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PSQH: Patient Safety & Quality Healthcare, June 19, 2020
It may be a long time coming, but what's very much needed is a mechanism for identifying, by individual facility, specific systemic sources of patient stress.
This article was originally published June 18, 2020 on PSQH by Benjamin E. Ruark
Seated beneath every solution is a new set of problems. Thus, for every newly installed solution, there needs to be built-in contingencies. For instance, if asked, a majority of patients wouldn’t hesitate to ask this single burning question about healthcare: Despite the hubbub about its many cutting-edge fields, why are systemic stressors so widespread and allowed to thrive? Further, looking specifically at skilled nursing home care: Why aren’t management, the delivery system, and staff uniquely equipped to eradicate, minimize, or mitigate various systemic stressors, thereby preventing them from dampening the restorative effects of healthcare delivery?
As it stands now, if healthcare had a gold medallion awarded for superior service, it would mint with two heads, no tail. Its two heads would be ruefully symbolic of the industry’s two-faced nature. The front side’s motto would unsurprisingly tout we do no harm, while the reverse side would contritely amend apologies for systemic harm suffered. Skilled nursing care facilities, meanwhile, appear to be resting on their alleged laurels, presuming they’ve advanced considerably from the days of “human warehousing.” Yet a quick tour today would reveal their present operations have their fair share of systemic stressors: system-borne and maintained sources of stress thrust upon resident patients and staff alike, but mainly on patients.
It may be a long time coming, but what’s very much needed is a mechanism for identifying, by individual facility, specific systemic sources of patient stress. We might call this a Systemic-Stress EMM (SSEMM) audit. “EMM” denotes eradication, minimization, and mitigation. Depending on a source and its context, one of these three tactics will be more feasible than the other two.
The purpose, then, of an SSEMM audit is to identify actual stressor sources and their average stress degree or level for a patient population. These findings are then labeled “actual” and considered baseline. With collaborative input from a psychologist, social worker, and management, a set of EMM standards for all identified sources is next created and approved. These standards are labeled “desired.” The driving aim is to replace actual stressor levels with the desired, EMM-mediated changes facilitywide. This effectively closes the gap between the two conditions of actual and desired, which is why this type of audit is informally termed a gap analysis. After design changes are instituted and sufficient time has passed, an evaluation is performed to gauge the success in systematically closing the gap—thereby allowing a facility to declare that it is as acute-stress-free for patients as possible (emphasis on acute).
Oddly, research literature about healthcare worker stress is in copious supply. Yet little is said about patient stress, chronic or acute. It’s been fairly well documented, in general, that chronic stress is associated with many conditions and diseases:
Accelerated aging
Alzheimer’s disease
Appetite issues
Asthma
Autoimmune diseases
Behavioral problems
Depression and anxiety
Digestive complications
Emotional problems
Headaches
Heart disease
Pain (all kinds)
Physical complaints
Poor concentration
Reproductive issues
Skin problems
Sleep disturbance
Social withdrawal
Thinking and memory problems
Weight issues
Chronic stress promotes the growth and spread (metastasis) of some forms of cancer as well; it also worsens treatment outcomes. And while short-term or acute stress is touted as a performance enhancer, repeat instances of it, in general, are roughly as harmful as any diagnosed state of chronic stress. For example, within a narrow time frame, some patients experience multiple clashes with different stressors; likewise, also within a narrow time frame, some patients experience the same or similar stressors repeatedly. Both cases are borderline with chronic stress, and it’s unclear how sharp the dividing line is between acute and chronic.
So, if we factor in patient population instances of acute stress, that should have everyone in a skilled nursing facility doing a double take. By sheer membership alone, resident patients already cope with the usual internal personal stressors: mentally coping with institutionalized care; dealing with fear and anxiety about their prognosis; and reliving daily a near-complete loss of the many personal freedoms and rights enjoyed by seniors who are still living independently.
For external locus-of-control (LoC) patients, facility-based systemic stressors are thankfully a bit less harrowing. By nature, these patients are more or less accustomed to being cared for and having someone else controlling how their day unspools. Conversely, for internal-LoC residents, facility-based stressors likely exacerbate their current health problems. By their nature, these patients don’t like having their personal power usurped in any way, shape, or form. They’re therefore destined to experience more types and longer durations of stress brought on by the routine grind of healthcare personnel making demands upon them from every direction.
Regarding SSEMM audits, the following rough categorical breakdown of facility stressors is suggested:
Activities unit/patient intake/physical therapy
Administration
Aides
Facility cleaning crew/maintenance
Mealtimes
Medical treatment (minor to major procedures/interventions; also medication dispensing)
Morning wake-up
Patient physical/psychological health
Resident rooms
Staff conduct
Let’s dispel all notions of a smooth, orderly, punctual operation: On any given day, residents are subjected to a typically unsettling tableau of activities. Various staff are likely to commit human error by way of slips and memory lapses that result in things like the following:
Delayed delivery of in-room meals or delayed start of communal dining
In-room meals being delivered cold
Inadequate cleanup of shared restrooms
Unreasonable response times to patients’ call lights
Wake-up schedules that counterintuitively offer pain medication to sleeping patients
Unexpected intrusions on patient privacy from staff or outside agency representatives
To that last point, there are any number of unscheduled, unannounced intruders who may find their way into patient rooms: daily cleanup crew members, ombudsmen, social workers, dietary staff, physicians, laundry personnel, physical therapists, maintenance personnel, med techs or nurses dispensing medications, activities personnel, visiting volunteers, outside agency representatives, or mail deliverers. Completing the roundup are various aides either wanting something or delivering something, even in the wee hours when such visits could wake nearby sleeping residents.
Here’s a quick sampling of some other potential stressors:
Physically sore pressure points on a patient’s body
Incessant screaming for help of a patient suffering from dementia
Loud noise blaring 24/7 from a resident’s television
Excessive questioning, bordering on interrogation, from staff that exploit their sense of power
Bad attitude from certain aides or other personnel
Brusque demeanor from certain doctors or nurses
Restraints that keep the patient from falling out of bed
Lack of confidence in certain staff due to obvious incompetence
Such a list is much longer than most facility administrators would ever think to construct themselves.
Finally, a few words about work culture as a potential macro-stressor contributor. To what degree do staff check their street personality at the door and enter the facility intent on presenting a professional demeanor? To what degree do their language, behavior, and worldview spill over into their work persona and assigned roles? That considered, how many learned helplessness and toxic culture variables infect current work practices and add to, rather than subtract from, the stressors already identified?
So, we can conclude, we do no harm’s flip side—apologies for systemic harm suffered—is long overdue for a redress; otherwise, the gloomier option prevails. The healthcare world anxiously awaits seeing the notion of an SSEMM audit reified, its first formal how-to guide available soon on the market.
Ben Ruark is a former learning & development and continuous quality improvement professional. He now devotes his time to writing on important subjects for various industries, healthcare included.
PSQH: Patient Safety & Quality Healthcare, June 18, 2020
Since the emergence of the novel coronavirus (SARS-CoV-2) in December 2019, public health authorities and professional societies have been scrambling to develop management guidelines for clinicians to utilize.
This article was originally published June 18, 2020 on PSQH by Henry P. Mishek and Karen Carlson, MD, FACOG
During the COVID-19 pandemic, professional societies have released clinical recommendations for management of infected patients in several demographics. Unfortunately, there is a lack of reliable data to produce sound management guidelines, especially relating to demographics with nuanced challenges of care like pregnant patients. The lack of evidence supporting the recommendations will likely force obstetricians to make management decisions that have the potential to compromise care for mothers and children. Reduction of visits and isolation could lead to poor maternal and fetal health outcomes, worsening of mental health conditions, and decreased likelihood of sustained breastfeeding.
Since the emergence of the novel coronavirus (SARS-CoV-2) in December 2019, public health authorities and professional societies have been scrambling to develop management guidelines for clinicians to utilize. In the United States, the Centers for Disease Control and Prevention (CDC) distributed their first guidance in late January and have made continual revisions to date, with many professional societies following suit (Donders et al., 2020; Poon et al., 2020; World Health Organization, 2020; American College of Obstetricians and Gynecologists, 2020; Royal College of Obstetricians & Gynaecologists, 2020; Patel & Jernigan, 2020). With a paucity of data to make informed patient care decisions, guidelines can make the best available evidence accessible to physicians on the front lines. These resources are of interest to physicians who care for vulnerable and niche demographics. Pregnant patients, in particular, require nuances of care that need to be addressed in practice guidelines.
OB-GYN professional societies in the United States and United Kingdom have generated practice guidelines based on recommendations from the World Health Organization, CDC, and National Health Service. These recommendations are built upon data from small case reports and retrospective analyses. The lack of sound scientific data, however, has made producing reliable guidance for obstetricians a challenge. For instance, the Royal College of Obstetricians and Gynaecologists (RCOG) suggests that vertical transmission of COVID-19 is probable (Royal College of Obstetricians & Gynaecologists, 2020), while both the American College of Obstetricians and Gynecologists (ACOG) and the International Society for Infectious Diseases in Obstetrics and Gynaecology state that there is no conclusive evidence of vertical transmission (Donders et al., 2020; American College of Obstetricians and Gynecologists, 2020). Variations in guidelines make interpretation of evidence difficult for obstetricians. This may lead to unnecessary risks and compromised quality of care (Woolf et al., 1999).
Currently, it appears that there is limited neonatal and maternal morbidity from COVID-19 infection. Fetal outcomes including rates of miscarriage and growth restriction are difficult to generate. Consequently, professional societies resort to drawing conclusions from the SARS and MERS outbreaks in the early 2000s (Royal College of Obstetricians & Gynaecologists, 2020) or from case reports. A systematic review of cases from Sweden published in April demonstrated only 3% ICU admissions and no fatalities in 108 pregnancies. The ICU admissions involved mothers with other complicating medical comorbidities. Only one of 75 neonates tested positive for COVID-19, and this neonate did well clinically (Zaigham & Andersson, 2020). Still, much remains unclear about maternal and neonatal outcomes based on this one systematic review. This uncertainty can lead to broad generalizations that may not adequately inform and account for patient preferences in individual situations (Woolf et al., 1999). Generalizations are made from necessity because of lack of evidence to suggest otherwise. This may be detrimental to mothers with suspected or confirmed COVID-19 in other ways than direct harm from infection.
In the prenatal period, obstetricians can educate mothers about their pregnancy course and monitor fetal development. In accordance with current guidelines for COVID-19, reduction of antenatal visits is encouraged. Also, implementation of telephone or telehealth follow-up is universally endorsed (Donders et al., 2020; Poon et al., 2020; American College of Obstetricians and Gynecologists, 2020; Royal College of Obstetricians & Gynaecologists, 2020; British Medical Journal, 2020). This could compromise follow-up for mothers who have poor adherence to appointments or have difficulty with technology. Obstetricians lose the face-to-face opportunity to answer questions and establish rapport with the pregnant patient. This may cause undue anxiety and perhaps lead to harm to both the mother and the fetus. Insufficient prenatal care utilization has been associated with insufficient weight gain, prenatal smoking, premature rupture of membranes, precipitous labor, choosing not to breastfeed, and postpartum smoking (Yan, 2017). For mothers who are self-isolating due to suspected COVID-19 infection, it is suggested that growth scans, oral glucose tolerance tests, and secondary care appointments be delayed until after the isolation period (Poon et al., 2020; Royal College of Obstetricians & Gynaecologists, 2020). Realistically, this may mean that some mothers are more likely to opt out of these important components of prenatal care due to compounding socioeconomic barriers. Asymptomatic bacteriuria, gestational hypertension, intrauterine growth restriction, and other pregnancy complications may go unnoticed without the clinical information and education that office prenatal visits afford.
Mental health monitoring is another important component of prenatal care that may suffer. The International Federation of Gynaecology and Obstetrics (FIGO), ACOG, and RCOG (Poon et al., 2020; American College of Obstetricians and Gynecologists, 2020; Royal College of Obstetricians & Gynaecologists, 2020) mention the need for mental health follow-up without specific details. Due to current recommendations, obstetricians may lose opportunities for formal mental health assessments and referrals that would be more likely done in office. Mental health conditions in pregnancy are likely to be exacerbated by the stress induced by COVID-19. These stressors include mass isolation, financial strain, concern for the pregnancy and newborn, anxiety, substance use, and domestic violence (Pfefferbaum & North, 2020). Furthermore, many women are prohibited from having visitors at prenatal ultrasounds. If there is news of a missed abortion or unanticipated findings on an anatomy scan, new mothers must face these challenges on their own without the support of a partner.
As with antepartum care in the pandemic, professional societies are forced to relay information about intrapartum care that is vague and unsupported by evidence. Some guidelines encourage the presence of an asymptomatic birth partner (Royal College of Obstetricians & Gynaecologists, 2020; British Medical Journal, 2020), whereas others state that birth partners should not be permitted in any case to reduce the risk of infection transmission (Donders et al., 2020; Poon et al., 2020). This is relevant to birth outcomes as it has been previously shown that continuous support from a birth partner is associated with lower rates of cesarean and operative vaginal delivery, less use of pain medications, slightly shorter labors, and higher satisfaction (Hodnett et al., 2013). Furthermore, both FIGO and RCOG encourage shortening the second stage of labor by operative vaginal delivery in COVID-19 (Poon et al., 2020; Royal College of Obstetricians & Gynaecologists, 2020). This recommendation is made despite the lack of evidence to assume the fetus is compromised due to maternal COVID-19 infection. Operative delivery does present risks to both the mother and fetus, including fetal and maternal trauma and postpartum hemorrhage. Similar risks must be accounted for in other aspects of intrapartum management.
Delayed cord clamping for confirmed COVID-19 patients is a practice that has been called into question. RCOG recommends continuation of this practice on grounds that the increased time is unlikely to increase infection risk (Royal College of Obstetricians & Gynaecologists, 2020). FIGO and Chinese expert consensus statements instead promote prompt clamping and transfer to the attending pediatric team (Poon et al., 2020; Chen et al., 2020). ACOG does not explicitly condemn the practice of delayed cord clamping and instead assumes continued routine intrapartum care as appropriate. Delayed cord clamping is known to decrease frequency of blood transfusions and iron-deficiency anemia, improve neurodevelopmental outcomes in term infants, and decrease incidence of intraventricular hemorrhage (Bayer, 2016). It is therefore imperative that further studies are done to elucidate the true risk of transmission and neonatal outcomes to ensure decisions are being made in the best interest of the mother and child. It is important to have dependable evidence to integrate with clinical acumen throughout the whole birthing process and postpartum period.
In the immediate postpartum period, close contact between mother and child is integral to establish appropriate bonding and breastfeeding. This presents a significant challenge in mitigating COVID-19 infection risk. Most guidance suggests that the benefits of breastfeeding outweigh the risks of infection (Donders et al., 2020; Poon et al., 2020; British Medical Journal, 2020). Physical distancing of newborn and mother, though, remains controversial. RCOG maintains that COVID-19–positive women and healthy babies not in need of neonatal care should remain together postpartum (Royal College of Obstetricians & Gynaecologists, 2020; British Medical Journal, 2020). Chinese experts suggest that the mother and newborn should be isolated separately until neonatal infection can be ruled out (Chen et al., 2020). FIGO suggests maintenance of contact precautions and PPE until the mother tests negative for COVID-19 by physical distancing of the baby and use of a curtain when the child is in the room with the mother (Poon et al., 2020). The decision on whether to isolate the mother from the child may have lasting impacts. Skin-to-skin contact immediately after birth has been shown to increase the likelihood of effective and sustained breastfeeding (Moore et al., 2016). Benefits of breastfeeding include lower rates of neonatal infection and illness, asthma, and allergies, as well as possible protection against childhood obesity. For mothers, breastfeeding facilitates postpartum weight loss, delays ovulation, and produces positive metabolic changes (Dieterich et al., 2013). These benefits are factors that must be seriously considered when developing practice recommendations.
Another risk in the postpartum period relates to postpartum contraception. The CDC initially discouraged elective procedures (Centers for Disease Control and Prevention, 2020), and many hospital systems in the United States continue to carry out this guidance. Postpartum tubal ligations are considered elective surgeries, and therefore obstetricians may have been unable to perform these for their patients while hospitalized after delivery. This may lead to an increase in short-interval pregnancies in patients who had tubal ligation in mind for postpartum contraception. Shortened intervals between pregnancy have been associated with worsening maternal morbidity and mortality, spontaneous preterm delivery, and increased stillbirth (Schummers et al., 2018).
Clinical practice guidelines help integrate evidence-based practices within individual patient scenarios amidst fast-paced decision-making. Unfortunately, the rapid clinical responses demanded during a pandemic often are not conducive to controlled scientific method. Consequently, recommendations may be generated from small case series and retrospective analyses. Professional societies must advise their members using what little clinical evidence is available. This leads to generalizations that fail to address nuances of care for special patient populations, like pregnant patients. Management guidelines from sound data related to this demographic should be generated to ensure that the safety and preferences of obstetricians and their patients are respected during the COVID-19 pandemic.
Henry Mishek is a fourth-year medical student at the University of Nebraska Medical Center. He hopes to pursue a career as an OB-GYN. Karen Carlson is an associate professor and associate clerkship director in the Department of Obstetrics and Gynecology at the University of Nebraska Medical Center and Nebraska Medicine.
PSQH: Patient Safety & Quality Healthcare, June 11, 2020
CDC information shows the increase in the frequency of disease outbreaks stemming from drug diversion.
This article was originally published June 10, 2020 on PSQH by John Palmer
Editor’s note: The following Q&A resulted from a conversation PSQH had with Tom Knight, CEO of Georgia-based Invistics, a provider of cloud-based software solutions that improve healthcare inventory visibility and analytics across complex healthcare systems and global supply chains.
Invistics commissioned a study by Porter Research revealing that while nearly all healthcare professionals agree that drug diversion is occurring across the country, two out of five hospitals still do not have effective drug diversion prevention programs in place.
PSQH: In your opinion, why do so few hospitals have drug diversion programs? As it is such a large problem, one would think it would be more of a priority.
Tom Knight: While many hospitals have drug diversion programs, sadly, many hospitals do not have formal programs. In our experience, there are several common reasons.
One common reason is that many healthcare leaders believe that informal drug diversion programs will be enough, or that drug diversion is not an issue at their facility. Unfortunately, drug diversion is an ongoing issue across the country, causing patient safety problems all too often.
CDC information shows the increase in the frequency of disease outbreaks stemming from drug diversion:
In the 14-year span between 1985 and 1999, 48 outbreaks from drug diversion were documented.
Between the 14-year span of 2004 and 2018, though, 148 outbreaks were reported.
There are other examples, too. In 2017, reports surfaced that incidents of missing or stolen prescription medications at Veterans Administration hospitals increased more than 800% in seven years, from 272 in 2009 to 2,457 in 2016.
A second reason is that healthcare organizations sometimes cite the lack of adequate financial resources—but the real issue may be that they may think other spending should take priority. This is understandable, as hospitals have had to invest millions in infrastructure, electronic health records (EHR), and security to bring themselves into compliance with regulations. Many are afraid of spending too much on solutions for drug diversion unless they’ve been burned or seen a competitor impacted by the problem.
The Porter Research survey commissioned by Invistics found that nine out of 10 surveyed believe their facility’s drug diversion program is the same or even better than other organizations, and two out of three are confident or very confident that their drug diversion program successfully identifies employees who divert drugs. But there is definitely a disconnect, because 70% of participants said they believe most diversion incidents in the U.S. go undetected. It’s important that we continue to increase education to help mitigate these numbers.
PSQH: What advice do you have for hospital officials who would like to start a program, but don’t know where to start?
Knight: I would first advise hospital officials to review best practices for drug diversion programs from organizations who have studied this, like the American Society of Health-System Pharmacists (ASHP) or Council of State and Territorial Epidemiologists (CSTE), or our nonprofit public-private partnership, HealthcareDiversion.org. There are some great materials that can be quickly adopted, such as forming a Drug Diversion Oversight Council or training rapid response teams to quickly investigate diversion when it is suspected.
If needed, hospital officials can also consult with experts or other organizations that have already started drug diversion programs and ask specific questions such as the following:
How did they launch a program?
What kind of technology solutions did they use?
Are there other areas that could bear improvement?
How did they measure the success of their actions, such as through an increase in the number of reported incidents?
Consider how their best practices can be applied to your own healthcare setting. Through research and planning, it will be easier to see where the gaps exist. Some organizations have had success from putting together an opioid task force with leaders from every department to develop solutions to address drug diversion.
It’s worth mentioning that one way to address drug diversion is to ramp up in-house training. National nursing boards, pharmaceutical associations, and other groups frequently offer free or low-cost web-based programs to help employees understand the scope of diversion, recognize the signs of diversion, and learn what to do when they suspect a colleague is diverting medications. An organization can make this training mandatory for new staff or even host a “lunch and learn” event where staff can watch and learn from these programs.
PSQH: What are some of the most important parts of a successful drug diversion prevention program?
Knight: The foundation of a successful drug diversion prevention program is awareness. A healthcare organization must first recognize drug diversion is an issue and take proactive steps to address it through employee training programs.
For example, go beyond handing a new employee a training manual that includes a section on drug diversion. Take the extra steps to look into a potential employee’s work history (looking closely at job changes or geographical moves), and make sure that individual participates in mandatory drug diversion training before they come into contact with patients. The most successful organizations are committed to preventing drug diversion at every level, from the job interview to the patient’s bedside to the pharmacy.
Resources are also needed. We’ve seen that the equivalent of at least one full-time employee assigned to drug diversion detection can help. There are also impressive advancements in machine-learning technologies, which can help to isolate patterns associated with drug diversion and reduce false positives.
PSQH: Are there parts of the country where the problem is more prevalent? Is the lack of programs due to finances, lack of interest, or something else?
Knight: At this time, we don’t have enough data to speak to geographical hotspots. But we can say that drug diversion is happening in every healthcare setting, from hospice and hospitals to nursing homes and community health centers. It’s not just limited to rural pockets of America or major urban centers. As noted earlier, the lack of formal drug diversion programs could mean that hospital leaders are prioritizing other initiatives or don’t believe diversion will impact their facility.
The lack of drug diversion programs also stems from the fact that drug diversion can be difficult to detect. If you can’t see the problem right in front of you, that makes it harder to rationalize allocating resources to addressing it: 70% of healthcare workers who responded to the 2019 Porter Research survey on drug diversion said they strongly agree that “most” drug diversion goes undetected, a number that has increased since 2017.
PSQH: Your survey shows machine learning is a good way to uncover drug diversion. How does this work, and is it effective?
Knight: Machine-learning technologies are trained to recognize known patterns of behavior consistent with diversion. We have a large data set containing many cases of diversion from hospitals across the country and have used that data set to teach the machine-learning algorithms to detect those same patterns.
These algorithms look at data from multiple computer systems—such as EHRs, employee timecards, and medication dispensing cabinets—to find patterns. For example, when a nurse who is diverting medications at a patient’s bedside enters falsified data into the EHR, the machine-learning algorithm is able to detect patterns in that data that provide clues to detect the diversion. Some of those patterns are fairly easy to detect, like a nurse who accidentally charts the medication administration incorrectly in the EHR, while other patterns are more sophisticated, like a nurse who enters accurate but falsified records for medication administration, pain scores, or other clinical data.
The great thing about the technology is that it grows smarter as our training data set grows. The more health systems contribute data, the larger our data set grows and the more accurate the machine-learning algorithms become. We are seeing two exciting developments with this machine-learning approach.
First, the software is growing more accurate because it learns from its mistakes. For example, if the software flagged diversion incorrectly, and the hospital concludes diversion did not occur, then the “false positive” is logged in the training set to avoid making this mistake in the future.
Second, whenever some new diversion incident occurs, and this new pattern is added to the data set, then the software will be able to detect that pattern elsewhere, avoiding a “false negative.” This is particularly helpful because if one hospital finds a new pattern of diversion, that new pattern will then be recognized if it happens at any hospital in the country using the technology. In short, every time a hospital in the network confirms an incident of drug diversion happened, all hospitals become more effective at detecting diversion.
PSQH: About 70% of your respondents say most drug diversion goes undetected. Is this to say that the problem is much bigger than we know even now? What needs to be done to fix this?
Knight: Based on the survey findings, it is clear that more diversion is happening than what is being reported. In 2018 alone, the Department of Justice made only 50 enforcements and about 280 administrative actions related to drug diversion, and this is clearly just a small fraction of the diversion that is happening.
Moreover, the problem could be worsening. For example, the surge of patients with COVID-19 into hospitals could lead to clinicians missing some of the signs of diversion or clinical staff having an easier time circumventing detection.
While no single approach to fixing the problem is guaranteed, improving training, hiring one or more dedicated drug diversion professionals, and investing in machine-learning technology are three big ways we can reduce diversion in healthcare settings.
We also need to engage in broader conversations throughout the healthcare system. The current healthcare culture is often one where workers are sometimes reluctant to speak up due to the stigma attached to drug diversion. We need to change the culture so workers know that speaking up helps everyone. It helps protect our patients and it helps protect our coworkers. There’s too much at stake to ignore the problem. Drug diversion has clinical, legal, and financial consequences.
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.
PSQH: Patient Safety & Quality Healthcare, June 10, 2020
Coronavirus fears drive medication adherence ups and downs.
This article was originally published June 10, 2020 on PSQH by Megan Headley.
The cost of poor medication adherence is tremendous—nearly $177 billion each year in direct and indirect healthcare costs—but the cost of nonadherence during the COVID-19 pandemic has the potential to be much higher. Medication nonadherence can drive up otherwise avoidable hospital admissions, burdening healthcare systems already struggling to care for coronavirus patients and putting other patients at greater risk of contracting COVID-19.
Since medication nonadherence already accounts for 50% of treatment failures, approximately 125,000 deaths, and up to 25% of hospitalizations each year, it has become more important than ever for physicians, pharmacists, and insurance companies to work together to keep patients on their prescriptions.
An old problem presents a new challenge
The negative impacts of medication nonadherence are well documented, including poor health outcomes, additional illnesses, avoidable hospital admissions, premature deaths, and billions in unnecessary healthcare expenditures each year. Barriers to adherence range widely as well, from high cost and inconvenience in accessing prescriptions to negative side effects and poor communication between providers and patients.
Today, however, there’s a new barrier to add to the list: fear. People have avoided healthcare locations—from emergency room visits to routine checkups—to stay out of contact with patients who may have the coronavirus. For example, a May 2020 study from researchers with the CDC found that vaccinations for children have dropped significantly since the start of the COVID-19 pandemic, prompting concerns of forthcoming outbreaks of vaccine-preventable diseases. Measles vaccinations for children under age 2 dropped by half from March 13 through March 23, while vaccinations for children ages 2–18 dropped from 2,500 per week pre-pandemic to fewer than 500 per week. Researchers attribute the decline to parents’ concerns of exposing their children to COVID-19 during visits to healthcare providers.
However, routine healthcare, including vaccinations and medication management for chronic diseases, may be even more important now to maintain patient health and keep people out of hospitals. Addressing these concerns with open communication and documented safety procedures will be critical in bringing people back to the physician’s office for routine care.
On the other end of the spectrum, fear is in some cases driving up medication adherence. A study from researchers with the American Academy of Allergy, Asthma & Immunology, published in The Journal of Allergy and Clinical Immunology: In Practice, found a 14.5% increase in adherence in controller inhaler use between January and March 2020, at the start of the COVID-19 pandemic in the United States.
An analysis of controller inhaler use for 7,578 patients using Propeller Health, a digital platform that employs electronic medication monitors to track inhaler use and send alerts to patients about missed doses, saw that in the last seven days of March 2020, more than 53% of patients achieved 75% or greater medication adherence, up 14.9% from the first seven days of January. The data indicated similar medication adherence increases across all age groups, with older patients showing an overall higher baseline adherence.
“We are encouraged by the increase in patient adherence to their medications for asthma and COPD, which is critical to avoiding symptoms and keeping patients out of the hospital during this pandemic,” commented author Leanne Kaye, PhD, MPH. “This research further supports that digital health tools can improve adherence and provide insight into patient well-being between office visits.”
Reexamine communication strategies
For both patients and providers, awareness of solutions to medication barriers is a critical first step in improving adherence. Because many patients are reaching out less as a result of social distancing, providers will need to take the first step in building this awareness.
“Patients are feeling more isolated,” says pharmacist Heidi Polek, RPh, strategic program manager with DrFirst, a technology company focused on providing doctors, pharmacists, and patients with tools that help them stay connected. “Their daily activities have been disrupted. They can’t just walk into a pharmacy or their doctor’s office anymore.” However, patients can still communicate with these professionals through telehealth solutions and automated medication alerts.
The DrFirst technology solution alerts patients when scripts are written or ready for pickup, helping maintain communication between providers and patients. Those simple reminders can make a big impact. As Polek explains, a company solution that sends prescription information from the doctor to the patient, with a reminder of what the prescription is for and why it’s important to take it, has prompted a 6% boost in medication adherence for clients.
The way providers ask about medication adherence can also have a big impact. In an episode of the AMA’s Moving Medicine podcast, Marie T. Brown, MD, a geriatric and internal medicine specialist at Rush University Medical Center in Chicago, commented, “Patients really have been encouraged to hide their nonadherence.”
From Brown’s perspective, physicians tend to chastise patients when they learn of nonadherence. After all, physicians see medication adherence as the patient’s responsibility in the mutual work of improving the patient’s health. “Because of their social desirability, patients want to say yes when the doctor that they’ve known for a long time, or even a new doctor, asks them if they’re taking their medicine,” Brown said.
By changing the conversation to acknowledge that medication adherence is difficult for lots of people and for lots of reasons, patients get a safe space to begin to explain their specific barriers. This conversation must evolve at every patient interaction, Brown added. “If one person on the team understands why a patient has a reasonable reason for not taking their medicine and respects that reason and then can tailor the message, but if not everybody on the team understands it, then the patient will get mixed signals.”
Reduce cost and access barriers
Since the start of the COVID-19 pandemic, there has been ample communication encouraging consumers to fill prescriptions early or in larger quantities in order to limit trips to pharmacies.
“Luckily, insurance companies have relaxed some of their rules on when patients can get prescriptions refilled,” Polek says. “We’re encouraging patients to reach out to their physician and their insurance company to see what options they have.”
Data from AllazoHealth, an AI and machine-learning company that focuses on driving behavioral changes in patients through personalized and proactive intervention, indicates this encouragement and relaxation of insurance rules is working.
Upon reviewing a subset of its clients’ data to better understand the effects on medication access after the spread of COVID-19 in the United States, AllazoHealth researchers found that the percentage of prescriptions filled more than a week before their due date increased 18% within one week. The company concludes that the surge in early medication refills was motivated by patients’ fears of being unable to access their medications for an undetermined period of time. This may have been compounded by news reports warning of potential drug shortages due to pharmaceutical demand and supply chain disruptions.
However, the individuals stocking up on medications may already have been aware of the importance of medication adherence. After all, getting the medication is only part of the access problem. Cost is yet another barrier.
Polek notes that DrFirst is pushing physicians to acknowledge this issue early in medication conversations through its tool that lets providers see the cost of a prescription before they write it. “It gives them a great opportunity to speak to that patient at the point of encounter and make sure the patient can afford their medication,” she says.
DrFirst also works to send patients secure messages about cost-saving alternatives to their prescription. “If that isn’t everything the patient needs, doctors and pharmacies can help find local organizations to help or connect patients to their insurance company who might be able to help. We’re also seeing programs from manufacturers for patients who are in need,” Polek adds.
Continue to strengthen connections
Polek believes a large part of the solution to medication nonadherence will come through awareness of the options available for connecting patients to needed medications. However, medication adherence during and after the pandemic will also depend upon providers’ awareness of their role in addressing patients’ potential barriers to medication access. The COVID-19 pandemic has challenged more people than ever in filling their prescriptions. But it’s also driving new strategies for connecting with patients, ones that have the potential to open up new chains of communication.
“It’s important that everybody stay connected,” Polek urges. “We’re here as a company to help keep that circle of care connected, and I just want to remind people to reach out: to your doctor, your pharmacist, your family, your friends. That’s the most important thing to do today.”
The flipside is also true: It’s more important than ever that clinicians, pharmacists, and other care providers reach out to patients with chronic problems to improve patient care and reduce the ongoing burden on our health system.
PSQH: Patient Safety & Quality Healthcare, June 9, 2020
Kedar Mate, MD previously previously served as IHI's Chief Innovation and Education Officer.
This article was originally published June 9, 2020 on PSQH.
The Institute for Healthcare Improvement (IHI) this week announced that Kedar Mate, MD, will take over as its new president and CEO. Effective July 1, Mate will succeed current president and CEO Derek Feeley, who announced in January that he was leaving the organization to spend more time with his family in Scotland.
Mate is currently the IHI’s chief innovation and education officer. IHI Board Chair and CEO of Northwell Health, Michael Dowling, who led the multi-month executive search process, said in a press release: “We are thrilled to announce Dr. Mate’s appointment. Kedar is a perfect match to lead IHI into its next phase of work. He has the full confidence of IHI staff and the Board.”
“It is an honor to be named IHI’s next president and CEO,” Mate said in the release. “Time and again throughout my years with IHI, I have been in awe of the work undertaken by our staff, fellows, faculty, board members, and our many partners around the world to improve the safety and quality of health care, and the health and wellbeing of their communities. This is a pivotal time for all of us as we confront simultaneous clinical and financial challenges and the need to make good on the commitment to improving equity in all our endeavors. Even with the difficult times of the past few months, I’ve witnessed the courage, dedication, and effectiveness of IHI’s partners and the achievement of remarkable results with patients, families, and communities. IHI is absolutely committed to achieving better care and better health for every person and every community we have the pleasure of serving.”
Mate previously led IHI’s programs in South Africa and the Middle East and has also worked with Partners in Health and the World Health Organization. In addition to his responsibilities at IHI, Mate is an internal medicine physician and is faculty in the Department of Medicine at Weill-Cornell Medical College. His scholarly work has focused on health system design, healthcare quality, strategies for achieving large-scale change, and approaches to improving value.
In addition, Mate has been serving as the senior executive for the groundbreaking Age-Friendly Health Systems movement, which aims to have 1,000 healthcare practices and health systems engaged with transforming quality of care for older adults in the U.S. by the end of this year.
PSQH: Patient Safety & Quality Healthcare, June 9, 2020
Don't lose business—or, more importantly, the chance to help patients in need—due to weak website design.
This article was originally published June 5, 2020 on PSQH by Katie Lundin.
If you’re in the healthcare industry, you know it’s important to cultivate trust.
Health can be a very personal matter. Healthcare providers make life-and-death decisions for their patients. And patients make themselves vulnerable (financially with their health insurance and physically with their medical team) with every interaction. The personal stakes can’t get any higher. That’s why building a foundation of competence, credibility, and trustworthiness is essential for every business in the healthcare industry.
Since your website is your primary online ambassador and a core part of your brand identity, if it fails to inspire trust, you will lose customers. Don’t just take my word for this: Seventy-five percent of people judge the credibility of a business based on its website. And people may judge healthcare businesses even more harshly because the potential stakes are so high.
Don’t lose business—or, more importantly, the chance to help patients in need—due to weak website design. Here are eight tips for making your healthcare website design more credible and trustworthy.
Keep your website patient-centric
Patients—people—are the lifeblood of the healthcare industry, so your website must be designed with your patients in mind. If patients or prospective patients can’t find what they need easily, then your website has failed in its sole purpose—and you’ve likely lost a customer.
Avoid healthcare industry jargon
The healthcare industry is complex, and so is the language spoken among healthcare professionals. But on your website, it’s important to keep the language simple and easy for patients and prospective patients to understand.
To make your website accessible, double-check all of its copy from a layperson’s perspective. Will the average patient understand what you’ve written? If not, revise your copy until it’s clear, easy to understand, and free of baffling industry terminology.
Make it easy for people to contact you
Many people will come to your website to schedule a visit, get an answer to a question about their insurance, or find out how to speak with their doctor. But whatever the reason for their visit, they’ll likely have to give you a call as their next step. Therefore, make it easy for people to find your contact information.
Display contact info clearly on every page so that patients can easily reach you when they’re ready. This simple act shows your willingness to interact with your patients—and demonstrates that you care.
Additionally, be sure that the business name your company operates under is accurate and clear. Many healthcare businesses incorporate under one name but operate under an assumed name. If you do this, you must register a “Doing Business As” (DBA) name with your state and/or local governments. To learn more, review how to file a DBA in each U.S. state and territory.
Provide clean, simple website navigation
The last thing a patient needs to deal with while navigating healthcare issues (and your website) is a confusing layout. Overly minimalist designs that hide all of the menu options—or overblown sites that jam in too many navigation options—are poor choices for a healthcare website.
Avoid hidden navigation in favor of organized menus that clearly address patients’ most common needs. The most important pages should be easy to find. Mayo Clinic does a fantastic job of this on their homepage (shown above).
Pro tip: Use Google Analytics to determine which pages of your website receive the most traffic. Then verify that those pages are easily accessible from your home page’s navigation menus. And be sure that your mobile navigation is equally clean and simple.
Design your website for fast load speeds
A website that takes too long to load is one that nobody will stick around to see.
As we’ve emphasized: Did you know that viewers start abandoning your website after mere seconds of load time? Between seconds four and five of your website’s load time, 20% of viewers have already left your site. The percentage only increases from there. Not only that, the faster your website loads, the higher it ranks with search engines and the easier it is to find.
Design with load speeds in mind. Not sure how? Learn more here.
Make your website accessible
People of all health levels will need to access your website. According to the Centers for Disease Control and Prevention, 61 million adults in the United States have some type of disability. That’s just over one-quarter of Americans.
Add to that number those who are sick and those who are stressed as a result of a family member’s injury or illness, and you can assume many of your website’s visitors will be experiencing an impairment of some kind. It’s essential that your website design allows these users to get what they need.
Accessible web design ensures that all people visiting your website can navigate it successfully. And it shows that your healthcare business knows and cares about its audience.
Keep in mind the following accessibility tips:
Use higher contrast ratios to improve visibility
Avoid designs that rely too heavily on color—consider colorblind users
Use a consistent navigation scheme for ease of use
Ensure your website can be navigated using a mouse or a keyboard
Use responsive design to adapt to whatever type of screen your visitor is using
Use plenty of white space to make your website easy to read
For more detailed guidance on web-accessible design, read this article from UC Berkeley.
Ensure your website is HIPAA compliant
As you know, in the U.S. healthcare system, the Health Insurance Portability and Accountability Act (HIPAA) governs much of what healthcare companies do.
Many of today’s patients are also aware of HIPAA. If your website isn’t HIPAA compliant, you run the risk of appearing wildly unprofessional (at a minimum), paying expensive fines, or even doing jail time (at a maximum).
What does a HIPAA-compliant web design look like? Here are a few guidelines to get you started:
Your website must protect patient data. All files, data storage, and data transmissions must be SSL encrypted.
Electronically protected health information (ePHI) should not appear anywhere on your website. This includes testimonials, case studies, and web copy.
Does your website encourage new patients to fill out a form to schedule an appointment? Make sure the data in that form is protected. Even simple contact info (name, email, and phone number) should be encrypted.
Create a unique website design that inspires trust
As we’ve mentioned, patients trust the healthcare industry with their well-being. But it’s hard to give a business that trust if their website is full of typos or poor design.
There’s no room for error in your copy, your coding, or your design. Failure to pay attention to details like these will drive visitors away.
In addition, if your site uses a template and looks like thousands of other healthcare sites, your patients and prospective patients won’t be able to differentiate you from your many competitors. This also holds true for elements of your brand identity, including your business name and your logo. Be sure both are unique.
As we’ve emphasized in our guide to starting a business, a new business depends on its website as a vital ambassador and a crucial component of its marketing and branding strategy. But this is equally true for an existing business. It’s too easy for people to assume a lack of attention to detail on your website means you’ll be similarly lax with the healthcare or health insurance tasks that are so important to your patients.
When building or updating your website, be sure to:
Proofread your web copy for grammatical, spelling, and informational errors.
Get a professional to design your website. Avoid website builders and generic website templates (even if they’re free).
Test your website for functional errors. Ensure all links and forms are working as they should.
Review your website with the same critical eye you would apply to a patient’s chart or insurance paperwork. No detail is too small. If you don’t find the errors, potential patients will.
Web design trends
Web design never stops evolving. That constant movement leads to evolution, innovation, and occasionally some regrettable web design trends. Still, it’s smart to keep an eye on trends, as they often lay the foundation for new best practices. Here’s a good look at the latest website design trends.
Healthcare has never been more important. And your healthcare business—whether you provide medical support or financial support—plays a vital role in the well-being of patients. Don’t let your important work be held back by poor web design.
Your business needs a strong, professional website to best serve its patients. Follow the tips we’ve shared and you’ll make a stronger impression and win over more patients.
Katie Lundin is a marketing and branding specialist at crowdspring, one of the world’s leading marketplaces for crowdsourced logo design, web design, graphic design, product design, and company naming services.
PSQH: Patient Safety & Quality Healthcare, June 8, 2020
Laser technology has lowered complications for this very common procedure, allowing patients to heal at home.
This article was originally published June 5, 2020 on PSQH by Amy E. Krambeck, MD.
Benign prostatic hyperplasia (BPH), or enlarged prostate, is exceedingly common, affecting half of men in their 50s and about 90% of men aged 80-plus (American Urological Association, 2019). As a result, although most patients are treated with medication, surgical procedures to treat BPH are very common as well, making up a significant portion of urological surgeries in any hospital.
With any BPH procedure, tissue is removed to open the urethra. Patients typically stay at least one night in the hospital. There has been a successful ongoing effort to reduce inpatient time for BPH surgery by limiting complications, especially postoperative bleeding.
At my Level I trauma hospital, which runs near capacity at all times, sometimes beds were not available for my patients, and they had to spend the night in the recovery room. We postulated that we could free up beds and offer better treatment for our patients by performing BPH surgery on an outpatient basis. Because we were performing very safe surgery with the latest laser technology, it seemed we had finally reached the point where it was safe to send patients home.
Transitioning to outpatient surgery
Patients with BPH who undergo transurethral resection of the prostate (TURP) or suprapubic prostatectomy stay one or two nights in the hospital with a catheter irrigating the bladder to prevent clots from forming. We began performing holmium laser enucleation of the prostate (HoLEP) with a 120-watt holmium laser that modulates the laser pulse (“the Moses effect”) and specially designed fibers that, used together, allow us to remove tissue more efficiently for shorter procedure time. Compared to other HoLEP technologies, the system has shortened our HoLEP cutting time by 30%–40% and reduced cautery time by 50%.
The procedure causes much less bleeding during and after surgery compared to alternatives like TURP. The modulated laser pulse delivers energy to the tissue more efficiently, without scatter, and cuts and coagulates simultaneously. Because HoLEP produces so little bleeding, we found patients’ urine was almost clear after surgery. They did not need irrigation overnight, thus it appeared that we could send them home the same day with a catheter.
We did not take this change lightly. We spent three months following nearly 100 patients from check-in to discharge, gathering data about our process. Satisfied that we hadn’t overlooked any advantages of the hospital stay, we sent the first HoLEP patients home the day of surgery, and we have done so for virtually all patients for the past six months. We place no restrictions based on prostate size or use of anticoagulants, but we still keep patients overnight if they have acute comorbidities.
Patients go home with a catheter, the home care for which is explained by medical assistants using an educational template. The catheter is removed the next day in our office or, if the patient has traveled for surgery, at a physician’s office closer to home.
Better for patients and the hospital
Aside from reducing patients’ stress after BPH surgery by allowing them to convalesce at home, HoLEP has significant advantages for our patients. Transurethral HoLEP has one of the lowest postoperative morbidity rates of all BPH options, the least blood loss, the shortest catheter time, and lower retreatment rates (Kuntz et al., 2008; Gilling et al., 2012). Short catheter dwell time means lower risk of urinary tract infection compared to TURP (Cornu et al., 2015).
Anecdotally, we’ve seen that our HoLEP outpatients tend to do better than inpatients for any BPH procedure. When we remove the catheter the next day, they are more likely than inpatients to successfully urinate. We speculate that this is because patients move more at home than they do in the hospital, where they also may receive narcotics or other medications that can affect urination.
Moving to outpatient surgery also lowers healthcare costs. We’ve opened up beds in our hospital for other, more critical patients. None of the BPH outpatients have presented to the ER with surgery-related complications. It’s a tremendous savings, particularly when multiplied for such a common procedure.
My colleagues and I are now tracking the outpatient program so we can compile data, but at this point, it appears to be a success. I think in the future, patients are going to insist on getting HoLEP not only because of its clinical advantages, but also because they can go home the same day. They don’t want significant bleeding and prolonged catheterization after BPH surgery; they want to get back on their feet quickly, without complications. As more surgeons performing HoLEP shift from inpatient to outpatient BPH surgery, hospitals will no doubt help drive this change as well.
Amy Krambeck is the Michael O. Koch Professor of Urology at Indiana University School of Medicine in Indianapolis. She is a consultant for Boston Scientific and Lumenis.
PSQH: Patient Safety & Quality Healthcare, June 5, 2020
UR nurses speak a different language than most other bedside nurses.
This article was originally published June 5, 2020 on PSQH by Sandra Salley, RN, MSN, CHCQM.
Why do we care about patient status, documentation, and complying with recommended guidelines?
It’s how the hospital and therefore “we” get paid. Although patient care is the number one priority, I like to say that most nurses wouldn’t be caring for patients if they didn’t get a paycheck. Utilization review (UR) is the process of reviewing an episode of care. The review confirms that the insurance company will provide appropriate financial coverage for medical services. The UR process and the UR nurse facilitate minimizing costs.
What do UR nurses do?
UR nurses speak a different language than most other bedside nurses. In all settings, to justify payment or suggest an alternative status, the hospital UR nurse and the insurance UR nurse first discuss medical necessity criteria. If there is disagreement between the nurses about status and therefore payment, then the physicians discuss medical necessity during a scheduled peer-to-peer conference. If there is still a disagreement between the physicians, then the hospital appeals the case with the insurance company.
Why do we follow a UR process?
The UR process is necessary to treat patients. Hospitals cannot admit Medicare beneficiaries without a UR plan. The Code of Federal Regulations (42 CFR 456 and 42 CFR 482.30) and the Medicare Benefit Policy Manual provide the guidelines that the hospital and the insurance company must follow (U.S. Government Publishing Office, 2020; Centers for Medicare and Medicaid Services, n.d.).
What are the most common guidelines that hospitals use?
Acute inpatient hospitals use Milliman and InterQual criteria to help determine the appropriateness of care. Both sets of criteria are evidence-based screening tools used by providers and insurance companies. They do not substitute for the physician advisors’ professional opinions when determining medical necessity. If there is a disagreement between the insurance company and the provider, the insurance company may issue a denial. If so, physician advisors discuss the case during a peer-to-peer conference. If after this conference there is still a disagreement, the hospital can file a written second-level appeal with the patient’s permission. Some insurance companies (e.g., United, Aetna, Cigna, AvMed, Humana) use the Milliman language, while others (e.g., TRICARE, Blue Cross, Sunshine State) use the InterQual language. It is beneficial to know how to use both tools.
What do all nurses need to know about this process?
Documentation is of the utmost importance. It is important to document objective information. Often, reviews will start with the present situation provided by the nurse’s note. This note often includes oxygen saturation, oxygen administration mode, pain, intake, output, and abnormal signs or symptoms. The physician note should contain past medical history and other relevant information such as the plan of care. This information is consulted when deciding status/payment. Although nurses treat all patients equally despite payment, it is important for nurses to be conscious of payment and for patients to know how they will be billed. Also, insurance companies usually pay substantially more when the patient is in inpatient status.
Does Medicare/CMS (Centers for Medicare and Medicaid Services) care about Milliman or InterQual criteria?
CMS recommends admission guidelines as one of many factors to consider when making an admission decision, but it does not endorse any particular criteria or assign specific authority to them. Medicare started issuing a paper notification to observation (Medicare Part B) patients, called the Medicare Outpatient Observation Notice (MOON). Patients in observation status usually pay a percentage of the hospital stay cost (usually 20%), known as a coinsurance payment (Medicare.gov, n.d.). Patients in inpatient status (Medicare Part A) pay a deductible for their stay, which for 2020 is $1,408 (Centers for Medicare and Medicaid Services, 2019). Commercial insurance has similar guidelines. Sometimes the inpatient deductible can be less than the 20% coinsurance in observation status. A Medicare patient has to have a three-day qualifying stay for Medicare to pay for a SNF stay. Neither the hospital stay nor the SNF stay can be considered custodial in nature. Medicare pays for the first 20 days of a hospital stay. After 20 days, the patient is responsible for a daily deductible for days 21–100 (currently $176 per day). If the patient has secondary insurance, both Medicare and the secondary insurance will cover the 100 days per episode of care.
Sandra Salley works in utilization management at Baptist Medical Center in Jacksonville, Florida. She has 12 years’ experience in utilization review covering acute medical, inpatient rehabilitation, behavioral health, and acute pediatric patients.
PSQH: Patient Safety & Quality Healthcare, June 3, 2020
California's ATD standard requires that employers protect workers at healthcare facilities and other services and operations from airborne diseases like COVID-19.
This article was originally published June 2, 2020, in EHS Daily Advisor by Guy Burdick.
The California Division of Occupational Safety and Health (Cal/OSHA) issued interim guidance for protecting employees in hospitals from exposure to SARS-CoV-2 and a guide to the state’s Aerosol Transmissible Disease (ATD) standard.
Coronavirus disease 2019 (COVID-19) is a respiratory illness caused by the SARS-CoV-2 virus.
California’s ATD standard requires that employers protect workers at healthcare facilities and other services and operations from airborne diseases like COVID-19 and tuberculosis (TB), influenza, and pertussis (whooping cough). There is no corresponding federal standard.
Requirements under the standard include written programs and procedures; engineering and work practice controls; biosafety plans for laboratories; respiratory protection; medical services such as vaccinations and postexposure evaluations; and follow-up, training, and recordkeeping.
Written ATD plans for hospitals must, at a minimum, include:
Name or title of the person, knowledgeable in infection control measures, who is responsible for administering the hospital’s plan;
List of job classifications that have occupational exposure to aerosol transmitted diseases and that perform high-hazard procedures;
List of all high-hazard procedures and operations performed in the hospital and by hospital employees, as well as all assignments or tasks requiring personal protective equipment (PPE) and/or respiratory protection;
Methods of engineering controls, work practices, PPE, and respiratory protection to be used under the plan;
Source control measures implemented at the hospital, such as ensuring patients with suspected or confirmed COVID-19 are masked when possible;
Procedures to identify, temporarily isolate, and move suspected and confirmed COVID-19 patients to isolation rooms or areas—procedures must include methods to limit employee exposure to patients when they are not in an airborne infection isolation room or area;
Procedures to communicate with employees and other employers regarding the suspected or confirmed infectious disease status of persons to whom employees are exposed and procedures to investigate and evaluate each exposure incident;
Descriptions of medical services and training under the plan;
Procedures to ensure the hospital has an adequate supply of PPE and other equipment used to minimize employee exposure to aerosol transmitted diseases in normal operations and foreseeable emergencies, such as surge events; and
Procedures for handling surge events that include appropriate work practices, decontamination facilities, and PPE.
Training must cover descriptions of SARS-CoV-2 and COVID-19; signs, symptoms, and modes of transmission of COVID-19; tasks and activities that may expose employees to COVID-19 and source controls to be used with suspected and confirmed COVID-19 patients; use and limitations of methods to prevent or reduce exposure to COVID-19, including engineering and work practice controls, PPE, and respiratory protection; the employer’s surge plan; and what to do if an exposure incident occurs.
Engineering controls include isolation rooms and airtight barriers to eliminate employee exposures, as well as air disinfection, high efficiency particulate air (HEPA) filtration, and local exhaust ventilation in patient rooms.
Work practice controls include:
Limiting the movement of suspected and confirmed COVID-19 cases within a facility;
Bundling or combining care activities to minimize room entries;
Screening, delaying, or redirecting elective and nonserious visits when possible;
Using alternative means of communication, such as telephone and video calls, when possible and medically appropriate;
Placing multiple patients infected with the same respiratory pathogen together in dedicated areas—a practice known as “cohorting”;
Cleaning and disinfecting work surfaces, tables, tools, instruments, and equipment frequently using EPA-approved products (List N) for use against COVID-19;
Washing articles and linens after each use; and
Implementing frequent hand-washing procedures and procedures for safe donning and doffing of PPE and respiratory protection equipment.
Appropriate PPE includes coveralls or gowns, eye and face protection, gloves, and respirators. Healthcare facilities have experienced shortages of filtering facepiece respirators such as N95 respirators during the pandemic. Due to shortages, employees otherwise required to wear an N95 respirator should be provided with surgical masks. Employers must manage respirator supplies to prioritize the protection of employees engaged in high-hazard or aerosol-generating procedures.
PSQH: Patient Safety & Quality Healthcare, May 8, 2020
The administration has issued interim guidance of decontamination and reuse of N95 respirators during the COVID-19 pandemic on a case-by-case basis.
Editor’s note: This article was originally published May 6, 2020, in EHS Daily Advisor by Guy Burdick.
The Occupational Safety and Health Administration (OSHA) issued enforcement guidance allowing the decontamination and reuse of N95 respirators during the COVID-19 pandemic on a case-by-case basis. The interim guidance to the agency’s Compliance Safety and Health Officers (CSHO) allows the reuse, in certain circumstances, of filtering facepiece respirators (FFR) decontaminated using methods that have shown promise in limited research.
The National Institute for Occupational Safety and Health (NIOSH) and the Centers for Disease Control and Prevention (CDC) provided guidance based on limited research indicating that ultraviolet germicidal irradiation, vaporous hydrogen peroxide, and moist heat have shown the most promise as potential methods of decontaminating FFRs. However, there are no NIOSH-approved methods of decontamination for FFRs. Because decontamination may affect the fit and performance of N95 and other FFRs, decontaminated respirators are not NIOSH-certified.
OSHA instructed its CSHOs to exercise discretion in making decisions about the enforcement of the respiratory protection standard (29 CFR §1910.134).
COVID-19 is a respiratory disease caused by a novel coronavirus, SARS-CoV-2, first identified in Wuhan City, China, in December 2019. U.S. employers have experienced shortages of N95s and other FFRs during the COVID-19 pandemic.
The CDC, NIOSH, and OSHA, along with state agencies, have issued guidance to help healthcare facilities and emergency services maximize the available supply of N95 respirators. Decontamination and reuse of respirators may be one method of extending existing supplies.
OSHA Guidance for Employers
According to OSHA, employers should:
Make a good-faith effort to provide and ensure workers use the most appropriate respiratory protection available for expected workplace hazards;
Ensure decontamination is performed according to CDC guidance;
Ensure employees perform a user seal-check each time they don a respirator and not permit use of a respirator on which the user cannot perform a successful user seal-check;
Train employees to follow appropriate precautionary measures detailed in the CDC’s guidance before using a decontaminated FFR;
Train employees using decontaminated respirators to understand that if the structural and functional integrity of any part of the respirator is compromised, it should not be used for respiratory protection—an inability to achieve a successful user seal-check could be an indicator that the integrity of the respirator is compromised;
Visually inspect, or ensure that workers visually inspect, FFRs to determine if the structural and functional integrity of the respirators has been compromised—components such as the straps, nose bridge, and nose foam material may degrade over time or as a result of decontamination and affect the quality of the respirators’ fit and seal; and
Train employees on the procedures for properly donning and doffing respirators to prevent self-contamination.
If employers have no manufacturer or third-party guidance or procedures for specific decontamination methods, then workers should avoid using decontaminated FFRs when performing aerosol-generating procedures on patients who are or may be infected with SARS-CoV-2. Aerosol-generating procedures include bronchoscopy, cardiopulmonary resuscitation, intubation and extubation, nebulizer therapy, and sputum induction. Decontamination may degrade FFR performance, and decontaminated respirators may not provide the level of protection needed during such procedures.
OSHA instructed CSHOs to exercise discretion in issuing citations if FFRs are decontaminated and reused in cases when:
Other feasible measures, such as using partitions, restricted access, the cohorting of patients, other engineering controls, work practices, or administrative controls to reduce the need for respiratory protection, were implemented to protect employees;
The employer has made a good-faith effort to obtain other alternative FFRs, reusable elastomeric respirators, or powered air-purifying respirators (PAPRs), including NIOSH-certified equipment or previously NIOSH-certified equipment past its manufacturer’s recommended shelf life;
The employer has monitored its supply of FFRs, prioritized their use according to CDC guidance, and controlled the number of times a respirator is decontaminated before issuing a new one, given supply-level and burn-rate considerations; and
Surgical masks and eye protection such as face shields and goggles were provided as an interim measure to protect against splashes and large droplets.
OSHA reiterated that surgical masks are not respirators and are not appropriate during aerosol-generating procedures.