On Patient Safety: How Can Orthopaedic Surgeons Improve Patient Safety at Nursing Homes?
J. Rickert, President, The Society for Patient Centered Orthopedics, Bloomington, IN, USA
J. Rickert MD, IU Health Southern Indiana Physicians, 583 S Clarizz Blvd., Bloomington, IN, 47401 USA, Email: gro.htlaehui@1trekcirj
Received 2019 Jul 11; Accepted 2019 Aug 3.
Copyright © 2019 by the Association of Bone and Joint Surgeons
Following elective arthroplasty surgery, orthopaedic surgeons commonly discharge patients either to an independently run inpatient rehabilitation hospital or to a skilled nursing facility (SNF). Both types of facilities have checkered reputations regarding patient safety [ 11 , 12 ].
Some years ago, I treated an elderly patient who had sustained a wrist, hip, and rib fracture. While I was told that the injuries resulted from a fall, I had a nagging worry that I was never given a complete explanation of the incident. I treated her orthopaedic injuries and moved on after voicing my concerns to nursing home administrators. However, after learning a good deal more about nursing home safety, I now wish I had been a much more zealous advocate for that patient, and I also recognize the need to be vigilant of my nursing home patients’ safety.
A 2016 Office of Inspector General (OIG) report, (one of a series of reports that the OIG is doing on adverse events in healthcare settings) found that 29% of Medicare enrollees experienced adverse or temporary harm events while staying at rehabilitation hospitals—46% of these events were preventable and typically caused by substandard treatments (such as dehydration from inadequate fluid intake resulting in kidney failure or administering medication despite documented patient allergy), inadequate patient monitoring, and the failure to provide needed treatment [ 11 ]. They also reported that nearly a quarter of the patients who had a harm event required admission to an acute-care hospital [ 11 ]. The OIG report revealed a number of other serious safety concerns at SNFs [ 12 ]. The statistics are staggering:
33% of post-acute care patients in SNFs had an adverse event or temporary harm event at the facility and 59% of these events were preventable;
22% of SNF residents had serious adverse events ranging from pressure ulcers to falls to medication errors;
79% of affected patients required hospital care or their SNF stay was prolonged;
14% required interventions to sustain their life, while 6% of these incidents contributed to or resulted in patient death; and
looking solely at preventable events, auditors concluded that substandard treatment was responsible for 56% of events, while 37% were caused by inadequate patient monitoring, and 25% by a lack of necessary medical treatment.
These statistics are unacceptable and yet research into nursing home safety continues to lag behind efforts in other practice settings [ 2 , 4 ]. I worry that little is being done to improve safety in these institutions. New OIG data published just this spring did not find that nursing home safety had improved in the past few years [ 13 ] despite their previous reports detailing deficiencies. Therefore, our action is needed now.
As orthopaedic surgeons, we have a substantial role in solving this problem, and there is much we can do. We should be aware that Centers for Medicare & Medicaid Services (CMS) directs nursing home patients to follow-up with their treating physician if there are patient care—including safety—concerns [ 6 ]. In fact, most states require physicians to report suspected elder abuse, including neglect (defined as “failure by a caregiver or other responsible person to protect an elder from harm”) in these facilities [ 7 ]. The onus is on us to recognize the signs of neglect or poor care. Whenever our nursing home patients present with injuries, we should ask them directly what happened in order to ascertain if a safety lapse may have occurred. For example, in patients without joint contractures or similar pathology, sacral pressure ulcers or heel ulcers should never occur. If we see such ulcers, and there are no extenuating circumstances, we should report to proper authorities. Both CMS [ 6 ] and the American Academy of Orthopaedic Surgeons maintain lists of proper reporting agencies that we may easily access for this purpose [ 3 ].
Additionally, many situations occur where injury may be prevented. Risk factors for preventable falls include obstructed floors and inadequate lighting [ 9 ]. Knowing that many nursing home patients suffer recurrent falls [ 10 ], we should attempt to intervene to fix the situation when a patient reports falling due to poor lighting or obstructed walkways. I suggest, as a first step in dealing with environmental hazards, a phone call to the nursing home administrator. In my experience, this type of call is a rarity, and the nursing home will take a treating physician’s concerns seriously and investigate the incident in-house. At the very least, nursing home administration will know a doctor is actively watching for safety occurrences. If no action is forthcoming, follow-up with proper regulatory authorities should be strongly considered. Furthermore, we or a member of our staff, should be proactive in determining whether nursing homes caring for our patients have instituted safety processes as recommended by the Agency for Healthcare and Research Quality [ 1 ]. We can also suggest systems-based fall reduction strategies such as Timed Toileting that have shown to reduce fall risks in the hospital setting [ 5 ].
Nursing homes can be a dangerous place for our patients, and we, along with all treating physicians, have a duty to intervene on their behalf. The problem of nursing home safety is seemingly intractable and recent research suggests that we can and must be more actively involved in nursing home safety issues [ 8 ]. Indeed, determined physician effort will be required to help move the needle and improve the safety of our patients.
A note from the Editor-in-Chief: We are pleased to present our next installment of “On Patient Safety.” Dr. Rickert is on the clinical faculty at Indiana University School of Medicine and serves as President of The Society for Patient Centered Orthopedics. The goal of this quarterly column is to explore the relationships among patient safety, value, and clinical efficacy by engaging with diverse perspectives, including those of orthopaedic surgeons, patients, consumer and patient advocates, and medical insurers. We welcome reader feedback on all of our columns and articles; please send your comments to gro.pohtronilc@cie .
The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.
The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.
1. Agency for Healthcare and Research Quality. Improving patient safety in nursing homes: a resource list for users of the AHRQ nursing home survey on patient safety culture. Available at: //www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/nursing-home/resources/nhimpptsaf.pdf . Accessed July 15, 2019.
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