NPSGs target anticoagulation therapy, patient deterioration

Underlying processes key to satisfying Joint Commission standards

The 2008 National Patient Safety Goals (NPSGs), recently published by The Joint Commission, contain two new goals, both of which have significant implications for hospital quality managers. The first, Goal 3E, states: "Reduce the likelihood of patient harm associated with the use of anticoagulation therapy." The second, Goal 16, states: "Improve recognition and response to changes in a patient's condition." Goal 16A elaborates: "The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient's condition appears to be worsening." (Complete list of the 2008 goals.)

Why were these particular goals added? "It gets back to our overall process in the review and prioritization of topics, which we get from the Sentinel Event Advisory Group and a variety of interest and special societies, as well as direct input from field review," explains Peter Angood, MD, vice president and chief patient safety officer for The Joint Commission. "The advisory group has very robust discussions and prioritization processes, as well as a general sense from the field as to how much they can absorb."

The need for greater attention to patient deterioration was brought to the fore recently with the well-publicized ED waiting room death of a Los Angeles woman. (See the cover story in the August 2007 issue of ED Management.)

What are the most common potential sources of patient harm involved with anticoagulation therapy? "The types of medications used place the patient at risk for under-dosing as well as over-dosing," explains Angood. "Under-dosing creates a situation where the disease is not adequately managed, while over-dosing creates increased risk for bleeding and other various complications." Accordingly, says Angood, it is important for these medications to be maintained in a therapeutic range — both for inpatients and outpatients.

"This goal does not replace existing clinical guidelines developed by other professional societies, but focuses rather on trying to ensure there are adequate processes and systems in place within the health care organization to make sure the patient is identified and followed, the staff is educated appropriately, and any adverse outcomes are evaluated on a regular basis," he explains.

What The Joint Commission wants

Exactly what is The Joint Commission looking for in terms of compliance? For anticoagulation therapy: "The processes should be defined and [the issue] established as a distinct management program, with recognition of different types of therapies," says Angood. "The ways they are administered — oral, IV, and so forth — should be protocol-driven strategies with well-established laboratory parameters for therapeutic range, and policies for testing and management." There also should be education programs for staff and patients, he says.

When it comes to patient deterioration, and "a suitable method" for response when a patient's condition worsens, is The Joint Commission speaking specifically about Rapid Response Teams? "[The data on Rapid Response Teams are] a little ambiguous, so we are taking the approach it's not the method of response, but the underlying process to identify and respond that's most important," says Angood. "For detection, there should be some identified parameters and established frequency for how often patients are evaluated — as well as criteria for when extra help and resources should be contacted, and who they are. Along with that is the whole issue of educating providers and patients and empowering staff to initiate a response. Also, there needs to be a good, ongoing monitoring system that evaluates effectiveness of the program and can measure the outcomes — cardiac arrest rate declines, mortality rate decreases, and so forth."

Anticipate, anticipate, anticipate

Quality managers agree that the best way to ensure compliance with the NPSGs is to be proactive with your quality and safety programs, and anticipate where The Joint Commission may be headed.

"The good news is that we have been anticipating the goal specific to anticoagulant therapy and have been talking about it in patient safety rounds for a year," says Rita Stockman, RN, MSA, director, hospital quality, at William Beaumont Hospital in Royal Oak, MI. She adds that her facility has a Rapid Response Team in place to deal with patients whose conditions worsen.

"We certainly will revisit [our processes], but we think we have a good handle on both areas," adds Phyllis Voreis, RN, BSN, CIC, director of accreditation and regulatory readiness for the University of Michigan Hospital and Health Centers in Ann Arbor. "If nothing else, we'll be tightening up [processes] and making sure there are no loose ends — and everyone's on the same page."

For Stockman, staying on top of the NPSGs is part of an ongoing process. Each year an interdisciplinary team goes out to every department and lets them know what the next patient safety initiative will be. "We are on the road [with the new goals]," she notes. "As of yesterday, we passed out the list to the hospital performance improvement committee. We will revisit what we are currently doing and then look at inpatient and ambulatory sites on campus."

As she indicated previously, much of the work has already been done. "We have met with the group that does 'anti-coags' on the outpatient side, and looking at the feedback mechanisms they use to be sure patients are therapeutic — and if not, how patients should be educated," she says. "This goal will help us firm that up — it's an extensive clinical process that involves letting the patient know exactly where things stand, how to get what they need, where to get draws and results, and so forth."

Interesting approach to falls prevention

One interesting approach the facility is taking involves fall prevention. "If you prevent falls, you are also promoting safety with anticoagulation therapy," says Stockman, noting that the stomach and the brain are the two most vulnerable areas. "And don't forget, the population is aging, so the spectrum of people who may be on these medications now is widening. Since some people may not be able to get medical information, enough medical care, or may not have the money to get blood drawn; we need to improve our methods for detecting people at risk for self-medicating."

The Rapid Response Team has been implemented "incrementally" across the hospital in all adult patient areas "in order to encourage staff to be more comfortable with it," Stockman says. "Today, any staff nurse can call the team." It has been well received, she says, adding, "I know we have decreased the number of codes." Now, however, she wants to build on that success, and is moving into the pediatrics area, which will involve having parents initiate calls. "We want to get to the point the where family members are able to initiate calls," she says.

Since the University of Michigan has both ambulatory centers and inpatient facilities, a single group has been created to look at anticoagulation therapy in both settings, Voreis says. "We are going to make sure we are consistent," she says. "From what I can tell, the same pharmacist is involved in every case, but I want to make sure there are no holes."

In terms of patient education, there is general information available on the University of Michigan Hospital and Health Centers' web site. "But when the therapy is actually started, the patients have one-on-one meetings with the nurse and pharmacist to talk about food interactions, and so forth, and they receive information packets as well."

To help keep doses within the therapeutic range, the system has recommendations or monitoring protocols and all doses. (See sample.)

Direct response for patient deterioration

Voreis also has established what she calls a Direct Response Team to handle patient deterioration. "We've just expanded into some areas where we had not been — to the pediatric area, and a freestanding cardiovascular center we just opened — but we already have policies and procedures to look at the metrics and determine how affective we are," she says. As far as calling the team, "Right now it's primarily set up for staff nurses on the floor, but a lot of house officers are using it, too — which surprised us," Voreis says. "Thus far, however, we do not have a mechanism for the family to call the team."

[For more information, contact:

Peter Angood, MD, Vice President and Chief Patient Safety Officer, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, IL 60181. Phone: (630) 792-5000.

Rita Stockman, RN, MSA, Director, Hospital Quality, William Beaumont Hospital, Royal Oak, MI. Phone: (248) 551-3104. E-mail:

Phyllis Voreis, RN, BSN, CIC, Director of Accreditation and Regulatory Readiness, Quality Improvement, University of Michigan Hospital and Health Centers, 2101 Commonwealth Avenue, Suite 1021, Ann Arbor, MI 48109-0729. Phone: (734) 615-7243.]