mha 2015 fall regional meetings

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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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

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

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]

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


Hospital Acquired Pressure Ulcers (Stage 2) by UnitJuly 2014-June 2015

0

2

4

6

8

MS1 3

ICU 7

PCU 5

OR 8


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


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.


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.


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.


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.


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.


Waffle cushionStatic air is an inexpensive and effective way to redistribute pressure in the chair or bed.


Wedges• Offload sacrum• Maintain 30 degree

lateral position


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


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

1

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”



– 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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Falls/mo Falls with Harm/year C-Diff/10K pt days CAUTI/Year CLABSI/year

Freq

uen

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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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mha 2015 fall regional meetings

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