IPC To Prevent Blood Clots in Stroke Patients Recommended at International Stroke Conference

Presenting at a standing-room-only meeting at the recent International Stroke Conference (ISC), health experts recommended shortened door-to-treatment times and the use of intermittent pneumatic compression (IPC) to help prevent deep vein thrombosis (DVT) and pulmonary embolism (PE) in stroke patients.

(VTE patients can be both old and young, said Michael Wong, JD, Executive Director, Physician-Patient Alliance for Health & Safety at ISC)

Stroke is a leading cause of death and disability in the U.S., with 800,000 cases occurring each year. Each year in the United States, an estimated 300,000 cases of VTE occur. Mortality can be as high as 3.8 percent in patients with DVT and 38.9 percent in those with PE. VTE is associated with a high risk of death in the U.S. and Europe, with an estimated incidence rate of 1 in 1,000 patients. VTE is particularly common after a stroke. Approximately 20 percent of hospitalized immobile stroke patients will develop DVT, and 10 percent a PE.^[1]

In reviewing the treatment approaches to prevent DVT in stroke patients, Mark J. Alberts, MD (Clinical Vice-Chair for Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center) spoke about the results of the recent CLOTS 3 study which showed a 29 percent reduction in life-threatening DVT — and a 14 percent reduction in overall mortality — for patients receiving IPC therapy.

Although there are many different types of IPC (calf or thigh-length, single or sequential, asymmetric or circumferential, fixed or variable frequency, rapid or slow inflation), only thigh-length sleeves were tested in CLOTS 3. Using thigh-length IPC makes intuitive sense, explained Dr. Alberts, as it applies pressure on areas of the leg where blood clots are likely to develop.

Moreover, Dr. Alberts pointed out five key benefits to using thigh-length IPC:

1. Non-invasive approach
2. Generally well tolerated
3. Minimal side effects
4. Less costly than medications
5. Can be used in all types of stroke patients

Assessing and treating stroke patients should be done in as short a period of time as possible. Successful health outcomes in stroke patients often depends on having as short a door-to-treatment time as possible, emphasized Laurie Paletz, BSN, PHN, RN-BC (Stroke Program Coordinator, Cedars-Sinai Medical Center). Delays in evaluation and initiation of therapy should be avoided because the opportunity for improvement is greater with earlier treatment. This not only means having a collaborative team effort, but looking at anything that might shorten door-to-treatment times, including having designated parking for stroke patients.

Ms. Paletz also highlighted the need to use the treatments that Dr. Alberts discussed. For example, clinicians should make sure that the IPC is being used and not hanging across the bedrail, and that the patient is not only wearing IPC, but that it is turned on.

Unfortunately, the provision of needed prophylaxis has been sub-optimal. Ms. Paletz encouraged clinicians to use available VTE treatments:

Mr. Wong discussed the Stroke VTE Safety Recommendations. These Recommendations may help reduce death and disability among stroke victims due to VTE. Developed by a group of leading neurological health and patient safety experts brought together by the Physician-Patient Alliance for Health & Safety, the Stroke VTE Safety Recommendations incorporate the latest research.

The Stroke VTE Safety Recommendations provide four concise steps that:

1. Assess all admitted patients with a stroke or rule out stroke diagnosis for VTE risk with an easy to use checklist.

2. Provide the recommended prophylaxis regimen, which includes the use of mechanical prophylaxis and anticoagulant therapy.

3. Reassesses the patient every 24 hours, prior to any surgical or procedural intervention or change in the patient’s condition.

4. Ensure that the patient is provided appropriate VTE instructions and information upon hospital discharge or transition to rehabilitation.

A pdf of the Stroke VTE Safety Recommendations can be viewed by clicking here.

For a pdf of the presentation given at ISC, please click here.

^[1] Dennis MS, Sandercock P, Reid J, et al. Effectiveness of Intermittent Pneumatic Compression in Reduction of Risk of Deep Vein Thrombosis in Patients Who Have Had a Stroke (CLOTS 3): a Multicenter Randomized Controlled Trial. The Lancet. Published online May 31, 2013.

Weekly Must Reads in Patient Safety (Feb 13, 2015)

We hope there are no superstitious people reading on this Friday the 13th.

Let’s get to it. Must Reads from the past week.

New Stroke VTE Safety Recommendations Prevent Blood Clots In Stroke Patients

Earlier this week, PPAHS announced the release of safety recommendations targeting the prevention of venous thromboembolism (VTE) in stroke patients.

Stroke is a leading cause of death and disability in the U.S., with 800,000 cases occurring each year.

Download the Stroke VTE Safety Recommendations here.

Four Reasons to Expand Capnography

Advance Healthcare Network for Respiratory Care & Sleep Medicine published an article outlining why health systems should expand the use of capnography.

1. Enhancing patient safety
2. Newer guidelines and checklists to monitor patients
3. Improved outcomes
4. Improved consistency of care.

Citing experts like Dr. Bhavini Kodali, Dr. Frank Overdyk (who sits on the PPAHS board of advisors)—and referencing the PPAHS PCA Safety Checklist—the article is a good summary of why capnography use should be expanded outside the OR.

Health Illiteracy a Root Cause of Medical Error

In 2004, The Institute of Medicine (IOM) released a report, saying that that 90 million people in America have difficulty understanding and using health information.

On a personal blog, Thomas Sharon, RN, MPH, recently shared his perspective on patients who lacked basic health literacy after encountering thousands of patients in the home environment over two decades. It is always good to get perspectives from the field, so we thought we would highlight this blog article.

Both the IOM report brief and Mr. Sharon’s article may be worth reading.

Patient Satisfaction Scores Not Affected by Amount of Opioids Given in Emergency Room

Pain Medicine News reports that researchers at two New England hospitals performed a retrospective analysis of medical records and completed surveys of nearly 5,000 patients seen in the ER department.

The researchers asked whether the amount of opioids administered in the ER were associated with Press Ganey scores, a common tool to measure patient satisfaction, according to the authors. The answer, they found: no.

According to Chris Pasero, pain management educator and clinical consultant:

“What’s happening nation-wide is a focus on opioid-only treatment plans. This is problematic.”

The new research may strengthen the case for multi-modal pain management programs.

Can Turning Down Alarms Improve Patient Safety?

A study from one of the intensive care units at Abbott Northwestern Hospital looked at whether changing default settings of pulse-rate alarms could improve patient safety.

By changing the thresholds, the study found that the number of pulse rate alarms dropped 76 percent within six months without any emergencies being missed.

Researchers at Dartmouth-Hitchcock Medical Center likewise observed benefits from revising default alarm settings.

Thanks, @AAMIFoundation and others, for tweeting about the Abbott story.

https://twitter.com/AAMIFoundation/status/564820613559513089

New Stroke VTE Safety Recommendations Prevent Blood Clots In Stroke Patients

Health Expert Panel Encourage Use of Venous Thromboembolism Recommendations to Reduce Adverse Events and Save Lives

The Physician-Patient Alliance for Health & Safety is pleased to announce the release of safety recommendations targeting the prevention of venous thromboembolism (VTE) in stroke patients.

Stroke is a leading cause of death and disability in the U.S., with 800,000 cases occurring each year.

“Evidence shows that the health of approximately one in three stroke patients will deteriorate within 24 hours after suffering a stroke. This points to a critical need for intensive continuous monitoring of blood pressure, temperature, oxygenation and blood glucose of all stroke patients to rapidly assess and protect their health and safety,” explains Deborah V. Summers (Stroke Program Coordinator, Saint Luke’s Health System’s Marion Bloch Neuroscience Institute). “One of the deteriorating conditions that may develop within 24 hours of a stroke incident and which may be preventable is PE [pulmonary embolism], which may be fatal. If VTE [venous thromboembolism] risk factor and prophylactic measures are instituted early on, fatal PE may be prevented.”

VTE is a common and potentially avoidable cause of death and illness in hospitalized patients. With about 300,000 total cases per year, VTE is particularly common in stroke patients. Approximately 20 percent of hospitalized immobile stroke patients will develop a deep vein thrombosis (DVT), and 10 percent a pulmonary embolism (PE).

Mortality can be as high as 3.8 percent in patients with DVT and 38.9 percent in those with PE.

Despite these statistics, the use of VTE prophylactic treatment has been shown to be suboptimal for admitted patients in general.^[1] When specifically looking at stroke patients, it has been found to be “underutilized and rarely started after the first day of hospitalization”^.

”Based on the high incidence of DVT and PE in patients with stroke, prophylaxis of VTE is recommended for all patients with stroke admitted to the hospital with weakness”, says

Mark Reiter, MD, MBA (CEO, Emergency Excellence Residency Director, The University of Tennessee at Murfreesboro; President, American Academy of Emergency Medicine).

Dr. Reiter recommends the use of intermittent pneumatic compression and cites the landmark Clots 3 study. “We have the clinical evidence – let’s use it,” says Dr. Reiter. “Martin Dennis, MD (University of Edinburgh, Western General Hospital) led a study of nearly 3,000 stroke patients in the United Kingdom comparing the efficacy and safety of intermittent pneumatic compression (IPC) therapy against routine care (hydration, aspirin, graduated compression stockings and/or anticoagulants). The study’s purpose was to evaluate the effectiveness of IPC in decreasing the risk of proximal DVT in patients who have had a stroke. Sponsored by the University of Edinburgh and the National Health Service, the randomized study found a 29-percent reduction in life-threatening DVT — and a 14 percent reduction in overall mortality — for patients receiving IPC therapy. Clots 3 is a landmark study that should transform the clinical practice to prevent DVT in stroke patients.”

The Stroke VTE Safety Recommendations may help reduce death and disability among stroke victims due to VTE. Developed by a group of leading neurological health and patient safety experts brought together by the Physician-Patient Alliance for Health & Safety, the Stroke VTE Safety Recommendations incorporate the latest research.

The Stroke VTE Safety Recommendations provide four concise steps that:

1. Assess all admitted patients with a stroke or rule out stroke diagnosis for VTE risk with an easy to use checklist.

2. Provide the recommended prophylaxis regimen, which includes the use of mechanical prophylaxis and anticoagulant therapy.

3. Reassesses the patient every 24 hours, prior to any surgical or procedural intervention or change in the patient’s condition.

4. Ensure that the patient is provided appropriate VTE instructions and information upon hospital discharge or transition to rehabilitation.

A pdf of the Stroke VTE Safety Recommendations can be viewed by clicking here.

^[1] Gaspar L, Stvrtina S, Ocadlik I et al. Autopsy-proven pulmonary embolism: a major cause of death in hospitalized patients. Adv Orthop. 2010;2:8-14.

Caprini JA, Tapson VF, Hyers TM, et al; for the NABOR Steering Committee. Treatment of venous thromboembolism: adherence to guidelines and impact of physician knowledge, attitudes, and beliefs. J Vasc Surg. 2005;42:726-733.

Yu HT, Dylan ML, Lin J, Dubois RW. Hospitals’ compliance with prophylaxis guidelines for venous thromboembolism. Am J Health Syst Pharm. 2007;64:69-76.

Recommendations for Reducing Death and Disability among Stroke Victims to be released at International Stroke Conference 2015

Guidelines Poised to Change Standard of Care for Stroke Treatment and Help Caregivers Lower Incidences of Venous Thromboembolism (VTE) in Ischemic and Hemorrhagic Stroke Patients

To reduce death and disability among stroke victims – and help healthcare providers lower rates of life-threatening venous thromboembolism (VTE) in ischemic and hemorrhagic stroke patients – leading neurological health and patient safety experts will release Stroke VTE Safety Recommendations during the International Stroke Conference (ISC) 2015, February 11-13 in Nashville.

Created by a group of leading neurological health and patient safety experts brought together by the Physician-Patient Alliance for Health & Safety, the Stroke VTE Safety Recommendations will be presented at a special luncheon taking place on the opening day of ISC 2015 – Wednesday, February 11 – from 12:50-1:30pm – CV Expert Theater, Booth 636.

Presenters will include:

• Mark J. Alberts, MD (Clinical Vice-Chair for Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center)
• Laurie Paletz, BSN, PHN, RN-BC (Stroke Program Coordinator, Cedars-Sinai Medical Center)
• Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)

The recommendations take direct aim at reducing VTE, commonly referred to as blood clots, which is a common and preventable cause of death and illness in hospital patients. Each year in the United States, an estimated 300,000 cases of VTE occur.[i] Mortality can be as high as 3.8 percent in patients with deep vein thrombosis (DVT) and 38.9 percent in those with pulmonary embolism (PE). [ii] VTE is associated with a high risk of death in the United States and Europe, with an estimated incidence rate of 1 in 1,000 patients. [iii] VTE is particularly common after a stroke. Approximately 20 percent of hospitalized immobile stroke patient will develop DVT, and 10 percent a PE.[iv]

Culminating many months of lively dialogue and intensive research among the members of the Stroke VTE Safety Recommendations Working Group, the guidelines incorporate the landmark CLOTS 3 study – a groundbreaking study of nearly 3,000 stroke patients in the United Kingdom that compared the efficacy and safety of intermittent pneumatic compression (IPC) therapy against routine care (hydration, aspirin, graduated compression stockings and/or anticoagulants). Sponsored by the University of Edinburgh and the National Health Service, the randomized study found a 29-percent reduction in life-threatening deep vein thrombosis — and a 14 percent reduction in overall mortality — for patients receiving IPC therapy.[v]

CLOTS 3 was led by Martin Dennis, MD (University of Edinburgh, Western General Hospital), a member of the VTE Safety Recommendations Working Group, who predicts the study will transform the clinical practice to prevent DVT in stroke patients.

“CLOTS 3 showed for the first time that thigh-length IPC reduces the risk of DVT after stroke, and moreover improved survival,” Dr. Dennis said. “Therefore, I would expect its use to increase rapidly. Certainly in the UK, there are national programs to introduce IPC into all stroke units (and) national stroke audits are monitoring its use.”

The ISC 2015 luncheon is sponsored by the Covidien Group of Medtronic, the global leader in medical technology – alleviating pain, restoring health and extending life for millions of people around the world.

“The presentation of the Stroke VTE Safety Recommendations at the International Stroke Conference 2015 represents not only a landmark event in the advancement of patient safety, but also an incredible opportunity for clinicians throughout the world to significantly reduce the incidence of DVT in ischemic and hemorrhagic stroke patients,” said Michael Tarnoff, MD, vice president and chief medical officer, Covidien Group, Medtronic. “As a company, improving patient safety underscores everything we do and we are truly honored to be associated with this milestone occasion.”

[i] Furie, KL, MD, MPH, FAHA, et al. Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. 2011.

[ii] Bosson JL. Deep vein thrombosis in elderly patients hospitalized in subacute care facilities: a multicenter cross-sectional study of risk factors, prophylaxis, and prevalence. Arch Intern Med. 2003 Nov 24;163(21):2613-8.

[iii] Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing. NICE Guidelines. August 2014. http://www.nice.org.uk/guidance/CG144

[iv] Dennis MS, Sandercock P, Reid J, et al. Effectiveness of Intermittent Pneumatic Compression in Reduction of Risk of Deep Vein Thrombosis in Patients Who Have Had a Stroke (CLOTS 3): a Multicenter Randomized Controlled Trial. The Lancet. Published online May 31, 2013.

[v] Dennis MS, Sandercock P, Reid J, et al. Effectiveness of Intermittent Pneumatic Compression in Reduction of Risk of Deep Vein Thrombosis in Patients Who Have Had a Stroke (CLOTS 3): a Multicenter Randomized Controlled Trial. The Lancet. Published online May 31, 2013.

Weekly Must Reads in Patient Safety (Feb 6, 2015)

While the Patient Safety, Science & Technology Summit called for “orders of magnitude” change, the story of Amber Scott, a mother who slipped into a coma during delivery, illuminates why improving safety for even a single person matters.

Can Business Savvy, Clout, and Charisma Supercharge Patient Safety?

Medical professionals congregated at the Patient Safety Summit to support the goal of eliminating preventable medical errors by 2020.

Forbes contributors Michael Millenson and Dan Munro penned two pieces, here and here respectively, that are both worth a read—Millenson’s, for its fresh perspective as a first-time attendee, and Munro’s, for its breakdown of a rather provocative quote about “evil” people in the health care industry.

Mother Who Gave Birth During Coma on Road to Miraculous Recovery

WDSU News published a follow-up piece on Amber Scott, the woman who 2.5 years ago slipped into a coma after giving birth. Amber is well on the road to recovery as she and her husband raise their two-year old daughter Adeline.

The coma complications were related to venous thromboembolism (VTE), a leading cause of maternal morbidity and mortality in the USA.

Amber’s story, which PPAHS has previously shared, highlights the risk of blood clots for new and expectant mothers.

Risk factors for VTE can be reduced by simple and cost-effective measures. PPAHS developed OB VTE Safety Recommendations to help hospitals reduce the risk of VTE.

Standardized Alarms to Combat Alarm Fatigue

The Journal of the American Society for Blood and Marrow Transplantation and the American Journal of Nursing recently published research papers on standardized alarm care processes.

PPAHS Advisor Maria Cvach, Assistant Director of Nursing, Clinical Standards at The Johns Hopkins Hospital, has recommended standardized care processes among other possible solutions.

Weekly Must Reads in Patient Safety (Jan 16, 2015)

Achieving patient safety is the watchword for this week’s Must Reads.

2015 National Patient Safety Goals

The Joint Commission’s 2015 National Patient Safety Goals were released. Although TJC says that it has “no new Goals for 2015”, it is probably a good presentation for all healthcare facilities to look at to make sure they are meeting these objectives.

The first two articles may help achieve better patient safety. The latter two were shared by the Twitter health care and patient safety community – many thanks for making these Must Reads a collaborative effort.

Using Capnography to Effectively Measure How Patients Are Breathing

The Journal of Clinical Engineering discusses how Glendale Adventist Medical Center (Glendale, CA) is improving patient safety by using capnography to monitor patients during moderate sedation.

Michael O’Connor (Director of Respiratory Therapy, Glendale Adventist Medical Center) explains:

Glendale Adventist Medical Center is committed to providing the highest quality of care. Our widespread use of capnography to monitor the breathing of patients who are being sedated is in line with the latest requirements from the ASA [American Society of Anesthesiologists] and underscores our dedication to patient safety.

New Toolkit to Reduce Alarm Fatigue

The National Association of Clinical Nurse Specialists (NACNS) released a toolkit “to facilitate CNSs’ efforts to facilitate appropriate alarm management and help staff implement strategies to ensure alarm safety”.

“As leaders in ensuring evidence-based care, CNSs have an important role to play in reducing the potentially dangerous and deadly problem of alarm fatigue,” said NACNS 2014 President Les Rodriguez, MSN, MPH, RN, ACNS-BC, APRN. “Our toolkit was developed by a group of national experts whom NACNS convened to address this important issue and provide resources that will help nurses across the country combat this problem. It is intended to help guide their efforts to improve patient safety and quality of care. The toolkit includes everything a CNS needs to work collaboratively with an interprofessional team to assess the clinical environment, and then develop implement and evaluate appropriate interventions.”

New Rules to Curb ‘Epidemic’ of Cesarean Births in Brazil

From the article:

Brazil has unveiled new rules aimed at stemming the South American nation’s “epidemic of cesareans” and promoting natural births among private health care providers.

Health Minister Arthur Chioro called Brazil’s obsession with cesareans, which account for more than eight out of 10 births handled by private health providers, a “public health problem.”

New Rules to Curb 'Epidemic' of Cesarean Births in Brazil- 84% of births covered by health plans are C-section http://t.co/4fX0RLGrBX

— Minas International (@MinasIntl) January 9, 2015

Hat tip to @MinasIntl for sharing this article on Twitter. Dr. Peter Cherouny said in a past webinar “no patients are low risk” when it comes to cesarean delivery and venous thromboembolism.

Recent Research About Nursing, December 2014

“After a while, alarms stop being so alarming.”

Yikes.

Read the article here.

Hat tip to @comunikator and others for sharing this article on Twitter.

Sharing Nursing's Knowledge Research Re #Nursing: Study finds "alarm fatigue" poses dangers http://t.co/wc4ihrVbRo

— Linda Wright Moore (@LindaWrightMoor) January 7, 2015

Weekly Must Reads in Patient Safety (Jan 9, 2015)

The Physician-Patient Alliance for Health & Safety wishes you and your loved ones a Happy and SAFE New Year!

We particularly emphasize SAFE, because the latest news on patient safety shows that there is a lot work yet to be done … or perhaps we haven’t started? …

No Improvement in Patient Safety in Last 15 Years

HC Pro’s Patient Safety Monitor reports that, according to health experts testifying to a Senate subcommittee, that there has been no improvement in patient safety in the last 15 years:

If the truth hurts, any patient safety advocates that tuned into the Senate subcommittee hearing on patient safety were probably cringing.

No one minced words at the hearing for the Subcommittee on Primary Health and Aging on July 17, as health experts testified that patient safety has remained largely stagnant for the last 15 years. In some respects, it’s worse, failing to prevent as many as 400,000 patient deaths each year, four times more than estimates from the Institute of Medicine (IOM) in 1999.

Penalties for Hospital-Acquired Conditions

Validating this sober assessment, more than 700 hospitals “will see their total Medicare payments docked by 1 percent in fiscal 2015 as part of the first year of a federal penalty program aimed at reducing preventable harm and improving patient safety”, reports Modern Healthcare. Hospital-acquired conditions included pressure ulcers and pulmonary embolisms.

Although one would think that teaching hospitals would be the vanguard of innovation and safety, hospitals penalized include many well-known teaching hospitals – including Intermountain Medical Center, Ronald Reagan UCLA Medical Center, the Cleveland Clinic, Geisinger Medical Center, Brigham and Women’s Hospital, NYU Langone Medical Center and Northwestern Memorial Hospital.

That said, if you have a choice of hospitals, data from AHRQ’s Healthcare Cost and Utilization Project suggests that being admitted at a hospital in the West is preferable to going to one in the South:

Rates of potentially preventable hospitalizations in the United States declined 14 percent from 2005 to 2011, but rates varied widely by geographic region, according to a new statistical brief from AHRQ. Potentially preventable hospitalizations are admissions for certain acute illnesses or worsening chronic conditions that may have been avoided with higher-quality outpatient treatment and disease management. Data from AHRQ’s Healthcare Cost and Utilization Project showed that rates of potentially preventable hospitalizations in 2011 were lowest in the West (at 1,220 discharges per 100,000 population) and highest in the South (at 1,845 discharges per 100,000). Hospitals in the South had a 17.2 percent higher rate of potentially preventable hospitalizations than the overall national rate in 2005, but by 2011 it was reduced to 10.5 percent higher than the national rate.

Pregnancy-related deaths on the rise in the US

Moreover, a new study has found that even something as common as childbirth may no longer be safe:

A century ago, deaths during pregnancy or childbirth were not uncommon; however, advances in prenatal care have made great strides in increasing the likelihood of a good outcome for both mothers and their offspring. However, a new study has reported that pregnancy-related mortality has increased in recent years in the United States.

The Answer

Maureen F. Cooney, DNP, FNP, BC (Westchester Medical Center, Valhalla, NY), who spoke at the inaugural meeting of the National Coalition to Promote Continuous Monitoring of Patients on Opioids, says the answer (at least for patients receiving opioids) is continuous monitoring. However, she reminds us that technology alone is not the answer. We also need trained bedside nurses to keep patients safe from opioids and the dangers of high-alert medications:

Continuous monitoring of patients receiving opioid therapy to prevent opioid-related respiratory depression certainly offers the hope of reducing devastating outcomes from our well-intended efforts to assure patient comfort. However, in this climate of rapid, high-tech, outcomes-driven healthcare, it is essential to keep in mind the end user—particularly the bedside nurse.

Thanks @HIEcentral for tweeting about this!

Top 16 Patient Safety Must Reads of 2014

This year, the Physician-Patient Alliance for Health and Safety introduced a weekly round-up of must-read articles in patient safety. The hand-picked list has consistently seen high engagement from our dear readers.

With that in mind, we thought we would compile a list of the Top Patient Safety Must Reads of 2014.

Expansion of Use of Capnography for Patient Safety
August 22, 2014

For postsurgical patients receiving opioid pain medications, effective and continuous electronic respiratory monitoring is critical. As a result, an increasing number of health care institutions are expanding their use of capnography to ensure maximum patient safety and prevent adverse events that are predictable.

To read this RT Magazine article, please click here.

National Coalition for Alarm Management Safety
August 29, 2014

The National Coalition for Alarm Management is a group of thought-leaders sharing information with other pioneers in the “alarm-management space,” driving improvement in alarm management nationwide, and seeking standardization where possible. Members come from all aspects of alarm management: the clinical community; industry; device regulators; hospital accreditors; and professional societies.

For more information on the National Coalition for Alarm Management and this month’s presentation, please click here.

Understanding healthcare’s top technology hazard
September 4, 2014

“Even with some of the world’s top device manufacturers (General Electric, Phillips, Stanley, Medline, etc.) working to develop “smart alarm” systems, the dangers are still very real. On the Emergency Care Research Institute (ECRI) Top 10 Health Technology Hazards for 2013, alarm hazards ranked number one. The issue of alarm fatigue has many facets.”

For the article, please click here.

Joan Rivers’ Death
September 12, 2014

What Killed Joan Rivers? Piecing Together a Medical Mystery

Dr Karen Sibert offers a thoughtful discussion that raises questions and offers useful information about routine procedures. As she observes, “There are minor operations and procedures, but there are no minor anesthetics. This could turn out to be the one lesson learned from the ongoing investigation into the death of comedian Joan Rivers.”

4 Lessons Learned from the Death of Joan Rivers

This article we co-authored with Kenneth P. Rothfield, M.D., M.B.A., Chairman, Department of Anesthesiology, Saint Agnes Hospital (Baltimore, MD). It offers 4 lessons to be learned from the death of Joan Rivers that can help others better prepare for safe medical procedures.

Capnography Outside the Operating Rooms
September 19, 2014

This article in Anesthesiology, “Capnography Outside the Operating Rooms” written by Dr Bhavani Kodali (Associate Professor, Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School), sheds light on capnography outside the operating room.

Alarm Fatigue – Not Just an Annoyance to Nursing Staff
September 26, 2014

Hats off to @DicksonData for pointing out this article that reminds us that “noise is an environmental stressor that can have physiological and psychological effects” on patients.

C-section America’s most common major surgery?
October 3, 2014

Hats off to @JuanGrvas for asking “How did the C-section become America’s most common major surgery?” and pointing out this video by Chileshe Nkonde-Price, a cardiologist at the University of Pennsylvania, who wants to avoid an unnecessary C-sections.

An Unnecessary Cut? How did the C-section become America’s most common major surgery? http://t.co/BSGMrqI41X

— Juan Gérvas (@JuanGrvas) October 5, 2014

Helping Hospitals Fight The Battle Against Alarm Fatigue
October 17, 2014

Robert J. Szczerba’s Forbes article made waves as it looked at alarm fatigue. As Szczerba notes:

“One of the top technologies hazards in the healthcare system is the problem of alarm fatigue, in which the sheer number, variety, and frequency of machine alarms in a hospital room leads to many of them being ignored or muted. The negative results range from annoyance to patient deaths.”

To help reduce alarm fatigue, we offer advice from members of our advisory board:

• 10 ways to reduce alarm fatigue by Gina Pugliese (Vice President, Premier Safety Institute)
• Three Tips For Decreasing Alarm Fatigue interviewing and citing research by Maria Cvach, RN, MSN, CCRN (assistant director of nursing and clinical standards at The Johns Hopkins Hospital)

Actions Produce Results
October 24, 2014

Hats off to @TGandhi_NPSF for tweeting about this study about the affects of rounds, culture, and caregiver burnout. If leaders want to change culture and behavior, they need to be involved.

“We can’t always predict when a patient will slip from moderate sedation to deep sedation”
October 31, 2014

In this Wall Street Journal article, our own advisory board member, Frank Overdyk, MSEE, MD (Executive Director for Research, North American Partners in Anesthesiology; Professor of Anesthesiology, Hofstra North Shore-LIJ School of Medicine) reminds us:

We can’t always predict when a patient will slip from moderate sedation to deep sedation,” he says, and if the staff is unaware or inexperienced, and help isn’t available to deal with breathing and airway issues, a patient can suffer an oxygen-related brain injury “in approximately five minutes.”

Death During Childbirth
November 7, 2014

ABC news reports that “Kymberlie Shepherd, 26, died shortly after giving birth … The cause of her death was a rare amniotic fluid embolism (AFE), a leading cause of maternal mortality in the developed world.”

(Kymberlie Shepherd with her fiancé, Wayde)

Observational study counts alarms in ICUs to better understand alarm fatigue
November 21, 2014

The number of alarms collected during one month in five ICUs is “staggering” according to researchers who found that, in nearly 50,000 hours, 2.5 million unique audible and inaudible alarms occurred. The research calls for smarter monitors.

Also, hat tip to @Krista_Bones for sharing this article in Fierce Healthcare. Some good commentary by Krista, who points out that patients and families get fatigued from all the alarms—not just clinicians.

Awesome! Patients & families get alarm fatigue too! MT @FierceHealthIT: Team-based approach cuts alarm fatigue by 80% http://t.co/lGmo7Kld90

— Krista Bones (@Krista_Bones) November 13, 2014

Make Health Technology Safer
November 28, 2014

In this interview with Institute for Healthcare Improvement Executive Director and patient safety expert, Frank Federico, RPh (who we are proud to say is on our advisory board) offers these tips to make health technology safer.

1.3 million adverse events prevented since 2010
December 5, 2014

The Agency for Healthcare Research and Quality (AHRQ) estimates that 1.3 million fewer patients were harmed in U.S. hospitals from 2010 to 2013. AHRQ attributes this to “focused and widespread efforts to reduce surgical-site infections, adverse drug events and other preventable incidents.”

Modern monitoring systems contribute to alarm fatigue in hospitals, UNC study shows
December 12, 2014

Hats off to @UNC for an example of winning the battle against too many alarms.

Modern monitoring systems contribute to alarm fatigue in hospitals, UNC study shows. http://t.co/zNZ0qZv1SA

— UNC-Chapel Hill (@UNC) December 7, 2014

The Value of Safer Care
December 19, 2014

A survey by Altarum Institute and Drexel University found that “most respondents would choose a hospital with a higher patient safety rating, even if it meant paying an additional $1000 in out-of-pocket costs.”

Top 8 Blood Clot Patient Safety Articles in 2014

Of the more than 125 articles we posted in 2014, below are eight of the most read and most discussed articles on blood clots (order is by publication date):

1. New VTE Safety Recommendations Prevent Blood Clots In Pregnant Mothers: Healthcare Organizations Encourage Use of Venous Thromboembolism Recommendations to Reduce Adverse Events and Save Lives (December 5, 2013)

The Physician-Patient Alliance for Health & Safety, the Institute for Healthcare Improvement and the National Perinatal Association are pleased to announce the release of safety recommendations targeting the prevention of venous thromboembolism (VTE) in maternal patients.

Maternal death rate in the USA has more than doubled in the last 25 years and data from the Centers for Disease Control and Prevention (CDC) show that pregnancy-related mortality is rising in the United States:

2. Managing Risk and Reducing Readmissions: New Safety Recommendations Prevent Venous Thromboembolism in Maternal Patients (January 2014)

The importance of the OB VTE Safety Recommendations:

Patients undergoing general surgery overall are at high risk to develop DVT. It has been reported that the cost associated with a thromboembolic event averages $10,804 for a DVT and $16,644 for a pulmonary embolism (PE). The CDC includes reduction in DVT as one of ten major factors for reducing adverse events. 

3. “No patients are low risk” when it comes to cesarean delivery and venous thromboembolism (February 4, 2014)

According to Peter Cherouny, MD, Emeritus Professor, Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont, Chair and Lead Faculty of the IHI Perinatal Improvement Community:

“Essentially every patient is at moderate risk. The only exceptions to that would be patients who have surgery less than 30 minutes who are under 40 who have no other risk factors. I would make the argument that no patients are low risk.”

As Dr. Cherouny explains, even though some cesarean surgeries are performed in less than 30 minutes, the VTE risk clock starts during induction of anesthesia.

“If you take that into account,” Dr. Cherouny says, “there is really no case of a patient in the low risk category undergoing a cesarean section.”

4. Put the “M” Back in Maternal-Fetal Medicine: Implementing VTE Prevention Guidelines (February 19, 2014)

Every physician knows that venous thromboembolism (VTE) kills. Often, there are symptoms, such as pain and swelling in the leg or a severe headache. If a patient communicates these symptoms to you, there is a good chance that if a VTE is responsible it can be identified and managed. But sometimes, VTE is sudden and has catastrophic results, as it did with Amee VanTassell, pictured left with her father. She died from a blood clot 4 days after delivering her daughter via cesarean section at the age of 36.

Other patients, such as Amber Scott, are luckier. Amber, now age 30 (pictured right with her daughter), fell into a coma because of a blood clot that developed in her brain. While in a coma, a cesarean section was performed, and Amber was delivered of a healthy baby girl. More than a year later, Amber’s recovery from the blood clot that nearly claimed her life continues with daily outpatient rehabilitation sessions.

The good news is that new guidelines for VTE prevention in pregnancy have been released, and incorporating them into your clinical practice should result in minimizing the number of cases of VTE in pregnant patients admitted for delivery or other procedures.

 

6. Mother Dies After Childbirth – What you need to know about Amniotic Fluid Embolism Now (May 1, 2014)

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.

7. Preventing Blood Clots in Stroke Patients: An Interview with Dr. Martin Dennis on the Clots 3 Study (August 2014)

Venous thromboembolism (VTE) is a common and potentially avoidable cause of death and illness in hospitalized patients. Each year in the United States, it has been estimated that about 300,000 cases of VTE occur. Mortality can be as high as 3.8 percent in patients with deep vein thrombosis (DVT) and 38.9 percent in those with pulmonary embolism (PE). VTE is associated with a high risk of death in the United States and Europe, with an estimated incidence rate of one in 1,000 patients. VTE is particularly common after a stroke. Approximately 20 percent of hospitalized immobile stroke patient will develop DVT and 10 percent a PE.

The Clots 3 study led by Martin Dennis, MD of University of Edinburgh, Western General Hospital may change the clinical practice to prevent DVT in stroke patients.

8. Take the Challenge Out of Managing the Complex Obstetric Patient (June 10, 2014)

In this case study, a case study is discussed of a unique, complex, obstetrical patient who was morbidly obese (BMI > 67) and who underwent a cesarean delivery with anesthesia, and had other complex medical issues.

This patient was significantly helped by guidance from the recently released OB VTE Safety Recommendations, which offer a defined clinical process that covers the entire continuum of care.

Weekly Must Reads in Patient Safety (Dec 12, 2014)

Too little and too many – that’s the theme of this week’s must reads.

Too Little

Too little is known about amniotic fluid embolism – 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.

The Boston Herald reported earlier this year that Colleen Celia died shortly after giving birth to her fourth child from amniotic fluid embolism. NBC’s affiliate in Charlotte, NC, recently reported that Declan Jay Bugal “died shortly after giving birth to what doctors at the Medical Center of Aurora described as a 7-pound, 4-ounce-miracle.” Please click on the image to view the report.

Too Many

Hats off to @UNC for an example of winning the battle against too many alarms.

Modern monitoring systems contribute to alarm fatigue in hospitals, UNC study shows. http://t.co/zNZ0qZv1SA

— UNC-Chapel Hill (@UNC) December 7, 2014

Although Jessica Zegre-Hemsey (assistant professor, UNC-Chapel Hill School of Nursing) and her team found that “more than 2.5 million alarms were triggered on bedside monitors in a single month,” in five ICU units at the UCSF Medical Center, she offered this advice to better manage the number of alarms:

If alarm settings were tailored more specifically to individuals that could go a long way in reducing the number of alarms health care providers respond to.

This advice is consistent with that given by Christopher Dandoy, MD (Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital). Dr. Dandoy led a study of alarms at his hospital and found that “up to 95% of these alarms are false—usually traceable to non-customized parameters and inadequate staff-training—and that nurses spend up to 30 minutes per shift simply dealing with false alarms.”

For further advice of managing alarms, leading health experts discussed these 4 keys for reducing alarm fatigue in a webinar hosted by Premier Safety Institute as part of its Advisor Live series.

Thanks @TodaysHospital for pointing out this study.

Alarm fatigue: Team-based approach slashes number of false alarms http://t.co/6JG5PgM6ye

— Today's Hospitalist (@TodaysHospital) December 6, 2014