The Becker's Infection Control & Clinical Quality editorial team chose the following 10 patient safety issues for providers to prioritize in 2017, presented below in no particular order, based on news, study findings and trends reported in the past year.
Health equity. In 2001, the Institute of Medicine established six aims for improvement in healthcare: to make it safe, effective, patient-centered, timely, efficient and equitable. While great strides have been made toward the first five, progress on health equity has lagged, according to the Institute for Healthcare Improvement. IHI called health equity the "forgotten aim" in a 2016 whitepaper.
Health equity, per the IHI, is defined as "when everyone has the opportunity to attain their full health potential." When access to health isn't equitable, it can lead to poor health outcomes for patients. For instance, black people have much lower life expectancies compared to white people in the U.S., and people in households with lower incomes have higher relative risk of mortality than those with higher incomes.
While social determinants play a large role in health outcomes, healthcare organizations have a big part to play in improving health equity in their communities. The IHI, the CDC and other organizations have made resources available to show hospitals and physicians how to make health equity a strategic priority, decrease institutional racism and develop partnerships with other organizations in their community.
Growth of antibiotic resistance. Bacteria and fungi continue to grow more resistant to antimicrobials, even last-resort antibiotics like carbapenem and colistin. CDC Director Tom Frieden, MD, told The Washington Post in May that "the end of the road isn't very far away for antibiotics — that we may be in a situation where we have patients in our intensive care units, or patients getting urinary tract infections for which we do not have antibiotics."
Hospitals can do their part to stymie the growth of antibiotic resistance by implementing antibiotic stewardship programs. The CDC and the National Quality Forum released "Antibiotic Stewardship in Acute Care: A Practical Playbook," in May to help hospitals set up such programs, which are so vital to stopping the growth of antibiotic resistance that the Joint Commission added an antimicrobial stewardship standard to its accreditation process for 2017.
Patient care transitions. Patient handoffs are always a risky moment in a patient's care journey, whether the move is from care team to care team or from acute care to post-acute care or to home. A study published in JAMA in December further solidified that truth, finding the end-of-rotation transition between resident care teams was associated with a significantly higher risk of in-hospital patient mortality.
Fortunately, several patient handoffs tools and checklists exist to strengthen this process, and an analysis of such protocols published in November 2016 in Human Factors: The Journal of the Human Factors and Ergonomics Society, showed those protocols do help. It found "good evidence for the general benefit of using handoff protocols, regardless of setting or protocol type."
Sterilization and reprocessing issues. Problems in the sterile processing department can put patients at risk of contracting various infections via surgical tools and medical devices. Hospitals and clinics continued to encounter problems cleaning, reprocessing or sterilizing reusable medical instruments in 2016.
Some of the challenge stems from instrument design. A study published in October 2016 in Infection Control & Hospital Epidemiology found removing all contamination from robotic surgical instruments is close to impossible, for instance. Experts have also called duodenoscopes — which have been linked to outbreaks of multidrug-resistant organisms — "almost impossible to clean correctly."
Other issues arose due to lack of training for SPD staff. For example, a state investigation into Detroit Medical Center in fall 2016 found a lack of a "robust, consistent, repeatable, comprehensively documented and well-maintained training system" for central sterile processing employees was one of numerous issues that exposed DMC surgery patients to infection risk.
Hospitals can stymie this problem by ensuring staff are trained properly on the latest sterilization procedures and making it as easy as possible for staff to follow manufacturers' cleaning instructions.
Quality data transparency. In 2016, CMS moved forward with its controversial Overall Hospital Quality Star Rating program, which assigns hospitals a performance rating ranging from one to five stars. CMS touted the ratings as a way to "help millions of patients and their families learn about the quality of hospitals, compare facilities in their area side by side, and ask important questions about care quality when visiting a hospital or other healthcare provider."
However, the star ratings did not come without criticism. Several stakeholders spoke out about the shortfalls in CMS' program, including inadequate risk adjustment for data that makes larger hospitals that treat more complex patients less likely to receive a high star rating.
Other critics can paint CMS' star ratings as one more voice in an already conflicting crowd of rankings and ratings. A JAMA viewpoint published n November noted "virtually no agreement among the rating systems identifying 'better' or 'worse' hospitals. Hospital ratings systems offer conflicting information, as they rarely agree on which hospitals are top performers and which are poor performers."
Some systems have taken quality data transparency into their own hands. For instance, Meridian Health in New Jersey started displaying performance reports for its hospitals online, so patients can see more current data and make comparisons to other facilities in the area.
"We own it, and put it into a format we believe would be easier for folks in our community to understand, and it's more current," Marty Scott, MD, co-chief quality officer of Hackensack Meridian Health, told Becker's in an interview.
Contaminated water. In 2016, hospitals faced a myriad of patient safety challenges related to contaminated water. The spread of Legionella bacteria, which incites a type of pneumonia, was especially prominent. For instance, in September, five patients at University of Washington Medical Center in Seattle contracted Legionnaires' disease. Two of the patients died. The infections may have contributed to the deaths. A subsequent investigation detected Legionella bacteria in an ice machine and two sinks in UW Medical Center's cardiac unit.
In October, STAT examined the unintended consequences of having more sinks in hospitals. While installed to encourage better hand hygiene, sinks' splashing have the potential to aerosolize contaminated water droplets and therefore infect patients nearby. The article cited a number of cases in which hospital sinks were linked to patient infections around the world. In one such instance in the Netherlands, sinks were removed from all patient rooms to inhibit the spread of bacteria.
To avoid this, Michael Gardam, MD, director of infection control at Toronto-based University Health Networks, suggested, "Don't have the gooseneck [faucet] drain directly into the drain; have it drain off to the side of the bowl. Don't allow it to splash. Make sure it's deep enough that it can't splash on you and splash on your clothing. Make sure that the stuff around [the sinks] is waterproof."
Vaccine coverage. Low adherence to immunization schedules resulted in outbreaks of preventable illnesses in 2016. Multiple mumps outbreaks brought cases of the resurgent virus to a 10-year high, according to the CDC. As of Dec. 3, 46 states and Washington, D.C., had reported 4,258 mumps cases combined.
Influenza is also largely preventable with a vaccine, but few Americans are vaccinated. Flu shots prevented an estimated 5 million illnesses and more than 70,000 hospitalizations in 2015, but the percentage of people inoculated against the potentially deadly virus remained low in 2016. Approximately two in five Americans received a flu shot this past year, which is comparable to the rate in 2015.
"We have a tool that is proven to prevent flu illness and hospitalization but millions of people are not taking advantage of it. Too many people are unprotected," said Nancy Messonnier, MD, director of CDC's National Center for Immunization and Respiratory Diseases.
Though misinformation surrounding vaccines remains abundant, the healthcare community must remain vigilant in educating patients and families about the protective power of vaccination in 2017.
To see the CDC's immunization strategies for healthcare practices and providers, click here.
Behavioral health management protocols. When patients suffering from mental illness or substance abuse end up in emergency rooms, the experience can be trying for both the patient and providers, and these encounters can sometimes culminate in violence.
In 2016, The New York Times reported an instance of a patient shot at St. Joseph Medical Center in Houston. The incident involved Alan Pean, an unarmed, bipolar patient experiencing mental distress who was shot in his hospital room by security. After being hospitalized, Mr. Pean began repeatedly walking into the hallway naked and employees would then guide him back into the room. The patient was reportedly not aggressive or threatening, but after nurses got him into a gown, he refused to fasten it. The nurses, following protocol, alerted the off-duty Houston police officers providing security that morning. After the officers arrived at Mr. Pean's room, they entered and closed the door behind them, and a struggle with the officers ensued. Mr. Pean was Tased, shot and handcuffed.
The case helped fuel the debate over the necessity and safety of staffing armed security guards in hospitals. The Times article also cited a study by Gabor Kelen, MD, director of emergency medicine at Johns Hopkins Medical School. The study found 23 percent of all emergency department shootings involved guns stolen from hospital security.
Hospital administrators can protect their organizations and patients from such situations by ensuring that hospital security is adequately trained to handle crises involving confused or aggressive patients.
Catheter-associated urinary tract infections. A report on the CDC's Winnable Battles initiative released Dec. 5 showed strong progress in the reduction of hospital-associated infections, with one exception: catheter-associated urinary tract infections. Although previous studies suggest as many as 69 percent of CAUTIs are preventable, the infection continues to prove problematic for hospitals.
CDC began Winnable Battles in 2010 and set ambitious goals to be reached by 2015. The results show targets of 60 percent reductions in both central line-associated bloodstream infections and invasive methicillin-resistant Staphylococcus aureus infections are on track to be achieved. Additionally, achieving the target of a 30 percent reduction in surgical site infections looks to be feasible. However, the target of reducing CAUTIs in acute care hospitals by 30 percent was not reached. While CDC data did show a 24 percent decrease of CAUTIs in hospital wards, hospital intensive care units saw a 16 percent increase in CAUTI occurrence.
However, a recently published study examining the efficacy of a CAUTI reduction collaborative effort supported by the Agency for Healthcare Research shows promise. The initiative provided Quality Comprehensive Unit-based Safety Program toolkits for CAUTI reduction to physicians and nurses across 603 hospitals. Program adherence was associated with a reduction of approximately one-third for CAUTIs in general wards.
To learn more about the CUSP toolkit, click here.
Emerging diseases/new outbreaks. The Zika virus captured the attention of both the public and infectious disease experts alike in 2016. As of Nov. 30, the CDC had tallied 1,172 Zika infections among pregnant women in the United States. The infections have resulted in the delivery of 32 infants with birth defects. An additional five fetuses with birth defects were lost in pregnancy due to Zika.
In October, Dr. Frieden, director of the CDC, described the spread of pathogens like Zika as the "new normal" in an age of global travel and trade, dense metropolises and climate change.
Emerging diseases like Zika in 2016 and Ebola in 2014 will continue to present problems for hospitals as they encounter communities where immunities have yet to be developed. Infectious disease experts should do their best to keep themselves apprised of emerging viruses like Mayaro, Rift Valley fever or Usutu that could cause outbreaks in the future.
An emerging pathogen to watch in 2017 is a deadly yeast infection that made its way to the U.S. for the first time in 2016, infecting 19 people thus far. The CDC expects more cases in the future. Some strains of the yeast infection, called C. auris, have developed resistances to all three major classes of antifungal drugs. The deadly yeast has caused outbreaks in healthcare settings in multiple countries across several continents.
To read the CDC's interim guidance for C. auris, click here.