Shared Learning for Infection Prevention
THA Collaborative on Reducing HAIs
August 2008Tori Howk, Director of Risk and Regulatory
THA – August 2008
Collaborative Aims
• Improve the culture of safety• Reduce patient harm by reducing
CLBSI• MRSA• 25% reduction in surgical
complications by implementing SCIP
THA – August 2008
New Name for ICP
• Infection Preventionists– “The term infection preventionist clearly and
effectively communicates who our members are and what they do.
– Infection Preventionists develop and direct performance improvement initiatives that save lives and resources for healthcare facilities, so this was a natural transition – or a right-sizing of the name – to more accurately reflect their role.”
THA – August 2008
Improvement Opportunity
• $5 billion to US healthcare costs every year
• 1.7 million hospital-acquired infections in 2002 associated with 99,000 deaths
• “Research has shown that hospitals are not following recommended guidelines to avoid preventable hospital-acquired infections.”
• 87% of hospitals completing Leapfrog survey do not follow recommendations to prevent many of the most common hospital-acquired infections.
THA – August 2008
Benefits of Reducing Infections
• Better patient outcomes• Reduced mortality• Improved satisfaction
– Physician– Nursing– Patients and families
• Financial benefits
THA – August 2008
Bundle
• …“is a group of interventions related to patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually.”
• 2005 Institute for Healthcare Improvement
THA – August 2008
What Are Hospital Acquired Conditions? (HAC)
• Section 5001(c) of the Deficit Reduction Act (DRA) of 2005 required the Secretary of the Department of Health and Human Services to select at least two conditions that are: (1) high cost, high volume, or both; (2) identified through ICD-9-CM coding as a complicating condition (CC) or major complicating condition (MCC) that, when present as a secondary diagnosis at discharge, results in payment at a higher MS-DRG; and (3) is reasonably preventable through application of evidence-based guidelines.
• Last year, CMS selected eight conditions for the HAC provision.
• Beginning October 1, 2008, Medicare will no longer pay at a higher weighted MS-DRG for the original eight conditions plus three, as well as any conditions CMS is proposing to add in this year’s rule. (5 HAIs)
THA – August 2008
Hospital-Acquired Conditions (HAC)
Never Events/Rare Occurrences
Patient Safety Infection Prevention
•Delivery of ABO-Incompatible Blood
•Falls and fractures, dislocations, intracranial and crushing injury and burns
•Surgical Site Infections - Mediastinitis after coronary artery bypass graft (CABG) surgery - Orthopedic surgeries - Bariatric surgery
•Objects left in during surgery
•Pressure Ulcers •Vascular catheter-associated infections
•Air Embolism •Glycemic Control •Catheter-associated urinary tract infections
•Pressure Ulcers/DVT
THA – August 2008
TriStar Shared Learnings
• MRSA• Central Line Bloodstream Infections• SCIP
THA – August 2008
Improvement Triad
Leadership
System and Process Improvements
Measurement and Feedback
SuccessSuccess
THA – August 2008
Approach
• Understand the opportunity– Literature search– Assess current performance metrics and practice (Gap
Analysis)• Collaborative Improvement
– Identify best practices– Refine tools and systems based on Gap Analysis– Test improvements
• Shared Learning– Deploy toolkits, checklists, policies, resources, supply
recommendations, education modules, system enhancements
• Metrics Review
THA – August 2008
MRSA
• Death and complications• MRSA among most common and
problematic of HAIs• 50% post surgical infections for
CABG and orthopedic prosthetics• Excess costs• Malpractice claims• Proven strategies to reduce or nearly
eliminate nosocomial MRSA
THA – August 2008
Active Surveillance (Systems/Processes)
THA – August 2008
Active SurveillanceHigh Risk Patient Screening
• ICU admissions/transfers
• Outborn transfers to NICUs
• Long term care facility admissions
• Hemodialysisadmissions
• Previous MRSA history
• Preoperative Screens– Total hip– Total knee– Open spine procedures– Cardiac surgeries
• Private rooms, cohorting, and isolation
THA – August 2008
Barrier Precautions
THA – August 2008
• Standard precautions for all patients• Contact isolation of positive patients• Personal protective equipment
• Gown• Gloves• Mask with shield
• Dedicated equipment• Ticketing for non compliance
Barrier Precautions
THA – August 2008
Compulsive Hand Hygiene
THA – August 2008
• Expectation of 100% compliance with soap and water or other hand hygiene products
• Vendor assistance with alcohol gel strategy
• Patient encouraged to question hand hygiene practices of caregiver
• Staff pledge
Compulsive Hand Hygiene
THA – August 2008
Disinfection/Environmental Cleaning
THA – August 2008
• Proper disinfection techniquesProper supplies
• Proper equipment• Environmental services education• Workload analysis• Observation for adherence
Disinfection/Environmental Cleaning
THA – August 2008
• Executive and Physician Champions• Interdisciplinary taskforce• Executive walk arounds • Medical Executive Committee engagement• MEC and Board reports• Recognition and reward
Executive Ownership/Leadership
THA – August 2008
• Executive messaging
• Collaborative calls
• Patient/visitor information cards
• Banners, posters, buttons, static clings
• Waterless sanitizer/soap dispenser signage
• Isolation signage
• Staff newsletters
• Electronic triggers and trackers
Campaign
THA – August 2008
• Target audience--patients, caregivers, physicians, non-clinical staff, visitors, volunteers, vendors
• Community collaboration—EMS, local health department, other healthcare providers
• Data collection, analysis, and dissemination
Campaign
THA – August 2008
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07
6/29/07 7/31/07 8/31/07 9/30/07 10/31/07 11/30/07 12/31/07
TriStar 80.9% 90.4% 90.8% 90.2% 89.3% 92.5% 90.8%
2007 TriStar Monthly %: MRSA Swabs of High Risk Groups
Measurement - 2007 MRSA Swabbing Rate
THA – August 2008
Jan 08 Feb 08 Mar 08 Apr 08 May 08 Jun 08 Jul 08 Aug 08 Sep 08 Oct 08 Nov 08 Dec 08
TriStar 92.3% 93.2% 94.1% 94.2% 95.5% 95.4% 96.0% 0.0% 0.0% 0.0% 0.0% 0.0%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
TriStar Monthly %: MRSA Swabs of High Risk Groups
2008 MRSA Swabbing Rate
THA – August 2008
THA – August 2008
THA – August 2008
Central Line Infections
• Prolongation of hospitalization: 11-23 days
• Cost to healthcare system: $33,000 - $35,000/episode
• Attributable mortality: 12-25%
THA – August 2008
Central Line Bundle
1. Hand hygiene2. Maximal barrier precautions3. Chlorhexadine skin antisepsis4. Optimal catheter site selection, with
subclavian vein as the preferred site for non-tunneled catheters in adults
5. Daily review of line necessity with prompt removal of unnecessary lines
THA – August 2008
CLBSI System/Process Improvement
• Healthcare worker education– Hand hygiene– Practice guidelines/IHI Bundles– Checklist pocket reminders– Medical staff education on bundles– Checklists for line insertion– Surveillance rates to determine current
performance
THA – August 2008
CLBSI System/Process Improvements
• Supply Chain• Evaluation of all kit components for
chlorhexadine• Drape and barrier availability through
supply chain and all-inclusive carts• Computer screen standardization
– Checklists on screen (or paper)– Daily site surveillance review of necessity
added to flowsheet
THA – August 2008
CLBSI Measurement and Feedback
• Computer screen standardization– Automatic capture of data for
documentation and data collection• Physician documentation tools• Insertion observation• Performance feedback
THA – August 2008
Central Line Insertion Monitor DATE:________________ PHYSICIAN INSERTING:_____________________________SITE: IJ Subclavian PICC Femoral NOTE: PICC or SUBCLAVIAN sites preferred. If not utilized, must document justification for
utilizing another site. Morbid Obesity Respiratory Condition Prohibiting Emergency______________________________________________________________________________________________________________________________________________
HAND HYGIENE performed by MD and Assistants? MASK worn by MD? STERILE GOWN worn by MD? STERILE GLOVES worn by MD LARGE STERILE DRAPE used? CAP worn by MD? CHLORAPREP used? Back and forth motion for 30 seconds/allow to dry for 30 seconds OTHER PREP used? If “Y”, explain: CXR Ordered/Completed?Nurse:___________________________________________________ REMEMBER: Nurse must document ALL Vascular Line STARTS on IV Screen!
THA – August 2008
SCIP
• Among patients admitted for surgery, SSIs account for 38% of hospital-associated infections
Emori & Gaynes, Clinical Micro Reviews, 1993
• On average, SSI results in 7.3 excess hospital days and adds $3150 to cost of hospital care (1992 dollars)
CDC, MMWR, 1992
• Cost of treatment for an SSI associated with total joint replacement (hip or knee) is $50,000
Hanssen AD et al, J Bone Joint Surg Am, 1992
THA – August 2008
P ro p o rtio n o f A d verse E ve n tsM o st F req u en t C a teg o ries
0%
5%
10%
15%
20%
25%
D ru g -re la te d
W o u n din fe c t.
T e c h .c o m p .
L a tec o m p .
D ia g .m is h a p
T h e ra p .m is h a p
N o n te c h .c o m p .
Pro c .re la te d
B ren n an . N E n g l J M ed . 1991;324 :370 -376
N o n -su rg ica lS u rg ica l
THA – August 2008
SCIP National Quality MeasuresSCIP 1 Prophylactic antibiotic received within one hour prior to surgical
incision
SCIP 2 Appropriate prophylactic antibiotic selected for surgical patients consistent with current guidelines
SCIP 3 Prophylactic antibiotic discontinued within 24 hours after the end of surgery (within 48 hours after the end of surgery for CABG or other cardiac surgery)
SCIP 4 Cardiac surgery patients with controlled 6 A.M. postoperative blood glucose < 200mg/dL on Post Op Day 1 AND Post Op Day 2
SCIP 6 Surgery patients with appropriate hair removal
SCIP 7 Colorectal surgery patients with immediate postoperative normothermia > 98.6*F within first 15 minutes after leaving OR
THA – August 2008
SCIP Leadership & Responsibility
• Surgical services director may be a logical leader for SCIP compliance throughout the facility (IC, Quality)
• An executive sponsor is needed to support the director in implementing changes
• A physician champion, surgeon or anesthesiologist, is needed to assist with education and address physician practice issues.
• The quality director should provide frequent updates on performance and opportunities for system and process improvement
37
THA – August 2008
SCIP System/Process Improvements
• Evidence-based order sets– Preprinted, service-specific preprinted orders
• Preop and post-op– Antibiotic dosing charts
• Communication– Scripted time-out poster– Hand-off– Pharmacy notice of close time, times next dose(s)– Antibiotic dosing
• IT Screens– Prompts, reminders, required fields, inclusion of
antibiotic administration in OR nursing documentation (IV unless otherwise)
– Positive DVT screen, then auto-printing of pre-printed order
THA – August 2008
Improvement through IT System• Core Measures are embedded in the
following screens*:– Pre-op Prep– Pre-op Outcomes– Intraoperative RN Checklist and Assessment– Intraoperative Prep– Intraoperative RN Outcomes– PACU Admission Assessment– PACU Outcomes
* Screens reflect core measures for discharges effective 10/01/07 to 3/31/07. Core measure screens will be updated as data elements change. SCIP Core measure related queries are worded EXACTLY as defined by National Hospital Quality Measures.
THA – August 2008
Screen Example
• If razor is selected for hair removal method, a “pop-up” box will appear for the nurse to confirm that razor is the accurate response.
THA – August 2008
SCIP Measures Poster
41
Education
THA – August 2008
Time Out Poster
42
Checklists
THA – August 2008
SCIP Improvement Tactics
System/Process Improvement Tactic Measures Impacted
Evidence based order sets (Pre-operatively & Post-operatively)
SCIP 1, 2, 4, 7SCIP VTE 1, 2
Antibiotic dosing chart and selection chart
SCIP 1,2,3
Computer screen standardization SCIP 1,2, 6,VTE 1, VTE 2, CARD 2
VTE mechanical and chemical prophylaxis chart
SCIP VTE 1, VTE 2
Pharmacy review of medication orders
SCIP 1, 2, 3, 4,VTE 1, VTE 2, CARD 2
43
THA – August 2008
SCIP System/Process Improvements
• Education and Competency– Clinical Staff– Physician– Abstractor
• Worksheets• Standard Order sets• IT Screens• Core Measures designated “bulleted” on order
sets• Pharmacy interfaces (close time report)
THA – August 2008
Core Measure Concurrent Management
• Concurrent management– Core measure checklist on charts– Interact with physicians & staff
• Preview OR schedule• Presence in PAT, PACU, and floor
– Debriefing forms• Form• Abstraction tool• Applicable portion of medical record• Routed/reviewed with Clinical Service Director
– Real-time understanding of process and opportunities
THA – August 2008
Concurrent Abstraction
• Real-time opportunity to improve• Feedback• Within 7-10 days• Correlation with improved performance• Abstraction
– Into Vendor System– Into Clinical Documentation System
• Rolls into Vendor system– Into Quality Management Module
• Rolls into Vendor system
THA – August 2008
Measurement and Feedback• Performance
– Employee• 1:1• Director
– Physician• 1:1 (verbal or written)• Hospitalist Coordinator• Medical Director• Ongoing Professional Practice Evaluation/Profile• Peer Review?• Incentive Plan• Profile for Ongoing Professional Practice Evaluation
(OPPE)• Medical Director or Clinical Service Director
– Department, Facility, and Division Comparison
THA – August 2008
Measurement and Feedback
• Weekly Core Measure Meetings– Laptop with system access– Review rationale, record, TJC, – Directors of clinical services (ED, Ph, ICU, Nsg, OR, ER,
Q, CNO, Hospitalist Coord.)– Current outliers– Export to EXCEL – to director of that area, dates, MR#,
during meeting– Follow-up on previous and new outliers
• Facility Feedback– Routinely at all meetings (Department, Quality, MEC, Board)
• Division– Weekly metrics– Quarterly/annual trends and comparisons
THA – August 2008
Important to Remember…
• Core measure requirements are revised and changed every April and October.
• Be sure you get the updates and change your practice accordingly.
• These measures are evidence based and as the evidence changes and progresses, so do these measures.
• Ultimate in continuous improvement cycle.
49
THA – August 2008
TriStar Division Measurement
• Metrics – MRSA Reports– HAC Reports– Hand Hygiene– Concurrent management– Concurrent abstraction– Weekly metrics– QOR Review– QM review screens
THA – August 2008
THA – August 2008
Count of ACCOUNT # CategoryFACILITY Cath-assoc. UTI Decubitus Fracture Intracranial Injury Grand Total
A 3 1 4B 2 2C 1 1D 1 1E 2 2F 3 1 4G 1 1H 1 3 1 5I 1 1J 1 1K 2 2L 3 3
Grand Total 1 18 7 1 27
COUNTS BY FACILITY - June 2008
HOSPITAL ACQUIRED CONDITIONS
THA – August 2008
Improvement Triad
Leadership
System and Process Improvements
Measurement and Feedback
SuccessSuccess
THA – August 2008
Measurement / Celebration
THA – August 2008
Measurement
THA – August 2008
Steps
• Leadership must understand where you are and what the improvement opportunity is
• Thoroughly understand the evidence behind the clinical care recommendations
• Flowchart to clearly understand the current clinical practice to determine gaps between care and EBM
• Deliver clinical care message at facility staff and physician staff meetings
– Include data that illustrates where hospital stands in current performance
• Improve systems and processes through adoption of evidence - based practices (tools, policies, orders, algorithms, systems)
• Revise forms and processes to implement practices from high-performing facilities
• Meet individually with physicians that have specific concerns
• Measure performance and provide feedback
56
THA – August 2008
Shared Learning for Infection Prevention
THA Collaborative
August 2008
Thank You!