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 one nurses’s traumatic experience of caring for patients during the pandemic, atrial fibrillation and surgical cancellations, and how being “activated” may save your life.

As 2021 ends, the International Year of the Nurse and the Midwife also draws to a close. The World Health Organization originally declared 2020 the Year of the Nurse, marking the 200th anniversary of Florence Nightingale’s birth, but they extended it for another year in recognition of nurses’ vital role in patient care during the pandemic.

Cassandra Alexander, a registered nurse with 14 years of experience in burn care, critical care transport, and intensive care, shares what it is like on the front lines and the toll it has taken on her mental health. Hers is a deeply personal and painful story, yet also a traumatic experience shared by many nurses around the United States:

“I volunteered to take patients with COVID on March 14, 2020, right out of the gate, the first ones that my facility thought we had, largely because like most ICU nurses, I believed myself to be both tough and invincible. I didn’t have kids or local family to protect, and I was full of that foolish spirit that makes some of us run toward danger a little harder than others, that I think a fair amount of people who work in healthcare will recognize.

“And by April 2021 I was broken.”

 

Emergence delirium—an altered mental state resulting from an anesthetic—poses risks to the patient and staff. During the bout of delirium/agitation, the patient may act violently (including punching, kicking, hitting, or biting), show aggression or combativeness, scream, disconnect with current time and place, attempt to remove medical apparatuses, or engage in other harmful behavior. What do we know about the causes and what can we do to prevent it?

To answer these questions, researchers turned to the Pennsylvania Patient Safety Reporting System (PA-PSRS). They examined 97 event reports of bouts of delirium and agitation associated with anesthetics and/or adjunct agents that occurred before, during, and after an operation. Their deep dive into the data revealed novel insights into how delirium and agitation have varying safety implications depending on the operative period.

Incorporating best practices of the 63 facilities included in this study, existing literature, and guidelines from the VA Pittsburgh Healthcare System, the authors also developed an intervention package to prevent, treat, and de-escalate bouts of delirium and agitation. Highlights of this resource include three strategies (patient restraint, readministration of an anesthetic and/or adjunct agent, and call for additional staff), as well as four key phases: patient evaluation with individualized plan, preoperative actions, intraoperative actions, and postoperative actions.

 

Every medication has associated risks, but what happens when they’re used in combination? In particular, guidelines discourage using benzodiazepines in conjunction with opioid pain medications in older adults—so is it still happening, how often does it occur, and what are the consequences for geriatric patients?

Researchers examine the risks that are created when these drugs are administered together in the hospital, including an increased risk of overdose. They identified 80 reports from the Pennsylvania Patient Safety Reporting System (PA-PSRS) in which a patient may have experienced an adverse drug reaction (ADR) to the combined use of a benzodiazepine and an opioid pain medication.

They determined that changes in mental status were the most common ADRs, occurring in more than two-thirds of reports, followed by respiratory reactions (51.3%) and cardiovascular reactions (25.0%). In 70% of reports, the patient received a reversal agent, either flumazenil or naloxone, or both. The inappropriate use of benzodiazepines and opioid pain medications in combination among patients 65 years and older is a growing problem, and an increased awareness may be the first step for providers to begin addressing it.

Atrial fibrillation (AF or “AFib”) is the most common cardiac arrhythmia, manifested by the heart beating too slowly, too fast, or in an irregular way. People with AF can be symptomatic or asymptomatic and are at increased risk for stroke. AF also presents patient safety concerns for ambulatory surgical facilities (ASFs)—resulting in cancellations, transfers, or providing additional services to complete a procedure, which may disrupt workflow processes.

Researchers surveyed 322 Pennsylvania ASFs in March 2021 and completed a five-year study of Pennsylvania Patient Safety Reporting System (PA-PSRS) reports identifying new-onset AF, in order to examine the impact of AF on surgical facilities and identify opportunities for improvement. Among their discoveries: Cardiac arrhythmia was the most frequently identified reason for a transfer, and nearly 60% of respondents identified medical issues missed/identified during preoperative screening as one of the top four reasons for cancellations in their facility. More than 86% of the patients with new-onset AF were asymptomatic, and most were identified during the preoperative phase. For this reason, preoperative screening may identify patients at risk for AF.

Based on the results of the analysis and review of the literature, researchers identified areas of opportunity for future improvement broadly and at the facility level. Two areas for future research include screening for new-onset AF using smart devices and nurse-driven preoperative screening processes.

 

In the recent Patient Safety Authority summary of 2020 data from acute care facilities in Pennsylvania, reporting rates and fall rates were provided for Q1 and Q2 2020 based on the latest data available at the time of publication, June 2020. This data snapshot completes the reporting rates for 2020 now that all hospital patient days and surgical encounters data from 2020 have made available for rate calculations.

Urinary tract infections (UTIs) are often treated in long-term care (LTC) facilities, but they’re notoriously difficult to diagnose. To better understand the reasons and risks for residents, researchers studied the patient safety event reports and share the trends in rates and most common types of infections, as well as a toolkit they developed to help reduce the occurrence UTIs and promote antibiotic stewardship.

Their analysis shows that despite regulations to improve infection prevention practices and decreased use of urinary indwelling catheters, the rates of UTIs continued to rise from 2016 to 2020, and pose a significant threat of morbidity and mortality for residents of LTC facilities as well as diagnostic and treatment challenges for providers.

They encourage patient safety officers, administrators, and infection preventionists to share their toolkit of best practices for UTI prevention with frontline staff, nursing, pharmacy, and laboratory management. It includes indications, insertion, and maintenance practices for use of indwelling urinary catheters; recommendations to prevent overtreatment of UTIs; and antibiotic stewardship practices that may help to reduce long-term resident harm associated with UTIs, overuse of antibiotics, and adverse effects of antibiotics.

The good news: We’re living longer. The bad news: Longevity increases the likelihood of developing geriatric syndromes, such as falls, delirium, dementia, sleep disorders, and weight loss. Author Richard Kundravi shares how his mother’s lifestyle helped her avoid many of these problems associated with aging.

“As the son of a fiercely independent woman who lived well into her 10th decade, I had the privilege of observing firsthand how important managing these common conditions was for her staying self-sufficient. I am especially grateful for the lessons my mother taught me for staying healthy and happy.

“My mom did not have a technical term for her approach to staying healthy but rather a focus that I classify as ‘My Mom’s 5 Ms for Staying Healthy,’ which, in no particular order, are medication management, meal maintenance, mobility, mentation, and moisture monitoring.”

 

Studies show patients who are more “activated” (i.e., invested in their care) are more likely to have better outcomes. Dr. Judith H. Hibbard, researcher and professor emerita at the University of Oregon, explains what it means to be activated—and how being so may just save your life:

“Patient activation has a specific definition: an individual with the knowledge, skill, and confidence to manage their health and their healthcare. They understand their role in that process and feel capable of doing it. Patient engagement is a term that is used to mean lots of different things. Sometimes they mean patient activation. Sometimes they mean involving the patient in the care process, which is quite different than the patient feeling some ownership and understanding their role and gaining the skills and confidence that they need.”

Activated patients have six characteristics that empower them to participate more effectively in their own care, with better outcomes, which include the ability to self- manage their illness or health problems, the ability to collaborate with their healthcare providers, and the ability to navigate the healthcare system.

“The key is meeting people where they are,” Hibbard says. “If they are overwhelmed or have low confidence or a limited idea of what their role is in the care process, you want to work with them differently than someone who’s being very proactive about their health and wants to have a major role in their care.”

Cancellations and transfers out of an ambulatory surgical facility (ASF) are reportable events under the Medical Care Availability and Reduction of Error (MCARE) Act, and present numerous challenges to the timely delivery of preventative, diagnostic, and elective care.

Two researchers recently took a closer look at this problem, with a particular focus on the impact of new-onset atrial fibrillation (AF, commonly known as “AFib”)— the first diagnosis of a cardiac arrhythmia characterized by an irregular rhythm and often rapid heart rate. Because AF poses a safety risk to surgical patients, the planned procedure often must be canceled or the patient must be transferred, resulting in a delay in treatment.

As part of their investigation, the authors looked at data from the Pennsylvania Patient Safety Reporting System (PA-PSRS), completed a literature review, and interviewed staff at three Pennsylvania ophthalmology and endoscopy centers about how they manage patients with new-onset AF. Each facility had its own approach, including addressing hydration status, using a nurse-based preoperative screening process, and working collaboratively with cardiologists and primary care physicians.

 

In response to the article “Comparison of Simulation-Only Versus Simulation Plus Live Training in Paracentesis” (Patient Safety, September 2021), authors weigh in on the benefits of in situ, team-based simulation for creating a safe environment in which to learn nontechnical skills (such as leadership, teamwork, and communication) and slowing skill and knowledge decay.

The authors emphasize: “To achieve maximum benefit from a simulation-based training module, it is essential to match the goals of the simulation module with the identified clinical need. The clinical need varies depending on location and learners involved but can encompass task training, process evaluation, or team training for effective emergency responses.”

An additional benefit: When such training uses data from event reporting systems to develop training scenarios, it also promotes reporting as an important and helpful tool that aids in patient safety.