psc newsletter 2008 summer

8/14/2019 PSC Newsletter 2008 Summer

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HAND HYGIENE:A PRIORITY FOR THE MILITARY HEALTH SYSTEM

SUMMER 2008 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY

INSIDE: More About MSRA Infection Reduction Across the MHS

SUMMER 2008

Patient Safety Survey Update6Summer Reading Picks5

Varied Strategies Employed to Reduce MSRA Infections

The reduction of methicillin-resistant

Staphylococcus aureus(MRSA) infec-

tion is a universal priority across thespectrum of healthcare today. Although

long recognized as major contributing fac-tors, improving hand hygiene and environ-

mental decontamination have proven to bevexing problems. Standardization of thesepractices has been oddly resistant to wide-

spread, effective intervention, despite therelative ease of strategies such as increased

hand-washing and use of alcohol-basedhand rub products.

Collaborative efforts by the Center for Dis-ease Control (CDC), the World HealthOrganization (WHO), the Institute forHealthcare Improvement (IHI) and The

Joint Commission have combined to high-light the risks associated with MRSA and

the specific steps that healthcare organiza-tions can and must take to reduce those

risks. Both the CDC and WHO have pub-lished hand hygiene guidelines (see:http://www.cdc.gov/handhygiene an d

http://www.who.int/patientsafety/information_centre/guidelines_hhad/en/index.html).

The Joint Commission has expanded

National Patient Safety Goal #7A to includethe WHO hand hygiene guidelines. Begin-ning in 2008, organizations are required to

be compliant with either the WHO or CDCguidelines. (http://www.jointcommission

.org/PatientSafety/NationalPatientSafetyGoals/08_hap_npsgs.htm). The IHI Five

Million Lives Campaign counts reducingMSRA infections as one of its goals. Among

a list of helpful information and tools, aPowerPoint presentation outlining impor-

tant data, interventions and strategies isavailable on the IHI website: www.ihi.org/IHI/Programs?Campaign/MRSAInfection.htm.

Military Treatment Facilities (MTFs),

providers and staff across the Military

Health System have been active in theirefforts to reduce MRSA infections. Featured

in the pages of this Summer Newsletter is acall to even greater personal responsibility

for infection control. The creativity shownby Tripler Army Medical Center, and the

breath of efforts at the Naval Health ClinicAnnapolis, highlighted herein, illustrate therange of strategies employed by the DoD

MTF Infection Preventionists and PatienSafety Managers to protect patients from

preventable infections.

Revised Call for Patient Safety Awards3

Tripler AMC Infection Control & Epidemiology Program Manager Stephen Yamada and GuyDickinson, Lead Medical Support Assistant, Adult Medicine Clinic, demonstrate how patientsreturn their hand hygiene data cards to the hand-fan receptacle.


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2 SUMMER 2008 PATIENT SAFETY

Like most hospitals across the nation, TriplerArmy Medical Center has long had a hospi-tal-wide program in place to encourage hand

hygiene among its providers. Unlike most

hospitals however, Tripler reexamined theirestablished efforts. They wondered how theycould be sure hand hygiene practices were

being followed in areas like the out-patientclinic where monitoring hand washing prac-tices are notoriously difficult. Their ques-

tions led to a unique patient-centered moni-toring system. With patients as active part-

ners in infection control Tripler has not onlyimproved its own compliance with hand-

hygiene goals, it has developed an improve-ment model that can be adopted across theMilitary Health System and beyond.

Recognizing that the out-patient setting pres-

ents a particularly challenging venue forhand hygiene monitoring with its multiple

encounters in separate examination rooms,COL Michael Brumage, then Chief of theDepartment of Preventive Medicine, led a

team effort to devise a completely new mon-itoring system. Thinking well outside the

established box, the team, comprised of COLBrumage, Stephen Yamada, Infection Control

& Epidemiology Program Manager, and JoanGodich, Infection Control Nurse, recognized

that patients provided an untapped resource.Together they developed a process utilizingpatients as monitors of clinic hand-washing

practices. The process was piloted in theAdult Medicine Clinic in January 2007.

Each patient was given a 3 x 5 card when

they registered in the clinic. Side 1 of thecard included a simple explanation of theproject and a brief set of instructions. Side 2

of the card included lines for the clinicname, the date, what health care provider

was being observed (doctor, nurse, other),and a simple yes or no check line as to

whether hand hygiene was performed.Patients were asked to drop their completedcards in a special receptacle, easily recogniz-

able by its hand-fan motif.

Results of the pilot project showed that patientobservations of hand-washing practices were

generally similar to staff observations. Howev-er, the increased reliability of objective patientreports added value to the pilot data. Addi-

tionally, a welcome unintended consequenceof the patient monitoring was noted. Physi-cian hand hygiene compliance rates improved

at Tripler during the course of the pilot project

and from December 2007 to May 2008 haveconsistently exceeded 95 percent.

No longer a pilot project, the patient handhygiene partnership at Tripler continues andhas expanded to other out-patient clinics

Obstetrics, Medical Specialties, Schofield Bar-racks Family Practice and Tripler Family

Practice. The Infection Control Service hastaken leadership of the partnership, providing

data cards, collecting and aggregating dataand reporting feedback on a monthly basis.Internally the feedback has been appreciated

and used to great advantagethe ObstetricsDepartment adopted hand hygiene as a per-

formance improvement project and achievednearly 100 percent compliance.

In an effort to share what it believes tounique, cost-effective and easily repliimprovement strategy, Tripler has prod

the impressive hand hygiene poster repr

herein. The poster, exhibited at vapatient-safety conferences, won an awardHawaii Patient Safety Conference in M

2008. Triplers hand hygiene partnershunder consideration by the Joint Commifor inclusion as a best practice in an upc

ing monograph on hand hygiene. Elegaits simplicity, Triplers initiative proves

even good practices can be improvedthat our patients can be powerful partne

our efforts to keep them safe.

For more information, please con

Stephen Yamada, Infection ControlEpidemiology, Department of Preve

Medicine, Tripler Army Medical C([email protected]).

TRIPLER ARMY MEDICAL CENTERJOINS HANDS FOR CLEAN HANDS

Patients Enlisted as Partners in Creative Hand Hygiene Pilot Effort

Award-winning Poster from Tripler AMC depicting its innovative partnership with patients to mtor hand-washing in out-patient settings.


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PATIENT SAFETY SUMMER 2008 3

Feedback and Suggestions Based on Your ReportingNEWS FROM THE PATIENT SAFETY CENTER

Healthcare associated or hospital acquired

nfections (HAI) were responsible for 394,129dditional hospital days at a cost of $3.5 bil-ion in 2005 in one statePennsylvania. Mul-

iplied by 50 states, plus the federal healthcareystems such as DoD and the VHA, the annu-

l cost of HAI in the U.S. is measured in manyillions of dollars and millions of excess hos-

pital days. HAI Reduction is not only a U.S.ssue, it is a global challenge.

HAI is also largely a preventable tragedy.

National and international organizationsdedicated to public health (World Health

Organization, Centers for Disease Control),quality improvement (Institute for Health-are Improvement), accreditation (The Joint

Commission), and federal healthcareDepartment of Defense and Veterans

Healthcare Administration) all have initia-ives to reduce HAI. While differing in

mphasis they have a common threadwash your hands between patients.

The DoD Patient Safety Program websitehttp://dodpatientsafety.usuhs.mil/) recently

aunched a section devoted to hand hygiene.The introduction to hand hygiene includes

he following:

The observations of Oliver Wendell Holmes in843 and, Ignaz Semmelweis in 1846 concern-ng the development of puerperal fever

hrough cross contamination by the unwashedhands of healthcare providers provided some

of the earliest evidence as to the importance ofppropriate hand hygiene. Semmelweis was

ble, though the mandatory use of a chlorineolution as an antiseptic hand-wash by physi-ians and students between patient contacts,

o significantly reduce maternal mortalityates. Medical historians believe that the use of

ungloved and unwashed fingers to probe theullet wound of James Garfield, the 20th US

President, after an assassination attempt, andhe resulting infection was a proximate cause

of his death.

Hand hygiene is currently widely acceptedas the single most important interventionfor preventing transmission of pathogens

in healthcare facilities. Although there is a

substantial literature to support this, theadherence by healthcare personnel varieswidely, in part related to setting and

required frequency. The introduction ofwaterless alcohol based antiseptic gels thattake less time than traditional hand-wash-

ing, and in the majority of cases are lesstraumatic to the hands than the repeated

use of soap and water, has helped improvecompliance. However a clear understand-

ing of the use and limitations of theseagents is required as they are not effectiveagainst Clostridium difficile and some

viruses and must be applied appropriately.Most importantly, sustained improvement

in hand hygiene behavior requires a long-term educational program with reinforce-

ment, peer acceptance, and continuedinstitutional commitment.

The Joint Commission has made handhygiene a priority issue in its NationalPatient Safety Goals. Knowledge of andcompliance with the hand hygiene guidelines

are a major component of the recentlyreleased goals for 2009 to implement best

practices to facilitate the prevention of multi-ple drug resistant organisms infections withan emphasis on methicillin-resistant Staphy-lococcus aureus[MRSA] and Clostridium dif-

ficile-associated disease along with best prac-

tices for the prevention of catheter-associatedbloodstream infections.

Goal 7: Reduce the risk of healthcare-associ-ated infections.

Requirement 7A: Comply with current

World Health Organization (WHO) HandHygiene Guidelines or Centers for Disease

Control and Prevention (CDC) handhygiene guidelines.

Rationale for Requirement 7A: Compli-ance with the WHO Hand Hygiene Guide-

lines or CDC hand hygiene guidelines willreduce the transmission of infectious

agents by staff to [patients], therebydecreasing the incidence of healthcareassociated infections.

Another excellent website is that developedby (HCA) Hospital Corporation of America(http://www.hcahealthcare.com/) which has

a section devoted to MRSA. Their material

are publically available and, while targetingMRSA, are widely applicable to all HAI.

Hand hygiene is the essential core compo-nent of all HAI reduction program. Handhygiene is not everybody'sresponsibilityitis your responsibility.

WASH YOUR HANDSIts YOUR Responsibility

Geoffrey Rake, M.D.Director, DoD Patient Safety Center

REVISED CALL FOR PATIENT SAFETYAWARD SUBMISSIONS

Deadline is November 7, 2008

The Office of the Chief Medical Officer

(OCMO) at TRICARE Management Activ-

ity (TMA), sponsor of the Department of

Defense (DoD) Patient Safety Awards, is

calling for submissions for the 2008

Patient Safety Awards. Now in its sixth

year, the Patient Safety Award recognizes

efforts designed to improve the care deliv-

ered within the Military Health System.

Please note that this years time-frame has

changed. The deadline for awards sub-

missions is November 7, 2008. However,

since the awards will be presented at the

annual Military Health System (MHS)

Conference, whose date has yet to be

finalized, the award submission deadline

may be subject to further adjustment

The formal awards Announcement and

Application Guide can be found on the

Patient Safety website: http://dodp

atientsafety.usuhs.mil/patientsafetyawards

. The seven-page Guide includes an

explanation of the award categories, the

application process and requirements,

instructions for the components to be sub-

mitted, and an example scoring guide

and sheet.

Please continue to check the Patient Safe-

ty website for further announcements

regarding Award submission deadline

changes.


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The shipboard terminology ship, ship-

mate, self was based on sailors com-mitment to placing their common

welfare ahead of their own in order to sur-

vive at sea. This mentality was as critical tothose onboard the USS Forestall as it was onUSS Cole. The same commitment is needed

to combat Methicillin-resistant Staphylococ-

cus aureus(MRSA) as well as other commu-

nicable diseases.

According to CDC, nearly 90 million people

in the U.S. carry naturally occurring bacteriastaph on their skin and nose.Over 2 millionof these carriers have MRSA, the mutated

form of staph that is resistant to many antibi-otics. Serious MRSA infections occur inapproximately 94,000 persons each year and

are associated with approximately 19,000deaths. Of these infections, about 86% are

healthcare-associated (HA-MRSA) and 14%are community-associated (CA-MRSA).

Deadly MRSA infections are preven

with personal protective measures. Thwhere you come in! What would you

you saw smoke coming from the

engine room? You would report it! Wwould you do if critical watertight intewas lost? You would secure it! This same

tude taken towards combating diseaseensure your safety as well as that of your

and shipmates.


Experiences and Suggestions From the FieldPATIENT SAFETY IN ACTION

Article from Trident Newspaper Outlines Annapolis Collaborative

SHIPMATES NEEDED TO FIGHT MRSA

Graphic representation of the collaborative effort between the Naval Academy and Naval Health Clinic Annapolis to reduce MRSA rates amonmidshipment by enhancing hand hygiene practices.


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PATIENT SAFETY SUMMER 2008 5

CA-MRSA is found in settings where the fiveCs (crowding, frequent skin-to-skin contact,uts or abrasions, contaminated items and

urfaces, lack of cleanliness) increase the risk

f spread. These settings include schools,military units, and athletic venues. CA-MRSA is most often spread through direct

ontact with contaminated skin, sharedlothing, towels, personal hygiene items orraining equipment. Prolonged person-to-

erson contact and lapses in personalygiene can create ideal conditions for CA-

MRSA transmission.

The following are personal protective meas-res for you and your shipmates in the battlegainst MRSA:

Check your skin routinely. Report unusu-

al cuts or wounds, abscesses, boils, orother pus-filled lesions to medical for an

evaluation.

Keep skin infections covered with a clean

dressing and avoid swimming, whirlpools,& saunas, contact sports, and other close

contact activities. Medical recommenda-tions for activity restrictions should be

taken seriously to prevent potential spreadof the infection.

Thoroughly wash your hands with soapand water a minimum of 5 times per day,

including before meals and after toileting.An alcohol-based hand sanitizer serves as a

great alternative when soap and water isnot readily available.

Take adequate showers daily or more fre-quently as necessary. Shower immediately

following physical activity.

Do not share personal items such as tow-els, wash cloths, razors, bar soap, other toi-

letries, or clothing such as undergarmentsand athletic jerseys with others.

Do not reuse soiled clothes or towels.Launder these items daily with detergent

and hot water.

Disinfect athletic areas and sports equip-ment at least weekly using a commercialdisinfectant (look for EPA-approved, hos-

pital-grade germicide on the productlabel) or a fresh (daily mix) solution of 1part bleach to 100 parts water (1 table-

spoon bleach in 1 quart of water). Bleach

solution must be left on surfaces for atleast 5 minutes to achieve maximum dis-infection.

Wipe surface of sports equipment and ath-letic gear prior to use with a clean dry

towel. Use sanitary wipes if available toclean equipment before use.

Use a towel or clothing as a barrier

between the skin and shared equipment.

Disinfect commonly touched or soiled sur-

faces in your living quarters on a regularbasis using an EPA-registered product effec-

tive against Staph: http://www.epa.gov/.Follow label instructions for use.

Launder clothing, towels, and sheets inwater with laundry detergent at hottest

suitable temperature. Dry in a dryer athottest suitable temperature. Avoid line

drying your clothing.

a. Launder uniforms on a regular basis. If

laundering once weekly, recommendchanging uniform at least mid-week to

ensure cleanliness. Uniforms may needmore frequent laundering/changingdepending on the temperature and activi-

ty. Be a friend and tell your shipmate ifhe/she needs to change his/her uniform!

b. Launder used towels, athletic gear daily.

These easy and practical personal protectivemeasures were put to the test over the courseof plebe summer 2007. In a collaborative

effort between Naval Health Clinic Annapo-lis and Naval Academy leadership, these

measures as well as other education andinfection prevention initiatives were imple-

mented to improve hygiene and control theincidence of CA-MRSA infections amongplebe midshipmen. MRSA prevention edu-

cation sessions were provided to plebes,training cadre, and the medical staff. Hand-

washing was emphasized, and hand sanitizerwas made readily available in the mess hall

and as issue in medical welcome aboardpackages for plebes. In addition, showeringtimes were increased to 35 minutes in

length, weekly antiseptic showers wereencouraged, and weekly environmentacleaning of plebe personal spaces and gea

was recommended. These efforts con

tributed to an 83% drop in the incidence ofMRSA wound infections as well as a 71%reduction in lost physical training time

among Plebes.

These observations support the premise tha

education and enhanced hygiene are reasonable strategies to help control the incidence

of skin infections that are easily spreadthrough close contact with individuals

and/or contaminated objects. Monitoring oMRSA cases and considerations for contin-ued improvement are ongoing at Nava

Health Clinic Annapolis.

Article reprinted with permission oTrident Publications and the United States

Naval Academy, Annapolis, Maryland.

Experiences and Suggestions From the FieldPATIENT SAFETY IN ACTION

SUMMER READING PICKS

The Best Practice Charles Kenny

IHI highly recommends this first ever docu-

mentation of health care's quality move-

ment for anyone interested in understand-

ing today's efforts to transform health care.

Joint Commission Alert: Behaviors That

Undermine A Culture of Safety

This Alert by the Joint Commission

addresses intimidating and disruptive

behaviors among health care profession-

als, describing such actions as a serious

threat to patient safety and the overall

quality of care.

http://www.jointcommission.org/Sen-

tinelEvent/SentinelEventAlert/sea_40.htm.

2009 Patient Safety GoalsAccess the official, approved 2009 Patient

Safety Goals and helpful solutions for

meeting them at http://psnet.ahrq.gov/

resource.aspx?resourceID=8135&sour-

ceID=1&emailD=16003


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The first phase of the 2008 MHS PatientSafety Culture survey concluded on May 182008 with the completion of data collec-

tion. There were 72,478 raw responses sub-

mitted by MHS facility personnel for a rawresponse rate of 58%. Phase 2, data clean-ing and validation, has been completed.

Data cleaning removes invalid surveys fromthe total. Reasons for removal are respon-dents who straight-lined all their responses

or did not answer any of the survey ques-tions. After data cleaning there were 70,837

validated responses for an overall 57%response rate MHS wide. When the survey

was given initially in 2005/2006 the MHSresponse rate was 53%. The graph includedat right shows the number of validated

responses by Services as well as the overallMHS responses. The graph also compares

the 2008 survey results with the results

from the 2005/2006 survey. In the currentsurvey, the Air Force had a 69% response

rate followed by the Navy with 53% and theArmy with a 52% response rate.

The response to this survey was exception-al. Thirty-five facilities came in at over 85%

response rates with twenty-eight of those

over 90%. Only six facilities MHS-widecame in at less than 40% response rates.We anticipate survey analysis to be com-

pleted by August with reporting distributedby mid-September.

The DoD Patient Safety Program staffthanks all of you who took the time to par-

ticipate in the survey and the Service repre-sentatives for their help in ensuring maxi-

mum participation. Special recognition goesto Ms Kristi Yarcho, Air Force survey POC,for the outstanding 69% showing in the Air

Force. We look forward to your impressionson the culture of patient safety in the MHS.

374 MDG, Yokota AFB Shares Patient BoardThe Patient Board pictured above was devel-oped by Capt Brian Smith, NC, USAF to helpimprove hand-offs while including the patientin the process. Located in the patients room,the Patient Board has proven to be a usefulreminder about the current plan of the day toboth the patient and the health care team.Feedback has been positive for this HIPAA-approved tool. Patients appreciate the trans-parency the board has brought to their careplans. They report feeling more a part of theirplanning. Nurses have found that the boardhelps them avoid mistakes that come frommisplacing or losing paper checklists. Formore information, contact Scott Chittenden,Patient Safety Manager at the 374th MDG.([email protected])

TeamSTEPPS Modules On-LineTeamSTEPPS modules for the Fundamentalsand Essentials courses are now available onthe Patient Safety website. This is exciting

news for TeamSTEPPS trainers, who can nowimmediately access all course materials any-where in the world where internet serviceexists. The modules include slides and sup-porting video clips, which play right inside theslide and are accessed with a simple click onthe screen. The screen shot pictured above isfrom the Team Structure module in the Funda-mentals course. It captures a moment on thevideo clip which presents a team failure roleplay scenario. To access TeamSTEPPS modulesgo to http://dodpatientsafety.usuhs.mil/teamsteppsmodules.

Published quarterly by the Department of Defense(DoD) Patient Safety Center to highlight the progress

of the DoD Patient Safety Program.

DoD Patient Safety ProgramOffice of the Assistant Secretary

of Defense (Health Affairs)

TRICARE Management ActivitySkyline 5, Suite 810, 5111 Leesburg Pike

Falls Church, Virginia 22041703-681-0064

PATIENT SAFETYPROGRAM NEWSLETTER

Forward comments and suggestions to:DoD Patient Safety Center

Armed Forces Institute of Pathology1335 East West Highway, Suite 6-100

Silver Spring, Maryland 20910Phone: 301-295-7242

Toll f ree: 1-800-863-3263DSN: 295-7242 Fax: 301-295-7217

E-Mail: [email protected]: http://dodpatientsafety.usuhs.mil

E-Mail to editor: [email protected]

DIVISION DIRECTOR,PATIENT SAFETY PROGRAM

COL Steve Grimes

DIRECTOR, PATIENT SAFETY CENTERGeoffrey Rake, MD

DIRECTOR, CENTER FOR EDUCATIONAND RESEARCH IN PATIENT SAFETY

Eric S. Marks, MD

DIRECTOR, HEALTHCARE TEAMCOORDINATION PROGRAM

Ms. Heidi King

SERVICE REPRESENTATIVESARMY

LTC Anthony BohlinNAVY

Ms. Carmen BirkAIR FORCE

Lt Col Anne Coyne

PATIENT SAFETY PROGRAM NEWSLETTER EDITORPhyllis M. Oetgen, JD, MSW


Patient Safety: All Day, Every Day Across the MHS

PATIENT SAFETY PHOTO ALBUM

MILITARY HEALTHSYSTEM (MHS)Patient Safety Culture Survey Update

80,000

60,000

40,000

20,000

008 Validated Results

Air Force

Army

Navy

MHS

Patient Safety Culture Survey

24,077

26,577

20,183

70,837

22,016

21,689

18,843

62,548

05-06 Validated Results

SEND YOUR PHOTOS TO NEWSLETTER EDITOR at [email protected]

psc newsletter 2008 summer

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