Antimicrobial Stewardship, Behavioral Health, and System-Wide Standardization: The Top 10 Patient Safety Concerns for 2019

ECRI Institute and Annals of Long-Term Care: Clinical Care and Aging (ALTC) have joined in collaboration to bring ALTC readers periodic articles on topics in risk management, quality assurance and performance improvement (QAPI), and safety for persons served throughout the aging services continuum. ECRI Institute is an independent nonprofit that researches the best approaches to improving health care.

Organizations across the continuum of care are striving to become high-reliability organizations, and part of being highly reliable means staying vigilant and identifying problems proactively. ECRI Institute creates an annual list of Top 10 Patient Safety Concerns to support organizations in their efforts to proactively identify and respond to threats to patient safety.

Our patient safety organization (PSO), ECRI Institute PSO, began collecting patient safety events data in 2009, and we and our partner PSOs have since received more than 2.8 million event reports. In selecting items for this year’s list, ECRI Institute reviewed these event reports and gathered input from ECRI Institute staff and expert advisors. Events and information reported to ECRI Institute PSO come from hospitals, physician practices, skilled-nursing facilities, and include incidents that result in harm to patients or residents, near misses, and other types of reports, such as root-cause analyses submitted for review. Expert reviewers include ECRI Institute’s multidisciplinary staff of physicians, nurses, risk managers, attorneys, engineers, and other professionals, as well as the PSO Clinical and Advisory Council. In short, the 10 patient safety concerns on this list are very real. They are harming people, sometimes seriously (Table 1).

But development of the list is not an exercise in simple tabulation. The list does not necessarily represent the issues that occur most frequently or are most severe. Most organizations already know what their high-frequency, high-severity challenges are. Rather, this list identifies concerns that might be high priorities for other reasons, such as new risks, existing concerns that are changing because of new technology or care delivery models, and persistent issues that need focused attention or pose new opportunities for intervention.

The Top 10 report highlights patient safety concerns from across the continuum of care because strategies increasingly focus on collaborating with other provider organizations, community agencies, patients or residents, and family members.

In this excerpt, we discuss 3 of the 10 safety concerns that directly impact aging services providers: antimicrobial stewardship in physician practices and aging services; reducing discomfort with behavioral health; and standardizing safety efforts across large health systems. 

Antimicrobial Stewardship in Aging Services

Antibiotic stewardship is not a concern only in physician practices. In aging services, 40% to 75% of the antibiotics prescribed to residents are prescribed incorrectly.¹ 

“In aging services, the diagnosis is important,” says Sharon Bradley, RN, CIC, senior infection prevention and patient safety analyst/consultant, ECRI Institute. “Providers should use all diagnostic tools available to be certain the illness is one that will respond to an antibiotic.” 

Urinary tract infections are one of the most commonly prescribed-for conditions in aging services, Ms Bradley notes, pointing to guidelines for management, such as those from the Centers for Disease Control and Prevention (CDC), regarding antibiotic stewardship in long-term care settings. Groups such as the Infectious Diseases Society of America and the CDC recommend against screening for and treating asymptomatic bacteriuria in community-dwelling older adults.^1,2 Most older adults who live in a community likely have asymptomatic bacteriuria, notes Ms Bradley, so care providers should instead look for symptoms of a true urinary tract infection, such as fever, low back or pubic pain, gross hematuria, or new or marked increase in incontinence, urgency, or frequency.

Reset Patient Expectations

Perhaps, the most significant challenge facing antibiotic stewardship is managing patient expectations. Patients “expect an antibiotic to help them get better,” says Stephanie Uses, PharmD, MJ, JD, patient safety analyst/consultant, ECRI Institute PSO. Moreover, Dr Uses adds, unnecessary antibiotic administration puts patients at unnecessary risk of adverse drug reaction. The broadest concern, she notes, is that overprescribing leads to antimicrobial resistance. 

Instead, prescribers need to be empowered to say, “You have a virus; you do not need an antibiotic, but we’ll give you something to treat your symptoms,” suggests Dr Uses. 

Ms Bradley agrees: “Patients need to feel like they are being taken care of, even without a prescription for an antibiotic,” she explains. “Instead, give them a prescription for what to do, what to watch for. Follow up with them. Everyone needs to know their role: the physician needs to know what to do, and the patient needs to know what to do.” 

“Antibiotic stewardship does not mean withholding necessary treatment,” emphasizes Ms Bradley. “But we have casually and cavalierly handed around the candy dish of antibiotics without a second thought as to how we may be harming our patients.”

Reducing Discomfort With Behavioral Health

When working with individuals who have behavioral health needs, “you fear what you don’t know, and fear can make you react defensively,” says Nancy Napolitano,  patient safety analyst, ECRI Institute. This fear can lead providers and staff to behave in ways that fail to meet patients’ physical or behavioral health needs. Fear-driven actions can even escalate situations, with consequences for patients and staff. Consider the following event report (proprietary data; December 2018) from ECRI Institute PSO’s database:

A nurse was trying to grab items from an emergency department (ED) patient on psychiatric hold (because the items were not allowed for patients on psychiatric hold). Her approach and methods were very mean-spirited and bully-like. I was walking by and noticed the situation escalating, so I stepped in to help. The patient was yelling, “She put her hands on me!” I saw that the nurse was grabbing a watch, a newspaper, and candy from the patient. The patient began to push the nurse, and I helped keep the patient from running down the hall (with minor physical restraint). The ED nurse yelled at me and other staff, “You have to stop being so nice to these people.” As we were guiding the patient back to his room, the nurse elbowed me. She said to me, very aggressively, “You get out of here.” When security staff and others arrived at the patient’s room, the patient asked to be taken to jail and began threatening to fight staff. The ED nurse took the same approach to two other patients on psychiatric hold. The ED nurse’s attitude and mean actions made the situation much worse than it had to be.

In many health care settings, behavioral health and physical health are siloed, both physically and conceptually. But people with behavioral health needs are in every setting, and providers and staff might not know when a person has such needs. A behavioral health need “is not a broken leg that you can see and feel,” says Ms Napolitano. “How do we change our mindset so that everyone belongs here and is treated with dignity and respect?”

Build and Practice Skills

Empathy and compassion are key. Dementia simulations, in which staff complete a task while wearing clouded glasses and headphones playing distracting sounds, can build staff empathy for people with dementia by helping them understand these individuals’ perspectives and challenges, Ms Napolitano explains.

Providers and staff also need skills in communication and de-escalation. Although the training may vary by setting, unit, or role, “everybody needs those skills,” says Ms Napolitano. Options include certified communication and de-escalation training, training led by internal experts, training led by consultant psychiatrists or psychologists, behavioral health first-aid workshops led by community behavioral health professionals (which may be offered for free), or a combination of modalities.

Opportunities to practice skills are key to reducing fear. “The only way not to be afraid of something is to experience it positively over and over again,” says Ms Napolitano. “That’s why I encourage behavioral response mock codes.” These simulations give people a chance to practice in a safe environment and debrief afterward, helping providers and staff improve and keep learned skills sharp. “If they don’t use them, they lose them,” says Ms Napolitano.

Develop Support Systems

Providers and staff across the continuum may need someone to turn to for help. Health care organizations can develop support systems that call on both internal and external resources. 

Even organizations without psychiatrists or counselors can develop internal resources. For example, behavioral emergency response teams are not just for hospitals with psychiatric units. A doctor who is not a psychiatrist can be a team leader and champion, and nurses with experience, interest, or aptitude in behavioral health can also serve on the team. “Use people’s talents,” says Ms Napolitano. In aging services, examples include additional training for “specialist” certified nursing assistants; behavioral health training for medical directors; and comprehensive, person-centered dementia care programs. 

Partner With External and Community Resources

Health care organizations across the continuum can work with community partners to improve care coordination and identify creative ways to develop more behavioral health skills and support in nonbehavioral-health settings. Examples include patients and families, inpatient and outpatient behavioral health providers, community health workers, crisis teams, social service workers, patient navigators, health coaches, peer-support specialists, and advocacy groups. 

Health care organizations can also help their own providers and staff better understand what community resources are available. Ms Napolitano suggests having “lunch and learn” meetings with police, the fire department, and other first responders to build mutual respect and understanding. “Engage these groups in learning what you do for the community and how they can get involved in it and be a support,” says Ms Napolitano. “Community partnerships are critical.”

Standardizing Safety Efforts Across Large Health Systems

“Health care organizations as we used to know them are now becoming nationwide ‘mega-systems,’” says Sheila Rossi, MHA, manager, ECRI Institute PSO. Such significant upscaling can bring with it a host of complications. Organizations may struggle reconciling cultures, not only across different facilities within the organization, but also across different regions of the country. 

As this evolution occurs, “how do you keep patient safety at the forefront?” asks Ms Rossi. “How do organizations internally structure themselves to address patient safety needs?” Ms Rossi points to such processes as reporting and quality initiative prioritization that require careful attention: “You are adding layers to these processes,” and these layers can hinder safety efforts if not thoughtfully implemented. 

Create a Cultural Foundation

When creating a larger health system, it can be difficult to identify uniform priorities across the organization or to champion concerns from one location to corporate leadership. “How are patient safety events that occur across facilities reported up through the system to make sure that leadership is aware?” asks Ms Rossi. “How do you ensure that the issue isn’t inadvertently buried?” Implementation of standardized systems and processes can help to ensure that patient safety events receive necessary attention at all levels of the organization—from the front lines to leadership.

“Another benefit to systematizing—to standardizing—is that there’s a much greater opportunity for sharing information,” Ms Rossi says. “But you have to break down the cultural barrier of blame when events are shared. In bigger systems especially, providers can really learn from each other, but the organization has to create a culture where learning can be shared.”

Standardize Deliberately to Reap Benefits

“There are efficiencies to be gained” by standardizing systems and processes across the system, notes Ms Rossi. For example, committee structure can be aligned across the organization, as can the structure of the organization’s risk management information system, claims management processes, electronic health record and other health information technology software, and reporting processes for adverse events, near misses, or hazardous conditions. “How to standardize is complex,” Ms Rossi emphasizes, “but in doing so, there are significant benefits to be gained.”

When standardizing committee structure, the committee’s goals, selection of data the committee will review, and methods of information dissemination are all factors that can be standardized across the entire organization. For example, organization falls committees across all facilities should review the same falls data (eg, fall risk assessment findings and call light data) and determine how to engage staff in prevention initiatives (eg, use storytelling). The committees can then use standing agenda items, action plans, and progress updates—all of which are also standardized—to stay informed throughout analysis, implementation of an initiative, and monitoring of postimplementation progress. Risk, safety, and quality staff should look for and work to reduce variance across the entire system, streamlining inconsistent processes. 

When scaling up to a large health care system, safety, risk, and quality leaders should differentiate best practices for smaller vs larger organizations. For example, inclusive committee structures that may be ideal for a smaller organization may be impractical across many facilities. However, organization size should not limit engagement among leadership, providers, and staff. Consolidation of patient safety efforts “will not be successful via emails or other impersonal communication,” emphasizes Ms Rossi. “Corporate patient safety leaders need to make it a point to speak, in person, with patient safety leaders at each level of the organization—to hear their ideas, ask about culture, understand challenges, and more. Time needs to be built into these roles to allow for face-to-face engagement.”

Prioritize Patient Safety

Regardless of organization size, the goal is to institute structures that effectively allow patient safety leaders to support organization leadership in engaging with patient safety priorities. Foundational principles of continuous communication up and down the chain of command, clear organizational structure, consistent committee configuration, and universal strategic planning and implementation can help the organization reduce inconsistencies and embed a strong focus on patient safety.

How to Use This Information

The Top 10 Patient Safety Concerns list is meant to be a starting point for patient safety discussions, setting priorities, and allocating necessary resources to achieve those priorities. This list is not meant to dictate which issues organizations should address. Rather, it can serve as a catalyst for discussion about the top patient safety issues your organization faces. 

Aging services providers may face any of the 10 issues in the list, not just the 3 discussed above. Topics like burnout, recognizing change in condition, and diagnostic safety are just a few of the additional issues that can arise in any organization. Risk, quality, and safety leaders can investigate whether and to what extent these problems are occurring in their own organizations and whether systems and processes are in place to address them. Providers can use the strategies listed here when implementing broader quality assurance and performance improvement programs that can make care safer.

To download the full Executive Brief, go to
https://www.ecri.org/landing-top-10-patient-safety-concerns-2019. 

For more information about ECRI Institute PSO, contact us at clientservices@ecri.org or go to https://www.ecri.org/solutions/pso/.

References

1. Centers for Disease Control and Prevention. The Core Elements of Antibiotic Stewardship for Nursing Homes. cdc.gov website. https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html. Updated January 4, 2019. Accessed March 22, 2019.   

2. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654. doi:10.1086/427507