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.

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Benefits of Reducing Infections

• Better patient outcomes• Reduced mortality• Improved satisfaction

– Physician– Nursing– Patients and families

• Financial benefits

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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

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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

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TriStar Shared Learnings

• MRSA• Central Line Bloodstream Infections• SCIP

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Improvement Triad

Leadership

System and Process Improvements

Measurement and Feedback

SuccessSuccess

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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

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Active Surveillance (Systems/Processes)

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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

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Barrier Precautions

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• 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

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Compulsive Hand Hygiene

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• 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

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Disinfection/Environmental Cleaning

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• Proper disinfection techniquesProper supplies

• Proper equipment• Environmental services education• Workload analysis• Observation for adherence

Disinfection/Environmental Cleaning

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• Executive and Physician Champions• Interdisciplinary taskforce• Executive walk arounds • Medical Executive Committee engagement• MEC and Board reports• Recognition and reward

Executive Ownership/Leadership

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• 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

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• 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

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0.0%

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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

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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

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Central Line Infections

• Prolongation of hospitalization: 11-23 days

• Cost to healthcare system: $33,000 - $35,000/episode

• Attributable mortality: 12-25%

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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

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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

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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

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CLBSI Measurement and Feedback

• Computer screen standardization– Automatic capture of data for

documentation and data collection• Physician documentation tools• Insertion observation• Performance feedback

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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!

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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

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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%

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10%

15%

20%

25%

D ru g -re la te d

W o u n din fe c t.

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N o n te c h .c o m p .

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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

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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

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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

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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.

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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.

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SCIP Measures Poster

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Education

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Time Out Poster

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Checklists

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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

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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

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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

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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.

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TriStar Division Measurement

• Metrics – MRSA Reports– HAC Reports– Hand Hygiene– Concurrent management– Concurrent abstraction– Weekly metrics– QOR Review– QM review screens

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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

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Improvement Triad

Leadership

System and Process Improvements

Measurement and Feedback

SuccessSuccess

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Measurement / Celebration

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Measurement

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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

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THA – August 2008

Shared Learning for Infection Prevention

THA Collaborative

August 2008

Thank You!