Transcript Slide 1

Welcome to the
NQF Safe Practices for Better Healthcare Webinar:
Preventing CLABS Infections:
Safe Patients, Smart Hospitals
(Safe Practice 21)
Hosted by TMIT
To join the online webinar, go to:
www.safetyleaders.org
Online Access Password: Webinar1 (case-sensitive)
© 2010 TMIT
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Welcome
Charles Denham, MD
Chairman, TMIT
Co-chairman, NQF Safe Practices Consensus Committee
Chairman, Leapfrog Safe Practices Program
Safe Practices Webinar
March 18, 2010
© 2010 TMIT
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© 2010 TMIT
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Panelists
Charles Denham
Kathy Warye
Peter Pronovost
Charles Denham:
Welcome and Safe Practices Overview
Kathy Warye:
APIC Resources for Targeting Zero HAIs
Peter Pronovost:
Safe Patients, Smart Hospitals
© 2010 TMIT
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Panelists
Deborah Hobson
Melinda Sawyer
Patti O’Regan
Deborah Hobson
& Melinda Sawyer: Clinical Pearls for Nursing to Eliminate CLABSIs
Patti O’Regan:
© 2010 TMIT
The Role of the Patient Advocate
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Disclosure Statement
The following panelists certify:

that unless otherwise noted below, each presenter provided full disclosure information, does
not intend to discuss an unapproved/investigative use of a commercial product/device, and has
no significant financial relationship(s) to disclose. If unapproved uses of products are
discussed, presenters are expected to disclose this to participants.
Charles Denham: Chairman, TMIT; education grant (CareFusion) and co-production with Discovery Channel
Peter Pronovost: Grants, AHRQ, NPSA (Reducing CLABSI), honoraria from hospitals and healthcare systems
(speaking on quality and safety), co-authored book Safe Patients, Smart Hospitals
Kathy Warye: Employed by Association for Professionals in Infection Control and Epidemiology (APIC)
Deborah Hobson, Melinda Sawyer, and Patti O’Regan have no relevant financial interests in this
presentation
© 2010 TMIT
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The Role of the Patient Advocate
Patti O’Regan, ARNP, ANP, NP-C, PMHNP-BC
Nurse practitioner, Port Richey, FL
Founding member, TMIT Patient Advocate Panel
Safe Practices Webinar
March 18, 2010
© 2010 TMIT
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Safe Practice Overview
Charles Denham, MD
Chairman, TMIT
Co-chairman, NQF Safe Practices Consensus Committee
Chairman, Leapfrog Safe Practices Program
Safe Practices Webinar
March 18, 2010
© 2010 TMIT
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Harmonization – The Quality Choir
© 2010 TMIT
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The Patient – Our Conductor
© 2010 TMIT
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2010 NQF Safe Practices for Better
Healthcare: A Consensus Report
34 Safe Practices
• Criteria for Inclusion
• Specificity
• Benefit
• Evidence of Effectiveness
• Generalization
• Readiness
© 2010 TMIT
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History of NQF Safe Practices for Better Healthcare
2009 Final Report:
2010 Final Report:
• From 30 to 34 practices
• Culture Practice Elements
Broken Up into 4 Practices
• 2 Practices Discontinued
• 4 Medication Management
Practices Combined into 1
• 2 Communication Practices
Combined into 1
• 8 New Practices Added
• CMS Care Settings Defined
• Patient and Family
Involvement Section Added
© 2010 TMIT
• Format Structure Preserved
• Problem Statement and Implementation
Guide Thoroughly Updated
• Minor Specification Changes
• Updated References
• Corrections and Clarifications
• Care Setting Clarification Using CMS
Classification
• Measures Section Updated Thoroughly
with NQF-Endorsed and Other Practical
Measures for Consideration
• Soft Copy Document Hyperlinks
• Crosswalk Tables
• Glossary
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2003, 2006, and 2009 Update Versions
© 2010 TMIT
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Culture
2010 NQF Report
Consent & Disclosure
Consent and Disclosure
Workforce
Information Management and
Continuity of Care
Medication Management
Healthcare-Associated
Infections
Condition- &
Site-Specific Practices
© 2010 TMIT
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Culture
Structures
and Systems
Culture Meas.,
FB., and Interv.
Team Training
and Team Interv.
ID and Mitigation
Risk and Hazards
CHAPTER 2: Creating and Sustaining a Culture of
Patient Safety (Separated into Practices]
 Leadership Structures and Systems
 Culture Measurement, Feedback, and Interventions
 Teamwork Training and Team Interventions
 Identification and Mitigation of Risks and Hazards
Consent
& Disclosure
Consent
and
Informed
Consent
Life-Sustaining
Treatment
Care of
Caregiver
Disclosure
Workforce
2010
NQF Report
Nursing
Workforce
Direct
Caregivers
CHAPTER 4: Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care
ICU Care
Information Management and Continuity of Care
Patient
Care Info.
Read-Back
& Abbrev.
Labeling
Studies
Discharge
System
CHAPTER 3: Informed Consent and Disclosure
• Informed Consent
• Life-Sustaining Treatment
• Disclosure
• Care of the Caregiver
CPOE
Medication Management
CHAPTER 5: Information Management and Continuity
of Care
 Patient Care Information
 Order Read-Back and Abbreviations
 Labeling Studies
 Discharge Systems
 Safe Adoption of Integrated Clinical Systems
including CPOE
CHAPTER 6: Medication Management
 Medication Reconciliation
 Pharmacist Leadership Role Including: High-Alert
Med. and Unit-Dose Standardized Medication
Labeling and Packaging
Med. Recon.
Pharmacist Systems Leadership:
High-Alert, Std. Labeling/Pkg., and Unit-Dose
Healthcare-Associated Infections
Influenza
Prevention
Hand Hygiene
Sx-Site Inf.
Prevention
VAP
Prevention
Central V. Cath.
BSI Prevention
MDRO
Prevention
UTI
Prevention
Condition-, Site-, and Risk-Specific Practices
Wrong-site
Sx Prevention
Contrast
Media Use
Organ
Donation
Press. Ulcer
Prevention
Glycemic
Control
DVT/VTE
Prevention
Falls
Prevention
Anticoag.
Therapy
Pediatric
Imaging
CHAPTER 7: Hospital-Associated Infections
• Hand Hygiene
• Influenza Prevention
• Central Venous Catheter-Related Blood Stream
Infection Prevention
• Surgical-Site Infection Prevention
• Care of the Ventilated Patient and VAP
• MDRO Prevention
• UTI Prevention
CHAPTER 8:
• Wrong-Site, Wrong-Procedure, Wrong-Person
Surgery Prevention
• Pressure Ulcer Prevention
• DVT/VTE Prevention
• Anticoagulation Therapy
• Contrast Media-Induced Renal Failure Prevention
• Organ Donation
• Glycemic Control
• Falls Prevention
• Pediatric Imaging
LEADERSHIP STRUCTURES and SYSTEMS
Patients and
Community
Leadership Structures
and Systems
Values
Culture Measurement,
Feedback, and Intervention
Systems
Structures
Teamwork Training and
Skill Building
Behaviors
Identification and Mitigation
of Risks and Hazards
Outcomes
NQF 34 Safe
Practices
© 2010 TMIT
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HAI Guidelines
© 2010 TMIT
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APIC Resources for Targeting Zero HAIs
Kathy L. Warye
Chief Executive Officer, Association for Professionals
in Infection Control and Epidemiology (APIC)
Safe Practices Webinar
March 18, 2010
© 2010 TMIT
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The Association for Professionals in
Infection Control & Epidemiology
• Mission
To improve health and patient safety by reducing the risks of
infection and related adverse outcomes
• Global leader in infection prevention
Over 13,000 members worldwide, responsible for infection
prevention and hospital epidemiology in a variety of
healthcare settings
• Cores services
Education, practice guidance, research, communications and
public policy
Developing and Validating
Clinical Best-Practices
– APIC works with 28 healthcare organizations
to facilitate consensus on practice
recommendations.
– Ensures that the development of standards
and guidelines are evidence-based.
Targeting Zero…
• Setting the theoretical goal of elimination of HAIs
• An expectation that IPC measures will be
applied consistently
• A safe environment for healthcare workers, empowered to
hold each other accountable
• Systems and administrative support that provide the necessary foundation
• Transparency and continuous learning
• Prompt investigation of HAIs
• Real-time data to front line staff to drive improvement
• Zero tolerance for unsafe behaviors and practices that put patients and
healthcare workers at risk
APIC 2008 Targeting Zero Position Statement: www.apic.org
Targeting Zero: CRBSI/CLAB Resources
Online Course: Elimination of Catheter-Related Bloodstream Infections
– Part of APIC ANYWHERE™ Online Course Offerings, delivered via Healthstream
•
•
Helps healthcare workers recognize the role they play in the transmission and prevention of
CR-BSIs
Participants are provided with resources and checklists to assist in developing prevention
strategies
Eliminating Catheter-Related Complications Toolkit
•
CNE-certified, features video demonstration of proper catheter insertion, check-lists for
insertion and maintenance, additional learning modules and discussion of the cultural
attributes of reaching zero CR-BSIs.
Guide to the Elimination of Catheter-Related Bloodstream Infections
•
Provides step-by-step guidance to facilitate the bedside implementation of relevant clinical
evidence and best practices for eliminating CR-BSIs
Webinars
•
•
Strategies to Prevent Catheter-Related Bloodstream Infections
Access Site and Hub Disinfection: The Missing Link in the CR-BSI Prevention Bundle
Visit www.apic.org/guidelines to access the CDC Guidelines for CR-BSIs, and more.
Safe Patients, Smart Hospitals
Peter J. Pronovost, MD, PhD, FCCM
Professor, Johns Hopkins University School of Medicine
(Departments of Anesthesiology and Critical Care Medicine,
and Surgery), Bloomberg School of Public Health
(Department of Health Policy and Management), and School of Nursing
Medical Director, Center for Innovation in Quality Patient Care
Safe Practices Webinar
March 18, 2010
© 2010 TMIT
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A National Program to Eliminate CLABSI
Peter Pronovost, MD, PhD
“Safe Patients, Smart Hospitals”
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Regulatory
Scientifically
Sound
x
Feasible
Local Wisdom/Market
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Measure
Have We Created a Safe Culture?
How Do We know We Learn
from Mistakes?
How Often Do we Harm?
Are Patient Outcomes
Improving?
CUSP
Comprehensive Unit-based
Safety Program
(TRiP)
Translating Evidence Into Practice
1.
2.
3.
4.
5.
1.
2.
3.
4.
Educate staff on science of safety
Identify defects
Assign executive to adopt unit
Learn from one defect per quarter
Implement teamwork tools
Summarize the evidence in a checklist
Identify local barriers to implementation
Measure performance
Ensure all patients get the evidence
IMPROVE
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www.safercare.net
Pronovost BMJ 2008
Checklist to Prevent CLABSI
• Remove Unnecessary Lines
• Wash Hands Prior to Procedure
• Use Maximal Barrier Precautions
• Clean Skin with Chlorhexidine
• Avoid Femoral Lines
MMWR 2002;51:RR-10
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Identify Barriers
• Ask staff about knowledge
– Use team check up tool
• Ask staff what is difficult about doing these behaviors
• Walk the process of staff placing a central line
• Observe staff placing central line
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Ensure Patients Reliably
Receive Evidence
Senior
leaders
Team
leaders
Staff
Engage
How does this make the world a better place?
Educate
What do we need to do?
Execute
What keeps me from doing it?
How can we do it with my resources and
culture?
Evaluate
How do we know we improved safety?
Pronovost: Health Services Research 2006
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Ideas for ensuring patients receive
the interventions: the 4Es
• Engage: stories, show baseline data
• Educate staff on evidence
• Execute
– Create line cart that contains all needed supplies
– Empower nurses to stop takeoff
– Learn from mistakes: review all infections as defects
• Evaluate
– Feedback performance
– View infections as defects
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Partnership
• To help with 4Es, Partner with
− ICU physician and nurses
− Infection control staff
− Hospital quality and safety leaders
− Nurse educators
− Physician leaders
ICU staff must assume responsibility for reducing CLABSI
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Comprehensive Unit-based Safety Program (CUSP)
An Intervention to Learn from Mistakes and Improve Safety Culture
1. Educate staff on science of safety
http://www.safercare.net
2. Identify defects
3. Assign executive to adopt unit
4. Learn from one defect per quarter
5. Implement teamwork tools
Pronovost, J Patient Saf, 2005
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Science of Safety
• Understand system determines performance
• Use strategies to improve system performance
– Standardize
– Create Independent checks for key process
– Learn from Mistakes
• Apply strategies to both technical work and team
work
• Recognize that teams make wise decisions with
diverse and independent input
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Learning from Mistakes
• What happened?
• Why did it happen (system lenses)?
• What could you do to reduce risk?
• How do you know risk was reduced?
– Create policy / process / procedure
– Ensure staff know policy
– Evaluate if policy is used correctly
Pronovost, JCJQI 2005
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Teamwork Tools
• Call list
• Daily Goals
• AM briefing
• Shadowing
• Culture check up
• TEAMSTepps
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Pronovost, JCC, JCJQI
CRBSI Rate Summary Data
Study Period
No. of ICUs
Baseline
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No. of Infections
Median
(Q1, Q3)
2 (1, 3)
Catheter Days
Median
(Q1, Q3)
551 (220, 1091)
Infection Rate
Median
Mean
(Q1, Q3)
(SD)
2.7 (0.6, 4.8)
7.7 (28.9)
IRR (95% CI)
During Implementation
96
1 (0, 2)
447 (237, 710)
1.6 (0, 4.4)
2.8 (4.0)
0.81 (0.61, 1.08)
After Implementation
Initial Evaluation
Period
0-3 mo
95
0 (0, 2)
436 (246, 771)
0 (0, 3.0)
2.3 (4.0)
0.68 (0.53, 0.88)
4-6 mo
95
0 (0, 1)
460 (228, 743)
0 (0, 2.7)
1.8 (3.2)
0.62 (0.42, 0.90)
7-9 mo
96
0 (0, 1)
467 (252, 725)
0 (0, 2.0)
1.4 (2.8)
0.52 (0.38, 0.71)
10-12 mo
95
0 (0, 1)
431 (249, 743)
0 (0, 2.1)
1.2 (1.9)
0.48 (0.33, 0.70)
13-15 mo
95
0 (0, 1)
404 (158, 695)
0 (0, 1.9)
1.5 (4.0)
0.48 (0.31, 0.76)
16-18 mo
95
0 (0, 1)
367 (177, 682)
0 (0, 2.4)
1.3 (2.4)
0.38 (0.26, 0.56)
19-21 mo
89
0 (0, 1)
399 (230, 680)
0 (0, 1.4)
1.8 (5.2)
0.34 (0.23, 0.50)
22-24 mo
89
0 (0, 1)
450 (254, 817)
0 (0, 1.6)
1.4 (3.5)
0.33 (0.23, 0.48)
25-27 mo
88
0 (0, 1)
481 (266, 769)
0 (0, 2.1)
1.6 (3.9)
0.44 (0.34, 0.57)
28-30 mo
90
0 (0, 1)
479 (253, 846)
0 (0, 1.6)
1.3 (3.7)
0.40 (0.30, 0.53)
31-33 mo
88
0 (0, 1)
495 (265, 779)
0 (0, 1.1)
0.9 (1.9)
0.31 (0.21, 0.45)
34-36 mo
85
0 (0, 1)
456 (235, 787)
0 (0, 1.2)
1.1 (2.7)
0.34 (0.24, 0.48)
Reference
Sustainability Period
CRBSI Rate Over Time
Median and Mean CRBSI Rate
9
8
C R BS I R at e
7
6
5
4
3
2
1
6
4
-3
3
3
1
-3
0
3
8
-3
7
2
5
-2
4
2
2
-2
1
2
9
-2
8
1
6
-1
5
1
3
-1
2
1
1
0
-1
-9
7
-6
4
-3
0
n
o
ti
n
e
rv
In
te
B
a
se
l in
e
0
Time (months)
Media n CRBSI Ra te
46
Mea n CRBSI Ra te
VAP Rate Over Time
47
Michigan ICU Safety Climate
Improvement
Effect of CUSP on Safety Climate
% " N e e d s I m p r o v e m e n t" *
100
90
87
80
70
60
47
50
40
30
20
10
0
Pre vs. Post Intervention
Pre-CUSP (2004)
Post-CUSP (2006)
* “Needs Improvement” - Safety Climate Score <60%
How do we move to level 4? 5?
Level 1
Enroll in program
Level 2
Implement the checklist or bundle but do
not collect data on CLABSI, or CLABSI rates
remain high
Level 3
Culture change; junior nurse can stop a
senior physician who does not comply with
checklist when placing a catheter; and the
interaction goes well
Level 4
Profound and Sustained reduction in
CLABSI, Improvement in Culture, Joy in
work
Level 5
Self sustaining; Develop new efforts that
are just as effective
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Action Plan
• Join your states effort to eliminate CLABSI – contact your
state hospital association or email [email protected] to
find contact person
• Meet with ICU team, infection control staff, quality
and safety leaders, nurse educators and physician
champions
• Understand barriers (walk the process)
• Use 4E grid to develop strategy to engage, educate,
execute and evaluate
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Focus and Execute
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References
Measuring Safety
•
Pronovost PJ, Goeschel CA, Wachter RM. The wisdom and justice of not
paying for "preventable complications". JAMA. 2008; 299(18):2197-2199.
•
Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: An
elusive target. JAMA. 2006; 296(6):696-699.
•
Pronovost PJ, Sexton JB, Pham JC, Goeschel CA, Winters BD, Miller MR.
Measurement of quality and assurance of safety in the critically ill. Clin Chest
Med. 2008; in press.
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References
Translating Evidence into Practice
•
Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into
practice: A model for large scale knowledge translation. BMJ. 2008;
337:a1714.
•
Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease
catheter-related bloodstream infections in the ICU. NEJM. 2006; 355(26):27252732.
•
Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in
intensive care units in michigan. J Crit Care. 2008; 23(2):207-221.
•
Peter J Pronovost, Christine A Goeschel, Elizabeth Colantuoni, Sam Watson,
Lisa H Lubomski, Sean M Berenholtz, David A Thompson, David J Sinopoli, Sara
Cosgrove, J Bryan Sexton, Jill A Marsteller, Robert C Hyzy, Robert Welsh,
Patricia Posa, Kathy Schumacher, and Dale Needham.
Sustaining reductions in catheter related bloodstream infections in Michigan
intensive care units: observational study. BMJ. 2010;340:c309, doi:
10.1136/bmj.c309
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References
•
Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a
comprehensive unit-based safety program. J Patient Saf. 2005; 1(1):33-40.
•
Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C.
Improving communication in the ICU using daily goals. J Crit Care. 2003;
18(2):71-75.
•
Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: A
model for safety improvement. Jt Comm J Qual Saf. 2004; 30(2):59-68.
•
Thompson DA, Holzmueller CG, Cafeo CL, Sexton JB, Pronovost PJ. A morning
briefing: Setting the stage for a clinically and operationally good day. Jt
Comm J Qual and Saf. 2005; 31(8):476-479.
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Clinical Pearls for Nursing
To Eliminate CLABSIs
Deborah Baugher Hobson, BSN
Quality Improvement Chairperson/Staff Nurse
Johns Hopkins Hospital Surgical Intensive Care Unit
Patient Safety Clinical Specialist,
Center for Innovation in Quality Patient Care
Melinda Sawyer, RN, MSN
Patient Safety Officer, Department of Medicine,
The Johns Hopkins Hospital
Senior Clinical Research Coordinator,
The Johns Hopkins University Quality
and Safety Research Group (QSRG)
Safe Practices Webinar, March 18, 2010
© 2010 TMIT
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Clinical Pearls for Nursing
to Eliminate CLABSIs
• Putting evidence into every day practice: “walking the
process”
• Empowering the Nurses to stop the process at any step with
every insertion
• Now that the line is inserted…how do we maintain the line to
remain “infection-free”?
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Q&A
Charles Denham
Deborah Hobson
© 2010 TMIT
Kathy Warye
Peter Pronovost
(Denise Graham - proxy)
Melinda Sawyer
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Patti O’Regan
The Role of the Patient Advocate
Patti O’Regan, ARNP, ANP, NP-C, PMHNP-BC
Nurse practitioner, Port Richey, FL
Founding member, TMIT Patient Advocate Panel
Safe Practices Webinar
March 18, 2010
© 2010 TMIT
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© 2010 TMIT
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© 2010 TMIT
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