Blog

According to the New York Times, the fourth-leading cause of death in the United States is hospital-acquired infections (nosocomial infections). Nosocomial infections are infections, such as pneumonia, that patients contract while receiving treatment in hospitals. These infections cost the U.S. healthcare system over $40 billion every year.

Hospitals across the nation are taking steps to decrease the prevalence of nosocomial infections, making incredible progress in some areas. Yet, studies show there is still a long way to go.

Safety Checklists Prove Effective

---

An experiment conducted in 2003 in Michigan demonstrated the effectiveness of a simple checklist in reducing certain types of patient infections. To reduce the occurrence of central-line catheter infections, the Michigan Health and Hospital Association required 103 intensive-care units to use a five-point checklist when inserting catheters into patients. The results were incredible: the median rate of infection dropped to zero and remained at zero throughout 15 months of follow-up monitoring.

The same hospitals implemented a similar checklist method to reduce ventilator-associated pneumonia. Again, by using the checklist method, the hospitals were successful in eliminating this infection, reducing the median infection rate to zero.

Risks of Hospital-Acquired Infections

---

Despite the success of checklists in reducing hospital-acquired infections, there is still great room for improvement. One of the main causes of nosocomial infections is the hospital workers’ failure to wash their hands frequently enough. A study published in the American Journal of Medicine Quality revealed that most hospitals have hand-washing rates below 50 percent. The study also showed that medical personnel in intensive care units only wash their hands one quarter as often as they should.

Atul Gawande, author of The Checklist Manifesto, says implementing checklist systems in more hospitals nationwide will help improve rates of basic tasks such as hand washing. He says hospital checklists work well for several key reasons. First, lists are reminders to busy hospital personnel who may overlook a step in a routine procedure when doing many things at once. Second, lists instill a sense of responsibility among the people involved in performing a procedure; everyone is responsible for the success or failure of the procedure. Each person has the right and the duty to say something if someone is skipping a step on the checklist.

In a recent survey conducted by the Association for the Advancement of Medical Instrumentation (AAMI), clinical engineers and biomedical engineering technicians were asked to report the biggest biomedical challenges they see in their hospitals. Interfacing devices and information systems were the top challenges, but managing alarm systems and computerized IT systems were also ranked highly (#3 and #2, respectively).

The information was collected through a research survey conducted in November 2010 by Stratton Research. There were 418 responses to the survey, which was sent to more than 2,500 hospital biomedical technicians and clinical engineers. The results were published in the March/April 2011 issue of the Biomedical Instrumentation & Technology. Clinical engineers and hospital professionals discussed the findings at the recent AAMI conference held on June 27.

The top 10 biomedical challenges were:

1. Interfacing between devices and information systems
2. Maintaining computerized IT systems
3. Managing alarms
4. Maintaining and processing endoscopes
5. Broken connectors
6. Wireless management
7. Battery management
8. Problems with patient monitors
9. Problems with dialysis equipment
10. Managing the radiation dose from CT

“In terms of solutions to these challenges, clinical engineering veterans and other professionals hit the same broad themes: better education and training, stronger and communication and cooperation among departments, and often a need for standards,” stated Paul W. Kelley, CBET, of Washington Hospital Healthcare System in Fremont, Calif.

“The successful implementation of interoperability requires defined objectives and measurable goals”, noted Carol Davis-Smith, CCE, Premier Healthcare Alliance in Charlotte, N.C., “as well as a complete and well-maintained physical inventory of the applicable items included in the network.” Davis-Smith recommended prioritizing and making data-driven decisions when implementing interoperable devices.

“What we’re finding out there in the community, is that one, our basic CMO mass inventory is not clean. We need to get that cleaned up, and the reason being, because we need to have IT collect this really granular data about each of those individual devices, what can talk and what cannot talk, to what extent does it talk and how does it talk,” Davis-Smith said. “Bringing this level of granularity might be an ice-breaker in the IT department.”

Kelley said, “We learned [from the survey] that IT plays a huge role in biomedical engineering, as three of the top 10 challenges are IT-related. The IT department, clinical engineers, clinicians and vendors have to work together. Healthcare is most definitely a team sport.”

Related to interoperability, alarm management was also a strong focus of Monday’s discussion. Managing alarms has become a widespread issue—gaining media exposure with stories in The Boston Globe, The Washington Post, CBS Nightly News, and National Public Radio—as hospitals are attempting to manage the alarm fatigue caused by the countless visual and audible alarms directed at nurses each day.

“In terms of the top 10 medical device challenges, it really interacts with so many of the other challenges: interfacing, computer updates, broken connectors, patient monitors,” said J. Tobey Clark, CCE, of the University of Vermont in Burlington. “All of those other hazards directly impact clinical alarms.”

Clark said that sounds are actually just a portion of the problem. He said caregivers cannot recognize more than six different alarm sounds and have difficulty distinguishing between high- and low-priority alarms.

“This clinical alarm problem is very complex,” he said. “The stumbling block is human limitations. Because it’s a complex problem, you need a complex solution,” Clark said. “We need a multi-disciplinary approach to resolve this problem. False alarms and nuisance alarms [are] by far the biggest problems that lead to alarm fatigue.”

The issue of clinical alarm fatigue will be the focus of an upcoming AAMI summit in Herndon, Virginia, Oct. 4-5.

Nurses spend most of their time working on documentation, care coordination, and medication administration. In order to complete these tasks along with the necessary dictation and charting, nurses must constantly be on the move throughout the hospital. Unfortunately, this leaves nurses with very little time to interact with their patients, usually less than 5 minutes per patient for each hour during a shift.

To help ease the burden on nurses and improve relationships with patients, many hospitals are incorporating nurse messaging into their communications plan. With this type of setup, nurses can send and receive calls or text messages on their wireless phones as they travel throughout the hospital.

Hospitals that implement a wireless nurse messaging system typically see immediate benefits for their nurses and their patients. Messaging software can be connected to devices within patient rooms so that nurses can receive alert messages on their phones detailing them about the patient’s condition or actions. Since caregivers can receive and respond to alerts more quickly with messaging, the risk of “never events” (such as patient falls or pressure ulcers) is reduced.

Text messages can convey simple task requests more quickly than voice communications; thus, messaging saves time for caregivers because many clinical communications do not require extended voice interaction.

Also, since wireless messaging allows nurses to receive specific patient care alerts and updates on the go, messaging improves nursing workflow. For example, because they are receiving alert messages on their phones in real-time, nurses are able to prioritize the alerts, ensuring that the speed and quality of care given corresponds to each patient’s level of need. Similarly, the wireless phones can be programmed to sound different alert tones to signify different levels of urgency. Some hospitals have reported seeing nursing efficiency improve by nearly 25% within the first three months of implementing a wireless messaging system.

Unit secretaries and operators can greatly benefit from wireless messaging systems as well. Incoming patient calls can be screened and forwarded, or the operator can send the nurse a message which identifies the patient’s need. From their desk, operators can also message physicians or housekeeping to keep the processes of patient admission and discharge running smoothly. Instead of calling back and forth between patients, nurses, and physicians, wireless messaging systems allow operators to generate or forward concise messages to the appropriate caregiver quickly.

Messaging can also greatly improve patient satisfaction. When nurses become more efficient they gain more time to interact with their patients. The patients perceive their nurses as being more attentive to their needs and, consequently, are more likely to view their experience as a positive one. The time nurses spend with their patients is incredibly valuable; time spent in positive communication with patients affects not only patient satisfaction, but nurses’ job satisfaction as well.

The Joint Commission, a national organization that accredits hospitals, has announced that addressing alarm fatigue is one of its highest priorities this year. The Joint Commission is planning to meet with the Food and Drug Administration over the next few months to develop a strategy for effectively addressing alarm fatigue.

The announcement comes just months after a Boston Globe investigation revealed that over 200 alarm-related patient deaths occurred between 2005 and 2010. In many of these cases, medical personnel either didn’t notice the alarms or failed to react with the urgency required—both typical signs of alarm fatigue.

“There is uniform agreement that this is a major problem,” said Dr. Paul Schyve, a senior vice president at the Joint Commission, in a recent telephone interview. And that problem may be even worse than reported. The health care industry often fails to report these types of incidents, leading some researchers to believe the number of alarm-related deaths is much higher.

Having Too Many Alarms Reduces Usefulness

---

Schyve said the issue is much more complex now than it was just 10 years ago, because medical device manufacturers have “put a lot more alarms’’ on their devices. He cited devices in intensive care units as an example, explaining that these devices now sound alarms not only when a patient’s heart rate has gone above or below a predetermined level, but also whenever the patient’s heart rate appears to be headed in the wrong direction, no matter if it is a life-threatening situation or not.

Not only are there more alarms on devices than there were in the past, there are more devices with alarms in patients’ rooms than ever before. Studies show that the vast majority of alarms are false, triggered by something as insignificant as the patient turning in bed or coughing. “If you have that many alarms going off all the time, they lose their ability to work as an alarm,’’ Schyve said.

Health care professionals and device manufacturers all agree that alarm hazards, particularly alarm fatigue, need to be addressed. However, no panacea has yet been found. Some industry experts say that device manufacturers need to redesign their devices so that they produce fewer false alarms. Others say that hospitals should hire extra caregivers to improve alarm response statistics.

“Sooner or later, there is going to have to be a meeting with the users of alarms and people who put the alarms on their equipment,’’ Schyve said. “Neither side alone is going to be able to figure out how to address this problem.’’

Alarm Integration As a Possible Solution

---

Often hospitals will provide extra training for nurses to try to reduce alarm-related incidents but “telling nurses and doctors to be more careful and reeducating them isn’t the solution,’’ says Dr. Peter Pronovost, director of the Quality & Safety Research Group at Johns Hopkins Hospital in Baltimore.

“In the ICU there is somewhere between 50 and 100 electronic pieces of equipment, and each of them has alarms. Each individual device maker makes its alarms the most annoying. It’s an arms race of alarms. No one has worked on integrating them. The FDA could require that all these monitors link into a common platform,’’ Pronovost said.

In a recent statement to the Boston Globe, the FDA said it is collaborating with the Association for the Advancement of Medical Instrumentation, a nonprofit education organization run by the health care industry and the ECRI Institute, a nonprofit health care research organization “on raising the awareness of these issues and challenging the industry and the Joint Commission to work with us on a strategic approach moving forward.’’

Adverse events errors that are serious enough to harm patients occur in hospitals at least ten times more frequently than previously recorded, according to a report recently released by the journal Health Affairs.

Researchers visited three large hospitals in the U.S., all of which have well-established patient safety systems. The research team then tested a newer, more expensive, and more thorough system from the Institute for Healthcare Improvement called the “Global Trigger Tool (GTT),” against two common but less sensitive systems: the voluntary reporting method and the Agency for Healthcare Research and Quality’s Patient Safety Indicator.

Currently, most hospitals use these two adverse event detection systems:

• The voluntary system used by nearly all hospitals. When a nurse or other provider notices a problem and notifies the appropriate person, an investigation is launched to determine whether the incident should be reported to higher authorities.
• The Agency for Healthcare Research and Quality’s Patient Safety Indicators review, which encompasses more than the voluntary reporting system but less than the GTT. The AHRQ PSI only searches for certain codes in medical records.

With the GTT, hospital employees closely review closed charts for codes, summaries, medications problems, lab results, operation reports, and nursing notes to detect any signs that a mistake may have occurred.

“A trigger could be a notation indicating, for example, a medication stop order, an abnormal lab result, or use of an antidote medication,” the authors wrote. An investigation would then ensue.

Commonly Used Systems are Inefficient

---

In the study, the GTT detected 354 adverse events, compared to the AHRQ system which detected 35 events and the voluntary method which found detected four. All detected errors were serious enough to require intervention, says lead author of the report, David Classen, associate professor of medicine at the University of Utah in Salt Lake City.

Classen says, “The point of all this is that we need to develop better tools to measure the safety of care that we deliver.” He adds that many hospitals are just not as aware of patient safety pitfalls in existing systems as they need to be. “It’s a learning curve that a lot of places have to go through,” he says.

The GTT recorded a wide variety of events ranging from extremely serious events to events that could be resolved quickly. These events included infections, venous thromboembolisms, pressure ulcers, device failures, and falls. Among less serious events, medication was required to fix a problem provoked by the incident; however, among the most serious events, a patient actually died because of the adverse event.

The GTT did not distinguish between preventable and unavoidable errors in this study, but Classen says that other studies suggest that 40-60% of the errors captured by patient safety system tools are considered preventable.

According to the study, for extreme events, the GTT and the AHRQ systems each detected four events that the voluntary system missed entirely. For less serious events, the GTT caught 204 errors, AHRQ captured 23, and the hospital voluntary reporting system caught none.

GTT’s Use Limited By Cost and Time

---

Classen says that only 2% of the country’s hospitals currently use the GTT. That’s mostly because the method is expensive and time consuming, especially if hospitals lack a well-developed electronic medical record system.

He explains that the AHRQ method often fails because hospital staff who are tasked with inserting codes “are not necessarily highly trained clinical individuals.”  This results in poor documentation of the adverse event, effectively preventing the AHRQ system from find it. “If it’s not obvious and apparent, they won’t see it and even if it is, they may miss it,” he says.

Classen offers the example, “If a patient has a side effect from a drug that requires an antidote to be ordered, the AHRQ system would miss it, but under the GTT, our reviewers would have picked it up.”

The study’s results don’t surprise him. He says, “I do work in hospitals all the time, and I see the use of these other approaches – which are much cheaper and easier to do – often seem to miss these problems.”

Of all healthcare professionals, nurses play the greatest role in coordinating care. They are tasked with providing patient care, communicating with physicians, and administering medication. Unfortunately, this strenuous workload sometimes results in nursing errors. Some of the most common errors are also some of the most preventable. In regards to patient safety, these preventable errors include patient falls, infections, and medication administration. Hospitals working to improve patient safety have implemented some interesting techniques that have helped nurses address these three preventable events.

Patient Falls

---

Patient falls often occur because patients attempt tasks that they believe do not require nurse assistance, such as going to the bathroom or moving to pick up something out of reach. To help prevent unattended movements in the patient’s room, several practices have been introduced in hospitals. Hourly rounding has become a near industry-wide practice that has proven to help reduce patient falls and improve patient satisfaction.

A more recent falls prevention technique involves the use of communications technology to alert nurses via text message to their wireless phones. In such a setup, bed exit pads or bed fall pads are connected to the alarm system in the patient’s room, which creates and sends alerts to the nurse’s phone when the patient triggers an alarm. This allows nurses to stay mobile while still receiving patient updates in real time. In some hospitals, these systems are modified to allow patients to call their nurses’ phones directly if they need assistance.

Preventing Infections

---

As a basic rule of thumb, hand hygiene is incredibly important for controlling and preventing infections. Additionally, nurses must disinfect equipment and other items in the environment, and they must wear protective equipment.

Clinicians have historically considered infection an accepted risk, but modern medical care is now evolving so that nurses know they can prevent patients’ infections. The Institute for Healthcare Improvement at Johns Hopkins University packages collections of best-practice interventions into checklists that have been shown to reduce infection rates. For example, to prevent central line bloodstream infections, nurses should use appropriate hand hygiene, use chlorhexidine for skin preparation, ensure full barrier precautions are taken, and maintain a sterile field during insertion, and ask if the line can be removed each day. To prevent ventilator-associated pneumonia, nurses need to keep the head of the bed elevated and perform daily oral care with chlorexidine.

While such checklists can prove effective, clinicians may achieve even greater success when combining the checklists with a comprehensive unit-based safety program (CUSP), which is a team-based approach to learning more about safety, identifying unit hazards and addressing the associated risks. This open style of learning encourages communication between physicians, nurses, and other unit staff, which promotes positive interaction and can actually increase unit efficiency.

Preventing Medication Errors in the Hospital

---

Interruptions are a primary cause of medication errors. Nurses deal with multiple questions and other interruptions from coworkers and physicians while collecting, measuring, and administering medications. These distractions create an unnecessary risk for patients receiving medication. Understanding this risk, some hospitals are adopting a standardized medication administration process, which includes a quiet zone for nurses preparing medication, and having those nurses wear a sash to signal to others not to disturb them.

Vague or overly similar labeling can also contribute to errors. Nurses must take extra precautions when administering medications that come in easily confused bottles. Bar-coding medication and confirming the correct dose, route, time and rate for an administered drug can help prevent mistakes.
FILED UNDER BLOG · TAGGED WITH PREVENTING INFECTION, PREVENTING MEDICATION ERRORS, PREVENTING PATIENT FALLS

This post continues an article on methods of lowering patient readmission rates in hospitals. Click here for the first part of this article.

Stephen F. Jencks, M.D., M.P.H., and Amy Boutwell, M.D., internist at Newton-Wellesley Hospital in Newton, MA and Director of Health Policy Strategy for the Institute for Healthcare Improvement are experts on the subject of patient readmissions. They have developed a list of 12 preventative strategies suggested to help hospitals reduce readmission rates.  Strategies 1-6 were discussed in the first part of this article, here are the remaining 7-12 methods.

7. Understand What’s Happening After Discharge

---

Kaiser Permanente now uses video cameras to monitor home settings as well as the entire care process to determine what happens to the patient after discharge to provoke readmission. The team also video documents the care team (including the pharmacist, home care providers, nurses, and physicians) about the care provided to the patient to uncover flaws in the system that contributed to the patient’s readmission.

Kaiser officials are pleased with the results of the project thus far, citing a readmission rate reduction from 15.7% to 9% at Kaiser’s South Bay Medical Center.

8. Provide Preschedulable Home Care

---

Case management, housekeeping services, transportation to and from pharmacies and physicians’ offices can all be scheduled in advance. Boutwell says that at Piedmont Hospital in Atlanta, patients who undergo elective knee surgery receive coupons and prescheduling “so that by the time you get out of the hospital, it’s waiting there for you,” She adds that  although this kind of a prearrangement for post-transition care is mainly being tried with elective patients, it is “spreading like wildfire” among hospitals.

9.  Consider Physician Medication Reconciliation

---

A recent essay in the New England Journal of Medicine by Yuting Zhang, from the University of Pittsburgh, noted the wide variation among physicians’ prescribing practices with medications that should typically be avoided in patients older than 65. She also noted the variation in prescribing practices for drugs that carry a high risk for negative drug-disease interaction.

Jencks says that Zhang is “pointing us to a rather important gap in the most common thinking about transitions—that we are to make sure that patients are able to get and take medications, get recommended follow-up, and generally do as they are told. But we know that medication plans can be in life-threatening error, that physicians often recommend a time-to-follow-up that is too long, that discharge plans are often written in ignorance of the patient’s pre-admission history and experience. In general, we need to be much more critical of the plans patients get.”

10. Prove that the Patients Understand

---

Patients need to be engaged in “teach back,” in which they (or their caregivers) repeat the instructions they’ve been given. Jencks tells caregivers that they need to understand that patients are often heavily medicated, stressed, tired, or confused. Their state of illness often impairs their ability to fully comprehend and remember what they are being told.

11. Focus on Highest-risk Patients

---

Hospitals need to examine their readmission rates and see which patients, with which conditions, have the most readmissions. Limited resources should be pushed toward these select groups of patients in a more focused way to see if the expanded effort improves the rates.

For example, Jencks has documented depending upon the disease or condition, and depending upon the part of the country, readmission rates can be even higher than the national average of 21%. For example, the readmission rate for heart failure patients is 27%; for those with psychoses, 24.6%; chronic obstructive pulmonary disease, 22.6%. Patients with pneumonia are readmitted at a rate of 21%, and those with gastrointestinal problems are readmitted at 19.2%.

12. Listen to the Patient

---

Emergency rooms, hospice, and home health providers need to be involved in the effort as well, in order to ensure that patients only come to the emergency room for true emergent care issues.  If patients and their families are provided with informed options, opportunities for advance directives, and counseling in the emergency room, unnecessary admissions can be reduced.

Jencks says, “There really needs to be a care plan that reflects the patient’s wishes. This is quite different from either a medical power of attorney or what is often called a living will because it lays out the goals of treatment.”

Jencks continues, “This kind of plan has little relevance to persons without substantial chronic conditions, but it is totally relevant to a patient with one or more chronic conditions that have required hospitalization.  With such a plan, one can often avoid readmissions that really do not serve the patient’s needs or values.  What is, after all, worse than a readmission?  Readmission of a patient who does not want to be readmitted.”

Starting in late 2012, the Centers for Medicare & Medicaid Services (CMS) will begin penalizing hospitals with higher than expected readmission rates.  This is alarming because recent studies have shown that nearly 21% of discharged patients are readmitted within 30 days, and 34% are readmitted within 90 days.

Stephen F. Jencks, M.D., M.P.H., and Amy Boutwell, M.D., internist at Newton-Wellesley Hospital in Newton, MA and Director of Health Policy Strategy for the Institute for Healthcare Improvement are experts on the subject of patient readmissions. They have developed a list of 12 preventative strategies suggested to help hospitals reduce readmission rates. Some of their strategies have yet to be fully tested in some care settings, but high readmission rates are pushing many healthcare facilities to put these proposals to the test.

1. Discharge Summaries

---

Complete discharge summaries within 24 hours of discharge. Most hospitals abide by the old standard of completing discharge summaries within 30 days of discharge.

However, Boutwell says, “I was trained that the summary is a retrospective report of what happened in hospitalization. But what we need today is anticipatory guidance. Patients get discharged and go home. They can’t fill their meds, insurance doesn’t cover the med or they have questions. They’re nervous and worried. They call their primary care provider, who didn’t even know they were admitted.”

According to Boutwell, the 30-day standard practice “might have sufficed in a time gone by. But that doesn’t work anymore. Information needs to be available at the time of discharge. There’s a growing recognition of this need, but staff bylaws haven’t changed.”

2. Lengthen the Handoff Process

---

In every step of the patient care process, including discharge, care teams must talk to each other about the patient.  Boutwell suggests that discharges should actually be called “transitions.” Jencks says that “senders and receivers, for example hospital discharge planners and skilled nursing facility staff and home health” should meet often enough that they learn about the realities of the transitions, for both sending and receiving.

Boutwell says that “taking this person-centered approach shifts the concept from discharge, which is a moment in time and you’re done with it, to a transition—a shared accountability. We need to make sure the receiving providers understand who this patient is, with a 360-degree view.”

3. Provide Medication on Discharge

---

Patients should be sent home with a 30-day medication supply, packaged with clearly explained dosage directions. This may be a challenge for hospitals with Medicare patients because of distinctions between Part A and Part B payment; however, for certain high-risk patients, such as patients with congestive heart failure or those with a history of readmittance, it might be preferable for the hospital to just absorb the cost.

4. Make a Follow-up Plan Before Discharging

---

Hospital staff should make follow-up appointments with a patient’s physician and should only discharge the patient after this appointment is scheduled. It is important to make sure the patient has transportation to and from the physician’s office and the patient understands the value of meeting within the time frame. Staff should also follow up with a phone call to the physician to make sure that the visit was completed.

5. Telehealth

---

Home Healthcare Partners in Dallas utilizes health coaches, intensive care clinicians, and wireless technology to record daily vital signs for nearly 2100 discharged Medicare fee-for-service beneficiaries for periods of 60 to 120 days. So far, HHP has followed this method for about 7,000 unduplicated patients over the past two years in hundreds of hospitals.

Wayne Bazzle, HHP’s CEP, says that the method involves calling patients by phone. The 5 to 15 minute calls occur frequently enough that Bazzle says, “we have their trust. We can help them stay out of the hospital if they’re more truthful with us about what’s going on, and if we see some deterioration, we can help them cope.  Normally it’s a medication management issue, or they’ve become a little too relaxed with their diet.”

Patients targeted for intense monitoring include those with several co-morbidities, those who have a primary diagnosis of congestive heart failure, chronic obstructive pulmonary disease, diabetes, Alzheimer’s or hypertension.

6. Identify High-Risk Patient Groups

---

Hospitals need to retool their admission and readmission rates for demographic and disease characteristics to help identify high-risk patients. This can help hospitals to use their limited resources more effectively. Some hospitals have developed special programs for certain patient demographics, such as the group of hospitals in Los Angeles that discharges certain homeless patients to a nearby facility similar to a half-way house. That program saved the hospitals $3 million after just a few months.

For patients and their families, the emergence of a decubitus ulcer is painful and stressful. Thankfully, most decubitus ulcers are often noticeable in the earliest stages and are easily treated, with very few passing beyond Stage 2. In fact, many hospitals have special monitoring programs in place to prevent the development of pressure ulcers all together.

However, Kennedy Terminal Ulcers are not so easily prevented or treated. Named after the nurse practitioner who discovered them, Kennedy Terminal Ulcers typically occur in geriatric patients and often transforms from an initial blister directly to a Stage 4 pressure ulcer with just a few hours. Treatment for these ulcers usually focuses on pain relief because, as the name suggests, patients typically do not recover from them. In fact, most patients who develop Kennedy Terminal Ulcers die within 24 hours.

Proper treatment involves stringent turning regimens and wound treatment. Depending on the amount of drainage, caregivers will typically use a hydrocolloid, foam, gel, or calcium alginate if there are high amounts of drainage. Typically, however, these ulcers do not have much drainage. If there is slough (yellow tissue) or necrotic tissue (black tissue) caregivers will move to a debridement method such as an enzymatic debriding agent, autolytic debridement method (thin film, hydrocolloid) or mechanical debridement method (wet to dry).

Although it is unlikely for patients to recover from Kennedy Terminal Ulcers, recovery is sometimes possible if the treatment methods are ideal. Turning patients is the simplest and most effective method for preventing and treating pressure ulcers, yet ensuring that patients are turned in a timely fashion can be difficult in the busy hospital environment.  Today, technology such as Dalcon Alert exists that automatically notifies clinicians when it is time  to turn patients.

2011 looks to be an exciting year for healthcare reform. Some of the new healthcare bill’s changes are already being implemented.

Hospital-Acquired Infection Reporting

---

Starting this month, hospitals are now required to report hospital-acquired infection rates to Medicare. Hospitals that fail to do so will lose 2% of their Medicare reimbursement money in 2012. Reducing hospital-acquired infection rates has the potential to save $45 billion per year. The data collected will be readily available on hospital compare.

Physician Compare

---

A “Physician Compare” website is also in the works. This site is wrapped in controversy as it will publish physician-specific data on efficiency, outcomes of diagnoses/treatment, care coordination, and more. It will also contain data on specific non-physician caregivers, such as nurses and nurse practitioners. While the rules for the website will certainly undergo a thorough revision process, individual specific healthcare data will become easily accessible to the American public.

However, this year may also see the death of the reform bill. The new House Committee Chair of healthcare policy, Rep. Fred Upton (R-Mich.), has vowed that if the House cannot repeal the bill in its totality, representatives will “go after the bill piece by piece. We will look at these individual pieces to see if we can’t have the thing crumble.”

Democrats in the Senate have sworn to defend the reform bill should a repeal vote come up through the House. Democrats argue that consumers already are benefitting from the changes being made. They claim that undoing the law would increase the number of uninsured Americans, place control of health insurance back into the hands of insurers, and increase the federal budget deficit.
FILED UNDER BLOG · TAGGED WITH HEALTHCARE REFORM, HOSPITAL ACQUIRED INFECTIONS, PHYSICIAN COMPARE

Androscoggin Valley Hospital (AVH) is a 25 bed critical access hospital located in the white mountains of New Hampshire.  AVH may be small, but the hospital is home to a wide variety of services and technologies that place it on the level of much larger facilities.

Click Here to See the Dalcon/Polycom AVH Success Story PDF

The staff at Androscoggin is serious about fall prevention.  Patients are assessed for fall risk factors upon admission and at each shift. Patients determined to be at risk of falling are placed in a special program called the “ruby slippers” program.  The ruby slippers program is designed to make staff aware of a patient’s fall status and put additional preventative measures in place, such as ambulation assistance.  Ruby slipper patients and their families are educated on the seriousness and importance of the program.

Investing in New Fall Prevention Technology

---

Kirk 4040 with Bed Fall Alert
AVH uses Stryker bed alarm systems for ruby slipper patients who are disoriented or unable to follow directions or call for assistance.  When a patient on bed alarm begins to sit up to get out of bed, the Stryker bed sets off an audible alarm.  Additionally, this bed alarm is captured by AVH’s Dalcon Alert Remote Patient Monitoring system.  Dalcon Alert forwards the bed alarm directly to Kirk phones carried by hospital staff.  The wireless phones receive a text message that communicates the location and type of alarm.  As a result, clinicians know exactly which room to respond to decreasing the time of response.

When responding to a fall alarm, time is of the utmost importance.  A few seconds can be the difference between finding a patient still trying to get out of bed, and finding a patient on the floor.  As an added measure to buy clinicians more time to respond, Dalcon Alert relays audible announcements in the patient room telling the patient to “please get back into bed, your nurse is on the way” when a bed alarm is tripped.

Measuring Results

---

The emphasis Androscoggin has placed on fall prevention has been successful.  Since implementing Dalcon Alert and incorporating the system’s fall prevention technology into their fall policy, AVH’s fall rate has dropped significantly.

The average fall rate, measured in percentage of patients who fall for the three quarters Dalcon Alert has been installed at AVH is 0.43%.  The average fall rate for the three quarters before the Dalcon Alert installation was 0.67%.  Thus the average for the three quarters after installing Dalcon Alert resulted in 36% fewer falls than the average for the three quarters prior to Dalcon Alert being installed.

Since the Centers for Medicare & Medicaid Services (CMS) began to refuse reimbursement to hospitals for hospital acquired stage III/IV pressure ulcers labeled “never events,” there has been considerable controversy surrounding the subject.

Stage III/IV pressure ulcers are serious wounds that are very expensive to treat, some cases costing upwards of $70,000.  Not only has CMS refused to pay for the treatment of these events, private insurers have followed suit as well.  Additionally, hospitals are prohibited from passing the costs on to the patients of their families.

Compounding the high costs, late stage decubitus ulcers occur relatively frequently.  The National Pressure Ulcer Prevalence Survey showed that late stage decubitus ulcers occurred in approximately 0.65% of all patients in US acute care hospitals on average.

Are Decubitus Ulcers 100% Preventable?

---

The source of the controversy is from the concept that some experts believe that not all decubitus ulcers are preventable, regardless of the usage of best practices and technology.  Lee Ann Krapfl, a wound care nurse and recent public policy committee chair of the Wound, Ostomy and Continence Nurses Society, notes that CMS itself has stated not all decubitus ulcers are preventable.  In the long term care setting, CMS states, “a resident who enters the facility without pressure sores [must] not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable.”

According to CMS, “unavoidable” means: “the resident developed a pressure ulcer even though the facility had evaluated the resident’s clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of interventions; and revised the approaches as appropriate.”

Obviously, this seems to conflict with CMS’s policy regarding reimbursement of never event decubitus ulcers.  However it must be noted that this ruling is for long term care facilities, and it may well be that CMS is holding acute care facilities to a higher standard of care.

Incidentally, should CMS decide to change its stance on decubitus ulcers in acute care hospitals, there is a good chance it will place the burden of proof regarding the avoidability of a decubitus ulcer incident on the hospitals.

Regardless of the setting, experts agree that decubitus ulcer prevalence can be reduced significantly using best practices and technology.  Also, although experts disagree on the topic of unavoidable pressure ulcers, most agree that they are very rare if they exist.

FILED UNDER BLOG · TAGGED WITH CENTERS FOR MEDICARE & MEDICAID SERVICES, DECUBITUS ULCERS, NATIONAL PRESSURE ULCER PREVALENCE SURVEY, NEVER EVENTS

Communicating in the modern nursing work environment is difficult.  In order to provide the best level of patient care, nurses need to be constantly accessible by several sources.  At any given time nurses need to be aware of patient and family requests, while maintaining ongoing communication with physicians.  In addition, nurses must also keep track of patient conditions that are communicated through mechanical devices such as patient monitors.

Juggling information from these sources is already complex, yet the majority of US hospitals add to the problem by lacking effective communication technology.  A study by Forrester Research showed that the inefficient communication methods most nurses are forced to rely on cause major drains on productivity.

A few examples from the study:

• “The majority of nurses stated they would save somewhere between 30 minutes to one hour per day with instant access to experts.”
• “A sizable percentage of nurses — 65% — said they spent from 20 minutes to more than one hour per day trying to reach other medical staff. This includes 26% that spend more than one hour per day and another 39% that spend from 20 minutes to one hour.”
• Regarding elimination of physician-nurse missed communications and phone tag, “estimates of up to one hour per day would be saved by 54% of nurses, and another 26% indicated it would save them from 16 to 30 minutes per day.”

It is no secret that the largest item on the average hospitals expense sheet is employee compensation.  Accordingly, this collective drain on nurse productivity adds a big cost for hospitals.  What isn’t as obvious is the negative impact poor nurse communications has on patient care.

Aside from time wasted on poor communications that could be spent with patients, inferior communication platforms also lead to more troubling outcomes.  Take for example, the fall risk patient who needs to use the restroom and caregivers are too slow to respond to their nurse call request—and arrive only in time to see the patient has fallen while trying to use the restroom by themselves.

Wireless Nurse Communication as a Solution

---

Current nurse communication problems stem fr0m the fact that most nurses, 78% according to the Forrester Research study, use telephones as their main communication vehicle.  Yet the majority of US hospitals rely on wired telephones, even though nurses are highly mobile.  As a result, communication breakdown is inevitable.

New nurse communication technology such as Dalcon Alert provide a wireless solution for the modern hospital.  Dalcon Alert, in tandem with wireless phones, allows nurses to stay in constant contact with patients, staff, and physicians while staying on the move. The Forrester Research study showed that 74% of nurse respondents could save a significant amount of time each day with wireless phones.

In addition to improved productivity, Dalcon Alert improves patient care by allowing nurses to receive patient care alerts directly on their wireless device.  For example, caregivers receive nurse calls, iv-pump alerts, fall alerts and more on their phones.

The benefits of hourly rounding can be very encouraging for hospitals considering implementing the program.  However, according to the Studer Group, the hospital consulting organization credited with first documenting the benefits of hourly nurse rounding, hospitals should not attempt to execute the program halfheartedly.  Having the nurses merely get “face-time” in with the patients each hour is not enough.  In order for hospitals to see real results, the Studer Group advocates that nurses follow the following eight-step rounding procedureeach time they enter a room during their hourly round:

1. Use opening Key Words.
2. Accomplish scheduled tasks.
3. Address the “Three Ps”—pain, potty, position.
4. Address additional comfort needs.
5. Conduct environmental assessment.
6. Ask, “Is there anything else I can do for you? I have time.”
7. Tell each patient when you will be back.
8. Document the round.

The most critical component, according to the Studer Group, for a successful hourly rounding implementation is maintenance.  Nurse Managers must be committed to the program, and must continually validate the program or it quickly falls apart.  Validation consists of not only making sure that nurses are consistently making hourly rounds, but also that they are faithfully following rounding procedure.

Trust but Verify

---

The Studer Group suggests that nurse managers execute a “trust but verify” policy.  It is important that nurses do not perceive that they are being “checked up on” by their managers because they are untrustworthy.  Instead, managers need to communicate that they are simply double checking to make sure activities do not “fall through the cracks”  and that bad habits are not formed.

Hourly Nurse Rounding Validation through Technology

---

Dalcon provides a solution to help hospitals implement nurse rounding as a part of its Dalcon Alert Remote Patient Monitoring system.

Dalcon Alert captures patient monitoring device alerts and sends them to wireless phones carried by hospital staff via text message.  In addition to monitoring patient device alerts, Dalcon Alert also sends periodical bed turn alerts to staff as well as rounding reminder alerts.  Nurses cancel their rounding reminder alert via Dalcon Alert’s Remote Alarm Monitor at the patient bedside.  As a result, hourly rounding is assured.  However, it is still the responsibility of the nurse managers to confirm that nurses are following rounding procedure accurately and diligently.

Hourly nurse rounding seems counter-intuitive.  At first glance, adding a major task to an already demanding job in order to decrease workload doesn’t make sense.

Yet researchers have found that adding an hourly nurse rounding program in hospitals makes a dramatic impact in two important areas:

1. Significantly increased staff productivity and satisfaction.
2. Significantly increased quality of patient care and patient satisfaction.

The fact that hourly nurse rounding actually decreases staff workload comes as a surprise to many.  Yet consideration of the impact of hourly rounding on the work environment quickly explains this phenomenon.

In a traditional acute care setting, nurses typically are conditioned to react to patient problems and requests instead of focusing on preventing them.  This strategy of inconsistency creates a high stress environment.  Because nurses are not proactively resolving patient needs, patients learn to rely heavily on their nurse call buttons to get assistance.  Due to the interrupting and distracting nature of nurse calls, as nurse calls increase, staff productivity usually goes down.

Reducing these resource-consuming nurse calls is the first area hourly rounding pays off.  As patients learn to expect nurses at specific times throughout the day, they begin to rely less on the nurse call system, using it for urgent needs only.

The effects are dramatic.  A recent study across 27 nursing units in 14 hospitals by the Studer Group, a hospital consulting organization, showed that hourly rounding decreased nurse calls by almost 40%.  In addition, patient falls were reduced by 50%. According to Christine Meade, PhD and chief researcher of the study, “It’s essentially like adding the time of one full-time RN to complement the staff for a week because of the hours not used answering call lights — and the patients love it.”

A secondary benefit of hourly rounding is the increase in the quality of patient care.  Patients feel like their needs are better cared for when patient care is provided proactively instead of as a reaction.  Also, Because hourly rounding takes care of all non-urgent patient needs, the nurse call system can regain its sense of urgency.  As a result, nurse call response times are drastically reduced.

Implementing Hourly Rounding with New Technology

Dalcon Alert, Dalcon’s Remote Patient Monitoring and Alert Management solution, has hourly rounding alerts built into the system.  Dalcon Alert captures patient monitoring device alerts and sends them via text message to wireless phones carried by facility staff.  In addition to these monitoring device alerts, Dalcon Alert also sends periodic bed turn reminder alerts and nurse rounding alerts.

Because Dalcon Alert hourly rounding alerts can only be canceled via the Remote Alarm Monitor (RAM) at the patient’s bedside, accidental staff negligence of rounding is eliminated.

One of the largest complaints of hospital patients and staff nationwide is the abundance of noise in the hospital. Uncomfortable and unsafe noise levels inhibit the healing process of patients that need it most.

In fact a recent study at Johns Hopkins University Hospital has shown that loud hospital environments can have a major negative impact on patients including:

• Elevated blood pressure levels.
• Sleep disruption.
• Decreased oxygen saturation.
• Decreased rates of wound healing.

The consequences of a loud environment on staff include emotional exhaustion and burnout as well as a raised risk of medical errors due to miscommunication. Recently, a patient at Massachusetts General Hospital died because his heart monitor had been turned off by a staff member. The investigators cited “alarm fatigue” as a cause of the problem. Alarm fatigue occurs when nurses become overwhelmed by the number and variety of alarms in the healthcare environment. As a result, nurses begin ignoring or even turning off alarms.

A Mayo Clinic study performed several years ago showed peak noise levels at night in one facility rising to 113 decibels, equivalent to a chainsaw or jackhammer.

Major sources of noise include hospital ventilation systems as well as overuse of the hospital paging system and an abundance of alarms. The Johns Hopkins study noted that though audible alarms were significantly quieter than other sources of noise, patients ranked them as being more irritating than more intense sources.

New Technology as a Solution to Hospital Noise Pollution

---

Dalcon provides solutions that, as a secondary benefit, help eliminate hospital noise pollution.

Dalcon Alert for Remote Patient Monitoring connects with various patient monitoring devices such as heart monitors, IV pumps, ventilators, pulse oximeters, and more. When a patient monitoring device triggers an alarm connected to Dalcon Alert, the system sends a text message to wireless phones (or pagers) held by hospital staff.

Because Dalcon Alert allows hospital staff to more efficiently manage hospital alarms, alarm fatigue is significantly reduced. Also, since Dalcon Alert incorporates wireless phones or pagers to be carried by hospital staff, use of the overhead pager can be dramatically decreased as well.

As hospitals move further into the 21st century, decentralized nursing stations are becoming the standard for enhancing the quality and efficiency of nursing care.

In the past, when medical information was stored on paper, centralized nursing stations were necessary to keep all medical data stored in an easy to access place. However, with the advent of new digital information storage and communication technology, centralized nursing stations have become an increasing burden on the quality of patient care.

The Value of Decentralization

---

The primary benefit of a well-managed system of decentralized nursing stations is the positive impact the system has on patient care. Having multiple nursing stations located throughout a floor instead of one centrally located station puts nurses in closer proximity to the patients. A result of close nurse-patient proximity is improved nurse response time and room observations.

Also, the close nurse to patient proximity helps hospitals with decentralized nurse stations better prevent never events due to patient falls.

Decentralized nursing stations also save nurses thousands of steps each day traveling back and forth from patient rooms to the central station. Less travel fatigue leads to enhanced quality of care. Also, hospitals with successfully implemented decentralized systems experience lower staff turnover due to improved work satisfaction.

When planning the decentralization process, it is important that nurses retain an area where they can gather and collaborate. Nurses, like many workers, enjoy camaraderie and need to have particular areas allocated for their gathering. Effective nursing requires teamwork, and the social aspect of the job must be respected. Thus, a central nursing workroom is an important part of any decentralized system.

Hospitals looking to incorporate decentralized nursing stations should be prepared to expand their supply inventories since there will be more stations. However, the added cost of expansion will be offset by decreased nursing staff turnover and more efficient workspace.

Importance of Nurse Communication

---

Communication is a key issue when developing a successful decentralization plan. Because the stations are spread out, effective nurse communications become a more important factor in determining quality of patient care. Communications technology to solve this problem is currently available. Dalcon has multiple communication solutions, including Dalcon Alert, that can effectively bridge this nurse communication gap by placing wireless phones in the hands of caregiving staff.

Dalcon Alert is a Remote Patient Monitoring system that places fully functional wireless phones in the hands of caregiving staff. When a patient monitoring device triggers an alert connected to Dalcon Alert, the system sends a text message to caregivers’ wireless phones so they can respond to the patient immediately. Alerts are simultaneously sent to the PC displays of all nursing stations. The alert is tracked in real time so that caregivers at each station can observe which alerts have been canceled and which have not.

In October 2008, the Center for Medicare & Medicaid Services (CMS) began requiring hospitals that receive federal funding from Medicare and Medicaid to begin disclosing “never events.”  CMS has stated that they will no longer reimburse hospitals for any costs associated with never events, and hospitals are prohibited from passing costs onto the patient.

What are Never Events?

---

Never events are a series of medical errors that are defined by CMS as, “clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility.” Included in the CMS financial year 2009 list of never events that will be denied federal reimbursement are the following medical errors:

How Dalcon Alert Helps Prevent Pressure Ulcers (Bed Sores)

Obviously, never events can be quite costly for hospitals.  Yet some occur much more frequently than others.  Preventing bed sores can be difficult, but new technology is available to help hospitals prevent bed sores. Dalcon Alert is a system that contains 3 distinct sections that help nurses treat and prevent pressure ulcers.

1. Remote Patient Monitoring
2. Alert Management Software
3. Pressure Ulcer Management System

Dalcon Alert Remote Patient Monitoring

---

Remote Patient Monitoring is achieved by integrating with existing patient monitoring devices in the hospital.  Dalcon Alert automatically forwards all device alerts—via a text message—to wireless phones carried by the nursing staff.

Although Dalcon Alert contains the technology for nurses to remotely monitor patients via wireless phones, the pressure ulcer management system does not require their use or purchase.  If desired, hospitals can implement Dalcon Alert‘s Alert Management software & Pressure Ulcer Management System as a stand alone system, and use it as a tool to create and manage bed turn alerts using current hospital policy.

Dalcon Alert Alert Management Software

---

Dalcon Alert’s Alert Management application helps caregivers actively manage the many patient monitoring alerts that are created in the hospital. The Alert Management software is similar to a web application, but it can only be accessed from the browsers of computers on the hospital network.

The function of the Alert Management software is to display, in real time, all active alerts that are being managed by the Dalcon Alert system. Combined with Dalcon Alert’s pressure ulcer management system, Dalcon Alert‘s Alert Management software makes sure no pressure ulcer treatment is overlooked by staff.

Dalcon Alert Pressure Ulcer Management System

Dalcon Alert’s pressure ulcer management system is a unique solution. When this feature is turned on, the system automatically creates a “bed turn” alert that reoccurs after a set period of time (dictated by the hospital).  This “bed turn” alert is treated the same as any other alert that Dalcon Alertmanages; relevant caregivers receive the alert on their wireless phone, and the alert is reported on the system’s alert management software.  Thus, caregivers are continually reminded to attend to and turn at risk patients. Because Dalcon Alert helps nurses pro-actively prevent pressure ulcer negligence, the occurrence of dangerous pressure ulcers in at risk patients is significantly reduced.

The Center for Medicare & Medicaid Services (CMS) creates guidelines for long term care facilities (nursing homes) that receive federal funding via Medicaid and Medicare.  Licensed state surveyors perform annual checkups on nursing homes to make sure that these facilities are meeting the expectations of CMS—if not, those facilities are ineligible for CMS reimbursement.

In June 2009, CMS updated their guidelines for long term care facilities (nursing homes) in several ways.  Out of the many changes made, the new “Homelike Environment” guideline is one of the most revolutionary.

Section §483.15(h) Homelike Environment

---

The actual CMS guideline reads, “The facility must provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.” CMS interpretation of this guideline suggests that, “A ‘homelike environment’ is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment.” What this means for nursing homes across the nation, is that sweeping changes will have to be made gradually to transform and deinstitutionalize these facilities.

Some of the more drastic “homelike environment” changes include:

• Removing overhead paging and piped in music.
• Removing institutionalized signage and labeling (such as closet and bathroom labels).
• Removing medicine carts and centralized nursing stations.
• Discontinuing long term use of patient monitoring systems that use audible alarms.
• Eliminating mass-purchased furniture displayed throughout the building.

Homelike Environment Compliance Expectations

---

Obviously, many of these CMS homelike environment suggestions represent sweeping changes for many nursing homes throughout the nation.  CMS has stated that these guidelines have been effective since June 12, 2009; but in their own words they don’t expect most nursing homes to be able to meet them immediately.  However, they are expecting nursing homes to actively pursue the new guidelines—or face the consequences:

“Many facilities cannot immediately make these types of changes, but it should be a goal for all facilities that have not yet made these types of changes to work toward them. A nursing facility is not considered non-compliant if it still has some of these institutional features, but the facility is expected to do all it can within fiscal constraints to provide an environment that enhances quality of life for residents, in accordance with resident preferences.”

Meeting Homelike Environment Expectations

New technologies exist, such as Dalcon’s patient care communications system Dalcon Alert, that help nursing homes meet numerous “Homelike Environment” expectations. However, CMS has also stated that physical changes alone won’t fit the bill of a “Homelike Environment.”  They are expecting serious culture change by nursing home staff; including a shift towards person centered care, and quality staff-to-resident relationship building.

Patient falls are of great concern for health care facilities; they cause the patient unnecessary physical and emotional pain, and they are expensive. Not only do fall caused injuries cost thousands of dollars each; they also consume valuable time and tarnish the reputations of hospitals.

Many techniques, tools, and technologies have been utilized to reduce fall rates in hospitals, but fall rates are still remain high.  The primary reason patient monitors fail to stop falls is because caregivers are unable to receive patient monitor alarms remotely.  As a result, caregivers are only able to act upon those alarms they can see and hear in their close vicinity.

Solutions Offered by New Technology

---

Dalcon Alert helps hospitals prevent patient falls by managing and remotely communicating patient monitor alarms.

Dalcon Alert sends patient monitor alarms directly to wireless phones carried by caregivers.  Remotely communicating alarms directly to caregivers allows caregivers to react to all changes in patient status, and provide their best possible patient care.
Dalcon Alert also sends alarms to the nursing station console where they can be viewed in real-time.  This up-to-date tracking of all patient monitoring alarms assures that no alarm will be overlooked.

Specifically, Dalcon Alert connects with up to five common monitoring devices including, but not limited to:

• IV pumps 
• bed fall pads
• bed exit pads
• patient monitors

By working with existing patient care devices, Dalcon Alert can dramatically reduce patient fall rates, thus saving hospitals tens of thousands of dollars annually.

For more information about the severity of patient fall liability, and methods used to prevent falls, see the white paper “An Assessment of Falls in Patients’ Rooms and Methods of Prevention.”