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Joint Commission addresses wrong-site surgery

Thu, 01 Dec 2011 04:00:00 GMT

Joint Commission addresses wrong-site surgery

Pilot organizations discuss their experiences

This fall, The Joint Commission Center for Transforming Healthcare will release its Targeted Solutions Tool™ addressing wrong-site surgery. The tool is part of the Center's Targeted Solutions series and is available to any organization accredited or certified by The Joint Commission.

But Mark Chassin, MD, FACP, MPP, MPH, president of The Joint Commission in Oakbrook Terrace, IL, urged organizations not to wait for the tool, instead advising them to begin conducting risk assessments now.

"Unless an organization has taken a systematic approach to studying its own processes and determining its risk of wrong-site surgery, it is literally flying blind," Chassin said in a June 29 news conference that announced, along with the upcoming release of the Targeted Solutions Tool, a series of solutions to reduce risk of wrong-site surgery. The solutions were developed through a collaborative effort between the Center for Transforming Healthcare, five hospitals, and three ASCs. The tool will be an application organizations can use to develop customized solutions to address specific barriers to excellent performance, similar to already released tools for improving hand hygiene.

Although historically seen as rare events, Chassin said some estimates put wrong-site, wrong-side, and wrong-patient procedures at a national rate of 40 times per week, and in 2010 surgical errors were the third most common type of sentinel event reported to The Joint Commission.

Organizations often mistakenly assume that a history of zero wrong-site surgeries indicates a safe system, said Chassin. Because the events remain rare, organizations should not determine risk by counting occurrences.

"They are so uncommon that an individual surgeon or even an individual hospital or surgery center may not have experienced one of these events in their recent past and may think that, therefore, they're not at risk of having one in the future," said Chassin.

Instead, organizations should measure the risk of an event occurring, he said. This analysis might indicate that your process is not as safe as you thought and help gain compliance with new efforts to reduce that risk.

"It's a systematic attention to identifying the risks and then measuring their magnitude that is very helpful in getting everybody on board with the improvement phase," Chassin said.

The Joint Commission's history of efforts and standards

The wrong-site surgery problem is not a new one. In 1998, The Joint Commission released a Sentinel Event Alert on the topic, and followed up with another in 2001. In 2003, the accrediting body held a summit on the topic, and published the Universal Protocol™ standards in 2004.

The Wrong-Site Surgery Project began in 2009 with hospitals owned by Lifespan Corporation in Rhode Island, including Rhode Island Hospital in Providence, which experienced several highly publicized wrong-site surgeries. In 2010, five other organizations joined the effort.

The project uses Robust Process Improvement™, a systematic and data-driven solutions methodology that incorporates Lean Six Sigma and change management methods. The Joint Commission has also partnered with the American College of Surgeons and the American Academy of Orthopedic Surgeons to continue to find ways to reduce wrong-site surgery risk.

Despite the substantial work being done by the Center for Transforming Healthcare, no new standards have yet been released, Chassin said.

"What we found is that the principles that are embedded in the Universal Protocol are really universal," he said. "It is certainly possible that we may want to refine the standards, but right now we don't see any reason for changing any of the components of the Universal Protocol. The principles work, but what we found is that individual organizations need to specify exactly how they'll be carried out."

Chassin noted that although the project resulted in a set of solutions for particular problems, not all interventions would be necessary in every place.

"In fact, what we found is that these focused solutions are much easier to sustain because they're targeted at the causes that each individual organization has ... and the distribution of cause differs from place to place, so not all of the same solutions will be required at every organization," he said.

Causes and solutions

Project leaders warned against searching for a silver bullet solution to the complex problem.

"It turns out that this is a much more complicated problem than it might seem to be at first," said Chassin. "There isn't a simple way to prevent wrong-site surgery; it takes a comprehensive approach."

Chassin and Mary Cooper, MD, JD, senior vice president and chief quality officer of Lifespan, also warned that technology, often seen as the solution, should be considered more of an aide to better process.

"Wrong-site surgery can happen even in the face of automation, and there are many solutions out there that are technology-based that can certainly help, but there is also the introduction of technology in the [operating room (OR)] that can distract people from what is fundamentally a cognitive decision," said Cooper.

Chassin added that technology is most useful to aid in a solution to a specific, well-defined problem.

For example, Lifespan installed cameras in its ORs, but Cooper said they are intended as an auditing and performance improvement tool, not as a means to prevent wrong-site surgery.

Despite a need for individualized solutions, the project did identify some common problems and solutions that may apply more widely. They ranged from simple solutions, such as refraining from using pens for site marking that wash off during surgical preparation, to more complex solutions, such as remodeling the receiving unit for charts to prevent errors from appearing downstream in the ORs.

The project encompassed all procedures undergone in the OR and all regional blocks performed by anesthesia, both in preoperative areas or ORs in a variety of settings, including teaching and nonteaching hospitals. The number of surgeries ranged from 5,000 to about 38,000 annually.

The project succeeded in reducing what's known as "defective cases," or the cause of a particular risk, in three defined areas: Defects decreased from 39% to 21% in surgical booking, 52% to 19% in preoperative areas, and 59% to 29% in the OR itself. Major defects included:

Booking errors
Verification errors
Distractions or rushing
Inconsistent site marking
Lack of a culture of safety
Errors in timeouts

Project leaders emphasized that hospitals should conduct assessments to establish baseline risk, as the magnitude of the risk is often unknown. For example, the project found that in 39% of cases, errors were introduced in the scheduling process. This risk presents itself before the patient even enters the perioperative or operating room. Scheduling concerns are not addressed by Universal Protocol and overlooked in many cases.

"In the surgical scheduling area, one of the problems that we encounter that explains errors creeping into the process is that there is the lack of a standardized way of collecting information that is essential to perfectly identifying the patient and identifying exactly what procedure is planned," said Chassin. One reason for errors is that such information is usually obtained from outside organizations, and there is no standardized protocol for communicating the information.

Documentation was the main issue during this phase, including unverified booking documents, accepting verbal requests for surgical booking, missing consent or H&P, and confusing or absent surgeons' orders at the time of booking. Unapproved abbreviations and illegible handwriting also presented problems.

Still older issues once again surfaced in the project. For instance, problems with conducting timeouts and site marking are still alive and well.

In fact, Lifespan decided to script the timeout to ensure the focus of the entire surgical team, and included the question, "Can everyone see the mark?" to help avoid the possibility of an error occurring after the site mark is covered up with surgical drapes, said Cooper.

Organizational culture was also seen as a potential problem. Project leaders suggested that leadership be engaged and focused on patient safety, staff is empowered to speak up, and policy changes are followed with adequate training. They also noted that marketplace competition has led to significant pressure to increase surgical volume, possibly by creating shortcuts to protocol, and suggested setting the expectation that staff speak up with any safety concern to reduce this risk.

FDA focuses on preventing surgical fires

Thu, 01 Dec 2011 04:00:00 GMT

FDA focuses on preventing surgical fires

Agency makes tools and resources available

Christiana Care Health System in Wilmington, DE, knows more about surgical fires than it ever hoped to.

Back in 2003, the health system had two fires in its operating rooms (OR) within an eight-month period. The fires had a profound impact and renewed the health system's commitment to preventing this medical error, said Kenneth Silverstein, MD, chair of the Department of Anesthesiology.

Christiana developed and integrated a fire risk assessment in its Universal Protocol™ used by staff prior to the start of each surgical procedure, said Silverstein, who became leader of the department in 2004. Now, Christiana is one of the partners in the FDA's Preventing Surgical Fires Initiative.

Silverstein spoke about Christiana's efforts to prevent surgical fires during a stakeholders teleconference to announce the launch of the initiative in October.

Why the FDA?

The FDA has a stake in the prevention of surgical fires because it regulates the drugs (e.g., oxygen and alcohol-based skin preparation agents) and devices (e.g., electrosurgical units [ESU], lasers, and surgical drapes) that are components of the so-called fire triangle, said Karen Weiss, MD, the FDA's director of the Safe Use Initiative. The FDA also reviews product labeling to ensure that manufacturers include appropriate warnings about the risk of fire.

While surgical fires are rare events, they are preventable, said Weiss.

Surgical fires are fires that occur in, on, or around a patient who is undergoing a medical or surgical procedure. An estimated 65 million surgeries are performed in the United States each year, Weiss said. The ECRI Institute, a nonprofit organization that focuses on patient safety, estimates that 600 surgical fires occur in the United States annually, some causing serious injury, disfigurement, and even death.

A surgical fire occurs about once in every 100,000 surgeries-about the same risk as a wrong-site surgery occurring, Weiss said.

Root cause analysis of these surgical fires shows three elements that make up the "triangle" for causing these fires, she said.

Surgical fires can occur any time all three elements are present:

An ignition source, such as ESUs, lasers, and fiber-optic light sources
A fuel source, such as surgical drapes, alcohol-based skin preparation agents, and even the patient's skin or hair
An oxidizer, such as oxygen, nitrous oxide, and room air

No surgery is risk-free, but some surgeries are more high risk than others, Weiss said. Materials that may not burn in normal room air can ignite easily and burn fiercely in an oxygen-enriched environment, which is when most surgical fires occur.

Preventing surgical fires requires awareness about the risks across the entire surgical team, Weiss said.

The FDA has partnered with other leaders in the effort to prevent surgical fires, she said. It has launched a new website at www.fda.gov/preventingsurgicalfires, which contains recommendations for healthcare organizations as well as tools and resources.

A risk assessment process

Silverstein said Christiana wants to share the lessons it learned through a root cause analysis of the surgical fires it experienced. Organizations must ensure communication among members of the surgical team and establish a system to raise consciousness about the risks, he said.

At Christiana, the surgical team performs a fire risk assessment as part of the timeout immediately prior to the start of each procedure in the OR or at the bedside in the peri-anesthesia areas.

Staff members assess the potential fire risks based on whether there is an open oxygen source or an available ignition source, or if the surgical site is above the patient's xiphoid.

The risk assessment tool assigns a score of 1-3 based on risk factors, Silverstein said. The hospital has protocols written for each score that address factors such as the proper draping of patients to minimize oxygen concentration and the proper drying time for alcohol-based solutions for surgical preparation.

By incorporating the fire risk assessment into the Universal Protocol-The Joint Commission's process by which staff confirm they have the correct patient receiving the correct procedure at the correct time-Christiana is able to raise staff awareness about the fire triangle in every procedure.

A key to preventing surgical fire is to open the door to a culture of communication, Silverstein said.

Protection of patients

Cathy Reuter Lake knows from experience the devastating consequences of a surgical fire. "You don't want to have to tell a family member a loved one was involved in a fire," she told the teleconference listeners.

Lake's mother was critically burned during surgery because a topical solution was not allowed enough time to dry before a physician used an electrosurgical cauterizing tool. A fire ignited and Lake's mother received serious burns to her chest, throat, face, and ear.

Lake is dedicated to making sure other patients and families do not go through that experience and founded the website www.surgicalfire.org. The key to prevention is communication, she said, adding that if the hospital had used a checklist to assess risk factors, she believes her mother would not have been burned in a fire.

Another group partnering with the FDA is the Association of periOperative Registered Nurses (AORN), which has made its fire safety toolkit available free of charge for a limited time. It contains tools for developing fire risk assessment checklists as well as fire drills for healthcare facilities.

Byron Burlingame, RN, MS, CNOR, who is AORN's perioperative nursing specialist, said his organization is committed to raising awareness about the dangers of surgical fires. In addition to following recommended practices and promoting staff communication, healthcare organizations need to conduct fire drills in the OR so staff members know how to respond if a fire occurs, he said.

The FDA is promoting tools and strategies developed by healthcare organizations and associations to reduce the risk of fires. The tools include a free fire safety video developed by the Anesthesia Patient Safety Foundation.

Keeping obese patients safe through surgery

Thu, 01 Dec 2011 04:00:00 GMT

Keeping obese patients safe through surgery

Identifying high body mass index for patients is key

The U.S. population is growing in size. The CDC estimates that about one-third of the nation's adults are obese, and many of them become patients at U.S. hospitals, in need of surgeries of varying kinds.

Patients are considered obese if their body mass index (BMI), calculated using height and weight measurements, is higher than 35. (Measuring BMI is more favorable than considering weight alone because BMI factors in a patient's height, giving a more accurate picture of health.) This population has specific risks that make surgery more dangerous.

"I think everybody needs to consider BMI," says Diane Graham, MS, RN, CNS, CNOR, clinical nurse specialist at the 313-bed John Muir Medical Center in Concord, CA. "Clearly, the population out there isn't getting any smaller."

After two sentinel events involving high-BMI patients occurred in 2007, Graham helped lead a BMI task force to implement new processes that would ensure high-BMI patients are safe in surgery. "Preventing Perioperative Complications in the Patient With a High Body Mass Index," published in the October issue of AORN Journal, highlights the task force's efforts, which revolved around ensuring those involved in the care of the patient were notified of the patient's high BMI prior to surgery.

"We felt part of the reason why the situations occurred was that we really didn't have advance notification that we were having a patient who had a high or morbidly obese BMI until they were already present in the preop room," says Graham. "The whole impetus of the task force was early notification."

High-BMI patient risks

Such notification may have helped prevent those sentinel events, one of which included a high-BMI patient who succumbed to rhabdomyolysis, a breakdown of muscle fibers that releases a pigment into the circulatory system, potentially causing renal failure. The condition occurred because the patient was in one position for a long period in the operating room (OR), and the patient's weight put too much pressure in one spot.

The hospital has since purchased pressure-relief mattresses that distribute the body mass over a broader surface, lessening the strain on pressure points.

Another high-BMI patient needed intubation during surgery, and there was unanticipated difficulty with the intubation. But difficult intubations are a common occurrence with high-BMI patients.

"There's additional adipose tissue in the neck area, which can mean an inability to hyperextend the neck," says Graham. "If you can't hyperextend the neck during intubation, the anesthesia care provider cannot visualize the vocal cords."

A fiber-optic intubation device can help, but these devices are not usually found in the OR. As a first step, physically assess patients prior to surgery to determine whether intubation would be difficult.

Graham says it's critical to know ahead of time that a patient has a high BMI, otherwise the necessary precautions will not be taken. Such precautions include not only pressure-relief mattresses and fiber-optic intubation devices, but also oxygen in the transfer between the OR and the postoperative recovery area. High-BMI patients often have sleep apnea, which negatively affects the heart by not oxygenating it properly, leaving such patients in greater need of oxygen.

As an additional concern, high-BMI patients' extra adipose tissue allows for greater absorption of anesthetic drugs, meaning it will take them longer to become wakeful after surgery. The extra tissue also means a higher risk of deep vein thrombosis.

Putting precautions in place

The high-BMI patient task force consisted of the medical director of quality, the medical director of surgery (who is also an anesthesiologist), the bariatric clinical nurse specialist, the perioperative staff, the OR staff, the postacute care unit (PACU) staff, and the postsurgical inpatient unit.

The entire implementation process took about two years to accomplish, says Graham. In September 2008, nurses were provided with education, and an organizationwide in-service educational program, "Care for the High BMI Patient," was rolled out in 2009. Now, every new hire must complete this internal online learning module. The education also addresses how to care for high-BMI patients with sensitivity and without discrimination.

The topic of high BMI was included in the hospital's internal newsletter and shared with the nurse quality council, whose members in turn shared the information with their units.

A high-BMI questionnaire was also created to be completed by the short-stay unit preoperative RN, who then sends the questionnaire to the OR and PACU charge nurse; the charge nurses then share the information with personnel who lift and transfer patients. The questionnaire also provides information regarding whether a patient has sleep apnea.

The task force worked to get BMIs greater than 35 included on the confidential surgery schedule. They are displayed with white lettering on a black background. To reduce clutter, only BMIs greater than 35 are noted.

"We want to highlight only those that are of concern," says Graham, noting that the schedule is given out the night prior so staff can prepare ahead of time for any additional equipment or necessary precautions.

Getting the BMI measurement prior to surgery proved to be a struggle at times, even though the hospital sent notification to physicians' offices letting them know that a patient's height and weight would be required when scheduling surgery. The hospital's surgery schedulers would communicate with physician offices that did not have scales, or whose scales did not register more than 350 pounds.

"But now it has become a standard of care that we get that number," says Graham.

Luckily, a preoperative checklist was already being revised, and this presented an opportunity to create a space on the checklist for BMI information. By November 2009, 92% of 50 audited charts included the patient's BMI on the surgery schedule, and 94% included it on the preoperative checklist.

Graham notes that John Muir's emergency department (ED) has historically failed to collect BMI information. Now, though, the ED features beds that can weigh the patient; as a result, she hopes to expand the BMI program to that area of the hospital.

She advises other hospitals to assess their patient population when possible.

"Calculate BMI. Find out what the risk of your patient population is," Graham says. "We had quality management do a retrospective analysis of what our BMI is of our patient population, and we were very surprised to see what our risk factor was."

John Muir found that of its patients who had undergone general and vascular surgery from the beginning of 2007 through March 2008, 28% had a BMI between 30 and 40 (30 or higher is considered obese) and 19.8% had a BMI equal to or greater than 35.

If the risk is there, "it's just a matter of time before something bad is going to happen," warns Graham.

Mercury spills still a healthcare hazard

Thu, 01 Dec 2011 04:00:00 GMT

Mercury spills still a healthcare hazard

You don't see it reported as much now compared to a few years ago, but in September a Houston-area family medical practice was evacuated when a blood pressure device fell and leaked mercury, according to Your Houston News. Less than an ounce of mercury was spilled, but the event necessitated calling for hazmat response.

In general, healthcare has done a good job of eliminating or reducing mercury-containing products. The EPA and the American Hospital Association voluntarily agreed to "virtually eliminate" all mercury-containing waste coming from hospitals by 2005 and to halve the volume of all medical waste by 2010. The American Nurses Association also supports these goals. The American Academy of Pediatrics has asked pediatricians to stop using mercury thermometers and encourages parents to do the same.

When a bead of mercury is exposed to air, it vaporizes immediately and may reach harmful levels. A series of videos from Bowling Green State University (http://tinyurl.com/3lmv2t7) shows how mercury vapors, which cannot be seen with the naked eye, can quickly disperse through a room from spills such as blood pressure devices and thermometers, as well as improperly cleaned spills on carpets.

Use the checklist below, compiled from HCPro's OSHA Program Manual for Medical Facilities and the Michigan Department of Environmental Quality, to assess how to respond to mercury spills in your medical or dental practice.

Self-inspection checklist: Mercury spill

If a mercury thermometer breaks in your workplace:

For large mercury spills (more than 2 tablespoons) such as blood pressure device breakages or leaks:

Considerations for cleaning up a mercury spill by yourself:

Source: Adapted with permission from HCPro's OSHA Program Manual and the Michigan Department of Environmental Quality's mercury spill resources (www.michigan.gov/deq).

Ambulatory Quality & Compliance Insider, December 2011

Thu, 01 Dec 2011 04:00:00 GMT

Joint Commission addresses wrong-site surgery

Pilot organizations discuss their experiences

"It's a systematic attention to identifying the risks and then measuring their magnitude that is very helpful in getting everybody on board with the improvement phase," Chassin said.

The Joint Commission's history of efforts and standards

Despite the substantial work being done by the Center for Transforming Healthcare, no new standards have yet been released, Chassin said.

Chassin noted that although the project resulted in a set of solutions for particular problems, not all interventions would be necessary in every place.

Causes and solutions

Project leaders warned against searching for a silver bullet solution to the complex problem.

Chassin added that technology is most useful to aid in a solution to a specific, well-defined problem.

For example, Lifespan installed cameras in its ORs, but Cooper said they are intended as an auditing and performance improvement tool, not as a means to prevent wrong-site surgery.

Booking errors
Verification errors
Distractions or rushing
Inconsistent site marking
Lack of a culture of safety
Errors in timeouts

Still older issues once again surfaced in the project. For instance, problems with conducting timeouts and site marking are still alive and well.

FDA focuses on preventing surgical fires

Agency makes tools and resources available

Christiana Care Health System in Wilmington, DE, knows more about surgical fires than it ever hoped to.

Silverstein spoke about Christiana's efforts to prevent surgical fires during a stakeholders teleconference to announce the launch of the initiative in October.

Why the FDA?

While surgical fires are rare events, they are preventable, said Weiss.

A surgical fire occurs about once in every 100,000 surgeries-about the same risk as a wrong-site surgery occurring, Weiss said.

Root cause analysis of these surgical fires shows three elements that make up the "triangle" for causing these fires, she said.

Surgical fires can occur any time all three elements are present:

An ignition source, such as ESUs, lasers, and fiber-optic light sources
A fuel source, such as surgical drapes, alcohol-based skin preparation agents, and even the patient's skin or hair
An oxidizer, such as oxygen, nitrous oxide, and room air

Preventing surgical fires requires awareness about the risks across the entire surgical team, Weiss said.

A risk assessment process

At Christiana, the surgical team performs a fire risk assessment as part of the timeout immediately prior to the start of each procedure in the OR or at the bedside in the peri-anesthesia areas.

Staff members assess the potential fire risks based on whether there is an open oxygen source or an available ignition source, or if the surgical site is above the patient's xiphoid.

A key to preventing surgical fire is to open the door to a culture of communication, Silverstein said.

Protection of patients

Keeping obese patients safe through surgery

Identifying high body mass index for patients is key

High-BMI patient risks

The hospital has since purchased pressure-relief mattresses that distribute the body mass over a broader surface, lessening the strain on pressure points.

Another high-BMI patient needed intubation during surgery, and there was unanticipated difficulty with the intubation. But difficult intubations are a common occurrence with high-BMI patients.

Putting precautions in place

The topic of high BMI was included in the hospital's internal newsletter and shared with the nurse quality council, whose members in turn shared the information with their units.

"But now it has become a standard of care that we get that number," says Graham.

She advises other hospitals to assess their patient population when possible.

If the risk is there, "it's just a matter of time before something bad is going to happen," warns Graham.

Mercury spills still a healthcare hazard

Self-inspection checklist: Mercury spill

If a mercury thermometer breaks in your workplace:

For large mercury spills (more than 2 tablespoons) such as blood pressure device breakages or leaks:

Considerations for cleaning up a mercury spill by yourself:

Source: Adapted with permission from HCPro's OSHA Program Manual and the Michigan Department of Environmental Quality's mercury spill resources (www.michigan.gov/deq).

Watch out for needlestick hazards in nonhospital �settings

Tue, 01 Nov 2011 04:00:00 GMT

Watch out for needlestick hazards in nonhospital settings

Despite the volume and complexity of procedures, hospitals don't have a monopoly on needlestick and sharps injuries suffered by healthcare workers.

That point was made clear in "Achieving Sharps Safety Compliance in Non-Hospital Healthcare Settings," an August 8 Web conference hosted by the International Healthcare Worker Safety Center at the University of Virginia in Charlottesville, and sponsored by Becton, Dickinson, and Company.

Three experts in healthcare worker safety and facility compliance looked at why, more than 10 years after the passage of the Needlestick Safety and Prevention (NSP) Act, nonhospital settings still struggle with preventing needles and sharps injuries, and how this situation is related to misinformation about OSHA compliance and, consequently, low adoption of safety devices.

No data doesn't mean no problems

There is a disconnect in the level of safety provided in accordance with the Bloodborne Pathogens standard in hospitals compared to nonhospital settings, said Janine Jagger, MPH, PhD, director of the International Healthcare Worker Safety Center, who presented first on the program.

The Center-through EPINet, which Jagger developed in 1991-provides healthcare facilities with a standardized system for tracking occupational blood exposures and is used by more than 1,000 U.S. hospitals.

But nonhospital settings, such as doctors' offices, urgent care clinics, dental facilities, long-term care facilities, dialysis centers, ambulatory surgery centers, and laboratories, are difficult to reach in terms of enforcement, documentation, and surveillance.

"They fall into the situation that we refer to as ‘no data, no problem,' " said Jagger. "While we do not have good direct data reflecting the situation in these settings, that doesn't mean there are not problems."

What EPINet does show is a dramatic increase in the use of safety devices versus conventional devices-especially in IV catheters, phlebotomy devices, and needles and syringes in hospitals. This increase comes just a few years after the November 2000 passage of the NSP Act. Market share data on the use of safety disposable syringes, however, shows significantly lower adoption rates for alternate sites compared to hospitals, said Jagger; the adoption rate for alternate sites in 2003 was less than half that of hospitals.

Another consideration coming from EPINet data is the risk of injury and exposure attendant to procedures and the devices used in those procedures.

Jagger shared data showing that injury rates along the spectrum of devices-syringes, butterfly blood collection sets, phlebotomy devices, IV catheters, and lancets-are similar between hospitals and outpatient settings. "The procedures and devices used are what determines risk level, so we must have the same level of safety compliance in nonhospital settings as hospitals," said Jagger. "The ‘no data, no problem' attitude is a poor defense for what we need to do to protect healthcare workers and comply with OSHA's Bloodborne Pathogens standard."

A needlestick is a needlestick is a needlestick

Not too far into her presentation, Elise M. Handelman, RN, MEd, an occupational and environmental health consultant who worked in OSHA for nearly 20 years, quoted from OSHA's Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens:

Where engineering controls will reduce employee exposure by removing, eliminating, or isolating the hazard, they must be used.

And that applies to nonhospital settings, period, Handelman adds. She explains that the engineering controls section of the standard requires employers to seek input from frontline workers in identifying, evaluating, selecting, implementing, and training on safety devices.

"A needlestick is a needlestick is a needlestick, regardless of where it happens, and the goal of the standard is to reduce or eliminate those occurrences," said Handelman.

It is a common misconception that small employers are not covered. "Any private business with even one employee is still covered by the standard if there is a reasonable expectation that their employees are exposed to blood or OPIM," she said.

Another point of confusion on Bloodborne Pathogens coverage concerns recording and reporting requirements. "OSHA does say that if you have less than 10 employees, you do not have to keep OSHA logs, which includes the sharps injury log," Handelman explains. However, all other provisions apply.

Handelman next identified other costs of noncompliance:

Increased insurance rates if self-insured
Potential workers' compensation costs
Potential legal action from workers or unions
Lost employee work time due to testing or treatment
Expenses related to temporary or permanent replacement workers
Bad press

Lost work time and additional expenses for replacing workers pose particular difficulties for small healthcare facilities, she notes.

Compliance in the use of safety needles and sharps makes for a safer, more healthful work environment. Handelman lists the following example benefits:

Lower workers' compensation costs
Better CMS and Joint Commission surveys
Enhanced worker productivity with fewer days lost
Increased recruitment and retention of skilled workers, keeping facilities competitive

Recruitment and retention of workers is important in all healthcare settings, including nonhospital settings, said Handelman.

To access a recording of the conference, go to http://bit.ly/nqUHjZ. The program is 1 hour and 6 minutes in length and includes a Q&A at the end.

You can find more resources on sharps safety and EPINet on the International Healthcare Worker Safety Center website at www.healthsystem.virginia.edu/internet/epinet.

Five myths about needlestick safety noncompliance

As part of the "Achieving Sharps Safety Compliance in Non-Hospital Healthcare Settings" August 8 Web conference, Pamela Dembski Hart, CHSP, BS, MT(ASCP), principal consultant for Healthcare Accreditation Resources, LLC, in Holliston, MA, debunked the five most common myths in healthcare facilities that supposedly excuse noncompliance with the part of the Bloodborne Pathogens standard amended by the Needlestick Safety and Prevention Act. Here are the differences between myth and fact as she saw them:

Myth #1: Annual training.

Response: Isn't it just about watching a video?

Fact: Annual training must include an explanation about evaluation and use of safety devices. This usually is not possible using a generic video, said Dembski Hart. And annual really means every year. Additionally, credentials do not exempt anyone-even doctors-from the training requirement, she noted.

Myth #2: What annual safety device evaluation really means.

Response: We looked at them. The sales rep showed us some samples.

Fact: Annual documentation on evaluation must be completed, and a cross-section of staff must provide input. That doesn't mean having input only from the nurse manager, which is one of the most frequent misunderstandings, said Dembski Hart. Again, annual does mean every year.

Myth #3: Purchase is required, but use is not.

Response: Is having a box on the shelf enough?

Fact: Having achieved consensus in selection, you now must implement and monitor compliance. Dembski Hart recommended notifying staff that the safety devices have arrived and are ready for use. Remember, it is the employer's responsibility to monitor and enforce compliance among staff members, she added.

Myth #4: The prohibitive cost justifies lack of evaluation or use.

Response: Safety devices are just too expensive.

Fact: "This is probably the biggest barrier I have found to implementation," said Dembski Hart. Yet not only have there been huge improvements in design and cost, prevention itself is cost-effective. The perceived direct and indirect cost of adopting safety devices pales in comparison to the actual cost of a sharps-related injury. "An injury with no time lost is at least $100; an injury with time lost could cost $3,000; an injury with seroconversion could go to $300,000," she explained.

Myth #5: Staff refusal to participate is acceptable.

Response: Staff members aren't interested in changing. What we have now is just fine.

Fact: The Needlestick Safety and Prevention Act is multifaceted, which you can use to promote individual accountability, said Dembski Hart; she recommended safety officersmake sure leadership knows about and supports safetydevice evaluations. Remind them that adoption of safetydevices can lead to a 90% decrease in sharps injuries, she said. Ultimately, you may have to assess and document noncompliance in annual performance evaluations, Dembski Hart added. Also, make sure you are not still using first-generation safety devices. Many new devices include design improvements that eliminate the objections surrounding their earlier versions, she explained.

CDC checklist puts more focus on infection control in �outpatient settings

Tue, 01 Nov 2011 04:00:00 GMT

CDC checklist puts more focus on infection control in outpatient settings

The CDC has posted a 16-page checklist to use as acompanion to its infection prevention guide for outpatient settings. Infection Prevention Checklist for Outpatient Settings: Minimum Expectations for Safe Care became available two months after the guidance document and consists of two sections, used to assess policies and procedures for safe care, and personnel adherence through direct observation.

There are 12 areas of focus in the policies section andeight areas in the personnel and patient care observations section, including injection and point-of-care testing safety (see the checklist on p. 5), environmental cleaning, and detailed check-offs for sterilization and high-level disinfection of instruments.

Types of facilities that should use the checklist

The CDC recommends that healthcare facilities, such as hospital- and non-hospital-based outpatient clinics and ambulatory surgery centers, use the checklist to assess infection prevention controls for all procedures performed in those facilities.

The organization notes that sections of the checklist may not be applicable to all facilities.

However, if there are applicable sections that receive a "No" answer, a facility should correct the involved practice, appropriately educate healthcare personnel, and determine why the correct practice was not being performed.

Reacting to deficiencies

When using the checklist, facilities must also consider risks posed to patients by deficient practices. Unsafe injection practices can result in transmission of infection and should be halted immediately, according to the checklist.

"Identification of such lapses warrants immediate consultation with the state or local health department and appropriate notification and testing of potentially affected patients," the checklist adds.

Getting your hands on the checklist

A PDF version of the checklist is available at www.cdc.gov/HAI/prevent/prevention.html. A free Word version of the checklist is available for download from the Tools page of OSHA Healthcare Advisor at www.oshahealthcareadvisor.com.

Facility finds new ?takes' on improved hand hygiene �success

Tue, 01 Nov 2011 04:00:00 GMT

Facility finds new ‘takes' on improved hand hygiene success

Of all the challenges U.S. hospitals face, few are as unifying as hand hygiene-extremely important and, as many facilities struggle with compliance, extremely difficult to get right.

At Alamance Regional Medical Center (ARMC) in Burlington, NC, a reexamination of how hand hygiene compliance was measured has led to an improved and better overall process for supporting good hand hygiene practices.

The effort began with a serious look at ARMC's previous measurement practices.

"We had two ways of measuring hand hygiene compliance," says Sara Wall, RN, MSN, infection preventionist at ARMC. "When I first came [to ARMC], we had one way of measuring hand hygiene that had really good results, much better than what I was hearing that other organizations were getting, so we wanted to verify it."

Parallel to this tracking method, a second method was put in place with results that conflicted with the initial high-scoring numbers.

"We decided there was something wrong," says Wall. "We couldn't be doing so well with one monitor and not as well with the other."

Additionally, these statistics ended up in a bit of avacuum-there was not a good feedback loop for providing information back to the staff.

"We were getting the numbers but not getting improvements," says Wall.

In an effort to correct this imbalance, a team comprising representatives from nursing, training and development, quality resources, and infection prevention undertook the task of looking for ways to improve not only their measurement methods, but the facility's overall performance as well.

"We wanted to measure and report this data accurately and in a timely manner so that the information would be useful to departmental leadership, who could then in turn communicate with their staff," says Wall. "We also wanted to be able to provide immediate feedback to the person who is not doing hand hygiene right to help them improve."

This meant finding a way to respond in real time-not just queuing up issues to discuss in a staff meeting, but identifying a teaching style that could be applied immediately upon witnessing noncompliance.

The team visited some other organizations to look at various programs and their effectiveness before proceeding to develop their own.

The new method was called Take Five.

Take Five

It's a simple idea with a visual cue-five fingers, five minutes.

"We started out educating leadership about the concept-and beyond that, we then embarked on observer training," says Wall.

The plan was a pyramid scheme, she explains.

They first targeted inpatient nursing units and procedural areas. The plan was to have each observer take five minutes per day five days a week to do at least five observations each day. "That would give us, assuming a month had four weeks, for example, 100 observations a month per unit," says Wall.

One of the problems with the old system was that there was not enough data to be representative of the facility's actual compliance.

"Our observations were too skinny," says Wall. "But if you've got 100 observations a month with 14 units, that's 1,400 observations a month-and much more representative of reality."

And this was just the beginning.

Observer training

It isn't just about doing the right number of observations-ARMC also needed to do the right kind of observations. To this end, it invested in proper training for observers.

A one-hour class taught by an IP with very specific content for the prospective observers set the tone for the new process.

The organization rolled out training on a monthly basis-first it trained the observers who would be on the floor in this capacity for the first month, and when they hit the units running, a second set of observers were initiated into the training program.

"Ultimately we'll have observers for every unit with up to 12 observers per unit fully trained within a year," says Wall.

ARMC did not overreach by training observers forevery unit right off the bat-it began with key departments first and expanded incrementally.

"Because of the training, observations, and coaching, we have an increased awareness of how hand hygiene should be performed, and a good number of observers also coaching and serving as role models for others," says Wall.

Boosting the number of observers not only improves the accuracy of compliance numbers, but also prevents burnout.

Once a number of observers are trained in a specific unit, that unit can then rotate observational duties on whatever schedule works best for the department, rather than setting a fixed monthly rotation.

Observers are chosen through different methods depending on the unit. Some are volunteers; others are chosen because they are recognized leaders among their peers.

Originally, the only stipulation was that the observer had to be a licensed individual so that they would be comfortable coaching nurses and physicians. However, that condition has been removed and some excellent unlicensed observers have since been trained.

Coaching methods

For benchmarking purposes, ARMC uses the CDC hand hygiene guidelines (rather than World Health Organization guidelines). Observers monitor compliance with the indicators laid out by the CDC.

With regard to coaching, there are two methods observers employ, depending on the situation. Observers are trained through role-playing scenarios during the class and are encouraged to come up with their own ideas for scenarios to make them more lifelike.

These scenarios, which then enter into practice in the units, are of two types: either to prevent patient harm or to give immediate feedback and improve future performance.

When the first type is used, the process stops and feedback is given on the spot. Situations such as central line insertion, where the first check mark on the bundle is hand hygiene, is one such case.

"If you have a physician who is about to put on his gown and gloves and has not performed proper hand hygiene, how do you stop that process without making the patient lose confidence in the physician?" asks Wall.

Such scenarios are discussed, with suggestions such as offering the physician an application of pocket hand sanitizer.

A simple "Doctor, I have sanitizer for you" can be an easy method to make sure hands are washed without causing a scene.

For the latter type of observation, ARMC developed a script to minimize accusatory tones and make the interaction more educational and conversational.

Coaching should be private, objective, and nonargumentative. It is not about trying to embarrass anyone. For example, the observer might say, "I saw you go in and take vitals without washing your hands. Did I miss that?"

"It's possible to miss them washing their hands," says Wall. "If they say that they did perform hand hygiene, but we did not see it, we do not record the observation. We take their word for it."

That way, if physicians did wash their hands, they are not unjustly penalized. On the other hand, if they really did not wash their hands, the encounter serves as a reminder that they are being monitored and they need to do better. Monitors are educated to be nonconfrontational in the interactions.

"If they say that they forgot, we do record it as noncompliant and use it as an opportunity to teach about that situation as a CDC-indicated opportunity for hand hygiene," says Wall.

Database management

All of these observations are input into a database; data entry is expected of observers. The database is set up to take less than five minutes to enter a day's observations.

ARMC does not currently have palm-sized devices, which some other facilities use; instead, it uses an intranet-based system with a simple user interface. This system is updated in real time, meaning observations are immediately accessible. That way, if the team needs up-to-date figures for a 3 p.m. meeting, the stats entered earlier in the day would already be part of the ongoing data collection.

In terms of tracking, observers also complete manager feedback forms. These forms, officially known as Take Five Manager Report Forms, give the observer a chance to not only document coaching moments, but also document non-observers doing an exemplary job by setting an example or even providing coaching to other staff members.

These forms serve a few other purposes as well. For starters, they help track trends. With multiple observers, it is possible that the same person might receive coaching from separate observers during separate incidents. Using the manager form, a unit leader can identify staff who may need more help achieving compliance.

The forms also allow managers to speak with staff who were not coached at the time of the observation. "We don't want it done that way all the time, but there are times when you have to," says Wall. "And if you're going to do it that way, you have to be specific." For example, if the observer is uncomfortable approaching a specific noncompliant individual, he or she indicates "not coached" on the form and includes details of the observation. The manager or other appropriate person then assumes the coaching function.

A third benefit is the ability to track staff between departments. Some staff members move between floors, while observers are unit-based. The manager report forms provide an opportunity to get a big-picture look at how these non-unit-based staff perform from department to department.

The database allows managers to look not only at the big picture, but to narrow the search by any number of parameters, including date, location, and profession. This allows managers to determine where their departments need the most work in terms of performance improvement.

The real benefit of the database, though, is giving those who manage it a way to make this information accessible to all levels of the organization.

"I send it to administration, department directors, assistant directors, and a number of other places. I want them to share the information about how we are doing with staff," says Wall.

Interest in the classes has continued at a healthy pace. Generally, ARMC hosts three new hand hygiene monitor training courses per month.

Staff are taught during orientation about the importance of hand hygiene and the fact that monitoring occurs.

"Our compliance isn't perfect, but it is good and steadily improving. It really is all about doing the right thing and, by doing so, increasing the safety of both patients and staff," says Wall.

Ambulatory Quality & Compliance Insider, November 2011

Tue, 01 Nov 2011 04:00:00 GMT

Watch out for needlestick hazards in nonhospital settings

Despite the volume and complexity of procedures, hospitals don't have a monopoly on needlestick and sharps injuries suffered by healthcare workers.

No data doesn't mean no problems

Another consideration coming from EPINet data is the risk of injury and exposure attendant to procedures and the devices used in those procedures.

A needlestick is a needlestick is a needlestick

Where engineering controls will reduce employee exposure by removing, eliminating, or isolating the hazard, they must be used.

"A needlestick is a needlestick is a needlestick, regardless of where it happens, and the goal of the standard is to reduce or eliminate those occurrences," said Handelman.

Handelman next identified other costs of noncompliance:

Increased insurance rates if self-insured
Potential workers' compensation costs
Potential legal action from workers or unions
Lost employee work time due to testing or treatment
Expenses related to temporary or permanent replacement workers
Bad press

Lost work time and additional expenses for replacing workers pose particular difficulties for small healthcare facilities, she notes.

Compliance in the use of safety needles and sharps makes for a safer, more healthful work environment. Handelman lists the following example benefits:

Lower workers' compensation costs
Better CMS and Joint Commission surveys
Enhanced worker productivity with fewer days lost
Increased recruitment and retention of skilled workers, keeping facilities competitive