mha 2015 fall regional meetings
TRANSCRIPT
MHA 2015 Fall Regional MeetingsStrategies to Reduce Harms and Infections
Welcome and Agenda
Introductions
Missouri harms and infections data review
Infection prevention focus areas: sepsis, hand hygiene, antimicrobial stewardship programming
Shared best practices
Workshop activity
Networking!!!
Missouri’s Performance
Q4CY2013 Q1CY2014 Q2CY2014 Q3CY2014 Q4CY2014 Q1CY2015
Total Infections 1323 1381 1366 1117 1146 1198
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STATE LEVEL NUMBER OF INFECTIONS FROM Q4CY2013 -Q1CY2015
9.4%
Q4CY2013 Q1CY2014 Q2CY2014 Q3CY2014 Q4CY2014 Q1CY2015
Total Harm 667 630 564 582 324 352
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REPORTING TIMEFRAME
STATE LEVEL RAW DATA FOR TOTAL HARM FROM Q4CY2013-Q1CY2015
42%
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100
150
200
250
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10
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25
30
DV
T R
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TOTAL HARM BY OUTCOME MEASURE
Falls & Trauma Death Rate in Low Mortality DRG's
Pressure Rates DVT Rate
Falls = 38% increase
Antibiotic/Antimicrobial Stewardship
Goal #2:
Reduce health care costs without adversely affecting the quality of care
Stewardship Program Goals
Goal #1:
Optimize clinical outcomes while minimizing the unintended consequences of antimicrobial use
Antibiotic Resistance
Antibiotic resistance is not a new phenomenon
Within 10 years of penicillin’s discovery in 1928, group A streptococci and pneumococci had already developed modes of resistance
What is new?
the growing magnitude of the problem
the speed with which new resistant pathogens are emerging
the decline in new antibiotic research and development
Antibiotic Resistance
At least some clinical isolates of many pathogenic bacterial species are now resistant to most antibiotics
Most new antibiotic developments have failed to expand on the “golden era” of antibiotics
Poses a significant patient safety and public health issue
• Patient harm, morbidity, mortality
• Cost of care• Cross-transmission
Stats
In a survey of 505 acute care hospitals, 78% had evidence of redundant antibiotic usage
Antibiotic exposure is the single most important risk factor for the development of C. difficile
Antibiotic Resistance
Root-Causes
Prescribing incorrectly
Over-prescribing
Unnecessarily prescribing
Outside Pressures and Future Pay-for-Performance??
Antibiotic stewardship programs currently voluntary
CDC urging CMS to “put teeth” to it and include as part of pay-for-performance
“10 x ’20 initiative,” a call to action to develop 10 new antimicrobial drugs by the year 2020 (IDSA)
Strategies to Address Antimicrobial Resistance Act (H.R. 2400 known as STAAR) — introduced in May 2009
Educating providers on use and resistance
Guidelines for management of common infection syndromes
Computer decision support
Specific improvement interventions
Components of an AR Program*
Leadership commitment
Accountability via an interprofessional team with a designated leader
Designated pharmacy leader
Tracking of antibiotic use
Regular reporting on antibiotic use and resistance
*2014 CDC Core Elements of Hospital Antibiotic Stewardship Programs and 2007 Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship
Ensure the “Basics”
Anderson DJ, Kaye KS. Controlling antimicrobial resistance in the hospital. Infect Dis Clin North Am. 2009; 23:847-64, vii-viii.
Infection Preventionist
+Infectious Disease
Specialist+
Pharmacist
Triple Threat
Source: A Hospital Pharmacist’s Guide to AntimicrobialStewardship Programs
Recommended Strategies
• Hard stops• Care
bundles• Antibiotic
“timeouts”• Committee
structure• Antibiotic
cycling• Education
feedback strategies High Reliability Organization Principles!!
Data Needed!
Measurement methodology is not exact
Example: defined daily doses
Health care informatics focus areas and goal
Hospitals can measure antimicrobial use, track changes in antimicrobial use and resistance over time, compare to similar institutions, and provide data to regional and national databases to allow largescale tracking of trends
Encourage reporting through NHSN (HIDI Group)
Source: A Hospital Pharmacist’s Guide to AntimicrobialStewardship Programs
Quality – Finance Link: ASP Program Return on Investment• Calculation of anticipated savings may
be based on current use and practices and estimates of the impact of proposed interventions. Such calculations may be useful in obtaining initial support for the development of an ASP.
• Calculation of actual savings can be based on the results of specific patient-level interventions or on aggregate data for the entire hospital/facility from pre-and post-intervention periods. Such calculations may be one method of demonstrating the value of the ASP and justifying requests for additional financial support (e.g., personnel resources) for the program.
Associated Savings
Reduced LOS
Reduced incidence of C. difficile
Reductions in rates of antibiotic resistance among health care facility–associated pathogens
Reduced incidence of toxicity
Cost Savings Opportunities
Direct Savings
IV:PO Conversions
Reductions in use of high-cost antimicrobials
Reductions in performing therapeutic drug monitoring (TDM) lab tests
Reduction in overall antimicrobial use
Population Health Implications
Care Coordination
Cross-transmission among hospitals, LTC, and the community
Lack of systemic control of antibiotic use across domains of care
Increase in outpatient and LTC setting antibiotic usage
Population Health Implications
Antibiotic use in animal medicine/food animal production
Antibiotic use in agriculture for food production
Growing body of evidence noting link between antibiotic use in food/animals to antibiotic resistance in humans
Includes the direct acquisition of resistant pathogens through the food supply as well as the transfer of resistance genes to human bacterial populations
Recommendations to decrease/eliminate use
ASP Resources
CDC
IDSA
LeadStewardship.org
APIC
SHEA
ASHP
Society of Infectious Disease Pharmacists
The Ohio State University
UCLA Health System
The Nebraska Medical Center
ASP Resources
HAI Overview
Every day, 1 in 25 hospital patients suffer from at least one health care-associated infection
An estimate of 4,037 people died in Missouri hospitals because of an HAI in 2014
Pay-for-Performance
HAC Reduction Program penalty
VBP reimbursement
Costly
Substandard/not evidence based care
Link between HAI and Handwashing
Difficult to prove but studies with increasing hand hygiene show decreased infection rates
Key Structures to Hand Hygiene Programs
Successful hand hygiene educational programs should incorporate:
reinforcement of hand hygiene messages
knowledge of health care workers’ perceived importance of hand hygiene and its role in prevention of HAIs
monitoring and feedback of hand hygiene practices
practical education tools
role modeling by senior staff
supportive infrastructure and management
Meet Infection Control Barbie, Ami
Links to Hand WashingResources
Centers for Disease Control and Prevention
Institute for Healthcare Improvement
The Joint Commission
World Health Organization
Trending: Sepsis
Update
Effective October 1, 2015, CMS will enforce its new bundle measure for severe sepsis and septic shock as part of the Hospital Inpatient Quality Reporting (Hospital IQR) program
The new bundle is based on two time periods:
the first three hours of diagnosis
six hours of diagnosis
the clock starts as soon as presumed or confirmed severe sepsis is documented by diagnosis or criteria are met.
Sepsis Bundle Project: New CMS Guidelines
New measure beginning with 10/1/2015 discharges
Collected for CMS
Process measure
Added to align with CY 2015 IPPS Final Rule
Includes SEP-1 – Early Management Bundle, Severe Sepsis/Septic Shock
63 new data elements
Improvement noted as an increase in the rate
SEP Initial Patient Population
Population determined using five data elements
ICD-10-CM Principal Diagnosis Code
ICD-10-CM Other Diagnosis Code
Admission Date
Birthdate
Discharge Date
SEP Initial Patient Population
Patients admitted to the hospital for acute inpatient care with a PDC or ODC for sepsis as defined in Appendix A, Table 4.01
Age > or = to 18 years
LOS < or = to 120 days
SEP Sampling
Option of sampling quarterly or monthly
Hospitals selecting sample cases must ensure that the population and sample size meets the conditions
SEP Sampling
Quarterly Sample Size Based on Hospital’s Initial Patient Population Size for the Sepsis Measure
SEP Sampling
Monthly Sample Size Based on Hospital’s Initial Patient Population Size for the Sepsis Measure
It’s all about the lactate
Lactate Level
(mmol/L)
AssociatedMortality
Rate
≥ 4.0 27%
2.5-4.0 7%
<2.5 <5%
Surviving Sepsis Campaign
TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION*:
1. Measure lactate level
2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L
* “Time of presentation” is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review.
Surviving Sepsis Campaign, 2015.
Surviving Sepsis Bundle (update 2015)
Surviving Sepsis Bundle (update 2015)
TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:
5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg
6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings (next slide)
7. Re-measure lactate if initial lactate elevated.
Surviving Sepsis Campaign, 2015.
DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION WITH
EITHER:
Repeat focused exam (after initial fluid resuscitation) by licensed independent practitioner including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings.
OR TWO OF THE FOLLOWING:
Measure CVP
Measure ScvO2
Bedside cardiovascular ultrasound
Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge
Surviving Sepsis Bundle (update 2015)
Sepsis
Remains a serious, and growing, challenge
Rising Volumes Poor Outcomes Extreme Costs
2xHospitalizations for sepsis more than
doubled in the past decade
65% Percentage of sepsis
patients over 65
17%Increase in sepsis
inpatient hospital death rates in past decade
40-70% Mortality rates for septic
shock
700Patients die of severe
sepsis daily
$25,000Average cost per sepsis
case
6x Direct cost of treating
sepsis patient is six-fold higher than non-sepsis
patient
1Most costly reason for hospitalization in 2009
Sepsis Solutions International 2006The Advisory Board Group Company, 2014
Infections Inflammatory Response Progression
SIRS
• Temp >38° or <36°C, HR >90, RR >20 or PaCO2 <32, WBCs >12,000 or <4,000 or >10% bands
Sepsis
• SIRS + Infection
Severe Sepsis
• Sepsis + End Organ Damage
Septic Shock
• Severe Sepsis + Hypotension
(Systemic Inflammatory Response Syndrome)
Progress lags despite 13 year campaign
Surviving sepsis campaign yet to curb rising sepsis mortality rates
Increase in sepsis inpatient hospital death rates in the past decade
Physicians who follow pediatric sepsis guidelines
Physicians who adhere to 6-hour sepsis resuscitation bundle
17%
19%
31%
The Advisory Board Group Company, 2014
Many Hurdles Along Path to Delivering Sepsis Care
TriageEarly
ResuscitationOngoing
Management
Suspect sepsis Screen for sepsis Identify positive
screens Inform physician Kick-off 6 hr bundle Order sepsis panel
Draw cultures and lactate
Give antibiotics Collect test results Alert ICU or RRT Central line
insertion EGDT monitoring
ICU/Floor transfer Hand-off remaining
bundle steps Repeat lactate Collect culture
results Adjust antibiotics
47%Fail to order lactate with blood culture
50%Fail to administer
antibiotics within 6 hrs
72%Fail to document specific microbe
The Advisory Board Group Company, 2014
4-Tier Process for Severe Sepsis Program Implementation
Measuring Success and
CI
Implementation of the Sepsis
Bundle
Early Screening with Tools and Triggers
Organizational Consensus that Severe Sepsis Must be Managed
Early and Aggressively
Sepsis Solutions International 2006
Tier 1: Organizational Consensus and Support
Define Sepsis Program Goal and aligned with organizational goals
Identify Executive sponsor
Collect Baseline Data—essential step
Develop sepsis team(do we have all the right people here?) and schedule monthly (minimum) meetings for at least 6 months
Complete Team Charter
Identify nursing and physician champions in ED and ICU and ensure champions attend team meeting
Begin to define action plan and timeline for program development and implementation
Measuring Success and
CI
Implementation of the Sepsis
Bundle
Early Screening with Tools and Triggers
Organizational Consensus that Severe Sepsis Must be Managed
Early and Aggressively
Sepsis Solutions International 2006
Tier 1: Challenges and Barriers
Scheduling meetings and consistent attendance
Time
Skipping key steps
Charter
Communication plan (accountability)
Align within organization
Baseline data
Sepsis Solutions International 2006
Tier 2: Screening for Severe Sepsis
Define the Disease Continuum
Sepsis: presence of infection (suspected or confirmed) with systemic manifestations of infection
Severe Sepsis: Sepsis-induced tissue hypoperfusion or organ dysfunction
Septic Shock: Hypotension that persists despite adequate fluid resuscitation
Sepsis Solutions International 2006
Measuring Success and
CI
Implementation of the Sepsis
Bundle
Early Screening with Tools and Triggers
Organizational Consensus that Severe Sepsis Must be Managed
Early and Aggressively
Tier 2: Screening for Severe Sepsis
Develop screening process for ED, rapid response team and ICU (eventually housewide)
Develop audit process to evaluate compliance and effectiveness
Ensure screening process has clear “next steps” defined for nursing staff
Sepsis Solutions International 2006
Tier 3: Sepsis Bundle Implementation
Develop easy to use order sets (ED and ICU should be the same), organized by bundle
Order sets approved by appropriate medical and nursing leadership/committees
Identify resistance and barriers to bundle implementation and develop solutions
Ex: ability to get lactate quickly
Identify equipment needs and make capital requests
Develop triggers/processes to alert staff when time to move from first 3 hrs to shock bundle
Define educational plan for all staff
Develop implementation plan
Measuring Success and
CI
Implementation of the Sepsis
Bundle
Early Screening with Tools and Triggers
Organizational Consensus that Severe Sepsis Must be Managed
Early and Aggressively
Sepsis Solutions International 2006
Tier 3: Sepsis Bundle Implementation
Hospital resources often focus on planning phase and then back off after implementation.
The implementation phase is the most critical.
Frequent rounds by project champion recommended on unit to support staff and answer questions.
Defined resources for bedside nurse
Project champion has pager to be available 24/7 initially
Clinical nurse champions identified on each ICU unit and ED to be resources to bedside staff (these staff should be members of the sepsis team/committee
from the beginning)Sepsis Solutions International 2006
Tier 3: Sepsis Bundle Implementation
Identify who will oversee the implementation and the expectations of that person(sepsis nurse or program coordinator)
Define ICU/ED resources for staff that they can call at any time for questions and assistance
Create rounding schedule and process
Should begin as daily in the ICU and ED
Keep master list of all patients who go on the bundles (and those who should have but didn’t if possible)
Do real time interventions to ensure patients get the evidence based practices
Define follow up process for review and evaluate missed opportunities
Sepsis Solutions International 2006
Tier 4: Measure Success and Continuous Improvement
Define outcome and process data elements that will be collected
Develop and implement a data collection process
Revise and update goals and action plan as needed
Execute implementation plan
Measuring Success and
CI
Implementation of the Sepsis
Bundle
Early Screening with Tools and Triggers
Organizational Consensus that Severe Sepsis Must be Managed
Early and Aggressively
Sepsis Solutions International 2006
Tier 4: Measure Success and Continuous Improvement
Data Collection
Patient Log
Define how will find all patients that receive the bundles
Real time data collection is optimal—then used as checklist to ensure patient receives all appropriate interventions
Outcome
Mortality (ICU and Hosp)
Hosp LOS
Cost per case (total and direct)
Process
SSC database
Data elements that measure process achievement of the 3 & 6 hour bundles & outcome measures of the 6hrs
Sepsis Solutions International 2006
Strategies for Keeping Sepsis Front and Center
Align team with clinical and quality structures in organization
Sepsis program/goals part of hospital quality plan
Reporting progress and data quarterly to executive leadership
Report to hospital board annually
Standing agenda item on department meetings
Communication plan – includes flyers, newsletters, postings in units etc.
Code sepsis
Real time data measurement and feedback
Sepsis Solutions International 2006
Question
Where is your sepsis recognition priority
ED/EMS
Critical Care
Floors
Case Study 1Establishing an Emergency Department Sepsis Screen at St. Claire
Regional Medical Center, Kentucky
Discovering a Need at St. Claire Regional Medical Center
Chart reviews of patients with primary diagnosis of sepsis for the months of January-March 2012.
42 patients with primary diagnosis of sepsis.
21 patients met SIRS criteria at triage
13 of those 21 patients met SIRS criteria based on vital signs alone.
Only 3 of those 21 patients had the established sepsis order set initiated.
Bailey, P. (2014). St Claire Regional Medical Center.
Next Step at St. Claire Sepsis screening tool created and added into ED
triage assessment.
Performed on every adult patient upon arrival to emergency department.
If patient meets the criteria, the Triage Sepsis order set is initiated by the nurse and the patient is flagged on the tracker.
Bailey, P. (2014). St Claire Regional Medical Center.
Triage Sepsis Order Set at St. Claire
CBC
CMP
Magnesium
PTT, PT/INR
Lactate
Troponin
BNP
Blood culture x 2
CXR - portable
EKG
IV initiation and normal saline bolus
Bedside telemetry, non-invasive blood pressure, and continuous pulse oximetry monitoring
Bailey, P. (2014). St Claire Regional Medical Center.
Post-Intervention Data at St. Claire
Screening initiated on January 15th, 2013
235 positive screens from January 15th,2013 through June 30th, 2013
113 (48% of patients with positive screen) met criteria for diagnosis of sepsis
Main sources
Sepsis of urinary origin
Sepsis of pulmonary origin
Bailey, P. (2014). St Claire Regional Medical Center.
Case Study 2Reducing Sepsis Mortality at Wake Health
Case Study at Wake Forest: A Gradual Rollout to the Floors, ED, and ICU
Stepwise Approach Allows Initiative Refinement Along the Way
The Advisory Board Group Company, 2014
Wake Health’s Barriers to Optimal Sepsis Care Reflect Industry-wide Challenges
Multidisciplinary Staff Meeting to Uncover Barriers to
Optimal Sepsis Care at Wake Health
Meeting Attendees
Performance improvement experts
Faculty and house staff from medical, surgery, and neurology departments
ICU physicians
Respiratory therapy leaders
Frontline nurses
Pharmacists
Rapid response team
Barriers Identified
Guidelines not consistently followed in time-sensitive window
Responsibilities for identifying and treating sepsis in rapid timeframe not well-defined
Lack of education on sepsis and sepsis initiative among frontline staff
Clinicians took often take ad-hoc approach to screening and miss diagnoses
The Advisory Board Group Company, 2014
Reducing Sepsis Mortality at Wake Health Eight Tactics for Promoting Consistent, High-Quality Sepsis Care
IFormalize
Identification
1. Inpatient early warning sepsis screen
2. Acuity-sensitive ICU sepsis trigger
IIAccelerate Treatment
3. Simplified sepsis bundle
4. Top-of-license sepsis roles
5. Rapid response sepsis kit
6. Comfort care decision prompt
IIIHardwire
Accountability
7. Real-time protocol checklist
8. Phased bundle adherence accountability
The Advisory Board Group Company, 2014
Wake Health Roadmap
I: Formalize Identification
(Immersion Project coming Fall 2015!)
Definition of “Code Sepsis” at Wake Health
A patient emergency requiring immediate action for the treatment of potential sepsis and septic shock.
Early identification, communication, and intervention for patients with sepsis
Implementing the sepsis bundle (including antibiotics) within one hour
Signaling Initiative Importance with a Brand
“Code Sepsis” Logo
The Advisory Board Group Company, 2014
Wake Health Addresses Barriers to Identification
Barriers to Early Identification
Subtle symptoms often fly under the radar
Floor nurses not exposed to many sepsis cases
Nurses reluctant to sound alarm because of false positive
All clinicians extremely busy
Site of Care
Screen Used
Provider Responsible for Screening
Screening Frequency
Inpatient Floor
Early Warning System
Nursing assistant checks vitals and RN patient alertness
• Every 4 hours for first 24 hours
• If patient is stable after 24 hours, every hours
• Is EWS is between 5-7, every four hours
ICU SIRS and “snooze criteria”
Bedside nurse • Upon ICU admission• Every 12 hours as
needed
ED EWS RN During ED triage
Sepsis Identification Process Across Inpatient Floor, ED, and ICU
The Advisory Board Group Company, 2014
Sepsis Screen Tells Nurses When to Sound the Alarm
Early Warning Score Criteria
Used on inpatient floors and EDThe Advisory Board Group Company, 2014
“Post-Snooze Phase”
Nurses conduct sepsis screen every 12 hours or as needed: if positive for SIRES nurse draws lactate: if abnormal lactate and/or potential infection, nurse calls “Code Sepsis”
Sepsis Trigger in ICU Reduces False AlarmsICU sepsis screen accounts for high acuity
“Snooze Phase”
Patients expected to meet SIRS criteria, but not have sepsis: nurses do not trigger sepsis alert
Patient Timeline in ICU
Hitting the “Snooze” to Reduce False Alarms
“The sepsis trigger needs to be like an alarm clock when you hit the snooze alarm. ICU patients will meet SIRS criteria for a period of time and it shouldn’t always trigger an alert.”
ICU Physician, Wake Forest Baptist Health
The Advisory Board Group Company, 2014
Complete “Snooze” CriteriaLength of Time per “Snooze” Based on Diagnosis
“Snooze” time must elapse before triggering a sepsis alert for patient who meet SIRS Criteria
If a patient is… Snooze them for…
On ABX for Sepsis 96 hrs from new ABX start/change in ABX
Post-Arrest Hypothermia Protocol Patients
72 hours from arrival to facility
DNR/Comfort Care Permanent, unless order changed
Trauma Patient 48 hours from arrival to facility
Patient has CT Surgery 48 hours from return to unit
AMI patients (including STEMIs) 48 hours from return to unit
TAVR Value 24 hours from return to unit
Intracranial bleed 24 hours from arrival to ED
Surgery 24 hours from return to unit
The Advisory Board Group Company, 2014
Wake Health Roadmap
II: Accelerate Treatment
Rapid Treatment Crucial to Reduce Mortality
Impact of Compliance with 6-hour Sepsis Bundle on Hospital Mortality
The Advisory Board Group Company, 2014
Drawing the Link from Staff Activities to Mortality
The Advisory Board Group Company, 2014
Simplifying Guidelines to a Four-Component Bundle
Simplified, Time-Sensitive Sepsis Resuscitation Bundle at Wake
Forest Health
1. Measure serum lactate
2. Obtain blood cultures prior to antibiotic administration
3. Administer broad-spectrum antibiotics within one hour
4. Fluid resuscitation if MAP<65 or elevated lactate
The Advisory Board Group Company, 2014
Defined Roles Expedite Sepsis Care on the Floor
Initial Sepsis Care Actions and Parties Responsible at Wake Health
For Inpatient Floor Code Sepsis
The Advisory Board Group Company, 2014
Pharmacists
Pharmacist monitors timing between Code Sepsis page and receiving antibiotic order from physician; follows up with first-call provider if order is not received in a timely manner
Once a physician verbally confirms sepsis and site of infection to pharmacist over the phone, pharmacist places order for appropriate broad-spectrum antibiotics
Pharmacist delivers antibiotics directly to Code Sepsis patient’s bedside
Empowering Staff to Practice at Top-of-License
Rapid Response Nurses
All rapid response nurses have critical care experience and are highly regarded by the medical staff
Nurses take lactate tests to stat lab and draw blood culture for Code Sepsis patients
Physicians agreed to pass on these responsibilities to RNs after data showed physicians were not consistently doing lactate tests
The Advisory Board Group Company, 2014
Rapid Response Sepsis Kit Supply List
Minimizing Time Wasted on Gathering SuppliesSepsis kit ensures all necessary supplies are quickly available to RRT
The Advisory Board Group Company, 2014
Sample Treatment Decision Tree Before Calling RRT
When Curative Treatment is Not the Goal
Physician Feedback Prompts Mandated
Comfort Care Decisions
Physician feedback reveals providers occasionally choosing not to deliver sepsis bundle because it does not align with patient care goal of comfort care
Wake Health trains first call physicians to consider patient care goals before initiating sepsis bundle
Physicians may opt out of Rapid Response Team trigger if patient and family decide to pursue palliative care or hospice
The Advisory Board Group Company, 2014
Wake Health Roadmap
III: Hardwire Accountability
Driving Bundle Compliance, Real-TimeRapid Responses Sepsis Screening Tool at Wake Health
The Advisory Board Group Company, 2014
Tiered Monitoring Efforts Instill Accountability
Stages of the Sepsis Bundle Accountability Strategy at Wake Health
The Advisory Board Group Company, 2014
Follow-Up Email Prompts Compliance, FeedbackFollow-up email template for non-compliant physicians
The Advisory Board Group Company, 2014
Recognizing Physicians for Bundle Adherence
CMO-signed email reinforces sepsis as organization-wide priority
Thank-you email template for compliant physicians
The Advisory Board Group Company, 2014
Wake Health’s Across-the-Board Improvement
The Advisory Board Group Company, 2014
Key Takeaways from Wake Health
Make it a team effort: optimal sepsis care relies on a systematized, team approach (even if physicians know how to treat sepsis).
Approach non-adherence to the sepsis bundle as an opportunity to solicit feedback from clinicians on what barriers are standing in their way.
Getting clinicians comfortable with giving antibiotics to patients without confirmation of infection is a significant challenge, but critical to ensuring timely antibiotic administration.
Senior leadership involvement is a must to signal organizational commitment and promote accountability.
The Advisory Board Group Company, 2014
Packet Resources
Advisory Board 10 Imperatives to Reduce Sepsis Mortality
Surviving Sepsis Campaign Bundle
Questions?
Jessica Rowden, RN, BSN, MHA
Clinical Quality Improvement Manager
Missouri Hospital Association
(573) 893-3700, ext. 1391
6000 Hospital Drive
Hannibal, MO 63401
hrhonline.org
Pressure Ulcer Prevention Implementation
Sara Murphy and Amanda Echternacht
Abstract
More than 2.5 million people in the United States develop pressure ulcers each year (AHRQ, 2013).
Pressure Ulcers cause patient harm by increasing :• pain• risk of serious infection• health care utilization• cost for the patient and for the organization
During a CMS survey in 2012, it was discovered that Hannibal Regional Hospital was not preventing hospital acquired pressure ulcers and, as a result, causing patient harm. Additional findings indicated that team members lacked the ability to assess and properly document pressure ulcers.
Objectives
Increase pressure ulcer prevention knowledge for front line staff members and within the community.
Hardwire a Pressure Ulcer Prevention Program• Pressure Ulcer Prevention Implementation Team• Wound Warriors
Decrease hospital acquired pressure ulcers
17
3
1
4
6
34
7
4
8
45
0
2
4
6
8
10
12
14
16
18
HRH Hospital Acquired Pressure Ulcers
July 2014 - June 2015
Results
0
5
10
15
20
25
Pressure Ulcers
SDTI
Mucosal`
Stage 1
Stage 2
Stage 3
Stage 4
Column1
HRH Pressure Ulcer Data
Type of Hospital Acquired Pressure Ulcers
July 2014 – June 201565 Total
Hospital Acquired Pressure Ulcers (SDTI) by UnitJuly 2014-June 2015
0
2
4
6
8
10
12
MS1 4
ICU 11
PCU 8
CDU 2
HRH Pressure Ulcer Data
Hospital Acquired Pressure Ulcers (Stage 2) by UnitJuly 2014-June 2015
0
2
4
6
8
MS1 3
ICU 7
PCU 5
OR 8
HRH Pressure Ulcer Data
Materials and Methods
Pressure Ulcer Prevention Team developed• Interdisciplinary approach to preventing pressure ulcers.• Skin Bundle• Wound Warriors • Evaluate Team Members views on pressure ulcer prevention
Education • Quarterly skin and wound classes for Registered Nurses and
Patient Care Technicians, including pre-test and post-test evaluation and bedside competency
Materials and Methods
Pressure Ulcer Assessment• Initially, every patient on Intensive Care Unit, Progressive
Care Unit and Medical/Surgical Unit received a daily skin assessment by the wound nurses, in addition to shift to shift skin assessments completed by the oncoming and off-going primary nurses, to confirm competency in skin assessment and identification of pressure ulcers.
• Transitioned into oncoming and off-going primary nurses completing skin assessment together. Wound consults are submitted when assistance is needed.
• Wound nurse completes reassessment on all patients identified with pressure ulcers to confirm identification of pressure ulcer, consistency of documentation, and implementation of Clinical Practice Guidelines and interventions.
Skin Care Bundle
Composed of a straightforward set of evidence-based practices to assist our front line staff in recognizing patients at a high risk for developing hospital acquired pressure ulcers.
Assists the primary nurse with implementing appropriate interventions for the patient.
• PUP Paw magnets placed on door frames of patient rooms alert staff members that a patient is at high risk of developing pressure ulcers.
Hospital Acquired Pressure Ulcer Prevention
Responsibility
Registered Nurses Assess patients skin on admission and use nursing judgment for
interventions that are to be immediately implemented.
Reassessment of skin every shift by primary nurses. Measure existing pressure ulcers on admission, weekly (Measure Mondays) and on discharge.
Wound Warriors meet bi-monthly on each unit to discuss how we can better prevent pressure ulcers.
Products and interventions nurses may implement: Z-Guard, Clear-Aid, wedges, waffle cushions, turn team, heel boots, etc.
Provide education to patients on importance of preventing pressure ulcers.
Hospital Acquired Pressure Ulcer Prevention
Responsibility
Patient Care Technicians Work alongside the Registered Nurse to assess patient
skin during daily bath. Patient Care Tech’s report any signs of skin breakdown to the patient’s primary nurse.
Interventions• Clear-Aid product may be applied by Patient Care Tech
• Turn team members.
Hospital Acquired Pressure Ulcer Prevention
Responsibility
Dietitian
Assessment of at-risk patients upon admission.
Interventions
• Increase protein at every meal.
• Recommend multi-vitamins.
Education on proper nutrition for patient and family members prior to discharge.
• Sample menus
• Emphasis on importance of protein.
Hospital Acquired Pressure Ulcer Prevention
Responsibility
Respiratory Therapist Check skin condition under medical devices (bipap,
ventilators, oxygen tubing)
Interventions
• Boomerang pad for the bipap.
• Foam to cover oxygen tubing
• “Dots” to hold oxygen tubing in place and off of the skin.
Hospital Acquired Pressure Ulcer Prevention
Responsibility
Physical Therapy Assessment of patient’s mobility on admission if the risk assessment
is positive. This also allows signs of skin breakdown to be reported to the primary nurse.
Interventions
• Repositioning patients in bed or chair.
• Offer the restroom or change a soiled patient to decrease moisture on skin.
• Offer water to maintain hydration.
• Educate patients and family members on importance of mobility, repositioning and hydration to prevent pressure ulcers.
Pressure Ulcer Prevention Products
Heelmedix Heel Protector
Heels are offloaded and not touching the bed, pillow or boot.
Pressure Ulcer Prevention Products
Waffle cushionStatic air is an inexpensive and effective way to redistribute pressure in the chair or bed.
Pressure Ulcer Prevention Products
Wedges• Offload sacrum• Maintain 30 degree
lateral position
Pressure Ulcer Prevention Products
Gel pad for use with bi-pap or other face masks
• Protect nose from pressure
• Washable and reusable
• Store in box and keep at bedside
Materials and Methods
Data Collection Tools• Weekly Incidence and Prevalence by Wound Nurses• Daily pressure ulcer log• Audits by wound warriors• Event Reporting System
Ongoing data results shared house wide via monthly Pressure Ulcer Prevention Briefings, shift exchange huddles, emails, team meetings, communication boards and one-on-one.
Weekly meetings to do drill downs on documentation and process opportunities.
Conclusions
For Pressure Ulcer Prevention to be effective:
1. Acknowledge that you have a problem.2. Evaluate current processes and re-evaluate based on data and
team member feedback.3. Evaluate the attitudes of clinical team members on their role in
prevention.4. Explore and implement evidence-based practice options. 5. Educate, educate, educate.6. Perform case reviews to identify points of success and failure
while enhancing team member knowledge. 7. Collect and share meaningful data.8. Share stories of harm and lessons learned to promote awareness
and drive sustainability.9. Encourage front line involvement.10. Stay focused, never give up!
References
Agency for Healthcare Research and Quality (2013). Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care
Medline (2012). Pressure ulcer prevention program. Quick Reference Guide version of the NPUAP/EPUAP International Pressure
Ulcer Prevention Guidelines. Retrieved from National Pressure Ulcer Advisory Panel (NPUAP) and European PressureUlcer Advisory Panel (EPUAP) website: www.npuap.org.
Moore Z, Price P. (2004). Nurses’ attitudes, behaviors, and perceived barriers towards pressure ulcer prevention. J Clin Nurs,13:942-52.
Braden Scale (1988). Retrieved from Braden website: www.bradenscale.com/images/bradenscale.pdf. Reprinted with permission.
Gray-Siracusa, K. & Schrier, L. (2011). Use of an Intervention Bundle to Eliminate Pressure Ulcers in Critical Care. Journal of Nursing Care Quality,26 (3), 216-225.
Acknowledgments
Many thanks to:
Front-line team members that touch the lives of our patients each and every day.
Support team members who assist front-line in carrying out quality care.
Materials Management Team for assisting us with finding quality products and bringing in the items needed for quality care.
Medline for providing us with many hours of support, education and products.
Missouri Engagement Network for showcasing our work in 2013.
SSM HealthSt. Joseph Hospital Lake St. Louis
Janet Pestle RN MSN, CNO
MHA Regional Meeting
Clinical Excellence
September 2015
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Initiatives:
1. Physician Citizenship Committee
2. Pharmacy & Medication Safety
3. ER Throughput
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Physician Citizenship
• Back in 2012, there was this Physician……..
• CMO developed the Physician Citizenship Committee with input from others………
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Physician Citizenship Committee vs.Physician Peer Review
PCC• 7 members of Medical Staff
• Representative “reports out” to MEC
• Points can be assigned for behavior issues
• Referrals from others to CMO
• Given authority and deemed important to the Medical Staff
PPR• 10 members of Medical Staff
• Representative “reports out” to MEC
• Points can be assigned for practice issues
• Referrals from others to CMO
• Given authority and deemed important to the Medical Staff
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Points
• Scoring system– 0=incident lacks merit or credibility
– 1=slight risk to hospital operations and/or patient care. Includes slurs, derogatory comments, various nonprofessional behaviors
– 2=risk to hospital operations and/or patient care. Includes shouting or profanity, especially in front of a patient or visitor
– 3=significant risk to health or safety of patients, staff or visitors
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• Accumulation of 6 or more points over a 2-year period triggers an automatic FPPE or Performance Improvement Plan
• Any incident that scores 3 points also results in an immediate FPPE or PIP
• Total number of points are reviewed at each re-credentialing
• Anything egregious goes directly to the MEC for action
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Examples…..
– Response letter from physician apologizing for his behavior with comment that he had no idea the negative effect he had on the staff
– Significant improvement in physician-staff relationship between the top two physicians addressed by the committee
– One physician reappointed to med staff for only one year instead of two — humbling moment
– Nurse: “We sure have seen improvement in the behavior of Dr. _________ over the last few months.”
– ER Doctor: “I wanted to blow up at a Nurse today but I decide to talk to her instead because I didn’t want to have to go to Citizenship again….”
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By the numbers…….• Statistics to date (since inception Jan., 2013)
– 94 cases referred
– 60 letters of inquiry
– 51 cases assigned a level of “0”
– 21 cases assigned a level of “1”
– 2 cases assigned a level of “2”
– 12 cases were assigned an educational letter only
– 2 cases referred to peer review
• Has changed the culture of the medical and hospital staff at our hospital, and has been a significant stepping stone in hardwiring a culture of safety
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Pharmacy & Medication Safety
• Pharmacist Integration into Patient Care areas– Strategic Vision 5 years ago
– SJH LSL was chosen as pilot hospital from SSM St. Louis hospitals
– Pharmacist designed program based on vision
– Significant financial impact (additional FTEs)
– Metrics of Success• Medication Errors with Injury
• Patient Satisfaction as measured by HCAHPS
• Employee Satisfaction (top performer last 2 years)
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• HAM SALAD (High Alert Medication / Sound Alike Look Alike Drugs)
– SALAD list specific to patient care area
– HAM utilizing the HIPPOS document
• Lists drug classes as well as the actions to minimize risk of medication error
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Made it a Priority….
• No Harm meeting
– Weekly review of all medication event reports (Near Misses)
– Events referred to the Medication Error Reduction Team (MERT) for process improvement
– Multidisciplinary front line staff (those closest to the process)
– Identification of root cause
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• Barcode scanning reports reviewed each month
• Exceptional scanners recognized
• 100 or more medication administrations for the month
• 100% medication scan as well as 100% patient scan
• Awarded a “barcoded candy bar”
• Exceptional scanner poster displayed in patient care area
• Exceptional scanners with 12 consecutive months recognized at monthly leadership meeting
•
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The Current Results……..
• 31 consecutive months without a medication error with injury
• 2.34 million doses administered
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ER Throughput
• In 2010, Admissions from the ED to an Inpatient bed took an average of three hours (178 minutes)
• Increased volumes “everywhere” since 2010…….
• Major construction project to open 3 more inpatient floors in 2017
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Many Process Improvements….
• Pager notification for each step in the process (order placed, room assigned, etc)
• “Special needs” completed in ED
• Decreased report time (one call, standardized)
• Creation of “Virtual Units”…….
• Monitors, chairs, meals, TVS, etc.
• Dozens of process changes in 5 years to improve……
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Virtual Units, you say?
• EIU (2010)
Emergency Intermediate Unit
• PIU (2012)
Peri-Operative Intermediate Unit
• GIU (2015)
GI Intermediate Unit
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Data tells our story….
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2012 2013 2014 2015 YTD
SSM SJH-LSL IP Census
ADC (Non-OB) ADC (EIU) Bed Capacity
Scorecard for Throughput (Current)
SJHW Patient Thruput Scorecard (2015)
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Throughput 2014 Goal
IP: ADC (non-FBP) 93.2 N/A 102.0 99.2 102.0 105.3 96.6 97.7 99.7
IP: ADC (Total) 105.8 N/A 112.5 113.6 115.0 120.0 109.3 110.0 115.4
IP: Admissions (ED Non-FBP) 742.8 N/A 817 728 778 734 790 771 741
IP: Avg LOS (Traditional Medicare) 3.8 N/A 3.98 3.85 3.77 4.22 3.93 4.04 4.26
IP: Avg LOS (Managed Medicare) 4.2 N/A 4.21 4.12 4.01 3.92 4.45 3.97 4.77
IP: TAT (ED Admit Order to Bed Assign) (Min) 22.6 20 38.3 31.9 39.7 41.2 42.0 44.5 45.4
IP: TAT (Bed Assign to Admit) (Min) 58.8 30 60.1 63.4 61.1 69.4 64.6 65.7 61.8
IP: TAT (ED Admit Order to Admit) (Min) 80.8 60 98.6 95.1 100.9 110.6 106.6 110.2 107.1
IP: ED Admits to Floor < 60 Min (%) 43.8 60 39.3 36.0 36.1 30.2 33.3 26.7 32.8
IP: D/C by Noon (IPC) 50 46.7 43.4 52.1 46.0 38.8 45.0 35.8
ED: Door to Provider <30 Min (%) 70.9 90 75.0 66.6 61.9 65.8 69.6 71.8 66.3
ED: LWBS (% Total Volume) 0.7 < 2 0.7 1.5 2.0 0.9 0.7 1.4 0.9
ED: % D/C < 3 Hrs 61.9 80 62.0 59.0 55.0 60.5 59.0 61.6 60.2
ED: % Admits < 4 Hrs 50.5 60 44 46 40 37 42 38 36
ED Hold Hours 242.7 < 300 564 462 566 644 584 628 54
OR 1st Case On-Time Starts (% <5min) 74.7 80 82 84 84 82 84 79 71
OR Ave Room TAT (mins) 23.3 < 20 23 23 24 23 23 23 23
PACU Hold Hours 54.9 < 50 104 49 88 161 45 85 97
PACU % Admit Delays >30 min 19.9 < 10 17 10 14 24 6 13 15
EIU Hours (Any virtual unit open) 260.6 N/A 450 337 425 529 389 463 570
EIU Patients (Sum of all virtual admits) 107.8 N/A 238 140 193 310 168 196 216
EVS: % Beds Cleaned < 60 Min 75.8 90 72.1 67.6 70.1 66.0 63.5 63.5 64.6
EVS: % Stat Cleans 3.2 3 1.8 2.4 2.6 3.4 3.0 3.0 3.7
EVS: D/C Room Clean TAT (Median Min) 43.9 45 47.0 49.0 48.0 51.0 51.0 51.0 53.0
Lab: ED TAT - Chemistry (% Outliers) 2.7 ↓3 2.7 2.8 1.8 2.2 2.3 1.6
Lab: ED TAT - Hemotology (% Outliers) 0.9 ↓3 0.7 0.6 0.2 0.9 0.9 0.8
Lab: ED TAT - Rapid Tests (% Outliers) 2.4 ↓3 0.5 0.8 1 2.6 3.2 1.6
Lab: ED TAT - Urinalysis (% Outliers) 0.5 ↓3 0.4 0.3 0.4 0.5 0.3 0.4
Lab: ED TAT- Overall 1.9 ↓3 1.5 1.5 1.2 1.8 1.5 1.1
Lab: IP TAT - Reported by 7AM (%) 98.1 98 98.9 99.8 99.1 98.7 98.8 98.6
Rad: ED Plain Film (Mins Order to End) 34.3 30 39 37 43 42 38 43 35
Rad:ED CT Head (Stroke) (% Read <20 Min) 96.1 100 100 96.9 100 85.7 100 100 100
Rad: ED CT Head (% Read <30 Min) 95.7 90 98.8 96.5 99.6 99.1 100 99.5 96.2
Rad: ED CT Abd w/ Oral (%Read <30 Min) 86.2 90 89.6 90.24 96.1 99.3 96.2 99.2 93.9
Card Cath Lab Hold Hrs (Total) N/A N/A 22:27 10:22 26.35 25.56 4:42 18:03 4:45
Card Cath Lab Hold Hrs (Ave) N/A N/A 2:48 1:17 2:25 2:35 1:10 1:23 2:22
BHS Hold Hrs (ED) 234.3 N/A 173.1 353.5 359.2 397.9 568.3 440.8 644.8
BHS Hold Hrs (IP) 147.6 N/A 71.1 243.8 211.2 87.6 82.9 108.0 307.2
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Volumes, Throughput, Construction
2015 Jan Feb Mar Apr May Jun Jul
Days EIU/PIU Needed 29 25 28 28 23 29 30
Days EIU Open 26 19 24 27 21 26 26
Days PIU Open 13 6 7 16 4 4 6
Days GIU Open 13 11
# Hrs EIU/PIU Open 450 336.5 424.5 528.75 388.5 463 570
# EIU/PIU/GIU Patients 238 140 193 310 168 196 216
# Patients Overnight (11P-7A) 42 37 45 98 45 59 105
# Pts Transferred r/t Census 28 25 23 25 22 24 20
Average Daily Census (non
FBP) 102 99.2 102 105.3 96.35 97.7 99.7
2012
16.1/mo
12.7/mo
.7/mo
163.8/mo
52/mo
1.5/mo
4.9/mo
Data tells our story….
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0
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6
8
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Falls/mo Falls with Harm/year C-Diff/10K pt days CAUTI/Year CLABSI/year
Freq
uen
cy
SJH-LSL Quality Metrics
2013 2014 2015 YTD
Virtual Units: The benefits….
• Inpatient care started “sooner”
• Patient satisfaction/needs (meals, TV, bed)
• Physician satisfaction (MD Pt list populates sooner)
• Productivity benefits
• ER benefit
• Proactive Structure around a chaotic event….
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Thank you for your time today.
Janet Pestle RN BS MSN NE-BC
Vice President of Nursing, CNO
St. Louis Executive Champion for Respiratory Therapy
SSM St. Joseph Hospital Lake St. Louis
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