Issue link: https://beckershealthcare.uberflip.com/i/903742
8 INFECTION CONTROL & PATIENT SAFETY Hershey Medical Center Cited for Care Delays That Contributed to 2 Patient Deaths By Brian Zimmerman S tate health officials in September issued five citations against Penn State Health's Milton S. Hershey (Pa.) Medical Center over delayed care for three patients, two of which later died, according to a report from Lebanon Daily News. Here are six things to know. 1. e citations and subsequent corrective actions stemmed from an unannounced special monitoring survey conducted by the Pennsylvania Department of Health from July 3 to July 21. 2. e investigative survey found the hospital was noncompliant with several state require- ments and regulations. e hospital failed to implement emergency procedures in a timely manner aer a pediatric patient was assessed as having an elevated heart rate and high temperature. e child went into septic shock and was moved to the intensive care unit. Several days later, the child met criteria for brain death. e state found the rapid response team should have been called in to care for the patient around noon the day of incident. e team was called at 3:30 p.m. according to the Lebanon Daily News. 3. In a second case, the state found the hospital failed to initiate a "brain attack protocol" in a timely manner June 11. The protocol is meant to be initiated when a patient has had or is having a stroke. Hos- pital staff observed the patient was "not making sense, slow to follow commands/ had difficulty following commands" at 9:56 p.m. At 12:15 a.m., a nurse documented a discussion of the "need to call emergen- cy department brain attack at this time. Awaiting further orders." 4. On July 22, an injured patient who fell was admitted to the hospital from the emergency department. e staff ordered medication to treat blood clotting issues at 5:47 a.m. It was confirmed by the pharmacy at 6:49 a.m., but not administered to the patient until 8:36 a.m. e patient later died from a subdural hemorrhage. Aer conducting employee in- terviews, investigators determined part of the delay was caused by nurses waiting for a shi change before administering the medicine, according to the Lebanon Daily News. 5. e hospital will take several corrective actions in the wake of the citations, including educating staff about the rapid response team process, medication turn-around times and brain attack protocols. "Instances such as this are inconsistent with the high-quality care our community has come to expect from us — and which we expect from ourselves," said the hospital in a statement obtained by Lebanon Daily News. "We deeply regret when we fall short of those expectations. We realize the importance of our ongoing efforts to evaluate and improve our patient care practices; to ensure staff have the knowledge they need to consistently meet the highest standards of care; and to rein- force expectations for employees to elevate concerns they may have, particularly where patient care is involved." 6. e hospital has come under fire for patient safety issues in recent months. In Au- gust, state health officials cited the hospital in the death of a 6-year-old boy who was admit- ted to the emergency room Jan. 10 with low body temperature. e boy was subsequently wrapped in a heated blanket overnight and found dead the next morning. n The 2 Most Effective Operating Room Practices to Reduce SSIs By Mackenzie Bean P rioritizing patient skin and wound hygiene and tracking and reporting patient outcomes are the most effective operating room practices to reduce surgical site infections, according to a study published in the Journal of the American College of Surgeons. For the study, researchers polled surgeon leaders at 20 Texas hospitals affiliated with the Texas Alliance for Sur- gical Quality, a collaborative of the American College of Surgeons National Surgical Quality Improvement Program. In the survey, physicians ranked surgery, anesthesia and nursing adherence rates for 38 infection control prac- tices in six categories: attire, preoperative preparation, during-surgery protocols, antibiotics, postoperative care and outcomes reporting. Researchers also analyzed outcomes data on risk-adjusted odds ratios for surgical site infections using ACS NSQIP hospital-level risk-adjusted reports for July 2016. Most hospitals reported maximum adherence for surgi- cal care improvement project metrics, such as removing hair at the surgical site with clippers and properly using preventative antibiotic. Hospitals with the lowest SSI rates had the best compliance for eight other infection control practices, including preoperative showers, the use of clean instruments for wound closure and dressing chang- es, and transparent internal reporting of SSI data. Infection control practices relating to operating room attire did not correlate with SSI rates. "The best performing hospitals were vigilant about skin prep, using a clean closure and giving antibiotics appro- priately — all those things that happened right at the level of the wound," said lead author Thomas A. Aloia, MD, a surgeon at the University of Texas MD Anderson Cancer Center in Houston. "In addition, the hospitals that report- ed out their data on a formal basis — monthly or quarterly — to their surgeons, departments, and institutions also had the highest performance." n