Change in thinking drives lasting fall in infections

Large-scale healthcare improvement projects can be sustained in the long-term, say US researchers. They were commenting after finding that signficant reductions in bloodstream infection rates in hospital intensive care units (ICUs) were maintained a decade after being targeted by a state-wide intervention.
			The study was the first to demonstrate a 10-year impact of a quality improvement intervention, which had established a 'new normal for care'

Setting a new benchmark

The Michigan Keystone ICU project was cohort collaborative aimed at reducing the common problem of central line bloodstream infections (CLABSIs) in ICUs, through the use of improvement teams that promoted clinicians’ use of five evidence-based infection prevention recommendations.

The study, which covered data from 121 ICUs across 73 hospitals between March 2004 and December 2013, showed that the annual mean rate of bloodstream infections dropped from 2.5 infections/1000 catheter-days in 2004 to 0.76 in 2013. The rate remained below one infection per 1000 central-line days from 2008 onwards.

“It was found that the markedly reduced BSI [bloodstream infection] rates achieved in the initial Keystone ICU project were sustained for 10 years, setting a new benchmark for rates of CLABSI among ICU patients,” the authors wrote in the American Journal of Medical Quality.

The authors said the study was the first to demonstrate a 10-year impact of a quality improvement intervention, which had established “a new normal for care”.

Active involvement of hospital leaders and the Keystone Center, as well as ongoing monitoring and performance feedback ‒ with hospitals facing peer pressure to match infection rates of other hospitals ‒ had helped sustain the results, they suggested.

But they said the largest driver was likely a shift in the clinicians’ beliefs – from viewing such infections as inevitable to viewing them a preventable and acknowledging they could prevent them.

Meanwhile, a separate study on the first four cohorts of a program to reduce catheter use and catheter-associated urinary tract infections (UTIs) in US hospitals found that a collaborative effort focusing on both technical and socio-adaptive interventions reduced UTI rates in non-ICU settings, but not in ICUs.

Review confirms benefits of care bundles to cut ICU infections

Central-line bundles ‒ packages of care aimed at reducing central-line associated bloodstream infections (CLABSI) ‒ significantly reduce the incidence of such infections in ICUs, a major review has confirmed.

The researchers said bundles were sets of evidence-based practices that had been proven to improve patient outcomes, if completed collectively and reliably.

They reviewed evidence on central-line insertion and maintenance bundles, which were defined as a combination of evidence-based interventions, such as full barrier precaution during the insertion of a central line, cleaning of the skin with chlorhexidine, applying appropriate hand hygiene and prompt removal when the central line was no longer needed.

The meta-analysis of 79 studies covering neonatal, paediatric and adult ICUs showed that the incidence of infections decreased significantly from a median of 6.5 per 1000 catheter-days to 2.5 per 1000 catheter-days after implementation of bundles, according to findings in The Lancet Infectious Diseases.

While various implementation approaches were taken, the most successful was reported to be a combination of leadership by a recognised authority with strict protocol or checklist compliances, and when nurses were empowered to stop the procedure if a physician breached protocol.

“The question of whether central-line bundles are effective is no longer open to debate ‒ we have shown that they are,” the authors wrote.

They said the review also showed that using such bundles of care could achieve cost savings, estimated at $US42,609 per one prevented CLABSI.

The deadly legacy of sepsis

Patients who survive sepsis face an increased risk of mortality in the following two years, according to a US study which suggests such patients may benefit from interventions and discussion of end-of-life planning.

While sepsis mortality in hospitals was falling, many patients died over subsequent months and the researchers said there was debate about whether such “late mortality” reflected underlying comorbidities in patients who developed sepsis, or was a result of the sepsis itself.

They followed up 960 older US patients who were hospitalised with sepsis, and matched controls of 777 adults who were not currently in hospital, 788 patients admitted with non-sepsis infection, and 504 patients admitted with acute sterile inflammatory conditions.

More than one in five patients who survived sepsis died acutely within the next two years and their death was not explained by their prior health status – suggesting it was a consequence of the sepsis, the authors wrote in the BMJ.

They said interventions during the admission for sepsis, such as timely resuscitation and early mobility, may benefit patients with sepsis more than generic post-admission care.

The findings might also be of value to patients, families and health systems seeking information about life after an admission for sepsis, they said.

“The high rate of late mortality suggests that physicians should perhaps discuss advanced directives and end of life planning in patients who survive sepsis,” they wrote.

Bed moves increase risk of harm

Patients who move hospital beds several times face an increased risk of adverse events, according to an Australian study that suggests clear targets need to be set around bed moves.

Among 566 patients admitted to a tertiary referral hospital, 28% were moved once, 8% were moved twice and 5% were moved at least three times, according to the study in Australian Health Review.

An adverse event was almost three times more likely to occur among patients who were moved three or more times, compared with patients moved fewer times, it found.

Some of the reasons for patient bed moves were inevitable, such as return from theatre to a different ward if the patients’ condition deteriorated; moves from intensive care and from flexible bed/short-stay units, they said.

“However, most moves were classified as ‘bed needed for another patient’, and this group may need closer scrutiny,” they wrote.

The study also found that that the length of stay among patients who were moved three or more times was twice as long as for those moved fewer times. The authors said the study did not control for acuity and illness severity, so it was possible sicker patients had longer lengths of stay and were potentially exposed to more opportunities for adverse events too occur.

As well as safety concerns, there were substantial economic implications associated with frequent patient moves, they suggested. Based on an estimate of $A600 per bed day, an increased cost of about $A4200 could be incurred for each patient who was moved three or more times, as they stayed in hospital an extra seven days.

“Efforts to reduce the number of bed moves, both within and between wards, needs to be part of strategic planning, with clear targets set for acceptable standards,” they wrote.

Call to review four-hour rule targets for EDs

The National Emergency Access Targets (NEAT) ‒ which stipulate what proportion of patients should be admitted, discharged or transferred from EDs within four hours of presentation ‒ are only effective in reducing patient mortality up to a certain point, Australian research shows. The authors suggested their findings should be considered when formulating future targets for access to emergency care.
			We found that there is no robust evidence regarding a clinically significant mortality benefit associated with total and admitted NEAT compliance rates above 83% and 65% respectively

Mortality impact of targets studied

The NEAT targets, which varied from state to state, were set for all Australian EDs by the National Partnership Agreement in 2012, with the aim of incrementally increasing targets to 90% in all jurisdictions by 2015, in line with the UK’s “four-hour rule” target.

While the NEAT incentives are no longer funded following the end of the National Partnership Agreement in 2014, all states have so far maintained pursuit of some form of four-hour ED target, study author Dr Andrew Staib said.

The study examined the relationship between the risk-adjusted mortality of patients who were admitted acutely from ED and the NEAT compliance rates both for all patients who presented to ED (total NEAT) and for those who were admitted to hospital from the ED (admitted NEAT).

Findings in the MJA showed as the NEAT compliance rates increased, there was a decline in the in-hospital mortality among admitted patients, which was expressed as a risk-adjusted ratio of observed to expected number of deaths known as the ED Hospital Standardised Mortality Rate (eHSMR).

However, the eHSMR reached its lowest point of 73, when total NEAT total compliance rates rose to about 83%, and when the compliance rates for admitted patients reached 65%. When compliance with NEAT targets increased beyond those levels, there was no further reduction in mortality rates.

“We found that there is no robust evidence regarding a clinically significant mortality benefit associated with total and admitted NEAT compliance rates above 83% and 65% respectively,” the authors wrote.

They also suggested NEAT compliance rates should be embedded within a suite of patient-focused outcome measures that could signal any “unintended adverse consequences of pursuing ever higher NEAT compliance rates”.

Study reveals impact of nursing interruptions

Interruptions, often instigated by patients and family members, increase the amount of time it takes nurses to complete clinical tasks and could place patients at increased risk of harm, new research suggests.

The observational study looked at the effect of interruptions on common nursing interventions in the emergency department (ED) of a large US hospital.

Findings in BMJ Quality and Safety showed that the average time spent on an uninterrupted intervention was about five minutes, while interrupted interventions took 11.5 minutes.

After controlling for intervention type and other confounding factors, they found interrupted interventions were just over two minutes longer than interventions without interruptions, after excluding the length of the interruption.

One reason for the increased time may be that nurses performed task steps again if interrupted, the authors suggested. For example, after being interrupted while setting up an infusion pump, a nurse would repeat the last few pump inputs so as not to miss one accidentally.

The study found that family/patient interruptions had the greatest impact on the time taken to complete procedures, compared with interruptions by other staff.

“While seemingly trivial, in an emergency care setting, additional minutes translate into increased patient risk,” they wrote, adding that the additional time spent on tasks may also have financial implications.

“Organisationally, such interruptions lead to inefficient practice and a drag on productivity.”

They said findings should give clinical leaders and administrators an incentive to explore ways of reducing the interruptions that were most detrimental to care delivery, or perhaps making nursing practices more resilient to the potentially harmful effects of such interruptions.

Does patient experience equate with quality of care?

Measures of patient reported experience should not be used to conclude that the quality of healthcare is good, according to a study that suggests the data is best used to identify potential problems and priorities for improvement.

The review of 51 studies focused on the association between delivered care and patient reported experiences.

The authors said the studies revealed six broad themes, all of which influenced the association between patient reported experiences and the quality of care received: the patient characteristics; patients backing up their own healthcare choices; loyalty to health care professionals; the timing of the survey; and the questionnaire and item design.

For example, they said patient reported experience could be influenced by gratitude, loyalty and a need to maintain a good relationship with healthcare professionals. Also, patients with better health tended to report more positive experiences with healthcare, while those with high educational levels tended to be more critical.

While measures of patient experience were important and should remain a priority for healthcare managers, the study authors said the findings showed such measures might reflect neither high-quality care nor satisfied patients, according to their findings in Patient Experience Journal.

“Practitioners must be cautious when using the information in quality assessment and decision-making processes,” they wrote. “It is important to be aware of the differences between received care, patient experience and reported patient experience as these are very different concepts and a number of factors influence the association between them.”

They developed a model which they said was starting point for understanding the complex association between received care and patient reported experience and factors that influence that association.

Volunteer program helps impart safety message

A program in which volunteers were used to deliver safety messages to patients and their families in a paediatric hospital helped to impart key safety information, new research shows.

The researchers evaluated the Patient Safety Ambassador (PSA) program, which used trained volunteers to deliver information about inpatient safety to patients and their families. The volunteers delivered five key safety messages verbally and with a fact sheet, regarding:  infection control protocols; proper medication administration; utilisation of the SPOT (speed, proactive, outreach teaching) critical care team as necessary; and speaking up and asking questions.

The researchers examined whether 40 parents/guardians of children and four inpatients at a Canadian children’s hospital were able to recall the key safety messages imparted by the PSA program after 48 hours, either with or without cues such as key words.

The study found that 95% of parents could remember all safety messages with cues, but could only remember one or two messages without cues, according to findings in Patient Experience Journal.

The inpatient participants could remember up to four messages with cues, but none without cues.

Interviews with parents about their attitudes and perceptions about patient safety revealed they were most concerned with knowing about their child’s medication, being involved in their child’s care, having trust in the healthcare team, asking questions to understand their child’s medical situation, and in advocating on behalf of their child to facilitate ongoing patient safety.

Online cancer information falls short

Patients seeking online information about pancreatic cancer may end up confused or misguided, new research suggests. A study of 50 websites found they were designed for people with a reading level well above that of the general population, and lacked accurate information about alternative therapies.
			The general population and vulnerable groups with particularly low health literacy will likely struggle to understand this information, the authors said

Alternative therapy websites inaccurate

The researchers evaluated 50 websites that discussed five pancreatic cancer treatment methods, using standardised tests to assess the readability of the websites and an expert panel to assess the accuracy of information. 

Findings in JAMA Surgery showed that the median readability level of all website categories was higher than the recommended sixth-grade reading level, requiring at least 13 years of education to be understood ‒ a level that was attained by only 58% of the US adult population.

“The general population and vulnerable groups with particularly low health literacy will likely struggle to understand this information,” the authors said.

Overall, websites discussing treatment modalities for pancreatic cancer were reasonably accurate, except for those discussing alternative therapies.

“Alternative therapy websites contained more noticeable inaccuracies and contained seemingly incorrect information,” they wrote.

Non-profit, academic, and government websites had the highest accuracy, particularly websites relating to clinical trials and radiotherapy, the study found.

The authors said online health resources could be powerful tools to help patients become better informed, but unguided searches could have a negative effect on patient care, decision making and outcomes.

Healthcare professionals should be aware that online information on aggressive diseases like pancreatic cancers could be potentially harmful, and should take an active role in evaluating and recommending suitable online resources for patients, they suggested.