mha 2015 fall regional meetings -...

MHA 2015 Fall Regional MeetingsStrategies to Reduce Harms and Infections

Workgroup and Discussion Time

What is your priority harm/infection opportunity?

Debrief

PDCA

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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STATE LEVEL RAW DATA FOR TOTAL HARM FROM Q4CY2013-Q1CY2015

42%

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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

Trending: HAI

http://bit.ly/1FlLvJr

http://bit.ly/1FlLvJr

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

http://www.cdc.gov/handhygiene/Basics.html

http://www.ihi.org/resources/Pages/Tools/HowtoGuideImprovingHandHygiene.aspx

http://www.jointcommission.org/topics/hai_hand_hygiene.aspx

http://www.who.int/gpsc/country_work/en/

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.

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalRHQDAPU.html

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)


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


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


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


CI


Bundle





Tier 1: Challenges and Barriers

Scheduling meetings and consistent attendance

Time

Skipping key steps

Charter

Communication plan (accountability)

Align within organization

Baseline data


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



CI


Bundle




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


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


CI


Bundle






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


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


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


CI


Bundle





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


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


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.


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


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


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


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


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


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


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


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


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


Wake Health Roadmap

II: Accelerate Treatment

Rapid Treatment Crucial to Reduce Mortality

Impact of Compliance with 6-hour Sepsis Bundle on Hospital Mortality


Drawing the Link from Staff Activities to Mortality


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


Defined Roles Expedite Sepsis Care on the Floor

Initial Sepsis Care Actions and Parties Responsible at Wake Health

For Inpatient Floor Code Sepsis


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


Rapid Response Sepsis Kit Supply List

Minimizing Time Wasted on Gathering SuppliesSepsis kit ensures all necessary supplies are quickly available to RRT


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


Wake Health Roadmap

III: Hardwire Accountability

Driving Bundle Compliance, Real-TimeRapid Responses Sepsis Screening Tool at Wake Health


Tiered Monitoring Efforts Instill Accountability

Stages of the Sepsis Bundle Accountability Strategy at Wake Health


Follow-Up Email Prompts Compliance, FeedbackFollow-up email template for non-compliant physicians


Recognizing Physicians for Bundle Adherence

CMO-signed email reinforces sepsis as organization-wide priority

Thank-you email template for compliant physicians


Wake Health’s Across-the-Board Improvement


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.


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

[email protected]

(573) 893-3700, ext. 1391

mailto:[email protected]

MHA FALL REGIONAL MEETINGS September 24, 2015

Clinical Excellence: Reducing Patient Harm &

Infections

Dennis Manley, RN, HRM, CPHQ

Chief Nursing Officer

Mercy Hospital Joplin

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EF5 Tornado Impact on Mercy Hospital

Direct Hit

Windows and Walls blown out

Portions of roof pulled off

Building infrastructure severely damaged

Generators destroyed

All communication lost

Water, sprinkler, gas and sewer pipes disrupted

Liquid O2 tanks damaged

Massive debris throughout building

74

EF5 Tornado Impact on Mercy Hospital 86 Medical Staff Member’s Offices

destroyed or severely damaged

Medical Office building on property

heavily damaged

Rehab building heavily damaged

– some generator power

Helicopter destroyed

Disaster trailer destroyed

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Take-Aways You do what you practice/drill

Evaluate drills/responses to improve your plan Drill until you fail Add patient slippers/shoes to your weather plan

When under storm watches announce periodically to keep staff informed.

Know your contacts Local EOC-Coalition

Strong community group that plan and drill together State level positions Hospital Association

Store emergency response supplies where you will need to use them

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Take-Aways continuedMake emergency supplies easily portable

Grab bags at locations throughout facilityPaper and pen

Record where patients are evacuatedGloves Flashlights & batteries

Consider marking rooms that have been searched and evacuated

Establish communications as rapidly as possible –especially with other key sites Cell phone # - texting

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Take-Aways continued Respond to disaster situations with name badge

Educate

Security needs increase rapidly

Take care of yourself, your staff and their families Employee Assistant Program (EAP) – debriefing

Consider your staffing needs for Day #1 through?

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Storm Hardening

High Performance Windows

Safety Laminated

Greater than 140 mph rated

Greater than 250 mph rated

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IMG_0440.mov

Storm Hardening

Durable Exterior Skin Precast concrete exterior

No metal panels

No plastered exteriors

Poured concrete roof

No ballast

No metal decking

Hurricane-grade entry doors

Reinforced Penthouse

Designed for high impact/high wind

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Storm Hardening

Protected interiors Hallway safe zones

Heavy-duty storm doors

Reinforced walls

Additional ceiling supports

Ante room and storm doors at hallway ends

Emergency storage next to stairwells

Battery-powered lighting

83

Storm Hardening

Power on Generator partially buried in reinforced concrete structure

All fuel tanks buried – 96 hours of run time

Two independent power feeds from different power stations

All utilities connect to building via underground tunnel

All critical care ventilator and bassinets on uninterrupted

power sources

Function for 2 hours

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Completion Date: March 2015

Dennis Manley, RN, HRM, CPHQ

Chief Nursing Office

Mercy Hospital– Joplin, MO

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


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


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

http://www.ahcmedia.com/blogs/2-hicprevent/post/133720-cdc-looks-to-put-teeth-in-antibiotic-stewardship-policies-by-partnering-with-cms

http://www.ahcmedia.com/blogs/2-hicprevent/post/133720-cdc-looks-to-put-teeth-in-antibiotic-stewardship-policies-by-partnering-with-cms

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

http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

http://www.idsociety.org/Stewardship_Policy/

http://www.leadstewardship.org/resources.php

http://www.apic.org/

http://www.shea-online.org/

http://www.ashp.org/doclibrary/bestpractices/specificstantimicrob.aspx

http://www.sidp.org/

http://rx.osumc.edu/asp2/index.html

http://www.asp.mednet.ucla.edu/pages/

http://www.nebraskamed.com/careers/education-programs/asp

ASP Resources

http://www.ashpadvantage.com/docs/stewardship-white-paper.pdf

http://www.ashpadvantage.com/docs/stewardship-white-paper.pdf

http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf

http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf

http://www.shea-online.org/Portals/0/GNYHA_Antimicrobial_Stewardship_Toolkit_FINALv2 Dec2011.pdf

http://www.shea-online.org/Portals/0/GNYHA_Antimicrobial_Stewardship_Toolkit_FINALv2 Dec2011.pdf

Workgroup and Discussion Time

What is your priority harm/infection opportunity?

Debrief

PDCA

MHA Upcoming Events

Awaiting HEN 2.0 contract award

What’s Up Wednesday?

First Wednesday of the month, 12-1 pm

HEN 2.0 and Immersion Projects Kick-Off

Oct. 15, Columbia

Immersion Project registration by Oct. 31

– Introductory webinars – Sept. 23 and 30

Transparency Initiative Update – Sept. 25 and Nov.10

MHA Convention and Trade Show – Nov. 4-6

Quarterly Quality Webinar – Nov. 18

MHA:SQI - http://web.mhanet.com/strategic-quality/

Leslie Porth, Ph.D., R.N.

Division Vice President of Strategic Quality

Improvement

Triple Aim

Population Health

Oversight of division (Quality Improvement,

Quality Works, Emergency

Preparedness)

MONL

Alison Williams, R.N., BSN, MBA-

HCM

Vice President of Clinical Quality Improvement

Dana Downing, B.S., MBA-H,

CPHQ

Vice President of Quality Program

Development

National quality measures

Quality outcome transparency

Electronic clinical quality measures

MBQIP grant lead

MOAHQ

Jessica Rowden, R.N., BSN, MHA

Clinical Quality Improvement

Manager

Clinical quality SME

Data management and analytics

HEN/AHRQ grant projects

TeamSTEPPS

Host of WUW|LNL

MOAHQ

MONL

Cheryl Eads

Executive Assistant of Quality Improvement

Provides support to the SQI team

Coordinates webinars, conference calls and

meetings

Distributes correspondence and

communication

Assists in maintaining reports

[email protected]/893-3700x1305





Clinical quality SME

Oversight of Quality Improvement

Grant management

Collaborative management

Patient & Family Engagement

MONL

MOAHQ

http://web.mhanet.com/strategic-quality/






mha 2015 fall regional meetings -...

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