Healthcare Consulting Services
PO Box 1230
Grantham, NH 03753
ph: 716-550-1106
btruax
Healthcare Consulting Services with a Focus on Patient Safety Solutions and Quality Improvement Across the Health Care Continuum. Your Patient Safety Resource Solution.
July 7, 2020
Another Patient Found Dead in a Stairwell
Missing person found dead in stairwell. That’s a headline we’ve certainly heard many times in the past. The most recent one was slightly different in that this was not a patient in an acute care facility. But it does raise important points about what to do when a patient goes missing.
The 62-year-old man was a veteran living in a residential facility run by an independent not-for-profit company in a space it leases in a section of a building on a VA hospital campus (Romine 2020, Estes 2020, Cohan 2020, CBS Boston 2020). He was last seen at the facility on May 8 and had been reported missing on May 13. He was found dead in a stairwell on the campus of the adjacent VA hospital on June 12. The stairwell was only 60 feet from the room in which he resided, and he was found wearing the same clothing he had on the day he went missing. The cause of death has not yet been published, but early reports say foul play was not considered to have been a factor.
The residential facility did a search of its grounds once it was recognized the resident was missing. It also notified both the local town police department and the VA police responsible for the rest of the VA campus. Reports state that the agreement with the VA had some sort of wording that prevented the residential facility from searching any of the other VA property, including the stairwell where the resident was eventually found, though this restriction was disputed by the VA. The stairwell was an emergency-exit stairwell from a VA campus building. The VA campus has been described as a “sprawling 177-acre VA site, which resembles a college campus” and the local police and the VA police force apparently share jurisdiction for emergencies on the campus (Estes 2020).
It’s not clear from the reports whether the resident ended up in the stairwell by exiting the door that led to the stairwell, though the co-resident who found his body did apparently exit via that door into the stairwell.
Despite the finger-pointing about who was responsible for what, there are valuable lessons here. Many acute care hospitals have on their campus other facilities, like skilled nursing facilities or assisted living facilities. In addition, some acute care hospitals have on their campus privately managed areas that rent space (eg. a private MRI program or a physician-owned outpatient practice or a privately-run parking garage). In all such arrangements, there must be good communication, shared responsibility, and coordination of effort any time a patient or resident or even a visitor goes missing.
This topic was in the headlines several years ago after a patient was found dead 17 days after going missing at a San Francisco hospital in 2013 (see our October 15, 2013 Patient Safety Tip of the Week “Missing Patients” and our December 2013 What’s New in the Patient Safety World column “Lessons from the SFGH Missing Patient Incident”). But we had first addressed the issue in our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients” and most recently in our April 7, 2015 Patient Safety Tip of the Week “Missing Patients and Death”.
In the latter column we discussed multiple incidents and cases of missing patients and noted several themes recur:
And all types of facilities need to develop policies and procedures for:
1) doing an assessment for risk of wandering or elopement
2) implementing risk reduction strategies for those patients at risk
3) performing a prompt and thorough search when a patient is missing
It was noted above that residents of this facility were free to come and go. But we would expect that such a facility would have sign out/sign in logs (with planned destinations) to help them keep track of the residents. Having such a log should have led to earlier recognition that the resident had gone missing. When we said above “taking too long to issue a missing person code”, we were usually talking about minutes or hours, not days or a month. But even in this case, had the facility noted the resident had not returned overnight, initiating a search conceivably might have found him while still alive.
But the next most critical elements are what you do upon recognizing a patient has gone missing. When a patient is discovered to be missing a brief search of the local unit should be done. If the patient is not found immediately, the “code” for a missing patient should be issued. That is called to the hospital operator and announced over PA system. While most hospitals still use arcane codes for various emergencies, many are moving to “plain language” codes for these alerts. In the case of a missing patient a “plain language” code with the description of the missing patient has the additional advantage that visitors and other patients in the hospital might identify the missing patient. Some facilities use an alternative system to alert staff to missing patients. They may use text messages sent out in a “blast” fashion to computer terminals and staff smartphones, the equivalent of the well-known “Amber alert” when a child in the community goes missing. This sort of system can have the advantage of including a description of the patient and perhaps a photograph (that’s one of the many benefits of having digital patient photographs in your electronic health rccord). But the disadvantages of the “blast” system are that it may take longer to implement, and you lose the chance that a visitor or other patient might identify the missing patient.
Once the “code” is announced or the alert otherwise issued, there must be a coordinated effort to search for him/her. The facility should have a “grid search” where every area of the hospital and surrounding grounds has a designated person to search it. A central command post is set up, with a map having a predefined grid, and staff call in to that post once they have searched their sector. In addition, most facilities and campuses like this have closed-circuit TV (CCTV) monitoring of exits and other portions of the grounds. Someone must be assigned to look at those surveillance tapes, attempting to go back as far as the time the patient/resident was last seen. That might include CCTV feeds from areas such as parking ramps. Yes, these searches are resource intensive, both in terms of personnel needed and time needed. That highlights the point above about overreliance on “Security”. There is a tendency for everyone to think that ii is the job of the security force or police force to look for missing persons. When you are concerned about the health and safety of a patient or resident, it’s actually everyone’s concern. A well-coordinated “grid” search, where each square is assigned to one individual, can usually be performed expediently and with minimal distraction from their other responsibilities.
We also recommend early outdoor search since a patient can easily stray far from the building (or into automobile traffic) in a very short period of time. We also recommend that the local police department be notified immediately by the operator when the “code yellow” (or whatever code name you use for missing patients) is called (and don’t forget to include the police in your planning process).
And, of course, we invoke our old mantra “Never ass-u-me” because it will make an ass out of you and me. In this case, it sounds like several parties each “assumed” the other party had searched the implicated stairwell.
Doors. Several aspects of doors may be relevant. Most emergency-exit doors are self-locking. So, when someone exits through them, they cannot re-enter via that door. That was likely a factor in the death discussed in our December 2013 What’s New in the Patient Safety World column “Lessons from the SFGH Missing Patient Incident”. We even once got a cellphone call from a physician who responded to a cardiac arrest and got locked in a stairwell and could not get back into any unit! Also consider that there are times when your locked doors will be automatically unlocked (eg. fire alarms) creating an opportunity for a wandering patient to leave the unit.
Door alarms are only as good as the system you have in place to respond to a door alarm being triggered. It is unclear whether the door alarm in this facility was operational or not. The co-resident who found the deceased resident did exit via the emergency-exit door to that stairwell. Did an alarm trigger when he opened that door? Did anyone respond to that alarm if it did occur? And how often do you check to see if the door alarms are in working order?
In our June 16, 2020 Patient Safety Tip of the Week “Tracking Technologies” we also discussed motion-sensitive surveillance cameras. Some motion-sensitive surveillance cameras can distinguish humans from other causes of motion and send an alert to a smart phone or other notification device. They can be placed, for example, in a stairwell that a patient might utilize to abscond from a secure unit. In addition to providing the real-time alert, they also typically store video of an event for a specified time period. That may be important in the search for a patient found missing.
And, speaking of alarms, there are other alarm issues pertinent to missing patients. Review of the death of a patient who wandered out of a San Diego hospital several years ago (Luke 2014) illustrates several problems related to reliance on alarms. First, the patient’s bed alarm never sounded. Then, once staff realized the patient was missing, they tried unsuccessfully to page Security and then tried to contact Security by pushing a panic button twice, also with no response. When state inspectors investigated, they found that the panic button had been broken for 8 days. In fact, they found the hospital failed to routinely test the buttons and failed to repair them when broken and that one out of every four panic buttons at the hospital didn’t work.
In our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?” we described the following scenario: You implemented a “panic button” system to protect your behavioral health workers from assaults by patients on your locked behavioral health unit. The worker is in a situation where she fears potential harm from a patient and presses the panic button. However, the battery in the panic button is dead. Fortunately, other staff were within audible range of her shouts for help and responded before she was assaulted. The lesson is that any alarm or alert system, regardless of whether it is battery-operated or otherwise, needs frequent testing to ensure it is in working order.
Stairwells. In the current case, the man was found in the stairwell of part of the building that apparently had been closed off to stop the spread of the coronavirus (CBS Boston 2020). It’s not just wandering patients or patients seeking to elope that use stairwells. In our December 2012 What's New in the Patient Safety World column “Just Went to Have a Smoke” we mentioned a Denzel Washington movie “Flight”. In one scene there are 3 hospital inpatients who happen to come to the same hospital stairwell to smoke. One is a trauma patient, another an oncology patient, and the other a substance abuse patient recovering from an overdose. We wondered how often that scene might actually take place. To our amazement the same week a study came out in the Archives of Internal Medicine (Regan 2012) that answered our question! The answer: 18.4% of patients who smoke will smoke at some time during their inpatient hospitalization! That study was several years ago but we still continue to see smokers who get hospitalized and sneak off to smoke. Stairwells are often the most accessible locations to try to smoke.
In our April 7, 2015 Patient Safety Tip of the Week “Missing Patients and Death” we also mentioned that construction sites are particularly vulnerable for a few reasons. First, you often have outside workers there who are not thinking about patient safety. So, they may leave doors unlocked. Second, construction sites have lots of opportunities for someone to injure themselves. So, make sure you pay close attention to any sites at your facility with ongoing construction.
And don’t forget the risk of losing a patient to wandering or elopement during patient transports. One of the items we recommend including in your “Ticket to Ride” checklist/communication tool for transports (eg to Radiology) is information about wandering risk.
One of the recurrent themes we noted earlier is that someone often sees the patient but does not recognize they are wandering. Another case illustrates yet another common problem – staff may unwittingly facilitate the patient leaving the facility. Wandering patients or patients desiring to elope from behavioral health units often follow staff out of doors that are usually locked. A 65 y.o. man with a neurological condition and confusion was on an understaffed ward (Brooke 2017). He wandered off the ward and out of the hospital, only to be found many days later dead in a wooded area several miles from the hospital. Cause of death was presumed hypothermia. He had gotten out of the hospital by following a staff worker through a secure door and was let through further locked doors by a nurse who assumed he had previously been allowed through.
Many hospitals use color-coded wristbands (or color-coded hospital gowns) to identify patients at risk of wandering. That is generally a good idea. For example, in the case above, it might have alerted the staff member not to allow the patient to exit the door. The problem is that there is still no widely accepted standard for such color-coding. An orange wristband might signify wandering risk at one facility, but might signify something totally different at another facility. That can be problematic when staff work at more than one facility.
Our June 16, 2020 Patient Safety Tip of the Week “Tracking Technologies” discussed a whole host of potential technologies that can be used to track patient movements and location. These include devices that are based on RFID, GPS, Bluetooth, WiFi, infrared and other technologies. We’re not sure how applicable these are to the type of residential facility involved in the current case. But if you are a facility dealing with patients with delirium, dementia or other cognitive impairment who might be at risk for wandering, use of such tracking devices makes a lot of sense.
We’ve previously emphasized that technology will always be only part of the response to missing patients. It should never be the sole modality relied upon. A VA analysis suggests GPS beats RFID in most scenarios (VA 2013). But the specific technology chosen will likely differ from facility to facility and may depend upon the need to integrate with other technology needs. For example, though GPS probably would be best for locating patients who have left the facility or hospital grounds, some hospitals may prefer RFID because they are using an RFID system for inventory tracking. Bluetooth would have limited applicability because of limited range. Many of you probably already use low-power Bluetooth for tracking items like your keys (or maybe your TV remote!). But in the context of missing patients Bluetooth applications would most likely only be of use in alerting staff when a patient leaves the Bluetooth receiving area (about the size of a typical inpatient floor). Similarly, the bracelets used in newborns to prevent abduction can alert staff when a patient leaves the unit but are of little help in locating a patient once they have already left the unit.
Ironically, the VA had one of the earliest Real Time Location Systems (RTLS) but implementation of that system was cost-prohibitive and replete with errors and mismanagement, having been deployed without adequate oversite and without required security controls testing (VA OIG 2017).
Communication. In many of our prior columns on missing patients, we have stressed the importance of communication, both internally and externally. We recommend that the family or next of kin or significant other of the missing patient be notified as soon as possible and be kept up to date on the status of the search. Such communication is important, not only in the name of transparency, but also because the missing patient may contact those family members. Those family members may also have suggestions about where the patient might go. Multiple other communications issues were discussed in our December 2013 What’s New in the Patient Safety World column “Lessons from the SFGH Missing Patient Incident”.
We refer you back to our Patient Safety Tips of the Week for April 7, 2015 “Missing Patients and Death” and July 28, 2009 “Wandering, Elopements, and Missing Patients” for good discussion of assessment of patients for wandering risk, ways to reduce the risk of wandering, and staff education and drills. In those columns we also noted that it’s always a good time for facilities to say “could that happen here?” and do a thorough review of your policies and procedures for missing patient incidents, including making sure you do appropriate drills for such incidents. You probably will be unable to prevent every potential wandering patient or elopement. When one does occur, do a debriefing session as soon as possible to identify potential missed clues and other useful lessons. Then do a formal RCA (root cause analysis) within a short timeframe. There are always valuable lessons learned that hopefully can prevent other similar incidents in the future. But even if you’ve not already had a patient go missing it’s good to do a FMEA (failure mode and effects analysis) to determine your potential vulnerabilities. And make sure you do drills, with thorough critiques and debriefings following the drills. When you do your FMEA, consider also what happens to locking doors when a fire alarm goes off. You might even consider doing your missing patient drill immediately following a fire drill.
See our previous columns on wandering, eloping, and missing patients:
References:
Romine T. Veteran missing for a month found dead in stairwell at VA hospital. CNN 2020; June 16, 2020
https://www.cnn.com/2020/06/16/us/missing-veteran-found-dead-hospital/index.html
Estes A. A veteran died 20 yards from his room on the Bedford VA campus. No one noticed for five weeks. Congressional delegation demands federal investigation of Tim White's tragic death. Boston Globe 2020; June 18, 2020
Cohan A. Man found dead in stairwell at Bedford VA Hospital campus a month after he went missing. Had been reported missing on May 13. Boston Herald 2020; June 13, 2020
CBS Boston. Baker: Death Of Man At Bedford VA Hospital ‘A Terrible Tragedy’. CBS Boston 2020; June 15, 2020
https://boston.cbslocal.com/2020/06/15/charlie-baker-va-hospital-missing-man-death/
Luke S. Broken Bed Alarm Blamed for Walkaway Patient's Death. Thomas Vera died after he became disoriented and walked away from his hospital room at UCSD Medical Center in May 2013. NBC San Diego 2014 Published September 15, 2014, Updated on September 16, 2014
Regan S, Viana JC, Reyen M, Rigotti NA. Prevalence and Predictors of Smoking by Inpatients During a Hospital Stay. Arch Intern Med 2012; ():1-5, Published online ahead of print November 5, 2012
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1389239
Brooke C. Coroner blasts hospital staff after patient with degenerative brain condition escapes by wandering through secure unit and climbing over a wall before later being found dead. Daily Mail 2017; updated February 7, 2017
VA. VISN 8 Patient Safety Center of Inquiry, Tampa. Wandering and Missing Incidents in Persons with Dementia. Updated: October 24, 2013
https://www.visn8.va.gov/patientsafetycenter/wandering/
VA Office of Inspector General. Department of Veterans Affairs. Review of Alleged Mismanagement of the Real Time Location System Project. VA 2017; December 19, 2017
https://www.va.gov/oig/pubs/VAOIG-15-05447-383.pdf
Print “Another Patient Found Dead in a Stairwell”
To get "Patient Safety Tip of the Week "emailed to you, click here and enter "subscribe" in the subject field.
If you don't see the search term you expected to see here, its probably because that tip already went to our Tip of the Week Archive. We do a new tip every week. Click here to search the entire site or you can Go to Tip of the Week Archive a patient safety resource solution loaded with tips, tools, and techniques you can use in your patient safety and quality improvement initiatives. Or it may have moved to our What's New Archive.
Click here to see the consulting services and patient safety solutions that we provide.
Click on the "Contact Us" button at the left to send us your comments on our "What's New in the Patient Safety World" columns.
To get "Patient Safety Tip of the Week "emailed to you, click here and enter "subscribe" in the subject field.
July 2020
Medication reconciliation at any transition of care is important. But none are more critical that at the time of hospital discharge. Medication reconciliation at the time of discharge is different because the patient or his/her caregiver, rather than the hospital, is now responsible for ensuring any changes made to medications are adhered to. And we’ve often discussed how discharge is a very vulnerable time for patients. They are often so anxious to go home that they may not pay full attention to discharge instructions and thus may not fully understand any changes to their medication regimen.
That’s why the phone call (by a pharmacist, nurse, or physician) 24-48 hours after discharge is so important in ensuring patients understand those changes and will be adherent to the new medication regimen.
A new study (Weir 2020) addressed the impact of nonadherence to medication changes made at hospital discharge. The researchers found that 44% of 2655 patients were nonadherent to at least one medication change, and 32% were readmitted to hospital, visited the emergency department, or died in the 30 days post-discharge. Patients who were not adherent to any of their medication changes had a 35% higher risk of adverse events (after adjustment for confounders) compared to those who were adherent to all medication changes. Those who were adherent to some of their medication changes at discharge had a 10% elevated risk of adverse events in 30 days post-discharge compared to those who were adherent to all medication changes.
The impact of nonadherence on adverse events was mainly driven by not filling newly prescribed medications. There was no increased risk for nonadherence to discontinuations or dosage changes.
These were mostly elderly patients. The mean age of study patients was 69.5 years old. The study conclusions are somewhat limited because dispensing data was used to determine nonadherence. That could lead to erroneous conclusions if patients filled their prescriptions but did not take them or did not fill them but used existing supplies. Also, it is difficult to accurately assess doses from dispensing data (eg. patients could be pill-splitting). But, even given these limitations, the conclusions of the study are pretty compelling: we need to do a better job of not only performing accurate medication reconciliation at discharge but also ensuring adherence to changes made.
But such nonadherence should be anticipated. In our June 30, 2020 Patient Safety Tip of the Week “What Happens after Hospitalization?” we cited a study (Dharmarajan 2020) that showed disability in specific functional activities important to leaving home to access care and self‐managing health conditions is common, often new, and present for prolonged time periods after hospitalization for acute medical illness. One of those activities was taking medications. The researchers found that the proportion of patients newly disabled at 1 month after hospitalization for acute medical illness was 30% for taking medications.
Many patients following hospitalization have cognitive deficits or other impairments of activities of daily living that lead to medication nonadherence. We must anticipate those deficits and, therefore, work with caregivers to help improve adherence.
Previous research by these same authors (Weir 2019) suggested that failure to follow medication changes was highest for dose increases, symptom relief medications, those that require prior authorization, and medications that had not been administered during the hospital stay. At the patient level, those with at least one preadmission hospitalization, who did not have any medications dispensed prior to admission, and were discharged from thoracic surgery or to a long-term care facility, also had a higher risk of failure to follow changes.
There were 10,068 medication changes made at hospital discharge and 24% were not followed in the 30 days post discharge. Thirty percent of dose modifications were filled at the incorrect dose, 27% of new medications were not filled, and 12% of discontinued medications were filled. Factors associated with increased the risk of failure to follow medication changes were: increasing out-of-pocket medication costs (adjusted odds ratio 1.12), discharge to long-term care facility (aOR 2.29), and not having medications dispensed prior to admission (aOR 4.67).
Both Weir studies come out of hospitals in Montreal, Quebec.
Some of our previous columns on medication reconciliation:
October 23, 2007 “Medication Reconciliation Tools”
December 30, 2008 “Unintended Consequences: Is Medication Reconciliation Next?”
May 13, 2008 “Medication Reconciliation: Topical and Compounded Medications”
September 8, 2009 “Barriers to Medication Reconciliation”
August 2011 “The Amazon.com Approach to Medication Reconciliation”
January 2012 “AHRQ’s New Medication Reconciliation Tool Kit”
September 2012 “Good News on Medication Reconciliation”
October 1, 2019 “Electronic Medication Reconciliation: Glass Half Full or Half Empty?”
References:
Weir DL, Motulsky A, Abrahamowicz M, et al. Failure to follow medication changes made at hospital discharge is associated with adverse events in 30 days. Health Serv Res 2020; 00: 1-12
https://onlinelibrary.wiley.com/doi/full/10.1111/1475-6773.13292
Dharmarajan K, Han L, Gahbauer EA, Leo‐Summers LS, Gill TM. Disability and Recovery After Hospitalization for Medical Illness Among Community‐Living Older Persons: A Prospective Cohort Study. J Am Geriatr Soc 2020; 68: 486-495 Published online February 21, 2020
https://onlinelibrary.wiley.com/doi/10.1111/jgs.16350
Weir DL, Motulsky A, Abrahamowicz M, et al. Challenges at care transitions: failure to follow medication changes made at hospital discharge. Am J Med 2019; 132: 1216-1224.e5
https://www.amjmed.com/article/S0002-9343(19)30430-9/fulltext
Print “July 2020 Not Following Medication Changes after Hospitalization?”
Ah! Calculations! Talk about setting the stage for errors. Any time you have to calculate a drug dose, you are potentially vulnerable to error. You can enter wrong decimal points, use the wrong units, or simply make a mathematic mistake.
We’ve done several columns (listed below) on errors made in relation to patient weights. Most often that happens when a dose is calculated using a patient’s weight in pounds rather than kilograms. We’ve also discussed many examples of errors made in calculating IV medication doses when units like milligrams and milliliters are confused.
One of our favorite slides we use in several presentations is one showing typical human error rates for a variety of industries. That shows an error rate of 0.03 for simple arithmetic errors. That number comes from Park (Park 2012) in an earlier edition that is apparently no longer available. Smith (Smith 2005) had also noted studies show error rates in “doing arithmetic wrongly” to range from 0.01 to 0.03.
A recent article (Ressler 2020) notes that medication dosage miscalculations are, unfortunately, common and often go unnoticed. Prescriptions can be filled incorrectly by simply missing one crucial piece of information, like weight, or applying a proportion calculation incorrectly.
Ressler provides several examples of how such calculation errors can happen and how one error may even be compounded by a second error.
One example included the dosage of a drug being erroneously calculated based on weight in pounds, not kilograms and then the dosage was supposed to be split evenly every 12 hours but was instead prescribed to receive the full amount twice daily. The result was the incorrect calculation led to a dosage over four times higher than the intended dose.
Another example illustrates how incorrect dopamine concentration in a calculation led to potential overdose of this drug in a critical situation.
There’s even an example of how an incorrect calculation led to a pharmacy having a chargeback from Medicare Part D because of overbilling.
The article provides a link to an infographic the author suggests you hang in your pharmacy or classroom for these three scenarios that can help you illustrate the impact of a miscalculation.
Calculation of drug doses, particularly for high alert medications, is one process that may benefit from double checks. However, it is critical that those double checks be truly independent double checks.
Some of our other columns on errors related to patient weights:
March 23, 2010 “ISMP Guidelines for Standard Order Sets”
September 2010 “NPSA Alert on LMWH Dosing”
August 2, 2011 “Hazards of ePrescribing”
January 2013 “More IT Unintended Conseequences”
May 2016 “ECRI Institute’s Top 10 Patient Safety Concerns for 2016”
September 2017 “Weight-Based Dosing in Children”
January 2018 “Can We Improve Barcoding?”
June 2018 “Incorrect Weights in the EMR”
Some of our other columns on double checks:
January 2010 “ISMP Article on Double Checks”
October 26, 2010 “Confirming Medications During Anesthesia”
October 16, 2012 “What is the Evidence on Double Checks?”
December 9, 2014 “More Trouble with NMBA’s”
April 19, 2016 “Independent Double Checks and Oral Chemotherapy”
December 11, 2018 “Another NMBA Accident”
March 5, 2019 “Infusion Pump Problems”
August 27, 2019 “Double Check on Double Checks”
References:
Park K. Human Error, in Salveny G, ed.. Handbook of Human Factors and Ergonomics. Fourth Edition. Wiley 2012
Smith DJ. ‘Reliability, Maintainability and Risk” 7th Edition. Elsevier 2005
https://www.elsevier.com/books/reliability-maintainability-and-risk/smith/978-0-7506-6694-7
Ressler K. Bad Math: The Impact of Medication Dosage Miscalculations. Pharmacy Times 2020; June 8, 2020
https://www.pharmacytimes.com/news/bad-math-the-impact-of-medication-dosage-miscalculations
infographic
Print “July 2020 Medication Dosage Miscalculations”
We neurologists often take pride in being able to say we have completed half the neurological exam before the patient even sits down in our office. As the patient enters the room, we observe his stance and gait, gait speed, arm swing, any tremor or abnormal movements, and facial expression. As we introduce ourselves we get at least a glimpse of the patient’s speech articulation and prosody, if not a glimpse of a possible aphasia. And we usually shake hands with the patient (at least in the pre-COVID19 era!). The latter is, of course, a relatively subjective measure of grip strength. But, more and more, we have realized that formal measurement of grip strength provides a very powerful indicator of many patient vulnerabilities.
There are many parameters that have been used in various frailty indices (see our many columns on frailty listed below). Handgrip strength is one of those. In our June 2015 What's New in the Patient Safety World column “Get a Grip on It!” we noted that grip strength not only predicts surgical complications and outcomes but also predicts risk for stroke, MI, cardiovascular and all-cause death.
In an analysis of 351 consecutive patients undergoing major intra-abdominal operations Revenig and colleagues (Revenig 2015) found that “shrinking” and grip strength alone hold the same prognostic information as the full 5-component Fried Frailty Criteria for 30-day morbidity and mortality. When combined with American Society of Anesthesiologists (ASA) score and serum hemoglobin, they form a simple risk classification system with robust prognostic information.
Shortly after that publication, the results of the Prospective Urban-Rural Epidemiology (PURE) study were released (Leong 2015). This was a longitudinal population study done on approximately 140,000 subjects in 17 countries of diverse cultural and socioeconomic settings. Grip strength was measured with a dynamometer. Grip strength was inversely associated with all-cause mortality (16% increase for each 5 kg reduction in grip strength), cardiovascular mortality (17%), non-cardiovascular mortality (17%), myocardial infarction (7%), and stroke (9%). Grip strength was actually a stronger predictor of all-cause and cardiovascular mortality than systolic blood pressure.
In our May 16, 2017 Patient Safety Tip of the Week “Are Surgeons Finally Ready to Screen for Frailty?” we noted a study that looked at individual components of the Fried frailty phenotype measures (gait speed, hand-grip strength as measured by a dynamometer, and self-reported exhaustion, low physical activity, and unintended weight loss) in a primary care setting (Lee 2017). The researchers found that individual criteria all showed sensitivity and specificity of more than 80%, with the exception of weight loss. The positive predictive value of the single-item criteria in predicting the Fried frailty phenotype ranged from 12.5% to 52.5%. When gait speed and hand-grip strength were combined as a dual measure, the positive predictive value increased to 87.5%. They conclude that, while use of gait speed or grip strength alone was found to be sensitive and specific as a proxy for the Fried frailty phenotype, use of both measures together was found to be accurate, precise, specific, and more sensitive than other possible combinations and that assessing both measures is feasible within the primary care setting.
Analysis of data on over 500,000 patients in the UK (Celis-Morales 2018) found that reduced grip strength was associated with worse cardiovascular, respiratory, and cancer outcomes and all-cause mortality.
Probably the most extensive review of the literature on handgrip strength was done by Bohannon (Bohannon 2019). He concluded that there is adequate evidence to support the use of grip strength as an explanatory or predictive biomarker of specific outcomes such as generalized strength and function, bone mineral density, fractures, and falls, nutritional status, disease status and comorbidity load, cognition, depression, and sleep, hospital-related variables, and mortality. He suggested routine implementation of the measurement of grip strength for older adults in the community and healthcare settings.
Handgrip strength was a predictor of falls in the study by Xue (Xue 2011) and the review by Bohannon (Bohannon 2019). A recent article in Medscape (Millard 2020) discussed a study from Brazil that was scheduled to be presented at the recently cancelled American College of Sports Medicine (ACSM) 2020 Annual Meeting. The study of 204 elderly women found that the risk for falls was 2.73 times higher in women who had poor handgrip strength than in those who had normal handgrip strength. The risk was even greater in women with impaired balance.
But there are 2 additional important parameters on grip strength that we need to take into consideration:
The Women's Health and Aging Study (Xue 2011) found that a decline in grip strength over time is a stronger predictor of a greater variety of subsequent adverse outcomes compared with a single observation of grip strength, Outcomes included falls, walking speed slower than 0.4 m/s, the WHAS frailty phenotype, and difficulty in 1 or more task of the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scales. Independent of baseline grip strength, a greater rate of decline in grip strength over time, was significantly associated with higher risk for all outcomes except ADL disability. The risk of developing an IADL disability was 1.32 times higher for every 0.5-SD unit increase in the rate of decline in grip strength. The associations were independent of age, disease burden, lifestyle, nutritional status, inflammation, and mental well-being. That led the authors to suggest that “becoming weaker” is important in addition to “being weak.”
A new study evaluated both grip strength (HGS) and asymmetry of grip strength in relation to cognitive function (McGrath 2020). McGrath and colleagues used a dynamometer to measure grip strength in elderly patients. Asymmetry was considered as any difference of more than 10% between sides. They found that weakness of grip strength and asymmetry of grip strength (even without weakness) were both predictive of lower cognitive function. Relative to those with symmetric HGS and no weakness, each HGS asymmetry and weakness group had greater odds for lower cognitive functioning: 1.15 for any HGS asymmetry alone, 1.64 for weakness alone, and 1.95 for any HGS asymmetry and weakness. Each HGS asymmetry dominance and weakness group also had greater odds for lower cognitive functioning: 1.12 for asymmetric dominant HGS alone, 1.27 for asymmetric nondominant HGS alone, 1.64 for weakness alone, 1.89 for weakness and asymmetric dominant HGS, and 2.10 for weakness and asymmetric nondominant HGS.
Measurement of handgrip strength is a simple, inexpensive way to identify patients who are at risk for frailty and a variety of adverse health outcomes. Reduced grip strength (and also asymmetric handgrip strength or worsening handgrip strength over time) is a marker for patients having multiple comorbidities that collectively reduce their physiologic reserve and make them more vulnerable to adverse outcomes. It can be used to predict increased risk for complications in patients undergoing surgery, predict patients at risk for falls, and many other conditions.
Some of our prior columns on preoperative assessment and frailty:
References:
Revenig LM, Canter DJ, Kim S, et al. Report of a Simplified Frailty Score Predictive of Short-Term Postoperative Morbidity and Mortality. J Am Coll Surg 2015; 220(5): 904-911
https://www.journalacs.org/article/S1072-7515%2815%2900116-7/abstract
Leong DP, Teo KT, Rangarajan S, et al. Prognostic value of grip strength: Findings from the Prospective Urban Rural Epidemiology (PURE) study. Lancet 2015; 386(9990): 266-273, July 18, 2015
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)62000-6/fulltext
Lee L, Patel T, Costa A, Bryce E, Hillier LM, Slonim K, et al. Screening for frailty in primary care. Accuracy of gait speed and hand-grip strength. Can Fam Physician 2017; 63: e51-7
http://www.cfp.ca/content/63/1/e51
Celis-Morales Carlos A, Welsh Paul, Lyall Donald M, Steell Lewis, Petermann Fanny, Anderson Jana et al. Associations of grip strength with cardiovascular, respiratory, and cancer outcomes and all cause mortality: prospective cohort study of half a million UK Biobank participants BMJ 2018; 361 :k1651
https://www.bmj.com/content/361/bmj.k1651
Bohannon R. W. (2019). Grip Strength: An Indispensable Biomarker For Older Adults. Clinical Interventions in Aging 2019; 14: 1681-1691
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6778477/
Xue Q, Walston JD, Fried LP, Beamer BA. Prediction of Risk of Falling, Physical Disability, and Frailty by Rate of Decline in Grip Strength: The Women's Health and Aging Study. Arch Intern Med 2011; 171(12): 1119-1121
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/487086
Millard E. Handgrip Strength Could Be a Simple Way to Predict Fall Risk. Medscape Medical News 2020; June 10, 2020
https://www.medscape.com/viewarticle/932070
McGrath R, Cawthon PM, Cesari M, et al. Handgrip Strength Asymmetry and Weakness Are Associated with Lower Cognitive Function: A Panel Study. J Am Geriatr Soc 2020; first published 30 May 2020
https://onlinelibrary.wiley.com/action/showCitFormats?doi=10.1111%2Fjgs.16556
Print “July 2020 Getting a Grip on Things”
Your own electronic health record (EHR) says you are allergic to penicillin. You are not, in fact, allergic to penicillin. Yet, you might at some time in the future be denied appropriate use of penicillins or other antibiotics cross-reacting with penicillin.
You once received a trial of amitriptyline for a neuropathic condition. An intern, after review of your medication list, assumed you received it for depression and added depression to the problem list in your EHR. Physicians might avoid prescribing medications to you in the future that are contraindicated in patients with a history of depression.
A pharmacy error incorrectly listed digoxin in your medication list. As a result, a health care provider added congestive heart failure to your problem list. A whole host of medications may be contraindicated in patients with heart failure and physicians might avoid prescribing some of those that might be of benefit to you.
Inclusion of erroneous information in the EHR can have important patient safety implications. The presence of erroneous information in the EHR may be more prevalent than you think. In a 2017 study of the OpenNotes movement (Bell 2017), patients and care partners reported potential safety concerns in about one-quarter of reports, often resulting in a change to the record or care. Patients and care partners documented potential safety concerns in 23% of reports. 2% of patients did not understand the care plan and 21% reported possible mistakes, including medications, existing health problems, something important missing from the note or current symptoms. Among these, 64% were definite or possible safety concerns on clinician review, and 57% of cases confirmed with patients resulted in a change to the record or care.
In a more recent survey of almost 30,000 respondents (Bell 2020), 21.1% of patients who read a note reported finding a mistake in their EHR and 42.3% perceived the mistake as serious. The most common mistakes were perceived in current or past diagnoses (27.5%), medical history (23.9%), medications or allergies (14.0%), physical examination, and tests, procedures, or results (8.4%). Notably, 6.5% reflected notes reportedly written on the wrong patient. Of very serious errors, 58.9% included at least 1 perceived error potentially associated with the diagnostic process (eg, history, physical examination, tests, referrals, and communication).
Older and sicker patients were twice as likely to report a serious error compared with younger and healthier patients, indicating important safety and quality implications. The authors conclude that sharing notes with patients may help engage them to improve record accuracy and health care safety together with practitioners.
So, it’s pretty clear that mistakes in the EHR are both alarmingly frequent and potentially dangerous. Encouraging patients to access their medical records could go a long way toward avoiding potentially serious consequences.
HIPAA, of course, mandates that patients have access to their medical records. It also has a provision that patients may request a change, or amendment, to their record. The health care provider or health plan must respond to such requests (Heath 2019). The health care provider or health plan may, in some cases, deny changes to the medical record but the patient has the right to submit a statement of disagreement with such decisions into the medical record. The Heath article, though, notes that we should address such disagreements as possible communication gaps or signals that patient education may have fallen short. These should be considered as opportunities to improve the physician-patient relationship.
In a 2016 article (Klein 2016), Klein and colleagues pointed out that having patients read their patient encounters in their medical records provides many opportunities to improve care. Not only might that uncover errors in the medical record, it may also identify gaps in patient understanding of their diagnoses and/or treatment plan. So, in addition to improving patient safety, it may improve doctor-patient rapport. Klein et al. also note the importance of making notes clear and succinct, addressing concerns directly and respectfully, and using supportive language.
And encouraging patients to access their EHR’s can have a positive impact on health outcomes. Neves et al. (Neves 2020) recently performed a systematic review and meta-analysis on this issue. They found a beneficial effect in effectiveness by reducing absolute values of HbA1c. A significant reduction of absolute values of systolic blood pressure was also found but lost in sensitivity analysis for studies with low risk of bias. Regarding efficiency of care, 80% of studies found either a reduction of healthcare usage or no change. A beneficial effect was observed in a range of safety outcomes (ie, general adherence, medication safety), but not in medication adherence.
While 90% of healthcare providers offer patient portals, only about a third of patients actually access the portals (GAO 2017). While, on average, hospitals gave 95 percent of discharged patients access to view, download, and transmit their information, only about 10% of patients access their medical records (Lin 2019). A recent Health Affairs Blog (Bechtel 2020) posits that patient demand is not the reason for low rates of accessing EHR’s and describes barriers to access and potential ways to increase such access.
So, we are probably missing good opportunities to make our EHR’s more accurate and to improve on communication and our relationships with our patients.
References:
Bell SK, Gerard M, Fossa A, et al. A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships. BMJ Quality & Safety 2017; 26: 312-322
https://qualitysafety.bmj.com/content/26/4/312
Bell SK, Delbanco T, Elmore JG, et al. Frequency and Types of Patient-Reported Errors in Electronic Health Record Ambulatory Care Notes. JAMA Netw Open. 2020; 3(6): e205867
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2766834
Heath S. Understanding Patient Requests for EHR Corrections, Changes. PatientEngagementHIT 2019; accessed December 3, 2019
https://patientengagementhit.com/news/understanding-patient-requests-for-ehr-corrections-changes
Klein JW, Jackson SL, Bell SK, et al. Your Patient Is Now Reading Your Note: Opportunities, Problems, and Prospects. The American Journal of Medicine 2016; 129(10): 1018-1021
https://www.amjmed.com/article/S0002-9343(16)30548-4/fulltext#sec7
Neves AL, Freise L, Laranjo L, et al. Impact of providing patients access to electronic health records on quality and safety of care: a systematic review and meta-analysis. BMJ Quality & Safety 2020; Published Online First: 12 June 2020
https://qualitysafety.bmj.com/content/early/2020/06/12/bmjqs-2019-010581
GAO (US Government Accountability Office) Health Information Technology:HHS Should Assess the Effectiveness of Its Efforts to Enhance Patient Access to and Use of Electronic Health Information. GAO-17-305: Published: Mar 15, 2017. Publicly Released: Mar 15, 2017
https://www.gao.gov/products/GAO-17-305
Lin SC, Lyles CR, Sarkar U, Adler-Milstein J. Are Patients Electronically Accessing Their Medical Records? Evidence From National Hospital Data. Health Affairs 2019; 38(11): November 2019
https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05437
Bechtel C, Ricciardi L, deBronkart D, at al. Why Aren’t More Patients Electronically Accessing Their Medical Records? (Yet!). Health Affairs Blog 2020; January 13, 2020
https://www.healthaffairs.org/do/10.1377/hblog20200108.82072/full/
Print “July 2020 Patient Requests for EHR Corrections”
Print “July 2020 What's New in the Patient Safety World (full column)”
Print “July 2020 Not Following Medication Changes after Hospitalization?”
Print “July 2020 Medication Dosage Miscalculations”
Print “July 2020 Getting a Grip on Things”
Print “July 2020 Patient Requests for EHR Corrections”
Print “May 2020 What's New in the Patient Safety World (full column)”
Print “May 2020 PPSA on IV Vancomycin Safety”
Print “May 2020 Poor Timeout Compliance: Ring a Bell?”
Print “May 2020 A Takeoff On The Patient Safety Scavenger Hunt”
Print “May 2020 The Aging Surgeon Paradox”
Go to the "Whats New Archive"
To get "What's New in the Patient Safety World"emailed to you,click here and enter "subscribe" in the subject field.
To get "What's New in the Patient Safety World"emailed to you,click here and enter "subscribe" in the subject field.
Copyright 2012 The Truax Group Healthcare Consulting Patient Safety Solutions Tools Tips & Resources. All rights reserved.
PO Box 1230
Grantham, NH 03753
ph: 716-550-1106
btruax