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Patient Safety Monitor Journal

Patient Safety Monitor Journal answers your most important patient safety questions and offers field-tested compliance strategies to ensure your patient safety efforts measure up to The Joint Commission.

  • Flu vaccine programs for providers: Making it legal, effective, and mandatory

    With a new flu season right around the corner, now is the time for hospitals and other healthcare facilities to consider implementing a mandatory vaccination program for seasonal influenza. Some employees may initially object, but most experts agree that flu shots are a necessity for healthcare workers.

    “It’s really important for healthcare personnel to be vaccinated because they are in really close contact with the most vulnerable of our populations,” says Terri Rebmann, PhD, RN, CIC, FAPIC, director of the Institute for Biosecurity at Saint Louis University. “If the healthcare personnel become infected, regardless of whether or not they have symptoms, when they shed the influenza virus during patient care activities, they can then expose those really high-risk patients.”

    Many healthcare workers already understand that getting a flu shot every fall helps protect not only themselves, but also coworkers, friends and family, and of course patients. Others, however, will require more than a reminder of the 2017–2018 flu season, which was the worst in nearly a decade, to go get vaccinated for the flu.

    The Centers for Disease Control and Prevention (CDC), which recommends annual flu vaccinations for all healthcare personnel, reported that during the 2015–2016 flu season, there was a vaccination rate of over 95% for healthcare workers whose employers required them to get vaccinated for seasonal influenza, compared to a 79% vaccination rate overall among healthcare workers.

    “For many years, seasonal influenza vaccines have been offered to healthcare personnel and there have been a number of initiatives, educational campaigns, and other types of interventions that have been attempted in order to increase healthcare worker intake of seasonal influenza vaccine,” says Rebmann. “But over and over again, the research has shown that the mandatory vaccination policies are the strongest indicator of high vaccination rates among healthcare personnel.”

    Rebmann is quick to point out that a mandatory vaccination policy doesn’t mean that every single healthcare worker must be vaccinated against the flu; “there are legitimate reasons why some healthcare personnel cannot be vaccinated.” Some are allergic to the vaccine or a component of the vaccine. Others have religious or philosophical objections to being vaccinated, which some healthcare organizations will respect if a worker submits proof.

    Rebmann says that mandatory flu vaccination for healthcare personnel is recommended by organizations such as The Infectious Diseases Society of America, The Society for Healthcare Epidemiology of America, and The Pediatric Infectious Diseases Society.

    In May, the Association of Occupational Health Professionals in Healthcare joined the club, releasing a position statement recommending flu shots, among other vaccinations, for healthcare workers. It also asks “administrators to consider a policy that makes annual influenza vaccination mandatory (with medical exemptions) or offer alternatives to vaccination such as requiring the use of surgical masks for patient care by healthcare workers who refuse the vaccine.”

  • Update: Identifying human trafficking patients alert

    If staff at your healthcare organization have not yet encountered a human trafficking victim, it is “very likely they will,” says Elizabeth Even, MSN, RN, CEN, associate director of Clinical Standards Interpretation in the Division of Healthcare Improvement at The Joint Commission.

    Trafficking is the fastest-growing criminal industry in the world, and America is one of the largest markets for victims. The Health and Human Services Department estimates that 88% of trafficking victims visit a healthcare provider at least once during their captivity and aren’t recognized as victims.

    In June, The Joint Commission released Quick Safety Issue 42 on identifying human trafficking victims. Its intent is eliminating the misconceptions that have caused many providers to inadvertently send victims back to their captors. 

    “Human trafficking is modern-day slavery and a public health issue that impacts individuals, families, and communities,” The Joint Commission wrote in a news release. “The alert provides health care professionals with tips to recognize the signs of human trafficking, including a patient’s poor mental and physical health, abnormal behavior, and inability to speak for himself/herself due to a third party insisting on being present and/or interpreting.” 

    Even went on to say that many fail to realize that human trafficking exists in every corner of the United States and that victims are hiding in plain sight. Healthcare leaders must ensure that their staff are educated on what human trafficking is and how to recognize it. If they don’t, it’ll most likely be overlooked and the opportunity to help a victim will be lost.

    The human trafficking industry in America is worth $32 billion a year (for comparison, Starbucks’ 2017 revenue is $22.4 billion). It’s difficult to gauge how many victims there are in the U.S. However, in the past 10 years there’s been over 40,000 human trafficking cases reported to the National Human Trafficking Hotline.

  • AHRQ databases saved; ECRI takes over National Guidelines Clearinghouse

    As promised, the Agency for Healthcare Research and Quality (AHRQ) has shut down its operation of the National Guidelines Clearinghouse (NGC). But on July 17, a day after the site went dark, ECRI Institute announced it will take over sponsorship of the clearinghouse sometime this fall.

    As reported in April, AHRQ shut down both the NGC and the National Quality Measures Clearinghouse on July 16 when federal funding to operate the two critical online databases ran out.

    For more than two decades, hospitals, clinicians, and others in healthcare have used the two clearinghouses to find vetted, evidence-based information on which to set policy, create clinical treatment plans, and objectively measure quality outcomes.

    ECRI Institute, a nonprofit patient safety organization in Plymouth Meeting, Pennsylvania, has worked for the federal government since NGC was established to develop and maintain the guidelines database. And after the funding was cut, ECRI worked behind the scenes to address concerns in the healthcare industry about the loss of such a critical resource.

    The July 17 announcement confirmed that ECRI was ready to launch what it called an interim website this fall to allow continued access to the NGC information.

    “ECRI Institute’s team of highly trained guideline and measure experts are taking the lead to ensure the global healthcare community has access to guidelines,” says Karen M. Schoelles, MD, SM, FACP, director of the ECRI Institute-Penn Medicine Evidence-based Practice Center and director of ECRI’s Health Technology Assessment Consulting Services.

  • FDA: Only you can prevent surgery fires

    This June, FDA issued an alert reminding healthcare professionals and facility staff of “factors that increase the risk of surgical fires on or near a patient.” The agency also recommended practices to reduce the occurrence of surgical fires, including “the safe use of medical devices and products commonly used during surgical procedures.”

    The alert is targeted at healthcare professionals involved in surgical procedures—such as surgeons, surgical technicians, anesthesiologists, anesthesiologist assistants, certified registered nurse anesthetists, physician assistants, and nurses—and staff responsible for patient safety and risk management.

    “Although surgical fires are preventable, the FDA continues to receive reports about these events,” read the alert. “Surgical fires can result in patient burns and other serious injuries, disfigurement, and death. Deaths are less common and are typically associated with fires occurring in a patient's airway.”

    This report comes 13 months after the FDA warned that certain lithium battery–powered medical carts had been overheating, igniting, smoking, burning, or exploding. In some cases, firefighters have had to bury medical carts to put out the flames.

    When fires break out
    ECRI Institute estimates that, based off the nonprofit research organization’s reporting data from Pennsylvania that has been scaled to encapsulate the entire country, there are between 90 and 100 surgical fires in the U.S. every year, down from 550–650 in 2007. ECRI Institute estimates that about 10%–15% of these surgical fires are major, leading to serious injuries or disfiguration.

    In 2016, a man in Florida was getting a cyst removed from his forehead when a surgical tool caught cloth on fire during surgery, causing third-degree burns on his face, according to a news report. Another news report out of Chicago said that in 2012, a man having a catheter implanted in his chest suffered surgical fire burns so painful that he "prayed to God to just let me die."

    In rare cases, as the FDA noted, surgical fires can be fatal. For example, a 65-year-old woman undergoing surgery at an Illinois hospital in 2009 died six days after being burned during a “flash fire” in the OR.

    It’s not just patients who can be harmed. Healthcare workers are also at danger of being injured when surgical fires occur. Plus, medical equipment and devices are at risk of damage, too.

    Fire starters
    “A surgical fire can occur when all elements of the fire triangle are present,” Scott Lucas, PhD, PE, director of ECRI Institute’s Accident and Forensic Investigation team, explained via email. Those three elements, he wrote, are a fuel, such as drapes, gauze, breathing tubes, or prepping agents; an oxidizer, such as oxygen or nitrous oxide; and an ignition source, such as a laser or electro-surgical pencil.

    “Procedures involving the face, head, neck and upper chest (above the xiphoid) are of the greatest risk, particularly in the presence of supplement oxygen,” Lucas wrote in the email.

    Lucas also noted that more than 70% of surgical fires involve oxygen enrichment, which OSHA defines as any atmosphere that contains more than 22% oxygen. He added that “alcohol-based prepping agents also pose a high risk of fire if the agent has not dried prior to beginning the procedure.” The recommended drying time for prepping agents should be listed in product instructions, Lucas wrote.

    In its alert, the FDA wrote that it “reviews product labeling for drugs and devices that are components of the fire triangle to ensure the appropriate warnings about the risk of fire are included.”

  • Cleanliness sensors: Using technology to improve hand hygiene compliance

    Infection preventionist Jessica Strauch shares an amusing anecdote to show how hand hygiene monitoring technology has improved the culture at Lutheran Medical Center in Colorado.

    Picture one of Lutheran’s nurses standing in front of her kitchen sink at home. Dinner is hot and ready, and the nurse stops to wash her hands before everyone digs in. Then, even though she is out of her scrubs and wearing civilian clothes, she waves her hands in front of an imaginary badge.

    Oh, shoot, she isn’t at work anymore. But hey, at least the nurse remembered to wash her hands without a beep or a buzz from her BioVigil badge reminding her to perform hand hygiene.

    “It’s funny to hear nurses say that,” says Strauch, chuckling.

    Lutheran is among the healthcare organizations nationwide that in recent years decided to try hand hygiene monitoring technology in the hopes it could improve hand hygiene compliance—and in the process reduce the number of infections and avoid citations from accrediting organizations like The Joint Commission, which in January put stricter enforcement in place.

    Previously, a healthcare organization wasn’t punished for individual hand hygiene failures if it had an otherwise compliant hand hygiene program. Now, if a Joint Commission surveyor sees an individual who directly cares for patients fail to perform required hand hygiene, the healthcare organization will receive an RFI under Infection Prevention and Control (IC) standard IC.02.01.01, element of performance 2, which requires organizations to use precautions such as hand hygiene to reduce infection risk.

    “While there are various causes for HAI, The Joint Commission has determined that failure to perform hand hygiene associated with direct care of patients should no longer be one of them,” according to the December 2017 issue of Joint Commission’s Perspectives magazine.

    Additionally, The Joint Commission requires that healthcare organizations meet National Patient Safety Goal (NPSG) 07.01.01, which requires them to implement and maintain a hand hygiene program.

    The majority of U.S. hospitals and outpatient facilities do not currently use hand hygiene monitoring technology, though perhaps the increased surveyor focus on hand hygiene compliance and more success stories like Strauch’s will encourage others to pony up.

    The cost can certainly be a turnoff for cost-conscious C-suite execs. Some employees will be concerned about nonstop surveillance, too. But research shows that, somehow, thousands and thousands of healthcare workers still don’t wash their hands as often as they should despite everything now known about the impact of hand hygiene on infection control. So, it makes sense for organizations that struggle with hand hygiene compliance to at least consider new technology.

    “You hate to see a forcing function,” says Marge MacFarlane, PhD, MT(ASCP), CHSP, CHFM, HEM, MEP, CHEP, principal of Superior Performance in Eau Claire, Wisconsin. “But if you don’t have some kind of forcing function—whether they alarm you or your hands turn blue or your hair turns blue or whatever—I’m not sure if people will wash their hands the way they’re supposed to.”

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