Presentation on theme: "PI CME in a Community Hospital"— Presentation transcript:
1 PI CME in a Community Hospital Nancy Carrier, RN, BSNQuality SupportTift Regional Medical CenterTifton, 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 AuthorityState accredited CME providerStaff- 120 physicians on staff representing 15 specialties- 1,600 employees
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 structureOutreach 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 DirectorCME - monthlyRSS Activities (4)Other Activities:Physician case based research (PoC)Enduring CMEPI CME
8 PI CME Started in 2007 with first project on Sepsis Developed a model for all future projectsChange 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 meetingBack ground research done
10 Needs AssessmentThe MRSA Risk assessment for 2008 revealed an increase in SSI with MRSAOrthopedic statistics were the highestIncrease in community acquired MRSA in areaPatients 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 identifiedOnly patients with acute infections are culturedNo decolonization guidelines for patientsNo formalized educational support resourcePre op antibiotic selection not consistent
12 Where do you go to get this information? Close the GAPResearch Best Practice – evidenced basedIdentify national performance measuresHow 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)CDCNational OrganizationsEvidenced 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 & ObjectivesScreen 100% of patients scheduled for elective total joint replacements for MRSA during their pre op assessmentAll colonized patients will complete a decolonization protocol before surgery2% mupirocin ointment to nose bid x 5 days pre-op4% chlorohexidine gluconate body wash x 5 days pre-opColonized patients will be screened again prior to surgeryColonized patients will be placed in Contact Precautions upon admission
16 Goals & Objectives Patient Outcomes Surgical site infections will decrease in total joint patientsReduce use of Vancomycin for surgical prophylaxis
17 PI CME – 1st steps This PI CME project started in March, 2009 Planning startedCME & QI brainstormingIC and the Ortho group requested to “take on the challenge”Provide background information & literatureNeeded to identify championIC Committee chair
18 Project leader / physician champion Passion for the projectFinalize team members identified to participateInvited physicians to participate by letterFollow up with a phone callWant cross section representation of all departments involved when ever possibleWe 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 nursesInfection PreventionistOrthopedic PAsPharmacyQI/ Data analysistCME
20 Initial kick-off meeting Provide a meal for the initial meetingOverview of QI / PI CME activityEstablish ground rulesPeer protectionConfidentialityExpected time frameWhat commitment would involveRequired to sign letter of commitmentEducational backupLiterature & articlesWeb sitesGrand rounds and 1:1 time with expertBenefits of participantsBecome resources for peersDevelop guidelines they would be measured againstCME CreditSeveral free lunches / dinners
21 Next Steps Letter of Commitment Confirmation of goals Schedule of future meetingsReading AssignmentSHEA/IDSA Practice Recommendation, “Strategies to Prevent Transmission of MRSA in Acute Care Hospitals” Oct 2008CDC “Management of Multidrug-Resistant Organisms” 2006
22 Meeting Calendar Dinner Kick-off and assignments Sub-Committee report backGuideline draft presented / approvedGuideline roll-outPossible Grand RoundsFinal Meeting / Wrap-up
23 Letter of CommitmentYou 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 monthsparticipation _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: PediatricsDr phone:Title: Pre-op MRSA screening & treatment for elective Total Joint ReplacementsPurpose: 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 ICConfidentiality: committeeExpectations: 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 measuresReview their commitment and documentation required to be awarded creditAnswer all questions
26 Stage A Learning from current practice performance assessment The team Physicians review patient dataMay request additional informationObjectives for PI CME activity are definedPublic reportingReview current practice and make recommended changes in physician practice (hospital-wide)Develop P&P as neededStandardize educational materialsDevelop Stage A measuresPhysicians challenged data which required further record reviewsPhysicians involved office practices for additional dataThese objectives were defined and fine tuned by the 14 physicians in the project
27 MRSA Screening Performance Measures GoalIndicatorDefinition100%Percent of population screenedNumber of patients cultured/number of planned total hips and kneesPercent compliant with decolonization protocolNumber of colonized patients who completed decolonization protocol/number of colonized patientsEffective decolonizationNumber of negative follow up screens/number completing decolonization< 1%Surgical Site Infection (SSI) rate for total hips and kneesNumber of SSIs/total number of hips and kneesPatient Education on MRSA screeningNumber of patients receiving education/number of patients screenedEstablishTRMCPrevalencePercent of populations colonized with MRSANumber 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 proceduresProvide surgical and orthopedic staff educationProvide patient educationStandardize educational materials for patientsDevelop discharge planning tools for patientsDevelop checklistsWrite policies and proceduresReview antibiotic practicesWe used IHIs sepsis bundle template as the 7 measures for the groups to customize to TRMCThis 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 approvalStaff educationMRSAPre-op assessments and schedulingNasal swabbingMedications usedDocumentation requirementsPatient educationMRSA bookletPre op & post op instructions
30 Building patient & hospital interest Living with MRSAThis is really serious! I need to do something about this now!Learning how to control the spread ofMethicillin-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 ProtocolPeople 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 tominimize 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 implementedAnalyze chart reviewsReview compliance with new guidelinesImplementation successDetermine opportunities for improvementDo 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 dataGuidelines are reviewed & edited as neededComplete final evaluation & credit request formsAWARD 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 electivetotal joint replacementsApril, 2009Stage CActivity: please check areas you have completed, respond to the questions and signI completed the implementation plan for the Performance Improvement CME project for MRSA InitiativeI evaluated the progress made through implementation of this planPlease describe below whether the intervention (Individual Action Plan)you implemented improved your department practice/performance inthose areas identified. If not, please provide an explanation as to why.Factors such as systems failures or other barriers to success should beincluded……..
35 Results from activity Goal Indicator Results 100% Percent of population screenedPercent compliant with decolonization protocol92%Effective decolonization< 1%Surgical Site Infection (SSI) rate for total joint replacements0.67%Patient Education on MRSA screeningEstablishTRMCPrevalencePercent of populations colonized with MRSA17%All this data has beencollected since 5/18/09
36 Barriers Identified Determining benefit of active surveillance screeningMonitoring compliancewith decolonizationFollow up on decolonizationfailuresAvailability of 4% chlorohexidine gluconateCompliance with ContactPrecautionsThis was a learningcurve that soon wasovercomeThis was based onpatient report so was out ofour controlA discharge instruction sheet was designed
37 BenefitsPre-op showers with4% chlorohexidine gluconate for alltotal joint patientsImproved compliance withContact PrecautionsStandardized patienteducation on MRSADeveloped dischargeinstructions for patients colonizedwith MRSAAppropriate use ofVancomycin as a pre-op antibioticSSI rate decreased (>50% through 2010)TRMC now uses all 4% chloro-hexidine gluconate showers for ALL surgeries not just jointsStaff education and awarenesson Ortho unitMRSA booklet providingstandardized educationP&P developedMarketing tools and postersDecrease in Vancomycin useimproving resistance rates
38 Recommendations Any implants such as hernia mesh as well as Continue MRSAscreening for total jointsand extend to otherproceduresConsider 4% chloro –hexidine gluconate for all pre-op showersInvestigate all surgicalsite infections and observe forany trends or common linksAny implants such ashernia mesh as well asall spinal implants.
39 Final Discussion & Roll Out Physician champion & IC presentedfindings to the hospital QualityCouncil then to the BoardThis data will be presented at theDepartment of Surgery. Even thoughthe hernia infection rate is <1.5%, thereis always room for improvementIC will work on a cost analysis forprevention costs as compared toinfection costs (selling point for admin)All implants must be followed forinfections for 12 months. At the end ofthis time, IC will report a final infectionrate.20 Category one credits will beawardedGreat Job!Presentation to QualityCouncilGeneral SurgeonEducationCost analysisFinal report from InfectionControlCME creditsAdjournment
40 Tips for engaging physicians Recruit a strong physician leaderFollow the “ground rules” established in your first meetingKeep within the time frames agreed uponMake sure it is physician drivenFeed them!SHOW THEM THE DATAWhen physicians make the decisions, the outcomes are more successfulThis is a lesson we have learned the hard wayPhysicians 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 projectPreparations for each meeting(pre-meeting meetings)Clear expectationsDefined budgetFoodCelebrate successOne of the project physicians was the VP Medical AffairsHave 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 peersBe prepared for the time commitmentStrong non-medical leaderCME Director backingRecord keepingFacilitate CME complianceAfter the first project; you establish your own “model” which can lead into the next projectWe are taking one “big project” a year to help change physician practice and improve patient outcomesPlus you learn tips to make the next easier and better
43 Comments from the MRSA Physician Champion It IS doableRecommend a strong support teamThe Physician champion will coordinate with the support staff to keep everyone working in the same directionBe available by phone or ; it will save on overall time commitment and meetings
44 Just play! Have fun. Enjoy the game! -- Michael Jordan
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