Preventing needlestick injuries could save $1 billion a year

Needlestick and sharps injuries affect more than half a million health care personnel every year, creating more than $1 billion in preventable costs and an immeasurable emotional toll, according to Safe in Common, a nonprofit organization that represents health care personnel, industry leaders, policymakers and scientists.

After examining the findings from the Massachusetts Sharps Injury Surveillance System, SIC determined approximately 1,000 percutaneous injuries per day in U.S. hospitals alone adds $1 billion in unnecessary annual costs. Cross referenced with the most recent CDC reports of the cost to treat health care personnel, that amounts to an estimated $3,042 per victim each year. The costs are attributed to laboratory fees for testing exposed employees, labor associated with testing and counseling, and the costs of post-exposure follow-ups.

"These completely preventable injuries, needless cost burdens on the health care system and psychological trauma inflicted on personnel is startling when safer equipment and smarter work practices are available to personnel across the healthcare spectrum," said Safe in Common Chairperson Mary Foley, R.N.

Foley said that introducing adequate safety-engineered devices and providing education and techniques can help make needlestick and sharps injuries a "never event."

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Study examines problem physician behaviors

A study of 381 non-Vanderbilt physicians referred to the Vanderbilt Comprehensive Assessment Program in the Department of Psychiatry found that those referred for mental health, substance abuse and improper sexual boundary issues are less likely to receive a "fit for duty" recommendation than those referred for disruptive behavior.

VCAP has been doing fitness-for-duty assessments for professionals in crisis since 2001, recommending appropriate remediation strategies based upon a thorough independent evaluation, to enhance professionalism and restore them to practice. The program has assessed more than 500 physicians from 37 states and four Canadian provinces.

The study of physicians evaluated between 2001 and March 2012, was supported by a grant from Vanderbilt Institute for Clinical and Translational Research and is available online in General Hospital Psychiatry.

"Ours is a forensic evaluation," said A.J. Reid Finlayson, M.D., associate professor of clinicalpPsychiatry.

"We're not providing treatment for these doctors, but we try to understand their behavior and recommend ways to help them practice safely and more effectively.

"This report is a beginning and we hope to evaluate what we are doing, but acquiring follow-up data can be challenging. To be honest, our subjects aren't always entirely pleased at first with their reports, but the medical boards, hospitals and clinics that refer practitioners often rely upon independent comprehensive evaluations to make administrative decisions."

A multidisciplinary team of specialists in psychiatry, addiction, internal medicine, psychology, neuropsychology, sexual disorders, social work and nursing works closely with the client to explore and understand the issues underlying the behavior that is problematic. Occasionally, subspecialists in other Vanderbilt departments are enlisted for their input on clinical issues.

The outpatient assessment process takes place over two to four days. With consent, the team also gathers additional information about the physician from relevant third parties that may include the physician's spouse, therapist, family members and colleagues. "Our goal is to get the complete picture of the doctor as a person. It helps us make a very thorough assessment to determine what they need to change if they plan to improve their ability to practice professionally."

After the evaluation, a comprehensive report is generated that includes a diagnosis and recommendations, if appropriate, which are made to improve the health and well-being of the doctor and to enhance their professional practice.

Finlayson said that VCAP referrals most often originate from state physician health programs and are more likely to be middle-aged, white males who received their training in the United States. The single most common reason for referral was disruptive behavior, such as threatening, intimidating or demeaning behavior to patients or staff.

"Far from lacking knowledge or skill, disruptive physicians are often well-respected surgeons, internists, gynecologists, or other specialists. But their dysfunctional or inappropriate interactions with others around them, often happening under stress, may interfere with the optimal clinical outcome.  Our hope, by using a thorough evaluation to tailor appropriate recommendations, is that we can facilitate more effective leadership and professional practice," Finlayson said.

Program manager Ron Neufeld, a social worker and licensed addiction counselor, said VCAP has seen an increase in the referral of physicians exhibiting disruptive behavior. In 2008, The Joint Commission, which accredits and certifies more than 20,000 health care organizations and programs in the United States, issued guidelines to create a "culture of safety" in health care organizations. Since then, responsibility for physician conduct has shifted from self-governance by the profession itself toward the institutions where physicians are employed or practice.

This change in the culture of health care delivery and the evolving role of the physician's role are reflected in curriculum changes at medical schools such as Vanderbilt's, Finlayson said.

"We're now teaching doctors to work on teams and promoting the effective leadership skills necessary when stakes are high and things go wrong as they sometimes do," he said. "But the most important finding in our research, so far, is that those physicians who behave badly can often be restored to full practice with appropriate management rather than discarded. So much is invested in training physicians that society cannot afford to discard them if at all possible."

Pediatric readmission rates not indicator of hospital performance

Readmission rates of adult patients to the same hospital within 30 days are an area of national focus and a potential indicator of clinical failure and unnecessary expenditures. However, an UC San Francisco study shows that hospital readmissions rates for children are not necessarily meaningful measures of the quality of their care.

In the first multi-state study of children's and non-children's hospitals, assessing pediatric readmission and revisit rates — being admitted into the hospital again or visiting the emergency room within 30 days of discharge — for common pediatric conditions, UCSF researchers found that diagnosis-specific readmission and revisit rates are limited in their usefulness as a quality indicator for pediatric hospital care.

The study found that when comparing hospitals' performance based on revisits, few hospitals that care for children can be identified as being better or worse than average, even for common pediatric diagnoses.

"As a national way of assessing and tracking hospital quality, pediatric readmissions and revisits, at least for specific diagnoses, are not useful to families trying to find a good hospital, nor to the hospitals trying to improve their pediatric care," said Naomi Bardach, MD, an assistant professor of pediatrics at UCSF Benioff Children's Hospital and lead author. "Measuring and reporting them publicly would waste limited hospital and health care resources."

The work was published in the September issue of journal Pediatrics.

Using a multistate database called the State Inpatient and Emergency Department Databases, sponsored by the U.S. Department of Health & Human Services, the researchers looked at 958 hospitals admitting children, which were mostly large or medium-sized, and urban. Focusing on seven common inpatient pediatric conditions – asthma, dehydration, pneumonia, appendicitis, skin infections, mood disorders and epilepsy – the researchers then calculated the rates of readmissions and revisits to the hospital within 30 and 60 days of discharge, broken down by the condition for which they were treated.

All of the hospitals in the study had 30-day readmission rates of less than 5 percent in all areas except for epilepsy (6.1 percent), dehydration (6 percent) and mood disorders (7.6 percent).

"With average 30-day readmission rates hovering around 5 percent, there is little space for a hospital to be identified as having better performance," said Bardach.

For example, of the more than 900 hospitals admitting children, looking at revisit rates for:

  1. Asthma – One performed better than average and four performed worse;
  2. Appendicitis – Two performed better than average and two performed worse;
  3. Pneumonia and dehydration – no hospitals were better or worse than all the other hospitals; and
  4. Seizures – Only one hospital of more than 600 was different than average, performing worse than the others. 

"The low number of outliers is likely due to the fact that most hospitals just don't admit very many kids, because children are healthier than adults," said Bardach.

The researchers suggest that to improve pediatric readmissions or revisits as a quality measurement, patients admitted with similar diagnoses could be looked at as a group, to increase the sample size at each hospital and lead to the identification of more outliers. "That has the potential to improve the usefulness of readmission rates as a quality indicator," said Bardach.