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Shared Learning for Infection Prevention

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1 Shared Learning for Infection Prevention
THA Collaborative on Reducing HAIs August 2008 Tori Howk, Director of Risk and Regulatory Thank you, Darlene Good morning everyone. My role 17 hospitals in KY, TN, and north Georgia. See ____________patients

2 Collaborative Aims Improve the culture of safety
Reduce patient harm by reducing CLBSI MRSA 25% reduction in surgical complications by implementing SCIP Whatever we do, we want to do it the best way we can. For you, that may be raising family, hobby, or at work in the hospital or other healthcare organization. And when you go about that activity, you look to others for advice, ideas, best practices, outcomes? Not an IC expert. Come to you in the name of sharing. Improvement and sharing: Part of the job I love. Culture – manner in which we go about this. The environment, norms, expectations, and history. Reduce harm: Not just because CMS, TJC, Leapfrog, NQF, CDC, etc., Something to do with your relatives, my family, and our friends. So to do this, it takes a team. Teamwork, might be overstated, but still critical. We are in this together! THA – August 2008

3 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.” Congratulations to the ICP’s. Now “preventionists” per APIC. Previously it was the Infection Control Nurse, IC Coordinator, IC Practitioner, now this is more fitting. Tremendous undertaking and responsibility to reduce infections in an organization. Responsible to develop and direct PI activities to save lives THA – August 2008

4 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. How BAD is this, and why are we in this situation? CDC estimates that $5billion to US healthcare costs every year…Much greater impact now. “Not following recommendations”, CMS in their HAC transmittal a couple weeks ago “Not following recommendations”, Leapfrog Information is out there. Amazed at the volume of material, evidence, and “case” for improvement. Haven’t adopted them quickly enough. Why? Because it’s difficult to keep up. Not b/c don’t know or don’t care. Complex inter-woven systems and processes involved. Humans – want to do a good job, but distracted, forget, tired, I do it differently, no standard process or systems to support that. THA – August 2008

5 Benefits of Reducing Infections
Better patient outcomes Reduced mortality Improved satisfaction Physician Nursing Patients and families Financial benefits So this is WHY we need to improve. For clinical reasons obviously, but also the business case for Infection Control to reduce infection. Through core measures, we have seen a willingness to support the business case for Quality. Why we’re going to do it THA – August 2008

6 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 HOW we can do it IHI defines a “bundle”, like Central Lines. For infection prevention, substitute a group of strategies related to infection prevention, when implemented together, result in better outcomes than when implemented individually. The combination of various tools, techniques, related systems, that create the improvement. Orchestra, a clarinet, while a lovely sound, contributes far more as part of the ensemble than alone. We will talk about a multi-pronged approach we undertook (underTAKING) to improving systems and processes, and thus results. THA – August 2008

7 What Are Hospital Acquired Conditions? (HAC)
Section 5001(c) of the Deficit Reduction Act (DRA) of 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) The HAC listing, out this year & recently updated for new hospital acquired conditions. Medicare will no longer pay the higher weight DRG if is identified through coding as a CC. Rate adjustment for Hospital-Acquired Condition payments CMS will then collect, compare, and display HAC rates THA – August 2008

8 Hospital-Acquired Conditions (HAC)
Never Events/Rare Occurrences Patient Safety Infection Prevention Delivery of ABO-Incompatible 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 By Category Infection Prevention last column, highlighting 3 major areas and 5 conditions. 3 of which are specific surgery types THA – August 2008

9 TriStar Shared Learnings
MRSA Central Line Bloodstream Infections SCIP So the opportunity for Infection Prevention is deep and wide. For MRSA, Central Line BSI, and SCIP, I will share some approaches that we have found effective in our company, in our division, and in our hospitals. Shared learning. THA – August 2008

10 Improvement Triad THA – August 2008
Leadership – about culture and expectations. Friend…Fish rots from the head down. Leadership is essential. Sets the tone, provides direction and resources, supports the work of the subject matter experts. Systems and Process Improvements Anytime the process is standardized, the risk of error decreases. Still humans, and there will be risk of error (or noncompliance), but it will be minimized. Make it easy to do it right and hard to do it wrong. Measurement and Feedback We improve what we measure. Need feedback; want feedback; perpetuates the improvement cycle. Also readjusting. THA – August 2008

11 Approach Understand the opportunity Collaborative Improvement
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 The basic process improvement is essential. It is an approach to improving, tried & true PI model. Opportunity: Determine where your performance is now Establish the priorities Colllaboration: Develop a team of individuals who have the knowledge, skills, and abilities to facilitate change. Compare current practice with science. Research “smart people”. Understand the evidence and literature Share Implement the changes Change is hard; people get into habits. If can recognize the need for change, can believe in it, work through it, support it, and sustain it. Measure Celebrate Complex set of initiative such as these, stick to the plan. Don’t forget any step of this. Cycle 1Gap Analysis Conduct gap assessment of current practice Completed accurately and verified Identify gaps Individualize project plan based on gaps Update project plan based on results Specific tasks for HAC MD education or awareness MEDITECH documentation implementation Changes to supplies Implementation of protocols Facility-Defined Action Plan for HACs with Gaps Revise policies, procedures, competencies, etc. Educate staff on changes Implement changes Other tasks as identified by facility Effectiveness monitored by POA report and ongoing reviews Carefully read the guidance documents and resources Compare and assess hospital’s process and protocol to the guidance documents, and revise as necessary Revise related clinical practices as needed Raise hospital and medical staff awareness of the risks and evidence-based prevention strategies through education Revise/implement forms and documentation tools as needed THA – August 2008

12 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 HCA Same message with all Costs (human, economic, and society) Preventable Evidence published to prevent THA – August 2008

13 Active Surveillance (Systems/Processes)
Active Surveillance, the first system and process change THA – August 2008

14 Active Surveillance High Risk Patient Screening
Previous MRSA history Preoperative Screens Total hip Total knee Open spine procedures Cardiac surgeries Private rooms, cohorting, and isolation ICU admissions/transfers Outborn transfers to NICUs Long term care facility admissions Hemodialysis admissions Process changes involving Admissions, Infection Control, Surgery, ICU/Nursing, Physicians THA – August 2008

15 Barrier Precautions THA – August 2008 Barrier Precautions – not new
Signs placed THA – August 2008

16 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 THA – August 2008

17 Compulsive Hand Hygiene
Signage at doors, patient care areas, brochures, letters to patients THA – August 2008

18 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 THA – August 2008

19 Disinfection/Environmental Cleaning
Great work with EVS Specialized education THA – August 2008

20 Disinfection/Environmental Cleaning
Proper disinfection techniques Proper supplies Proper equipment Environmental services education Workload analysis Observation for adherence THA – August 2008

21 Executive Ownership/Leadership
Executive and Physician Champions Interdisciplinary taskforce Executive walk arounds Medical Executive Committee engagement MEC and Board reports Recognition and reward THA – August 2008

22 Campaign Executive messaging Collaborative calls
Patient/visitor information cards Banners, posters, buttons, static clings Waterless sanitizer/soap dispenser signage Isolation signage Staff newsletters Electronic triggers and trackers THA – August 2008

23 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 Clean hands are cool hands site and campaign for kids THA – August 2008

24 Measurement - 2007 MRSA Swabbing Rate
Original goal was 80% THA – August 2008

25 2008 MRSA Swabbing Rate Goal of 90% THA – August 2008

26 THA – August 2008

27 THA – August 2008 How long implemented
We knew from those we caught on the front-end that we would impact MRSA and decrease risk of transmission. Study / results? THA – August 2008

28 Central Line Infections
Prolongation of hospitalization: days Cost to healthcare system: $33,000 - $35,000/episode Attributable mortality: 12-25% Same message: Cost Preventable Evidence – slow to adopt THA – August 2008

29 Central Line Bundle 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 Daily review of line necessity with prompt removal of unnecessary lines You are familiar with this THA – August 2008

30 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 TriStar examples Checklist computerized now, previously paper tool or poster THA – August 2008

31 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 THA – August 2008

32 CLBSI Measurement and Feedback
Computer screen standardization Automatic capture of data for documentation and data collection Physician documentation tools Insertion observation Performance feedback THA – August 2008

33 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! Observation – 100% Nurse pulls out form THA – August 2008

34 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 Significant financial, resource, and human costs THA – August 2008

35 2nd highest adverse event
THA – August 2008

36 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 Company Division Facility-specific Toolkits, shared sites, signage THA – August 2008

37 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 Move to first Champion for CLBSI and MRSA, too. Someone needs to “own” it, knowing it will be a team activity Leadership is key, nothing will happen without that. Message, visibility, resources, removing barriers, and acknowledge progress MD / Surgeon champion is key. Change is not their friend. Quality source for improvement, data, and compliance THA – August 2008 3737

38 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 THA – August 2008

39 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. THA – August 2008

40 Screen Example Tremendous support from IT (Division – facility). Meets with users and key stakeholders (Pharmacy, IC, Falls team, RT, Nursing) Working currently on HAC screen modifications 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. THA – August 2008

41 Education SCIP Measures Poster Sample THA – August 2008 4141

42 Checklists Time Out Poster THA – August 2008 42 Checklists
Human Factors previous work Retained foreign body Pre-procedure time-out THA – August 2008 42

43 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 Summary grid of improvement tactics THA – August 2008 43

44 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) Webcasts CBT Just-in-time reminders Executive walk-arounds Order sets to prompt physicians “I’ll do anything; just prompt me along. I can’t keep up with it all.” Core measures change too much. IT screens to guide clinicians and also capture data Bulleted with blue ribbon on order sets Pharmacy involvement. Close time prints on one report, scanned to Pharmacy, movement of patient to the floor. Sets antibiotic d/c time THA – August 2008

45 Core Measure 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 Clinical director for employee and/or MD Hospitalist coordinator for MD Talk about “relationships”. The quality of the product (or service) is directly proportional to the quality of the relationship involved between those who create it. You can see it. THA – August 2008

46 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 3 days for bill to drop Data pulled from Coding System Compared to coding guidelines for HAC Sent back out to hospitals SPAE THA – August 2008

47 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

48 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 Show why didn’t meet Homework Followup with old and then new one Bottom line: a living priority, active management, intimate knowledge of the process and the people doing that. “dog it” THA – August 2008

49 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. The consummate improvement initiative. Constant, targets moving, everyone is getting better, entire team, leadership priority, stakeholders recognize quality and the return, CFO $ & Core measures? continual cycle of evaluating current performance, understanding opportunities and “misses”, implementing changes, leading the change, re-evaluating, etc. THA – August 2008 49

50 TriStar Division Measurement
Metrics MRSA Reports HAC Reports Hand Hygiene Concurrent management Concurrent abstraction Weekly metrics QOR Review QM review screens Collaborative Don’t reinvent the wheel Familiar Visible High-profile from employees to leaders, physicians, and Division leaders What gets measured gets improved THA – August 2008

51 Every Monday To everyone Comments THA – August 2008

52 New HQC From Coding system, using coding guidelines and ICD9 codes THA – August 2008

53 Improvement Triad THA – August 2008 Again…
Leadership – about culture and expectations. Leadership is essential. Sets the tone, provides direction and resources, supports the work of the subject matter experts. Systems and Process Improvements Anytime the process is standardized, the risk of error decreases. Still humans, and there will be risk of error (or noncompliance), but it will be minimized. Make it easy to do it right and hard to do it wrong. Measurement and Feedback We improve what we measure. Need feedback; want feedback; perpetuates the improvement cycle. Also readjusting Measurement. Leadership, critically important. Serious role being responsible for the heatlhcare outcomes of those who come to us trusting for safe and effective, and compassionate healthcare. One of our leaders is so passionate about this professional responsibility… THA – August 2008

54 Measurement / Celebration
All “green” Weekly! Personal responsibility… anything more personal than your hair? Especially the “color”? THA – August 2008

55 Measurement THA – August 2008 Yellow and green
An “opportunity for improvement” Red? THA – August 2008

56 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 Circle goes around, never-ending, 100% reliable healthcare THA – August 2008 56

57 THA – August 2008 Just when you think you aren’t going to make it.
You can’t handle one more CMS transmittal, core measure change, or external source for advice… You can. Because… THA – August 2008

58 Shared Learning for Infection Prevention
Thank You! Shared Learning for Infection Prevention THA Collaborative August 2008

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