Tennessee Center for Patient Safety Data Reporting

Tennessee Center for Patient Safety Data Reporting

Scope of TCPS Data Collection

• Methicillin-resistant Staphylococcus aureus (MRSA)

• Central Line Associated Blood Stream Infections

• Surgical Care Improvement Project (SCIP) data from core measures

• AHRQ Hospital Survey on Patient Safety Culture

MRSA Data Reporting

• Reported monthly by hospitals participating in the MRSA collaborative via THA web site

• Data collection initiated August 2008

• Data included for units that reported complete data for January – August 2008– Baseline is defined as January - June

Definitions for MRSA based on CDC MDRO Module NHSN Definitions

• MRSA includes S. aureus cultured from any specimen that tests oxacillin (or cefoxitin for oxacillin) resistant by standard susceptibility testing methods, or by a positive result from molecular testing for mecA and PBP2a; these methods may also include positive results of specimens tested by any other FDA approved PCR test for MRSA.

• Healthcare Facility-onset (HO) Incident: LabID Event > 3 days after admission (i.e. on or after day 4).

• Community-onset (CO): LabID Event collected as an outpatient or an inpatient ≤ 3 days after admission (i.e. day 1, day 2 or day 3 of admission).

• These data do not include results from active surveillance tests.

Number of Admissions, Patient Days and Cases of Hospital Onset MRSA in Tennessee Hospitals Reporting Facility Wide MRSA Data by Month of Occurrence, 2008

Includes 24 hospitals that reported data for every month

JAN FEB MAR APR MAY JUN JUL AUG

Admissions 19,125 18,587 18,646 18,061 18,115 17,785 18,668 19,073

Cases 79 85 90 90 74 79 78 64

Patient Days 83,116 81,068 81,952 76,595 78,783 75,950 79,413 80,687

Rate Per 1000 Admit 4.13 4.57 4.83 4.98 4.09 4.44 4.18 3.36

Rate Per 1000 Pat Day 0.95 1.05 1.1 1.18 0.94 1.04 0.98 0.79

Number of Admissions, Patient Days and Cases of Hospital Onset MRSA in Tennessee Hospitals Reporting Inpatient Adult Critical Care

Unit MRSA Data by Month of Occurrence, 2008

Includes 5 hospitals that reported unit data for every month


Admissions 688 637 651 668 679 625 703 653

Cases 12 8 17 6 8 6 4 7

Patient Days 2,762 2,699 2,615 2,678 2,641 2,411 2,540 2,475

Rate Per 1000 Admit 17.44 12.56 26.11 8.98 11.78 9.6 5.69 10.72

Rate Per 1000 Pat Day 4.34 2.96 6.5 2.24 3.03 2.49 1.57 2.83

Number of Admissions, Patient Days and Cases of Hospital Onset MRSA in Tennessee Hospitals Reporting Inpatient Adult Unit MRSA

Data by Month of Occurrence, 2008


Admissions 563 580 595 517 510 492 559 514

Cases 1 4 1 6 3 3 4 2

Pat Days 3018 2895 2909 2812 2584 2561 2798 2736

Rate Per 1000 Admit 1.78 6.9 1.68 11.61 5.88 6.1 7.16 3.89

Rate Per 1000 Pat Day 0.33 1.38 0.34 2.13 1.16 1.17 1.43 0.73

Includes 4 hospitals that reported unit data for every month

Rate per 1000 Admissions of Hospital Onset MRSA for Selected Units Within Tennessee Hospital B, January - August 2008

5.62 5.49

23.26

0.00

39.15

15.50

29.90

13.89

4.48

21.19

16.67

22.22

0.00

9.62

6.024.88

13.38

7.46

0.000.00 0.00

0.000.00

15.87

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

45.00


Surgical Cardiothorasic Critical Care

Medical Surgical Critical Care

Solid Organ Transplant

Number of Admissions, Patient Days and Cases of Community Onset MRSA in Tennessee Hospitals Reporting Facility Wide MRSA Data by

Month of Occurrence, 2008


Admissions 16,236 15,765 15,851 15,422 15,426 15,154 16,003 16,647

Cases 386 500 376 358 440 426 392 510

Patient Days 71,353 69,766 70,921 66,227 68,172 65,700 68,280 69,641

Rate Per 1000 Admit 23.77 31.72 23.72 23.21 28.52 28.11 24.5 30.64Rate Per 1000 Pat Day 5.41 7.17 5.3 5.41 6.45 6.48 5.74 7.32

Includes 16 hospitals that reported data for every month

Rate per 1000 Admissions of Community Onset MRSA for all Reporting Tennessee Hospitals Compared with Hospital A, January -

August, 2008

51.60

41.09

50.70

65.06

46.48

23.77

31.72

24.50

30.64

37.40

47.85

42.37

28.11

23.72

23.21

28.52

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00


Hospital A Rate per 1000 Admissions

All Reporting Facilities Rate per 1000Admissions

Rate per 1000 Admissions of Community Onset and Hospital Onset MRSA in Tennessee Hospital C by Month, 2008

48.59

118.05

52.74

73.670.89

62.11

57.14

62.7

6.794.246.945.2

8.797.335.26.56

0

20

40

60

80

100

120

140


Community Onset

Hospital Onset

Rate per 1000 Admissions of Facility Wide Community Onset and Hospital Onset MRSA for all Reporting Hospitals and for Tennessee Hospital C, January -

August, 2008

48.59

118.05

52.74

73.670.89

6.79

31.72 30.64

3.36

62.7

62.11

57.14

4.246.945.28.797.335.26.56

23.77 24.528.1128.52

23.2123.72

4.184.444.094.984.834.574.130

20

40

60

80

100

120

140


Community Onset

Hospital Onset

Community Onset - StateTotal

Hospital Onset - StateTotal

Central Line Associated Bloodstream Infections

• Definition of CLABSIs to be reported based on CDC NHSN

– Reportable primary bloodstream infections are either laboratory confirmed bloodstream infections (LBCI) or in the case of neonates (30 days old or younger) and infants (1year old and younger) clinical sepsis (CSEP).

• Central line is an intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring.

• The following are considered great vessels for the purpose of reporting central line infections and counting central line days (as defined for the NHSN system):

– Aorta, pulmonary artery, superior vena cava, inferior vena cava,– Brachiocephalic veins, interjugular veins, subclavian veins,– External iliac veins, common femoral veins


Patient Safety Center reporting options Data reported directly to THA via web reporting tool Hospital requested data be submitted to THA from CDC NHSN data by the

Department of Health

CDC NHSN reporting requirement for Tennessee T.C.A. 68-11-263: Facilities must join the CDC National Healthcare Safety

Network (NHSN) to report central line bloodstream infections in ICU’s Excludes facilities with average daily census of 25 or less Excludes burn units and level 1 trauma units Hospitals began submission of required data January 2008


• Data collection initiated August 2008• Data included for units that reported complete data for

January – August 2008• Baseline defined as January - June

• Initial data from State received in mid October • 31 hospitals reported data for 74 units since August

• 24 hospitals reported complete data for 47 units for January through August, 2008

• Of the 47 units with complete data, 18 reported 0 infections during the entire 8 month period

Number of Central Line Bloodstream Infections in Tennessee Hospitals Reporting Adult Medical/Surgical Critical Care Unit

Infections Every Month, January – August, 2008

The 2007 national incidence rate for all hospitals reporting CLABSIs for medical/surgical ICUs to NHSN is 2.6 per 1,000 central line days in teaching facilities and 1.9 in non-teaching facilities.


Number of Units 23 23 23 23 23 23 23 23

Central Line Infections 5 4 4 5 4 4 5 4

Central Line Days 2,383 2,382 2,392 2,252 2,079 1,864 2,120 1,782Rate Per 1,000 Central Line Days 2.1 1.68 1.67 2.22 1.92 2.15 2.36 2.24Device Utilization Rate 1000 Patient Days 477.27 528.39 526.06 543.7 494.41 505.29 528.94 479.68

Number of Central Line Bloodstream Infections in Tennessee Hospitals Reporting Adult Surgical Critical

Care Unit Infections Every Month, January – August, 2008

The 2007 national incidence rate for all hospitals reporting CLABSIs for adult surgical ICUs to NHSN is 3.1 per 1,000 central line days.


Number of Units 3 3 3 3 3 3 3 3


Central Line Days 444 359 492 380 426 512 313 370Rate Per 1,000 Central Line Days 4.5 0 2.03 0 4.69 1.95 0 2.7Device Utilization Rate 1,000 Patient Days 643 541 636 534 592 669 436 497

Number of Central Line Bloodstream Infections in Tennessee Hospitals Reporting Adult Medical Critical Care

Unit Infections Every Month, January – August, 2008


Number of Units 6 6 6 6 6 6 6 6


Central Line Days 808 735 819 740 709 629 527 602

Rate Per 1,000 Central Line Days 1.24 1.36 3.66 1.35 0 0 1.9 0

Device Utilization Rate 1,000 Patient Days 294 274 272 298 270 241 246 249

The 2007 national incidence rate for all hospitals reporting CLABSIs for adult medical ICUs to NHSN is 2.8 per 1,000 central line days.

AHRQ Hospital Survey on Patient Safety Culture

• The Hospital Survey on Patient Safety Culture was sponsored by the Quality Interagency Coordination Task Force (QuIC), a group established to ensure that all Federal agencies involved in purchasing, providing, studying, or regulating health care services are working together and toward a common goal of improving quality care.

• The survey was funded by the Agency for Healthcare Research and Quality

(AHRQ).

• The development of this safety culture assessment tool included a review of published and unpublished safety culture assessment tools and the scientific literature pertaining to safety, error and accidents, as well as error reporting.

• Hospital employees and managers were interviewed to identify key patient safety and error reporting issues.

• The TCPS makes the survey available to all safety partners at no cost

Value to Hospitals of Participating in the TCPS Survey

• You can’t fix what you don’t measure• Survey results provide:

– Demographic characteristics of responders– Four overall patient safety outcomes:

• Overall perceptions of safety• Frequency of events reported• Number of events reported• Overall patient safety grade

– Scores on ten dimensions of culture pertaining to patient safety

Demographic Data for Respondents, Tennessee Hospital, 2008

1. Primary hospital work area, department or clinical area where respondents spend most of their work time:

6% Many different units / No specific unit 9% Intensive care unit (any type)12% Medicine (non-surgical) 0% Psychiatry / mental health 10% Surgery 4% Rehabilitation 5% Obstetrics 6% Pharmacy 4% Pediatrics 12% Laboratory 1% Emergency department 5% Radiology

26% Other 1% Anesthesiology

2. Staff position in the hospital:

41% Registered nurse 2% Pharmacist0% Physician assistant / Nurse practitioner 1% Dietician 5% LVN / LPN 7% Unit assistant / Clerk / Secretary 2% Patient care asst / Aide / Care partner 1% Respiratory therapist 0% Attending / Staff physician 3% Physical, occupational, or speech therapist 0% Resident physician / Physician in training15% Technician (e.g., EKG, Lab, Radiology)

18% Other 6% Administration / Management

Overall Patient Safety GradeTennessee Hospital, 2008

Please give your work area/unit in this hospital an overall grade on patient safety.

28%

51%

19%

2%0%

0%

10%

20%

30%

40%

50%

60%

A - Excellent B - Good C - Acceptable D - Poor E - Failing

Pe

rce

nt

of

Re

sp

on

de

nts

Note: 0% of respondents did not answer

Tennessee Hospital Safety Culture Composite Scores, 2008

Safety Culture Composites

Tennessee Hospital's

Composite Score Average % of positive

responses

2008 National Comparative Data

from AHRQ Average % of

positive responsesOverall Perceptions of Safety (4 items--% Agree/Strongly Agree) 68% 64%Frequency of Events Reported (3 items--% Most of the time/Always) 71% 60%Supervisor/Manager Expectations & Actions Promoting Patient Safety (4 items--% Agree/Strongly 83% 75%Organizational Learning--Continuous Improvement (3 items--% Agree/Strongly Agree) 79% 70%

Teamwork Within Units (4 items--% Agree/Strongly Agree) 80% 79%

Communication Openness (3 items--% Most of the time/Always) 67% 62%Feedback & Communication About Error(3 items--% Most of the time/Always) 68% 62%Nonpunitive Response to Error (3 items--% Agree/Strongly Agree) 42% 44%

Staffing survey items (4 Items --% Agree/Strongly Agree) 56% 55%Hospital Management Support for Patient Safety (3 items--% Agree/Strongly Agree) 74% 70%Teamwork Across Hospital Units (4 survey items--% Agree/Strongly Agree) 57% 57%Hospital Handoffs & Transitions (4 survey items--% Agree/Strongly Agree) 43% 45%

519 hospitals and 160,176 hospital staff respondents are included in the AHRQ national comparative data.

Area of Strength

Graphs also are available by specific job titles( RN, PT, dietician…) work areas (ICU, medicine, pharmacy…) and whether or not the employee has direct contact with patients (yes or no)

Tennessee Hospital 2008 Overall Facility Score

Overall Perceptions of Safety

1. Patient safety is never sacrificed to get more work done.

2. Our procedures and systems are good at preventing errors from happening.

R3. It is just by chance that more serious mistakes don’t happen around here.

R4. We have patient safety problems in this unit.

64% 15% 21%a

76% 17% 7%a

65% 20% 15%a

68% 17% 15%a

Positive Neutral Negative


Teamwork Across Hospital Units

1. There is good cooperation among hospital units that need to work together. (F4)

2. Hospital units work well together to provide the best care for patients. (F10)

R3. Hospital units do not coordinate well with each other. (F2)

R4. It is often unpleasant to work with staff from other hospital units. (F6)

27% 16%56%a

22% 9%68%a

44% 27% 28%a

26% 15%59%a


Graphs also are available by specific job titles (RN, PT, dietician…) work areas (ICU, medicine, pharmacy…) and whether or not the employee has direct contact with patients (yes or no)


Communication Openness1. Staff will freely speak up if they see something that may negatively affect patient care. (C2)

2. Staff feel free to question the decisions or actions of those with more authority. (C4)

R3. Staff are afraid to ask questions when something does not seem right. (C6)

80% 17% 3%a

49% 29% 22%a

23% 7%71%a


Area of Strength

Graphs also are available by specific job titles (RN, PT, dietician…) work areas (ICU, medicine, pharmacy…) and whether or not the employee has direct contact with patients (yes or no)

Survey Respondent Comments from Tennessee Hospital 2008

• With our current staff level and the expectations of some departments, we often feel that we are living on the edge as far as committing serious errors.

• I am not certain the management team is on the same page in regards to patient safety.

• I think the hospital strives daily to maintain a safe and error free environment. I feel that if there are errors made they are addressed immediately.

• Staffing is my main concern, not enough staff or some staff (same people) do not work together well thus making pt. safety issues a real concern. Poor staffing is not healthy for anyone.

• I can only speak for my own department. There is so much equipment we use on patients there should be more biomed techs to check equipment monthly, not after there is a breakdown.

• Event reporting is loose in my area, not enough guidelines taught to us about what does and does not need to be reported.

• I feel we are making progress with patient safety, however, shift reports and dissemination of patient information to staff is lacking.

• I think our hospital should be more proactive in giving feedback about errors and make the data available to everyone. Often times it seems as though quality data is kept a secret here.

Documents

Tennessee Center for Patient Safety Data Reporting