I. Problem/Challenge.

Management of patients in the hospital can provide many advantages for patients who are medically unstable, require rapid diagnostic or treatment intervention, or specialized coordinated care. However, it is important to recognize that there are associated risks with the inpatient setting. As a hospital based provider, depending on expectations at your institution, you will at minimum be expected to be aware of common hospital associated complications as well as the established protocols to manage these conditions. Some institutions will expect more active participation in quality of care improvement initiatives around complication prevention.

II. Identify the Goal Behavior.

Thoughtful management of the hospitalized patient requires an ongoing assessment of patient risks as well as coordinated evidence based efforts towards the prevention of common hospital acquired conditions.

III. Describe a Step-by-Step approach/method to this problem.

Step 1: Recognize complications that are more prevalent in the hospital setting:

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Patients in the hospital setting might be at increased risk for the following conditions:

1. Venous Thromboembolism (VTE)

2. Hospital associated infections including catheter associated infections

3. Delirium

4. Falls/Deconditioning

5. Pressure Ulcers

6. Poor glycemic control

7. Gastrointestinal and Iatrogenic bleeding

8. Iatrogenic other (medication and procedure associated risk)

Step 2: Assess and mitigate the patient’s risk:

A. What is the evidence for who is at risk?

B. Do your patient’s characteristics match the at-risk population?

C. What protocols does your hospital already have in place?

D. Are there national standards that need to be met?

E. What additional measures need to be put in place to increase your patient’s safety?

Step 3: Common considerations:

1. Venous thromboembolism (VTE)

There is a significant amount of literature surrounding risk for venous thromboembolism disease. Becoming familiar with the more established literature is important. If your hospital has not developed a local protocol for assessing and mitigating risk for your patient population, you might want to look at tools being used at other local institutions.

Another option is the DVT Risk Assessment form available on the DVT prevention coalition website which is endorsed by the American College of Chest Physicians (ACCP). The American College of Chest Physicians periodically publishes evidence based guidelines for treatment. Referencing the most recent evidence based consensus guidelines from the ACCP in the Chest Journal is a good first step towards determining appropriate prophylaxis and treatment for your patient.

2. Hospital-acquired Infection

Each site/type of infection has its own associated literature. There might be regional or local differences in pathogens more commonly encountered at your institution. There will also be different approaches to procedure and indwelling device associated infections. You will want to quickly understand the epidemiological factors present at your hospital and in your patient population. Most hospitals have an infection control committee. You will want to see if they have established guidelines for you to follow. Handwashing protocols and contact precautions are increasingly recognized as a universal preventative step. Catheter Bundled protocols are being studied in conjunction with indwelling device associated infections.

3. Delirium

Literature indicates that up to one-third of hospitalized older patients will have issues with delirium during their hospital stay. One-half of those will be admitted with delirium. Delirium carries significant morbidity and mortality risks including impaired functional status, increased length of stay and death. Carrying the same risk, but often less easily recognized is hypoactive delirium. Even in the palliative care literature, where the expected outcome is known to be death, the literature supports that proactive diagnosis and treatment to improve outcomes.

The following patient factors are recognized as being associated with a higher risk for delirium:

1. Age 65 or older

2. Impaired cognitive function at baseline

3. Current hip fracture

4. Severe illness

If a patient is clinical suspected of having delirium, the use of the confusional assessment method (CAM) or equivalent is recommended to confirm diagnosis. Treatment is usually aimed at treating the underlying cause as well as focusing on addressing the environmental factors that may be contributing. Supportive environmental factors include frequent reorientation, adequate sensory support, and avoidance of disturbances in the sleep-wake cycle. Additional supportive methods include maintaining adequate nutrition and hydration, increasing mobility, and controlling pain. The use of psychotropic agents is also being looked at and may be appropriate in certain conditions. Use of physical restraints should be avoided if possible. See additional guidelines housed in the National Clearinghouse for guidelines cited in references.

4. Falls/deconditioning

Falls and deconditioning in the hospital setting are noted to increase length of stay as well as morbidity and mortality in the hospital setting. The risk factors for both conditions are similar and multifactorial in nature. Common factors include premorbid condition, severity of illness, and attachment to IV lines, urinary catheters, oxygen, and other treatments that tether the patient to the hospital bed. Cognitive impairment and medications that increase sedation also contribute. Frequent assessment of patients at regular intervals to begin removing tethering treatments as they are no longer needed is an important preventative measure. Increasing mobility is also key in prevention.

5. Pressure ulcers

Established risk factor assessment scales include the Norton and Braden. These scales look at specific patient factors that lead to increased skin breakdown and include factors such as moisture, mobility, etc. Other scales are also described in the literature. There are slight variations in each of these scales and there is no universally accepted scale. Each is designed in some way to identify patients who might be at increased risk. More important than the actual scale used is the training, understanding and use of consistent methods of assessment. It is important to note that the scale is only one part of the assessment for pressure ulcers.

Other equally important factors include overall patient risk assessment and a thorough skin assessment. Additional risk factors, often not taken into account in the various scales include existence of prior pressure ulcers, hypoperfusion, vascular disease, diabetes, smoking history, restraint use, spinal cord injury, end of life care, and patients who have had a prolonged OR or ER stay especially if greater than 4 hours. A thorough skin assessment will include the entire skin. In addition to the commonly thought of sacrum, coccyx, less commonly thought of but vulnerable areas of the skin will include behind the ears (especially when patients have been on prolonged nasal cannula oxygen therapy), skin folds, heels, feet, IV sites, skin over bony prominences.

6. Poor glycemic control

Poor diabetic control has generally been associated with poor outcomes. At admission, patient should be assessed to determine prehospital long term diabetic control. Then goals for in hospital control should be established. Decision making for short term control during the stay should take into account multiple factors including whether the patient’s nutrional intake will be variable during the hospital stay and whether any of the patient’s long-term hypoglycemic medications will be held.

Literature around glycemic control in postop and ICU setting has suggested aggressive control is warranted. However, more recent literature suggests that tight control in the general ward setting may increase rather than decrease risk. Tight control is still considered standard in certain conditions, including sepsis especially in the ICU setting. However, the aim on the general ward setting is establishing the best consistent glucose levels that can be achieved without episodes of hypoglycemia. Furthermore, documentation of glycemic control should be readily available in such a way that all members of the healthcare team have access.

Commonly accepted methods include a diabetic flowsheet which give care providers access to information about glucose levels throughout the hospital stay along with treatment provided. In addition, all care providers should be aware of the hospital established protocols for hypoglycemia. Finally, the treatment of diabetes in the hospital setting should take into account basal, nutritional and correctional needs. Further guidelines are available in the National Guideline Clearinghouse through the AHRQ website.

7. Gastrointestinal and iatrogenic bleeding

Most of the research that supports reduction of risk for bleeding stress ulcers is in the ICU literature. General ward patients are unlikely to benefit from prophylactic treatment unless other specific risk factors beyond general hospitalization are present. Therefore, because of the drug to drug interactions and other associated risks, widespread use of anti stress ulcer medication is not indicated on the general ward.

Invasive procedures may also lead to increased iatrogenic bleeding especially if patients have certain risk factors. Patient factors associated with increased risk of bleeding in the hospital setting include use of anticoagulants, liver disease, and renal disease. Consideration of risk mitigation in these conditions around a procedure will be important.

8. Iatrogenic other (medication and procedure)

Hospitals are increasingly being held responsible for procedure and medication associated complications that are viewed as preventable. Further, hospitals are being asked to put in place protocols that will prevent such events from occurring. Examples of such measures include medication bar coding and surgical pauses.

You will want to familiarize yourself with the protocols your hospital already have in place to prevent such events as well as the methods of reporting when these events occur. In addition, there are some events that are considered ‘never events’. These are rare events to begin with but hospitals are being increasingly held responsible for eliminating them altogether. Please refer to the never event primer on the AHRQ website.

IV. Common Pitfalls.

The most common pitfall for in-hospital prevention is doing the risk assessment only once, usually at admission. Risk assessment should be an ongoing process, readdressed at key portions of the hospital stay including but not limited to transitions of care.

V. National Standards, Core Indicators and Quality Measures.

Established guidelines or consensus documents:

1. a. Prevention of VTE: http://chestjournal.chestpubs.org/content/133/6_suppl/381S.full.pdf+html

b. National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism: Policy, Preferred Practices, and Initial Performance Measures (NQF standards being used by joint commission): http://www.qualityforum.org/Publications/2006/12/

2. a. Hospital Infections, A Practical Guide: http://www.who.int/csr/resources/publications/drugresist/en/whocdscsreph200212.pdf

b. Infection Control and Hospital Epidemiology: http://www.jstor.org/stable/10.1086/593984

c. Who Guidelines on Hand Hygiene: http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf

d. 5 Million Lives Campaign. Getting Started Kit: Prevent Central Line Infections How-to Guide. Cambridge, MA, Institute for Healthcare Improvement, 2008. Available at http://www.ihi.org.

3. Delirium Prevention: National Clearinghouse Guideline: http://www.guidelines.gov/content.aspx?id=24121

Geriatric Review Syllabus: http://www.geriatricsreviewsyllabus.org/. Chapter on Delirium.

4. a. Fall Prevention: http://www.patientsafety.gov/CogAids/FallPrevention/index.html#page=page-1

b. Exercise for acutely hospitalised older medical patients.Cochrane Database Syst Rev. 2007 Jan 24;(1):CD005955.

5. Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. AHRQ Publication No. 11-0053-EF, April 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/ltc/pressureulcertoolkit/

6. Diabetes in Different Settings: National Clearinghouse Guideline: http://www.guidelines.gov/content.aspx?id=25334

7. ASHP guidelines on stress ulcer prophylaxis (will be updated in 2011): http://www.ajhp.org/content/56/4/347.full.pdf

8. Never Events: AHRQ Primer: http://psnet.ahrq.gov/primer.aspx?primerID=3

VI. What's the evidence?