By Kelly M. Pyrek
This year's list of top patient safety concerns issued by the ECRI Institute provides healthcare professionals with the opportunity to evaluate the performance of their institutions relating to patient outcomes and establishing priorities for improvement. Let's examine in more detail a number of these issues.
Antimicrobial Stewardship in Physician Practices and Aging Services
“We need to combat antibiotic resistance before the situation gets worse,” says Stephanie Uses, PharmD, MJ, JD, patient safety analyst/consultant with ECRI Institute's Patient Safety Organization (PSO), noting that not many newly approved drugs are antibiotics. As antibiotic resistance increases, “your treatment options can be limited,” she explains.
Perhaps the most significant challenge facing antibiotic stewardship is managing patient expectations. Patients “expect an antibiotic to help them get better,” Uses says. Moreover, unnecessary antibiotic administration puts patients at unnecessary risk of adverse drug reaction. And the broadest concern, she notes, is that overprescribing leads to antimicrobial resistance.
William M. Marella, MBA, MMI, executive director of PSO operations and analytics at ECRI Institute, offers some advice for how infection preventionists (IPs) at all levels of experience can become more involved with their facility's antimicrobial stewardship program.
"For a novice IP in the hospital, the important things to focus on are: who to know, what to know, and what to do," says Marella. "For who to know: become friendly not only with hospital epidemiologists and the infectious disease physicians but also nursing, pharmacy, and prescribers. For what to know: antibiotic stewardship is all about using those medications at the right time, using the right one based on the infection and the organism, and using them for the right duration of treatment. Learn what pathogens are prevalent in your organization and how antibiograms are communicated to physicians and whether they are influencing prescribing. For what to do: A novice IP should use the CDC core elements checklist, the CMS infection control assessment tools and the Joint Commission standards to guide risk assessment, gap identification, goals, measuring and monitoring, and educating patients and families. Partner with the epidemiologist, and the infectious disease physician to provide information from surveillance data, culture reviews, outbreak investigation, and resistance trends to the stewardship team."
Marella continues, "In our Top 10 Patient Safety Concerns for 2019, we talked about extending antibiotic stewardship to ambulatory settings--physician practices and aging services. An IP working in a health system might start to look at antibiotic use in these settings, and for aging services, pharmacists are required to review patients’ charts. Some of the problems we see in these settings that an IP could help prevent are treating infections empirically and not modifying treatment based on culture results, and continuing antibiotics for too long. In any setting, it’s important to help patients understand when antibiotics aren’t appropriate and what they can do instead to help them feel better."
“Patients need to feel like they are being taken care of, even without a prescription for an antibiotic,” explains Sharon Bradley, RN, CIC, senior infection prevention and patient safety analyst/consultant, ECRI Institute. “Instead, give them a prescription for what to do, what to watch for. Follow up with them. Everyone needs to know their role: the physician needs to know what to do, and the patient needs to know what to do.” Organizations need to be able to implement and support antimicrobial stewardship programs.
Bradley recommends that the provider ask four questions to determine an antibiotic’s appropriateness for the patient being treated:
1. Does this patient have an infection that will respond to antibiotics?
2. If so, is the patient on the right antibiotic(s), dose, and route of administration?
3. Can a more targeted antibiotic be used to treat the infection (de-escalate)?
4. How long should the patient receive the antibiotic(s)?
“Antibiotic stewardship does not mean withholding necessary treatment,” Bradley adds. “But we have casually and cavalierly handed around the candy dish of antibiotics without a second thought as to how we may be harming our patients.”
Early Recognition of Sepsis Across the Continuum
Sepsis can be difficult to detect, but early recognition is vital because sepsis can quickly turn deadly. “We’re in a time rush,” says James Davis, MSN, RN, CCRN-K, HEM, CIC, FAPIC, senior infection prevention and patient safety analyst/consultant, ECRI Institute. The challenge is, “Can we intervene quicker to get patients the care they need to prevent shock and death?” Davis adds.
In recent years, sepsis has gained attention in acute-care. But as healthcare delivery changes, “we’re moving that early recognition of sepsis outside the hospital” as much as possible, says Davis. Timely screening and recognition of sepsis is a challenge for other settings as well, including aging services and physician practices.
Healthcare workers throughout the continuum of care must be able to recognize sepsis.
"IPs have mixed involvement in sepsis prevention programs," Marella says, but an IP could make a significant contribution to sepsis management, particularly with respect to evaluating how long invasive medical devices are used in treating the patient and removing them as early as possible. Outside the hospital, a physician practice or aging services provider doesn’t likely have an IP, but there should be someone there who is the owner of the sepsis recognition protocol. In these settings, it’s all about early recognition and transferring the patient to an appropriate level of care. As healthcare systems are consolidating and acquiring physician practices and long-term care sites, IPs have an opportunity to raise awareness, and educate staff in these settings on recognition and quick response."
The ECRI Institute report adds that healthcare personnel such as certified nursing assistants can be trained to use screening tools, and physician practices can screen for sepsis both in the exam room and on the phone. Simulation and skills practice can help workers recognize sepsis and communicate their concerns.
To facilitate timely diagnosis and management, the ECRI Institute report says that "healthcare organizations across the continuum should have protocols for response when sepsis is suspected, much as they do for chest pain. Organizations may use checklists, tools, or algorithms to support the response. Another key is sharing information across the continuum. For example, knowing that an individual normally has only mild confusion can help providers suspect sepsis when that person seems very confused. Settings across the continuum can also identify opportunities for collaboration. Because hospital readmissions are concerns for both hospitals and nursing facilities, they may collaborate to address problems-for example, by ensuring safe discharge, communicating necessary information, sharing strategies, and establishing a consultation system."
“Foster that cooperative behavior,” advises Davis. “Are there things we can do to help each other out?"
Infections from Peripherally Inserted IV Lines
Peripheral intravenous (PIV) catheters are commonly used items in healthcare. Often, PIVs are inserted upon admission as a matter of course, in case the patient needs IV therapy at a later point. However, PIVs can expose patients to a significant risk of infection-one that is underreported, underrecognized, and often ignored, according to Davis.
“Any time you break the skin, you’re breaking down the body’s first line of defense against infection,” says Davis. “Patients might not need a peripheral line, but your staff might put one in just because the patient is admitted and they may need it at some point. Staff may say, ‘Well, it’s only going to be in for an hour or two,’ not realizing that that’s enough time for an infection to develop.”
Tracing infections back to the PIV line can be difficult, according to Davis, because healthcare workers tend to overestimate their safety. “If a patient gets both a peripheral line and a central line and later develops a bloodstream infection, clinicians will often attribute it to the central line without even considering the PIV line,” says Davis.
Increased awareness of PIV-catheter-related infections, coupled with routine active surveillance and follow-up reporting, can help reduce the risk. “Staff need to understand that it can happen, and that it can be serious,” says Davis.
Staff should also slow down and assess whether a patient actually needs a PIV catheter inserted. “Staff need to respect putting in that PIV catheter, so that they slow down and treat it with the same reverence as if they were making an incision,” says Davis. “It is a thoughtful process."
"Not very long ago, expertly staffed IV teams were common, but many hospitals now perceive these teams as an unnecessary luxury, Marella emphasizes. "In the absence of this, it becomes more important to have good processes for developing the skills of new nurses, particularly in how they cope with patients who are difficult to gain IV access or when a patient’s existing lines are failing. It would also help to make more consistent decisions about when to place lines, which lines to use in different applications, and how long to leave them in. The latter is easily accomplished by reinstating IV teams that work in conjunction with the IP and other disciplines."
Marella continues, "On surveillance, IPs should be surveilling not only for infections but also the precursors to infection, such as patients whose lines have been left in too long, and similar things like placement location or dressing integrity, that increase risk of a bloodstream infection. They can also do general surveillance for proper care and maintenance of IV lines, dressings, and phlebitis. It’s also important to feed findings of this kind of surveillance back to management and staff to foster improvement. The IP should not be alone in these efforts. It is important to have a team approach to surveillance. IV teams for example can show value by performing surveillance, just in time education, in-services, and other activities that prove worth, increase patient and nursing satisfaction, all the while preventing infections."
ECRI Institute. 2019 Top 10 Patient Safety Concerns Executive Brief. Available at: https://www.ecri.org/landing-top-10-patient-safety-concerns-2019.