1. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Audit Your Care A Closer Look at CLABSI and SSI Audit Forms Armstrong Institute for Patient Safety and Quality Presented by: Kathleen Speck, MPH Bickey Chang Elizabeth Martinez, MD, MHS

2. January is an exciting month for CSTS! SSI Team Checkup Tool questions SSI numerators and denominators Audit data collection Relational Coordination and Transitions of Care survey CLABSI and TCT reports and data export Armstrong Institute for Patient Safety and Quality 2

3. Learning Objectives You will be able to: –Explain why measuring process is critical to success –Describe process measures planned for collection –Detail the planned collection process Armstrong Institute for Patient Safety and Quality 3

4. Donabedian Model Structure Outcome How we organize care What we do during care delivery The results we achieve E.g., presence of policies or committees E.g., how often are evidence-based interventions performed E.g., how/ how many patients are harmed Process 4

5. Four Types of Audits CLABSISSI VAPCUSP Armstrong Institute for Patient Safety and Quality 5

6. CLABSI and SSI Audits OR CLABSI Central Line Insertion SSI Skin Prep Abx Redosing ICU or Universal CLABSI Central Line Insertion Central Line Maintenance Floor CLABSI Central Line Maintenance Armstrong Institute for Patient Safety and Quality 6

7. CLABSI: Central Line Insertion Armstrong Institute for Patient Safety and Quality 7 Someone who is not involved in the insertion watches at least 10 line insertions this month Group of observers discuss how they will do observations to make them as uniform as possible OBSERVATION 1 DATE:_________________________YesNo Yes, after reminder 1)Was an assistant present during line insertion? 2)Was hand hygiene performed prior to line insertion? 3)Were full barrier precautions used? a.IF NO, circle what was missed: Full Drape Hat Mask Gown Gloves b.IF NO, circle who was not fully covered: Assistant Inserter 4)Was the sterile field maintained? 5)Was chlorhexidine used to clean the site? a.IF YES, was CHG applied using a rigorous back and forth motion? 6)Was the skin prep allowed to dry for 2 minutes? 7)Was the line insertion site NOT the femoral site? 8)No other procedures were performed at the same time as line insertion (e.g., placement of a urinary catheter). 9)Is the dressing adhering well to the skin?

8. Tally the information across the number of observations completed this month Report the numbers to the CSTS web-based data reporting system CLABSI: Central Line Insertion ANSWER/ NUMBER 1)Month and year: 2)How many observations were done this month? 3)How many Yes answers were there for question 1? 4)How many Yes, after reminder answers were there for question 1? 5)How many Yes answers were there for question 2? 6)How many Yes, after reminder answers were there for question 2? Armstrong Institute for Patient Safety and Quality 8

9. Someone who is not involved in the line watches at least 10 central line activities this month (line use, line check, or dressing change) Group of observers discuss how they will do observations to make them as uniform as possible CLABSI: Central Line Maintenance OBSERVATION 1 DATE:_________________________YesNo Yes, after reminder 1.Was proper hand hygiene (hand washing with soap and water or with alcohol-based hand sanitizer) used by all personnel involved in line care for this patient? 2.Did the care provider inspect the line insertion site for infection? 3.Was the needleless connector scrubbed for 30 seconds with 70% alcohol or Chlorascrub before access? 4.If the dressing was soiled, damp or non-occlusive was it changed? 5.Was the dressing changed for any other reason? (i.e., date indicated a dressing change was needed) 6.If dressing was changed, was chloraprep or 2% chlorhexidine in 70% isopropyl alcohol used for skin antisepsis? Leave blank if N/A 7.If the dressing was changed, was the skin prep allowed to dry for 2 minutes? Leave blank if N/A 8.If the dressing was changed, was sterile technique maintained during dressing change? 9.If the dressing was changed, was the change documented in the patient’s record? Armstrong Institute for Patient Safety and Quality 9

10. Tally the information across the number of observations completed this month Report the numbers to the CSTS web-based data reporting system CLABSI: Central Line Maintenance ANSWER/ NUMBER 1)Month and year: 2)How many observations were done this month? 3)How many Yes answers were there for question 1? 4)How many Yes, after reminder answers were there for question 1? 5)How many Yes answers were there for question 2? 6)How many Yes, after reminder answers were there for question 2? Armstrong Institute for Patient Safety and Quality 10

11. Daily Central Line Audit and Infection Control Report – Not Reported Armstrong Institute for Patient Safety and Quality 11

12. Someone who is not involved in the preparation for incision watches at least 10 skin preparations this month Group of observers discuss how they will do observations to make them as uniform as possible SSI: Skin Prep OBSERVATION 1 DATE:_________________________ 1)What type of skin prep was used for this case? Circle: Betadine Chloraprep Duraprep Other/Combo Name if other: __________________ 2)Was the skin prep allowed to air dry for 2 minutes (please time it)? YesNoYes, after reminder 3)If Chloraprep, was CHG applied using a rigorous back and forth scrubbing motion? YesNoYes, after reminder 4)Who prepared the skin for incision? Circle: Any available staff Designated person Armstrong Institute for Patient Safety and Quality 12

13. Tally the information across the number of observations completed this month Report the numbers to the CSTS web-based data reporting system SSI: Skin Prep ANSWER/ NUMBER 1)Month and year: 2)How many observations were done this month? 3)How many times was “Chloraprep” circled for question 1? 4)How many Yes answers were there for question 2? 5)How many Yes, after reminder answers were there for question 2? Armstrong Institute for Patient Safety and Quality 13

14. Pull at least 10 charts randomly for this month (e.g. all charts with numbers ending in “X”). Mark answers to the following questions for each patient chart. Group of abstractors discusses beforehand how they will do reviews to make them as uniform as possible Report the numbers to the CSTS web-based data reporting system SSI: Abx Redosing Patient Chart 1 Date of procedure:_________________________ Was a short-acting cephalosporin used for this patient?  Yes  No (IF NO, replace chart and do not count it in the audit numbers. Pull a replacement chart.) Fill in Antibiotic Name: _______________________________ Time of 1 st administration (the preop dose): _________________________ Time of 2 nd administration (1 st redose,): _________________________ Time of 3 rd administration (2 nd redose): _________________________ Time of 4 th administration (3 rd redose): _________________________ Time of 5 th administration (4 th redose): _________________________ Surgery start time (incision): _________________________ Surgery end time (surgeon end time, skin closed): _________________________ Armstrong Institute for Patient Safety and Quality 14

15. Audit data: “How To” Reminder email will tell you what to audit for the coming month Report on the 15 th of each month for the previous month When you enter web tool, it will tell you what audit data is due this month Web-based data entry forms Armstrong Institute for Patient Safety and Quality 15

16. Audit Form Data Entry Process Select Month Select Form Begin Data Entry All forms due that month are shown 16 Armstrong Institute for Patient Safety and Quality

17. Click on Month to access audit forms Begin data collection in January 2012 for December 2011 data Select Month 17 Armstrong Institute for Patient Safety and Quality

18. Forms due will be shown Refer to Audit Form Timeline for schedule of audit forms Select Form 18 Armstrong Institute for Patient Safety and Quality

19. Click on form name to begin data entry Begin Data Entry 19 Armstrong Institute for Patient Safety and Quality

20. How process measurement helps you Compliance is key to providing evidence- based practice EBP allows you to meet your outcomes goals Process measures provide a “map” to what’s working well and what’s not Regular feedback on performance essential to performance and buy-in (transparency) Use your data to inform, motivate, communicate laterally and upward Armstrong Institute for Patient Safety and Quality 20