As with healthcare-associated infections (Chapter 10), the patient safety movement has broadened the concept of “adverse event” to include such outcomes as patient falls, delirium, pressure ulcers, and venous thromboembolism (VTE) occurring in healthcare facilities. The rationale for this inclusion is that the strategies to prevent these complications of medical care are similar to those used to prevent other errors. Such strategies include education, culture change, audit and feedback, improved teamwork, and the use of checklists and bundles.

Moreover, as a practical matter, inclusion of these complications under the broad umbrella of patient safety has increased their visibility, thus making available more resources to combat them. It has also facilitated their inclusion within policy initiatives being used to promote safety. For example, postoperative VTE is on the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators list (Appendix V), and is included among the preventable adverse events that are no longer reimbursed by Medicare (Appendix VIII).1

This chapter will highlight a few key complications of healthcare and the strategies that can help prevent them. Strategies to prevent readmissions and other handoff-related adverse events are covered in Chapter 8.

Hospitalized or institutionalized patients often have conditions that place them at high risk for VTE, including inactivity, comorbid diseases that increase the risk for clotting (e.g., cancer, nephrotic syndrome, heart failure), and indwelling catheters. Moreover, because such patients often have limited cardiopulmonary reserve, a pulmonary embolism (PE) can be quite consequential, even fatal. In fact, autopsy studies have shown approximately half the patients who die in hospitals have had a PE, with most of these cases unrecognized antemortem.2

The risk of VTE in a hospitalized patient is hard to determine with certainty, because it varies widely depending on the ascertainment method. Studies relying on clinical diagnosis have found rates of 20% for deep venous thrombosis and 1% to 2% for PE after major surgical procedures in the absence of prophylaxis. Rates after certain orthopedic procedures are even higher. Studies using more aggressive observational methods (i.e., Doppler ultrasounds on every postoperative patient) have found much higher rates. It is not known how many of these asymptomatic clots would have caused clinical problems, but surely some would have.

A detailed review of strategies to prevent VTE is beyond the scope of this chapter; the interested reader is referred to a number of excellent reviews, particularly the regularly updated guidelines published by the American College of Chest Physicians (ACCP).3 Instead, in keeping with the patient safety focus on systems, our emphasis will be on creating systems that ensure that every eligible patient receives appropriate, evidence-based prophylaxis.

Given the complexity of the VTE prophylaxis decision (which varies by patient group and clinical situation, and changes rapidly with new research and pharmacologic agents), it seems unlikely that physician education, the traditional approach, is the best strategy to ensure that research is translated into practice. Rather, the emphasis should be on developing standardized protocols, through order sets and similar mechanisms and, when possible, building these protocols into clinical decision support systems (Chapter 13). In fact, the most recent ACCP guidelines strongly recommend that “every hospital develop a formal strategy that addresses the prevention of VTE.”3

In a study of 2500 hospitalized patients, half the patients received standard care, while the other half’s physicians received a computerized notice of their patient’s own risk of thromboembolism. The latter group was required to acknowledge the notice and then explicitly choose to withhold prophylaxis or order it (graduated compression stockings, pneumatic boots, unfractionated or low-molecular-weight heparin, or warfarin). Physicians receiving the alerts were far more likely to order appropriate prophylaxis, and the rates of clinically diagnosed deep venous thrombosis or PE fell by 41% in their patients.4 Two ICU-based studies reported on the adoption of a series of tools that promoted team communication, prompted clinicians with evidence-based recommendations for ICU prophylaxis (for VTE and other targets including ventilator-associated pneumonia and stress ulcers), and gave them real-time feedback on their performance. Both studies found significant improvements in the use of evidence-based prophylaxis.5,6 In a comprehensive review of patient safety practices that several colleagues and I conducted for AHRQ, promoting the appropriate use of VTE prophylaxis was the most highly rated practice on the strength of evidence regarding impact and effectiveness.7

As with many patient safety targets, moving from local improvement strategies to national reporting and payment changes comes with some complexity. Many national programs determine whether VTE was present based on hospital administrative records, largely created for billing purposes. Several studies have shown that such data lack specificity for hospital-acquired VTE, because either the thrombosis was present on admission or the coding was inaccurate.8–11

In addition to accuracy of coding, the issue of preventability arises when hospitals are no longer reimbursed for certain cases of VTE.1 Streiff and Haut have argued for a reimbursement strategy in which the presence of the adverse event—VTE in this case—would lead to a chart review to determine whether the evidence-based processes were carried out; reimbursement would be withheld only if they were not.11 Although unwieldy and expensive, such a strategy seems fairer than penalizing hospitals when they did everything right.12 A similar argument, of course, can be made for the other events on Medicare’s “no pay” list that are only partly preventable (Appendix VIII).

Pressure ulcers—damage to skin or underlying structures caused by unrelieved pressure—cause pain, delay functional recovery, and predispose patients to local and systemic infections. It is estimated that about one in seven hospitalized patients in the United States has or develops a pressure ulcer, that 2.5 million patients are treated for pressure ulcers each year, and that more than 50,000 patients die each year from complications.13,14

Similar to patient falls (see Section “Preventing Falls”), the first step in preventing pressure ulcers is identifying at-risk patients with a validated risk assessment tool. A variety of such tools are available—most assess nutritional status, mobility, incontinence, and sensory deficiencies. In the United States, the most commonly used tool is the Braden Scale.15,16 Risk should be assessed on admission (to the hospital or skilled nursing facility), then subsequently (daily, in the case of hospitalized patients). The goals of risk assessment are both overall prevention and preventing early stage pressure ulcers from becoming more severe (i.e., Stages III and IV) with deep tissue injury (Table 11-1).

These risk assessments are followed by a variety of preventive activities focused on at-risk patients. The Institute for Healthcare Improvement’s (IHI) bundle includes the following strategies: daily inspection of skin from head to toe (with a special focus on high-risk locations such as sacrum, buttocks, and heels), keeping the patient dry and treating overly dry skin with moisturizers, optimizing nutrition and hydration, and minimizing pressure through frequent repositioning and the use of pressure relieving surfaces such as special beds. While several institutions have reported anecdotal success in decreasing pressure ulcer rates through the systematic implementation of these risk assessment and mitigation strategies,17,18 to date, no large-scale, methodologically strong clinical trial has defined evidence-based best practices or the degree to which pressure ulcers are truly preventable.19

Patient falls are common—each year, more than one-third of community-dwelling elders fall—and frequently morbid. As older patients are hospitalized or institutionalized, placed on multiple medications, and often immobilized, the risk of falls grows, with some studies suggesting that more than 50% of nursing home residents fall each year.20 Approximately 20% of falls in institutionalized patients result in serious injury.21

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