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September 18, 2018
More on Hospital Suicides
Suicide in hospitals has been a frequent topic in our Patient Safety Tips of the Week. Since our last column on this topic, there have been several published cases with lessons learned plus a timely review of the prevalence of hospital suicides.
There has been some debate over the prevalence of hospital suicides in the past. The Joint Commission, in its Sentinel Event Summary Statistics, has noted hospital suicides have remained relatively stable at an average of about 90 per year (range 84-98) from 2014 to 2017. But, since not all hospitals have reported completely to the Joint Commission, those figures are likely an underestimate.
Now, a recent study (Williams 2018) uses reliable data to provide good current estimates. Those researchers added to the Joint Commission Sentinel Events reports data from 27 states reporting to the National Violent Death Reporting System (NVDRS) for 2014-2015. They found that 73.9% of these suicides occurred during psychiatric treatment. They estimate that between 48.5 and 64.9 hospital inpatient suicides occur per year in the United States. Of these, 31.0 to 51.7 are expected to involve psychiatric inpatients. Many of our prior columns have focused on the 26% that attempt or commit suicide when housed in locations other than behavioral health units.
In the Williams study (Williams 2018), hanging was by far the most common method for suicide in the hospital, accounting for about 70% of cases in both databases when a method was specified. Over 50% of the sentinel event suicides occurred in the bathroom.
Our August 29, 2017 Patient Safety Tip of the Week “Suicide in the Bathroom” discussed several cases of inpatient suicides occurring in bathrooms and highlighted many contributing factors, with recommendations to mitigate risks. Two recent published cases also reinforce the need for attention to suicide risks in the bathroom. In one (Glathar 2018) a patient hanged himself from the top hinge of a shower door (the case had other issues, such as staff failing to carry out 15-minute observations). In another case (Mills 2018), a patient who had cut both of her forearms with a kitchen knife in a suicide gesture, had her forearm laceration sutured and bandaged with gauze padding. She was then transferred to the inpatient psychiatric unit. There, she asked to use the bathroom, where she unwrapped the gauze bandage from her wrist, wrapped it around her neck and over the shower bar in the bathroom, and attempted to hang herself. Fortunately, staff heard a noise and responded and were able to cut the gauze before any serious injury occurred. (By the way, while we always recommend removing things like belts and shoelaces from patients on behavioral health units, who would have thought about the gauze bandage as a tool for suicide?).
We’ve discussed the VA’s Mental Health Environment of Care Checklist (MHEOCC) in many of our columns. That checklist is available online on the VA Patient Safety website, as is an excellent video narrated by Peter Mills, MD. In our February 14, 2017 Patient Safety Tip of the Week “Yet More Jumps from Hospital Windows” we mentioned 2 publications (Watts 2016, Mills 2016) showing sustained results from implementation of the Mental Health Environment of Care Checklist (MHEOCC). The checklist and program became mandated at all VA hospitals in 2007. Inpatient suicide rates in VA hospitals dropped from 4.2 per 100,000 admissions to 0.74 per 100,000 admissions from 2000 to 2015. The reduction in suicides coincided with introduction of the MHEOCC and has been sustained since implementation in 2007. The authors stress that the physical changes brought about by the MHEOCC likely have a bigger impact on inpatient suicide reduction than the numerous other interventions used.
One very pertinent question asked in the MHEOCC is “Are doors that are within rooms and that open to other in-room areas such as bath/shower/toilet areas (i.e., not corridor doors) designed to eliminate anchor points?”. But keep in mind that almost any type of solid door might be used as an anchor even if it lacks latches, hooks, or other obvious loopable items. One could still conceivably loop bedsheets or clothing over the top of a solid door even if it has a “sloped” surface. Therefore, the MHEOCC recommends soft break-away doors for bathrooms and showers.
In our August 29, 2017 Patient Safety Tip of the Week “Suicide in the Bathroom” we recommended the following:
But it’s not enough to just ensure that bathrooms on your inpatient behavioral health unit meet the MHEOCC standards. Consider that the potentially suicidal patient on an intrahospital transport, such as a trip to the radiology suite, may lock him/herself in a bathroom in that suite and there are a number of loopable items in those bathrooms. You’ll recall that in our March 16, 2010 Patient Safety Tip of the Week “A Patient Safety Scavenger Hunt” we included the items below as ones to search for in your patient safety scavenger hunt:
And, speaking of intrahospital transports, don’t forget to the specific risks for wandering, elopement and/or suicide on your “Ticket to Ride” checklist for intrahospital transports (see, for example, our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport”). Suicide risk should be considered when patients are transported to Radiology (or other sites) whether the patient is on a behavioral health unit or medical unit (see our prior columns January 6, 2009 “Preventing Inpatient Suicides”, February 9, 2010 “More on Preventing Inpatient Suicides” and December 2010 “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”).
Two recent California Department of Public Health reports also illustrate other risks during transports or transfers from one unit to another. In one (CDPH 2018a), a patient was sent to ED from a psychiatry unit, eloped from the ED, and was hit by a car. In the other (CDPH 2018b), a suicidal patient was being transferred back from the ED to a psychiatric unit, jumped up and ran away and jumped 25-40 feet from a building, suffering skull and spine fractures and numerous other fractures and body trauma. He survived but had a long hospitalization, multiple procedures, and multiple deficits. During the transport, the patient had been accompanied by a nurse assistant who had no training in managing suicidal patients and two security guards who were not authorized to restrain patients. They called local police but it was too late to prevent the jump from the building.
In the Williams study (Williams 2018), when a method of suicide was specified, 6-10% of the suicides involved jumping from heights. Several of our columns have discussed patients who jump from windows and we’ve noted features that are common to such incidents (see our Patient Safety Tips of the Week for April 12, 2016 “Falls from Hospital Windows”, February 14, 2017 “Yet More Jumps from Hospital Windows”, and July 10, 2018 “Another Jump from a Hospital Window”). These are typically patients who are being housed on general medical or surgical units and there is a a pattern evolving. The typical patient is a young or middle-aged male, but occasionally elderly patients or females have also jumped through or out of windows. The patient is often admitted for an attempted suicide but, again, not always. Typically he/she is confused or hallucinating. It’s not just patients with known psychiatric disorders or a history of suicide attempt that are at risk. Patients with brain injuries or delirium are at risk, particularly those who have demonstrated a tendency to wander or have verbalized their intent to “get out of here” or “go home”. And the incidents have commonly occurred while patients are already on 1:1 continuous observation and the observer is actually in the room.
In these cases, patients were able to stand up on the bed and “launch themselves” through the window from the bed. That implies a proximity of the bed to the window. So one key lesson is to position the patient’s bed in the room at a reasonable distance away from the window so such “launches” are not possible.
Second, positioning of the observer may be important. The observer is usually positioned in the room on the side away from the window and near the door. We suspect that is intentional and may be a consideration for the safety of the observer plus it would allow the observer to easily yell for help if necessary. But that obviously needs to be rethought.
And some other less obvious equipment needs to be removed: the second bed in a 2-bed room should probably be temporarily moved. That can only hinder someone from attempting to rescue a patient who is trying to jump out of a window.
And since the patient often uses an object in the room to break the window, such as a chair or piece of medical equipment, care must be taken to make sure such objects are not in reach for a patient even for a very brief time. For example, if the observer needs to briefly leave the room perhaps the chair should be removed.
In our October 6, 2015 Patient Safety Tip of the Week “Suicide and Other Violent Inpatient Deaths” we noted that another potential vulnerability has to do with fire alarms. In one case a patient pulled a fire alarm which automatically unlocked doors on a behavioral health unit, allowing him to escape and jump to his death from a rooftop (Pfeiffer 2010). After we heard about that case we began to include inspection of stairwells and rooftop access points adjacent to behavioral health units in our patient safety walkrounds or environmental walkrounds.
Another recent case did not involve an actual suicide but serves as a reminder of how patients may use fire alarms to facilitate elopement (Fettes 2018). A patient on a behavioral health unit set his mattress and bedding on fire, triggering the facility's fire alarm. The alarm automatically disarmed the facility's fire doors and the patient left the unit. Fortunately, he was later found and returned to the unit. But the case illustrates a problem we’ve seen before. The behavioral health unit involved did not have a specific policy for "a combined fire and security incident". You’ll recall we have recommended that facilities consider combining safety drills to account for such incidents. For example, you could do a fire drill and then immediately do a drill for a missing patient (or an abducted child).
Since several cases mentioned in today’s column have also involved the emergency department, it is worth noting a recent study on improving documentation of suicide risk factors in the ED (Reshetukha 2018). The researchers did an educational intervention on suicide for all emergency medicine and psychiatry physicians. This was followed by the placement of a suicide risk assessment prompt within local ED’s. Documentation of 34/40 and 33/40 suicide risk factors was significantly improved by emergency medicine and psychiatry physicians, respectively, after the interventions and maintained six months later. Another recent study also emphasized chronic pain as a significant risk factor in 10% of suicides (Petrosky 2018). While a wide variety of causes for chronic pain were noted, the most common were related to back pain, cancer, and arthritis, all common in patients seen in the ED.
Some of our prior columns on preventing hospital suicides:
Some of our past columns on issues related to behavioral health:
See our previous columns on wandering, eloping, and missing patients:
References:
The Joint Commission. Sentinel Event Summary Statistics.
https://www.jointcommission.org/assets/1/18/Summary_4Q_2017.pdf
Williams SC, Schmaltz SP, Castro GM, Baker DW. Incidence and Method of Suicide in Hospitals in the United States. Jt Comm J Qual Patient Saf 2018; Published online September 3, 2018
https://www.jointcommissionjournal.com/article/S1553-7250(18)30253-8/fulltext#cebibl1
Glathar B. Failed patient checks linked to suicide at Wyoming State Hospital.
Uinta County Herald 2018; September 12, 2018
Mills PD. Web M&M. Suicide Risk in the Hospital. AHRQ PSNet 2018; May 2018
https://psnet.ahrq.gov/webmm/case/445
Mental Health Environment of Care Checklist (VA)
http://www.patientsafety.va.gov/docs/MHEOCCed092016508.xlsx
video
http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp
Watts BV, Shiner B, Young-Xu Y, Mills PD. Sustained Effectiveness of the Mental Health Environment of Care Checklist to Decrease Inpatient Suicide. Psychiatric Services 2016; Published Online Ahead of Print: November 15, 2016
http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600080
Mills PD. Use of the Mental Health Environment of Care Checklist to Reduce the Rate of Inpatient Suicide in VHA. TIPS (Topics in Patient Safety) 2016; 16(3): 3-4 July/August/September 2016
http://www.patientsafety.va.gov/professionals/publications/newsletter.asp
CDPH (California Department of Public Health). Complaint Intake Number: CA00479941; CDPH 2018
CDPH (California Department of Public Health). Complaint Intake Number: CA00462955; ; CDPH 2018
Pfeiffer R. Man survives plunge from roof of hospital. Niagara Gazette 2010; October 17, 2010
Fettes J, Scott E. Patient escapes from Canberra Hospital's mental health unit by starting fire, disarming fire door. ABC (Australia) News 2018; Posted 29 Aug 2018
http://www.abc.net.au/news/2018-08-30/mental-health-patient-escapes-canberra-hospital/10179584
Reshetukha TR, Alavi N, Prost E, et al. Improving suicide risk assessment in the emergency department through physician education and a suicide risk assessment prompt. General Hospital Psychiatry 2018; 52: 34-40
https://www.sciencedirect.com/science/article/pii/S0163834317303183
Petrosky E, Harpaz R, Fowler KA, et al. Chronic Pain Among Suicide Decedents, 2003 to 2014: Findings From the National Violent Death Reporting System. Ann Intern Med 2018; Epub ahead of print 11 September 2018
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September 25, 2018
Foley Follies
One of the most frustrating things in patient safety is when we fail to improve despite a robust evidence base for best practices. One of the conditions for which we have such a robust evidence base is the catheter-associated urinary tract infection (CAUTI).
Way back in the early 1990’s we used a simple chart sticker to get a 50% reduction in unnecessary urinary catheters (see our May 8, 2007 Tip of the Week “Doctor, when do I get this red rubber hose removed?”). Then we saw further reductions once we began to use clinical decision support built into our electronic medical records. Other useful measures have included daily “huddles” or “catheter rounds”, nurse-led protocols, automatic discontinuation orders, and flagging catheter duration in the EMR. Especially helpful has been suggesting alternatives to indwelling catheters (eg. condom catheters in males, use of bladder ultrasound to determine bladder volume). A major step was when clinicians from the University of Michigan (Meddings 2015) published appropriateness criteria for urinary catheters (see our June 30, 2015 Patient Safety Tip of the Week “What Are Appropriate Indications for Urinary Catheters?”). After that, more hospitals began auditing practices to ensure that catheter use was in line with appropriateness.
But CAUTI’s haven’t disappeared. In fact, the latest AHRQ data on hospital acquired conditions show that CAUTI’s actually increased in recent years (AHRQ 2018). And Medicare stopping reimbursement for hospital-acquired conditions has had little impact, though changes in coding by hospitals may play a role in that (Calderwood 2018).
Historically, there have been 3 areas in the hospital where urinary catheters are often inserted for dubious reasons (and then often left in for unnecessary durations): the ER, the OR, and the ICU. And the bane of those practicing in the hospital is the “surprise” Foley catheter (see our Patient Safety Tip of the Week for May 8, 2007 “Doctor, when do I get this red rubber hose removed?” and our July 2016 What's New in the Patient Safety World column “Holy Moly, My Patient has a FOLEY!”). This is when, unbeknownst to the attending physician, his/her patient has a Foley catheter inserted during the evening or night and its presence is not readily recognized.
Our June 2013 What's New in the Patient Safety World column “Barriers to CAUTI Prevention” highlighted the barriers to implementation of best practices to prevent CAUTI’s seen in the highly successful Keystone initiative in Michigan to prevent CAUTI’s (Krein 2013). Not surprising was lack of buy-in from physicians and nurses, or insertion of the catheter in the ER. A surprising barrier, however, was requests from patient or family for the catheter.
While many guidelines and protocols call for timely postoperative removal of urinary catheters placed prior to surgical procedures, there has been a lack of guidelines to help determine in which procedures a catheter is needed at all. We recall working with a small hospital that had only two general surgeons. One routinely used a urinary catheter during appendectomies, the other did not. Once we pointed out the discrepancy, the other surgeon realized he did not need a catheter when doing a routine appendectomy.
Now, the Michigan group (Meddings 2018) has again come to the rescue! They have developed guidelines for patients undergoing general and orthopedic surgery. Procedural appropriateness ratings for catheters were summarized for clinical use into three groups:
Specific recommendations were provided by procedure, with postoperative day 1 being appropriate for catheter removal for first voiding trial for many procedures. You’ll have to go to the article itself for details about the individual procedures. But the first category (no need for a catheter) includes things like laparoscopic cholecystectomy, open appendectomy, most hernia repairs, and unilateral knee and hip procedures. Examples of procedures where removal of the catheter before the patient leaves the OR include bilateral hip and knee procedures, hip replacement revision surgery, and several bariatric procedures. Lastly, the category where catheter use for at least one post-op day is appropriate includes procedures like colectomies and abdominoperineal resections.
And, while we have focused on CAUTI prevention, don’t forget there are many other reasons to avoid unnecessary use of Foley catheters. The Michigan group, again, has recently published an analysis of the various complications of indwelling urinary catheters (Saint 2018). 71% of the patients were male (largely because some of the hospitals studied were VA hospitals). 76% had the catheter removed within 3 days of insertion. Almost 80% of the patients studied had short-term catheters placed for surgical procedures. Noninfectious complications were 5 times more frequent than infectious ones.
57% of patients reported at least 1 complication due to the indwelling urethral catheter over the 30 days of followup. Infectious complications were reported by 10.5% and noninfectious complications (eg, pain or discomfort, blood in the urine, or sense of urinary urgency) by 55.4%.
Pain, discomfort, bleeding, or trauma at the time of catheter placement were noted by only 2% of patients who had the catheters placed for a surgical procedure but by 57% of those who had the catheter placed for bladder obstruction or urinary retention. Leaking urine, urinary urgency or bladder spasms, and difficulty starting or stopping the urine stream were the most common symptoms in those who had their catheter removed. In those who still had catheters in place the most common symptoms were pain, urgency or bladder spasms, or hematuria. Those who still had a catheter also experienced considerable limitation of activities of daily living or restriction of social activities (the old “one-point restraint”). Of those who had their catheter removed, 5% had sexual dysfunction. As you’d expect, longer duration of catheter use was associated with both more infectious and noninfectious complications. Women were more likely to report an infectious complication than men (15.5% vs. 8.6%), a point attributed to the shorter female urethra and closer proximity of perineal bacterial colonization to the insertion site of the indwelling catheter.
In view of the above study, you have even more reason to ensure appropriate use of urinary catheters. We hope that you’ll implement the many interventions we’ve discussed in detail in our numerous columns listed below and mentioned briefly at the beginning of today’s column. Recently, one hospital system implemented many of those interventions in a serial fashion and achieved excellent results (Youngerman 2018). After training on best practices, they standardized electronic documentation. In the second phase, duration of urinary catheter use was tracked in real time. In the third phase, clinicians were prompted by an alert reminding them of catheter duration. And in the final phase, orders for new urinary catheters included automatic expiration and required input of an appropriate indication plus suggestions for alternatives. CAUTI rate per 10,000 patient days decreased incrementally in each phase (from 9.06 in phase 1 to 1.65 in phase 4 or a relative risk 0.182). New catheters per 1,000 patient days declined from 53.4 in phase 1 to 39.5 in phase 4 (RR 0.740) and catheter days per 1,000 patient days decreased from 194.5 in phase 1 to 140.7 in phase 4 (RR 0.723). The reinsertion rate also declined.
Our evidence base to avoid inappropriate use of urinary catheters is very strong. It’s time we apply our knowledge of best practices to reduce their use and avoid both the infectious and noninfectious complications associated with them.
Our other columns on urinary catheter-associated UTI’s:
References:
Meddings J, Saint S, Fowler KE, et al. The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Obtained by Using the RAND/UCLA Appropriateness Method. Ann Intern Med 2015; 162(9_Supplement): S1-S34
http://annals.org/article.aspx?articleid=2280677
AHRQ (Agency for Healthcare Research and Quality). AHRQ National Scorecard on Hospital-Acquired Conditions. Updated Baseline Rates and Preliminary Results 2014–2016. AHRQ 2018; June 2018
Calderwood MS, Kawai AT, Jin R, Lee GM. Centers for medicare and medicaid services hospital-acquired conditions policy for central line-associated bloodstream infection (CLABSI) and cather-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement. Infection Control & Hospital Epidemiology 2018; 39(8): 897-901 Published online: 28 June 2018
Krein SL, Kowalski CP, Harrod M, Forman J, Saint S. Barriers to Reducing Urinary Catheter Use: A Qualitative Assessment of a Statewide Initiative. JAMA Intern Med 2013; 173(10): 881-886
http://archinte.jamanetwork.com/article.aspx?articleid=1672274
Meddings J, Skolarus TA, Fowler KE, et al. Michigan Appropriate Perioperative (MAP) criteria for urinary catheter use in common general and orthopaedic surgeries: results obtained using the RAND/UCLA Appropriateness Method. BMJ Qual Saf 2018; Published Online First: 12 August 2018
https://qualitysafety.bmj.com/content/early/2018/08/11/bmjqs-2018-008025
Saint S, Trakutner BW, Fowler KE, et al. A Multicenter Study of Patient-Reported Infectious and Noninfectious Complications Associated With Indwelling Urethral Catheters. JAMA Intern Med 2018; Published online July 2, 2018.
Youngerman BE, Salmasian H, Carter EJ, et al. Reducing indwelling urinary catheter use through staged introduction of electronic clinical decision support in a multicenter hospital system. Infection Control & Hospital Epidemiology 2018; 39(8): 902-908 Published online: 13 June 2018
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September 2018
ISMP (Institute for Safe Medication Practices) has long been the “go to” resource for information and tools regarding medication safety. One of ISMP’s most valuable medication safety tools is its List of High-Alert Medications. ISMP recently updated that list, based upon review of errors submitted to the ISMP National Medication Errors Reporting Program (ISMP MERP), literature review, input from various safety experts, and responses to a survey of readers of ISMP newsletters.
Survey respondents most frequently identified the following medications: anticoagulants, insulin, neuromuscular blocking agents, chemotherapy, opioids, hypertonic sodium chloride injection (concentrations greater than 0.9%), adrenergic agonists, and other concentrated electrolytes.
See ISMP’s newsletter (ISMP 2018) detailing the responses to the survey and the deliberations that went into their update of the list. Several additions were made to the list:
Other changes included:
Hospitals and ambulatory sites are required to have lists of high-alert medications (Joint Commission standard). The list of high-alert medications will vary from hospital to hospital, depending upon the pattern of medication use most prevalent at each hospital. For example, the list at a behavioral health facility will likely differ from that at a general hospital, and that at a pediatric hospital will likely be different from both.
Hospitals may well include some drugs not on ISMP’s list. While drugs on the list are usually those frequently prescribed at the hospital, we also caution hospitals to consider putting on the list drugs that may be dangerous and which their staff may be relatively unfamiliar with. For example, we recommend hospitals consider including desmopressin on their list. Particularly since this drug is being prescribed more and more for treatment of nocturia, patients are showing up in the hospital who have been on it at home. Staff are frequently unfamiliar with it and the other medical conditions that led to the hospitalization may render the patient even more vulnerable to the unwanted side effects of desmopressin. We refer you to our Patient Safety Tips of the Week for March 18, 2008 “Is Desmopressin on Your List of Hi Alert Medications?” and October 25, 2016 “Desmopressin Back in the Spotlight” for details.
One surprising finding in the responses to ISMP’s recent survey was that, even though almost all hospitals had a high-alert drug list, only 64% reported that they utilized special precautions to minimize and prevent errors for all of the high-alert medications on their list. The whole point of such a list is not only to alert all staff to the dangers but also to provide guidance about precautions to minimize risk of these agents.
References:
ISMP (Institute for Safe Medication Practices). High-Alert Medication Survey Results Lead to Several Changes for 2018. ISMP Medication Safety Alert! Acute Care Edition 2018; 23(17): August 23, 2018
http://www.ismp.org/resources/high-alert-medication-survey-results-lead-several-changes-2018
ISMP (Institute for Safe Medication Practices). High-Alert Medications in Acute Care Settings. August 23, 2018
http://www.ismp.org/recommendations/high-alert-medications-acute-list
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One of our most frequent topics has been communication errors that cause diagnostic errors and delays that may lead to disastrous patient outcomes (see list of columns at the end of today’s column). Recently, there have been several initiatives or studies that have expounded upon this issue.
ECRI Institute partnered with multiple organizations and convened an expert advisory panel to address the issues of errors or delays in diagnosis related to failure to follow up and errors related to changes or discontinuation of medications (ECRI Institute 2018). That Partnership for Health IT Patient Safety identified three key safe practice recommendations:
We hope you’ll access the ECRI Partnership toolkit which also contains an excellent slide presentation. The report and toolkit are very valuable resources that every healthcare organization can benefit from.
Meanwhile, our neighbors to the north have launched a campaign Greg’s Wings, highlighted by the film Falling Through the Cracks: Greg's Story. This is a powerful story of how failures in communication (“no news is good news”) led to diagnostic and therapeutic delays and ultimately the death of a young man. You’ve heard us so many times use the phrase “stories, not statistics” to drive buy-in from healthcare workers in a variety of patient safety issues. This film provides such a story.
One of the salient features in Greg’s Story is faxed referrals to specialists being lost and ignored. We highlighted the surprising continued role faxes play in healthcare and the problems associated with them in our January 16, 2018 Patient Safety Tip of the Week “Just the Fax, Ma’am”. An editorial in the Canadian press (Picard 2018) notes that, just as in the US, Canadian physicians still rely primarily on fax for communication with other physicians, despite the fact most have electronic medical record systems.
And failures in communication about diagnoses also happen when patients are transferred from one hospital to another. A recent study from University of Minnesota researchers (Usher 2018) looked at adult patients transferred between 473 acute care hospitals from 5 states from 2011 to 2013. The researchers found that discordance in diagnoses occurred in 85.5% of all patients. 73% of patients gained a new diagnosis following transfer while 47% of patients lost a diagnosis. Moreover, diagnostic discordance was associated with increased adjusted inpatient mortality (OR 1.11).
But when both involved hospitals shared data via health information exchange (HIE) there was a reduced diagnostic discordance index (3.69 vs. 1.87%) and decreased inpatient mortality (OR 0.88).
All these endeavors highlight the need for better communication on multiple levels in the healthcare continuum to reduce diagnostic errors and delays that may lead to adverse patient outcomes.
See also our other columns on communicating significant results:
Some of our prior columns on diagnostic error:
References:
ECRI Institute. ECRI Institute's Partnership for Health IT Patient Safety Releases New Recommendations to Avoid Testing and Medication Mix-ups. Publicly available report offers important tools and guidance for all healthcare systems. ECRI Institute 2018; Press release July 26, 2018
Partnership for Health IT Patient Safety. Health IT Safe Practices for Closing the Loop. Mitigating Delayed, Missed, and Incorrect Diagnoses Related to Diagnostic Testing and Medication Changes Using Health IT. ECRI Institute 2018
https://www.ecri.org/Resources/HIT/Closing_Loop/Closing_the_Loop_Toolkit.pdf
Greg’s Wings
Film: Falling Through the Cracks: Greg’s Story
http://gregswings.ca/fttc-gregsstory/
Picard A. Why are fax machines still the norm in 21st-century health care? The Globe and Mail (Toronto, Ontario) 2018; June 11, 2018
Usher M, Sahni N, Herrigel D, et al. Diagnostic Discordance, Health Information Exchange, and Inter-Hospital Transfer Outcomes: a Population Study. Journal of General Internal Medicine 2018; 33(9): 1447-1453
https://link.springer.com/article/10.1007/s11606-018-4491-x
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It seems we’ve done all too many columns on the unintended consequences of healthcare IT. So we’re happy to highlight this month some success stories for clinical decision support systems (CDS).
Cedars-Sinai Medical Center integrated select recommendations from the Choosing Wisely campaign as CDS alerts into their EHR. This included many alert-based CDS interventions, both inpatient and ambulatory. Providers, when presented with an alert, had the option to cancel, change, or justify the order, They analyzed the impact of these CDS alerts on inpatient encounters (Heekin 2018). The researchers found that encounters in which providers adhered to all alerts had significantly lower total costs, shorter lengths of stay, a lower probability of 30-day readmissions, and a lower probability of complications compared with nonadherent encounters. Full adherence to Choosing Wisely alerts was associated with savings of $944 from a median encounter cost of $12,940.
Another recent study (Wachsberg 2018) demonstrated that an educational intervention, combined with real-time clinical decision support (CDS), reduced blood utilization among hospitalized solid tumor cancer patients without adversely affecting outcomes. The odds of receiving a transfusion were cut by almost half in the postintervention cohort. There were no significant differences in readmission, outpatient transfusion within seven days of discharge, or inpatient mortality. Patients in the postintervention cohort also had lower odds of ICU transfer (OR = 0.29).
And another study in a large academic medical center (Eaton 2018) showed a mixed impact of nonintrusive clinical decision support systems on laboratory test utilization, reminding us to focus on areas where a positive impact is seen and avoid unnecessary alerts that don’t change outcomes. The study focused on CDS for red blood cell folate, hepatitis C virus viral loads and genotypes, and (blood) type and screens. Appropriate indications for these labs were incorporated into text that accompanied the laboratory orders in the hospital's EHR. There was a 43% decrease in the rate of hepatitis C virus tests per monthly admissions after the CDS was implemented. But there was no significant change in type and screen orders or folate orders. The authors stress that nonintrusive CDS should be evaluated for individual laboratory tests to ensure only effective alerts continue to be used so as to avoid increasing EHR fatigue.
The last point is very important. Avoiding alert fatigue is critical in any clinical decision support program. We stress to hospitals that they need to have an interdisciplinary group that works with their IT staff to evaluate the impact of every new CDS rule implemented. That means looking to see what the adherence/override rate is for each alert and whether the alert results in the desired change in ordering.
These three studies, however, clearly show that careful planning, implementation, and evaluation of clinical decision support tools can be beneficial to patient care and can be done in a manner that is nonintrusive.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
References:
Heekin AM, Kontor J, Sax HC, et al. Choosing Wisely Clinical Decision Support Adherence and Associated Inpatient Outcomes. Am J Manag Care 2018; 24(8): 361-366
Wachsberg KN, O'Leary KJ, Buck R, et al. Impact of Real-Time Clinical Decision Support on Blood Utilization and Outcomes in Hospitalized Patients with Solid Tumor Cancer. The Joint Commission Journal on Quality and Patient Safety 2018; Published online: August 17, 2018
https://www.jointcommissionjournal.com/article/S1553-7250(17)30485-3/fulltext
Eaton KP, Chida N, Apfel A, et al. Impact of nonintrusive clinical decision support systems on laboratory test utilization in a large academic centre. Journal of Evaluation in Clinical Practice 2018; 24(3): 474-479 First Published: 15 February 2018
https://onlinelibrary.wiley.com/doi/abs/10.1111/jep.12890
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In multiple presentations on healthcare policy (outside of our patient safety activities) we have discussed the impact of mergers and acquisitions in healthcare. Having participated directly or indirectly in several mergers, we’ve focused primarily on the financial implications.
The American Hospital Association (AHA 2017) released a report in 2017 (Noether 2017) touting that:
Call us skeptics. While every merger promises the community incredible financial benefit, few deliver on those promises. Theoretically, mergers should produce much savings by eliminating duplication. But, in reality, such mergers usually result in putting negotiating clout in one system and eventually rising healthcare costs for the community.
A number of years ago we participated in a panel discussion with Alan Sager, Ph.D., from Boston University School of Public Health, who had done extensive research on the community impact of hospital closures. His research showed that hospital closings have repeatedly failed to cut costs, and can even result in increased costs. Moreover, hospital closings have harmed access to care—particularly in underserved areas and communities of color (Sager 2006).
But until now there has been little attention to the patient safety repercussions of hospital mergers. Haas and colleagues (Haas 2018) recently published a Viewpoint in JAMA, highlighting several key challenges and barriers that may interfere with clinical care following mergers.
The authors identified 3 key risks to patient care resulting from mergers:
Post-merger, patients may be cared for by clinicians and staff who have little existing knowledge about them. Changes in supplies, equipment, formularies, protocols, and information systems also lead to unfamiliarity that may adversely impact patient care. And physicians, especially specialists, may now be required to travel to new settings where they may be unfamiliar with infrastructure, processes, teams, and clinical cultures that may differ significantly from one organization to the other(s).
Importantly, in collaboration with their Ariadne Labs, they make available for free a guide and patient safety toolkit to help with clinical planning between institutions prior to mergers. It also includes a checklist for developing a joint clinical integration council.
Mergers are not easy on clinicians and healthcare staff and ultimately may jeopardize patient safety. These resources are extremely valuable for any organizations considering merger and need to be tapped very early in any discussions about merger.
References:
AHA (American Hospital Association). New Research Finds Hospital Mergers Drive High-Value, High-Performing Health Care. AHA Press Release 2017; January 25, 2017
Noether M, May S. Hospital Merger Benefits: Views from Hospital Leaders and Econometric Analysis. Charles River Associates 2017; January 2017
https://www.aha.org/system/files/2018-04/Hospital-Merger-Full-Report-FINAL-1.pdf
Sager A, Socolar D. Closing Hospitals in New York State Won’t Save Money But Will Harm Access to Health Care. A Short Report Prepared for The Committee of Interns and Residents New York City. 20 November 2006
https://www.bu.edu/sph/files/2015/05/Sager-Hospital-Closings-Short-Report-20Nov06.pdf
Haas S, Gawande A, Reynolds ME. The Risks to Patient Safety From Health System Expansions. JAMA 2018; 319(17): 1765-1766
https://jamanetwork.com/journals/jama/article-abstract/2678285
Ariadne Labs. Patient safety toolkit for system expansion.
https://www.ariadnelabs.org/safe-expansion/
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