Study Finds Patients Admitted to Hospitals on Weekends are at Greater Risk for “Never Events”

Falls and infections are more common among patients admitted to hospitals on weekends, according to a new study conducted by researchers at the University of Southern California and published in the British Medical Journal. The research team analyzed data from more than 350 million hospital admissions from 2002 to 2010. Even though the vast majority (81 percent) of the admissions were on weekdays, there were more complications in patients admitted on weekends (5.7 percent of complications compared with 3.7 percent for patients admitted on week days). The most common kinds of hospital-acquired infections among patients admitted on weekends were pressure ulcers and catheter-associated urinary tract infections.

The research team could not determine whether the higher proportion of complications were due to lower staffing rates on weekends or patients with more urgent treatment needs being admitted during those times.

These findings are consistent with a body of research showing that patients admitted during off-peak hours (like evenings and weekends) experienced more health problems, and were less likely to survive in-hospital cardiac arrest, and that newborns born on weekends were more likely to die than babies born during the week.

An INQRI-funded study led by Patti Hamilton and Gretchen Gemeinhardt found that nurses’ “off-peak” work environments play a significant role in the increased patient mortality during these time periods.  In particular, the researchers found that nurses who participate in hospital plans that allow them to work only weekend shifts for full pay and benefits are less familiar with their institutions’ initiatives and priorities that govern policies, procedures, principles and regulations for providing care, because those initiatives and priorities are stressed more during peak periods.

Nurses Working in Wound Care Produce Innovative Research, Best Practices

Nurses working in wound care often become innovators, devising new research, treatments, and best practices for the field, in their ongoing daily efforts to provide the best care for their patients, according to a Nurse.com article.

The article cites the work of Janice Beitz, director of the new Wound, Ostomy, and Continence Nurses Society program at Rutgers School of Nursing, who along with her colleagues has been creating algorithms for nursing care, including the prevention of pressure ulcers. They developed a one-page, 26-step visual algorithm to help nurses understand and prevent pressure ulcer formation.

Development of such best practice documents is not uncommon in the fields of wound and ostomy care, since best practices learned while treating patients regularly overlap with ongoing research, Beitz told Nurse.com.

“The great strength of this is that it captures much research evidence on various patient risk factors that are routinely collected and modifiable, and places them in one succinct visual aid,” Beitz said.

The INQRI funded project “Interdisciplinary Mobility Team Approach to Reduction of Facility-Acquired Pressure Ulcers” developed a sustainable, system-wide program for pressure ulcer prevention that enhances mobility of long-term care (LTC) residents. The primary goal, under nursing's leadership, was to reduce LTC facility-acquired pressure ulcer incidence by 50 percent using a cost-effective innovative program to increase resident active or passive movement. The team, which developed and implemented a program that involved using musical cues to remind residents to move or staff to help residents move, was led by Tracey Yap, a nurse researcher, and  Jay Kim, an engineer.

Patient Sensor Improves Pressure-Ulcer Prevention Compliance

A three month study of a wearable ulcer prevention technology showed that it was effective in preventing the occurrence of pressure ulcers by increasing adherence to established protocols, according to Leaf Healthcare, Inc., the company that developed the device.

The Leaf system is a wearable sensor that electronically monitors a patient's position and movements and then wirelessly communicates the data collected to central monitoring stations or mobile devices so that nurses and other caregivers can check on patient position and movement. The Leaf sensor also will sound alerts when necessary to ensure that all patients are repositioned according to established turning schedules, to reduce the incidence of pressure ulcers.

Results of the clinical trial were presented this month at the American Nurses Credential Center National Magnet Conference in Dallas. The trial found that use of the monitoring device increased compliance with hospital turn protocols from a baseline of 64 percent at the start of the trial, to 98 percent after the system was implemented.

The INQRI funded project “Interdisciplinary Mobility Team Approach to Reduction of Facility-Acquired Pressure Ulcers” developed a sustainable, system-wide program for pressure ulcer prevention that enhances mobility of long-term care (LTC) residents. The primary goal, under nursing's leadership, was to reduce LTC facility-acquired pressure ulcer incidence by 50 percent using a cost-effective innovative program to increase resident active or passive movement. The team, which developed and implemented a program that involved using musical cues to remind residents to move or staff to help residents move, was led by Tracey Yap, a nurse researcher, and Jay Kim, an engineer.

Rates of Infections, Falls, Pressure Ulcers, Other Hospital Acquired Conditions Drop

Hospitals saw a nine percent decrease in harms experienced by patients from 2010 to 2012, according to a new report from the U.S. Health and Human Services Department (HHS). There were reductions in adverse drug events, falls, infections, pressure ulcers, and other areas, estimated to have prevented nearly 15,000 deaths and 560,000 cases of patients being harmed in hospitals.

The HHS report also shows that the incidences of hospital-acquired infections dropped from 145 per 1,000 discharges in 2010 to 132 per 1,000 discharges in 2012, resulting in 560,000 few incidents in two years, FierceHealthcare reports. Falls and trauma declined 14.7 percent and pressure ulcers fell 25.2 percent.

In addition to lives saved, the reduction in harm to patients saved $4.1 billion according to the report, which credits factors such as diverse public-private partnerships, active engagement by patients and families, and new tools provided by the Affordable Care Act (ACA), with the improvement. In 2011, under the ACA, HHS launched the Partnership for Patients, a nationwide public private initiative to keep patients from being harmed in hospitals and heal without complication. The Partnership shares best practices with more than 3,700 hospitals enrolled in the initiative.

INQRI grantees have conducted a number of studies into how nurses can lead efforts to reduce medical errors and patient harm, including:

• Reducing central line-associated bloodstream infections was the focus of an INQRI-funded study led by David Thompson and Jill Marsteller. Their study, involving 45 intensive care units in 35 hospitals in 12 states, tested a nurse-led intervention that used a bundle of evidence-based practices to reduce infections. The intervention was successful in significantly reducing infections and also highlighted the importance of promoting a culture of safety and communication. It also established that nurses should play a central role in quality improvement interventions.
• The INQRI funded project “Interdisciplinary Mobility Team Approach to Reduction of Facility-Acquired Pressure Ulcers” developed a sustainable, system-wide program for pressure ulcer prevention that enhances mobility of long-term care (LTC) residents. The primary goal, under nursing's leadership, was to reduce LTC facility-acquired pressure ulcer incidence by 50 percent using a cost-effective innovative program to increase resident active or passive movement. The team, which developed and implemented a program that involved using musical cues to remind residents to move or staff to help residents move, was led by Tracey Yap, a nurse researcher, and Jay Kim, an engineer.
•  INQRI grantee Patti Dykes worked with a team to develop the Falls: Tailoring Interventions for Patient Safety (Falls TIPS) online tool kit to educate patients and families about how they can work with nurses and other providers to prevent falls. The toolkit was developed based on the Fall TIP: Validation of Icons to Communicate Fall Risk Status and Tailored Interventions to Prevent Patient Falls study, which involved developing and validating a set of icons designed to communicate fall risk status, and developing tailored interventions to prevent patient falls in hospitals.

The full HHS report is available here.

Evidence to Improve the Quality of Care

This post originally appeared on the Robert Wood Johnson Foundation (RWJF) Human Capital Blog.

Richard Kronick, Ph.D., was named director of the Agency for Healthcare Research and Quality (AHRQ) in August 2013. Dr. Kronick is a health policy researcher with a background in academia as well as in Federal and State government.  He received an RWJF Investigator Award in Health Policy Research in 1998.

Human Capital Blog (HCB): Congratulations on your new position at AHRQ. This is an exciting time for health care. What do you see as AHRQ’s place in the U.S. health care universe?

Richard Kronick: Thank you! You’re right—this is an exciting time.

We have an almost $3 trillion health care system. We pour tremendous resources into the delivery of medical care—but comparatively little effort into trying to understand how health care can be delivered more safely, with higher quality, and be more accessible and affordable. AHRQ’s role is to produce evidence that can be used to make health care safer, higher quality, more accessible, equitable, and affordable, and to work with the U.S. Department of Health and Human Services (HHS) and other partners to make sure that the evidence is understood and used.

HCB: What is your agenda and what are your priorities for AHRQ?

Kronick: We have four priorities. The first is dissemination and implementation of patient-centered outcomes research. One way we’ll be doing this is to support small- and medium-sized primary care practices to help build their ability to use PCOR findings. In particular, we want to support practices in improving their patients’ outcomes on cardiovascular risk factors, the so-called ABCS (aspirin, blood pressure, cholesterol, and smoking), and more broadly to help practices adopt PCOR findings as they emerge. In addition, we are interested in knowing if and how this type of support can help practices achieve those goals so future Agency PCOR dissemination initiatives might draw on the lessons learned.

The second priority is to produce evidence that will make health care safer. AHRQ’s work has already had a substantial impact here. For instance, in one project, our work has contributed to an approximately 40 percent reduction in central line-associated bloodstream infections in a broad set of hospitals. The same intervention has led to an approximately 20 percent reduction in catheter-associated urinary tract infections so far in the project, although these are preliminary numbers. We will be extending this work to surgical site infections and ventilator acquired pneumonia, as well as working on reducing harm from other adverse events—particularly reducing falls, pressure ulcers, and harms from obstetric care.

Our third priority is to produce evidence to make health care more accessible. Chiefly we will do this by evaluating the effects of the Medicaid and marketplace coverage expansions under the Affordable Care Act, with a focus on producing the evidence that decision makers will need to increase access in the future. 

Our fourth priority is to produce evidence that will increase the affordability of health care. One way we will do this is by working with states to increase the transparency of health care prices—to improve data, measures, and public reporting strategies so consumers can understand the price of services as well as their quality.  We will also work on producing information to compare the resources and quality of care produced by health care systems within the United States.   

HCB: How would you characterize the quality of care in the United States today?

Kronick: I would characterize it as uneven. In some areas we do very well, but in some we do not. Only about 50 percent of patients with high blood pressure have it controlled, and many people with high cholesterol are not working with members of their health care team on making progress. There’s too much variation, across regions and across providers, without adequate effort to understand the effects of different methods of delivering care on health outcomes. 

HCB: What are some of the barriers to improving quality? How can AHRQ help us overcome these barriers?

Kronick: The first barrier is access. There are millions of people who currently don’t have health insurance—and the evidence is clear that they receive lower quality care than those who do have insurance.

And, of course, there are tremendous disparities in health care quality by race, ethnicity, and socioeconomic status, as AHRQ documents each year in our National Healthcare Quality Report and National Healthcare Disparities Report.

A third barrier is that our incentives for providing high-quality care aren’t very mature yet. Although we’ve learned a lot recently, it’s still very difficult to measure what it is we want providers to do. We struggle to develop accountability mechanisms that will reward quality.

I should point out that many of these quality problems are endemic throughout the world. They’re not unique to the United States—but some of them are magnified in the United States. This is particularly true with fragmentation. In many places in the United States, providers don’t talk much with each other, care is not well coordinated, and patients can fall through the cracks.

The key to overcoming these barriers is to understand how access to the system can be improved. That’s one thing that AHRQ can do: we can produce evidence to help providers, patients, and policy makers understand how to improve access to care.

HCB: You won a Robert Wood Johnson Foundation Investigator Award in Health Policy Research in 1998, and were a professor at the University of California at San Diego. In academia, you focused on whether and how markets can be made to work well in health care, particularly for vulnerable populations. Will you tackle this issue at AHRQ?

Kronick: Yes. And, as an aside, the RWJF award was among very important opportunities for me to expand my thinking on these issues.  But, our health care system remains a market-based system, and that’s not changing. So the challenge we face is to make the market work as well as it can for as many Americans as possible, including the ones who have limited access.

That’s where our third and fourth priorities—concerning access and affordability—will be important. Understanding the effects of coverage expansion means paying attention to the effects of competition between insurers and between providers at the local level. At AHRQ we will be very focused on producing evidence needed by the Secretary of HHS and by members of Congress going forward.

For instance, with the coverage expansion, how much will utilization increase? I’m pretty confident utilization will increase, but less confident by how much. When the State of Oregon embarked on its coverage expansion, the thinking was that use of outpatient services might increase by 80 percent or even double, but the reality was closer to 35 percent. These are the things we need to understand on a national scale as we increase coverage, because the Affordable Care Act won’t be static. We’ve already seen some changes in it, and I anticipate we may see more changes as we understand its effects more fully. This is the kind of information that the Secretary and the Congress will demand.

HCB: Is there upcoming AHRQ research that you expect will have a significant impact?

Kronick: We do have some research that should get some well-deserved attention. For instance, we will have a study coming out early in 2014 about the effect of patient safety improvements in reducing adverse events in treatment of certain conditions.

We’ll also release some work on CUSP for catheter-associated urinary tract infections. CUSP has been a very important program, and we are looking at ways to extend it beyond healthcare-associated infections to other patient safety problems.

Indiana Program Illustrates Potential of Nurse-Led Initiatives

A series of nurse-led initiatives in Indiana improved patient outcomes and is projected to save health care organizations in the state more than $5.2 million. These results demonstrate the importance of increasing nurses’ leadership opportunities, a key recommendation of the Institute of Medicine’s (IOM) landmark “Future of Nursing” report.

The American Association of Critical-Care Nurses (AACN) launched the Clinical Scene Investigator (CSI) Academy last year as a team-oriented and hands-on educational experience that placed nurses as clinician leaders. The nurses led initiatives and generated quantifiable improvements in the quality of patient care and hospital finances. Nurse-led initiatives studied in the program helped to:

• Improve patient satisfaction by as much as 20 percent;
• Reduce stays in the pediatric intensive care unit (ICU) by 0.5 days;
• Cut incidences of patient falls and hospital-acquired device-related nose and mouth pressure ulcers by more than 50 percent;
• Decrease overall pressure ulcers by more than 60 percent; and
• Drop mechanical ventilation days for ICU patients by 0.44 days.

Forty-two hospitals spanning six U.S. regions are participating in the preliminary national program rollout. The program continues to run at hospitals in Massachusetts, New York, North Carolina, Pennsylvania, and Texas. Ongoing projects include preventing ventilator-associated pneumonia, catheter-associated urinary tract infections, central line-associated bloodstream infections, pressure ulcers, falls, extubation, and improving communication and teamwork.

Media coverage of the AACN findings included Infection Control Today, Nurse.com and Advanced Healthcare Network for Nurses.

INQRI-funded research has focused on nurse-led initiatives in many of these areas,  including patient falls, central line-associated bloodstream infections and pressure ulcers.

Preventing Pressure Ulcers is the New Priority

Preventing pressure ulcers, rather than dealing with them as a “normal complication” for sick patients, is now common practice in many health facilities, according to an article in HealthLeaders.

One such facility, Crouse Hospital in Syracuse, N.Y., took action against pressure ulcers after it ranked higher than all but 105 other acute care hospitals reporting data on pressure ulcers in 2011, according to the article. Crouse launched numerous initiatives to reduce all of its preventable hospital-acquired conditions (HACs), including a control chart that tracks pressure ulcers at all severity stages by quarter. Teams with both nurse and physician educate frontline staff to be on the lookout for the earliest signs of skin redness and work with a team of wound ostomy nurses to evaluate patients who might be at higher risk.

In addition to the control chart, patient skin assessments are taken on a daily basis at Crouse and new beds designed to prevent pressure ulcers were purchased for the entire hospital. With these pre-emptive initiatives in place, Crouse's rates of severe decubitus ulcers are dropping, hospital officials told HealthLeaders.

The INQRI funded project “Interdisciplinary Mobility Team Approach to Reduction of Facility-Acquired Pressure Ulcers” developed a sustainable, system-wide program for pressure ulcer prevention that enhances mobility of long-term care (LTC) residents. The primary goal, under nursing's leadership, was to reduce LTC facility-acquired pressure ulcer incidence by 50 percent using a cost-effective innovative program to increase resident active or passive movement. The team, which developed and implemented a program that involved using musical cues to remind residents to move or staff to help residents move, was led by Tracey Yap, a nurse researcher, and  Jay Kim, an engineer.

Do Alarms Really Help Keep Patients Safe?

A recent article in the Washington Post by Lena H. Sun discusses the fact that with so much alarm-caused noise in a hospital (ventilators going off, infusion pumps beeping, blood pressure monitors emitting tone after tone), it's difficult to know when an alarm is indicating a serious problem or is just over-sensitive.  As a result, Sun writes that health care workers suffer "alarm fatigue" that leads them to turning down the volume on devices, turning them off, or just ignoring them.  These actions could definitely put patients at risk when an alarm does indicate an emergency.

An INQRI-funded study found one way to use different sounds to 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 couldn't move on their own. Dr. Yap blogged about the study and some unexpected results on the RWJF Human Capital blog for National Nurses Week.

But, what about those traditional alarms?  Do they keep patients safe or do we need to find another way? 

INQRI Team Publishes New Article on Intragroup Social Dynamics, Methods

INQRI grantee Tracey Yap and her team recently a new article in the Journal of Mixed Methods Research which discusses intragroup social dynamics and the work of their nursing and education research team as a community of research practice interested in organizational cultures and occupational subcultures. The dynamics were characterized by processes of socialization through reeducation and group social identity formation that allowed members to cross disciplines and produce interdisciplinary mixed methods combinations.

Yap's INQRI team developed a sustainable, system-wide program for pressure ulcer prevention that enhances mobility of long-term care (LTC) residents. The primary goal was to reduce LTC facility-acquired pressure ulcer incidence by 50% using a cost-effective innovative program to increase resident active or passive movement. The team was led by Yap, a nurse researcher, and Jay Kim, PhD, an engineer.

To learn more about their new article, please visit the journal's website.

Skilled Nursing and Post-Acute Care Has Improved in 9 of 10 Quality Areas

Last week, the Alliance for Quality Nursing Home Care and American Health Care Association, released their annual report that showed America's nursing facilities are continuing to build upon quality improvements reported in previous years, including measurable improvements in nine out of 10 quality measures since 2009. In the past year, nursing facilities have improved in all short-stay measures, which include patient delirium, pain and pressure ulcers, and a vast majority of long-stay measures including measureable improvements in activities of daily living (ADL), high-risk pressure ulcers, resident mobility and pain. It should also be noted that INQRI program leader, Mary D. Naylor, Ph.D., RN, FAAN, and her team at the University of Pennsylvania, greatly contributed to the findings in this report.

Click here to read the full press release.

Click here to access the full report (in e-book format).

Reduction of Pressure Ulcers Vitally Important for Patient Safety

Two hospitals in Wisconsin are reporting that some of their patients have contracted hospital-aquired bedsores at a rate of more than twice the national average, according to a recent article in the Green Bay Press-Gazette.

As writer Doug Schneider notes, "Bedsores — a common risk in patients confined to bed for long periods — are less common than they were a decade or two ago, but still can lead to complications ranging from painful infections to a type of cancer."

To address this need, INQRI researchers at the University of Cincinnati have developed a sustainable, system-wide program for pressure ulcer prevention that enhances mobility of long-term care (LTC) residents. The primary goal, under nursing's leadership, is to reduce LTC facility-acquired pressure ulcer incidence by 50% using a cost-effective innovative program to increase resident active or passive movement.  The team has received widespread recognition for their innovative program which involves playing music over a loudspeaker every two hours as a prompt for caregivers to make sure residents are repositioned.

Click here to learn more.

INQRI Grantees' Work Preventing Pressure Ulcers Recognized Nationwide

The INQRI program is proud to present news coverage detailing the superb work of one of our grantee teams. An interdisciplinary team led by Tracey Yap, Ph.D., a nurse researcher and Jay Kim, Ph.D., an engineer, at the University of Cincinnati has developed a sustainable, system-wide program for pressure ulcer prevention that enhances mobility of long-term care residents. This program entails playing music over a loudspeaker every two hours with the music prompting caregivers to stop when the music starts and make sure residents are repositioned.

Click here to access the Cincinnati Enquirer article

Click here to access the Courier-Journal article.

Click here to access the local CBS affiliate, WKRC, report.

Click here to view the Miami Herald's piece.

Click here to access more information about this and other INQRI teams' research.

"There is Absolutely Nothing as Painful as a Pressure Ulcer"

In a new article, "County Hospitals Reporting Fewer Medical Errors," the Ventura County Star reports on the reduction of infections in Ventura county, California.

Data from the California Department of Public Health shows the county's hospitals are reporting a decrease in adverse medical errors — “never events” ranging from surgery on the wrong body part to bed sores so deep that bone is damaged.  Although pressure ulcers or sores are not technically a “never event” (since some are unavoidable), Jim Conway, a patient safety expert who was quoted in the article believes that they belong on the list for two very simple reasons. 

“There is absolutely nothing as painful as a pressure ulcer and lots and lots of pressure ulcers are preventable,” he said.

An INQRI team at the University of Cincinnati agrees with him. Tracey Yap, Ph.D., a nurse researcher and Jay Kim, Ph.D., an engineer, are leading an interdisciplinary research team which will develop a sustainable, system-wide program for pressure ulcer prevention that enhances mobility of long-term care residents.  Check out a recent blog post by the Yap-Kim team, detailing the ways that teamwork can reduce the risk of infection.

Reducing Pressure Ulcers

Smart Card Revolutionizes Wound Care at NYU Langone

By Marcia Frellick

Medical teams using a cutting-edge communication and tracking tool in treating wound patients at NYU Langone Medical Center in New York City, now can put clinical data behind their success.

With the help of the National Institutes of Health, Harold Brem, MD, chief of the Division of Wound Healing & Regenerative Medicine in the Helen & Martin Kimmel Wound Center, found that what he developed as a “smart card” was able to prevent 93% of Stage II pressure ulcers, or bed sores, from progressing to Stages III and IV, even in the most critically ill, bed-bound hospitalized patients, and decreased limb amputation rates by 75%.

Click here to read the rest of the article.

***

An INQRI team at the University of Cincinnati is also working to prevent pressure ulcers. Tracey Yap, Ph.D., a nurse researcher and Jay Kim, Ph.D., an engineer, are leading an interdisciplinary research team which will develop a sustainable, system-wide program for pressure ulcer prevention that enhances mobility of long-term care residents. The primary goal, under nursing's leadership, is to reduce LTC facility-acquired pressure ulcer incidence by 50% using a cost-effective innovative program to increase resident active or passive movement. This team was funded by the INQRI progam this October and has just begun their work.