CT Center for Patient Safety
CT Center for Patient Safety Newsletter

September  2015
In This Issue
September Health Hint 

September is Sepsis Awareness Month: 
Fewer than Half of Americans Have Heard of this Devastating Illness

According to the CDC, sepsis affects more than a million Americans each year and kills up to half of them, yet fewer than half of all Americans have ever even heard of the term 'sepsis' according to a survey published by the Sepsis Alliance.

The CDC recognizes September as Sepsis Awareness Month with events occurring at various locations nationally.  

The CDC defines sepsis as "a serious illness that can develop when the body's normal reaction to fight an infection goes awry and can quickly become life-threatening. The body's immune system releases chemicals into the blood to fight infections but sometimes those chemicals can cause inflammation, which can lead to blood clots and organ damage. In severe cases, sepsis can weaken the heart, shut down other organs, and may lead to death.  Early recognition of patients with possible sepsis is critical for preventing severe outcomes."

Those at higher risk for sepsis include people with weakened immune systems, infants and children, elderly people, people with chronic illnesses and those who suffer severe burns or physical trauma. Patients who develop and survive sepsis have an increased risk of complications and death later, and they face higher healthcare costs and longer treatment.  

For more information visit the CDC website at: http://www.cdc.gov/sepsis/index.html
The Peggy Lillis Foundation:
Raising National Awareness of C. diff

C. difficile is one of the  722,000 hospital acquired infections (HAI) in the U.S that can be a killer.  It can also lead to sepsis.  In fact, in only 6 days it took the life of Peggy Lillis, an otherwise healthy 56 year old teacher who contracted C. diff following dental work for an abscess and being prescribed the antibiotic Clindamycin.  

In her memory, her sons, Christian and Liam, founded the Peggy Lillis Foundation whose mission is to build a nationwide clostridium difficile awareness movement by educating the public, empowering advocates, and shaping policy. 

Recently, I participated in the Peggy Lillis Foundation's first-ever Summit for C. diff Advocates in New York City. Over two days, this amazing group of advocates and individuals whose lives had been impacted by C. diff, and who came from across the country, heard from presenters who shared information about the disease, various treatments and also strategies for grassroots advocacy that will be the foundation for them to begin or continue local awareness movements in their hometowns. 

The Centers for Disease Control reports that Clostridium difficile was estimated to cause almost half a million infections in the United States in 2011, and 29,000 died within 30 days of the initial diagnosis.  Peggy was not an exceptional case! 
We also know that this is a preventable infection.  According to the CDC, poor prescribing practices put patients at risk for C. difficile infections. More than half of all hospitalized patients will get an antibiotic at some point during their hospital stay, but studies have shown that 30-50% of antibiotics prescribed in hospitals are unnecessary or incorrect.  We also now know that alcohol does not kill Clostridium difficile spores, and that use of soap and water works better than alcohol-based hand rubs.
So the next time that you are receiving any medical care, think of Peggy and ask your caregiver, "Did you wash your hands?" If your provider wants you to take an antibiotic, Consumer Health Choices suggests that you ask them if you really need an antibiotic.  Antibiotics fight bacterial infections, like strep throat, whooping cough and symptomatic bladder infections. But they don't fight viruses-like common colds, flu, or most sore throats and sinus infections. 
How a North Carolina insurer posted what it pays providers on the Web

During our last legislative session, Connecticut passed a some patient friendly legislation that assures more transparency of health information than we have seen in the past.  It is stipulated that our health insurance exchange will develop a consumer website that will contain information comparing the quality, price and cost of health care services.  Access Health anticipates the website to launch in late 2016.  We do not yet know what this will look like, but it is the beginning of access to more information that consumers need in order to make wise healthcare choices. 

In North Carolina, where consumers did not have the information needed to find out the cost of medical and surgical procedures, Blue Cross and Blue Shield of North Carolina did something that had unexpected results.  Following the state's passage of their transparency law, BCBS launched a website that allows the public to see how much they pay certain providers for certain services. The amounts are based on their claims data and includes all costs-the discounted payment, physician fees, facility fees, drug and medical supply costs, as well as consumers' cost-sharing.

Surprisingly, one group who got behind this transparency was the physicians.  As the payment models are changing, and as physicians are being reimbursed more and more through value of care based contracts, as opposed to fee for service, this information helps them see to who and where they can make higher quality, lower cost referrals.  Consumers who are paying more of their medical expenses out of pocket are also benefiting in much the same way.  

It will be interesting to see what happens in Connecticut with the launch of our states website - or might the insurance companies here do the same thing as in North Carolina?

To read more about this, follow this link to an article in Modern Healthcare, How a North Carolina insurer posted what it pays providers on the Web

Please Don't Forget that we have a donor who will match your donation
dollar for dollar to support our patient safety educational outreach program. 
Will your employer match your donation?

For more information contact: [email protected]
Dear Members,

Dear Members,

Rather recently, I experienced our health care system from the other side of a stethoscope.  Having awoken to chest and upper arm pain that was unrelenting, common sense told me to call 911.  The last time that I had reason to call an ambulance was six years ago.  In-between then and now, as a patient advocate I am acutely aware of many of the problems in our healthcare system.  I have also witnessed many positive changes in healthcare from my seat at various "tables," my attendance and participation at conferences, and my leadership role as a teacher, consultant and CTCPS Executive Director. This was a real-time test of all that I see and hear about.

I was pleased to see that as a result of electronic health records (EHR's), and health IT, my treatment started in the ambulance with full knowledge of all of my medical information.  In fact, in the emergency room they asked me about things that were in my record that I had long ago forgotten or just didn't have the presence of mind to recall at the moment, but they knew it.  After the first few hours, my 36-hour hospital stay was unremarkable.  At the same time, I experienced first-hand why a patient needs an advocate with them when they go to the hospital.  As well trained as I am, at least initially, I was not in the best state of mind to handle my own affairs. 

As smooth as my entrance went, so did my discharge.  The discharge instructions were not the handwritten, almost unreadable form that I had seen years ago but rather a completely legible summary and clear instructions regarding my condition, medication changes and needed follow-up with my personal doctors.  More impressive were the three follow-up calls that I received within days of my discharge.  The day after discharge an APRN from my primary care provider's office, who was hired for the sole purpose of following up with discharges and making sure that care was being properly coordinated, called to do just that.  Two days later, a nurse from the attending specialist's office called for the same purpose, specific to the medical issue that I had experienced.  Several days later, I was called by a nurse from my insurance carrier.  She asked if I had scheduled follow-up services, if I had any questions regarding medications or anything to do with my hospitalization, and if there was anything else that she could help me with.  I am not sure how many people have the same experience as I did, and in fact, I know that many people don't.  But I must say that if this improved coordination of care is the result of the penalties that CMS is imposing on hospitals for re-admissions, then they are moving toward their goals!

While things are improving in the hospital, I did feel that there is still a distance to go before care is truly patient-centered.  When a nurse came to give me my medications, I was told that the hospitalist had added a new medication to my treatment plan.  I was not part of any conversation about it, and I did not feel that I necessarily needed it.  I refused the medication, but the doctor still never spoke to me about it. When they came to give it to me the next day, I refused it again.  Where was the patient in the care team?  The nurses were wonderful and always asked me if I was comfortable or needed anything.  Shift changes, which I would have liked to see at the bedside so that as a member of my care team I could also be brought up to date, occurred elsewhere.  The big eye-opener will be when I get the bills.  I still have no idea how much of this was covered and how much wasn't....   as deductibles, co-pays or non-covered charges.  This should not be a mystery.  Let's hope that the answer doesn't land me back in the hospital in shock!

I heard various comments as well. I heard that "now the nurses are spending more time charting and less time with patients."  I heard from a doctor that he is concerned with other docs using "cut and paste" as a means to input into the EHR.  I heard that caregivers are too busy with administrative tasks and have too little face-to-face time with patients.  Yet, there are systems across the country where they have found ways to do things differently and are resolving many of these similar issues.  We need to explore how those who are successfully engaging with changing times are doing so.

I came away from this experience appreciating how much has changed over recent years.  From first-hand experience, much of the data I have heard was borne out as truth. There are certainly some rough spots; as we know, change is not easy.  But I saw marked improvements that are quite significant, in both transitions and communication - two areas that have been identified as having causal relationships to avoidable medical errors. That said, the patient's role on the care team still needs attention.  And I saw definite confirmation that the work that we are doing at CTCPS and that other patient advocates are doing to advance patient safety and healthcare transparency is effective, has brought about change, and is still very much needed if we want to continue reducing medical errors and patient harm.  We have important work in front of us, but if we look behind us, it is clear that we are moving along what might be a bumpy road, but we are moving forward and need to stay the course. 

Lisa Freeman 
Patients First
Cheryl Green, PhD, DNP, RN, LCSW, CNL

When I first became a nurse over 25 years ago, I had been trained at a small women's Catholic College in Chicopee, Massachusetts called College of Our Lady of the Elms. I learned the value and importance of human life and the necessity of recognition that every life deserves to be treated honorably and unmistakably unblemished. It was then, and is now, a gift from God to serve the patients that I provide nursing care to in a time of vulnerab
ility, confusion, and pain. The landscape of health care is changing. In 1997, President William Jefferson Clinton held an Advisory Commission on Consumer Protection and Quality in the Healthcare Industry.  
The Institute of Medicine's  (IOM) reports and summaries on the healthcare industry within the United States identified problems in healthcare delivery, quality of care Americans receive, the availability of services, and consumer protection (Finkelman & Kenner, 2007). In 1999, the IOM report, To Err is Human sounded the alarm to Americans that safety was an issue in our health care industry and patients came first. The IOM found that 98,000 people die each year as a result of safety problems in the healthcare system. The Agency for Healthcare Research and Quality (AHRQ) recommends five steps to maintaining your safety as a patient within the healthcare environment, they are:
  1. Ask questionsif you have doubts or concerns
  2. Keep and bring a list of all medications you take
  3. Get the results of any test or procedure
  4. Talk to your doctor about which hospital is best for your health needs
  5. Make sure you understand what will happen if you need surgery
It is imperative that healthcare providers teach patients to advocate for themselves and provide support to them as they navigate the healthcare system.  Patients, as a healthcare provider, I encourage you to bring a notebook and pen to the pharmacy, hospital, nursing home, walk-in clinic, emergency department, and any other healthcare facility that you can may interface with. Ask questions and seek clarification, know your medications you take (dosages, length of time prescribed and reason for taking the medication), allergies that you have or any questionable reactions you have had in the past to food items, environmental irritants, or medications. Create and keep your own medical records in a safe place in your home, ensuring accessibility to this data in the event you become ill, to family and close friends. Patients, remember, to maneuver safely within the healthcare environment, you must identify yourself as a member of the healthcare team; your personal team. Be empowered and remember, as a patient in the healthcare system, your health and well-being come first!

Dr. Green is an Assistant Professor of Nursing at Southern Connecticut State University and Adjunct faculty at the University of Bridgeport Nursing Department, teaching within the RN to BSN program. She works as an Off-Shift Nurse Leader at Yale-New Haven Hospital.
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