Shared Learning for Infection Prevention

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Shared Learning for Infection Prevention

• THA Collaborative on
• Reducing HAIs
• August 2008
• Tori Howk, Director of Risk and Regulatory

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Collaborative Aims

• Improve the culture of safety
• Reduce patient harm by reducing CLBSI
• MRSA
• 25 reduction in surgical complications by
  implementing SCIP

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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.

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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
  years rule. (5 HAIs)

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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
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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

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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

• Previous MRSA history
• Preoperative Screens
• Total hip
• Total knee
• Open spine procedures
• Cardiac surgeries
• Private rooms, cohorting, and isolation

• ICU admissions/transfers
• Outborn transfers to NICUs
• Long term care facility admissions
• Hemodialysisadmissions

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Barrier Precautions
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Barrier Precautions

• Standard precautions for all patients
• Contact isolation of positive patients
• Personal protective equipment
• Gown
• Gloves
• Mask with shield
• Dedicated equipment
• Ticketing for non compliance

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Compulsive Hand Hygiene
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Compulsive Hand Hygiene

• 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

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Disinfection/Environmental Cleaning
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Disinfection/Environmental Cleaning

• Proper disinfection techniquesProper supplies
• Proper equipment
• Environmental services education
• Workload analysis
• Observation for adherence

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Executive Ownership/Leadership

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

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Campaign

• 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

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Campaign

• Target audience--patients, caregivers,
  physicians, non-clinical staff, visitors,
  volunteers, vendors
• Community collaborationEMS, local health
  department, other healthcare providers
• Data collection, analysis, and dissemination

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Measurement - 2007 MRSA Swabbing Rate
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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

• Hand hygiene
• Maximal barrier precautions
• Chlorhexadine skin antisepsis
• Optimal catheter site selection, with subclavian
  vein as the preferred site for non-tunneled
  catheters in adults
• 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?

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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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SCIP National Quality Measures

• SCIP 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 lt 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 gt 98.6F within first
  15 minutes after leaving OR

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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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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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Education
SCIP Measures Poster
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Checklists
Time Out Poster
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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, 7 SCIP 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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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)

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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

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Measurement and Feedback

• Performance
• Employee
• 11
• Director
• Physician
• 11 (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

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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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Improvement Triad
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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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Shared Learning for Infection Prevention
Thank You!

• THA Collaborative
• August 2008