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Welcome to the Kentucky Hospital Improvement
Innovation Network - February Update
Agenda 1. Site Visits Update 2. Fellowships – QI and PFE 3. 1-2-3 for Equity Pledge 4. SNAP – Safety Network to Accelerate Performance
Update 5. Fishbowl?! 6. Data and Ky. Quality Counts Update 7. Topic-Based Info-Nuggets 8. Hospital Highlight – Baptist Health LaGrange and Oldham
County EMS 9. K-HIIN Delirium/Care of the Aging Patient Series 10. Upcoming HRET and K-HIIN Events 11. Timeline and Next Steps
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Site Visits
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The K-HIIN team is STILL on the road! So far - 53 Visits completed, thank you! Preparation – •Invite key team members – Senior Leadership, clinical leaders, data collectors and analysts, physician leaders, risk managers, IP, etc. •Let us know location of meeting, media and Internet capabilities •Be thinking about your WHY and your areas of focus
We are learning lots of great things that our hospitals are up to – you may be the next Hospital Highlight!
Fellowships Back by popular demand!
1. QI Fellowships – KY enrollment: Foundations for Change – 17 enrollees Accelerating Improvement – 4 enrollees
2. Patient and Family Engagement – 7 enrollees Thank you for participating - there’s still time to sign up
for PFE (Sorry, QI is now closed) – remember, our goal is to have at least one Fellow from each hospital!
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Disparities impact statement
#123forEquity
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#123ForEquity
#123forEquity Pledge National Call to Action Pledge to address the following areas in the next 12 months-
By end of month one, choose a quality measure to stratify by race, ethnicity, or language preference (or other socio-demographic variable such as income, veteran status, sexual orientation or gender, or other)
By end of month three, determine if a health care disparity exists in this measure – if yes, design a plan to address the gap
By end of month six, provide cultural competency training for all staff or develop a plan to ensure your staff receives cult. comp. training
By end of month nine, have a dialogue with board and leadership team on how you reflect the community you serve, and what actions can be taken to address any gaps if the board and leadership do not reflect the community you serve
SNAP Update
Safety Network to Accelerate Performance • The first SNAP topic is enhanced recovery
after surgery with a focus on colorectal surgery.
• SNAP applications are closed for this round – 2 Kentucky Hospitals applied - and were
accepted! Baptist Health LaGrange and King’s Daughter’s Medical Center - we look forward to hearing about your progress!
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Fishbowl? • HRET is piloting a new idea – a “fishbowl”
is an opportunity for a hospital to bring the HRET and Cynosure leads into their quality team meetings for consultation, tips, etc. via SKYPE or other interactive methods.
• First topic is ADE, next Readmissions • Would you like to be in a fishbowl? Contact K-HIIN by Feb.27 for more information! 9
DATA UPDATE
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Adverse Drug Events
2.3 2.1
0.4
3.4
3.9
0.5
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
ADEs - excessive anticoagulation ADEs - hypoglycemia ADEs - opiods
Adverse Drug Events
State BL Rate HRET BL Rate
11 Baseline Varies Preferred Baseline - 2014
CACCAUTI
12
0.8
0.9
1
1.2
0
0.2
0.4
0.6
0.8
1
1.2
1.4
CAUTI Rate - all except NICUs CAUTI Rate - ICUs except NICUs
Rate
per
100
0 Ca
thet
er D
ays
CAUTI Rate
State BL Rate HRET BL Rate
25.8
61.2
22.3
57.8
0
10
20
30
40
50
60
70
Catheter Utilization -all except NICUs
Catheter Utilization -ICUs except NICUs
Cath
eter
Day
s/Pa
tient
Day
s
Catheter Utilization Ratio
State BL Rate HRET BL Rate
Baseline Period: 2015
CLABSI
13
0.7
0.9 0.9
1.1
0
0.2
0.4
0.6
0.8
1
1.2
CLABSI Rate - All CLABSI Rate - ICUs
Rate
per
100
0 Pa
tient
Day
s
CLABSI Rate
State BL Rate HRET BL Rate
20.1
45.3
19.1
40.5
0
5
10
15
20
25
30
35
40
45
50
Central line utilization - All Central line utilization - ICUs
Line
Day
s/Pa
tient
Day
s
Central Line Utilization
State BL Rate HRET BL Rate
Baseline Period: 2015
MDROs
14
6.6
6.1
5.8
5.9
6
6.1
6.2
6.3
6.4
6.5
6.6
6.7
C. diff Rate Facility-wide-all except NICUs
Rate
per
10,
000
Patie
nt D
ays
C. Diff
State BL Rate HRET BL Rate
0.1 0.1
0
0.02
0.04
0.06
0.08
0.1
0.12
Hospital-onset MRSA bacteremia events
Rate
per
100
0 Pa
tient
Day
s
MRSA Bacteremia
State BL Rate HRET BL Rate
Baseline Period: 2014
Falls With Injury Pressure Ulcer/Injury
15
0.8
0.7
0.64
0.66
0.68
0.7
0.72
0.74
0.76
0.78
0.8
0.82
Falls
Rate
per
100
0 Pa
tient
Day
s
Fall With Injury
State BL Rate HRET BL Rate
0.4
0.2
1.2
0.3
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Pressure ulcer rate, stage 3+ Pressure ulcer prevalence, stage 2+
State BL Rate HRET BL Rate
Rate
per
100
0 Di
scha
rges
Rate
per
Disc
harg
e
Baseline Period Varies Baseline Period: Stage III or Greater – 2014 Stage II and Greater Prevalence - Varies
Readmissions
16
8.5
11
8.9
11.9
0
2
4
6
8
10
12
14
Readmissions Hospital wide all cause readmissions, Medicare
Rate
Readmissions
State BL Rate HRET BL Rate
Baseline Period Varies
Surgical Site Infections
17
6.9
1.9
0.7 1.1
5.2
1.5
0.7
1.2
0
1
2
3
4
5
6
7
8
SSI rate, colon surgeries SSI rate, abd hyst SSI rate, knee surgeries SSI rate, hip surgeries
Rate
SSI Rate
State BL Rate HRET BL Rate
Baseline Period: Colon and Abd Hyst - 2014
Baseline Period: Hip or Knee Surgery - Varies
Post-Op Sepsis Post-Op VTE
18
10.7
6.9
0
2
4
6
8
10
12
Sepsis Post-op Rate
Rate
per
100
0 Su
rgic
al D
ischa
rges
Post-Operative Sepsis
State BL Rate HRET BL Rate
3.5
3.7
3.4
3.45
3.5
3.55
3.6
3.65
3.7
3.75
Post-operative VTE or DVT
Rate
per
100
0 Su
rgic
al D
ischa
rges
VTE
State BL Rate HRET BL Rate
Baseline Period: 2014
Ventilator Associated Events
19
3.7
1.1
5.7
1.9
0
1
2
3
4
5
6
Ventilator-associated condition rate Infection-related ventilator-associated condition rate
Rate
per
100
0 Ve
ntila
tor D
ays
VAE
State BL Rate HRET BL Rate
Baseline Period: 2015
Worker Safety Harm Events
20
0.3
0.1
0.2
0.1
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
Worker Safety harm events - patient mobilitization Worker Safety harm events - workplace violence
Rate
per
FTE
Worker Safety Harm Events
State BL Rate HRET BL Rate
Baseline Varies
Monitoring Data
Monthly Monitoring Data • Beginning with October 2016 data
Monitoring Data (October 2016 – December 2016) will be due to KY Quality Counts by
March 1, 2017
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KY Quality Counts Data Collection System
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https://khaqualitydata.org
And a Few Info-Nuggets Adverse Drug Events – from recent ADE listserv activity… Authors Barnett, Olenski and Jena published a fascinating article in NEJM
analyzing “Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use”. You can find the article here http://www.nejm.org/doi/full/10.1056/NEJMsa1610524?query=TOC.
Here’s what they found: • Within individual hospital emergency departments, rates of opioid
prescribing varied widely between low-intensity and high-intensity prescribers
• Long-term opioid use was significantly higher among patients treated by high-intensity prescribers than among patients treated by low- intensity prescribers (adjusted odds ratio, 1.30; 95% confidence interval, 1.23 to 1.37; P<0.001)
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• In addition, they found that within 12 months after being seen by high-intensity prescribers, patients were more likely to be seen in a hospital for:
FALLS – Relative Risk = 6.5 % increase – Absolute Risk = 2.8 excess falls per 1000 patients – Number Needed to Injure (NNI) = 1 out of every 357 patients
and OPIOID POISONING
– Relative Risk = 42% increase – Absolute Risk = 0.3 excess opioid poisonings per 1000 patients – Number Needed to Injure (NNI) = 1 out of approximately every
3300 patients
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In summary:
• There is wide variation within individual hospital Emergency Physicians regarding their opioid prescribing practices.
• Patients treated by high-intensity prescribers (more scripts, higher doses; longer durations) were: – 30% more likely to become long-term opioid users, – 6.5% more likely to be treated for a fall, and – 42% more likely to be treated for opioid poisoning.
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• Here are some suggested actions and measures to consider: • Share this article • Identify the opioid prescribing practices of your ED physicians
– % of patients who leave with an opioid prescription • Numerator = patients who leave with an opioid Rx from
Physician A • Denominator = all patients discharged by Physician A
– Morphine equivalence • Numerator = total morphine equivalence prescribed
(dose x frequency x duration x number of scripts) by Physician A
• Denominator = all patients discharged by Physician A
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– % of patients who leave the ED with a script for more than X days (7, 10 or 14 days; no standard, choose one) supply of opioids
• Numerator = patients who leave with an opioid Rx from Physician A if taken as prescribed would last X days or more
• Denominator = all patients discharged by Physician A – NOTE: Each denominator is “all patients discharged by the
physician”, not just the patients discharged on an opioid • How much variance is there? • Share the results with your physicians to create “light” not “heat” • Engage your PFAC team to work with ED staff and patients to
create awareness of short term and long term opioid adverse events
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• Engage your PFAC team and nursing staff to begin to manage pain expectations as soon as the patient comes through triage
• Check out your staff’s current state of knowledge about opioid safety: – Take the Pennsylvania Opioid Knowledge Self-Assessment
Test http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/opioids/Documents/assessment.pdf
– Do your physicians know who’s low risk for opioids? Who’s high risk?
– Do your physicians know that opioid naïve patients should get very low doses of short acting opioids (if their pain cannot be managed by other non-opioid alternatives such as acetaminophen or ibuprofen)?
– Does your staff know the definition of opioid tolerant? This term means that the patient must have received at least 60 mg of morphine equivalence DAILY for the last 7 days.
• What else might you do?
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Antibiotic Stewardship Program
• Checklist for Core Elements of Hospital Antibiotic Stewardship Program: – Leadership Support – Accountability – Drug Expertise – Actions to Support Optimal Antibiotic Use – Tracking: Monitoring Antibiotic Prescribing, Use
and Resistance – Reporting Information to Staff on Improving
Antibiotic Use and Resistance – Education
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And a Few Info-Nuggets
Readmission Views From the Road • Strategies for reducing readmissions are numerous! • Today in Hospital Highlight you will hear from Baptist Health
LaGrange and Oldham County EMS about an innovative solution for keeping patients at home and healthy.
• Be sure to register for the Quality Symposium March 14-15, in Louisville Pat Teske, national HIIN resource on readmissions, will speak on defining the readmissions population and developing strategies to drive down readmission rates.
• At that Symposium we will also hear from two hospitals in Kentucky who have had success in implementing strategies to keep potential readmission in the community.
• All these examples were learned during our recent site visits and we’re eager to share them.
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Info Nuggets- C. difficile
• Perspectives from recent studies courtesy of Dr. Eric Dubberke at Washington University in St. Louis
• C. difficile is truly ubiquitous!! – People are normally colonized with C. diff (We all get it,
clear it and get it again all our lives. – We have constant exposure through our food, water,
dust…..It’s on our shoes and in bathrooms. – It is when our microbiome is changed that we become
ill. • Exposure to antibiotics- proven • Gastric acid suppression? • Exposure to infants?
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Info Nuggets- C. difficile • Why are we seeing more positives?
– Increased surveillance – Increased testing – Increasingly difficult to treat infections and inappropriate
use of antibiotics
• Conclusions: – C. diffcile is a clinical diagnosis- our patient is ill
and has appropriate symptoms to be suspicious for C. difftest!
– If at least 15% of all patients are colonized at time of admission, must be very careful about screening policies and testing protocols
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Hospital Highlight – Baptist Health LaGrange and Oldham County EMS
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Upcoming Events K-HIIN Delirium/Care of the Aging Patient Series
begins February 23, 1:00 p.m. – 2:00 p.m. ET HRET HIIN CAUTI Virtual Event – February 23
from 12:00 p.m. – 12:50 p.m. ET HRET HIIN Falls Virtual Event – March 7 from 12:00 p.m. – 12:50 p.m. ET HRET HIIN CDI Virtual Event – March 9 from 12:00 p.m. – 12:50 p.m. ET KHA Quality Symposium March 14 & 15, Crowne
Plaza Hotel, Louisville
http://www.hret-hiin.org
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Timeline and Next Steps • Site Visits - Schedule yours now if not
already scheduled • Join the PFE Fellowship! • Continue entering Monitoring Data into
KQC >
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KEEP CALM AND HIIN ON
Questions?
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