Transcript Shared Learning for Infection Prevention THA Collaborative on Reducing HAIs

Shared Learning for
Infection Prevention
THA Collaborative on
Reducing HAIs
August 2008
Tori Howk, Director of Risk and Regulatory
Collaborative Aims
• Improve the culture of safety
• Reduce patient harm by reducing
CLBSI
• MRSA
• 25% reduction in surgical
complications by implementing SCIP
THA – August 2008
New Name for ICP
• Infection Preventionists
– “The term infection preventionist clearly and
effectively communicates who our members are
and what they do.
– Infection Preventionists develop and direct
performance improvement initiatives that
save lives and resources for healthcare
facilities, so this was a natural transition – or a
right-sizing of the name – to more accurately
reflect their role.”
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Improvement Opportunity
• $5 billion to US healthcare costs every year
• 1.7 million hospital-acquired infections in 2002
associated with 99,000 deaths
• “Research has shown that hospitals are not
following recommended guidelines to avoid
preventable hospital-acquired infections.”
• 87% of hospitals completing Leapfrog survey
do not follow recommendations to prevent
many of the most common hospital-acquired
infections.
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Benefits of Reducing Infections
• Better patient outcomes
• Reduced mortality
• Improved satisfaction
– Physician
– Nursing
– Patients and families
• Financial benefits
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Bundle
• …“is a group of interventions related
to patients with intravascular central
catheters that, when implemented
together, result in better outcomes
than when implemented individually.”
• 2005 Institute for Healthcare Improvement
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What Are Hospital Acquired Conditions?
(HAC)
• Section 5001(c) of the Deficit Reduction Act (DRA) of 2005
required the Secretary of the Department of Health and
Human Services to select at least two conditions that are:
(1) high cost, high volume, or both; (2) identified through
ICD-9-CM coding as a complicating condition (CC) or major
complicating condition (MCC) that, when present as a
secondary diagnosis at discharge, results in payment at a
higher MS-DRG; and (3) is reasonably preventable through
application of evidence-based guidelines.
• Last year, CMS selected eight conditions for the HAC
provision.
• Beginning October 1, 2008, Medicare will no longer pay at a
higher weighted MS-DRG for the original eight conditions
plus three, as well as any conditions CMS is proposing to
add in this year’s rule. (5 HAIs)
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Hospital-Acquired Conditions (HAC)
Never
Events/Rare
Occurrences
Patient Safety
Infection
Prevention
•Delivery of ABOIncompatible Blood
•Falls and fractures,
dislocations,
intracranial and
crushing injury and
burns
•Surgical Site Infections
- Mediastinitis after coronary
artery bypass graft (CABG)
surgery
- Orthopedic surgeries
- Bariatric surgery
•Objects left in during
surgery
•Pressure Ulcers
•Vascular catheter-associated
infections
•Air Embolism
•Glycemic Control
•Catheter-associated urinary
tract infections
•Pressure Ulcers/DVT
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TriStar Shared Learnings
• MRSA
• Central Line Bloodstream Infections
• SCIP
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Improvement Triad
Leadership
Success
Measurement
and Feedback
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System and Process
Improvements
Approach
• Understand the opportunity
– Literature search
– Assess current performance metrics and practice (Gap
Analysis)
• Collaborative Improvement
– Identify best practices
– Refine tools and systems based on Gap Analysis
– Test improvements
• Shared Learning
– Deploy toolkits, checklists, policies, resources, supply
recommendations, education modules, system
enhancements
• Metrics Review
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MRSA
• Death and complications
• MRSA among most common and
problematic of HAIs
• 50% post surgical infections for
CABG and orthopedic prosthetics
• Excess costs
• Malpractice claims
• Proven strategies to reduce or nearly
eliminate nosocomial MRSA
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Active Surveillance (Systems/Processes)
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Active Surveillance
High Risk Patient Screening
• ICU
admissions/transfers
• Previous MRSA history
• Preoperative Screens
• Outborn transfers to
NICUs
• Long term care facility
admissions
• Hemodialysis
admissions
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–
–
–
–
Total hip
Total knee
Open spine procedures
Cardiac surgeries
• Private rooms, cohorting,
and isolation
Barrier Precautions
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Barrier Precautions
• Standard precautions for all patients
• Contact isolation of positive patients
• Personal protective equipment
• Gown
• Gloves
• Mask with shield
• Dedicated equipment
• Ticketing for non compliance
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Compulsive Hand Hygiene
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Compulsive Hand Hygiene
• Expectation of 100% compliance with
soap and water or other hand hygiene
products
• Vendor assistance with alcohol gel
strategy
• Patient encouraged to question hand
hygiene practices of caregiver
• Staff pledge
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Disinfection/Environmental Cleaning
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Disinfection/Environmental Cleaning
• Proper disinfection techniques
Proper supplies
• Proper equipment
• Environmental services education
• Workload analysis
• Observation for adherence
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Executive Ownership/Leadership
• Executive and Physician Champions
• Interdisciplinary taskforce
• Executive walk arounds
• Medical Executive Committee engagement
• MEC and Board reports
• Recognition and reward
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Campaign
• Executive messaging
• Waterless sanitizer/soap
dispenser signage
• Collaborative calls
• Isolation signage
• Patient/visitor
information cards
• Staff newsletters
• Banners, posters,
buttons, static clings
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• Electronic triggers and
trackers
Campaign
• Target audience--patients, caregivers,
physicians, non-clinical staff, visitors,
volunteers, vendors
• Community collaboration—EMS, local
health department, other healthcare
providers
• Data collection, analysis, and
dissemination
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Measurement - 2007 MRSA Swabbing Rate
2007 TriStar Monthly %: MRSA Swabs of High Risk Groups
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
TriStar
Jun-07
Jul-07
Aug-07
Sep-07
Oct-07
Nov-07
Dec-07
6/29/07
7/31/07
8/31/07
9/30/07
10/31/07
11/30/07
12/31/07
80.9%
90.4%
90.8%
90.2%
89.3%
92.5%
90.8%
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2008 MRSA Swabbing Rate
TriStar Monthly %: MRSA Swabs of High Risk Groups
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Jan 08 Feb 08 Mar 08 Apr 08 May 08 Jun 08 Jul 08 Aug 08 Sep 08 Oct 08 Nov 08 Dec 08
TriStar 92.3% 93.2% 94.1% 94.2% 95.5% 95.4% 96.0%
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0.0%
0.0%
0.0%
0.0%
0.0%
THA – August 2008
THA – August 2008
Central Line Infections
• Prolongation of hospitalization: 11-23
days
• Cost to healthcare system: $33,000 $35,000/episode
• Attributable mortality: 12-25%
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Central Line Bundle
1.
2.
3.
4.
Hand hygiene
Maximal barrier precautions
Chlorhexadine skin antisepsis
Optimal catheter site selection, with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5. Daily review of line necessity with
prompt removal of unnecessary
lines
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CLBSI System/Process Improvement
• Healthcare worker education
– Hand hygiene
– Practice guidelines/IHI Bundles
– Checklist pocket reminders
– Medical staff education on bundles
– Checklists for line insertion
– Surveillance rates to determine current
performance
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CLBSI System/Process Improvements
• Supply Chain
• Evaluation of all kit components for
chlorhexadine
• Drape and barrier availability through
supply chain and all-inclusive carts
• Computer screen standardization
– Checklists on screen (or paper)
– Daily site surveillance review of necessity
added to flowsheet
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CLBSI Measurement and Feedback
• Computer screen standardization
– Automatic capture of data for
documentation and data collection
• Physician documentation tools
• Insertion observation
• Performance feedback
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Central Line Insertion Monitor
DATE:________________
PHYSICIAN INSERTING:_____________________________
SITE:  IJ
 Subclavian
 PICC
 Femoral
 NOTE: PICC or SUBCLAVIAN sites preferred. If not utilized, must document justification for
utilizing another site. 
 Morbid Obesity
 Respiratory Condition Prohibiting
 Emergency
_______________________________________________________________________
_______________________________________________________________________
 HAND HYGIENE performed by MD and Assistants?
 MASK worn by MD?
 STERILE GOWN worn by MD?
 STERILE GLOVES worn by MD
 LARGE STERILE DRAPE used?
 CAP worn by MD?
 CHLORAPREP used? Back and forth motion for 30 seconds/allow to dry for 30 seconds
 OTHER PREP used? If “Y”, explain:
 CXR Ordered/Completed?
Nurse:___________________________________________________
 REMEMBER: Nurse must document ALL Vascular Line STARTS on IV Screen!
THA – August 2008
SCIP
• Among patients admitted for surgery, SSIs account
for 38% of hospital-associated infections
Emori & Gaynes, Clinical Micro Reviews, 1993
• On average, SSI results in 7.3 excess hospital
days and adds $3150 to cost of hospital care (1992
dollars)
CDC, MMWR, 1992
• Cost of treatment for an SSI associated with total
joint replacement (hip or knee) is $50,000
Hanssen AD et al, J Bone Joint Surg Am, 1992
THA – August 2008
Proportion of Adverse Events
Most Frequent Categories
25%
Non-surgical
Surgical
20%
15%
10%
5%
0%
Drugrelated
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Wound
infect.
Tech.
comp.
Late
comp.
Diag.
mishap
Therap. Nontech. Proc.
mishap comp. related
Brennan. N Engl J Med. 1991;324:370-376
SCIP National Quality Measures
SCIP 1 Prophylactic antibiotic received within one hour prior to surgical
incision
SCIP 2 Appropriate prophylactic antibiotic selected for surgical patients
consistent with current guidelines
SCIP 3 Prophylactic antibiotic discontinued within 24 hours after the end of
surgery (within 48 hours after the end of surgery for CABG or other
cardiac surgery)
SCIP 4 Cardiac surgery patients with controlled 6 A.M. postoperative blood
glucose < 200mg/dL on Post Op Day 1 AND Post Op Day 2
SCIP 6 Surgery patients with appropriate hair removal
SCIP 7 Colorectal surgery patients with immediate postoperative
normothermia > 98.6*F within first 15 minutes after leaving OR
THA – August 2008
SCIP Leadership & Responsibility
• Surgical services director may be a logical leader
for SCIP compliance throughout the facility (IC,
Quality)
• An executive sponsor is needed to support the
director in implementing changes
• A physician champion, surgeon or anesthesiologist,
is needed to assist with education and address
physician practice issues.
• The quality director should provide frequent
updates on performance and opportunities for
system and process improvement
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3
7
SCIP System/Process Improvements
• Evidence-based order sets
– Preprinted, service-specific preprinted orders
• Preop and post-op
– Antibiotic dosing charts
• Communication
–
–
–
–
Scripted time-out poster
Hand-off
Pharmacy notice of close time, times next dose(s)
Antibiotic dosing
• IT Screens
– Prompts, reminders, required fields, inclusion of
antibiotic administration in OR nursing documentation
(IV unless otherwise)
– Positive DVT screen, then auto-printing of pre-printed
order
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Improvement through IT System
• Core Measures are embedded in the
following screens*:
–
–
–
–
–
–
–
Pre-op Prep
Pre-op Outcomes
Intraoperative RN Checklist and Assessment
Intraoperative Prep
Intraoperative RN Outcomes
PACU Admission Assessment
PACU Outcomes
* Screens reflect core measures for discharges effective 10/01/07 to 3/31/07.
Core measure screens will be updated as data elements change. SCIP Core
measure related queries are worded EXACTLY as defined by National Hospital
Quality Measures.
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Screen Example
•
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If razor is selected for hair removal method, a “pop-up” box will
appear for the nurse to confirm that razor is the accurate
response.
Education
SCIP Measures
Poster
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4
1
Checklists
Time Out Poster
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SCIP Improvement Tactics
System/Process Improvement Tactic
Measures Impacted
Evidence based order sets
(Pre-operatively & Post-operatively)
SCIP 1, 2, 4, 7
SCIP VTE 1, 2
Antibiotic dosing chart and selection
chart
SCIP 1,2,3
Computer screen standardization
SCIP 1,2, 6,VTE 1, VTE 2,
CARD 2
VTE mechanical and chemical
prophylaxis chart
SCIP VTE 1, VTE 2
Pharmacy review of medication
orders
SCIP 1, 2, 3, 4,VTE 1, VTE
2, CARD 2
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SCIP System/Process Improvements
• Education and Competency
– Clinical Staff
– Physician
– Abstractor
•
•
•
•
Worksheets
Standard Order sets
IT Screens
Core Measures designated “bulleted” on order
sets
• Pharmacy interfaces (close time report)
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Core Measure Concurrent Management
• Concurrent management
– Core measure checklist on charts
– Interact with physicians & staff
• Preview OR schedule
• Presence in PAT, PACU, and floor
– Debriefing forms
•
•
•
•
Form
Abstraction tool
Applicable portion of medical record
Routed/reviewed with Clinical Service Director
– Real-time understanding of process and
opportunities
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Concurrent Abstraction
•
•
•
•
•
Real-time opportunity to improve
Feedback
Within 7-10 days
Correlation with improved performance
Abstraction
– Into Vendor System
– Into Clinical Documentation System
• Rolls into Vendor system
– Into Quality Management Module
• Rolls into Vendor system
THA – August 2008
Measurement and Feedback
• Performance
– Employee
• 1:1
• Director
– Physician
•
•
•
•
•
•
•
1:1 (verbal or written)
Hospitalist Coordinator
Medical Director
Ongoing Professional Practice Evaluation/Profile
Peer Review?
Incentive Plan
Profile for Ongoing Professional Practice Evaluation
(OPPE)
• Medical Director or Clinical Service Director
– Department, Facility, and Division Comparison
THA – August 2008
Measurement and Feedback
• Weekly Core Measure Meetings
– Laptop with system access
– Review rationale, record, TJC,
– Directors of clinical services (ED, Ph, ICU, Nsg, OR, ER,
Q, CNO, Hospitalist Coord.)
– Current outliers
– Export to EXCEL – to director of that area, dates, MR#,
during meeting
– Follow-up on previous and new outliers
• Facility Feedback
– Routinely at all meetings (Department, Quality, MEC, Board)
• Division
– Weekly metrics
– Quarterly/annual trends and comparisons
THA – August 2008
Important to Remember…
• Core measure requirements are
revised and changed every April and
October.
• Be sure you get the updates and
change your practice accordingly.
• These measures are evidence
based and as the evidence changes
and progresses, so do these
measures.
• Ultimate in continuous improvement
cycle.
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TriStar Division Measurement
• Metrics
– MRSA Reports
– HAC Reports
– Hand Hygiene
– Concurrent management
– Concurrent abstraction
– Weekly metrics
– QOR Review
– QM review screens
THA – August 2008
THA – August 2008
HOSPITAL ACQUIRED CONDITIONS
COUNTS BY FACILITY - June 2008
Count of ACCOUNT # Category
FACILITY
Cath-assoc. UTI
A
B
C
D
E
F
G
H
I
J
K
L
Grand Total
THA – August 2008
Decubitus
Fracture
3
1
2
1
1
2
1
1
3
1
3
1
1
2
3
18
1
7
Intracranial Injury Grand Total
4
2
1
1
2
1
4
1
5
1
1
2
3
1
27
Improvement Triad
Leadership
Success
Measurement
and Feedback
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System and Process
Improvements
Measurement / Celebration
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Measurement
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Steps
•
Leadership must understand where you are and what the improvement
opportunity is
•
Thoroughly understand the evidence behind the clinical care recommendations
•
Flowchart to clearly understand the current clinical practice to determine gaps
between care and EBM
•
Deliver clinical care message at facility staff and physician staff meetings
–
Include data that illustrates where hospital stands in current performance
•
Improve systems and processes through adoption of evidence - based
practices (tools, policies, orders, algorithms, systems)
•
Revise forms and processes to implement practices from high-performing
facilities
•
Meet individually with physicians that have specific concerns
•
Measure performance and provide feedback
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THA – August 2008
Thank You!
Shared Learning for
Infection Prevention
THA Collaborative
August 2008