Changes to Alarms Helps Reduce Noise Fatigue, Protect Patients

A new study aims to address reports of alarm fatigue, which have plagued nursing staff and contributed to negative health outcomes for patients, by determining variables that would safely reduce noncritical alarms on a general medical-surgical unit.

For the study, published in the Journal of Cardiovascular Nursing, Boston Medical Center reduced its weekly audible cardiac alarm rate by 89 percent, which increased the satisfaction rates of nurses and other staff, and their patients. Deborah A. Whalen led the study, which involved changing alarms for bradycardia, tachycardia, and heart rate limits to "crisis," FierceHealthcare reports.

Nursing staff who participated in the study had to view and act on the alarm each time it sounded, and self-resetting alarms were eliminated. The research team found that by eliminating alarms with self-reset capabilities, hospitals can significantly reduce the volume of calls without compromising patient safety.

The Joint Commission praised the Boston Medical Center study in a news release. The Commission previously issued a Sentinel Event Alert about alarm-related deaths and identified alarm safety as a 2014 National Patient Safety Goal. The Commission's two-phase National Patient Safety Goal aims to combat alarm fatigue, FierceHealthcare previously reported. The first phase, which began January 1, 2014 heightens awareness of the potential risks associated with clinical alarms and the second phase, which will begin January 1, 2016, will introduce requirements to mitigate those risks.

An INQRI-funded study found a unique way to use different sounds to reduce alarm fatigue and help keep patients safe. Led by Tracey Yap and Jay Kim the team used music to reduce the incidence of pressure ulcers. The study used music to cue patients in long-term care facilities to move in order to avoid getting pressure ulcers. The music also cued staff to help to move those patients who could not  move on their own. Dr. Yap blogged about the study and some unexpected results on the RWJF Human Capital blog.

Joint Commission Guidelines for Preventing Bloodstream Infections Emphasize Role of Nurses

Guidelines and a toolkit released this week by the Joint Commission highlight the key role nurses play in preventing central line-associated bloodstream infections (CLABSIs). CLABSIs are among the most deadly and costly hospital-associated infections, accounting for 31,000 deaths annually and costing the health system an estimated $9 billion. Studies funded by INQRI revealed that nurses can play a key role in preventing these infections.

Patricia Stone, PhD, MPH, RN, FAAN, a principal investigator for an INQRI-funded study on the impact of nurse staffing, skill mix, and experience on quality and costs in long-term care, contributed to the new guidelines.  Stone is the Centennial Professor of Health Policy in Nursing at Columbia University School of Nursing.

An INQRI-funded study published last year in Critical Care Medicine found that a nurse-led intervention combining a “bundle” of evidence-based practices with a comprehensive safety program dramatically reduced the mean rate of infections. The study was conducted by David Thompson, DSNc, MSN, RN, and Jill Marsteller PhD, MPP, associate professors at Johns Hopkins University in the School of Medicine and Bloomberg School of Public Health, respectively, and by J. Bryan Sexton, PhD, now at the Duke University Health System Patient Safety Center.

“It’s important to note that this was a nurse-led intervention,” Marsteller said. “The units’ success in reducing infections not only demonstrates the effectiveness of the intervention, but also confirms that nurses can have and should play a central role in quality improvement interventions.”

Transitions of Care: The need for collaboration across entire care continuum

The Joint Commission enterprise is in the first year of a three-year initiative to define methods to achieve improvement in the effectiveness of the transitions of patients between health care organizations and provide for the continuation of safe, quality care for patients in all settings. All three components of The Joint Commission enterprise will offer various interventions and resources that are designed collectively to improve transitions of care. The interventions will apply to six accreditation programs: hospital, critical access hospital, behavioral health care, home care, nursing and rehabilitation center, and ambulatory care. As part of this work, The Joint Commission has defined a “transition of care” as the movement of a patient from one health care provider or setting to another.

Developing ways to assure safe transitions of care requires collaboration among providers all along the care continuum. The Joint Commission recently organized a series of learning visits and focus groups to better understand the progress providers are making and the challenges they still face.

The brief identifies that organizations in all settings must establish seven “foundations” to assure safe transitions from one health care setting to another:
 • Leadership support
• Multidisciplinary collaboration
• Early identification of patients/clients at risk
• Transitional planning
• Medication management
• Patient and family action/engagement
• Transfer of information

INQRI grantees have contributed much to this field of research. Led by Barbara Roberge and Ken Minaker, a team at Massachusetts General Hospital tested the impact of identifying and communicating a pre-hospital preventive patient risk profile on nurse-sensitive outcomes for hospitalized older adults. Researchers at Marquette University, led by Marianne Weiss and Olga Yakusheva, studied what hospital-based nurses do to influence outcomes after a patient is discharged from a hospital. They identified the contributions that nursing staff make to the quality of discharge teaching and the impact of that teaching on patient outcomes, readiness and readmission rates of patients who are discharged home. Cynthia Corbett, Stephen Setter and their team at Washington State University used information technology to help home care nurses more efficiently and effectively identify and resolve medication discrepancies as patients transitioned from the hospital to home. Researchers at the University Pennsylvania, led by Nancy Hanrahan and Phyllis Solomon, are working on a translation of the Transitional Care Model for use with people with serious mental illness as they transition in an out of psychiatric hospitals and emergency services.

Click here for the second issue of "Transitions of Care: The need for collaboration across entire care continuum" from the Joint Commission. 

Click here to access research from INQRI grantees related to transitions of care

Hospitals' Approach to Quality Care

Kaiser Health News recently reported that the Joint Commission has released their annual report announcing which hospitals have excelled at meeting basic requirements for treating common illnesses.  The report recognizes the accomplishments of 620 hospitals, with 18% of them listed as "top performers," having followed recommended protocols at least 95% of the time.

This announcement comes at the same time that USA Today has published an interview with

Marty Makary, a surgeon at Johns Hopkins Hospital.  Dr. Makaray has recently written a new book, Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care, in which he suggests that hospitals aren't forthcoming about medical errors, readmission rates and other quality issues.

What do you think about these two sides of the quality discussion?  Comment below.

Click here to read the story about the Joint Commission's announcement.
Click here to read the interview with Dr. Makaray.

Joint Commission: New Advanced Certification for Palliative Care

The Joint Commission has announced that their new Advanced Certification Program for Palliative Care will be available as of September 1, 2011.  This program was created to "recognize hospitals that demonstrate exceptional patient and family-centered care in order to optimize the quality of life for patients with life-limiting illnesses."

The dependable delivery of high quality palliative care is incredibly important.  In fact, INQRI researchers at Oregon Health Science University are currently examining nursing's contributions to quality palliative care.  Very little is known about the relationships between quality palliative nursing care delivered in intensive care units (ICUs) and patient and family outcomes or how to measure and improve these outcomes. Led by Lissi Hansen, Ph.D., R.N. and Richard Mularski, M.D., an interdisciplinary team of researchers will identify the role that nurses play in the delivery of high quality palliative care provided both to patients and their families.

Learn more about the Joint Commission's Advanced Certification Program for Palliative Care.

Joint Commission Annual Report Shows Big Improvements for Hospital Care

The Joint Commission released its annual report last week which showed great improvements in the quality of care being delivered to patients and significant progress in consistently using evidence-based treatments.

“It is very encouraging that this year’s report shows high rates of performance on these critical process measures and high levels of consistent excellence among hospitals on many measures,” said Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint Commission. “Hospitals devote enormous resources and energy to using these performance measures to drive improvement in their clinical processes. This report demonstrates that these efforts are resulting in consistently improving patient care in America’s hospitals.”

Notable Improvements:

• In 2002, hospitals achieved 81.8 percent composite performance on 957,000 opportunities to perform care processes related to accountability measures. In 2009, hospitals achieved 95.4 percent composite performance on 12.5 million opportunities – an improvement of 13.6 percentage points. 
• Hospital performance on measures of quality relating to inpatient care for childhood asthma has increased dramatically in the two years since being introduced. The 2009 children’s asthma care result is 88.1 percent, up from 70.7 in 2007.
• The 2009 pneumonia care result is 92.9 percent, up from 72.4 percent in 2002 – an improvement of 20.5 percentage points.
• The surgical care result improved to 95.8 percent in 2009 from 77.4 percent in 2004.

Areas for Improvement:

• Only 55.2 percent of hospitals achieved 90 percent compliance or better in providing fibrinolytic therapy within 30 minutes of arrival to heart attack patients. 
• Only 67.5 percent of hospitals achieved 90 percent compliance or better in providing antibiotics to intensive care unit pneumonia patients within 24 hours of arrival.

Click here to download the report, Improving America’s Hospitals:  The Joint Commission’s Report on Quality and Safety 2010.

Click here to read the press release.

Joint Commission: Updated List of Top 10 Sentinel Events

Last week, The Joint Commission released their newest figures for sentinel event reporting. Their organization has reviewed 6,923 sentinel events since implementation of the sentinel event database in January, 1995.

The top ten list of reported sentinel events, in order of most reported since 1995, are:

• Wrong-site surgery
• Suicide
• Operative/post-operative complication
• Delay in treatment
• Medication error
• Patient fall
• Unintended retention of foreign body
• Assault, rape or homicide
• Perinatal death or loss of function
• Patient death or injury in restraints

For more information, please read the newest edition of The Joint Commission Online.

Evidence-based treatments have improved care quality, Joint Commission says

This week, Victoria Forlini wrote a piece for FierceHealthcare, explaining the way that the Joint Commission says that evidence-based practices improve patient care.

Hospitals are striving for--and hitting--many outcome improvements, the Joint Commission reports. National improvement on 12 outcomes, reflecting best evidence-based treatments for heart attacks, heart failure and pneumonia, rose between 4.9 percent and 58.8 percent between 2002 to 2008, according to Improving America's Hospitals: The Joint Commission's Report on Quality and Safety 2009.

"In addition to saving lives and improving health, improved quality reduces healthcare costs by eliminating preventable complications," said Mark Chassin, the accreditor's president. Hospital improvements included:

• Overall heart failure care results improving so that evidence-based treatments were given 91.6 percent of the time, up from 59.7 percent in 2002.
• Evidence-based treatments being given 92.9 percent of the time in pneumonia cases in 2008, up from 72.3 percent in 2002.

The report presents scientific evidence of improvement and how it relates to common medical conditions and procedures. The Joint Commission measures 31 outcomes, including several for children's care. More than 3,000 Joint Commission-accredited hospitals contributed data.

For more information, check out this press release.

Joint Commission Sentinel Event Alert - "Leadership Committed to Safety"

Issue 43, August 27, 2009

In a Sentinel Event Alert released today, the Joint Commission urges health care leaders to take a stronger role in preventing medical errors. As they say, "Leadership is a critical function in promoting high quality, safe health care. In health care organizations, leadership is provided by the governing body, the chief executive and senior managers, and the leaders of the clinical staff. When a sentinel event occurs in a health care organization, inadequate or ineffective leadership is often one of the contributing factors."

To read the alert, click here.

Nursing Care Quality in Acute Care Hospitals: New Linkages to Patient Outcomes

Dr. Arlyss Anderson Rothman and Dr. R. Adams Dudley present their INQRI project: "Nursing Care Quality in Acute Care Hospitals: New Linkages to Patient Outcomes" at the 4th Annual INQRI meeting.





Project Description: Increased public reporting of hospital performance and the emergence of hospital pay-for-performance initiatives provide new impetus to defining and maximizing all aspects of hospital care. This interdisciplinary team has examined whether increases in nurse staffing and skill mix improve hospital performance on a subset of JCAHO core measures, enhance patient perceptions of nursing performance, and improve overall nursing performance as measured by composite indicators that capture patients' perceptions of care and other selected outcomes of care such as complication rates.

Measuring How Nurses Contribute to Patient Safety and Health Care Quality

Update from RWJF on the Joint Commission's Work

In 2007 and 2008, the Joint Commission tested specifications for 15 "nursing sensitive" performance measures in 49 acute-care hospitals across the United States. The goal was to determine the reliability and feasibility of these measures for assessing and improving the ways nurses contribute to patient safety and health care quality.

Key Findings

• All 15 performance measures, individually and as a set, were effective in improving patient care, and hospitals could feasibly collect data on them all.
• Specifications for some of the measures needed further refinement and clarification. For example, hospitals are not consistent in the way they classify injuries from falls or how they measure the onset of infection.

Key Recommendations

• Performance measures can be strengthened and greater uniformity achieved across hospitals by clarifying the definitions of what is being assessed, refining data-collection approaches and collaborating with others to align terminology.

Funding

The Robert Wood Johnson Foundation (RWJF) supported this unsolicited project from January 2007 to December 2008 with a grant of $299,490.

(c) RWJF, 2009

INQRI's Work on the NQF-15

In INQRI's first year, our call for proposals focused on measurement, with special attention paid to the 15 nursing sensitive measures endorsed by the National Quality Forum. Several INQRI teams have examined these measures.

• Developing and Testing Nursing Quality Measures with Consumers and Patients
  Baruch College
  Led by scholars in health policy, public policy and nursing, the goal of this project was to develop nursing-sensitive quality measures that patients and other decision-makers will find important and useful. In addition to checking out, with recent patients, how they respond to existing nursing quality measures, the project also worked on new measures in an area that both patients and professionals often point to as critical: the coordination of their care. The Baruch team recently held a briefing in Washington, DC to discuss their findings. Click here for more information.

• Quality Care on Acute Inpatient Units
  The University of California, San Francisco
  The goal of this project led by a nurse scholar was to test the power of the National Quality Forum-endorsed measures to advance quality nursing research and design, test other measures as potential indicators of nursing quality, and determine the impact of nurse staffing on these indicators in specific types of patient care units.

• Validating NQF Nursing-Sensitive Performance Measures
  University of Pennsylvania
  Led by a nurse scholar, the goal of this team was to analyze and validate measures from the National Quality Forum nursing-sensitive measure set using data collected from approximately 600 acute care hospitals in three states, as well as Medicare hospital performance measures, in 2005-2006.

• Lessons Learned from State Roll-Out of the NQF Nursing Sensitive Measures
  Massachusetts Hospital Research and Education Association, Inc.
  Led by a team of health services researchers, the goal of this team was to evaluate two statewide implementations of the NQF Nursing-Sensitive Measures created to provide hospitals and the public with comparative measures of nursing quality. The two statewide implementations are a voluntary effort in Massachusetts hospitals and a government mandated effort in Maine hospitals.

• Improving the NQF Failure to Rescue Metric
  Mayo Clinic
  Led by scholars in nursing and health services research and informatics, the goal of this team was to refine one of the most controversial measures of nursing-sensitive quality of care: failure to rescue.

Study Finds Failure to Include Nurses in Process of Admitting Errors to Patients, Families

Need for team approach to disclosing medical mistakes shown


OAKBROOK TERRACE, Ill., Jan. 7 /PRNewswire-USNewswire/ -- Even though nurses routinely disclose nursing errors to their patients, a new study published in the January 2009 issue of The Joint Commission Journal on Quality and Patient Safety shows that nurses often are not included when physicians tell patients about more serious mistakes.

Nurses play such a hands-on role at the bedside of their patients that the study's authors conclude that the absence of nurses from discussions to plan for or disclose errors can diminish the quality of the disclosure experienced by the patient or their family. For example, when nurses are not involved in the planning for disclosure, they may seem evasive in answering patients' questions or stall by encouraging families to write down their questions or set up a meeting with doctors. The study, "Disclosing Errors to Patients: Perspectives of Registered Nurses," systematically explores nurses' attitudes toward and experiences with error disclosure to patients.

"Improving the quality of error disclosure to patients is a top priority in health care," says Sarah E. Shannon, Ph.D., R.N., vice associate dean for academic services in the University of Washington School of Nursing, associate professor of behavioral nursing and health systems at the University of Washington, and lead author of the study. "Error disclosure needs to be a team sport. This means quickly sharing information among the team about the error: what happened, why it occurred, what is being done to mitigate potential harm and prevent future errors, and what the patient has been told, will be told, and when."

The study of nearly 100 nurses reports that nurses say they talk with patients about errors that are within their control, such as late or missed medications or treatments. But nurses in the study said they hesitate to independently disclose errors that involved serious harm or actions of other members of the health care team. In these situations, the nurses said the responsibility fell to the patient's attending physician. The nurses said, however, that they would like a role in the disclosure process as a way to both communicate directly with the patient about nursing's role in the event and to avoid being blamed for the event. The study also found low awareness of institutional disclosure policies.

The study's authors -- three nurses and one physician -- conclude that a team disclosure process is best and recommend that health care organizations establish policies that permit nurses and other caregivers to participate in and raise concerns about the disclosure process. The authors point out that a lack of collaboration and communication in the disclosure process may lead to moral distress, increased job dissatisfaction and job turnover among nurses. In addition, the authors suggest that nurse managers should receive training on how to tell patients and families that a mistake has occurred.

This study was supported by the Greenwall Faculty Scholars Program and the Agency for Healthcare Research and Quality.

The Joint Commission Journal on Quality and Patient Safety, published monthly by Joint Commission Resources (JCR), features peer-reviewed research and case studies on improving quality and safety in health care organizations. Click here to order this article in the January 2009 issue. To subscribe to The Joint Commission Journal on Quality and Patient Safety, please call JCR Customer Service toll-free at 800-746-6578, or visit www.jcrinc.com.

Note: No statement in The Joint Commission Journal on Quality and Patient Safety should be construed as an official position of The Joint Commission or Joint Commission Resources, Inc. (JCR) unless otherwise stated. In particular, there has been no official review with regard to matters of standards compliance.

Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from The Joint Commission. JCR educational programs and publications support the accreditation activities of The Joint Commission, but are separate functions. Attendees at JCR educational programs and purchasers of JCR publications receive no special consideration or treatment in, or confidential information about, the accreditation process. Learn more about Joint Commission Resources at www.jcrinc.com.