Transcript Tennessee Center for Patient Safety Data Reporting

Tennessee Center for Patient
Safety Data Reporting
Scope of TCPS Data Collection
• Methicillin-resistant Staphylococcus
aureus (MRSA)
• Central Line Associated Blood Stream
Infections
• Surgical Care Improvement Project (SCIP)
data from core measures
• AHRQ Hospital Survey on Patient Safety
Culture
MRSA Data Reporting
• Reported monthly by hospitals participating in
the MRSA collaborative via THA web site
• Data collection initiated August 2008
• Data included for units that reported complete
data for January – August 2008
– Baseline is defined as January - June
Definitions for MRSA based on CDC
MDRO Module NHSN Definitions
• MRSA includes S. aureus cultured from any specimen that tests
oxacillin (or cefoxitin for oxacillin) resistant by standard susceptibility
testing methods, or by a positive result from molecular testing for mecA
and PBP2a; these methods may also include positive results of
specimens tested by any other FDA approved PCR test for MRSA.
• Healthcare Facility-onset (HO) Incident: LabID Event > 3 days after
admission (i.e. on or after day 4).
• Community-onset (CO): LabID Event collected as an outpatient or an
inpatient ≤ 3 days after admission (i.e. day 1, day 2 or day 3 of
admission).
• These data do not include results from active surveillance tests.
Number of Admissions, Patient Days and Cases of
Hospital Onset MRSA in Tennessee Hospitals Reporting
Facility Wide MRSA Data by Month of Occurrence, 2008
JAN
FEB
MAR
APR
MAY
19,125
18,587
18,646
18,061
18,115 17,785
79
85
90
90
83,116
81,068
81,952
76,595
Rate Per 1000 Admit
4.13
4.57
4.83
4.98
4.09
Rate Per 1000 Pat Day
0.95
1.05
1.1
1.18
0.94
Admissions
Cases
Patient Days
JUL
AUG
18,668
19,073
79
78
64
78,783 75,950
79,413
80,687
4.44
4.18
3.36
1.04
0.98
0.79
74
Includes 24 hospitals that reported data for every month
JUN
Number of Admissions, Patient Days and Cases of Hospital Onset
MRSA in Tennessee Hospitals Reporting Inpatient Adult Critical Care
Unit MRSA Data by Month of Occurrence, 2008
JAN
Admissions
Cases
FEB MAR APR MAY JUN
JUL
AUG
688
637
651
668
679
625
703
653
12
8
17
6
8
6
4
7
Patient Days
2,762 2,699 2,615 2,678 2,641 2,411 2,540 2,475
Rate Per 1000 Admit
17.44 12.56 26.11
Rate Per 1000 Pat Day
4.34
2.96
6.5
8.98 11.78
2.24
3.03
Includes 5 hospitals that reported unit data for every month
9.6
2.49
5.69 10.72
1.57
2.83
Number of Admissions, Patient Days and Cases of Hospital Onset
MRSA in Tennessee Hospitals Reporting Inpatient Adult Unit MRSA
Data by Month of Occurrence, 2008
JAN FEB MAR APR MAY JUN JUL AUG
Admissions
Cases
563 580
1
4
595
517
1
6
510 492 559
3
3
4
514
2
Pat Days
3018 2895 2909 2812 2584 2561 2798 2736
Rate Per 1000 Admit
1.78
Rate Per 1000 Pat Day
0.33 1.38 0.34 2.13 1.16 1.17 1.43 0.73
6.9 1.68 11.61 5.88
Includes 4 hospitals that reported unit data for every month
6.1 7.16 3.89
Rate per 1000 Admissions of Hospital Onset MRSA for Selected Units
Within Tennessee Hospital B, January - August 2008
45.00
40.00
39.15
Surgical Cardiothorasic Critical Care
35.00
Medical Surgical Critical Care
Solid Organ Transplant
30.00
29.90
25.00
23.26
22.22
21.19
20.00
15.87
16.67
15.50
15.00
13.89
13.38
9.62
10.00
6.02
4.88
5.62
5.00
7.46
5.49
4.48
0.00
0.00
JAN
0.00
0.00
FEB
0.00
0.00
0.00
0.00
MAR
APR
MAY
JUN
JUL
AUG
Number of Admissions, Patient Days and Cases of Community Onset
MRSA in Tennessee Hospitals Reporting Facility Wide MRSA Data by
Month of Occurrence, 2008
JAN
Admissions
Cases
Patient Days
Rate Per 1000 Admit
Rate Per 1000 Pat
Day
FEB
MAR
APR
MAY
16,236 15,765 15,851 15,422 15,426
386
500
376
358
440
71,353 69,766 70,921 66,227 68,172
JUN
JUL
AUG
15,154 16,003 16,647
426
392
510
65,700 68,280 69,641
23.77
31.72
23.72
23.21
28.52
28.11
24.5
30.64
5.41
7.17
5.3
5.41
6.45
6.48
5.74
7.32
Includes 16 hospitals that reported data for every month
70.00
Rate per 1000 Admissions of Community Onset MRSA for all
Reporting Tennessee Hospitals Compared with Hospital A, January August, 2008
65.06
60.00
51.60
50.00
50.70
46.48
47.85
37.40
40.00
41.09
42.37
31.72
30.00
28.52
30.64
28.11
23.72
24.50
23.77
23.21
20.00
Hospital A Rate per 1000 Admissions
All Reporting Facilities Rate per 1000
Admissions
10.00
0.00
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
Rate per 1000 Admissions of Community Onset and Hospital
Onset MRSA in Tennessee Hospital C by Month, 2008
140
120
118.05
Community Onset
Hospital Onset
100
80
73.6
70.89
57.14
60
62.7
62.11
52.74
48.59
40
20
6.56
5.2
7.33
8.79
5.2
6.94
4.24
6.79
0
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
Rate per 1000 Admissions of Facility Wide Community Onset and Hospital
Onset MRSA for all Reporting Hospitals and for Tennessee Hospital C, January August, 2008
140
120
118.05
Community Onset
Hospital Onset
Community Onset - StateTotal
100
Hospital Onset - StateTotal
80
73.6
70.89
62.7
60
62.11
57.14
52.74
48.59
40
31.72
23.77
28.52
23.72
28.11
24.5
23.21
30.64
20
6.56
0
4.13
JAN
5.2
4.57
FEB
7.33
4.83
MAR
8.79
4.98
APR
5.2
4.09
MAY
6.94
4.44
JUN
4.24
4.18
JUL
6.79
3.36
AUG
Central Line Associated Bloodstream
Infections
•
•
•
Definition of CLABSIs to be reported based on CDC NHSN
– Reportable primary bloodstream infections are either laboratory
confirmed bloodstream infections (LBCI) or in the case of neonates (30
days old or younger) and infants (1year old and younger) clinical sepsis
(CSEP).
Central line is an intravascular catheter that terminates at or close to the
heart or in one of the great vessels which is used for infusion, withdrawal of
blood, or hemodynamic monitoring.
The following are considered great vessels for the purpose of reporting
central line infections and counting central line days (as defined for the
NHSN system):
– Aorta, pulmonary artery, superior vena cava, inferior vena cava,
– Brachiocephalic veins, interjugular veins, subclavian veins,
– External iliac veins, common femoral veins
Central Line Associated Bloodstream
Infections
 Patient Safety Center reporting options
 Data reported directly to THA via web reporting tool
 Hospital requested data be submitted to THA from CDC NHSN data by the
Department of Health
 CDC NHSN reporting requirement for Tennessee
 T.C.A. 68-11-263: Facilities must join the CDC National Healthcare Safety
Network (NHSN) to report central line bloodstream infections in ICU’s
 Excludes facilities with average daily census of 25 or less
 Excludes burn units and level 1 trauma units
 Hospitals began submission of required data January 2008
Central Line Associated Bloodstream
Infections
• Data collection initiated August 2008
• Data included for units that reported complete data for
January – August 2008
• Baseline defined as January - June
• Initial data from State received in mid October
• 31 hospitals reported data for 74 units since August
• 24 hospitals reported complete data for 47 units for January
through August, 2008
• Of the 47 units with complete data, 18 reported 0
infections during the entire 8 month period
Number of Central Line Bloodstream Infections in Tennessee
Hospitals Reporting Adult Medical/Surgical Critical Care Unit
Infections Every Month, January – August, 2008
JAN
Number of Units
Central Line Infections
Central Line Days
Rate Per 1,000 Central Line
Days
Device Utilization Rate 1000
Patient Days
FEB
MAR
APR
MAY
JUN
JUL
AUG
23
23
23
23
23
23
23
23
5
4
4
5
4
4
5
4
2,383
2,382
2,392
2,252
2,079
1,864
2,120
1,782
2.1
1.68
1.67
2.22
1.92
2.15
2.36
2.24
543.7 494.41
505.29
528.94
479.68
477.27 528.39 526.06
The 2007 national incidence rate for all hospitals reporting CLABSIs for
medical/surgical ICUs to NHSN is 2.6 per 1,000 central line days in teaching
facilities and 1.9 in non-teaching facilities.
Number of Central Line Bloodstream Infections in
Tennessee Hospitals Reporting Adult Surgical Critical
Care Unit Infections Every Month, January – August, 2008
JAN FEB MAR APR MAY JUN JUL AUG
Number of Units
3
3
3
3
3
3
3
3
Central Line Infections
2
0
1
0
2
1
0
1
444
359
492
380
426
512
313
370
0 4.69 1.95
0
2.7
436
497
Central Line Days
Rate Per 1,000 Central Line
Days
Device Utilization Rate 1,000
Patient Days
4.5
643
0 2.03
541
636
534
592
669
The 2007 national incidence rate for all hospitals reporting CLABSIs for adult
surgical ICUs to NHSN is 3.1 per 1,000 central line days.
Number of Central Line Bloodstream Infections in
Tennessee Hospitals Reporting Adult Medical Critical Care
Unit Infections Every Month, January – August, 2008
JAN FEB MAR APR MAY JUN JUL AUG
Number of Units
6
6
6
6
6
6
6
6
Central Line Infections
1
1
3
1
0
0
1
0
808
735
819
740
709
629
527
602
1.24 1.36 3.66 1.35
0
0
1.9
0
270
241
246
249
Central Line Days
Rate Per 1,000 Central Line
Days
Device Utilization Rate 1,000
Patient Days
294
274
272
298
The 2007 national incidence rate for all hospitals reporting CLABSIs for adult
medical ICUs to NHSN is 2.8 per 1,000 central line days.
AHRQ Hospital Survey on
Patient Safety Culture
•
The Hospital Survey on Patient Safety Culture was sponsored by the Quality
Interagency Coordination Task Force (QuIC), a group established to ensure
that all Federal agencies involved in purchasing, providing, studying, or
regulating health care services are working together and toward a common
goal of improving quality care.
•
The survey was funded by the Agency for Healthcare Research and Quality
(AHRQ).
•
The development of this safety culture assessment tool included a review of
published and unpublished safety culture assessment tools and the scientific
literature pertaining to safety, error and accidents, as well as error reporting.
•
Hospital employees and managers were interviewed to identify key patient
safety and error reporting issues.
•
The TCPS makes the survey available to all safety partners at no cost
Value to Hospitals of Participating in
the TCPS Survey
• You can’t fix what you don’t measure
• Survey results provide:
– Demographic characteristics of responders
– Four overall patient safety outcomes:
•
•
•
•
Overall perceptions of safety
Frequency of events reported
Number of events reported
Overall patient safety grade
– Scores on ten dimensions of culture
pertaining to patient safety
Demographic Data for Respondents, Tennessee Hospital,
2008
1. Primary hospital work area, department or clinical area where respondents
spend most of their work time:
6%
12%
10%
5%
4%
1%
26%
Many different units / No specific unit
9% Intensive care unit (any type)
Medicine (non-surgical)
0% Psychiatry / mental health
Surgery
4% Rehabilitation
Obstetrics
6% Pharmacy
Pediatrics
12% Laboratory
Emergency department
5% Radiology
Other
1% Anesthesiology
2. Staff position in the hospital:
41%
0%
5%
2%
0%
0%
18%
Registered nurse
2%
Physician assistant / Nurse practitioner 1%
LVN / LPN
7%
Patient care asst / Aide / Care partner 1%
Attending / Staff physician
3%
Resident physician / Physician in training
15%
Other
6%
Pharmacist
Dietician
Unit assistant / Clerk / Secretary
Respiratory therapist
Physical, occupational, or speech therapist
Technician (e.g., EKG, Lab, Radiology)
Administration / Management
Overall Patient Safety Grade
Tennessee Hospital, 2008
Please give your work area/unit in this hospital an overall grade on patient
safety.
60%
51%
Percent of Respondents
50%
40%
30%
28%
19%
20%
10%
2%
0%
0%
A - Excellent
Note: 0% of respondents did not answer
B - Good
C - Acceptable
D - Poor
E - Failing
Tennessee Hospital Safety Culture
Composite Scores, 2008
Tennessee
Hospital's
Composite Score
Average % of positive
responses
2008 National
Comparative Data
from AHRQ
Average % of
positive responses
68%
64%
71%
60%
83%
75%
79%
70%
Teamwork Within Units (4 items--% Agree/Strongly Agree)
80%
79%
Communication Openness (3 items--% Most of the time/Always)
Feedback & Communication About Error
(3 items--% Most of the time/Always)
Nonpunitive Response to Error (3 items--% Agree/Strongly
Agree)
67%
62%
68%
62%
42%
44%
Staffing survey items (4 Items --% Agree/Strongly Agree)
Hospital Management Support for Patient Safety
(3 items--% Agree/Strongly Agree)
Teamwork Across Hospital Units (4 survey items--%
Agree/Strongly Agree)
Hospital Handoffs & Transitions (4 survey items--%
Agree/Strongly Agree)
56%
55%
74%
70%
57%
57%
43%
45%
Safety Culture Composites
Overall Perceptions of Safety (4 items--% Agree/Strongly
Agree)
Frequency of Events Reported (3 items--% Most of the
time/Always)
Supervisor/Manager Expectations & Actions Promoting
Patient Safety
(4 items--% Agree/Strongly
Organizational Learning--Continuous Improvement
(3 items--% Agree/Strongly Agree)
519 hospitals and 160,176 hospital staff respondents are included in the
AHRQ national comparative data.
Tennessee Hospital 2008 Overall Facility Score
Overall Perceptions of Safety
Positive
Neutral
1. Patient safety is never sacrificed
to get more work done.
2. Our procedures and systems are
good at preventing errors from
happening.
R3. It is just by chance that more
serious mistakes don’t happen
around here.
R4. We have patient safety
problems in this unit.
a
64%
76%
15%
a
17%
a
65%
68%
Negative
a
7%
20%
17%
15%
Graphs also are available by specific job titles( RN, PT, dietician…) work areas (ICU,
medicine, pharmacy…) and whether or not the employee has direct contact with patients
(yes or no)
21%
Area of
Strength
15%
Tennessee Hospital 2008 Overall Facility Score
Teamwork Across Hospital Units
Positive
Neutral
Negative
a
56%
27%
16%
1. There is good cooperation among hospital
units that need to work together. (F4)
2. Hospital units work well together to
provide the best care for patients. (F10)
R3. Hospital units do not coordinate well
with each other. (F2)
R4. It is often unpleasant to work with staff
from other hospital units. (F6)
a
68%
a
44%
59%
27%
22%
9%
28%
a
26%
Graphs also are available by specific job titles (RN, PT, dietician…) work areas (ICU, medicine,
pharmacy…) and whether or not the employee has direct contact with patients
(yes or no)
15%
Tennessee Hospital 2008 Overall Facility
Score
Communication Openness
1. Staff will freely speak up if they see
something that may negatively affect
patient care. (C2)
2. Staff feel free to question the
decisions or actions of those with more
authority. (C4)
R3. Staff are afraid to ask questions
when something does not seem right.
(C6)
Positive
Neutral
Negative
a
80%
17%
3%
Area of Strength
a
49%
29%
71%
22%
a
Graphs also are available by specific job titles (RN, PT, dietician…) work areas
(ICU, medicine, pharmacy…) and whether or not the employee has direct contact
with patients (yes or no)
23%
7%
Survey Respondent Comments from
Tennessee Hospital 2008
•
•
•
•
•
•
•
•
With our current staff level and the expectations of some departments, we often feel
that we are living on the edge as far as committing serious errors.
I am not certain the management team is on the same page in regards to patient
safety.
I think the hospital strives daily to maintain a safe and error free environment. I feel
that if there are errors made they are addressed immediately.
Staffing is my main concern, not enough staff or some staff (same people) do not
work together well thus making pt. safety issues a real concern. Poor staffing is not
healthy for anyone.
I can only speak for my own department. There is so much equipment we use on
patients there should be more biomed techs to check equipment monthly, not after
there is a breakdown.
Event reporting is loose in my area, not enough guidelines taught to us about what
does and does not need to be reported.
I feel we are making progress with patient safety, however, shift reports and
dissemination of patient information to staff is lacking.
I think our hospital should be more proactive in giving feedback about errors and
make the data available to everyone. Often times it seems as though quality data is
kept a secret here.