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THE BOARD’S ROLE IN THE BOARD’S ROLE IN PATIENT SAFETY & QUALITYPATIENT SAFETY & QUALITY
by
James E. OrlikoffSenior Consultant,Center for Healthcare Governance
President,Orlikoff & Associates, Inc.4800 S. Chicago Beach DriveSuite 307NChicago Il 60615-2054773-268-8009
c Copyright Orlikoff & Associates, Inc. 2005
THE GREAT OBSTACLE TO PROGRESS IS NOT IGNORANCE BUT THE ILLUSION OF KNOWLEDGE
DANIEL BOORSTIN
A BRIEF HISTORY OF QUALITY
THE CODE OF HAMMURABI (CIRCA 2,000 B.C.)
“IF THE SURGEON HAS MADE A DEEP INCISION IN THE BODY OF A FREE MAN AND HAS CAUSED THE MAN’S DEATH OR HAS OPENED THE CARBUNCLE IN THE EYE AND SO DESTROYS THE MAN’S EYE, THEY SHALL CUT OFF HIS FOREHAND.”
THE CALIFORNIA MEDICAL INSURANCE FEASIBILITY STUDY – 1977
THE HARVARD MEDICAL PRACTICE STUDY – 1991
THE INSTITUTE OF MEDICINE REPORT - 1999
THE INSTITUTE OF MEDICINE REPORT - 1999
EXTRAPOLATING FROM THESE AND OTHER STUDIES, THE IOM REPORT STATED THAT:
ERRORS CAUSE BETWEEN 44,000 AND 98,000 DEATHS EVERY YEAR IN AMERICAN HOSPITALS.
THIS MEANS THAT HOSPITAL ERRORS ARE BETWEEN THE FOURTH AND SEVENTH MOST COMMON CAUSE OF DEATH IN THE UNITED STATES!!
Crossing the Quality Chasm:IOM Guiding Principles
• Health Care Should Be:– Safe No unintended injuries– Effective Based on evidence– Timely No harmful delays– Efficient Not wasteful– Equitable No variance in quality– Patient Centered
QUALITY
The Latest Large Study:Patients Received 54.9% of Scientifically Indicated Care (Acute: 53.5%; Chronic 56.1%; Preventive: 54.9%)
Conclusion: The “Defect Rate” in the Technical Quality of Care is Around 45% !!
McGlynn, et al “The Quality of Health Care Delivered to Adults in the US” NEJM (June 26, 2003)
QUALITY
The Trends:
More Reporting/Release of Comparative Quality data to the Public
Pay for Performance
THE CHALLENGE OF QUALITY AS A SYSTEMS ISSUE
LESSONS LEARNED:
AS INDIVIDUAL EXPERTISE AND CONFIDENCE GROWS, RESPECT FOR AND COMPLIANCE WITH SYSTEM RULES DECLINES.
BREAKING SYSTEM AND SAFETY RULES IS USUALLY POSITIVELY REWARDED, REINFORCING THE TENDENCY OF INDIVIDUALS TO DO SO.
THE CHALLENGE OF QUALITY AS A SYSTEMS ISSUE (CONT.)
AT THE PRECISE TIME THAT SYSTEM RULES SHOULD BE FOLLOWED, THEY ARE MOST LIKELY TO BE BROKEN: UNDER EXTREME TIME PRESSURE, CRITICAL OR EMERGENCY SITUATIONS.
SYSTEMS OFTEN FAIL BECAUSE INDIVIDUALS FOCUS ON THE SITUATION AND NOT THE PROCESS.
INCOMPATIBLE OR CONFLICTING SUB-SYSTEMS WITH DIFFERENT GOALS AND RULES STRESS OVERALL SYSTEM INTEGRITY AND CAUSE FAILURE.See references: The Logic of Failure
A SYSTEMS APPROACH
• Key attributes of other High Reliability Organizations (HROs):– Example of Commercial Aviation
• Reporting cultures
• Non-punitive event analysis
• Examine “near misses” for systems improvement
• Engaged in and dedicated to learning
• Institute standardized, proven processes
• Continual improvement mentality
• Willing to invest financially in improving quality / safety
HOW LEADERS DRIVE CHANGE:
THE POWER OF QUESTIONS
ARE WE READY TO MOVE FROM
“WHAT” TO “HOW”?
THE POWER OF QUESTIONS:
REGARDING QUALITY, PATIENT SAFETY, REDUCING NEEDLESS
DEATHS:
DO WE HAVE A “HOW GOOD OR HOW MUCH BY WHEN” TARGET?
SOME IS NOT A NUMBER.
SOON IS NOT A TIME.
THE 100,000 LIVES CAMPAIGN
Don Berwick, M.D.
Institute for Healthcare Improvement
December 14, 2004
SAVE 100,000 LIVES
BY JUNE 14, 2006
BY IMPLEMENTING SIX INTERVENTIONS
100k LIVES CAMPAIGN:
1. RAPID RESPONSE TEAMS
2. IMPROVE AMI CARE
3. PREVENT ADVERSE DRUG EVENTS
4. PREVENT CENTRAL LINE BLOODSTREAM INFECTIONS
5. PREVENT SURGICAL SITE INFECTIONS
6. PREVENT VENTILATOR-ASSOCIATED PNEUMONIA
HOW MANY DEATHS COULD BE PREVENTED?
230 LIVES PER YEAR IN A 500-BED HOSPITAL!
RRTs – 120 LIVES
AMI CARE – 50 LIVES
ADEs – 10 LIVES
CR-BSIs – 10 LIVES
SSIs – 30 LIVES
VAPs – 10 LIVES
DON BERWICK, MD, IHI CONFERENCE, DEC. 14, 2004.
WHAT BOARDS CAN DO:
1. DEBATE, UNDERSTAND, APPROVE AND ROUTINELY OVERSEE A FOCUSED SET OF SYSTEM LEVEL QUALITY INDICATORS
2. ESTABLISH SPECIFIC “HOW GOOD BY WHEN” TARGETS FOR IMPROVEMENT OF THESE SYSTEM-LEVEL INDICATORS
3. LEAD TO ACHIEVE THE TARGETS:
* SPEND BOARD & COMMITTEE TIME
* ASSIGN/ACCEPT ACCOUNTABILITY
* CHANGE SYSTEMS
ALIGN INDICATORS AND TARGETS WITH LEADERSHIP:
1. WHAT IS THE “HOW GOOD BY WHEN” SYSTEM LEVEL QUALITY INDICATOR?
2. WHAT ARE 2 OR 3 KEY DRIVERS OF THAT SYSTEM-LEVEL QUALITY TARGET?
3. WHAT SET OF PROJECTS, WITH DEFINED SCOPE AND TIMELINES, WILL MOVE THE KEY DRIVERS TO ACHIEVE THE TARGETS?
EXAMPLE: ALIGN INDICATORS AND TARGETS WITH LEADERSHIP:
1. SYSTEM LEVEL QUALITY INDICATOR: REDUCE HOSPITAL STANDARDIZED MORTALITY RATE FROM 100 TO 80 BY JUNE 2006
2. KEY DRIVERS: PREVENTABLE ARRESTS; NEEDLESS INFECTIONS
3. PROJECTS: RRT’s IN ALL HOSPITALS -11/05; SSI REDUCTION PROTOCALS ALL HOSPITALS – 12/05.
Stages of Facing Reality
• Stage 1 “The data are wrong”
• Stage 2 “The data are right but, it is not a problem”
• Stage 3 “The data are right; it is a problem but, not my problem”
• Stage 4 “I accept the burden of improvement”
KEY BOARD STRATEGIES FOR QUALITY
DEVELOP SPECIFIC “HOW GOOD BY WHEN” PATIENT SAFETY AND QUALITY TARGETS FOR YOUR ORGANIZATION – IMPLEMENT THE IHI 100K LIVES INTERVENTIONS
EMPHASIZE QUALITY/PATIENT SAFETY BY MAKING IT THE FIRST MAJOR AGENDA ITEM AT EACH BOARD MEETING.
BUNDLES: MEASURE THE COMPOSITE NOT THE COMPONENTS.
TELL “STORIES” AT EACH BOARD MEETING – MAKE THE NEED FOR IMPROVEMENT REAL.
THE BOARD MUST LEAD!
KEY LEADERSHIP STRATEGIES FOR QUALITY
MAKE QUALITY IMPROVEMENT A CORE ORGANIZATIONAL STRATEGY, CLOSELY LINK QUALITY IMPROVEMENT ACTIVITIES TO STATEGIC PRIORITIES.
ALLOCATE SUFFICIENT FINANCIAL RESOURCES TO QUALITY IMPROVEMENT (INCLUDING INFORMATION SYSTEMS); FOR EXAMPLE: 1-3% OF GROSS EXPENSE BUDGET. REVIEW ANNUALLY AS PART OF BOARD OVERSIGHT OF BUDGET.
PROVIDE A CLEAR VISION OF THE QUALITY IMPROVEMENT PROCESS AND ITS GOALS.
REGULARLY MONITOR AND OVERSEE THE SYSTEM-WIDE QUALITY IMPROVEMENT PROCESS
FOCUS ON SYSTEMS IMPROVEMENT AND INTEGRATION, NOT INDIVIDUALS.
IT IS NOT THE STRONGEST WHO SURVIVE, OR THE FASTEST.
IT IS THE ONES WHO CAN CHANGE THE QUICKEST.
Charles Darwin
1. RAPID RESPONSE TEAMS
GOAL: PREVENT DEATHS IN PATIENTS WHO ARE
PROGRESSIVELY FAILING OUTSIDE THE ICU
CARDIAC ARREST OR SHOCK OCCURS IN 0.6% OF MEDICAL PATIENTS AND 0.5% OF SURGICAL PATIENTS
ONLY 17% OF PATIENTS WHO EXPERIENCE A CARDIAC ARREST SURVIVE TO DISCHARGE. SURVIVAL RATES ARE HIGHER WHEN ARRESTS OCCUR IN MONITORED UNITS.
MOST PATIENTS WHO HAVE A CARDIAC ARREST IN THE HOSPITAL HAVE IDENTIFIABLE SIGNS OF DETERIORATION PRIOR TO THEIR ARREST
1. RAPID RESPONSE TEAMS (RRTs)
RRT MAY BE SUMMONED AT ANY TIME BY ANYONE IN THE HOSPITAL TO ASSIST IN THE CARE OF A PATIENT WHO APPEARS ACUTELY ILL, BEFORE PATIENT HAS A CARDIAC ARREST OR OTHER ADVERSE EVENT
SEVERAL RRT MODELS, RANGING FROM AN ICU MD/RN TEAM TO AN ICU RN/RESPIRATORY THERAPIST. MD MAY BE A SENIOR RESIDENT, FELLOW, OR STAFF
CRITERIA TO CALL THE RRT CAN INCLUDE:
ACUTE CHANGE IN VITAL SIGNS; ACUTE DROP IN 02 SATURATION; DECREASED URINE
OUTPUT; ALTERED MENTAL FUNCTION;
ANY STAFF MEMBER CONCERN ABOUT THE PATIENT
1. RAPID RESPONSE TEAMS (RRTs) SUCCESS STORIES
REDUCTION IN CARDIAC ARRESTS AND DEATHS, REDUCTION IN ICU AND HOSPITAL BED-DAYS AMONG SURVIVORS OF CARDIAC ARREST.
IN SURGICAL PATIENTS, REDUCTION IN RESPIRATORY FAILURE, STROKE, SEVERE SEPSIS, AND ACUTE RENEAL FAILURE. REDUCTION IN NUMBER OF ICU ADMISSIONS, LOS, AND POSTOPERATIVE MORTALITY.
1. RAPID RESPONSE TEAMS (RRTs) SUCCESS STORIES
AUSTIN HOSPITAL IN HEIDELBERG, VICTORIA, AUSTRALIA, SAW A 65% DROP IN CARDIAC ARRESTS AND A 37% REDUCTION IN MORTALITY AFTER INTRODUCING RRTs.
BAPTIST MEMORIAL HOSPITAL, MEMPHIS, TN, EXPERIENCED A 28% DROP IN CODES. FURTHER, MORE OF ALL CODES NOW OCCUR IN THE ICU. FLOOR NURSES REPORT THAT THEY ARE NOW MORE CONFIDENT IN THEIR ABILITY “TO RESCUE PATIENTS BEFORE THEY GET INTO SERIOUS TROUBLE.”
2. IMPROVED CARE FOR AMI
GOAL: PREVENT DEATHS IN PATIENTS HOSPITALIZED FOR
AMI BY RELIABLE DELIVERY OF EVIDENCE-BASED CARE
1.1 MILLION PEOPLE HAVE AN AMI EACH YEAR. ONE-THIRD DIE DURING THE ACUTE PHASE
THERE ARE CLEAR GUIDELINES FOR MANAGEMENT OF PATIENTS WITH AMI: AMERICAN COLLEGE OF CARDIOLOGY, AMERICAN HEART ASSOCIATION
2. IMPROVED CARE FOR AMI
IMPLEMENTING THESE GUIDELINE THERAPIES REDUCES AMI MORTALITY. PROMPT ASPRIN ADMINISTRATION REDUCES RISK OF DEATH BY 15%. BETA-BLOCKERS REDUCE RISK OF DEATH IN FIRST WEEK AFTER AMI BY 13% AND LONG-TERM MORTALITY BY 23%.
YET, A RECENT RAND STUDY SHOWED THAT ONLY 61% OF AMI PATIENTS RECEIVED ASPRIN AND ONLY 45% RECEIVED BETA-BLOCKERS.
2. IMPROVED CARE FOR AMI
INTERVENTIONS:
EARLY ADMINISTRATION OF ASPIRIN
ASPIRIN AT DISCHARGE
EARLY ADMINISTRATION OF BETA-BLOCKER
BETA-BLOCKER AT DISCHARGE
ACE-INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKERS AT DISCHARGE FOR PATIENTS WITH SYSTOLIC DYSFUNCTION
TIMELY INITIATION OF REPERFUSION
SMOKING CESSATION
2. IMPROVED CARE FOR AMI
SUCCESS STORIES
HACKENSACK U. MEDICAL CENTER DEVELOPED STANDARDIZED PROCESSES FOR AMI CARE, INCREASING COMPOSITE AMI SCORE FROM AN AVERAGE OF 72% 1st QUARTER 2003 TO 91% BY 4th QUARTER 2003, RESULTING IN A DECREASE IN AMI INPATIENT MORTALITY FROM 7% TO 5.2% DURING THE SAME PERIOD.
McLEOD REGIONAL MEDICAL CENTER, FLORENCE, SC, INCREASED PERCENT OF PATIENTS WHO RECEIVED ALL AMI KEY MEASURES FROM 80% IN JAN. 2001 TO 100% BY NOV. 2003. THIS REDUCED THE AVERAGE INPATIENT MORTALITY RATE FOR AMI TO 4% , BELOW CMS REPORTED AVERAGE OF 7% IN 2003.
3. PREVENT ADVERSE DRUG EVENTS (ADEs)
GOAL: PREVENT ADEs BY IMPLEMENTING MEDICATION
RECONCILIATION
HOSPITALIZED PATIENTS WHO EXPERIENCE AN ADE ARE ALMOST TWICE AS LIKELY TO DIE AS THOSE WHO DON’T.
ADEs MAY CAUSE AS MUCH AS 20% OF UNNECESSARY HOSPITAL DEATHS
ADEs ACCOUNT FOR 6.3% OF MEDICAL MALPRACTICE CLAIMS
3. PREVENT ADVERSE DRUG EVENTS (ADEs)
46% OF ALL MEDICATION ERRORS OCCUR AT TRANSITION POINTS SUCH AS HOSPITAL ADMISSION, TRANSFER BETWEEN UNITS, AND DISCHARGE.
MEDICICATION RECONCILIATION ENSURES THAT PATIENTS RECEIVE ALL INTENDED MEDS AND NO UNINTENDED MEDS FOLLOWING TRANSITIONS AND CAN VIRTUALLY ELIMINATE ERRORS OCCURRING AT TRANSITIONS IN CARE
3. PREVENT ADVERSE DRUG EVENTS (ADEs)
SUCCESS STORIES
LUTHER MIDELFORT, MAYO HEALTH SYSTEM ELIMINATED VIRTUALLY ALL ADEs IN THE TELEMETRY/INTERMDEIATE CARE UNIT THROUGH A MEDICICATION RECONCILIATION SYSTEM
OSF HEALTHCARE SYSTEM, PEORIA, IL REDUCED ITS ADE RATE PER 1,000 UNITS OF MEDICATION ADMINISTERED FROM 3.84 TO 1.39
4. PREVENT CENTRAL LINE-ASSOCIATED BLOODSTREAM
INFECTIONS
GOAL: PREVENT CENTRAL VENOUS CATHETER-RELATED BLOODSTREAM INFECTIONS
(CR-BSI) AND DEATHS BY IMPLEMENTING THE “CENTRAL
LINE BUNDLE”
48% OF ICU PATIENTS HAVE CENTRAL VENOUS CATHETERS, EQUALS 15 MILLION CENTRAL VENOUS CATHETER DAYS PER YEAR IN ICUs
THERE ARE APPROXIMATELY 5.3 CR-BSIs PER 1,000 CATHETER-DAYS IN ICUs
THE MORTALITY RATE FOR CR-BSIs IS 18%. THUS, THERE ARE ABOUT 14,000 DEATHS ANNUALLY DUE TO CR-BSIs IN ICUs. MAY BE AS HIGH AS 28,000 DEATHS
4. PREVENT CENTRAL LINE-ASSOCIATED BLOODSTREAM
INFECTIONS
4. PREVENT CENTRAL LINE-ASSOCIATED BLOODSTREAM
INFECTIONS
A “BUNDLE” BRINGS TOGETHER THOSE SCIENTIFICALLY GROUNDED CONCEPTS
THAT ARE BOTH NECESSARY AND SUFFICIENT TO IMPROVE OUTCOMES.
THE KEY IS TO MEASURE THE COMPLETION OF THE COMPOSITE BUNDLE, NOT THE COMPONENTS.
HAND HYGINE
MAXIMAL BARRIER PRECAUTIONS
CHLORHEXIDINE SKIN ANTISEPSIS
APPROPRIATE CATHETER SITE AND ADMINISTRATION SYSTEM CARE
NO ROUTINE REPLACEMENT
4. PREVENT CR-BSIs: THE CENTRAL LINE BUNDLE
BAPTIST MEMORIAL HOSPITAL, MEMPHIS, TN; ALLEGHENY GENERAL HOSPITAL, PITTSBURGH, PA; JOHNS HOPKINS, BALTIMORE, MD AND MANY OTHERS HAVE VIRTUALLY ELIMINATED CR-BSIs BY IMPLEMENTING THE CENTRAL LINE BUNDLE.
ICU LOS ALSO DECLINED
4. PREVENT CR-BSIs: THE CENTRAL LINE BUNDLE
SUCCESS STORIES
5. PREVENT SURGICAL SITE INFECTIONS (SSIs)
GOAL: PREVENT SSIs AND DEATHS BY IMPLEMENTING SSI BUNDLE
SSIs ACCOUNT FOR 14 -16% OF ALL HOSPITAL-ACQUIRED INFECTIONS; 40% OF INFECTIONS IN SURGICAL PATIENTS .
SSIs OCCUR IN 2% TO 5% OF EXTRA-ABDOMINAL SURGERIES, AND IN UP TO 20% OF INTRA-ABDOMINAL SURGERIES.
SURGICAL PATIENTS WHO DEVELOP SSIs ARE TWICE AS LIKELY TO DIE AS THOSE WHO DON’T
GUIDELINE-BASED USE OF PROPHYLACTIC ANTIBIOTICS
APPROPRIATE SURGICAL SITE HAIR REMOVAL (NO SHAVING!)
PERIOPERATIVE GLUCOSE CONTROL
5. PREVENT SSIs: THE SSI BUNDLE
6. PREVENT VENTILATOR-ASSOCIATED PNEUMONIA (VAP)
GOAL: PREVENT VAPs AND DEATHS BY IMPLEMENTING THE
“VENTILATOR BUNDLE”
VAP OCCURS IN UP TO 15% OF PATIENTS RECEIVING MECHANICAL VENTILATION.
THE MORTALITY RATE FOR VENTILATOR PATIENTS WITH VAP IS 46%, COMPARED TO 32% FOR THOSE WHO DO NOT DEVELOP VAP.
VAP INCREASES VENTILATION TIME, ICU STAY, HOSPITAL STAY, AND COSTS.
ELEVATION OF THE HEAD OF THE BED 30 DEGREES
PERIODIC “SEDATION VACATIONS”
DAILY EXTUBATION ASSESSMENT
PEPTIC ULCER DISEASE PROPHYLAXIS
DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS
6. PREVENT VAPs: THE VENTILATOR BUNDLE
4. PREVENT CENTRAL LINE-ASSOCIATED BLOODSTREAM
INFECTIONS
GOAL: PREVENT CENTRAL VENOUS CATHETER-RELATED BLOODSTREAM INFECTIONS
(CR-BSI) AND DEATHS BY IMPLEMENTING THE “CENTRAL
LINE BUNDLE”
48% OF ICU PATIENTS HAVE CENTRAL VENOUS CATHETERS, EQUALS 15 MILLION CENTRAL VENOUS CATHETER DAYS PER YEAR IN ICUs
THERE ARE APPROXIMATELY 5.3 CR-BSIs PER 1,000 CATHETER-DAYS IN ICUs
THE MORTALITY RATE FOR CR-BSIs IS 18%. THUS, THERE ARE ABOUT 14,000 DEATHS ANNUALLY DUE TO CR-BSIs IN ICUs. MAY BE AS HIGH AS 28,000 DEATHS
4. PREVENT CENTRAL LINE-ASSOCIATED BLOODSTREAM
INFECTIONS
4. PREVENT CENTRAL LINE-ASSOCIATED BLOODSTREAM
INFECTIONS
A “BUNDLE” BRINGS TOGETHER THOSE SCIENTIFICALLY GROUNDED CONCEPTS
THAT ARE BOTH NECESSARY AND SUFFICIENT TO IMPROVE OUTCOMES.
THE KEY IS TO MEASURE THE COMPLETION OF THE COMPOSITE BUNDLE, NOT THE COMPONENTS.
HAND HYGIENE
MAXIMAL BARRIER PRECAUTIONS
CHLORHEXIDINE SKIN ANTISEPSIS
APPROPRIATE CATHETER SITE AND ADMINISTRATION SYSTEM CARE
NO ROUTINE REPLACEMENT
4. PREVENT CR-BSIs: THE CENTRAL LINE BUNDLE
BAPTIST MEMORIAL HOSPITAL, MEMPHIS, TN; ALLEGHENY GENERAL HOSPITAL, PITTSBURGH, PA; JOHNS HOPKINS, BALTIMORE, MD AND MANY OTHERS HAVE VIRTUALLY ELIMINATED CR-BSIs BY IMPLEMENTING THE CENTRAL LINE BUNDLE.
ICU LOS ALSO DECLINED
4. PREVENT CR-BSIs: THE CENTRAL LINE BUNDLE
SUCCESS STORIES
5. PREVENT SURGICAL SITE INFECTIONS (SSIs)
GOAL: PREVENT SSIs AND DEATHS BY IMPLEMENTING SSI BUNDLE
SSIs ACCOUNT FOR 14 -16% OF ALL HOSPITAL-ACQUIRED INFECTIONS; 40% OF INFECTIONS IN SURGICAL PATIENTS .
SSIs OCCUR IN 2% TO 5% OF EXTRA-ABDOMINAL SURGERIES, AND IN UP TO 20% OF INTRA-ABDOMINAL SURGERIES.
SURGICAL PATIENTS WHO DEVELOP SSIs ARE TWICE AS LIKELY TO DIE AS THOSE WHO DON’T
GUIDELINE-BASED USE OF PROPHYLACTIC ANTIBIOTICS
APPROPRIATE SURGICAL SITE HAIR REMOVAL (NO SHAVING!)
PERIOPERATIVE GLUCOSE CONTROL
5. PREVENT SSIs: THE SSI BUNDLE
6. PREVENT VENTILATOR-ASSOCIATED PNEUMONIA (VAP)
GOAL: PREVENT VAPs AND DEATHS BY IMPLEMENTING THE
“VENTILATOR BUNDLE”
VAP OCCURS IN UP TO 15% OF PATIENTS RECEIVING MECHANICAL VENTILATION.
THE MORTALITY RATE FOR VENTILATOR PATIENTS WITH VAP IS 46%, COMPARED TO 32% FOR THOSE WHO DO NOT DEVELOP VAP.
VAP INCREASES VENTILATION TIME, ICU STAY, HOSPITAL STAY, AND COSTS.
ELEVATION OF THE HEAD OF THE BED 30 DEGREES
PERIODIC “SEDATION VACATIONS”
DAILY EXTUBATION ASSESSMENT
PEPTIC ULCER DISEASE PROPHYLAXIS
DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS
6. PREVENT VAPs: THE VENTILATOR BUNDLE
SELECTED REFERENCESInstitute for Healthcare Improvement: www.ihi.org
www.ihi.org/ihi/programs/campaign
RAPID RESPONSE TEAMS:
Peberdy MA et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14,270 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003;58:297-308.
Sandroni C. et al. In-hospital cardiac arrest: survival depends mainly on the emergency response. Resuscitation. 2004;62:291-297
Schein RM et al. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest. 1990;98:1388-1392
Hillman K. et al. Redefining in-hospital resuscitation: the concept of the medical emergency team. Resuscitation. 2001;48:105-110
Buist MD et al. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in-hospital: preliminary study. British Medical Journal. 2002;324:387-390.
Bellomo R. et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Critical Care Medicine. 2004;32:916-921.
SELECTED REFERENCES
AMI CARE:
Antman et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of American Cardiology. 2004; 44:671-719.
Hennekens et al. Adjunctive drug therapy for acute myocardial infarction – evidence from clinical trials. New England Journal of Medicine 1996;335:1660-1667.
McGlynn et al. The quality of healthcare delivered to adults in the United States. New England Journal of Medicine 2003;348:2635-2645
CENTERS FOR MEDICARE AND MEDICAID SERVICES www.cms.hhs.gov/quality/hospital; CMS National Acute Myocardial Infarction Project: www.medqic.org/content/nationalpriorities/topics
AMERICAN COLLEGE OF CARDIOLOGY www.acc.org/index.htm
SELECTED REFERENCES
ADVERSE DRUG EVENTS:
Classen DC et al. Adverse Drug Events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1997;277;301-306.
Phillips DP et al. Increase in U.S. medication-error deaths between 1983 and 1993. Lancet. 1998; 351:643-644
Rothschild JM et al. Analysis of medication-related malpractice claims. Causes, preventability, and costs. Archives of Internal Medicine. 2002;162:2414-2420
Pronovost P. et al. Medication reconciliation: a practical tool to reduce the risk of medication errors. Journal of Critical Care. 2003;18:201-205.
Rozich JD et al. Medication safety: one organization’s approach to the challenge. JCOM. 2001;8(10):27-34
Leape LL et al. Reducing Adverse Drug Events. Boston: Institute for Healthcare Improvement, 1998.
SELECTED REFERENCES
PREVENT CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS:
Pittet, D. et al. Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1994;271;1598-1601.
Saint, S. Chapter 16. Prevention of intravascular catheter-related infection. Making healthcare safer; a critical analysis of patient safety practices. AHRQ evidence report, number 43, July 20, 2001. www.ncbi.nlm.nih.gov/books
Berenholtz SM, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Critical Care Medicine. 2004;32:2014-2020.
O’Grady NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Morbidity Mortality Weekly Report 2002;51(RR-10):1-29.
SELECTED REFERENCES
PREVENT SURGICAL SITE INFECTIONS:
Kirkland KB, et al. The impact of surgical-site infections in the 1990s; attributable mortality, excess length of hospitalization, and extra costs. Infection Control Hosp Epidemiology. 1999;20;725-730.
Mangram AJ; et al. Guidelines for prevention of surgical site infection, 1999. Infection Control Hosp Epidemiology. 1999;20;247-278.
Adams, K; et al. Priority areas for national action: transforming health care quality. Washington, DC: The National Academies Press, 2003.
Surgical Care Improvement Project (SCIP) www.medqic.org/scip
Van den Berghe G; et al. Intensive insulin therapy in critically ill patients. New England Journal of Med. 2001;345:1359-1367.
SELECTED REFERENCES
PREVENT VENTILATOR-ASSOCIATED PNEUMONIA:
Ibrahim EH; et al. The occurrence of ventilator-associated pneumonia in a community hospital: risk factors and clinical outcomes. Chest. 2001;120:555-561.
Guidelines for Preventing Health-Care-Associated Pneumonia, 2003. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR 2004;53(No.RR-3):1-36.
Dodek P, et al. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann intern Med. 2004;141:305-313.
Kress JP, et al. Daily interruption of sedative infusions in critically ill patients. N Eng J Med 2000;342-1477.
Surgical Care Improvement Project (SCIP) www.medqic.org/scip
Drakulovic, MB, et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomized trial. Lancet. 1999;354:1851-1858.
