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PSQH: Patient Safety & Quality Healthcare, July 17, 2020
The urgency with which hospitals must act to improve patient, staff, and visitor safety cannot be overstated.
This article was originally published July 15, 2020 on PSQH by David Goldsteen, MD
Improving patient safety has always been a priority for hospitals and health systems, but COVID-19, and the possibility of a second surge in a few weeks or months, is bringing new urgency to these efforts.
All hospitals must quickly assess their current safety-related processes, identify optimization opportunities, and implement new approaches that foster a safer environment—not just for patients with COVID-19, but for all patients, staff members, and visitors.
A recent survey of 100 hospital leaders, physicians, pharmacists, and infection preventionists reveals some of the new safety-enhancing approaches that hospitals should consider. In the survey, conducted by healthcare consultancy Sage Growth Partners just prior to the COVID-19 outbreak in the United States, respondents identified their top safety challenges, evaluated their safety performance, and identified their most successful safety improvement approaches. Here are three of the biggest takeaways.
Hospital leaders say it’s time to look beyond the EHR for safety support.
As hospitals seek to improve patient safety, they need processes and approaches that enhance their ability to identify, track, and monitor safety problems in real time. The survey found that a growing number of hospitals (29%) are implementing clinical surveillance technology to help accomplish this mission.
Clinical surveillance continuously pulls information from electronic health records and other data sources, analyzes that data, and uses it to produce patient care insights and reports. The technology also issues real-time alerts to healthcare providers (via email, in task lists, or through dedicated notification channels) when potential patient safety problems arise.
Nearly all survey respondents (95%) said clinical surveillance improves patient safety and identified its top benefits as:
Identifying and managing safety events
Identifying medication errors
Identifying opportunities to improve antibiotic use
Ensuring safer opioid prescribing
In relation to COVID-19 specifically, clinical surveillance provides many safety-enhancing benefits. These include alerting healthcare providers and infection preventionists to test results in real time, providing outbreak and exposure alerts and investigation tools, assisting with contact tracing, and managing drug shortages.
Hospitals that use real-time alerts have stronger safety performance.
Real-time alerts provided by clinical surveillance technology ensure physicians, pharmacists, and infection preventionists are notified as soon as potential safety problems are identified or critical information is available, such as that related to medication errors, non-optimal antibiotic or opioid use, or COVID-19 test results.
The survey findings underscore the safety-enhancing benefits of real-time alerts. Respondents who said their organization uses them were much more likely to be satisfied or very satisfied with their hospital’s safety performance. They were also more likely to:
Say their organization could respond to a viral or disease outbreak immediately
Say their process for identifying patients at risk for sepsis is very or extremely effective
Say medication error rates and opioid prescribing rates had fallen in the past year
Real-time alerts also help hospitals optimize medication usage when certain medications are in short supply. With a second COVID-19 surge likely here in the U.S. and in other countries, providing pharmacists with real-time alerts related to medication usage is even more important.
For example, if pharmacists receive alerts whenever a necessary medication for COVID-19 patients is ordered for a patient who does not have COVID-19, they can quickly determine whether an alternative medication can be used instead.
Hospital leaders say safety-event reporting tools are critical to fostering improvement.
Nearly all survey respondents (98%) said a robust safety-event management system—in which safety-event information pertaining to patients, staff members, visitors, security, and housing is collected, assessed, and managed—is important or very important to supporting patient safety initiatives.
Still, only about half of respondents said they use safety-event management tools to support safety improvement efforts, and only 51% said their approach to safety-event reporting is extremely or very effective.
These findings are particularly concerning given the possibility of a second COVID-19 surge. Hospitals that did not have an effective safety-event reporting system during the first wave will have a harder time identifying where they made missteps and how they can improve moving forward.
The urgency with which hospitals must act to improve patient, staff, and visitor safety cannot be overstated. The good news is that hospital leaders report significant benefits from new approaches, which include clinical surveillance, real-time alerts, and robust safety-event reporting solutions. As hospitals seek to improve patient care, they all should begin exploring opportunities to implement these tools.
David Goldsteen, MD, is the cofounder of VigiLanz, and serves as chair and CEO. He is a founder and former chair and CEO of Vascular Science, Inc., purchased by St. Jude Medical. Dr. Goldsteen is a graduate of the University of Minnesota Medical School. He performed his residency in internal medicine at Hennepin County Medical Center in Minneapolis.
PSQH: Patient Safety & Quality Healthcare, July 16, 2020
Frost & Sullivan researchers are projecting a sevenfold growth in telehealth usage by 2025, for a five-year compound annual growth rate of 38.2%.
This article was originally published July 15, 2020 on PSQH by Megan Headley
After years of efforts to change telehealth regulations that would broaden use of remote medical care, the COVID-19 pandemic has seemingly removed a great deal of resistance to the idea. Thanks to waivers that have allowed reimbursement for a broader range of services, exponentially more providers and patients have moved their healthcare online.
And now that patients are becoming more accustomed to seeking care this way, healthcare organizations are expecting telehealth will continue to grow. Frost & Sullivan researchers are projecting a sevenfold growth in telehealth usage by 2025, for a five-year compound annual growth rate of 38.2%.
During the pandemic, telehealth solutions have proven critical in ensuring continuity of care and communication—the “most important parts of healthcare,” says Heather Annolino, senior director of Ventiv Technology’s healthcare practice. Yet Annolino calls for providers to ensure they’re not implementing solutions today without due attention to the risks tomorrow might bring.
“There are still the same risks that were in place before COVID-19,” Annolino points out. That makes now a perfect time to make sure your risk management is caught up.
Security risks
On March 17, as social distancing policies began to impact U.S. hospitals, CMS issued guidance to states seeking to expand telehealth for Medicaid in response to the pandemic. During a White House coronavirus briefing, CMS Administrator Seema Verma lifted a variety of federal restrictions on the use of the service and praised telehealth’s potential to keep at-risk populations from needing to leave home for care.
The lifting of restrictions also relaxed many HIPAA requirements so that doctors could provide telehealth with their own electronic equipment.
While this federal action did fill critical gaps in care, it has also opened health systems to many of the security risks that had long been feared from telehealth implementation. Back in 2017, a federal task force on healthcare cybersecurity said staffing problems and outdated equipment and software put healthcare at risk of creating a public health crisis.
As of September 2019, a report by cybersecurity firm Kaspersky found that one in four U.S. healthcare workers had never received cybersecurity training from their employer. In mid-2020, these remain real concerns.
Investigators are seeing “tons” of fraud cases linked to COVID-19, Kaiser Health News reports. These cases have included using patient accounts to bill for bogus coronavirus emergency kits, or billing for thousands of dollars’ worth of useless tests.
It was a June data breach of U.K. telehealth app Babylon Health that demonstrated the security risks many had feared. The breach allowed app users to access other patients’ appointments. Although Babylon Health stated the breach was likely the result of a software error, rather than a cyberattack, the incident still points to the importance of having risk management processes in place.
Process gaps
While there are always risks of hacking and phishing, many of the perils health systems face today have more to do with a lack of the proper safeguards that make up traditional risk management. As Annolino says, it’s critical that providers put a consistent risk management framework in place to mitigate the compounding risk factors associated with COVID-19. That framework should include the following steps:
Ensure proper credentialing. In March, the National Committee on Quality Assurance exempted organizations through September 1 from credentialing practitioners outside their network or practice if they were providing care as a result of the public health emergency. Insurance companies are offering provisional credentialing to expand their network of providers. However, this opens patients and providers up to serious fraud risk. Before connecting patients to their next step in care, ensure you have medical credentialing processes in place.
Check licensing. CMS has allowed states to request a waiver to temporarily allow out-of-state practitioners to provide services locally, so long as they are licensed in another state. Although industry advocates such as the American College of Physicians have requested CMS extend waivers for “interstate licensure flexibility” through the end of 2021, or until a vaccine or effective treatment for COVID-19 has been developed, there is no guarantee this exemption will remain in place. Ensuring appropriate licensure now will help guarantee seamless care later.
Update liability insurance. Health systems working with out-of-state specialists should verify that these providers have professional liability insurance through their employer or individually.
Create processes for standard IT procedures. Do you have backup and downtime procedures in place for managing remote visits? Are clinicians using secure employer-issued equipment, or are they making unsecured calls from their personal laptops? Are telehealth visits being conducted in private, away from high-traffic areas? Educating providers on security protection will reduce risks of data breaches.
“Establish as many of these things now as you can. It will help in the long run,” Annolino says.
Minimize gaps in care
Annolino offers a few additional tips to ensure a seamless telehealth experience for patients and avoid exposure to harm through gaps in care. First, she advises, ensure providers have easy access to their patient’s permanent medical records while conducting the telehealth visit. Make sure any documentation is maintained in a central location where it can be easily accessed by other providers who may be also treating that patient via telehealth.
Of course, shared access to information has been a sticking point for transitions of care even prior to the pandemic. “For instance, [if] you go into a [CVS] MinuteClinic or your local pharmacy, your physician doesn’t know you’ve done that unless you personally tell them,” Annolino explains. “How do we make sure that communication goes back to the medical records and to the people who typically see you? That’s a huge risk.”
But it’s also an opportunity. Encouraging more patients to seek services from one easy-to-reach physician or practice presents a chance to create a more continuous flow of care.
Create a program with staying power
Putting risk management processes in place today allows health systems to gather data on what works and what doesn’t, even if analyzing that data may have to wait for calmer times. If practitioners want to maintain telehealth’s tremendous momentum, it’s critical for them to understand what aspects of remote care function best.
As of June 29, 340 organizations had signed a letter urging congressional leaders to make telehealth flexibilities created during the COVID-19 pandemic permanent. Following proper strategies for reducing risk will help prove that telehealth is a trustworthy option for ensuring consistent communication and continuity of care.
“Some things have gone by the wayside, like physician-patient relationships being established prior to meeting,” Annolino says. “But you still need to know there’s a follow-up plan. We don’t want this to impact the continuity of care.”
PSQH: Patient Safety & Quality Healthcare, July 5, 2020
When used according to manufacturers' instructions, cleaners and disinfectants can be effective control measures for infectious diseases, including Ebola and influenza.
This article was originally published July 2, 2020 on PSQH by Guy Burdick
The National Institute for Occupational Safety and Health (NIOSH) recently collected safety and health information on cleaners and disinfectants that employers can use in their hazard communication programs. The NIOSH material includes a table of health hazards and protective measures for chemicals used as disinfectants.
When used according to manufacturers’ instructions, cleaners and disinfectants can be effective control measures for infectious diseases, including Ebola and influenza.
Guidelines issued by the Centers for Disease Control and Prevention (CDC) and Occupational Safety and Health Administration (OSHA) since the beginning of the coronavirus disease 2019 (COVID-19) pandemic have referred employers and building owners to the Environmental Protection Agency’s (EPA) “List N” of Disinfectants for Use Against SARS-CoV-2 (COVID-19).
COVID-19 is a respiratory illness caused by the SARS-CoV-2 virus. COVID-19 currently is widespread in most U.S. communities and considered a workplace hazard.
Some of the chemicals on the EPA’s list have health or flammability hazards. The NIOSH table includes the following information for several commonly used disinfectants:
The chemical name and common names for that chemical,
The chemical abstract service number (CAS No.),
Globally Harmonized System of Classification and Labelling of Chemicals (GHS) pictograms,
Health and flammability-related hazard statements,
Recommended glove barriers, and
Recommended respiratory protection.
OSHA’s hazard communication standard (HCS), often referred to as “worker right-to-know” (29 CFR §1910.1200), requires that employees be informed of potential work hazards and trained on associated safe practices, procedures, and protective measures.
Employers must ensure employees have access to cleaning products’ safety data sheets (SDS) and are informed of potential hazards and trained on the associated safe practices as detailed in the products’ SDS.
In healthcare facilities, employers also should comply with the 2008 Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines recommending that each worker be informed of the possible health effects of exposures to chemicals in the workplace.
Employees specifically need to be informed of documented health risks from exposure to hydrogen peroxide, acetic acid, and peracetic acid, as well as chemicals found in other cleaners.
In addition to hazard communication requirements for labels, SDS, and training, employers need to maintain sufficient ventilation in areas where chemicals are used, as well as provide any protective clothing, gloves, or safety goggles needed.
Employers need to consider factors in the use of cleaners and disinfectants, including:
Chemical ingredients of the cleaning product;
How the cleaning product is being used or stored;
Ventilation in the area where the cleaning product is used;
Whether there are splashes and spills;
Whether the cleaning product comes in contact with the skin; and
Whether mists, vapors, and/or gases are released.
Poison control centers have seen an increased number of calls about exposures to cleaners and disinfectants since the pandemic began.
The CDC released a report noting that calls to U.S. poison control centers about cleaner and disinfectant exposures increased 20 percent the first 3 months of 2020.
The first U.S. laboratory-confirmed case of COVID-19 was reported on January 19, and the CDC recommended proper cleaning and disinfection of high-touch surfaces to help mitigate the transmission of SARS-CoV-2.
From January 2020 to March 2020, poison control centers received 45,550 exposure calls related to cleaners and disinfectants—an increase of 20.4 percent from January 2019 to March 2019 and 16.4 percent from January 2018 to March 2018.
PSQH: Patient Safety & Quality Healthcare, July 4, 2020
Prevent serious health events and improve clinician experience through smarter, data-driven workflows and interventions.
This article was originally published July 1, 2020 on PSQH by John Zaleski, PhD, NREMT
COVID-19 has raised the general public’s awareness of healthcare functioning amid a pandemic. With more than 2.2 million cases confirmed in the U.S., approximately 120,000 deaths, and nearly 700,000 recovered, the intense focus on caring for and managing these patients has drawn much attention worldwide (John Hopkins University & Medicine Coronavirus Resource Center, n.d.). The evolving state of the virus, together with our understanding from the medical perspective, has caused changes in treatment and management of these patients. Whereas intense mechanical ventilation was the end state early on in treatment for a small fraction of unfortunate patients, the prevailing objective is now to keep patients from being intubated and placed on mechanical ventilation for as long as possible. The focus of much of the acute treatment has been in ICUs, although many health systems had evolved other units into makeshift ICUs, in preparation for an expected overwhelming patient intake. Reality has proven that the great overwhelm, in general and countrywide, has not come to pass, although there are hot spots of intense focus—principally in the major cities on the seaboards with dense populations.
While much of the focus has been on the ICU and the many monitoring and therapeutic patient care devices used to maintain and manage patients’ airway, breathing, and circulation (ABC), there is also a growing need outside of these high-acuity settings for monitoring patients. What the general public—and even hospital leadership—might not be aware of is that outside of critical care, there is a patient safety concern that could be growing, in part, due to clinical staffing pressures associated with COVID-19. In these non-critical units, patients with lower-acuity COVID-19 or other conditions may be at greater risk of suffering adverse events simply by being overlooked. These assertions are expressed in multiple ways, including reports of the need for emergency intubation and mechanical ventilation in more than 40,000 patients per year in the U.S. alone, and with interventions for opioid-induced respiratory depression estimated at $2 billion per year. Furthermore, estimates of complications associated with mechanically ventilated patients are estimated to exceed $1 billion annually (Wong, 2018).
Additional staffing in these units would help prevent these events, but it is not always feasible considering that hospitals face significant financial challenges, which have been exacerbated under COVID-19. Rather, clinicians need support in preventing adverse events through an enhanced clinical surveillance strategy that involves new data-driven workflows. Enhanced real-time clinical surveillance goes beyond monitoring physiologic parameters to detect emergent clinically actionable events and improve operational efficiency, enabling clinicians to safely care for larger numbers of patients.
More devices, less actionable information
Outside of the ICU, monitoring of vital signs can be episodic, roughly every four to six hours, depending on hospital or unit policies. Episodic data collection can result in gaps that do not capture key vital sign activity. If tachycardia or bradycardia occur, even for a sustained duration of 15 to 20 seconds, they may not be captured if discrete heart rate measurements are taken at one-minute or five-minute intervals.
Hence, when data collection is not continuous, events such as these are unknown to the clinician unless observed directly. Continuous data collection is important, particularly in lower-acuity settings, because the occurrence of “in-hospital respiratory failure [has been] associated with a mortality of nearly 40%” (Morris et al., 2017). This necessitates close surveillance of patients to catch respiratory decline, which in turn necessitates continuous monitoring.
Continuous capture of medical device data alone, however, will not solve this challenge, even when the devices are integrated through a single platform. A single clinician responsible for numerous patients could find it impossible to coherently interpret a stream of unfiltered data, especially with the multiple devices that many patients require. Such an unmanaged data flow would also contribute to nuisance alerts that feed into the alarm fatigue reported as a patient safety concern, as well as cognitive overload, which is another cause of clinician burnout.
With COVID-19, such alarms create unnecessary virus exposure risk for clinicians. Responding in person also requires clinicians to don personal protective equipment (PPE) before entering the patient’s room. Considering that PPE is still in short supply—and that demand will only increase now that hospitals are resuming elective procedures—wasting such gear on false alarms should be avoided.
Streamlining clinical surveillance
Instead of responding to every alert or concerning device output in person, hospitals need to be more strategic with their surveillance workflows. That requires clinicians in the ICU and in lower-acuity departments to have remotely available analytic tools to make sense of the stream of real-time patient data coming from devices. The data flow can be compared to historical EHR information to identify clinically relevant trends, sustained conditions, reoccurrences, and combinatorial indications to help clinicians predict health decompensation before it occurs, which can prevent harm and improve outcomes.
Along with analytics, clinicians should also be able to configure alerts so that they are relevant and clinically actionable. For example, in patients who receive postoperative opioid analgesia, remote alerts can be configured by taking a combination of vital signs into account and notifying clinicians only after a specific period of time has passed that indicates a worsening trend. A smarter alert such as this can reduce the alarm frequency without increasing risk to the patient. Clinicians can also respond to such alerts more fully informed about the patient’s status and prepared to intervene.
For hospitals using mobile secure messaging applications, these alerts should be integrated and bolstered with additional context, such as patient ID and location, trended data, device settings, and other measurements at the time the alert occurred. Mobile communication is crucial when surveilling patients with COVID-19 to minimize potential virus exposure while ensuring a rapid and prepared response to a critically ill patient.
Early detection saves lives
Whether for COVID-19 or any other condition, early detection of patient deterioration saves lives. Such early detection, however, is especially challenging outside of the ICU where the ratios of patients to clinicians are typically higher. Key advancements in real-time healthcare and advanced data analysis are driving continuous clinical surveillance and present a significant opportunity for hospitals and health systems to push patient safety initiatives into the realm of proactive healthcare, both during and after the pandemic.
PSQH: Patient Safety & Quality Healthcare, July 3, 2020
During the pandemic, patients are also likely to rate their ambulatory service experience based on how carefully you protect them from exposure to COVID-19, and how well you prepare them for the changes those protections create during their visits.
This article was originally published July 1, 2020 on PSQH by Alexa B. Kimball, MD, MPH
As we hear the phrase “the new normal” frequently and work to understand what exactly it will mean for patients, providers, and our healthcare system, one thing is clear: COVID-19 has changed healthcare. While some changes may be temporary and immediate in response to acute crises, many changes are here to stay: increased use of telehealth, for example, and improved infection prevention practices both during patient visits and at home.
One thing that has not changed is providers’ desire to provide excellent patient care and service, and patients’ need to feel comfortable and well cared-for in the ambulatory environment. It is also still true that patients often judge the overall quality of their care based on the service experience at the hospital or office, and that perception is based on a comparison between their pre-visit expectations and their actual experience during the visit. During the pandemic, patients are also likely to rate their ambulatory service experience based on how carefully you protect them from exposure to COVID-19, and how well you prepare them for the changes those protections create during their visits.
With this in mind, here are five ways that you can make sure your patients’ experience will meet—and exceed—their expectations.
Pre-visit: Expectations and preparation
While pre-visit registration via telephone had become routine well before COVID-19, it’s important to have your registration staff well trained to answer questions and provide information about how the patient visit will differ due to the pandemic. When your office or hospital calls to remind patients of their visit or to pre-register them, devote a portion of the message or call to COVID-19 changes. For example, tell patients that they will be greeted outside by a professional who will take their temperature and ask them questions to pre-screen them for COVID-19 symptoms. Explain what will happen if they or another patient has a temperature or shows signs of the virus. Your registration staff should ask if the patient has any questions or concerns, and should confidently assure patients that the hospital or office is taking proper safety precautions.
Arrival: Greeting
Properly training the “greeting” staff (who greet patients to take a survey of any symptoms they might be experiencing and take their temperature) is essential. These greeters should explain what is happening in a friendly and calm manner. Recent stories of patients having a thermometer stuck on their forehead with only a “Hi” make it clear that some of us need simple training in empathetic patient service—even if it may seem obvious. If possible, patients should be given a disposable mask to use during the visit only, and should be asked to sanitize their hands before entering. The greeter should also give a brief introduction to what has changed as a result of COVID-19 precautions. Carefully explaining this initial screening, sanitation, and other processes that may have changed will go a long way in helping patients feel comfortable and secure during their visit. This introduction should create a team environment, emphasizing that everyone helps protect the vulnerable by wearing a mask, washing their hands, practicing social distancing, and using hand sanitizer.
During the visit: A sanitized ‘chain of custody’
With legal evidence, such as a stolen credit card with fingerprints on it, the prosecutor must show that the police kept the evidence secure from collection through trial, such that no one could tamper with it or change it. Similarly, ambulatory facilities should take a “chain of custody” approach: Having medical staff wear masks and change gloves often is not helpful if the office staff takes and hands back a credit card without changing their gloves or wearing any gloves at all. Each step of the visit should be “secured”: from sanitizing the waiting areas and restrooms, to setting up properly distanced seating, to making sure all interactions occur with proper PPE and sanitation, to considering what articles may move from room to room (including pens and clipboards). Small errors in handling undermine both the integrity of the process and patients’ confidence in it. It’s a good idea to do a mock run-through with staff to check for small issues, and to see how staff is interacting with patients and handling sanitation and other aspects that may have changed due to COVID-19. Finally, letting patients see the change of gloves or other sanitization methods that might normally take place after they leave will provide both a sense of security and a real difference in potential for virus spread.
During the visit: Making the patient feel comfortable
As healthcare professionals, we were taught to use body language, facial expressions, eye contact, and good listening skills to put patients at ease. This not only improves the patient experience, it also makes patients more likely to share important information about their physical condition. But wearing masks and other PPE makes communication via facial expressions and smiling difficult and less effective. Consequently, it’s important to supplement those nonverbal cues with verbal ones, helping the patient feel at ease with words in addition to a smile. And do smile! Even with a mask on, patients can see your smile through your eyes or other visual cues.
The details
With heightened stress and challenges during COVID-19, it’s especially important to manage operational efficiency and precision, staying on top of seemingly small details that can make a difference in patient experience. Ensuring that wait times are kept to a minimum while not making patients feel rushed is especially important, and while wait times cannot always be helped, clear communication regarding the expected wait is essential, particularly when patients may be distancing by waiting in their cars or other areas outside of the office. An office’s thoughtfulness in regard to safety can be seen in how patients flow through the office for the visit, with appropriate distancing through floor markers (as seen in grocery stores) and processes that can be conducted in the patient room to reduce the risk of exposure to other patients. Making sure that everyone in the office wears a mask properly (covering both their nose and mouth) conveys caring, as does making sure that hand sanitizer dispensers are available in multiple locations and are filled and working properly.
Like so many practices put in place to improve patient service, changes due to COVID-19 have the goal of improved patient care, safety, and experience. And as always, the first step in caring for patients is showing them that you care. At this time, it is especially important to have your organization and providers use complete safety precautions, and have procedures in place to consistently execute those precautions, while helping patients to feel comfortable with what is new and different.
PSQH: Patient Safety & Quality Healthcare, July 2, 2020
Brad Gair says, "In truth, if your reliance is on getting FEMA funding 'fast' in a hospital environment, that is your first mistake."
This article was originally published July 1, 2020 on PSQH by John Palmer
Among the numerous challenges that U.S. hospitals are facing during the COVID-19 pandemic—besides keeping their facilities open, safe, and able to treat patients—is how to get paid by the federal government for the services they provide to the community.
A broad range of federal programs were allocated funding through the $175 billion Coronavirus Aid, Relief, and Economic Security (CARES) Act passed by Congress. But getting that money, either through FEMA or other agencies, has caused some confusion for governments, institutions, organizations, and individuals in search of COVID-19–related aid.
Brad Gair, senior managing director of Witt O'Brien's, a Washington, DC–based emergency management and disaster response consultancy firm shares how hospitals and healthcare systems can secure funding during the pandemic.
Gair formerly served as deputy commissioner of New York City's Office of Emergency Management, and as NYU Langone Health's first vice president for emergency management and enterprise resilience. In both roles, he helped oversee disaster financial responses after 9/11 and Hurricane Sandy in New York City.
This interview has been lightly edited for clarity.
PSQH: What do you think are some of hospitals’ biggest emergency funding needs, and what are the challenges in getting them met?
Brad Gair: Hospitals have several immediate needs, including the following:
Personal protective equipment (PPE). This is an issue because essential workers continue to care for COVID-19 patients, and the counts are on the rise. This holds true for care delivered within a hospital or in an outside triage testing unit. Even in states where the COVID-19 patient levels are stabilized, if the facility has not planned and forecasted for additional PPE to cover the next surge, they are going to find themselves in the exact same position they were in when COVID-19 impacted the U.S. in March and April. Hospitals should be forecasting their future burn rates through September at the very least.
Staff capacity. This is an ongoing issue, especially if they continue to have staffing needs 24/7. Hospitals need to determine how they are going to best address their ongoing resource needs in that environment. Some have secured commitments for reserve staffing through mutual aid agreements. Large organizations can do this within their own hospital structures. Public hospitals or state hospitals will have a greater challenge—all the more reason to best understand what their staffing resource priorities will be for extended COVID-19 responses.
Cash flow. Because there is a significant sustained COVID-19 resurgence, cash flow is going to be a big issue for hospitals that are not in a strong position or that have not already secured CARES funding. The linchpin is understanding the whole ecosystem of funding that is out there, and how to plug costs into the right place to get the most linear, point-to-point funding opportunity, and how to do that in a manner that lets your application go through smoothly and quickly, and be rock solid so it won’t get challenged in the future. One of the biggest challenges is that aside from large, sophisticated organizations, few healthcare organizations really understand the whole scheme and how to plug into it.
PSQH: A disaster like COVID-19 is different than, say, Hurricane Katrina or Sandy, because with those two storms, you could see the damage—the lights went out, the basements got flooded, etc. With a pandemic, it’s different as facilities are technically still operational. Is it more difficult to get insurance companies and FEMA to label this as a disaster that needs emergency funding, and how do hospitals convince FEMA that they need funding immediately?
Gair: One misconception that can trip up hospitals is that FEMA reimbursement is not immediate or even fast. This is the case for a number of reasons, and the primary culprit is not having the documentation from the applicants necessary to justify funding.
In truth, if your reliance is on getting FEMA funding “fast” in a hospital environment, that is your first mistake. You need to understand what the total sources available are, and then the proper way of slotting in your costs into each of those funding opportunities so you can package those into an application for reimbursement.
The reality is that none of the federal funding that has been provided has been perfect. None has hit every potential variable right or anticipated every impact. There are going to be actions that hospitals take that are deemed appropriate that will never get funding from the federal government programs. It’s best to focus on the eligible funds you can get. And since some funding is first come first serve, focus on developing the best applications possible and getting them to the right funding source. And once the money is in your bank account, do not sweat it. Just have a plan to spend it appropriately.
PSQH: There have been some obvious costs for things (such as drive-through testing, field hospitals, etc.) that can’t really be planned for ahead of time. Are hospitals finding it difficult to get funding for these emergency services?
Gair: Testing is the biggest problem because it is really not a hospital’s responsibility to set up mass testing in another facility. That is fundamentally the government’s job. FEMA initially was setting up their own testing sites, and then states and local jurisdictions began operating their own.
It is going to be an interesting eligibility decision when it comes down to submitting those costs, and what the funding stream is going to do about it.
Hospitals need to be up front and not try to blur the lines. They should know what is covered and by whom. For example, a hospital may set up a triage unit outside the emergency room to do testing; this activity is likely to be considered by FEMA for reimbursement as there is a low chance of a duplication of benefit from another funding source such as insurance.
PSQH: One of the biggest things that experts suggest when disaster planning is to conduct a hazard assessment before bad things happen. In reality, could this pandemic (and the emergency funding it requires) have been planned for, and how does asking FEMA for assistance fit into that plan?
Gair: Yes, it could and should have been assessed in advance. This is not our first trip to the pandemic rodeo. Good hospital crisis-scenario planning should include pandemic response. Gauging the scope and depth of the event is a challenge, and sometimes you may have to be doing assessments on the fly, when you are in the thick of it. If you have somebody who understands the emergency planning process, they can help you work through even the most unimaginable scenarios. An expert who really knows how to navigate the government funding waters can help you find opportunities, define them, and slot your costs into the appropriate places to be in the best position for reimbursement.
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.
PSQH: Patient Safety & Quality Healthcare, June 29, 2020
The change will make it easier for hospitals to comply because it requires only that doors only close, not that they must latch.
Editor's note: This article was originally published June 23, 2020 on PSQH by A.J. Plunkett, editor of Inside Accreditation & Quality, a Simplify Compliance publication.
Remember to keep checking for a new Survey Activity Guide (SAG) from The Joint Commission (TJC), which is promised for July and will include new information on surveys as they slowly resume in areas with a slowed rate in COVID-19 cases.
You’ll be able to find the SAG on TJC’s revamped website by going to the Snapshot of Survey Day page, which can be found here. Then look for the “Get your Survey Activity Guide” link under the photo.
Remember also that TJC has updated several of its hospital accreditation standards, primarily related to last year’s long-awaited revisions to the CMS Conditions of Participation(CoP) on burden reduction and discharge planning.
Many of the changes were announced in late February and effective March 15. Then in late May, TJC announced more updates, some related again to the CoP revisions and effective September 13. All of the revisions had to be approved by CMS.
However, there were a few standards updated that were effective as of July 1, and those were the result of the federal review of TJC standards as part of TJC’s February reapplication to be a deeming authority for CMS for hospitals that want to bill Medicare. The changes were required by CMS, said a TJC spokeswoman.
A check of the “What’s New” section of the July 1 hospital accreditation manual also shows some notable revisions, including a requirement under Life Safety standard LS.02.01.50, EP 10, which says that linen and waste discharge service doors should only be self-closing.
The change will make it easier for hospitals to comply because it requires only that doors only close, not that they must latch.
The spring-loaded doors have a fusible link that melts in a fire and fully closes the door when activated, so the risk of smoke passing up through the chute is negligible, says Ernest E. Allen, ARM, CSP, CPHRM, CHFM, a former TJC Life Safety surveyor and now a patient safety executive with The Doctors Company in Columbus, Ohio.
“Sometimes it is difficult to get the door to latch, as the latching mechanism may get dirty or slightly out of alignment with heavy use of hundreds of trash bags falling a great distance out the chute and knocking the latch just slightly to the side,” says Allen.
“Hospitals do need to check soiled-linen and trash chute doors frequently. It is also important to clean out the discharge room of trash and soiled linen on a daily basis,” says Allen. “I have seen some soiled linen rooms that are full and the bags continue up into the chute, thereby preventing the discharge door from closing in the event of a fire.”
The revision does not represent a huge change, notes Brad Keyes, CHSP, founder of Keyes Life Safety Compliance. TJC is just catching up to changes made earlier by the National Fire Protection Association (NFPA) to its standard regarding the chute discharge.
Among the revisions to the standard is a reference to a Tentative Interim Amendment (TIA) by the NFPA.
The revision does not mean the facility needs to remove the positive latching devices, it just means it is no longer required, says Keyes.
A.J. Plunkett is editor of Inside Accreditation & Quality, a Simplify Compliance publication.
PSQH: Patient Safety & Quality Healthcare, June 24, 2020
A collaborative relationship is intended to help patients manage their conditions and stay healthy; make better health-related decisions; and become more interested in their ongoing care.
This article was originally published June 23, 2020 on PSQH by Paul Rooprai and Neel Mistry
Patient safety can be defined as the absence of preventable injuries arising from the process of healthcare. Including patients in clinical discussions is central to patient safety, and this can be accomplished by patient-centered decision-making, establishing a culture of safety, and effective communication and teamwork.
Patient engagement is important to promote safety in healthcare, and patient-centered decision-making is a central means to facilitate this engagement. There are several clinical trials suggesting that engaged patients have a significant mortality reduction (Darkins et al., 2015; Darkins et al., 2008). Activated and engaged patients who collaborate with their clinician are likely to have better health outcomes.
A collaborative relationship is intended to help patients manage their conditions and stay healthy; make better health-related decisions; and become more interested in their ongoing care. Providers should be respectful and responsive to patients’ preferences, needs, and values and ensure that these aspects guide all medical decisions. The need for patient engagement is foundational as the majority of individuals spend only a small proportion of their time in medical facilities and frequently must make daily health decisions on their own.
Further, patient engagement has an ethical basis: Engagement supports patient autonomy, promotes trust in the physician-patient relationship, and helps to set reasonable expectations and improve knowledge. A practical need for engaging patients exists as well. Almost all medical decisions inherently have a trade-off of harms and benefits. A good decision can be made by including the patient’s values and preferences. Patients themselves must engage in behavior change and health management.
Without an understanding of care and buy-in, patients are less likely to manage their health effectively. Case studies in diverse medical settings show resulting improvements in healthcare quality and outcomes when patients are engaged (Laurance et al., 2014). These findings demonstrate how engagement can shift the paradigm from “what is the matter?” to “what matters to you?” Ultimately, patient participation in healthcare decision-making has clear benefits such as better adherence to treatment plans, higher levels of satisfaction with care, and improved health outcomes.
Healthcare today is complex, highly efficient, and costly. Due to this inherent complexity, there is a need for the establishment of a culture that encourages safety at the system and individual level (Taran, 2011). With the tests and procedures that are conducted today in addition to the intricacy of the system, healthcare can cause harm. Errors can be the result of recklessness at the individual level.
But it is also important to recognize that they are caused by faulty processes, systems, and other circumstances that lead to mistakes or fail to prevent them. The number of errors can be reduced by redesigning the medical system at all levels to improve safety. Through a broad lens, this system must have practices that address the following: 1) error prevention; 2) detecting errors as they arise so they can be intercepted; and 3) reducing the effects of errors that go undetected.
A culture of safety is a necessity. Such an environment would involve workers who accept responsibility for the safety of not only themselves, but also their coworkers and patients. In this culture, safety is prioritized above operational and financial goals. Leaders support and reward identification of errors, open communication, and resolution of issues surrounding safety. They ensure that the organization learns from accidents and provide the resources, accountability, and structure to maintain successful safety systems. Overall, the novel safety culture emphasizes learning each time an error occurs. The strategy is to identify failures at the system and individual level within a safe environment that encourages reporting.
Physicians can work with patients to improve safety in healthcare by being effective communicators and collaborators. Failure in communication can do more than hamper safety—it can erode trust in care providers, reduce the quality of care delivered, and result in poorer health outcomes (McGlynn et al., 2003). Physicians have the responsibility to present a balanced overview of medical options. This is important as objective and complete information empowers patients to make informed decisions in line with their preferences; however, providing this depth of information may be difficult due to barriers such as time constraints.
To address this issue, beyond taking additional training to learn how to better communicate, doctors can provide patients with decision aids—supplemental decision-support material. It is important that the information being used to generate these decision aids be complete, unbiased, and understandable by a wide range of people. There is now considerable evidence, based on more than 50 randomized trials, that when high-quality decision aids are available, patients are more informed and participate more in decision-making (Stacey et al., 2017). Using decision aids alone, however, is not enough. It is also necessary to have a physician-patient interaction that incorporates the patients’ concerns and goals into the decision-making process.
Communication goes hand in hand with teamwork and is just as essential in ensuring patient safety. Teamwork is a skill that often needs to be learned, and literature highlights the importance of team training in realizing improvements in patient safety and communication (Barach & Small, 2000). The skills acquired through team training can be taught using various techniques, including simulation strategies that can measure team competency (Zheng et al., 2008). A simple way of introducing team-centered activity and skills into healthcare settings is by training doctors as a team around completing specific tasks. Also referred to as “task-tailored training,” this type of training can be effective for numerous processes that take place in hospitals (e.g., handovers, surgical procedures, clinical rounds) (Johns et al., 2009).
In conclusion, health systems and doctors should strive to maintain patient safety by promoting patient-centered approaches, establishing a culture of safety, and improving physician relationships by facilitating communication through team structures. Ultimately, patient engagement is an integral component of patient safety, and physicians must work with their patients in order to support this.
Paul Rooprai is a medical student at the University of Ottawa who is passionate about evidence-based medicine, clinical research, and patient safety. Neel Mistry is a medical student at the University of Ottawa who is passionate about medical education, public policy, and health management.
PSQH: Patient Safety & Quality Healthcare, June 24, 2020
Patient safety culture is a cornerstone of healthcare quality. Fostering patient safety culture requires an understanding of an organization's values, beliefs, and norms.
This article was originally published June 23, 2020 on PSQH by Soumya Upadhyay, PhD, MHA
According to the Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Network, patient safety is defined as “freedom from accidental or preventable injuries produced by medical care” (Agency for Healthcare Research and Quality [AHRQ], n.d.a). The Institute of Medicine has indicated that patient safety is not different from quality healthcare, emphasizing it as an essential domain of the overarching healthcare quality (Erickson et al., 2003). There have been reports and studies on the large amount of deaths that happen each year due to medical errors (Donaldson et al., 2000; James, 2013; Makary & Daniel, 2016). Even though these estimates and the methodology behind calculating these deaths may be questionable, it is undeniable that adverse events are a concern that needs to be addressed (Shojania & Dixon-Woods, 2016). The issue of patient safety poses a risk to the public, thus providing motivation to providers, policymakers, and researchers to pay attention to this issue.
Definition of patient safety culture
AHRQ uses the British Health and Safety Commission’s definition of patient safety culture as “the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of an organization’s health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures” (AHRQ, 2009).
Patient safety culture is an important component of an organizational culture. Organizational culture is referred to as a core set of values surrounded by layers including shared beliefs; attitudes; values; norms and rituals; and employee stories and behavioral characteristics (Morello et al., 2013). To establish an organization in which excellence in healthcare quality can flourish, a change in culture needs to be brought about alongside structural reorganization and system reform (Davies, Nutley, & Mannion, 2000).
Patient safety culture is a cornerstone of healthcare quality. Fostering patient safety culture requires an understanding of an organization’s values, beliefs, and norms. Furthermore, it requires an understanding of the appropriate attitudes and behaviors related to patient safety (AHRQ, 2009). To understand the phenomenon of patient safety culture, healthcare systems and hospitals ask staff opinions and perceptions on patient safety. Prior research has also found that patient safety culture perceptions are associated with patient safety outcomes. For example, high perceptions of safety culture are related to lower readmission rates, lower mortalities, and decreased lengths of stay (Hansen et al., 2011). Results from these studies have allowed hospitals and healthcare systems to develop measures and interventions to improve patient safety outcomes (Sammer et al., 2010).
Background
This section of the paper will provide an evolutionary overview of the patient safety movement in the United States. We discuss the macro-environmental changes and legislative efforts and policies that helped shape the nation’s current patient safety environment.
The Institute of Medicine (IOM) report era
The IOM’s 1999 report To Err Is Human was one of the first to herald the culture of safety in the U.S. healthcare system. However, the creation of the IOM report was spurred by changes that happened during President Bill Clinton’s administration. Clinton commissioned an Advisory Commission on Consumer Protection and Quality in the Health Care Industry in March 1998. The aim of this commission was to advise the president on changes in the healthcare system and suggest measures that would be important to improve the quality of healthcare. As a result of the advisory commission, a Quality Interagency Coordination Task Force was formed that focused on improving quality measures, improving information systems, enhancing workforce infrastructure, and keeping patients informed (AHRQ, n.d.c). The advisory commission also led to the formation of the National Quality Forum, which aims at making patients safer and achieving better health outcomes. Its mission is to lead national collaboration to improve healthcare outcomes through measurement (National Quality Forum, 2016).
The aforementioned changes exerted pressure on healthcare professionals to modify their practices, thus leading to the generation of To Err Is Human, which caught the attention of the healthcare community, media, and policymakers. This report estimated that approximately 98,000 people die each year due to medical errors (Donaldson et al., 2000). It exposed an underlying truth: High levels of adverse medical errors are unacceptable and can be prevented.
There was a significant reaction to the IOM report on Capitol Hill. Hearings were held even when Congress was in recess during December 1999. The purpose of these hearings was to evaluate the pros and cons of voluntary and mandatory reporting systems on adverse events and patient safety data. Proposals regarding establishment of a National Center for Patient Safety within the Department of Health and Human Services were considered (AHRQ, 2005). Eventually, the National Center for Patient Safety was developed as part of the Veterans Affairs (VA) department, the largest integrated system in the country. The focus of this center is to lead VA patient safety efforts and develop and nurture a culture of safety throughout the VA health system (U.S. Department of Veterans Affairs, n.d.).
The IOM report and subsequent hearings initiated the introduction of several bills in Congress that focused on disclosing nurse staffing levels and outcomes data; and the establishment of voluntary and confidential reporting systems; these included the Medical Error Reduction Act of 2000 (2000), the Stop All Frequent Errors (SAFE) in Medicare and Medicaid Act of 2000 (2000), and the Patient Safety and Errors Reduction Act (2000). Besides reporting systems, there were efforts to foster research into the causes of errors and promotion of patient safety. In the 106th Congressional session, there was an increased momentum to advance the development of research to reduce medical errors as well as to create a national patient safety database that would allow aggregation of data at the federal and local levels (The Patient Safety and Errors Reduction Act, 2000).
The Patient Safety and Quality Improvement Act of 2005 was signed into law on July 29, 2005 by President George W. Bush (AHRQ, n.d.b). The objective of this law, also known as the Patient Safety Act, was to encourage reporting of adverse medical events. Patient Safety Organizations were created to improve safety; collect and analyze data; maintain a patient safety network database; develop and disseminate recommendations regarding best practices; and utilize a qualified staff (American Medical Association, 2009).
Emergence of high reliability organizations
In recent years, healthcare organizations have become aware of the need to be highly reliable (Hansen et al., 2011). The concept of high reliability organizations originated in the aviation and nuclear power industries and recently became popular in the healthcare industry. Studies have explored ways of achieving high reliability in hospitals (DuPree, 2015; Leykum et al., 2015; Wilson, 2014), alluding to the fact that high reliability can potentially become an antecedent of achieving safety culture in hospitals. The most important attribute of high reliability in hospitals is making the culture safe by directing the organization’s knowledge, beliefs, and attitudes toward reducing preventable harm (Zohar, 1980).
Based on the aviation reporting system, a patient safety reporting system (PSRS) was a confidential and non-punitive program administered for hospitals by the National Aeronautics and Space Administration (Patient Safety Reporting System, 2016). The goal for PSRS is to serve as a main system responsible for encapsulating close calls, adverse events, and concerns regarding patient safety issues (Patient Safety Reporting System, 2016). The concept of high reliability has been welcomed and accepted by leading organizations such as The Joint Commission, IOM, and the Centers for Medicare & Medicaid Services (CMS). The Joint Commission indicated that leadership involvement, organizationwide culture of safety, and effective process improvement tools are necessary components to achieving high reliability in organizations (Chassin & Loeb, 2011).
Over the years, patient safety improvement has happened, but examples are few and isolated. Moreover, their impact is far less than the severity of errors that still occur. Hospital-acquired infections, mortalities due to errors, medication errors, and readmissions due to complications continue to take place (Chassin & Loeb, 2011). In an effort to reduce these events, the hospital community attempts to emulate characteristics of high reliability organizations to work toward a culture of safety (Chassin & Loeb, 2011). High reliability emphasizes developing a mindset to develop a safety culture, with the following characteristics: (1) sensitivity to operations (i.e., quickly identifying system problems to avoid potential mistakes); (2) reluctance to simplify (i.e., understanding that challenges within a complex system are complicated); (3) preoccupation with failure (i.e., proactively eliminating potential accidents); (4) deference to expertise (i.e., de-emphasizing hierarchy and deferring to those most knowledgeable of the issue); and (5) resilience (i.e., retaining well-trained staff to respond to system failures) (Weick et al., 2008).
The Affordable Care Act
President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law in 2010. Through this act and the efforts of the AHRQ, the ultimate aim regarding patient safety was to reduce preventable hospital-acquired conditions as well as prevent readmissions by keeping patients safe (Patient Protection and Affordable Care Act, 2010). Under the ACA, there is a focus on improving systems and procedures to improve patient safety. Additionally, the goal is to enhance open communication between patients and providers, reduce the rates of preventable medical errors, and reduce the cost of medical liability insurance (Clinton & Obama, 2006). The ACA aims to achieve safety in overall quality of care through clinically integrated practices. These practices may achieve coordination of care across all conditions, providers, and care settings over a period of time (Belmont et al., 2011).
Under the ACA, there is a focus on restricting federal payments for “never events.” On June 6, 2011, CMS published a rule, Implementing Provider Preventable Conditions, which was authorized by section 2702 of the ACA. Under the provisions of this rule, federal payments to states were restricted if hospitals in those states spend money on conditions that were due to hospital errors or were acquired in the hospital (McHugh et al., 2011). Furthermore, in 2012, as part of the ACA, CMS’ Hospital Compare website added data on the readmission reduction program and measures that were voluntarily submitted by hospitals. Hospitals are required to report their quality measures, including readmission rates for each diagnosis, hospitalwide readmission rates, and hospital-acquired infections, on Hospital Compare (Centers for Medicare & Medicaid Services, n.d.). This allows greater transparency of clinical data regarding patient safety and holds hospitals accountable if they have high medical errors.
In 2013, there were legislative efforts regarding nurse staffing standards. A bill was introduced in Congress to impose minimum nurse staffing ratios to have adequate nurses on the staff to assist in improving quality of care and patient safety (Nurse Staffing Standards for Patient Safety and Quality Care Act of 2013, 2013). The bill suggests that hiring registered nurses, reducing turnover, including stipends for loan repayment, and implementing mentorship projects would help guarantee patient safety. The bill also authorizes a nurse to raise objections against situations where minimum ratios are violated. With this bill, nurses may refuse to take part in those tasks or duties that may present patient safety issues due to lack of training and education (Nurse Staffing Standards for Patient Safety and Quality Care Act of 2013, 2013). Overall, there was a focus on staffing standards against the background of the ACA.
Future trends
In the future, the patient safety movement is expected to see greater involvement from patients as well as patient safety teaching in higher education. Research indicates that patients need to play a more active role in patient safety, but before that, their role should be recognized and encouraged by our healthcare system. Patients need to be well informed about the benefits, harms, and side effects of their treatment (Vincent & Coulter, 2002). Educating healthcare professionals from multidisciplinary teams improves shared learning by students of different professions, thus enhancing their capacity for teamwork across units/departments (Leotsakos et al., 2014). To this effect, the World Health Organization (WHO) has developed the Multi-Professional Patient Safety Curriculum Guide to ensure that patient safety learning is delivered in a coordinated and an integrated way (World Health Organization, 2017).
In summary, patient safety has been on the national radar for the last decade or so. There have been several nationwide efforts to reduce adverse events related to patient safety. The above paragraphs discuss legislative efforts that have shaped the macro-environmental scenario for patient safety movement in the United States. In addition, there have been efforts from both federal and private organizations. For example, the AHRQ has spent $532 million for patient safety research from 2001 to 2011 (AHRQ PSNet Patient Safety Network, 2017). In July 2002, the Joint Commission established the National Patient Safety Goals (Chassin & Loeb, 2011), and the Institute for Healthcare Improvement launched the 100,000 Lives Campaign in 2004 and the 5 Million Lives Campaign in 2006 (Institute for Healthcare Improvement, n.d.). Most recently, in 2014, the National Patient Safety Foundation has established that patient safety will not be elective (Meyer & Wachter, 2017). Patient safety will continue to be an important issue in decades to come, and leading organizations in patient safety will maintain their efforts in this area.
Soumya Upadhyay is an assistant professor in the Department of Healthcare Administration and Policy, School of Public Health, at the University of Nevada at Las Vegas.
PSQH: Patient Safety & Quality Healthcare, June 19, 2020
Once upon a time, workers were told to use their surgical masks only once. Today, those masks get put into a bag at the end of a shift and used the next day—and maybe the day after that.
This article was originally published June 18, 2020 on PSQH by John Palmer
It’s not an understatement to say that most people who work in healthcare organizations long for the days when just getting their workers to wear the proper personal protective equipment (PPE) was the biggest issue.
Times have changed, of course, in the new normal brought on by COVID-19. Where hospitals were once coached by safety professionals to ensure they had enough PPE stockpiled, they are now begging the U.S. government to share PPE from the stockpile. Once upon a time, workers were told to use their surgical masks only once. Today, those masks get put into a bag at the end of a shift and used the next day—and maybe the day after that.
Some communities have brought in huge PPE cleaning machines that can disinfect thousands of masks in one sitting, while other healthcare workers have turned to procuring their own masks, gloves, and respirators from painting suppliers and home improvement stores. It’s become a free-for-all in some places.
“Because of the scarcity, PPE has become a protected resource inside hospitals,” says Benjamin Kanter, MD, FCCP, chief medical information officer (CMIO) for Vocera Communications, a California-based company that develops platforms to improve clinical communication and workflow.
“Hospitals are taking special precautions and establishing new protocols for accessing and preserving PPE,” he says.
Kanter spoke to PSQH about the state of PPE supplies, procedures, and protocols in the United States, and how it might change the way hospitals prepare and respond to future pandemics.
PSQH: What are some alternate PPE procedures and protocols being developed by hospitals to help preserve PPE supplies and extend the life of the PPE that healthcare workers have access to?
Kanter: The situation is complex, in part because COVID-19 recommendations have been in flux as we learn more about the disease.
Hospitals are establishing protocols to avoid confusion and minimize stress about the type of PPE required in different situations, such as in a standard droplet precaution room, where a surgical mask can be worn, versus a negative air room that requires wearing an N95 mask. Hospitals are now also adopting systems that decontaminate N95 masks, which originally were designed for single use but are sometimes worn throughout a worker’s full shift because of mask shortages. The decontamination systems make it possible for N95 masks to be used on multiple occasions over a longer period of time.
PSQH: What are some safety measures that organizations can take now to help keep patients and staff safer, and will these continue to be in place even after the COVID pandemic?
Kanter: One of the most important ways that hospitals can keep staff and patients safe is to minimize the number of times that a doctor or nurse has to take on and off protective gear.
There is a widely held misconception, even among healthcare workers, that if I put on PPE, I am safe. Unfortunately, that isn’t the case for a number of reasons. If you are going to don and doff PPE, it must be done vigilantly and in a very specific way to avoid gaps in coverage. A large study published last year by a major U.S. medical center found that roughly 40% of their trained physicians and nurses removed their PPE incorrectly, putting themselves at risk of self-contamination. If you are self-contaminated and don’t know it, you could touch a surface and unwittingly put everyone else at risk. Even in the best-case scenario where everyone is vigilant and following CDC guidelines, you are at risk of infection every time you go into a patient’s room.
PSQH: What about communications? Working in PPE can sometimes be very difficult, especially if you need to communicate with a team.
Kanter: Hospitals are working hard to find solutions that keep staff protected, preserve PPE, and minimize the number of times staff members need to go in and out of a room. One way to do this is to allow two-way communication between care team members or a patient in the room and staff outside the room. Having the ability to communicate remotely, instead of going into a patient’s room, saves time and PPE. More importantly, staff members don’t have to risk contamination to communicate.
In addition, hospitals are giving staff hands-free communication devices that can be worn under PPE. If you are wearing full PPE and in a patient’s room, you need an easy way to communicate with care team members outside of the room without having to remove PPE and step outside the room. I think we’ll see modern PPE include a hands-free communication component like what first responders have as part of their uniform. We would never send a firefighter into a burning building without protective gear or require them to remove their gear in order to communicate with team members. The same holds true now for hospital staff: We need to help clinicians perform their jobs while protected with PPE. Doctors and nurses never work alone, and even if they are isolated in a patient’s room, they need to stay connected with care team members without having to risk contamination by taking off PPE.
An additional way that hospitals can keep patients and staff safe is to add two-way communication technology for temporary pop-up hospital beds. To manage patient loads during surges, many hospitals have set up pop-up beds, though they are rarely equipped with nurse call systems. To ensure patients in these pop-up locations can communicate directly with their care teams, hospitals are attaching wireless two-way communication devices to these beds, which keep staff and patients connected.
PSQH: How does the PPE response compare to previous pandemics, such as the H1N1 pandemic? Why did we seem to have enough PPE then but not now?
Kanter: During H1N1, I was working in a San Diego hospital, and we did run short of N95 masks and we did have to borrow ventilators from facilities outside of the county in order to care for all of the influenza cases at that time. Surgeries were cancelled and influenza patients on ventilators were scattered throughout the hospital.
COVID-19 is quite different from H1N1, and there are still many unknowns. With influenza, we have medications that minimize the symptoms. We also have vaccinations that decrease the risk of contamination. Today, we have a situation where we still don’t understand who is resistant to the virus, and there is no vaccine or simple way to administer treatment. A further complication is that COVID-19 symptoms for some people can be so minor you may not even know you are infected but could still be a vector transmitting the disease to other people. Because signs and symptoms of COVID-19 are so variable, the risk of contamination is higher and requires a different protocol for PPE. Patients with COVID-19 (for now) continue to require contact precautions (gloves and gowns) in addition to airborne isolation, whereas that isn’t true for influenza; COVID-19 places a bigger burden on healthcare supplies than influenza.
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.