listed below describe several different clinical decision rules that have been used to help guide clinicians in their decisions about CT scanning in adults with minor head trauma. There are also clinical decision rules for ordering CT scans in pediatric patients with minor head trauma. Intermountain Healthcare (Knighton 2022) was using a clinical pathway based on the PECARN (Pediatric Emergency Care Applied Research Network) risk stratification criteria for clinically important traumatic brain injury. Their Primary Children’s Hospital, which had participated in the development of those criteria, had pretty good compliance with the pathway but compliance at general ED’s in their 21 other system hospitals was not as good.
They initially deployed an intranet-based lookup tool, a care pathway, and a mobile flashcard application across general ED’s. But emergency physicians perceived the retrieval of guideline information as cumbersome and it did not fit well with their workflows.
So, they developed a clinical decision support system to accompany the clinical pathway. Part of it included automated feedback and education (both at the site level and individual physician level). But the major intervention was embedding an easy-to-understand, information-rich graphic “pop-up” alert providing current PECARN risk stratification criteria and supporting evidence, along with a risk assessment prompt linked to a head CT scan order or an “observation” order. (The article has nice screen shots of the “pop-up” alert for children less than 2 years old and those older than 2 years.)
They observed 4% lower odds of ordering a CT scan during the intervention months versus the control months. The CT scan rate remained significantly below the control
Months during the sustainment months (35.4% in the sustainment months versus 38.6% in the control months). As you’d expect a higher percentage yield of abnormalities by doing CT scans only in those children at higher risk, they found CT positivity rates increased from 6.0% during the control months to 9.3% during the sustainment months. CT scans with clinically important findings increased from 9.2% during the control months to 33.3% during the sustainment months. And no 72-hour readmissions with confirmed clinically important traumatic brain injury were identified.
The authors do acknowledge that the alert was only evoked in about half the eligible encounters and they discuss the issue of alert fatigue. However, they surmise that the educational value of seeing the alert led to later improved compliance with the criteria even when the clinicians did not subsequently see the alert.
The “pop-up” alert is a pretty simple tool and this study showed it can have a positive impact on care.
Some of our previous columns on CT scans in minor head trauma:
April 16, 2007 “Falls With Injury”
July 17, 2007 “Falls in Patients on Coumadin or Heparin or Other Anticoagulants”
March 2010 “CATCH: New Clinical Decision Rule for CT in Pediatric Head Trauma”
November 23, 2010 “Focus on Cumulative Radiation Exposure”
June 5, 2012 “Minor Head Trauma in the Anticoagulated Patient”.
July 8, 2014 “Update: Minor Head Trauma in the Anticoagulated Patient”
January 2017 “Still Too Many CT Scans for Pediatric Appendicitis”
March 2017 “Update on CT Scanning after Minor Head Trauma”
September 2017 “Clinical Decision Rule Success”
August 21, 2018 “Delayed CT Scan in the Anticoagulated Patient”
September 21, 2021 “Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective”
December 14, 2021 “Delayed Hemorrhage After Head Trauma in Anticoagulated Patients”
References:
Knighton AJ, Wolfe D, Hunt A, et al. Improving Head CT Scan Decisions for Pediatric Minor Head Trauma in General Emergency Departments: A Pragmatic Implementation Study. Annals of Emergency Medicine 2022; Published June 23, 2022
https://www.annemergmed.com/article/S0196-0644(22)00279-7/fulltext
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Most of the literature on checklists focuses on their use prior to surgery or other procedures. But how about using checklists after a procedure? A recent study (Siewert 2022) looked at the impact of a post-procedure “close-out” checklist during image-guided procedures. The authors found that the post-procedure close-out checklist improved patient outcomes by decreasing the number of adverse events that occur from inadequate safety processes at the conclusion of an image-guided procedure by 43%, the need for repeat procedures by 80%, and the severity of impact of an error.
Overall compliance with the postprocedure closeout checklist was in the high 90% range but compliance was lower in the group of patients with procedural errors reported (60%). In reviewing those incidents where the checklist was not used, the authors felt that most adverse events would have been prevented by use of the checklist.
Preventable errors were mostly related to obtaining and handling of specimens and retained foreign objects such as guidewires.
They did note some new error types after implementation of the checklist and plan to revise the checklist further. They anticipate that, with further modification of the checklist, 70% of incidents would have been preventable.
Some of our prior columns on checklists:
References:
Siewert B, Brook OR, Swedeen S, et al. Impact of a post-procedure close-out checklist on the incidence of preventable adverse events during interventional radiology procedures: an initiative to improve outcomes. Journal of Vascular and Interventional Radiology 2022; Published July 04, 2022
https://www.jvir.org/article/S1051-0443(22)01052-1/pdf
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