The economic burden of patient safety targets in acute care: a systematic review

Nanosilver/DCOIT-containing surface coating effectively and constantly reduces microbial load in emergency room surfaces

BACKGROUND

Colonization of near-patient surfaces in hospitals plays an important role as a source of healthcare-associated infections. Routine disinfection methods only result in short-term elimination of pathogens.

AIM

To investigate the efficiency of a newly developed antimicrobial coating containing nanosilver in long-term reduction of bacterial burden in hospital surfaces to close the gap between routine disinfection cycles.

METHODS

In this prospective, double-blinded trial, frequently touched surfaces of a routinely used treatment room in an emergency unit of a level-I hospital were treated with a surface coating (nanosilver/DCOIT-coated surface, NCS) containing nanosilver particles and another organic biocidal agent (4,5-dichloro-2-octyl-4-isothiazolin-3-one, DCOIT), whereas surfaces of another room were treated with a coating missing both the nanosilver- and DCOIT-containing ingredient and served as control. Bacterial contamination of the surfaces was examined using contact plates and liquid-based swabs daily for a total trial duration of 90 days. After incubation, total microbial counts and species were assessed.

FINDINGS

In a total of 2880 antimicrobial samples, a significant reduction of the overall bacterial load was observed in the NCS room (median: 0.31 cfu/cm²; interquartile range: 0.00-1.13) compared with the control coated surfaces (0.69 cfu/cm²; 0.06-2.00; P < 0.001). The nanosilver- and DCOIT-containing surface coating reduced the relative risk of a critical bacterial load (defined as >5 cfu/cm²) by 60% (odds ratio 0.38, P < 0.001). No significant difference in species distribution was detected between NCS and control group.

CONCLUSION

Nanosilver-/DCOIT-containing surface coating has shown efficiency for sustainable reduction of bacterial load of frequently touched surfaces in a clinical setting.

Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings

AIMS

To identify the costs associated with nurse sensitive adverse events and the impact of these events on patients' length of stay.

DESIGN

Retrospective cohort study using administrative hospital data.

METHODS

Data were sourced from patient discharge information (N = 5544) from six acute wards within three hospitals (July 2016-October 2017). A retrospective patient record review was undertaken by extracting data from the hospitals' administrative systems on inpatient discharges, length of stay and diagnoses; eleven adverse events sensitive to nurse staffing were identified within the administrative system. A negative binomial regression is employed to assess the impact of nurse sensitive adverse events on length of stay.

RESULTS

Sixteen per cent of the sample (n = 897) had at least one nurse sensitive adverse event during their episode of care. The model revealed when age, gender, admission type and complexity are controlled for, each additional nurse sensitive adverse event experienced by a patient was associated with an increase in the length of stay beyond the national average by 0.48 days (p = .001). Applying this to the daily average cost of inpatient stay per patient (€1456), we estimate the average cost associated with each nurse sensitive adverse event to be €694. Extrapolating this nationally, the economic cost of nurse sensitive adverse events to the health service in Ireland is estimated to be €91.3 million annually.

CONCLUSION

These potentially avoidable events are associated with a significant economic burden to health systems. The estimates provided here can be used to inform and prepare the way for future economic evaluations of nurse staffing initiatives that aim to improve care and safety.

IMPACT

As many of these nurse sensitive adverse events are avoidable, in addition to patient benefits, there is a potential substantial financial return on investment from strategies such as improved nurse staffing that can reduce their occurrence.

In-Hospital Patient Safety Events, Healthcare Costs and Utilization: An Analysis from the Incident Reporting System in an Academic Medical Center

The possible association of patient safety events (PSEs) with the costs and utilization remains a concern. In this retrospective analysis, we investigated adult hospitalizations at a medical center between 2010 and 2015 with or without reported PSEs. Administrative and claims data were analyzed to compare the costs and length of stay (LOS) between cases with and without PSEs of the three most common categories during the first 14 days of hospitalization. Two models, including linear regression and propensity score-matched comparison, were performed for each reference day group of hospitalizations. Of 14,181 PSEs from 424,635 hospitalizations, 69.8% were near miss or no-harm events. Costs and LOS were similar between fall cases and controls in all of the 14 reference days. In contrast, for cases of tube and line events and controls, there were consistent differences in costs and LOS in the majority of the reference days (86% and 57%, respectively). Consistent differences were less frequently seen for medication events and control events (36% and 43%, respectively). Our study approach of comparing cases with PSEs and those without any PSE showed significant differences in costs and LOS for tube and line events, and medication events. No difference in cost or LOS was found regarding fall events. Further studies exploring adjustments for event risks and harm-oriented analysis are warranted.

Hospitalized After Medical Readiness for Discharge: A Multidisciplinary Quality Improvement Initiative to Identify Discharge Barriers in General Medicine Patients

Reducing the length of hospitalization is a shared priority for patients, clinicians, and other health care stakeholders. However, patients can remain hospitalized after being "medically ready" for discharge, accumulating delayed discharge bed days (DDBDs). As part of a quality improvement initiative, the authors developed a method to measure DDBD and define discrete barriers to discharge identified by inpatient clinicians. Patients with delayed discharge had a higher rate of in-hospital complications compared to those who were discharged routinely. To identify modifiable barriers among patients with delayed discharges, 2 patient subgroups were defined: prolonged hospitalization (>19 DDBDs, top quintile accumulated) and extended hospitalization (≤19 DDBDs). Patients with prolonged hospitalization were more likely than those with extended hospitalization to have financial (P < .001) or behavioral (P < .001) barriers, homelessness (P < .05), and impairment of decision-making capacity (P < .01). Understanding the characteristics and discharge barriers of patients who are hospitalized despite medical readiness may increase appropriateness of inpatient resources.

Impact of participation in a surgical site infection surveillance network: results from a large international cohort study

BACKGROUND

Surveillance of surgical site infections (SSIs) is a core component of effective infection control practices, though its impact has not been quantified on a large scale.

AIM

To determine the time-trend of SSI rates in surveillance networks.

METHODS

SSI surveillance networks provided procedure-specific data on numbers of SSIs and operations, stratified by hospitals' year of participation in the surveillance, to capture length of participation as an exposure. Pooled and procedure-specific random-effects Poisson regression was performed to obtain yearly rate ratios (RRs) with 95% confidence intervals (CIs), and including surveillance network as random intercept.

FINDINGS

Of 36 invited networks, 17 networks from 15 high-income countries across Asia, Australia and Europe participated in the study. Aggregated data on 17 surgical procedures (cardiovascular, digestive, gynaecological-obstetrical, neurosurgical, and orthopaedic) were collected, resulting in data concerning 5,831,737 operations and 113,166 SSIs. There was a significant decrease in overall SSI rates over surveillance time, resulting in a 35% reduction at the ninth (final) included year of surveillance (RR: 0.65; 95% CI: 0.63-0.67). There were large variations across procedure-specific trends, but strong consistent decreases were observed for colorectal surgery, herniorrhaphy, caesarean section, hip prosthesis, and knee prosthesis.

CONCLUSION

In this large, international cohort study, pooled SSI rates were associated with a stable and sustainable decrease after joining an SSI surveillance network; a causal relationship is possible, although unproven. There was heterogeneity in procedure-specific trends. These findings support the pivotal role of surveillance in reducing infection rates and call for widespread implementation of hospital-based SSI surveillance in high-income countries.

A literature-based economic evaluation of healthcare preventable adverse events in Europe

Purpose

To establish from the literature, cost of preventable adverse events (PAEs) to member states of the Joint Action European Union Network for Patient Safety and Quality of Care.

Data sources

We searched MEDLINE, EMBASE and CINAHL for studies in Europe estimating cost of adverse events (AEs) and PAEs (2000-March 2016). Using data from the literature, we estimated PAE costs based on national 2013 total health expenditure (THE) data reported by World Health Organization and converted to 2015 Euros.

Study selection/Data extraction

Information on type, frequency and incremental cost per episode or estimated cost of AEs was extracted. Total annual disability-adjusted life years (DALYs) resulting from PAEs in 30 EU nations were calculated using an estimate from a published study and adjusted for the percentage of AEs considered preventable.

Result of data synthesis

Published estimates of costs of AEs and PAEs vary based on the care setting, methodology, population and year conducted. Only one study was from primary care, the majority were conducted in acute care. Nine studies estimated percentage of THE caused by AEs, 13 studies calculated attributable length of stay. We estimated the annual cost of PAEs to the 30 nations in 2015 to be in the range of 17-38 billion Euros, total DALYs lost from AEs as 3.5 million, of which 1.5 million DALYs were likely due to PAEs.

Conclusion

The economic burden of AEs and PAEs is substantial. However, whether patient safety interventions will be 'cost saving' depends on the effectiveness and costs of the interventions.

Investigating the cost and efficiency of incident reporting in a specialist paediatric NHS hospital and impact on patient safety

Objectives

The aim of this study was to investigate the incident reporting process (IR1s), to calculate the costs of reporting incidents in this context and to gain an indication of how economic the process was and whether it could be improved to yield better outcomes.

Methods

A retrospective analysis of a sample, 10.47% (n=150) selected from 1432 medication incident report summaries, generated at Birmingham Children's Hospital, a specialist tertiary referral paediatric centre, during 2014 and collated through the national Datix incident reporting system software was analysed and the associated staff time required to complete each step of the incident reporting process was costed. The staff costs for various grades of staff were averaged across the staff actually involved, using data calculated by the Personal Social Services Research Unit.

Results

The analysis showed that the incident reporting process involved 262 staff on 2942 occasions (19.16 staff episodes per incident form completed) at a cost of £337.16 per incident form completed.

Conclusions

The study showed that the incident reporting system was a labour intensive process. The numbers of staff involved in the process particularly as a result of the email distribution activity did appear to have room for efficiencies. However, it proved to be relatively inexpensive from a cost perspective. With redesign, arguably the emphasis could be moved away from the recording process to learning in order to gain improved patient safety outcomes.

[Economic impact of nosocomial bacteraemia. A comparison of three calculation methods]

INTRODUCTION

The excess cost associated with nosocomial bacteraemia (NB) is used as a measurement of the impact of these infections. However, some authors have suggested that traditional methods overestimate the incremental cost due to the presence of various types of bias. The aim of this study was to compare three assessment methods of NB incremental cost to correct biases in previous analyses.

METHODS

Patients who experienced an episode of NB between 2005 and 2007 were compared with patients grouped within the same All Patient Refined-Diagnosis-Related Group (APR-DRG) without NB. The causative organisms were grouped according to the Gram stain, and whether bacteraemia was caused by a single or multiple microorganisms, or by a fungus. Three assessment methods are compared: stratification by disease; econometric multivariate adjustment using a generalised linear model (GLM); and propensity score matching (PSM) was performed to control for biases in the econometric model.

RESULTS

The analysis included 640 admissions with NB and 28,459 without NB. The observed mean cost was €24,515 for admissions with NB and €4,851.6 for controls (without NB). Mean incremental cost was estimated at €14,735 in stratified analysis. Gram positive microorganism had the lowest mean incremental cost, €10,051. In the GLM, mean incremental cost was estimated as €20,922, and adjusting with PSM, the mean incremental cost was €11,916. The three estimates showed important differences between groups of microorganisms.

CONCLUSIONS

Using enhanced methodologies improves the adjustment in this type of study and increases the value of the results.

Epidemiology and microbiology of nosocomial bloodstream infections: analysis of 482 cases from a retrospective surveillance study

In many traditional Chinese medicine (TCM) hospitals, most patients are elderly with chronic diseases. Nosocomial bloodstream infections (nBSIs) are an important cause of morbidity and mortality. A retrospective surveillance study was performed to examine the epidemiology and microbiology of nBSIs in a TCM hospital from 2009 to 2011. A total of 482 patients with nBSIs were included in the study period. The incidence rate was 5.7/1000 admissions. Escherichia coli (25.5%) was the most common Gram-negative and coagulase-negative staphylococcus (CoNS) (14.1%) was the most common Gram-positive organism isolated. One-third of the E. coli and Klebsiella pneumoniae isolated from the nBSIs were the third-generation cephalosporin-resistant. Half of the Acinetobacter species isolates were resistant to imipenem. Of all the CoNS isolates, 90.7% were resistant to methicillin. Carbapenems and glycopeptide were the most frequently used for nBSI therapy. Only about one-third of patients (157/482) received appropriate empirical therapy. Septic shock, hemodialysis, Pitt bacteremia score >4, urinary tract infection, and appropriate empirical therapy were most strongly associated with 28-d mortality. The incidence of nBSIs was low in the TCM hospital but the proportion of nBSIs due to antibiotic-resistant organisms was high. A high Pitt bacteremia score was one of the most important risk factors for mortality in nBSIs. Therefore, the implementation of appropriate empirical therapy is crucial to improve the clinical outcome of nBSIs.

A new UV-LED device for automatic disinfection of stethoscope membranes

BACKGROUND

Stethoscopes are widely used by doctors and nurses. Poor stethoscope hygiene is a potential source of nosocomial infection. This study aimed to propose an innovative solution, based on the latest advances in ultraviolet (UV) light-emitting diodes (LEDs), for disinfecting stethoscope membranes automatically and efficiently.

METHODS

Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, and Enterococcus faecalis were sown on 28 stethoscope membranes and then transferred to Petri dishes. Treatment involved illuminating exposed Petri dishes with a UVC LED for 1 minute. For each microbe, the number of colony-forming units (cfu) at 36°C was compared in control and treated dishes using the Wilcoxon signed-rank test. The Kruskal-Wallis test was used to assess percent reductions in bacteria. Statistical significance was set at 99%.

RESULTS

A significant reduction in cfu counts after UV treatment (P < .01) was found for all bacteria: 85.5% for E faecalis, 87.5% for S aureus, 94.3% for E coli, and 94.9% for P aeruginosa . No significant differences in percent reduction in cfu were found between bacteria (P > .01).

CONCLUSION

The stethoscope, symbol of medicine and health care professionals, has been demonstrated to be a carrier of microorganisms. The treatment technique was effective and efficient in disinfecting the membranes. These promising results represent a step forward toward eliminating stethoscope membrane contamination with an innovative approach.

Demographic characteristics of patients and their assessment of selected hygienic practices of hospital personnel in the context of safety climate of hospitalization

BACKGROUND

Hand hygiene (HH) is a key factor in hospital infection prevention and patient safety. The objectives of this article were to examine patients' observations concerning compliance with selected procedures for hospital hygiene among medical personnel and assess the correlation between patients' key demographic characteristics and their awareness and sense of safety associated with hospitalization.

METHODS

The study was conducted in January 2012 on a sample of 491 subjects by means of a standardized 10-minute computer-assisted telephone interview survey.

RESULTS

There was a statistically significant correlation between the sense of safety associated with hospitalization declared by patients and their observation of HH practices among health care personnel. A positive correlation was also found between the respondents experiencing personal complications in the form of health care-associated infections themselves or among their family members and the sense of safety associated with hospital treatment.

CONCLUSIONS

Performing HH among hospital staff is one of the factors affecting patients' increased sense of safety during their hospitalization; therefore, HH contributes to the perception of good quality of service provided. Knowledge of the risk of HH does not affect the patients' sense of safety, in contrast with their real-life experiences.

Barriers to discharge in an acute care medical teaching unit: a qualitative analysis of health providers' perceptions

BACKGROUND

The complex process of discharging patients from acute care to community care requires a multifaceted interaction between all health care providers and patients. Poor communication in a patient's discharge can result in post hospital adverse events, readmission, and mortality. Because of the gravity of these problems, discharge planning has been emphasized as a potential solution. The purpose of this paper is to identify communication barriers to effective discharge planning in an acute care unit of a tertiary care center and to suggest solutions to these barriers.

METHODS

Health care providers provided comments to a single open-ended question: "What are the communication barriers between the different health care providers that limit an effective discharge of patients from Unit 36?" We conducted qualitative thematic analysis by identifying themes related to communication barriers affecting a successful discharge process.

RESULTS

Three broad themes related to barriers to the discharge process were identified: communication, lack of role clarity and lack of resources. We also identified two themes for opportunities for improvement, ie, structure and function of the medical team and need for leadership.

CONCLUSION

While it was evident that poor communication was an overarching barrier identified by health care providers, other themes emerged. In an effort to increase inter-team communication, "bullet rounds", a condensed form of discharge rounds, were introduced to the medical teaching unit and occurred on a daily basis between the multidisciplinary team. To help facilitate provider-patient communication, electronic transfer of care summaries were suggested as a potential solution. To help role clarity, a discharge coordinator and/or liaison was suggested. Communication can be enhanced through use of electronic discharge summaries, bullet rounds, and implementation of a discharge coordinator(s). The findings from this study can be used to aid future researchers in devising appropriate discharging strategies that are focused around the patient and inter-health care provider communication.