PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

#3400.159 Rev. 10/16

Clinical Excellence and Evidence-Based Practice

Clinical Transformation and

Infection Prevention

K. Alex Daneshmand, DO, MBA Ashraf Khan, FACE, MD, MPH, MBA Mary Beth Saunders, D.O., FACOI Nazareth Asorian, DO, FACOS, CHCQM-PHYADV Cora M. Murphy, MSN, RN, CNL

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

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Quality and Process Improvement Structure for System-Wide

Evidenced-Based Medicine

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

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The 5 Steps of Evidence-Based Medicine

Healthcatalyst.com

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

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PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

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PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

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PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

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CAUTI (Catheter Associated Urinary Tract Infections)

&

CLABSI (Central Line Associated Blood Stream Infections

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

CAUTI Performing at 5-Star Level

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PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

CLABSI Performing at 3-Star Level

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PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

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C. diff (Clostridioides difficile)

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

C. diff Performing at 4-Star Level Clostridioides difficile

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PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

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MRSA Bloodstream Infections (Lab ID)

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

MRSA Performing at 3-Star Level Methicillin Resistant Staph Aureus

90 Day Action Plan - Current:

• Increased post event analysis • Review of usage of MRSA toolkit by staff • Monitor Chlorhexidine (CHG) cleansing for MRSA

positive nasal screens • Monitor gown/linen changes with each CHG cleansing • Monitoring of daily CHG cleansing

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

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Sepsis

Although sepsis is mainly caused by bacterial infection, it can be caused by a viral, fungal or even a parasitic source

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

• Quality Measure Performance Updates as of yesterday Provides near real time performance Includes drill downs

Managing Sepsis Performance

© 2018 Epic Systems Corporation. Used with permission.

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

Epic Drill Down Reports

© 2018 Epic Systems Corporation. Used with permission.

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

Severe Sepsis and Septic Shock Mortality

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

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ERAS & SSI COLON Enhanced Recovery After Surgery

and Surgical Site Infection- Colon

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

SSI Colon Data

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

Questions?

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

Thank You