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INFECTION CONTROL: CUSP program found to reduce UTIs in non-ICU units

The federal government funded the Comprehensive Unit-based Safety Program (CUSP), a multi-year, nationwide effort to decrease the rate of urinary tract infection associated with the use of catheters in hospitalized patients.  This project was under the leadership of AHA’s Health Research & Educational Trust (HRET).  The project involved disseminating information and tool kits about best practices and collecting data.  Data from over 600 hospitals were studied; these findings represent part of the hospitals that participated.  It was found that hospital units that were not ICUs benefited from the program – as evidenced by a reduced UTI infection rate – but ICUs did not.

Reductions occurred mainly in non-ICUs, where catheter-associated UTI rates decreased from 2.28 to 1.54 infections per 1000 catheter-days…”

Source: Saint, S., and others. (2016, June 2). A program to prevent catheter-associated urinary tract infection in acute care. The New England Journal of Medicine, 374(22), 2111-2119.  Click here for free full text: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1504906  Posted by AHA Resource Center (312)422-2050, rc@aha.org

PATIENT SAFETY: Checklist compares ‘never events’

This article contains two interesting tables related to “never events,” a term introduced in 2001 by Dr. Kenneth Kizer, then the CEO of the National Quality Forum, to describe the most serious types of health care errors.  The first table itemizes the lists of never events developed by four organizations in a side-by-side comparison.  For example, retention of a foreign object in the patient after surgery is listed by all four organizations, which include:

  • National Quality Forum / Leapfrog Group
  • Centers for Medicare & Medicaid Services (CMS)
  • The Joint Commission
  • The National Health Service (United Kingdom)

The second table compares each of the states and the District of Columbia on whether hospitals are required to report adverse events, whether the state reports individual hospital data, and whether the state reports aggregate data.

What I like about this article: 1.) Useful side-by-side comparison of existing lists of never events.  (One of the recommendations of the article is that work should be done on creating a single definition of never events.)  2.) Authoritative source – the authors are with the Armstrong Institute for Patient Safety and Quality at Johns Hopkins.  Dr. Pronovost, especially, is a prolific author on topics related to patient safety.

Source: Austin, J.M., and Pronovost, P. (2015, June). “Never events” and the quest to reduce preventable harm. The Joint Commission Journal on Quality and Patient Safety, 41(6), 279-288. Retrieved from http://www.jcrinc.com/reducing-never-events-and-preventable-harm-in-health-care/  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

Top 10 most frequently occurring hospital-acquired conditions in 2012

The Partnership for Patients is a federal initiative with over 3,700 participating hospitals nationwide that is intended to improve patient safety.  Data are available for 2011 and 2012 on the rate of hospital-acquired conditions per 1,000 discharges for specific conditions in this brief document.  Here are the 2012 rates for this large group of hospitals.

Most Frequently Occurring Hospital-Acquired Conditions / 1,000 Discharges

  • 39.43 pressure ulcer
  • 23.21 adverse drug event associated with hypoglycemic agents
  • 10.58 catheter-associated urinary tract infections
  •  9.52 adverse drug event associated with low molecular weight Heparin and Factor Xa inhibitor
  •  7.16 falls
  •  5.25 contrast nephropathy associated with catheter angiography
  •  4.53 adverse drug event associated with Warfarin
  •  4.33 adverse drug event associated with IV Heparin
  •  3.74 mechanical complications associated with central venous catheters
  •  3.30 Hospital-acquired antibiotic-associated C. difficile

Total for This Group of Hospitals in 2012

  • 132 hospital-acquired conditions / 1,000 discharges
  • 4,337,000 total number of hospital-acquired conditions

Total for This Group of Hospitals in 2011

  • 142 hospital-acquired conditions / 1,000 discharges
  • 4,659,000 total number of hospital-acquired conditions


U.S. Centers for Medicare & Medicaid Services. About the Partnership for Patients.  Click here for access to this webpage: http://partnershipforpatients.cms.gov/about-the-partnership/aboutthepartnershipforpatients.html

U.S. Agency for Healthcare Research and Quality. (2014, Sept.). Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012.  Click here for access to this document: http://www.ahrq.gov/professionals/quality-patient-safety/pfp/hacrate2011-12.html

How preventable are patient falls?

A study published in the July issue of the Journal of the American Academy of Orthopaedic Surgeons examines the effectiveness of fall prevention programs to actually reduce the number of patient falls. Fall prevention is a significant challenge for hospitals, not only in terms of patient well-being but also with regard to costs. The Centers for Medicare and Medicaid Services no longer reimburses hospitals for injuries related to falls that occur inside the hospital that could have been prevented by following evidence-based guidelines.  The authors of the article found no conclusive medical evidence that evidence-based guidelines are effective in fall prevention.

Source: Clyburn, T. A., and Heydemann, J. A. Fall prevention in the elderly: analysis and comprehensive review of methods used in the hospital and in the home. Journal of the American Academy of Orthopaedic Surgeons. 19(7):402-409, July 2011. http://www.jaaos.org/cgi/content/abstract/19/7/402

Posted by the AHA Resource Center, (312) 422-2050, rc@aha.org