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VHIG Digest: Volume 2, No. 5

Posted by on Monday, March 28, 2011 in Digest, Our Blog and Digest, Uncategorized, Volume 2.

by Natalie Ausborn, VMS II

In the News

1. ICU Central-line Infections Drop Dramatically Nationwide – 3/14/11

The Center for Disease Control and Prevention released a report indicating that U.S. intensive care units reduced central line-associated bloodstream infections by approximately 60% over the past ten years, with an estimate of 27,000 lives saved and $1.8 billion in medical costs saved. The report compared ICU blood infection rates reported from 260 participating hospitals in 2001 to 1600 participating hospitals in 2009. Robert Wachter, MD, Division of Hospital of Medicine Chief, University of California, San Francisco Medical Center noted that scientific rigor is what has set apart the national effort to reduce bloodstream infections. The central line bundle has been well-studied by researchers such as Peter Pronovost, MD, PhD. About 25% of all patients with bloodstream infections die, and central-line infections are also a problem in other areas of the hospital outside of the ICU.

2. Riddled With Metal by Mistake in a Study – 3/21/11

A breast cancer study involving a metal surgical device has left thirty women with hundreds of tiny particles of tungsten in their breast tissue. While it is not known if the metal is dangerous due to limited data, the issue has raised great concern, leading one woman to consider a radical mastectomy. The faulty device has been recalled, although initially approved by the FDA. in an abbreviated 501(k) process that did not require tests on humans.

3. HHS Releases National Quality Strategy – 3/22/11

The department of Health and Human Services (HHS) recently revealed its National Strategy for Quality Improvement in Health Care in response to the federal health reform law, which called for a strategy to guide efforts to improve health care from the local to national levels. HHS used evidence-based results to set several priorities including reducing medical errors, engaging patients and families as partners in care, promoting prevention and effective treatments for leading causes of mortality, and collaborating with communities to promote best practices.

The full report:

In the Literature

1. Case Study: Advancing Patient Safety in the U.S. Department of Veterans Affairs

A decade ago, the VA formed its National Center for Patient Safety to foster an organizational culture of safety within its nationwide network of hospitals and outpatient clinics. A recent medical team training program designed to improve communication among operating room staff was associated with a reduction in surgical mortality and improvements in quality of care, on-time surgery starts, and staff morale. The program is now being expanded to other clinical units, along with a patient engagement program that prevents errors by facilitating communication relating to patients’ daily care plans. A recognition program stimulated facilities to conduct timelier and higher-quality root-cause analyses of reported safety events to identify stronger actions for preventing their recurrence. Other initiatives have reduced rates of health care-associated infections, patient mortality, and post-operative complications. Success factors include leadership accountability for performance and organizational support for testing, expanding, and adopting improvements.

2. Interventions to Reduce Hospitalizations from Nursing Homes: Evaluation of the INTERACT II Collaborative Quality Improvement Project

A substantial proportion of hospitalizations of nursing home residents may be avoidable. Interventions to Reduce Acute Care Transfers (INTERACT) II is a quality improvement intervention that includes a set of tools and strategies designed to assist nursing home staff in early identification, assessment, communication, and documentation about changes in resident status. INTERACT II was evaluated in 25 nursing homes in three states in a 6-month quality improvement initiative. There was a 17% reduction in self-reported hospital admissions in these 25 nursing homes from the previous year. The average cost of the 6-month implementation was $7,700 per nursing home with projected savings to Medicare of approximately $125,000 per year. INTERACT II should be further evaluated in randomized controlled trials to determine its effect on avoidable hospitalizations and their related morbidity and cost.