Are You Preventing Surgical Site Infections? No Outcome, No Income

Transcription

1 Are You Preventing Surgical Site Infections? No Outcome, No Income Dale Bratzler, DO, MPH Kathy Haig, RN Frances Griffin, RRT, MPA Jennifer Dingman Hayley Burgess, PharmD Charles Denham, MD February 25,

2 NQF Safe Practices for Better Healthcare: A Consensus Report 30 Safe Practices Criteria for Inclusion Specificity Benefit Evidence of Effectiveness Generalization Readiness 2

3 NQF Safe Practices Maintenance Committee Safe Practice 2008 Update Process SWOT analysis of each practice Comprehensive literature search Expert technical advisory support from more than 250 experts Participation by The Joint Commission, CMS, and AHRQ Input from hospitals and facility involved in 5 Million Lives Campaign Feedback from the Field - Hospitals that reported publicly through The Leapfrog Group and TMIT National Research Test Bed 3

4 Harmonization The Quality Choir 4

5 The Patient Our Conductor 5

6 Culture SP NQF Report Culture Consent & Disclosure Consent & Disclosure Workforce Information Management & Continuity of Care Medication Management Healthcare-Assoc. Infections Condition- & Site-Specific Practices 6

7 2007 NQF Report CHAPTER 1: Background Summary, and Set of Safe Practices Structures & Systems Consent & Disclosure Informed Consent Culture Meas., F.B., & Interv. Culture Life-Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback, and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Nursing Workforce Workforce Direct Caregivers ICU Care CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies Pharmacist Central Role Critical Care Info. Discharge System Medication Management High-Alert Meds. CPOE Med. Recon. Order Read-back Std. Med. Labeling & Pkg. Abbreviations Unit-Dose Medications CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Hand Hygiene Healthcare-Associated Infections Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Influenza Asp. + VAP Wrong-site Sx Central V. Cath. BSI Anticoag. Therapy Periop. MI 7 DVT/VTE Sx-Site Inf. Contrast Media Use CHAPTER 7: Healthcare-Associated Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical Site Infection Hand Hygiene Influenza CHAPTER 8: Condition- & Site-Specific Practices Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

8 2007 NQF Report Culture Culture SP 1 CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Structures Culture Meas., Team Training ID Mitigation & Systems F.B., & Interv. & Team Interv. Risk & Hazards Culture Measurement, Feedback, and Interventions CHAPTER 2: Creating and Sustaining a Culture of Teamwork Patient Training and Team Safety Interventions Identification and Mitigation of Risks and Hazards CHAPTER 1: Background Summary, and Set of Safe Practices Leadership Structures & Systems Consent & Disclosure Culture Measurement, Feedback, and Interventions Informed Life-Sustaining Disclosure Consent Treatment Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTERS 2-8 : Practices By Subject Nursing Workforce Workforce Direct Caregivers ICU Care CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies Pharmacist Central Role Critical Care Info. Discharge System Medication Management High-Alert Meds. CPOE Med. Recon. Order Read-back Std. Med. Labeling & Pkg. Abbreviations Unit-Dose Medications CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Hand Hygiene Healthcare-Associated Infections Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Influenza Asp. + VAP Wrong-site Sx Central V. Cath. BSI Anticoag. Therapy Periop. MI 8 DVT/VTE Sx-Site Inf. Contrast Media Use CHAPTER 7: Healthcare-Associated Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical-Site Infection Hand Hygiene Influenza CHAPTER 8: Condition- & Site-Specific Practices Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

9 2007 NQF Report Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices CHAPTERS 2-8 : Practices By Subject Structures & Systems Consent & Disclosure Information Management & Continuity of Care Labeling Studies Pharmacist Central Role Critical Care Info. Culture Meas., F.B., & Interv. Discharge System Medication Management High-Alert Meds. Culture CPOE Med. Recon. Team Training & Team Interv. Order Read-back Std. Med. Labeling & Pkg. ID Mitigation Risk & Hazards ICU Care Abbreviations Unit-Dose Medications CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback, and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Life-Sustaining Informed Consent Consent Treatment Disclosure Life-Sustaining Treatment CHAPTER 3: Informed Consent & Disclosure Disclosure Informed Consent Workforce Life-Sustaining Treatment Nursing Direct Workforce Caregivers Disclosure CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Hand Hygiene Healthcare-Associated Infections Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Influenza Asp. + VAP Wrong-site Sx Central V. Cath. BSI Anticoag. Therapy Periop. MI 9 DVT/VTE Sx-Site Inf. Contrast Media Use CHAPTER 7: Healthcare-Associated Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical-Site Infection Hand Hygiene Influenza CHAPTER 8: Condition- & Site-Specific Practices Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

10 2007 NQF Report Culture Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices Structures & Systems Consent & Disclosure Informed Consent Culture Meas., F.B., & Interv. Life-Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback, and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject CHAPTER 4: Workforce Direct Nursing Workforce Workforce Caregivers Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies Pharmacist Central Role Critical Care Info. Discharge System Medication Management High-Alert Meds. CPOE Med. Recon. Order Read-back Std. Med. Labeling & Pkg. ICU Care Abbreviations Unit-Dose Medications CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Hand Hygiene Healthcare-Associated Infections Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Influenza Asp. + VAP Wrong-site Sx Central V. Cath. BSI Anticoag. Therapy Periop. MI 10 DVT/VTE Sx-Site Inf. Contrast Media Use CHAPTER 7: Healthcare-Associated Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical-Site Infection Hand Hygiene Influenza CHAPTER 8: Condition- & Site-Specific Practices Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

11 2007 NQF Report Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices Structures & Systems Culture Meas., F.B., & Interv. Culture Consent & Disclosure Informed Consent Life-Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback, and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Hand Hygiene Healthcare-Associated Infections Influenza Workforce CHAPTER 4: Workforce Nursing Workforce Direct Caregivers Nursing Direct Workforce Caregivers ICU Care ICU Care CHAPTER 5: Information Management & Continuity of Care Critical Care Information Information Management & Continuity of Care Labeling Studies Critical Order Care Info. Read-back Discharge Systems Labeling Discharge CPOE Abbreviations Studies System Safe Adoption of Integrated Clinical Systems including Medication Management CPOE Med. Recon. Order Read-back Pharmacist High-Alert Std. Med. Unit-Dose Central Role Meds. Labeling & Pkg. Medications Abbreviations Asp. + VAP Central V. Cath. BSI Sx-Site Inf. CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications CHAPTER 7: Healthcare-Associated Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical-Site Infection Hand Hygiene Influenza Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Wrong-site Sx Anticoag. Therapy Periop. MI 11 DVT/VTE Contrast Media Use CHAPTER 8: Condition- & Site-Specific Practices Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

12 2007 NQF Report Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices Structures & Systems Consent & Disclosure Informed Consent Culture Meas., F.B., & Interv. Culture Life-Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback, and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Nursing Workforce Workforce Direct Caregivers ICU Care CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Hand Hygiene Critical Care Info. Influenza Asp. + VAP Central V. Cath. BSI Order Read-back CHAPTER 6: Medication Labeling Discharge Management CPOE Abbreviations Studies System Pharmacist Role Medication Management Medication Reconciliation Med. Recon. High-Alert Medications Pharmacist High-Alert Std. Med. Unit-Dose Central Role Meds. & Pkg. Medications Standardized Medication Labeling & Packaging Unit-Dose Medications Healthcare-Associated Infections Sx-Site Inf. CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications CHAPTER 7: Healthcare-Associated Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical-Site Infection Hand Hygiene Influenza Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Wrong-site Sx Anticoag. Therapy Periop. MI 12 DVT/VTE Contrast Media Use CHAPTER 8: Condition- & Site-Specific Practices Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

13 2007 NQF Report Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices Structures & Systems Culture Consent & Disclosure Informed Consent Culture Meas., F.B., & Interv. Life-Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback, and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Nursing Workforce Workforce Direct Caregivers ICU Care CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies CHAPTER 7: Healthcare-Associated Infections Healthcare-Associated Infections of Aspiration and Ventilator- Associated Pneumonia Asp. + VAP Central Venous Catheter-Related Blood Stream Infection Central Venous Catheter-Related Blood Stream Surgical-Site Infection Influenza Central V. Cath. Sx-Site Inf. Hand Hygiene Hand Hygiene BSI Influenza Condition- & Site-Specific Practices Press. Ulcer Critical Care Info. Evidence- Based Ref. Discharge System Wrong-site Sx Anticoag. Therapy CPOE Periop. MI 13 Order Read-back Abbreviations CHAPTER 7: Healthcare-Associated Infections Medication Management of Aspiration and Med. Recon. Ventilator- Associated Pneumonia, Pharmacist High-Alert Std. Med. Unit-Dose Central Role Meds. Labeling & Pkg. Medications Hand Hygiene Influenza Infection Surgical-Site Infection DVT/VTE Contrast Media Use CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications CHAPTER 8: Condition- & Site-Specific Practices Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

14 2007 NQF Report Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices Structures & Systems Culture Meas., F.B., & Interv. Culture Team Training & Team Interv. Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback, and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Nursing Workforce Workforce Direct Caregivers ICU Care CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies CHAPTER 7: Healthcare-Associated Infections Healthcare-Associated Infections of Aspiration and Ventilator Associated Pneumonia Asp. + VAP Central Venous Catheter-Related Blood Stream Infection Wrong-Site, Wrong-Procedure, Wrong-Person Surgical-Site Infection Influenza Central V. Cath. Sx-Site Inf. Hand Hygiene Hand Hygiene BSI Influenza Press. Ulcer Critical Care Info. Discharge System Wrong-site Sx CPOE Periop. MI 14 Order Read-back Abbreviations CHAPTER 8: Condition- Medication or Management Site-Specific Practices Evidence-Based Referrals Med. Recon. Anticoagulation Pharmacist Therapy High-Alert Std. Med. Unit-Dose Central Role Meds. Labeling & Pkg. Medications DVT/VTE Pressure Ulcer Surgery Perioperative Condition- Myocardial & Site-Specific Infarct/Ischemia Practices Evidence- Anticoag. DVT/VTE Based Ref. Therapy Contrast Media-Induced Renal Failure Contrast Media Use CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications CHAPTER 8: Condition- & Site-Specific Practices Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

15 2007 NQF Report Culture SP 1 CHAPTER 1: Background Summary, and Set of Safe Practices Structures & Systems Consent & Disclosure Informed Consent Culture Meas., F.B., & Interv. Culture Life-Sustaining Treatment Team Training & Team Interv. Disclosure ID Mitigation Risk & Hazards CHAPTER 2: Creating and Sustaining a Culture of Patient Safety Leadership Structures & Systems Culture Measurement, Feedback, and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Consent & Disclosure Informed Consent Life-Sustaining Treatment Disclosure CHAPTERS 2-8 : Practices By Subject Nursing Workforce Workforce Direct Caregivers ICU Care CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care Information Management & Continuity of Care Labeling Studies Pharmacist Central Role Critical Care Info. Discharge System Medication Management High-Alert Meds. CPOE Med. Recon. Order Read-back Std. Med. Labeling & Pkg. Abbreviations Unit-Dose Medications CHAPTER 5: Information Management & Continuity of Care Critical Care Information Order Read-back Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including CPOE Abbreviations CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Role Standardized Medication Labeling & Packaging High-Alert Medications Unit-Dose Medications Hand Hygiene Healthcare-Associated Infections Condition- & Site-Specific Practices Press. Ulcer Evidence- Based Ref. Influenza Asp. + VAP Wrong-site Sx Central V. Cath. BSI Anticoag. Therapy Periop. MI 15 DVT/VTE Sx-Site Inf. Contrast Media Use CHAPTER 7: Healthcare-Associated Infections of Aspiration and Ventilator Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical-Site Infection Hand Hygiene Influenza CHAPTER 8: Condition- & Site-Specific Practices Evidence-Based Referrals Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Perioperative Myocardial Infarct/Ischemia Pressure Ulcer DVT/VTE Anticoagulation Therapy Contrast Media-Induced Renal Failure

16 EXECUTIVE SUMMARY OVERVIEW 2004 Weight 2007 Weight CHAPTER 2: Creating and Sustaining A Culture of Patient Safety Practice Element 1: Leadership Structures and Systems Practice Element 2: Culture Survey Measurement and Feedback Practice Element 3: Teamwork & Team interventions 263 (Prior SP 1)* 300 SME Points Spread Over 30 Practices 3 New & 3 Redefined Practice Element 4: Identification & Mitigation of Risks and Hazards 120 CHAPTER 3: Informed Consent and Disclosure Safe Practice 2: Informed Consent (Prior SP 10) 9 4 Safe Practice 3: Life-Sustaining Treatment (Prior SP 11) 12 Safe Practice 4: Disclosure NA CHAPTER 4: Matching Healthcare Needs With Service Delivery Capacity Safe Practice 5: Nursing Workforce (Prior SP 3) EXECUTIVE SUMMARY OVERVIEW CHAPTER 7: of Healthcare-Associated Infections Safe Practice 19: of Aspiration and VAP (Prior SP 19) 2004 Weight Weight 20 Safe Practice 6: Direct Caregivers NA New 20 Safe Practice 20: CVC BSI (Prior SP 20) Safe Practice 7: ICU Care CHAPTER 5: Facilitating Information Transfer and Clear Communication Safe Practice 8: Critical Care Information ( Prior SP 9) Safe Practice 9: Order Read-Back (Prior SP 6) Safe Practice 10: Labeling Studies (Prior SP 13) Safe Practice 11: Discharge Systems (Prior SP 8) Safe Practice 12: Safe Adoption of CPOE Leap Leap Safe Practice 21: Surgical-Site Infection (Prior SP 21) Safe Practice 22: Hand Hygiene (Prior SP 25) Safe Practice 23: Influenza (Prior SP 26) Chapter 8: Condition- and Site-Specific Practices Safe Practice 24: Evidence-Based Referrals Safe Practice 25: Wrong-Site, Wrong-Procedure, Wrong-Person Surgery (Prior SP 14) Leap Safe Practice 13: Abbreviations (Prior SP 7) CHAPTER 6: Improving Patient Safety Through Medication Management Safe Practice 26: Perioperative Myocardial Infarct/Ischemia (Prior SP 15) Safe Practice 14: Medication Reconciliation Safe Practice 15: Pharmacist Role (Prior SP 5) Safe Practice 16: Standardizing Medication Labeling and Packaging (Prior SP 28) Safe Practice 17: High-Alert Medications (Prior SP 29) Safe Practice 18: Unit-Dose Medications (Prior SP 30) NA New Safe Practice 27: Pressure Ulcer (Prior SP 16) Safe Practice 28: DVT/VTE (Prior SP 17) Safe Practice 29: Anticoagulation Therapy (Prior SP 18) Safe Practice 30: Contrast Media-Induced Renal Failure (Prior SP 2)

17 EXECUTIVE SUMMARY OVERVIEW CHAPTER 2: Creating and Sustaining A Culture of Patient Safety Practice Element 1: Leadership Structures and Systems Practice Element 2: Culture Survey Measurement and Feedback Practice Element 3: Teamwork & Team interventions Practice Element 4: Identification & Mitigation of Risks and Hazards 2004 Weight 263 (Prior SP 1)* 300 SME 2007 Weight What went up or is new? Culture 263 to 300 Disclosure 25 Direct Care Giver - 20 Medication Reconciliation - 35 CHAPTER 3: Informed Consent and Disclosure Safe Practice 2: Informed Consent (Prior SP 10) 9 4 EXECUTIVE SUMMARY OVERVIEW 2004 Weight 2007 Weight Safe Practice 3: Life-Sustaining Treatment (Prior SP 11) 12 4 CHAPTER 7: of Healthcare-Associated Infections Safe Practice 4: Disclosure NA CHAPTER 4: Matching Healthcare Needs With Service Delivery Capacity Safe Practice 5: Nursing Workforce (Prior SP 3) Safe Practice 19: of Aspiration and VAP (Prior SP 19) Safe Practice 20: CVC BSI (Prior SP 20) Safe Practice 6: Direct Caregivers NA New 20 Safe Practice 21: Surgical-Site Infection (Prior SP 21) Safe Practice 7: ICU Care Leap 2 Safe Practice 22: Hand Hygiene (Prior SP 25) CHAPTER 5: Facilitating Information Transfer and Clear Communication Safe Practice 8: Critical Care Information ( Prior SP 9) Safe Practice 23: Influenza (Prior SP 26) Safe Practice 9: Order Read-Back (Prior SP 6) Chapter 8: Condition- and Site-Specific Practices Safe Practice 10: Labeling Studies (Prior SP 13) Safe Practice 24: Evidence-Based Referrals Leap 3 Safe Practice 11: Discharge Systems (Prior SP 8) Safe Practice 12: Safe Adoption of CPOE 17 Leap 1 25 Safe Practice 25: Wrong-Site, Wrong-Procedure, Wrong- Person Surgery (Prior SP 14) Safe Practice 13: Abbreviations (Prior SP 7) CHAPTER 6: Improving Patient Safety Through Medication Management Safe Practice 26: Perioperative Myocardial Infarct/Ischemia (Prior SP 15) Safe Practice 14: Medication Reconciliation NA New 35 Safe Practice 27: Pressure Ulcer (Prior SP 16) Safe Practice 15: Pharmacist Role (Prior SP 5) Safe Practice 16: Standardizing Medication Labeling and Packaging (Prior SP 28) Safe Practice 28: DVT/VTE (Prior SP 17) Safe Practice 29: Anticoagulation Therapy (Prior SP 18) Safe Practice 17: High-Alert Medications (Prior SP 29) Safe Practice 18: Unit-Dose Medications (Prior SP 30) Safe Practice 30: Contrast Media-Induced Renal Failure (Prior SP 22)

18 Overview Hayley Burgess, PharmD, BCPP Director, Performance Improvement TMIT 18

19 New Safe Practice Considerations Methicillin-resistant Staph aureus (MRSA) Urinary Tract Infections (UTI) Handover/Hand-off Second Patient Organ Donorship 19

20 Safe Practice 21 Surgical-Site Infection 20

21 NQF Report 2008 Update CHAPTER 1: Background Summary, and Set of Safe Practices Hand Hygiene Healthcare-Associated Infections Influenza Asp. + VAP Central V. Cath. BSI Sx-Site Inf. CHAPTER 7: Healthcare-Associated Infections of Aspiration and Ventilator- Associated Pneumonia Central Venous Catheter-Related Blood Stream Infection Surgical-Site Infection Hand Hygiene Influenza CHAPTER 7: Healthcare-Associated Infections Alignment and harmonization with SCIP and IHI 5M Lives Campaign Safety Objective 21: To reduce surgical-site infections. Safe Practice 21: Prevent surgical-site infections by implementing four components of care: [1] appropriate use of antibiotics; appropriate hair removal; maintenance of postoperative glucose control for patients undergoing major cardiac surgery; and establishment of postoperative normothermia for patients undergoing colorectal surgery. 21

22 SP 21: Surgical-Site Infection PRACTICE Surgical-Site Infection: Prevent surgicalsite infections by implementing four components of care. ADDITIONAL SPECIFICATIONS CHECKLIST This practice should include all of the following elements: Implement explicit policies and procedures regarding prevention of SSIs, including selection, timing, and discontinuation of antibiotics Give antibiotics within one hour of surgical incision. (Due to the longer infusion time required for vancomycin, it is acceptable to start this antibiotic within 2 hours prior to incision.) Administer postoperative antibiotics only when indicated by the procedure and discontinue their use within 24 hours after surgery, or 48 hours after cardiac surgery. Remove hair only when necessary and then by clipping or depilatory methods not razors. Maintain postoperative glucose control, with initial focus on cardiac/coronary artery bypass graft surgeries. Glucose control is defined as serum glucose levels below 200 mg/dl, collected once on each of the first two postoperative days. Tight glucose control (e.g., using an insulin drip) generally should be performed in an appropriately monitored setting. For patients undergoing colorectal surgery, establish postoperative normothermia (excludes patients for whom therapeutic hypothermia is being used). 22

23 Are you preventing surgical-site infections? No outcome, No income Objectives: Describe the impact of surgical care complications as it relates to postoperative infections for the nation's healthcare patient population. Prepare for pay-for-performance requirements. Discuss tips for meeting core measure compliance for patients undergoing select surgical procedures. Hear how high-performing organizations have successfully sustained surgical care complication prevention programs. 23

24 The Surgical Care Improvement Project Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality

25 Why focus on surgical quality 30 million operations annually Patients who experience a postoperative complication have dramatically increased hospital length of stay, hospital costs, and mortality On average, the length of stay for patients who have a postoperative complication is 3 to 11 days longer Odds of dying within 60 days increases 3.4- fold in patients with a complication* *Silber JH, et al. Changes in prognosis after the first postoperative complication. Med Care. 2005;43:

26 Odds of Death after First Postoperative Complication Within days Major cardiac Stroke DVT GI bleed Respiratory compromise CHF Pneumonia Sepsis Deep wound infection Urinary tract infection Silber JH, et al. Changes in prognosis after the first postoperative complication. Med Care. 2005;43: Odds Ratio

27 Who Pays for Surgical Complications? Hospital Reimbursement Costs of care Profit Profit margin $ $ $ % (uncomplicated) (complicated) Complications were always associated with an increase in costs to healthcare payers: complications were associated with an average increase in payment of $7,645 (54%) per patient. Dimick JB, et al. Who pays for poor surgical quality? Building a business case for quality improvement. J Am Coll Surg. 2006;202:933-7.

28 All of this occurs at a time when Tremendous increase in antimicrobial resistance for a number of organisms Recognition of high death rate from preventable complications Greater medicolegal liability for preventable events 28

29 NQF-Endorsed Safe Practices are a set of voluntary consensus standards that serve as a tool for healthcare providers, purchasers, and consumers to identify and encourage practices that will reduce errors and improve care. 1. Strong evidence base 2. Are generalizable 3. Significant benefit to patient safety 4. Knowledge usable by consumers, purchasers, providers, and researchers

30 Surgical Care Improvement Project Performance measures Process Surgical infection prevention Antibiotics» Administration within one hour before incision» Use of antimicrobial recommended in guideline» Discontinuation within 24 hours of surgery end Glucose control in cardiac surgery patients Proper hair removal Normothermia in colorectal surgery patients NQF Safe Practice #21 of Surgical-Site Infections

31 Clin Infect Dis. 2007; 44:921 7.

32 Discontinuation of Prophylaxis Numerous clinical trials have compared short-term to long-term antimicrobial prophylaxis Many compared single-dose prophylaxis to multiple dose prophylaxis Wide variety of operations using a wide variety of antimicrobial agents Infection rates are the same regardless of duration of prophylaxis Prolonged prophylaxis has been associated with higher rates of infections with resistant organisms (when infection occurs). Prolonged prophylaxis only changes the flora it does not lower infection rates. Prolonged prophylaxis is a patient safety issue.

33 Antibiotic prophylaxis for >24 hours appeared to be of no added benefit (RR, 1.28; 95% CI, 0.82 to 1.98).

34 Patients undergoing vaginal or abdominal hysterectomy should receive single-dose antimicrobial prophylaxis. A recent report noted that as many as one-half of women undergoing hysterectomy receive either inappropriately timed or no antibiotic prophylaxis. Hospital policies can significantly increase the appropriate use of prophylactic preoperative antibiotics.

35 Glucose control reduces the risk of surgical-site infections (data most robust for cardiac surgery). Furnary et al. Ann Thorac Surg 1999:67:352

36 Pre-operative shaving Shaving the surgical site with a razor induces small skin lacerations potential sites for infection disturbs hair follicles which are often colonized with S. aureus Risk greatest when done the night before Patient education be sure patients know that they should not do you a favor and shave before they come to the hospital!

37 Consequences of Hypothermia Perioperative patients Adverse myocardial outcomes 1.5º C core temperature decrease triples the risk of morbid myocardial events Coagulopathy impairs platelet function and coagulation cascade Reduces drug metabolism Thermal discomfort (patient satisfaction) Surgical wound infection thermoregulatory vasoconstriction Sessler DI, Akca O. Clin Infect Dis. 2002;35:

38 Surgical Care Improvement Project Hospital Voluntary Self-Reporting, Qtr. 2, 2007 National Average* Benchmark Percent Antibiotics w/in 1 hour Correct Antibiotic Antibiotic DCed w/in 24 hours Glucose Control (cardiac) No Razor Normothermia Benchmark rates were calculated for all HQA reporting hospitals in the US based on discharges using the Achievable Benchmarks of Care TM methodology (

39 Surgical Care Improvement Project Hospital Voluntary Self-Reporting, Qtr. 2, 2007 National Average* Benchmark Percent Perioperative Beta-blockers Recommended VTE Prophylaxis Timely VTE Prophylaxis Benchmark rates were calculated for all HQA reporting hospitals in the US based on discharges using the Achievable Benchmarks of Care TM methodology (

40 Public Accountability and SCIP

41 Reporting Hospitals (Voluntary) Surgical Care Improvement Project Proposed IPPS rule suggested that hospitals needed to start reporting SIP measures in January to avoid losing 2% of their Medicare annual payment update. Final rule did not require reporting until July # Hospitals Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q2

42 42

43 VBP Program Goals Improve clinical quality Address underuse, overuse, and misuse Encourage patient-centered care Reduce adverse events and improve patient safety

44 VBP Design Assumptions Would build on infrastructure of the Reporting Hospital Quality Data for Annual Payment Update Program (RHQDAPU) the pay-for-reporting program Would not include additional funding 2-5% withhold of base DRG funding for all Medicare patients (not just the core topics) recommended in draft report Replaces the RHQDAPU Program VBP payments based on the quality of care provided not the fact that data were reported. If you don t report data, you can t play!

45 Performance Model Overview 70% of performance score based on process measures 30% of performance score based on HCAHPS (patient satisfaction survey data) CMS currently working to incorporate the 30-day mortality measures, and is designing new measures of complications, hospital readmission, and efficiency

46 Assumes 5% withhold of hospital s base DRG payments. Hospital A would lose $ for every case submitted in DRG 498.

47 More Reports of Success Henry D, et al. J Healthc Qual. 2007;29:50-6. The result of the study was antibiotic prophylactic delivery 60 minutes prior to incision in the abdominal hysterectomy population from a baseline of 10% to greater than 90% from 2003 to McCahill LE, et al. Arch Surg. 2007;142: The clearly defined roles of a cross-disciplinary team and the process improvements discussed in this article can easily be implemented in other institutions. These elements were integral to our success in improving the timely delivery and discontinuation of prophylactic surgical antibiotics. Hedrick TL, et al. Surg Infect. 2007;8: The implementation of a prevention protocol resulted in a substantial trend toward a reduction in the incidence of SSI. These data support the use of protocol implementation as a cost-effective method of reducing perioperative infectious morbidity associated with intra-abdominal surgery.

48 Summary We need to find ways to make evidencebased processes of care routine for patients undergoing surgery Recognize that there is now a national commitment to improving outcomes for surgical patients Public accountability (public reporting and pay-for-performance) is here to stay

49 PATIENT ADVOCATE Jennifer Dingman Founder: PULSE Colorado Division Co-founder: American Division 49

50 SURGICAL SAFETY REDUCTION OF SURGICAL- SITE INFECTIONS Kathy Haig Corporate Patient Safety Officer OSF Healthcare System Peoria, Il. 50

51 Objectives Discuss ideas to reduce surgical adverse events Review process changes to reduce potential of surgical-site infections Present ideas for change to aide in compliance with Joint Commission and CMS SCIP measures 51

52 IHI Surgical Safety Change Package SSI Bundle Select appropriate antibiotic Administer prophylactic antibiotic within 60 minutes of incision Maintain normothermia Increase FiO2 for 1 hour post op in the PACU Eliminate razors 52

53 Additional Process Changes DVT Prophylaxis Protocol Periop Beta Blocker Protocol Preoperative Site Identification Insulin Drip Protocol 53

54 SSI Bundle Normothermia (patient temperature 36 degrees or more on arrival to the PACU) Increased OR room temperature 2-3 degrees Use of warmed blankets Purchased insulated surgical caps Use of warm IV and irrigation fluids Obtained heated mattresses for every OR 54

55 Prophylactic Antibiotic Selection Medical Executive Committee approved a Surgical Prophylaxis Protocol Protocol is used as a default if a prophylaxis antibiotic is not ordered Antibiotics on the protocol: Are based on the procedure type Include dosages Include alternate med/dosages if the patient is allergic to the recommended antibiotic Include re-dosing guidelines for long procedures An increase in SSI cases prompted review found where weight-based dosing was indicated 55

56 Prophylactic Antibiotic Selection Surgical Infection - Prophylactic Antibiotic Selection (all procedures) 100% Goal 95% 80% Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct -06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Goal SIP-2 Anti-B Selection 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% Rate SIP-2 Anti-B Selection (overall) 95% 88% 92% 92% 93% 98% 98% 97% 98% 97% 100% 93% 98% 97% 97% 100% 94% 56

57 Process changes Antibiotic administration within 60 minutes of incision 1 st Test Pre-op holding staff gave prophylactic antibiotic 2 nd Test Pre-op holding staff hung prophylactic antibiotic; circulator started the infusion 3 rd Test Prophylactic antibiotic was provided in syringes 4 th Test Pre-op holding staff gave a test dose of 1cc to test for allergy Anesthesia/circulator completed the infusion in the OR 57

58 Prophylactic Antibiotic Administration Surgical Infection - Prophylactic Antibiotic Received Within 1 Hour Prior To Surgery (all procedures) 100% Goal 95% 80% Jan- 06 Feb- 06 Mar- 06 Apr- 06 May- 06 Jun- 06 Jul- 06 Aug- 06 Sep- 06 Oct- 06 Nov- 06 Dec- 06 Jan- 07 Feb- 07 Mar- 07 Apr- 07 May- 07 Goal SIP-1 Anit-B w /1hr 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% Rate SIP-1 Anti-B w i/1hr (overall) 97% 93% 94% 100% 89% 100% 96% 93% 98% 97% 94% 91% 93% 97% 94% 98% 97% 58

59 Process Changes FiO2 > 80% for 1-2 hours post-op Use of non-rebreather masks in the PACU Hidden benefits Less nausea and vomiting post-op Less need for pain medication Neurosurgeons added this intervention to their standing orders for craniotomy procedures 59

60 Interventions Elimination of razors Tested two different brands for OR staff buy-in Removed razors from OR rooms, then removed from OR ante-rooms and finally removed from OR department Removed razors from nursing units Clippers were supplied to the OR and nursing units for use for all procedures, including special procedure and IV starts 60

61 Process Changes DVT Prophylaxis Protocol Protocol uses a scored risk assessment Includes co-morbidities, age, medications, history Interventions are based on the assessment score Includes early ambulation, SCDs, Lovenox, or Warfarin Protocol is completed on all medical and surgical adult inpatient admissions 61

62 Interventions Beta Blocker Protocol Major Indicators the protocol applies if EITHER is identified. History of Coronary Artery Disease (previous MI, angina, previous positive stress test) Previous/current vascular surgery Minor Indicators the protocol applies if 3 or more are identified. Age greater than or equal to 65 years Hypertension History of stroke Abnormal EKG (atrial fib, ST-T abnormalities, LVH, LBBB) Diabetes 62

63 Beta Blocker Protocol If fewer than 3 minor indicators and no major indicators are identified, Anesthesia will determine the need for a perioperative beta blocker based on the Surgical Risk Index. Pre-Admission Testing staff screen patients. Anesthesia is notified of patients meeting the criteria. Anesthesia evaluates the patient & orders the med. Beta Blocker is either started several days pre-op or given IV prior to the beginning of the procedure. 63

64 Interventions Elimination of Wrong-Site Surgery Universal protocol created for all types of procedures Process based on AORN and Joint Commission recommendations Insulin Drip Protocol CV Surgeons reviewed multiple protocols Six Sigma team revised the protocol Education was provided to ICU staff Efforts started with post-op diabetic Open Heart patients in the ICU setting Effort spread to all ICU/PICU patients based on admission blood sugar results 64

65 FMEA of the Pre-Admission Process Pre-op Process Pre-op Order Sheet was developed One call scheduling for physician satisfaction Nurse interviews the patient 3-7 days pre-op Registration information obtained Criteria developed for anesthesia evaluation The patient is cleared or referred for further evaluation If further evaluation is required, the surgeon is notified 65

66 Space Constraints Impacts PAT Identified space constraints in the current location Construction of Surgical Staging Unit All patients are prepared for any type of surgery in the Surgical Staging Unit Outpatients return for recovery and discharge Inpatients are admitted to the Surgical Unit 66

67 Culture Team Resource Management Training Started with OR staff in April 2004 Surgical Briefings on Patients Briefing passport starts at the time the procedure is scheduled Pertinent information is added throughout the preadmission process Final time-out is conducted immediately prior to the incision Trigger was added to the OR Nurse s Notes for documentation of briefings and time-outs. 67

68 Measurement Outcome measures Reduction of SSI Reduction of Perioperative Harm Process measures Compliance with interventions in the change packet Measurement population included all patients having selected high-volume procedures CABG Vaginal and Abdominal Hysterectomies Total Joint Replacements Neurosurgical procedures Data collected and reported monthly to Quality Council Data shown in statistical process control charts 68

69 Perioperative Harm Trigger Tool Trigger Present Adverse Event Harm Category* Description of Adverse Event Y or N Y or N T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 T13 T14 T15 T16 T17 T18 T19 T20 T21 T22 T23 Unplanned return to surgery Unexpected change in procedure Unplanned ICU admission Intubation or reintubation in PACU Unplanned x-ray Transfusion of RBCs or blood first intra-op or first 24 hours post Overnight stay of ambulatory patient Cardiac/pulmonary arrest Death intra-op or post-op Mech vent > 24 hours Intra-op meds Pos blood culture DVT / PE Increased troponin Readmission within 30 days Change of anesthesia Consult in PACU Complication Path report normal or unrelated to dx Insertion central or a-line mid-procedure or in PACU Intra-op time > 6 hours Unplanned organ removal, injury, repair Other 69

70 Analysis Conducted small tests of change Process revised based on analysis of data Process retested High Reliability Preoccupation with Failure Each variance is evaluated 70

71 Barriers Slow staff buy-in initially Physician buy-in slow acceptance of evidence-based practice; questioned literature sources We already do this attitude with briefings Reluctance to eliminate razors Lack of consistent process for ordering & administering prophylactic antibiotics Logistics of Pre-admission area 71

72 Keys to Success Administrative approval for involvement in IHI Collaborative Administrative support: Team employee resources Team education expenses IHI Learning Sessions TRM training Warmers for each bed in the OR Creation of Surgical Staging Area as recommended in the FMEA TRM training incorporated in the strategic plan and hospital team award Medical Executive Committee Approved Protocols as defaults 72

73 73

74 Survey Focus: Awareness Accountability Ability Action 74

75 PATIENT ADVOCATE Jennifer Dingman Founder: PULSE Colorado Division Co-founder: American Division 75

76 Practical Tips for Improvement to SSI Processes Fran Griffin, RRT, MPA Director Institute for Healthcare Improvement 76

77 Healthcare processes Current - Variable, lots of autonomy not owned, poor if any feedback for improvement, constantly altered by individual changes, performance stable at low levels Desired variation based on clinical criteria, no individual autonomy to change the process, process owned from start to finish, can learn from defects before harm occurs, constantly improved by collective wisdom - variation Terry Borman, MD, Mayo Health System

78 Plan for Human Factors Reliance on memory Distractions/interruptions Fatigue Sleep deprivation Shift work Lack of training and experience Overload Psychosocial factors 78

79 Examples of Strategies TOPIC RELIABILITY CONCEPT STRATEGY Pre-op dose Pre-op dose Standardization, decreased reliance on memory Taking advantage of habits & patterns (human factors) Protocol for pharmacy autodispensing abx based on surgical type & patient criteria Dose of antibiotic started at door to OR Discontinuation Hair removal Opt out rather than opt in, standardization Forcing function Abx auto discontinued Removal all razors from the hospital 79

80 Strategies Protocols for antibiotic selection, dosing and discontinuation based on surgical type and patient-specific criteria of hypothermia for all surgical patients Pre-procedural briefing in OR to verify all SSI prevention measures 80

81 Protocols, protocols, protocols Design protocols based on surgery type Initiate protocol as a standard Nursing and/or pharmacy drives protocol No reliance on individual physician memory Include guidance for exceptions Beta Lactam allergy Use your own formulary to narrow choices Makes protocol easier and saves costs 81

82 Appropriate Antibiotics: Timing of the first dose Identify owners clearly: who starts it and who documents it Set a narrower performance margin If goal is 0-60, strive for A few strays will still be within the goal Take advantage of habits and patterns Dose of antibiotic started when staff hit button to open door to OR easy to remember 82

83 Appropriate Antibiotics: Timing of the first dose Verify prior to incision time Final check at pre-procedural briefing or timeout Write the dose time on a white board in OR Reliable procedures take coordination between preoperative nursing and anesthesia services. 83

84 Appropriate Antibiotics: Discontinuation of antibiotics Opt-out vs. Opt-in Discontinuation of antibiotics automatic If doses required, times set by nursing or pharmacy to end within 24 hours Allow options for appropriate clinical exceptions UTI, fever, etc Review all cases with opt-out 84

85 Q & A 85