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PSQH: Patient Safety & Quality Healthcare, September 19, 2019
The Joint Commission issues recommendations to prevent drug diversion at hospital facilities.
The full version of this article by John Palmer originally appeared on PSQH.
Amid an expanding problem of illegal opioids and a growing concern over abuse and theft by hospital staff, The Joint Commission has released advice and guidelines for preventing drug diversion in facilities.
The Joint Commission said diversion of opioids is seen across all levels of an organization, from chiefs to frontline staff, and across all clinical disciplines. Only a fraction of those who divert drugs are ever caught, The Joint Commission noted, "despite clear signals such as abnormal behaviors, altered physical appearance, and poor job performance. Direct observation is vital to detecting diversion and may be the only way to identify an impaired colleague."
"Leaders have a responsibility to establish processes that support staff while enabling rapid detection of diversion," said The Joint Commission.
Signs of diversion to look for
The Joint Commission recommended that drug surveillance programs start with noticing patterns and trends in drug utilization. Quick Safety 48 listed the following behaviors or indications to watch for:
A nurse removes controlled substances without a doctor's orders, for patients not assigned to that nurse, or for recently discharged or transferred patients
Product containers are compromised
A substitute drug is removed and administered while the controlled substance is diverted
A verbal order for controlled substances is created but not verified by the prescriber
Prescription pads are diverted and forged to obtain controlled substances
A prescriber self-prescribes controlled substances
Volume is removed from a premixed infusion
Multidose vial overfill is diverted
Prepared syringe contents are replaced with saline solution
Written prescriptions are altered by patients
Medication is documented as given but not administered to the patient
A provider has excessive pulls for PRN (as-needed) medications compared to his or her peers
Drug dispensing machines show discrepancies or overrides
Wasting of medications is not adequately witnessed
Controlled substance waste is removed from an unsecure waste container
Controlled substance waste in a syringe is replaced with saline
Expired controlled substances are diverted from a holding area
Patients continue to complain about excessive pain, despite documented administration of pain medication
Potential falsification of medical records, indicated by late documentation of certain medications only or by coworkers assisting others in completing documentation
"Batching" assessments and treatments for pain
Frequent efforts by a particular nurse to help other nurses administer pain medication
What can be done?
The problem with drug diversion is that hospitals often don't have an effective prevention and accountability program in place. Abusers learn how to circumvent processes to fit their needs, which frequently puts patients at risk of harm.
What's more, if the abuser is discovered, the hospital often allows the person to simply resign from his or her position, which then permits the person to get a job at another hospital and repeat the pattern of diversion.
"Many times I find in institutions where they've had, for instance, a lack of auditing for a period of time, that diverters will test the system—and when they find that they can divert undetected, they can become very, very bold. That comes primarily from lack of reporting diversion," says Kimberly New, JD, a nurse, attorney, and consultant specializing in helping hospitals prevent, detect, and respond to drug diversion. New also helped The Joint Commission develop the latest guidelines.
In the Quick Safety report, there are several suggestions for tackling the problem of drug diversion in hospitals:
1. Make prevention your primary goal. If your employees know you're watching and holding them accountable, they will think twice about attempting to steal drugs. Healthcare facilities must have systems to facilitate early detection. The Joint Commission suggests video monitoring of high-risk areas, active monitoring of pharmacy and dispensing record data, and remaining alert for behaviors and other signs of potential diversion activity. Teach your employees to follow the mantra: "See something, say something."
2. Even your best employees might be diverters. Diverters don't fit commonly held perceptions or stereotypes of individuals who are stealing and abusing drugs, which is important for staff to understand when watching for diversion activity.
3.Consider how easy it is to obtain medications. Diversions can happen in places with little supervision of nurses or overnight shifts where nurses know no one would be holding them accountable for the medications they are dispensing to patients. Ensure you have safety protocols in place on all shifts, in every unit, and hold every staff member accountable.
4.Beware of agency nurses or temps. Many hospitals employ nurses contracted by outside agencies, many of whom work in several hospitals at once. This not only gives diverters more access to drugs, but it also makes it harder to get caught. In some cases, agency nurses are not held to the same standards as hospital employees.
John Palmer is a freelance writer who has covered healthcare safety for numerous publications.
PSQH: Patient Safety & Quality Healthcare, September 13, 2019
Research shows that many physicians are unprepared for conducting behavioral health screening and brief interventions.
This article was first published by PSQH on August 29, 2019.
By Megan Headley
Behavioral health is getting big attention, but one of the biggest attention-grabbers is the realization that few primary care providers (PCP) know how to address it.
An estimated 65 million Americans will have a mental health or substance use disorder in their lifetime, which raises the risk of disease and mortality as well as increases healthcare costs.
A recent survey of physicians found 57% reported that they don’t feel adequately prepared to screen patients for substance use or mental health disorders or to provide patients with information about the associated health impacts.
The survey's report, "Are Healthcare Professionals Ready to Address Patients' Substance Use and Mental Health Disorders?" was co-authored by Deborah Finnell, DNS, faculty consultant at Johns Hopkins School of Nursing, and Glenn Albright, PhD, co-founder and director of research for the health simulation company Kognito.
The authors note that at a time when the prevalence of drug overdoses is contributing to a reduction in life expectancy, when alcohol accounts for one in every 10 adult deaths in the United States, and when depression and suicide rates continue to rise at an unprecedented rate, there is renewed impetus to treat substance use and mental health issues like other health conditions. The authors suggest that better-prepared PCPs can make a bigger dent in lowering these statistics.
"There is … evidence that people with substance use disorders are more willing to enter treatment in a primary care setting than in a specialty setting," the report says. "For healthcare providers to keep pace with this need, they must have the knowledge and skills to address the needs of patients with behavioral health conditions as part of routine practice and on par with any physical illness."
SBIRT model of care
With the prevalence of behavioral health and substance abuse problems among Americans, it is more important than ever for caregivers to become competent in using screening and brief intervention (SBI) techniques that can help identify patients who may need treatment.
The Institute of Medicine recommends the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model of care as an approach to identifying people at risk of substance abuse disorders. The model features three components:
1.Screening: A healthcare professional assesses a patient for risky substance use behaviors using standardized screening tools.
2.Brief intervention: A healthcare professional engages a patient showing risky substance use behaviors in a short conversation, providing feedback and advice.
3.Referral to treatment: A healthcare professional provides a referral to brief therapy or additional treatment to patients who screen in need of additional services.
Despite the value in this approach, the Kognito report reveals the concerns physicians have about implementing SBI such as adding time to patient visits and problematic reimbursement of these services. Instead of SBI, many physicians opt to skip straight to referral, hoping for adherence as they shift the burden to other caregivers.
Despite feeling unprepared, 84% of the Kognito survey respondents reported they were likely to use the SBIRT model for some patients. While this may indicate a willingness to help, it also can yield healthcare cost increases due to unnecessary specialist billing.
Barriers to successful screening
World Health Organization guidelines for identifying alcohol use disorders suggest that only about 5% of the total population will require a brief intervention and referral to a specialist, but an additional 25% would benefit from a brief intervention.
Early identification of people at risk for substance abuse, as well as countless others suffering from mental health disorders, can be lifesaving and cost-effective. Kognito points to research indicating that every dollar spent on SBI for alcohol use can lead to $4 in savings on future healthcare costs. Team-based care for depression integrated into primary care can save up to $6 for every dollar invested. And yet, the survey clearly demonstrates that few PCPs feel comfortable with screening techniques.
Chris Dorval, MSW, LICSW, became project coordinator of the Rhode Island College School of Social Work SBIRT Training and Resource Center after years of working in the substance abuse world, where he often wondered how many of his patients could have benefited from much earlier interventions.
"It happened time and again, where people came to me with multiple health complications like hypertension, Type 2 diabetes, and kidney or liver issues, which were all related to their substance use," he says. "I would ask if they had spoken about the relationship between their health conditions and their substance use with their healthcare professional, and they would almost always say, 'No, it never came up' or, 'They didn’t ask, so I didn’t tell.' "
A lack of training and education on available resources is one significant obstacle for PCPs, but there may be other factors holding physicians back.
"I think sometimes primary care physicians don't ask because the stigma around substance use is still very much there and creates an uncomfortable situation for both patient and provider," Dorval says. "It is unfortunate, because not asking the questions and normalizing the questions themselves covertly reinforces that stigma by suggesting that asking that question is somehow 'bad' or 'taboo.' Others don't ask because they are not trained how to ask, or what to do if the patient does indicate that they are using in an unhealthy way.
Dorval offers a few tips for normalizing questions during the screening process because "asking people about substance use is only as uncomfortable as we make it out to be.” He suggests physicians:
Be assumptive with open-ended questions. Ask, "How often do you drink alcohol?" not "Do you drink alcohol?" Ask, "How often do you use drugs?" not "Do you use drugs?" Asking in this way normalizes the behavior and allows for conversation. The patient can always say, "I don’t drink or use drugs," but this phrasing gets the conversation started.
Use recovery-friendly language. Avoid words like "clean," "dirty," "alcoholic," or "addict." Words like this can reinforce stigma and make conversations more difficult. An August 2018 article on substance use, recovery, and linguistics shows just how much language matters. Certain terms, including "substance abuser," "addict," "alcoholic," and "opioid addict," elicit strong negative biases, the article says. Changing language is a first step toward removing the stigma around substance abuse and developing a mindset for both client and clinician that the client can benefit from treatment.
The Center for Integrated Health Solutions, funded by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration, provides a number of screening tools online. The American Mental Wellness Association provides additional resources.
Collaborate on brief interventions
Screening is daunting but starting a conversation around behavioral health can seem like even more of a challenge. Yet having a conversation is the key to a successful intervention. A brief intervention should not be a lecture on the need to "break a bad habit" or seek treatment. Instead, experts advise using a collaborative communication style, such as motivational interviewing.
Motivational interviewing is a client-centered counseling style in which the client, not the clinician, voices the reasons for change. It may seem a foreign concept for physicians accustomed to giving instructions. Confusion about how to intervene left 64% of the Kognito survey respondents feeling inadequately prepared to use motivational interviewing to enhance their patients' motivation to change their behavior or seek help. Likewise, 62% reported that they did not feel adequately prepared to collaborate with their patients to create an action plan.
Kathleen Sciacca, who provides consulting and training on dual diagnosis and motivational interviewing, explains in her video series for the Motivational Interviewing Network of Trainers that the collaborative style behind motivational interviewing is vastly different from the authoritarian approach of most client-provider relationships. "An authoritarian approach is simply telling, without doing very much listening. That tends to put the person out of the process and will likely result in non-adherence or a discordant relationship," she says.
Sciacca offers four guidelines for effective motivational interviewing:
Ask permission: When giving advice or expertise, always ask permission. For example, a clinician might say, "Would you like to learn more about the aids that are out there for smoking cessation?"
Give reflective feedback: Reflective listening is about listening for the patient's experiences and perceptions and reflecting those back. This helps patients feel heard and know that what they say is important.
Try elicit-provide-elicit: Rather than heading right into treatment advice, the clinician should find out what the client already knows to avoid providing repetitive information that the client might tune out. The clinician can then give information, and finish by asking again how the client sees options working for him or her.
Grow more directive as the relationship grows: The goal in SBI is to facilitate change. However, this process needs to focus on why change is beneficial to the client rather than why the clinician thinks it is beneficial. If a client engages in sustained talk such as "Things are OK the way they are," it's up to clinicians to steer the client toward change talk such as "Is there anything at all that concerns you about leaving things this way?”
Referrals to the right partner
About 5% of the total population will require referral to a specialist, but Kognito's survey found a 25% referral rate to be more typical. The result, in many cases, is systematic referral of patients to specialists who could benefit from a brief intervention and treatment in primary care, leading to higher costs and a decreased likelihood of patients pursuing follow-up care.
While improving the SBI process can help, it also is critical that PCPs connect early on with behavioral health experts or substance use treatment providers so that when they do start screening, they can get people into treatment quickly.
“Substance use treatment is unique from many other healthcare treatments in that many people who need it do not necessarily want it. Providers making a referral need to make the referral quickly before the patient's window of willingness closes. The referral needs to stick as well. Handing them a card or a number to call is not enough. They need to schedule the appointment with the patient at the substance use treatment facility before they leave the office," Dorval says.
Brent Westhoven, CFO of Arlington, Virginia-based Advantia Health, noted at a recent event that a warm handoff to a mental health professional within the same building has a much higher compliance rate. One expert with whom he worked saw her patients' compliance rate in pursuing psychiatric care jump from 10% to 70% following a warm handoff.
Ongoing education
As the focus on behavioral health grows across the country, training and educational opportunities are likely to increase as well. Ongoing education on new ways to interact with and serve patients will be critical in expanding care.
"Providers, patients, and communities need to be educated on what addiction is, what recovery is, and what treatment is," Dorval says. "This is a big undertaking, but it needs to be done if we are ever going to make a dent in the progressive growth of substance use in our society."
Dorval encourages clinicians to reach out to state health departments, professional development agencies, or colleges to find resources offering training and information on SBIRT. And the burden should not fall on the PCP alone.
"Many primary care offices are lacking in the resources to be able to provide integrated behavioral health services," Dorval says. "Managed care organizations need to make these integrated services a billable service compensated at a reasonable rate so that providers are able to offer a full continuum of services to their primary care patients."
Megan Headley is a freelance writer and owner of ClearStory Publications. She has covered healthcare safety and operations for numerous publications. Headley can be reached at megan@clearstorypublications.com.
PSQH: Patient Safety & Quality Healthcare, September 6, 2019
Particularly among surgeons, cognitive decline and degraded skills raise concern over patient safety.
This article was first published by PSQH on August 29, 2019.
By John Palmer
It turns out the doctor doesn’t always know best—at least not when it comes time to hang up the scalpel.
An accepted norm in the medical field is that with age comes more experience, and therefore more knowledge. That may hold true—but at what point does old age mean that surgeons can’t do their job anymore? Is there a point where a doctor’s age makes him or her a danger, given a profession where a simple slip of a scalpel or lapse in judgment could mean the difference between life and death?
A 2017 study published in JAMA Surgery took on this question, and several recent media reports have asked whether it’s time to start questioning the elders and take such steps as requiring a mandatory retirement age for surgeons.
According to the study, the number of practicing physicians older than 65 in the United States has increased by more than 374% since 1975. In addition, in 2015, 23% of practicing physicians were 65 or older.
The article notes that between the ages of 40 and 75, the mean cognitive ability of most people declines by more than 20%, but there is significant variability from one person to another. This indicates that while some older physicians are visibly impaired by their age, others more easily retain their ability and skills.
Mandatory retirement for surgeons
What criteria should be used to determine that a surgeon is just too old to continue working in the surgical field? And who should make the final decision? Not surprisingly, many other high-stakes professions have mandatory evaluations and/or retirement ages, yet the medical industry still has some catching up to do. For example, federal requirements cap an airline pilot’s career at 65, yet a surgeon’s career can extend well past that point.
“There are age-based requirements for periodic testing and/or retirement for many professions including pilots, judges, air traffic controllers, Federal Bureau of Investigation employees, and firefighters,” the article concludes. “While there are not similar requirements for physicians, a few hospitals have introduced mandatory age-based evaluations.”
But while hospitals may be able to get away with mandatory evaluations of their staff, can they force retirement on doctors who feel they are still cognitively able to perform their jobs—and who can still pass those evaluations? And is such a move prudent when years of experience are so highly regarded by patients?
“A mandatory retirement age could be discriminatory and take many competent physicians out of practice and risk a physician shortage,” the report concludes. “An increasing body of evidence regarding the relationship between physicians’ age and performance has led organizations, such as the American College of Surgeons [ACS], to revisit this challenge.”
The April 2014 issue of the Bulletin of the American College of Surgeons explored this relationship, and the ACS found that in a study of 359 surgeons, “subjective perception of cognitive changes did not correlate well with objective assessments.” In other words, older surgeons may think they are just fine to keep doing their jobs, but outside evaluations might say otherwise. Yet most hospitals seem willing to side with the surgeon—that is, until he or she makes a mistake and causes the hospital to be sued.
“Patients, colleagues, payors, hospital administrators, plaintiffs’ attorneys, and physicians all have a stake in this issue, which calls for an urgent response from the surgical community,” the report concluded. “The profession must be able to assure patients that their surgeons are trained to deliver safe care. The profession must also be able to prove that it has developed thoughtful, proactive, logical policies or risk the imposition of external regulation.”
'I kind of dozed off'
A prominent surgeon at Englewood Hospital and Medical Center in New Jersey, Dr. Herbert Dardik, allowed the professional consequences of his own aging to become scrutinized. In a February 2019 article in the New York Times, the respected 80-year-old chief of vascular surgery at the hospital humbly described nodding off during a 2015 carotid endarterectomy, a delicate operation during which the carotid artery is cleared of plaque, improving blood flow to the brain.
To be clear, Dardik was not operating on the patient in this case. He chose not to do the surgery himself because he was recovering from a minor procedure he had undergone a few days prior, but after the patient insisted, he agreed to act as a supervisor for the surgeon performing the lengthy procedure.
“I was really an accessory,” he told the Times. “It was so boring, I kind of dozed off.”
One could maybe laugh at the scenario if Dardik was, say, a schoolteacher dozing off in the middle of proctoring an exam, but it’s a different story when his snoozing could have meant overlooking a crucial mistake in a dangerous operation.
A nurse present in the room reported the incident to hospital administrators, who then asked Dardik to reduce his workload at the hospital. Initially, he was angry at the request, but days later, after subconsciously questioning the age of a pilot he saw while taking a flight, he realized that people judged him as a doctor in the same way.
“You think you’re invincible,” he told the Times. “But the clock ticks, and I’ve become an advocate for evaluation.”
After he began experiencing back pain, Dardik decided to voluntarily step down from operating in 2016 and instead focus on research and teaching. He also decided to take part in a two-day aging surgeon assessment program, started by Sinai Hospital in Baltimore to evaluate older surgeons and determine whether they could safely continue practicing. Ultimately, the program found Dardik capable of continuing his career.
Evaluation of aging doctors
For its part, the ACS says that age alone is a poor predictor of how risky a surgeon will be in the operating room, mostly because we all age differently and our cognitive and technical skills decline at different rates. At the same time, we are our worst enemies; a peer’s critical review of behavior and skills is likely to unleash a bit of insecurity. No one likes to be told they are getting old, but sometimes a surgeon’s own word isn’t enough to convince others that he or she is fit to continue practicing.
“Considering the fact that personal healthcare issues may contribute to the decline of cognitive and technical skills, periodic medical evaluation is an essential part of the assessment,” according to the ACS report findings. “Whereas the individual surgeon may fail to recognize or may deny diminishing skills, peer evaluation by direct observation also is important.”
Then there’s the matter of how to recommend further assessment to a doctor. ACS says that sometimes, it’s difficult to detect subtle changes in a person’s decision-making skills or technical skills simply through peer observation, and therefore further testing is warranted.
“It is also essential that these appraisals be applied equally and be carried out in a confidential manner that maintains the dignity of the surgeon,” the report notes. In other words, if you’re going to require it for one person, you should require it for everyone.
The report singles out Stanford University Medical Center in California, which now employs a policy requiring all medical staff ages 75 and older to have a physical examination, cognitive screening, and peer assessment of their performance every two years. The findings are kept confidential and referred to a committee, which determines whether further steps are needed.
Would it be safer to have surgeons to reduce their number of surgeries as they age? Well, unfortunately, surgery isn’t like riding a bike: The ACS report suggests that unless surgeons use their skills regularly, they’re likely to get rusty.
“Aging surgeons who gradually decrease the volume of these procedures may experience a counterproductive deterioration in the skill sets necessary for safe conduct suggesting that an ‘all or none’ approach to complex procedures is better to maintain skills and a safe practice,” the report authors conclude.
For those surgeons who may need to be removed from the operating room but want to remain in practice somehow, there is plenty for them to do. ACS says they can still play a vital role in several areas:
Assisting in operations, focusing on an office-based or an academic practice, staffing clinics, and rounding on clinical services
Mentoring junior colleagues, ranging from offering informal advice to developing a departmentally defined relationship
Teaching surgical topics and anatomy to both residents and medical students
Administrative and quality/performance improvement activities, such as establishing and implementing quality improvement programs
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, September 3, 2019
The business case for age-friendly health systems offers push to standardize best practices.
This article was first published by PSQH on August 29, 2019.
By Megan Headley
By 2030, every one of the 78 million baby boomers will be over 65, reports the U.S. Census Bureau, a figure that will exceed the number of children for the first time in history. These are staggering statistics, and to effectively care for all these aging adults, providers must implement solutions today.
While healthcare providers are aware of these statistics, and many health systems are already hitting upon effective solutions to care for older adults, there's an overall lack of consistency in how systems approach this challenge.
That's what the Institute for Healthcare Improvement (IHI) is trying to change.
A framework for elder care
"We have a growing number of older adults in the system," says Leslie Pelton, MPA, senior director for IHI. "We know that they are harmed more often by the system, and we also know that their care can be quite complex. We also know how to take care of those adults really, really well. That's the 4Ms."
The 4Ms are the framework that emerged from IHI's Age-Friendly Health Systems initiative, launched together with the John A. Hartford Foundation, the American Hospital Association, and the Catholic Health Association of the United States in 2016.
IHI describes an age-friendly health system as one where older adults get the best care possible, experience no healthcare-related harms, and are satisfied with the care they receive. These systems are optimized for all participants in this process, including families and caregivers. Achieving these goals is based on meeting four elements that make up the 4Ms framework:
What Matters: Align care across settings and in accordance with each older adult's health outcome goals and care preferences, including but not limited to end-of-life care.
Medication: If medication is necessary, use age-friendly medication that does not interfere with What Matters to the older adult, Mobility, or Mentation across settings of care.
Mentation: Prevent, identify, treat, and manage dementia, depression, and delirium across care settings.
Mobility: Ensure that older adults move safely every day to maintain function and do What Matters.
The 4Ms do not introduce a new way of delivering care; rather, they standardize best practices to ensure care is consistently high-quality. As Pelton puts it, the framework is "about moving from the evidence-based care happening sometimes, with some older adults in some places some days, to the reliable practice of the evidence-based care."
The business case for age-friendly care
In driving adoption of the 4Ms framework, IHI observed that a piece was missing to get more health systems to create a framework for the processes they already were putting in place.
"As the 4Ms emerged and there was more and more interest in adopting those in health systems across the country, we recognized that the places that the 4Ms were in practice weren't necessarily articulating the business case for doing so," Pelton says. As she puts it, there are two perspectives that must come together: the clinical care perspective and the business perspective.
This year IHI published a report titled The Business Case for Becoming an Age-Friendly Health System and introduced a return on investment (ROI) calculator that can help health systems form their own business case perspective for adoption of the 4Ms.
As the report explains it, "Making the business case means providing evidence regarding financial returns—the instrumental value—from investing in becoming an age-friendly health system. The business case does not include improved outcomes or satisfaction—the intrinsic value—that result for patients and their families. If the age-friendly health system can show instrumental value, however, its intrinsic value is more likely to be sustained."
Value has become central to every discussion in today's healthcare environment. With the cost of healthcare rising to 17.9% of the U.S. GDP in 2017, health systems are cracking down on balancing lifesaving practices with the cost of implementation.
So, IHI set out to develop an ROI calculator that would enable health systems to look at the financial impact of reliably practicing evidence-based care. IHI director Victor Tabbush, PhD, adjunct professor emeritus at the UCLA Anderson School of Management, was recruited to develop a spreadsheet that systems can download to run their own calculations. That tool is now available at IHI.org/agefriendly.
Perhaps not surprisingly, the evidence seems to indicate that reliable evidence-based care is all-around good.
Hartford Hospital tracks the data
Hartford Hospital, an 850-bed inner-city teaching Level I trauma center and one of seven hospitals within the Hartford Healthcare Network, is an example of how a standardized approach can make a strong business case for implementation. The hospital's approach to screening for delirium is a case study within the new IHI report.
Since 1990, the hospital has had a team of geriatricians and nurse practitioners within its Division of Geriatric Medicine and Gerontology who provide care to seniors in the acute care hospital, sub-acute, long-term, and community settings. The inpatient geriatric consult service, comprised of a geriatrician and an advanced practice registered nurse certified in geriatrics, was frequently asked to see older adults with impaired mental status, fall risk, and frailty; providers and nurses sought help with understanding these patients' problems and guidance on how to care for them.
"Many of these patients were experiencing delirium and required a more thorough workup to explain the etiology of the delirium and a comprehensive plan of care to keep them safe and cognitively and functionally engaged," explains Christine M. Waszynski, DNP, APRN, GNP-BC, with Hartford Hospital. "Delirium prevention, treatment, and management were identified by our team as an area in which improvements could be made."
The hospital's geriatrics team developed a plan to implement a comprehensive, standardized, and evidence-based delirium program. First, they developed inpatient geriatric consult service team members as true delirium experts. Next, they set out to justify the need to pay attention to delirium by establishing a baseline measurement of delirium prevalence.
A retrospective review of 596 randomly selected patient records from January 1, 2002 to December 31, 2005 found 36.9% of patients experienced delirium during their hospitalization. Moreover, 87.5% of patients who died had experienced delirium at some point during their hospitalization, and 70% of patients who died met criteria for delirium at the time of death. "The collection of data enabled us to demonstrate delirium to be a common syndrome for our patients associated with poor outcomes," Waszynski explains.
But Hartford Hospital still had gaps to address before turning the numbers around. At that point, there was no formal screening tool in place to assess for delirium, and there was no standardized order set to guide the diagnostic workup and care of these patients. That had changed by 2006, when nursing staff pilot-tested a delirium screening tool that ultimately was rolled out to all units and all patients.
More data supported the corrective actions taken. "As we went to the electronic medical record in 2010, we were able to quantify delirium rates and related outcomes. As we shared this information with hospital leadership, it became evident that delirium prevention and evidence-based treatment and management strategies should be a priority," Waszynski says.
In 2011, Hartford Hospital launched its Actions for Delirium Assessment Prevention and Treatment (ADAPT) program to screen all patients for delirium, treat those that showed signs, and manage cases that could not be resolved.
An interprofessional team set out to create a pathway for clinicians to work with patients at high risk for or already experiencing delirium. "This team has continued to meet over time to refine our approach based upon new evidence and to review our impact. Our unit geriatric resource nurses play a critical role in the day-to-day oversight of delirium care," Waszynski says.
Demonstrated cost and care improvement
The time spent managing cases related to delirium was staggering. In 2018, the hospital diagnosed delirium ranging between 5% and 50% of all hospitalized patients within ADAPT-participating units. And that time was associated with incredibly high costs. For example, the hospital spent $96 million in care related to delirium from July 2015 to June 2016 alone.
As the IHI report notes, "While the financial dimension is generally not the decisive factor for adopting the 4Ms, an attractive ROI should serve to encourage the scale-up and spread of age-friendly hospital care."
Certainly, that was the case for Hartford Hospital. "Leadership of healthcare organizations need evidence to determine where resources should be prioritized in order to better service their patient population," Waszynski points out.
According to Dr. Robert Dicks, Hartford Hospital's geriatrics program director, "It is optimal to demonstrate not only the projected cost saving but the actual impact of a program using your own data. Real-time data allows for feedback, quality assurance, and the engagement of clinicians and leadership."
Prior to running the numbers through IHI's ROI calculator for age-friendly health systems, Hartford Hospital tracked its own ROI across several criteria through a delirium registry that captures the hospital's delirium prevalence and incidence with related outcomes.
With the assistance of ADAPT team members of the Hartford HealthCare Research Institute, that data has demonstrated a 40% cumulative decrease with an incremental 8% decrease annually in delirium-attributable days—without an increase in hospital mortality or readmission in patients developing delirium. The team also has demonstrated a decrease in 30-day readmission rates and an increase in return-to-home transition at time of hospital discharge for this vulnerable population. "This was accomplished in spite of increased acuity and census," Waszynski adds.
And the business case? Waszynski says, "We found that the number on the calculator was very close to the number we had calculated ourselves: $6 million in savings annually from the ADAPT program."
ADAPT screened more than 31,000 patients at Hartford Hospital in 2018. Plans are in process to replicate ADAPT across the system's hospitals, starting with a demonstration project in one setting. Components of ADAPT have been implemented in postacute settings with an ongoing evaluation of the impact.
Adding to the evidence
Health systems understand the impact of tying the business case to clinical care. On a recent call introducing the ADAPT program, more than 50 health systems asked questions about how to use the ROI calculator to build their own business case for being an age-friendly health system. These systems have the tools in place but haven't yet quantified their usefulness.
Pelton also sees this ROI calculator as a way of empowering champions of older adults. "It allows them to make sure they can articulate the business case side by side with the right clinical care for older adults," she says.
For health systems pulled in so many directions, it pays to understand what actions can be taken to reduce costs—and to apply that funding to broader ways of providing safe, quality care.
Megan Headley is a freelance writer and owner of ClearStory Publications. She has covered healthcare safety and operations for numerous publications. Headley can be reached at megan@clearstorypublications.com.
PSQH: Patient Safety & Quality Healthcare, July 31, 2019
The best resuscitation care was associated with rapid-response teams that had dedicated staff without competing responsibilities and that could be activated by a member of the care team without fear of repisal.
A new study found that, in top-performing hospitals, rapid response teams (RRT) have a dedicated staff and clear autonomy.
The study, published in JAMA Internal Medicine,examined RRT programs at nine hospitals to determine how they differed between facilities that provided resuscitation care.
Researchers interviewed 158 hospital staff members, including nurses, physicians, and administrators, during site visits to hospitals participating in the Get With the Guidelines-Resuscitation program. The RRTs at top-performing hospitals for resuscitation care had dedicated staff without competing responsibilities, served as a resource for bedside nurses to provide surveillance of at-risk patients, collaborated with nurses during and after a rapid response, and could be activated by a member of the care team without fear of reprisal.
According to the study, in-hospital cardiac arrest (IHCA) affects more than 200,000 patients annually in the U.S. RRTs are part of a strategy to prevent IHCA and are used by most acute-care hospitals in the country. The cost of staffing and maintaining an RRT is estimated at more than $1 million over a five-year period at a medium-size hospital.
For hospitals considered not to be top performers, the researchers found there was more of an ad hoc approach to RRTs, where new members were routinely brought to the teams; the new members had varying levels of skill and communication and may have hindered the success of the teams. RRT activations were treated as individual events addressed in the moment and were less likely to provide collaborative opportunities for shared learning and improvement over time, according to the study. Fear of reprisal and worries over being judged as less competent may have led to a reduced willingness from nurses to activate an RRT.
PSQH: Patient Safety & Quality Healthcare, June 20, 2019
Organizations should clarify what symptoms require exclusion from work and develop policies for working while symptomatic, says the study's lead author.
Many healthcare workers may be putting patients at risk by continuing to work when they have symptoms of cold, flu, or other respiratory illnesses, according to a new study published in Infection Control & Hospital Epidemiology.
The study found that 95% of healthcare workers have worked while sick, most often because the symptoms were mild or began during their work shift.
"We found that physicians and people working in areas that required the most intensive contact with patients were less likely than other workers to stay home or to leave work if symptoms progressed after the start of the day," said Brenda Coleman, PhD, clinical scientist in the Infectious Disease Epidemiology Research Unit at Mount Sinai Hospital, Toronto, and lead author of the study, in a release. "Managers and senior staff need to both model and insist on workers staying home when symptomatic as it protects both patients and coworkers from infection."
The study, published in the journal for the Society for Healthcare Epidemiology of America, found that 92% of healthcare workers report to work while symptomatic for an acute respiratory viral illness. Hospital-acquired respiratory viral infections cause significant illness and death, in addition to increased healthcare costs. The Centers for Disease Control and Prevention recommends that healthcare workers with fever and respiratory symptoms consider temporary reassignment or exclusion from work while they are symptomatic.
Researchers conducted a four-season prospective cohort study of influenza and other respiratory illnesses in nine Canadian hospitals in Toronto, Hamilton, and Halifax. Healthcare workers in hospitals who worked more than 20 hours per week filled out daily online illness diaries whenever they developed symptoms; these included information about symptoms, possible exposure, attendance at work, reason for work or absence, and medical consultations.
In all, 10,156 illness diaries were completed by 2,728 participants. Diaries of workers who were not scheduled to work were excluded, which left 5,281 diaries for analysis. Sixty-nine percent of participants said they worked during an illness because their symptoms were mild and they felt well enough to work, 11% said they had things to finish at work, 8% said they felt obligated to work, and 3% responded that they couldn’t afford to take the time off. Half of the participants said they had episodes of acute respiratory viral illness during influenza season, with 95% of those working one or more days of their illness. Of the study participants, 79% said they were entitled to paid sick leave.
Coleman said the study illustrates the need to educate healthcare workers, managers, workplace health/safety/infection control staff, and administrators about the transmission risk associated with respiratory viral infection. Organizations should also clarify what symptoms require exclusion from work and develop and roll out policies for working while symptomatic, she added.
PSQH: Patient Safety & Quality Healthcare, June 18, 2019
Patients say they are concerned for their own safety when they notice healthcare workers experiencing burnout.
The issue of healthcare professional burnout is a major concern for 74% of Americans, according to a new survey released this week by the American Society of Health-System Pharmacists (ASHP).
The survey was conducted online in May by The Harris Poll on behalf of ASHP, polling 2,000 U.S. adults. It follows a 2018 study published in the American Journal of Health-System Pharmacy (AJHP) that found 53% of pharmacists reported a high degree of burnout caused by increased stress and job demands. In addition, a Mayo Clinic study found that burnout costs the U.S. healthcare system approximately $4.6 billion per year.
In the ASHP survey, a quarter of Americans said they believe hospital pharmacists (26%) and retail pharmacists (25%) are often burned out. The AJHP study found that pharmacists say burnout is driven by increased workloads, periodic drug shortages, and demands from electronic health records, insurance, and regulatory requirements.
The new poll found that 91% of respondents feel it is important that their physician, pharmacist, nurse, or other healthcare professional should do whatever is necessary to avoid burnout. Another 77% said that when they notice their clinician feeling burned out, they become concerned about their own care and safety.
Patients are aware of healthcare professional burnout, with 47% saying they would avoid asking questions if they thought their care provider appeared burned out so as not to add to the provider’s stress.
ASHP recently rolled out a new portal, WellBeing & You, to provide pharmacists, student pharmacists, and pharmacy technicians with a place to share their experiences with burnout and find resources to help them deal with the issue. To boost resilience, ASHP encourages healthcare organizations to:
Recognize the presence and risk of burnout in the workplace
Identify risk factors for burnout
Form a committee to explore burnout causes and resilience solutions
Evaluate changes to confirm an increase in employee resilience
PSQH: Patient Safety & Quality Healthcare, May 22, 2019
The presence of mold forces the facility to reschedule or move dozens of surgeries.
Seattle Children’s Hospital shut down four of its 14 operating rooms (OR) this week after mold was detected last weekend, forcing the facility to reschedule or move dozens of surgeries.
A routine check discovered the Aspergillus mold, according to a Seattle Times report. No date was given for when the ORs could be reopened.
“Patient safety is our top priority, and we are taking this situation very seriously,” Alyse Bernal, the hospital’s public relations manager, told the Times. “All affected operating rooms have been closed and will remain so until we are confident that the areas are clear of Aspergillus.”
Aspergillus is a common type of mold that poses a low risk to surgical patients, but Seattle Children’s is contacting about 3,000 patients who underwent procedures in the past four months, said Bernal. People with weakened immune systems or lung disease could develop complications after exposure to the mold.
About 50 surgical procedures were rescheduled, moved to Seattle Children’s Bellevue campus, or will take place in other rooms on the hospital’s Seattle campus, the Times reported.
The hospital is currently working to figure out how the ORs came to have Aspergillus in them. Its cleaning protocols include using an antimicrobial cleaner after each surgery and at the end of each day and using air filtration to keep the ORs under positive pressure, Bernal said.
Mold found in Staten Island University Hospital (SIUH) North's maternity unit is being blamed for dozens of employees falling ill in recent months, according to a New York Daily News report.
Approximately 53 nurses and other healthcare workers in the maternity unit reported illnesses such as headaches, dizziness, and swollen throats after air monitoring devices found the presence of mold and trace amounts of anesthetic gases. Hospital officials say no patients have had symptoms.
In September, staff reported a chemical odor in the nursery on the hospital's maternity floor; several reported suffering from headaches and experiencing dizziness. After the odor was reported, nurses requested that the babies be moved to a backup nursery in the maternity unit.
One nurse, Robyn Jacobs, 65, told the Daily News that she would get sick every time she entered the nursery. Her symptoms included headaches, swollen glands, and sore throats. She also indicated that as many as eight nurses became sick the first day the odor was identified.
After air monitoring was done, mold was found at moderately elevated levels, with waterborne mold found behind a sink wall. The area was decontaminated, and the nursery is being rebuilt after recent air monitoring results found the air to be clear, according to the report.
The hospital has conducted numerous air quality tests and in a recent statement said there was "no risk to patients, staff, or visitors."
"Hospital administration has been directly communicating with staff multiple times a week, met with union representatives numerous times and notified the appropriate regulatory agencies to proactively address this matter," SIUH Executive Director Brahim Ardolic, MD, said in a statement to NBC 4 New York. "Our main focus has been to properly mitigate the nursery area to continue providing care in the safest environment possible for our patients and staff."
More to the point, CMS is seeking public opinion on this issue. On December 18, the federal agency pre-published a request for information on "Medicare Program: Accrediting Organizations Conflict of Interest and Consulting Services."
"This request for information seeks public comment regarding the appropriateness of the practices of some Medicare-approved Accrediting Organizations (AOs) to provide fee-based consultative services for Medicare-participating providers and suppliers as part of their business model," according to the notice published in the Federal Register.
"We wish to determine whether AO practices of consulting with the same facilities which they accredit under their CMS approval could create actual or perceived conflicts of interest between the accreditation and consultative entities. We intend to consider information received in response to this RFI to assist in future rulemaking," CMS says.
CMS: Public Trust an Issue
"We are concerned that the practice of offering both accrediting and consulting services – and the financial relationships involved in this work – may undermine the integrity of accrediting organizations and erode the public's trust," said CMS Administrator Seema Verma, in a prepared statement announcing the initiative on December 19.
Noting that healthcare providers that seek reimbursement through Medicare or Medicaid must meet sometimes lengthy Conditions of Participation in Medicare or Conditions of Coverage, the agency also notes in its RFI that some providers go through AOs for what is referred to as "deemed status" to be able to bill CMS.
There are several AOs for various healthcare providers and suppliers, but one of the largest and oldest is The Joint Commission. (Some histories of the CoPs note that TJC's predecessors were accrediting hospitals for decades before Medicare existed and that some believe TJC standards were used as a model for the CoPs in the 1960s.)
TJC and other AOs came under fire over the past few years after CMS highlighted disparities between patient safety problems identified by AO surveyors and those found by CMS state surveyors in follow-up surveys several weeks later.
While compliance officers and consultants have noted that often problems found by CMS surveyors did not exist at the time an AO was on site, the disparity rates were reported to Congress as part of CMS' annual report on how it manages hospital and healthcare accreditation. That, combined with an article in September in the Wall Street Journal critical of TJC, spurred a House subcommittee to launch an investigation into the integrity of AO operations. [Editor's note: See correction at bottom.]
Investigation Spurs RFI
That investigation is, in part, behind CMS' request for comment on potential conflicts of interest AOs might have if they have associated interests in consulting services, according to the federal notice. CMS is also looking for ideas for potential solutions to prevent such conflicts of interest.
CMS notes that, as part of its responsibility for oversight and approval of AO accreditation programs, the federal agency reviews each AO's standards, "survey processes and procedures, surveyor training, and oversight and enforcement of provider entities. In addition, we also review the qualifications of the surveyors, staff, and the AO's financial status."
Also, "an AO submitting an application must include a copy of the AO's 'organization's policies and procedures to avoid conflicts of interest, including the appearance of conflicts of interest, involving individuals who conduct surveys or participate in accreditation decisions.' This provision is implemented by CMS's review of submitted documentation to determine that no conflicts of interest exist," according to the notice.
TJC is a non-profit organization headquartered in Oakbrook Terrace, Illinois. Any consulting services are provided through its not-for-profit arm, Joint Commission Resources Inc. On TJC's website, in a brochure with information for those who might want to work for the commission, the commission states:
"Joint Commission Resources, Inc. (JCR), a not-for-profit wholly-owned affiliate of The Joint Commission, provides innovative solutions designed to help health care organizations improve patient safety and quality. The Joint Commission and JCR maintain strict separation policies and have stablished a 'firewall' that prohibits The Joint Commission and the consulting services of JCR from sharing any organization-specific, confidential information about accredited organizations or certified programs, as well as certain accreditation process information."
TJC has released a statement on CMS' request for information:
"The Joint Commission is currently reviewing the Centers for Medicare & Medicaid Services (CMS) request for information seeking comment on accrediting organizations' potential conflict of interest and consulting services.
The Joint Commission recognizes the importance of assuring the integrity of the accreditation process, which we accomplish by prohibiting any sharing of information about consulting services for individual organizations with anyone involved in accreditation. The Joint Commission as an accrediting organization and Joint Commission Resources, Inc. as a provider of education and consulting services are two separate organizations. The Joint Commission enterprise has long-standing firewall policies, practices and procedures in place that assure that this goal is achieved."
In its statement, CMS said the information received through the request for information "will assist in developing potential future rulemaking or guidance. As part of this process, CMS will determine whether revisions should be made to the AO application and renewal process to identify actual, potential, or perceived conflicts of interest."
How to Comment
Comments will be accepted for 60 days after official publication in the Federal Register, which is scheduled for December 20. Note that CMS may not respond to your comment, although you may be contacted for further information. In addition, comments may be made public and materials you submit will not be returned.
Comments should refer to file code CMS-3367-NC. CMS will not accept fax copies of comments. They can be submitted electronically by following the "submit a comment" instructions on http://www.regulations.gov, by regular mail or by overnight express mail.
To find out more about what information CMS hopes to learn, and specifics on how to comment, read the rule at here.
Correction: A previous version of this article incorrectly identified the Congressional committee behind an investigation into the performance of accrediting organizations. It was the Energy and Commerce committee in the House, not the Senate.