Transcript Document

THE BOARD’S ROLE IN
PATIENT SAFETY & QUALITY
by
James E. Orlikoff
President,
Orlikoff & Associates, Inc.
4800 S. Chicago Beach Drive
Suite 307N
Chicago Il 60615-2054
773-268-8009
c Copyright Orlikoff & Associates, Inc. 2005
Senior Consultant,
Center for Healthcare Governance
THE GREAT OBSTACLE TO PROGRESS
IS NOT IGNORANCE BUT THE
ILLUSION OF KNOWLEDGE
DANIEL BOORSTIN
A BRIEF HISTORY OF QUALITY
THE CODE OF HAMMURABI (CIRCA 2,000 B.C.)
“IF THE SURGEON HAS MADE A DEEP INCISION IN
THE BODY OF A FREE MAN AND HAS CAUSED THE
MAN’S DEATH OR HAS OPENED THE CARBUNCLE IN
THE EYE AND SO DESTROYS THE MAN’S EYE, THEY
SHALL CUT OFF HIS FOREHAND.”
THE CALIFORNIA MEDICAL
INSURANCE FEASIBILITY STUDY – 1977
THE HARVARD MEDICAL PRACTICE
STUDY – 1991
THE INSTITUTE OF MEDICINE
REPORT - 1999
THE INSTITUTE OF MEDICINE
REPORT - 1999
EXTRAPOLATING FROM THESE AND OTHER
STUDIES, THE IOM REPORT STATED THAT:
 ERRORS CAUSE BETWEEN 44,000
AND 98,000 DEATHS EVERY YEAR IN
AMERICAN HOSPITALS.
THIS MEANS THAT HOSPITAL ERRORS ARE
BETWEEN THE FOURTH AND SEVENTH MOST
COMMON CAUSE OF DEATH IN THE UNITED
STATES!!
Crossing the Quality Chasm:
IOM Guiding Principles
• Health Care Should Be:
–
–
–
–
–
–
Safe
No unintended injuries
Effective
Based on evidence
Timely
No harmful delays
Efficient
Not wasteful
Equitable
No variance in quality
Patient Centered
QUALITY
The Latest Large Study:
Patients Received 54.9% of
Scientifically Indicated Care
(Acute: 53.5%; Chronic 56.1%;
Preventive: 54.9%)
Conclusion: The “Defect Rate” in
the Technical Quality of Care is
Around 45% !!
McGlynn, et al “The Quality of Health Care Delivered
to Adults in the US” NEJM (June 26, 2003)
QUALITY
The Trends:
More Reporting/Release of
Comparative Quality data to
the Public
Pay for Performance
THE CHALLENGE OF QUALITY
AS A SYSTEMS ISSUE
LESSONS LEARNED:
 AS INDIVIDUAL EXPERTISE AND CONFIDENCE
GROWS, RESPECT FOR AND COMPLIANCE WITH
SYSTEM RULES DECLINES.
 BREAKING SYSTEM AND SAFETY RULES IS
USUALLY POSITIVELY REWARDED,
REINFORCING THE TENDENCY OF INDIVIDUALS
TO DO SO.
THE CHALLENGE OF QUALITY
AS A SYSTEMS ISSUE (CONT.)
 AT THE PRECISE TIME THAT SYSTEM RULES
SHOULD BE FOLLOWED, THEY ARE MOST
LIKELY TO BE BROKEN: UNDER EXTREME TIME
PRESSURE, CRITICAL OR EMERGENCY
SITUATIONS.
 SYSTEMS OFTEN FAIL BECAUSE INDIVIDUALS
FOCUS ON THE SITUATION AND NOT THE
PROCESS.
 INCOMPATIBLE OR CONFLICTING SUBSYSTEMS WITH DIFFERENT GOALS AND RULES
STRESS OVERALL SYSTEM INTEGRITY AND
CAUSE FAILURE.
See references: The Logic of Failure
A SYSTEMS APPROACH
• Key attributes of other High Reliability
Organizations (HROs):
– Example of Commercial Aviation
•
•
•
•
•
•
•
Reporting cultures
Non-punitive event analysis
Examine “near misses” for systems improvement
Engaged in and dedicated to learning
Institute standardized, proven processes
Continual improvement mentality
Willing to invest financially in improving quality / safety
HOW LEADERS DRIVE CHANGE:
THE POWER OF QUESTIONS
ARE WE READY TO MOVE FROM
“WHAT” TO “HOW”?
THE POWER OF QUESTIONS:
REGARDING QUALITY, PATIENT
SAFETY, REDUCING NEEDLESS
DEATHS:
DO WE HAVE A “HOW GOOD OR
HOW MUCH BY WHEN” TARGET?
SOME IS NOT A NUMBER.
SOON IS NOT A TIME.
THE 100,000 LIVES CAMPAIGN
Don Berwick, M.D.
Institute for Healthcare Improvement
December 14, 2004
SAVE 100,000 LIVES
BY JUNE 14, 2006
BY IMPLEMENTING SIX
INTERVENTIONS
100k LIVES CAMPAIGN:
1. RAPID RESPONSE TEAMS
2. IMPROVE AMI CARE
3. PREVENT ADVERSE DRUG EVENTS
4. PREVENT CENTRAL LINE BLOODSTREAM
INFECTIONS
5. PREVENT SURGICAL SITE INFECTIONS
6. PREVENT VENTILATOR-ASSOCIATED
PNEUMONIA
HOW MANY DEATHS COULD BE
PREVENTED?
230 LIVES PER YEAR IN A 500-BED
HOSPITAL!
 RRTs – 120 LIVES
 AMI CARE – 50 LIVES
 ADEs – 10 LIVES
 CR-BSIs – 10 LIVES
 SSIs – 30 LIVES
 VAPs – 10 LIVES
DON BERWICK, MD, IHI CONFERENCE, DEC. 14, 2004.
WHAT BOARDS CAN DO:
1. DEBATE, UNDERSTAND, APPROVE AND
ROUTINELY OVERSEE A FOCUSED SET OF
SYSTEM LEVEL QUALITY INDICATORS
2. ESTABLISH SPECIFIC “HOW GOOD BY
WHEN” TARGETS FOR IMPROVEMENT OF
THESE SYSTEM-LEVEL INDICATORS
3. LEAD TO ACHIEVE THE TARGETS:
* SPEND BOARD & COMMITTEE TIME
* ASSIGN/ACCEPT ACCOUNTABILITY
* CHANGE SYSTEMS
ALIGN INDICATORS AND TARGETS
WITH LEADERSHIP:
1. WHAT IS THE “HOW GOOD BY WHEN”
SYSTEM LEVEL QUALITY INDICATOR?
2. WHAT ARE 2 OR 3 KEY DRIVERS OF THAT
SYSTEM-LEVEL QUALITY TARGET?
3. WHAT SET OF PROJECTS, WITH DEFINED
SCOPE AND TIMELINES, WILL MOVE THE
KEY DRIVERS TO ACHIEVE THE TARGETS?
EXAMPLE: ALIGN INDICATORS AND
TARGETS WITH LEADERSHIP:
1. SYSTEM LEVEL QUALITY INDICATOR:
REDUCE HOSPITAL STANDARDIZED
MORTALITY RATE FROM 100 TO 80 BY
JUNE 2006
2. KEY DRIVERS: PREVENTABLE ARRESTS;
NEEDLESS INFECTIONS
3. PROJECTS: RRT’s IN ALL HOSPITALS -11/05;
SSI REDUCTION PROTOCALS ALL
HOSPITALS – 12/05.
Stages of Facing Reality
• Stage 1 “The data are wrong”
• Stage 2 “The data are right but, it is
not a problem”
• Stage 3 “The data are right; it is a
problem but, not my problem”
• Stage 4 “I accept the burden of
improvement”
KEY BOARD STRATEGIES FOR
QUALITY
DEVELOP SPECIFIC “HOW GOOD BY WHEN”
PATIENT SAFETY AND QUALITY TARGETS FOR YOUR
ORGANIZATION – IMPLEMENT THE IHI 100K LIVES
INTERVENTIONS
EMPHASIZE QUALITY/PATIENT SAFETY BY MAKING
IT THE FIRST MAJOR AGENDA ITEM AT EACH BOARD
MEETING.
BUNDLES: MEASURE THE COMPOSITE NOT THE
COMPONENTS.
 TELL “STORIES” AT EACH BOARD MEETING –
MAKE THE NEED FOR IMPROVEMENT REAL.
 THE BOARD MUST LEAD!
KEY LEADERSHIP STRATEGIES
FOR QUALITY
 MAKE QUALITY IMPROVEMENT A CORE
ORGANIZATIONAL STRATEGY, CLOSELY LINK
QUALITY IMPROVEMENT ACTIVITIES TO STATEGIC
PRIORITIES.
 ALLOCATE SUFFICIENT FINANCIAL RESOURCES
TO QUALITY IMPROVEMENT (INCLUDING
INFORMATION SYSTEMS); FOR EXAMPLE: 1-3% OF
GROSS EXPENSE BUDGET. REVIEW ANNUALLY AS
PART OF BOARD OVERSIGHT OF BUDGET.
 PROVIDE A CLEAR VISION OF THE QUALITY
IMPROVEMENT PROCESS AND ITS GOALS.
 REGULARLY MONITOR AND OVERSEE THE
SYSTEM-WIDE QUALITY IMPROVEMENT PROCESS
 FOCUS ON SYSTEMS IMPROVEMENT AND
INTEGRATION, NOT INDIVIDUALS.
IT IS NOT THE STRONGEST WHO
SURVIVE, OR THE FASTEST.
IT IS THE ONES WHO CAN
CHANGE THE QUICKEST.
Charles Darwin
1. RAPID RESPONSE TEAMS
GOAL: PREVENT DEATHS IN
PATIENTS WHO ARE
PROGRESSIVELY FAILING
OUTSIDE THE ICU
CARDIAC ARREST OR SHOCK OCCURS IN 0.6% OF
MEDICAL PATIENTS AND 0.5% OF SURGICAL PATIENTS
 ONLY 17% OF PATIENTS WHO EXPERIENCE A
CARDIAC ARREST SURVIVE TO DISCHARGE. SURVIVAL
RATES ARE HIGHER WHEN ARRESTS OCCUR IN
MONITORED UNITS.
 MOST PATIENTS WHO HAVE A CARDIAC ARREST IN
THE HOSPITAL HAVE IDENTIFIABLE SIGNS OF
DETERIORATION PRIOR TO THEIR ARREST
1. RAPID RESPONSE TEAMS (RRTs)
RRT MAY BE SUMMONED AT ANY TIME BY ANYONE IN
THE HOSPITAL TO ASSIST IN THE CARE OF A PATIENT
WHO APPEARS ACUTELY ILL, BEFORE PATIENT HAS A
CARDIAC ARREST OR OTHER ADVERSE EVENT
 SEVERAL RRT MODELS, RANGING FROM AN ICU
MD/RN TEAM TO AN ICU RN/RESPIRATORY THERAPIST.
MD MAY BE A SENIOR RESIDENT, FELLOW, OR STAFF
 CRITERIA TO CALL THE RRT CAN INCLUDE:
ACUTE CHANGE IN VITAL SIGNS; ACUTE DROP
IN 02 SATURATION; DECREASED URINE
OUTPUT; ALTERED MENTAL FUNCTION;
ANY STAFF MEMBER CONCERN ABOUT THE
PATIENT
1. RAPID RESPONSE TEAMS (RRTs)
SUCCESS STORIES
REDUCTION IN CARDIAC ARRESTS AND
DEATHS, REDUCTION IN ICU AND HOSPITAL
BED-DAYS AMONG SURVIVORS OF CARDIAC
ARREST.
 IN SURGICAL PATIENTS, REDUCTION IN
RESPIRATORY FAILURE, STROKE, SEVERE
SEPSIS, AND ACUTE RENEAL FAILURE.
REDUCTION IN NUMBER OF ICU ADMISSIONS,
LOS, AND POSTOPERATIVE MORTALITY.
1. RAPID RESPONSE TEAMS (RRTs)
SUCCESS STORIES
 AUSTIN HOSPITAL IN HEIDELBERG,
VICTORIA, AUSTRALIA, SAW A 65% DROP IN
CARDIAC ARRESTS AND A 37% REDUCTION IN
MORTALITY AFTER INTRODUCING RRTs.
BAPTIST MEMORIAL HOSPITAL, MEMPHIS,
TN, EXPERIENCED A 28% DROP IN CODES.
FURTHER, MORE OF ALL CODES NOW OCCUR
IN THE ICU. FLOOR NURSES REPORT THAT
THEY ARE NOW MORE CONFIDENT IN THEIR
ABILITY “TO RESCUE PATIENTS BEFORE THEY
GET INTO SERIOUS TROUBLE.”
2. IMPROVED CARE FOR AMI
GOAL: PREVENT DEATHS IN
PATIENTS HOSPITALIZED FOR
AMI BY RELIABLE DELIVERY OF
EVIDENCE-BASED CARE
 1.1 MILLION PEOPLE HAVE AN AMI EACH
YEAR. ONE-THIRD DIE DURING THE ACUTE
PHASE
THERE ARE CLEAR GUIDELINES FOR
MANAGEMENT OF PATIENTS WITH AMI:
AMERICAN COLLEGE OF CARDIOLOGY,
AMERICAN HEART ASSOCIATION
2. IMPROVED CARE FOR AMI
 IMPLEMENTING THESE GUIDELINE
THERAPIES REDUCES AMI MORTALITY.
PROMPT ASPRIN ADMINISTRATION REDUCES
RISK OF DEATH BY 15%. BETA-BLOCKERS
REDUCE RISK OF DEATH IN FIRST WEEK
AFTER AMI BY 13% AND LONG-TERM
MORTALITY BY 23%.
YET, A RECENT RAND STUDY SHOWED THAT
ONLY 61% OF AMI PATIENTS RECEIVED
ASPRIN AND ONLY 45% RECEIVED BETABLOCKERS.
2. IMPROVED CARE FOR AMI
INTERVENTIONS:
 EARLY ADMINISTRATION OF ASPIRIN
 ASPIRIN AT DISCHARGE
EARLY ADMINISTRATION OF BETA-BLOCKER
 BETA-BLOCKER AT DISCHARGE
 ACE-INHIBITOR OR ANGIOTENSIN RECEPTOR
BLOCKERS AT DISCHARGE FOR PATIENTS WITH
SYSTOLIC DYSFUNCTION
 TIMELY INITIATION OF REPERFUSION
 SMOKING CESSATION
2. IMPROVED CARE FOR AMI
SUCCESS STORIES
 HACKENSACK U. MEDICAL CENTER DEVELOPED
STANDARDIZED PROCESSES FOR AMI CARE,
INCREASING COMPOSITE AMI SCORE FROM AN
AVERAGE OF 72% 1st QUARTER 2003 TO 91% BY 4th
QUARTER 2003, RESULTING IN A DECREASE IN AMI
INPATIENT MORTALITY FROM 7% TO 5.2% DURING THE
SAME PERIOD.
 McLEOD REGIONAL MEDICAL CENTER, FLORENCE,
SC, INCREASED PERCENT OF PATIENTS WHO
RECEIVED ALL AMI KEY MEASURES FROM 80% IN JAN.
2001 TO 100% BY NOV. 2003. THIS REDUCED THE
AVERAGE INPATIENT MORTALITY RATE FOR AMI TO 4%
, BELOW CMS REPORTED AVERAGE OF 7% IN 2003.
3. PREVENT ADVERSE DRUG
EVENTS (ADEs)
GOAL: PREVENT ADEs BY
IMPLEMENTING MEDICATION
RECONCILIATION
 HOSPITALIZED PATIENTS WHO EXPERIENCE AN ADE
ARE ALMOST TWICE AS LIKELY TO DIE AS THOSE WHO
DON’T.
 ADEs MAY CAUSE AS MUCH AS 20% OF UNNECESSARY
HOSPITAL DEATHS
 ADEs ACCOUNT FOR 6.3% OF MEDICAL MALPRACTICE
CLAIMS
3. PREVENT ADVERSE DRUG
EVENTS (ADEs)
 46% OF ALL MEDICATION ERRORS OCCUR
AT TRANSITION POINTS SUCH AS HOSPITAL
ADMISSION, TRANSFER BETWEEN UNITS, AND
DISCHARGE.
 MEDICICATION RECONCILIATION ENSURES
THAT PATIENTS RECEIVE ALL INTENDED
MEDS AND NO UNINTENDED MEDS
FOLLOWING TRANSITIONS AND CAN
VIRTUALLY ELIMINATE ERRORS OCCURRING
AT TRANSITIONS IN CARE
3. PREVENT ADVERSE DRUG
EVENTS (ADEs)
SUCCESS STORIES
 LUTHER MIDELFORT, MAYO HEALTH
SYSTEM ELIMINATED VIRTUALLY ALL ADEs IN
THE TELEMETRY/INTERMDEIATE CARE UNIT
THROUGH A MEDICICATION RECONCILIATION
SYSTEM
OSF HEALTHCARE SYSTEM, PEORIA, IL
REDUCED ITS ADE RATE PER 1,000 UNITS OF
MEDICATION ADMINISTERED FROM 3.84 TO
1.39
4. PREVENT CENTRAL LINEASSOCIATED BLOODSTREAM
INFECTIONS
GOAL: PREVENT CENTRAL
VENOUS CATHETER-RELATED
BLOODSTREAM INFECTIONS
(CR-BSI) AND DEATHS BY
IMPLEMENTING THE “CENTRAL
LINE BUNDLE”
4. PREVENT CENTRAL LINEASSOCIATED BLOODSTREAM
INFECTIONS
 48% OF ICU PATIENTS HAVE CENTRAL
VENOUS CATHETERS, EQUALS 15
MILLION CENTRAL VENOUS CATHETER
DAYS PER YEAR IN ICUs
 THERE ARE APPROXIMATELY 5.3 CR-BSIs
PER 1,000 CATHETER-DAYS IN ICUs
 THE MORTALITY RATE FOR CR-BSIs IS
18%. THUS, THERE ARE ABOUT 14,000
DEATHS ANNUALLY DUE TO CR-BSIs IN
ICUs. MAY BE AS HIGH AS 28,000 DEATHS
4. PREVENT CENTRAL LINEASSOCIATED BLOODSTREAM
INFECTIONS
A “BUNDLE” BRINGS TOGETHER THOSE
SCIENTIFICALLY GROUNDED CONCEPTS
THAT ARE BOTH NECESSARY AND
SUFFICIENT TO IMPROVE OUTCOMES.
THE KEY IS TO MEASURE THE
COMPLETION OF THE COMPOSITE
BUNDLE, NOT THE COMPONENTS.
4. PREVENT CR-BSIs: THE
CENTRAL LINE BUNDLE
 HAND HYGINE
 MAXIMAL BARRIER PRECAUTIONS
 CHLORHEXIDINE SKIN ANTISEPSIS
 APPROPRIATE CATHETER SITE
AND ADMINISTRATION SYSTEM
CARE
 NO ROUTINE REPLACEMENT
4. PREVENT CR-BSIs: THE
CENTRAL LINE BUNDLE
SUCCESS STORIES
 BAPTIST MEMORIAL HOSPITAL,
MEMPHIS, TN; ALLEGHENY GENERAL
HOSPITAL, PITTSBURGH, PA; JOHNS
HOPKINS, BALTIMORE, MD AND MANY
OTHERS HAVE VIRTUALLY ELIMINATED
CR-BSIs BY IMPLEMENTING THE
CENTRAL LINE BUNDLE.
 ICU LOS ALSO DECLINED
5. PREVENT SURGICAL SITE
INFECTIONS (SSIs)
GOAL: PREVENT SSIs AND DEATHS
BY IMPLEMENTING SSI BUNDLE
 SSIs ACCOUNT FOR 14 -16% OF ALL
HOSPITAL-ACQUIRED INFECTIONS; 40% OF
INFECTIONS IN SURGICAL PATIENTS .
 SSIs OCCUR IN 2% TO 5% OF EXTRAABDOMINAL SURGERIES, AND IN UP TO 20% OF
INTRA-ABDOMINAL SURGERIES.
 SURGICAL PATIENTS WHO DEVELOP SSIs
ARE TWICE AS LIKELY TO DIE AS THOSE WHO
DON’T
5. PREVENT SSIs: THE SSI BUNDLE
 GUIDELINE-BASED USE OF
PROPHYLACTIC ANTIBIOTICS
 APPROPRIATE SURGICAL SITE
HAIR REMOVAL (NO
SHAVING!)
 PERIOPERATIVE GLUCOSE
CONTROL
6. PREVENT VENTILATORASSOCIATED PNEUMONIA (VAP)
GOAL: PREVENT VAPs AND DEATHS
BY IMPLEMENTING THE
“VENTILATOR BUNDLE”
 VAP OCCURS IN UP TO 15% OF PATIENTS RECEIVING
MECHANICAL VENTILATION.
 THE MORTALITY RATE FOR VENTILATOR PATIENTS
WITH VAP IS 46%, COMPARED TO 32% FOR THOSE WHO
DO NOT DEVELOP VAP.
 VAP INCREASES VENTILATION TIME, ICU STAY,
HOSPITAL STAY, AND COSTS.
6. PREVENT VAPs: THE
VENTILATOR BUNDLE
 ELEVATION OF THE HEAD OF THE
BED 30 DEGREES
 PERIODIC “SEDATION VACATIONS”
 DAILY EXTUBATION ASSESSMENT
 PEPTIC ULCER DISEASE
PROPHYLAXIS
 DEEP VEIN THROMBOSIS (DVT)
PROPHYLAXIS
4. PREVENT CENTRAL LINEASSOCIATED BLOODSTREAM
INFECTIONS
GOAL: PREVENT CENTRAL
VENOUS CATHETER-RELATED
BLOODSTREAM INFECTIONS
(CR-BSI) AND DEATHS BY
IMPLEMENTING THE “CENTRAL
LINE BUNDLE”
4. PREVENT CENTRAL LINEASSOCIATED BLOODSTREAM
INFECTIONS
 48% OF ICU PATIENTS HAVE CENTRAL
VENOUS CATHETERS, EQUALS 15
MILLION CENTRAL VENOUS CATHETER
DAYS PER YEAR IN ICUs
 THERE ARE APPROXIMATELY 5.3 CR-BSIs
PER 1,000 CATHETER-DAYS IN ICUs
 THE MORTALITY RATE FOR CR-BSIs IS
18%. THUS, THERE ARE ABOUT 14,000
DEATHS ANNUALLY DUE TO CR-BSIs IN
ICUs. MAY BE AS HIGH AS 28,000 DEATHS
4. PREVENT CENTRAL LINEASSOCIATED BLOODSTREAM
INFECTIONS
A “BUNDLE” BRINGS TOGETHER THOSE
SCIENTIFICALLY GROUNDED CONCEPTS
THAT ARE BOTH NECESSARY AND
SUFFICIENT TO IMPROVE OUTCOMES.
THE KEY IS TO MEASURE THE
COMPLETION OF THE COMPOSITE
BUNDLE, NOT THE COMPONENTS.
4. PREVENT CR-BSIs: THE
CENTRAL LINE BUNDLE
 HAND HYGIENE
 MAXIMAL BARRIER PRECAUTIONS
 CHLORHEXIDINE SKIN ANTISEPSIS
 APPROPRIATE CATHETER SITE
AND ADMINISTRATION SYSTEM
CARE
 NO ROUTINE REPLACEMENT
4. PREVENT CR-BSIs: THE
CENTRAL LINE BUNDLE
SUCCESS STORIES
 BAPTIST MEMORIAL HOSPITAL,
MEMPHIS, TN; ALLEGHENY GENERAL
HOSPITAL, PITTSBURGH, PA; JOHNS
HOPKINS, BALTIMORE, MD AND MANY
OTHERS HAVE VIRTUALLY ELIMINATED
CR-BSIs BY IMPLEMENTING THE
CENTRAL LINE BUNDLE.
 ICU LOS ALSO DECLINED
5. PREVENT SURGICAL SITE
INFECTIONS (SSIs)
GOAL: PREVENT SSIs AND DEATHS
BY IMPLEMENTING SSI BUNDLE
 SSIs ACCOUNT FOR 14 -16% OF ALL
HOSPITAL-ACQUIRED INFECTIONS; 40% OF
INFECTIONS IN SURGICAL PATIENTS .
 SSIs OCCUR IN 2% TO 5% OF EXTRAABDOMINAL SURGERIES, AND IN UP TO 20% OF
INTRA-ABDOMINAL SURGERIES.
 SURGICAL PATIENTS WHO DEVELOP SSIs
ARE TWICE AS LIKELY TO DIE AS THOSE WHO
DON’T
5. PREVENT SSIs: THE SSI BUNDLE
 GUIDELINE-BASED USE OF
PROPHYLACTIC ANTIBIOTICS
 APPROPRIATE SURGICAL SITE
HAIR REMOVAL (NO
SHAVING!)
 PERIOPERATIVE GLUCOSE
CONTROL
6. PREVENT VENTILATORASSOCIATED PNEUMONIA (VAP)
GOAL: PREVENT VAPs AND DEATHS
BY IMPLEMENTING THE
“VENTILATOR BUNDLE”
 VAP OCCURS IN UP TO 15% OF PATIENTS RECEIVING
MECHANICAL VENTILATION.
 THE MORTALITY RATE FOR VENTILATOR PATIENTS
WITH VAP IS 46%, COMPARED TO 32% FOR THOSE WHO
DO NOT DEVELOP VAP.
 VAP INCREASES VENTILATION TIME, ICU STAY,
HOSPITAL STAY, AND COSTS.
6. PREVENT VAPs: THE
VENTILATOR BUNDLE
 ELEVATION OF THE HEAD OF THE
BED 30 DEGREES
 PERIODIC “SEDATION VACATIONS”
 DAILY EXTUBATION ASSESSMENT
 PEPTIC ULCER DISEASE
PROPHYLAXIS
 DEEP VEIN THROMBOSIS (DVT)
PROPHYLAXIS
SELECTED REFERENCES
Institute for Healthcare Improvement: www.ihi.org
www.ihi.org/ihi/programs/campaign
RAPID RESPONSE TEAMS:
Peberdy MA et al. Cardiopulmonary resuscitation of adults in the hospital: a report of
14,270 cardiac arrests from the National Registry of Cardiopulmonary
Resuscitation. Resuscitation. 2003;58:297-308.
Sandroni C. et al. In-hospital cardiac arrest: survival depends mainly on the emergency
response. Resuscitation. 2004;62:291-297
Schein RM et al. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest.
1990;98:1388-1392
Hillman K. et al. Redefining in-hospital resuscitation: the concept of the medical
emergency team. Resuscitation. 2001;48:105-110
Buist MD et al. Effects of a medical emergency team on reduction of incidence of and
mortality from unexpected cardiac arrests in-hospital: preliminary study. British
Medical Journal. 2002;324:387-390.
Bellomo R. et al. Prospective controlled trial of effect of medical emergency team on
postoperative morbidity and mortality rates. Critical Care Medicine. 2004;32:916921.
SELECTED REFERENCES
AMI CARE:
Antman et al. ACC/AHA guidelines for the management of patients with STelevation myocardial infarction executive summary. A report of the
American College of Cardiology/American Heart Association Task Force
on Practice Guidelines. Journal of American Cardiology. 2004; 44:671719.
Hennekens et al. Adjunctive drug therapy for acute myocardial infarction –
evidence from clinical trials. New England Journal of Medicine
1996;335:1660-1667.
McGlynn et al. The quality of healthcare delivered to adults in the United
States. New England Journal of Medicine 2003;348:2635-2645
CENTERS FOR MEDICARE AND MEDICAID SERVICES
www.cms.hhs.gov/quality/hospital; CMS National Acute Myocardial
Infarction Project: www.medqic.org/content/nationalpriorities/topics
AMERICAN COLLEGE OF CARDIOLOGY www.acc.org/index.htm
SELECTED REFERENCES
ADVERSE DRUG EVENTS:
Classen DC et al. Adverse Drug Events in hospitalized patients.
Excess length of stay, extra costs, and attributable mortality.
JAMA. 1997;277;301-306.
Phillips DP et al. Increase in U.S. medication-error deaths between
1983 and 1993. Lancet. 1998; 351:643-644
Rothschild JM et al. Analysis of medication-related malpractice
claims. Causes, preventability, and costs. Archives of Internal
Medicine. 2002;162:2414-2420
Pronovost P. et al. Medication reconciliation: a practical tool to reduce
the risk of medication errors. Journal of Critical Care.
2003;18:201-205.
Rozich JD et al. Medication safety: one organization’s approach to the
challenge. JCOM. 2001;8(10):27-34
Leape LL et al. Reducing Adverse Drug Events. Boston: Institute for
Healthcare Improvement, 1998.
SELECTED REFERENCES
PREVENT CENTRAL LINE-ASSOCIATED BLOODSTREAM
INFECTIONS:
Pittet, D. et al. Nosocomial bloodstream infection in critically ill
patients. Excess length of stay, extra costs, and attributable
mortality. JAMA. 1994;271;1598-1601.
Saint, S. Chapter 16. Prevention of intravascular catheter-related
infection. Making healthcare safer; a critical analysis of patient
safety practices. AHRQ evidence report, number 43, July 20,
2001. www.ncbi.nlm.nih.gov/books
Berenholtz SM, et al. Eliminating catheter-related bloodstream
infections in the intensive care unit. Critical Care Medicine.
2004;32:2014-2020.
O’Grady NP, et al. Guidelines for the prevention of intravascular
catheter-related infections. Morbidity Mortality Weekly Report
2002;51(RR-10):1-29.
SELECTED REFERENCES
PREVENT SURGICAL SITE INFECTIONS:
Kirkland KB, et al. The impact of surgical-site infections in the
1990s; attributable mortality, excess length of hospitalization, and
extra costs. Infection Control Hosp Epidemiology. 1999;20;725730.
Mangram AJ; et al. Guidelines for prevention of surgical site
infection, 1999. Infection Control Hosp Epidemiology.
1999;20;247-278.
Adams, K; et al. Priority areas for national action: transforming health
care quality. Washington, DC: The National Academies Press,
2003.
Surgical Care Improvement Project (SCIP) www.medqic.org/scip
Van den Berghe G; et al. Intensive insulin therapy in critically ill
patients. New England Journal of Med. 2001;345:1359-1367.
SELECTED REFERENCES
PREVENT VENTILATOR-ASSOCIATED PNEUMONIA:
Ibrahim EH; et al. The occurrence of ventilator-associated pneumonia
in a community hospital: risk factors and clinical outcomes.
Chest. 2001;120:555-561.
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