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JCAHO announces potential 2008 National Patient Safety Goals

Briefings on Patient Safety, Dec. 6, 2006

The JCAHO has released its potential 2008 National Patient Safety Goals. The potential goals include requirements and implementation expectations on anticoagulant use, electronic patient identification, teams that respond to changing patient conditions, obstructive sleep apnea-related harm, worker fatigue, and catheter misconnections. The list was announced on December 4.

The proposals put forth would go into effect in January 2008, and a finalized list may not arrive until mid-2007. In the meantime, hospitals must implement the 2007 goals by January 1, 2007. The JCAHO will accept comments and questions on the potential goals until January 26, 2007.

Four of the potential changes--anticoagulant use, electronic patient identification, reducing harm from worker fatigue, and responding to changes in a patient's condition--were considered for the 2007 goals. Preventing catheter misconnections was the topic of an April Sentinel Event Alert. Sleep apnea, however, is a new topic.

Sleep apnea

The potential new goal on obstructive sleep apnea (OSA) focuses on preventing post-operative complications and harm. It is estimated that nearly 90 percent of patients with OSA are not diagnosed.

Under the potential goal, hospitals must:

Screen patients who show signs that they may have sleep apnea
Consider OSA when developing the anesthesia plan of care
Develop a protocol to deal with OSA that must be based on evidence-based best practices.
The developed protocol is used for patients who are diagnosed with OSA and for patients who are not diagnosed but shows signs that may have apnea as well. The screening process should help hospital staff identify the latter patients.

Some patients with sleep apnea have gone into cardiac arrest and died following surgery, Elizabeth Zhani, media relations specialist for the JCAHO, said in an e-mail response to HCPro.

“[Sleep apnea] is a documented risk for anesthesia and has received particular attention recently in the outpatient surgery literature,” Zhani said. “The Joint Commission’s Ambulatory Health Care Advisory Council specifically recommended this topic for consideration as a National Patient Safety Goal.”

The problem for sleep apnea patients following surgery is they can’t wake themselves up under heavy sedation, according to Kevin Finkel, MD, an anesthesiologist at Barnes Jewish Hospital in St. Louis, MO, speaking to HCPro's Quality Improvement Report newsletter. About 90 percent of sleep apnea patients are undiagnosed, he said. For that reason hospital staff needs to look for signs of the condition and ask patients if they snore. Patients who are obese or have a neck circumference of more than 17 inches are also at more likely to have sleep apnea.

Finkel, who has done extensive research on the issue, says to reduce risk hospitals should:

closely monitor the patient’s oxygen levels
place patients on their sides
consider different forms of pain control, such as epidurals
About 20 percent of surgical patients suffer from sleep apnea, Finkel said. Approximately 2 percent of American women and 4 percent of American men suffer from obstructive sleep apnea, about 18 million in total.

Electronic patient identification

Requirement 1A, which requires the use of two patient identifiers when treating patients, has a potential new implementation expectation requiring hospitals to investigate and plan to implement new technology, such as bar coding or a radio frequency identification system. When investigating a system, the organization should determine:

what kind of system to use
a timeline for evaluating and implementing the new technology
the scope of the implementation
what resources would be needed to implement the system
an assessment of risk stemming from a new system
This is a new version of a previous candidate goal, which required that hospitals establish a bar coding system for patient identification. That goal received a lot of attention in years past, especially because it included firm dates for establishing and using the system. The proposed 2008 goal offers no timeline, other than mandating hospitals develop their own schedule to implement this change.

Anticoagulant use

Requirement 3E under the potential 2008 goals calls for better control and use of anticoagulants. Blood thinners are a vital tool for treating many ailments, but must be tightly controlled to ensure they don't harm the patient.

Although anticoagulants have made the candidate list for its third year, the topic is much more thoroughly presented for the 2008 list. To meet the potential goal, healthcare providers must meet the following implementation expectations, each of which has its own subset of criteria to consider:

Minimize risks in medication "selection and procurement." That includes using only oral, parenatal unit doses and pre-mixed infusions.
Minimize risk in storing anticoagulants. A formulary committee must biannually review the organization's anticoagulants practices and review the number of heparin concentrations allowed. Pharmacists must use an established monitoring system when dispensing Warfarin.
Minimize risks in ordering and dispensing anticoagulants, which include using established protocols for anticoagulant treatment, as determined by the disease being treated, reviewing anticoagulant medication errors and implementing changes, and notifying the dietary department of anticoagulant use to minimize any negative food-drug interactions.
Minimize risks in administering and monitoring anticoagulants, including the use of programmable pumps, obtaining baseline tests before administering the medication, and implementing a "defined anticoagulation management service."
Educate staff, patients, and other caregivers about safe anticoagulant use. That includes annual staff training and thoroughly explaining anticoagulant use, benefits, risks, side effects, compliance, monitoring, dietary change, the danger of contraindicating with other medications, and safe use.

Responding to changes in the patient's condition

The requirement for recognizing and responding to changing patient conditions includes using a trained team or individual to assist when a patient's condition deteriorates. Rapid response teams (RRT) are one way to address this goal. The teams, which were initially developed in the Australian healthcare industry, gained widespread use through the Institute for healthcare Improvement's "100,000 Lives" campaign. This is the second year a version of this goal has been proposed.

The potential goal is to respond to the early warning signs the patient presents, so you can treat them before cardiac or respiratory failure. The goal has six implementation expectations:

The hospital/facility chooses an early response system that fits their needs
Criteria are developed for using the early response system
The hospital/facility allows staff, patients and families to engage the early response system
Education on the selected process is provided to the people in the facility who will likely use the system
The hospital/facility must measure the selected system's effectiveness
Cardiopulmonary and respiratory arrests and mortality rates are measured both before and after a selected system is installed at the hospital/facility

Healthcare worker fatigue

This is worker fatigue's second year as a potential goal. It was proposed last year and prompted a large response from the field, according to the JCAHO. Reducing the hours hospital staff work is a management issue and has serious financial considerations. The JCAHO makes a strong case for reducing worker hours and addressing other impacts of fatigue.

Under the proposed goal, healthcare providers would have to address the following implementation expectations:

Recognize worker fatigue as an "unacceptable risk to patient care"
Identify tasks that are impacted by fatigue
Minimize that impact by re-examining worker scheduling, on-call systems, limiting hours staff members can work, identifying tasks that may not be performed by staff members who may be fatigued, and offering fatigue training.

Catheter misconnections

The JCAHO's April Sentinel Event Alert listed several steps hospitals can take to prevent harm associated with misconnecting catheters and other tubes. Connecting the wrong catheter to a port on the patient can have fatal consequences.

The potential goal has four implementation expectations:

Assess the risk of misconnections for all tubing currently used and those the organization may purchase
Develop a "line reconciliation" process, which should include rechecking all lines, tubes, and catheters, tracing the lines from patient to device, and labeling all lines at the point of connection
Trace lines from the source to the patient to verify a correct connection
Provide staff education on the importance of preventing tubing misconnections
The language in the implementation expectations is a bit confusing. Although one expectation calls for tracing lines from the source to the patient, the expectation about line reconciliation asks that lines be traced from patient to source. The JCAHO did not immediately return calls seeking comment.

The potential goals are now open to field review. The review period closes on January 26, 2007. To read the complete list of potential goals and to submit comments for the field review, click here OR click here