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AHRQ PIPS, MRSA, and OIG on PS in VHA ORs

(05-00379-91)

Noel Eldridge, MSNational Center for Patient Safety

National Patient Safety Managers’ Conference3/20/07

202 273-8878

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It’s nice to get a break away from the office!

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What is he talking about?

I. “Partnerships for Implementing Patient Safety” projects funded and managed by the Agency for Healthcare Research and Quality

II. The new VHA Program to prevent Methicillin-Resistant Staphylococcus aureus in VA patients, and

III. The VA Office of Inspector General Report on Patient Safety in the Operating Room in VHA Facilities (Report # 05-00379-91)

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I. AHRQ PIPS Projects

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PIPS Program Overview

17 Projects Implementing Evidence-Based Interventions Generalizable, Realistic, Replicable & Sustainable PIPS Project Teams - PI 20%, Multi-Disciplinary,

Sharp-End

PIPS Goals Assist sharp-end users in implementing

interventions Provide information for implementation

(both what works & what does not!) Provide toolkits to put interventions into

practice

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PIPS Program Timeline

Patient Safety Intervention Implementation Activities July 2005 – July 2006

AHRQ Site Visits & PIPS Presentations Presentations/Posters at AHRQ PS Conference: June 2006

PIPS Projects Analysis & Evaluation Activities July – November 2006

AHRQ PIPS Technical Assistance Workshop & Presentations October 25-26, 2006

PIPS Toolkit & Website Development & Refinement November 2006 - June 2007

PIPS Toolkits & Evaluations Available July 2007

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Focus of PIPS Projects

Discharge & Transitions 3 PIs: Jack, Noskin,

Williams Deep Vein

Thrombosis and/or Anticoagulation 2 PIs: Maynard, Zierler

Medication Reconciliation and Safety 9 PIs: Fairbanks, Jack,

Jones/Mueller, Leonhardt, Levett, Muller, Noskin, Sirio, Williams

Simulation 2 PIs: Guise,

Patterson Team Training &

Communication 4 PIs: Daugherty,

Fairbanks, Noskin, Sirio

Workflow & Processes 4 PIs: Burdick,

Landrigan, Maynard, Speroff

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PIPS Toolkits

Minimum Guidance for Maximum Flexibility

Identify Problem Define & Measure the Intervention How (and How Not) to Implement the Intervention Results: Evidence-Based Patient Safety Tools

Website CD/Video “How To” Guide & Checklist Training Materials – Online Training, Workbooks Data Analysis & Tracking Spreadsheets Poster & PowerPoint Presentations

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PIPS Program: Next Steps

17 PIPS Representatives at National Patient Safety Foundation (NPSF) Congress - May 2-4, 2007, DC 3 Presenting in Research Track Session 14 “Meet the Experts” in Exhibit Hall

AHRQ Marketing & Rollout Plan in Development

Plan to Conduct National Call(s) for VHA Patient Safety Managers and other VHA Personnel in July/August 2007

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Take Home Message:AHRQ PIPS projects

17 AHRQ PIPS Projects Near Completion Most are on Topics Relevant to VHA NCPS Plans to Organize National Calls

focusing on Toolkits in July – August 2007

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II. MRSA Program

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Why a New Program & this New Program? MRSA is a Growing Problem in US

Healthcare, Including VHA Facilities The VA Pittsburgh Healthcare System has

Demonstrated Good Results (reduced MRSA rates and transmission of MRSA) that Appear Replicable

Related JCAHO Finding from 2006 Surveys 7 of 33 (21%) VAMCs received RFIs for Hand

Hygiene

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

'50 '60 '78-'82 '83-'87 '88-'92 '93-'97 2000

Denmark, Finland and the Netherlands ( <1%).

USA: This MRSA trend accompanies a 36% rise in the overall national nosocomial infection rate from 1975 to 1995.

Percent of Staph Aureus Resistant to Methicillin is Rising in the USA…But has been Controlled in Denmark, Finland and the Netherlands

(Source: CDC NNIS data)P

erce

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f Sta

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esis

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illin VHA 2006

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VAPHS (4-West Surgical Ward) Nosocomial MRSA Infection Rate

Fig 1. MRSA Infections/1000 BDOC - 4W Surgical Ward

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

24 Mo. Pre FY02 FY03 FY04 FY05

Intervention begun

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VAPHS (Surgical Intensive Care Unit) MRSA Infection Rates

Fig. 2. MRSA Infections/1000 BDOC - SICU

0

1

2

3

4

5

6

24 Mo Pre FY04 FY05

Intervention begun

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Four Basic Aspects of MRSA Program from VA Pittsburgh Healthcare System

1. Hand Hygiene

2. Active Surveillance Cultures

3. Contact Isolation

4. Cultural Transformation from within

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VAPHS MRSA Bundle:1. Hand Hygiene

Before and after every patient contact

BEST: Alcohol hand sanitizer Still must wash hands if visibly

soiled Monitor: peer data collection

(Standard Methods being Developed)

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Hand Hygiene Questions

Which of these do/does the VHA Directive/ Joint Commission NPSG/ CDC Guideline Require?

Keeping Natural Fingernails Short (<4mm free edge)? No Artificial Fingernails on Anyone Who Does Direct

Patient Care? Providing Pocket-sized Alcohol-based Hand-rub to

Staff? Providing Facial Tissues (“Kleenex”) to Staff? Different Practices in a Norovirus Outbreak? Decontaminate Hands Before and After Gloving?

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VAPHS MRSA Bundle: 2. Active Surveillance Cultures

Nares Swabs• Admission• Discharge or Transfer• CTB is considered discharge

Open wounds

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Active Surveillance Cultures? VA-wide Application of Active

Surveillance? VAMCs with low baseline MRSA

Bloodstream Infection Rates May be Able to Opt Out of Some Aspects of Active Surveillance

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Implement Action Plan as submitted

Facility review of FY06 Baseline MRSA BSI (Bloodstream Infections) rateBaseline MRSA BSI rate =

# unique nosocomial episodes (>48 hrs) MRSA BSIs # Acute care Bed Days of Care

Small facilities that do not have a single case of BSI should consult MRSA Program Office for

assistance in determining an appropriate measurement tool.

Directive 2007-002

Methicillin-Resistant Staphylococcus aureus (MRSA) Initiative

MRSA Bundle

1Active Surveillance Cultures

2Aggressive Hand Hygiene3Contact Precautions for MRSA-colonized patients4Cultural change

Targeted Active Surveillance for high-risk units

Based on internal assessment

Apply to Taskforce for Exemption from Active Surveillance Cultures

Active Surveillance Exemption Not Approved

Implementation of Full MRSA Bundle, including Active Surveillance Cultures

(Admission/Discharge)

NOTE:Review Exemption criteria:

Strong Action Plan*Reduce infection rate by 20% in FY07

Reassess 6 months after implementation: has goal to reduce nosocomial MRSA BSIs by 20% or to ZERO been achieved?

No

MRSA BSI Rate <median, maintains Contact Precautions for patients MRSA-INFECTED or colonized based on clinical culture AND components 2 & 4 of

MRSA Bundle are fully implementedMRSA BSI Rate >median

Single case of VRSA in last 12mos., or at any time during surveillance

No. Facility must implement full MRSA Bundle with active surveillance

Facility Choice

x 1000( )

Active Surveillance ExemptionApproved

Yes. Facility may choose approach

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VAPHS Bundle:3. Contact Isolation &

4. Cultural Transformation

Contact Isolation– all MRSA+ patients• HH, Gown, Glove• Designated or Disinfected Equipment

Cultural Transformation from Within• Staff – own and operate solutions

• Leaders - Set direction, create freedom and opportunities for staff to co-create and implement solutions, remove barriers

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Take Home Message:VHA MRSA Program

MRSA Program has New Interventions and Requirements, and New Funding (Planned)

Some Aspects will Vary by VAMC Currently 17 Beta Sites at VAMCs Some Methods Still Being Developed

e.g., standard measurement methods for some processes

MRSA Program has Potential to Focus and Improve Various VHA and VAMC-wide Efforts to Prevent Infections

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III. OIG Report on Patient Safety in the Operating

Room

www.va.gov/oig/54/reports/VAOIG-05-00379-91.pdf

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Purpose of OIG Review To “determine whether”:

1. “facility leaders established and implemented effective policies, procedures, and guidelines to ensure patient safety in the OR”;

2. “facility leaders established surgical improvement program and identifies potential problem areas needing improvement; and

3. “there was coordination between Supply, Processing, and Distribution (SPD) and the OR”

Eight (8) VAMCs Visited by OIG Staff

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Summary of Findings

Issue 1: Compliance with VHA Directives, AORN Guidelines, & JCAHO Standards

Issue 2: Surgical Performance Improvement Program

Issue 3: SPD Coordination with the OR

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Accentuating the Negative Ensuring Correct Surgery

We found that …two (of 8) facilities… had policies that only addressed side/site verification.

We found that two (of 8) facilities… had incident or near miss incorrect surgery events in fiscal year (FY) 2005. The first facility reviewed the event of the wrong site surgery and

determined that (a) the surgeon did not possess the consent form when the site was marked, (b) the nurse circulator did not mention the variance between the marked site and the consent, and (c) a time-out briefing with the informed consent was not performed.

At the second facility, a patient had the wrong eye anesthetized (blocked)…The incident was reviewed and monitors were developed and implemented to ensure the correct site was identified and marked.

Related JCAHO Finding from 2006 Surveys 12 of 33 (36%) VAMCs received RFIs for “Universal Protocol”

(11 Time-outs and 1 Mark Operative Site).

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Accentuating the Negative

Disclosure of Adverse Events We found that three (of 8) facilities failed to document

disclosure of adverse surgical events.

At one facility, two patients had to return to surgery with partially retained drains. (no record of disclosure)

At a second facility, the surgeon administered a regional block into the wrong eye. (no record of disclosure)

In the third facility, we reviewed three surgery-related deaths that involved delay in diagnosis or treatment… (no record of disclosure)

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Other Topics Reviewed Preventing Retained Surgical Items (VHA Directive 2006-030) Environment of Care

HVAC (e.g., air exchanges) Equipment Management (preventive maintenance schedules) Anesthesia Cart Security (e.g., unmarked filled syringes)

Resident Supervision Morbidity and Mortality Peer Review (Directive 2004-054) Mortality Assessment (Directive 2005-056) Credentialing and Privileging Availability of Supplies Missing, Broken, and Incorrect Instruments Contaminated Surgical Instruments

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Who Can Make this Better?

I don’t think that we can’t fix this from VACO No thousand mile

screwdriver We don’t know how

Different places, Different Problems, Different Solutions

Do you and your colleagues know how? Let us know how we can help Especially re communicating

non-optional aspects

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Who Needs to Participate in a Time-out in the Operating Room?

Everyone in the Operating Room? Attending Surgeon? Anesthesia Provider? Circulating Nurse? Surgical Nurse? Do Midline Sites Need to be Marked? How About Out-of-OR?

Is a time-out required for thoracentesis?

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Summary of VHA Follow-ups

Plan to Require Check of Local Policies, Processes and Practices (OR and Management), & Aspects of the Physical Environment Paper Reviews (e.g., policies and committees w/minutes) Observations

Pre-operative Processes (marking sites, “time-outs”…) Intra-operative Processes (counting sponges…) Environment of Care/Engineering/Equipment, etc.

Method for Reporting Results to VACO is TBD No Plan for a New Mandatory Standardized

Checklist to be Used for Every Surgical Case

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Thanks for Examples of OR Checklists from VISNs and VAMCs

Carol Bills, VISN 23 Christine Carlin, San

Diego Sandra Hart, Danville (IL) Kerry Inhofe, Oklahoma

City Tanya Kotar, Milwaukee Patricia Lingenfelter,

Baltimore

Karen Pierce, Loma Linda

Phyllis Trainor, Providence

Edith Villaruz, Los Angeles

Medical Team Training Program Sites

And Anyone I missed

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Take Home Message:OIG report on PS in VHA ORs

OIG Review Found Variation in Processes Some were disturbing (e.g., marking “Ace bandage”)

VHA Follow-up will Focus on Local Policies and Self-Assessments (Observation) of Processes Details of Reporting to VACO Not Yet Defined

You Should Read This Entire Report NCPS-led Medical Team Training Program

Focusing on Some of Same Process Issues NSQIP Data has Demonstrated Morbidity and

Mortality Improvements in VA Surgical Patients

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Some Context: Good NewsVA & US Inpatient Discharges and Mortality

5060708090

100110120130140150

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

1998

= 1

00

VA Discharges

VA Mortality

US Discharges

US Mortality

1995-1998 (Pink Oval): ● US discharges and mortality flat ● VA discharges down 28% and mortality up 14%1999 to Date (Yellow Oval):● US discharges up (8% thru 2003) and mortality down (14% thru 2004)● VA discharges flat (down 2% thru 2006) and mortality down (35% thru 2006)

VHA Inpatient Mortality (Unadjusted) is Down 35%

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Enjoy the Conference!

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Wish me luck!