Topic 3 DQ 2 need 3-4 responses to any of the DQ

Topic 3 DQ 2

Apr 4-8, 2022

The Center for Medicare and Medicaid Services (CMS) publishes a list of health care-acquired conditions (HACs) that reasonably could have been prevented through the application of risk management strategies. What actions has your health care organization (or have health care organizations in general) implemented to manage or prevent these “never events” from happening within their health care facilities? Support your response with a minimum two peer-reviewed articles.

REPLY TO DISCUSSION

Emily Sabin

Posted Date

Apr 7, 2022, 8:17 AM(edited)

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CMS is the list of both HCAPS and the list of diagnoses; the list of HCAPS sees the new standard of care for specific diagnoses. The list of diagnoses states that if a patient is discharged with not enough care information, follow-up is required, or the patient will readminister back in the hospital. The health facility will not receive any additional funds for the second admission. This is because they have released a patient without educating him on how to maintain healthy living. Therefore, some healthcare facilities have implemented several actions that will help to prevent such cases from happening, thus losing healthcare facility reimbursements (Monegro et al., 2020). These actions include self-care for nurses-get, rest, eating right, exercising, and being spiritually and mentally fit. Also, counseling and religious services are offered at work for all stakeholders and staff.

The other implemented action regards education or reduction of the healthcare workers to have sufficient knowledge regarding patients’ needs in the facility. This will also help in minimizing medical errors. Health facilities have also considered technology implementation for electronic health records and barcoding medications. Also, the change in both healthcare procedures and policy enables them to meet the current care standards and evidence-based practice. Many facilities use identification bracelets that are durable to identify patients before anything is done. Then after identification, they use skin markers to the site appropriately and count and recount again before surgery to avoid retainment of surgical instrument or sponge. They then use the scrub in and out to prevent contaminating other patients (Schultz et al., 2018).

Additionally, the bottom line is that healthcare organizations are in business to make some revenue and have a positive cash flow. If patients are readmitted without paying, it causes a severe threat to the healthcare facility’s financial status and puts them at risk of closing down. They should be a balance between doing what is suitable for the patient and what is best for the organization.

References:

Monegro, A. F., Muppidi, V., & Regunath, H. (2020). Hospital-acquired infections. In StatPearls [Internet]. StatPearls Publishing. Monegro, A. F., Muppidi, V., & Regunath, H. (2020). Hospital-acquired infections. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441857/

Schultz, K. A. P., Williams, G. M., Kamihara, J., Stewart, D. R., Harris, A. K., Bauer, A. J., … & Hill, D. A. (2018). DICER1 and associated conditions: identification of at-risk individuals and recommended surveillance strategies. Clinical Cancer Research, 24(10), 2251-2261. https://clincancerres.aacrjournals.org/content/24/10/2251.short

Eleanor Hayden

Posted Date

Apr 7, 2022, 5:56 AM

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The Center for Medicare and Medicaid Services (CMS) monitors for preventable health care acquired conditions that could worsen patients overall health. Examples of hospital acquired conditions surgical site infections, deep vein thrombosis, or falls that could lead to worsened injuries. All of these are considered preventable as they can be easily prevented with certain interventions in place (Haque et al., 2020). Recognizing that healthcare organizations often develop risk management plans as preventative measures for potential risks to keep employees and patients safe. Healthcare organizations tend to have many risk managements plans to address the potential risk that could arise. Risk managements teams work to keep patients safe through innovated interventions and evidence based practice (Monegro et al., 2021).

The healthcare facility I currently work for has a program called reaching for zero, this program encourages all healthcare providers and workers to follow the recommended guidelines to prevent any healthcare associated infections or injuries. All events including infections or falls that is monitored closely with a goal of zero events to ultimately reach the goal of zero. All new employees are required to attend the mandatory training sessions that educate on how to prevent infections through the required polices and guidelines. This may include mandatory hand washing, falls preventative measures, or more based on risk managements recommendations. Preventing healthcare acquired infections is a priority at this hospital as we have seen the detrimental causes that could happen including death. I believe it is imperative for all healthcare facilities to have appropriate risk management plans in pace to prevent this. In conclusion having safety measures in place allows healthcare workers to apply the polices and interventions within patient care and promote health and wellbeing by doing so (Reaching for Zero, 2021).

References

Haque, M., McKimm, J., Sartelli, M., Dhingra, S., Labricciosa, F. M., Islam, S., … Charan, J. (2020). <p>Strategies to prevent healthcare-associated infections: A narrative Overview</p>. Risk Management and Healthcare Policy, 13, 1765-1780. doi:10.2147/rmhp.s269315

Monegro, A. F., Muppidi, V., & Regunath, H. (2021). Hospital Acquired Infections. StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK441857/

Reaching for Zero – Norton Healthcare Nursing Excellence. (2021, February 24). Retrieved from https://nortonnursingexcellence.com

Delvis Tabares

Posted Date

Apr 6, 2022, 8:52 PM

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Replies to Emily Sabin

The CMS contains a list of Hospital Consumer Assessment of Providers and Systems (HCAP) that is adhered to as the new principles of patient care for particular diagnosis. Additionally, the CMS has a list of certain diagnosis that when a patient gets discharged from hospital without care, proper patient education, and necessary follow ups and thus gets readmitted within 30 day, the health care organization will not get paid for the readmission (Bae, 2017). My health care organization has implemented several actions to prevent HACs from being experienced within the facility. These actions were developed with the concept that as much as some incidences are entirely unavoidable in the health care field, the CMS measures can help in preventing plenty of them.

The top way my facility is trying to manage the occurrence of HACs is by ensuring the health care providers get sufficient rest, proper diets, exercise, and mental, emotional, spiritual, and physical support. As the primary caregivers, health care professionals must receive utmost care themselves or else they will not be of any help availing care to their patients. The organization understands quite well that successful prevention of HACs is coming up with policies for preventing and treating illnesses and then converting them to executable clinical pathways (Chalmers et al., 2021). Further, my organization utilizes infection prevention and control (IPC) to avoid acquisition and spread of hospital related infections. Infections can be easily attained in a health café facility especially with poor hygiene. Hand hygiene and hand washing measures are now part of the compulsory and regular training programs in my organization.

References

Bae, S. (2017). CMS Nonpayment Policy, Quality Improvement, and Hospital-Acquired Conditions. Journal Of Nursing Care Quality, 32(1), 55-61. https://doi.org/10.1097/ncq.0000000000000202

Chalmers, K., Gopinath, V., Brownlee, S., Saini, V., & Elshaug, A. (2021). Adverse Events and Hospital-Acquired Conditions Associated With Potential Low-Value Care in Medicare Beneficiaries. JAMA Health Forum, 2(7), e211719. https://doi.org/10.1001/jamahealthforum.2021.1719

Tamara Smith

replied toDelvis Tabares

Apr 7, 2022, 8:06 AM

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Replies to Delvis Tabares

Thanks Delvis

daily chlorhexidine baths for each patient.

The goal is to prevent all HAIs and they use the best evidence based practices in all areas to prevent them.

The New England Journal of medicine found that the use of these wipes daily decreased hospital acquired infections by 23% (Climo, et al. 2013). Have you seen this in practice?

Climo, M. W., Yokoe, D. S., Warren, D. K., Perl, T. M., Bolon, M., Herwaldt, L. A., … Wong

S. (February 7, 2013). Effect of Daily Chlorhexidine bathing on hospital-acquired infection. The New England Journal of Medicine. Doi: 10.1056/NEJMoa1113849. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMoa1113849#t=abstract

Shaina LaCount

Posted Date

Apr 6, 2022, 6:56 PM

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Replies to Emily Sabin

Health care acquired conditions and diseases or “provider preventable conditions” are an unfortunate reality of being hospitalized or going in for a surgical procedure.There are about 5,700 registered hospitals in the United States and 1 out of 25 patients contracts a potentially fatal infection during their stay at a hospital. (Wellington, 2016) These infections can take the form as central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated pneumonia, and surgical site infections. (Types of healthcare-associated infections, 2014) The centers of Medicare and Medicaid Services oversees and dictates a lot of how health care facilities stay in compliance via the ability for a facility to participate in the program and be reimbursed for seeing medicare and medicaid patients.

There has been major efforts made to reduce the number of health care acquired incidences and research has shown a dramatic reduction of around 70%. A few steps that can be taken to help in the continued reduction of these incidences are – establishing a communication plan for monitoring adherence to infection control protocols, determine high-traffic areas within the facility, minimize the number of entry areas, implementing facility-wide infection control training, and being aware of governing health care association requirements, just to name a few. (Wellington, 2016) By adhering to these concepts a health care facility can have a plan in place to identify, modify, and prevent; such as determining high traffic areas, this can increase chances of infection for those who may be immuno-compromised if housed in a high traffic area. Facility training of infection control is also very important. This allows all employees to know and understand what causes infection, and what actions need to be done and at what frequency to help reduce errors that may lead to infection.

Structure- My employer has an infection control program structured in the following way– that their clinics’ infection control is managed by the Health, Safety and Security Director as part of the Environmental Health and Safety Department that report to the Compliance Officer. Infection control for the ASC’s are under the direction of the ASC quality manager. Each clinic and ASC are staffed with at least 1 infection preventionist with administrative support.

Review- The EHS committee provides program oversight, annually review and approve of the plan and any subsequent revisions regarding infection control, review of surveillance data, and provides a forum to discuss infection prevention issues with risk management. (Remote.ksnet.com, 2021)

My employers infection control goals and implementation include: performing risk assessments, developing and prioritizing goals based on risk assessment, collaborating with clinical services and quality improvement programs to develop and implement respiratory prevention programs, screenings and vaccinations of employees, and manage potential exposures, develop and implement approved infection control policies, continual surveillance for the continued prevention of healthcare associated infections, monitoring and improving hand hygiene compliance, complying with standard procedures, prevention and training of proper sterilization techniques for medical equipment, and education to all employees and associates of the facility. (Remote.ksnet.com, 2021)

(reference number 2 and 4 are peer reviewed and from the GCU library, #3 is my employer’s intranet, and # 1 sourced from internet)

References:

Centers for Disease Control and Prevention. (2014, March 26). Types of healthcare-associated infections. Centers for Disease Control and Prevention. Retrieved April 6, 2022, from https://www.cdc.gov/hai/infectiontypes.html

CMS issues proposed rule prohibiting Medicaid payment for healthcare-acquired conditions. (2011, April 1). Healthcare Financial Management, 65(4).

Remote.ksnet.com. (2021, August). Retrieved April 6, 2022, from https://remote.ksnet.com/f5w-687474703a2f2f70756c73652e6b736370756c73652e636f6d$$/strategic-planning/qi/Pages/Infection-Control.aspx

Wellington, T. (2016). Risk Management: Keeping Diseases out of Healthcare Facilities. EHS Today, 9(5), 32–33.

Tamara Smith

replied toShaina LaCount

Apr 7, 2022, 8:08 AM

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Replies to Shaina LaCount

Thanks Shaina

To clarify: Given what you said about your facility,

Where is the weakest point of this procedure? How would you improve this?

Shaina LaCount

replied toTamara Smith

Apr 7, 2022, 11:29 AM

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Replies to Tamara Smith

I think my employer is very thorough in their planning, committees, policies and procedures, implementation, and continual monitoring and staff education. A healthcare facility can have the best plan in place (I summarized heavily, our infection control policy is way more detailed) but it is the human element that is the variable; you can train and educate employees all you want, but if they do not do the right thing, make sure they adhere to standards, then other than reprimanding up to and including termination, that is all you can do. I would not change anything about how my organization works, they have passed all levels of inspection for over 70 years with flying colors and maintained a certification that is hard to get here in Texas, along with several other high esteemed accreditations, they constantly review and revise policies, and we are always being emailed and updated on policy changes.

Shavonte Mcintosh

Posted Date

Apr 6, 2022, 1:14 PM

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Replies to Emily Sabin

Hospital-acquired conditions (HACs) are the result of oversight, accident, infection, or negligence in healthcare facilities. The U.S. Centers for Medicare and Medicaid Services (2021) have a list of HACs on their website and provide extensive documentation on the HAC Reduction Program, since HACs affect Medicare payments for hospitals. Lavallée et al. (2018) call these conditions “never events” since they are preventable adverse medical events or errors that should not occur in health facilities, and their impact ranges from increased healthcare costs to harming the patient.

Healthcare organizations create protocols to prevent the occurrence of HACs. The first step in addressing the problem is to recognize their causes and how often they happen by using patient statistics (Mody et al., 2017). Another action is to follow correct mitigation procedures targeted toward addressing each particular HAC as suggested by the Department of Health and Human Services, the Centers for Disease Control and Prevention, and the Centers for Medicare and Medicaid Services. Some of the risk mitigation measures are instituted to prevent falls, to reduce improper dosage, to ensure patients take their medicines on time, and to prevent skin infections. Other actions that healthcare organizations strictly impose include frequent and correct hand hygiene measures by all patients and staff, keeping the healthcare facility and its surroundings clean, and following prescribed procedures when caring for wounds. Medicare and Medicaid will not reimburse claims unless the claim form distinguishes between treatment for conditions that were present on admission (POA) and HACs. Healthcare facilities, therefore, risk both litigation from affected patients and penalties from Medicare and Medicaid if they do not attend to HACs.

Hospitals have risk management strategies to monitor and prevent HACs and enhance patient safety. HACs are avoidable, and most of them are caused by patient or staff negligence. Creating risk strategies reduces the number of readmissions and lengthy hospital stays, and ultimately benefits both patients and healthcare facilities.

References

Chan, J., Gardner, A., Mann, A., & Kapp, D. (2018). Hospital-acquired conditions after surgery for gynecologic cancer — An analysis of 82,304 patients. Gynecologic Oncology, 150(3), 515–520. https://doi.org/10.1016/j.ygyno.2018.07.009

Lavallée, J. F., Gray, T. A., Dumville, J., & Cullum, N. (2018). Barriers and facilitators to preventing pressure ulcers in nursing home residents: A qualitative analysis informed by the Theoretical Domains Framework. International Journal of Nursing Studies, 82, 79–89. https://doi.org/10.1016/j.ijnurstu.2017.12.015

Mody, L., Greene, M. T., Saint, S., Meddings, J., Trautner, B. W., Wald, H. L., Crnich, C., Banaszak-Holl, J., McNamara, S. E., King, B. J., Hogikyan, R.,

Edson, B. S., & Krein, S. L. (2017). Comparing catheter-associated urinary tract infection prevention programs between VA and non-VA nursing homes. Infection Control and Hospital Epidemiology, 38(3), 287–293. https://doi.org/10.1017/ice.2016.279

U.S. Centers for Medicare & Medicaid Services. (2021). Hospital-acquired conditions. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions

Tamara Smith

replied toShavonte Mcintosh

Apr 7, 2022, 8:07 AM

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Replies to Shavonte Mcintosh

Shavonte Yes, and checklists are great.

These types of policies are part of what can make a hospital great… or not.

Sometimes we live in a bubble here in the US. Let’s consider solutions from other sources. How do we rate compared to hospitals in Australia or the UK? Globally, do we measure up?

Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement (2011). Retrieved September 8, 2011, from http://www.commonwealthfund.org.

Shyra Lovingood

Posted Date

Apr 6, 2022, 9:41 AM

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Replies to Emily Sabin

Hello Class,

Retained Foreign body object

Working in the surgery department I have seen many things happen. Before we start any case whether is is a short procedure or a big abdominal case, we count every instrument and supply to ensure we will have the same count when we close body cavities. This is called a “time-out”. The never events has happen at other facilities such as retaining foregn body or performing surgery on the wrong body part. Retaining foreign body from a patient means that a surgical instrument, cotton sponges or irrigation tubes has been left in the patient after the patients body cavity has been closed and sutured is discharged out of the department. This causes many injuries to the patient causing the retained forgeign body to travel to other parts of the body making it a patient safety challenge, Rajneesh Kumar, & Ankur Hastir. (2017). This is a lack of communication between the surgical team not ensuring all instrumentation and other material has been counted for preoperative and postoperative. In some cases, patients on a more serious scale that has died from a scalpel blade or a suture needle that punctures major organs. This is a rare event to come across but many hospitals has ensured that all “time-out” protocols are up to regulations.

At my facility there are regulations implemented to ensure these “never events” occur in the surgical department. Ensuring that every surgical case whether big or small, every patient is treated the same and there are no cutting corners. There is another protocol to do after the case is is done with the surgeon initiating it called a “debriefing”. Reiterating that all instruments and surgical instruments are counted for, if there are any questions or concerns or suggestions for future references. Everything is documented during the case from the surgical team to all the equipment that was used. If the hospital organizations do not have these rules implemented, there will be many cases that involve serious injuries. However, there are some instances where a patient has been brought to the hospital for numerous of reasons and there has been a retrieval of a lap sponge or a surgical instrument from their body from another hospital. In these cases that is called an sentinel event.

In conclusion, These events occur but not frequently due to the risk management organization of hospital facilities ensuring the safety of their patients. In some cases, there are hospital facilities that never had this kind of issue do to strict surgical time out and debriefing protocols for each case. If all communication between the surgical team is efficient, this “never event” will continue to be a never event.

Best,

Shyra L.

Reference:

Rajneesh Kumar, & Ankur Hastir. (2017). Surgical blade retrieval from Abdomen by Laparotomy after 5 yrs! – Case report and Review of literature on retained foreign bodies in abdomen. International Journal of Surgery and Medicine, 3(3). https://doi-org.lopes.idm.oclc.org/10.5455/ijsm.retained-surgical-sponge

Nicholas Derkowski

replied toShyra Lovingood

Apr 6, 2022, 1:38 PM

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Replies to Shyra Lovingood

Hi Shyra,

I work in surgery also, and time is taken each and every case to ensure nothing is left behind before we close the patient up. So far I haven’t had to deal with this at my facility, but I’ve only been working there for a short time!

Although there was one case that comes to mind when I say this.

We had some podiatry case come in and there had to be a pin and screw inserted. Well, everything was all fine and dandy until the drill bit broke off in the bone of the patient! The surgeon was unable to get it out and didn’t want to keep trying unsuccessfully. As far as I know, they will remove it at a later date if it causes problems, but for now, he is out and about walking with a drill bit in his foot/ankle. Not really a forgotten foreign body, but an interesting side e not hopefully.

As I have been acclimated to the unit and the workflow a few concepts have been hammered in.

I am the patients voice when they are in anasthesia
Count everything!
Don’t light anything on fire, especially the ETT

As sponges are the most commonly found retained foreign body special care must be taken to ensure all are accounted for before the end of the surgery (Rajneesh Kumar, & Ankur Hastir, 2017). Counting twice is recommended (Rajneesh Kumar, & Ankur Hastir, 2017). We do this by using a scanning system, each sponge has a unique barcode and gets scanned into a counting system before we close up the patient. Then the circulating nurse counts over everything with the surgical tech and only then can sewing or stapling commence.

References

Jo Landino Garcia

Posted Date

Apr 5, 2022, 4:15 PM(edited)

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Replies to Emily Sabin

Dr. Smith and class,

Hospital Acquired Conditions (HACs) are known to be conditions caused by viral, bacterial, and fungal pathogens, that affect patients or visitors when they are being treated for something else at hospitals.

During the SARS-CoV-2 (Covid-19) pandemic, many facilities have taken risk management plans to avoid the spread of the virus in the facilities profoundly seriously. According to several reports, the SARS-CoV-2 hospital-acquired infection rate is 12–15% (Barranco, 2021).

Reinforcing personal protective equipment (PPE) has been necessary and obligatory. Staff are reminded to wash their hands, wipe surfaces before and after use, keep distance, and maintain masks-on at all times.

Despite numerous measures to contain the infection and limit its spread, cases of SARS-CoV-2 infections acquired in hospitals have been reported consistently (Barranco, 2021)

At the hospital where I work, to control the spread of the virus in the facility, certain risk management implementation were put into place. Experts have carefully developed strategies and protocols focused on mitigating COVID-19 within the health care setting, where halting transmission is critical (Mayo Clinic, 2020).

Limiting the access to the clinic for patients and visitors, reducing surgeries and other procedures unless absolutely necessary, having personnel work remotely from home depending on their role, and utilizing technology to continuously help and assist patients through virtual appointments have been some of the several approaches at Mayo Clinic Hospital. By reducing the personnel and visitors’ access to the clinic it was easier to contain the virus and avoid the spread to those in more critical health condition and immunocompromised patients.

References

Rosario Barranco, Luca Vallega Bernucci Du Tremoul, & Francesco Ventura. (2021). Hospital-Acquired SARS-Cov-2 Infections in Patients: Inevitable Conditions or Medical Malpractice? International Journal of Environmental Research and Public Health, 18(489), 489. https://doi-org.lopes.idm.oclc.org/10.3390/ijerph18020489

Mayo Clinic. 2020. COVID-19 Resources for Business. Retrieved from https://www.mayoclinic.org/products-services/international-business- collaborations/covid-19-resources-for-businesses

Shyra Lovingood

replied toJo Landino Garcia

Apr 6, 2022, 9:59 AM

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Replies to Jo Landino Garcia

Hello Jo,

The spread of the Covid-19 virus among patients happen more drastically than the public knows about. Not to scare people or worry many but working on those floors sometimes to help out due to staff shortages and cancelling of elective cases, it was quite the scene you see in a movie. But reducing the spread of the virus by eliminating visitors in the hospitals was a strategic step in the right direction. On the other hand, the bigger problem was among staff members by not being familiar with cross contamination when dealing with Covid patients. The amount of sterility that needed to occur would have been strenuous on all staff members and that includes environmental services. Disinfecting areas that were used and to be cleaned for the next the patients had to be strategically done to not contaminate clean surfaces. On the other hand the staff members were already compromised by having the same scrubs on for a 12 hour shift causing the HAI infection rates to continue to increase. In recent times, now healthcare organizations understand what needs to be in order to lower the risk factors by continuing to implement rules and regulations for the safety of patients.

Best,

Shyra L.

Jo Landino Garcia

replied toShyra Lovingood

Apr 6, 2022, 6:09 PM

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Replies to Shyra Lovingood

Hi Shyra,

Yes, indeed. As you mentioned, one of the biggest problems the healthcare industry faced during Covid-19 and possibly still does is that employees would take personal protective equipment (PPE) slightly. They have been implemented and made general standard requirements by OSHA (Occupational Safety and Health Act) for a reason (OSHA. 1910.132, General requirements).

It is absurd that many employees had to be reminded to comply with the general standards of PPE used. It is something as simple as washing their hands before and after seeing or entering a patient’s room to avoid cross contamination that makes the difference.

One of the hospitals in the area where I live requires all personnel who come in direct contact with a patient, to change to their scrubs as soon as their shift starts and changed before the end of their shift. The facility even obtained a disposable scrubs machine for third party associates that will be present during a procedure to avoid external personnel using the same scrubs as the employees.

Reference:

OSHA (Occupational Safety and Health Act). General Requirements. United States Department of Labor. Retrieved from https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.132

Best,

~Jo

Jamiu Raheem

Posted Date

Apr 4, 2022, 2:18 PM

Status

Published

Replies to Emily Sabin

Healthcare-acquired conditions (HACs) refer to the conditions that patients develop while they are in a healthcare clinical being treated for another disease. These conditions possibly harm patients while being treated for something else. An example of HACs is pressure ulcers, which are common in hospitalized patients caused by prolonged exposure to pressure on the patient’s skin. HACs such as nosocomial infections can be caused by fungal pathogens, bacteria, and viral, with other common types being urinary tract infection, ventilator-associated pneumonia, surgical site infection, and bloodstream infection. Healthcare organizations have installed actions like risk mitigation strategies and created a safety culture to manage or prevent these “never events” within their healthcare facilities.

The first action healthcare organizations have installed to prevent HACs is to have risk mitigation strategies. This includes having specific procedures that help to prevent a specific never event by following Center for Medicare and Medicaid Services recommendations. For instance, healthcare organizations must frequently reposition patients to prevent them from developing pressure ulcers while under treatment (Cortés et al., 2021). Other risk mitigations procedures that specifically aim at preventing pressure ulcers include avoiding excessive bed rest, recognizing risk, and preserving the integrity of the skin.

Proper hand hygiene and clean techniques are part of the way to prevent nosocomial infections, above all, it takes continuous training and education by the risk management such as the infection control nurse to implement and keep tracking of the prevention methods. Also to ensure that all staff is practicing hand hygiene and clean techniques as laid down in the risk management policy.

Another healthcare organization’s action to prevent HACs is creating a safety culture. This includes training, educating, and mentoring healthcare workers to adopt best nursing practices that prevent exposure of hospitalized patients to any other risks (Shah et al., 2020). Building a safety culture in healthcare organizations also involves implementing technologies that help reduce these HACs. For instance, Computerized physician order entry and clinical decision support systems have been implemented to reduce medical error by enhancing medical allergies and interaction identification and ensuring order completeness and legibility, significantly reducing HACs.

References

Cortés, O. L., Herrera-Galindo, M., Villar, J. C., Rojas, Y. A., del Pilar Paipa, M., & Salazar, L. (2021). Frequency of repositioning for preventing pressure ulcers in patients hospitalized in ICU: protocol of a cluster randomized controlled trial. BMC nursing, 20(1), 1-10. https://doi.org/10.1186/s12912-021-00616-0

Shah, S. S., Abdi, A., Özcem, B., & Basgut, B. (2020). The rational use of thromboprophylaxis therapy in hospitalized patients and the perspectives of health care providers in Northern Cyprus. PloS one, 15(7), e0235495. https://doi.org/10.1371/journal.pone.0235495

Jared Blake

replied toJamiu Raheem

Apr 5, 2022, 7:22 PM

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Replies to Jamiu Raheem

Jamiu,

I would agree with you that hand hygiene plays a big role in preventing the spread of infections and diseases. In my six years of working in a military hospital and working as the primary for my clinic’s infection control program, I have put a lot of effort into emphasizing the importance. Each medical group I have been at has required the infection control monitor to perform monthly training with staff members on hand hygiene. I am also required to randomly select ten staff members and watch them wash their hands while they explain the process. As tiresome as it may be to complete this checklist each month, I certainly see the benefit and necessity of the process. A task as simple as washing your hands before and after each patient can easily be forgotten during a busy day. However, I think the past two years have heightened our awareness toward this simple task and the importance of it.

Jared

Yasmany Aguiar Alvarez

replied toJamiu Raheem

Apr 6, 2022, 1:40 AM

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Replies to Jamiu Raheem

Jamiu,

I agree with your post, i can add that nurses play a crucial role in the prevention of never events because they are often the final line of defence between error and patient. The prevention of these never events often comes down to sufficient training and education with an emphasis on patient safety and proper documentation. In my opinion, the most important preventative measures are continued education and documentation. Training that is relevant to incidents that are likely to occur within an organization as well as proper documentation improves the knowledge and competency of health care workers, reduces the likelihood of never events and establishes accountability. Many organizations lack historical data about all types of incidents. This data can irradiate potentially risky decisions and identify gaps in the process to assimilate information and data into actionable steps that prevent or eliminate never events.

Reference

MedTrainer. (2018). Preventing Never Events and Ensuring Quality Patient Care. Retrieved from

https://medtrainer.com/preventing-never-events-and-ensuring-quality-patient-care/#:~:text=The%20Prevention%20of%20Never%20Events%20Nurses%20play%20a,an%20emphasis%20on%20patient%20safety%20and%20proper%20documentation

Nicholas Derkowski

replied toJamiu Raheem

Apr 6, 2022, 12:36 PM

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Replies to Jamiu Raheem

Hi Jamiu,

I think you are right on with the culture of safety promoted through diligent education. To err is to human highlighted the fact as people we are bound to make mistakes, but with the recognition of the fact comes the responsibility to do something about it (Barnsteiner, 2011). To realize errors are possible aligns healthcare workers to accept the numerous checks in each step of the healthcare continuum (Barnsteiner, 2011). An open attitude is essential to internalize safety teachings (Barnsteiner, 2011). The more we can accept the shortcomings of being human the easier it will be to find opportunities for improvement.

Barnsteiner, J. (2011). Teaching the culture of safety. OJIN: The Online Journal of Issues in Nursing, 16(3). https://doi.org/10.3912/ojin.vol16no03man05

Nicholas Derkowski

Posted Date

Apr 4, 2022, 8:50 AM

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Replies to Emily Sabin

July 31st of 2008 Centers for Medicare and Medicaid services put out an official list of ten categories of conditions acquired in the hospital that would not be reimbursable. Included in the list are falls, poor glycemic control, UTI’s, SSI’s, DVT’s, Foreign object retention, and a few others made the list too (Clancy, 2008). This was the first time a list like this was made and changed the attitude of prevention from a moral standpoint to a financial standpoint.

The incentivization or lack of for these hospitals acquired conditions forced new policy, procedure, and safety onto the healthcare system. The list also gave healthcare organizations conditions or events to focus on and improve (Wald et al., 2012). At the hospital I work at there are numerous measures taken to prevent the items on this list, and most are specifically addressed in educational material when being hired or in continuing education classes.

Some of the actions I have noticed are in my hospital system:

Falls
Application of bright yellow wristbands
Symbols in the entryway communicating patient fall risk
Reinforcement of call light usage and placement.
Foreign Object Retention
Sponge counting tablet that reads unique barcodes on each surgical sponge used
Counting surgical objects and tools before and after surgery
Surgical sponges containing a radiopaque band that is easily identified on x-ray

III. UTI’s

Education on proper cleaning technique
The push for rapid catheter removal
Less catheters used overall

References

Wald, H., Richard, A., Dickson, V. V., & Capezuti, E. (2012). Chief nursing officers’ perspectives on medicare’s hospital-acquired conditions non-payment policy: Implications for policy design and implementation. Implementation Science, 7(1). https://doi.org/10.1186/1748-5908-7-78

Clancy, C. M. (2008). Medicare’s New Policy Targets Hospital-acquired conditions. AORN Journal, 88(6), 1001–1003. https://doi.org/10.1016/j.aorn.2008.11.022

Shyra Lovingood

replied toNicholas Derkowski

Apr 6, 2022, 10:11 AM

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Replies to Nicholas Derkowski

Hello Nicholas,

There are numerous “never events” that happen at hospital facilities. In your statement you’ve named a few events that help in the prevention of these particular events. This is a result of health care organizations (risk management team) implementing protocols and regulations to ensure the safety of their patients. These rules help to identify common outcomes when dealing with patients that are a fall risk or the cleanliness of supplies. This a step further in the right direction to reduce these risks for hospitals reputation. If a facility does not have a good organization that is patient led, then these events will occur frequently risking a shut down of a hospital. I believe that all staff members should treat each event with a responsible mind, because we never know when a love one or ourselves are put in these patients positions.

Best,

Shyra L.

Jared Blake

replied toNicholas Derkowski

Apr 6, 2022, 7:52 PM

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Replies to Nicholas Derkowski

Nicholas,

Procedures must be in place to know whether a condition happened before or after a patient was admitted to the hospital to try and track the Hospital-Acquired Conditions. It is great that your hospital includes a lot of their prevention training in the beginning with new hires. An interesting study was done on using a penalty program to try and reduce Hospital-Acquired Conditions (Castellucci, 2019). However, it was not successful. Due to the hospital not wanting to be penalized, a big problem became underreporting (Castellucci, 2019). I think the most crucial part is what the hospital team can do to improve. “Scare tactics” do not work for most people as a long-term solution. Employees should want to learn how to avoid Hospital-Acquired Conditions because it is better for the patient’s health, not out of fear from hospital management. There is always room for improvement in a problem like this, but it starts with a positive attitude focused on patient care.

Jared

Reference

Castellucci, M. (2019). Penalties didn’t drive drop in hospital-acquired conditions. Modern Healthcare, 49(44), 9.

Shaina LaCount

replied toNicholas Derkowski

Apr 7, 2022, 10:55 AM

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Replies to Nicholas Derkowski

Hi Nicholas,

You made some very good points. These hospital acquired infections were the reason why some people never wanted to go to a hospital because either themselves, friends, or family had a bad experience while being under hospital care. The fact that CMS became involved and mandated that HAI prevention be implemented is a great step forward; the easiest way to get someone motivated is money, so the fact that they would deny payment got a lot of health care facilities in line.

CMS evaluates payments to health care facilities by 3 major metrics – the hospital readmissions reduction program, the Value-Based Purchasing (VBP) Program, and the Hospital-Acquired Condition (HAC) Reduction Program. By requiring these protocols, it has also helped to reduce the cost of treating healthcare acquired infections. These infections cost the healthcare system around $9.8 billion annually. (Vokes et al., 2018)

Your employer has good protocols to help reduce the possibility of infections. My employer also has a very detailed protocol system, and committees on committees that oversee all of the initiatives, policy review, implementation, and education for infection prevention.

reference:

Vokes, R. A., Bearman, G., & Bazzoli, G. J. (2018, July 26). Hospital-acquired infections under pay-for-performance systems: An administrative perspective on management and change – current infectious disease reports. SpringerLink. Retrieved April 7, 2022, from https://link.springer.com/article/10.1007/s11908-018-0638-5

Yasmany Aguiar Alvarez

Posted Date

Apr 4, 2022, 5:16 AM

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Replies to Emily Sabin

Hospital-acquired infections (HACs) impact 5–10% of people hospitalized in the United States each year. Every year, over 1.9 million HACs occur in hospitals in the United States, resulting in 99,000 deaths and an estimated $20 billion in healthcare costs. HACs lengthen admissions, necessitate extra tests, and use valuable human resources (Nero & Callahan, 2017). The key to preventing HACs is to develop preventative and treatment policies, which are then translated into clinical pathways that may be advocated and implemented inside the EHR. Predictive models for early detection, as well as protocols to ensure speedy response times and adequate treatment, should be included in policies.

I worked in an organization that employed scoring systems to continuously take information from a patient’s chart and calculate a risk level in real-time. Depending on the severity of the problem, physicians could evaluate acuity levels on a need-to-know basis, or an alert could be displayed directly to the clinician if quick action was required. Rapid action on critical patient information can dramatically boost the percentage of successful outcomes (Deeter, et al., 2019). This can be accomplished by introducing real-time feedback into the current workflows. When consumers are aware of their shortcomings, they are more willing to address them.

This necessitates a more efficient approach for managing and acting on orders. Users should be able to readily insert and alter order groups that are appropriate for the patient’s needs. They should also have the tools necessary to easily grasp any remaining duties associated with those orders.

References

Deeter, L., Seaton, M., Carrougher, J. G., McMullen, K., Mandell, S. P., Amtmann, D., & Gibran, S. N. (2019, February). Hospital-acquired complications alter quality of life in adult burn survivors: Report from a burn model system☆. Burns, 45(1), 42-47. Retrieved August 09, 2021, from https://www.sciencedirect.com/science/article/abs/pii/S0305417918304121

Nero, D. C., & Callahan, M. A. (2017, January 01). Hospital-acquired infections (HACs) impact. Journal of Health Care Finance, 38(3), 40-49. Retrieved August 09, 2021, from https://europepmc.org/article/med/22515043

Tamara Smith

replied toYasmany Aguiar Alvarez

Apr 7, 2022, 8:09 AM

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Replies to Yasmany Aguiar Alvarez

Thanks Yasmany

Let’s talk more about real time risk.

Code Pink- what’s your policy?

Code Pink: Never event

What is this?

There have been a reported 140 infant/children taken from hospitals since 1965( www.missingkids, n.d.).

How does your hospital prevent this?

Missing kids. Retrieved from http://www.missingkids.com/theissues/infantabductions#bythenumbers

Emily Sabin

replied toTamara Smith

Apr 7, 2022, 9:15 AM

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Replies to Tamara Smith

A code pink is when an infant less than 12 months of age is suspected or confirmed missing. When a code pink happens security and health care workers check all stairwells, account for all patients, have people posted at every entry and exit, start checking bags and wrist bands, start doing parent and employee identification and reporting anything suspicious to security.

Some steps to prevent a code pink are telling parents to never leave their baby unattended (even in play rooms) and to never give the baby to someone they do not know. Some other steps staff use to prevent a code pink are patient identification band, logging children on and off unit and making sure a child does not leave the unit without a family member or healthcare worker.

Reference:

What is a code pink/purple? – visitors. Loma Linda University Health. (n.d.). Retrieved April 7, 2022, from https://lluh.org/patients-visitors/visitors/security-services/crime-information/what-code-pinkpurple

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