IHA Daily Briefing: April 22

In Today’s Issue
MAPS PSO Releases White Paper on Top Patient Safety Issues in 2024
Agencies Issue Ransomware Alert, Guidance for Securely Deploying AI
Class I Recall: Boston Scientific Obsidio Conformable Embolic
ACOG Advises More Screening During Pregnancy as Newborn Syphilis Cases 
FDA Adds New Warning to CAR-T Therapies
COVID-19 Information 
Briefly Noted
Leading the News

MAPS PSO Releases White Paper on Top Patient Safety Issues in 2024
Nearly 20% of the 35 million U.S. patients discharged annually experience an adverse event within three weeks of discharge. A recently released white paper from the Midwest Alliance for Patient Safety (MAPS) Patient Safety Organization (PSO) addresses the critical issue of care transitions along with other top issues for 2024.

The research-driven document is built on statistics, such as Illinois youth aged 5-19 accounted for over 81,000 emergency department visits for suicidal ideation from 2016 to June 2020, and takes a multifaceted view of how to enhance patient safety. For example, hospitals with governing boards that prioritize patient safety outperform their peers in providing safer, higher-quality care.

The white paper, distributed to MAPS PSO members for the sixth year, provides extensive resources on persistent and emerging patient safety concerns. This year’s top 10 issues are:

  • Preventing medication errors;

  • Mitigating community birth risk by improving acute care transfers;

  • Addressing the pediatric mental health crisis;

  • Preventing diagnostic errors in ambulatory settings;

  • Preventing and minimizing the effects of healthcare-related cybersecurity incidents;

  • Increasing the use and safety of virtual nursing;

  • Preventing falls across the care continuum;

  • Mitigating the risks of AI on patient safety;

  • Improving care transitions across healthcare settings; and

  • Engaging governing boards in patient safety oversight.

MAPS is a federally certified PSO and a non-profit subsidiary of IHA. The white paper and all MAPS services are part of membership. See our summary flyer. MAPS is hosting a complimentary webinar on May 13 on three of the top 10 issues. The webinar is open to all IHA members and other healthcare organizations. Register today.

Contact us with questions.

Agencies Issue Ransomware Alert, Guidance for Securely Deploying AI
The U.S. joined European agencies late last week to issue a cybersecurity advisory recommending organizations implement certain best practices to protect against the latest versions of Akira ransomware, which has attacked critical infrastructure and other organizations in North America, Europe and Australia over the past year. It is recommended healthcare organization cybersecurity teams review the alert, consider disabling remote access tools and initiate alerts for activation of the described tools, especially the AdFind tool related to Active Directory discovery. 

The U.S. and international agencies also released best practices for deploying artificial intelligence (AI) systems securely. The AI guidance is a resource most applicable to organizations deploying and operating externally developed AI systems on premises or in private cloud environments. The best practices are not applicable to organizations leveraging AI systems deployed by others. 

Class I Recall: Boston Scientific Obsidio Conformable Embolic
Boston Scientific Corporation is recalling Obsidio Embolic by issuing a correction, according to a recent Food and Drug Administration notice. An investigation determined that delivery of Obsidio Embolic using the aliquot technique, a commonly used delivery method in embolization procedures for lower gastrointestinal (GI) bleeding embolization, poses a high risk of bowel ischemia. Boston Scientific does not recommend that the aliquot technique be used to deliver Obsidio Embolic for lower GI bleed embolization procedures because use of this product with the aliquot technique may prevent blood and oxygen flow to organs, which may lead to prolonged hospitalization, the need for additional surgery, or death. There have been 11 incidents reported, seven injuries, and two deaths related to this issue.

ACOG Advises More Screening During Pregnancy as Newborn Syphilis Cases 
In the context of rapidly increasing rates of congenital syphilis across the country, the American College of Obstetricians and Gynecologists (ACOG) has issued updated guidance for obstetrician-gynecologists recommending that they now screen pregnant individuals for syphilis three times during pregnancy.

According to a new ACOG Practice Advisory, obstetrician-gynecologists and other obstetric care professionals should screen all pregnant individuals serologically for syphilis at the first prenatal care visit, followed by universal rescreening during the third trimester and again at birth. This is a change from previous guidance, which recommended risk-based testing in the third trimester only for individuals living in communities with high rates of syphilis and for those who have been at risk of syphilis acquisition during pregnancy.

According to the Centers for Disease Control and Prevention (CDC), reported syphilis cases increased 80% in the U.S. between 2018 and 2022, (from 115,000 to more than 207,000), compounding a decades-long upward trend. New CDC data reveal that more than 3,700 babies were born with syphilis in 2022, which was more than 10 times the number in 2012. The increase in newborn syphilis follows rising syphilis cases among women of reproductive age combined with social and economic factors that create barriers to high-quality prenatal care and ongoing declines in the prevention infrastructure and resources.

FDA Adds New Warning to CAR-T Therapies
The Food and Drug Administration (FDA) announced last week it has decided to issue a boxed warning of serious risk for six approved Chimeric Antigen Receptor T cell (CAR-T) immunotherapies. The FDA said it evaluated data from adverse events and clinical trials and found patients may develop mature T cell malignancies, including tumors, as soon as weeks following CAR-T cell infusion. The FDA began investigating CAR-T therapies in November, and in January reported it was reviewing reports of patients contracting blood cancer. In January the FDA began calling for warning labels on all commercial CAR-T therapy products, sending letters to six pharmaceutical makers of the products outlining the safety-related labeling changes. 

COVID-19 Information
The Illinois Dept. of Public Health (IDPH) has launched a weekly Infectious Respiratory Disease Surveillance Dashboard that will be updated weekly on Friday. This report provides the public with the latest data on hospital visits, seasonal trends, lab test positivity and demographic data. 

Click here to visit the IDPH COVID-19 resources webpage. IDPH will continue to report the weekly number of people with COVID-19 admitted to hospitals from emergency departments, deaths and vaccinations, with COVID-19, influenza and respiratory syncytial virus information also reported through the dashboard of the Illinois Wastewater Surveillance System.

Briefly Noted
Two large multi-state studies uncovered a highly effective way to improve antibiotic selection for patients hospitalized with pneumonia or urinary tract infections (UTI), enabling better antibiotic stewardship in hospitals, according to recent research studies published in the Journal of the American Medical Association (JAMA). A media statement said that in half of the hospitals, clinicians were given algorithm-driven computerized alerts with information about the best antibiotic match for an individual patient at the moment antibiotics were being prescribed. This resulted in a better match for 28% of pneumonia patients and 17% of patients with UTI when compared to hospitals where physicians were not provided with alerts according to the trials.

Leading the News

Illinois is now home to a federally-recognized tribal nation
WGLT reported (4/19) that, “Illinois is, once again, home to a federally recognized tribal nation. 175 years ago, Potawatomi Chief Shab-eh-nay left his home in DeKalb County to visit family in Kansas. He returned home to find the U.S. government had illegally sold 1,280 acres of his northern Illinois land. The tribe says the U.S. Department of the Interior has now placed portions of that land into a trust for the Prairie Band Potawatomi Nation.”

Large health systems may need to rethink growth: Moody's
Becker’s Hospital Review reported (4/19) that, “Scrutiny on nonprofit health system mergers and acquisitions is intensifying and Moody’s warned it could become a tougher exit strategy for distressed hospitals, and affect growth of large systems, according to an April 18 2024 Healthcare Quarterly report.”

How much 8 health systems are paying for EHRs
Becker’s Hospital Review reported (4/19) that, “Becker’s outlines how much eight hospitals and health systems are expected to pay or have paid for the cost of purchasing, installing and upgrading a new or current electronic health record system.