Clinical Tip, Patient Monitoring

Procedural Sedation guidelines for Tonsillectomy and Adenoidectomy: The Basics

By Lynn Razzano, RN, MSN, ONCC (Clinical Nurse Consultant, Physician-Patient Alliance for Health & Safety)

The American College of Emergency Physicians (ACEP) defines procedural sedation as:

“a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function. Procedural sedation and analgesia (PSA) is intended to result in a depressed level of consciousness that allows the patient to maintain oxygenation and airway control independently.”

The number of noninvasive and minimally invasive procedures performed outside of the operating room has grown exponentially over the last several decades. Sedation, analgesia, or both may be needed for many of these interventional or diagnostic procedures. Medications that elicit pharmacologic effects, such as anxiolysis, amnesia, or analgesia, provide patient comfort during various procedures. Understanding the efficacy and safe administration of these agents is essential to the practitioner performing interventional procedures.

Sedation and analgesia introduces an independent risk factor for morbidity and mortality in addition to the procedure itself. The Joint Commission on Accreditation of Healthcare Organizations recognizes the risks involved with sedation and analgesia for procedures and mandates that sedation practices throughout an institution be monitored and evaluated by the department of anesthesia. The American Society of Anesthesiologists (ASA) has responded to this challenging responsibility by developing practice guidelines for non-anesthesiologists who provide sedation and analgesia.

Sedation Definitions

Understanding the various depths of sedation is essential to provide safe and effective procedural sedation and analgesia. The ASA has defined the various sedation depths. As defined below, minimal sedation or moderate sedation is used for PSA.

Minimal sedation (anxiolysis) is as follows:

  • Response to verbal stimulation is normal.
  • Cognitive function and coordination may be impaired.
  • Ventilatory and cardiovascular functions are unaffected.

Moderate sedation/analgesia (formerly called conscious sedation) is as follows:

  • Depression of consciousness is drug-induced.
  • Patient responds purposefully to verbal commands.
  • Airway is patent and spontaneous ventilation is adequate.
  • Cardiovascular function is usually unaffected.

Deep sedation/analgesia is as follows:

  • Depression of consciousness is drug-induced.
  • Patient is not easily aroused but responds purposefully following repeated or painful stimulation.
  • Independent maintenance of ventilatory function may be impaired.
  • Patient may require assistance in maintaining a patent airway.
  • Spontaneous ventilation may be inadequate.
  • Cardiovascular function is usually maintained.

General anesthesia is defined as follows:

  • Loss of consciousness is drug-induced, where the patient is not able to be aroused, even by painful stimulation.
  • Patient’s ability to maintain ventilatory function independently is impaired.
  • Patient requires assistance to maintain patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function.
  • Cardiovascular function may be impaired.

For more information, see ASA’s Continuum of Depth of Sedation Definition of General Anesthesia and Levels of Sedation/Analgesia.

Additionally, clinicians must recognize procedures performed outside of the operating room that may require monitored anesthesia care (MAC). For more information, see ASA’s Distinguishing Monitored Anesthesia Care (“MAC”) From Moderate Sedation/Analgesia (Conscious Sedation).

Monitoring

Health Care Practitioners must

  • be skilled in providing procedural sedation
  • be proficient in airway management and cardiovascular support, and
  • possess the skills required to rescue a patient from sedation deeper than intended.

Continually evaluating and monitoring respiratory and circulatory requirements prior to, during, and following the procedure is essential.

There is no other option for maximally patient safety when receiving procedural sedation other than continuous electronic monitoring during the critical time points during the pre, peri and post procedure interventions. Equally important is The Joint Commission expects and requires that practitioners and clinicians using continuous electronic monitoring be competent in managing sedations and reversal of sedation if this requires moving from one level of sedation to a deeper level that anticipated for the particular procedures.

In keeping with The Joint Commission’s expectations surrounding competency in managing sedation reversal from one level deeper than anticipated or planned for due to surgical difficulties or longer procedure than originally planned. If we look at what the responsibilities of the competent sedation clinician, we can start to identify a checklist of actions and plan of care that are relevant when procedural sedation is used.

The following are key points that provide the Basics and Key Elements of Safe Procedural Sedation:

  • Monitor vital signs before, during, and after the procedure.
  • ECG monitoring should be continuous for high-risk patients, during prolonged procedures, or during deep sedation.
  • Consider continuous pulse oximetry for patients with comorbidities (e.g., chronic obstructive pulmonary disease [COPD], asthma, congestive heart failure) or when high doses of sedatives or multiple drugs that may depress respirations are used.
  • Observe the patient’s appearance.
  • Monitor airway patency.
  • Monitor response to physical stimuli and verbal command.
  • Measurement of blood gas level may be required.
  • Use of capnography/pulse oximetry for high-risk patients and all patients requiring opioids or sedation agents/medications.

According to a 2010 randomized controlled trial of 132 adult patients receiving propofol sedation in the ED, adding capnography to standard monitoring resulted in a decrease in hypoxia and identified all hypoxic events before onset. For more information, see ASA’s Standards for Basic Anesthetic Monitoring.

Clinical Tip, Patient Safety, VTE

5 Steps to Keep New Mothers Safer from VTE (blood clot) development

By Lynn Razzano, RN, MSN, ONCC

Following delivery, mothers are at risk for developing blood clots much longer than previously thought – twice as long – according to research presented February 13, 2014 at the American Stroke Association’s International Stroke Conference.

It was a well-known and established fact that the risk of venous thromboembolism (VTE or commonly referred to as “blood clots”) remains high for one month after giving birth. However, this research significantly extends the at risk time frame – the VTE risk window post delivery and the identification of level of increased risk for the following duration weeks:

  • Weeks 0-6: 10.8 times higher
  • Weeks 7-12: 2.2 times higher
  • Weeks 13-18: 1.4 times higher

This new research suggests five steps that new mothers and their doctors can do:

  1. New mothers should be provided education on this new VTE risk window extension of 12 weeks post delivery. The patient should be provided this information to the nurse when discharge is anticipated. In addition, the information should be sent to her primary care provider or for the next scheduled follow up appointment.
  2. In accordance with the newly release OB VTE Safety Recommendations, the appropriate prophylatic regimen should be discussed with the patient during discharge, which discussion should include this extended VTE risk window discussion and compliance with physician-prescribed recommendations, both pharmacological prophylaxis and compression devices with appropriate instructions for “wear time” discharge.
  3. The new mother’s physician should obtain the appropriate order for home mechanical prophylaxis and initiate a DME (durable medical equipment) referral to provide to patient on arrival to home.
  4. The post discharge call by the discharging clinician should occur and validate the patient has received the compression device, knows how to apply and the necessary wear time. In addition the patient should be instructed in proper skin inspection and removal of the device for all ambulation periods.

The new mother should verbalize “read back” knowledge of all post discharge instructions. Her significant other or caregivers should be provided this information as well.

Clinical Tip, Patient Safety, VTE

Clinical Tip: Mother Dies After Childbirth – What you need to know about Amniotic Fluid Embolism Now

By Lynn Razzano, RN, MSN, ONCC

The Boston Herald recently reported that 32-year old Colleen Celia on January 15, 2014, shortly after giving birth to her fourth child.  The young mother died from amniotic fluid embolism, where amniotic fluid enters the mother’s bloodstream

After reading about yet another who dies after childbirth, I felt the clinical need to write this article. I honestly had not heard of this before and consider myself an expert on VTE and the prevention of the occurrence. Having done some considerable work with the release of the new OB VTE Safety Recommendations with the OB team of experts, I think this condition is worthy of researching and gaining knowledge. There is really very little written on the subject and I wanted to find out the incidence as well as any alert criteria and prevention modalities that would save a future mother from succumbing from such an rare condition.

I hope I do justice to explaining what Amniotic Fluid Embolism is and increase awareness of this condition with OB clinicians across the country. Another goal I have is to empower and engage pregnant women by educating them on this diagnosis so they may speak up with their respective OB clinicians and be a safety vehicle for their own welfare.

An amniotic fluid embolism is a rare but serious condition that occurs when amniotic fluid — the fluid that surrounds a baby in the uterus during pregnancy — or fetal material, such as hair, enters the maternal bloodstream.  There is some information, in addition, that points to the possibility of meconium being released into the mother’s system.

An amniotic fluid embolism is most likely to occur during childbirth or immediately afterward, which is the immediate post partum period.  This identifies to possible alerts as to the time frame of intense observations or monitoring that should occur with the OB patient.

Not surprising, an amniotic fluid embolism is difficult to diagnose which leads to clinical challenges while critical time may be wasted. In terms of patient education, OB clinicians should be teaching them. If your doctor suspects you might have an amniotic fluid embolism, you’ll need immediate treatment to prevent potentially life-threatening complications.

What are the symptoms the patient would display or exhibit if a pending amniotic fluid embolism is suspected. The urgent nature and important fact is – amniotic fluid embolism develops suddenly and rapidly.

Signs and symptoms of an amniotic fluid embolism might include:

  • Sudden shortness of breath
  • Excess fluid in the lungs (pulmonary edema)
  • Sudden low blood pressure
  • Sudden circulatory failure (cardiovascular collapse)
  • Life-threatening problems with blood clotting (disseminated intravascular coagulopathy)
  • Altered mental status, such as anxiety
  • Nausea or vomiting
  • Chills
  • Rapid heart rate or disturbances in the rhythm of the heart rate
  • Fetal distress, such as a slow heart rate
  • Seizures
  • Coma

Preparation for monitoring these above symptoms could be developed into a safety checklist that clinicians could have on the patient board or reduce and carry a pocket size version easily accessible to them. All emergency equipment should be on hand and easily available so as to manage, abort symptoms,, before any undue harm to the OB patient.

What Causes Amniotic Fluid Embolism to present itself and what is the significance clinically? :

It is not a comforting fact that amniotic fluid embolism occurs as this isn’t well understood and due to its supposed rareness is not well researched.

An amniotic fluid embolism occurs when amniotic fluid or fetal material enters the maternal bloodstream, possibly by passing through tears in the fetal membranes. It’s likely that amniotic fluid contains components that cause an inflammatory reaction and activate clotting in the mother’s lungs and blood vessels. This should be a red alert to the clinician and activate a proactive treatment and prevention plan.

However, amniotic fluid embolisms are rare — and it’s likely that some amniotic fluid commonly enters the maternal bloodstream during delivery without causing problems. It’s not clear why in some cases this leads to an amniotic fluid embolism.

Further research on what causes amniotic fluid embolisms is needed.

Due to the rarity of Amniotic fluid embolisms, it is difficult to identify risk factors. It’s estimated that there are between 1 and 12 cases of amniotic fluid embolism for every 100,000 deliveries.

Frequency

United States

Incidence of AFE is estimated at 1 case per 8,000-30,000 pregnancies. The true incidence is unknown because of inaccurate diagnoses and inconsistent reporting of nonfatal cases.

International

Incidence is similar to that of the United States.

Mortality/Morbidity

  • Maternal mortality approaches 80%.
  • Mortality was 61% in the US national registry, which listed 46 cases.
  • AFE is the cause of 5-10% of maternal mortality in the United States.
  • Of patients with AFE, 50% die within the first hour of onset of symptoms. Of survivors of the initial cardiorespiratory phase, 50% develop a coagulopathy.

Research suggests that several factors might be linked to an increased risk of an amniotic fluid embolism, however, including:

  • Advanced maternal age. If you’re 35 or older at the time of your child’s birth, you might be at increased risk of an amniotic fluid embolism.
  • Placenta problems. If there are abnormalities in your placenta you might be at increased risk of an amniotic fluid embolism. Abnormalities might include the placenta partially or totally covering the cervix (placenta previa) or the placenta peeling away from the inner wall of the uterus before delivery (placental abruption). There may be disruption in the physical barriers between mother and baby.
  • Preeclampsia. If you have preeclampsia including high blood pressure and excess protein in the urine after 20 weeks of pregnancy there might be an increased risk of developing an amniotic fluid embolism.
  • Medically induced labor. Limited research suggests that certain labor induction methods are associated with an increased risk of amniotic fluid embolism. Research on this link, however, is conflicting with no firm clinical consensus.
  • Operative delivery. Having a C-section, a forceps delivery or a vacuum extraction might increase your risk of an amniotic fluid embolism.  It’s not clear, however, whether operative deliveries are true risk factors for amniotic fluid embolisms or are used after the condition develops to ensure a rapid delivery.
  • Genetics. Some experts believe that genetics might play a role in determining a woman’s risk of amniotic fluid embolism.

Complications

An amniotic fluid embolism can cause serious complications for mother and baby.

If you have an amniotic fluid embolism, you’re at increased risk of:

  • Brain injury. Low blood oxygen can cause permanent, severe neurological damage or brain death.
  • Lengthy hospital stay. Women who survive an amniotic fluid embolism often require treatment in the intensive care unit and depending on the extent of their complications may necessitate weeks or months in the hospital.
    • This increases cost expenditures in terms of transfer to a higher level of acuity and a longer length of stay.

It’s estimated that amniotic fluid embolisms cause up to 10 percent of maternal deaths in developed countries. Death can occur within an hour of the start of symptoms.

An amniotic embolism, places the unborn baby at increased risk of a brain injury due to a lack of oxygen, which may prove fatal.

Clinical considerations for managing amniotic fluid embolism suspicion might include:

  • Standards: Use of the new OB VTE Safety Recommendations would provide the assessment process and earlier recognition to manage the patient and provide the required intervention. The most significant course of clinical action that is critical is for “early on” detection of an possible amniotic fluid embolism is consistent and complete baseline assessment of OB VTE risk factors on all patients. In particular the VTE risk factors that have been identified above and common to the OB patient.
  • Clinician Education: Due to the rare nature of the condition, there needs to be vigilant education with clinicians and patients. Accountability and responsibility is still a clinical expectation even when a condition is termed rare- this does not prevent the jurisprudence that is still a clinical expectation for maximum OB patient safety.
  • Recommendations: Develop patient safety recommendations using the symptoms detailed above to serve as a clinical guide in assessing patients for suspicion or alert to potential amniotic fluid embolism. See the new OB VTE Safety Recommendations as an example of recommendations.
  • Monitoring: Ensure increased patient monitoring is provided to a patient that may have one or more of the high risk factors for developing amniotic fluid embolism.
  • Training: Ensure there is adequate cross trained skills and competencies from both OB nurses to Critical care nurses who need the specific nuances and clinical algorithms to care for the critical OB patient.
  • Patient Awareness: Consistently educate and engage the pregnant woman in the condition and provide opportunities to have the patient be their own safety advocate. This will go far in preventing mortality or complications.

For additional knowledge and clinical guidance on this rare condition, amniotic fluid embolism, please read the paper, by Katherine J. Perozzi, RN, MSN and Nadine C. Englert, RN, MSN., “Amniotic Fluid Embolism An Obstetric Emergency” in Critical Care Nurse

Clinical Tip, VTE

Four simple safety steps pave the OB DVT Prevention Road

By Lynn Razzano, RN, MSN, ONCC

In a recent article “Safety: 4 Ways to Stop DVT in Its Tracks”, Cheryl Marsh provides four very useful steps to prevent deep vein thrombosis (DVT). As she writes, this is patient safety issue that needs attention:

“The stakes are high when it comes to preventing deep vein thrombosis and pulmonary emboli. Between 300,000 and 600,000 people suffer DVT and PE each year, with 60,000 to 100,000 ultimately dying from the complications. When it’s not fatal, DVT can cause post-op morbidity, prolonged hospitalization and increased healthcare costs.”

More alarming is that the risk of DVT and PE (otherwise known as venous thromboembolism or VTE) escalates for pregnant women, as Dr. Andra James (Professor of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Virginia School of Medicine) points out:

“For pregnant women, the risks of VTE is 4-5 times higher than women who are not pregnant. Moreover, this risk is at least twice as much following cesarean delivery.”

In reviewing the alarming statistics for pregnant women and their inherent risk for VTE occurrence, can four safety steps make the difference in prevention from a silent killer?

The facts:

  • Pulmonary embolism (PE) has been a leading cause of maternal mortality in the United States since 1985. More maternal deaths have occurred due to PE than by hypertensive disorders, obstetric hemorrhage, obstetric infection, and ectopic pregnancies.
  • One woman in a thousand will experience a VTE during her pregnancy and the risk doubles for Cesarean section.

All pregnant women should be assessed consistently for the risk of VTE. This is what will guide the clinician in the ordering and initiating the appropriate DVT prophylaxis in a timely manner.

To know the risks, here are some useful steps:

Step 1 – Know the risks: pregnant women are four to five times more likely to develop VTE.

Step 2 – Select the correct prophylaxis and the two most effective measures are either sequential compression devices or venous foot pumps, otherwise known as intermittent pneumatic compression devices [cite ACOG guidelines]

Step 3 – Establish standard procedures and protocols to ensure consistent delivery of quality care. The Physician-Patient Alliance for Health & Safety, together with a panel of health experts, is developing safety recommendations to prevent VTE in maternal patients.

Step 4 – Educate patients on why VTE prevention matters and why they need to wear Intermittent pneumatic compression devices is a crucial part of compliance and empowering the patient for her own self care management. Risks of VTE remain even after the patient is discharged and in OB the risk window remains up to one month post-partum.

Is it really as simple as 4 safety steps? Yes, that is all it takes to stop the clot! Do it consistently, every time, for maximal patient protection from VTE harm and ensuring safe and effective positive patient outcomes. We owe it to all pregnant mothers and their families!

Clinical Tip, Patient Safety, VTE

Watch Out 30 Day Readmissions are Avoidable for Stroke Patients – Startling News Requires Action

By Lynn Razzano, RN, MSN, ONCC

A recently published study, December 2013, on preventable readmissions within 30 days of ischemic stroke among Medicare beneficiaries looked at the proportion of post stroke readmissions that are potentially preventable or avoidable. This continues to remain unknown.  Preventable readmissions were identified based on 14 Prevention Quality Indicators developed for use with administrative data by the US Agency for Healthcare Research and Quality. National, hospital-level, and regional preventable readmission rates were estimated.

The findings based on the prevention quality indicators identified a small proportion of readmissions were classified as preventable. Clearly more research needs to be conducted in this area but the clinical significance, in the interim, is hospital level programs should reduce all-cause readmissions and costs should target high risk patients. Intensive work need to be done in how best to clinically identify the high risk patient criteria and develop a workable process, safety checklist, and protocol to identify the patient and interventions to prevent avoidable readmissions in the stroke patient population

The implications of this study are clear –  A call to action we should all be aware of and advocate stopping VTE in its tracks to reduce and preventis 30-day readmissions for stroke patients. We need to be on a vigilant watch on the warning signs of possible readmissions in the stroke patient. These patients face clinical challenges as well as mobility and functional hurdles that are next to none in terms of high-risk patient populations. We need to ask ourselves what are we maximally doing to prevent these and are there any ensuing signs that the stroke patient may be in a risk state for re admission.

The costs to our healthcare system we operate in daily are staggering for readmissions and I use VTE which is preventable and deemed a “never event “as the example. If the patient has just been recently discharged and medically complex they may be likely to be readmitted, having a recent hospitalization places patients at a higher risk for VTE development. In terms of the stroke patient this is even high due to insufficient ability to be mobile and ambulatory to the point that it would aid in VTE prevention.

This recent study is consistent with previous research on this same issue.

In a 2010 study published in Stroke, researchers found that almost two-thirds of Medicare beneficiaries discharged from hospital after an ischemic stroke die or are readmitted within a year. We still have considered, as well, those patients that have hemorrhagic stroke, Cerebral Vascular Disease and neurologically compromised disorders. The problem is indeed challenging and the volume of patients affected continue to grow so an answer is needed to provide the clinical guidance we should assess at time of discharge and transition to home or post-acute setting. There are many clinical stakeholders that should have a committed interest in developing a readmission checklist that could be used to baseline assess the patient before discharge.

The 2010 study also showed that these post discharge death and rehospitalization rates varied considerably among hospitals. Although academic hospitals and those in the Northeast and West had slightly more favorable outcomes, the size of an institution or its stroke center designation did not make much of a difference in terms of mortality and readmission rates.

“The very high rates of death and rehospitalization are in a sense staggering, and despite some advances, stroke continues to place a burden on this patient population, which is fee-for-service Medicare beneficiaries,” said lead study author Gregg C. Fonarow, MD, professor of cardiovascular medicine at the University of California at Los Angeles and associate chief of the Division of Cardiology at the David Geffen School of Medicine. “Also striking is the very substantial variation in clinical outcomes by hospitals”

What is the current impact of stroke in our health care system currently? Stroke is a major cause of hospitalization in the elderly individuals and is estimated to affect about 800,000 people per year in the United States.     

This number will continue to grow in volume due to the increasing numbers of “baby boomers” that may have significant risk factors for stroke, medically complex and chronic conditions, and repeated hospitalizations for stabilization of medical condition. For this fact and often readmission are avoidable in the stroke patient population, it is clinically significant to identify those factors that place the stroke patient at an escalated risk for re admission and re hospitalization post discharge.

In my clinical experience and through researching this topic to validate what I found to be in my clinical practice are the precursors/trigger factors to readmission in the stroke patient population are the following:

  • Hospitalization length of stay greater than 10 days
  • Medically complex or chronic conditions that may not have been well managed-in particular Congestive Heart Failure (CHF) and Cerebral Vascular Disease (CVD)
  • Readmitted within 30 days for elective procedures(medical and surgical) that were not well coordinated
  • Readmitted due to lack or inadequate outpatient care coordination. This could be eliminated if  follow up appointments would occur within 5-7 days of discharge or patient’s should be assigned a discharge coach, provided assistance with transportation to appointments/outpatient testing.
  • Readmitted due to lack of completed initial evaluation and stabilization. Inadequate evaluation and documentation would also be included in this trigger
  • Readmitted due to delay in palliative care consultation, coordination and or treatment which was necessary for the patient.
  • Readmitted after discharge due to inadequate or ill-defined discharge instructions that resulted from insufficient well-coordinated discharge instructions. This should be communicated to the patient, caregiver, significant other(s), the next transition of care facility i.e. rehabilitation and the patient’s PCP.
  • Potential for VTE development due to high risk factors for stroke patients and the fact of an readmission reoccurring within 30 days of discharge. The patient should be assessed prior to discharge for any VTE RFA and VTE prevention including anticoagulation and mechanical IPC should be ordered post discharge for home care VTE prevention.

In researching this topic for current successful ideas for preventing readmission for patients with complex medical conditions such as stroke I located one that has been trialed and appears novel with a unique approach to preventing readmissions. Louisiana Health Care Review lowered readmissions rates by 80 percent with care transition coaches:

The program works by pairing older patients with a “transition coach.” The patient agrees to meet with the coach within 48 hours of discharge and the coach helps the individual put together a list of questions for their primary care physician. Transition coach and patient teams also discuss questions about medications and devise a self-care plan after leaving the hospital, among other collaborative measures.

In conclusion, I think well-developed clinical recommendations that identify the factors that precipitate a readmission within 30 days for the stroke patient can promote patient safety, quality and lessen the associated economic costs that go hand in hand with a readmission to the hospital pot discharge. I think strong critical evaluation of current practice standards in your respective Stroke centers would benefit significantly in preventing avoidable readmissions. Use of patient safety checklists and engagement of the patient along with education goes a long way and has been proven highly successful in preventing adverse events and unnecessary hospitalization.

I hope this article has provided clinical insight into a significant problem we now face as two thirds of Medicare beneficiaries discharged from a hospital after an ischemic stroke die or are readmitted within one year, a new study has found. We can certainly change this type of statistics with updating our current practice, utilizing readmission trigger checklists and provide the comprehensive discharge planning, engagement and care coordination that is identifiably needed for this patient population.

Clinical Tip, Patient Safety, VTE

Clinical Tip: 7 Steps to Prevent VTE

By Lynn Razzano, RN, MSN, ONCC (Clinical Nurse Consultant)

New Study Demonstrates Risk of Blood Clots in Pregnant Women Admitted for Other Than Delivery and After Discharge

For a complete copy of this clinical tip, please see ObGyn.net.

  1. Focus on assessment and review the OB VTE risk assessment currently in place.
  2. Ensure that VTE risk reassessment of pregnant women is occurring for every admission to the hospital.
  3. Identify patients at risk for VTE.
  4. Utilize VTE prevention prophylaxis and make sure these are adhered to in “real time”.
  5. Communicate practice changes to the OB clinicians as well as hospital administration and get “buy in” for changes to ensure all OB admissions are captured for any reason in particular for non-delivery diagnosis.
  6. Proactively approach all discharge planning, so that pregnant woman are provided with a VTE prevention plan and the necessary prophylaxis for up to 28 days post discharge.
  7. Use proper VTE prevention communication to other healthcare providers of the patient’s care consistently as you would do for medication reconciliation.
Alarm Fatigue, Clinical Tip

Clinical Tip: Alarm Fatigue the Newest Clinical Hazard

By Lynn Razzano RN, MSN, ONCC (Clinical Nurse Consultant)

Increasingly we are seeing publications, alerts and evidence of the clinical phenomena entitled: “Alarm Fatigue”. What is the scope of this latest hazard and what are the new implications for clinical practice change.

The Joint Commission 2014 NPSG is about to be implemented and reinforces the defined problem called alarm management that is caused from Clinicians experiencing alarm fatigue. What have you done to start the implementation process of this NPSG? Increasing staff education, instilling alert reminders in the Health Record and the Nursing Care Plan are a start, but what other thoughts come to mind?   Ideas that come to mind – addition of a safety alarm checklist and imbedding it in patient safety rounds, and increased oversight in all areas where continuous monitoring is occurring.

The ECRI has issued a Top Ten Technological Hazard List for 2014 and although ECRI acknowledges that patient monitors are undoubtedly beneficial, ECRI says that the frequency of alarms can be detrimental:

“Excessive numbers of alarms—particularly alarms for conditions that aren’t clinically significant or that could be prevented from occurring in the first place—can lead to alarm fatigue, and ultimately patient harm. That is:

  • Caregivers can become overwhelmed, unable to respond to all alarms or to distinguish among simultaneously sounding alarms.
  • They can become distracted, with alarms diverting their attention from other important patient care activities.
  • They can become desensitized, possibly missing an important alarm because too many previous alarms proved to be insignificant.”

Implications for Clinical Practice to prevent Alarm Fatigue:

The goals of acting on prevention start with premier staff education so all clinicians involved in use of continuous monitoring equipment clearly know there role in maintaining appropriate alarms in maximum working state. This encompasses development of and maintaining valid clinical annual competencies, tracer methodology in direct observation and querying clinicians using monitoring equipment about reason and purpose of alarms. Proper alarm setting instructions or a checklist could accompany all monitoring equipment. Alert signs hung outside the patient’s door or cubicles are both visual cues which would serve as reminders. Electronic alerts could be imbedded in the physician order section and activated whenever there is an order for continuous monitoring equipment.

Moreover, a recent national survey found that hospitals would like tools to more easily and accurately assess a patient’s condition, such as a single assessment indicator. Seven out of 10 hospitals (70.7 percent) would like “a single indicator that accurately incorporates key vital signs, such as pulse rate, SpO2, respiratory rate, and etCO2.”

Could such a single assessment tool be implemented successfully?

Alarm Management and the potential for alarm fatigue has become a national patient safety issue that is preventable and needs to be recognized in order to reduce patient harm and decrease cost expenditures. Clinicians need to be aware of this and recognize this to the extent of developing and implementing, for example, a single assessment indicator as mentioned above. The necessary staff training and education should occur continually on the use of the assessment tool until it is verified as a best practice standard of care.

Quality checks and auditing should be ongoing in real time to readily identify when the standard practice and assessment has not been utilized and followed up on in the care of a specific patient or groups of patients.  Pro active corrective action plans can then be readily implemented and mandatory re- education using mentors can be instituted to ensure no further adverse patient occurrences.

What other tools or training would you recommend or like to see in your clinical practice?

Clinical Tip

Clinical Tip: Talking is not the same as Communicating

by Michèle Curtis, CeeShell Consulting, lead editor of “Glass’ Office Gynecology”

As the world becomes more global and more technological, opportunities for communication errors only increases.  Communication errors are one of the fundamental precursors for safety and quality errors in healthcare.  Supporting this is data showing that a shared language between health care provider and patient results in better outcomes and quality as well as improved hospital costs and patient satisfaction.  In the healthcare setting, we rely on the words as well as the physical cues and signals patients give us when they are telling us their story.  But if the provider and the patient don’t speak the same language, the risk for misunderstandings and errors increases dramatically, especially if they try to ‘muddle through’ or if information is obtained through a family member or friend who is helping to translate.

Healthcare providers spend quite a few years learning ‘the language’ of healthcare and medicine.  Our skills in good communication with patients rely, in part, on our ability to ‘translate’ the complex ideas and processes of medicine into everyday terms and explanations.  In a very real sense then, healthcare providers act as interpreters when they are speaking their native language with another native language speaker in the context of a healthcare setting.  If the patient doesn’t share the same language as the healthcare provider, then an interpreter is needed.  But for the conversation to be optimal, the interpreter must also be familiar with medical concepts and terms and colloquialisms used regarding those terms (in both languages), as well as the culture relative to the patient’s native language.  For this reason, medical interpreters should be trained professionals (for more information, go to the International Medical Interpreters Association and the independent National Board of Certification for Medical Interpreters websites).

The overall goal of a healthcare encounter is to establish a good relationship with the patient but for health care providers, having a communication intermediary feels awkward or unwieldy.  Healthcare providers are taught how to communicate and interview patients during their training years; the use of interpreters is another way of communicating and interviewing but it also requires special training. Unfortunately, most healthcare providers never receive it, although there is data demonstrating effective training concepts as well as productive approaches and practices to be used in the actual clinical setting.   It is time to incorporate training health care providers the skill set of optimally working with interpreters, either in person or over the phone, as a means of delivering safer, high quality care to patients.

Here are some tips for working with a medical interpreter:

1)       Talk with the interpreter about the expected content of the interaction and the expectations of the interpreter, as well as providing relevant information to the interpreter about the patient

2)      Let the interpreter know what your style of communication as well as preferred method of interpretation and seating arrangements (having the interpreter sit behind the patient may help avoid conversations between the interpreter and patient for extended periods, which contributes to privileging the interpreter-patient relationship over the provider-patient relationship)

3)      Ask the interpreter if there are any cultural issues or factors that may create difficult areas of conversation or exploration as well as possible ways to mitigate them without sacrificing them as communication items

4)      Introduce the interpreter to the patient and explain what the process is going to be like; do this while looking at the patient directly, not the interpreter

5)      Look at the patient while talking – not the interpreter

6)      Plan what you want to say ahead of time – this helps to keep the interpreter from having to back up or rephrase things; avoid colloquialisms and idioms

7)      Use consecutive, not simultaneous, translation and keep sentence short

8)      If you have never worked with an interpreter, practice with one, using a colleague or, if you are lucky enough, a bilingual standardized patient

9)      At the end of the patient encounter, debrief with the interpreter over what went well and what to look to improve- you will most likely work with them again in the future!

Clinical Tip, VTE

Clinical tip: Completely preventable problems cost an average-sized hospital millions per year

By Lynn Razzano RN, MSN, ONCC (Clinical Nurse Consultant)

That’s the bottom line of a report from the Healthcare Management Council (HMC). HMC analyzed federal data to identify the most common hospital-acquired conditions (HACs) as well as their annual cost per patient and the annual average cost to hospitals.

The results are startling. According to the report, HACs cost a 200-bed hospital roughly $2 million extra annually. Here are the results, broken down by most common type of complication:

  1. Decubitus ulcers, more commonly known as bedsores, cost a mid-size facility roughly $536,000 per year, and $9,200 per patient.
  2. Post-operative pulmonary embolisms (PE) and deep-vein thrombosis (DVT) cost hospitals $564,000 annually, at $15,500 per patient.
  3. Accidental punctures and lacerations cost $248,100 per hospital — $8,300 per patient.
  4. Post-operative respiratory failure cost $261,000 per hospital — $21,900 per patient.
  5. Hospital-acquired infections cost an average hospital $252,000 — $24,500 per patient.

The Physician-Patient Alliance for Health & Safety has brought together a panel of healthcare experts to develop safety recommendations to prevent PE and DVT in maternal patients and help reduce maternal morbidity that has doubled since 1987.

What have you and your healthcare facility done to address preventable costs?