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Premier SafetyShare – January 2009

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2006 Malcolm Baldrige National Quality Award Reipient

January 27, 2009 Premier SafetyShare

Dear Colleague:

We still have work to do on some longstanding safety issues highlighted in this issue, including reuse of syringes, prevention of pressure ulcers, and eliminating problem organisms.

Gina Pugliese, editor
Vice President, Premier Safety Institute




Syringe reuse among infection control lapses, leading to 33 outbreaks

Thirty-three outbreaks in non-hospital settings and seven hospital outbreaks are examined in a recent study by the Centers for Disease Control and Prevention (CDC). Multiple failures in basic infection control practices in non-hospital settings such as the reuse of syringes has led to the testing of over 60,000 U.S. patients for viral hepatitis.

The total outbreaks outside of hospitals in 15 states identified during the past decade included 12 in outpatient clinics, six in hemodialysis centers and 15 in long-term care facilities, resulting in more than 400 people acquiring HBV or HCV infection. The outbreaks are described in a recent
review (Annals of Internal Medicine, January 6, 2009) of all healthcare-associated viral hepatitis outbreaks investigated by the CDC over the last 10 years.

Infection practice lapses This number is likely an under-representation, as test results and epidemiologic information were not always available. Healthcare personnel (HCP) failed to follow several basic infection control procedures and aseptic technique in injection safety, including reusing syringes, contaminating multi-dose vials with unclean syringes, using single-dose vials for multiple patients, re-using end-caps from single-use syringes, using fingerstick devices on multiple patients without cleaning, and using blood-sugar measuring devices on multiple patients without cleaning.

Dr. Denise Cardo, director of CDC′s Division of Healthcare Quality Promotion, noted that more innovative engineering controls and public awareness are needed because more patients in the United States are receiving their healthcare in outpatient settings. The
report highlights the need for ongoing professional education for healthcare providers. By contrast, unpublished CDC data from hospital settings identified only seven incidents of viral hepatitis outbreaks, resulting in 48 individuals acquiring HBV or HCV infection.

Recommendations for infection prevention and control in hospital settings are well established and infection prevention specialists conduct surveillance, monitor practices and provide education and training on appropriate infection control practices. In non-hospital settings, such specific infection control resources and oversight are not always in place.

Recommendations The CDC review emphasizes the need for more
education specifically related to aseptic technique in injection safety, regular review of practices and training, and the implementation of a consistent state oversight in detecting and preventing the transmission of bloodborne pathogens in healthcare settings. The review also indicates that the continuing outbreak activity may lead to recommendations for hepatitis B vaccination for diabetic long-term care residents.

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79 percent increase in pressure ulcers in past decade: AHRQ

Hospital stays involving patients with pressure ulcers increased 79 percent from 1993 to 2006, according to a recent Agency for Healthcare Research and Quality (AHRQ) study of the patterns of utilization and costs for adult hospital stays involving the treatment of pressure ulcers in 2006. The new AHRQ statistical brief is based on data from the Healthcare Cost and Utilization Project (HCUP).

Changing characteristics
In 2006, there were 503,300 hospital stays that included pressure ulcers – a 78.9 percent increase from 1993, when there were only about 281,300 hospital stays with pressure ulcers. The
report noted that in 2006, more than 90 percent of pressure ulcer-related adult hospitalizations had pressure ulcers as a secondary diagnosis, rather than the principal reason for admission. The most common reasons for hospitalizations during which pressure ulcers were noted were septicemia, pneumonia and urinary tract infection. More than half of all pressure ulcer stays (53.4 percent as a primary diagnosis and 54.5 percent as a secondary diagnosis) were discharged to long-term care, more than three times the rate of hospitalizations for all other conditions (16.2 percent). Seventy-two percent of adult patients with a secondary pressure ulcer diagnosis were 65 years and older, a finding that also indicated Medicare was the most common payer of adult stays related to pressure ulcers. Mortality was higher for all pressure ulcer-related hospitalizations; approximately one in 25 hospitalizations ended in death, with pressure ulcers as a primary diagnosis, compared to one in eight when pressure ulcers were a secondary diagnosis.

Morbidity and costs
In patients younger than 65, paralysis and spinal cord injury were the most common coexisting conditions with hospitalizations principally for pressure ulcers. Fluid and electrolyte disorders, nutritional disorders, diabetes without complications, and dementia were more common among patients 65 and older. The cost for adult hospital stays that included a diagnosis of pressure ulcers, totaled almost $11 billion in 2006. Pressure ulcer-related hospitalizations are generally longer and more expensive than many other hospitalizations. According to the AHRQ report, the overall average hospital stay is five days and costs about $10,000; however, the average pressure ulcer-related stay is from 12.7 to 14.1 days and costs between $16,800 and $20,400.

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HHS shares metrics to assess reduction of healthcare-associated infection in newly released plan

An Action Plan to reduce HAIs such as catheter-associated bloodstream (CA-BSI) infection was released on January 6, 2009, by the U.S. Department of Health and Human Services (HHS). HHS is seeking public input into its plan by February 6 to identify key actions in the prevention of HAIs to better coordinate agency prevention efforts. The document attempts to establish national targets for enhancing and coordinating HHS-supported efforts to prevent and reduce HAIs, a top priority for the department.

The HHS Steering Committee for the Prevention of HAIs was established in July 2008 and set six high priority HAI-related areas within the hospital setting as the initial focus of the HHS effort. Infections in four categories account for over 80 percent of all HAIs and include: surgical site infections (SSI); central line-associated bloodstream infections, or CA-BSIs; ventilator-associated pneumonia (VAP); and catheter-associated urinary tract infections (CA-UTIs). The remaining two additional initial priorities are infections associated with
Clostridioides difficile and Methicillin-resistant Staphylococcus aureus (MRSA).

HHS has established a set of five-year national prevention targets as well as metrics to assess progress toward these targets. HHS is planning a series of meetings for the spring of 2009 to provide opportunities for public comment on improving and strengthening the plan and stakeholder engagement in its implementation strategy. Comments on the HHS Action Plan to Prevent Healthcare-Associated Infections can be submitted to

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Slow start to flu season leads to lower vaccinations at season mid-point; not too late for flu shots as flu activity increases

Midway through the current flu season, a Rand Corporation survey found that only 30 percent of U.S. adults had received the influenza vaccine. A slow start to the season and uncertainty regarding the impact of the flu as well as the benefits of vaccination may contribute to low vaccination rates. The current increased flu activity compared to earlier weeks, along with recent concerns about antiviral drug resistance among this year’s flu strains, makes continuing immunization through March increasingly important.

The Rand study was released as part of a nationwide initiative to raise public awareness of the importance of flu vaccination and to urge providers to extend their vaccination efforts into the rest of the flu season. A total of 3,969 adults responded to the online survey between November 7 and November 19. Survey results indicated 30 percent of respondents had already been vaccinated. Seventeen percent planned to receive a flu shot, although 53 percent said they were not planning to get a flu shot.

High risk groups
Among those respondents with high-risk conditions, 42 percent reported receiving flu shots and an additional 18 percent reported they planned to receive one. Forty-seven percent of adults over 50 responded they had received the vaccine and 19 percent intended to do so. Among healthcare personnel (HCP), 30 percent reported already having been vaccinated, while 57 percent stated they did not intend to get vaccinated. William Schaffner, MD, president-elect of the National Foundation for Infectious Diseases, in commenting on the findings, noted that he suspected that the HCP numbers would be higher since some healthcare institutions were still conducting their vaccination programs when the survey was taken.

Reasons cited by respondents for not getting the flu shot included:

  • Not having enough time (41 percent);
  • Thinking they don’t need it (25 percent);
  • Not believing in the flu vaccine (20 percent);
  • Fear of sickness or side effects (19 percent); and
  • Thinking that others need it more (8 percent).

Additional reasons were lack of physician recommendation and cost. Yet ironically, a new
study shows that workers age 50-64 who received influenza vaccine lost substantially
fewer days of work and worked fewer days while ill. But influenza vaccine is underutilized. Millions of doses were thrown away at the end of the last two flu seasons and this survey may point to another such season.

The survey results indicate that much work still needs to be done to encourage the public – especially those with high-risk conditions and healthcare
personnel – to get vaccinated.

Healthcare personnel risk for others
Dr. Benjamin Brewer, writes in his
Wall Street Journal column that getting a flu shot typically reduces one’s risk of contracting the illness by 50 percent to 70 percent. Persons older than 65 or already sick could find the shot life saving. Brewer also noted that unvaccinated healthcare personnel present an unacceptable risk to his practice’s patients, despite debating whether or not unvaccinated personnel should have contact with patients.

The 2008-2009 flu vaccine protects against the three main flu strains that will likely cause the most illnesses during the flu season, or at least make an illness milder if infected with a related but different influenza virus strain.

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Fewer blood transfusions and shorter length of surgeries linked to lower incidence of surgical infections

The use of fewer blood transfusions and surgical procedures that are shorter in duration characterize high-performing hospitals that have a lower incidence of surgical site infections, (SSI) according to a new study.

In this study, 20 high-performing hospitals (hospitals with lower than expected SSI risk-adjusted rates) were compared with 13 low-performing hospitals with higher-than-expected SSI rates. Researchers looked at patient characteristics, laboratory values, operative variables, structural variables and processes of care.

The procedures at low-performing hospitals took significantly longer (25 minutes) compared with high performers. The hospitals with high SSI rates were also larger and had a higher number of young surgeons in training. Hospitals with low SSI rates had significantly fewer inpatients who were anemic prior to surgery, and were administered fewer blood transfusions. Other general characteristics of high performers (though not significant) included a lower 30-day mortality rate, smaller size, greater efficiency in the delivery of care and little operative staff turnover.

Perioperative policies and practices were similar between the low- and high-performing hospitals. Comparisons of potential best practices were very similar except hospitals with low SSI rates reported less foot traffic in the operating room. Study authors suggest that reducing the length of operations and the number of blood transfusions should complement basic aseptic technique in the operating room, and recommend more research on reducing operating room traffic.

This study was based on data reported from 117 academic and community hospitals participating in the ACS-N5QIP, and represents the analysis of 113,891 patients operated on during 2006.

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AMI mortality among women greater than men; linked to delayed diagnosis and treatment

A recent study confirmed the importance of increased screening of women for acute myocardial infarction (AMI). Researchers examining sex differences in care processes and in-hospital deaths among patients with AMI found that for some types of AMI, women were nearly twice as likely as men to die in the first 24 hours of hospitalization, causing concern about the diagnosis and treatment between men and women after a more severe heart attack. The “Get With the Guidelines – Coronary Artery Disease” database was used to examine sex differences in care processes and in-hospital death among 78,254 patients with AMI in 420 U.S. hospitals from 2001 to 2006.

Overall and adjusted mortality rates
The researchers examining sex differences in care processes and in-hospital deaths among patients with acute myocardial infarction (AMI) found that women had higher unadjusted in-hospital mortality rates than men. After adjustment for baseline risks, sex-based differences for early death after AMI seemed to disappear. That is, there were no differences in
overall hospital mortality rates after AMI with one important exception – ST-elevation myocardial infarction (STEMI). The
report (Circulation, December 2008) found women were older, had more comorbidities, and less often presented with STEMI. However, women who
did suffer STEMI had nearly twice as high adjusted mortality rates than men – 10.2 compared to 5.5.

Diagnosis and treatment
The study also found that, compared to men, some recommended treatments for women are delayed and underused. Researchers found that women were 14 percent less likely to receive early aspirin; 10 percent were less likely to receive beta blockers; 25 percent were less likely to receive reperfusion therapy (to restore blood flow); 22 percent were less likely to receive reperfusion therapy within 30 minutes of hospital arrival; and 13 percent were less likely to receive angioplasty within 90 minutes of hospital arrival. Women also experienced lower use of cardiac catheterization and revascularization procedures after AMI.

Compared to rates a decade before, when women had an overall higher death rate after heart attack compared with men, the study found that the study hospitals used high rates of evidence-based therapies that have shown an increased survival after heart attack. Researchers conclude that underuse of evidence-based treatments and delayed reperfusion among women represent potential opportunities for reducing sex disparities in care and outcome after AMI.

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Quality of care measure for heart attack patients retired by CMS

Changes in practice guidelines for heart attack patients will lead to retirement of a CMS quality measure used under its hospital quality pay-for-reporting program. The change in reporting requirements on the retired measure, “Beta-blocker within 24 hours of hospital arrival for acute myocardial infarction patients,” occurs as of April 1, 2009, with subsequent changes on the HospitalCompare
Web site.

The change in the CMS measure, referred to as performance measure AMI-6, is the result of data on heart attack patients without beta-blocker contraindications who received a beta blocker within 24 hours after hospital arrival. The retirement of this measure is a result of changes in practice guidelines for heart attack patients based on new data regarding the importance of treating acute myocardial infarction (AMI) patients with beta-blocker therapy. The “Clopidogrel and Metoprolol in Myocardial Infarction Trial” (COMMIT) found that while beta-blockers
reduced the risk of death from arrhythmia and re-infarction, they also could significantly
increase the risk of cardiogenic shock within the first 24 hours of admission in some patients with a previous history of heart failure. As a result, the new American College of Cardiology/American Heart Association (ACC/AHA) guideline recommends that early intravenous beta blockers should specifically be avoided in some patient populations. Increased decision-making complexity makes data on a revised AMI-6 measure very difficult to collect, since there are many clinical circumstances where beta blockers are recommended therapy for patients with both acute and chronic coronary artery disease, including early use in some patients with AMI.

CMS collects 30 quality measures as part of its Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program, which requires most hospitals to submit data for specific quality measures for health conditions common among people with Medicare, and which typically result in hospitalization. The hospital quality of care information gathered through the initiative is available to consumers on the
Hospital Compare Web site.

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Joint Commission standards become more prescriptive to meet CMS requirements: good news and bad news

Eighty-three percent of hospitals participating in Medicare use Joint Commission (TJC) surveys to obtain what is known as “deemed status,” enabling them to receive Centers for Medicare & Medicaid Services (CMS) reimbursement without a CMS inspection. However, as of January 1, 2009, CMS required TJC to incorporate CMS language into some standards, challenging accredited hospitals with an increased prescriptiveness of standards in order to maintain deemed status. TJC
has provided a cross walk of the old standards with the new CMS-adapted standards.

The recent change, according to TJC, is in preparation for the submission of its application to the CMS for continued hospital deeming authority. Compliance with any requirements that are completely new will be reviewed by surveyors beginning January 1, 2009, but will not be scored until July 2009. The changes require a grasp of CMS’ interpretive guidelines of the actual CMS Conditions of Participation (CoP) standards.

Impact for hospitals
Prior to January, TJC standards typically stated a simple desired outcome and permitted some flexibility in how the hospital chose to achieve the goal. The revised standard in many cases now requires specific elements in the process to achieve the goal.

Infection control impact
For example, one current infection control standard states that the organization “identifies the individual(s) responsible for the infection prevention and control program.” The CMS standard language from Medicare’s CoP adds much more specificity. The good news is that it will ensure that experts in infection prevention guide the program. However, the CMS standard states that this individual is also responsible for “maintaining a log of incidents related to infections and communicable diseases.” This prescriptive statement appears to take a step backward to a prescriptive requirement of “line listings” and “paper logs.”

Fortunately, recent updates of the CMS IC Interpretive Guidelines, interpret this “log” rule more broadly. According to CMS, the log may be a paper log, various data manuals or provided in electronic format. The CMS intent is that “regardless of the format, the information must at all time be safe/secure from unauthorized access, up-to-date, and accessible and readily retrievable by authorized personnel.” Compliance with these CMS changes requires familiarity with the CMS standards and interpretive guidelines.

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Recent rise in “apology” laws in 36 states protect physicians from malpractice

Thirty-six states (72 percent) have enacted apology laws that protect physicians in varying degrees from malpractice during voluntary disclosure. Most laws have passed in the past three years. Increased physician education is needed to encourage physicians to achieve increased comfort in apologizing to patients.

A new study reviews the disclosure statutes from all 50 states to determine the current legal climate regarding physician apologies. Previous studies demonstrate that patients want to be made aware of errors and receive an apology from their physician. Such communications improve patient satisfaction and trust. Physicians, however, are often still reluctant to disclose errors.

Physician disclosure of errors and apologies to patients can be used against them in malpractice trials, causing reluctance to disclose errors. In an effort to increase disclosure and apology, some states are enacting apology laws.
However, most physicians are unfamiliar with the apology laws in their states.

  • Thirty-six states (72 percent) have enacted apology laws protecting some form of voluntary disclosure.
  • Twenty-eight of these states have a “sympathy only” type law that protects physician expressions of sympathy from being used against them in a malpractice case, but not admissions of error.
  • The remaining eight states have apology laws that protect both expressions of sympathy and admission of error by physicians from being used in litigation.
  • There are still important differences; for example, in one state, only oral – not written – physician statements are protected.
  • Four states have mandatory disclosure laws that protect against the disclosure being used in a malpractice case.

Most of these laws were enacted only recently – within
the past three years – which may contribute to physicians lack of awareness. The impact of the apology laws on patient-physician communication of errors and whether disclosure reduces errors are unknown. Physicians will only begin increasing disclosure if they are familiar with their legal protection. Authors note that individual states need to find ways to inform their physicians about existing apology laws. They see apology laws as potential opportunities for physicians to discuss difficult topics with patients.

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Safety Tools

Premier – Free audioconference on eliminating problem organisms; January 28

The “Essentials to eliminating bad bugs” is being present on January 28 by Robert A. Weinstein, MD, at 2-3 p.m. ET. Preventing healthcare-associated infection (HAI) has become a national priority, with implementation of major strategies to combat the issue. Dr. Weinstein, a national leader in HAI prevention efforts, will address the following: the clinical benefits of traditional infection prevention methods; alternative methods of preventing
HAIs; and the impact of recent guidelines and regulations on
HAIs. Dr. Weinstein is chairman, Department of Medicine, Stroger Hospital, chief operating officer of the outpatient Ruth M. Rothstein CORE Center for the Prevention, Care, and Research of Infectious Diseases, and professor of medicine at Rush University Medical College.
Registration is still open, and following the program, a live recording and handouts will be available at no charge through the Advisor Live Web site at

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U. Penn – Video promotes influenza vaccination; available on YouTube

An influenza immunization promotional video – “U Penn Fights the Flu: Baby Be Wise – Immunize!” starring the staff and employees of the hospital of the University of Pennsylvania is available on YouTube. According to the hospital, the use of the video has increased their influenza vaccination rates. They report having dispensed 40 percent more vaccine compared to this time last year. The video had been viewed over 2,300 times in one month.

See it at

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HHS – DHS pandemic flu updates; Report VI; state assessments; antiviral drug use and stockpiling

A number of useful HHS reports were released at the beginning of the year evaluating the past year and past administrations’ progress in several areas:

  • The sixth update (Report VI) from the Secretary of Health and Human Services (HHS) was published January 16 regarding the state of pandemic influenza preparedness in the United States. The update reviews the current progress and current status of preparedness.
  • Healthcare personnel (HCP) likely to be exposed to influenza during a pandemic should receive preventive doses of antiviral medications, according to HHS’ “Guidance on Antiviral Drug Use during an Influenza Pandemic." The document replaces the 2005 recommendations and provides guidance to planners on antiviral drug use strategies and the number of antiviral regimens that would be needed to support implementation.
  • A related guidance document – “Considerations for Antiviral Drug Stockpiling by Employers in Preparation for an Influenza Pandemic" – outlines considerations for antiviral medication stockpiling. It provides information to employers (both public and private sector) so that informed planning and implementation decisions on antiviral drug stockpiling for pandemic influenza can be made and, if drugs are stockpiled, to assure that they are maintained and used optimally.
    This guidance does not establish the requirement or expectation that all employers stockpile antiviral drugs.
  • HHS and the Department of Homeland Security (DHS) issued a joint report on each state’s individual
    readiness. A chart provides each state with an assessment for different aspects of preparedness.

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AHRQ English and Spanish brochure and video on safe use of blood thinners

An easy-to-understand
brochure and
video to help English and Spanish speaking patients know what to expect and watch out for while using blood thinners. The brochure “Blood Thinner Pills: Your Guide to Using Them Safely” (Pastillas que diluyen la sangre: Gu