Hospital Consult - December 2015
Hospital Access Management - Hospital Case Management - Hospital Employee Health
Hospital Infection Control - Hospital Peer Review - Healthcare Risk Management
Case Management Advisor - IRB Advisor - Medical Ethics Advisor - Same-Day Surgery
Hiring Foreign-Trained Nurses Leads to Patient Satisfaction Declines
PHILADELPHIA – Hiring foreign trained nurses might be the only option for hospitals struggling to find staff, but a new study suggests that the practice comes at a cost to patient satisfaction.
The study, conducted through collaboration between the University of Pennsylvania School of Nursing and United Kingdom nursing schools, finds that every 10-point increase in the percent of non-U.K. educated nurses providing direct care was associated with 10% lower odds of getting a good or excellent rating from patients.
Results were published recently in the journal BMJ Open.
For the study of more than 12,000 patients in a representative sample of 31 National Health Service (NHS) Trusts in England, researchers analyzed the annual patient satisfaction survey conducted by the NHS. Specifically, patients in hospitals with larger percentages of nurses trained abroad were significantly less likely to report being treated with respect and dignity, getting easy-to-understand answers to their questions, and having the purpose of their medications explained. The hospitals in the study employed anywhere from 1% to 50% of non-U.K. educated nurses for bedside care duties.
"This study was motivated by findings from a previously published U.S. study documenting higher mortality for patients in U.S. hospitals that employed more non-U.S. educated nurses, and evidence that NHS hospitals were increasing nurse recruitment abroad despite public concerns about quality," explained senior author Linda H. Aiken, PhD, RN, director of Penn Nursing's Center for Health Outcomes and Policy Research.
Study authors point out that nurses are in short supply in England because the NHS funds too few nursing school slots.
"National workforce planning in England has failed to consistently deliver enough professional nurses to work in the NHS,” added co-author Professor Peter Griffiths, chair of Health Services Research at the University of Southampton. “Relying on bringing in large numbers of foreign educated nurses to make up the shortfall is not a simple solution and may not be effective."
The study recommends that nursing education be expanded to meet the needs of the many qualified students in the U.K. and U.S. who want to enter the professions but can’t be admitted to a program.
Clinical Workstations Can Harbor Dangerous Bacteria in ICUs
SYDNEY, AUSTRALIA – Sanitation staff cleaning hospital intensive care units (ICUs) might be overlooking an area that can harbor a multitude of dangerous bacteria: clinical workstations.
That’s according to a pilot study published recently in American Journal of Infection Control.
For the investigation, researchers from Western Sydney University in Australia employed three different sampling methods in a busy ICU to uncover where multidrug-resistant organisms (MDROs) might still be hiding after routine environmental cleaning.
“The location of MDROs within an ICU may be subject to patterns of localization and dispersion,” study authors explain. “The transfer of these MDROs away from the patient area and throughout the ICU is thought to occur largely via unwashed hands and gloved hands. High-touch objects (HTOs) are located throughout clinical areas and can provide a likely transit point for microbes owing to the frequency of hand touches.”
Tracing the steps of healthcare workers (HCWs) in between their workstations and patient bedsides and sampling commonly touched objects along the way for MDROs, the researchers confirmed that nine of 13 MDROs still lurking came from clinical workstations -- on chairs, clipboards, keyboards, telephones, and a computer mouse.
The study also found that using two commercially available adenosine triphosphate (ATP) bioluminometers was more than seven times as likely to positively identify MDROs as microbial swabbing –33.3% vs. 4.3%.
"In this pilot study, we found that many of the high touch objects from which MDROs were recovered were not items included in cleaning protocols," the researchers point out. "The findings of this study suggest the need to review the hygiene standards adopted in the clinical workspace, away from the immediate patient zones in busy ICUs, and indicate that ATP testing may help identify high touch objects with less than optimal cleanliness."
The study adds that specific MDRO locations were not limited to the immediate patient surroundings or to any specific HTO or type of surface. Still, the researchers note, “The use of ATP testing helped rapidly identify the soiled locations for MDRO sampling. The greatest density of positive MDRO locations was around and within the clinical staff work station.”
PPI Overuse Increases Infection Risk for Hospitalized Patients
ANN ARBOR, MI – For many U.S. hospitals, providing patients with proton pump inhibitors (PPIs) is routine practice to reduce heartburn or prevent stomach or gut bleeding.
In fact, a new study suggests that about half of hospitalized patients use the drugs at any point in time. The problem, however, according to the report in the Journal of General Internal Medicine, is that the drugs might increase the risk for infections, which ups the risk of death more than gastric bleeding.
In a computer simulation based on real-world risk and benefit data, researchers from the University of Michigan and the VA Ann Arbor Healthcare System found that about 90% of hospital inpatients who were first prescribed PPIs in the hospital have a higher risk of dying when they're taking them, compared with their risk without the drugs.
A small increase in dying also exists for about 80% of patients who were already on PPIs when they were admitted and stayed on them in the hospital.
Extra mortality risk exists because reducing stomach acid can increase the risk of infections, especially pneumonia and Clostridium difficile, according to the report.
"Many patients who come into the hospital are on these medications, and we sometimes start them in the hospital to try to prevent gastrointestinal, or GI, bleeds," explained lead author Matthew Pappas, MD, MPH. "But other researchers have shown that these drugs seem to increase the risk of pneumonia and C. diff, two serious and potentially life-threatening infections that hospitalized patients are also at risk for.”
For the study, the researchers used a computer model. Otherwise, they said, achieving the results would have required an impractically large clinical trial.
Pappas said while the effect found by the study is not large, it is consistent. In a University of Michigan press release, he recommends that very few hospital patients should start taking or continue on PPIs as a preventive measure against gastrointestinal bleeding.
Reducing PPI use in hospitals to the most appropriate patients, essentially those with existing GI bleeding, will be difficult because the medications are so much part of routine care. For example, he noted, physicians prescribing high-dose steroids in the hospital often automatically prescribe a PPI to prevent the GI bleeding that steroids can cause.
"In fact, in running our simulation, we thought we would find some populations such as those on steroids or other medications often prescribed together with PPIs, who would not experience the increased mortality risk," Pappas recounted. "But that turned out not to be the case."
Emergency General Surgery Plagued by High Readmission Rate
BOSTON – Increasingly, hospital readmission rates following surgery are used as markers of quality patient care in pay-for-performance metrics. So, when one group of surgery patients has especially high complication and readmission rates, hospital administrators sit up and take notice.
A study published online recently by JAMA Surgery points out that about half of all patients undergoing emergency general surgery (EGS) will have a postoperative complication, which are closely linked to hospital readmission.
To help determine the extent of the problem, a study team led by researchers from Brigham and Women's Hospital in Boston examined adult rates and risk factors for readmission after common EGS procedures using the California State Inpatient Database from 2007-2011. The five most commonly performed EGS procedures in each of 11 diagnosis groups were identified with information collected on patient demographics, hospital length of stay, complications, and discharge disposition.
Most (57%) of the 177,511 patients meeting inclusion criteria were white and older than 45 (51%); about half were privately insured.
Laparoscopic appendectomy (35%) and laparoscopic gallbladder removal (19%) were the most common procedures. With the overall 30-day hospital readmission rate at 5.9%, readmission rates ranged from 4% for upper gastrointestinal surgery to 17% for cardiothoracic surgery. Readmissions occurred at a different hospital than the surgery site for 17% of cases.
Among the predictors of readmission were the following:
- scoring higher on an index of coexisting illnesses,
- being discharged against medical advice, and
- having public insurance.
Surgical site infections (17%), gastrointestinal complications (11%), and pulmonary complications (4%) were the most common reasons for readmission, according to the study results.
"Reducing readmissions is a noble cost-saving goal with benefits not only to the hospitals, but also to the patients. However, it is critical to understand the underlying factors associated with readmission to appropriately identify quality-improvement measures that address the true problem,” study authors write. “Focused and concerted efforts should be made to incorporate readmission-reducing strategies into the care of EGS patients, particularly among those at higher risk for readmission.”
In an associated commentary, O. Joe Hines, MD, of the David Geffen School of Medicine at the University of California, Los Angeles, points out that while “local programs can be instituted to prevent complications and readmissions, the incorporation of electronic health records and the creation of large health systems will facilitate better care for the 15% to 20% of patients who are readmitted to a different hospital. All of the components are in place to make meaningful progress in surgery, and with our leadership, we can realize substantial change and, most importantly, happy healthy patients."
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