Despite the value of hand sanitizers—whether they are available at unit entrances, along the floors, at individual rooms, or carried in tiny dispensers that can be attached to a stethoscope—some pathogens, such as the now-epidemic Clostridium difficile, are not vulnerable to the antisepsis in those mechanisms.
“C. dif is a set of spores that are less effectively cleaned by the topical hand sanitizers,” says Dr. Alverson, who is also an assistant professor of pediatrics at Brown University in Providence, R.I. “In those cases, soap and water is what you need.”
Peter Angood, MD, FRCS(C), FACS, FCCM, vice president and chief patient safety officer of JCAHO, Oakbrook, Ill., says provider hand-washing is a huge patient safety issue and, in general, a multi-factorial problem that is more complicated than it would seem on the surface.
“We can rationalize and cut [providers] all kinds of slack, but at the bottom line is human behavior and their willingness to comply or not comply,” he says. “It’s like everything else: Why do some people speed when they know the speed limit is 55?”
Addressing the solution must be multi-factorial as well, but all hospitalists can serve as role models for their colleagues and students, including remaining open to reminders from patients and families.
5. Remain on Kidney Alert
Contrast media in radiologic procedures can cause allergic reactions that lead to kidney failure. This is a particularly vexing problem for elderly patients at the end stages of renal dysfunction and patients who have vascular disease, says Dr. Manning. Although the effects are not generally fatal, the medium can be organ-damaging. “This is a hazard that’s known, and it has some mitigating strategies,” he says, “but often it can’t be entirely eliminated.”
Measures that reduce the chance of injury, say Dr. Manning, include ensuring that the contrast medium is required; confirming that the procedure is correct for the patient, with the right diagnosis, with a regulated creatinine, and well coordinated with the radiology department; “and then getting true informed consent.” But at a minimum, he emphasizes, is the importance of hydration. “There is some evidence that hydration with particular types of intravenous fluids can help reduce the incidence of the kidney revolting.” And, he says, “there are a number of things that we have to do to make sure this is standardized.”
6. Use Rapid Response Teams
Use of “[r]apid response teams [RRTs] is one of the most powerful items on the list,” says Dr. Manning, who serves on SHM’s committee on Hospital Quality and Patient Safety as well as the committee helping to design the Ideal Discharge for the Elderly Patient checklist. “Whereas every hospital has a plan for response,” he says, RRTs are “really a backup plan.”
In 2003, Dr. Manning served as faculty for an IHI program in which a collaborative aimed at reducing overall hospital mortality. The formation and application of RRTs at six hospitals in the United States and two in the United Kingdom was the most promising of the several interventions, with impact on a variety of patients whose conditions were deteriorating in non-ICU care areas.
The advantage of RRTs with children, says Daniel Rauch, MD, FAAP, director of the Pediatric Hospitalist Program at NYU Medical Center, New York City, is that it is often difficult for providers to know what may be wrong with a child who is exhibiting symptoms. “Is the kid grunting because they’re constipated, because that’s the developmental stage they’re in, they’re in pain, or are they really cramping on you?” he asks.