Hospital Consult - August 2015
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Hospitals Warned About Dual Measurements on Oral Dosing Devices
HORSHAM, PA – It’s time to replace the outdated dosing cups that your hospital may still be using.
That’s according to an alert from the Institute of Safe Medication Practice’s National Medication Errors Reporting Program. The ISMP reported a patient death after a nurse confused two dosing scales that appear on an oral liquid dosing cup, mistaking fluid drams for milliliters.
“Unfortunately, these cups are still available from major vendors, so it’s possible they will be found in your healthcare facility,” according to the alert. “In their place, available oral syringes that measure only in mL should be used to measure doses of oral liquid medications whenever possible. If a dosing cup must be used, ideally it should allow measurement in mL only.”
ISMP points out that, while the cups “are not widely available at this time, some suppliers can customize dosing cups to measure in mL only.” If hospitals can’t get a customized cup, they may still have to use those with the dual mL and household measurements until mL-only cups can be supplied, the group concedes.
“Make sure your purchasing group or department knows what type of cup to purchase,” the alert adds. “Also, only purchase dosing cups that have printed, rather than embossed, measurement scales, so they are easier to read.”
In the fatal event cited in the alert, a nurse measured a dose of morphine sulfate oral solution 20 mg/mL incorrectly for an opioid-naïve hospice patient, misreading the scale marked drams as mL and administering 1 dram of the medication instead of 1 mL. One dram is equivalent to 3.7 mL, so the patient received close to 75 mg of morphine.
In a second case described by the alert, a nurse gave a patient 5 drams of a formerly available acetaminophen liquid concentrate, 100 mg/mL, instead of 5 mL, a total of 18.45 mL, or 1.845 g of acetaminophen.
“While progress is being made in hospitals in regards to prescribing liquids in mL, many hospitals still use dosing devices that have household measures (e.g., tea spoonful, dessertspoonful, tablespoonful) and, as above, even drams and ounces,” according to the ISMP. “This sets healthcare professionals up to fail because the dosage scales on embossed cups are difficult to read, have dangerous abbreviations that are easily confused (e.g., TBS and TSP), and measures that are no longer used (e.g., drams).
Drams and ounces, which also appear on these cups, are from an outdated apothecary no longer in clinical use.
A proposed change from United States Pharmacopeia, endorsed by government agencies and a number of medical and pharmaceutical associations, requires that gradations on dosing devices “shall be legible and indelible, and the associated volume markings shall be in metric units and limited to a single measurement scale that corresponds with the dose instructions on the prescription container label.”
Healthcare Workers Fall Short On Personal Protective Equipment Protocols
MADISON, WI – Very few healthcare workers followed all national Centers for Disease Control and Prevention recommendations on removal and disposal of personal protective equipment (PPE), according to an observational study at a Wisconsin hospital.
The brief report, published recently in the American Journal of Infection Control, found fewer than one in six – four out of 30 – hospital staff members fully complied with protocol.
“In our study we found that the majority of HCWs did not remove PPE in the correct order,” write study authors from the William S. Middleton Veterans Hospital and the University of Wisconsin, both in Madison. “Further, many of those who did remove the PPE in the correct order failed to properly dispose of their contaminated PPE in the isolated patient's room. Deviations from protocol were common.”
For the study, a trained observer watched healthcare personnel entering and exiting patient rooms with isolation precautions on various units of the hospital from Oct. 13-31, 2014.
According to CDC recommendations, gloves should be removed first, followed by the careful removal of the gown from the back while still in the patient's isolation room.
Of the 30 healthcare workers observed removing PPE, 17 removed the gown out of order, 16 wore their PPE out into the hallway, and 15 removed their gown in a manner that was not gentle, which could cause pathogens from the gown to transfer to their clothes.
"As a result of the current Ebola outbreak, the critical issue of proper PPE removal has come front and center," the authors state. "Healthcare facilities should use this opportunity of heightened interest to undertake practice improvement focused on PPE removal protocol, including technique, for all healthcare-associated conditions that require the donning and doffing of PPE."
The study also found that many HCWs did not tie the back of their gowns, which could then drape over patients and increase contamination risk. Furthermore, PPE garments sometimes were removed by rolling the equipment against previously uncontaminated work clothes or bare hands before disposal.
“These breaches of PPE removal protocol may be due to a lack of awareness of the proper protocol, time constraints, or lack of realization of the importance of proper PPE removal,” suggest the authors, who call for more education.
Protocol Identifies Hospitalized Patients for Sleep Apnea Screening
PHILADELPHIA – Screening patients for obstructive sleep apnea (OSA) might be an effective way to reduce readmissions, according to a new study which found that overnight assessment of oxygen desaturation helped identify the condition.
The report, published recently in the Journal of Clinical Sleep Medicine, describes a clinical pathway developed by a multi-disciplinary group of researchers and physicians at Thomas Jefferson University and Hospitals to identify OSA in higher-risk, hospitalized patients.
"The results showed that our screening process identified sleep disordered breathing in 87% of patients who followed up with a polysomnography," first author Sunil Sharma, MD, said in a Thomas Jefferson press release. “We confirmed the high prevalence of undetected sleep disordered breathing among hospitalized patients and also validated a low-cost protocol to detect it."
Reviewing patients admitted to the hospital under cardiology, internal medicine and family medicine, those with a body mass index over 30 – a known risk factor for sleep apnea – were automatically screened with the Snoring, Tiredness during daytime, Observed apnea, high blood Pressure questionnaire.
Patients who screened positive received a formal sleep consult during their hospital stay and underwent overnight pulse-oximetry testing, which assessed the patient's oxygen desaturation index (ODI) as another indicator of potential sleep apnea.
If their ODI measured high, patients then were recommended to undergo overnight polysomnography as an outpatient. With636 patients classified as high risk and 118 as low risk for OSA, 149 ultimately followed up with the recommended polysomnography; 87% of them were diagnosed with sleep disordered breathing.
Based on that, the authors suggest that overnight pulse-oximetry can be used as a simple low-cost device in hospitalized settings to determine if referral to polysomnography is appropriate.
A side effect of the program, according to the authors, was an increasing number of direct sleep medicine consult requests as admitting physicians and house staff were made more aware of OSA.
"Sleep disordered breathing is associated with cardiovascular complications and sudden death," Sharma said. "This study should be of great interest to hospitals looking at ways to reduce complications. Recent data suggests that for inpatients with cardiovascular disorders, early diagnosis and intervention for sleep apnea may lead to reduced readmission rates."
More Newborns of All Weights Being Admitted to U.S. NICUs
LEBANON, NH – Neonatal intensive care units (NICUs) originally were developed in the United States to provide optimal treatment of very low-birth-weight infants, but admission rates now are increasing for newborns of all weights.
An article published online by JAMA Pediatrics reports that, from 2007 to 2012, NICUs increasingly admitted term infants of higher birth weights and, by 2012, nearly half of all NICU admissions were for normal-birth-weight infants or for those born at 37 weeks gestation or older.
Dartmouth Institute for Health Policy and Clinical Practice researchers looked at data for nearly 18 million live births to U.S. residents from January 2007 through December 2012 in 38 states and the District of Columbia. They found that overall admission rates increased from 64.0 to 77.9 per 1,000 live births and that admission rates had increased for all birth weight categories.
NICUs have been a significant success story for hospitals: The neonatal mortality rate is less than a quarter of what it was 55 years ago – from 18.73 per 1,000 live births to 4.04 per 1,000 live births in 2012 – when the first ward opened in the United States to provide highly specialized care to premature and sick infants.
Because a 2003 revision to the U.S. Standard Certificate of Live Birth includes a new field to indicate whether a newborn was admitted to the NICU, researchers now are able to study trends in neonatal intensive care for the majority of the U.S. newborn population across time.
In 2012, the researchers identified 43 NICU admissions per 1,000 normal-birth-weight infants, defined as 2,500 to 3,999 grams, while the admission rate for very low-birth weight infants, less than 1,500 grams, was 844.1 per 1,000 live births. From 2007 to 2012, however, NICUs increasingly admitted term infants of higher birth weights.
In fact, by 2012, the study found that nearly half of all NICU admissions were for normal-birth-weight infants or for those born at 37 weeks gestation or older.
"Newborns in the United States are increasingly likely to be admitted to a NICU, and these units are increasingly caring for normal-birth-weight and term infants,” the authors write. “The implications of these trends are not clear, but our findings raise questions about how this high-intensity resource is being used.”
In a related commentary, Aaron E. Carroll, MD, MS, of the Indiana University School of Medicine, emphasizes that the study does not suggest that the admissions of higher birth weight babies is fraudulent or wasteful.
“It is entirely possible that the admissions are justified,” Carroll argues. “However, there is no doubt that they are expensive and carry potential harm. If hospitals want to argue that NICUs are necessary, they will need to prove that the need exists, especially in light of the increasing share of infants admitted who are at or near full term. If hospitals are unable to demonstrate that NICUs are necessary, then it is very likely that, at some point in the near future, policies will force them to reduce those admissions, which will have major implications for NICU and hospital finances."
