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Shared Learning for Infection Prevention THA Collaborative on Reducing HAIs August 2008 Tori Howk, Director of Risk and Regulatory.

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Presentation on theme: "Shared Learning for Infection Prevention THA Collaborative on Reducing HAIs August 2008 Tori Howk, Director of Risk and Regulatory."— Presentation transcript:

1 Shared Learning for Infection Prevention THA Collaborative on Reducing HAIs August 2008 Tori Howk, Director of Risk and Regulatory

2 THA – August 2008 Collaborative Aims Improve the culture of safety Reduce patient harm by reducing CLBSI MRSA 25% reduction in surgical complications by implementing SCIP

3 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.

4 THA – August 2008 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.

5 THA – August 2008 Benefits of Reducing Infections Better patient outcomes Reduced mortality Improved satisfaction –Physician –Nursing –Patients and families Financial benefits

6 THA – August 2008 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 Institute for Healthcare Improvement

7 THA – August 2008 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 years rule. (5 HAIs)

8 THA – August 2008 Hospital-Acquired Conditions (HAC) Never Events/Rare Occurrences Patient SafetyInfection 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 EmbolismGlycemic Control Catheter-associated urinary tract infections Pressure Ulcers/DVT

9 THA – August 2008 TriStar Shared Learnings MRSA Central Line Bloodstream Infections SCIP

10 THA – August 2008 Improvement Triad Success

11 THA – August 2008 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

12 THA – August 2008 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

13 THA – August 2008 Active Surveillance ( Systems/Processes)

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

15 THA – August 2008 Barrier Precautions

16 THA – August 2008 Standard precautions for all patients Contact isolation of positive patients Personal protective equipment Gown Gloves Mask with shield Dedicated equipment Ticketing for non compliance Barrier Precautions

17 THA – August 2008 Compulsive Hand Hygiene

18 THA – August 2008 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 Compulsive Hand Hygiene

19 THA – August 2008 Disinfection/Environmental Cleaning

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

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

22 THA – August 2008 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 Campaign

23 THA – August 2008 Target audience--patients, caregivers, physicians, non-clinical staff, visitors, volunteers, vendors Community collaborationEMS, local health department, other healthcare providers Data collection, analysis, and dissemination Campaign

24 THA – August 2008 Measurement MRSA Swabbing Rate

25 THA – August MRSA Swabbing Rate

26 THA – August 2008


28 Central Line Infections Prolongation of hospitalization: days Cost to healthcare system: $33,000 - $35,000/episode Attributable mortality: 12-25%

29 THA – August 2008 Central Line Bundle 1.Hand hygiene 2.Maximal barrier precautions 3.Chlorhexadine skin antisepsis 4.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

30 THA – August 2008 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

31 THA – August 2008 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

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

33 THA – August 2008 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!

34 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

35 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

37 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 37

38 THA – August 2008 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

39 THA – August 2008 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.

40 THA – August 2008 Screen Example 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.

41 THA – August 2008 SCIP Measures Poster 41 Education

42 THA – August 2008 Time Out Poster 42 Checklists

43 THA – August 2008 SCIP Improvement Tactics System/Process Improvement TacticMeasures 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 standardizationSCIP 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 43

44 THA – August 2008 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)

45 THA – August 2008 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

46 THA – August 2008 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

47 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

48 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

49 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. 49

50 THA – August 2008 TriStar Division Measurement Metrics –MRSA Reports –HAC Reports –Hand Hygiene –Concurrent management –Concurrent abstraction –Weekly metrics –QOR Review –QM review screens

51 THA – August 2008


53 Improvement Triad Success

54 THA – August 2008 Measurement / Celebration

55 THA – August 2008 Measurement

56 THA – August 2008 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 56

57 THA – August 2008

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

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