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Tip of the Week Archive Jan-Mar 2023

Tips, Tools, Techniques, and Resources You Can Use in Your Patient Safety and Quality Improvement Initiatives

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Patient Safety Tip of the Week

January 3, 2023

Helping Inpatients Sleep - Failing Grades

Common sense tells us that helping inpatients get restful sleep is desirable and doing so without using sleep meds makes even more sense. We’ve done several columns highlighting the poor job we do at allowing patients to sleep when they are hospital inpatients (see our Patient Safety Tips of the Week for August 6, 2013 “Let Me Sleep!”, May 15, 2018 “Helping Inpatients Sleep”, and November 6, 2018 “More on Promoting Sleep in Inpatients”). Our November 6, 2018 Patient Safety Tip of the Week “More on Promoting Sleep in Inpatients” cited several studies showing inpatients average significantly less sleep in hospital compared to at home.

We know the many factors contributing to poor sleep in inpatients:

excessive noise
light exposure
other environmental factors like temperature
pain
stress related to medical conditions
psychological stress
waking patients to obtain vital signs
waking patients for phlebotomy

And we already have lots of tools and programs that can address many of those factors and make it easier for inpatients to sleep (see below for details). We want to avoid using sedative/hypnotic medications to induce sleep in such patients because they are risk factors for falls, delirium, medication-induced respiratory depression, and other undesirable complications.

So how are we doing? Pretty poorly, according to a recent study. Affini et al. (Affini 2022) surveyed and interviewed section chiefs of Hospital Medicine at the 2020 US News and World Report (USNWR) Honor Roll pediatric and adult hospitals. Nearly all (96%) hospitalist leaders at those top hospitals rated patient sleep as important, but fewer than half (43%) were satisfied with their institution's efforts to improve patient sleep.

Fifty-two percent of the surveyed institutions reported having no sleep-friendly practices in place. The most common practices in those that did have some practices included:

reducing overnight vital sign monitoring (43%)
decreasing ambient ward lights (43%)
adjusting lab and medication schedules (35%)
implementing quiet hours (30%)

The researchers identified both barriers to adoption of sleep-promoting practices and factors that helped adoption of such practices. Barriers to success were related to the hospital environment and culture (e.g.,inflexible workflow, time conflicts, noisy alarms) and fixed standards of care (not differentiating low-risk and high-risk patients). A key contributor to successfully improving patient sleep was buy-in from hospital staff. Examples included providers reducing room entries through batched care or enforcing quiet hours among peers. External initiatives, such as patient care initiatives or funded innovation projects were also important for patient sleep.

Respondents also suggested that grouping tasks and decreasing interventions, when appropriate, would be opportunities for improvement.

Affini et al. also asked about sleep equity and found that only one hospital addressed sleep equity (but did not reveal how it did so). By sleep health equity the authors meant improving sleep for racial/ethnic minorities, patients with pre-existing risk factors, communication barriers, or limited familiarity with hospital services.

The authors conclude that some key reasons for slow progress are that (1) the culture is such that providers want to improve patient sleep, but not at the expense of changing standard workflow, and (2) there is a lack of incentives and programs to support changes. They call upon both clinicians and hospital leaders to address the issues, develop a culture that promotes sleep, and adopt best practices for patient sleep.

It's worth reiterating here recommendations from our prior columns. In our “Let Me Sleep!” column we noted that the Hospital Elder Life Program (HELP) program (Inouye 2013) includes a systemic effort to improve sleep in hospitalized patients by noise reduction, a nonpharmacologic sleep protocol, and coordination of nighttime care. Inouye points out that besides vital sign monitoring and blood draws, patients’ sleep is often disrupted by medication administration, IV changes or IV alarms, intermittent pneumatic compression devices, breathing treatments, fingersticks for glucose monitoring, paging systems, room or hallway lights, conversations, cleaning and waxing floors at night, etc. Moreover, Inouye notes there is often a striking lack of coordination amongst staff that could minimize these disruptions. Simply having the phlebotomist tag team with the nurse or aide doing vital signs could avoid one disruption.

Another study (Bartick 2010) implemented the “Somerville Protocol” and documented a 38% reduction in patients noting sleep disruption due to hospital staff and a 49% reduction in patients receiving prn sedatives (actually a 62% reduction for patients aged 65 and older). The protocol consisted of 10 components:

“Quiet Time” designated as 10PM to 6AM
Timing of “routine” vital signs changed to 6AM, 2PM and 10PM
Getting physicians to understand the difference between daily, BID, TID, QID vs. q24 hours, q12 hours, q8 hours, q6 hours
Avoid standing diuretic doses after 4PM
Avoid blood transfusions during Quiet Time where possible
Use of a noise detection device in the nursing station
Lullaby over the PA system at 10PM to alert patients, staff, visitors, etc. to Quiet Time
Timer to dim hallway lights automatically at 10PM
Nurses perform a bedtime routine before Quiet Time (vital signs, bedtime meds, toilet patient, ensure IV bag won’t empty at night, close patient door, etc.)
Avoid antecubital IV catheter site where possible (easier to occlude flow here and set off alarm at night) and even avoid nighttime IV fluids if possible

A couple of those interventions merit further discussion. At many (perhaps most) hospitals, the incoming nursing staff gets vital signs when their shift starts. Hence, many patients get their vital signs checked between 11PM and midnight. Simply changing policy and procedure so that vital signs are checked by the outgoing staff at 10PM can help avoid one obvious potential sleep disruption. (Of course, you’d have to look for potential unintended consequences such as interfering with shift handoffs).

Getting physicians to understand that “three times daily” and “every 8 hours”, for example, are not the same takes some time and hard work. If I order a medication today at 10AM and enter it as “every 8 hours” my patient will be wakened at 2AM to get a dose. On the other hand, if the order is written for “three times daily” the hospital will have standard times that such are given to avoid that disruptive nighttime dose. (Note that you have to be very careful. Today’s CPOE systems often don’t make it clear when the first dose will be given. We have seen some systems where the first dose or even all the first day’s doses will not be given when the order is written this way.)

A noise monitoring device for the nursing station doesn’t need to be expensive. If a teacher can use a free or $0.99 decibel meter for his/her iPhone to alert him/her to classroom noise exceeding a specified level, we can certainly find a cheap solution to avoiding excessive noise at the nursing station or elsewhere. But even Bartick and colleagues note that reduction in noise and light probably did not significantly improve patients’ sleep. Rather, a reduction in the physical disruptions probably played the major role.

There are, of course, several other protocols and programs for improving sleep in hospital inpatients. See our November 6, 2018 Patient Safety Tip of the Week “More on Promoting Sleep in Inpatients” for descriptions of the “Quiet Time”, Sommerville, and “TUCK-in” protocols, plus the Hospital Elder Life Program (HELP) program.

Promoting natural sleep is also not simply a nocturnal event. What you do during the daytime is also important in promoting sleep. Regular exercise is an example of an important contributor to nocturnal sleep. Reducing ambient light at night is highly recommended. But what about light levels at other times? In our December 2013 What's New in the Patient Safety World column “Lighten Up Your Patient’s Day” we noted a study (Bernhofer 2013) that used light meters and wrist actigraphy to assess the sleep-waking patterns of hospital inpatients and correlated those parameters with patients’ pain levels and mood. Light exposure levels were low and sleep time was poor and fragmented. There was little sleep–wake synchronization with light. Fatigue and total mood disturbance scores were high and inversely associated with light. Pain levels were also high and positively associated with fatigue, but not directly with light exposure. Low light exposure significantly predicted fatigue and total mood disturbance. They concluded that inpatients were exposed to light levels insufficient for circadian entrainment. Nevertheless, higher light exposure was associated with less fatigue and lower total mood disturbance in participants with pain. Though the study was small (40 total patients) this research demonstrates the need for further studies to see if altering light exposure for inpatients would be beneficial in affecting sleep–wake disturbances, mood and pain.

Our May 15, 2018 Patient Safety Tip of the Week “Helping Inpatients Sleep” also noted a non-pharmacologic multidimensional program at an academic tertiary care hospital which produced promising results (Herscher 2018). Components of the intervention were:

an education and awareness campaign for day and evening staff through staff meetings and daily huddles, and use of signs and posters
identification of local unit champions from nursing and patient care advocates (PCA’s)
delivery of a sleep package that included an eye mask, earplugs, lavender scent pad, and non-caffeinated tea
the PCA’s asked patients whether they would like the TV turned off, blinds closed, lights off, or anything else to improve sleep

And see our March 16, 2021 Patient Safety Tip of the Week “Sleep Program Successfully Reduces Delirium” for a study by Gode et al. (Gode 2021) that successfully reduced delirium by focusing on a program to improve non-pharmacologic sleep in inpatients.

Avoiding sleep meds and using non-pharmacologic interventions to promote sleep is something every hospital should strive for. Don’t forget that we often have ourselves to blame. It is still common for physicians to leave orders for prn sleep meds in the admission orders, presumably so no phone call is needed at night requesting such. In our March 23, 2010 Patient Safety Tip of the Week “ISMP Guidelines for Standard Order Sets” we stressed the importance of avoiding inclusion of “prn” sleep meds in standard order sets. We also refer you back to our August 2019 What's New in the Patient Safety World column “Tools for Reducing Sleep Meds in Hospitals” for some interventions to avoid use of sleep medications in hospitalized patients.

We do have the means to promote non-pharmacologic sleep in our inpatients. We need to institutionalize the importance of this issue and foster a culture that is more patient-centered. That means abandoning some of our old customary practices

Some of our previous columns on safety issues associated with sleep meds and promoting sleep in inpatients:

August 2009 “Bold Experiment: Hospitals Saying No to Sleep Meds”

March 23, 2010 “ISMP Guidelines for Standard Order Sets”

May 2012 “Safety of Hypnotic Drugs”

November 2012 “More on Safety of Sleep Meds”

March 2013 “Sedative/Hypnotics and Falls”

June 2013 “Zolpidem and Emergency Room Visits”

August 6, 2013 “Let Me Sleep!”

June 3, 2014 “More on the Risk of Sedative/Hypnotics”

May 15, 2018 “Helping Inpatients Sleep”

June 2018 “Deprescribing Benzodiazepine Receptor Agonists”

November 6, 2018 “More on Promoting Sleep in Inpatients”

June 2019 “FDA Boxed Warning on Sleep Meds”

August 2019 “Tools for Reducing Sleep Meds in Hospitals”

March 16, 2021 “Sleep Program Successfully Reduces Delirium”

January 4, 2022 “Spin or Not: A Useful Secondary Finding in a Study”

References:

Affini, MI, Arora, VM, Gulati, J, et al. Defining existing practices to support the sleep of hospitalized patients: A mixed-methods study of top-ranked hospitals. J Hosp Med. 2022; 17(8): 633-638

https://shmpublications.onlinelibrary.wiley.com/doi/10.1002/jhm.12917

Inouye SK. No Rest for the Weary…or the Sick: Comment on “A Prospective Study of Nitghtime Vital Sign Monitoring Frequency and Risk of Clinical Deterioration”. JAMA Intern Med. 2013; (): doi:10.1001/jamainternmed.2013.7809 Published online July 1, 2013

http://archinte.jamanetwork.com/article.aspx?articleid=1705720

Bartick MC, Thai X, Schmidt T, et al. Decrease in As-needed Sedative Use by Limiting Nighttime Sleep Disruptions from Hospital Staff. Journal of Hospital Medicine 2010; 5: E20–E24

http://www.researchgate.net/publication/26826221_Decrease_in_as-needed_sedative_use_by_limiting_nighttime_sleep_disruptions_from_hospital_staff/file/9fcfd50be5de55a8e8.pdf

Bernhofer EI, Higgins PA, Daly BJ, et al. Hospital lighting and its association with sleep, mood and pain in medical inpatients. Journal of Advanced Nursing 2013; Article first published online : 27 OCT 2013, DOI: 10.1111/jan.12282

http://onlinelibrary.wiley.com/doi/10.1111/jan.12282/abstract

Herscher M, Mikhaylov D, Turakhia P, et al. The Sleep Hygeine In The Hospital Project: Shh! Society of Hospital Medicine (HM) 2018 Annual Meeting: Abstract 413905. Presented April 9, 2018

https://www.shmabstracts.com/abstract/the-sleep-hygeine-in-the-hospital-project-shh/

Gode A, Kozub E, Elizabeth Joerger K, et al. Reducing Delirium in Hospitalized Adults Through a Structured Sleep Promotion Program. Journal of Nursing Care Quality 2021; 36(2): 149-154

https://journals.lww.com/jncqjournal/Abstract/2021/04000/Reducing_Delirium_in_Hospitalized_Adults_Through_a.11.aspx

ISMP (Institute for Safe Medication Practices). ISMP’s Guidelines for Standard Order Sets. 2010

https://www.ismp.org/guidelines/standard-order-sets

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January 10, 2023

Diagnostic Errors in the ED

AHRQ recently published a study (Newman-Toker 2022) on diagnostic errors in the emergency department that has garnered substantial interest from the lay press. The study has been largely criticized in that some of the data came from European or Canadian emergency departments, rather than US emergency departments, and that it unfairly targets ED physicians. But the authors make it very clear that the diagnostic error rates found in the ED are very comparable to those found in hospital inpatient care or primary care.

We’ve long criticized the landmark report “To Err Is Human” in that it sensationalized statistics that garnered attention for a short period and ultimately did little to improve patient safety over the next decade. So, let’s cast aside the criticisms of the new AHRQ study, ignore the focus on statistics, and instead focus on the important lessons learned from the study.

The emergency department, by its very nature, is a high-risk venue. Interactions with patients are generally for a short period of time, often done under time pressure and multiple potential distractions. Most importantly, the clinician doing the ED evaluation may never see that patient again. Ensuring a proper handoff to the clinician who will next care for the patient is critical. Our current systems for care coordination are not very good. We can’t tell you the number of times we hear a primary care physician say “I didn’t even know {my patient} had been in the ED”. Patients are often discharged from the ED before final imaging reports are available and we’ve all seen patients “fall through the cracks” when an important imaging finding is never communicated to someone who would ensure follow-up. Particularly in small rural hospitals, lack of specialty consultants may be a further problem. Add to all this the problem of overdiagnosis and impact of the “diagnostic cascade” that can itself lead to patient harm and add to healthcare expenditures.

The study was really a systematic review and meta-analysis based on an extensive review of the literature, encompassing 279 studies. An estimated 5.7% of all ED visits had at least one diagnostic error. Estimated preventable adverse event rates were 2.0% for any harm severity, 0.3% for any serious harms, and 0.2% for deaths. That translates to about 1 in 18 ED patients receiving an incorrect diagnosis, 1 in 50 suffering an adverse event, and 1 in 350 suffering permanent disability or death. Again, these rates are comparable to those seen in primary care and hospital inpatient care.

So those are the statistics. Yes, those are the ones garnering all the headlines in the lay press (New York Times, Boston Globe, CNN, and multiple others). And the statistics do little to help us improve patient safety. Rather, we must look at the real opportunities to improve patient safety. The more important questions to ask are “what are the serious conditions that are more likely to be missed?” and “what are the presenting symptoms that often lead to missed diagnoses?”. When seeing patients in any healthcare venue, the two most important questions we usually ask ourselves are “What could I be missing?” and “What’s the most serious thing I could be missing?”.

The top 15 clinical conditions associated with serious misdiagnosis-related harms, accounting for 68% of serious harms, were (in order of frequency):

stroke
myocardial infarction
aortic aneurysm and dissection
spinal cord compression and injury
venous thromboembolism
meningitis and encephalitis
sepsis
lung cancer
traumatic brain injury and traumatic intracranial hemorrhage
arterial thromboembolism
spinal and intracranial abscess
cardiac arrhythmia
pneumonia
gastrointestinal perforation and rupture
intestinal obstruction

The top five conditions noted above account for 39 percent of serious misdiagnosis-related harms.

But even knowing the clinical conditions most often missed is not enough. Patients don’t come to the ED with a complaint “possible spinal cord compression”. While it is nice to know the conditions most often missed, it would also be nice to know which diagnoses made were most often in error. For example, if it turns out a diagnosis of “vestibular neuritis” was erroneous 15% of the time, that might prompt ED clinicians to always think twice any time they consider such a diagnosis. And our focus should be on the presenting symptoms most often associated with missed diagnoses.

The AHRQ study did find that clinical presentation was important. For example, the average rate for missed stroke was 17% but it was 40% when the presenting symptom was dizziness/vertigo vs. 4% when the presenting symptom was weakness. The authors found that nonspecific, mild, transient, or “atypical” symptoms frequently contributed to missed diagnoses. In fact, atypical or non-specific symptoms were the strongest and most consistent predictors of increased risk for a missed diagnosis across diseases studied.

The authors provided a table with the most common “atypical” presenting symptoms and their related misdiagnosed diseases:

Abdominal pain	Myocardial infarction, aortic aneurysm/dissection, appendicitis, diverticulitis, ovarian disease, gallbladder pathology, cancer
Back pain	Spinal abscess or other spinal cord compression, myelitis, aortic aneurysm/dissection
Dyspnea/shortness of breath	Myocardial infarction, aortic aneurysm/dissection
Fever	Sepsis, aortic aneurysm/dissection (aortitis)
Headache	Stroke, (other diseases with headaches as a more “typical” presentation include subarachnoid hemorrhage, meningitis/encephalitis, raised intracranial pressure, and giant cell arteritis)
Syncope/fall	Myocardial infarction, aortic aneurysm/dissection, venous thromboembolism, stroke
Altered mental status/confusion	Stroke, sepsis
Dizziness/vertigo	Stroke
Fatigue/malaise/generalized weakness	Myocardial infarction, stroke, sepsis
Gait disturbance	Stroke
Nausea/vomiting	Stroke, appendicitis, myocardial infarction

Atypical or non-specific symptoms were the strongest and most consistent predictors of increased risk for a missed diagnosis across diseases studied.

Patient age, gender, and race may impact error rates. For example, older age increases risk of missed appendicitis, while younger age increases risk of missed stroke 6.7-fold. The lay press (Medaris 2022) recently highlighted the latter problem, describing 3 patients in their 20’s whose strokes were misdiagnosed as being due to migraine or drugs.

Female sex and non-White race were often associated with important (20–30%) increases in misdiagnosis risk in the AHRQ study. There was also significant variation by hospital (for example, the rate of missed myocardial infarction varied from 0% to 29% across hospitals within a one study). Other notable predictors of misdiagnosis included care provided by less experienced clinicians, at non-teaching hospitals, with high ED discharge fraction, and during off hours. The diagnostic performance gap with academic (teaching) ED’s having lower false negative rates than community (non-teaching) ED’s was a fairly consistent finding, but it is unknown whether lower academic false-negative rates were achieved through greater overall diagnostic accuracy or by favoring overutilization, leading to arbitrarily greater admission fractions and resulting in higher false-positive rates.

The AHRQ study also cites previous work from malpractice claims on factors contributing to ED diagnostic error. Such factors include failure/delay in ordering diagnostic test; lack of/inadequate patient assessment with premature discharge; narrow diagnostic focus in patient assessment with failure to establish differential diagnosis; failure to appreciate and reconcile relevant signs, symptoms, or test results; failure/delay in obtaining a consultation or referral; misinterpretation of diagnostic test studies (e.g., X-rays); issues related to lack of health insurance; inadequate communication among providers regarding the patient’s condition; off-hours care (weekend, night shift, or holiday); inadequate history or physical examination.

Of course, we always need to balance the risk of misdiagnosis against the risk of overdiagnosis or unintentionally initiating the “diagnostic cascade”. For example, though stroke was often misdiagnosed when vertigo/dizziness was a presenting symptom, we certainly don’t want every patient with vertigo or dizziness to get a CT scan or MRI scan. We know that the diagnostic cascade not only adds to the cost of healthcare but may also lead to unnecessary procedures that, in turn, may lead to patient harm.

From the studies done on diagnostic error in the ED, it is also difficult to understand the likely role of fatigue, which we know increases error rates in a variety of venues. There is also one other consideration never assessed in these studies. We’ve often cited a study on shift workers in fields other than healthcare (Folkard 2003) which showed that the risk of incidents increased each consecutive day worked. For example, on average for night shifts risk was 6% higher on the second night, 17% higher on the third night, and 36% higher on the fourth night (for morning/day shifts the corresponding risks were 2%, 7% and 17%). There’s little reason to think that such trends might not also occur in healthcare, particularly in the ED where long consecutive-day shifts are common.

The AHRQ study wasn’t the only recent study on diagnostic errors in the ED. Baartmans et al. (Baartmans 2022) studied 23 serious error event reports of diagnostic events in emergency departments of Dutch general hospitals and identified human errors. Twenty-one reports contained a diagnostic error, in which the authors identified 73 human errors. These were mainly based on intended actions (n = 69) and could be classified as mistakes (n = 56) or violations (n = 13). Most human errors occurred during the assessment and testing phase of the diagnostic process.

Similar to the AHRQ report, most prevalent missed or delayed final diagnoses were cardiovascular (n = 11) or neurological (n = 5) conditions, such as aorta dissection, ruptured abdominal aortic aneurysm, subarachnoid hemorrhage, and spinal cord injury. They found that diagnostic errors occurred most often in the assessment and testing domains. Other human errors sometimes occurred during referral or consultation, history taking, the physical exam, follow-up, and at access to care or presentation. Most human errors involved a failure or delay in recognizing the urgency of the situation or putting too much weight on a competing or coexisting diagnosis (for example, the working diagnosis of a migraine disrupted the search for other causes of the symptoms of a patient with a subarachnoid hemorrhage). Other recurring themes were the failure or delay to consider a diagnosis, failed or delayed follow-up of (abnormal) test results, failure or delay in ordering needed tests, wrong test orders, and failure or delayed communication or follow-up of a consultation.

The authors note that hospitals seldom propose overarching interventions to support the diagnostic process, for example, evidence-based strategies to improve specific knowledge, reforming training methods, structural feedback and reflection on diagnostic discrepancies, implementation of diagnostic decision support systems to improve diagnostic calibration, or implementing team-based diagnosis. They also note that system-aimed interventions (e.g., lowering work pressure and crowding in the ED, improving patient safety culture, teamwork interventions, and cultural aspects) are also rarely proposed, while these types of recommendations may have a better chance of being effective in preventing similar cases and to improve diagnostic safety.

Diagnostic error remains our greatest patient safety challenge. It’s an area for which we’ve had the fewest solutions to date, and it applies to every healthcare venue, not just the ED. Sensationalizing the statistics is not likely to lead to any productive changes. Rather, focusing on the nature of the errors and factors contributing to them is much more likely to lead to productive changes. In that regard, the AHRQ study is a useful beginning.

References:

Newman-Toker DE, Peterson SM, Badihian S, et al. Diagnostic Errors in the Emergency Department: A Systematic Review. Comparative Effectiveness Review No. 258. (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. 75Q80120D00003.) AHRQ Publication No. 22(23)-EHC043. Rockville, MD: Agency for Healthcare Research and Quality; December 2022

https://effectivehealthcare.ahrq.gov/products/diagnostic-errors-emergency/research#field_report_title_3

Medaris A. Doctors dismissed these 3 young people's symptoms as migraines or drug-related — but they were really having strokes. Insider 2022; Dec 26, 2022

https://www.insider.com/doctors-dismissed-young-peoples-strokes-as-drugs-alcohol-migraines-2022-11

(Medaris 2022)

Folkard S, Tucker P. Shift work, safety and productivity. Occupational Medicine 2003; 53: 95-101

http://occmed.oxfordjournals.org/content/53/2/95.full.pdf+html?sid=a10ee101-4552-4258-8490-8a6d91a2b925

Baartmans MC, Hooftman J, Zwaan L, et al. What Can We Learn From In-Depth Analysis of Human Errors Resulting in Diagnostic Errors in the Emergency Department: An Analysis of Serious Adverse Event Reports. Journal of Patient Safety 2022; 18(8): e1135-e1141

https://journals.lww.com/journalpatientsafety/Fulltext/2022/12000/What_Can_We_Learn_From_In_Depth_Analysis_of_Human.10.aspx

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January 17, 2023

Patient Safety with NOAC’s and DOAC’s

Oral anticoagulants are the mainstay for prevention of stroke in patients with atrial fibrillation. With the advent of non-vitamin K antagonist oral anticoagulants (NOAC’s)/direct oral anticoagulants (DOAC’s), many of the safety concerns we had when using warfarin were expected to be bypassed. These new oral anticoagulants no longer needed to be titrated to a lab value and had fewer drug and food interactions than seen with warfarin. And clinical trials of most of these newer agents showed efficacy at least as good as warfarin along with fewer serious bleeding consequences. So, combining simpler regimens with better safety profiles has led to greater uptake of these agents in patients with atrial fibrillation, including their use in patients in whom we’d previously have been wary of using warfarin.

Ko et al. (Ko 2022) looked at trends between 2010 and 2020 in initiation of oral anticoagulants in Medicare Advantage patients age 65 and older with atrial fibrillation. Indeed, rates improved from 20.2% to 32.9% (with the rate of DOAC uptake increasing from 1.1% to 30.9%). Over the same period, warfarin initiation decreased from 19.1% to 2.0%. Among patients who were initiated on oral anticoagulants, there was an increase in DOAC uptake from 5.4% in 2010 to 93.9% in 2020. Moreover, nonadherence rates decreased from 52.2% to 39.0%. But patients with dementia, frailty, and anemia were still less likely than patients without those conditions to have an oral anticoagulant initiated. The authors conclude that, despite the improved rates of oral anticoagulation, such management has remained suboptimal. They call for additional strategies to improve stroke prophylaxis in all older adults with atrial fibrillation including those with coexisting dementia, frailty, and anemia.

A recent Medscape article (Wajngarten 2022) summarized several recent studies on safety issues with NOAC’s/DOAC’s in patients with atrial fibrillation. He cited a a systematic review and meta-analysis by Caso et al. (Caso 2022) that found frequent inappropriate dosing of non-vitamin K antagonist oral anticoagulants (NOAC’s) in patients with atrial fibrillation. Compared with recommended DOAC dosing, overdosing was associated with an increased risk of major bleeding, as expected. Underdosing was associated with a null effect on stroke outcomes and bleeding outcomes (the latter unexpected) but an increased risk of all-cause mortality. Increased age, history of minor bleeds, hypertension, congestive heart failure and low creatine clearance were associated with an increased risk of underdosing.

Physicians have been reluctant to use anticoagulants in patients at risk for falls. We’ve done several columns on the risk of intracranial hemorrhage after head trauma in patients taking oral anticoagulants, with studies offering mixed conclusions. Wajngarten cited a new Canadian study (Grewal 2021) that found patients on warfarin seen in the emergency department with a head injury had higher relative risks of intracranial hemorrhage than matched patients on a DOAC and patients not on anticoagulation, respectively. The risk of intracranial hemorrhage for patients on a DOAC was not significantly different compared with no anticoagulation.

Another patient group in which anticoagulant prescription has been low is those with frailty. Wajngarten cited a recent study (Kim 2022) that showed in frail patients with AF, oral anticoagulant treatment was associated with a positive net clinical outcome. DOAC’s provided lower incidences of stroke, bleeding, and mortality, compared with warfarin.

Taken together, these studies suggest that many of the barriers to prescribing oral anticoagulants in patients with atrial fibrillation still exist, despite evidence that their use in such patients might be justified, particularly when NOAC’s/DOAC’s are used rather than warfarin.

Some of our previous columns on head trauma in the anticoagulated patient:

April 16, 2007 “Falls With Injury”

July 17, 2007 “Falls in Patients on Coumadin or Heparin or Other Anticoagulants”

June 5, 2012 “Minor Head Trauma in the Anticoagulated Patient”.

July 8, 2014 “Update: Minor Head Trauma in the Anticoagulated Patient”

August 21, 2018 “Delayed CT Scan in the Anticoagulated Patient”

September 21, 2021 “Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective”

December 14, 2021 “Delayed Hemorrhage After Head Trauma in Anticoagulated Patients”

References:

Ko D, Lin KJ, Bessette LG, et al. Trends in Use of Oral Anticoagulants in Older Adults With Newly Diagnosed Atrial Fibrillation, 2010-2020. JAMA Netw Open 2022; 5(11): e2242964

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2798659

Wajngarten M. Oral Anticoagulant Mistakes to Avoid in Older Adults With AF. Medscape Medical News 2022; December 23, 2022

https://www.medscape.com/viewarticle/986128?src=WNL_dne1_221226_MSCPEDIT&uac=14695HV&impID=5032296

Caso V, de Groot JR, Sanmartin Fernandez M, et al. Outcomes and drivers of inappropriate dosing of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation: a systematic review and meta-analysis. Heart. 2022; Published Online First: 31 October 2022

https://heart.bmj.com/content/early/2022/10/31/heartjnl-2022-321114.long

Grewal K, Atzema CL, Austin PC et al. Intracranial hemorrhage after head injury among older patients on anticoagulation seen in the emergency department: a population-based cohort study. CMAJ 2021; 193(40): E1561-E1567

https://www.cmaj.ca/content/193/40/E1561.long

Kim D, Yang PS, Sung JH, et al. Effectiveness and Safety of Anticoagulation Therapy in Frail Patients With Atrial Fibrillation. Stroke 2022; 53(6): 1873-1882

https://www.ahajournals.org/doi/10.1161/STROKEAHA.121.036757

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January 24, 2023

Tale of 2 Graces

Our December 17, 2019 Patient Safety Tip of the Week “Tale of Two Tylers” showed a healthcare mix-up of a hockey player and a basketball player, both named Tyler Ennis. X-rays of one Tyler Ennis were mistaken for those of the other Tyler Ennis. Fortunately, there were no adverse consequences from the mix-up but there could have been.

While it is not, per se, a patient safety example, a recent Kaiser Health News story (Kreidler 2022) showed how the same type of patient misidentification can lead to nightmares for a patient. The snafu involved 31-year-old Grace E. Elliott and 81-year-old Grace A. Elliott. Grace E. had a hospital visit with a small bill 8 years earlier while visiting her parents in Venice, Florida. Grace A. had an expensive shoulder replacement at the same hospital years later. But a bill addressed to Grace E. was sent to Grace E’s mother with charges for a shoulder replacement (Grace E. was no longer living in Florida). Initially suspecting possible identity theft, Grace E. contacted the hospital. After several weeks and multiple phone calls, the corporate office for the hospital let Grace E. know of the hospital’s error and promised to correct it. But, in the interim, the account had been turned over to a collection agency and the misidentification was not communicated to the collection agency. Two appeals to the collection agency were denied. It was only after involvement of a reporter that the snafu was ultimately resolved. In all, it took nearly a year of hours-long phone calls to undo the damage.

In addition to the patient identification error, there were obviously communication errors. Hospital ownership had changed, and the hospital had actually closed prior to this case being resolved. Moreover, in one of the collection agency’s denial letters several pages of the older woman’s medical information were disclosed (certainly sounds to us like there may be HIPAA implications). Though the case involves billing records, the latter issue also raises the question about whether any medical information has been incorrectly included in the medical records of either or both of these patients.

Correct patient identification is the responsibility of all hospital personnel, not just clinicians. Two-factor identification is the minimum requirement. Most hospitals and healthcare facilities use patient name and date of birth as the two identifiers. Grace E. and Grace A. had different dates of birth. But even using date of birth may not be an adequate safeguard. In our March 26, 2019 Patient Safety Tip of the Week “Patient Misidentification” we noted a near-miss when two patients had the same name and same date of birth and noted the fact that, in one hospital district in Texas, 2488 patients were named Maria Garcia, and 231 of these (9.3%) also shared the same date of birth! (Lippi 2017).

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. Obviously in the current case photographs could also have easily distinguished patients of widely different ages.

Our December 17, 2019 Patient Safety Tip of the Week “Tale of Two Tylers” also has a discussion on how a long-overdue national patient identifier (NPI) system could serve as a means of preventing patient misidentification.

We recommend you read the entire Kaiser Health News story (Kreidler 2022) for all the details of the current example. This is an excellent story you should include in your orientation of non-clinical personnel in your organization to emphasize the importance of correct patient identification at all times.

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”

March 24, 2020 “Mayo Clinic: How to Get Photos in Your EMR”

June 16, 2020 “Tracking Technologies”

November 17, 2020 “A Picture Is Worth a Thousand Words”

August 3, 2021 “Obstetric Patients More At-Risk for Wrong Patient Orders”

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”

March 24, 2020 “Mayo Clinic: How to Get Photos in Your EMR”

November 17, 2020 “A Picture Is Worth a Thousand Words”

References:

Kreidler M. The case of the two Grace Elliotts: A medical billing mystery. Kaiser Health News 2022; December 21, 2022

https://khn.org/news/article/mistaken-identity-two-grace-elliotts-medical-billing-mystery/

Lippi G, Chiozza L, Mattiuzzi C, Plebani M. Patient and Sample Identification. Out of the Maze? J Med Biochem 2017; 36(2): 107-112. Published online 2017 Apr 22

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5471642/

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January 31, 2023

Alert on Oxygen Cylinder Use

We’ve written about problems with oxygen cylinders in several columns (see our What's New in the Patient Safety World columns for November 2016 “Oxygen Tank Monitoring” and February 2018 “Oxygen Cylinders Back in the News”). And, of course, running out of oxygen during patient transports was a major reason that the “Ticket to Ride” checklist was developed (see below for our many columns on the “Ticket to Ride”).

England’s NHS (National Health Service) recently issued a patient safety alert regarding oxygen cylinders (NHS 2023). NHS saw an increased number of incidents involving oxygen cylinders as there was a surge in demand for oxygen for respiratory-related illnesses. That surge raised issues around oxygen cylinders regarding not only patient safety, but also fire safety and physical safety. It found 120 patient safety incidents related to oxygen cylinders over a 12 month period. These included incidents such as:

cylinder empty at point of use
cylinder not switched on
cylinders inappropriately transported
cylinders inappropriately secured

Some of these reports described compromised oxygen delivery to the patient, leading to serious deterioration and cardiac or respiratory arrest. In addition, there is a need to conserve oxygen cylinder use to ensure a robust supply chain process.

NHS recommends that hospitals and healthcare facilities undertake a risk assessment, including attention to the following:

avoiding unnecessary use of cylinder oxygen and excessive flow rates by ensuring oxygen treatment is optimized to recommended target saturation ranges
ensuring safe use of oxygen cylinders by clinical staff including:

safe activation of oxygen flow
initial and ongoing checks of flow to patient
initial and ongoing checks of amount of oxygen left in the cylinder
especially during transfer or whilst undergoing diagnostic tests

fire safety, including:

appropriate ventilation (both in physical environments and in ambulances)
safe storage of cylinders

physical safety, including:

awareness of manual handling requirements
safe transportation of cylinders using appropriate equipment
safe storage of cylinders

NHS also notes that priority should be given to escalation/transient areas being used to acutely care for patients (eg corridors, non-inpatient areas such as physiotherapy departments, ambulances outside emergency departments).

NHS had also just released a guidance “Safe Use of Oxygen Cylinders” that stresses patient safety issues, fire safety, physical safety, and conservation of resources. It begins by reminding us that oxygen treatment should be optimized to target saturation ranges as recommended in BTS Guideline for oxygen use in adults in healthcare and emergency settings (O'Driscoll 2017). Fixed performance (or "Venturi") masks should be used preferentially to ensure that oxygen saturations remain within the target range. Organizations should ensure that these are available in sufficient quantities. NHS England support patients requiring CPAP or non-invasive ventilation, especially if in an ambulance, to be prioritized for transfer to a clinical area where oxygen via the MGPS (medical gas pipeline systems) is available. If this is not possible, use the lowest flow device available. It stresses ongoing clinical checks, with oxygen saturation checks using appropriate oximeter positioning and probes, and both initial and regular flow checks to ensure oxygen is flowing to the patient.

Regarding patient safety issues, it recommends:

When using an integral valve oxygen cylinder, ensure appropriate activation and flow (it provides several links to resources on this process).
If using devices to deliver oxygen therapy such as nasal high flow or other forms of non-invasive ventilation in transient parts of the emergency department, escalation areas or ambulances waiting to offload, please note that some devices are reliant on main power and have no battery backup mode when the patient is then transported to another setting.
It discusses various sizes and types of cylinders and notes care must be taken to ensure the right regulator has been connected to the right medical gas.
To avoid confusion between cylinders, there should be effective separation of oxygen and other medical gas cylinders, and of the related regulators, in all storage areas.

Because of the current supply issue, the guidance notes it is important the cylinders are used until the cylinder content display is nearing empty, to ensure maximal use. But that also has important patient safety implications. It is therefore essential when using any oxygen cylinder to always check the cylinder contents display and estimate the approximate residual volume according to the prescribed flow rate. (A generic guide covering commonly used cylinders can be downloaded and displayed in clinical areas or laminated and tagged to standalone cylinders). Care must be taken that cylinders do not fully empty, and patients no longer receive oxygen. On transfer: ensure patients requiring oxygen are transferred with an oxygen cylinder and that there is sufficient oxygen left to facilitate the transfer and/or the time to undertake diagnostic tests. That is a point we emphasize in our columns on the “Ticket to Ride” checklist. On arrival to ward, ensure patient is attached to oxygen via MGPS (medical gas pipeline systems), eliminating the risk of inadvertent connection to medical air via a flowmeter and oxygen cylinders are returned as soon as possible.

Regarding physical safety issues, the guidance recommends:

Medical gas cylinders are only transported using dedicated holders – they should never be placed on the patients’ bed or carried by the patient.
Only staff trained in the use of manual handling aids move large medical gas cylinders to avoid manual handling injuries
Staff connecting cylinders to regulators are trained in their use – training resources are available on-line from your medical gas cylinder supplier.
Cylinders in use are effectively secured to prevent falling (risk of damage and risk of crushing)
Empty cylinders are returned as soon as possible to the empty medical gas cylinder store to prevent trip hazards and make them available for refilling.
Cylinders that are ready to be deployed are only stored in designated and signed medical gas cylinder stores with appropriate warning signs.

The NHS guidance discusses fire safety issues as well. It recommends:

Spaces that have been converted or adopted for patient use may have inadequate ventilation, leading to rising oxygen concentration – this should be monitored ensuring that there is adequate ventilation.
Cylinders that are ready to be deployed should only be stored in designated and signed medical gas cylinder stores with appropriate warning signs.
The Fire Risk Assessment should be revisited with consideration of:

Spaces that have been converted or adopted for patient use may have inappropriate surface finishes and fixtures for the spread of flame
Spaces that have been converted or adopted may impede access or egress in the event of an emergency – safe evacuation routes should be maintained.
Oxygen use may lead to oxygen saturation of materials increasing likelihood of ignition and fire intensity
Portable Oxygen equipment and associated apparatus are at risk of leakage, increasing the risk of fire.

Patients and public should not smoke, vape or use a lighter in areas where oxygen concentration may be high – this includes close to hospital entrances and ambulances.

Our October 2022 What's New in the Patient Safety World column “Portable Oxygen and Ambulance Fire” discussed the role of portable oxygen in a fatal ambulance fire. The recent NHS guidance specifically addresses the use of oxygen in ambulances, noting that prolonged use of supplemental oxygen in an enclosed ambulance “saloon” may increase the risk of fire due to raised ambient oxygen concentrations. To minimize this risk the following should be considered:

Any patient receiving supplemental oxygen should have their oxygen saturations monitored continuously, and oxygen administration titrated to oxygen saturations in accordance with JRCALC guidelines on the administration of oxygen.
Consider permanently or intermittently opening the roof vent on the ambulance saloon to facilitate equilibration of internal and external ambient oxygen concentrations.

With extended use of supplemental oxygen in the ambulance “saloon” it may be necessary to change onboard cylinders during deployment. Care should be taken to ensure that all valves, regulators and fitments are clean, dry and free from grease or any other contaminant before re-attachment to a cylinder. Following reattachment, valves should be opened slowly into an open supply, i.e. with the flowmeter open, to reduce the risk of fire or explosion from “adiabatic compression” – following instructions for use available for medical gas cylinder supplier. It provides a link to a very interesting discussion about an oxygen cylinder that caught fire whilst being prepared for a patient who was being transferred to another hospital (Kelly 2014). That fire seemed to arise from within the cylinder and they discuss and the article discusses both the potential fuels within a cylinder plus the “adiabatic” heating of the gases that could lead to combustion.

Don’t forget oxygen cylinders have been projectiles in fatal MRI accidents (see our many columns on MRI safety listed below). We’ve also recommended you carry out simulations or drills with your local police or fire departments. You don’t want any of their personnel entering an MRI suite with an oxygen cylinder.

Our February 2018 What's New in the Patient Safety World column “Oxygen Cylinders Back in the News” was triggered by a previous NHS safety alert based on over 400 incidents involving oxygen cylinders. We hope you’ll go back to that column for our comments. We criticized that NHS alert because the recommended actions were primarily educational, and we’ve often pointed out that educational interventions are among the least effective interventions. We are pleased to see that the current NHS alert goes well beyond recommendations for educational interventions.

The current “tripledemic” of respiratory illnesses has undoubtedly resulted in potential problems in use, storage, and transport of oxygen cylinders. Now is a good time to review your own vulnerabilities to incidents involving oxygen cylinders. Even if you don’t have a Medical Gas Committee you should at least incorporate assessment of oxygen cylinders into your Patient Safety Walk Rounds (not only assessing cylinders in storage areas but also checking safety issues any time you find an oxygen cylinder with a patient during an intrahospital transport). And for those of you looking for a topic for a FMEA (Failure Mode and Effects Analysis), this is a good topic.

Some of our prior columns on potential harmful effects of oxygen and other oxygen issues:

April 8, 2008 “Oxygen as a Medication”

January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!”

April 2009 “Nursing Companion to the BTS Oxygen Therapy Guidelines”

October 6, 2009 “Oxygen Safety: More Lessons from the UK”

July 2010 “Cochrane Review: Oxygen in MI”

December 6, 2011 “Why You Need to Beware of Oxygen Therapy”

February 2012 “More Evidence of Harm from Oxygen”

March 2014 “Another Strike Against Hyperoxia”

June 17, 2014 “SO2S Confirms Routine O2 of No Benefit in Stroke”

December 2014 “Oxygen Should Be AVOIDed”

August 11, 2015 “New Oxygen Guidelines: Thoracic Society of Australia and NZ”

November 2016 “Oxygen Tank Monitoring”

November 2016 “More on Safer Use of Oxygen”

October 2017 “End of the Oxygen in MI and Stroke Debate?”

February 2018 “Oxygen Cylinders Back in the News”

June 2018 “Too Much Oxygen”

July 2021 “Unique Way to Rapidly Identify Oxygen Flow”

October 2022 “Portable Oxygen and Ambulance Fire”

January 2023 “Oxygen During Surgery”

Some of our prior columns on intrahospital transports and the “Ticket to Ride” concept:

April 8, 2008 “Oxygen as a Medication”
November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
August 11, 2009 “The Radiology Suite…Again!”
March 13, 2012 “Medical Emergency Team Calls to Radiology”
August 25, 2015 “Checklist for Intrahospital Transport”
September 1, 2015 “Smarter Checklists”
November 2016 “Oxygen Tank Monitoring”
February 2018 “Oxygen Cylinders Back in the News”
May 22, 2018 “Hazardous Intrahospital Transport”
October 30, 2018 “Interhospital Transfers”
March 31, 2020 “Intrahospital Transport Issues in Children”
June 23, 2020 “Telemetry Incidents”
July 14, 2020 “A Thesis on Intrahospital Transports”
August 4, 2020 “Intravenous Issues”
February 2021 “Risk from Intrahospital Transfer: Healthcare-Associated Infection”
May 25, 2021 “Yes, Radiologists Have Handoffs, Too”
July 2021 “Unique Way to Rapidly Identify Oxygen Flow”
April 2022 “Safety Issues in Interhospital Transports”

Some of our prior columns on patient safety issues related to MRI:

February 19, 2008 “MRI Safety”

March 17, 2009 “More on MRI Safety”
October 2008 “Preventing Infection in MRI”
March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”
January 25, 2011 “Procedural Sedation in Children”
February 1, 2011 “MRI Safety Audit”
October 25, 2011 “Renewed Focus on MRI Safety”
August 2012 “Newest MRI Hazard: Ingested Magnets”
October 22, 2013 “How Safe Is Your Radiology Suite?”
October 21, 2014 “The Fire Department and Your Hospital”
August 25, 2015 “Checklist for Intrahospital Transport”
August 2016 “Guideline Update for Pediatric Sedation”
October 2016 “MRI Safety: There’s an App for That!”
January 17, 2017 “Pediatric MRI Safety”
August 8, 2017 “Sedation for Pediatric MRI Rising”
March 2018 “MRI Death a Reminder of Dangers”
March 2018 “Cardiac Devices Safe During MRI But Spinners!?”
November 2018 “OMG! Not My iPhone!”
April 2, 2019 “Unexpected Events During MRI”
September 2019 “New MRI Hazard: Magnetic Eyelashes”
October 15, 2019 “Lots More on MRI Safety”
November 5, 2019 “A Near-Fatal MRI Incident”
November 2019 “ECRI Institute’s Top 10 Health Technology Hazards for 2020”
January 7, 2020 “Even More Concerns About MRI Safety”
March 2020 “Airway Emergencies in the MRI Suite”
October 2020 “New Warnings on Implants and MRI”
January 2021 “New MRI Risk: Face Masks”
June 1, 2021 “Stronger Magnets, More MRI Safety Concerns”
November 2021 “Yet Another Risk During MRI”
January 2022 “MRI Safety Issues”
July 26, 2022 “More Risks in the Radiology Suite”

References:

NHS England. Patient Safety Alert. Use of oxygen cylinders where patients do not have access to medical gas pipeline systems. NHS England 2023; January 10, 2023

https://www.england.nhs.uk/wp-content/uploads/2023/01/10-January-2023-Oxygen-Safety-NaPSA-FINAL-v5.pdf

NHS England. Safe Use of Oxygen Cylinders. NHS England 2023; 5 January 2023, Version 1

https://www.england.nhs.uk/wp-content/uploads/2023/01/Official-sensitive-Oxygen-Cylinder-Comms-FINAL-v2.pdf

O'Driscoll BR, Howard LS, Earis J on behalf of the British Thoracic Society Emergency Oxygen Guideline Group, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax 2017; 72(Supplement 1): ii1-ii90

https://thorax.bmj.com/content/72/Suppl_1/ii1

Kelly, F.E., Hardy, R. and Henrys, P. Oxygen cylinder fire – an update. Anaesthesia 2014; 69: 511-513

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.12698

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February 7, 2023

Reducing Unnecessary Telemetry

When hospitals ask “Where should we start?” in addressing alarm fatigue, we always tell them the first place to look is at unnecessary telemetry. There are two key elements in programs to reduce such use:

Only begin telemetry in patients who meet accepted guidelines for telemetry use
Stop telemetry once patients no longer meet criteria for continued use

A hospital system recently did just that (Patidar 2022). They did 2 key interventions across 4 hospitals (a large academic quaternary center, a tertiary care center, a small community hospital, and a large community hospital) with a total of 1700 beds. The 2 key elements were:

Hardwiring the 2017 American Heart Association practice guidelines on the appropriate use of telemetry into their EHR-based protocol for telemetry
Developing a nursing-driven discontinuation protocol with an electronic nursing screening task form for safe discontinuation of telemetry

There was a statistically and clinically significant 24% decrease in telemetry duration between pre- and post-intervention time periods (P < 0.0001). Mean telemetry duration was 4.11 and 2.36 days in pre- and post-intervention periods, respectively, a 1.75 day reduction across each of the four hospitals.

The authors projected a substantial cost avoidance from this project. Though they did not measure it, there was also likely also a substantial reduction in alarm fatigue as a result of the project.

The Patidar article details the project planning by a multidisciplinary team and the communication rollout that was important in preparing for the implementation of the automated protocol.

The results are remarkably similar to a program we highlighted in our October 2014 What's New in the Patient Safety World column “Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring”, in which researchers at Christiana Care Health System successfully reduced unnecessary non-ICU telemetry and achieved substantial financial savings while not adversely impacting patient safety (Dressler 2014). A multidisciplinary team designed the program and ensured appropriate training of impacted departments. The key component was hardwiring the AHA guidelines into their electronic ordering system. Providers were now required to choose an indication from a list, each of which included a duration based upon the AHA guidelines. In addition, they removed telemetry orders from order sets for conditions where monitoring was not supported by the AHA guidelines. Also, guidelines were established for automatic discontinuation of telemetry monitoring. After implementation there was a 70% reduction in the mean daily number of patients being monitored by telemetry. The mean weekly number of telemetry orders dropped 43% and the mean duration of telemetry dropped by 47%.

Another striking reduction in telemetry was achieved on a hospitalist service (Edholm 2018). Interventions included education, process change, routine feedback, and a financial incentive. A system-wide change to the telemetry ordering process was also introduced without the other components. Among hospitalist service patients, telemetry utilization was reduced by 69%. On the non-hospitalist services the reduction was a less marked 22%. There were no significant increases in mortality, code event rates, or care escalation, and there was a trend toward improved utilization appropriateness. The EHR telemetry order was modified to discourage unnecessary telemetry monitoring. The new order required providers ordering telemetry to choose a clinical indication and select a duration for monitoring, after which the order would expire and require physician renewal or discontinuation. These were the only changes that occurred for nonhospitalist providers.

The authors also noted there had been an immediate decrease in telemetry orders after removing the telemetry order from their admission order set. They also attributed success on the hospitalist service to standardization of rounds to include daily discussion of telemetry and the provision of routine feedback. They could not discern whether other components of the program (such as the financial incentives) contributed more or less to the program, though the sum of these interventions produced an overall program that required substantial buy in and sustained focus from the hospitalist group.

Our own take on these programs is that there are some key success factors:

A multidisciplinary team must be involved in planning and implementation
There should be clinical champions from both your medical and nursing staffs
Evidence-based guidelines for telemetry use need to be integrated into your electronic health record ordering process
A strong communication program prior to rollout
Your medical staff must buy into the concept of either automatic discontinuation or a nurse-driven discontinuation process
Your nursing staff must be confident in that nurse-driven discontinuation process and not fear retribution from medical staff
You need to measure desired outcomes and give feedback to all stakeholders

Though such programs likely achieve significant financial savings, you staffs are more likely interested in outcomes other than financial ones. Though measurement of alarm fatigue is difficult, you can at least do informal surveys of stakeholders about the perceived benefit as it pertains to alarm fatigue.

Prior Patient Safety Tips of the Week pertaining to alarm-related issues:

March 5, 2007 “Disabled Alarms”
March 26, 2007 “Alarms Should Point to the Problem”
April 2, 2007 “More Alarm Issues”
June 19, 2007 “Unintended Consequences of Technological Solutons”
April 1, 2008 “Pennsylvania PSA’s FMEA on Telemetry Alarm Interventions”
February 23, 2010 “Alarm Issues in the News Again”
March 2, 2010 “Alarm Sensitivity: Early Detection vs. Alarm Fatigue”
March 16, 2010 “A Patient Safety Scavenger Hunt”
November 2010 “Alarms in the Operating Room”
February 22, 2011 “Rethinking Alarms”
February 2013 “Joint Commission Proposes New 2014 National Patient Safety Goal”
May 2013 “Joint Commission Sentinel Event Alert: Alarm Safety”
July 2, 2013 “Issues in Alarm Management”
August 2013 “Joint Commission Formalizes 2014 NPSG on Alarm Management”
February 4, 2014 “But What If the Battery Runs Low?”
October 2014 “Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring”
December 15, 2015 “Vital Sign Monitoring at Night”
February 9, 2016 “It was just a matter of time…”
August 16, 2016 “How Is Your Alarm Management Initiative Going?”
February 21, 2017 “Alarm Fatigue in the ED”
April 18, 2017 “Alarm Response and Nurse Shift Duration”
April 25, 2017 “Dialysis and Alarm Fatigue”
October 17, 2017 “Progress on Alarm Management”
November 21, 2017 “OSA, Oxygen, and Alarm Fatigue”
May 1 2018 “Refrigerator Alarms”
April 16, 2019 “AACN Practice Alert on Alarm Management”
September 2019 “Alarm Fatigue in the Emergency Room”
October 8, 2019 “Another Freezer Accident”
June 23, 2020 “Telemetry Incidents”
August 2020 “Pulse Oximetry in Children”
September 15, 2020 “An Eerily Familiar Incident”
January 26, 2021 “This Freezer Accident May Cost Lives”

Some of our prior columns on the hazards associated with telemetry:

June 19, 2007 “Unintended Consequences of Technological Solutions”
April 1, 2008 “Pennsylvania PSA’s FMEA on Telemetry Alarm Interventions”
February 23, 2010 “Alarm Issues in the News Again”
July 2011 “What's New in the Patient Safety World”
February 4, 2014 “But What If the Battery Runs Low?”
May 22, 2018 “Hazardous Intrahospital Transport”
June 23, 2020 “Telemetry Incidents”

References:

Patidar V, Park JM, Khasnavis T, et al. Evaluation of a Multifaceted Protocol in Reducing Unnecessary Telemetry Monitoring Across a Large Healthcare System. South Med J 2022; 115(12): 930-935

https://sma.org/southern-medical-journal/article/evaluation-of-a-multifaceted-protocol-in-reducing-unnecessary-telemetry-monitoring-across-a-large-healthcare-system/

Dressler R, Dryer MM, Coletti C, et al. Altering Overuse of Cardiac Telemetry in Non–Intensive Care Unit Settings by Hardwiring the Use of American Heart Association Guidelines. (Research Letter). JAMA Intern Med 2014; 174(11): 1852-1854 published online first September 22, 2014

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1906998

Edholm K, Kukhareva P, Ciarkowski C, et al. Decrease in Inpatient Telemetry Utilization Through a System-Wide Electronic Health Record Change and a Multifaceted Hospitalist Intervention. Journal of Hospital Medicine 2018; 13: 531-536

https://shmpublications.onlinelibrary.wiley.com/doi/abs/10.12788/jhm.2933

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February 14, 2023

Code Terminology Still Problematic

In our September 18, 2007 Patient Safety Tip of the Week “Wristbands: The Color-Coded Conundrum” we noted the lack of standardization of color-coding of wristbands was problematic. Problems may arise when a healthcare worker who usually works at another facility is now exposed to a colored wristband at a new facility that has a different meaning.

The same problem can occur with the nomenclature of emergency “codes”. In our October 15, 2013 Patient Safety Tip of the Week “Missing Patients” we noted a good piece of advice from the Minnesota Hospital Association (MHA 2011). Most of you are aware of the movement to replace “codes” with plain language for paging emergencies in hospitals (and other healthcare settings). Again, that is because a “Code Yellow” may mean one thing at one hospital and a different thing at another hospital.

So, are we doing any better? Apparently not, according to a new study. Harris et al (Harris 2022) sought to assess the ability of clinical and non-clinical employees across the State of Georgia to correctly identify their facility’s emergency codes.

Anonymous electronic surveys asked 304 employees at 5 facilities to identify the codes for 14 different emergencies. Participants correctly identified the emergency codes with only 44.37% accuracy on average. Codes for fire, infant abduction, and cardiac arrest were most commonly identified correctly (≥90%). Codes for hostage situation, internal disaster, pediatric emergency, and mass casualty incident were incorrectly identified by more than 85% of participants.

They also sought to identify significant predictors of emergency code identification accuracy. Code identification accuracy was significantly higher in participants who received training at employee orientation, had knowledge of emergency code activation procedures, and had worked at their current facility for two to five years. However, accuracy was lower in employees who had worked at four to five facilities in their careers, suggesting that code confusion becomes particularly pronounced after having more than three healthcare employers.

They also assessed employees’ opinions of emergency alert systems. Most survey participants favored a color-code-based alert system over a plain language-based alert system, citing concerns of causing panic in patients and visitors, and of maintaining confidentiality and discretion. But, obviously, the color-code-based systems are not cutting it. Most code systems in the US use color-based codes (e.g., “Code Red” for a fire), predicated on the idea that colors are easier to remember and serve as a tool to increase encoding among a target audience. But individuals often associate specific colors with specific images that may not be universal.

Harris et al. point out that approximately one in five healthcare workers has at least two jobs, and each employer may have its own emergency code designations. Moreover, staffing issues have resulted in many new or temporary healthcare workers at any facility, particularly since the COVID-19 era began.

Hospital associations in more than 25 states in the US have recommended the introduction of a standardized set of emergency codes and multiple hospital associations have advocated using “plain language” codes (Wallace 2015).

There is currently no national standard in the United States for such warning systems in healthcare facilities. Harris et al. conclude that transitioning to plain language overhead emergency alerts will better position employees, as well as patients and visitors, to effectively respond to emergencies and disasters occurring within a healthcare facility. They note that both the U.S. Federal Emergency Management Agency (FEMA) and the Department of Health and Human Services (DHHS) advocate for plain language communications in all emergency and disaster communications.

The commonly cited reasons against plain language-based alerts are fear of causing panic in patients and visitors, and of maintaining confidentiality and discretion. We’ll counter that by noting that patients and visitors can play an important role in resolution of the incident leading to the alert. They might not know what a “Code Gray” or “Code Pink” means, but they could certainly help identify a wandering patient or abducted infant if the alert was more specific.

The Harris study showed that both clinical and non-clinical employees have limited accuracy in identifying their hospital’s emergency codes. Code identification accuracy was significantly associated with training at orientation, knowledge of emergency code activation procedures, facility experience, and total facilities in the career. The majority of survey participants favored a code-based alert system over a plain language-based alert system, citing concerns of causing panic in patients and visitors and maintaining confidentiality and discretion. The Harris study and the Wallace study cite several other studies demonstrating “code confusion”.

Hasn’t the time come for standardization of emergency alerts in healthcare? While the time-honored use of colors in naming codes could be standardized, we strongly favor transition to plain language-based alerts.

References:

MHA (Minnesota Hospital Association). Plain Language Overhead Emergency Paging. Implementation Toolkit. 2011

http://www.mnhospitals.org/Portals/0/Documents/ptsafety/overhead-paging-toolkit-2011.pdf

Harris C, Zerylnick J, McCarthy K, et al. Breaking the Code: Considerations for Effectively Disseminating Mass Notifications in Healthcare Settings. Int J Environ Res Public Health 2022; 19(18): 11802

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9517086/

Wallace SC, Finley E. Standardized Emergency Codes May Minimize “Code Confusion”. Pa Patient Saf Advis 2015; 12(1): 1-6

http://patientsafety.pa.gov/ADVISORIES/Pages/201503_01.aspx

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