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Learning Objective 1: Define the term 'aspiration' and recognize three patient diagnosis that may contribute to aspiration risk in the hospital setting.
Learning Objective 2: Describe three specific guidelines to be implemented by the healthcare team for safe care delivery of a patient determined to be at risk for aspiration.
It is a source of serious illness and death among hospitalized patients and elderly residents of long term care facilities.
In 2008 there were 2,349 aspiration events in 101,210 admissions at select acute care facilities of a prominent, metropolitan health system in the U.S.
That number represents 2.3% of those admissions. 18% mortality was recognized during the same hospitalization. 432 lives lost as a result of aspiration, the vast majority preventable.
In June 2004-January 2009 the Pennsylvania Patient Safety Authority determined that miscommunication between healthcare providers was a contributing factor in 5% of aspiration patients studied.
Observations at a major health system revealed that healthcare personnel and visitors were not aware that a patient was on aspiration precautions. Also unrecognized were the specific measures that should be implemented for patient safety. The data revealed two areas of concern. One was the uncertainty as to where recommendations were located in the electronic record. Two, the time involved in retrieving the information.
The aspiration prevention team designed a snapshot of the electronic record recommendations. Presented as colorful, eye catching head of bed signage, this tool allowed information to be seen in real time by staff, visitors, the patient and other disciplines.
After implementation, a post interview was conducted with patients, visitors and RN’s. Impressive results offered a 60% increase in aspiration risk awareness by patients and visitors. Equally inspiring was a 90% increase in patient and visitor’s working knowledge of specific aspiration guidelines. 52% of RN's surveyed reported that the signage directly influenced their care delivery.