Over­all ‘ad­verse events’ de­cline in hos­pi­tals

Re­ports of pres­sure ul­cers, falls and burns climb in state hos­pi­tals

New Haven Register (Sunday) (New Haven, CT) - - NEWS - By Cara Ros­ner This story was re­ported un­der a part­ner­ship with the Con­necti­cut Health I-Team, a non­profit news or­ga­ni­za­tion ded­i­cated to health re­port­ing. (c-hit.org)

Con­necti­cut hos­pi­tals re­ported in­creases in pa­tients suf­fer­ing from pres­sure ul­cers, as well as se­ri­ous in­juries or deaths as­so­ci­ated with falls and burns in 2017, com­pared to 2016, ac­cord­ing to a new state re­port.

Over­all, the to­tal num­ber of “ad­verse events” re­ported by hos­pi­tals dropped from 431 in 2016 to 351 in 2017, a 19 per­cent de­cline, the state De­part­ment of Pub­lic Health said. But most of the de­cline was due to the elim­i­na­tion of two cat­e­gories in 2017: se­ri­ous in­juries or death re­sult­ing from per­fo­ra­tions dur­ing open, la­paro­scopic or en­do­scopic pro­ce­dures; and those re­sult­ing from surg­eries. To­gether those cat­e­gories ac­counted for 72 ad­verse events in 2016.

The re­port­ing re­quire­ment for the two cat­e­gories was elim­i­nated af­ter a work group of the Qual­ity in Health Care Ad­vi­sory Com­mit­tee con­cluded that the vast ma­jor­ity of per­fo­ra­tions that oc­cur dur­ing some pro­ce­dures aren’t pre­ventable, and that se­ri­ous in­juries or death re­sult­ing from surgery are al­ready bet­ter cap­tured by other cat­e­gories, the DPH re­port said.

The ma­jor­ity of ad­verse events in 2017, at 296, or 84 per­cent, oc­curred at acute-care or chil­dren’s hos­pi­tals. Slightly more than half of events, 188, or 54 per­cent, oc­curred among pa­tients age 65 and older, the re­port said.

As ex­pected, some of the state’s largest hos­pi­tals re­ported the high­est num­ber of to­tal ad­verse events: Yale New Haven Hos­pi­tal, 62; Bridge­port Hos­pi­tal, 32; Hart­ford Hos­pi­tal, 24, and St. Fran­cis Hos­pi­tal and Med­i­cal Cen­ter in Hart­ford and St. Vin­cent’s Med­i­cal Cen­ter in Bridge­port, 20 each. Stam­ford Hos­pi­tal re­ported 18.

The hos­pi­tals with the high­est rates of events based on in­pa­tient days were Mil­ford Hos­pi­tal with 30.2 per 100,000 pa­tient days; Bridge­port Hos­pi­tal, 29.4; Stam­ford Hos­pi­tal, 24.7; Nor­walk Hos­pi­tal, 22.5; St. Vin­cent’s, 23.9, and Bris­tol Hos­pi­tal, 23.7. Yale had 14.4 and Hart­ford re­ported 10.3.

Danbury and New Mil­ford Hos­pi­tals had 12 ad­verse events, a rate of 12.4; Green­wich Hos­pi­tal, 7 ad­verse events, a rate of 12.9; Grif­fin, 5 ad­verse events, a rate of 16.3; Char­lotte Hunger­ford, 2 ad­verse events, a rate of 8.5; Mid­dle­sex Hos­pi­tal, 7, ad­verse events, a rate of 13.0.

Among the 28 acute-care hos­pi­tals, three re­ported zero ad­verse events in 2017: Day Kim­ball Health­care in Put­nam, Rockville Gen­eral Hos­pi­tal in Ver­non, and Sharon Hos­pi­tal in north­west­ern Con­necti­cut.

There were 208 re­ports of Stage 3, Stage 4 and un­stage­able pres­sure ul­cers in 2017, up from 186 the year prior. Falls in­creased from 74 to 84, pa­tient death or in­jury as­so­ci­ated with a burn rose from four to eight; and se­ri­ous in­jury or death as­so­ci­ated with in­travas­cu­lar air em­bolism rose from zero to two.

In 2017 sev­eral cat­e­gories showed im­prove­ments: surg­eries per­formed on the wrong site dropped from 18 to 10; the wrong sur­gi­cal pro­ce­dure per­formed on a pa­tient fell from six to three; and the re­ten­tion of a for­eign ob­ject in the pa­tient af­ter surgery dropped from 20 to 17. Med­i­ca­tion er­rors dropped from seven to four.

Con­necti­cut hos­pi­tals be­gan a se­ries of “high re­li­a­bil­ity” ini­tia­tives six years ago, in­tended to fo­cus more on pa­tients’ per­spec­tives and im­prove care and out­comes, and that work con­tin­ues, said Dr. Mary Cooper, chief qual­ity of­fi­cer and se­nior vice pres­i­dent for clin­i­cal af­fairs at the Con­necti­cut Hos­pi­tal As­so­ci­a­tion.

“We’re happy over­all that we’re show­ing some progress in var­i­ous ar­eas,” she said.

Over the past year, Cooper said, high re­li­a­bil­ity ef­forts have fo­cused on ed­u­cat­ing and train­ing hos­pi­tal work­ers in self-care to help them in turn bet­ter pro­vide care to pa­tients, and bed­side ef­forts to get pa­tients and fam­ily mem­bers more proac­tively in­volved in pa­tients’ care.

But Lisa Free­man, ex­ec­u­tive di­rec­tor of the Con­necti­cut Cen­ter for Pa­tient Safety, sees lit­tle im­prove­ment. If you con­sider the two cat­e­gories no longer in­cluded in the re­port­ing, there were only eight fewer ad­verse events in 2017 than in 2016, Free­man said.

“That’s not a change. It’s just re­flec­tive of no im­prove­ment in my mind,” Free­man said. “There are still far too many med­i­cal harm events. And these aren’t mi­nor ones, these are ones re­sult­ing in death or sub­stan­tial in­juries. This is very dis­cour­ag­ing, ac­tu­ally. We’ve got to look as to why we con­tinue to have this level of harm.”

Even as hos­pi­tals work to re­duce ad­verse events, the events keep hap­pen­ing, Free­man said. “We’re do­ing some good things, [but] we need to look at why are they still fail­ing to cut down on med­i­cal harm events.”

The num­ber of sex­ual as­saults re­ported, which had surged to 24 in 2016 com­pared to pre­vi­ous years, dropped to five in 2017 — due in part to a change made last Jan­uary in guide­lines for re­port­ing sex­ual as­saults that clar­i­fied what con­sti­tutes a “sub­stan­ti­ated al­le­ga­tion,” ac­cord­ing to the DPH re­port.

“These num­bers (un­der the new def­i­ni­tion) are more ac­cu­rate,” Cooper said.

The most com­mon ad­verse events in 2017 were Stage 3, Stage 4 or un­stage­able pres­sure ul­cers, which ac­counted for 59 per­cent of all events. The pres­sure ul­cer num­ber has been on the rise since about five years ago when DPH added un­stage­able pres­sure ul­cers to the tally, ac­cord­ing to Cooper. The term “un­stage­able” in­cludes skin that is at risk of break­down, even be­fore it red­dens and be­comes a Stage 1 pres­sure ul­cer, she said. Var­i­ous fac­tors can af­fect pa­tients’ risk for pres­sure ul­cers, in­clud­ing whether they smoke or have di­a­betes, she said.

“We have seen the se­ri­ous [pres­sure ul­cers] re­ally, re­ally, re­ally go down,” Cooper said. Iden­ti­fy­ing some­thing as un­stage­able, she said, “al­lows us to take pre­ven­ta­tive mea­sures be­fore it starts to evolve into ul­cer­ated skin.”

High re­li­a­bil­ity ef­forts should help re­duce ad­verse events, but more needs to be done, Free­man said.

“No­body wants to see these num­bers,” she said. “These are big prob­lems and we re­ally owe it to ev­ery pa­tient and ev­ery per­son in Con­necti­cut to have this at the very top of our con­cerns.”

Yale New Haven Hos­pi­tal. Over­all, the to­tal num­ber of “ad­verse events” re­ported by hos­pi­tals dropped from 431 in 2016 to 351 in 2017, a 19 per­cent de­cline, the state De­part­ment of Pub­lic Health re­ported.

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