Avoiding Patient Misidentification: A Practical Guide

By | Uncategorized | No Comments

This year, Rhode Island Hospital made headlines when they were reported for four cases of patient misidentification, all of which resulted in unnecessary and incorrect medical care[1]. In three cases, patients received imaging and/or diagnostic tests that were intended for another patient — actions which carry moderate risk but could be determined to be relatively neutral. However, in the fourth and most impactful case, a patient underwent an incorrect operation on the non-designated part of the spine, a shocking medical error which will have ramifications throughout the patient’s life. Rhode Island Hospital has made investments, financial and operative, to ensure that such errors will not occur again. However, such a case demonstrates that the issue of patient misidentification is still frequent in the United States healthcare sector, even in largely industrialized and sophisticated hospital systems. Particularly in the anesthesiology and surgical fields, addressing patient misidentification is crucial for effective,appropriate, and ethical patient care.

Patient identification refers to the confirmation that an individual is both (a) the person whom they claim to be and (b) receiving the services that are intended for the person whom they claim to be. If both conditions are not met in the healthcare setting, then this is considered a breach of patient identification and could imply both legal and medical ramifications for the health system. According to the World Health Organization, the major healthcare fields in which patient misidentification is most likely to occur are drug administration, phlebotomy, blood transfusions, and surgical interventions[2]. Inherent to anesthesiology is, of course, drug administration and surgical interventions, rendering patient misidentification as a core issue to the field.

misidentificationTherefore, what specific interventions can anesthesiology and surgical practices make to avoid patient misidentification? In the age of an increasing emphasis on patient safety, there are many options at both the provider and practice level. At the practice management level, standards of practice should be related to all providers, from anesthesiologists to Certified Registered Nurse Anesthetists (CRNAs) to operating room nurses. Policies could include two corroborating patient identifiers as proof of identity, physical markers with the identity of the patient place on the patient at all time during stay, multiple verbal verifications, or dedicated time during the procedure to verify patient identity and site of surgery, for example[3]. In addition, policies must be enforced at the practice management level. Although anesthesia professionals are often highly booked, it must be a strategic priority of the operating room manager or chief of department to enforce standards of practice as related to patient identification, whether that means providing a team member or volunteer that is responsible for the task of patient identification or providing in-service ongoing training to practitioners to ensure education is up to the current standard.

In light of technological advancements, more sophisticated options for patient identification are entering the sphere of conversation. Several companies have come forth with advanced biometric identification solutions, such as matching the individual to the identity by utilizing palm-vein technology, thumb scans, two-step secure verification, or facial analysis techniques[1]. While such technologies may be expensive at first to integrate into each hospital system’s electronic medical records (EMR) system, they will likely prove to be the next generation method of securely verifying a patient’s identification.

In and out of the operating room, patient identification is critical for delivery of patient care, particularly in the anesthesia. By strengthening pillars of standards of practice and integrating novel biometric technologies, anesthesia providers as well as anesthesia management organizations, can ensure that hospital and health systems move forward in delivering enhanced care for patients.

 

[1] Miller, G. Wayne. “R.I. Hospital Enters Consent Agreement after 4 Patient Errors in 4 Weeks.” Providence Journal, Providencejournal.com, 9 June 2018, www.providencejournal.com/news/20180608/ri-hospital-enters-consent-agreement-after-4-patient-errors-in-4-weeks.

[2] World Health Organization, et al. “Patient Safety Solutions.” World Health Organization, 2007, www.who.int/patientsafety/solutions/patientsafety/PS-Solution2.pdf.

[3] AST Education and Professional Standards Committee. “Standards of Practice for Patient Identification, Correct Surgery Site and Correct Surgical Procedure.” Association of Surgical Technologists, Oct. 2006, www.ast.org.

[4] Wood, Megan. “How Biometric Identification Enhances Patient Safety and the Hospital’s Bottom Line.” Becker’s Hospital Review, Dec. 2017, www.beckershospitalreview.com/cybersecurity/how-biometric-identification-enhances-patient-safety-and-the-hospital-s-bottom-line.html.

Herbal Supplement Use: Anesthetic Implications

By | Uncategorized | No Comments

Americans spend over $27 billion yearly on herbal supplements, botanicals, and other alternative medicines. Many are unaware of the potency and potential side effects of these agents, which are not subject to federal regulation. Some supplements may cause electrolyte disturbances, anticoagulation effects, interactions with other medications, or interaction with anesthetic agents. Moreover, not only do patients often not disclose the supplements they are taking to their anesthesia providers, providers may be unaware of the implications of these herbal supplements on their anesthetic.

A brief review of some common herbs and supplements that may have anesthetic implications is presented below. However, the list of available supplements patients take is so vast, it is difficult to cover them all. The anesthesia provider should address with the patient if she/he is using herbal supplements, and to make an effort to determine if any potentially serious side effects could arise from their continued use perioperatively. While it is generally safe to advise patients to discontinue herbals one or two weeks prior to surgery, it may be dangerous to abruptly stop some agents. These may require tapering or continuation during the perioperative period.

herbalSupplements known to increase the risk of bleeding include garlic (inhibits platelet aggregation), ginkgo (inhibits platelet activating factor), ginseng (inhibits platelet aggregation; also decreases blood glucose), saw palmetto (unknown mechanism), black cohosh (NSAID-like properties), chamomile (contains phytocoumarins which have an additive effect with warfarin), feverfew (inhibits platelet aggregation and has additive effects with antiplatelet drugs and warfarin), fish oil (dose-dependent), and vitamin E (can also affect blood pressure).

Herbals that increase clotting risk include coenzyme Q10 (through a decreased response to warfarin), goldenseal (opposes effects of warfarin and heparin), and St John’s Wort (reduces blood levels of warfarin).

Other supplements also have different effects. Ephedra (Ma-Huang) may interact with blood pressure medications and cause tachycardia and hypertension. Kava can increase the effect of anesthesia and has been implicated in liver dysfunction in rare cases. Valerian can prolong the effects of some types of anesthesia. Abrupt discontinuation of this agent may cause benzodiazepine-like withdrawal symptoms.

Further resources for information on supplements include www.naturaldatabase.com and www.fda.gov (which reports adverse events). While sometimes time-consuming (some patients may be taking ten or more supplements), it is good to at the very least, to have an open discussion with patients regarding the use and potential side effects of the medications they are taking, whether prescription or alternative.

References:

http://www.asahq.org/lifeline/anesthesia%20topics/herbal%20supplements%20and%20anesthesia

https://www.asahq.org/whensecondscount/wp-content/uploads/2017/10/asa_supplements-anesthesia_final.pdf

https://www.openanesthesia.org/aba_herbal_supplements/

Patients and Medical Records 101

By | Uncategorized | No Comments

In the modern age of healthcare, one’s medical record isn’t merely a set of pages held together in a binder behind the office. Rather’s, a patient’s medical record is a complex set of electronic documents that is comprised of physician appointments, medical exams, testing results, scheduled operations, and operative reports. In the wake of the transition from paper to electronic, medical records have increased in complexity — including the levels of authority at which access is granted. It is important to remember that, ultimately, electronic medical records (EMRs) are centered on providing the highest level of patient care. Physicians, clinicians, researchers, and administrators are granted access to highly sensitive information in order to act in the best interests of the patient, in clinical and non-clinical capacities. However, as patients are navigating the world of patient portals, it is important to recognize which elements about an EMR are most critical for the patient to understand.

The first crucial entity to understand when discussing EMRs is HIPAA. HIPAA, or the Health Insurance Portability and Accountability Act of 1996, is a law that protects individual medical and health information throughout the United States. All healthcare providers and employees of healthcare providers, including clinical and non-clinical professionals, are required to comply with HIPAA. This essentially means that as a patient, one’s medical information must be protected to the highest degree, including encryption, password protection, and the use of anonymization. Patients should be cognizant that HIPAA does not only apply to their physician or nurse — it applies to all staff in the hospital, the third-party vendor that processes images or testing, health insurance companies, and any party that may be privy to a patient’s medical information at any point before, during, or after their clinical episode. HIPAA is built to protect patients from their confidential and sensitive medical information being shared with inappropriate parties. EMRs facilitate higher compliance with HIPAA requirements, and patient protection more broadly, because they can be secured with multiple methods of security. Undoubtedly, the healthcare provider or individual attempting to access a patient’s medical information will have to log-in through a secure server. Depending on the institution, the login may include additional security features, such as two-factor authentication, biometric identification, or VPN requirements. Such actions ensure that your EMR is highly protected and only accessible to the appropriate individuals or parties.

patientsAlongside the security features, EMRs are more conducive to secure sharing amongst institutions. For example, if a patient decides to move healthcare providers or to seek a second opinion at a different institution, historically such a process would be laborious and require either direct mailing or faxing of health information — each of which are non-secure methods. However, with EMR, hospitals and healthcare providers can subscribe to Electronic Health Records, which are comprehensive software systems that allow for sharing amongst the licensed healthcare providers and institution that align. The inclusion of EHRs increases patient engagement in their own clinical journey, as well as the patient’s autonomy to move to the provider that they prefer for treatment.

In the coming years, healthcare technology will continue to improve and manifest itself in greater advantages for patients, providers, and institutions alike. Patients should take heed of such developments, understanding that their medical information is a critical resource in their diagnosis and treatment during clinical episodes, and throughout the rest of their lives.

References:

Agency for Healthcare Research and Quality. “Electronic Medical Record Systems”. US Department of Health and Human Services. Web. https://bit.ly/1MWVlUA

Garrett and Seidman. “EMR vs EHR – What is the Difference?”. The Office of the National Coordinator for Health Information Technology. Web. 2011. https://bit.ly/2aqf7PV

Kruse, Clemens Scott et al. “Security Techniques for the Electronic Health Records.” Journal of Medical Systems 41.8 (2017): 127. PMC. Web. 18 Sept. 2018.

OCR Privacy Brief. “Summary of the HIPAA Privacy Rule”. Web. 2013. https://bit.ly/2of1vOw

Deep Sedation for Percutaneous Mitral Valve Repair

By | Uncategorized | No Comments

Mitral regurgitation is a common valvular pathology that can lead to heart failure, so surgical correction is advised. However, some patients are unable to receive mitral valve surgical repair due to the increased perioperative risk. Percutaneous edge to edge mitral valve repair (PMVR) using the MitraClip system has been demonstrated to be a safe and effective alternative to treat severe mitral regurgitation in these patients. Unlike other percutaneous interventions, such as transcatheter aortic valve replacement (TAVR) that is getting more commonly performed under conscious or deep sedation, most PMVR procedures are currently being performed under general anesthesia. While general anesthesia provides advantages such as guaranteed immobility, ability to give breath holds for challenging anatomic conditions, and control of the airway, disadvantages include greater hemodynamic swings, greater incidence of perioperative hypotension, and increased duration of anesthesia. These disadvantages have been shown to be risk factors for prolonged hospital stay and increased morbidity.

Two European prospective studies were published last year comparing general anesthesia to deep sedation for PMVR. Each consisted of over 200 patients. Patients were not randomized in either study, but in the Patzelt study they were individually evaluated by the cardiology and anesthesia teams regarding suitability for deep sedation (patients selected for general anesthesia may have a more challenging anatomy, for example, which may have benefited from controlled ventilation). The Horn study used its scheduling system to assign patients to either group regardless of patient characteristics, though more patients ended up being in the deep sedation group. Both studies used midazolam and propofol as primary sedatives for the deep sedation group.

Deep sedation for Percutaneous Mitral Valve RepairDespite significant differences between patient groups in the Patzelt study (general anesthesia patients were younger but tended to have more severe disease and comorbidities, though pulmonary hypertension was more prevalent in the deep sedation group), both studies nevertheless found similar outcomes. There was no difference found between the two groups in terms of procedure success, surgical complications, major cardiac and cerebrovascular events, or postoperative pneumonia. Both studies found advantages to deep sedation, including shorter preparation time in the cath lab and ICU stay duration. The Horn study found longer procedure time and fluoroscopy time for the general anesthesia group, however this may be confounded by baseline patient characteristic differences between the two groups.

These two single institution prospective studies provide encouraging data for the safety of deep sedation for percutaneous mitral valve repair procedures. For eligible patients, it may be worth discussing whether this anesthetic approach may be appropriate.

References:

Horn P, Hellhammer K, Minier M, Stenzel MA, Veulemans V, Rassaf T, Luedike P, Pohl J, Balzer J, Zeus T, Kelm M, Westenfeld R. Deep sedation Vs. general anesthesia in 232 patients undergoing percutaneous mitral valve repair using the MitraClip® system. Catheter Cardiovasc Interv. 2017 Dec 1;90(7):1212-1219.

Patzelt JI, Ulrich M, Magunia H, Sauter R, Droppa M, Jorbenadze R, Becker AS, Walker T, von Bardeleben RS, Grasshoff C, Rosenberger P, Gawaz M, Seizer P, Langer HF. Comparison of Deep Sedation With General Anesthesia in Patients Undergoing Percutaneous Mitral Valve Repair. J Am Heart Assoc. 2017 Dec 2;6(12)

Surgical Site Infections

By | Uncategorized | No Comments

Surgical site infections (SSIs) affect 1-3% of patients within 30 days after surgery.1 While some infections are superficial and associated with mild irritation and discharge, deeper infections can impair wound healing, causing incisions to re-open and infection to spread. For most surgeries involving a significant skin incision, follow-up visits are typically scheduled within 2 weeks. However, sometimes compliance with follow-up is not perfect, and brewing infections can go unnoticed for a long period of time.

Surgical Site Infection

Prior to surgery, the anesthesiologist and surgeon evaluate for conditions that predispose a patient to SSI, including diabetes, cancer, kidney and liver disease, as well as habits including cigarette use, heavy alcohol or intravenous drug use. Longer procedures, especially near the intestines which normally harbor bacteria, can progressively increase the risk of bacterial infection and abscess formation. A risk calculator has been developed (and freely available) to assist surgeons, patients, and families in understanding the risks of major complications after surgical procedures.3

Such infections after surgery require a thorough evaluation (with an assessment for the need for re-operation) and several weeks of antibiotics, contributing significantly to healthcare costs that can exceed $20,000.4 For example, SSIs are a cost burden to the healthcare system; it adds more than $20,000 to the patient’s bill and contributes to almost $2 billion in additional healthcare expenditures nationally each year.4,5 For this reason, anesthesia and perioperative care teams emphasize multiple evidence-based strategies during the pre-operative visit and enforce them during the day of surgery:

– Patient pre-operative instructions:

– Patients are instructed to shower the night before many surgeries using an antiseptic rinse, typically chlorhexidine gluconate.

– Hand-washing:

– Hand hygiene protocols in hospitals call for adequate hand washing and scrubbing in a sub-sterile environment immediately prior to entering the operating room.

– Hand sanitizers are recommended for intermittent use during and after procedures, especially when the anesthesia team goes between different equipment and medications.

– Sterile precautions:

– The anesthesia and operating room management have standardized the use of sterile gloves, autoclaved instruments, and large blue surgical barrier drapes.

– In addition, skin preparation with chlorhexidine (i.e. Chloraprep) or iodine (i.e. Betadine) is mandatory.

– Antibiotic prevention:

– Cefazolin (i.e. Ancef, Kefzol) is given by the anesthesiologist within 30-60 minutes of the anticipated start of surgery to prevent potential infections in the vast majority of procedures involving skin incision. Different antibiotics may be given as “prophylaxis” if the operative team anticipates exposure to specific types of bacteria.

– Wound irrigation and post-operative antibiotics:

– The surgeon will thoroughly explore for any potential debris and instill irrigation fluid prior to closing the surgical incision.

– Patients with a compromised immune system and those deemed to already have a severe infection will be continued on antibiotics after surgery, sometimes receiving multiple doses a day through an intravenous catheter for several weeks.

REFERENCES

  1. Klevens, R.M., Edwards, J.R., Richards, C.L. Jr., Horan, T.C., Gaynes, R.P., Pollock, D.A. et al. Estimating health care-associated infections and deaths in US hospitals, 2002. Public Health Rep. 2007;122:160–166.
  2. Razavi SM, Ibrahimpoor M, Sabouri Kashani A, Jafarian A. Abdominal surgical site infections: incidence and risk factors at an Iranian teaching hospital. BMC Surgery. 2005;5:2
  3.  Walraven C, Musselman R (2013) The Surgical Site Infection Risk Score (SSIRS): A Model to Predict the Risk of Surgical Site Infections. PLOS ONE 8(6): e67167.
  4. Reichman DE, Greenberg JA. Reducing Surgical Site Infections: A Review. Rev Obstet and Gynecol. 2009;2(4):212-221.
  5.  Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaugn BB. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009 Jun;37(5):387-397.