The Good and Bad about Hospital Acquired Conditions

The federal government announced in December 2014 that American hospitals are getting safer.

The Agency for Healthcare Research & Quality (AHRQ) reported a 17 percent drop in patient infections and medical errors from 2010 to 2013, and estimated that 50,000 deaths were averted over that span.  Hospital Acquired Conditions (HACs) fell from 145 per thousand discharges to 121 per thousand, thus saving $12 billion.

U.S. Secretary of Health and Human Services, Sylvia Burwell, said that the data represent “significant progress on improving the quality of care that patients receive while spending our health care dollars more wisely.”  To read this article, ‘Hospitals Make Unprecedented Strides in Patient Safety,’ click here.

Left unsaid was that H&HS originally set a goal of reducing HACs by 40 percent by the end of 2013, with 60 thousand fewer deaths, 1.8 million fewer harms and $35 billion in savings.

That’s good news!

 

However, medical errors still affect one in ten patients, according to Dr. Peter Angood of the American Association for Physician Leadership.  He noted that the report finds that one in 10 hospital patients still experience such errors.

“A 10 percent error rate that creates harm, disability and possible death is way too high in American health care,” Angood said.

U.S. Hospitals Making Fewer Deadly Errors

The federal report’s authors speculated that the decline reflects financial incentives and pressures from payers, public reporting of harmful events and the ‘technical assistance offered by quality improvement organizations’ all contributed.

While it’s good to know the ‘Carrot and the Stick’ strategy still works, it seems odd that hospitals need to implement a culture of safety, given their mission.  Still, a record 2,610 hospitals are under CMS penalties for readmissions.  The Joint Commission, which accredits more than 75% of U.S. hospitals, found infection prevention and control deficiencies in about half of the hospital reviews it conducted in the first half of 2014.  More than a third of U.S. hospitals do not have a certified infection prevention specialist on staff.

Until recently, infection was considered an inevitable risk of healthcare delivery.  While progress is being made, it’s clear that healthcare providers need more tools to protect patients, healthcare workers and the general population.  Problems continue due to non-standard infection control processes and unique organization-specific characteristics.  While improvements are evident, there is still concern about how well hospitals are prepared to handle serious contagious diseases.

There are several new technologies designed to improve patient safety, but technology has proven to be only as good as the people using it.  For example, Leapfrog Group President, Leah Binder, believes this is due to a lack of discipline concerning infection control in many hospitals.

“If an Ebola patient walks into a hospital that has a high rate of infection for other illnesses,” she stated, “they are going to be woefully unprepared.”

As automated patient flow technology has expanded into a real-time operational management platform, it has become a second line of defense against infection spread.  It does this by bridging the departmental silos and protocol breakdowns that contribute to inadvertent infection exposure among hospital employees who haven’t been alerted to the presence of infection in a patient or patient room.

Most hospitals still use manual processes to distribute warnings, including physically posting isolation status at the entrance to patient rooms.  Hospital automation technology can distribute infection alerts to any and all employees as soon as a patient has been diagnosed.  In addition, that infection status stays with the patient as long as the condition lasts and wherever the patient travels within the hospital.

RTLS technology can track infected patients throughout the hospital as well as equipment which may have also been exposed to infection.  A recent British hospital study illustrated the importance of this capability when it was determined that a patient with a HAC came in contact with 216 people in one day.

When time is of the essence, it’s important that your institution have the means to identify in minutes the hospital personnel who came in contact with a contagious patient.

To determine if your organization has a ‘Culture of Safety’, begin with these five questions.

1. Does executive leadership set the tone?

Posters, balloons, and events create awareness that “safety comes first.”  But accountability, transparency and regular communication drives continuous success. Manually tracking and monitoring infectious patients is laboriously time-consuming. Now, healthcare IT is bringing real-time operational visibility to patient safety and care delivery. If infection rates are trending up, find out whether hospital leadership has explored the infection-tracking technologies now available.

2. How transparent is your organization?

The “silo” effect between departments can lead to hospital employees unknowingly entering isolation rooms or transporting infected patients. Manual alert processes may not adequately protect staff in today’s overcrowded hospital environment. Determine if infection alerts currently take minutes or hours.

3. Is there a ‘Single Point of Truth’?

Are employees required to actively check for a patient’s infection status? Information buried in a patient’s electronic medical record requires hunting for that information. Find out if there is one source where everyone can go to confirm a patient’s infection status?

4. Does your current technology have infection control features?

Installed workflow technologies may not have been optimized to support infection prevention. Some systems come with embedded features which only need to be activated. Among these are RTLS systems, patient flow systems, and capacity management platforms.

5. Is there a communications plan for infection events?

Communicating the presence and location of a contagious patient is as important as following the latest CDC treatment guidelines when it comes to infection containment. Find out what methods are in place to instantly disseminate a contagion warning throughout your hospital.

An enterprise effort like this requires a single “champion” who can mobilize key stakeholders, organize a targeted communications plan, drive it through the organization and work with external government health departments and emergency management.

Ask yourself if you might be that person.

To download our whitepaper, ‘Overlooked and Under-protected,’ click here.