PREVENTING HEALTHCARE ACQUIRED CONDITIONS

Alan Lembitz, MDChief Medical OfficerCOPIC

Objectives

• Examine the National Quality Forum “Serious Reportable Events” (SREs)

• Examine the CMS Non-reimbursable “Hospital Acquired Conditions” (HACs)

• The Scope of these Conditions• Impact on Risk, Quality and Liability• Introduce “Always Events”: practical safety initiatives

to reduce preventable healthcare acquired conditions

SREs and HACs

• Two circles with a zone of overlap• Preventable, Predictable, and Impact on financial

reimbursement are key to understanding the differences

• Public media calls both “never events”

National Quality Forum SREs• Detailed in the Resources link• In general, rare events with great harm• One-time occurrence of such an event should

trigger patient risk management, early intervention and possibly settlement

• Repeated patterns can be serious problems; “should have known”

National Quality Forum SREs

• Examples– Post-operative death in a normal health patient– Wrong site/wrong patient– Foreign body

• “Preventable”– have guidelines based on risk– Impersonation– Abduction– Infant discharge to wrong persons– Patient suicide or attempt with harm within facility

National Quality Forum SREs• Examples

Death/disability from certain conditions• Medication error• Contaminated drugs/devices• Use of device other than intended

– off-label vs. investigational• Patient elopement• Neonatal hyperbilirubenemia• Spinal manipulative therapy• Physical assault• Use of restraints --“disability”; do you have a choice?• Low risk maternal delivery; “definition?”• Physical assault on facility grounds

CMS HACs• The worrisome events that might not be 100%

preventable but active steps to reduce them are available.– Falls– Catheter associated UTI– Vascular associated infection– Surgical site infection s/p CABG– Surgical site infection s/p bariatric surgery– Surgical site infection s/p THA, TKA– DVT s/p THA, TKA

OIG REPORT October 2011• “____% of hospitalized Medicare beneficiaries

experienced an adverse event during their hospital stays. Those events resulted in a prolonged hospital stay, permanent harm, life-sustaining intervention, or death.”

Predictability and Preventability

• Discussion

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/Downloads/LaBresh_Guidelines_for_HAC_June_2011.pdf

Always Events

• Derived from Patient Safety Literature and our own experience

• Do not set a standard of care, but do establish goals• Practical charge

– Reporting internal and external– Prioritize– Investigate– Intervention– Measure– Remember CQI…

The Checklist

Lists of 10 Always Events• See Resources for

details of all lists– OR– Office Practice– ED– Medication Errors– EHRs– Avoiding Litigation

⁻ Orthopaedics⁻ Obstetrics and Gynecology⁻ Communication

Always Events for the OR1. Review the patient’s medication list before surgery. Check for possible

interactions and be sure that time-sensitive medications have been given. Ensure that contraindicated medications have been held and that appropriate monitoring tests have been checked.

2. Obtain and review labs and imaging studies. This can help avoid wrong site surgeries and check that no obvious medical conditions prohibiting surgery exist.

3. Risk-stratify patients for DVT prophylaxis and ensure indicated preventive measures are taken. Documentation that this was performed is imperative.

4. Risk-stratify patients for obstructive sleep apnea. If they have already been diagnosed and treatment has started, they can use their masks postoperatively. If they are newly-diagnosed, they should be monitored carefully for hypoventilation following established protocols.

Always Events for the OR

5. Review the equipment, device, and implant needs before surgery. This helps to avoid having nurses leave the OR frequently during surgery, having to terminate the surgery prematurely, placing the wrong device or using the wrong equipment.

6. Use correct-site protocol and empower all personnel to speak up if they feel something is amiss.

7. Administer the appropriate antibiotic, if indicated. Be sure it’s the correct dose and timing. Discontinue use at the appropriate time.

8. Be aware of those patients who are at the greatest risk of retained foreign bodies. This includes cases of emergency surgery, patients who are obese, prolonged procedures, shift changes, etc. Have a low threshold for imaging studies to identify possible objects.

Always Events for the OR

9. Maintain the patient’s warmth during surgery, especially for pediatric patients and during prolonged procedures.

10.Use good team communication. Know everyone’s name and ask team members to speak up if they see opportunities for avoiding problems or for improving pre-op. Read back requests throughout and respect and value the input of others.

Always Events for Office-Based Practice

1. Test tracking2. Test follow-up contact system: “no news is good

news” sets the wrong expectations for all parties3. Telephone call charting:– When a significant change in the treatment plan is made.– Direction to a medical facility for urgent or emergent

evaluation is given. – When a prescription is ordered, or when a significant

diagnosis is made that requires subsequent care or follow-up.

Always Events for Office Based Practice

4. Refilling medication.5. Tracking medications dispensed in the office.6. Avoiding wrong patient procedures.7. Avoiding specimen mix-up.

Always Events for Office Based Practice

8. Assessing performance of PAs and APNs.9. On-call sign-out procedure.10.Reporting and reviewing adverse events in the

office.

Always Events for the ED1. Know the high-risk diagnoses: “heads, hearts, guts, and bugs.”

– Heads. Acute presentations that ultimately lead to serious neurologic sequellae (e.g., cerebral vascular accident, subarachnoid hemorrhage, subdural/epidural hematoma, encephalitis and meningitis).

– Hearts. Myocardial infarction, pulmonary embolism and aortic dissection.

– Guts. Abdominal pain, conditions such as abdominal aortic aneurysm, appendicitis, perforated viscus and ischemic bowel.

– Bugs. Serious infections, particularly conditions that are difficult to diagnose in a critical timeline such as necrotizing fasciitis, discitis, epidural abscess, and rapidly developing sepsis.

2. Underappreciated mechanism of injury and underappreciated trauma can lead to missed findings

Always Events for the ED3. Have systems in place to ensure adequate information exchange.

– The need to reconcile the final imaging report with the read that was available at the time of care, such as a night-hawk or preliminary read.

– The need to recognize critical values and communicate them for subsequent care.

– The need to check and communicate test results that were ordered but not available at the time of disposition, admission or transition in care.

– The need to communicate follow up information, pending studies, and expectations to subsequent providers and the patients and/or their families.

4. Schedule follow-up. A specified follow-up time, place and provider is much more defensible than “Follow up PRN.” Make sure the patient understands that at the current time, no serious condition exists; however, the only way to be certain is to be reevaluated in the near future. From a medicolegal perspective, an informed patient who understands the risks and chooses not to follow your advice assumes more of the liability for their actions.

Always Events for the ED

5. Don’t miss the “second” fracture. It is advisable to evaluate the joint above and below the injury.

6. Don’t forget the “road test” (including discharge vitals). The documentation should be in agreement and actions match that documentation.

Always Events for the ED7. Be aware of shift changes.8. Define expectations for PAs and APNs. PAs and APNs get

sued for the same reasons as physicians. Know the regulations for PAs and for APNs.

9. Attempt to match your actions with your documentation for incompetent and incapacitated patients.

– Remember, incompetent patients cannot sign out against medical advice.

10. Get to know and use the Colorado Physician Drug Monitoring Program (PDMP).

Always Events for Medication Errors1. Accurate and legible.2. Allergies.3. Drug-drug interactions.4. High-risk medications.5. Long-term pain management.

Always Events for Medication Errors6. Look alike, sound alike.7. Herbals/OTCs.8. Monitor and evaluate.9. FDA warnings.

– HCNN

10. Samples and refills.

Always Events for EHRs1. Back up (it’s number one for a reason!). 2. Only document what you actually do. 3. Look closely at anything you print. Items that appear one

way on your screen can take an entirely different form when they are printed, faxed, or transmitted to another system. We’ve seen screen shots that are cut-off and distorted.

4. Take passwords seriously.5. Protect your mobile device; when you lose it, your

password or encryption protection will protect you from a very lengthy disclosure process.

Always Events for EHRs

6. Accept (once and for all) that good documentation slows you down.

7. Read the screen, and know what lies behind that screen.

8. Use your EMR’s “tickler system.”9. Maintain critical lists. There is no single button that

says “summarize this chart.”10. Learn from your mistakes. The only way to make

them safer, more usable and more efficient is to complain—but constructively.

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A five-minute exam.Really?

Always Events to Avoid Litigation

1. Bedside manner.2. Always follow-up.3. Make medications a priority.4. Avoid negative comments about others.5. Never alter records.

Always Events to Avoid Litigation6. Take depositions seriously.7. Informed consent is a critical process.8. Document your differential diagnosis and

your thought process.9. Recognize problem patients.10.Call COPIC.

A Call to Action

• Prioritize.• Empower with champions.• Measure.• TELL STORIES…..

Questions?

Thank you!