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PSQH: Patient Safety & Quality Healthcare, February 15, 2021
Quick-off-the-tongue when slow-off-the-mark is the better proposition.
This article was originally published February 15, 2021 on PSQH by Benjamin E. Ruark
The configuration of day-to-day healthcare practice varies considerably, depending on the type and level of care administered. Anyone familiar enough with different types and levels of care can attest to the general informality with which medical answers and solutions get bandied around in the rhythmic press and exigency of ongoing daily activity, especially in settings peppered by periods of downtime. The glaring exception, of course, is those wards where clinical decision-making steadfastly rules, and where medical answers and solutions more directly reflect the serious nature and high stakes of nonstop care.
What looms as aberrantly apparent, to some at least, is how these two worlds of practice exist side by side, yet only one of them reliably produces answers to questions and valid solutions to medical problems. Still, the other world’s cavalier state of practice conveys hasty answers/solutions that are equally conveyed with 100% certainty, presumed to be actionable. This world is peopled by staff who are unaware they’re functioning more or less in “sleep mode.” In other words, they’re sleepwalking.
The world of the waking, so to speak, is precisely the opposite: characterized by its solemnity in generating, examining, and evaluating potential answers or solutions upon which an informed decision will rest. That decision offers the best chance for success, but only after first articulating how success has been defined. This world is populated by critical thinkers. Obviously, this is the world we should expect all healthcare professionals to inhabit.
Hasty or premature conclusions offered as answers to questions or as solutions to be administered are nothing more than hypotheses cloaked as a sure thing. Across many work contexts, these become unwitting fodder for dialogues of consequence between medical staff, or between a staff member and a patient. In a nutshell, such conclusions are too quick-off-the-tongue when they arguably need to be slow-off-the-mark. Why? Because they can have real consequences if acted upon, and those outcomes are just as likely to harm as they are to help. With this in mind, any time an answer or solution gets uttered so freely, the stakes in the dialogue change. No bells will ring, no alarms will sound—yet the potential for things to go sideways has just ratcheted up considerably.
Lineup of culprits: The usual suspects (influencers), but it’s none of them
Research literature suggests that degradation of nurse judgment and decisions can be traced to the usual lineup of suspects: Time crunch leads to added stress, which leads to fatigue, which leads to poor problem-solving and decision-making. Or, as Goldsby and colleagues (2020) summarize, “Decision-making by nurses is complicated by the stress, chaos, and challenging demands of the work.” Just to clarify: As used here, a judgment is making an evaluation to form an opinion. A decision is arriving at a determination to take a specific course of action, or to take no action at all.
In “Nursing: Inseparably Linked to Patient Safety,” the first chapter from the 2004 book Keeping Patients Safe: Transforming the Work Environment of Nurses, produced by a committee of the Institute of Medicine, we find the oft-repeated statistic of 44,000 to 98,000 hospitalized Americans dying annually as a result of medical errors. Bringing the problem closer to home, Nibbelink and Brewer (2018) cite an Institute of Medicine figure directly attributing 98,000 patient deaths, yearly, to poor decision-making. They also support my earlier claim that nurse decision-making varies by care setting (for example, intensive, emergency, and urgent care vs. primary and long-term care).
This book also mentions a 2002 survey that sampled the American public’s perception of our error-riddled healthcare system. Among its findings:
42% said that they or a family member experienced a medical error
24% added that the error caused serious health consequences
10% reported the death of a family member
11% specified long-term disability as an end result
16% claimed they suffered severe pain
Many of these disastrous outcomes likely link back to “judgment and decision performance” (Yang et al., 2014). Since outcomes are the products of judgment and decision strategies, ploys dependent upon reasoning (if any is to be found) are used to form whatever judgment or decision is invoked.
This reinstates my contention that quick-off-the-tongue answers and solutions—i.e., performances—are rashly and automatically reached, absent of reasoning and reflection. Hence, they are premature and partially accurate at best. In a critical care unit (CCI), for example, we’d assume judgments are formed prudently, regardless of time pressures. And yet Yang and colleagues report that CCI nurses make a judgment every 30 seconds. It’s hard to imagine a high rate of accuracy being sustainable in a work environment where the stresses of recurrent time constraints inflict mental fatigue and erode judgment accuracy.
In her dissertation, McClelland (2007) cites previous research arguing this point: “Fatigue and sleep loss associated with longer shifts often leads to a variety of negative outcomes such as … slower problem-solving, and decreased mental agility … as well as poor decision-making, degraded judgment, and degraded decision-making.” Regardless of shift length (eight vs. 12 hours), there never seems to be adequate time. A 2018 time-motion study of nurses reported results similar to previous studies of hospital environments as follows: 34% of time was spent in patients’ rooms, 21% to 41% was spent on documentation (charting and review), and 8% to 16% was spent on activities that could have been delegated to others—thus viewed as time ill spent (Yen et al., 2018).
The figures are comparable with those reported in similar research by Butler and her cadre of researchers (2018): Nurses spent about 33% of their time in patients’ rooms, 12% outside those rooms (ostensibly writing and reviewing notes), 12% at a nurses’ station (ostensibly charting), and roughly 24% on activities elsewhere within the facility.
These studies seem to agree that nurses spend very little of their shift time in direct contact with their patients. Judgments and decisions are thus surely made outside of patients’ rooms, though we don’t know to what degree. Borrowing a phrase from Ronda Hughes’ seminal chapter in the Patient Safety and Quality (2008) handbook, “the everydayness of errors” suggests that time, stress, and fatigue potentially contribute to mistakes. But the sleeper variable at work in many instances is what I call abject disrespect for the intrinsic severity of decision-making. By frequently making judgments and decisions across wide-ranging situations of varying gravity, those judgments and decisions are at risk of losing their “gravitational pull” over time: waning toward weightlessness and insubstantiality.
Extending this thought, the healthcare environment’s stressors likely exacerbate a tacit norm that it’s OK to bench critical thinking when it’s inconvenient to the moment, or when staff forget to be ever mindful. And with the ever-present effect of modeling—observing coworkers offering answers and solutions on the fly to others’ medical questions and complaints—staff are presented with a ubiquitous notion of “license to violate” that inadvertently snubs more deliberate versions of critical forethought.
The prevailing root cause is unawareness of the repercussions of premature conclusions. There is no norm, policy, or mandate to carefully choose one’s words at all times when discussing potentially actionable answers and solutions; to always preface when a discussion is expressly hypothetical versus when it’s potentially or explicitly actionable. As it currently stands, only select care units impose any form of imperative to be consciously alert to every impending judgment and decision. In care units without that imperative, there is no external mechanism to drive critical thought.
Sleepwalking’s quick-off-the-tongue moniker: System 1 thinking
Supporting my claim that healthcare staff routinely formulate premature conclusions and offer them as answers or solutions are Daniel Kahneman’s System 1 and System 2 thinking concepts, which were introduced in his 2011 book, Thinking, Fast and Slow. In it, he doesn’t reference which brain sites are likely associated with each system, but emphasizes how divided the two systems are in their functioning and real-world consequences. See Figure 1 for a summary.
Kahneman’s System 1 refers to our unconscious mind supplying instant answers out of the blue—i.e., entering consciousness, or quick-off-the-tongue. By their nature, they’re ready-made, instant, or canned answers that aren’t thought through. This renders them vastly incomplete, partially correct at most, and significantly impractical for any intended recipient. Moreover, they have no reference point: They’re missing a patient’s history and other pertinent variables normally gathered through sober and extensive discussion. Such responses are only serviceable for casual conversation with no associated objective.
Paradoxically, questions are useful triggers for arousing slower System 2 thinking and its more deliberate, effortful answers. Yet, when staff are preoccupied for various reasons—such as stress, fatigue, daydreaming, boredom, or roused emotions—they are in an unreflective mental state. In this state, they are more prone to take the path of least resistance: When asked a question, they will rely on their dependably fast and automatic System 1 thinking to respond, and therefore supply whichever answer first pops into their head. This brings us back to the idea of sleepwalking. Brain imaging studies have shown that, during sleepwalking, the prefrontal cortex (PFC) (executive function) and hippocampus exhibit delta waves, indicating snoozing, while the limbic system (including the basal ganglia, mentioned in Figure 1), displays alpha waves, signifying wakeful activity (Berman, 2017).
With the PFC shut down, the executive function of the prefrontal cortex (directly behind the forehead) is temporarily off duty. On hiatus, then, are focused attention, reasoning, motivation, and purposeful intention—all housed there. Meanwhile, System 1’s storehouse of readymade conclusions—aka its fount of textbook and canned answers—is open for business, as poignantly illustrated by three scenarios in Figure 2. In each of them, an answer or solution (seemingly helpful but actually rash) sets off circumstances that result in harm and suffering for patients, and possibly for others as well.
Intentionally slow-off-the-mark with answers & solutions from System 2: Standard practice
As stated in the subtitle, the prized objective of System 2 thinking needs to become standard practice across most care units, except perhaps emergency/urgent care. If need be, staff could apply mental ploys to ensure the fidelity of their System 2 thinking when proffering cure-based answers to questions and suggesting medical interventions to patients and other staff.
For starters, all care units would adopt the following prohibitions:
No judgment or decision in the absence of a focused mind (System 2 must be “on”).
No short or abbreviated answers. Those prove to be partial answers with hidden information gaps.
No shortcuts or cutting corners to arrive at a solution. Instead, take the necessary time to contemplate, ask questions that encompass all pertinent perspectives of a presenting medical problem, reason through the variables involved, and so on.
They would also adopt these unwavering principles:
Trigger a mental alarm whenever formulating a medically related judgment or decision. That alarm shouldn’t abate until the person is reasonably sure their judgment/decision is based on a comprehensive, relatively detailed conclusion that, above all else, is patient-specific. This emphasis, alone, implies looking at any medical problem through a lens of relevant patient information and the patient’s perspective.
Any judgment/decision so made meets two criteria: (a) it is deemed actionable, either as it stands or with explicit caveats amended to it; (b) it speaks directly to the stakes involved if acted upon.
All of the above can point nurses and other medical staff in the direction of habitual critical thinking. However, the bulleted principles would become unnecessary if medical staff were to convert to ubiquitous critical thinking. Toward this purpose, readers are therefore referred to Winningham’s Critical Thinking Cases in Nursing (Harding et al., 2013). Once its five prescribed steps become a matter of personal routine—second nature—the probability of forming premature conclusions drops to zero.
Figure 3 illustrates my recent addition (circled) to the so-called active sharp end of possible influencers of error in healthcare practice. Sharp refers to influencers of error directly attributable to various medical staff, divided into six categories. The circled recent addition, premature conclusions that routinely get proffered as viable answers/solutions, is clearly a subordinate to the category Flawed Cognition. Also, listed on the latent blunt end of influencers are the many organizational and system factors that, when inadequately designed and/or executed, indirectly set up adverse conditions and a greater likelihood for error.
I hope healthcare will soon hold an industrywide conversation in which medical staff decide to habituate en masse to slow-off-the-mark, System 2 forethought and its signature routine of thinking critically. I hope that they choose this as their new norm, their new standard of practice, and that they shun the quick-off-the-tongue answers and solutions we now know pose far too many unacceptable risks.
Benjamin E. Ruark is a former learning and 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, February 2, 2021
Here are lessons in preventing data breaches in healthcare organizations.
This article was originally published February 1, 2021 on PSQH by Matt Phillion
As vaccines for COVID-19 begin to reach more and more people, excitement is building at the prospect of a return to normalcy. But the rollout has also highlighted an ever-present threat in healthcare—and all industries—that has become more prevalent during the pandemic: cyberattacks.
The risks of cyberattacks on hospitals and other healthcare settings was already high pre-pandemic, as these institutions work with sensitive data, like patient information. But attackers never let an opportunity go to waste, and they’ve already targeted the manufacturing and distribution of COVID-19 vaccines—including a known attack on Pfizer.
Healthcare is in a unique position when it comes to cyberattacks. Its data is valuable, and the prominence of contractors, contingent workers, and non-human workers (think medical devices with internet access, for example) offers additional channels for cyberattacks to target. These workers, human and non-, require access to key systems and data to get their jobs done. But securing that access can sometimes be an afterthought for organizations as they look to upgrade or improve their overall cybersecurity posture.
What are the biggest security risks right now for healthcare organizations?
“Third parties are really a top risk. In fact, 59% of all breaches are linked to third parties,” says David Pignolet, president and CEO of SecZetta, which addresses the growing need for better IT security and identity and access management across multiple industries. Roughly half of the organizations SecZetta works with are in healthcare.
“So how can healthcare organizations do a better job? They have to manage the human, and their relationship with the organization,” says Pignolet.
He notes, “You manage the risk of the individual whom you’re granting access to by properly managing their identity life cycle. Typically, organizations have good rigor in place to do this for their full-time employees, but in a healthcare organization there’s a lot of third parties—doctors, nurses, you go down the enterprise and you’ll often find the number of third parties are in excess of the actual population of employees.”
There are tools to manage those risks, however. With the rise of remote workers, the need for comprehensive identity and access management is more important than ever before. “In a pandemic world, you’ve got the riskiest type of users with the riskiest type of access and a fraction of the control you have over employees,” says Pignolet.
One of the issues hospitals need to deal with is something often seen in other areas of safety: A vendor may say they’re taking steps to secure your information, but are they really? It’s worth verifying that a vendor is as secure as they claim.
“It goes beyond controls for access,” says Pignolet. “You’ll want to verify who they are, where they’re located. If someone’s supposed to be in the U.S. and suddenly logs in from China, that’s a problem.”
In addition to human third-party users, many third parties are non-human workers such as devices, robotic process automation, bots, or scripts. These users can sometimes require privileged access, and often that access is not as well managed as it is for humans. “There’s no relationship to a manager in the organization, per se,” says Pignolet.
He goes on to say that you have to tie sponsorship to these non-human workers. Somebody in the organization should be able to attest whether the third parties should exist at all, let alone be granted the access they’re requesting.
Nothing is forever—including access to data
One of the reasons these issues exist, Pignolet says, is slow termination of access. These outside entities, be they third parties or non-human workers, are defined by what they do for the business, not the access they’re granted.
“You end up with all this orphaned account access being used, or worse, the credentials being stolen,” says Pignolet.
Keeping up with access management can be difficult given how many regulatory and compliance demands are placed on the healthcare industry. Those demands aren’t unreasonable, but they can create a culture of checking a box rather than focusing on the underlying reason for the security measures.
“A lot of these regulatory or compliance demands have driven security that may not be sufficient, but they check the box, at least,” says Pignolet. “What healthcare needs to do is move on from check-the-box compliance to actual risk mitigation. Actually controlling risk in the organization, not just doing the things that will get them past an audit.”
It’s a matter of taking that next step in the thinking process. “Why do the regulatory compliance demands exist? To protect people’s data,” says Pignolet. And while legislation might be well meaning, it can’t move fast enough to set forth the controls needed to define risk in a world of cyberthreats that change day to day, if not minute to minute.
How do we look forward?
While it’s one thing to have a policy on cybersecurity risk management, it’s another thing to enforce it. Organizations that look at cybersecurity as a “task” rather than as risk mitigation will tend to generate stopgap measures instead of a culture shift.
“There’s a problem they need to solve, so they throw Band-Aids at it,” says Pignolet.
Of particular interest is the “Wild West” of third-party access, Pignolet says. Organizations tend to use employee-centric policies and tools for managing third-party access, which is often not effective.
“You have control over the employees, and it’s much more well defined, centralized, and controlled by the organization itself. Access is trusted based on that control,” he says. “With third parties, you have controls agreed upon by the vendor, but if you grant access as an employee, there’s more risk. We think you should silo these populations, manage them in a purpose-built way. Their relationship is very different from an employee.”
It’s pivotal to treat these third parties and non-human workers as unique, and to manage them specific to their needs and security risks. “We need to be extra diligent,” says Pignolet.
Best practices to consider adopting should address risk-based authentication, onboarding, and ensuring access is terminated in a timely fashion. “That can be driven by good process relationship management,” Pignolet says.
In addition, anyone you grant access to should be offered security awareness training, particularly in times of greater risk.
“Education is key within any enterprise,” says Pignolet, and not just for the end users. Selling better security controls to the C-suite pays dividends, too. Security goes beyond just buying a tool—the tool needs to be implemented and managed if it’s going to prevent an expensive breach.
“Everyone should be on guard,” he says. “Foster a culture of security awareness.”
Attackers will often go after low-hanging fruit, phishing for credentials from low-level users to leverage for deeper access. Using a good authentication tool, something that includes geographic location, time to log in, and other factors for validating the user, can go a long way. In many cases, Pignolet says, there’s a movement away from even using usernames and passwords at all and relying on more secure—and less easily stolen—methods for providing access.
Another factor to consider: the ability to turn off access quickly and effectively in the event of a breach. “If you’re a provider and you just read that your vendor was breached, most organizations don’t even have a collective source for how many people with that vendor have access. Single-click turnoff for access, or even an automated function to turn it off—there’s all kinds of functions you can put in place,” says Pignolet.
Interestingly, Pignolet adds, the focus on cybersecurity is now at the forefront for many higher-ups in ways it wasn’t just a few years ago.
“Mitigation and risk and access of systems is rising. It’s usually a board-level conversation now,” he says. “Five years ago, that might not have been the case.”
Healthcare cyberattacks by the numbers
Hospitals lack dedicated security staff: in 2019, a survey by Black Book Market Research found that only 21% of hospitals surveyed reported having a dedicated security executive—and only 6% of those respondents identified that person as the chief information officer.
Facilities are relying more on contingent labor: Via Modern Health, 83% of hospitals are now using contingent labor to fill vacant positions.
Breaches are expensive: According to the Healthcare Innovation Group, the average cost for a healthcare breach is $429 per breached record, nearly three times the cross-industry average.
Breaches are on the rise: According to the HIPAA Journal, in 2019, the industry saw a 196% increase in breaches from the previous year—including 510 healthcare data breaches of 500 records or more.
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.
PSQH: Patient Safety & Quality Healthcare, February 2, 2021
Exploring the future of telehealth and remote care during COVID-19 and beyond.
This article was originally published February 1, 2021 on PSQH by Matt Phillion
COVID-19 has changed almost every aspect of healthcare, if not all of day-to-day life itself. One of the pieces of healthcare we’ve seen fall away significantly since the pandemic began is face-to-face, in-person visits between patients and providers. This change has often been fueled by necessity—limiting exposure and contact, for example. But without this in-person contact, healthcare organizations and professionals are under extra pressure to get the full picture of their patients’ health.
For many organizations, this has meant a shift to telehealth. This technology has been available for some time, of course, but was not nearly as widely used as it is today. How can providers make sure they have the know-how to help their patients maintain their care, live healthy lives, and get the medications and treatments they need, all while working with them remotely?
“If we take a step back, the pandemic surprised people in some sense, but we’ve been preparing for some time for something like this,” says Steve LoSardo, vice president of healthcare solutions with Mobiquity, a digital consultancy firm. “Digital solutions, telemedicine: Those things have been available, but fewer people were using them.”
His organization has been tracking the shift to telehealth, looking at whether both patients and physicians are ready for virtual visits—the move to digital is a culture shift for both parties, after all.
“The question is, can you get the same level of care from televisits?” says LoSardo.
Encouragingly, his organization has seen that patients across the age spectrum—be they seniors, baby boomers, or younger patients—have taken to telehealth during this crisis. “The technology is in place, and people are realizing it’s a viable way to care and communicate,” says LoSardo.
While the technology is there, given the access to smartphones and other devices, organizations should be aware of other barriers to success beyond just talking online or by phone—specifically the ability to capture data and share information.
Information sharing is key
Many current challenges with telehealth tie back into long-standing conversations in healthcare, particularly around the topic of electronic health records (EHR).
Roughly 10 years ago, the push for EHR hit full speed, and electronic records were rolled out across the U.S. The vendors who provided EHR platforms also started to think about things like mobile applications, digital portals, and other options for patients to communicate with physicians and provide input into medical records. Vendors of billing systems also looked for ways to connect with other systems.
For a variety of reasons, patients didn’t necessarily use these options. But they put the industry in a good place to transition to more remote or telehealth modalities when the need arose.
“This technology let you talk to your healthcare facility, your physician, or even your payer. It wasn’t as hard of an extension to move to more virtual” during the pandemic, LoSardo says. “The pieces were in place, but people didn’t use them, and then suddenly it’s the only tool they had.”
Some barriers remained, naturally. Even tech-savvy people can struggle with new technology—perfectly capable adults get turned around by digital assistants like Alexa or Siri, for example. So an early barrier to success was frustration, and friction in the use of mobile apps or platforms.
LoSardo points to user experience as key in avoiding that friction. “The tech was put into place without a lot of thought to user experience,” he says. “Now, the thought process is start with user experience and worry about the technology later.”
His group works with hospitals, pharmaceutical companies, and even biotech to look at ways other industries have taken user experience into account. As examples, he brings up mobile apps that even non-tech-savvy users find helpful. “Consumer products, retail, the food industry have all been on the bandwagon of removing friction and making lives easier,” LoSardo says.
Focusing on aspects that mitigate user frustration, such as minimizing clicks or simplifying a user interface, makes a huge difference. Importantly, so does talking to the users themselves.
“If we’re going to design things for users, why aren’t we talking to the users?” he says. “If you start with the technology for technology’s sake, you’re making a huge mistake.”
What are patients looking for? How about providers?
For the most part, users will explain what they need—if given the opportunity. And “users” aren’t just patients. Physicians and other healthcare providers are just as susceptible to user-unfriendly interfaces and apps, so hearing from them is vital as well.
“We recruit both patients and providers. We want to hear both sides of the equation,” LoSardo says. This also includes capturing feedback from other countries and cultures, as this can have a huge impact on the design and usability of a portal or app.
It’s also worth looking at what’s already out there. “You don’t want to reinvent the wheel. You want to enhance it and learn from those who came before you,” LoSardo says. “If you pull all this into a solution, it’s a tool patients and providers will use.”
What you do with the data
Technology in general, and especially in healthcare, is often about pushing information out into the world. “What has not been done as much,” LoSardo notes, “is things like patient-reported outcomes.”
If you look at the big picture, he says, the healthcare industry knows a lot about how patients are diagnosed, how their conditions are progressing, and what their costs are. The piece often left out when assessing quality of care is how patients are doing with their care. Newer technology enables artificial intelligence to capture freeform text from patients, make sense of it, and use it to support improvement initiatives.
“For example, we’re working with a pharma company looking to help patients who struggle with medication adherence. The patients have trouble remembering to take the drug,” says LoSardo. “A companion app asks questions they answer every day. How are they sleeping, are they feeling depressed, how are they feeling? The data can then be matched up to see why they might stop taking the drug or aren’t seeing improvements. It’s actually collecting and using information from the patients.”
It’s important to note that patients opt in to sharing information knowing that their privacy is protected and data is secure, in accordance with government regulations like the Health Insurance Portability and Accountability Act (HIPAA).
Beyond just providing care remotely, telehealth during the pandemic has begun to open doors to things like clinical trials. “When the pandemic began, virtually all clinical trials were delayed or canceled. People were afraid to travel”—including to hospitals; facilities, for their part, also discouraged all but emergency patient visits, LoSardo says.
LoSardo has talked about methods for setting up remote clinical trials to avoid risks of exposure to COVID-19, and these trials actually have additional benefits. For example, they can recruit patients from further afield, expanding the base of patients, and remove or decrease the burden of traveling to a clinical trial site often.
Increasing access to physicians
Another unplanned benefit from an increase in remote treatments or telehealth is the potential to lessen physician burnout.
Doctors are overburdened, LoSardo notes, particularly in certain specialties. Digital tools used in telehealth can give them time back in their days. It also allows physicians to remain in the workforce if they choose.
“Maybe they’re of retirement age, or they can’t do clinical hours anymore,” he says. “Telehealth can provide these physicians who may still want to work in some capacity the opportunity to triage, make use of their vast medical knowledge, help a patient in a virtual call, and then refer the patient to a physical site if needed.”
This could change the employment picture for physicians in the future, attracting more providers to the system or keeping those who might be considering dropping out. “We know there’s a shortage and that the system is taxed,” says LoSardo. “So we want to find ways to do the job more gracefully that doesn’t feel like a factory, that enables them to spend more time with the patient.”
All of this feeds into the future of healthcare based on interoperability standards, where patient and physician experience meets data collection and analysis. This leads to a frictionless healthcare ecosystem where the information collected can be mined for ways to improve outcomes and lower costs.
“It’s gaining a lot of traction,” says LoSardo. “It’s an opportunity to engage patients wherever they might be with innovative digital solutions and a platform approach.”
PSQH: Patient Safety & Quality Healthcare, January 21, 2021
A free online calculator from NIST helps examine aerosol travel in an indoor environment.
This article was originally published January 20, 2021 on PSQH by Matt Phillion
Indoor air quality isn’t a new issue for healthcare facilities. Ensuring the quality of the air we breathe is a safety concern all organizations take into consideration both in daily life and when planning for alterations, updates, or improvements. The advent of COVID-19, however, has given healthcare facilities a fresh reason to examine the air quality in their buildings, with an eye to new risks and ways to prevent those risks from harming patients and staff.
Fortunately, tools are available to make that research easier. The indoor air quality experts at the National Institute for Standards and Technology (NIST) have developed a free tool, recently featured in a new article in the ASHRAE Journal. It estimates exposure to potentially infectious aerosols for people in a room. Calculations are based on information about the aerosols themselves as well as the room’s HVAC system and air filters.
The tool is designed for building managers and engineers to better identify strategies, such as adjusting ventilation rates or setting up portable air cleaners, that could help reduce exposure to the coronavirus in indoor spaces—like hospital rooms, waiting areas, or offices.
The tool, called the Fate and Transport of Indoor Microbiological Aerosols (FaTIMA), determines what happens with infectious aerosols in a building environment, as well as the impact of different control measures. It takes into consideration the effects of ventilation, filtration, deposition, and inactivation. Although FaTIMA doesn’t examine risk of infection, it can be of particular use for anyone working to determine the effectiveness of planned control measures for COVID-19 safety protocols.
New views on an age-old problem
COVID-19 is just the latest in an ever-evolving series of challenges that give researchers a new angle to apply decades of solid science.
“We at NIST have been studying airflow for decades, with a variety of motivations,” says Andrew Persily, chief of NIST’s Energy and Environment Division. “Using less energy, improving indoor environments, improving the productivity of the occupants under normal situations.”
When new challenges like COVID-19 arise, NIST has a chance to look at methods for improving indoor environments. After 9/11 and a series of anthrax-related events years ago, for example, the organization was able to investigate issues surrounding airflow and quality and how they related to those sorts of threats. Today, the pandemic has opened the door for more research on airborne viruses.
“Fortunately, while the challenges change, the physics hasn’t—air moves for the same reasons,” Persily says. “Ventilation has always been important. Ancient civilizations did all kinds of cool things to make buildings comfortable. And as we and our buildings evolved and things like urbanization increased, we’ve devoted more awareness and attention to airflow.”
The team is able to leverage their decades of applicable research to tackle new problems and build tools like FaTIMA to address current challenges.
How it works
The FaTIMA tool can be used to look at key removal mechanisms for the coronavirus, running simulations for 24 hours and displaying a time history of how much airborne concentration and surface loading occurs. Variables it examines include:
Filtration (within the ventilation system and via room cleaner)
Deactivation
Deposition of particles onto walls, floors, ceilings, and other surfaces
Organizations looking for ways to limit the spread of COVID-19 in their environments can use the tool to study potential options.
“Ventilation is one strategy for reducing aerosol disease transmission in buildings,” Persily says. “Over the years, we’ve learned that, with respect to the way air moves around buildings and the way ventilation systems work, there’s often a disconnect between design intent and what actually happens. Now, if a system is not operating as intended, it can have more serious consequences.”
Tools like FaTIMA offer a way to predict air, and therefore contaminant, movement throughout a building. To do this, “FaTIMA makes use of a software called CONTAM, which has been available for decades,” Persily says. (See the sidebar for more on this software.)
Making use of FaTIMA does require some knowledge about buildings and ventilation systems, so hospitals or healthcare organizations will want a bit of in-house expertise from their facilities or building planning teams. For example, the user would want to know and understand information like ventilation rates and related information to be able to add the correct inputs into the tool.
“In general, it could be used by anyone who has some sense of building ventilation, filtration technology, airborne particles, or aerosols,” Persily says. “They don’t need to have a PhD, but should have some familiarity with those phenomena. It could be a building ventilation designer or an operator who has had time to work with a tool like this.”
“In response to COVID, we wanted to create an online tool or calculator to make it easier for people to look at the relative impact of ventilation and filtration,” Persily says.
FaTIMA is somewhat limited in scope, focusing on a single zone representation in a building, so it can only approximate an entire building’s airflow. But the tool is designed to make analysis easier as organizations seek to limit the spread of COVID-19 in their facilities.
Who is using FaTIMA?
So far, NIST has seen organizations like public school systems use the tool to help decide how to keep students safer. Researchers are also using it to look into calculating the benefits of filtration versus ventilation versus indoor mask wearing.
“Ideally, what they’ll get out of it first is some understanding of how more ventilation would stack up to high-efficiency filtration versus a portable air cleaner, for example,” Persily says. “It helps with understanding how these options compare with each other.” If you better understand the potential air quality impacts of a change, you’ll be able to make a more informed decision regarding measures to help prevent COVID-19 spread within a building.
The tool isn’t strictly for COVID-19, either, so facilities looking at other airflow improvements can make use of it as well. FaTIMA allows the user to select the particle size, so it is adjustable to the needs of the problem being addressed. “Another application that comes to mind is protection against wildfire smoke particles getting into the building, and [exploring] what you can do to reduce indoor exposure,” says Persily.
Both uses of the tool can help organizations examine occupants’ particle exposure and possible measures to counteract it. And FaTIMA could play a role in future public health crises as well. “We are all reading that this isn’t going to be our last epidemic, and that we can’t let our guard down,” Persily says. “Assuming we get this one under control, we can then look to what could be next.”
NIST hopes organizations in healthcare and beyond can take advantage of the tool to better understand the impact of airflow during a crisis. “It’s in the public domain, so anyone can go there and make use of it,” Persily says. “It allows you to do the calculations reliably without having to create your own tool.”
What is CONTAM?
FaTIMA employs the solver of the CONTAM program, which was developed by NIST and has been used for decades for multi-zone, whole-building airflow and contaminant transport analysis. CONTAM predicts:
Airflow
Contaminant concentration
Personal exposure
CONTAM’s ability to calculate building airflow rates and relative pressures between zones of the building is useful for:
Assessing the adequacy of ventilation rates in a building
Determining the variation in ventilation rates over time
Determining the distribution of ventilation air within a building
Estimating the impact of envelope air-tightening efforts on infiltration rates and associated energy implications
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.
PSQH: Patient Safety & Quality Healthcare, January 20, 2021
Starting with basic needs to improve chronic conditions during COVID-19 and beyond.
This article was originally published January 19, 2021 on PSQH by Matt Phillion
Winston Churchill famously said, “Never let a good crisis go to waste.” In the current healthcare climate, one crisis is front and center on everyone’s mind—COVID-19. But this crisis also offers a chance to reexamine long-term challenges for providing quality care, many of them worsened by the pandemic.
One longstanding problem in American healthcare is medication adherence. This “was a problem before the pandemic, during the pandemic, and will be a problem after the pandemic—people don’t take their meds,” says Jason Rose, CEO of AdhereHealth. “And this causes over a half-trillion dollars in annual unnecessary medical costs.”
A host of additional snares have arisen during the past year, but Rose points out that, pandemic or not, patients struggle with three main medication adherence challenges: The patient never takes a prescribed medication at all. This can occur for a number of reasons such as misunderstanding their chronic diagnosis or the need for taking a medication.
The patient takes a medication, but not per evidence-based guidelines and doctor’s orders. Instead, they might split pills or miss doses.
The patient doesn’t discontinue taking drugs when advised. For example, if they’re prescribed a statin drug, then later prescribed a replacement statin, they might not realize they should stop taking the first drug.
All of these issues contribute to that half-trillion dollars in annual medical costs, as nonadherent patients often need rehospitalization, emergency treatment, or other interventions. But as we’ve come to understand in recent years, social determinants of health play a huge part in successfully keeping patients on their meds.
“The reason for these medical costs isn’t the patient’s genetic code, it’s their ZIP code,” Rose says.
Rose frames the problem in terms of Maslow’s Hierarchy of Needs, with a healthcare-specific angle. Patients need the basics: food, shelter, health literacy, and access to care. “If you look across the world, you’ll see we’re talking about the same issues for people,” he says.
COVID-19 has created a seemingly endless array of issues with regard to hospitalization. But, Rose contends, if the industry focuses on the core issues of basic needs and access to care, it can prevent a great deal of sickness, hospitalization, and mortality.
“I kept wondering when the story would come out to back this up,” Rose says. Eventually, the CDC figures showed that 94% of COVID-19-related deaths involved issues stemming from chronic conditions. “I asked, who are these people? The elderly, minorities, people residing in the ZIP codes with social determinants of health referenced earlier in the year.”
And this presents an opportunity to make a difference.
Contributing factors
It’s tempting to simply look at the communities most impacted and whether they have access to doctors or healthcare facilities, but the challenge with medication adherence starts long before that. Looking back at Maslow’s Hierarchy of Needs, it begins with the very basics. These core needs take precedence even over economic factors, like paying for the medications involved.
Chief among the core needs is food. “If you don’t have food in your fridge, if you can’t feed your family, if you’re rationing food, you’re going to make that your priority, not taking a drug on a daily basis that you need,” Rose says.
“Some of these patients will have zero-dollar copays due to their government-sponsored health benefits, so it’s not always about cost,” he observes. These patients may need help accessing or learning about food programs, such as Meals on Wheels or local pantries, to move up that hierarchy of needs in their medication adherence journey.
The other absolute basic need patients often lack is shelter. “Medicaid patients are often nomadic,” Rose explains. “They move around a lot.” Programs exist for medication delivery, but that only helps so much if the patient doesn’t have a stable home to deliver to.
And even if they have a residence established, environmental issues can exacerbate chronic conditions, including conditions that have come into play for many COVID-19 patients. “In a shelter, they may not have the best environment to live in,” Rose says. “There may be issues with dust or uncleanliness that lead to respiratory issues, for example. And for some, they may not understand how important those environmental factors are.”
If the patient isn’t educated or can’t make sure their environments are consistent and clean, they are likely not in a position to pay attention to something further up the hierarchy, including taking their meds.
Access to care
Once the most basic building blocks of healthy living are provided for, it will be more possible to help patients address a longer-recognized problem: access to doctors and healthcare facilities. Many live in “pharmacy deserts,” where the issue is a lack of convenient access to medications and trained pharmacists. Unfortunately, COVID-19 has shuttered many businesses, making these pharmacy deserts even more common.
“So they may no longer have access to a local pharmacy, in addition to no access to a private-courier or mail-order option,” Rose says.
Rose adds that his organization believes pharmacists should be on the front line of care. “They are so effective for patients to understand the drugs they are prescribed, why they’re important, what would happen if they don’t take them,” he says. “And then coordinating with the doctor if adjustments are needed. They really are the experts in medications.”
Some states, such as Ohio, have started to put pharmacists on the primary care team, moving in the direction of coordinating all aspects of care for high-risk, high-cost patients.
Delivery isn’t enough
Roughly 25% of patients who struggle with medication adherence fall into the aged, blind, or disabled (ABD) category. They may have a stable living situation and a place to have medication delivered, but “because they are ABD, they may literally not be able to walk to their mailbox,” Rose says.
Once again, COVID-19 has made a problematic situation worse. Many ABD patients have lost their caregiver due to the pandemic—a dangerous situation for patients who often need medications hand-delivered to them.
Telehealth, meanwhile, has been a savior for many patients, but it may be less helpful for chronically ill patients at greater risk, including patients who struggle with medication adherence.
“Telehealth is great, but is limited,” Rose says. While video telehealth calls have been popular during the pandemic, the vast majority of telehealth calls are telephonic—and this means the patient not only needs a phone, but the plan minutes to use it. “The patients we focus on often get phones from the local or state government as part of their Medicaid benefits,” he notes. “But they run out of minutes by the end of the month.”
Another issue with telehealth: It’s not focused on managing chronic conditions.
“It’s great that you can call a doctor. Many systems or practice groups have been income-damaged by the pandemic and switched over to telehealth. But the problem is they’re not geared today toward managing chronic conditions,” Rose says. “Telehealth [has] nearly completely focused on subacute issues, like the sniffles or a rash, rather than helping manage an ongoing condition.”
Tying it all together for better care
Managing chronic conditions can be an administrative challenge—the average Medicare patient sees 5.2 doctors per year, and health records are rarely connected enough to enable, for example, a telehealth line or walk-in clinic to know the patient’s full medical history.
The underlying issue centers around data. If the health records are not connected, the data won’t offer a seamless look at the patient, so a doctor seeing the patient for the first time won’t have the background they need to make a fully informed decision. The patient may not be able to explain all the medications they’re on, let alone articulate whether they are keeping up with their doses.
So who has this data? “The health plans,” Rose says. “It’s the claims data. If you look at the data from the health plans, it’s pretty solid in terms of accuracy and timeliness.”
The problem, though, is making full use of the data. “There’s a lot of killer apps out there,” Rose says. “Apple watches and portals, wellness apps. But these apps don’t have integrated claims data. They’re hitting the peripheral, not the core issues.”
AdhereHealth partners primarily with health plans. Their clinical workflow tool, Adhere, pulls patient data into a workflow for patients who have the gaps in care discussed above. It bridges a key technology gap for patients—documenting issues with accessing food, making copayments, or even having bus fare to get to their doctor for follow-up visits and filling medications—to enable follow-up and tracking.
“You click through, drop down, and now you have a plan with discrete data that integrates real-world patient responses from right now, along with pharmacy and medical data,” Rose says. “The artificial intelligence within the system will say, ‘Call the patient back within 14 days. Make sure they have food, shelter, scheduled a doctor’s visit.’
And if they haven’t, now we take a more proactive approach—arrange a call right now. Coordinate with Meals on Wheels. You really need a holistic point of view of the patient: their background, what’s occurred with them during and after their visits, and if they have follow-up.”
All of this is designed to help patients stay on track with their health, from their very base needs to remembering their daily medications.
“You don’t need a Bluetooth-enabled pill bottle,” Rose says. What’s needed is a synchronized system. “If you go back to all these issues, it’s the patient experience,” he says. “If we tackle these hierarchy-of-needs and medication issues, we can really plow some ground.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.
PSQH: Patient Safety & Quality Healthcare, January 5, 2021
Facilities must 'identify, isolate, and inform' during the resumption of operations.
Editor's note: This article by the Accreditation Association for Ambulatory Health Care was originally published by the HCPro Accreditation & Quality Compliance Center.
The emergence of the COVID-19 pandemic has created new burdens and unprecedented challenges for the U.S. healthcare system. Healthcare facilities around the country are constantly adapting to rapid changes and adopting novel strategies as they navigate executive orders and the coronavirus itself, while ensuring staff, patient, and visitor safety.
Whether offering limited services, operating at full capacity, or preparing to reopen after temporary closure, ambulatory healthcare facilities must continue to stay up to date on the coronavirus situation to implement best practices, both during the state of emergency and following the gradual reopening of state healthcare systems.
Following guidelines from the Centers for Disease Control and Prevention (CDC), the Accreditation Association for Ambulatory Health Care (AAAHC) has released recommendations to help organizations safely navigate the evolving stages of the COVID-19 pandemic, with an emphasis on steps to identify, isolate, and inform.
Identify
The three key components that must be identified to help protect a healthcare facility during a public health emergency are 1) an emergency preparedness plan, 2) potential risks, and 3) patient scheduling and pre-screening procedures.
Emergency preparedness plan: Conduct a thorough review of the written emergency preparedness plan, and ensure it addresses internal and external threats.
Infection control risk assessment: Comprehensive infection prevention and control includes evaluations of equipment and staff training.
Patient scheduling and pre-screening: In anticipation of the possible need to manage an influx of COVID-19 patients, your organization should have a plan for how to assess patients prior to entry into your system.
To ensure the plan is optimized for COVID-19 prevention, update the section addressing the prevalence of infectious diseases and isolation policies.
A comprehensive plan should include strategies to manage patient flow and capacity. Consider staffing issues that may occur due to exposure; provisions for safe evacuation, especially for those who are at greater risk; and measures for participation in a potential community health crisis. This includes possible coordination with the city, county, state, or Centers for Medicare & Medicaid Services (CMS). Once the emergency preparedness plan is sufficiently updated and approved by all necessary executive parties, disseminate the document to your entire staff. All staff should be educated on these updates in a timely manner.
Outside assistance to conduct infection control risk assessments can prove beneficial because internal management teams may be too deeply involved with daily operations.
Optimize the supply of personal protective equipment (PPE) by fully understanding your ongoing PPE inventory and utilization rates. The CDC has a spreadsheet-based PPE burn rate calculator that will help healthcare facilities plan and optimize the use of PPE. It is recommended that facilities review their PPE plan to incorporate strategies for PPE prioritization. The CDC addresses prioritization in three ways:
Conventional capacity, which involves strategies that should already be in place
Contingency capacity measures, which conserve supply during periods of PPE shortages
Crisis capacity, which is implemented when supplies cannot meet the facility’s utilization rate
Designate time to educate staff on CDC updates, revised facility procedures, PPE, COVID-19 symptoms, management and notification, and transmission-based precautions. Ensure all employees become familiar with infection prevention and control guidance for managing COVID-19 patients for the duration of the pandemic.
Depending on your state and local guidelines, you may proceed with some elective and non-urgent appointments and eventually resume more standard operations. However, continue to offer patients alternatives to office visits, such as telehealth, patient portals, and advice lines, to further reduce risk. Additionally, eliminate any penalties in place for cancellations to encourage sick patients to stay home or seek an office visit alternative as discussed above.
To help prevent transmission, pre-screening patients about previous COVID-19 testing results and symptoms during a pre-visit call is essential. Ask specific questions about testing dates, recent travel, or known exposures, and note if they have had fevers or any other COVID-19 symptoms. Create algorithms to identify which patients can be managed by telephone and advised to stay home, and which patients will need to be sent for emergency care or come to your facility.
Consider reaching out to patients who may be at higher risk of COVID-19-related complications, such as seniors and those with medical comorbidities or respiratory diseases, to ensure adherence to current medications and therapeutic regimens. Confirm they have sufficient medication refills, and provide instructions to notify their provider by phone if they become ill.
Some healthcare facilities have incorporated rapid antigen testing into pre-screening processes. Rapid tests are now commonly used in the diagnosis of COVID-19 for symptomatic persons within the first five to seven days of symptom onset, and a list of tests is available on the Food and Drug Administration website. The CDC also provides specific guidance on the collection and handling of clinical specimens.
Isolate
Isolation is needed to prevent a spike in cases and avoid overwhelming hospitals and health centers. This involves a focus on transmission-based precautions, patient monitoring and placement, and environmental cleaning.
Transmission-based precautions
Standard precautions, both at the pandemic’s height and in the foreseeable future, assume that every person is potentially infected or colonized with a transmittable pathogen. Therefore, facilities need to have safeguards in place to protect patients and staff from cross-infection. At minimum, your organization should have written policies and procedures that ensure the isolation or immediate transfer of patients with COVID-19 symptoms, timely communication to public health authorities of reportable conditions, and adequate surveillance of people and facilities. Reinforce the necessary safety measures as much as possible among both staff and patients. Hand hygiene audits should be conducted—the foundation of transmission-based precautions. Educate everyone to thoroughly wash their hands for a minimum of 20 seconds. Alcohol-based hand rub (ABHR) should have at least 60% alcohol and be readily accessible for makeshift pre-screening zones in the absence of a hand basin with soap and water.
Staff should strictly follow the procedures for safely and correctly donning and removing PPE. In surgical settings, stress that staff must don their mask before entry into the patient room and put on eye protection, gloves, and gowns upon entry. In other settings, staff should be wearing PPE before coming within 6 feet of any patient.
Patient monitoring and placement
Patient management is key to maintaining high-quality service and protecting the health of both patients and staff.
Healthcare facilities should limit the number of patients allowed inside at one time. Start by implementing triage before patients even enter your facility. Avoid having visitors in the facility, or limit to only one visitor at a time to accompany patients under 18, patients with disabilities (ADA), and/or post-procedure patients. Inform patients that you require drivers to wait outside. In some settings, medically stable patients might opt to wait in a personal vehicle or outside the healthcare facility where they can be contacted by mobile phone when it is their turn to be evaluated.
Pre-screened symptomatic patients who need to be seen in a clinical setting should be asked to call before they leave home, so staff are ready to receive them using appropriate infection control practices and PPE.
Upon arrival, take each patient’s (and visitor’s) temperature and clean the thermometer. Establish separate, well-ventilated spaces for patients with symptoms of suspected COVID-19, with easy access to respiratory hygiene supplies, and away from other patients seeking care.
Environmental cleaning
Increased attention to sanitation and assessment of cleaning practices is important to help isolate COVID-19. Evaluate all your environmental cleaning practices, from discharge cleaning and wipe-downs of high-touch objects to terminal cleaning and sterilization of dedicated medical equipment. In-depth cleaning throughout the entire facility should be done between every shift, while high-touch surface areas should always be cleaned between patients as well as regularly in high-traffic areas, such as waiting rooms and nurse stations.
The CDC recommends EPA-registered hospital disinfectants that are effective against other respiratory pathogens, such as seasonal influenza and other human coronaviruses. Educate staff on the appropriate surface contact time for each cleaning agent and ensure that manufacturers’ recommendations for use are followed, such as dilution and care in handling.
Inform
Amidst the dynamics of this rapidly changing situation, monitor reliable sources of information, such as the World Health Organization and CDC, as well as state and county health departments that can provide local updates.
As a cross-infection prevention measure, establish an internal system to track persons under investigation (PUI) and confirmed cases in your facility and local area. Identify staff to collaborate with local and state health authorities and notify them of reportable conditions. Additionally, ensure that communication protocols include completion and submission of the PUI case report to the CDC.
Effectively stay up to date and streamline communications by designating a small team of employees to monitor related local and national news. Next, implement mechanisms and policies to promptly alert key facility staff and then disseminate relevant updates to all employees.
To ensure everyone understands the COVID-19 plans and protocols, consider allowing staff to submit questions, or hold regular Q&A sessions. An easy way to keep everyone informed is to send daily or real-time e-newsletters with any changes or updates in protocols. Or consider holding a morning meeting with key staff members who can then distribute the information to the rest of the employees.
Last but not least, remind staff about patient confidentiality.
Conclusion
All organizations across all settings should remain vigilant about practices that impact employee and patient safety and the quality of care delivered. By providing clear, actionable methods, accreditation allows ambulatory healthcare centers to meet the challenges of COVID-19 by setting a foundation on which to build an appropriate emergency preparedness plan, identify areas for quality improvement, and assess adherence to guidelines during all phases of the pandemic and throughout the reopening process.
To support efforts to mitigate risk of spreading infection, AAAHC has been guiding its accredited organizations through the necessary processes and carefully following recommendations from the CDC to help healthcare providers maintain essential services and provide safe and quality care as operations resume more widely. For the foreseeable future, AAAHC accreditation processes will include a heightened focus on infectious disease protocols, including preparation for managing patients with COVID-19. Indeed, the accreditation process can be used as a starting point to effectively incorporate quality improvement initiatives needed to adapt to this dynamically evolving pandemic.
Like most initiatives with great vision, accreditation first requires a significant commitment from those adopting the model, and then ongoing evaluation, refinements, and time to succeed. It is a transformative process that can prove invaluable during turbulent times. Ultimately, the AAAHC accreditation process can help pinpoint areas of improvement for a facility’s emergency plans and protocols specific to COVID-19 identification, isolation, and information.
PSQH: Patient Safety & Quality Healthcare, December 20, 2020
Hospitals are a critical part of our healthcare system and a place where very ill people can get excellent, and often life-saving, care.
This article was originally published December 18, 2020 on PSQH by Marcie Metroyanis, DNP, RN, NEA-BC, Patricia Reagan Webster, PhD, CPPS, and Robert Panzer, MD
Abstract
Background: Medical errors are the third leading cause of death in the United States (Makary & Daniel, 2016). Situational awareness, monitoring, and remediating risks in the clinical setting are hallmarks of the high reliability necessary to prevent patient harm.
Design: To enhance awareness of hazards of medical errors that jeopardize the safety of patients, we created a “Medical Mayhem Room” to simulate safety risks that may be found in the patient care environment. Scenarios for each simulated patient included diagnosis, age, allergies, and precautions or special considerations. We deliberately introduced mistakes and hazards into each of these scenarios. The Medical Mayhem Room staged four patients with a total of 95 patient safety risk factors.
Implementation: A team of experienced nurses developed simulation scenarios, compiled medical supplies, and staged the scenarios with deliberate medical errors. This team also greeted participants, explained how to navigate through the activity, and provided a debriefing.
Outcomes: Participants in this learning activity included 310 nurses, attending physicians, advanced practice providers, patient care technicians, pharmacists, environmental service workers, and other clinical support staff. The average time spent for participants to assess all of the patients was approximately 45 minutes. While participants identified 100% of the risks, some errors were far less likely to be detected than others. Eighty percent of the participants indicated that they learned something new about a safe environment in a patient care area, while 93% indicated that they found value in the activity.
Background
Hospitals are a critical part of our healthcare system and a place where very ill people can get excellent, and often life-saving, care. However, it has been well established that hospitals can also be very dangerous for patients (Institute of Medicine, 2000; James, 2013). Patient safety specialists work with caregivers and clinical staff to develop systems, processes, and protocols that reduce safety risks associated with hospitalization. While these tools are important in preventing or mitigating human error, they do not replace the vigilance needed by all healthcare workers to keep patients from experiencing preventable harm.
The further reduction of safety risks requires that all providers, nurses, and other staff in the clinical environment are aware of the unsafe conditions they routinely see and often, unintentionally, cause. Aspects of the high reliability necessary to prevent patient harm include situational awareness, monitoring, and remediating risks in the clinical setting (Fore & Sculli, 2013). Nursing and medical schools are increasingly aware of the importance of teaching students about the hazardous conditions found in hospitals through use of experiential safety activities (Penn State News, 2013; Farnan et al., 2016; Clay et al., 2017). However, as these students become busy caregivers and clinicians in hospitals, they often overlook the risks that could harm their patients. Safety hazards become part of the clinical landscape.
To increase situational awareness of safety hazards in the hospital setting, quality improvement staff at Strong Memorial Hospital, the flagship hospital of a large academic medical center, implemented an experiential learning activity, the Medical Mayhem Room, during National Patient Safety Week in March 2019. This workplace-based activity was designed as a voluntary educational opportunity for nurses, resident and attending physicians, pharmacists, and other clinical support staff.
Implementation
To begin the development of the Medical Mayhem Room, six experienced nurses of varying expertise formed a project team. Prior to moving forward with project planning, the team had to identify adequate physical space to accommodate four simulated patients. Once this was done, the project team outlined the various components required to develop the activity. First, the team created basic scenarios for each patient and included diagnosis, age, allergies, and precautions or special considerations. This was followed by gathering supplies and equipment based on the details of the scenarios. The planning also incorporated costs and advertising (Figure 1).
Figure 1. Advertising Methods
Design of the workplace simulation
There are a variety of methods to increase learning and engagement among healthcare workers and achieve patient safety goals. We decided to adopt the “Room of Horrors” simulation approach by staging errors and hazards for healthcare workers to identify during an assessment (Farnan et al., 2016). The activity here is referred to as the “Medical Mayhem Room,” a simulated hospital room filled with medical and environmental issues and concerns.
The first Medical Mayhem Room session consisted of four patient scenarios including a medical/surgical patient, an adult critical care patient (Figure 2), a child, and an infant (Figure 3). Each patient had unique types of errors according to their age and acuity, plus similar errors that occurred across all four patients. In total, 95 types of patient safety risk factors and environmental issues were staged among the four simulated patients. Types of errors and hazards within the room included, but were not limited to, patient physical safety, appropriate use of devices, IV medication management, oxygen management, patient identification, expired items, and patient documentation management (Table 1).
Figure 2. Adult Critical Care Patient
Figure 3. Infant
Table 1. Sample of Patient Safety Risks Included
The next step was to develop tools such as an activity sheet for participants to track their findings while assessing the patients and their patient care environment. As participants toured the room and assessed the patients, they would record the mistakes and hazards they found for post-project evaluation.
Once each participant completed the activity, they were offered an opportunity to review the errors compared to their own findings. Upon exiting the room, each participant was provided a debriefing that included risk reduction strategies and information about high reliability and the journey to zero preventable harm. Following the debriefing, participants could undergo a voluntary evaluation.
Outcomes
Participants in this learning activity included 310 nurses, attending physicians, advanced practice providers, patient care technicians, pharmacists, environmental service workers, and other clinical support staff. Nonclinical healthcare workers enjoyed the experience and were also able to identify what they thought were errors and hazards. For example, one environmental service worker was assessing a patient and stated, “I do not know what this is, but it doesn’t look right.” This reflected an effective safety culture as we strive to encourage all hospital employees to “see something, say something.”
A total of 95 types of errors were staged among the four simulated patients. To accommodate a consistent learning experience despite any time constraints, some of the same errors were staged on each patient. As a result, each simulated patient had 28–42 safety risks staged as part of the learning experience (Table 2).
Participants were not evaluated on their ability to find all of the staged risks because we did not have control over the amount of time each participant could devote to the activity. Furthermore, participants often worked in teams and may have only turned in one scoring sheet for the team. Based on the conversations between facilitators and participants, the variation in time spent during the activity was primarily due to the availability of time away from clinical care or other work duties. On average, participants took 10 minutes to assess one patient followed by 5–10 minutes of debriefing; therefore, it took approximately 45 minutes to complete the entire activity.
We were able, however, to assess the relative likelihood of detecting different medical and environmental safety risks. The number of identified risks varied across participants. While all of the risks were identified by at least one participant or team, some types of risks were far more likely to be identified than others. Over 200 participants caught food at the bedside of an NPO (i.e., nothing by mouth) patient, while only five identified the illegibility of an initial signature on a blood transfusion. Similarly, though 238 participants found an overfilled small sharps container at the bedside, just 14 found an unlocked vent and only six found unclamped saline locks. One hundred twenty-five participants found scissors and supplies left in a child’s bed, while only two participants caught a pump due for inspection. Likewise, 162 participants found expired unlabeled breast milk, while only 19 participants noted the infant’s wrong weight and just two participants identified an infiltration. Table 2 demonstrates the range in the likelihood that safety risks would be detected.
Table 2. Likelihood That Safety Risks Are Detected
According to the post-survey results, 70%–80% indicated that they identified safety concerns as well as they expected and learned something new about safe patient care and a safe environment; 93%–96% had a positive experience and reported that they would participate in future activities. Eighty percent of the participants indicated that they learned something new about a safe environment in a patient care area, while 93% concluded that they found value in the activity (Table 3).
Table 3. Medical Mayhem Post-Activity Evaluation
Key insights
Our experience with the Medical Mayhem Room safety simulation demonstrated that:
Hospital caregivers have varying degrees of awareness regarding patient safety risks based on errors and hazards that occur at or around the bedside.
Simulating patient safety errors and risks in a setting that mimics a typical hospital room helps teach and reinforce the importance of complying with protocols, standards, and guidelines.
Establishing the simulated patient room near patient care units ensured that more healthcare workers could take part in the educational activity.
The number of errors discovered among participants varied, and some participants may have been overconfident that they would recognize all of the errors prior to completing the exercise; both of these findings indicate an ongoing need for patient safety education.
Participants learned while performing assessments, having discussions with each other, and generally enjoying the experience.
The most frequently overlooked safety risks and errors provided insight into areas that may require further education and reinforcement. Some of these included (in addition to the ones mentioned previously) past-due PICC line dressing change, no allergy band, wrong precaution sign, inaccurate weight programmed in IV pump, wrong IV fluid maintenance rate, and crossed IV lines (IV fluids and medications infusing on wrong channel at opposite rates).
Next steps
The Medical Mayhem Room served as a pilot for developing future experiential learning opportunities around patient and staff safety. Based on the data and observations collected during the activity, the Medical Mayhem Room was a positive experience for a majority of participants. As most claimed the activity was enjoyable and valuable, the activity will continue to be offered on an ongoing basis. During the COVID-19 pandemic, the structure of the program will convert from a hands-on method to an electronic interactive approach (Figure 4) to ensure the safety of our staff, nurses, and providers. The goal is to develop a library to accommodate all clinical specialties, support staff, and students. This will require simulated setup and staging of a wide range of patient populations. It will also require clinical experts from each department and nursing service to collaborate with the Medical Mayhem Room coordinators to ensure that each scenario is accurate and that common and high-risk errors are identified. Each room will be recorded, capturing all medical and environmental errors. The program will then be available online in an interactive format to enhance the learning opportunity.
Figure 4. Online Learning Module
Marcie Metroyanis, DNP, RN, NEA-BC, isassistant quality officer, Patricia Reagan Webster, PhD, CPPS, is associate quality officer, and Robert Panzer, MD, is chief quality officer at University of Rochester Medical Center.
PSQH: Patient Safety & Quality Healthcare, December 19, 2020
The lack of information and the inability to communicate with family members became more disheartening over the last several months because of the COVID-19 pandemic.
This article was originally published December 18, 2020 on PSQH by John Palmer
One of the most harrowing experiences for the family or loved ones of a patient going into the hospital, whether for routine or emergency care, is the lack of communication that they have with a caregiver.
It’s often not the caregiver’s fault—they could be busy with clinical work, engaged in seeing other patients, or simply not have any new information.
Since radio silence can be troubling for the patient’s family, even a small gesture from a physician—like a positive update or a pat on the back with some good news—can promote a sigh of relief and a sense of closure. But the ability to reach out isn’t always as easy as it should be.
“The problems of communication are quite real, and they’ve been around for 200 years,” says Kevin de la Roza, MD, a pediatric cardiac anesthesiologist at The Heart Center at Orlando Health Arnold Palmer Hospital for Children and an assistant professor of anesthesiology at the University of Central Florida College of Medicine. “Operating rooms are closed-off places, with not a lot of information and people sealed in. We are trying to break down those barriers.”
That lack of information and the inability to communicate with family members became more disheartening over the last several months because of the COVID-19 pandemic, which found some patients going into the hospital and never coming out—in some cases dying alone while hooked up to ventilators.
The pandemic has made communication between care teams and families particularly challenging, leading hospitals to seek new ways to reach out to loved ones who often can’t be by a patient’s side—or even in the waiting room—during a surgery. Having a means to communicate securely beyond the hospital walls, whether the receiving family member is waiting in their car outside the facility or at home across the country, is essential for reducing anxiety, increasing understanding, and creating a better healthcare experience.
“[COVID-19] has highlighted the problem to a greater degree because when a person comes into a hospital they may not come out, which really is always the case,” de la Roza says. “Communication can’t prevent COVID, but it can make it more bearable. If they are going into surgery, you still can’t be there, but we wanted to find a way where the family can take the journey with them.”
The answer to his problem came almost accidentally in November 2012 when his colleague Hamish Munro, MD, director of pediatric cardiac anesthesiology with The Heart Center, began providing patients’ families with updates through pictures and videos on Instagram and Twitter.
At first Munro was only doing this a few patients, but a woman whose daughter was having heart surgery was insistent to the point of tears that the doctor keep her updated—as it was the only way she could imagine getting through the operation with her daughter.
It was then that the two doctors realized they might be on to something. They convinced their superiors at the hospital to allow them to collect research on 50 patients and developed a revolutionary patient app known as EASE.
Munro and de la Roza continued their research, figuring out how to get through the HIPAA loopholes, working with developers, and dealing with security challenges to launch the secure app to the public in 2013. Industry leaders took note of the app’s positive impact on patient and family experience, and in 2020, Vocera Communications, Inc., acquired EASE.
It’s a pretty basic system. First, the patient adds friends and family members to their distribution list. Then, with a simple tap, the doctor or nurse can send texts, photos, and videos about the patient’s progress to that list. More than 1.6 million messages have been sent since the app was first rolled out in 2013.
“Patients are also a lot less scared if they know their loved ones have information,” de la Roza says. “We realized this could go elsewhere. We wanted to create complete experiences where the minute you come into the hospital to the minute you leave, you are getting messages.”
EASE is certainly not the only app of this type to be invented. Hundreds of hospitals across the country have adopted secure communication tools to help families stay connected with patients and enable care team members to send them texts, photos, and videos. Such solutions provide families with peace of mind while also preserving the safety of care providers, patients, and themselves.
Examples include an app called myICUvoice, which was designed by an ICU doctor in the United Kingdom and uses touchscreen technology on an iPad® to facilitate communication with patients.
Another system developed by Israeli company EyeControl is wearable, screenless, and lightweight. It uses a heat-mounted infrared camera to track the patient’s eye movements, then translates those movements into audio communication.
While they all work differently, the apps are designed with one goal in mind: bringing communication into areas of the hospital where visitors aren’t typically allowed, to keep family members connected and make the hospital experience a little less scary. De la Roza says he foresees a time when EASE will be used in places like the ICU, emergency department, and radiology lab.
“Our team understood how difficult it can be for families and friends waiting for updates about loved ones who are undergoing surgery,” says Hope Johnson, DNP, MSN, MBA, RN, CNOR, NEA-BC, administrator of perioperative services at Lehigh Valley Health Network in Nazareth, Pennsylvania, which has used the EASE app since 2018.
Johnson says that EASE has provided the organization with a secure way to update families in real time before, during, and after a surgical procedure. Families have the freedom to leave the waiting room without worrying that they will miss an update from a care team member. Loved ones who cannot come to the hospital can also stay updated. Care team members can send updates to patients’ loved ones via text, photos, and videos.
“We wanted to help ease some of that stress and worry,” says Johnson. “Vocera EASE helps us improve the healthcare experience by improving communication with patients and families.”
The healthcare organization started using the app in 2018, and since then has sent more than 172,000 secure messages and photo updates to patients’ loved ones across 50 states. In turn, these families and friends have been able to respond to care teams with more than 136,000 emojis, including thumbs-up, hearts, and prayer hands.
Part of EASE’s helpful functionality, says Johnson, is its customizability, so messages can be personalized. In addition, it’s secure—all messages, photos, and videos disappear 60 seconds after being viewed. It’s free for family members and easy to load on their personal devices, and the app can send messages in nine languages.
During the COVID-19 pandemic, Lehigh Valley has found EASE to be vital in helping families when visitors aren’t allowed to accompany patients to the hospital.
“The app does not replace the face-to-face meetings our surgeons have with families post-surgery, but this digital communication bridges the gaps between the time patients go in for surgery and this postoperative conversation,” Johnson says. “Clinicians can also use the app to notify family members that they need to come back to the waiting area if they stepped away and a face-to-face is needed.”
The app has also been used to connect families that have U.S. military members operating overseas.
“One of our patients shared that a family member receiving our EASE updates was her son, who was deployed in Afghanistan,” Johnson says. “Being able to keep him connected and updated on her progress in real time was a relief for them both, and it really meant so much to the care team.”
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, December 17, 2020
The issue that healthcare organizations struggle with now is where to get the resources to develop a med rec team that is dedicated to collecting patient medication histories.
This article was originally published December 16, 2020 on PSQH by Megan Maddox, PharmD, BCPS, CDE
With the widespread implementation of the electronic medical record (EMR) and the ability to trigger that reconciliation gets completed at various stages of a patient’s healthcare encounter, the focus of medication reconciliation has now turned to how to collect the most accurate and updated medication list on our patients on admission or during clinic visits.
In addition, organizations are focusing on opportunities to ensure patients are being discharged with the medication list the provider intended. What has been identified over the past decade by healthcare organizations working on med rec is a patient’s medication list is ever changing and the reality is the medication list needs to be reviewed and updated at each healthcare encounter. To do this well, it typically requires dedicated resources that focus solely on collecting medication histories. The issue that healthcare organizations struggle with now is where to get the resources to develop a med rec team that is dedicated to collecting patient medication histories. Bottom line: You need to be creative!
Up until lately, when it was truly identified how inaccurate medication lists are in the EMR, the responsibility of collecting medication histories largely fell on the admitting nurse as one of a dozen tasks that need to be completed in the first couple hours of that patient’s admission.
We know nurses can collect an accurate medication list—but the reality is that for the admitting nurse, collecting the medication list, while important, has become a task on a very long to-do list that makes it hard to be a priority when everything on that list is important. What many organizations are realizing is to provide the safest care possible to their patients, it is imperative to have an accurate and up-to-date medication list upon admission so they are strategically looking at what resources are available to do this work and where they can get the biggest return on investment with those resources.
Medication Reconciliation Team Models
Focus on high-volume entry points
When deciding on where to place med rec resources, start by looking at where most of your admissions come from. For many hospitals, admissions largely come from planned surgical procedures or the Emergency Department, so these are prime areas in which to consider having a med rec team collect medication histories. At Sanford Medical Center in Sioux Falls, South Dakota, the initial focus for our med rec team was planned surgical patients who were going to be admitted, because this accounted for a big portion of our daily admissions. Next, we needed to determine how we were going to staff this team and decided to use an interdisciplinary approach that included a specific group of preop nurses and staff pharmacists on the team. This ended up being a great combination because there was one nurse and one pharmacist on the team every day, so both professions were able to work closely together and ask each other questions. The nurses relied heavily on consulting the pharmacists when a medication history didn’t make sense; likewise, the pharmacists utilized the nurses’ preop knowledge of all that goes into getting a patient ready for the operating room when trying to collect medication histories on these patients before they are headed up to surgery. In 2015, this dedicated med rec team of nurses and pharmacists interviewed more than 6,000 patients in our pre-surgical area and on average found more than four discrepancies on every patient’s EMR medication list.
Focus on high-risk patient entry points
Another option to consider for med rec team placement is looking at admission points for higher-risk patients. At Sanford Medical Center in Sioux Falls, once we had established the med rec team in the preop admission unit, we expanded to collecting medication histories in our pre-admission area for cardiac catheterization lab (CCL) patients—knowing these patients typically had long medication lists, complex disease states, and were likely taking high-risk medications. Initially, this area was staffed only by pharmacists who were on the med rec team, but the number of patients being admitted through that area continued to increase, so we followed the same model we had over in the preop area and recruited specific CCL pre-admission nurses to join the med rec team. The team in the CCL pre-admission unit saw more than 5,600 patients in 2015 and on average, found four discrepancies on every patient’s EMR medication list.
Direct admissions
Another high-risk area to focus on and a likely high-volume admitting area as well is the Emergency Department. This can be a more challenging population to ensure an accurate medication history is completed because the patients can go anywhere and may or may not enter the hospital through a venue that lends itself to being staffed with a member of the med rec team. There are different approaches to getting this set of patients’ medication history collected. One option is to assign med rec team members who are responsible for collecting medication histories on direct admits and these team members carry spectra link phones so they can be notified by the nurse who is receiving the direct admit. Another option is to utilize your EMR and give med rec team members a patient list that identifies newly admitted patients who still require their medication lists to be collected and updated.
Utilizing the EMR and designated criteria to stratify which patients need med rec
As noted earlier, many organizations have frontline nursing staff collecting medication histories on admission to the best of their ability and thus, it is completed in a timely manner. Then when able, a med rec team member or pharmacist re-interviews the patient to ensure the medication list is up to date and accurately reflects what the patient is taking, and, if there are any changes, contacts the provider who reviewed and ordered the home medications. To ensure the high-risk patients are seen by the med rec team or pharmacists as soon as possible, healthcare organizations are utilizing their EMR to help stratify and determine who the high priority patients are and the order in which med rec should be completed on patients based on predetermined factors.
Sanford Medical Center in Fargo, North Dakota, is utilizing its EMR to prioritize patients that need pharmacist-completed medication histories with the following factors outlined.
The med rec scoring list assigns a score, allowing you to prioritize your work. The highest possible score is a “4”:
1 point if the patient has >/= 10 home medications on their list
1 point if the patient’s med list is marked something other than complete
1 point if the patient is on a high-risk/low therapeutic index medication (immuno-suppressants, insulin, anticoagulation, etc.)
1 point if the patient resides in a nursing home
Pharmacy technician or pharmacy intern collect medication histories
Many healthcare organizations are thinking outside the box and paving new roads regarding who can be part of the med rec team and collect medication histories. Because resources are limited and organizations want to be cost effective, many have started to employ pharmacy technicians and pharmacy interns as part of their med rec team. Both of these are excellent options so long as this is allowed by the Board of Pharmacy in your state and appropriate pharmacist oversight is in place. Pharmacy technicians are very knowledgeable on names of medications and what strengths they come in, which can be very helpful when interviewing patients.
In addition, they can make phone calls to other resources such as community pharmacies, physician offices, nursing facilities, home health nurses, and others to clarify any questions regarding medications to ensure the list is as accurate as possible. A recent study involving pharmacy technicians, working under pharmacist supervision, found that they completed admission med rec on 1,797 patient encounters and identified 1,748 discrepancies with the most common discrepancy type being omission of medications (Sen, S., Siemianowski, L., Murphy, M., & McAllister, S. C., 2014). Involving pharmacy interns on the med rec team is an excellent opportunity to ensure your patients’ medication lists are up to date and, in addition, helps these future pharmacists sharpen their medication history taking skills and the ability to utilize their clinical knowledge to ask questions to the supervising pharmacist when something on the medication list doesn’t make sense.
Characteristics of good med rec team members
If your organization has chosen a med rec design that involves a designated team collecting medication histories, the following characteristics can be beneficial when selecting those team members: detail-oriented, excellent communication skills, team player, problem solver, good at time management, strong investigator. Many times, these individuals have to call numerous pharmacies, physician offices, nursing homes, etc., to answer questions or spend time digging into the patient’s chart to find answers. Getting the right people on the team is important because the impact on patient safety is significant.
Admission vs. discharge
Another common question that comes up when discussing med rec is: Where is the best place to put your resources—on admission or on discharge? This is a really challenging question—and the best answer is both—but this typically is not realistic.
References
Sen, S., Siemianowski, L., Murphy, M., & McAllister, S.C. (2014). Implementation of pharmacy technician-centered medication reconciliation program at an urban teaching medical center. American Journal of Health-System Pharmacy71:51–6.
PSQH: Patient Safety & Quality Healthcare, December 17, 2020
A collaboration announced in October 2020 between the Association for Vascular Access (AVA) and B. Braun Medical Inc. seeks to improve clinician training on the placement of PIVCs.
This article was originally published December 16, 2020 on PSQH by John Palmer
Vascular access is the most common invasive procedure performed in healthcare, with more than 380 million peripheral intravenous catheters (PIVC) placed in patients annually in the United States. It’s estimated that up to 70% of PIVCs fail before the completion of treatment and more than 50% of adults describe insertion as moderately painful or worse. Collectively, this can lead to serious implications for patients, including increased costs and length of treatment.
To counter the problem, a collaboration announced in October 2020 between the Association for Vascular Access (AVA) and B. Braun Medical Inc. seeks to improve clinician training on the placement of PIVCs. Together, the organizations will develop and provide a series of online courses free of charge to schools of medicine, nursing, respiratory therapy, and other allied health professionals—the first of which is being currently piloted at several leading nursing schools.
The eLearning modules in testing feature interactive graphics and high-definition videos and focus on key aspects like proper device placement, assessment, and insertion to instill confidence in students of all skill levels.
Editor’s note: The following Q&A resulted from a conversation PSQH had with Judy Thompson, MSNED, RN, director of clinical education for the AVA since early 2018. Her professional experience includes work as a registered nurse in oncology, telemetry, emergency, outpatient surgery, telemedicine nursing, and vascular access.
PSQH: What are the reasons for the failure of so many placed PIVC lines? More than a third of lines places fail, and that seems like an awful lot.
Judy Thompson: It is an awful lot. The main source of failure is the lack of a comprehensive approach to teaching this skill. We expect clinicians to inherently know how to place a needle in a vein. When clinicians are in school, they breeze over this topic and then are expected to go into a facility with only a modest amount of knowledge. Unfortunately, they often don’t have that baseline training. It is not fair to the clinician nor the patient. It is critical that clinicians acquire the knowledge of how to place IVs and then be given opportunities to practice the skill under a trained eye. You can’t be competent in a vacuum without having the knowledge behind the skill or the chance to test the skill.
Another reason lines fail is because of the location we place them; if we place them in areas of flexion, they can move in and out as the patient moves their arm. The easiest place to put a PIV is often not the best place for the patient.
Finally, another reason for failure is lack of visualization equipment such as ultrasound or vein viewers. Staff nurses often are not trained with visualization equipment and only have access to shorter IVs to stick patients. So, the nurse cannot see a vein and then the shorter IV only stays in the vein until the patient moves their arm a few times.
PSQH: What is missing from current PIVC placement training? What are some of the courses or new information that nurses should be taught?
Thompson: PIV insertion, care, and maintenance isn’t taught comprehensively in medical, nursing, or even respiratory therapy school. When it is taught, the entirety of the program is not fully mapped out in a way that is conducive to information retention.
We need to layer the learning; being taught how to put a needle in a patient is not the first thing a medical or nursing student needs to be taught. Instead, information that leads to safe practices must be first, including the anatomy and physiology of the veins, how to engage with the patient, how to avoid skin injuries, and even legal aspects of the practice.
Understanding the care and maintenance of an IV is also critical. It takes about 10 minutes to put in the IV itself, but it will be inside the patient for hours, days, and maybe even weeks. Without proper maintenance, a multitude of issues can and likely will occur. In fact, IV infections are often grossly underreported, simply because not enough facilities check to see if there is one.
Another important aspect that needs to be better understood by clinicians is the type of medicine running through the IV. As clinicians care for patients, we think about the holistic impact of the medicine or the drug-on-drug interactions. But we need to think about the full impact the medicine has on the body, including how it reacts to the vascular system and how the location of the IV impacts dwell and complications.
PSQH: How will changing the standard of care impact the patient experience?
Thompson: Right now, patients expect to be stuck a number of times to get an IV inserted. It is awful that patients accept this. Along with food quality and lack of sleep, PIVs are one of the biggest complaints in healthcare. More comprehensive education will lead to fewer sticks, fewer complications, more positive health outcomes, and an improved patient experience.
PSQH: What are some of the specific details of the new training approach, and how will it increase nurse confidence?
Thompson: The course is being created as if the instructor is speaking to an in-person audience, or an actual classroom. We’ve made a concerted effort to make the content engaging and interactive to ensure students understand these concepts and embed the information.
We have engaged subject matter experts and specialists to teach all areas: an attorney wrote and presents the legal aspects, an infection preventionist brings her expertise, university professors are instrumental in knowledge checks and course design, and much more. We sought out people that are passionate about this topic and who really care about improving the standard of care to teach the course. The goal is to show the students the impact that PIVs have in healthcare. This little device is so terribly underappreciated. Future clinicians must have a greater understanding and respect for PIVs.
The hard part isn’t understanding the needle or the catheter; it’s understanding how the infusate and the patient’s medical history and current condition impact their decision-making before inserting the IV.
PSQH: What are some of the long-term health benefits of proper IV placement?
Thompson: For patients that are chronically ill, we need to worry about their vasculature significantly earlier than we currently do. In the case of a sick infant who is frequently getting IVs, the constant sticks over time can damage the veins so extensively that by the time the infant is an adult, he won’t have any viable veins to stick. Chronic conditions such as short gut, sickle cell, cystic fibrosis, and many others have lifelong consequences when venous access is not planned for or taken for granted. These patients run out of veins, sometimes in early adulthood. Venous access is truly their lifeline.
There are many benefits to proper IV placement, but I think critical thinking, reduction in infection, and increased patient satisfaction are the key issues we should aim to solve.
PSQH: Can you provide any examples of hospitals or training programs that have utilized the new training approaches, and talk about the success that they have had?
Thompson: Our beta test is kicking off right after the new year, and we’re excited to share our results once the program starts to be utilized. We have heard from our partners that the type of curriculum we are offering will absolutely change how students are taught and ultimately the patient experience. As with any major shift in education or training, this is evolution and not revolution, so we don’t anticipate a single solitary swing in the industry. But we do know that this will help influence true change in the years ahead.