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March 24, 2020
Mayo Clinic: How to Get Photos in Your EMR
Patient misidentification has been a topic of many of our columns. We’ve long been advocates of including patient photographs in the EMR as a means of reducing patient identification errors. And there are many other benefits of having patient photographs in the EMR.
Our December 17, 2019 Patient Safety Tip of the Week “Tale of Two Tylers” showed a glaring example of how patient photographs in the EMR might prevent a wrong patient error. It also described the mechanical steps one hospital uses to get patient photographs into the EMR. In a study by Blanchfield et al. (Blanchfield 2019) the patient photographs were taken when the patient presented to the ED. The ease with which we can today take a digital photograph today and upload it to the EHR enables the use of up-to-date patient photos. In the Blanchfield study, they created a new standard of care and implemented a new workflow for ED registration staff. Using iPod touch devices, ED registration staff took photos of consenting patients either at the front desk when patients check-in, or at the end of the registration process.
But having the equipment and a protocol is the easy part. Actually, achieving a goal of getting photos in all patient EMR’s is more complicated. A study from the Mayo Clinic (Aseem 2020) is informative in that regard. A survey of all physicians practicing in their executive medicine division showed overwhelming support of respondents (92.3%) for inclusion of a patient photograph in the upper left corner of the EMR to help them in responding to phone messages and other issues of patient care. But, before they began a quality improvement intervention, the mean weekly measurement of the rate of photograph inclusion in the EMR was only 49.5%. Their multidisciplinary quality improvement team set a goal of increasing the rate of photo inclusion in the EMR by 20%, with a target rate of 70% or greater within 6 months of intervention.
They describe 3 PDSA cycles, each lasting 6 to 9 weeks. In the first, they gave visual cue cards to patients. The cards reinforced the importance of having a picture in their medical record to aid in proper identification, while addressing potential privacy concerns. It also gave them options to get the photos into the EMR.
The second PDSA cycle involved face-to-face meetings between the clinical staff and front office staff. This resulted in changes to workflow that made it easier to capture a patient photograph at the time of check-in for their medical appointment.
The third PDSA cycle focused on feedback and encouragement. Weekly results were shared in clinical staff meetings, on a notice board, and in the form of a poster. Barriers
to implementation were discussed and all encouraged ideas to streamline workflow. Encouragement was passed back on to staff to continue with their improved process.
After the first cycle, the photograph inclusion rate increased from 49.5% to 59.4%. After the second cycle, the rate increased to a peak of 74.7%, but then began to regress toward previous levels, After the third cycle, the rate remained relatively static at 76.0%. Overall, after 3 PDSA cycles, the mean weekly rate of patient photographs included in the EMR was 71.4%, meeting their original goal.
The article includes a nice graphic representation of the results on a weekly basis. It demonstrates 2 important elements: first, you will see some week-to-week variation in rates and, second, quality improvement projects need to be monitored for sustainability of results.
Some barriers were noted. These were patients in an executive medicine clinic, many of whom “seek to maintain a low profile” or were otherwise concerned with privacy issues.
Importantly, the researchers did look for unintended consequences. Fortunately, they did not find any. One bonus noted was that clinical assistants found that having a patient photograph allowed them to more easily identify the patient in the waiting area, improving the patient experience.
They also concluded that the intervention can be implemented inexpensively and without significant impact on workflow.
Note that the study did not measure the ultimate goal: reduction in patient misidentification errors. If you were to implement such a project in your organization, you might use the RAR (Retract-and-Reorder) methodology (see our July 17, 2012 Patient Safety Tip of the Week “More on Wrong-Patient CPOE”) to identify instances where a user initially entered an order on the wrong patient. The RAR methodology is also nicely described in the supplement to the Adelman study (Adelman 2019) that we referenced in our May 21, 2019 Patient Safety Tip of the Week “Mixed Message on Number of Open EMR Records”. It is a tool we’ve recommended you use in tracking and monitoring patient misidentification issues as part of your quality improvement program (see our March 26, 2019 Patient Safety Tip of the Week “Patient Misidentification”). The RAR methodology, of course, measures near misses (by definition, it identifies instances where the user recognized the error and corrected it). But it is one of the only proxies we have for assessing the frequency of potential wrong-patient ordering errors.
Our June 26, 2012 Patient Safety Tip of the Week “Using Patient Photos to Reduce CPOE Errors” described how Children’s Hospital of Colorado successfully implemented use of patient photographs to reduce CPOE errors (Hyman 2012). Beginning with a nice review of the literature on patient-note mismatches, they implemented tools to help avoid such mismatches during CPOE. First, they modified their CPOE workflow to include a verification screen asking the provider to verify that this is the patient on whom he/she intends to enter orders. They then began taking photographs of patients at admission or registration and including these on the above noted verification screen. They found a dramatic reduction in the number of events of actual ordering on the wrong patient or near-misses. And when such events or near-misses did occur, it was usually in charts that did not have a photograph of the patient. While they could not separate out the impact of the verification screen from that of the photograph, they felt that the photographs played a large role in reducing the number of orders placed in the records of wrong patients. They noted that, unlike other CPOE alerts that have a high likelihood of being ignored, the presence of the large centrally placed photograph is effective in capturing the attention of the CPOE user. They did note that photographs have limitations, particularly for newborns and when pictures are poorly exposed. And they note that photographs need to be updated at appropriate times.
The Blanchfied study mentioned above (Blanchfield 2019) demonstrated that a passive display of patient photos in the EHR was associated with reduced rates of wrong patient orders and near misses in the Brigham and Women’s Emergency Department. While the study looked at how having patient photos in the EHR helped physicians identify the correct patient when entering orders in the EHR, one can readily see how having the photo at the top of every screen (in the EHR or the radiology PACS system), along with their name and DOB and medical record number, would help whomever is searching for an image identify the correct patient.
What could go wrong? The biggest risk would be that the photo could be inadvertently be put into the EMR of the wrong patient. Staff inputting the photos obviously need to comply with 2-factor patient identification. A double check would not be practical for those offices with only a single receptionist and would likely be fraught with error in busy reception areas. But, for those EMR systems that provide patient access, you might ask the patient to confirm their photo is the correct one.
Some have questioned whether photos in the EMR might enable fraud. Actually, using photos in the EMR probably is a deterrent to fraud. Someone fraudulently using the ID of another patient would now likely be recognized as not being the intended patient.
People’s appearances change as they age and their appearance may also change for other reasons. They change their hair color or hair length, they lose their hair, they get new glasses, they get facial surgery, etc. So that raises the issue of when and how patient photographs should be taken. Your organization should have a policy on how often or under what other circumstances you should require a new photo. Most DMV’s require a new photo every 2 years or so when you renew your driver’s license. Your front office staff might also play a role in spotting cases where a new photo should be taken. Many front office staff get popup screens when registering patients that ask useful questions like “Do you have a current advance directive?”. You could easily add a question about whether there is an up-to-date photo.
There is also something to be said about real-time photographs in certain settings. Our November 12, 2019 Patient Safety Tip of the Week “Patient Photographs Again Help Radiologists” showed how real-time photographs, taken at the same time a radiology study was being done, were of great value not only in identifying the correct patient but also improving the clinical information available to the radiologist. And, in the Blanchfield study (Blanchfield 2019) the patient photographs were taken when the patient presented to the ED. The ease with which we can today take a digital photograph today and upload it to the EHR enables the use of up-to-date patient photos. In the Blanchfield study, they created a new standard of care and implemented a new workflow for ED registration staff. Using iPod touch devices, ED registration staff took photos of consenting patients either at the front desk when patients check-in, or at the end of the registration process.
Could facial recognition software eventually play a role? One might anticipate someone calling in to an office might have their identity verified via facial recognition on a cell phone or computer, with matching occurring against the photo in the EMR. Just a thought… That might lead to more confusion given the current state of the art, but who knows in the future? And you’d have to figure out what would happen with identical twins.
The Mayo system was thought to be especially helpful when clinicians were talking to patients on the phone (the photo reminding them about the patient). We think the most important value of the photo is when you search on a patient name in the EMR and the EMR truncates to the first result meeting the search criteria. You then have the opportunity of seeing a photo that may tell you it’s the wrong patient.
There, of course, are other benefits to having patient photographs in the EMR. In our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients” we briefly mentioned using photographs of patients when broadcasting an alert for a missing patient. We recommend that you include in your IT system a digital photograph of patients you identify as being at risk for wandering and elopement. Many communities, often in conjunction with their local chapter of the Alzheimer Association, have programs where families provide photos of their relatives with Alzheimer’s Disease or other dementia to the local police department to facilitate searches when such individuals go missing.
Inclusion of patient photographs would be a logical tool to use in avoiding wrong patient surgeries or mix ups in medication administration. In fact, there are programs that have used patient photographs to reduce the risk of patient misidentification during medication administration (AHRQ Health Care Innovations Exchange). The JPS Health Network in Fort Worth, Texas implemented such a system on its psychiatry units. They first implemented it on adolescent psychiatry in 2000 then, based on success of that program, extended it to their adult psychiatry service in 2006. They noted that this additional method of correct patient identification is especially needed on psychiatry because patients frequently remove their wristband identifications and may be unable or unwilling to respond to questions at the time of medication administration. In the year after implementation on the adult unit, there were no misidentification errors on either unit. Reappearance of misidentification errors a year later led to a reeducation effort and such errors again fell to almost zero.
Radiologists have also found patient photographs to be helpful. In our December 2008 What’s New in the Patient Safety World “Patient Photographs Improve Radiologists’ Performance” we noted a paper presented at the Radiological Society of North America’s annual meeting showing that inclusion of photographs of patients improved accuracy of radiologists’ reports. Putting a photograph of the patient aside their images on a PAC screen resulted not only in the radiologists feeling more empathy toward the patient but they also identified more incidental findings (the files were chosen because of incidental findings in this randomized study) without taking more time to review the images.
Another study (Ridley 2012) demonstrated that including patient photographs in PACS systems likely leads to fewer misidentification errors. Researchers at Emory University developed a low-cost system for obtaining patient photographs at the time an imaging procedure was being done and integrating them via wireless connection with the images going to their PACS system. They then gave radiologists imaging studies to read that purposefully including some instances of misidentification. Those reading without patient photographs picked up only 12.5% of the misidentified patients. Those reading with the patient photographs detected 64% of the errors.
Our November 12, 2019 Patient Safety Tip of the Week “Patient Photographs Again Help Radiologists” showed how real-time photographs, taken at the same time a radiology study was being done, were of great value not only in identifying the correct patient but also improving the clinical information available to the radiologist. Another article detailed how digital photographs can be integrated with medical imaging studies (Ramamurthy 2013).
So, it’s pretty clear that use of patient photographs has an important role in multiple aspects of patient safety. The current Mayo Clinic study provides some useful guidance on how your organization can promote the use of patient photos in the EMR.
Some of our prior columns on use of patient photographs in patient safety:
December 2008 “Patient Photographs Improve Radiologists’ Performance”
January 12, 2010 “Patient Photos in Patient Safety”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic Identification to Prevent Errors”
January 19, 2016 “Patient Identification in the Spotlight”
March 26, 2019 “Patient Misidentification”
November 12, 2019 “Patient Photographs Again Help Radiologists”
December 17, 2019 “Tale of Two Tylers”
Some of our prior columns related to patient identification issues:
May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”
November 17, 2009 “Switched Babies”
July 17, 2012 “More on Wrong-Patient CPOE”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic Identification to Prevent Errors”
August 2015 “Newborn Name Confusion”
January 12, 2016 “New Resources on Improving Safety of Healthcare IT”
January 19, 2016 “Patient Identification in the Spotlight”
August 1, 2017 “Progress on Wrong Patient Orders”
June 19, 2018 “More EHR-Related Problems”
November 2018 “More on Hearing Loss”
March 26, 2019 “Patient Misidentification”
May 21, 2019 “Mixed Message on Number of Open EMR Records”
September 10, 2019 “Joint Commission Naming Standard Leaves a Gap”
December 17, 2019 “Tale of Two Tylers”
References:
Blanchfield BB, Salmaisian H, Landman A. Abstract #56. Adding Patient Photos to the Electronic Health Record to Improve Patient Identification and Reduce Wrong Patient Order Errors. Ann Emerg Med 2019; 74(4s): S22-23 October 2019
https://www.annemergmed.com/article/S0196-0644(19)30733-4/fulltext
Aseem S, Ratrout BM, Litin SC, et al. A Process of Acceptance of Patient Photographs in Electronic Medical Records to Confirm Patient Identification. Mayo Clinic Proceedings: Innovations, Quality & Outcomes 2020; 4(1): 99-104
https://mcpiqojournal.org/article/S2542-4548(19)30152-3/fulltext
Adelman JS, Applebaum JR, Schechter CB, et al. Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors. A Randomized Clinical Trial. JAMA 2019; 321(18): 1780-1787
https://jamanetwork.com/journals/jama/fullarticle/2733207
Hyman D, Laire M, Redmond D, Kaplan DW. The use of patient pictures and verification screens to reduce computerized provider order entry errors. Pediatrics 2012; 130(1): e211-e219
https://pediatrics.aappublications.org/content/130/1/e211?download=true
AHRQ Health Care. Innovations Exchange. Innovation Profile: Use of Photographs as Second Means of Identifying Patients on Psychiatry Units Virtually Eliminates Medication Errors Related to Misidentification. Last Updated: 10/09/2013
Ridley EL. Integrating digital photos within PACS may cut ID errors. AuntMinnie.com June 20, 2012
http://www.auntminnie.com/index.aspx?sec=sup&sub=pac&pag=dis&ItemID=99747
Ramamurthy S, Bhatti P, Arepalli CD, Salama M, Provenzale JM, Tridandapani S. Integrating patient digital photographs with medical imaging examinations. J Digit Imaging 2013; 26(5): 875-885
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3782605/pdf/10278_2013_Article_9579.pdf
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March 2020
We’ve done many columns on things that can go wrong while patients are in the radiology suite or the MRI suite. The MRI suite, in particular, presents special challenges for those responding to unanticipated events. That is the reason that training and simulation exercises are so important in preparing all staff for such events.
One such event is the airway emergency occurring in a patient in the MRI suite. Patients undergoing MRI often have multiple acute medical conditions plus comorbidities that may place them at risk for events during MRI. Many of the inpatients are receiving opiates or other drugs that may depress respiration. Add to that the fact that many patients are given sedation before undergoing MRI because of claustrophobia and it should be no surprise that airway emergencies happen in the MRI suite.
Anesthesiologists McClung and Subramanyam (McClung 2020) addressed airway emergencies in the MRI suite in a recent issue of the APSF (Anesthesia Patient Safety Foundation) Newsletter. They begin with a discussion about the importance of understanding the MRI environment is divided into four Zones designated I through IV, with Zone IV being the MRI scanner magnet room. They stress that the MRI magnetic field is “invisible, always on, and can affect ferromagnetic equipment of any size in Zone IV, potentially converting it to a projectile that is drawn into the scanner with a strength and speed that can be deadly”. They also note that, in addition to risks to humans, damage to equipment can occur from such events. (You may recall in our January 7, 2010 Patient Safety Tip of the Week “Even More Concerns About MRI Safety” we noted a Swedish study showing that material injuries were more common than actual human injuries in MRI projectile incidents but the potential for serious human harm was very high).
They then discuss equipment issues, noting that very few airway devices have been specifically designed for safe use in MRI. Medical devices and equipment that might be used in the MR environments should be labelled as MR unsafe, MR conditional, or MR safe. Some laryngeal mask airways and endotracheal tubes contain small amounts of ferromagnetic material but may be designated “MR conditional” because, while they might affect image quality, they are not likely to cause patient harm. Those airway devices have been used safely along with plastic oropharyngeal airways and bag mask ventilation units. But they stress that classic metal laryngoscopes are considered unsafe as malfunction with sudden failure to operate can occur in Zone IV and nickel in the laryngoscope battery is ferromagnetic. Instead, single-use or reusable “MRI-conditional” devices should be used. (Some such devices are expensive but cost considerations would pale compared to costs of a malpractice settlement related to using MR-unsafe devices.)
Next, they stress process and procedures, relying heavily on the most recent update of the ASA practice advisory on anesthetic care for magnetic resonance imaging (ASA 2015). That stresses that, during an airway emergency, anesthesia professionals and other health care providers must be prepared to enter Zone IV quickly. The advisory states that “Alternative MRI safe/conditional airway devices should be immediately available in the MRI suite.” Personnel must recheck themselves for presence of ferromagnetic objects and equipment prior to entering the scanner. That is where we think it’s important for the MRI staff to serve as “traffic cops” during that emergency to enforce checking for ferromagnetic objects. The practice advisory states that airway equipment immediately available to the team in Zone III should be MR-conditional for all scanners in the location. “If it is safe, the airway should be supported with bag mask ventilation while the patient is removed from Zone IV to a nearby location in Zone III or Zone II where a full complement of airway and resuscitation equipment can be used and emergency personnel summoned for help.”
We think it is critical that every facility performing MRI imaging conduct drills and simulations so that all staff responding to an event in the MRI suite are aware of the hazards and know how to properly respond in a manner safe to all. That can be especially problematic in academic medical centers where hew housestaff are continually rotating in and out or in small community or rural facilities where locum tenens or temporary staff are being used. In such circumstances, it is crucial that their initial orientation to the facility include education about the hazards of the MRI suite.
This is actually a good topic for a FMEA (failure mode and effects analysis). You need to ask questions about availability of MR-safe equipment in the MRI suite, what training responding staff are likely to have had, how MRI staff are deployed to help those responders avoid safety issues as they arrive, and others.
Some of our prior columns on patient safety issues related to MRI:
References:
McClung H, Subramanyam R. Airway Emergencies and Safety in Magnetic Resonance Imaging (MRI) Suite. APSF Newsletter 2020; 35(1): 10-11 February 2020
https://www.apsf.org/wp-content/uploads/newsletters/2020/3501/APSF3501.pdf
ASA (American Society of Anesthesiologists). Practice advisory on anesthetic care for magnetic resonance imaging: an updated report by the American Society of Anesthesiologists task force on anesthetic care for magnetic resonance imaging. Anesthesiology 2015; 122: 495-520
https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2091587
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A year ago (see our March 5, 2019 Patient Safety Tip of the Week “Infusion Pump Problems”) we did an extensive column on safety issues related to infusion pumps. We hope you’ll go back to that column to review our many recommendations.
But ISMP (Institute for Safe Medication Practices) has now published its long awaited “Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps” (ISMP 2020). We have no intention of replicating here the details of that thorough, practical, up-to-date guideline. You’ll have to read it yourselves.
It describes the various types of errors associated with infusion pumps, including dose-rate and infusion-rate mix up errors, concentration errors, multiple line errors, and others. It summarizes results of several surveys that ISMP undertook in recent years on infusion pump issues and then discusses infrastructure issues, drug library issues, clinical workflow issues, continuous quality improvement (CQI) data, and interoperability with the electronic health record. There is also a section on clinical alerts, soft limits, hard limits, and alarm management.
The guideline also discusses dose error-reduction systems (DERS), a feature of some smart pumps. Facility-customized DERS warn healthcare providers about potential prescribing, calculation, and programming errors by generating alerts intended to prevent infusions from being programmed outside facility-established limits.
The section on building a drug library is especially important. ISMP stresses independent double checking for the entry or modification of each drug-specific element such as the
standardized drug name, applicable tall man lettering, dosing units, concentration, dose limits, and associated clinical alerts.
ISMP recommends you establish care areas/profiles that are tailored to specific patient populations, acuity, and/or patient weight. But you must remember when transferring patients to a different clinical unit to ensure the drug library care area/profile is appropriate for the receiving unit.
Standardization is critical. That includes standardizing the nomenclature of the drug name (including any TALL MAN LETTERING), dose/dosing units (e.g., weight-based versus non-weight-based dosing; mcg/kg versus mg/kg), and dose-rate (e.g., mg/kg/min versus mg/kg/hr) in the drug library. It is also important to make sure this nomenclature is consistent with the EHR, pharmacy infusion labels, and pharmacy IV workflow systems. Standardizing and limiting the number of drug concentrations for continuous and intermittent infusions in the drug library is also important.
Performance of double checks at certain points in the clinical workflow is emphasized.
When starting selected facility-defined high-alert medication infusions and at additional facility-defined steps (e.g., change of shift/handoffs, change in the rate/dose of infusion, change in bag/bottle/syringe) require that a double check be performed and documented to verify the following before starting the infusion:
ISMP notes that technology (eg. barcoding) is the preferred method for double checking most of these items but use of a second practitioner is necessary to perform and document an independent double check for line attachment.
It outlines considerations for differentiating infusion pumps used to administer medications and fluids via different routes of administration (e.g., IV, enteral, epidural).
One often overlooked point: “Immediately discard all continuous IV medications and epidural infusions (e.g., continuous infusions of magnesium, neuromuscular blocking agents, and opioids) after discontinuation (i.e., do not leave hanging on an IV pole or at the bedside).”
The ISMP guideline is aimed primarily at use of smart infusion pumps in facilities. It does not delve into issues related to use of infusion pumps in the home setting. We covered some of the latter issues in our March 5, 2019 Patient Safety Tip of the Week “Infusion Pump Problems”. Especially important in the home setting is one of our own critical warnings that applies to any sort of infusion pump, smart or otherwise: never put a potentially lethal amount of a medication in a bag/bottle/syringe, lest some sort of error leads to infusion of the entire amount over too short a period. We have done several columns in which fatal or near-fatal overdoses of chemotherapy agents have been infused inadvertently over several hours when they had been intended to infuse over several days (see our Patient Safety Tips of the Week for September 11, 2007 “Root Cause Analysis of Chemotherapy Overdose” and April 6, 2010 “Cancer Chemotherapy Accidents” and September 15, 2015 “Another Possible Good Use of a Checklist”).
The ISMP guideline also includes multiple metrics that should be monitored as part of your quality improvement program.
This ISMP guideline is a must-read for anyone who encounters infusion pumps in their practice. It has a strong evidence base, is well-referenced, and has many practical recommendations.
As above, we hope you’ll also go back to our March 5, 2019 Patient Safety Tip of the Week “Infusion Pump Problems” for our extensive review of safety issues related to infusion pumps. The current ISMP guidelines also don’t go into detail about some of the special issues involved with PCA (patient-controlled analgesia) pumps. We’ve also included below a list of our prior columns dealing with PCA issues.
Our prior columns related to infusion pump issues:
Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:
References:
ISMP (Institute for Safe Medication Practices). Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps. ISMP 2020; February 10, 2020
https://www.ismp.org/guidelines/safe-implementation-and-use-smart-pumps
Print “March 2020 ISMP Smart Infusion Pump Guidelines”
In 2014 AORN (Association of periOperative Registered Nurses) issued its revised guidelines for surgical attire. There were several recommendations that met with considerable controversy. Two of those were the requirement to wear a bouffant rather than other head covering in the OR and to wear a garment that covered the arms in the OR. A third recommendation was that personal clothing should not be worn beneath scrubs. The Joint Commission and other regulatory agencies began enforcing those recommendations. Surgeons and anesthesiologists pushed back considerably, particularly about the head covering issue which effectively banned the traditional surgical skull cap, citing the lack of a strong evidence base for these practices. We discussed the disparities between the AORN guidelines and those issued by the American College of Surgeons (ACS 2016) in our September 2016 What's New in the Patient Safety World column “American College of Surgeons Statement on Operating Room Attire”.
Taking all arguments into consideration, AORN published updated guideline for surgical attire in July 2019 (AORN 2019), That new guidelines say no recommendation can be made for the type of head covers worn in the semi-restricted and restricted areas. It also says that no recommendation could be made regarding long sleeves, with the exception that long sleeves should be used when performing skin antisepsis. And it left the issue of personal clothing underneath scrubs up to individual hospital policy.
Timely is a study done at the University of Alabama at Birmingham (Wills 2020). Researchers there were able to track SSI’s (surgical site infections) during 3 separate time periods, one in which neither bouffants nor surgical jackets were required, one during which long-sleeved surgical jackets were mandated, and another during which both surgical jackets and bouffants were required. They looked at over 34,00 inpatient surgical cases over a 22-month study period. They found no significant difference in the risk of SSI (1.01% vs 0.99% vs 0.83%), mortality (1.83% vs 2.05% vs 1.92%), postoperative sepsis (6.60% vs 6.24% vs 6.54%), or wound dehiscence (1.07% vs 0.84% vs 1.06%) between the 3 groups.
They estimated expenditure of more than $300,000 annually on surgical jackets. Bouffants were found to be less expensive than surgical skull caps. They conclude that surgical jackets and bouffants are neither beneficial nor cost-effective in preventing SSI’s and that institutions should evaluate their own data to determine whether recommendations by outside governing organizations are beneficial and cost-effective.
A thoughtful editorial (Dipp Ramos 2020) accompanying the Wills paper reminds us that there are other common-sense recommendations regarding attire:
The issue of transmitting pathogenic bacteria is serious and such transmission can take place in both directions (i.e. from hospital to home, or from home to hospital). Mitchell and colleagues (Mitchell 2015) summarized the literature on the role of apparel worn in healthcare settings in the acquisition and transmission of healthcare-associated pathogens. In some countries all laundering of healthcare workers’ uniforms is carried out in-house under regulated conditions. Laird et al. (Laird 2018) discussed in detail the issue of domestic laundering of nurses’ uniforms vs. hospital or commercial laundering and noted the following rules that should be followed if healthcare attire is laundered at home:
In our February 2014 What's New in the Patient Safety World column “SHEA’s New Recommendations for Hospital Attire” we discussed the guidance statement from the Society Healthcare Epidemiology of America (SHEA) for hospital attire outside the OR (Bearman 2014). The guidance attempts to balance professional considerations against the potential risk of transmission of pathogens to patients. It reviewed the laboratory evidence of contamination of various pieces of healthcare workers’ attire with pathogens, including multi-drug resistant pathogens. Though the authors made it clear that the actual role of hospital attire in causing infections in patients was unclear at the time, the guidance has recommendations that are based on practical, theoretical and biologically plausible considerations to reduce the likelihood of transmission of pathogens to patients.
One recommendation was “bare below the elbows (BBE)”, a recommendation used widely in Europe. This means healthcare workers should wear short sleeves during patient contact and have no wristwatch, rings or other jewelry below the elbows.
They also had recommendations regarding the traditional white coats worn by healthcare workers. Workers should have at least 2 white coats available and a convenient and economical way of laundering them. The institution should provide onsite laundering at no cost or low cost when possible. The institution should also provide coat hooks for healthcare workers to remove their white coat (or other long-sleeved outerwear) prior to patient contact. While they note that attire worn in patient contact should be laundered after daily use, they recommend that white coats worn during patient care should be laundered at a minimum once a week or when visibly soiled. While they did not take a firm stance on whether attire should be laundered at home or professionally, they did recommend that if attire is laundered at home a hot-water wash cycle with bleach be used, followed by a cycle in the dryer.
The SHEA paper noted a huge gap between hospital attire policies and their enforcement, with enforcement rates as low as 11%. Given the number of healthcare workers we still see in scrubs in hospital cafeterias, other parts of the hospital, and even shopping alongside us in our local grocery stores, we know it will take much more than a policy to foster true change.
Now is a good time to review your organization’s policies on attire in various areas. Yes, you may find that you can save some costs as pointed out in the Willis paper. But we also suspect that, if you do an audit of compliance with attire guidelines, you’ll find that your staff regularly breaks the rules.
See our prior columns regarding hospital or surgical attire:
References:
ACS (American College of Surgeons). Statement on Operating Room Attire. Online August 4, 2016
https://www.facs.org/about-acs/statements/87-surgical-attire
AORN (Association of periOperative Registered Nurses). Guidelines for perioperative practice: surgical attire. AORN Facility Reference Center. July 2019
https://www.aornguidelines.org/guidelines/content?sectionid=173717946&view=book#221232892
Wills BW, Smith WR, Arguello AM, McGwin G, Ghanem ES, Ponce BA. Association of Surgical Jacket and Bouffant Use With Surgical Site Infection Risk. JAMA Surg 2020; Published online February 12, 2020
https://jamanetwork.com/journals/jamasurgery/fullarticle/2760957
Dipp Ramos R, Itani KMF. Emotions, Common Sense, and Evidence in Operating Room Attire. JAMA Surg 2020; Published online February 12, 2020
https://jamanetwork.com/journals/jamasurgery/article-abstract/2760951
Mitchell A, Spencer M, Edmiston C. Role of healthcare apparel and other healthcare textiles in the transmission of pathogens: a review of the literature. Journal of Hospital Infection 2015; 90(4): 285-292
https://www.journalofhospitalinfection.com/article/S0195-6701(15)00142-5/fulltext
Laird K, et al (2018) Domestic laundering of nurses’ uniforms: what are the risks? Nursing Times 2018; 114: 2, 18-21
Bearman G, Bryant K, Leekha S, et al. SHEA Expert Guidance. Healthcare Personnel Attire in Non-Operating-Room Settings. Infect Control Hosp Epidemiol 2014; 35(2): 107-121 February 2014 electronically published January 16, 2014
https://www.jstor.org/stable/10.1086/675066#metadata_info_tab_contents
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We’ve done many columns on patient safety issues related to behavioral health (see list at the end of today’s column). But virtually all our columns have focused on patients in the hospital setting. We have largely neglected patient safety risks for this population in the outpatient setting.
A case-control study in Sweden recently reported on patient-related factors associated with risk of preventable harm in first-line health care in 2 settings – primary care and the emergency department (Fernholm 2020). The researchers found that all psychiatric diagnoses, regardless of severity, nearly doubled the risk of being a reported case of preventable harm (odds ratio 1.96). Excess risk in this group persisted even after adjustment for income and education.
The preventable harm was mostly somatic harm as oppose to psychiatric harm/suicide, and primarily involved diagnostic errors of somatic disease (46% of all preventable harm in this category was due to diagnostic errors). Smaller categories were harm from falls, surgical complications, medication-related and cross infections.
The most common psychiatric diagnoses were depression and anxiety and alcohol- or drug-related psychiatric disorders, with less frequent diagnoses being dementia, bipolar
disease, and psychotic disorders.
Differences in income and education did have some impact on the risk of preventable harm. But even after adjustment for these, the risk of preventable harm for those with psychiatric diagnoses remained significant (odds ratio 1.69).
The authors cite several prior large studies which showed that people with mental illness die prematurely and have higher rates of comorbidities than the general population. They speculate some of this may be due to “diagnostic overshadowing”, where physical symptoms are misattributed to mental illness. They note that patients with mental illness can present physical symptoms as behavioral changes, but they can also present mental discomfort as physical symptoms.
They also note that earlier studies found patients with a history of psychiatric disease have a significantly higher rate of early death after ED discharge than do patients in the
ED without such a history and that most such patients die of non-psychiatric causes
They note contributory factors identified in the hospital setting include difficulties of communication, different expressions of symptoms, problems in knowledge and information gathering, and substance misuse. But they note that reasons for increased risk in primary care have not explored.
Another recent study (Isbell 2020) looked at emotional responses of ED physicians and nurses to 3 types of encounters: one that elicited anger/frustration/irritation (angry encounter), one that elicited happiness/satisfaction/appreciation (positive encounter), and one with a patient with a mental health condition (mental health encounter). Emotions reported in angry and mental health encounters were remarkably similar, highly negative, and associated with reports of low provider engagement compared with positive encounters. The healthcare workers reported their emotions influenced their clinical decision-making and behavior most frequently in angry encounters, followed by mental health and then positive encounters. Emotions in angry and mental health encounters were associated with increased perceptions of patient safety risks; emotions in positive encounters were associated with perceptions of higher quality care.
We’ll speculate that the time factor may well play a role. In our experience, patients with those psychiatric diagnoses generally take more time during visits. So, in settings where busy schedules limit the amount of time spent with each patient (such as primary care and the emergency department), we might expect more errors to occur.
While the exact reasons for this excess risk in this population are unclear, this study should serve as a warning for first line healthcare professionals to use caution in addressing medical issues with such patients and be careful to avoid biases, particular with regard to diagnostic issues.
Some of our past columns on issues related to behavioral health:
References:
Fernholm R, Holzmann MJ, Wachtler C, et al. Patient-related factors associated with an increased risk of being a reported case of preventable harm in first-line health care: a case-control study. BMC Family Practice 2020; 21: 20
https://bmcfampract.biomedcentral.com/track/pdf/10.1186/s12875-020-1087-4
Isbell LM, Tager J, Beals K, et al Emotionally evocative patients in the emergency department: a mixed methods investigation of providers’ reported emotions and implications for patient safety. BMJ Quality & Safety 2020; Published Online First: 27 January 2020
https://qualitysafety.bmj.com/content/early/2020/01/27/bmjqs-2019-010110
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