A new Centers for Disease Control and Prevention Vital Signs report shows that the number of bloodstream infections in intensive care unit patients with central lines decreased by 58 percent between 2001 and 2009, This represents up to 27,000 lives saved and $1.8 billion in excess health care costs. Bloodstream infections in patients with central lines can kill as many as one in four.
In recent years, studies have proven that health care providers can prevent most bloodstream infections in patients with central lines by following CDC infection control recommendations, which include removing central lines as soon as medically appropriate. In hemodialysis patients, central lines only should be used when other options are unavailable.
"Preventing bloodstream infections is not only possible, it should be expected. Meticulous insertion and care of the central line by all members of the clinical care team, including doctors, nurses and others at the bedside, is essential. The next step is to apply what we've learned from this to other health care settings and other health care-associated conditions, so that all patients are protected," says Thomas R. Frieden, M.D., CDC director.
In addition to the ICU findings, the report found that about 60,000 bloodstream infections in patients with central lines occurred in such non-ICU health care settings as hospital wards and kidney dialysis clinics. About 23,000 of these occurred in non-ICU patients (2009) and about 37,000 infections occurred in patients at dialysis clinics (2008).
"This reduction is the result of hospital, local, state and national medical and public health efforts focused on tracking infection rates and then using that information to tailor and evaluate prevention programs," says Denise Cardo, M.D., director of the CDC's Division of Healthcare Quality Promotion. "The report findings point to a clear need for action beyond ICUs. Fortunately, we have a prevention model focused on full collaboration that can be applied broadly to maximize prevention efforts."
Infections are one of the leading causes of hospitalization and death for hemodialysis patients. At any given time, about 350,000 people are receiving hemodialysis treatment for kidney failure. Seven in 10 patients who receive dialysis begin that treatment through a central line.
To prevent bloodstream infections in patients with central lines, hospitals, dialysis centers and other medical care locations can:
- Make sure CDC infection control guidelines are followed every time a central line is put in and used.
- Encourage staff members to speak up when guidelines are not followed.
- Use data for action. Track infection rates and germ types with CDC's National Healthcare Safety Network to learn where and why infections are happening, target actions to stop them, and track progress.
- Recognize staff members or units that work hard to prevent central line infections or solve issues with infection control.
- Join state-based prevention programs such as On the CUSP: Stop BSIs. On the CUSP: Stop HAI is a joint effort of the American Hospital Association's Health Research & Educational Trust, the Johns Hopkins University Quality and Safety Research Group, and the Michigan Health and Hospital Association Keystone Center for Patient Safety and Quality, through a contract with the Agency for Healthcare Research and Quality to dramatically reduce health care-acquired infections in all 50 states, the District of Columbia and Puerto Rico.
Emergency patients suffering adverse drug events use more health care services, cost substantially more than other emergency patients
Patients who go to the emergency department with an adverse drug event are 50 percent more likely than other emergency patients to spend additional days in the hospital and incur almost double the health care costs of other emergency patients.
"Tese medication-related visits to the emergency department are common and costly, and nearly 70 percent of them are preventable," said lead study author Corinne Hohl, M.D., of the University of British Columbia in Vancouver, Canada. "Some of these patients have misused medications, but quite a few are having side effects or aren't taking their medications as directed. Medication-related problems are not necessarily the first thing we look for in an emergency patient when we are trying to diagnose what is wrong."
Researchers followed 1,000 emergency patients for six months, 12.2 percent of whom came to the emergency department because of an ADE. There was no difference in mortality between ADE patients and other patients, but the cost of treating those with ADEs was significantly higher than for other patients. After adjustment for baseline differences between patient groups, the group with ADEs cost 90 percent more than those without ADEs over six months after the ED visit. The risk of spending additional days in the hospital was 50 percent greater for ADE patients and ADE patients also had a 20 percent higher rate of outpatient health care encounters.
"The good news is that we are using data from this study to develop a new screening tool to help emergency physicians recognize patients at high risk of adverse drug events," says Hohl. "Down the road, we are working on an evaluation platform to help physicians with prescribing practices. We hope eventually to be able to prevent many of these events from even happening in the first place."
Adverse drug events are the most common cause of preventable nonsurgical adverse events in medicine. Results of this study, "Outcomes of Emergency Department Patients Presenting with Adverse Drug Events," were published in the Feb. 28 issue of Annals of Emergency Medicine.
Haphazard communication and poor coordination between emergency and primary care physicians undermines effective patient care
An examination of emergency and primary care physicians' ability—and willingness—to communicate found that haphazard communication and poor coordination can undermine effective care, according to a new study conducted by the Center for Studying Health System Change for the nonpartisan, nonprofit National Institute for Health Care Reform.
Little attention has been paid to care coordination for patients treated in hospital emergency departments, according to the study. As more people become insured under health reform coverage expansions, ED use likely will increase, along with the importance of better coordination between emergency and primary care physicians to avoid duplicative and misapplied treatment.
"There are no easy answers to the coordination issues between emergency and primary care physicians. Policymakers will need to examine a broad range of ways to address the problem; pieces of the puzzle include payment reforms, standards for health information technology and malpractice liability reform," said HSC senior researcher Emily Carrier, M.D., coauthor of the study.
The study's findings are detailed in a new NIHCR Research Brief—"Coordination Between Emergency and Primary Care Physicians." Researchers conducted 42 telephone interviews between April and October 2010 with 21 pairs of ED and primary care physicians. ED and primary care physicians were case-matched to hospitals so the perspective of both specialties working with the same hospital could be represented. Other key findings include:
- Real-time communication.While alternative methods could be useful in many cases, real-time, physician-to-physician communication was essential in some circumstances, according to respondents. However, they agreed that communicating via telephone was particularly time-consuming.
- Asynchronous communication.Asynchronous modes of communication, such as faxes, did not require breaks in task but had significant limitations as well. Faxed records can be reviewed at providers' convenience, but do not provide an opportunity to converse in real time and ask questions. Physicians had little confidence that faxes were reviewed carefully by their intended recipient and often reported that faxed records were poorly organized and difficult to decipher.
- Shared electronic health records.Sharing information through a fully interoperableelectronic medical record can address some barriers. In this model, emergency physicians could read patients' medical records to learn their history and could alert primary care physicians about their patients' ED visits by flagging a note for review or triggering an e-mail directing them to review the record. However, while EHRs are valuable tools for billing and liability documentation, they are not yet designed to offer a rapid overview of a patient's case that is relevant to a particular problem with sufficient detail to help an emergency provider direct care.
- Lack of time and reimbursement. Emergency and primary care physicians most commonly cited insufficient time and lack of reimbursement as significant barriers to communication. While the activities of care coordination—for example, placing and receiving telephone calls—might seem straightforward and quick, providers noted that each small action multiplied across dozens of patients can become a daunting burden, with little immediate reward.
- Limited role of cross-covering providers.Another overarching barrier to effective coordination is the role of cross-covering providers. The rise of larger groups and more elaborate cross-coverage systems mean that emergency physicians are less likely to speak with a physician who has direct knowledge of the patient. Respondents agreed that time invested in care coordination through a cross-covering primary care physician yielded much less value because cross-covering physicians rarely knew the patient and were less likely to offer information or suggestions that would change an emergency physician's plan of care.
- Changing interpersonal relationships.While rising hospitalist use and the growth of larger primary care groups help primary care physicians decrease their call responsibilities and maintain a more balanced lifestyle, they inevitably decrease interaction between office-based and hospital-based physicians. Many emergency physicians reported that they had no venues for ongoing collaboration with primary care practices in their community.
- Risk and malpractice liability concerns.Even if practical barriers to communication and coordination are removed, liability concerns may keep providers from participating fully in care coordination. Many respondents noted that emergency and primary care physicians are bound by different constraints and have fundamentally different assumptions regarding patients' reliability and resilience.
For more information, visit www.nihcr.org