Hospital Consult - November 2014
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Hand-Washing Compliance Declines at the End of Hospital Workers’ Shifts
PHILADELPHIA – Chances are that hospital staff packing up to go home after a shift are doing so with less-than-clean hands.
That’s according to new research that finds hospital workers who deal directly with patients wash their hands less frequently as their workday progresses, possibly because job demands deplete the mental reserves healthcare personnel need to continue to follow the rules.
The study, "The Impact of Time at Work and Time Off from Work on Rule Compliance: The Case of Hand Hygiene in Health Care," was published recently in the Journal of Applied Psychology.
Researchers led by Hengchen Dai, a PhD candidate at the University of Pennsylvania, looked at three years of hand-washing data from 4,157 caregivers in 35 hospitals in the United States. Data was provided by Proventix, which uses radio frequency identification (RFID) technology to monitor whether health care workers are washing their hands as recommended, essentially within a specified number of seconds of entering and leaving a patient's room. The workers’ RFID badges are read by communication units attached to hand soap and sanitizer dispensers.
With nurses being 65% of the health care providers in the sample, the remainder included patient care technicians (12%), therapists (7%), physicians (4%) and a small number of others.
Results show that "hand-washing compliance rates" dropped by an average of 8.7% from the beginning to the end of a typical 12-hour shift. Increased work intensity decreased compliance further, according to the report.
"Just as the repeated exercise of muscles leads to physical fatigue, repeated use of executive resources (cognitive resources that allow people to control their behaviors, desires and emotions) produces a decline in an individual's self-regulatory capacity," the authors write.
Workers who had more time off between shifts followed hand-washing protocols more carefully, however.
"Demanding jobs have the potential to energize employees, but the pressure may make them focus more on maintaining performance on their primary tasks (e.g., patient assessment, medication distribution), particularly when they are fatigued," Dai said in an American Psychological Association press release. "For hospital caregivers, hand-washing may be viewed as a lower-priority task and thus it appears compliance with hand hygiene guidelines suffers as the workday progresses."
Using past research – that a 1.0% increase in hand-washing compliance reduced the number of infections by 3.9 per 1,000 patients and that the cost per patient with a health care-acquired infection is $20,549 – the researchers calculated the potential impact of lower hand washing compliance at the end of shifts. Extrapolating their findings to all 5,723 registered hospitals in the United States, the study estimates the infection prevention lapses might cause an additional 600,000 infections per year at a cost of approximately $12.5 billion annually.
"We believe ours is the first study investigating whether accumulated work demands can affect rule compliance over the course of a single workday, as opposed to over weeks, months or years," said co-author Katherine L. Milkman, PhD. "We think this line of research could be applied to other types of workplace compliance, such as ethics standards in banking, safe driving behaviors in trucking and safety standards in manufacturing."
Chronic Lung Disease Readmission Penalties Hurt Safety-Net Hospitals
ANN ARBOR, MI – Hospitals that care for poor and minority patients will be disproportionately affected by fines the CMS assesses for too many readmissions for chronic lung disease, according to a new study.
The analysis by University of Michigan researchers was published recently in The American Journal of Respiratory and Critical Care Medicine.
"We worry that this policy may cause more harm than good," said author Michael Sjoding, MD, a pulmonary and critical care fellow in the U-M Medical School's Department of Internal Medicine. "Medicare is trying to improve patient care and reduce waste, but the hospitals they are penalizing may be the ones who need the most help to do so."
Fines for excessive readmissions are at an all-time high, with more than 2,600 hospitals being hit, according to Kaiser Health News’ recent analysis of federal records. One reason is that Medicare is evaluating readmissions of two new categories of patients: those admitted for elective knee or hip replacements, and those suffering from chronic lung disease such as chronic bronchitis and chronic obstructive pulmonary disease (COPD). For the past two years, readmissions above Medicare’s expectations have been penalized for heart failure, heart attack and pneumonia patients.
About 400 more hospitals than last year are facing penalties, according to the KHN analysis, which also noted that half of the hospitals in 29 states and the District of Columbia will be affected. In addition, the ceiling for fines increased this year to 3% of reimbursements.
For the University of Michigan study, researchers evaluated three years of data on 3,018 hospitals that cared for patients with COPD. Based on past admission rates, they discovered that teaching hospitals and safety-net hospitals will bear the brunt of the new financial penalties.
Poor or medically complex patients with COPD are at a higher risk for readmissions because of a large number of socioeconomic and health factors, according to the study.
While the Hospital Readmission Reduction Program was designed to motivate hospitals to improve the quality of care for select diagnoses by providing financial incentives to lower readmissions, study authors emphasize that patients often get readmitted for reasons outside a hospital's control.
"If patients can't afford medications, or have unstable housing situation, they may end up being readmitted to the hospital," Sjoding pointed out. "No interventions to date have effectively and sustainably reduced COPD readmissions, so it's unclear what a hospital can do to prevent them."
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‘Alarm Fatigue’ Cured by Reducing Unnecessary Cardiac Monitor Warnings
CINCINNATI – If monitor beeps are so ubiquitous at your facility that you hardly hear them anymore, you may be suffering from “alarm fatigue.”
That was the problem at Cincinnati Children’s Hospital Medical Center, where researchers developed a standardized, team-based approach to reduce the ubiquitous beeping of cardiac monitor alarms. When the median number of daily cardiac alarms dropped from 180 to 40, caregiver compliance with the process shot up from 38% to 95%.
An article on the process developed at the 24-bed, pediatric bone marrow transplant unit at Cincinnati Children's was published online recently by the journal Pediatrics.
"Cardiac monitors constitute the majority of alarms throughout the hospital," said lead author Christopher Dandoy, MD, of the Cancer and Blood Diseases Institute at Cincinnati Children's. "We think our approach to reducing monitor alarms can serve as a model for other hospitals throughout the country."
That is important because, according to The Joint Commission, 80 patients died from hospital alarm-related errors nationwide between January 2009 and January 2012.
The process to standardized cardiac monitoring included:
- initial ordering of monitor parameters based on age-appropriate standards,
- daily replacement of electrodes in a manner that was pain-free for patients,
- individualized daily assessment of cardiac monitor parameters and
- developing a reliable method for appropriate discontinuation of the monitors.
After testing and adaptation, the team then added some additional innovations, including family/patient engagement in the process; creation of a monitor care log to document parameters, lead changes, and discontinuation; further development of a pain-free process for electrode removal; and customized monitor delay and customized threshold parameters.
From January to November 2013, compliance with each of the four components of the new cardiac monitor care process increased steadily, according to the report.
“Implementation of the standardized CMCP resulted in a significant decrease in cardiac monitor alarms per patient day,” the authors write. “We recommend a team-based approach to monitor care, including individualized assessment of monitor parameters, daily lead change, and proper discontinuation of the monitors.”
The process was not unique to a pediatric unit, the authors emphasize.
"With fewer false alarms, the staff can address significant alarms more promptly," Dandoy pointed out. "We believe the roles and responsibilities entailed in this process can be applied to most units with cardiac monitor care."
Unused U.S. Surgical Supplies Could Improve Care for Third World Patients
BALTIMORE – Major hospitals across the United States collectively throw away at least $15 million a year in unused surgical supplies, according to new research that suggests the material could be salvaged and used to improve surgical care in developing nations.
A report on the research was published recently in the World Journal of Surgery. In it, Johns Hopkins researchers point out that salvaging the waste would be an opportunity for U.S. hospitals to help relieve the global burden of surgically treatable diseases, while also reducing the cost and environmental impact of medical waste disposal at home.
The investigation likely is one of the first systematic attempts to measure the national extent of the problem, the potential cost savings and the impact on patients' lives, according to study’s authors. They call for making donations of leftover operating room materials a standard protocol instead of the current situation where only some surgical facilities rely on organizations with donation programs.
"Perfectly good, entirely sterile and, above all, much-needed surgical supplies are routinely discarded in American operating rooms," pointed out lead investigator Richard Redett, MD, a pediatric plastic and reconstructive surgeon at the Johns Hopkins Children's Center. "We hope the results of our study will be a wakeup call for hospitals and surgeons across the country to rectify this wasteful practice by developing systems that collect and ship unused materials to places that desperately need them.”
Wasted surgical supplies often are the result of bundling surgical materials to streamline operating room readiness and efficiency. The problem, according to the researchers, is that once it’s opened everything in the bundle that is unused is thrown away.
"Such programs are acutely needed not only to help address serious needs in resource-poor settings but also to minimize the significant environmental burden at home institutions," added co-author Eric Wan, MD, a recent graduate of the Johns Hopkins University School of Medicine currently doing postdoctoral training at the National Institutes of Health. "This really is a win-win situation."
The study’s estimates were based on an existing program that recovers and delivers unused surgical supplies from The Johns Hopkins Hospital to two surgical centers in Ecuador. Items donated over a 3-year period from September 2010 to November 2013 were analyzed by quantity and weight, and an estimated projected value of the program was made assuming wider participation.
The authors tracked 19 high-demand surgical items donated to the Ecuadorian hospitals over three years, then extrapolated the amount and value of the donations to 232 U.S. surgical centers with caseloads similar to The Johns Hopkins Hospital.
Results indicate that, if the 232 American hospitals saved and donated unused surgical supplies, 2 million pounds of materials would be generated in a year, at a value of at least $15 million.
When the researchers then tracked outcomes among 33 Ecuadorian patients whose surgeries were made possible as a result of the donations, they found that donated surgical supplies prevented, on average, eight years of disability per patient.
In the study, materials topping the 19-item surgical supplies list included gauze, disposable syringes, sutures and surgical towels.
"Saving and shipping these materials is truly a low-hanging fruit enterprise, a simple strategy that could have a dramatic impact on surgical outcomes and public health in resource-poor settings and truly change people's lives," said Redett, who has been running the Johns Hopkins donation program since 2003.
Study authors caution, however, that items shipped should be tailored to the specific needs of each hospital. That prevents unnecessary shipping costs and avoids creating medical waste locally. The receiving hospital also must have a demonstrated capability and the equipment to clean and sterilize the shipped materials before use in the operating room, they add.
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