Presentation is loading. Please wait.

Presentation is loading. Please wait.

NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2

Similar presentations


Presentation on theme: "NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2"— Presentation transcript:

1 NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2

2 Speaker Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD
Medical Legal consultant 5447 Fawnbrook Lane Dublin, Ohio 43017 2 2

3 NQF 34 SAFE PRACTICES Released in 2003, updated 2006, 2009 and April 2010 These should followed in all healthcare facilities All clinical care settings to reduce risk of harm to patients A roadmap to preventing harm States 10 years after IOM report, To Err Is Human, uniformly reliably safety in healthcare has not been achieved

4 CHAPTER 7: Healthcare-Associated Infections
2010 NQF Report Culture Culture SP 1 CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards Structures & Systems Culture Meas., F.B, & Interv. Team Training & Team Interv. ID Mitigation Risk & Hazards CHAPTER 1: Background Summary, and Set of Safe Practices Consent & Disclosure Consent & Disclosure CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure Informed Consent Life-Sustaining Treatment Disclosure Workforce CHAPTERS 2-8 : Practices By Subject CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Nursing Workforce Direct Caregivers ICU Care CHAPTER 7: Healthcare-Associated Infections Hand Hygiene (Safe Practice 19) Influenza Prevention (Safe Practice 20) Central Line Associated Blood Stream Infection Prevention (SP 21P Surgical Site Infection Prevention (Safe Practice 22) Care of the Ventilated Patient (Safe Practice 23) Multidrug-Resistant Organism Prevention (Safe Practice 24) Catheter-Associated Urinary Tract Infection Prevention (SP 25) Information Management & Continuity of Care CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations Critical Care Info. Order Read-back Labeling Studies Discharge System CPOE Abbreviations Medication Management CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Med Recon. Pharmacist Central Role High Alert Meds Std. Med Labeling & Pkg Unit Dose Medications Hospital Acquired Infections CHAPTER 7: Hospital-Acquired Infections Prevention of Aspiration and Ventilator-Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Prevention Surgical Site Infection Prevention Hand Hygiene Influenza Prevention Asp +VAP Prevention Hand Hygiene Influenza Prevention Central V. Cath BSI Prevention Sx Site Inf. Prevention CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong Procedure, Wrong Person Surgery Prevention Perioperative Myocardial Infarct/Ischemia Prevention Pressure Ulcer Prevention DVT/VTE Prevention Anticoagulation Therapy Contrast Media-Induced Renal Failure Prevention Condition & Site Specific Practices Evidence- Based Ref. Anticoag. Therapy DVT/VTE Prevention Press. Ulcer Prevention Wrong-site Sx Prevention Periop. MI Prevention Contrast Media Use 1

5 Safe Practice 19 Hand Hygiene
Comply with current Centers for Disease Control (CDC) and Prevention Hand Hygiene Guidelines TJC has NPSG to comply with CDC or WHO 2009 guidelines TJC published document in 2009 on Measuring Hand Hygiene Adherence: Overcoming the Challenges and this is an important document IHI publishes “How-to Guide: Improving Hand Hygiene. A Guide for Improving Practices among Health Care Workers” Very important issue in reducing HAI

6 TJC Hand Hygiene NPSG Comply with current CDC or WHO hand hygiene guidelines and has 3 EPs, EP1 Implement a program that follows categories 1A, 1B, and 1C on one of the above, EP2 Set goals for improving compliance with hand hygiene guidelines, EP3 Improve compliance with hand hygiene guidelines based on established goals,

7

8 CDC Hand Hygiene Recommendations
CDC published guidelines Oct 25, 2002 at In CDC MMWR Recommendations and Reports, Report available at or go to Also new admission video on hand hygiene Hand hygiene interactive training class Monitored during infection control tracer by TJC

9

10

11 Hand Hygiene WHO Guidelines on Hand Hygiene in Health Care; Clean Hands are Safer Hands at Good website for children on importance of washing hands with colorful posters, puzzles, and quiz AT Henry the Hand at henrythehand.com Toolkits and posters at Clean your hand campaign at

12 Safe Practice 19 Hand Hygiene
Implement the CDC requirements with Category I requirements or WHO Encourage compliance with category II Ensure that all staff know what is expected of them with regard to hand hygiene Ensure compliance with hand hygiene

13 TJC NPSG FAQ

14 Safe Practice 20 Influenza Prevention
Comply with current Centers for Disease Control and Prevention (CDC) recommendations for influenza vaccinations for healthcare personnel and the annual recommendations of the CDC Advisory Committee on Immunization Practices for individual influenza prevention and control. CDC has website at

15

16

17

18 20 Flu Prevention Healthcare workers with direct patient contact should be immunization against the flu Unless contraindicated Patients should be immunized as per current CDC recommendations P&P on above along with flu program should be in place Document immunization status of all employees Implement CDC recommendations for flu prevention and control

19 20 Flu Prevention Educate staff on benefits of flu vaccine
Offer flu vaccine annually to all eligible healthcare personnel at no cost Use strategies such as flu cart, access during shift, modeling etc Also a TJC requirement CMS allows protocols for flu and pneumovac for patients

20 SP 21 Central Line -Associated Bloodstream Infection Prevention
Take actions to prevent central line-associated bloodstream infection (CLABSI) by implementing evidence-based intervention practices. 2011 CDC guidelines on recommendations Hospital Quality Reporting Program for ICU and NICU to CDC National Healthcare Safety Network (NHSN) Made popular by IHI How to Kit on central line bundle Keystone project showed wisdom of using checklist TJC 2011 NPSG Pa Patient Safety Authority has a toolkit on CLABSI risk reduction at

21

22 CDC Resources Has many resources on preventing catheter associated blood stream infection Device association module Central line insertion practices training course Many resources on MDRO and CDAD Note TJC requires the use of a checklist and need to place the checklist in the medical record or most hospitals have a checkbox that says central line checklist used

23 CDC Website

24 Keystone Project Changes Everything

25 Pa Patient Safety Toolkit

26

27 Revised How to Kit Central Lines

28 Safe Practice 21 Central Lines
Educate staff about central line-associated bloodstream infection (CLABSI) prevention who insert or maintain lines Use checklist Perform hand hygiene before you insert or manipulate Avoid using femoral vein for access in adults Use maximal sterile barrier precautions (mask, gloves, sterile gown, and cap by all involved in procedure)

29 Safe Practice 21 Central Lines
Use CHG alcohol if over two months of age and allow to dry Use protocol to disinfect catheter hubs, needless connectors and injection ports before accessing ports Remove nonessential catheters Perform surveillance and report data to nursing and medicine Use standardized protocol for nontunneled CVCs in adults and adolescents as changing transparent dressings every five to seven days

30 TJC NPSG Central Lines Implement best practices to prevent central line associated bloodstream infections, 13 EPS IHI has how to guides and other resources at (Keystone project) EP1 Educate staff and LIPs involved in procedures about HAI, central line infection and importance of prevention Must do education in orientation and annually and if procedure added to your job

31 TJC NPSG Central Lines Note that under reform law hospitals with ICUs or NICU must report central lines infections on the CDC National Healthcare Safety Network (NHSN) 2. Educate patients and families before inserting central line about central line associated bloodstream infection prevention (BSI), as needed 3. Implement P&Ps to reduce risk of BSI that meet regulatory and evidenced based standards

32 Central Lines P&P need to meet the regulatory requirements Need to be aligned with the CDC requirements And professional standards of care (APIC, AORN, SHEA, etc.) 4. Conduct periodic risk assessments for central line infection, measure BSI (blood stream infection) rate, and monitor compliance with best practices and how effective the prevention efforts are Need to do risk assessment conducted in the time frames defined by the hospital Surveillance is hospital wide and not targeted

33 TJC NPSG Central Lines 5. Provide CLAI (central line associated infection) rate data and prevention outcome measurement to staff and LIPs and clinicians 6. Use a catheter checklist and standard protocol for central line insertion 7. Perform hand hygiene before catheter insertion or manipulation 8. Do not put in femoral vein unless last resort for adult patients 9. Use standardized supply care or kit for central lines

34

35 TJC NPSG Central Lines 10. Use standardized protocol for maximum sterile barrier precautions during insertion 11. Use antiseptic for skin prep in patients during insertion that is cited in the scientific literature or endorsed by professional organizations 12. Use standardized protocol to disinfect catheter hubs and injection ports before accessing Such as wipe vigorously for 15 sections and let dry Surveyor will ask to see the protocol or P&P 13. Evaluate all central lines routinely and remove none essential catheters

36 Safe Practice 22 Surgical Site Infection
Surgical site infection prevention Take actions to prevent surgical-site infections by implementing evidence-based intervention practices. Safe Practice 22 is currently under ad hoc review by an expert panel. This practice will be updated in the coming months to reflect the review decision. CDC has guidelines TJC has 2011 NPSG

37

38 Four Changes to TJC 2011 NPSG

39 July 1, 2010 Changes NPSG EP 6:  A written policy addresses baseline and ongoing laboratory tests that are required for anticoagulants NPSG EP 11:  Use an antiseptic for skin preparation during central venous catheter insertion that is cited in scientific literature or endorsed by professional organizations (such as chlorahexidine alcohol and not povidone iodine but this specific wording removed)

40 July 1, 2010 Changes NPSG EP 7:  Administer antimicrobial agents for prophylaxis for a particular procedure or disease according to methods cited in scientific literature or endorsed by professional organizations NPSG EP 8: When hair removal is necessary, use a method that is cited in scientific literature or endorsed by professional organizations (Such as clippers and not razors but this language removed)

41 Proposed TJC NPSGs for 2012 TJC is seeking comments on NPSGs for 2012
Looking at two proposed additions Ventilator-associated pneumonia (VAP) Has seven elements of performance Catheter-associated urinary tract infections (CAUTI) Has four elements of performance Comment period ended January 27, 2012

42 TJC 2011 NPSG Surgical Site Infections
Implement best practices to prevent surgical site infections (SSI) There are 8 EPs 1. Educate hospital staff and LIPs involved in procedures about HAI, surgical site, and the importance of prevention Educate during orientation, annually, and if added to your job

43 Surgical Site Infections
2. Educate patients and families, who are undergoing surgical procedures, about preventing surgical site infections (SSI) 3. Implement P&P to reduce SSI that meet regulations and evidenced based practice (such as the CDC and other professional organizations) 4. Conduct periodic risk assessments for SSI, select measures using best practices or evidence based guidelines and monitor compliance with them and how effective they are

44 Surgical Site Infections
5. Measure surgical site infection rates for the first 30 days following a procedure that does not involve inserting implantable devices Measure for the first year procedures involving implantable devices Need to follow evidence based guidelines Surveillance may to targeted to certain procedures based on hospital risk assessment 6. Provide process and outcome data on SSI to stakeholders etc, such as the SS infection rate

45 Surgical Site Infections
Antimicrobial agents for prophylaxis are administered according to methods cited in the scientific literature or endorsed by professional organizations Still want to be sure that prophylactic antibiotics are administered timely in the operating room and rebolused when indicated When hair removal is necessary, use a method that is cited in the scientific literature or endorsed by professional organizations

46 Safe Practice 23 Care of the Ventilated Patient
Take actions to prevent complications associated with ventilated patients: specifically, ventilator-associated pneumonia (VAP), venous thromboembolism, peptic ulcer disease, dental complications, and pressure ulcers VAP bundle also an IHI initiative TJC NPSG 2011 standard

47 23 Care of the Ventilated Patient
Educate healthcare workers on daily care of ventilated patient and complications such as VAP, VTE, PUD, dental complications, and pressure ulcers Implement P&P on disinfection and sterilization of respiratory equipment Active surveillance for VAP and maintain data Educate patients and families about prevention measures

48 23 Care of the Ventilated Patient
Use checklist and standardized protocol Hand hygiene Regular antiseptic oral care HOB degrees Daily assessment of readiness to wean and sedation interruption Use weaning protocols Implement PUD prophylaxis (still controversial) VTE prophylaxis unless contraindicated

49 Safe Practice 24 MDRO Prevention
Implement a systematic multidrug-resistant organism (MDRO) eradication program built upon the fundamental elements of infection control, an evidence-based approach, assurance of the hospital staff and independent practitioner readiness, and a re-engineered identification and care process for those patients with or at risk for MDRO infections. Also a TDC NPSG for 2011 and CMS CoP requirement

50 24 MDRO Prevention Includes but is not limited to
Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) , and Clostridium difficile (C-diff) Multidrug-resistant gram-negative bacilli, such as Enterobacter species, Klebsiella species, Pseudomonas species, and Escherichia coli (Ecoli), and vancomycin-resistant Staphylococcus aureus, should be evaluated for inclusion on a local system level based on organizational risk assessments

51 24 MDRO Prevention LD assigns responsibility for oversight and coordination of the development, testing, and implementation of a MDRO prevention program Inf ection preventionist usually in charge of program Conduct risk assessment for MDRO acquisition and transmission Educate staff and LIPs about MDRO Include risk factors, routes of transmission and outcomes associated with prevention Educate patients with MRSA, VRE, or C-diff and their families or who are colonized with MRSA

52 24 MDRO Prevention Implement a surveillance program based on risk assessment and use contact precaution (MRSA) Measure and monitor prevention processes and outcomes Comply with evidenced based practices Implement an alert system that identifies readmitted or transferred MRSA colonized or infected patients Promote hand hygiene compliance Ensure cleaning and disinfecting of equipement

53 TJC NPSGs 2011 Implement evidenced based practices to prevent HAI due to multi-drug resistant organisms (MDROs), NPSG (7C) 9 EPs Applies to, but not limited to, MRSA, VRE, C-Diff, and MDRO gram negative bacteria Patients continue to acquire health care associated (HAI) infections at an alarming rate Need prevention and control strategies

54 Implement Evidenced Based Practices
Increased focus on cleaning and disinfecting equipment appropriately (IC ) Proper use of flash sterilization Making sure all scopes are cleaned according to the manufacturer Cleaning the patient environment is also important

55 TJC NPSG MRDO 1. Conduct periodic risk assessment for MDROs acquisition and transmission In time frame set by hospital See IC , EPs 1-5 that talks about identifying the risk of acquiring and transmitting infections Following slides on this provided for reference TJC infection control chapter very important and dove tails with these infection control NPSGs

56 Identify Risks for Transmitting Infections
IC The hospital identifies risks for acquiring and transmitting infections EP1 Hospital identifies risks based on geographic location, community, and population served NPSG EP1 Conduct periodic risk assessments in time frames set by hospital for multidrug-resistent organisms (MDRO) acquisitions and transmission MDRO includes methicillin-resistant Staphylococcus Aureus (MRSA), Vancomycin-resistant Enterococcus (VRE), Klebsiella , and Acinetobacter CDC has free MDRO infection (and CDAD) surveillance and training on the National Healthcare Safety Network (NISN) 1 1

57 Identify Risks for Transmitting Infections IC.01.03.01
EP2 Hospital identifies risk for acquiring and transmitting infections based on the care and treatment it provides (on MDRO) EP3 Look at risk for acquiring or transmitting an infection by doing an analysis of surveillance activities and other infection control data (including MRDO and adverse tissue reactions) EP4 Review and identify risks annually and when there is a significant change and get input from IP, MS, nursing, and leadership including MRDO EP5 Prioritize these risks

58 TJC NPSG MRDO Educate staff and LIPS about HAI, MDROs, and preventive strategies in orientation At hire and annually Use information from your risk assessment Education must reflect their diverse roles 3. Educate patient and their families about HAI strategies who are infected or colonized with MRDO, as needed

59 TJC NPSG MRDO 4. Implement a MDRO surveillance program based on your risk assessment Surveillance may be targeted rather than hospital wide CDC has MDRO surveillance training at Has many resources including training videos on MDRO surveillance, slide sets, protocols, reporting plan etc.

60

61

62

63 TJC NPSG MRDO 5. Measure and monitor MDRO prevention processes and outcomes including; MDRO infection rates using evidence based metrics, compliance with evidenced based practice, and evaluate education provided 6. Provide MRDO process and outcome data to key stakeholders, nurses, doctors, LIPs and other clinicians 7. Implement P&Ps to reduce transmission of MRDOs which meet CDC and other professional organization standards (APIC,SHEA,OSHA, AORN)

64 TJC NPSG MRDO 8. Implement a laboratory based alert system that identifies new patients with MDRO when indicated by the risk assessment The alert system can be manual or electronic and can use faxes, pages, telephones etc., 9. Implement an alert system that identifies readmitted or transferred MRDO positive patient when indicated by risk assessment Alert system can be in a separate database or integrated and can manual or electronic

65 MRDOs Resources CDC Management of MRDOs in Healthcare Settings 2006, 74 pages, at Provides strategies and practices to prevent MRSA, VRE and other MDROs, Includes gram neg bacilli (GNB), E. coli and Klebsiella pneumoniae, stenotrophomonas maltophilia, burkholderia cepacia, and ralstonia picketti,

66 MRDOs Resources CDC MRSA resources at Includes fact sheet on MRSA, MRSA in healthcare setting 2007, educational material, data, lab testing and practices etc, Isolation precaution 2007 at VRE resources at Guidelines for Prevention of Surgical Site Infections,

67 Resources APIC resources at and see standards and guidelines, Guidelines for Environmental Infection Control in Health Care Facilities, Guidelines for Prevention of Surgical Site Infections, Recommendations for Preventing the Spread of VRE, Guidelines to Prevent Intravascular Catheter Related Infections,

68 25. Catheter-Associated UTI Prevention
Take actions to prevent catheter-associated urinary tract infection by implementing evidence-based intervention practices. UTI most common HAI CDC issues Guidelines December 2009 TJC 2011 NPSG and 2011 SCIP Measure AHRQ Patient Safety Handbook chapter at Pa Patient Safety Authority has toolkit on how to prevent CAUTI at

69 AHRQ Patient Safety Handbook Cp 42

70

71 Pa Patient Safety Authority Toolkit

72 Resources AORN article on the 2011 SCIP measure regarding urinary catheter removal at https://www.aorn.org/News/Managers/November2009Issue/Catheter/ Urinary catheter removed on Postoperative Day 1 (POD1) or Postoperative Day 2 (POD2) with day of surgery being day zero Iowa Healthcare Collaborative toolkit for preventing UTIs at has evidenced based guidelines, sample policies, provider information  etc

73 Resources AHRQ has a website on “Efforts to Prevent and Reduce Healthcare-Associated Infections at IDSA as the “Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infections in Adults: 2009 International Clinical Practice Guidelines from the Infectious Disease Society of America” at

74 Resources IHI how to guide on preventing CAUTI
at Multiple tools on this website with slides and how to guide and APIC and SHEA documents etc APIC has a guide called :Guide to the Elimination of Catheter-Associated Urinary Tract Infections” at and see resources at

75 25. Catheter-Associated UTI Prevention
Document the education of staff involved in insertion, care, and maintenance of urinary catheters and about CAUTI Training should include alternatives Train in orientation and annually Prior to insertion of urinary catheter educate patient about CAUTI prevention Identify patients on units where surveillance should be conducted

76 25. Catheter-Associated UTI Prevention
Implement P&P to reduce risk of CAUTI and that are evidenced based Perform hand hygiene before and after manipulation of catheter or apparatus Ensure supplies are available for aseptic technique and use sterile equipment Insert catheters using sterile technique Obtain urine culture before starting antibiotics in patient with catheter Measure compliance with best practices Provide surveillance data to key stakeholders

77 CHAPTER 8: Condition- or Site-Specific Practices
2007 NQF Report Culture Culture SP 1 CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards Structures & Systems Culture Meas., F.B., & Interv. Team Training & Team Interv. ID Mitigation Risk & Hazards CHAPTER 1: Background Summary, and Set of Safe Practices Consent & Disclosure Consent & Disclosure CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure Informed Consent Life-Sustaining Treatment Disclosure Workforce CHAPTERS 2-8 : Practices By Subject CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Nursing Workforce Direct Caregivers ICU Care CHAPTER 8: Condition- or Site-Specific Practices Wrong Site Surgery (Safe Practice 26) Pressure Ulcer Prevention (Safe Practice 27) Venous Thromboembolism Prevention (Safe Practice 28) Anticoagulation Therapy (Safe Practice 29) Contrast Media-Induced Renal Failure Prevention (SP 30) Organ Donation (Safe Practice 31) Glycemic Control (Safe Practice 32) Fall Prevention (Safe Practice 33) Pediatric Imaging (Safe Practice 34) Information Management & Continuity of Care CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations Critical Care Info. Order Read-back Labeling Studies Discharge System CPOE Abbreviations Medication Management CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Med Recon. Pharmacist Central Role High Alert Meds Std. Med Labeling & Pkg Unit Dose Medications Hospital Acquired Infections CHAPTER 7: Hospital-Acquired Infections Prevention of Aspiration and Ventilator-Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Prevention Surgical Site Infection Prevention Hand Hygiene Influenza Prevention Asp +VAP Prevention Hand Hygiene Influenza Prevention Central V. Cath BSI Prevention Sx Site Inf. Prevention CHAPTER 8: Evidence-Based Referrals Wrong-Site, Wrong Procedure, Wrong Person Surgery Prevention Perioperative Myocardial Infarct/Ischemia Prevention Pressure Ulcer Prevention DVT/VTE Prevention Anticoagulation Therapy Contrast Media-Induced Renal Failure Prevention Condition & Site Specific Practices Evidence Based Ref. Anticoag Therapy DVT/VTE Prevention Press. Ulcer Prevention Wrong site Sx Prevention Peri-Op MI Prevention Contrast Media Use 1

78 Safe Practice 26 Prevent WSS
Implement the Universal Protocol for Preventing Wrong Site (WSS), Wrong Procedure, Wrong Person Surgery for all invasive procedures TJC has 2011 Universal Protocol Pa Patient Safety Authority has toolkit at Patient Safety Handbook has chapter also at

79 Safe Practice 26 Prevent WSS
Create and use a verification process to ensure relevant preoperative tasks are done Make sure information is correct and available Mark the surgical site and involve the patient in the marking process Use right/left distinction and multiple levels (spinal procedures) Do time out before any invasive procedure and any required implants

80

81

82 Pa Patient Safety Toolkit

83 Time Out Towel

84 TJC 2011 NPSG Universal Protocol
TJC has three sections in the NPSG on Universal Protocol These are to prevent wrong site surgery A copy of these standards are at the end of the presentation Hospital P&P should be consistent with these standards

85 Safe Practice 27 Pressure Ulcer
Take actions to prevent pressure ulcers by implementing evidence- based intervention practices. has 75 guidelines on pressure ulcers AHRQ Patient Safety Handbook has chapter at Minnesota Hospital Association has many resources on Safe Skin campaign at National Pressure Ulcer Advisory Panel (NPUAP) at

86 MN Hospital Association Safe Skin

87 AHRQ Patient Safety Handbook Chapter 12

88

89 NPUAP Staging System

90 Safe Practice 27 Pressure Ulcer
P&P on prevention of pressure ulcers (PU) Plans are in place for risk assessment, prevention, and early treatment of PU During admission identify patients at risk using a assessment guide Document risk assessment and prevention plan in patient’s record Assess and reassess skin for risk of developing a PU Maintain and improve tissue tolerance to PU

91 Safe Practice 27 Pressure Ulcer
Protect against the adverse effects of external mechanical forces Reduce the incidences of PU through staff education Perform quarterly prevalence studies to evaluate the effectiveness of the PU prevention program Educate about PU frequency and severity Implement PU prevention interventions Measure outcomes

92

93 SP 28 Venous Thromboembolism (DVT) Prevention
Evaluate each patient upon admission, and regularly thereafter, for the risk of developing venous thromboembolism. Utilize clinically appropriate, evidence-based methods of thromboprophylaxis. TJC has NPSG on anticoagulants

94 28 Venous Thromboembolism (DVT) Prevention
Multidisciplinary team develops evidence based protocols and have P&P Ongoing PI to make sure practices are followed Include risk assessment, prophylaxis, diagnosis and treatment Provide education on prevention, care, diagnosis, and treatment Document in medical record VTE risk assessment Provide education to patients with VTE with monitoring, dietary restrictions etc.

95 Safe Practice 29 Anticoagulant Therapy
Organizations should implement practices to prevent patient harm due to anticoagulant therapy. TJC has anticoagulant NPSG University of Washington has excellent resources Number of other anticoagulant toolkits

96 29 Anticoagulant Therapy
Need a defined anticoagulant management program to individualized the care Document patient’s medication plan in the medication record Clinical pharmacy medication review is conducted to ensure safe selection and to avoid drug-drug interactions Use only oral unit dose products, prefilled syringes and premixed IV bags INR for patients starting on Coumadin

97 29 Anticoagulant Therapy
Dietary is notified of patient getting Coumadin so food/medication interaction program Education is provided to all staff, prescribers and patients Need written policy for baseline lab tests for patients on Heparin and low molecular weight heparin therapies Hospital evaluates anticoagulation safety practices and takes action to improve its practice

98 Resources Source: AHRQ Press release, September 15, 2009, AHRQ Releases Two New Resources to Help Consumers and Clinicians Prevent Dangerous Blood Clots, at The clinician’s guide on Preventing Hospital-Acquired Venous Thromboembolism; A Guide for Effective Quality Improvement is available at Patient Guide to Preventing and Treating Blood Clots at

99

100

101

102

103

104

105

106

107 University of Washington Medical Center
Some of the AHRQ resources were from U of Washington Medical Center Has an excellent website! Coumadin (Warfarin) teaching booklet in 5 languages Coumadin dosing charts, how to adjust, guidelines for dosing and monitoring Lovenox (Enoxaparin) Treatment of VTE Duration of anticoagulants, peri procedural anticoagulation

108 Perdue Toolkit Anticoagulant Toolkit; Reducing Adverse Drugs and Potential Adverse Drug Events with Unfractionated Heparin, LMWH and Warfarin, Includes resource tools, self assessment, how to improve the process, improvement and sustaining improvement, physician order forms Available at

109

110

111 Anticoagulant Management Toolkit
Pa Patient Safety Authority has toolkit Has IHI anticoagulant toolkit Has ISMP self assessment tool for antithrombotic in hospitals Has video on benefits of anticoagulant management services and more At

112 SP30 Contrast Induced Renal Failure
SP is Contrast Media-Induced Renal Failure Prevention Utilize validated protocols to evaluate patients who are at risk for contrast media-induced renal failure and gadolinium-associated nephrogenic systemic fibrosis, and utilize a clinically appropriate method for reducing the risk of adverse events based on the patient’s risk evaluations. Pa Patient Safety Authority has toolkit

113 SP30 Contrast Induced Renal Failure
Use evidenced based protocols that are approved by the MS for the prevention of CIN (contrast media-induced nephropathy) based on the rapid evolution of contract agents and national guideline that is coming soon Monitor and document use of evidenced based protocols and document risk assessment in chart Document provider education Specify qualifications of staff allowed to initiate protocols for imaging

114 Pa Patient Safety Authority Toolkit

115 Contrast Induced Nephropathy
Kidney failure can occur from iodine dye used for x-rays (70 reports) Hospitals should amend informed consent to include this Especially with patients with known history of severe renal failure or impairment See ACR MRI Safety Guideline issued June, 2007 Consider doing a FMEA on this and they have a toolkit on this

116 Gadolinium Based Contrast
These can cause nephrogenic systemic fibrosis Be aware of BUN creatinine when ordering Magnetic resonance angiography (MRA) that requires IV contras, Uses MRI to take pictures of blood vessels Dose for MRA may be 3x higher than dose for MRI If patient being dialyzed do immediately after test Patients with severe renal impairment at risk for NSF Risk is 4% in this population- consider including in informed consent New box warning now

117 Contrast Induced Nephropathy
Angiography, IVP, and CT scans use iodine containing contrast material Can have allergic reaction or kidney damage Be careful in patients with sever renal impairment Make sure patient is adequately hydrated Use low osmolar contrast in patients with renal failure See ACR policy at Check serum creatinine level prior to scheduling contrast studies Make sure radiology department is aware if patient has severe renal failure before contrast is used

118 Safe Practice 31 Organ Donation
Hospital policies that are consistent with applicable law and regulations should be in place and should address patient and family preferences for organ donation, as well as specify the roles and desired outcomes for every stage of the donation process TJC and CMS have organ donation standards TJC has transplant chapter State laws on organ donation and procurement

119 31 Organ Donation Hospitals and OPOs work together to maintain program and develop protocols Have a process to define roles and responsibilities of hospital and OPO including PI Early donor evaluation and organ placement OPO will review death records for donor opportunity Organ donation performance outcomes at Address wishes to donate organs

120 Safe Practice 32 Glycemic Control
Take actions to improve glycemic control by implementing evidence- based intervention practices that prevent hypoglycemia and optimize the care of patients with hyperglycemia and diabetes

121 32 Glycemic Control Develop a process for improving glycemic control for patient Monitor the quality of the management and report to stakeholders Track glucose data Evidenced based order sets to guild management of hypo and hyperglycemia Written protocols for patient on insulin drips

122 32 Glycemic Control Reconcile patient medication on discharge
Education for newly diagnosed diabetics Include in their plan of care exercise, nutritional management, signs and symptoms of hyper or hypoglycemia Include instructions on use of blood glucose meter Sick day guidelines Who to contact in case of an emergency

123 Safe Practice 33 Falls Take actions to prevent patient falls and to reduce fall-related injuries by implementing evidence-based intervention practices TJC standard TJC sentinel event alert on falls CMS CoP requirement One of 10 CMS hospital acquired conditions with no additional pay

124 Safe Practice 33 Falls Have a fall reduction program
Program must do an appropriate evaluation of the patient Must include interventions based on risk Staff must be educated on fall reduction program Patient and family is educated on program Evaluate the effectiveness of the falls program

125 2011 TJC Standard Falls continue as a Joint Commission National Patient Safety Goal in 2009 but moved to standard in 201 0 under PC PC The hospital assesses and manages the patient’s risks for falls EP1 Hospital must assess the patient’s risk for falls based on the patient population and setting (elderly, behavioral health, pediatric patients) EP2 Hospital implements interventions to reduce falls based on the patient’s assessed risk

126 Why Look at Falls? Falls rate high on the list of sentinel events tracked by The Joint Commission (TJC) 6th leading cause of sentinel events September 30, 2010 data of 7,147 SE shows 481 falls which is 6.5% of all sentinel events reported Other Joint Commission standards that are applicable to falls are in EC and PI chapters (PI number of falls and number and severity of fall related injuries) TJC gives information on the root causes of falls

127

128 The Joint Commission Matrix for Falls RCA
TJC requires a RCA be done for reviewable sentinel events which includes a patient fall that results in death or major permanent loss of function as a direct These are the elements that must be included in the RCA So RCA must include area marked such as physical assessment process, medication management, staffing level etc.

129

130 CMS CoP Requirements CMS requires hospitals in the hospital CoPs to have a safe environment/setting CMS has this as hot spot in their Guidelines for Immediate Jeopardy CMS requires the health and safety of patients at risk are identified, investigated and resolved Having falls and no investigation would be a violation of this CoP which could come up during complaint or validation survey Source:

131 Intervention Strategies
Level of Risk Area of Risk High Med Low Frequent Falls Altered Elimination Muscle Weakness Mobility Problems Multiple Medications Depression Low beds X Non-slip grip footwear Assign patient to bed that allows patient to exit toward stronger side Lock movable transfer equipment prior to transfer Individualize equipment to patient needs

132 High risk fall room setup
X Non-skid floor mat Medication review Exercise program Toileting worksheet Color armband / Falling Star etc Perimeter mattress Hip protectors Bed/chair alarms

133 34. Pediatric Imaging When CT imaging studies are undertaken on children, “child-size” techniques should be used to reduce unnecessary exposure to ionizing radiation Recently receiving a lot of attention FDA issues guidelines on radiation exposure along with ACR

134 34. Pediatric Imaging Update protocols on CT imaging of children
Scan only when necessary Reduce or child size the amount of radiation used Scan only indicated area See ACR standard See Shield radiosensitive areas such as reproductive organs Scan once as single phase scan usually adequate in children

135 The Radiation Exposure Issue
August 2009 a team at Emory University in Atlanta reported in NEJM that 4 million Americans are exposed to high doses of radiation National Council on Radiation Protection and Measurement stated the US population is exposed to seven times more radiation each year for imaging exams than in 1980 GAO and JAMA reported that physicians refer patients to facility they have a financial interest in Dr. Kriste Guite and colleagues studied 978 CT scans of the abdomen and pelvis and found that 52.2% were unnecessary (university of Wisconsin at Madison, 2010) At that level 1 in 1,00 patients could get radiation-induced cancer

136

137 Radiation Exposure During CT
October 2009 disclosure by Cedars-Sinai Medical Center in LA that 206 patients were given up to eight times the normal radiation dose during a stroke scan (CT brain perfusion) over an 18 month period FDA identifies 50 additional patients who were also exposed up to 8 times the normal dosage and reports from other states Some patients had hair loss (40%) and skin redness High doses can cause some kinds of cancer and cataracts

138 Radiation Exposure During CT
A patient could get as much radiation from a CT scan then from 74 mammograms or 442 CXR from higher measurements Hospitals rarely record how much radiation the patient receives Doses can vary depending on the size of the patient, how large an area is scanned etc. At NIH, doctors will record the information and patients can take it with them FDA issues radiation recommendations Dec 2009

139

140

141 5 FDA Recommendations Facilities assess whether patients who underwent CT perfusion scans received excess radiation Facilities review their radiation dosing protocols for all CT perfusion studies to ensure that the correct dosing is planned for each study Facilities implement quality control procedures to ensure that dosing protocols are followed every time and the planned amount of radiation is administered Radiologic technologists check the CT scanner display panel before performing a study to make sure the amount of radiation to be delivered is at the appropriate level for the individual patient If more than one study is performed on a patient during one imaging session, practitioners should adjust the dose of radiation so it is appropriate for each study

142

143

144 Recommendations ACR, as part of Alliance for Radiation Safety, has imaging card for patients, especially kids1 They recommend patients should ask their doctors if they need the exam and if there are alternative Radiology tech should check the CT scanner display panel before performing the study to make sure amount of radiation to be delivered is appropriate The tech should check the dose indices displayed on the control panel after the CT scan is done Follow the FDA and ACR recommendations Report serious problems to the FDA MedWatch program 1

145

146

147 The End Questions Sue Dill Calloway RN, Esq. CPHRM
AD, BA, BSN, MSN, JD Medical Legal consultant 5447 Fawnbrook Lane Dublin, Ohio 43017 TJC NPSG UP and Resources 147 147

148 Patient Safety Material Resources
20 tips to prevent medication errors in children at 5 steps to safer health care at 20 tips to prevent medical errors at Quick Tips when getting medical tests at

149 Patient Safety Material Resources
Ways you can help your family prevent medical errors at When choosing healthcare at FDA’s tips on taking medication at Preventing medications at

150 Resources IHI (Institute for Healthcare Improvement) www.ihi.org,
FDA at American Society for Healthcare Risk Managers (ASHRM) monograms on disclosure, patient safety curriculum, John Hopkins Center for Public Awareness-patient safety modules

151 Resources WHO Patient Safety website at WHO taxonomy at AHRQ PS Net or patient safety network with journal articles at and see M&M at AHRQ medical errors and patient safety website at

152 Resources AHRQ TeamSTEPPES strategies and tools to enhance patient safety at TMIT Safety leaders at has research and workshops and webinars, FDA patient safety news at FDA Bad Bug Book at

153 Patient Education Resources
Five Steps to Safer Health Care, 10 Patient Safety Tips for Hospitals, 20 Tips to Help Prevent Medical Errors: Patient Fact Sheet, 20 Tips to Help Prevent Medical Errors in Children, 30 Safe Practices for Better Health Care: Fact Sheet, Available at Also mistake proofing the design of health care process,

154 Resources Appropriate use of antibiotics, Mangram, AJ, Pearson, MI, Guidelines for Preventing Surgical Site Infections, Infection Control Hosp Epidemiol. 20: Also includes information on avoidance of razors, Perioperative glucose control in majory cardiac surgery patients see: Furnary, Ap, Zerr, KJ, etc. Continuous intravenous insulin reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgery, Ann Thorac Surg, 1999;67: , Van den Berghe, Wouters, P, Weekers, F, Intensive insulin therapy in critically ill patients, N Engl J Med. 2001:345:

155 Resources Perioperative Normothermia in colorectal surgery patients see the following two articles, Kurtz A, Sessler DI, Lenhardt R, Perioperative normothermia to reduce the incidence of surgical wound infection and shorten hospital stay, NEJM 1996,334: , Melling AC, Ali B Scott, Leaper DJ, Effects of preoperative warming on the incidence of wound infection after clean surgery;a randomized control trial, Lancet, 2001;358: ,

156 Resources Sorry Works! Coalition at with sample hospital disclosure program and slides on disclosure, Premier Patient Safety Institute- and has section on framework for safety culture and reporting (www.premierinc.com/all/safety/resources/patient_safety/index_2.jsp)and data tool for doing survey on patient safety, National Patient Safety Foundation at disclosure after adverse medical event and disclosure statement of principles,

157 Resources Joint Commission at - national patient safety goals and International Center for Patient Safety at The patient safety group at AHRQ Patient Safety Network at tons of great articles and research, AHRQ Morbidity and Mortality Rounds on the web-http://webmm.ahrq.gov/,

158 Resources VIPCS Virginians Improving Patient Care and Safety at NPSF National Patient Safety Foundation at and resources at Patient Safety: Achieving a New Standard of Care; IOM Report 2003 at

159 Resources The Minnesota Alliance for Patient Safety (MAPS)- National Quality Forum- National Quality Forum (NFQ) Serious Reportable Events in Healthcare: A Consensus Report -Serious Reportable Events in Healthcare

160 Resources New pressure ulcer prevention protocol and skin safety plan at Safest in America Anesthesia Patient Safety Foundation at

161 Resources Mass Coalition for the Prevention of Medical Errors at ISMP List of Error Prone Abbreviations, Symbols and Dose Designations at University of Michigan Patient Safety Toolkit at , AORN Patient Safety at

162 Resources John Hopkins Center for Innovations in Quality Patient Care at CAPSLink at Ohio Patient Safety Institute at ,

163 Resources USP- US Pharmacopeia at www.usp.org-
Sign up for USP Patient Safety Newsletters at VA National Center for Patient Safety NCPS at Sign up for human factors resources at

164 Resources Leapfrog group at http://www.leapfroggroup.org/,
Canadian Patient Safety Institute athttp://www.patientsafetyinstitute.ca/index.html, Australian Council for Safety and Quality in Health Care at NPSA National Patient Safety Agency at

165 Resources State of NJ Patient Safety Report at Patient Safety Authority (PSA) in Pa- Web M&M by AHRQ at free 999 journals and over 1.5 million articles,

166 Resources Consumers Advancing Patient Safety CAPS at The Patient Safety and Quality Improvement Act of 2005 (PA ) amended Title IX of the Public Health Service Act (42 USC 299 et seq), protection for patient safety work products,

167 Resources National Coordinating Council for Medication Error Reporting and Prevention- Partnership for Patient Safety "Beyond Blame" video: Order online at or call (959)

168 Disruptive Practitioner Resources
Joint Commission standards at Rosenstein A, O’Daniel M. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians: nurses, physicians, and administrators say that clinicians’ disruptive behavior has negative effects on clinical outcomes. Nurs Manage 2005 Jan;36(1):18-29.

169 Resources Weber DO. Poll results: doctors’ disruptive behavior disturbs physician leaders. Physician Exec Sep-Oct;30 (5):16-7. Also available: articles/mi_m0843/is_5_30/ai_n American Medical Association. Physicians with disruptive behavior. In: Code of medical ethics: current opinions and annotations. Chicago (IL): AMA: p. 279–80.

170 Resources Disruptive Behaviors in Physicians, CME course from Texas Medical Board at and gives CME credit, Tennessee Medical Staff Foundation, Medical Staff Code of Conduct Policy, at

171 Resources Papadakis MA, Teherani A, Banach MA, Knettler TR, Rattner SL, Stern DT, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med 2005;353:2673–82, ECRI. Disruptive practitioner behavior. HRC Risk Analysis Supplement A. Plymouth Meeting (PA): ECRI; 2006.

172 Resources Disruptive Behavior, ACOG Committee Opinion, Number 366, May 2007. Porto G, Lauve R. Disruptive clinician: a persistent threat to patient safety. Patient Saf Qual Healthc 2006;144: 107–15. Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern Med 2006;144:107–115.

173 Resources Pfifferling J. The disruptive physician: a quality of professional life factor [online]. Physician Exec Mar-Apr [cited 2005 Dec 5]. Available from Internet: See HCA Code of Conduct, 38 pages, at SOX, or Sarbanes-Oxley Act of 2002, and related Securities and Exchange Commission rules,

174 Resources Cassidy M. Third circuit reaffirms HCQIA immunity for professional review actions [online]. [cited 2005 Dec 5]. Available from Internet: Gordon v. Lewiston case,

175 Resources American Medical Association. Reports of the Council on Ethical and Judicial Affairs: physicians with disruptive behavior. Available from Internet:http://www.ama-assn.org/ama1/pub/upload/mm/369/ceja_rep_106_0104.pdf, AMA Physicians and Disruptive Physician packet, July 2004, at

176 Fatigue Resources Ruggiero, JS, Correlates of fatigue in critical care nurses. Res Nurs Health Dec 2003; 26(6): Ahmed, DS, Fecik, S. The fatigue factor. When long shifts harm patients. Am J Nurs. Sep 1999, 99(9):12. Case Reports, AHRQ Evidence Report 151, Nurse Staffing and Quality of Patient Care March of 2007, at

177 Fatigue Resources Fatigue in Healthcare Workers, Healthcare Risk Control, January, 2006, ECRI Institute, Employment Issues 14, Institute of Medicine (IOM) report on Keeping Patients Safe; Transforming the Work Environment of Nurses, 2004, at Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. N Engl J Med 2002 Oct 17;347(16):

178 Fatigue Resources West S. Circadian rhythm, shiftwork and you! Collegian 2001 Oct;8(4):14-21. Eastridge BJ, Hamilton EC, O'Keefe GE, et al. Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill. Am J Surg 2003 Aug;186(2):169-74, Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med 2005 Jan 13;352(2):

179 Fatigue Resources Scott, LD, Hwang, WT, Effects of critical care nurses work hours on vigilance and patient safety. Am J Critical Care 2006 Jan:15(1):30-37, Rogers, AE, Hwang, WT, The working hours of hospital staff nurses and patient safety. Health Aff (Milwood) 2004; 23:

180 TJC NPSG Goal 1: UP Universal Protocol
Organization must meet expectation of UP UP Conduct a pre-procedure verification process, Changed because of universal protocol that is now a standard, effective July 1, 2004 changed 2009 and 2010 and continue into 2011, To prevent wrong site and wrong procedure surgery, Process must be briefly documented, TJC has great information on their website on this! 3 parts,

181

182 Pre-procedure verification process
It is an ongoing process that starts with decision to do procedure and continues up and includes time out before start of procedure, Want to be sure all documents and equipment is available before the procedure, That everything is correctly labeled and matched to the patient’ identifiers, Reviewed and consistent with patient’s expectation and team’s understanding of the procedure and site,

183 Pre-procedure verification process
Implement a pre-procedure process to verify correct patient, site, and procedure Identify what needs to be available for the procedure and use a standardize list (check list) to verify their availability and must include Relevant documentation (H&P, consent form, nursing assessment and pre-anesthesia assessment) Labeled diagnostic and radiology films, pathology, and biopsy reports and make sure properly displayed

184 Pre-procedure verification process
3. Match the items that are to be available in the procedure area to the patient WHO has a surgical checklist Can enlarge the individualized checklist to 2 by 3 feet and roll in before surgery and then do briefing and at end when you do debriefing

185 Getting It Right Do you verify that this is the right procedure at certain times to make sure you have it right such as; Time procedure scheduled, Time of PAT, Time of admission or entry into facility, Before patient leaves pre-procedure area, Anytime responsibility is transferred to another member of procedure team (including anesthesia provider) at time of and during the procedure, With the patient involved and awake and aware if possible,

186 Mark the Site UP 01.02.01 Mark the procedure site,
Procedure with incisions or percutaneous puncture or insertion, site is marked when more than one possible location, If performing in a different location would negatively affect quality or safety For spinal procedures need special intraoperative image technique to mark the right spot Mark before patient is moved to where procedure is to take place,

187 Mark the Site Patient should be involved if possible when marking the site. Site marking by LIP or other provider who is ultimately accountable for the procedure Must be present when the procedure is performed In limited circumstances LIP can delegate to another who is permitted by hospital and who meets the following qualification In medical residency program and is supervised by LIP performing the procedure

188 Mark the Site Licensed person who requires collaborating or supervising agreement with the LIP such as PA or NP Must be familiar with the patient and present when the procedure is done 4. Method of marking the site is unambiguous and is used consistently through out the hospital Mark is made at or near the site Mark must be present after draped and prepped,

189 Mark the Site 5. Alternative process if patient refuses or if anatomically impossible to mark Put temporary unique wristband, draw on anatomical picture and also if impractical to mark the site (perineum), Do not mark preemies as will be permanent. For teeth mark on the dental x-rays or diagram,

190 Mark the Site Person doing the marking has to be present at time of final time out (this is usually the surgeon), Has to clear marking and consistent through out the hospital, Preferable the surgeon’s initials with or without proposed incision line marking,

191 Time Out before Procedure UP.01.03.01
Time out is done before immediately before starting the procedure, Characteristics of the time-out Standardized process Done by designated team member, Initiated by designated member of the team Involves immediate members of the team including proceduralists, anesthesia providers, circulating nurse, OR tech, and other active participants involved in procedure,

192 Time Out Includes active communication, Even if doing spinal or local,
Other activities suspended during time out, Want all members to actively give thumbs up, If more than one procedure, need to repeat process for each one,

193 Time Out 4. Time out must address correct patient, correct site and procedure to be done Be sure that the site is marked, accurate consent form, agreement on what is being done, correct position, x-rays are properly labeled and displayed, need to administer antibiotics or fluids for irrigation, and safety precautions based on medication use, 5. Document the time out

194 Resources • Agency for Healthcare Research and Quality • Consumers Advancing Patient Safety (CAPS) (http://www.patientsafety.org/) • Partnership for Patient Safety (p4ps) (http://www.p4ps.org/) Further information go to TJC International Center for Patient Safety and click on 13A,


Download ppt "NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2"

Similar presentations


Ads by Google