1. PI CME in a Community Hospital
Nancy Carrier, RN, BSN
Quality Support
Tift Regional Medical Center
Tifton, GA

2. About Tift Regional Medical Center (TRMC)
Located in South Central Georgia
- Combined service area population - 250,400 (12 counties)
Governed by Hospital Board Authority
State accredited CME provider
Staff
- 120 physicians on staff representing 15 specialties
- 1,600 employees

3. About TRMC - 176 acute care 15 skilled nursing - 1,093 deliveries
191 licensed beds
- 176 acute care
15 skilled nursing
2010 Volume
- 1,093 deliveries
- 48,833 ER patients
- 12,244 inpatients
- 110,412 outpatients
- 7,595 surgical cases

5. Medical staff structure
This slide is added to point out that the Sepsis group was defined as a sub committee of critical care to allow for peer protection. I will discuss this more into the presentation.

6. Hospital structure
Outreach and Development has several arms; one of which is CME and physician relations. As CME Coordinator, I wear several hats as most of us do. It is a part time position, but the social and marketing efforts are shared.

7. CME Program CME Committee (working committee)
Very active and committed Director
CME - monthly
RSS Activities (4)
Other Activities:
Physician case based research (PoC)
Enduring CME
PI CME

8. PI CME Started in 2007 with first project on Sepsis
Developed a model for all future projects
Change happens when physician driven

9. Pre-op MRSA screening & intervention before elective total joint replacements (TJR)
Needs identified by Infection control and discussed in the Department of Surgery medical staff meeting
Back ground research done

10. Needs Assessment
The MRSA Risk assessment for 2008 revealed an increase in SSI with MRSA
Orthopedic statistics were the highest
Increase in community acquired MRSA in area
Patients colonized with MRSA are at risk for developing a SSI following an ortho procedure & have a 3.4 x higher risk of death and 2 x greater hospital costs.

11. Define the “GAP”
Pre –op patients colonized with MRSA are not identified
Only patients with acute infections are cultured
No decolonization guidelines for patients
No formalized educational support resource
Pre op antibiotic selection not consistent

12. Where do you go to get this information?
Close the GAP
Research Best Practice – evidenced based
Identify national performance measures
How do you do this?
Where do you go to get this information?
new ACCME reporting criteria

13. Evidence based Performance Measures (examples)
Physician Quality Reporting Initiative (PQRI)
Physician Consortium for Performance Improvement (PCPI)
Institute for Healthcare Improvement (IHI)
CDC
National Organizations
Evidenced based literature research

14. MRSA CDC & Surgical Care Improvement Project (SCIP) Guidelines
SHEA (Society for Healthcare Epidemiology of America)
IDSA (Infectious Diseases Society of America)

15. Goals & Objectives
Screen 100% of patients scheduled for elective total joint replacements for MRSA during their pre op assessment
All colonized patients will complete a decolonization protocol before surgery
2% mupirocin ointment to nose bid x 5 days pre-op
4% chlorohexidine gluconate body wash x 5 days pre-op
Colonized patients will be screened again prior to surgery
Colonized patients will be placed in Contact Precautions upon admission

16. Goals & Objectives Patient Outcomes
Surgical site infections will decrease in total joint patients
Reduce use of Vancomycin for surgical prophylaxis

17. PI CME – 1st steps This PI CME project started in March, 2009
Planning started
CME & QI brainstorming
IC and the Ortho group requested to “take on the challenge”
Provide background information & literature
Needed to identify champion
IC Committee chair

18. Project leader / physician champion
Passion for the project
Finalize team members identified to participate
Invited physicians to participate by letter
Follow up with a phone call
Want cross section representation of all departments involved when ever possible
We may affirm absolutely that nothing great in the world has ever been accomplished without passion. -- Georg Hegel

19. Adding Support Staff Laboratory OR Day Surgery and Assessment nurses
Ortho nurses
Infection Preventionist
Orthopedic PAs
Pharmacy
QI/ Data analysist
CME

20. Initial kick-off meeting
Provide a meal for the initial meeting
Overview of QI / PI CME activity
Establish ground rules
Peer protection
Confidentiality
Expected time frame
What commitment would involve
Required to sign letter of commitment
Educational backup
Literature & articles
Web sites
Grand rounds and 1:1 time with expert
Benefits of participants
Become resources for peers
Develop guidelines they would be measured against
CME Credit
Several free lunches / dinners

21. Next Steps Letter of Commitment Confirmation of goals
Schedule of future meetings
Reading Assignment
SHEA/IDSA Practice Recommendation, “Strategies to Prevent Transmission of MRSA in Acute Care Hospitals” Oct 2008
CDC “Management of Multidrug-Resistant Organisms” 2006

22. Meeting Calendar Dinner Kick-off and assignments
Sub-Committee report back
Guideline draft presented / approved
Guideline roll-out
Possible Grand Rounds
Final Meeting / Wrap-up

23. Letter of Commitment
You are being asked to participate in a Performance Improvement study at TRMC that involves improving pre-op MRSA screening
& treatment of patients who are scheduled for elective Total Joint Replacements.
This form provides you with information about the expectations of the study and encourages commitment of about 6 months
participation _is the Director of this project and is available to answer any questions that may arise.
Please review the following information and if you agree to participate, please sign in the appropriate sections.
Name:
Practice Specialty: Pediatrics
Dr phone:
Title: Pre-op MRSA screening & treatment for elective Total Joint Replacements
Purpose: To develop protocols designed to decrease the incidence of SSI by MRSA, including active surveillance cultures to identify patients colonized with MRSA and decolonization of patients with MRSA prior to surgery.
Benefits: Improve patient care by decreasing the incidence of SSI in elective Total Joint Procedures caused by MRSA.
Cost: No cost will be accrued to you for participating; however, there will be a time commitment.
Compensation: You will not receive payment for participating. Up to 20 CME credits will be awarded commiserate with your participation. Educational opportunities will be provided and any expenses incurred such as travel will be reimbursed.
Privacy Information will be shared that must remain confidential. The information discussed in this group will be peer protected through the IC
Confidentiality: committee
Expectations: We will ask your commitment to reading all literature provided, to attend any planned CME conference, and participate in the project as outlined. Periodic evaluations will be provided for you to complete, including a summary at the end of the designated time frame of the project.
Monthly meeting time will be set. We understand that your time is important. We will start and stop on time. You may be asked to review data collection summaries to validate the results. All HIPAA sensitive information and peer review must remain confidential.
You have been informed about this project’s purpose, benefits and expectations and have been given the opportunity to ask questions. By signing,
you voluntarily agree to participate in this project.
_______________________________________ __________________
Signature Date

24. Unless commitment is made, there are only promises and hopes; but no plans.
-- Peter F. Drucker

25. CME credit Give overview of the PI/CME process Explain Stages A, B & C
Review the evidenced based performance measures
Review their commitment and documentation required to be awarded credit
Answer all questions

26. Stage A Learning from current practice performance assessment
The team Physicians review patient data
May request additional information
Objectives for PI CME activity are defined
Public reporting
Review current practice and make recommended changes in physician practice (hospital-wide)
Develop P&P as needed
Standardize educational materials
Develop Stage A measures
Physicians challenged data which required further record reviews
Physicians involved office practices for additional data
These objectives were defined and fine tuned by the 14 physicians in the project

27. MRSA Screening Performance Measures
Goal
Indicator
Definition
100%
Percent of population screened
Number of patients cultured/number of planned total hips and knees
Percent compliant with decolonization protocol
Number of colonized patients who completed decolonization protocol/number of colonized patients
Effective decolonization
Number of negative follow up screens/number completing decolonization
< 1%
Surgical Site Infection (SSI) rate for total hips and knees
Number of SSIs/total number of hips and knees
Patient Education on MRSA screening
Number of patients receiving education/number of patients screened
Establish
TRMC
Prevalence
Percent of populations colonized with MRSA
Number of positive initial screens/total number of patients screened

28. Stage B Learning from the application of PI to patient care
Develop guidelines for identifying patients colonized with MRSA and steps to take to initiate decolonization procedures
Provide surgical and orthopedic staff education
Provide patient education
Standardize educational materials for patients
Develop discharge planning tools for patients
Develop checklists
Write policies and procedures
Review antibiotic practices
We used IHIs sepsis bundle template as the 7 measures for the groups to customize to TRMC
This was not a small task as several of these measures required change in department practice such as lab bringing tests in house, change in the way tests were ordered and change in Emergency department practices.
But all the right players were in place because the docs did their homework in the beginning

29. Stage B interventions Development of new guidelines Staff education
Committee approval
Staff education
MRSA
Pre-op assessments and scheduling
Nasal swabbing
Medications used
Documentation requirements
Patient education
MRSA booklet
Pre op & post op instructions

30. Building patient & hospital interest
Living with MRSA
This is really serious! I need to do something about this now!
Learning how to control the spread of
Methicillin-Resistant Staphylococcus Aureus (MRSA)

31. Total Joint Replacement Pre-Operative Screening Protocol
There is a simple, painless nasal swab test for a potentially dangerous pathogen called Staphylococcus aureus, also known as MRSA (Methicillin-resistant Staphylococcus aureus). This test identifies people who are potential reservoirs of infection. You can carry MRSA in your nose or on your skin without displaying symptoms. Approximately 1 in 5 people carry MRSA. An approach called Active Surveillance Culturing could reduce MRSA infections in hospitals by more than 70 percent.
Total Joint Replacement Pre-Operative Screening Protocol
People who harbor these bacteria in their nose, or on their skin, are called “carriers,” or are “colonized” with the bacteria.
MRSA colonized patients are at higher risk for developing MRSA infections after surgery at their surgical site.
During your pre-op assessment, the nurse will use a Q-tip swab to collect a culture from your nose to determine if you are an MRSA carrier.
If you test positive for MRSA, someone will contact you with further instructions prior to your surgery.
Your doctor will order a nasal ointment to be applied to your nose twice a day for 5 days just prior to your surgery.
Since this bacteria could also be living on your skin, it is very important that you bathe once a day using the Hibiclens body wash for 5 days just before your surgery.
Hibiclens can be purchased from your local Pharmacy without a prescription.
We are very committed to providing you the best care possible.
It is very important that you follow these instructions to
minimize the risk of complications after surgery.

32. Stage C Learning from the evaluation of the PI effort
Final chart reviews began one month after guidelines were completed and interventions were implemented
Analyze chart reviews
Review compliance with new guidelines
Implementation success
Determine opportunities for improvement
Do something. If it works, do more of it. If it doesn't, do something else. -- Franklin D. Roosevelt

33. Final meeting with participating physicians
Project physicians review their individual data
Guidelines are reviewed & edited as needed
Complete final evaluation & credit request forms
AWARD CME CREDIT!
Develop plan to communicate changes & educate

34. Continuing Medical Education Credit Request for Performance Improvement Activity
TRMC pre-op MRSA screening & treatment for elective
total joint replacements
April, 2009
Stage C
Activity: please check areas you have completed, respond to the questions and sign
I completed the implementation plan for the Performance Improvement CME project for MRSA Initiative
I evaluated the progress made through implementation of this plan
Please describe below whether the intervention (Individual Action Plan)
you implemented improved your department practice/performance in
those areas identified. If not, please provide an explanation as to why.
Factors such as systems failures or other barriers to success should be
included……..

35. Results from activity Goal Indicator Results 100%
Percent of population screened
Percent compliant with decolonization protocol
92%
Effective decolonization
< 1%
Surgical Site Infection (SSI) rate for total joint replacements
0.67%
Patient Education on MRSA screening
Establish
TRMC
Prevalence
Percent of populations colonized with MRSA
17%
All this data has been
collected since 5/18/09

36. Barriers Identified Determining benefit of active surveillance
screening
Monitoring compliance
with decolonization
Follow up on decolonization
failures
Availability of 4% chlorohexidine gluconate
Compliance with Contact
Precautions
This was a learning
curve that soon was
overcome
This was based on
patient report so was out of
our control
A discharge instruction sheet was designed

37. Benefits
Pre-op showers with
4% chlorohexidine gluconate for all
total joint patients
Improved compliance with
Contact Precautions
Standardized patient
education on MRSA
Developed discharge
instructions for patients colonized
with MRSA
Appropriate use of
Vancomycin as a pre-op antibiotic
SSI rate decreased (>50% through 2010)
TRMC now uses all 4% chloro-hexidine gluconate showers for ALL surgeries not just joints
Staff education and awareness
on Ortho unit
MRSA booklet providing
standardized education
P&P developed
Marketing tools and posters
Decrease in Vancomycin use
improving resistance rates

38. Recommendations Any implants such as hernia mesh as well as
Continue MRSA
screening for total joints
and extend to other
procedures
Consider 4% chloro –
hexidine gluconate for all pre-
op showers
Investigate all surgical
site infections and observe for
any trends or common links
Any implants such as
hernia mesh as well as
all spinal implants.

39. Final Discussion & Roll Out
Physician champion & IC presented
findings to the hospital Quality
Council then to the Board
This data will be presented at the
Department of Surgery. Even though
the hernia infection rate is <1.5%, there
is always room for improvement
IC will work on a cost analysis for
prevention costs as compared to
infection costs (selling point for admin)
All implants must be followed for
infections for 12 months. At the end of
this time, IC will report a final infection
rate.
20 Category one credits will be
awarded
Great Job!
Presentation to Quality
Council
General Surgeon
Education
Cost analysis
Final report from Infection
Control
CME credits
Adjournment

40. Tips for engaging physicians
Recruit a strong physician leader
Follow the “ground rules” established in your first meeting
Keep within the time frames agreed upon
Make sure it is physician driven
Feed them!
SHOW THEM THE DATA
When physicians make the decisions, the outcomes are more successful
This is a lesson we have learned the hard way
Physicians do not want to be told what they should be doing even if it is right!

41. Lessons learned Administrative support Committed medical leader
Buy-in from medical staff participating in project
Preparations for each meeting
(pre-meeting meetings)
Clear expectations
Defined budget
Food
Celebrate success
One of the project physicians was the VP Medical Affairs
Have a calendar set with all the dates prescheduled so physicians can plan ahead

42. Advice for other CME providers
Utilize your Resources
(QI loves this stuff!)
Excitement with success!
Share your success with peers
Be prepared for the time commitment
Strong non-medical leader
CME Director backing
Record keeping
Facilitate CME compliance
After the first project; you establish your own “model” which can lead into the next project
We are taking one “big project” a year to help change physician practice and improve patient outcomes
Plus you learn tips to make the next easier and better

43. Comments from the MRSA Physician Champion
It IS doable
Recommend a strong support team
The Physician champion will coordinate with the support staff to keep everyone working in the same direction
Be available by phone or ; it will save on overall time commitment and meetings

44. Just play! Have fun. Enjoy the game! -- Michael Jordan