Evidence-based practices outlined for patient safety

First government effort to respond to concerns

A new report from the Rockville, MD-based Agency for Healthcare Research and Quality (AHRQ) described dozens of evidence-based practices that can improve patient safety. The federal agency says the report is the government’s first major effort to respond to recent concerns about medical errors.

AHRQ investigators said 11 of the practices represent "clear opportunities" to improve patient safety, but they are not being performed regularly. These practices include administering antibiotics before surgery to prevent infections, using ultrasound to help guide the insertion of central intravenous lines and prevent punctured arteries, and giving surgery patients beta-blockers to prevent heart attacks.

The review of best practices is "a first effort to approach the field of patient safety through the lens of evidence-based medicine," the researchers wrote. "Just as [the Institute of Medicine (IOM) report] To Err is Human sounded a national alarm regarding patient safety and catalyzed other important commentaries regarding this vital problem, this review seeks to plant a seed for future implementation and research by organizing and evaluating the relevant literature."

The 640-page report is the result of a thorough review of the scientific literature to identify practices that are proven to be effective and thought to represent a significant opportunity for improvement. The report focused on hospital care, but also included information on care delivered in nursing homes, at ambulatory care sites, and by patients themselves in managing their care.

Public concerned about patient safety

Patient safety has become a major concern of the general public and of policy-makers largely because of the IOM’s 1999 report To Err is Human: Building a Safer Health System. In its report, the IOM highlighted the risks of medical care in the United States and shocked many Americans, in large part through its estimates of the magnitude of medical-errors-related deaths (44,000 to 98,000 per year) and other serious adverse events.

The report prompted a number of legislative and regulatory initiatives designed to document errors and begin the search for solutions. The AHRQ, the federal agency leading efforts to research and promote patient safety, promised to develop and disseminate "evidence-based, best safety practices to provider organizations."

To initiate the work, the agency in January 2001 commissioned the University of California at San Francisco-Stanford University Evidence-based Practice Center (EPC) to review the scientific literature regarding safety improvement. To accomplish this, the EPC established an editorial board that oversaw development of this report by teams of content experts who served as authors.

The EPC began its work by defining a "patient safety practice" as "a type of process or structure whose application reduces the probability of adverse events resulting from exposure to the health care system across a range of diseases and procedures." With that definition, the researchers identified evidence-based practices. In its report, the AHRQ notes that National Quality Forum plans to use this report to help identify a list of patient safety practices that consumers and others should know about as they choose among the health care provider organizations to which they have access.

Of the 79 practices reviewed in detail, 11 patient safety practices were most highly rated by the researchers in terms of strength of the evidence supporting more widespread implementation. These are the 11 recommended practices in descending order, with the most highly rated practices listed first:

1. appropriate use of prophylaxis to prevent venous thromboembolism in at-risk patients;

2. use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality;

3. use of maximum sterile barriers while placing central intravenous catheters to prevent infections;

4. appropriate use of antibiotic prophylaxis in surgical patients to prevent perioperative infections;

5. asking that patients recall and restate what they have been told during the informed consent process;

6. continuous aspiration of subglottic secretions to prevent ventilator-associated pneumonia;

7. use of pressure-relieving bedding materials to prevent pressure ulcers;

8. use of real-time ultrasound guidance during central line insertion to prevent complications;

9. patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications;

10. appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients;

11. use of antibiotic-impregnated central venous catheters to prevent catheter-related infections.

The AHRQ explained that the list generally is weighted toward clinical rather than organizational matters, and toward care of the very ill, rather than the mildly or chronically ill. Although more than a dozen practices considered were general safety practices that have been the focus of patient safety experts for decades (i.e., computerized physician order entry, simulators, creating a "culture of safety," crew resource management), most research on patient safety has focused on more clinical areas.

The agency also identified another 12 items considered high priority for research because they offer the potential for improving patient safety. These are the items the AHRQ urges researchers to focus on:

— improved perioperative glucose control to decrease perioperative infections;

— localizing specific surgeries and procedures to high-volume centers;

— use of supplemental perioperative oxygen to decrease perioperative infections;

— changes in nursing staffing to decrease overall hospital morbidity and mortality;

— use of silver alloy-coated urinary catheters to prevent urinary tract infections;

— computerized physician order entry with computerized decision support systems to decrease medication errors and adverse events primarily due to the drug-ordering process;

— limitations placed on antibiotic use to prevent hospital-acquired infections due to antibiotic-resistant organisms;

— appropriate use of antibiotic prophylaxis in surgical patients to prevent perioperative infections;

— appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk;

— appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and post-surgical patients;

— use of analgesics in patients with an acutely painful abdomen without compromising diagnostic accuracy;

— improved hand-washing compliance (via education/behavior change, sink technology and placement, or the use of antimicrobial washing substances).