CULTURE OF SAFETY
Staff keeps error reporting locked up
Despite increased attention to patient-safety issues in recent years, over half of hospital staff didn't report any medical errors in their facilities over a 12-month period, according to a major survey report from the Agency for Healthcare Research and Quality (AHRQ). Titled "The Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report," it includes data from 622 hospitals and 196,462 hospital staff respondents. More than two-thirds of respondents listed their staff position as RN or LPN/LVN.
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The survey was designed to evaluate hospital staff members' opinions about patient safety, medical errors, and adverse event reporting. It measured 12 elements of a culture of patient safety, including communication openness, frequency of events reported, handoffs and transitions, nonpunitive response to error, and management support for patient safety.
According to the report, three areas needing improvement are nonpunitive response to error, handoffs and transitions, and number of events reported. An area of strength for most hospitals was teamwork within units. On average, most (73%) of respondents gave their work area or unit a patient-safety grade of A (excellent) or B (very good), although grades varied widely among hospitals and units.
For complete results, search for the report name at AHRQ's Web site, http://www.ahrq.gov.
MODIFIED CPR PROTOCOL
Surviving out-of-hospital cardiac arrest
In a retrospective study, the survival rate for adults with bystander-witnessed cardiac arrest occurring outside of a hospital improved from 22% to 44% when rescuers followed a modified American Heart Association resuscitation protocol. The modified protocol, designed to emphasize strategies for increasing coronary perfusion pressure and optimizing defibrillation success, included minimized chest compression interruptions, increased compression rate, delayed intubation, and preshock chest compressions.
Researchers compared survival rates among adults who experienced out-of-hospital cardiac arrest (ventricular fibrillation or pulseless ventricular tachycardia) in Kansas City, Missouri, 3 years before and 1 year after the modified resuscitation protocol was implemented. When following the revised protocol, emergency responders performed at least 600 chest compressions before attempting intubation, maintained a 50:2 ratio of compression to ventilation, and minimized pauses for ventilation.
Overall survival after initiating the revised protocol increased from 7.5% to 13.9%. The findings were even more favorable among a subset of patients who were more likely to survive because their cardiac arrest was witnessed by bystanders and they had an initial shockable rhythm of ventricular fibrillation. Among these patients, return of spontaneous circulation improved from about 38% (54 of 143 patients) to 60% (34 of 57 patients). Survival until hospital discharge improved from about 22% (32 of 143 patients) to 44% (25 of 57 patients). Of the 25 survivors, 88% had a favorable neurologic outcome at hospital discharge.
Researchers say that when emergency responders reach a patient within 5 minutes-the "electric phase" of cardiac arrest-defibrillation is the optimal therapy. (The electric phase occurs immediately after cardiac arrest, when the myocardium remains highly receptive to electrical cardioversion into a perfusing rhythm.) But after 5 minutes, they recommend that rescuers focus on an optimal chest compression strategy that will create a better environment for successful defibrillation.
Source: Garza AG, Gratton MS, Salomone JA, et al. Improved patient survival using a modified protocol for out-of-hospital cardiac arrest. Circulation. 2009;119(19):2597-2605.
Nighttime dialysis: sweet dreams
Many patients with renal failure need hemodialysis (HD) treatments lasting 3 to 5 hours three times a week, and even this demanding schedule isn't always enough to adequately clear metabolic waste products from their blood. Research suggests that longer HD sessions are clinically superior, yet few clinics offer this option. An exception is a dialysis unit in the United Kingdom that offers three weekly overnight dialysis treatments, each lasting 6 hours or longer.
In a 10-year study, 146 clinic patients (about 11%) chose overnight dialysis. They varied widely in age, with 30 of them over age 70. Researchers evaluated various health parameters for 106 of the clinic's patients, who were divided equally between daytime and nighttime HD treatments.
They found that nighttime HD was associated with better control of anemia and an improved urea reduction ratio. Overnight HD was also well tolerated by most patients. Only a third of those on overnight HD switched back to the daytime protocol, mainly for reasons of personal preference rather than medical reasons.
Previous studies evaluating overnight dialysis found that it also reduces BP, serum phosphate levels, and the risk of premature death, but this study didn't evaluate these factors.
Source: Powell JR, Oluwaseun O, Woo YM, et al. Ten years experience of in-center thrice weekly long overnight hemodialysis. Clin J Am Soc Nephrol. 2009; 4:1097-1101.
TREATMENT AFTER STROKE
Wearing stockings doesn't help
In small trials, thigh-high graduated compression stockings (GCS) have reduced deep vein thrombosis (DVT) risk in postoperative patients, so many clinicians have assumed that they'd help stroke patients too. But is this assumption valid? To find out, researchers conducted an international study of more than 2,500 acute stroke patients. They discovered not only that GCS didn't prevent DVT, but also that they occasionally caused harm, such as skin ulcers and blisters.
About half of the patients in the study received standard care and wore GCS. Patients in the control group received just standard care. All patients had Doppler ultrasound of both legs after 7 to 10 days, and then again after 25 to 30 days when it was practical. About 10% of patients in both groups developed DVT, but 5% of patients who wore the GCS experienced adverse reactions, such as alterations in skin integrity, compared with 1% of those who didn't wear the stockings.
Current recommendations from the American Heart Association advise physicians to consider using GCS along with anticoagulants. Noting that GCS can be cumbersome and difficult for patients with paralysis to handle, researchers say the data don't support their use for these patients.
Source: The CLOTS Trials Collaboration. Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. Lancet. 2009;373(9679):1958-1965.
METASTATIC LUNG CANCER
Hospice care not under discussion
About half of patients with metastatic lung cancer didn't discuss hospice care with their healthcare provider within 7 months after diagnosis, according to a recent report. Blacks and Hispanics were significantly less likely than whites and Asians to discuss hospice care with their healthcare provider.
Using data from a regional study on 1,517 patients with stage IV lung cancer, researchers found that half had discussed hospice with a healthcare provider within 7 months after diagnosis. Patients least likely to have discussed hospice were black, Hispanic, non-English speaking, married or living with a partner, Medicaid beneficiaries, or had received chemotherapy. Just 53% of those who died within 2 months after the interview had discussed hospice.
Patients reporting the most severe pain or dyspnea weren't more likely to have discussed hospice than those who reported less severe symptoms or who were asymptomatic. Only a third of those who discussed do-not-resuscitate orders had also discussed hospice. The researchers concluded that better communication with healthcare providers could improve patients' awareness of hospice and clear up misunderstandings.
Source: Huskamp, HA, Keating NL, Malin JL, et al. Discussions with physicians about hospice among patients with metastatic lung cancer. Arch Intern Med. 2009;169(10):954-962.
Baseball caps and flip flops: Risky?
These popular summer caps and shoes leave the tips of the ears and the tops of the feet exposed to the sun's rays, raising the risk of skin cancer. What's more, people using sunscreen frequently overlook those parts of their bodies, leaving ears and feet even more vulnerable to sun damage.
The most common cancer type, skin cancer accounts for about half of all cancers in the United States, according to the American Cancer Society. Most are considered sun-related. Teach your patients to:
* Use a sunscreen with an SPF of 15 or more daily. Use a higher SPF at higher elevations.
* Wear protective clothing, including wide-brim hats and footwear that covers the top of the feet when outdoors.
* Stay out of the sun at midday (10 a.m. to 3 p.m.)
* Avoid sunbathing and tanning salons.
Source: How flip flops, baseball caps can raise your skin cancer risk. Loyola Medicine. May 20, 2009; http://www.loyolamedicine.org/News/News_Releases/.
ADVERSE SAFETY EVENTS
Mortality skyrockets after surgical mishaps
Patients who experience adverse safety events related to surgery are seven times more likely to die while hospitalized and are much more likely to be readmitted within 3 months than other patients, new study findings show. Researchers analyzed nine types of adverse safety events (as defined by the Agency for Healthcare Research and Quality) among almost 1.5 million adult surgery patients who were treated initially in short-stay hospitals in 2004. They controlled for many factors that could affect readmission or death, such as severity of illness, chronic conditions, age, and insurance status.
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The nine types of adverse safety events included:
* iatrogenic pneumothorax
* selected infections resulting from medical care
* accidental puncture or laceration
* various postoperative complications, including hemorrhage or hematoma, physiologic and metabolic derangements, respiratory failure, venous thromboembolism, sepsis, and wound dehiscence after abdominopelvic surgery.
In all, over 2% of patients experienced at least one adverse safety event. At 3 months, 25% of these patients had been readmitted, compared with 17% of patients in the control group. In-hospital mortality was about 9% for patients who experienced at least one adverse safety event, compared with about 1% for patients in the control group.
The study has a few limitations. For example, some patients may not have been readmitted because they died outside the hospital after the initial hospitalization. Even so, researchers say, the data shows that "more attention is warranted to assess the full extra cost of safety events, the factors influencing the rate of safety events, and strategies for health plans to improve incentives for safety."
Source: Friedman B, Encinosa W, Jiang HJ, Mutter R. Do patient safety events increase readmissions? Med Care. 2009;47(5):583-590.
Are your PCA pumps standardized?
Nurses who recently visited our Web site answered this question: Do you use a standardized PCA pump throughout your facility?
The Institute for Safe Medication Practices recommends limiting PCA pumps to one model to promote programming proficiency and reduce errors. Visit http://www.nursingcenter.com/poll to answer our monthly survey question and view results from other surveys.
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Dizzying implications of vestibular dysfunction
By impairing balance and causing dizziness, vestibular (inner ear) dysfunction can lead to falls. Yet little research has been done on the prevalence of vestibular dysfunction in the United States. To investigate, researchers conducted a 3-year study involving more than 5,000 men and women age 40 and over. Participants underwent specialized exams and balance testing to assess for early signs and symptoms of vestibular dysfunction. The findings indicated that from 2001 through 2004, over 35% of adults had vestibular dysfunction, with the incidence increasing with age and the presence of diabetes. Many participants were asymptomatic and unaware of their risk. Participants who had symptoms such as dizziness had a 12-fold increase in fall risk.
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People with diabetes were 70% more likely to have balance problems than those without the disease. Researchers say this may be because high glucose levels damage hair cells and small blood vessels in the inner ear, impairing balance.
Source: Agrawal Y, Carey JP, Della Santina CC, Schubert MC, Minor LB. Disorders of balance and vestibular function in US adults. Arch Intern Med. 2009;169(10):938-944.