WHAT YOU NEED TO KNOW

Our quarterly special editions feature articles, stories, interviews, and more from our journal, Patient Safety. In this issue you will read about simulation and live training, a study that examines the experiences of home care workers during COVID-19, and WellSpan’s Central Alert Team: a sepsis game changer.

In the United States, almost 1 million patients with sepsis are admitted to hospitals annually, and the average length of stay for sepsis is 75% longer than for most other conditions. Early identification and treatment are critical for survival, but sepsis—when the body’s immune system goes into overdrive, backfires, and attacks its own organs—is notoriously difficult to diagnose, as symptoms are often nonspecific and mimic other illnesses.

Four years ago, WellSpan Health asked, “What if there were a better way?” The answer they came up with was the Central Alert Team (CAT): an interdisciplinary team of critical care nurses who remotely monitor patients and review their charts, watching for the potential for sepsis. One of CAT’s founding members, Dana Gaultney, RN, explains, “We’re here to connect the dots when the bedside staff is consumed with everything they have to do. We have this laser focus for sepsis and we’re constantly looking for it.”

Patient Safety Managing Editor Caitlyn Allen interviewed six CAT team members about how they have decreased mortality rates systemwide and increased sepsis bundle compliance; how other organizations could replicate their success; and how their model might be used to watch for other dangerous conditions in patients, such as deterioration and cardiogenic shock.

Program Director Brenna Simcoe, PharmD, says, “For other places who would be interested in implementing this: Your team is important. These nurses are experienced and have the knowledge and experience to be able to build rapport and trust with the bedside team. If you don’t have the right people in place, the bedside teams are never going to trust their recommendations.”

 

Building a culture of safety in healthcare is a team effort, which includes involving patients and their families in addition to staff. But finding ways to engage and empower patients in their own care can be challenging. For some guidance, a team at the Veterans Affairs Connecticut Healthcare System looked to the best practices of high reliability organizations (HROs), such as the military, which is considered the gold standard for performing under duress.

A key focus of HROs is “preoccupation with failure,” in which they anticipate risk where all personnel are problem solvers. The unique patient population at the VA provided valuable insight into how patients can be a part of this process, when one U.S. Army veteran identified some safety concerns, including a broken hallway handrail, and informed a chaplain about it. The chaplain escalated the concerns to the medical center director, who then discussed them with the patient. As a result, the issues he had identified were repaired immediately, and a “Time Out for Safety” and “good catch” award were introduced—the first of which was presented to the proactive patient.

Learn about more ways the VA is involving patients in their safety initiatives and how your organization can take a similar journey toward high reliability.

Many of us have felt unseen at one time or another, but when this happens in a healthcare setting, it’s more than just upsetting or irritating—it could actually be dangerous. Patient safety liaison Megan Shetterly, MS, RN, likens it to wearing Harry Potter’s cloak of invisibility as she relates an experience she had while waiting in an outpatient laboratory to have her blood drawn.

“I approached the registration clerk after she called my first name, and she handed me paperwork with orders for lab work. The document included my first name but someone else’s last name and their unique patient information—not mine,” she writes. Anyone concerned about patient safety would be alarmed if this happened to them, and as an experienced clinician, Shetterly knew the potential safety risks of mixing up patients’ laboratory samples: inaccurately identified results and subsequent errors in treatment.

She reported the mistake to the facility to help them prevent it recurring, but many people don’t speak up when they notice something is wrong. They should. And facilities need to look at their processes, identify failure points, and do everything possible to prevent patient misidentification.

Suicide in skilled nursing facilities (SNFs)—centers that provide around-the-clock treatment and rehabilitation—is a serious yet underappreciated issue. Chronic physical ailments often take precedent over mental health issues, which can make it easy to overlook them. Tony Salvatore, director of Suicide Prevention at Montgomery County Emergency Service, provides insight into the problem and how we can better quantify it, and some simple fixes that can have a big impact.

“Moving to a nursing home can be traumatic,” Salvatore says. “People are giving up a lot to make that move, potentially their spouse, their home, their friends, or their community activities, which can lead to anxiety or depression.”

He points out that anyone is eligible for suicide and elder abuse, and everyone should be screened and treated appropriately when they enter an SNF; unfortunately, these screenings are usually brief and mental health screenings may not indicate a suicide risk. However, some factors might put a person at higher risk for suicide, which in an SNF often takes the form of self-neglect: in Montgomery County, people 65 and older are five times more likely to commit suicide than people under 20, and in SNFs these are most likely to be women. Preadmission behaviors such as missing appointments, not attending to daily activities of living, and too much or too little sleep can also be warning signs.

“We owe people in nursing homes an optimal outcome at the end of life, and suicide is not that. When you talk to people who have attempted suicide, their biggest misconception is no one will miss them. Nobody cares. It’s almost never true.”

 

Throughout the pandemic, much awareness has been raised about the sacrifices made by hospital workers. What about the staff who are providing hands-on care to patients in their own residences? To find out, researchers at the Betsy Lehman Center for Patient Safety carried out a mixed methods study—the first of its kind— interviewing 83 home care workers, including 39 personal care attendants employed directly by consumers and 44 agency employees.

They discovered that caring for patients in the home while protecting themselves from COVID-19 required home care workers to make many trade-offs and suffer anxiety about their safety and the safety of their family members; 25% of participants reported that they had served someone who had COVID and 75% were worried about getting it on the job, while 29% considered quitting home care work. Among the challenges: the impossibility of social distancing, insufficient personal protective equipment (PPE) and testing, reliance on their customers to communicate COVID risks and take appropriate precautions, and in some cases a lack of safety guidance from their agency. Home care workers also visited multiple people each day in a variety of settings, increasing the risk of exposure to infection.

Not surprisingly, the study found that “home care workers often prioritized their clients’/consumers’ needs despite the relatively high-risk nature of their work and a low pay and benefit structure.” Overshadowing their concerns about COVID-19 was the fear of losing their job or income, as well as their commitment to patients who had no one else to care for them. What can be done differently? There must be clearer policies and safety guidelines to protect vulnerable home care patients and workers, and home care workers themselves should be included in public health strategies (e.g., mass testing, PPE training and distribution, and vaccination plans) and empowered to implement policies and protocols.

Every year, 2 million Americans are injured in a motor vehicle crash (MVC). What does care look like in this unique population of patients who may be unconscious, incapacitated, or even unidentifiable? Elizabeth Kukielka, PharmD, MA, RPh, patient safety analyst at the PSA, shares her first-of-its-kind analysis of events involving patients who experienced an MVC. And it turns out that sometimes more accidents befell them in the hospital.

To better characterize challenges with treating these patients, who may be unable to participate in their own care, Kukielka identified, analyzed, and categorized 282 reports of patient safety events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) from 2018 to 2020. Among the findings is that 13.1% of the reports were classified as serious events (i.e., events that resulted in patient harm), compared with 2.9% in the full acute care PA-PSRS database—indicating that a patient safety event involving the care of a patient following an MVC may be more likely to be associated with patient harm.

Problems with monitoring or treatment were most common (43.3%), followed by problems with evaluation (18.4%), falls (11.7%), problems with documentation (7.4%), medication errors (7.4%), and problems with transfers (6.4%). Improvement efforts might be focused on contributing factors, including communication breakdowns, lack of policies or protocols or unawareness about existing policies or protocols for treating certain patient populations, and prioritization of conditions related to an MVC over underlying health conditions.

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When a device malfunctions, the facility reports it to the manufacturer, who investigates and fixes, replaces, or recalls the product. That’s how it usually works, but the pandemic is delaying not only delivery of timely medical care, but also reporting and investigation of events involving medical devices, such as dental implants, ventilators, and PPE.

Researchers at MedStar Health analyzed data from the Manufacturer and User Facility Device Experience (MAUDE) database, a repository for millions of medical device reports submitted to the U.S. Food and Drug Administration (FDA). Of the 816,470 reports from January 1, 2020, through July 31, 2020, 3,500 (0.43%) were connected to COVID-19: predominantly attributed to barriers manufacturers faced in investigating malfunctioning devices during the pandemic (90.3% of reports)—which affected clinical care in 85.8% of the reports.

Some of these barriers included restrictions to person-to-person contact, preventing investigation of implants; travel bans; limited capabilities; and a halt on shipping devices for evaluation to limit the spread of COVID-19. In response to such delays, the FDA released guidance on medical device reporting during a pandemic, waiving the mandated 30-day reporting period; however, it remains to be seen how manufacturers will catch up on delayed implant devices uninvestigated malfunctions, and the ultimate impact of these issues on patient safety.

 

You may know the consequences of misplaced nasogastric tubes (NGTs), but are you as confident in the best methods to ensure they’re placed correctly?

NGTs are used to deliver nutrition and medications to patients or remove stomach contents. Inserting these tubes is simple; however, wrong placement or dislodged tubes can lead to patient harm or even death, particularly if the problem isn’t discovered before they are used. Patient Safety Analyst Lea Anne Gardner, PhD, RN, and Patient Safety Liaison Susan Wallace, MPH, analyzed data from the Pennsylvania Patient Safety Reporting System (PA-PSRS) for events that occurred between January 1, 2017, and June 30, 2020 which indicated NGT placement verification methods, to determine how these activities aligned with NGT guidelines.

Their research showed that X-rays and pH aspirate, guideline-approved verification methods, were identified in 90.8% (544 of 599) of the reports; however, non- recommended verification methods (e.g., insertion of air bolus/auscultation) were used in 9.2% of the reports. Reports also indicated that non-recommended verification methods were used with infants compared to all other patients.

Gardner and Wallace also interviewed staff at three healthcare facilities about their NGT verification methods. To reduce the risk of misplaced NGTs, follow guidelines for best practices for verifying tube placement: radiography and pH aspirate testing.

More and more, automation is making our lives easier, including in healthcare, with robot-assisted surgery, natural language processing, clinical decision support, and simulation education. But computers still can’t fully replace human interactions—can they?

While there have been studies examining the efficacy of simulation and live training in developing skills in abdominal paracentesis (a procedure to insert a needle into the peritoneal cavity to remove ascitic fluid), a team at VA Pittsburgh Healthcare System is the first to look at the longer-term impact of simulation-only training and hybrid training (combining simulation and live training) on skills retention. They assigned a subset of internal medicine residents engaged in simulation-based training in abdominal paracentesis to participate in additional, structured, live training. Then they compared the procedural skills and medical knowledge of both groups following initial training and six months later.

While the simulation-plus-live-training residents scored slightly higher on the knowledge test at six months (by one question), it was not clinically significant, suggesting that overall procedure skills declined similarly for both groups. These results may indicate that structured, ongoing training is needed to maintain paracentesis skills, regardless of what training experience was first used to master them.

 

The I AM Patient Safety award is an annual contest that recognizes and celebrates healthcare staff for their individual or collective commitment to and influences on patient safety. It is a chance to celebrate the things that go right each day in healthcare to make patients safer.

Read the stories of our 2021 winners, including Brianna Thompson, PharmD, who received the Safety Story award for making good catches that ensured patients received appropriate care and initiating lasting process changes to protect future patients; Kelly Romano, MPH, who won the Individual Impact award for making a difference in the lives of patients and their families and having a profound impact on the culture of patient safety at Einstein Medical Center Montgomery; the Women’s Health Department at Pennsylvania Hospital, winners of the Improving Diagnosis award for revising their care processes regarding postpartum hemorrhage to improve outcomes and reduce disparities for their patients—and many others!​​