Presentation on theme: "Collaborative to Reduce Healthcare Associated Infections"— Presentation transcript:
1 Collaborative to Reduce Healthcare Associated Infections Alignment with National Initiatives
2 Joint Commission National Patient Safety Goals 2008 NPSG Goal 7Reduce the risk of healthcare-associated infectionsComply with WHO/CDC hand hygiene guidelinesManage as sentinel events all identified cases of unanticipated death or permanent loss of function associated with a healthcare-associated infection
3 Joint Commission 2009 National Patient Safety Goals 3 new requirements related to preventing healthcare-associated infections:Multiple drug resistant organismsCentral line associated bloodstream infectionsSurgical site infectionsAlign with Safety Center initiatives
4 Joint Commission 2009 National Patient Safety Goals Prescriptive elements of performance based on CDC recommendationsOne-year phase-in period with defined expectations for planning, development, testing at 3,6,9 months with full compliance by January 2010Each requires pilot testing in at least one unit by October 2009Each requires specific patient /family education
5 Joint Commission 2009 National Patient Safety Goals Goal NEWImplement evidence based practices to prevent health care-associated infections due to multi-drug resistant organismsMDRO risk assessments and surveillanceStaff and practitioner educationEducate patients and families who are infected or colonizedMeasure/monitor MDRO prevention processes and outcomes including MDRO infection rates and compliance with evidence based guidelinesEvaluation of the education programs for staffShare surveillance data with leaders, staff, LIPsLab-based alert system that identifies new MDRO patients and alert system for readmissions and transfers
6 Joint Commission 2009 National Patient Safety Goals Goal Implement evidence-based guidelines to prevent central line-associated bloodstream infections.Policies and procedures aligned with evidence-based standardsPeriodic risk assessments,measure CLBSI rates, monitor compliance with evidence-based guidelinesShare infection rates and compliance data with key stakeholders including leaders, staff, LIPsStandard insertion protocol and checklist (Document)Use bundles – standardized cart, hand hygiene, full barrier precaution, avoid femoral site, chlorhexidine prepUse standardized protocol to disinfect catheter hubs and injection ports before accessing. (Document)Evaluate need for catheter routinely and remove nonessential
7 Joint Commission 2009 National Patient Safety Goals Goal Implement best practices for preventing surgical site infectionsImplement policies and practices that meet regulatory requirements and align with evidence based standards (Document)Conduct periodic risk assessments, select and monitor measures, monitor compliance with evidence based guidelinesSSI rates measured for the first 30 days post op and for first year if implantable deviceShare SSI rate data and prevention outcome measures with leaders, staff and LIPsAntibiotic prophylaxis according to evidence based standardsWhen hair removal necessary, hospital uses clippers or depilatories (no shaving)
8 Joint Commission 2009 National Patient Safety Goals Goal 13 Encourage patients active involvement in their own care as a patient safety strategyEPPatient and family are educated on available reporting methods for concerns related to care, treatment, services and patient safety issuesProvide patient with information on infection control measures for hand hygiene, respiratory hygiene, and contact precautions according to patient condition on admission or as soon as possible (Document)Surgical patients educated on hospital measures to prevent adverse events in surgery such as patient identification, prevention of SSI, marking the site (Document)Hospital encourages patients/families to report concerns about safety
9 Joint Commission 2009 National Patient Safety Goals Updates, changes and new requirements to other existing safety goals forMedication ReconciliationTransfusion errorsUniversal Protocol for surgery and invasive procedures
10 CMS Hospital Public Reporting measures reported including SCIP process measuresnew measuresMost are calculated by CMS using Medicare administrative claims data versus clinical chart abstractionAHRQ quality and patient safety indicators software
11 Medicare Hospital-Acquired Conditions The Deficit Reduction Act of 2005 required CMS to identify at least two preventable complications of care that could cause patients to be assigned to a higher paying DRG.8 conditions adopted in CMS IPPS 2008 final rule:Object left in during surgeryAir embolismBlood incompatibilityCatheter associated urinary tract infectionsPressure ulcersVascular catheter associated infectionsMediastinitis after coronary artery bypass graftHospital-acquired injuries (including fractures, dislocations, intracranial injury, crushing injury, and burns)AHA is very concerned about the expansion of this list. We disagree with CMS’ decision to include more conditions on this list beyond what was recommended in the proposed rule. We believe that it is not always possible to know whether a condition is POA, and we have grave concerns about the ability of hospitals to implement POA coding for some of these conditions, such as pressure ulcers and catheter-associates urinary tract infections. Several of the selected conditions are not always reasonably preventable. Additionally, we are concerned that CMS refocused its discussion from injuries sustained from falls in the proposed rule to a broader category of injuries in the final rule. The agency did not receive the benefit of public comment and review on these conditions because they were not specifically listed in the proposed rule. We do not believe that burns, intracranial injuries or some of the other injuries listed by CMS are always related to falls in the hospital, and we do not believe they meet the statutory requirements of this provision as we are not aware of any evidence-based guidelines for the prevention of these injuries.
12 Medicare Hospital-Acquired Conditions 2009 CMS selected 2 additional hospital acquired conditions. Unless present on admission, if present these conditions will not result in a higher DRG complications payment rate.Poor Glycemic control in certain conditionsDeep-vein thrombosis/pulmonary embolism following certain orthopedic surgery casesExpanded SSI to include certain orthopedic and bariatric surgeries
13 Tennessee Statutes Public Chapter 904 Hospital reporting to CDC NHSN on central line bloodstream infection rates in ICU’sFirst public report released after 12 months of data (Jan 2008-Jan 2009)Public Chapter Passed May 2008Requires local MRSA risk assessments by all licensed healthcare facilities (hospitals, nursing homes, ambulatory surgery)Facilities to implement prevention and reduction strategies based on local risk.Strategies align with CDC guidelines. MAY include active surveillance testing
14 Alignment with National Initiatives IHI 5 Million Lives CampaignQIO 9th Scope of WorkCDC and professional society guidelinesNational Quality Forum Hospital Safe Practices
15 Alignment with National Initiatives Keep Patients as our North StarBut use the synergy of alignment with other requirements and national initiatives to build greater focus for your teams, elevate your team’s efforts on the priority list within the system and get the resources needed for your work!