Managing the Risks of Direct Oral Anticoagulants

The Joint Commission: Sentinel Event Alert

While DOACs offer ease of use to patients, stopping bleeding events in patients on DOACs is more complicated, requiring different strategies than those for patients on warfarin (Coumadin®) and heparin. Unlike the more widely available reversal agents for warfarin and heparin, reversal agents for DOACs are lesser known and may not be available in every care setting. Also, some DOACs have no FDA-approved reversal agent at this time. Therefore, bleeding complications can be severe if these patients are not assessed according to guidelines on the management of DOACs. Intracranial hemorrhage is the most serious emergent bleeding risk.

In response to an increase in adverse events related to these widely prescribed medications, this alert provides guidance on the safe use and management of DOACs to all medical practitioners and health care organization leaders, particularly chief medical officers, pharmacists, emergency department clinicians, and quality and safety officers.

VTE & VTE/COVID-19 Resources

North American Thrombosis Forum (NATF)

The North American Thrombosis Forum is dedicated to saving lives through education and prevention. A major part of this is helping healthcare professionals stay up to date on the latest research in the rapidly changing field of thrombosis. Through educational events and informative articles geared specifically towards clinicians, NATF provides clinicians with the information they need to best treat their patients. Topics covered include thrombosis, stroke prevention, atrial fibrillation, diabetes, cardiovascular-related illnesses, and more. Check back regularly for important updates on everything from the development of new medications to the release of novel research.

Partnering with Patients and Families During the COVID-19 Pandemic

American Institutes for Research (AIR) and IPRO Hospital Quality Improvement Contractor (HQIC)

The American Institutes for Research (AIR) and the IPRO HQIC hosted the March 2021 Patient and Family Engagement (PFE) webinar, titled Partnering with Patients and Families During the COVID-19 Pandemic.

During this 45-minute interactive event, the AIR team provided an overview of five PFE best practices and described how engaging patient and families can help both patients and clinical staff address the emergency. The event featured real-world examples of how hospitals are partnering with patients and families during the COVID-19 pandemic.

Webinar Materials:

March 30: Partnering with Patients and Families During the COVID-19 Pandemic – IPRO QIN-QIO

Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guidelines )

European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance

(Updated 05/21/24) In 2019, a full set of Clinical Practice Guidelines were developed, by the European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guidelines, The International Guideline and can be purchased for a fee. In addition, a Quick Reference Guide (QRG), which provides a summary of the recommended guidelines can be downloaded for no charge.

Pressure Injury- Learning and Action Network (LAN) – May 24th, 2021

IPRO & Telligen Hospital Quality Improvement Contractors (HQICs)

The LAN included:

  • A presentation of aggregated results from the IPRO & Telligen HQIC Hospital Baseline Assessment specific to pressure injury
  • An interactive discussion with quality and performance improvement subject matter experts on pressure injury identification, prevention, and management.

Attendees had the opportunity to discuss:

  • Pressure injury challenges in small rural and critical access hospitals (in general and with COVID-19)
  • Approaches to overcome these challenges, including patient and family engagement and health equity strategies.

Hospitals left “in action” with a variety of strategies and 17 salient resources for the front-line to further efforts in All-Cause Harm (Pressure Injury) prevention and management.

Building a Team to Reduce CLABSI and CAUTI

Prepared by the HAP Quality Initiatives Department
Healthcare Associated Infection Prevention Managers
September 2019 for IPRO HQIC

The purpose of this tool kit is to teach you the key elements that are essential in building a successful team to reduce central line associated bloodstream infections (CLABSI) and catheter associated urinary tract infections (CAUTI) on your unit. The tool kit will provide you with information on how to develop a team, assess your work practices, develop an action plan, implement changes, and evaluate your success.

Hospital Roadmap for Person and Family Engagement (PFE): Achieving the Five PFE Best Practices to Improve Patient Safety and Health Equity

This material was prepared by American Institutes for Research (AIR). It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

A growing body of work—captured in peer-reviewed
literature and the experiences of hospitals and health
systems across the United States—highlights the benefits
of PFE, suggesting that successful implementation of PFE
practices can contribute to better outcomes. This PFE Roadmap provides practical guidance to help hospitals implement five PFE best
practices.

How Person and Family Engagement Can Help Hospitals Achieve Equity in Health Care Quality and Safety

This material was prepared by American Institutes for Research (AIR). It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

Person and family engagement (PFE) is central to the mission of PfP and is recognized as a promising mechanism to aid in achieving equity in quality and safety. The PfP 3.0 Strategic Vision Roadmap for Person and Family Engagement lays out six overarching strategies to guide
hospitals in meaningfully engaging patients and families and describes how to apply these strategies to the five PFE metrics,

Preadmissions Planning Checklist (English)


This material was prepared by American Institutes for Research (AIR). It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

“HOW TO PREPARE FOR A SAFE HOSPITAL STAY”

This resource is a planning checklist for patients to use prior to admission to the hospital, while admitted, and before they leave the hospital

8 Lessons from a Covid-19 Surge Hot Spot

Institute of Healthcare Improvement (IHI)

This resource discusses surge preparedness and 8 key takeaways or lessons learned by a major healthcare system who was at the epicenter of the US Covid crisis. Even the most sophisticated trend analysis can only estimate how health care systems need to prepare for taking care of higher numbers of patients with COVID-19. Many across the globe are drawing on the best information available to date to guide preparations for an expected surge of patients in need of hospital-level care.

Guidance for Planning Vaccination Clinics Held at Satellite, Temporary, or Off-Site Locations

Centers for Disease Control and Prevention

The purpose of this resource is to provide guidance to assist with jurisdictional planning and implementation of satellite, temporary, or off-site vaccination clinics by public and private vaccination organizations. Other users may include public health preparedness professionals. The guidance primarily focuses on clinical considerations for planning a vaccination clinic, including vaccine storage, handling, administration, and documentation. 

National Healthcare Safety Network (NHSN): How to Use the Patient Impact and Hospital Capacity Module

National Center for Emerging and Zoonotic Infectious Diseases. Division of Healthcare Quality Promotion and the CDC

As part of CDC’s ongoing COVID-19 response, a new Patient Impact Module has been created in NHSN to help facilities track and monitor the number of cases reported in their facilities daily. The new module collects summary data which can be viewed in a table form without generating new analysis datasets. In addition, the summary data can be exported to excel/CSV for additional analysis outside the application. The data collected using this module will be informative and provide situational awareness at both state and national levels.