Category Archives: Patient Safety

What is the recent published evidence on risks and best practices for transporting critically ill patients within the hospital?

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Here are references from a PubMed search of the question concepts:  tranportation within the hospital and critically ill patients.  For a more specific search, add an outcome term to the search.

(“Transportation of Patients”[MeSH Terms] OR transport OR “Patient Transfer”[mesh terms]) AND intrahospital AND (critical care OR critically ill OR critical illness OR critical illnesses) Limit:  English

These references include reviews, prospective and retrospective studies, and guidelines.

Reviewed 4/15/2014 ldt

What is the evidence on use of surgical counting systems to prevent errors?

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Stawicki SP, et al. Retained surgical items: a problem yet to be solved. J Am Coll. Surg. 2013;216(1):15-22.
This study analyzed 59 cases of retained surgical items (RSIs) as well as 118 matched controls. Incorrect counts during a procedure elevated the risk of RSI. An odds ratio of 20 for RSI risk was found for any incorrect surgical count.

Cima RR, et al. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg. 2008;207(1):80-87.
Thirty-four cases of actual retained foreign objects (RFOs) in 21 patients occurred when the count had been reported as correct.

Jackson S, Brady S.  Counting difficulties:  retained instruments, sponges, and needles.  AORN.  2008;87(2): 513-21.
This review article discusses prevention of errors and references Association of Perioperative Registered Nurses (AORN) recommended practices.

Egorova NN, et al.  Managing the prevention of retained surgical instruments: what is the value of counting?  Ann Surg. 2008 Jan;247(1):13-8.
Reviews data on count prevalence of discrepancies in 153,263 operations. There were 1062 count discrepancies, and 1 in every 70 discrepancy cases had a retained item. Final count discrepancies prevented 54% of retained items. Due to the low incidence of retained foreign bodies, the positive predictive value of a count discrepancy for an actual retained foreign body was only 1.6.

Reviewed and updated 4/15/2014 ldt

Can a MRSA bundle prevent healthcare-associated MRSA infections in the ICU?

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Bottom line:  Use of a bundle decreased infection rates of healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) at Veterans Affairs (VA) hospitals.

Summary: Jain R, et al. Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.  N Engl J Med. 2011 Apr 14;364(15):1419-30.

The study compared rates of healthcare-acquired MRSA infections at VA units before (October 2005 – March 2007) and after (October 2007 – June 2010) implementation of a care bundle that included universal nasal surveillance for MRSA, contact precautions for patients colonized or infected with MRSA, promotion of hand hygiene, and a change in the workplace culture that made infection control the responsibility of every staff member who had contact with patients. During the period there was a total of  8,318,675 patient days. Rates of MRSA infections in ICU units were reduced by 62% while the rates at units other than ICUs were reduced by 45% during the same period.

Huskins WC, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med. 2011 Apr 14;364(15):1407-18.

This study of 18 ICU units looked at infection rates of MRSA and vancomycin-resistant enterococcus (VRE) in adult ICUs. Units were randomized to receive an intervention (n=10)  of increased surveillance and expanded barriers or to remain the same as a control (n=8). Intervention group patients were assigned to contact precautions based on history of MRSA or VRE in the past 12 months or results of nasal and perianal swabs. Patients in control units had swabs, but contact precautions were instituted based on hospital procedures and were blinded to the swab results. As Figure 3 summarizes, there was no significant difference in change of infection rates between the two groups. Authors concluded that the intervention was unable to reduce the transmission of MRSA and VRE. The surveillance cultures identified a significant subgroup of colonized patients who would not have been recognized otherwise, but the healthcare providers who participated in the study failed to use clean gowns and gloves and perform hand hygiene as often as was required by the intervention.

Two studies of antibiotic care bundles for MRSA in ICUs can be found here.

Reviewed and updated 4/11/2014 ldt

What can happen if patients’ intake and output is not properly monitored after surgery?

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Bottom line: Monitoring and documenting intake and output after surgery is important for detecting conditions, such as postoperative urinary retention (POUR), which is associated with risk of overdistention and permanent detrusor muscle damage, leading to difficulties with urination.  Decreased output can also be an indicator of a urinary tract infection.

Summary:  Feliciano T, et al.  A retrospective, descriptive, exploratory study evaluating incidence of postoperative urinary retention after spinal anesthesia and its effect on PACU discharge.  J Perianesth Nursing.  2008; 23(6): 394-400.

Postoperative care.  In:  Lippincott’s Nursing Procedures and Skills.  Revised October 4, 2013.

Reviewed and updated 4/11/2014 ldt

In performing an integumentary assessment, how do definitions of intact and not intact skin apply to documenting intentional breaks in the skin (eg, surgical incisions)?

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Bottom line:  There is no clear documentation in the literature designating intentional breaks in the skin, due to incisions, chest tubes, etc., as specifically not intact skin.

Summary:

CDC Key Terms
http://www.cdc.gov/nhsn/PDFs/HSPmanual/7_HPS_keyTerms.pdf
Non-intact skin is defined as “areas of the skin that have been opened by cuts, abrasions, dermatitis, chapped skin, etc.”

Larson E, et al. Prevalence and correlates of skin damage on the hands of nurses. Heart Lung. 1997 Sep-Oct;26(5):404-412.
This epidemiologic study of skin damage on nurses’ hands describes specifications for non-intact skin. Table II (p. 406) describes completely intact skin as that without abrasions or fissures.

Several nursing blogs include discussions of the ambiguity of how to document skin intactness for patients with surgical incisions.

Reviewed 4/25/2014 ldt

Are there randomized controlled trials of multi-pronged interventions to reduce falls in acute care settings?

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There are two randomized controlled trials on multiple interventions to prevent falls in acute care settings.

Dykes PC, et al.  Fall prevention in acute care hospitals : A randomized trial.  JAMA. 2010;304(17):1912-1918.
This study randomly assigned nursing units 1) to use an intervention including a specific risk assessment tool, care plan based on the assessment, patient and family education materials or 2) to provide usual care (control). Baseline characteristics of units were similar. Table 3 (p. 1916) summarizes differences in fall rates (per 1,000 patient days) for all patients as well as specifically for patients aged 65+. Significant differences favored the units using the intervention.

Ang E, Mordiffi SZ, Wong HB. Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial. J Adv Nurs. 2011;67(9):1984-1992.
There were 912 and 910 participants in the control and intervention groups, respectively. Intervention group patients received usual care and targeted multiple interventions based on individual risk factors of the Hendrich II Falls Risk Model; unfortunately, the article does not provide examples of interventional techniques. The fall incidence rates were 1·5% (95% CI: 0·9-2·6) and 0·4% (95% CI: 0·2-1·1) in the control and intervention groups, respectively. The relative risk estimate of 0·29 (95% CI: 0·1-0·87) favors the intervention group.

Reviewed and updated 4/10/2014 ldt

Does hourly or intentional rounding reduce the rate of accidental falls in acute care facilities?

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Bottom line:  Intentional rounding and hourly rounding are associated with reduced fall rates, but higher quality study designs are needed to determine the extent of benefit in various settings.

Summary:
Halm MA.  Hourly rounds: What does the evidence indicate? Am J Crit Care 2009;18:581-584.
Seven of nine studies in which falls were evaluated found a decrease in fall rates upon implementation of hourly rounding. Table 1 (p. 582) of this review summarizes effect on fall rates, as well as patient satisfaction and other indicators, in recent studies on hourly rounding.

Meade C, et al. (2006) is a highly cited study included in the review by Halm. This quasi-experimental, non-randomized study compared fall rates among units assigned to one of three groups:  1) hourly rounding 7am-3pm & every 2 hours 3pm-7am, 2) rounding every 2 hours, or 3) no specific procedure for rounding.  Groups 1 and 2 had specific procedure to follow.
RESULTS: Group 1 (hourly) – 25 falls during baseline period reduced to 12 falls during study period (p=0.01); Group 2 (every 2 hours) – 19 falls reduced to 13 falls; Group 3 (control) – 18 falls reduced to 17 falls.

Of the 11 articles not included in the review by Halm listed here, eight found a reduction in falls upon implementation of intentional rounds; note that some of the ten articles’ institutions implemented other fall prevention strategies in addition to intentional rounds. Only one of the eight articles stated that the reduction in falls was significant (Saleh et al., 2013). For the two remaining articles, the difference in the number of falls was not found to be significant in one article due to the infrequency of falls (Krepper et al., 2014), one did not experience consistently improved outcomes (Dyck et al, 2013), and the total number of falls did not change but the number of falls with injury was reduced (Sherrod, 2012). Dyck et al. (2013) discusses how they sustained participation in the program despite inconsistent outcomes.

Reviewed and updated 4/15/2014 ldt