A Good Defense

Prevention, not control, takes center stage in patient safety

Remember when the infection control professional in your hospital or IDN was called an “infection control manager” or “infection control practitioner?” Some JHC readers may already be working alongside the next-generation infection control professional, only his or her title is now infection preventionist.

In July 2008, the Association for Professionals in Infection Control and Epidemiology (APIC) announced that infection control professionals would henceforth be referred to as infection preventionists.

“The new name reflects our strategic vision for the future of the practice and the profession,” said Cathryn Murphy, RN, MPH, PHD, CIC, APIC board member and associate professor at Bond University in Queensland, Australia, at the time of the announcement. “With a declining arsenal of effective antibiotics, it was increasingly clear that the traditional orientation toward the control of [healthcare-acquired infections] needed to shift to one where preventing their occurrence was the priority.”

Rallying around the cause
Indeed, preventing infections and other potentially harmful errors in the hospital has taken center stage in the pursuit of patient safety. The federal government encouraged the approach by announcing last year that it would no longer reimburse providers for treatment of a number of conditions, including foreign objects left after surgery, surgical site infections, vascular catheter-associated infection, falls and trauma, and late-stage pressure ulcers.

Governmental, clinical and industry organizations have rallied around the cause. The Center for Medicare & Medicaid Services, for example, has launched (with assistance from other organizations) the Surgical Care Improvement Project (www.qualitynet.org), whose goal is to reduce preventable surgical morbidity and mortality by 25 percent by 2010. Others include Medline Industries and its new “Prevention Above All” product campaign; Premier Inc., with its Premier Safety Institute; and VHA, with its “Rapid Adoption Networks,” which are aimed at facilitating information-sharing among groups of VHA facilities, including information about patient safety.

“The word ‘prevention’ has always been my focus, if not in the actual title of all the positions I’ve held,” says Sue Barnes, RN, CIC, national leader of infection prevention and control and patient safety, Kaiser Permanente Program Offices, Oakland, Calif. “The position was originally referred to as ‘infection control manager’ or ‘coordinator.’ But prevention was always implied, and it was part of the job.”

The term “infection preventionist” reflects a branding strategy to “elevate the recognition and valuing of the profession as we become responsible for more and more aspects of patient care across the continuum of care, and as mandatory reporting becomes an issue,” says Barnes. That recognition is already on the rise, given the attention that patient safety has received – both as a patient-care issue as well as an economic one – in the professional and consumer press.

As for mandatory reporting, most states have already passed legislation demanding that acute-care hospitals report infection rates, so those rates can then be posted on the Web. Theoretically, members of the public can access that information to help them decide where to receive care. In the short term, such reporting requirements are straining the resources of short-staffed infection control departments, says Barnes. “But ultimately, that kind of attention will only help us, because it shines a bright light where there wasn’t one before, so we can increase resources and identify opportunities [to improve patient safety].”

Efforts are paying off
All the work and attention is already paying off in the form of safer inpatient facilities, says Barnes. “A lot more attention is being paid to making hospitals safer, to drawing upon learning [opportunities] and best practices, and to borrow from disciplines outside healthcare, such as aviation. We are making systems more reliable, in part by focusing on the human factors in those systems.”

Indeed, 90 percent or more of the 1,466 hospitals that received Joint Commission accreditation surveys during 2007 demonstrated compliance with 11 of the 18 requirements of the organization’s 2007 National Patient Safety Goals, according to the Joint Commission. The organization has been drawing up such goals on an annual basis since 2003.

Despite the improvements, though, patient safety is no sure thing for the future. Staff shortages are occurring across the country, says Barnes. “Our most experienced infection preventionists are retiring, so we’re having to replace them with nurses having no prior experience in infection prevention and control. And it’s a long learning curve. Our challenge is to create the infrastructure to train and mentor these new people on a long-term basis.”

Outpatient challenges
Another challenge facing infection preventionists is providing oversight across the continuum of care, especially in ambulatory settings. “As more invasive procedures are performed in ambulatory settings, the risk of infection increases, as does the need for infection preventionists,” says Barnes.

The issue hasn’t escaped the notice of the Joint Commission, which has a list of National Patient Safety Goals for ambulatory care, that mirror to some extent those for the acute-care setting. Nor has it escaped the attention of the Association for Professionals in Infection Control and Epidemiology (APIC). In January, the association sounded the alarm about unsafe injection practices in ambulatory care settings.

Citing a study in the Annals of Internal Medicine, APIC CEO Kathy Warye pointed out that 33 outbreaks of hepatitis B or C virus infection caused by unsafe injection practices in U.S. outpatient healthcare settings had occurred during the prior 10-year period. “This comes on the heels of a highly publicized outbreak in Nevada in which 40,000 people were notified of their possible risk of hepatitis C due to improper use of syringes at a Las Vegas endoscopy clinic,” Warye said. “These outbreaks were preventable and should never have occurred.”

One month later, the issue hit the consumer press. Citing information from the Centers for Disease Control and Prevention, The Wall Street Journal reported on Feb. 4, 2009, in an article entitled “Lax Needle Use in Clinics Raises Alarm,” that unsafe injection practices are one of the leading causes of infections in doctors’ offices, outpatient clinics and long-term-care facilities. “Although most healthcare workers are aware of the dangers of reusing needles, other injection guidelines aren’t always followed, including disposing of syringes after each use,” according to the newspaper. “Contaminated shots can lead to transmission of such diseases as hepatitis and HIV, along with other viral and bacterial infections.”

Challenges of ambulatory care
“What makes the ambulatory setting so challenging is that it’s all over the place,” says Richard Roberts, MD, JD, professor of family medicine at the University of Wisconsin Medical School in Madison and a practicing family physician. “Solo practices still make up 20 to 25 percent of primary care doctors.” Roberts is a past president of the American Academy of Family Physicians, president-elect of the World Organization of Family Doctors, and a member of the board of governors of the National Patient Safety Foundation.

His interest in patient safety and risk management goes way back, even before he became a doctor. He started his professional life as a young lawyer, working in the Carter White House in Washington. Early on, he was exposed to malpractice and risk management issues. He developed an interest in quality improvement and guidelines, then practice and systems redesign. “Patient safety has been a very large part of that,” he says.

What many people fail to understand is that while hospitals do indeed present a variety of safety-related risks to patients, far more care is delivered in the doctor’s office, says Roberts. “The place that care most often happens is the 2-to-3-doctor family physician practice,” he points out. Of the 1.1 billion doctor visits that occur each year in this country, a person is 30 times more likely to be seen in a doctor’s office than in a hospital.

From a patient-safety perspective, that is definitely a mixed bag.

Says Roberts, “The nice thing about the hospital for the patient-safety aficionado is this: It is a much more confined and focused environment, where there are clear leadership chains of command.” In the acute-care setting, safety policies can be implemented and reinforced. Physicians’ offices, on the other hand, are more informal and flexible. “Their practice systems may not be as well articulated … as those of hospitals.”

On the other hand, one could argue that doctors’ offices are more patient-sensitive than hospitals, whose staffs care for hundreds to thousands of patients every day. Because they operate on a smaller scale, doctors’ offices experience fewer hand-offs of patients from one caregiver to another. “And half the errors occur when you hand the care off to somebody else,” points out Roberts.

Even so, despite the fact that patient volume is lower at the doctor’s office than in the hospital, the typical family doctor may still “touch” as many as 130 to 150 patients a day, either in person, on the phone, through emails or consultations with other doctors, says Roberts. “There’s a constant swirl of chaos, and it’s easy for things to get lost.” Test results can go unreported, for example. The challenge for the doctor is to encourage his or her patients to become fully engaged in their own care. That might mean questioning the doctor’s judgment or prescribed course of action, bringing in medical articles from the Internet, and most important, following up on such things as lab tests.

Getting the patient engaged
Like Roberts, Kathleen Shostek, RN, senior risk management analyst for ECRI Institute, Plymouth Meeting, Pa., stresses the importance of patient involvement in helping improve patient safety and prevent errors. In the typical practice, there’s precious little time for providers to adequately educate their patients and answer their questions about medications, their condition and their treatment plan, she says. “It takes an enormous amount of effort to meet the patient at his or her level of understanding and to get them involved in their own care. Offices need to develop systems to support them in this effort.”

Twenty years ago, the term “patient safety” wasn’t readily used, she says. “Then, [it was an issue primarily of] avoiding malpractice suits and mitigating financial losses.” That changed with the Institute of Medicine’s 1999 report “To Err Is Human,” which pointed out the ubiquity of medical errors and subsequent patient deaths.

Since the publication of that report, caregivers have looked more critically at how they provide care, says Shostek. “A tremendous amount of work has been done, and we’re beginning to see positive changes. Safety is now at the forefront, from leadership to front-line caregivers.”

That extends to the physician office as well, and with good reason, says Shostek. “Eighty percent of all non-hospital care is provided in the physician’s office, and in about one of every four doctor’s office visits, errors and preventable events occur. That’s a huge opportunity for physicians to learn from treatment errors.”

Physicians and their staff have made strides in improving the diagnostic process, traditionally the area of most concern in doctors’ offices, says Shostek. “You see clinical prompts and protocols … that help them keep track of diagnostic tests and referrals.” For example, if a patient gets a referral for a colonoscopy, did she in fact have it? If so, did the physician get the results? If so, did he or she communicate them to the patient? And if that patient needs follow-up care, did the physician track whether she received it?

“You have to close the communication loop,” says Shostek. “‘No news is good news’ is often how lab tests are handled.” That’s not good enough anymore.

It’s true that physician practices that are affiliated with larger health systems have access to information, expertise and support systems that independent practices do not, says Shostek. They can draw on the hospital’s clinical engineering department or infection control professionals. But the fact is, some processes that work well in the acute-care setting don’t translate to ambulatory care. “There’s not a lot of research to say that the same systems in place in hospitals will work in physicians’ offices,” she says.

But the biggest challenge facing a physician practice – any physician practice – isn’t lack of concern or systems. It’s lack of training and even more, a lack of time. “Physicians and office staff have so many competing demands. Patient safety isn’t top of mind,” says Shostek.

For patient safety to take hold in the office, it has to permeate the culture of the practice, she adds. “Practice leaders – clinicians and office managers – may need to see the business case before making changes. But once they do, they’re usually on board.”

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