HOSPITAL-ACQUIRED PRESSURE ULCERS

Page 1263 EP 32 EO: Describe and demonstrate that nursing-sensitive indicator data aggregated at the organizational or unit level outperform the mean, median or other benchmark statistic provided by the national database used. Provide analysis and evaluation of data related to patient falls, nosocomial pressure ulcer prevalence and/or incidence, and two of the following: Blood stream infections Urinary tract infections Ventilator-associated pneumonia Restraint use Pediatric IV infiltrations Other specialty-specific nationally bench-marked indicators (MGH) collects and submits data to NDNQI for patient falls and nosocomial pressure ulcers for all units discussed in OOD 23. The additional two nurse sensitive indicators chosen for display in EP32EO are central line blood stream infections (CLABSI) and restraint use. CLABSI data are reported through the CDC National Healthcare Safety Network (NHSN) system and restraints are reported to NDNQI. As stated in OOD 23, MGH monitoring is an important component of achieving Excellence Every Day. To communicate the importance of nursing-sensitive indicators to the nursing staff, the Senior Vice President for Patient Care and Chief Nurse (CNO) wrote an article in the April edition of the PCS Caring Headlines newsletter. In this edition, the CNO tells her nursing colleagues: But to derive the most benefit from this data, we need to share it with clinicians at the unit level. We need to engage in conversations about what this data means and how we can craft improvements based on what it s telling us. We need to close that information loop. (Attachment EP 32EO.a). The role of the Patient Care Services (PCS) Office for Quality and Safety (OQS) in the dissemination and improvement process is described in EP 32. The outcomes for the nursing-sensitive indicator improvement are presented in the following sections. Data Overview The narratives included in this section for the four measures will describe and demonstrate the PCS data collection methods, analysis and evaluation of the past two years (eight consecutive quarters), and examples of best practices and strategies utilized to achieve the outcomes. The following sections provide detailed analysis of the four nursing-sensitive indicators selected for display. The information will describe and demonstrate how MGH utilizes data to inform nursing leadership and staff to drive quality improvement efforts. For each indicator, achievement of the goal is measured by whether more than 50% of units exceed the NDNQI mean greater than 50% of the time. In addition to analyzing these data at the unit and organizational level, an analysis by unit-type is included to describe unit-type specific successes and challenges. HOSPITAL-ACQUIRED PRESSURE ULCERS Benchmarking The MGH Patient Care Services has continually monitored hospital-acquired pressure ulcers and performance improvement activities. MGH Patient Care Services has elected to benchmark pressure ulcer prevalence rate against the NDNQI mean for participating hospitals with bed capacity of 500 or greater. Data have been submitted quarterly to NDNQI for 34 adult, pediatric and neonatal

Page 1264 inpatient units and as of January, a total of 35 units with the opening of a new ICU, Surgical ICU (Blake 12). Quarterly reports present these data for the 35 units by the following unit types: Critical Care - Adult Critical Care - Pediatric Level III Neonatal (Neonatal ICU (Blake 10)Unit) Medical - Adult Medical Surgical Combined Adult Medical Surgical Combined - Pediatric Surgical - Adult The quarterly reports are organized by unit level type and compare the outcomes for each unit type to the NDNQI mean. Evaluation and Analysis of Data July through June An evaluation of data for this two-year period indicates that performance overall is favorable to benchmark. Greater than 50% of the units outperform the comparative NDNQI benchmark greater than 50% of the time. Nineteen out of thirty-five units outperformed the mean for five or more quarters equaling 54.29% (see graphs below). MGH also analyzed performance based on the actual number of units outperforming the benchmark per quarter. This additional analysis demonstrates MGH outperformed the NDNQI mean for seven out of eight quarters. (Attachment EP 32EO.w). A summary of performance to benchmark by unit type is as follows: Critical Care Adult Pressure ulcer prevalence in three adult units, Cardiac Surgical ICU (Blake 8), Surgical ICU (Ellison 4) and Surgical ICU (Blake 12), underperformed the NDNQI mean and the remaining ICUs, the Cardiac ICU (Ellison 9), Neuroscience ICU (Lunder 6 formerly Blake 12) and the Medical ICU (Blake 7), outperformed the NDNQI mean. The three units underperforming the NDNQI mean mentioned above have continued to experience a higher percentage of pressure ulcers believed to be, in part, a result of the high-risk patient populations they serve (heart transplants, lung transplants and multi-trauma patients), corresponding mobility and repositioning limitations required by current treatment plans, as well as lengthy operating room procedure times. We continue to explore opportunities for improvement in these units including the use of Dolphin Mats (discussed later in this narrative) to increase repositioning for these high risk, complex patient populations. As a result of the interventions described below, we have experienced a decrease in pressure ulcer prevalence (positive trend) in the Cardiac ICU (Ellison 9) as well as with a zero pressure ulcer prevalence trend in the Neuroscience ICU (Lunder 6). Critical Care Pediatric The PICU (Bigelow 6) experienced pressure ulcer prevalence for five out of eight quarters. The NDNQI mean for this time period ranged between 2.17% to 4.86% demonstrating the MGH PICU (Bigelow 6) significantly outperformed the benchmark. Level III Neonatal ICU The Neonatal ICU (Blake 10) has experienced pressure ulcer prevalence for eight consecutive quarters.

Page 1265 The NDNQI mean for this time period ranged between 0.80% to 2.61% demonstrating the MGH Neonatal ICU (Blake 10) significantly outperformed the benchmark. Medical Adult Overall the results have demonstrated a positive trend (decreasing pressure ulcer prevalence) from a high of 5.66% to 1.95% over a six-quarter period with exception of the most recent quarter. The most recent quarter results demonstrate the need for additional improvement, as well as the need to sustain positive outcomes achieved, as result of the initiatives described below. Medical Surgical Adult Combined Both medical surgical adult combined units, Neuroscience (Lunder 8 formerly Ellison 12) and Neuroscience (Lunder 7 formerly White 12) combined, outperformed the benchmark for five out of the eight quarters. Neuroscience (Lunder 7 formerly White 12) has experienced a significant reduction in pressure ulcer prevalence and had sustained these positive outcomes for four consecutive months at (April - March ). These two units continue to share best practices to make further improvements. Medical Surgical Combined - Pediatric The medical surgical pediatric combined units have experienced pressure ulcer prevalence for eight consecutive quarters. The NDNQI mean for this time period ranged between 0.25% to 0.85% demonstrating the MGH medical surgical combined pediatric units significantly outperformed the benchmark. Surgical - Adult The surgical adult units combined have continued to decrease pressure ulcer prevalence and outperformed the benchmark for six out of eight quarters. These units have demonstrated a consistent positive trend, decreasing from pressure ulcer prevalence high of 4.69% to a low of 0.38%. The data displayed for July through September were not submitted to NDNQI within the appropriate timeframe and therefore MGH data are not included in the July through September NDNQI benchmark. The data is an internal calculation and is measured against the July through September NDNQI mean. The NDNQI benchmark for April through June was not available at the time of the MGH Magnet document submission. The metric used for analysis and benchmarking of the 8 th quarter (April -June ) is the 7 th quarter (January through March ). NDNQI mean. An updated version of the graphs will be sent to the ANCC Magnet Coordinator for MGH once the comparative benchmark for the eighth quarter is available mid to late October. The finalized data and graphs will be forwarded to the respective Magnet Appraisers by ANCC. Performance Improvement Initiatives Save Our SKIN (S.O.S) Initiative In the fall of, the Department of Patient Care Services held its annual strategic planning retreat. The first strategic goal, to improve patient care, sponsored a number of tactics including a goal for reduction in hospital-acquired pressure ulcers (HAPU). The objectives were twofold:

Page 1266 Create an evidence-based standardized approach to the prevention of HAPUs Evaluate the efficacy of specialty bed use The Clinical Nurse Specialist Wound Care Task Force standardized the actual/at risk alteration in skin problem list, outcomes, and interventions founded on the elements making up the Braden Scale for Predicting Pressure Sore Risk Assessment (Attachment EP 32EO.b). The task force also developed a standardized tool, Measurement Monday for clinical staff to use to systematically and consistently measure and describe wounds, including pressure ulcers (Attachment EP 32EO.c). In November, an Interdisciplinary Pressure Ulcer Strategic Initiative Task Force was established to evaluate factors contributing to the rise in pressure ulcer prevalence, examine best practice initiatives across the United States, and conduct a gap analysis to identify strategies to prevent HAPUs (Attachment EP 32EO.d). Following consultation with the former Chief Nurse from St. Vincent s Hospital in Jacksonville, FL and the Director of Clinical Excellence for Ascension Health, the task force adopted the SKIN Bundle from Ascension Health to frame the pressure ulcer prevention initiative. Additionally, the Save Our SKIN (S.O.S.) was adopted from the Minnesota Hospital Association as the theme for the program, including promotional materials featuring a life preserver emblazoned with SKIN Saver. The SKIN Bundle includes four essential components: S Skin assessment/risk assessment, surface type K - Keep moving/turning every one to two hours/no sitting longer than two hours, relieve pressure every 15 minutes while sitting I Incontinence care/toileting every one to two hours N - Nutrition assessed, assist or feed patients meals and nutritional supplements. The S.O.S. Campaign built on previous mechanisms for education, including: Mandatory training during orientation and annually regarding pressure ulcers and staging through the NDNQI pressure ulcer training modules Several HealthStream programs on Braden Scale Measurements, Braden Q Scale, and Pressure Ulcer Prevention programs. An educational program, Save Our SKIN A Strategic Initiative to Prevent Hospital Acquired Pressure Ulcers was instituted that focused specifically on the S.O.S Toolbox components. The program includes a questionnaire on unit implementation of the Skin Bundle (Attachment EP 32EO.e). In May of, the Save Our Skin Program was presented at Nursing Grand Rounds. A campaign to educate and engage staff participation in the initiative was launched. Program components included: S.O.S. posters for units Magnets for the doorframes of patient s rooms to indicate which patient was assessed to be at very high risk of pressure ulcer formation A plan for unit-based huddles and review form to occur whenever a new pressure ulcer is detected and weekly thereafter to ensure that the wound healing is progressing and treatment is appropriate An audit form for documentation of pressure ulcer assessment and staging A skin integrity problem list Measurement Monday sticker placed in the nursing progress notes.

Page 1267 Also in spring of, the task force began development of a patient/family educational resource on preventing pressures ulcers. The brochure defines a pressure ulcer, how to perform a skin inspection as well as techniques for pressure ulcer prevention (Attachment EP 32EO.f). To ensure appropriateness for the patient population, plain language, as well as sensitivity to the cultural values and beliefs of diverse communities, and literacy level was considered. The brochure was sent to the Maxwell & Eleanor Blum Patient and Family Learning Center in September of for review, edit, and approval. Patient Care Services developed a pressure ulcer prevention page as part of the Excellence Every Day portal page (Attachment EP 32EO.g) to update clinical staff and to utilize as a resource for the following: Improvement initiatives, Components of the S.O.S toolkit Policies, procedures and guidelines Hospital-acquired pressure ulcer prevalence data Wound care product formulary Resources and offerings Documentation tools Caring Headlines published additional articles to support the comprehensive work on HAPU prevention, including: What are pressure ulcers and how do you prevent them? (Attachment EP 32EO.h) Are you on board with the Save Our SKIN campaign? (Attachment EP 32EO.i) Staying on board the SOS Campaign (Attachment EP 32EO.j). There are several different mechanisms in place internally and externally to evaluate the effectiveness of the S.O.S. program and response to pressure ulcer prevalence. Following all prevalence studies, the nursing department completes an evaluation on all patients who experienced a stage II, III, IV, unstageable or deep tissue injury (DTI) Monitoring and documentation of pressure ulcer assessment is completed on all patients who have been identified with a healthcare-acquired pressure ulcer noted during the quarterly prevalence study (Attachment EP 32EO.k) When a patient develops a newly-detected pressure ulcer a system is in place to perform a unit-based interdisciplinary huddle (Attachment EP 32EO.l), which includes reviewing the current treatment plan and discussing what factors may have placed the patient at greater risk for acquiring a pressure ulcer. Immediately following the huddle, patients with newlydetected hospital-acquired pressure ulcers, stage II or greater, are reported through the Safety Reporting System (RL Solutions ) and monitored by the Patient Care Services OQS. For many years, panels of experts have convened to review the pressure ulcer prevalence rates and examine opportunities to reduce HAPU by upgrading the technology in hospital beds and the implementation of specialty devices. Currently, the MGH uses KCI Atmos Air 9000 pressurerelieving mattresses on all standard acute care beds and Hill Rom SPO2RT beds in the critical care settings. Given the complexity of MGH patients, nurses and physicians need to have the option of ordering high tech beds and a system needed to be put in place. The system developed empowers the Staff Nurse who recognizes the unique needs of his or her patient to consult the Clinical Nurse

Page 1268 Specialist. Together the Nurse and the Clinical Nurse Specialist review the patient record. Both assess the patient and review possible recommendations including the ordering of the Clinitron Rite Hite air fluidized rental bed for patients with actual or high risk for pressure ulcer formation. The process not only assists in controlling costs, but allows for the Clinical Nurse Specialist to mentor the Staff Nurse in the care of this complex patient population. Other devices available include: Clinitron air fluidized Rite Hite bed Gaymar cushions RoHo cushions Prevalon boots Padded O2 tubing CPAP/BIPAP collars 300 Wound surface Staff Nurses are often challenged in the care of patients at highest risk for pressure ulcers including those who cannot turn due to treatment plans, have infection, septicemia, impaired oxygenation, impaired perfusion, or impaired mobility. A recent best practices publication by the Advisory Board highlighted a novel technology, the Dolphin Mat, which was developed by Biologics Inc. in collaboration with the United States Navy in order to prevent pressure ulcers during air transport of dolphins to war zones, where they are very effective at detecting weapons in bodies of water. The technology which is based on fluid immersion technology did successfully prevent pressure ulcers in dolphins. However, although the current research base related to the Dolphin Mat is in its early stages, research on immobile healthy subjects has demonstrated that it can effectively preserve skin perfusion. Recognizing the potential to benefit our patients, the CNS Wound Care Task Force, Associate Chief Nurses and Chief Nurse advocated for funding of $116,000 to purchase seven Dolphin Mats. The request was approved during the FY capital budget process (TL 2). In these challenging financial times the commitment of the CNO and her advocacy to secure these funds benefit not only MGH patients but serve as a role model to Staff Nurses at MGH to always put the patient and their needs first. On June 20,, MGH nurses began trialing the Dolphin Mat during OR procedures. The first patient underwent an 8 hour abdominal surgery with heated intra-peritoneal chemotherapy. The patient shifted to a Dolphin Mattress on a Stryker frame for the 3-day stay in the Surgical ICU (Ellison 4) (one of the three critical care units below the NDNQI mean) with skin in pristine condition at discharge to the floor. The cardiac and thoracic surgery perioperative teams have also begun trialing the Dolphin Mats for extended procedures including lung transplant patients. Work will continue to expand use of the Dolphin Mats in both the perioperative and inpatient settings and evaluate its impact on pressure ulcer prevalence outcomes.

Page 1269 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Hospital Acquired Pressure Ulcers Medical-Adult General Medicine (White 11) General Medicine (White 11) 4.55% 5.00% NDNQI Medical-Adult Mean 3.11% 3.07% 3.28% 2.81% 2.93% 2.76% 2.64% 2.64% 25.00% General Medicine (White 11) vs. NDNQI Medical-Adult Mean 2 15.00% 1 5.00% General Medicine (White 11) NDNQI Medical-Adult Mean General Medicine (White 9) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Medicine (White 9) 4.17% 5.26% 5.26% NDNQI Medical-Adult Mean 3.11% 3.07% 3.28% 2.81% 2.93% 2.76% 2.64% 2.64% 25.00% General Medicine (White 9) vs. NDNQI Medical-Adult Mean 2 15.00% 1 5.00% General Medicine (White 9) NDNQI Medical-Adult Mean

Page 1270 with Hospital Acquired Pressure Ulcers Medical-Adult Cardiac Medicine (Ellison 10) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Cardiac Medicine (Ellison 10) 3.33% 3.33% 3.23% 3.23% NDNQI Medical-Adult Mean 3.11% 3.07% 3.28% 2.81% 2.93% 2.76% 2.64% 2.64% 25.00% Cardiac Medicine (Ellison 10) vs. NDNQI Medical-Adult Mean 2 15.00% 1 5.00% Cardiac Medicine (Ellison 10) NDNQI Medical-Adult Mean Cardiac Intervention (Ellison 11) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Cardiac Intervention (Ellison 11) 15.38% 11.11% 3.23% NDNQI Medical-Adult Mean 3.11% 3.07% 3.28% 2.81% 2.93% 2.76% 2.64% 2.64% 25.00% Cardiac Intervention (Ellison 11) vs. NDNQI Medical-Adult Mean 2 15.00% 1 5.00% Cardiac Intervention (Ellison 11) NDNQI Medical-Adult Mean

Page 1271 with Hospital Acquired Pressure Ulcers Medical-Adult General Medicine (Ellison 16) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Medicine (Ellison 16) 2.86% 6.45% 3.13% 4.00% 6.90% 6.25% NDNQI Medical-Adult Mean 3.11% 3.07% 3.28% 2.81% 2.93% 2.76% 2.64% 2.64% 25.00% General Medicine (Ellison 16) vs. NDNQI Medical-Adult Mean 2 15.00% 1 5.00% General Medicine (Ellison 16) NDNQI Medical-Adult Mean General Medicine (Phillips 20) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Medicine (Phillips 20) 12.50% 7.14% 5.26% 10.53% NDNQI Medical-Adult Mean 3.11% 3.07% 3.28% 2.81% 2.93% 2.76% 2.64% 2.64% 25.00% General Medicine (Phillips 20) vs. NDNQI Medical-Adult Mean 2 15.00% 1 5.00% General Medicine (Phillips 20) NDNQI Medical-Adult Mean

Page 1272 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Hospital Acquired Pressure Ulcers Medical-Adult General Medicine (White 8) General Medicine (White 8) 9.52% 4.00% 8.33% 10.53% 8.33% NDNQI Medical-Adult Mean 3.11% 3.07% 3.28% 2.81% 2.93% 2.76% 2.64% 2.64% 25.00% General Medicine (White 8) vs. NDNQI Medical-Adult Mean 2 15.00% 1 5.00% General Medicine (White 8) NDNQI Medical-Adult Mean General Medicine (White 10) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Medicine (White 10) 5.26% 5.56% 5.56% 11.11% 5.00% NDNQI Medical-Adult Mean 3.11% 3.07% 3.28% 2.81% 2.93% 2.76% 2.64% 2.64% 25.00% 2 15.00% 1 5.00% General Medicine (White 10) vs. NDNQI Medical-Adult Mean General Medicine (White 10) NDNQI Medical-Adult Mean

Page 1273 with Hospital Acquired Pressure Ulcers Medical-Adult General Medicine (Bigelow 11) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Medicine (Bigelow 11) 4.35% 9.09% 4.17% NDNQI Medical-Adult Mean 3.11% 3.07% 3.28% 2.81% 2.93% 2.76% 2.64% 2.64% 25.00% General Medicine (Bigelow 11) vs. NDNQI Medical-Adult Mean 2 15.00% 1 5.00% General Medicine (Bigelow 11) NDNQI Medical-Adult Mean Respiratory Acute Care & Medicine (Bigelow 9) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Respiratory Acute Care & Medicine (Bigelow 9) 11.11% 22.22% 22.22% 16.67% 5.88% 6.67% 11.76% 5.56% NDNQI Medical-Adult Mean 3.11% 3.07% 3.28% 2.81% 2.93% 2.76% 2.64% 2.64% 5 4 3 2 1 Respiratory Acute Care & Medicine (Bigelow 9) vs. NDNQI Medical-Adult Mean Respiratory Acute Care & Medicine (Bigelow 9) NDNQI Medical-Adult Mean

Page 1274 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Hem/Onc/BMT (Lunder 10 - formerly Ellison 14) with Hospital Acquired Pressure Ulcers Medical-Adult Hem/Onc/BMT (Lunder 10 - formerly Ellison 14) 4.55% 3.85% 3.13% NDNQI Medical-Adult Mean 3.11% 3.07% 3.28% 2.81% 2.93% 2.76% 2.64% 2.64% 25.00% 2 15.00% 1 5.00% Hem/Onc/BMT (Lunder 10 - formerly Ellison 14) vs. NDNQI Medical-Adult Mean Hem/Onc/BMT (Lunder 10 - formerly Ellison 14) NDNQI Medical-Adult Mean Lunder 9 (formerly Phillips House 21) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Lunder 9 (formerly Phillips House 21) 5.00% 5.26% 6.25% 3.57% 3.85% 11.11% NDNQI Medical-Adult Mean 3.11% 3.07% 3.28% 2.81% 2.93% 2.76% 2.64% 2.64% 25.00% Lunder 9 (formerly Phillips House 21) vs. NDNQI Medical-Adult Mean 2 15.00% 1 5.00% Lunder 9 (formerly Phillips House 21) NDNQI Medical-Adult Mean

Page 1275 with Hospital Acquired Pressure Ulcers Surgical-Adult Plastic/Burn ICU (Bigelow 13) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Surgical-Adult 4.55% 4.76% NDNQI Surgical-Adult Mean 2.38% 2.64% 2.43% 2.54% 2.00% 2.49% 2.18% 2.18% 16.00% Plastic/Burn ICU (Bigelow 13) vs. NDNQI Surgical-Adult Mean 12.00% 8.00% 4.00% Plastic/Burn ICU (Bigelow 13) NDNQI Surgical-Adult Mean Vascular (Bigelow 14) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Vascular (Bigelow 14) 4.00% 16.67% 8.00% 3.85% 4.17% 4.17% NDNQI Surgical-Adult Mean 2.38% 2.64% 2.43% 2.54% 2.00% 2.49% 2.18% 2.18% 2 Vascular (Bigelow 14) vs. NDNQI Surgical-Adult Mean 16.00% 12.00% 8.00% 4.00% Vascular (Bigelow 14) NDNQI Surgical-Adult Mean

Page 1276 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Hospital Acquired Pressure Ulcers Surgical-Adult Orthopaedics (Ellison 6) Surgical-Adult NDNQI Surgical-Adult Mean 2.38% 2.64% 2.43% 2.54% 2.00% 2.49% 2.18% 2.18% 16.00% Orthopaedics (Ellison 6) vs. NDNQI Surgical-Adult Mean 12.00% 8.00% 4.00% Orthopaedics (Ellison 6) NDNQI Surgical-Adult Mean Gyn./Oncology (Phillips House 21 - formerly Bigelow 7) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Gyn./Oncology (Phillips House 21 - formerly Bigelow 7) 10.53% NDNQI Surgical-Adult Mean 2.38% 2.64% 2.43% 2.54% 2.00% 2.49% 2.18% 2.18% 16.00% Gyn./Oncology (Phillips House 21 - formerly Bigelow 7) vs. NDNQI Surgical-Adult Mean 12.00% 8.00% 4.00% Gyn./Oncology (Phillips House 21 - formerly Bigelow 7) NDNQI Surgical-Adult Mean

Page 1277 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Hospital Acquired Pressure Ulcers Surgical-Adult General Surgery (Ellison 7) General Surgery (Ellison 7) 4.00% 7.41% 3.23% 4.55% 2.94% 6.67% NDNQI Surgical-Adult Mean 2.38% 2.64% 2.43% 2.54% 2.00% 2.49% 2.18% 2.18% 16.00% 12.00% 8.00% 4.00% General Surgery (Ellison 7) vs. NDNQI Surgical-Adult Mean General Surgery (Ellison 7) NDNQI Surgical-Adult Mean Cardiac Surgery (Ellison 8) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Cardiac Surgery (Ellison 8) 4.55% 12.50% 3.70% 3.85% 4.00% NDNQI Surgical-Adult Mean 2.38% 2.64% 2.43% 2.54% 2.00% 2.49% 2.18% 2.18% 16.00% Cardiac Surgery (Ellison 8) vs. NDNQI Surgical-Adult Mean 12.00% 8.00% 4.00% Cardiac Surgery (Ellison 8) NDNQI Surgical-Adult Mean

Page 1278 with Hospital Acquired Pressure Ulcers Surgical-Adult General Surgery (Phillips 22) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Surgery (Phillips 22) 7.69% 5.56% NDNQI Surgical-Adult Mean 2.38% 2.64% 2.43% 2.54% 2.00% 2.49% 2.18% 2.18% General Surgery (Phillips 22) vs. NDNQI Surgical-Adult Mean 16.00% 12.00% 8.00% 4.00% General Surgery (Phillips 22) NDNQI Surgical-Adult Mean Orthopaedics (White 6) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Orthopaedics (White 6) NDNQI Surgical-Adult Mean 2.38% 2.64% 2.43% 2.54% 2.00% 2.49% 2.18% 2.18% 16.00% Orthopaedics (White 6) vs. NDNQI Surgical-Adult Mean ( 12.00% 8.00% 4.00% Orthopaedics (White 6) NDNQI Surgical-Adult Mean

Page 1279 with Hospital Acquired Pressure Ulcers Surgical-Adult General Surgery (White 7) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Surgery (White 7) 4.35% 4.55% NDNQI Surgical-Adult Mean 2.38% 2.64% 2.43% 2.54% 2.00% 2.49% 2.18% 2.18% 16.00% 12.00% 8.00% 4.00% General Surgery (White 7) vs. NDNQI Surgical-Adult Mean General Surgery (White 7) NDNQI Surgical-Adult Mean Transplant (Blake 6) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Transplant (Blake 6) 16.67% 5.88% 6.67% 6.25% NDNQI Surgical-Adult Mean 2.38% 2.64% 2.43% 2.54% 2.00% 2.49% 2.18% 2.18% 2 16.00% 12.00% 8.00% 4.00% Transplant (Blake 6) vs. NDNQI Surgical-Adult Mean Transplant (Blake 6) NDNQI Surgical-Adult Mean

Page 1280 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Hospital Acquired Pressure Ulcers Surgical-Adult Thoracic/Medicine (Ellison 19) Thoracic/Medicine (Ellison 19) 7.14% 7.69% 3.85% 4.76% NDNQI Surgical-Adult Mean 2.38% 2.64% 2.43% 2.54% 2.00% 2.49% 2.18% 2.18% 16.00% Thoracic/Medicine (Ellison 19) vs. NDNQI Surgical-Adult Mean 12.00% 8.00% 4.00% Thoracic/Medicine (Ellison 19) NDNQI Surgical-Adult Mean

Page 1281 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Neuroscience (Lunder 8 - formerly Ellison 12) with Hospital Acquired Pressure Ulcers Med-Surg Comb.-Adult Neuroscience (Lunder 8 - formerly Ellison 12) 2.78% 3.03% 3.13% 3.45% 3.13% 3.23% NDNQI Med-Surg Comb.-Adult Mean 2.72% 2.51% 3.22% 2.70% 2.08% 2.33% 2.54% 2.54% 1 Neuroscience (Lunder 8 - formerly Ellison 12) vs. NDNQI Med-Surg Comb.-Adult Mean 8.00% 6.00% 4.00% 2.00% Neuroscience (Lunder 8 - formerly Ellison 12) NDNQI Med-Surg Comb.-Adult Mean Neuroscience (Lunder 7 - formerly White 12) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Neuroscience (Lunder 7 - formerly White 12) 4.35% 4.35% 3.45% NDNQI Med-Surg Comb.-Adult Mean 2.72% 2.51% 3.22% 2.70% 2.08% 2.33% 2.54% 2.54% 1 Neuroscience (Lunder 7 - formerly White 12) vs. NDNQI Med-Surg Comb.-Adult Mean 8.00% 6.00% 4.00% 2.00% Neuroscience (Lunder 7 - formerly White 12) NDNQI Med-Surg Comb.-Adult Mean

Page 1282 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 NDNQI Med-Surg Comb.-Pedi Mean 0.11% 0.23% 0.11% 0.07% 0.12% 0.12% 1 8.00% 6.00% 4.00% 2.00% Pediatrics (Ellison 17) NDNQI Med-Surg Comb.-Pedi Mean Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 8.33% NDNQI Med-Surg Comb.-Pedi Mean 0.11% 0.23% 0.11% 0.07% 0.12% 0.12% 1 8.00% 6.00% 4.00% 2.00% Pediatrics (Ellison 18) NDNQI Med-Surg Comb.-Pedi Mean

Page 1283 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Hospital Acquired Pressure Ulcers Critical Care-Adult Cardiac Surgical ICU (Blake 8) Cardiac Surgical ICU (Blake 8) 6.67% 7.14% 1 8.33% 42.86% 25.00% NDNQI Critical Care-Adult Mean 9.36% 8.53% 9.86% 8.86% 8.22% 8.15% 7.91% 7.91% 5 Cardiac Surgical ICU (Blake 8) vs. NDNQI Critical Care-Adult Mean 4 3 2 1 Cardiac Surgical ICU (Blake 8) NDNQI Critical Care-Adult Mean Cardiac ICU (Ellison 9) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Cardiac ICU (Ellison 9) 15.38% 7.69% 7.69% 7.14% NDNQI Critical Care-Adult Mean 9.36% 8.53% 9.86% 8.86% 8.22% 8.15% 7.91% 7.91% 25.00% Cardiac ICU (Ellison 9) vs. NDNQI Critical Care-Adult Mean 2 15.00% 1 5.00% Cardiac ICU (Ellison 9) NDNQI Critical Care-Adult Mean

Page 1284 with Hospital Acquired Pressure Ulcers Critical Care-Adult Medical ICU (Blake 7) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Medical ICU (Blake 7) 7.14% 13.33% 5.88% 6.67% 5.88% 7.14% NDNQI Critical Care-Adult Mean 9.36% 8.53% 9.86% 8.86% 8.22% 8.15% 7.91% 7.91% 25.00% Medical ICU (Blake 7) vs. NDNQI Critical Care-Adult Mean 2 15.00% 1 5.00% Medical ICU (Blake 7) NDNQI Critical Care-Adult Mean Surgical ICU (Ellison 4) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Surgical ICU (Ellison 4) 5.56% 11.76% 10.53% 14.29% 16.67% 13.33% 12.50% 1 NDNQI Critical Care-Adult Mean 9.36% 8.53% 9.86% 8.86% 8.22% 8.15% 7.91% 7.91% 25.00% Surgical ICU (Ellison 4) vs. NDNQI Critical Care-Adult Mean 2 15.00% 1 5.00% Surgical ICU (Ellison 4) NDNQI Critical Care-Adult Mean

Page 1285 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Hospital Acquired Pressure Ulcers Critical Care-Adult Surgical ICU (Blake 12) Surgical ICU (Blake 12) N/A* N/A* N/A* N/A* N/A* N/A* 15.38% NDNQI Critical Care-Adult Mean N/A* N/A* N/A* N/A* N/A* N/A* 7.91% 7.91% 25.00% Surgical ICU (Blake 12) vs. NDNQI Critical Care-Adult Mean 2 15.00% 1 5.00% *No data; unit opened in FY Q1. Surgical ICU (Blake 12) NDNQI Critical Care-Adult Mean Neuroscience ICU (Lunder 6 - formerly Blake 12) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Neuroscience ICU (Lunder 6 - formerly Blake 12) 5.56% 5.88% NDNQI Critical Care-Adult Mean 9.36% 8.53% 9.86% 8.86% 8.22% 8.15% 7.91% 7.91% 25.00% 2 15.00% 1 5.00% Neuroscience ICU (Lunder 6 - formerly Blake 12) vs. NDNQI Critical Care-Adult Mean Neuroscience ICU (Lunder 6 - formerly Blake 12) NDNQI Critical Care-Adult Mean

Page 1286 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Hospital Acquired Pressure Ulcers Critical Care-Pediatrics Pediatric ICU (Bigelow 6) Pediatric ICU (Bigelow 6) 33.33% 14.29% 2 NDNQI Critical Care-Pedi Mean 2.17% 4.26% 4.25% 4.38% 4.08% 4.86% 3.04% 3.04% 5 Pediatric ICU (Bigelow 6) vs. NDNQI Critical Care-Pedi Mean 4 3 2 1 Pediatric ICU (Bigelow 6) NDNQI Critical Care-Pedi Mean

Page 1287 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Hospital Acquired Pressure Ulcers Neonatal ICU Neonatal ICU (Blake 10) Neonatal ICU (Blake 10) NDNQI Level III Neonatal Mean 1.49% 2.61% 0.91% 1.03% 1.47% 0.82% 0.80% 0.80% 3.00% 2.50% 2.00% 1.50% 1.00% 0.50% Neonatal ICU (Blake 10) vs. NDNQI Level III Neonatal Mean Neonatal ICU (Blake 10) NDNQI Level III Neonatal Mean

Page 1288 RESTRAINT UTILIZATION Benchmarking The MGH Patient Care Services has monitored restraint utilization internally for several years. Data have been submitted quarterly to NDNQI for 35 adult, pediatric, neonatal and psychiatric inpatient units and as of January, a total of 36 units with the opening of a new ICU, Surgical ICU (Blake 12). Quarterly reports present the data for the 36 units by the following unit types: Critical Care - Adult Critical Care - Pediatric Level III Neonatal ICU Medical - Adult Medical Surgical Combined Adult Medical Surgical Combined Pediatric Psychiatry Adult Surgical Adult The quarterly reports are organized by unit level type and compare the outcomes for each unit type to the NDNQI mean. Evaluation and Analysis of Data - July through June An evaluation of data indicates that performance is overall favorable to benchmark. Greater than 50% of units outperform the comparative NDNQI benchmark greater than 50% of the time. Twenty-eight of thirty-six units outperformed the mean for five or more quarters equaling 77.78% (see graphs below). MGH also analyzed performance by quarter based on the actual number of units outperforming the benchmark. This additional analysis demonstrates MGH outperformed the NDNQI mean for eight out of eight quarters (Attachment EP 32EO.w). A summary of performance to benchmark by unit type is as follows: Critical Care Adult Restraint utilization continues to vary across the six MGH critical care units with a downward MGH mean restraint utilization trend from the first quarter, (39.73% in July through September ) to 21.28% for the most recent quarter (April through June ). Three units, the Surgical ICU (Ellison 4), Surgical ICU (Blake 12) and Neuroscience ICU (Lunder 6 - formerly Blake 12), have the highest utilization believed to be, in part, a result of the specific patient populations they serve. The majority of restraints utilized in the Neuroscience ICU (Lunder 6 - formerly Blake 12) are used to prevent the removal of lines, tubes and drains during the process of sedation lightening which is performed on a majority of patients every two hours. Sedation lightening allows for appropriate assessment of neurologic status. In these situations, limb restraints have been assessed to be the least restrictive effective intervention to maintain patient safety during this process. Critical Care Pediatric The Pediatric ICU (Bigelow 6) continues to demonstrate a restraint-free environment ( restraint utilization for the last seven out of eight quarters). The NDNQI mean for this time period ranged between 4.77% to 10.05% demonstrating the MGH Pediatric ICU (Bigelow 6) significantly outperformed the benchmark.

Page 1289 Level III Neonatal ICU The Neonatal ICU (Blake 10) has experienced restraint utilization for eight consecutive quarters. This is consistent with the NDNQI mean for all eight quarters. Medical Adult The medical adult units have seen continued restraint utilization reduction trends during this time period with the lowest utilization seen the most recent (8 th ) quarter; 0.33% outperforming the NDNQI mean of 0.78%. Overall the results have demonstrated a consistent positive trend; decreasing restraint utilization from a high of 2.20% to 0.33%. Medical Surgical Adult Combined Neuroscience (Lunder 7) and Neuroscience (Lunder 8), combined, outperformed the NDNQI benchmark for only one of the eight quarters. Both units continue to assess, implement and evaluate strategies to reduce restraint utilization for this complex, cognitively-impaired population at risk for injury to self. Although both units, combined, underperform the NDNQI benchmark, both have made significant progress and are experiencing positive restraint reduction trends as a result of their efforts. Both units combined have decreased from a high restraint utilization of 10.53% to 6.67% for the most recent (8 th ) quarter. Restraint utilization reduction remains one of the top priorities for the neuroscience practice committee. Medical Surgical Combined - Pediatric Pediatrics (Ellison 17) and Pediatrics (Ellison 18) have experienced restraint utilization for eight consecutive quarters, with the exception of one quarter where the mean for both units was 4.35%. The combined mean for both units outperformed the NDNQI benchmark for seven out of eight quarters. The NDNQI mean for the eight consecutive quarters ranged to 0.23% demonstrating the MGH medical surgical combined pediatric units outperformed the benchmark for seven out of eight quarters. Psychiatry - Adult Psychiatry (Blake 11) has experienced physical restraint utilization for eight consecutive quarters. The NDNQI mean for the eight consecutive quarters ranged between 0.06% to 0.68% demonstrating Psychiatry (Blake 11) significantly outperformed the benchmark. Surgical - Adult The surgical adult units, combined, continue to maintain low restraint utilization and outperformed the benchmark for six out of the eight quarters These units have demonstrated a consistent positive trend, decreasing from restraint utilization high of 2.29% to a low of. The data displayed for July-Sept were not submitted to NDNQI within the appropriate timeframe. The data is an internal calculation and measured against the NDNQI mean for the time period July-September. The NDNQI benchmark for April through June was not available at the time of the MGH Magnet document submission. The metric used for analysis and benchmarking of the 8 th quarter (April -June ) is the 7 th quarter (January through March ) NDNQI mean. An

Page 1290 updated version of the graphs will be sent to the ANCC Magnet Coordinator for MGH once the comparative benchmark for the eighth quarter is available mid to late October. The finalized data and graphs will be forwarded to the respective Magnet Appraisers by ANCC. Performance Improvement Initiatives Clinicians at recognize the ethical concerns and patient safety risks associated with restraints. MGH strives to reduce the use of restraints across patient care areas and identify safer interventions for our patients whose behaviors put them at risk for injury. When restraints are necessary, the goal is to reduce the length of time the patient remains in restraint and to comply with MGH and regulatory standards. Each quarter, Nursing Directors receive prevalence data and develop performance improvement plans related to restraint reduction. Analysis of these plans show broad-based commitment to reducing restraint utilization. Success in this endeavor requires a comprehensive approach with attention to healthcare team knowledge and attitudes, practice traditions, scientific evidence, and individual patient needs. A partnership among clinical, regulatory, and technical experts at MGH has helped to ensure that systems are in place to support effective patient assessment and use of least restrictive interventions as well as comprehensive documentation. This partnership is reflected in two MGH committees working hand in hand: The Collaborative Governance Restraint Solutions in Clinical Practice Committee and the Restraint and Seclusion Solutions Team. Restraint Solutions in Clinical Practice Committee (formerly known as the Restraint Usage Committee) (Attachment EP 32EO.m). The Restraint Solutions in Clinical Practice Committee is part of the PCS Collaborative Governance Structure. The team is co-led by two Staff Nurses and facilitated by a Psychiatric Clinical Nurse Specialist, a member of the Psychiatric Consult Service, and is frequently consulted by staff to assist with management of patients with behavioral issues. Other members of the committee include Clinical Nurses, Occupational Therapists, a Nurse from PCS OQS, and a representative from the Norman Knight Nursing Center for Clinical & Professional Development. Nurses represent a wide range of unit types including Critical Care, Medicine, Surgery, Orthopaedic, Neuroscience, and Psychiatry. The primary goal of the committee is to expand the use of interventions effective in reducing the use of restraint and to build expertise among committee members in the areas of restraint use and restraint reduction. Currently the committee is focused on use of sensory interventions to reduce restraint utilization. This focus builds on the successful use of sensory intervention in the inpatient psychiatric unit at MGH. The psychiatric unit nurses and occupational therapists partnered in an effort to explore sensory interventions to improve patient stress response and to reduce the need for restraint and seclusion. Grant money and donations were used to equip a Sensory Room with interventions including: Visual items (water fountain and a large saltwater aquarium with brightly colored fish and coral) Tactile items (weighted blankets, colored blocks, puzzles, back and neck massagers) Olfactory items (aromatic oils and lotions) Auditory interventions (relaxation tapes, music, and nature sound machine) Proprioceptive items (glider rocker). Patients were provided easy access to this room and equipment and were often encouraged to participate by staff particularly during times of increased distress.

Page 1291 The implantation of the sensory program resulted in a marked decline in the use of restraints and seclusion on the inpatient psychiatric unit. In addition, further research has been completed on the effects of sensory interventions in the setting of the Sensory Room (SR) on emotional states, emotion regulation, hemodynamic function of psychiatric inpatients, and subjective patient reports following exposure to these interventions. Use of sensory carts is expanding to the general care units. The committee is striving to reduce restraint use across MGH by a more structured evaluation and implementation of sensory interventions for all patient types and units. The occupational therapist committee members have educated the team about the types of sensory interventions (both calming and stimulating ). The group has noted challenges that include lack of empirical evidence, lack of systemic clarity in clinicaldecision-making for restraint utilization, and individual nature of sensory needs irrespective of patient population type. The committee concluded that the next steps would be for the occupational therapist members to work with nurses on one of the intensive care units to further explore the effectiveness of sensory interventions in reducing restraints in non-psychiatric settings. Two nurse members from the Surgical ICU (Ellison 4) and the unit s leadership agreed to participate due to the unit s above-average restraint utilization. Interdisciplinary collaboration to manage delirium/agitation is standard practice in the Surgical ICU (Ellison 4). The pilot would explore the effectiveness of sensory-related strategies to manage patients experiencing delirium and/or agitation as a least restrictive measure The Surgical ICU (Ellison 4) recently began with the first patient identified by the nurse members as appropriate for inclusion in the pilot. At the following Restraint Solutions in Clinical Practice Committee, the occupational therapists and Surgical ICU (Ellison 4) nurses described the use of a validated agitation scale to assess the patient s level of agitation and discussed the strategies they utilized which resulted in calming the patient without the need to implement restraints. Recognizing this is just a first step, the plan is to continue in the Surgical ICU (Ellison 4) and then expand to the Emergency Department, Medical, Surgical and Neuroscience Units. MGH Restraints and Seclusion Solution Team (formerly known as the Restraint and Seclusion Improvement Team) (Attachment EP 32EO.n) The MGH Restraints and Seclusion Solution Team is a multidisciplinary team of nurses, physicians, information technology staff, and administrative staff which was convened in to explore innovative ways to meet regulatory requirements related to restraints. The team is co-led by a Nurse from the PCS OQS and a Physician who chairs the Quality Committee in the Department of Psychiatry. Three of the Nurses from the Restraint Solutions in Clinical Practice Committee are also members of this committee which enhances collaboration between the two groups. Key areas of focus include compliance between type of restraint physically applied, the type of restraint ordered, compliance with documentation per standards, and the presence of an updated care plan. The team recognized that there are many required elements related to restraint documentation and that the current paper system of MGH documentation does not provide triggers to ensure that all elements are included. Building on earlier work completed in the Emergency Department, the team developed templates for documentation of clinician assessment and documentation. For nurses, triggers were set in a restraint sticker which the nurse embeds into the progress note. Triggers for providers were incorporated into the Physician Order Entry System. The team developed and implemented and a broad-based educational plan which included a wide selection of reference materials which were coalesced into a Restraint Tool Kit. Members attended unit or department based meetings, particularly in areas with high restraint utilization. This team continues to explore ways to promote clinician understanding of requirements, to identify barriers to compliance and to design and implement improvement strategies.

Page 1292 Unit-Specific Challenges There are specific patient populations that have presented special challenges to nurses and physicians related to keeping patients safe. Two populations include neurosciences patients, as mentioned above, as well as substance abuse patients experiencing withdrawal and delirium. Neuroscience patients Neuroscience patients are primarily admitted to the three Neuroscience Units identified above. The patient population in the Neuroscience ICU (Lunder 6 - formerly Blake 12) is, as described above, at risk for sudden changes in orientation, judgment and short term memory loss. These changes make it challenging to reorient the patient. Even when reoriented, this population often does not retain instructions around safety. In addition, these patients are at risk for secondary brain injury which can occur suddenly and also result in change in orientation and cognition. Clinicians minimize the use of sedation (sedation lightening described above) in order to frequently assess the patient s neurological status. Because this places the patient at greater risk of accidental removal of lines, tubes and drains, limb restraints are frequently assessed to be the least restrictive effective intervention to keep the patient safe. Nursing leadership in the Neuroscience ICU (Lunder 6 - formerly Blake 12) continue to try to identify effective interventions for this challenging patient population as evidenced by their recent contact with staff from Johns Hopkins and University of California at Los Angeles Neuroscience ICUs.The Neuroscience Units, as with all MGH units, implement a variety of strategies to keep patients safe prior to use of restraints: These include: Increased use of chair and bed alarms Family participation with care Behavioral techniques such as redirection and distraction Collaboration with physicians to address sleep deprivation issue to lessen agitation Reduced environmental stimuli that may provoke agitation Use of abdominal binders and other aids, e.g., sleeves and dressings to prevent displacement of gastric feeding tubes and central or peripheral IV lines Use of interpreter phones as a communication aid to reduce anxiety in non-english speaking patients. Patients in alcohol withdrawal and/or with delirium Patients with history of alcohol or other substances are present on many units but most prevalent on medical units as well as in the Surgical and Surgical ICU (Blake 12) as a result of the high number of trauma patients these units receive. The plan to minimize the use of restraint in patients with a history of alcohol abuse has focused on early initiation of the Alcohol Withdrawal Pathway, particularly on the General Medical Units. Physicians and nurses, including the Psychiatric Clinical Nurse Specialist, intervene early to minimize the agitation that occurs with withdrawal. The Pathway includes Nursing Management Guidelines (Attachment EP 32EO.o). Patient Observers are also often utilized in lieu of restraint in patients experiencing alcohol withdrawal and/or with delirium. Restraints are utilized only when the level of agitation is high and could result in injury to the patient and to staff. In this situation, the plan of care focuses on frequent reassessment of the patient and use of lease restrictive restraint and earliest discontinuation of restraint. Currently, MGH invests in more than 50 patient observer full-time equivalents to support the needs of our patients and staff.

Page 1293 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Physical Restraints (Limb and Vest) Medical-Adult General Medicine (White 11) General Medicine (White 11) 4.55% 4.55% 4.17% NDNQI Medical-Adult Mean 0.94% 0.93% 1.08% 0.70% 0.80% 0.76% 0.78% 0.78% 1 General Medicine (White 11) vs. NDNQI Medical-Adult Mean 8.00% 6.00% 4.00% 2.00% General Medicine (White 11) NDNQI Medical-Adult Mean General Medicine (White 9) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Medicine (White 9) 5.26% 4.35% 9.52% NDNQI Medical-Adult Mean 0.94% 0.93% 1.08% 0.70% 0.80% 0.76% 0.78% 0.78% 2 General Medicine (White 9) vs. NDNQI Medical-Adult Mean 16.00% 12.00% 8.00% 4.00% General Medicine (White 9) NDNQI Medical-Adult Mean

Page 1294 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Physical Restraints (Limb and Vest) Medical-Adult Cardiac Medicine (Ellison 10) Cardiac Medicine (Ellison 10) 3.33% 6.06% NDNQI Medical-Adult Mean 0.94% 0.93% 1.08% 0.70% 0.80% 0.76% 0.78% 0.78% Cardiac Medicine (Ellison 10) vs. NDNQI Medical-Adult Mean 1 8.00% 6.00% 4.00% 2.00% Cardiac Medicine (Ellison 10) NDNQI Medical-Adult Mean Cardiac Intervention (Ellison 11) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Cardiac Intervention (Ellison 11) NDNQI Medical-Adult Mean 0.94% 0.93% 1.08% 0.70% 0.80% 0.76% 0.78% 0.78% 1 Cardiac Intervention (Ellison 11) vs. NDNQI Medical-Adult Mean 8.00% 6.00% 4.00% 2.00% Cardiac Intervention (Ellison 11) NDNQI Medical-Adult Mean

Page 1295 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Physical Restraints (Limb and Vest) Medical-Adult General Medicine (Ellison 16) General Medicine (Ellison 16) NDNQI Medical-Adult Mean 0.94% 0.93% 1.08% 0.70% 0.80% 0.76% 0.78% 0.78% 1 General Medicine (Ellison 16) vs. NDNQI Medical-Adult Mean 8.00% 6.00% 4.00% 2.00% General Medicine (Ellison 16) NDNQI Medical-Adult Mean General Medicine (Phillips 20) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Medicine (Phillips 20) NDNQI Medical-Adult Mean 0.94% 0.93% 1.08% 0.70% 0.80% 0.76% 0.78% 0.78% 1 General Medicine (Phillips 20) vs. NDNQI Medical-Adult Mean 8.00% 6.00% 4.00% 2.00% General Medicine (Phillips 20) NDNQI Medical-Adult Mean

Page 1296 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Physical Restraints (Limb and Vest) Medical-Adult General Medicine (White 8) General Medicine (White 8) 4.76% 5.56% 4.00% 5.26% NDNQI Medical-Adult Mean 0.94% 0.93% 1.08% 0.70% 0.80% 0.76% 0.78% 0.78% 1 General Medicine (White 8) vs. NDNQI Medical-Adult Mean 8.00% 6.00% 4.00% 2.00% General Medicine (White 8) NDNQI Medical-Adult Mean General Medicine (White 10) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Medicine (White 10) 5.56% 5.26% NDNQI Medical-Adult Mean 0.94% 0.93% 1.08% 0.70% 0.80% 0.76% 0.78% 0.78% 1 General Medicine (White 10) vs. NDNQI Medical-Adult Mean 8.00% 6.00% 4.00% 2.00% General Medicine (White 10) NDNQI Medical-Adult Mean

Page 1297 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Physical Restraints (Limb and Vest) Medical-Adult General Medicine (Bigelow 11) General Medicine (Bigelow 11) 8.70% 4.55% 4.17% NDNQI Medical-Adult Mean 0.94% 0.93% 1.08% 0.70% 0.80% 0.76% 0.78% 0.78% 1 8.00% 6.00% 4.00% 2.00% General Medicine (Bigelow 11) vs. NDNQI Medical-Adult Mean General Medicine (Bigelow 11) NDNQI Medical-Adult Mean Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Respiratory Acute Care & Medicine (Bigelow 9) Respiratory Acute Care & Medicine (Bigelow 9) 5.56% 5.56% 11.11% 11.76% 5.88% 5.56% NDNQI Medical-Adult Mean 0.94% 0.93% 1.08% 0.70% 0.80% 0.76% 0.78% 0.78% 2 Respiratory Acute Care & Medicine (Bigelow 9) vs. NDNQI Medical-Adult Mean 16.00% 12.00% 8.00% 4.00% Respiratory Acute Care & Medicine (Bigelow 9) NDNQI Medical-Adult Mean

Page 1298 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Hem/Onc/BMT (Lunder 10 - formerly Ellison 14) with Physical Restraints (Limb and Vest) Medical-Adult Hem/Onc/BMT (Lunder 10 - formerly Ellison 14) NDNQI Medical-Adult Mean 0.94% 0.93% 1.08% 0.70% 0.80% 0.76% 0.78% 0.78% 1 Hem/Onc/BMT (Lunder 10 - formerly Ellison 14) vs. NDNQI Medical-Adult Mean 8.00% 6.00% 4.00% 2.00% Hem/Onc/BMT (Lunder 10 - formerly Ellison 14) NDNQI Medical-Adult Mean Lunder 9 (formerly Phillips House 21) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Lunder 9 (formerly Phillips House 21) NDNQI Medical-Adult Mean 0.94% 0.93% 1.08% 0.70% 0.80% 0.76% 0.78% 0.78% 1 Lunder 9 (formerly Phillips House 21) vs. NDNQI Medical-Adult Mean 8.00% 6.00% 4.00% 2.00% Lunder 9 (formerly Phillips House 21) NDNQI Medical-Adult Mean

Page 1299 with Physical Restraints (Limb and Vest) Surgical-Adult Plastic/Burn ICU (Bigelow 13) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Plastic/Burn ICU (Bigelow 13) 5.26% NDNQI Surgical-Adult Mean 0.57% 0.53% 0.62% 0.61% 0.43% 0.56% 0.57% 0.57% Plastic/Burn ICU (Bigelow 13) vs. NDNQI Surgical-Adult Mean 1 8.00% 6.00% 4.00% 2.00% Plastic/Burn ICU (Bigelow 13) NDNQI Surgical-Adult Mean Vascular (Bigelow 14) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Vascular (Bigelow 14) 4.00% NDNQI Surgical-Adult Mean 0.57% 0.53% 0.62% 0.61% 0.43% 0.56% 0.57% 0.57% 1 Vascular (Bigelow 14) vs. NDNQI Surgical-Adult Mean 8.00% 6.00% 4.00% 2.00% Vascular (Bigelow 14) NDNQI Surgical-Adult Mean

Page 1300 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Physical Restraints (Limb and Vest) Surgical-Adult Orthopaedics (Ellison 6) Orthopaedics (Ellison 6) NDNQI Surgical-Adult Mean 0.57% 0.53% 0.62% 0.61% 0.43% 0.56% 0.57% 0.57% 1 8.00% 6.00% 4.00% 2.00% Orthopaedics (Ellison 6) vs. NDNQI Surgical-Adult Mean Orthopaedics (Ellison 6) NDNQI Surgical-Adult Mean Gyn./Oncology (Phillips House 21 - formerly Bigelow 7) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Gyn./Oncology (Phillips House 21 - formerly Bigelow 7) NDNQI Surgical-Adult Mean 0.57% 0.53% 0.62% 0.61% 0.43% 0.56% 0.57% 0.57% 1 8.00% 6.00% 4.00% 2.00% Gyn./Oncology (Phillips House 21 - formerly Bigelow 7) vs. NDNQI Surgical-Adult Mean Gyn./Oncology (Phillips House 21 - formerly Bigelow 7) NDNQI Surgical-Adult Mean

Page 1301 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Physical Restraints (Limb and Vest) Surgical-Adult General Surgery (Ellison 7) General Surgery (Ellison 7) 5.88% 2.94% 3.33% NDNQI Surgical-Adult Mean 0.57% 0.53% 0.62% 0.61% 0.43% 0.56% 0.57% 0.57% 1 General Surgery (Ellison 7) vs. NDNQI Surgical-Adult Mean 8.00% 6.00% 4.00% 2.00% General Surgery (Ellison 7) NDNQI Surgical-Adult Mean Cardiac Surgery (Ellison 8) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Cardiac Surgery (Ellison 8) 3.57% NDNQI Surgical-Adult Mean 0.57% 0.53% 0.62% 0.61% 0.43% 0.56% 0.57% 0.57% 1 Cardiac Surgery (Ellison 8) vs. NDNQI Surgical-Adult Mean 8.00% 6.00% 4.00% 2.00% Cardiac Surgery (Ellison 8) NDNQI Surgical-Adult Mean

Page 1302 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Physical Restraints (Limb and Vest) Surgical-Adult General Surgery (Phillips 22) General Surgery (Phillips 22) NDNQI Surgical-Adult Mean 0.57% 0.53% 0.62% 0.61% 0.43% 0.56% 0.57% 0.57% 1 General Surgery (Phillips 22) vs. NDNQI Surgical-Adult Mean 8.00% 6.00% 4.00% 2.00% General Surgery (Phillips 22) NDNQI Surgical-Adult Mean Orthopaedics (White 6) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Orthopaedics (White 6) NDNQI Surgical-Adult Mean 0.57% 0.53% 0.62% 0.61% 0.43% 0.56% 0.57% 0.57% 1 8.00% 6.00% 4.00% 2.00% Orthopaedics (White 6) vs. NDNQI Surgical-Adult Mean Orthopaedics (White 6) NDNQI Surgical-Adult Mean

Page 1303 with Physical Restraints (Limb and Vest) Surgical-Adult General Surgery (White 7) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Surgery (White 7) 4.00% 4.17% NDNQI Surgical-Adult Mean 0.57% 0.53% 0.62% 0.61% 0.43% 0.56% 0.57% 0.57% 1 General Surgery (White 7) vs. NDNQI Surgical-Adult Mean 8.00% 6.00% 4.00% 2.00% General Surgery (White 7) NDNQI Surgical-Adult Mean Transplant (Blake 6) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Transplant (Blake 6) 13.33% NDNQI Surgical-Adult Mean 0.57% 0.53% 0.62% 0.61% 0.43% 0.56% 0.57% 0.57% 2 16.00% 12.00% 8.00% 4.00% Transplant (Blake 6) vs. NDNQI Surgical-Adult Mean Transplant (Blake 6) NDNQI Surgical-Adult Mean

Page 1304 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Physical Restraints (Limb and Vest) Surgical-Adult Thoracic/Medicine (Ellison 19) Thoracic/Medicine (Ellison 19) 3.85% 4.76% NDNQI Surgical-Adult Mean 0.57% 0.53% 0.62% 0.61% 0.43% 0.56% 0.57% 0.57% 1 Thoracic/Medicine (Ellison 19) vs. NDNQI Surgical-Adult Mean 8.00% 6.00% 4.00% 2.00% Thoracic/Medicine (Ellison 19) NDNQI Surgical-Adult Mean

Page 1305 with Physical Restraints (Limb and Vest) Med-Surg Comb.-Adult Neuroscience (Lunder 8 - formerly Ellison 12) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Neuroscience (Lunder 8 - formerly Ellison 12) 8.82% 8.33% 6.06% 9.09% 6.25% 6.25% 6.45% NDNQI Med-Surg Comb.-Adult Mean 0.98% 1.05% 1.28% 0.97% 0.90% 0.64% 0.80% 0.80% 25.00% Neuroscience (Lunder 8 - formerly Ellison 12) vs. NDNQI Med-Surg Comb.-Adult Mean 2 15.00% 1 5.00% Neuroscience (Lunder 8 - formerly Ellison 12) NDNQI Med-Surg Comb.-Adult Mean Neuroscience (Lunder 7 - formerly White 12) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Neuroscience (Lunder 7 - formerly White 12) 13.04% 13.04% 13.04% 5.00% 4.35% 9.68% 6.90% NDNQI Med-Surg Comb.-Adult Mean 0.98% 1.05% 1.28% 0.97% 0.90% 0.64% 0.80% 0.80% 25.00% Neuroscience (Lunder 7 - formerly White 12) vs. NDNQI Med-Surg Comb.-Adult Mean 2 15.00% 1 5.00% Neuroscience (Lunder 7 - formerly White 12) NDNQI Med-Surg Comb.-Adult Mean

Page 1306 with Physical Restraints (Limb and Vest) Critical Care-Adult Cardiac Surgical ICU (Blake 8) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Cardiac Surgical ICU (Blake 8) 6.67% 6.67% 1 8.33% 16.67% NDNQI Critical Care-Adult Mean 21.35% 19.87% 19.60% 18.42% 18.33% 17.88% 17.91% 17.91% Cardiac Surgical ICU (Blake 8) vs. NDNQI Critical Care-Adult Mean 10 9 8 7 6 5 4 3 2 1 Cardiac Surgical ICU (Blake 8) NDNQI Critical Care-Adult Mean Cardiac ICU (Ellison 9) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Cardiac ICU (Ellison 9) 37.50% 23.08% 7.69% 26.67% 7.69% 21.43% 15.38% NDNQI Critical Care-Adult Mean 21.35% 19.87% 19.60% 18.42% 18.33% 17.88% 17.91% 17.91% Cardiac ICU (Ellison 9) vs. NDNQI Critical Care-Adult Mean 10 9 8 7 6 5 4 3 2 1 Cardiac ICU (Ellison 9) NDNQI Critical Care-Adult Mean

Page 1307 with Physical Restraints (Limb and Vest) Critical Care-Adult Medical ICU (Blake 7) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Medical ICU (Blake 7) 7.14% 2 13.33% 5.88% 28.57% 6.67% 17.65% 42.86% NDNQI Critical Care-Adult Mean 21.35% 19.87% 19.60% 18.42% 18.33% 17.88% 17.91% 17.91% Medical ICU (Blake 7) vs. NDNQI Critical Care-Adult Mean 10 9 8 7 6 5 4 3 2 1 Medical ICU (Blake 7) NDNQI Critical Care-Adult Mean Surgical ICU (Ellison 4) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Surgical ICU (Ellison 4) 5 17.65% 10.53% 71.43% 22.22% 6.67% 37.50% 1 NDNQI Critical Care-Adult Mean 21.35% 19.87% 19.60% 18.42% 18.33% 17.88% 17.91% 17.91% Surgical ICU (Ellison 4) vs. NDNQI Critical Care-Adult Mean 10 9 8 7 6 5 4 3 2 1 Surgical ICU (Ellison 4) NDNQI Critical Care-Adult Mean

Page 1308 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Physical Restraints (Limb and Vest) Critical Care-Adult Surgical ICU (Blake 12) Surgical ICU (Blake 12) N/A* N/A* N/A* N/A* N/A* N/A* 33.33% 23.08% NDNQI Critical Care-Adult Mean N/A* N/A* N/A* N/A* N/A* N/A* 17.91% 17.91% 10 9 8 7 6 5 4 3 2 1 Surgical ICU (Blake 12) vs. NDNQI Critical Care-Adult Mean Surgical ICU (Blake 12) NDNQI Critical Care-Adult Mean *No data; unit opened in FY Q1. Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Neuroscience ICU (Lunder 6 - formerly Blake 12) Neuroscience ICU (Lunder 6 - formerly Blake 12) 83.33% 27.78% 37.50% 29.41% 22.73% 5 27.27% 22.73% NDNQI Critical Care-Adult Mean 21.35% 19.87% 19.60% 18.42% 18.33% 17.88% 17.91% 17.91% Neuroscience ICU (Lunder 6 - formerly Blake 12) vs. NDNQI Critical Care-Adult Mean 10 9 8 7 6 5 4 3 2 1 Neuroscience ICU (Lunder 6 - formerly Blake 12) NDNQI Critical Care-Adult Mean

Page 1309 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Physical Restraints (Limb and Vest) Neonatal ICU Neonatal ICU (Blake 10) Neonatal ICU (Blake 10) NDNQI Level III Neonatal Mean 1.00% 0.80% 0.60% 0.40% 0.20% Neonatal ICU (Blake 10) vs. NDNQI Level III Neonatal Mean Neonatal ICU (Blake 10) NDNQI Level III Neonatal Mean

Page 1310 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 NDNQI Med-Surg Comb.-Pedi Mean 0.11% 0.23% 0.11% 0.07% 0.12% 0.12% 1 8.00% 6.00% 4.00% 2.00% Pediatrics (Ellison 17) NDNQI Med-Surg Comb.-Pedi Mean Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 8.33% NDNQI Med-Surg Comb.-Pedi Mean 0.11% 0.23% 0.11% 0.07% 0.12% 0.12% 1 8.00% 6.00% 4.00% 2.00% Pediatrics (Ellison 18) NDNQI Med-Surg Comb.-Pedi Mean

Page 1311 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Physical Restraints (Limb and Vest) Critical Care-Pediatrics Pediatric ICU (Bigelow 6) Pediatric ICU (Bigelow 6) 16.67% NDNQI Critical Care-Pedi Mean 8.46% 7.08% 10.05% 5.20% 4.77% 8.97% 6.22% 6.22% 10 9 8 7 6 5 4 3 2 1 Pediatric ICU (Bigelow 6) vs. NDNQI Critical Care-Pedi Mean Pediatric ICU (Bigelow 6) NDNQI Critical Care-Pedi Mean

Page 1312 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 with Physical Restraints (Limb and Vest) Psychiatry-Adult Psychiatry (Blake 11) Psychiatry (Blake 11) NDNQI Psychiatry-Adult Mean 0.29% 0.12% 0.11% 0.68% 0.55% 0.28% 0.06% 0.06% 5.00% Psychiatry (Blake 11) vs. NDNQI Psychiatry-Adult Mean 4.00% 3.00% 2.00% 1.00% Psychiatry (Blake 11) NDNQI Psychiatry-Adult Mean

Page 1313 CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION (CLABSI) Benchmarking The MGH Infection Control Unit has routinely collected CLABSI data in intensive care units for several years for internal analysis and submission to the National Healthcare Safety Network (NHSN) database of the Centers for Disease Control and Prevention (CDC). Central line-associated bloodstream infections are identified by Infection Control Practitioners through chart review and microbiology reports. Identified cases of CLABSI are reported in real time to the NHSN. Central line days are acquired through the patient classification system, Quadramed Acuity Plus. A quarterly data summary is submitted to PCS Office of Quality and Safety (OQS) for further analyses and dissemination by the MGH Infection Control Unit. The data for ICUs are also reviewed by the Infection Control Committee, Critical Care Center Operations Group and the Critical Care Committee Quality Committee. The MGH Patient Care Services has elected to benchmark its CLABSI rate against the CDC/NHSN pooled mean for major teaching hospitals. Please note the Burn ICU (Bigelow 13) data are included in the CLABSI analysis as a Critical Care Unit. This is in accordance with CDC/NHSN classification guidelines. Evaluation and Analysis of Data - July through June Analysis of data for 9 ICUs- 7 adult, 1 Pediatric ICU and 1 Neonatal ICU An evaluation of quarterly data for nine ICUs indicates that performance is favorable to benchmark. More than 50% of the nine ICUs reported in this section outperform the comparative CDC/NSHN benchmark for their unit type more than 50% of the time. Five out of nine units outperformed the mean for five or more quarters equaling 55.56% (see graphs below). MGH also analyzed performance by quarter based on the actual number of units outperforming the benchmark. This additional analysis demonstrates MGH outperformed the NDNQI mean for six out of eight quarters (Attachment EP 32EO.w). A summary of ICU unit-level performance is as follows: Five of nine ICUs consistently outperformed the CDC/NSHN benchmark more than 50% of the time: Cardiac Surgical ICU (Blake 8), Medical ICU (Blake 7), Neuroscience ICU (Lunder 6 formerly Blake 12) Surgical ICU (Ellison 4), and the Neonatal ICU (Blake 10) One of nine ICUs, Surgical ICU (Ellison 4) outperformed the CDC/NSHN benchmarks for all eight quarters Two of nine ICUs, Neuroscience ICU (Lunder 6 formerly Blake 12), and Neonatal ICU outperformed the CDC/NSHN benchmarks for seven out of eight quarters Two of nine ICU s, the Cardiac Surgical ICU (Blake 8) and the Medical ICU (Blake 7) outperformed the benchmark six out of eight quarters. MGH is continuing to make progress with CLABSI prevention and reduction, however opportunities for improvement remain including continued focus in the Burn, Cardiac and Pediatric Critical Care areas. Due to the low volume of central lines hospital-wide, a small number of infections tend to result in a rate for the reporting unit to be above that of the comparative benchmark. In many cases, a single infection results in a unit s rate being above benchmark. This is particularly relevant for the Neonatal, Pediatric and Burn ICUs due to their extremely low central line days. Please note, the MGH Infection Control formerly reported two sets of data on bloodstream infections for the Neonatal ICU (Blake 10) per CDC/NHSN guidelines; Central Line-Associated Bloodstream Infection (CLABSI) and Umbilical Line-Associated Bloodstream Infection (UCAB).

Page 1314 These data are analyzed internally and are submitted to the NHSN database for benchmarking at the birth weight category level. The first five out of eight quarters include Neonatal ICU CLABSI and UCAB data reported individually by birth weight category. As a result of new CDC/NHSN Neonatal ICU blood stream infection reporting guidelines, the last three quarters (October through June ) of data report CLABSI and UCAB jointly by birth weight category. The analysis of the Neonatal ICU (Blake 10) blood stream infection data is based on all eight quarters in totality. For CLABSI and UCAB combined, more than 50% of the Neonatal ICU (Blake 10) birth weight categories outperform the comparative CDC/NSHN pooled mean for more than 50% of the time (seven of eight quarters). Two of the five birth weight categories (1501-2500g and >2500g) outperformed the comparative benchmark 100% of the time. CDC/NHSN benchmarks are not published on a regular frequency. Data collected July - March are benchmarked against CDC/NHSN benchmarks from the National Healthcare Safety Network (NHSN) Report: Data summary for 2006 through 2008, issued December 2009. This report is a summary of Device-Associated (DA) and Procedure-Associated (PA) module data collected and reported by hospitals and ambulatory surgical centers participating in the National Healthcare Safety Network (NHSN) from January 2006 through December 2008 as reported to the Centers for Disease Control and Prevention (CDC) by July 6, 2009. Data collected April - September are benchmarked against CDC/NHSN benchmarks from the National Healthcare Safety Network (NHSN) Report, Data Summary for 2009, Device-associated Module issued May. This report is a summary of Device-associated Module data collected by hospitals participating in the National Healthcare Safety Network (NHSN) for events occurring from January through December 2009 and reported to the Centers for Disease Control and Prevention (CDC) by October 18,. Data collected October June are benchmarked against CDC/NHSN benchmarks from the National Healthcare Safety Network (NHSN) Report, Data Summary for, Deviceassociated Module, which is a Summary of Device associated Module data collected by hospitals participating in the National Healthcare Safety Network (NHSN) for events occurring from January through December and reported to the Centers for Disease Control and Prevention (CDC) by July 7,. Performance Improvement Initiatives In 2009, an interdisciplinary team put into practice a CLABSI-prevention initiative. The team included experts from various MGH departments including the Intravenous Therapy (IV) team, Infection Control, Ambulatory, Radiology, Pediatrics, Inpatient Units and Hemodialysis. The goal of the initiative was to develop a standardized approach throughout MGH that adhered to evidencebased practices. The group s work led to several significant changes including: Developing a standardized central line insertion kit Creating a central line insertion checklist and monitor to ensure all steps for safe line placement were being taken (Attachment EP 32EO.p). Introducing chlorhexidine for skin prep Using maximal sterile barriers Establishing a formalized feedback mechanism for all CLABSI diagnosed in ICU patients: upon diagnosis of a CLABSI on the unit, Infection Control informs the unit leadership, who then perform an investigation to identify root cases and opportunities for learning

Page 1315 Using color coded stickers to indentify a line that was placed in strict adherence to infection control policies, versus those placed in less than ideal conditions (e.g., emergent situations) Developing the Excellence Every Day Portal page: Central Line Resource and CLABSI Prevention Resources. The IV team, in collaboration with Infection Control, PCS OQS and the Nursing Leadership team, continue to recommend, implement and evaluate several initiatives to decrease CLABSI at MGH. We also are fortunate the IV team Nursing Director is recently serving as President of the regional New England Chapter of the Infusion Nurses Society (March of through March of 2013) which has allowed MGH to remain informed of the most current IV/infusion practices as well as innovative devices available to prevent and/or reduce CLABSI. Following continued review of CLABSI data and current practice, one initiative, initiated in January-February focused on the implementation of BioPatch (Attachment EP 32EO.q), a chlorhexidine impregnated disc dressing designed to cover the insertion site of centrally accessed catheters. The literature has demonstrated that this type of dressing in combination with other strategies can assist with the prevention of catheter-related infections. Two units, the Cardiac Surgical ICU (Blake 8) and the Cardiac ICU (Ellison 9) were the first units to pilot BioPatch for all centralline dressings in June, due to frequency of use of triple lumen catheters, pulmonary artery lines as well as peripherally-inserted central catheters (PICC). The Cardiac ICU has demonstrated a steady decrease in CLABSI rates from 2.1 in October of to 0.91 in March of and BioPatch, in addition to other strategies, may have contributed to this positive trend. Other interventions implemented by the Cardiac ICU (Ellison 9) during this period include: Educating staff members on a 20-second scrub of access ports of all central lines Instituting the practice of changing the cap on the stopcock after every blood draw Coordinating with the Cardiac Catheterization Lab for proper central line dressing techniques and attaching all pulmonary artery catheter tubing set ups to the line following placement. Further analysis of CLABSI data demonstrated the majority of CLABSI were found to be related to PICC lines. A review by the Critical Care Center Quality Committee, Infection Control and the IV team considered three possible contributing factors leading to the incidence of PICC line CLABSI: Non-adherence to infection control standards during PICC line insertion Variations in practice regarding PICC line maintenance (flushing and scrubbing the ports for at least 15 seconds prior to injection) Not utilizing a chlorhexidine impregnated disc dressing for all PICC lines. The IV team reviews compliance with documentation of the Central Line Checklist on a quarterly basis. For the past 8 quarters, the compliance with documenting the procedure and adherence to infection control standards during insertion has been 100%, decreasing the likelihood of insertion technique as a primary contributing factor. This is further supported by the mean onset of PICC line infection of nine days post-insertion, suggesting maintenance and dressing choice as two possible key contributing factors. The two interventions to address the two possible contributing factors included implementing the use of BioPatch dressings for all inpatient PICC line insertions across all units, and the development of a PICC line maintenance education program. Biopatch funding was approved in November of and following staff education, was implemented in February of (Attachment

Page 1316 EP 32EO.r). The CLABSI PICC rate (all PICC lines) has continued to remain flat for the past three months and we look forward to further evaluating its effectiveness moving forward. The second intervention focused on care and maintenance of PICC lines including the Go with the Flow/Scrub the Hub campaign (Attachment EP 32EO.s) Staff were re-educated on the proper care of PICC lines including flushing techniques and scrubbing the hub of the PICC line port for at least 15 seconds prior to flushing. This intervention was implemented in the spring of. We continue to monitor CLABSI rates at the unit level to assess the intervention s impact. A third intervention, includes piloting the use of a new alcohol impregnated (70% alcohol) IV port cap. The Curos port (Attachment EP 32EO.t), once in place for three minutes, eliminates the need to scrub the hub for 15 seconds and also acts as a barrier between flushes. A recent study published in APIC in May of by Sweet, et al, showed a reduction in CLABSI rates in a cancer unit from 2.3 infections per 1000 central line days to 0.3 infections per 1000 central line days. MGH is currently piloting this product in five inpatient units; two neurosciences units, two cancer units and our Neuroscience ICU (Lunder 6 - formerly Blake 12). This intervention was initiated in July of and we look forward to evaluating its impact on CLABSI reduction. Other department-specific initiatives include yearly central line competencies such as those of the IV team and Hem/Onc/BMT (Lunder 10 formerly Ellison 14), a cancer care unit. Members of the IV Team who are deemed clinically competent to insert PICC catheters must undergo an annual competency review (Attachment EP 32EO.u) that includes direct observation by another qualified IV PICC team RN. All elements of maximum barrier insertion, the central line checklist and complication management are reviewed and demonstrated. The Lunder 10 central line competency was developed with the input of staff. Staff RNs from the Lunder 10 Quality Committee are taking a role in the implementation of the competency. The Lunder 10 competency delineates the steps needed to change a central line dressing and caps. A quality committee member or the Clinical Nurse Specialist will then objectively observe and evaluate another RN as she/he performs a central line dressing change, using the criteria in the competency. This provides a great opportunity for RNs to coach one another and also serves as a way for the unit as a whole to maintain uniformly sound practice.

Page 1317 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Central Line-Associated Bloodstream Infections (CLABSI) per 1000 Central Line Days Critical Care-Adult Cardiac Surgical ICU (Blake 8) Cardiac Surgical ICU (Blake 8) 0.00 0.88 0.98 1.82 0.97 0.00 1.66 0.00 CDC/NHSN Surgical Cardiothoracic Critical Care Pooled Mean 1.43 1.43 1.43 1.20 1.20 0.90 0.90 0.90 CLABSI per 1000 Line Days 6.00 5.00 4.00 3.00 2.00 1.00 0.00 Cardiac Surgical ICU (Blake 8) vs. CDC/NHSN Surgical Cardiothoracic Critical Care Pooled Mean (Major Teaching Hospitals) Cardiac Surgical ICU (Blake 8) CDC/NHSN Surgical Cardiothoracic Critical Care Pooled Mean Cardiac ICU (Ellison 9) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Cardiac ICU (Ellison 9) 0.00 2.84 0.00 1.95 1.99 1.14 0.91 2.31 CDC/NHSN Medical Cardiac Critical Care Pooled Mean 2.00 2.00 2.00 1.70 1.70 1.30 1.30 1.30 CLABSI per 1000 Line Days 6.00 5.00 4.00 3.00 2.00 1.00 0.00 Cardiac ICU (Ellison 9) vs. CDC/NHSN Medical Cardiac Critical Care Pooled Mean (Major Teaching Hospitals) Cardiac ICU (Ellison 9) CDC/NHSN Medical Cardiac Critical Care Pooled Mean

Page 1318 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Central Line-Associated Bloodstream Infections (CLABSI) per 1000 Central Line Days Critical Care-Adult Medical ICU (Blake 7) Medical ICU (Blake 7) 0.89 0.00 1.79 2.40 1.72 1.69 3.90 1.76 CDC/NHSN Medical Critical Care Pooled Mean 2.60 2.60 2.60 2.20 2.20 1.80 1.80 1.80 6.00 Medical ICU (Blake 7) vs. CDC/NHSN Medical Critical Care Pooled Mean (Major Teaching Hospitals) CLABSI per 1000 Line Days 5.00 4.00 3.00 2.00 1.00 0.00 Medical ICU (Blake 7) CDC/NHSN Medical Critical Care Pooled Mean Surgical ICU (Ellison 4) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Surgical ICU (Ellison 4) 0.00 0.83 0.00 0.00 0.00 0.00 0.00 0.87 CDC/NHSN Surgical Critical Care Pooled Mean 2.30 2.30 2.30 1.80 1.80 1.40 1.40 1.40 6.00 Surgical ICU (Ellison 4) vs. CDC/NHSN Surgical Critical Care Pooled Mean (Major Teaching Hospitals) CLABSI per 1000 Line Days 5.00 4.00 3.00 2.00 1.00 0.00 Surgical ICU (Ellison 4) CDC/NHSN Surgical Critical Care Pooled Mean

Page 1319 Central Line-Associated Bloodstream Infections (CLABSI) per 1000 Central Line Days Critical Care-Adult Surgical ICU (Blake12) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Surgical ICU (Blake12) N/A* N/A* N/A* N/A* N/A* N/A* 0.00 3.07 CDC/NHSN Surgical Critical Care Pooled Mean N/A* N/A* N/A* N/A* N/A* N/A* 1.40 1.40 6.00 Surgical ICU (Blake 12) vs. CDC/NHSN Surgical Critical Care Pooled Mean (Major Teaching Hospitals) CLABSI per 1000 Line Days 5.00 4.00 3.00 2.00 1.00 0.00 Surgical ICU (Blake12) CDC/NHSN Surgical Critical Care Pooled Mean *No data; unit opened in FY Q1. Neuroscience ICU (Lunder 6 - formerly Blake 12) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Neuroscience ICU (Lunder 6 - formerly Blake 12) 0.00 1.32 0.00 0.00 0.00 1.92 0.00 0.00 CDC/NHSN Neurosurgical Critical Care Pooled Mean 2.50 2.50 2.50 1.50 1.50 1.30 1.30 1.30 6.00 Neuroscience ICU (Lunder 6 - formerly Blake 12) vs. CDC/NHSN Neurosurgical Critical Care Pooled Mean (Major Teaching Hospitals) CLABSI per 1000 Line Days 5.00 4.00 3.00 2.00 1.00 0.00 Neuroscience ICU (Lunder 6 - formerly Blake 12) CDC/NHSN Neurosurgical Critical Care Pooled Mean

Page 1320 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Central Line-Associated Bloodstream Infections (CLABSI) per 1000 Central Line Days Surgical-Adult Plastic/Burn ICU (Bigelow 13) Burn ICU (Bigelow 13)* 0.00 5.65 0.00 6.80 4.90 9.97 4.26 10.36 CDC/NHSN Burn ICU Pooled Mean 12.00 5.50 5.50 5.50 5.30 5.30 3.50 3.50 3.50 Burn ICU (Bigelow 13) vs. CDC/NHSN Burn ICU Pooled Mean (Major Teaching Hospitals) CLABSI per 1000 Line Days 10.00 8.00 6.00 4.00 2.00 0.00 Burn ICU (Bigelow 13)* *CDC/NHSN data for this unit stratified in to Burn ICU; and Burns and Plastics. CDC/NHSN Burn ICU Pooled Mean

Page 1321 Neonatal ICU (Blake 10) Central Line-Associated Bloodstream Infections (CLABSI) per 1000 Central Line Days BirthWeight of Infants <=750g Rate 0.00 0.00 0.00 0.00 0.00 n 0 0 0 0 0 CDC/NHSN Pooled Mean* 3.90 3.90 3.90 3.30 3.30 751-1000g Rate 0.00 0.00 0.00 14.71 0.00 n 0 0 0 1 0 CDC/NHSN Pooled Mean* 3.40 3.40 3.40 2.80 2.80 1001-1500g Rate 0.00 0.00 0.00 0.00 10.10 n 0 0 0 0 1 CDC/NHSN Pooled Mean* 2.40 2.40 2.40 1.70 1.70 1501-2500g Rate 0.00 0.00 0.00 0.00 0.00 n 0 0 0 0 0 CDC/NHSN Pooled Mean* 2.40 2.40 2.40 1.40 1.40 >2500g Rate 0.00 0.00 0.00 0.00 0.00 n 0 0 0 0 0 CDC/NHSN Pooled Mean* 1.90 1.90 1.90 1.40 1.40 See below for Combined CLABSI & UCAB CLABSI 25.00 20.00 15.00 10.00 5.00 0.00 CLABSI in Infants <=750g CLABSI 25.00 20.00 15.00 10.00 5.00 0.00 CLABSI in Infants 751-1000g Neonatal ICU (Blake 10) CDC/NHSN Pooled Mean* Oct-Dec Neonatal ICU (Blake 10) CDC/NHSN Pooled Mean* CLABSI 25.00 20.00 15.00 10.00 5.00 0.00 CLABSI in Infants 1001-1500g CLABSI 25.00 20.00 15.00 10.00 5.00 0.00 CLABSI in Infants 1501-2500g Neonatal ICU (Blake 10) CDC/NHSN Pooled Mean* Neonatal ICU (Blake 10) CDC/NHSN Pooled Mean* CLABSI 25.00 20.00 15.00 10.00 5.00 0.00 CLABSI in Infants >2500g Oct-Dec Neonatal ICU (Blake 10) CDC/NHSN Pooled Mean* *Benchmark is CDC/NSHN Neonatal Critical Care (Level III) Pooled Mean

Page 1322 Umbilical Line-Associated Bloodstream Infections (UCAB) per 1000 Umbilical Line Days BirthWeight of Infants <=750g Rate 0.00 0.00 0.00 0.00 0.00 n 0 0 0 0 0 CDC/NHSN Pooled Mean* 3.90 3.90 3.90 4.40 4.40 751-1000g Rate 0.00 0.00 0.00 0.00 0.00 n 0 0 0 0 0 CDC/NHSN Pooled Mean* 2.50 2.50 2.50 2.60 2.60 1001-1500g Rate 0.00 0.00 0.00 0.00 15.38 n 0 0 0 0 1 CDC/NHSN Pooled Mean* 1.70 1.70 1.70 1.50 1.50 1501-2500g Rate 0.00 0.00 0.00 0.00 0.00 n 0 0 0 0 0 CDC/NHSN Pooled Mean* 0.90 0.90 0.90 1.00 1.00 >2500g Rate 0.00 0.00 0.00 0.00 0.00 n 0 0 0 0 0 CDC/NHSN Pooled Mean* 0.90 0.90 0.90 0.80 0.80 See below for Combined CLABSI & UCAB UCAB 25.00 20.00 15.00 10.00 5.00 0.00 UCAB in Infants <=750g Oct-Dec UCAB 25.00 20.00 15.00 10.00 5.00 0.00 UCAB in Infants 751-1000g Neonatal ICU (Blake 10) CDC/NHSN Pooled Mean* Neonatal ICU (Blake 10) CDC/NHSN Pooled Mean* UCAB 25.00 20.00 15.00 10.00 5.00 0.00 UCAB in Infants 1001-1500g UCAB 25.00 20.00 15.00 10.00 5.00 0.00 UCAB in Infants 1501-2500g Neonatal ICU (Blake 10) CDC/NHSN Pooled Mean* Neonatal ICU (Blake 10) CDC/NHSN Pooled Mean* UCAB 25.00 20.00 15.00 10.00 5.00 0.00 UCAB in Infants >2500g Neonatal ICU (Blake 10) CDC/NHSN Pooled Mean* *Benchmark is CDC/NSHN Neonatal Critical Care (Level III) Pooled Mean

Page 1323 Neonatal ICU (Blake 10) Line-Associated Bloodstream Infections (BSI) per 1000 Line Days BirthWeight of Infants <=750g Rate 8.40 0.00 0.00 n 1 0 0 CDC/NHSN Pooled Mean* 2.90 2.90 2.90 751-1000g Rate 8.26 0.00 0.00 n 1 0 0 CDC/NHSN Pooled Mean* 2.30 2.30 2.30 1001-1500g Rate 18.02 0.00 0.00 See above for UCAB and CLABSI data prior to n 2 0 0 CDC/NHSN Pooled Mean* 1.40 1.40 1.40 1501-2500g Rate 0.00 0.00 0.00 n 0 0 0 CDC/NHSN Pooled Mean* 1.00 1.00 1.00 >2500g Rate 0.00 0.00 0.00 n 0 0 0 CDC/NHSN Pooled Mean* 0.70 0.70 0.70 BSI 25.00 20.00 15.00 10.00 5.00 0.00 BSI in Infants <=750g Oct-Dec BSI 25.00 20.00 15.00 10.00 5.00 0.00 BSI in Infants 751-1000g Neonatal ICU (Blake 10) CDC/NHSN Pooled Mean* Neonatal ICU (Blake 10) CDC/NHSN Pooled Mean* BSI 25.00 20.00 15.00 10.00 5.00 0.00 BSI in Infants 1001-1500g BSI 25.00 20.00 15.00 10.00 5.00 0.00 BSI in Infants 1501-2500g Neonatal ICU (Blake 10) CDC/NHSN Pooled Mean* Neonatal ICU (Blake 10) CDC/NHSN Pooled Mean* BSI 25.00 20.00 15.00 10.00 5.00 0.00 BSI in Infants >2500g Oct-Dec Neonatal ICU (Blake 10) CDC/NHSN Pooled Mean* *Benchmark is CDC/NSHN Neonatal Critical Care (Level III) Pooled Mean

Page 1324 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Central Line-Associated Bloodstream Infections (CLABSI) per 1000 Central Line Days Critical Care-Pediatrics Pediatric ICU (Bigelow 6) Pediatric ICU (Bigelow 6) 4.76 4.72 0.00 10.71 0.00 0.00 2.51 0.00 CDC/NHSN Pediatric Medical Surgical Critical Care Pooled Mean 3.00 3.00 3.00 2.20 2.20 1.80 1.80 1.80 12.00 Pediatric ICU (Bigelow 6) vs. CDC/NHSN Pediatric Medical Surgical Critical Care Pooled Mean (Major Teaching Hospitals) CLABSI per 1000 Line Days 10.00 8.00 6.00 4.00 2.00 0.00 Pediatric ICU (Bigelow 6) CDC/NHSN Pediatric Medical Surgical Critical Care Pooled Mean

Page 1325 PATIENT FALLS Benchmarking MGH Patient Care Services has continually monitored patient falls and performance improvement activities. MGH Patient Care Services has elected to benchmark patient fall rates against the NDNQI mean for participating hospitals with bed capacity of 500 or greater. Data have been submitted quarterly to NDNQI for 30 adult intensive care and general care units. As of January, the number of units increased to 31 with the opening of a new ICU, Surgical ICU (Blake 12). Quarterly reports present these data for the 31 units by the following unit types: Critical Care - Adult Medical - Adult Medical Surgical Combined Adult Surgical - Adult The quarterly reports are organized by unit level type and compare the outcomes for each unit type to the NDNQI mean. Evaluation and Analysis of Data - July through June An evaluation of data for this two-year period indicates that performance overall is favorable to benchmark. Greater than 50% of units outperform the comparative NDNQI benchmark greater than 50% of the time. Seventeen out of thirty-one units outperformed the mean for five or more quarters equaling 54.84% (see graphs below). MGH also analyzed performance by quarter based on the actual number of units outperforming the benchmark. This additional analysis demonstrates MGH outperformed the NDNQI mean for eight out of eight quarters. (Attachment EP 32EO.w). A summary of performance to benchmark by unit type is as follows: Critical Care Adult o Two units, Medical ICU (Blake 7) and Cardiac Surgical ICU (Blake 8), outperformed the NDNQI mean for all eight quarters. o The Surgical ICU (Blake 12) has experienced zero patient falls, outperforming the NDNQI mean for the two quarters of data reported since the unit s opening. o Two units, Cardiac ICU (Ellison 9) and Neuroscience ICU (Lunder 6-formerly Blake 12), outperformed the NDNQI mean for five out of eight quarters. Medical Adult o The medical adult units have demonstrated a decreasing fall rate trend since July through September of (rate of 4.39 falls/1000 patient days) through quarter seven (January through March ) to a low of 3.15 falls/1000 patient days in quarter, outperforming the NDNQI mean of 3.49 for that same period. Medical Surgical Adult Combined o Neuroscience (Lunder 7 formerly White 12) and Neuroscience (Lunder 8 formerly Ellison 12), experienced variable mean fall rates ranging from a high of 5.96 to a low of 3.05. o Neuroscience (Lunder 7 formerly White 12) outperformed the NDNQI mean for 4 out of 8 quarters and demonstrated a steady decreasing fall rate trend for the past four quarters (7.75 in July-Sept to 2.59 in April-June ) as a result of the efforts described below.

Page 1326 Surgical - Adult o The surgical units combined outperformed the NDNQI mean for eight out of eight quarters. o The surgical unit fall rates range from a high of 2.70 to a low of 1.61. o Three units have demonstrated consistent decreasing fall rate trends: Vascular (Bigelow 14), Thoracic/Medicine (Ellison 19), and General Surgery (Ellison 7). o Three units with opportunities for improvement include Plastics/Burn ICU (Bigelow 13), General Surgery (White 7), and General Surgery (Phillips 22). In addition to outperforming the falls per patient days NDNQI mean, MGH has experienced a continued reduction in falls with injury. The graph below demonstrates MGH s consistent falls with injury reduction trend as a result of improvement efforts and how MGH compares favorably to other hospitals within the Partners Healthcare System. Adult Patient Falls with Injury per 1,000 Patients days Partners Health Care Hospitals 1.8 1.3 0.8 0.3 Q2 11 Q3 11 Q4 11 Q1 12-0.2 Hospital A Hospital B Hospital C MGH Hospital D Hospital E Hospital F The NDNQI benchmark for April through June was not available at the time of the MGH Magnet document submission. The metric used for analysis benchmarking of the 8 th quarter (April-June ) is the 7 th quarter (January through March ) NDNQI mean. An updated version of the graphs will be sent to the Magnet Commission once the comparative benchmark for the eighth quarter is available mid- to late-october. Performance Improvement Initiatives Significant work has been done in creating a fall reduction program as evidenced by greater than 50% of MGH units outperforming the NDNQI mean. The LEAF (Let s Eliminate All Falls) program has been the major initiative throughout the hospital in that has contributed to these results. As demonstrated in NK 7, a multifaceted campaign was implemented to raise staff awareness of the serious implications for patients related to falls. The program also provides proven strategies and tools for staff implementation. These included: o Development and implementation of a fall prevention bundle, including risk assessment, multimodal interventions, and post-fall guidelines and processes. o Staff education strategies; including prevention strategies, patient-centered care plans for prevention of falls, post-fall guidelines

Page 1327 o o o o o Communication of internal resources: Nurse Director, Clinical Nurse Specialist, Geriatric Specialist, Office for Quality and Safety, and Practice Committee. Inclusion of LEAF program in revised Collaborative Governance structure Communication and integration strategies for implementation of hourly rounding Ongoing coaching and monitoring of falls and unit-based falls bundle implementation Partnership with the MGH Center for Quality and Safety to develop MD policies related to the MD role in fall prevention and post-fall care. Many units have fully embraced all of these strategies in their efforts to reduce the risk for patient falls. Other units are working hard to implement the full range of strategies that will lead to improved, sustainable results. And still others have additional challenges that impact the number of falls given the patient populations they serve. However, even with difficult situations, the overall goal for all nursing units is to mitigate the factors that contribute to falls and continue to work towards zero falls. Some of the current strategies include: Continuing the spread of successful strategies to more units Finding new ways to disseminate falls data to inform improvement efforts Increase opportunities for direct care Nursing Staff to participate and drive change. The Collaborative Governance Falls Prevention Committee is the key group to impact many of these strategies. Nurses on this committee share improvement strategies with the team that can be brought back to their units. This will contribute to the spread of innovative ideas to other units. Many of the Staff Nurses who have joined this committee are new to data analysis at an organizational level but are eager to have an impact at a hospital level as well as a unit level. A Nurse Staff Specialist from is working with the membership to develop more comprehensive reports at both the unit and organizational level that will assist the committee to focus on specific areas in need of improvement as well as celebration. As a first step the committee has recognized through safety report activity that many patient falls are related to related to toileting, either while ambulating to the bathroom/commode or being left unattended in the bathroom/commode. During the July 19, Falls Prevention Committee meeting, the group discussed an opportunity to review our practice related to assisting patients to and from toileting as well as implementing a strategy to remain within an arms length during toileting. We currently are in the process of exploring this practice change including the development of education and implementation plans (Attachment EP 32EO.v).

Page 1328 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Falls per 1000 Patient Days Medical-Adult General Medicine (White 11) General Medicine (White 11) 4.76 2.43 4.01 4.48 6.00 2.60 4.39 4.59 NDNQI Medical-Adult Mean 3.95 3.91 3.87 3.64 3.72 3.76 3.49 3.49 10.00 General Medicine (White 11) vs. NDNQI Medical-Adult Mean Falls per 1000 Patient Days 8.00 6.00 4.00 2.00 0.00 General Medicine (White 11) NDNQI Medical-Adult Mean General Medicine (White 9) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Medicine (White 9) 2.82 2.87 5.00 4.47 1.94 3.64 2.42 2.02 NDNQI Medical-Adult Mean 3.95 3.91 3.87 3.64 3.72 3.76 3.49 3.49 10.00 General Medicine (White 9) vs. NDNQI Medical-Adult Mean Falls per 1000 Patient Days 8.00 6.00 4.00 2.00 0.00 General Medicine (White 9) NDNQI Medical-Adult Mean

Page 1329 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Falls per 1000 Patient Days Medical-Adult Cardiac Medicine (Ellison 10) Cardiac Medicine (Ellison 10) 3.98 3.01 2.67 3.35 1.98 2.68 2.99 3.85 NDNQI Medical-Adult Mean 3.95 3.91 3.87 3.64 3.72 3.76 3.49 3.49 10.00 Cardiac Med (Ellison 10) vs. NDNQI Medical-Adult Mean Falls per 1000 Patient Days 8.00 6.00 4.00 2.00 0.00 Cardiac Medicine (Ellison 10) NDNQI Medical-Adult Mean Cardiac Intervention (Ellison 11) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Cardiac Intervention (Ellison 11) 1.97 3.11 1.18 2.43 0.81 4.24 2.39 3.16 NDNQI Medical-Adult Mean 3.95 3.91 3.87 3.64 3.72 3.76 3.49 3.49 10.00 Cardiac Intervention (Ellison 11) vs. NDNQI Medical-Adult Mean Falls per 1000 Patient Days 8.00 6.00 4.00 2.00 0.00 Cardiac Intervention (Ellison 11) NDNQI Medical-Adult Mean

Page 1330 Falls per 1000 Patient Days Medical-Adult General Medicine (Ellison 16) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Medicine (Ellison 16) 7.07 3.62 2.96 4.05 4.95 2.18 4.37 5.43 NDNQI Medical-Adult Mean 3.95 3.91 3.87 3.64 3.72 3.76 3.49 3.49 10.00 General Medicine (Ellison 16) vs. NDNQI Medical-Adult Mean Falls per 1000 Patient Days 8.00 6.00 4.00 2.00 0.00 General Medicine (Ellison 16) NDNQI Medical-Adult Mean General Medicine (Phillips 20) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Medicine (Phillips 20) 3.37 3.31 1.12 4.54 2.86 6.48 0.58 1.72 NDNQI Medical-Adult Mean 3.95 3.91 3.87 3.64 3.72 3.76 3.49 3.49 10.00 General Medicine (Phillips 20) vs. NDNQI Medical-Adult Mean Falls per 1000 Patient Days 8.00 6.00 4.00 2.00 0.00 General Medicine (Phillips 20) NDNQI Medical-Adult Mean

Page 1331 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Falls per 1000 Patient Days Medical-Adult General Medicine (White 8) General Medicine (White 8) 6.25 2.21 5.29 0.47 4.10 5.17 2.85 4.67 NDNQI Medical-Adult Mean 3.95 3.91 3.87 3.64 3.72 3.76 3.49 3.49 10.00 General Medicine (White 8) vs. NDNQI Medical-Adult Mean Falls per 1000 Patient Days 8.00 6.00 4.00 2.00 0.00 General Medicine (White 8) NDNQI Medical-Adult Mean General Medicine (White 10) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Medicine (White 10) 5.27 6.89 4.17 4.21 0.00 7.91 3.62 6.91 NDNQI Medical-Adult Mean 3.95 3.91 3.87 3.64 3.72 3.76 3.49 3.49 10.00 General Medicine (White 10) vs. NDNQI Medical-Adult Mean Falls per 1000 Patient Days 8.00 6.00 4.00 2.00 0.00 General Medicine (White 10) NDNQI Medical-Adult Mean

Page 1332 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Falls per 1000 Patient Days Medical-Adult General Medicine (Bigelow 11) General Medicine (Bigelow 11) 4.12 9.64 6.20 3.89 4.77 3.56 3.44 2.41 NDNQI Medical-Adult Mean 3.95 3.91 3.87 3.64 3.72 3.76 3.49 3.49 12.00 General Medicine (Bigelow 11) vs. NDNQI Medical-Adult Mean Falls per 1000 Patient Days 10.00 8.00 6.00 4.00 2.00 0.00 General Medicine (Bigelow 11) NDNQI Medical-Adult Mean Respiratory Acute Care & Medicine (Bigelow 9) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Respiratory Acute Care & Medicine (Bigelow 9) 2.58 5.07 3.15 0.00 4.75 1.43 1.30 2.58 NDNQI Medical-Adult Mean 3.95 3.91 3.87 3.64 3.72 3.76 3.49 3.49 10.00 Respiratory Acute Care & Medicine (Bigelow 9) vs. NDNQI Medical-Adult Mean Falls per 1000 Patient Days 8.00 6.00 4.00 2.00 0.00 Respiratory Acute Care & Medicine (Bigelow 9) NDNQI Medical-Adult Mean

Page 1333 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Hem/Onc/BMT (Lunder 10 - formerly Ellison 14) Falls per 1000 Patient Days Medical-Adult Hem/Onc/BMT (Lunder 10 - formerly Ellison 14) 6.67 2.06 3.21 3.79 4.62 2.24 3.64 2.12 NDNQI Medical-Adult Mean 3.95 3.91 3.87 3.64 3.72 3.76 3.49 3.49 10.00 Hem/Onc/BMT (Lunder 10 - formerly Ellison 14) vs. NDNQI Medical-Adult Mean Falls per 1000 Patient Days 8.00 6.00 4.00 2.00 0.00 Hem/Onc/BMT (Lunder 10 - formerly Ellison 14) NDNQI Medical-Adult Mean Lunder 9 (formerly Phillips House 21) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Lunder 9 (formerly Phillips House 21) 2.79 3.94 6.84 2.88 1.46 4.90 4.24 3.17 NDNQI Medical-Adult Mean 3.95 3.91 3.87 3.64 3.72 3.76 3.49 3.49 Falls per 1000 Patient Days 10.00 8.00 6.00 4.00 2.00 Lunder 9 (formerly Phillips House 21) vs. NDNQI Medical-Adult Mean 0.00 Lunder 9 (formerly Phillips House 21) NDNQI Medical-Adult Mean

Page 1334 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Falls per 1000 Patient Days Surgical-Adult Plastic/Burn ICU (Bigelow 13) Plastic/Burn ICU (Bigelow 13) 0.00 0.60 0.59 1.81 3.54 1.23 3.77 2.47 NDNQI Surgical-Adult Mean 2.64 2.72 2.74 2.67 2.57 2.57 2.64 2.64 7.00 Plastic/Burn ICU (Bigelow 13) vs. NDNQI Surgical-Adult Mean Falls per 1000 Patient Days 6.00 5.00 4.00 3.00 2.00 1.00 0.00 Plastic/Burn ICU (Bigelow 13) NDNQI Surgical-Adult Mean Vascular (Bigelow 14) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Vascular (Bigelow 14) 4.33 3.43 1.75 3.47 0.45 0.93 1.40 2.82 NDNQI Surgical-Adult Mean 2.64 2.72 2.74 2.67 2.57 2.57 2.64 2.64 7.00 Vascular (Bigelow 14) vs. NDNQI Surgical-Adult Mean Falls per 1000 Patient Days 6.00 5.00 4.00 3.00 2.00 1.00 0.00 Vascular (Bigelow 14) NDNQI Surgical-Adult Mean

Page 1335 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Falls per 1000 Patient Days Surgical-Adult Orthopaedics (Ellison 6) Orthopaedics (Ellison 6) 1.03 2.00 2.06 1.05 2.81 0.76 3.34 0.72 NDNQI Surgical-Adult Mean 2.64 2.72 2.74 2.67 2.57 2.57 2.64 2.64 Falls per 1000 Patient Days 7.00 6.00 5.00 4.00 3.00 2.00 1.00 Orthopaedics (Ellison 6) vs. NDNQI Surgical-Adult Mean 0.00 Orthopaedics (Ellison 6) NDNQI Surgical-Adult Mean Gyn./Oncology (Phillips House 21 - formerly Bigelow 7) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Gyn./Oncology (Phillips House 21 - formerly Bigelow 7) 0.68 3.33 2.00 5.51 0.67 2.26 3.05 1.30 NDNQI Surgical-Adult Mean 2.64 2.72 2.74 2.67 2.57 2.57 2.64 2.64 Falls per 1000 Patient Days 7.00 6.00 5.00 4.00 3.00 2.00 1.00 0.00 Gyn./Oncology (Phillips House 21 - formerly Bigelow 7) vs. NDNQI Surgical-Adult Mean Gyn./Oncology (Phillips House 21 - formerly Bigelow 7) NDNQI Surgical-Adult Mean

Page 1336 Falls per 1000 Patient Days Surgical-Adult General Surgery (Ellison 7) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Surgery (Ellison 7) 3.42 3.83 2.88 3.92 1.34 1.46 4.29 2.54 NDNQI Surgical-Adult Mean 2.64 2.72 2.74 2.67 2.57 2.57 2.64 2.64 7.00 General Surgery (Ellison 7) vs. NDNQI Surgical-Adult Mean Falls per 1000 Patient Days 6.00 5.00 4.00 3.00 2.00 1.00 0.00 General Surgery (Ellison 7) NDNQI Surgical-Adult Mean Cardiac Surgery (Ellison 8) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Cardiac Surgery (Ellison 8) 1.89 2.61 2.30 3.08 2.28 1.23 0.38 0.39 NDNQI Surgical-Adult Mean 2.64 2.72 2.74 2.67 2.57 2.57 2.64 2.64 7.00 Cardiac Surgery (Ellison 8) vs. NDNQI Surgical-Adult Mean Falls per 1000 Patient Days 6.00 5.00 4.00 3.00 2.00 1.00 0.00 Cardiac Surgery (Ellison 8) NDNQI Surgical-Adult Mean

Page 1337 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Falls per 1000 Patient Days Surgical-Adult General Surgery (Phillips 22) General Surgery (Phillips 22) 4.16 2.34 1.19 1.84 2.35 3.98 4.25 3.29 NDNQI Surgical-Adult Mean 2.64 2.72 2.74 2.67 2.57 2.57 2.64 2.64 Falls per 1000 Patient Days 7.00 6.00 5.00 4.00 3.00 2.00 1.00 0.00 General Surgery (Phillips 22) vs. NDNQI Surgical-Adult Mean General Surgery (Phillips 22) NDNQI Surgical-Adult Mean Orthopaedics (White 6) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Orthopaedics (White 6) 1.18 1.15 1.54 1.60 4.50 2.17 1.25 2.42 NDNQI Surgical-Adult Mean 2.64 2.72 2.74 2.67 2.57 2.57 2.64 2.64 7.00 Orthopaedics (White 6) vs. NDNQI Surgical-Adult Mean Falls per 1000 Patient Days 6.00 5.00 4.00 3.00 2.00 1.00 0.00 Orthopaedics (White 6) NDNQI Surgical-Adult Mean

Page 1338 Falls per 1000 Patient Days Surgical-Adult General Surgery (White 7) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 General Surgery (White 7) 3.43 3.02 0.89 2.63 2.16 1.41 0.89 4.51 NDNQI Surgical-Adult Mean 2.64 2.72 2.74 2.67 2.57 2.57 2.64 2.64 7.00 General Surgery (White 7) vs. NDNQI Surgical-Adult Mean Falls per 1000 Patient Days 6.00 5.00 4.00 3.00 2.00 1.00 0.00 General Surgery (White 7) NDNQI Surgical-Adult Mean Transplant (Blake 6) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Transplant (Blake 6) 0.72 4.56 1.50 1.53 2.99 1.63 6.46 2.37 NDNQI Surgical-Adult Mean 2.64 2.72 2.74 2.67 2.57 2.57 2.64 2.64 7.00 Transplant (Blake 6) vs. NDNQI Surgical-Adult Mean Falls per 1000 Patient Days 6.00 5.00 4.00 3.00 2.00 1.00 0.00 Transplant (Blake 6) NDNQI Surgical-Adult Mean

Page 1339 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Falls per 1000 Patient Days Surgical-Adult Thoracic/Medicine (Ellison 19) Thoracic/Medicine (Ellison 19) 4.39 3.29 3.08 2.93 2.43 1.80 1.67 2.08 NDNQI Surgical-Adult Mean 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 7.00 Thoracic/Medicine (Ellison 19) vs. NDNQI Surgical-Adult Mean Falls per 1000 Patient Days 6.00 5.00 4.00 3.00 2.00 1.00 0.00 Thoracic/Medicine (Ellison 19) NDNQI Surgical-Adult Mean

Page 1340 Falls per 1000 Patient Days Med-Surg Comb.-Adult Neuroscience (Lunder 8 - formerly Ellison 12) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Neuroscience (Lunder 8 - formerly Ellison 12) 3.21 3.83 4.30 3.29 4.71 3.74 5.14 4.00 NDNQI Med-Surg Comb.-Adult Mean 3.65 3.71 3.42 3.45 3.42 3.43 3.47 3.47 12.00 Neuroscience (Lunder 8 - formerly Ellison 12) vs. NDNQI Med-Surg Comb.-Adult Mean Falls per 1000 Patient Days 10.00 8.00 6.00 4.00 2.00 0.00 Neuroscience (Lunder 8 - formerly Ellison 12) NDNQI Med-Surg Comb.-Adult Mean Neuroscience (Lunder 7 - formerly White 12) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Neuroscience (Lunder 7 - formerly White 12) 3.42 1.90 4.95 5.89 7.75 3.30 3.75 2.59 NDNQI Med-Surg Comb.-Adult Mean 3.65 3.71 3.42 3.45 3.42 3.43 3.47 3.47 12.00 Neuroscience (Lunder 7 - formerly White 12) vs. NDNQI Med-Surg Comb.-Adult Mean Falls per 1000 Patient Days 10.00 8.00 6.00 4.00 2.00 0.00 Neuroscience (Lunder 7 - formerly White 12) NDNQI Med-Surg Comb.-Adult Mean

Page 1341 Falls per 1000 Patient Days Critical Care-Adult Cardiac Surgical ICU (Blake 8) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Cardiac Surgical ICU (Blake 8) 1.05 0.00 0.00 0.00 0.97 0.00 0.83 0.84 NDNQI Critical Care-Adult Mean 1.06 1.01 1.02 0.96 0.99 0.98 0.91 0.91 5.00 Cardiac Surgical ICU (Blake 8) vs. NDNQI Critical Care-Adult Mean Falls per 1000 Patient Days 4.00 3.00 2.00 1.00 0.00 Cardiac Surgical ICU (Blake 8) NDNQI Critical Care-Adult Mean Cardiac ICU (Ellison 9) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Cardiac ICU (Ellison 9) 0.00 0.80 0.87 0.85 1.79 0.00 1.63 1.86 NDNQI Critical Care-Adult Mean 1.06 1.01 1.02 0.96 0.99 0.98 0.91 0.91 5.00 Cardiac ICU (Ellison 9) vs. NDNQI Critical Care-Adult Mean Falls per 1000 Patient Days 4.00 3.00 2.00 1.00 0.00 Cardiac ICU (Ellison 9) NDNQI Critical Care-Adult Mean

Page 1342 Falls per 1000 Patient Days Critical Care-Adult Medical ICU (Blake 7) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Medical ICU (Blake 7) 0.00 0.00 0.00 0.00 0.70 0.73 0.69 0.70 NDNQI Critical Care-Adult Mean 1.06 1.01 1.02 0.96 0.99 0.98 0.91 0.91 Falls per 1000 Patient Days 5.00 4.00 3.00 2.00 1.00 Medical ICU (Blake 7) vs. NDNQI Critical Care-Adult Mean 0.00 Medical ICU (Blake 7) NDNQI Critical Care-Adult Mean Surgical ICU (Ellison 4) Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Surgical ICU (Ellison 4) 0.64 1.92 1.31 0.63 0.62 1.99 1.99 1.42 NDNQI Critical Care-Adult Mean 1.06 1.01 1.02 0.96 0.99 0.98 0.91 0.91 5.00 Surgical ICU (Ellison 4) vs. NDNQI Critical Care-Adult Mean Falls per 1000 Patient Days 4.00 3.00 2.00 1.00 0.00 Surgical ICU (Ellison 4) NDNQI Critical Care-Adult Mean

Page 1343 Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Falls per 1000 Patient Days Critical Care-Adult Surgical ICU (Blake 12) Surgical ICU (Blake 12) N/A* N/A* N/A* N/A* N/A* N/A* 0.00 0.00 NDNQI Critical Care-Adult Mean N/A* N/A* N/A* N/A* N/A* N/A* 0.91 0.91 5.00 Surgical ICU (Blake 12) vs. NDNQI Critical Care-Adult Mean Falls per 1000 Patient Days 4.00 3.00 2.00 1.00 0.00 *No data; unit opened in FY Q1. Surgical ICU (Blake 12) NDNQI Critical Care-Adult Mean Fiscal Year/Quarter Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Neuroscience ICU (Lunder 6 - formerly Blake 12) Neuroscience ICU (Lunder 6 - formerly Blake 12) 2.70 0.00 2.12 0.71 0.64 2.28 0.59 0.59 NDNQI Critical Care-Adult Mean 1.06 1.01 1.02 0.96 0.99 0.98 0.91 0.91 5.00 Neuroscience ICU (Lunder 6 - formerly Blake 12) vs. NDNQI Critical Care-Adult Mean Falls per 1000 Patient Days 4.00 3.00 2.00 1.00 0.00 Neuroscience ICU (Lunder 6 - formerly Blake 12) NDNQI Critical Care-Adult Mean

Attachment EP 32 EO.a Page 1344 Jeanette Ives Erickson Nursing-sensitive indicators paint vivid picture of organizational commitment Today, nursingsensitive indicators are widely used as a barometer of quality care by the Centers for Medicare and Medicaid, the Patient Care Link, the National Quality Forum, and the Magnet Recognition Program. The use of nursing-sensitive indicators as a measure of quality care is a relatively new development in the healthcare industry. It wasn t until the mid- 1990s that many national healthcare organizations and regulatory agencies began to recognize a correlation between certain interventions performed by nurses and the overall quality and safety performance of healthcare institutions. In 1998, the Na tional Database of Nursing Quality Indicators (NDNQI) was established by the ANA to begin formally collecting data related to (at that time) ten nursing-sensitive quality indicators. In 2002, the Joint Commission started incorporating nursing-sensitive indicators into its standards for accreditation. And today, nursing-sensitive indicators are widely used as a barometer of quality care by the Centers for Medicare and Medicaid (CMS), the Patient Care Link (formerly Patients First), the National Quality Forum (NQF), and the Magnet Recognition Program (the American Nurses Credentialing Center). A broad definition of nursing-sensitive quality indicators might be: a set of standardized performance measures intended to help hospitals assess the extent to which nursing interventions have an impact on patient safety, quality, and the professional work environment. A partial list of nursing-sensitive indicators includes: Jeanette Ives Erickson, RN, senior vice president for Patient Care and chief nurse Mix of nurses and unlicensed staff caring for patients in the acute-care setting Total nursing-care hours provided per patient day Nosocomial infections Patient falls Pressure ulcer rate Patient satisfaction with overall care Patient satisfaction with nursing care Patient satisfaction with pain-management Patient satisfaction with educational information Staff nurse satisfaction If you think about what the data related to these indicators says about a particular healthcare organization, it really does paint a vivid picture of its commitment to, and focus on, quality and safety. Our interest in nursing-sensitive indicators dovetails with the new model put forth by the Amer ican Nurses Credentialing Center (ANCC) for the Magnet Recognition Program. In an effort to provide greater clarity and eliminate redundancy among the 14 Forces continued on next page Page 2 Caring Headlines April 7,

Attachment EP 32 EO.a continued Page 1345 Jeanette Ives Erickson (continued) When looked at over time, this data tells a story important themes and trends emerge that inform our practice and drive organizational decision-making. But to derive the most benefi t from this data, we need to share it with clinicians at the unit level. of Magnetism, the ANCC s new model re-configures the Forces into five components placing less emphasis on process and structure and more on outcomes. The Forces continue to be the foundation of the Magnet Recognition Program, but going forward, the primary question will shift away from, What do you do, and how do you do it? toward, What difference are you making? The new configuration puts Em pirical Outcomes at the center of the model supported by Structural Empowerment; Exemplary Professional Practice; New Knowledge, Innovations, and Improve ments, and Transformational Leadership. For several years we have collected data for our own internal use and for inclusion in a number of national databases (NDNQI, CDC, and others). We ve collected data to accompany our application for Magnet recognition and re-designation. When looked at over time, this data tells a story important themes and trends emerge that inform our practice and drive organizational decision-making. But to derive the most benefit from this data, we need to share it with clinicians at the unit level. We need to engage in conversations about what this data means and how we can craft improvements based on what it s telling us. We need to close that information loop. Starting this month, the PCS Office of Quality & Safety will assist us in this effort by preparing quarterly reports reflecting the data collected on each unit and sharing those reports with nursing directors. These unit-specific reports will serve as a tool to help staff identify unfavorable trends, brainstorm, and implement solutions. In this Issue Occupational Therapy...1 Jeanette Ives Erickson...2 Nursing-Sensitive Indicators Occupational Therapy Month...4 The Wii Comes to Blake 11...6 Clinical Narrative...8 Claire demercado, RN We ve already learned a great deal from data related to nursing-sensitive indicators. We ve developed new programs and initiatives based on the stories embedded in this data. Our LEAF program (Lets Eliminate All Falls) is an excellent example. Led by Deborah D Avolio, RN, LEAF is a comprehensive, evidencebased, fall-prevention program that has been rolled out on all inpatient units. The program uses a universal train-the-trainer approach to educate staff on all aspects of fall-prevention with special considerations for older and other at-risk patient populations. (Look for more about the LEAF program in future issues of Caring Headlines). Safety rounds is another initiative related to nursing-sensitive indicators. Studies show that rounding regularly in patient rooms to assess the seven Ps (Person, Plan, Priorities, Personal hygiene, Pain-management, Position, and Presence) has a dramatic affect on many of the areas measured by nursing-sensitive indicators (reducing falls and pressure ulcers, improving painmanagement, and increasing patient-satisfaction). Nursing-sensitive quality indicators are just another way of describing our efforts to achieve Excellence Every Day. It s important to remember: we don t strive for excellence just to raise a score on a spreadsheet. We strive for excellence to ensure our patients needs are met, to ensure they re safe and comfortable, and to ensure they consistently receive the highest-quality care we can provide. For more information about nursing-sensitive indicators, call Keith Perleberg, RN, director of the PCS Office of Quality & Safety at 3-0435. A Week in Burundi...10 New Graduate in Critical Care Nursing Program...12 Fielding the Issues...14 IPOP vs. VPOP Announcements...15 Vascular Nursing Lunch & Learn...16 April 7, Caring Headlines Page 3

Page 1346 BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK Patient=s Name Evaluator=s Name Date of Assessment SENSORY PERCEPTION ability to respond meaningfully to pressure-related discomfort 1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of con-sciousness or sedation. OR limited ability to feel pain over most of body 2. Very Limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over 2 of body. 3. Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. 4. No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.. MOISTURE degree to which skin is exposed to moisture 1. Constantly Moist Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. 2. Very Moist Skin is often, but not always moist. Linen must be changed at least once a shift. 3. Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day. 4. Rarely Moist Skin is usually dry, linen only requires changing at routine intervals. ACTIVITY degree of physical activity 1. Bedfast Confined to bed. 2. Chairfast Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 3. Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair 4. Walks Frequently Walks outside room at least twice a day and inside room at least once every two hours during waking hours MOBILITY ability to change and control body position 1. Completely Immobile Does not make even slight changes in body or extremity position without assistance 2. Very Limited Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. 3. Slightly Limited Makes frequent though slight changes in body or extremity position independently. 4. No Limitation Makes major and frequent changes in position without assistance. NUTRITION usual food intake pattern 1. Very Poor Never eats a complete meal. Rarely eats more than a of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR is NPO and/or maintained on clear liquids or IV=s for more than 5 days. 2. Probably Inadequate Rarely eats a complete meal and generally eats only about 2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR receives less than optimum amount of liquid diet or tube feeding 3. Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs 4. Excellent Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation. FRICTION & SHEAR 1. Problem Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction 2. Potential Problem Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. 3. No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair. 8 Copyright Barbara Braden and Nancy Bergstrom, 1988 All rights reserved Total Score

Attachment EP 32 EO.c Page 1347

Attachment EP 32 EO.d Page 1348 Pressure Ulcer Strategic Initiative Task Force Team Lead: Project Specialist: Virginia Capasso, PhD, ANP-BC, CWS Amanda Coakley, PhD, RN Executive Sponsors: Theresa Gallivan, MS, RN Gaurdia Banister, PhD, RN Members: Zary Amirhosseini Barbara Blakeney, RN Gino Chisari, RN; Deborah D Avolio, RN; Linda Brandt, RN; Jacqui Collins, RN Pat English, RRT Anthony Fataldo, RPh Deb Frost, RN; Susan Gavaghan, RN Patricia Grella, RN; Judith Gullage, R Deborah Jameson Maureen McCarthy, RN Nancy McCarthy, RN Joyce McIntyre, RN Mary O Brien, RN Charlene O Connor, RN Jill Pedro, RN Lori Powers Claire Seguin, RN. Sandra Silvestri, RN Tiash Sinha, RD Karen Waak, DPT

Attachment EP 32 EO.e Page 1349 Munn Award info sessions To: Capasso, Virginia,Ph.D.,N.P., R.N. Subject: RE: Implementation of the "Save Our SKIN (S.O.S.) " Campaign Dear colleagues, First of all, we have fabulous news: our pressure ulcer rate for September, was 1.7%!!! This reflects a decrease for three consecutive quarters (March, : 2.8%; June, : 1.9%; September, : 1.7%). Thanks to you and your staff for all you have done to achieve progress toward our desired outcome of 0%. During the first week of September,, the S.O.S. toolboxes were ready for pick-up (with the exception of those units transferring to the Lunder Building) from Theresa Rico on Founders 3. During the next few weeks, there were a few discussions about the S.O.S. Campaign in several forums. A small group of CNSs who belong to both the CNS Wound Care Task Force and the Pressure Ulcer Strategic Initiative Task Force met and agreed that the Campaign should continue as initially rolled-out for 8 weeks before evaluation and possible modification.thus, next week, you will be asked to complete a qualitative evaluation of components of the S.O.S. Campaign. To get a feel for the status of implementation, would you please reply to this email and answer the following questions: Unit: Y N PINS distributed to staff Y N POSTERS displayed Y N MAGNETS displayed on (non-lunder) doorframes to indicate Braden Score < 9 Y N "Huddle" occurs when new pressure ulcer is discovered Y N "Huddle" form is completed when new pressure ulcer is detected Y N Completed "Huddle" form is faxed to Deb Frost, PCS Quality & Safety Y N "Huddle" form is completed when weekly follow-up occurs on pressure ulcer Y N Safety reports are now completed for Stage II, as well as Stage III and Stage IV pressure ulcers Y N Each week, documentation is audited in two randomly selected charts Y N Occlusive and long-wear dressings are changed and dated every three days Other comments: In advance, thank you for taking the time to respond. Ginger Virginia Capasso, PhD, ANP-BC, CWS Clinical Nurse Specialist, Institute for Patient Care Nurse Scientist, Munn Center for Nursing Research Co-Director, Wound Care Center 55 Fruit Street (FND 341) Boston, MA 02114 Monday - Wednesday: 617-726-2066 (Page, 24/7) Thursday - Friday: 617-726-2760 Fax: 617-724-3754 Email: vcapasso@partners.org

Attachment EP 32.EO.f Page 1350 Preventing Pressure Ulcers While You are in the Hospital When you are in the hospital, you can develop a sore on your skin called a pressure ulcer. Since pressure ulcers can slow your recovery, preventing pressure ulcers is very important to the staff of. This flyer tells you what you and your caregivers can do to protect your skin and prevent pressure ulcers. What is a pressure ulcer? A pressure ulcer is a sore caused by lying or sitting in one place for a long time. Your skin and muscles are pressed between your tailbone, hipbone, heels or other bones and the bed or chair. This pressure slows the blood flow. Your skin and muscles do not get the oxygen and nutrients that you need to stay healthy and this can cause a pressure ulcer. There are many things that can increase your chance of having a pressure ulcer including: Infections Poor blood flow Trouble moving or changing position Sliding down in the bed or chair Rubbing your skin often Loss of bowel or bladder control (incontinence) Problems feeling pressure or pain What can we do to stop pressure ulcers? There are many things we can do together to decrease the chance that you will have a pressure ulcer while you are in the hospital. Look at your skin. We will look at your skin every day. This lets us see any early signs of a pressure ulcer. Tell your nurse if you see any redness on your skin, have pain, or decreased feeling in an area of your body.

Attachment EP 32.EO.f continued Page 1351 Keep moving! Change your position about every 2 hours when in bed. Change your position about every 15 minutes when in a chair. Do not sit up in a chair for more than 2 hours at a time. We will remind you to change your position when you are in the bed or a in a chair. We will help you to move and change your position as needed. Decrease the pressure. All standard mattresses at MGH help relieve pressure. We will get you a special chair pad if you need it. If you have an injury to your skin, your nurse will consult with the clinical nurse specialist or physical therapist to see if a different mattress or chair pad is needed. Keep your skin clean and dry. It is important to wash and dry yourself well. We will help you bathe if needed. Some patients can t control their bowel or bladder. This is called incontinence. When we visit you every 1-2 hours, we will help you use the bathroom and take care of your skin. Eat a healthy diet. Eat the food served at mealtimes. Drink liquids and nutritional supplements if they are ordered. We will help you to eat and drink as needed. Ask questions! Ask your nurse, clinical nurse specialist or doctor questions about your skin and your care. Write questions for your caregivers here: Taking care of your skin is very important to us. By working together, we can help to prevent pressure ulcers when you are in the hospital.

Attachment EP 32 EO.g Page 1352 EXCELLENCE EVERY DAY PORTAL click here Home About Us Excellence Every Day represents an MGH commitment to providing the highest quality, safest care that meets or exceeds all standards set by the hospital and external organizations. Portal Pages Scavenger Hunt Glossary External Resources Contact Us Other Topics: Central Lines Disabilities Diversity Ethics Fall Prevention Geriatrics Pain Patient Education/Health Literacy Patient Experience Pressure Ulcers Professional Development Restraints EED Home A focus on pressure ulcers preventing the most frequent and costliest hospital-acquired condition AN MGH NARRATIVE One of our patients, Ms. L, whose medical history and hospital course were extremely complicated, manifested a number of the risk factors for the development of pressure ulcers and illustrates the challenges facing providers who are trying to heal pressure ulcers. more... Heather Szymczak, RN, staff nurse, Internal Medical Associates, Urgent Care Clinic, previously a staff nurse on Ellison 22, Surgical THE DATA IMPROVEMENT INITIATIVES FYIs All Hospital-Acquired Pressure Ulcer Prevalence (point prevalence = % of patients) TREND: better than benchmark. Preliminary results show a decline in MGH prevalence of hospital-acquired pressure ulcers in 2.7% in March, 1.9% in June, and 1.7% in September. CLICK HERE for additional data Oct-Dec11 Adult MGH NDNQI Critical Care 6.06 8.13 Surgical 2.08 2.50 Medical 3.28 2.77 Med-Surg 1.96 2.33 Psychiatry 0.00 2.77 Jul-Sept 11 Adult MGH NDNQI Critical Care 6.49 8.22 Surgical 1.53 2.00 Medical 2.73 2.94 Med-Surg 1.82 2.08 Psychiatry 4.76 2.94 Preventing hospital-acquired pressure ulcers is a top priority for healthcare organizations across the country. At MGH, the interdisciplinary Pressure Ulcer Strategic Initiative Task Force helps educate staff throughout the hospital about best practices related to preventing hospital-acquired pressure ulcers. In recent months, the Task Force adopted a Save Our SKIN (SOS) campaign that deputizes all staff as SKIN Savers and employs the SKIN Bundle as a framework for safe SKIN practices. Preliminary results show a decline in MGH prevalence of hospital-acquired pressure ulcers in 2.7% in March, 1.9% in June, and 1.7% in September. SOS Toolkit SOS Poster Patient and Family Fact Sheet Wound Measurement Sticker Ulcer Documentation Audit Tool Huddle Data Form Policies, Procedures & Guidelines: (TROVE: internal access only) 2.7.1 Wound Care Product Formulary 16-8-1 Nursing Practice Guideline For Skin and Wound Care Interventions Specific to Braden / Braden Q Subscales Appendix A Braden Scale Appendix B Braden Q Scale Skin Integrity Problem List (Internal Access Only) Practice & Quality Subcommittee: Skin Care - Meets: 4th Tuesday monthly 1:00pm-3:00pm Yawkey 2-210 Conference Room NDNQI Benchmark: hospitals with 500+ beds Green = Favorable Red = Unfavorable IN THE NEWS Are you on board with the Save Our SKIN' Campaign?" Caring Headlines, July 21, What are pressure ulcers and how do you prevent them?" Caring Headlines, April 15, Raising the bar on patient safety Caring Headlines, March 4, PRESSURE ULCER RESOURCES

Attachment EP 32 EO.g continued Page 1353 MGH Resources Risk assessment tool: Braden Scale Pressure ulcer staging: National Dataset of Nursing Quality Indicators (NDNQI) Online Education Program HealthStream Offerings (internal access only) Save Our SKIN (available January, ) MGH Braden Scale Measurement of Risk for Pressure Ulcer Development Pressure Ulcer Prevention MGH Contacts: Pressure Ulcer Champions (Collaborative Governance) Clinical Nurse Specialist (CNS) Group Co-Chairs: Hannah Lyons, MSN, RN, BC, AOCN Paul Arnstein, RN, PhD, FAAN CNS Wound Care Task Force Co-Chairs: Susan L. Wood, MSN, ANP-BC Yassaman Khalili, MSc, RN Pressure Ulcer Strategic Initiative Task Force External Resources Agency for Healthcare Research and Quality (AHRQ) The mission of AHRQ is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. National Guideline Clearinghouse AHRQ pressure ulcer toolkit American Academy of Wound Management (AAWM) A national inter-disciplinary certifying board for healthcare professionals involved in wound care. American College of Certified Wound Specialists (ACCWS) Comprised of interdisciplinary wound care professionals who are certified as Certified Wound Specialists (CWS ). The ACCWS provides education, informational resources and research avenues to enhance the knowledge, skills, professional performance and relationships required by health professionals to serve their patients, public, and professions. Association for the Advancement of Wound Care (AAWC) A multidisciplinary organization that spreads awareness about advanced, evidence based wound care by promoting excellence in education, clinical practice, public policy, and research. (Membership required.) AAWC Pressure Ulcer Guidelines () MedlinePlus (National Library of Medicine and the National Institutes of Health): A comprehensive directory that links to different educational resources from reputable organizations on a variety of health topics. National Pressure Ulcer Advisory Panel (NPUAP) An independent not-for-profit professional organization dedicated to the prevention and management of pressure ulcers. NPUAP Pressure Ulcer Guidelines (2009) World Union of Wound Healing Societies (WUWHS) The mission of the WUWHS is to enhance the life of persons with wounds worldwide. Wound Healing Society Composed of clinical and basic scientists and wound care specialists, the mission of the WHS is to improve wound healing outcomes through science, professional education, and communication. Wound Ostomy Continence Nursing (WOCN) A professional nursing society that supports its members by promoting educational, clinical, and research opportunities to advance the practice and guide the delivery of expert health care to individuals with wounds, ostomies, and incontinence. (Membership required.) WOCN Pressure Ulcer Guidelines () EXTERNAL REVIEWERS Magnet Recognition National Patient Safety Goal 14.01.01 Pressure Ulcers (Risk assessment tools, preventative actions) Joint Commission Accreditation Manual The American Nurses Credentialing Center (ANCC) requires Magnet-designated organizations to track nationally-benchmarked nursing sensitive indicators (NSIs) to continually inform improvement efforts related enhance patient outcomes. Examples of NSIs include, but are not limited to: patient falls, hospital-acquired pressure ulcers, blood stream infections, ventilator-associated pneumonia, and restraint use. Centers for Medicare and Medicaid Services (CMS) GLOSSARY OF TERMS click here... There are numerous terms and acronyms in healthcare that may be unfamiliar. Please click here to visit a Glossary of Terms that may be helpful. And please email any suggested additions. This month's featured term: Pressure Ulcer A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are associated with formation of pressure ulcers. (National Pressure Ulcer Advisory Panel, ) Excellence Every Day represents an MGH commitment to providing the highest quality, safest care that meets or exceeds all standards set by the hospital and external organizations. If you have questions or suggestions related to the EED portal, please contact Georgia Peirce at (617) 724-9865 or via email at gwpeirce@partners.org. updated 4/4/12

Attachment EP 32 EO.h Page 1354 Fielding the Issues What are pressure ulcers and how do you prevent them? Question: What is a pressure ulcer? Jeanette: A pressure ulcer is a localized injury to the skin or underlying tissue as a result of pressure, or pressure in combination with shearing or friction. Pressure ulcers can develop quickly when circulation is compromised, and they re often difficult to heal. When they do occur, they put patients at risk for infection and prolonged hospitalization as well as adding to their emotional and financial burden. The National Pressure Ulcer Advisory Panel has defined stages of pressure ulcers based on amount of tissue that s affected. These guidelines are available at: http://www.npuap.org/pr2.htm, and will soon be added to patients green books. Question: Why is identifying pressure ulcers important? Jeanette: Pressure ulcers are preventable, adverse outcomes, and we should do just that prevent them from occurring. In October, 2009, the Centers for Medicare and Medicaid Services implemented regulations that identify hospital-acquired pressure ulcers as one of eight never events that will no longer be covered by Medicare. Pressure ulcers present on admission are excluded, but a head-totoe skin assessment and accurate staging must be documented by an admitting physician, nurse practitioner, or physician assistant, and a registered nurse. Clinical practice guidelines should include early identification of patients at risk for pressure ulcers and early interventions to prevent them. Pressure ulcers put patients at risk for other adverse events such as infection, prolonged admission, and emotional and financial burden. Question: Where should the skin assessment or pressure ulcer be documented? Jeanette: On admission, a thorough skin assessment should be documented on the Nursing Dataset. If pressure ulcers are present, complete the Pressure Ulcer Staging Section (Section 6) of the Dataset. The Nursing Progress Note should describe the wound(s), including length, width, depth, tissue type, a description of the wound bed, wound exudate, peri-wound area, and dressing or treatment plan. The Skin Integrity Problem Lists on the MGH Intranet can be used in creating a Plan of Care. The wound should be re-assessed and documented in the Post Hospital Discharge Plan within 24 hours of discharge. Question: How is risk for pressure ulcers determined? Jeanette: At MGH, the Braden Scale is used to identify patients at risk for developing pressure ulcers. The Braden Scale is a reliable tool for predicting patients at risk for pressure ulcers. The scale is composed of six sub-scales that reflect sensory perception, skin moisture, activity, mobility, friction and shear, and nutritional status. Completing the Braden Scale is the first step of a two-part pressure-ulcer prevention and treatment program. The second step is customizing a plan of care based on the Braden sub-scales, which can be found in the Skin Integrity Problem Lists. Question: What resources are available to guide early intervention and preventative measures? Jeanette: Increasing knowledge around pressure-ulcer prevention is key. The MGH intranet houses Skin Integrity Problem Lists with suggestions for interventions that correspond to the overall Braden score and specific interventions for sub-scale scores. Completion of the four on-line National Database of Quality Nursing Indicators (NDNQI) Pressure Ulcer Training modules is highly recommended to improve skill and accuracy in recognizing, staging, and treating pressure ulcers. Completion of Module One is required for all MGH nurses. The CNS Wound Care Task Force offers one- and two-day wound care classes throughout the year. This year s classes are: One-Day Wound Care Class April 16, September 9, and November 9 Two-Day Wound Care Class July 28 and 29 For more information or to register for a class, contact The Knight Nursing Center at 6-3111. Page 16 Caring Headlines April 15,

Attachment EP 32 EO.i Page 1355 Preventing Pressure Ulcers Are you on board with the Save Our SKIN campaign? by Virginia Capasso, RN, clinical nurse specialist The Pressure Ulcer Strategic Initiative Task Force was created to address this part of the PCS strategic plan and to help educate staff throughout the hospital about best practices related to preventing hospitalacquired pressure ulcers. Preventing hospital-acquired pressure ulcers is a top priority for healthcare organizations across the country. So important is it that the Patient Care Services Executive Committee included it as part of its strategic plan: Create an evidenced-based, standardized approach to the prevention of hospital-acquired pressure ulcers and use of specialty beds. This tactic was inspired partly by trends in MGH pressure-ulcer data reported to the National Data base of Nurs ing Quality Indicators (NDNQI) and to Patient Care Link, the publicly reported state database formerly known as Patients First. This data showed an upward trend in the rate of pressure ulcers from 3.2% in March of 2009 to 3.5% in March of. Pressure-ulcer prevalence rates were above the target goals in two Patient Care Link categories. The Pressure Ulcer Strategic Initiative Task Force was created to address this part of the PCS strategic plan and to help educate staff throughout the hospital about best practices related to preventing hospital-acquired pressure ulcers. The inter-disciplinary task force has met weekly since it was convened in November,. The group has built on other successful initiatives implemented by the CNS Wound Care Task Force and the PCS Office of Quality & Safety, including the Skin Integrity Problem List, nursing care guidelines, and hourly safety rounds that incorporate the 7Ps. Members of the task force conducted an analysis of programs already in place at MGH and reviewed recommendations for prevention of pressure ulcers published by the National Pressure Ulcer Advisory Panel. The task force reviewed the literature and assessed the feasibility of other successful programs, including Ascension Health s Safe ty for All initiative; the New Jersey Hospital Association s Pressure Ulcer Collaborative; Minnesota Hospital Association s Safe Skin Campaign; the NICHE program; and the Agency for Healthcare Research and Quality s Preventing Pressure Ulcers in Hospitals Tool Kit. After intensive deliberation, the Pressure Ulcer Task Force decided to adopt the Save Our SKIN (SOS) campaign, which deputizes all staff as SKIN Savers and employs the SKIN Bundle as a framework for safe SKIN practices. To help get the word out, the task force launched the Save Our SKIN (SOS) campaign on Thursday, May 26,, at a Nursing Grand Rounds presented by the leadership of the Pressure Ulcer Strategic Ini tiative Task Force. Though the campaign will not roll out in earnest until mid-summer, the overall prevalence ulcer rate has already begun to decline with a rate of 2.8% in March,, and 2.5% in June (preliminary results). continued on next page Page 10 Caring Headlines July 21,

Attachment EP 32 EO.i continued Page 1356 Preventing Pressure Ulcers (continued) Safe Skin Practices Conduct a skin assessment for risk of pressure ulcers using the Braden Scale upon admission and daily thereafter Check surfaces: use standard pressure-relief mattresses and chair pads. Use specialty beds if consultation with clinical nurse specialist deems it is warranted Use specialty chair pads per physical therapy Turn or re-position patients in bed every two hours; assist as needed Patients should move every 15 minutes while sitting in a chair; limit sitting in chair to two hours at a time Assess need for toileting or incontinence-management every hour Optimize nutrition: set up a tray or feed patient meals as needed and nutritional supplements as ordered Conduct unit-based SKIN huddles for patients with new pressure ulcers Submit a safety report for stage II, III, and IV pressure ulcers For more information on the work of the Pressure Ulcer Strategic Initiative Task Force, call Virginia Capasso, RN, at 6-3836. Are you a SKIN Saver? Pressure Ulcer Prevention Strategic Initiative Task Force Members of the Pressure Ulcer Task Force (seated l-r): Deborah Jameson; Sandra Silvestri, RN; and Claire Seguin, RN. (Standing): Maureen McCarthy, RN; Susan Gavaghan, RN; Jacquie Collins, RN; Jill Pedro, RN; Virginia Capasso, RN, team lead; Deb Frost, RN; Linda Brandt, RN; Gaurdia Banister, RN, executive sponsor; Tiash Sinha, RD; Karen Waak, PT; Mary O Brien, RN; Patricia Grella, RN; and Charlene O Connor, RN. Not pictured: Mandi Coakley, RN, project specialist; Zary Amirhosseini; Barbara Blakeney, RN; Gino Chisari, RN; Deborah D Avolio, RN; Pat English, RRT; Anthony Fataldo, RPh; Judith Gullage, RN; Nancy McCarthy, RN; Joyce McIntyre, RN; and Lori Powers. July 21, Caring Headlines Page 11

Attachment EP 32 EO.j Page 1357 Fielding the Issues I Staying on board the SOS Campaign In September of, the SOS (Save Our SKIN) Campaign was rolled out to help eliminate hospital-acquired pressure ulcers. In 2008, the Centers for Medicare and Medicaid Services (CMS) began recognizing hospital-acquired pressure ulcers as medical errors and discontinued payment for their care. The SOS Campaign consists of several components. The SKIN bundle includes: S = Skin assessment/risk assessment (Braden Scale) upon admission and daily thereafter Ensure that a provider is aware and documents any pressure ulcers present upon admission within 24 hours of admission Activate the Skin Integrity Problem List and appropriate interventions based on Braden and sub-scale scores for risk of pressure ulcers Document assessment findings each time the dressing is changed Document interventions that were implemented, patient s response to interventions, and changes made to treatment plan each shift S = Surfaces Ensure proper mattresses, beds, and chair cushions are employed K = Moving/turning Turn patient in bed every two hours or more frequently Don t allow patient to sit in chair for more than two hours at a time If patient sits in chair, relieve pressure every 15 20 minutes I = Incontinence management Toilet patient every one to two hours Prevent maceration in patients with incontinence or at risk for incontinence Are you a SKIN Saver? N = Nutrition Assist/feed patients meals and nutritional supplements as needed Ensure that a dietician is consulted for at-risk patients (a score of one or two on the Braden nutrition sub-scale) Ensure that dietician s recommendations are converted to physician orders Ensure nutritional supplements are recorded on the Treatment Sheet Other components of the SOS Campaign include: unit-based huddles of nursing staff and unit leadership when a new pressure ulcer is first detected and weekly thereafter completion of Huddle Data Form to evaluate adherence to the SKIN Bundle filing a safety report when a new Stage II, Stage III, Stage IV, un-stageable, or deeptissue injury is detected changing occlusive and long-wear dressings (such as Duoderm and Mepilex Border Lite) at least every three days a new Patient-Family Fact Sheet downloadable from the Excellence Everyday Skin Portal Page (http://www.mghpcs.org/ eed_portal/eed_skin.asp) soon all nursing staff will be required to complete a HealthStream program, SOS Campaign: a Strategic Initiative to Eliminate Hospital-Acquired Pressure Ulcers We re making excellent progress in preventing hospital-acquired pressure ulcers. Our prevalence rate has decreased in each of four consecutive quarters from 2.9% in December,, to 1.7% in September,. For more information about the SOS Campaign or any issues related to hospital-acquired pressure ulcers, consult your clinical nurse specialist or call Virginia Capasso, RN, at 6-3836. January 19, Caring Headlines Page 9

Attachment EP 32 EO.k Page 1358 MASSACHUSETTS GENERAL HOSPITAL Patient Care Services Quality and Safety Pressure Ulcer Documentation Audit: Inpatient Units April - June Data collection timeframe: June Method: Convenience sample: 18 patients including patients identified with hospital-acquired pressure ulcers during the quarterly prevalence study on June 6,. Concurrent audit at the time of the Pressure Ulcer Prevalence (PUP) audit (retrospective audit if patient discharged). Data sources: Patient record, Physician Order Entry (POE) Indicators: Skin integrity assessment on admission (Data Set) Completion of Braden Scale on admission and daily (Flow sheet) CNS consults initiated for stage 3 or greater pressure ulcers (progress notes, consult) Nutrition consults initiated for stage 3 or greater pressure ulcers (POE, progress notes) Daily progress notes describing wound, dressing and plan of care (2 days) Effectiveness of interventions (2 days) initiated in March Weekly description of wound, including measurements (progress notes, Measurement Monday sticker) Summary of Findings: June Compliance vs. March Compliance Documentation of skin assessment on admission has from 88% in January March to 94% Completion of the Braden scale on admission and daily both decreased slightly from 100% to 94% Compliance for initiation of CNS consults for stage 3 or greater pressure ulcers remains at 100% Compliance for initiation of Nutrition consults for stage 3 or greater pressure ulcers increased from 86% to 100%. Documentation of pressure ulcer descriptors daily remains at 100%, weekly documentation compliance decreased from 100% to 75% Compliance for documentation for pressure ulcer dressings changed by MD and not visualized by RN is at 100% Staff continue to use Measure Monday sticker in appropriate cases

Attachment EP 32 EO.k continued Page 1359 Patient Care Services Quality and Safety Pressure Ulcer Documentation Audit: Inpatient Units September, March, Data collection timeframe: September March Method: Convenience sample: 36 patients with hospital-acquired pressure ulcers identified during the prevalence studies in September,, December,, and March,. Concurrent audit at the time of the Pressure Ulcer Prevalence (PUP) audit (retrospective audit if patient discharged). Data sources: Patient record, Physician Order Entry (POE). Indicators: RN assessment and Braden scale completion upon admission Braden scale completed daily (2 days) Problem list initiated and completed for Braden scale <19 CNS consulted for stage 3 or > (progress notes, consult) Nutrition consulted for stage 3 or > (POE, progress notes) Daily progress notes describing wound, dressing and plan of care (2 days) Effectiveness of interventions (2 days) initiated in March Weekly description of wound, including measurements (progress notes, measurement Monday sticker) Summary of Findings: Documentation of skin assessed upon admission has slightly decreased from 100% in July September, to 88%, Jan March. Completion of the Braden scale on admission and daily has increased to 100%, respectively. The skin integrity problem list is initiated consistently for Braden scales <19 or documented pressure ulcers 100% of the time across three quarters. Compliance on consulting CNS for stage 3 or > pressure ulcers has improved from 70% in July September, to 100% in Jan March. Documentation of pressure ulcer descriptors daily and on a weekly basis has increased across the 3 quarters to 100%. The use of the Measure Monday sticker was measured in Jan March. Of the seven patients admitted for greater than a week requiring weekly documentation, 6 of the patient s documentation of pressure ulcer descriptors utilized a Measure Monday Sticker.

Attachment EP 32 EO.k continued Page 1360 MASSACHUSETTS GENERAL HOSPITAL Patient Care Services Quality and Safety Pressure Ulcer Documentation Audit Report: Inpatient Units September June PCS Compliance Summary Item # Criteria Jul-Sep N=10 Oct-Dec N=18 Jan-Mar N=8 Apr-Jun N=18 Indicator #1: Skin Integrity Assessed on Admission Section 6 of data set is complete 100% (9/9) 94% (17/18) 88% (7/8) 94% (17/18) Indicator #2: Braden Scale Completed on Admission Braden completed within 24 hours of admission 89% (8/9) 88% (15/17) 100% (8/8) 94% (17/18) Indicator #3: Braden Scale Completed Daily Check Braden scale for last 2 days 100% (10/10) 88% (16/18) 100% (16/16) 94% (33/35) Indicator #4: Skin Integrity Problem List is Initiated Patients with Braden <19, interventions checked off, problem list dated and signed 100% (10/10) 100% (16/16) 100% (8/8) ** Indicator #5: CNS is Consulted for Stage 3 or Greater Pressure Ulcers*** Evidence in progress notes that CNS was consulted and/or has assessed patient 70% (7/10) 86% (12/14) 100% (7/7) 100% (9/9) Indicator #6: Nutrition is Consulted for Stage 3 or Greater Pressure Ulcers** Evidence in POE, nursing orders or progress notes that Nutrition was consulted and/or has assessed patient 90% (9/10) 94% (15/16) 86% (6/7) 100% (8/8)

Attachment EP 32 EO.k continued Page 1361 Indicator #7: Appropriate Daily Documentation for Pressure Ulcer Dressings Changed by RN Daily: location 90% (18/20) 91% (30/33) 100% (16/16) 100% (22/22) description of wound bed wound exudate dressing choices plan of care Check progress notes for last 2 days Check YES if all elements of documentation complete Indicator #8: RN Documents Effectiveness of Interventions Daily Check progress notes for last 2 days as above N/A N/A 100% (15/15) 100% (20/20) Indicator #9: Appropriate Weekly Documentation for Pressure Ulcer Dressings Changed by RN Weekly above descriptors length, width, depth tunneling, undermining if present 80% (8/10) 88% (14/16) 100% (7/7) 75% (6/8) Check progress notes for last 7 days Indicator #10: Appropriate Daily Documentation for Pressure Ulcer Dressings Not Changed by MD, Not Visualized RN, RN Documents Daily condition of dressing date last changed N/A N/A N/A 100% (4/4) Notes: N= Number of individual patient records reviewed ** Measure discontinued *** CNS and Nutrition consult required for pressure ulcers, stages 2 or greater in September December, changed to stage 3 or greater as of Januar y

Attachment EP 32 EO.l Page 1362 Date: New? Weekly Review? Unit: Patient name: MRN: DOB: Admitting Diagnosis: LOS > 24 hours [ ] Y [ ] N S KIN Assessment / Risk Assessment Pressure Ulcer Location: Pressure Ulcer Stage: (X) [ ] I [ ] II [ ] III [ ] IV [ ] Deep Tissue Injury (DTI) [ ] Unstageable Braden Score: Adult Pediatric [ ] Very high risk (< 9) [ ] Low risk (22 28) [ ] High risk (10 12) [ ] Moderate risk (17 21) [ ] Moderate risk (13 14) [ ] High risk (< 16) [ ] Mild risk (15-18) Braden Subscale scores: HCUP Factors: Sensory Perception (1 4) [ X ] Moisture (1 4) [ ] Infection/Septicemia Activity (1 4) [ ] Impaired perfusion Mobility (1 4) [ ] Impaired oxygenation Nutrition (1 4) [ ] Impaired mobility Friction / Shear (1 3) Surface type: [ ] Atmos Aire 9000 [ ] Prevalon Boots [ ] SPO2RT Bed [ ] Gaymar chair cushion [ ] Rite Hite [ ] RoHo / other chair cushion [ ] Clinitron [ ] Other: K eep turning / repositioning every 2 hours? Documented? Incontinence care Documented? Method: Soap / water / facecloth Skin cleanser / paper cloths Baby wipes Nutritionally at risk [ ] Y [ ] N Braden nutrition subscore Nutritional consult done [ ] Y [ ] N Nutrition orders written [ ] Y [ ] N Nutrition orders carried out [ ] Y [ ] N - Nutritional supplements administered? [ ] Y [ ] N documented? [ ] Y [ ] N Treatment : Comments? Fax to: Debra Frost, PCS Quality and Safety: 617-643-0443 Retain Original on unit. Rev. 8/22/

Attachment EP 32 EO.m Page 1363 EXCELLENCE EVERY DAY PORTAL click here Home About Us Centers Programs & Initiatives Support Us Contact Us "promoting excellence every day" RESTRAINT SOLUTIONS IN CLINICAL PRACTICE COMMITTEE Goals Overview Responsibilities CG Restraint Champions Collaborative Governance Committees Diversity Patient Education Ethics in Clinical Practice Informatics Policy, Procedure & Products Practice & Quality Oversight Subcommittees Fall Prevention Pain Management Restraint Usage Skin Care Tiger Team Research & Evidence-based Staff Nurse Advisory Current work: Champions heard from Susan Gordon, RN, Nurse Director of the Neuroscience Unit at BWH on their work creating a restraint free unit. Susan and her staff accomplished this by sharing the evidence based articles, reviewing with every nurse, why the patient is in restraints and the plan to remove the restraints. They use patient observers and occasionally, the veiled bed but her unit is restraint free. This was an exemplar on leadership, consistency and the use of evidence to guide and develop practice. Look for an article in the July 19th issue of Caring Headlines on the new restraint brochure, which is available from Standard Register. Committee champions will be hosting a table at the September SAFER Fair. Please stop by and check out products that can be used to decrease the use of restraints and hear about the work of the committee. Goals Pilot project to explore the RN/MD decision making process for implementing and discontinuing restraints. Pilot project to assess the potential for sensory evaluation and interventions in the acute non-psychiatric inpatient units to prevent or decrease time in restraints. Collaboration with the Restraint Solutions Team regarding improvements in the education of nurses about current CMS/DMH regulatory issues, MGH policies and procedures. Meets: 3rd Tuesday monthly 1:00pm-3:00pm Founders 3-311 Conference Room Committee Contacts: Co-ChairsCatherine Mackinaw, RN, Staff Nurse, Neuroscience Meaghan Morrison- Rudolph, RN Staff Nurse, Psychiatry & General Medicine Advisor/Coach Jennifer Repper- DeLisi, RN, CNS, Psychiatric Nursing Consultation Service CG Restraint Champions RESTRAINT USAGE STEERING COMMITTEE OVERVIEW The Restraint Usage subcommittee will be engaged in identifying evidence-based interventions that can reduce the use of restraints. Champions will gain knowledge in identifying and intervening effectively to minimize a patient s likelihood of being restrained. Champions should have an interest in minimizing the use of restraints through early identification of patients at risk, collaboration with the patient s family, and the use of alternative therapies and interventions. return to top Responsibilities: Engage in joint projects with other Collaborative Governance committees. Align the work of the committee with PCS strategic goals. return to top PCS Home Chaplaincy Excellence Every Day Portal Institute for Patient Care Nursing Occupational Therapy Orthotics & Prosthetics Physical Therapy Respiratory Care Social Service Nursing Speech Language Swallowing Disorders Clinical Resources Contact PCS MGH Home Page MGH Intranet MassGeneral Hospital for Children Partners Healthcare 55 Fruit Street, Boston MA 02114 / (617) 726-2000 / TDD: 617-724-8800

Attachment EP 32 EO.n Page 1364 Restraint and Seclusion Solutions Team Charges Ensure that MGH policies and procedures re Restraint and Seclusion are compliant with current regulations including CMS Conditions of Participation and Joint Commission Standards Review current practice and make recommendations for improvements in the following areas: Restraint orders Documentation of assessment re least restrictive measures; alternatives attempted. Documentation of response to intervention and rationale for continued use. Documentation of description of patient s behavior and intervention used Modification of patient care plans when patients are restrained Clinician training Recommend an auditing strategy to the Center for Quality and Safety and PCS Office of Quality and Safety. Membership: R. Gino Chisari, RN, Knight Center Constance Cruz, RN, CNS, Blake 11, Inpatient-Psychiatry Mallory Davis, Compliance Office Abigail Donovan, MD, Acute Psychiatry Service Joanne Empoliti, RN, CNS, Orthopedics Elizabeth Johnson, Information Systems Andrew Karson, MD, Director, Clinical Decision Support Unit Carol Markus, RN, Staff Specialist, PCS Office of Quality and Safety, Co-chair Patricia Mian, RN, CNS, Emergency Department Claire Seguin, RN, Compliance Office Anthony Weiss, MD, Psychiatry, Co-Chair * Nursing members are highlighted in yellow

Attachment EP 32 EO.o Page 1365 NURSING MANAGEMENT GUIDELINES FOR PATIENTS IN ALCOHOL WITHDRAWAL Alcohol withdrawal can be life threatening. The goal of care is a safe withdrawal defined by stable vital signs & an absence of withdrawal symptoms. Physiological Assessment Screen every patient for alcohol use and abuse. Assess the amount and frequency of alcohol they have used and date of last drink. If the amount and frequency is negative, administer the CAGE. Note BAL if checked. Evaluate patient's vital signs Identify positive symptoms of withdrawal Note factors that might increase the risk of serious outcome in the context of alcohol withdrawal. Intervention Note appropriate treatment option for patient based on assessment (Watchful Waiting. Prophylaxis (Treatment # 1-3), Alcohol Withdrawal (Treatment 4-6». Follow the guidelines for assessment and medication administration based on ordered treatment option. Hold benzodiazepine for somnolence, ataxia, dysarthria, or decreased vital signs (RR<12, SBP< 100mm Hg). Call House Officer before holding second dose or if no timely response to treatment. Intake/ Food & Fluid Offer fluids & food regularly to maintain hydration and decrease gastric distress. Consider N hydration when patient is unable to take in adequate fluids. Somnolent patients are at risk for aspiration. Keep the HOB elevated and maintain the patient in an upright or sitting position to eat and drink. Consider a Nutrition consult for any patient with a risk of malnutrition. Output/Elimination If the patient is confused, place him/her on a regular toileting schedule. Offer urinal or bedpan, assist to bedside commode or ambulate to bathroom each time pt assessed/medicated. Avoiding the use of Foley catheters will decrease the likelihood of infection and prevent potential trauma, which may occur with a confused or sedated patient. Mobility Ambulate the patient frequently to reduce the risks associated with immobility and to reduce the emotional/physical stress associated with withdrawal. Consult PT and provide regular ROM exercises for the patient whose mobility is diminished. Restraint Restraints often increase a patient's agitation and create risks associated with immobility including increased morbidity. Use alternative interventions for the agitated patient including medication adjustment, observer and decreased environmental stimulation. Comfort measures Offer a patch for nicotine withdrawal if patient is a known smoker.

Attachment EP 32 EO.o continued Page 1366 Communication Approach the patient with respect. This fosters a secure environment in which the patient may be more receptive to treatment. Maintaining eye contact, asking how the patient would like to be addressed, and giving the patient your full attention will help to establish a positive relationship. Convey a sense of acceptance to the patient that alcoholism is a disease process. Alcohol is a common problem in many peoples lives. We treat it as we would any other disease. Provide education during the assessment and treatment process. Withdrawing from alcohol can make you ill. Knowing exactly how much and how frequently you are drinking will help us to prevent severe withdrawal symptoms." Be aware of your own feelings about alcohol and know when your "buttons" are being pushed. It is not unusual to experience a sense of futility or anger with the patient for continuing to use alcohol. "He did it to himself," "He'll just be back next week with the same problem," and "She takes away time from my 'real' patients" reflects the frustration oftreating the patient with this disease. Most alcohol dependent patients are aware of these opinions and often believe they are viewed by caregivers as a drinker first not a person or a patient. When behavioral problems present. Reevaluate the plan and interventions daily, troubleshooting what may be fostering noncompliance or unacceptable behavior. Verbal or physical aggression, frequent demands, restlessness and attempts to leave the unit may reflect inadequate treatment for withdrawal or be a symptom of delirium. Offer medication to treat the symptoms. If symptoms are stable, medication is optimized and behavior problems continue, let the patient know what behaviors need to stop. Use a calm voice and matter-of-fact tone. Avoid engaging in verbal struggles with the patient. For the patient who's yelling say, "This yelling is not OK. I can't care for you when you are yelling at me." If necessary, tell the patient you are leaving the room for 5 minutes so s/he can calm down, then return to the room within the stated time and continue care. When patients do not respond to verbal limits from staff or are threatening in any way, contact security for assistance with behavioral management. Environment Provide a safe environment by removing clutter and potentially dangerous objects. If patient is medically stable (Treatments 1,2,3) allow the patient to pace in a safe area or consider time off the unit to smoke or go to the cafeteria. Check the patient's belongings and remove alcohol and other medications or drugs. Have the patient wear a hospital gown, robe, and slippers to decrease the chance of elopement. Keep the room as quiet as possible, limiting unnecessary talk, TV, and radio.

Attachment EP 32 EO.o continued Page 1367 Documentation Delineate any signs and symptoms of withdrawal, discussing any changes in symptom presentation. Report amount and frequency of benzodiazepine administration with attention to total doses patient received. Note reason for holding medication. Note use of antipsychotic medication, behaviors precipitating treatment, and response to medication. Document reasons for initiating or discontinuing restraint or observer and response to these interventions, including alternative measures used. Update any physiological concerns (1&0, VS, mobility). Identify co-morbid issues that may affect patient response or treatment decisions. Psychiatric Nursing Consultation Service/MGH Dept of Nursing

Attachment EP 32 EO.p Page 1368 2-Hole 1/4 2 3/4-3-Hole 1/4 4 1/4 Goal Who What Where When How Roles: To decrease patient harm from catheter-related blood stream infections An operator & a monitor Assure compliance with and documentation of checklist elements At the site of the procedure During all central venous line insertions or rewires The monitor verifies that the steps have occurred, immediately informs the operator/supervisor of deviations, & completes the checklist Operator: the clinician placing the central line Supervisor: an experienced operator who is involved in training the operator in central line placement Monitor: an individual who is qualified to observe the procedure and watch for breaks in sterile technique. If a break in sterile technique is observed, the monitor asks the operator to repeat a portion of the procedure after correcting the observed break. Please identify a monitor for this line placement prior to the time out. Procedure Planning Line Insertion Site: Subclavian Internal Jugular Femoral PICC UA/UV Other (specify) Emergent placement Timeout documented separately Consent documented separately Yes No Comments/Reason If there is a deviation in any of the critical steps, immediately notify the operator and stop the procedure until corrected. If the step is completed properly, check the "Yes" box. If the step is not completed properly, check the "No" box and note the issue in the "Comments/Reason" section. Contact the Attending if any item on the checklist is not adhered to or with any concerns. Critical Step for Line Insertion Yes No Comments/Reason Before the procedure, the operator will: Confirm hand sanitizing (Cal Stat) or antimicrobial soap immediately prior Disinfect procedure site (chlorhexidine) using a back & forth friction scrub for 30 seconds. In patients < 2 months of age, use povidone iodine instead of chlorhexidine. Allow site to dry for 30 seconds Operator(s): hat, mask, sterile gown/gloves, eye protection Assistant/Monitor: hat, mask & standard precautions (if at risk for entering sterile field use sterile gown/gloves) Use sterile technique to drape from head to toe; Pediatrics use judgment to determine extent of draping. During the procedure, the operator will: Maintain a sterile field Flush and cap line before removal of drapes After the procedure, the operator will: Remove blood with antiseptic agent (chlorhexidine), if present, before placement of sterile dressing. Use sterile water/saline for patients < 2 months of age. Apply appropriate (green = all "yes", red = 1 or more "no") dated sticker on patient's line

Attachment EP EO.q Page 1369 BIOPATCH Disk is PROVEN to reduce CRBSI. 1 The ONLY device of its kind backed by rigorous clinical evidence. 1 PROVEN to reduce the incidence of CRBSI by 60%, and local infections by 44%. 1 Correct positioning allows for cleaning under the catheter hub to help keep your patients infection-free. Follow B.E.S.T. practice to ensure a uniform, high standard of care for all your patients: Use BIOPATCH Every Single Time. How to apply BIOPATCH Disk correctly: 1. Prepare insertion site according to hospital protocol. 2. Suture catheter at least 1.0" (2.5 cm) from insertion site. 3. Place BIOPATCH around catheter blue side up. 4. Align radial slit with catheter (for easy removal). 5. Ensure slit edges touch (for maximum efficacy). 6. Apply transparent film dressing according to hospital protocol. For Full Prescribing Information or technical support call 1-877-ETHICON (877-384-4266) or visit www.biopatch.com *WARNING: Not for use on premature infants or patients with known sensitivity to CHG. Safety and effectiveness in children under 16 years of age has not been established. References 1 Maki DG, Mermel L, Genthner D, Hua S, Chiacchierini RP. An evaluation of BIOPATCH Antimicrobial Dressing compared to routine standard of care in the prevention of catheter-related bloodstream infection. Johnson & Johnson Wound Management, a division of ETHICON, INC. 2000. Data on file. ETHICON, INC. 2008 BP-060

Attachment EP EO.q continued Page 1370 Reduce CRBSI: Always leave enough space for BIOPATCH Disk to be effective. 1.0 (2.5 cm) 1 2 Secure catheter at least 1.0" (2.5 cm) from insertion site. This allows for proper placement of BIOPATCH, which must have complete contact with skin for maximum efficacy. Correct positioning of catheter also allows sufficient room for cleaning of insertion site and under catheter hub to help keep patients infection-free. BIOPATCH is PROVEN to reduce CRBSI in patients with central venous and arterial catheters. 1 Always make sure it is applied correctly. Don t secure catheter too close to entry point. This will prevent proper placement of BIOPATCH and leave insufficient room to cleanse.

Attachment EP EO.r Page 1371 In-service Schedule BioPatch for PICC Lines Target Audience: ALL STAFF NURSES Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sunday 1/22/ 1/23/ 1/24/ 1/25/ 1/26/ 1/27/ 1/28/ 1/29/ 12:00 AM X Blake 6 Blake 6 Phillips 22 Ellison 3 White 7 Blake 8 Ellison 6 12:30 AM X Blake 7 White 6 Ellison 1 Ellison 1 White 6 Blake 10 Ellison 7 1:00 AM X Blake 8 White 7 Lunder 1 Ellison 16 Bigelow 6 Blake 11 Ellison 8 1:30 AM X Blake 10 White 8 Lunder 10 Ellison 17 Bigelow 7 Blake 12 Ellison 9 2:00 AM X Blake 11 White 9 Lunder 9 Ellison 18 Bigelow 9 Blake 13 Ellison 10 2:30 AM X Blake 12 White 10 Lunder 8 Ellison 19 Bigelow 11 Travel Ellison 11 3:00 AM X Blake 13 White 11 Break Phillips 20 Break Break Break 3:30 AM X Break Break Lunder 7 Phillips 22 Bigelow 12 Lunder 1 Ellison 13 4:00 AM X Travel Bigelow 14 Lunder 6 Break Bigelow 13 Lunder 6 Ellison 16 4:30 AM X Lunder 10 Bigelow 13 Travel Bigelow 6 Bigelow 14 Lunder 7 Ellison 17 5:00 AM X Lunder 9 White 13 Blake 6 Bigelow 7 Travel Lunder 8 Ellison 18 5:30 AM X Lunder 8 White 12 Blake 7 Bigelow 9 Ellison 16 Lunder 9 Ellison 19 6:00 AM X Lunder 7 Bigelow 12 Blake 8 Bigelow 10 Ellison 17 Lunder 10 Phillips 20 6:30 AM X Lunder 6 Bigelow 11 Blake 10 Bigelow 11 Ellison 18 Travel Phillips 22 7:00 AM Phillips 22 Lunder 4 Bigelow 10 Blake 11 Bigelow 12 Ellison 19 White 11 X 7:30 AM Phillips 20 Lunder 3 Bigelow 9 Blake 12 Bigelow 13 Phillips 20 White 10 X 8:00 AM Ellison 19 Lunder 2 Bigelow 7 Blake 13 Bigelow 14 Phillips 22 White 9 X 8:30 AM Ellison 18 Lunder 1 Bigelow 6 White 13 Blake 8 Travel White 8 X 9:00 AM Ellison 17 Ellison 1 Travel White 12 Blake 7 Ellison 1 White 7 X 9:30 AM Ellison 16 Ellison 3 Lunder 1 White 11 Blake 6 Ellison 3 White 6 X 10:00 AM Ellison 13 Travel Lunder 2 White 10 Blake 4 Ellison 4 Travel X 10:30 AM Ellison 11 Gray 3 OR Lunder 3 White 9 Travel Ellison 6 Lunder 1 X 11:00 AM Ellison 10 Gray 3 OR Lunder 4 White 8 Gray 3 OR Ellison 7 Lunder 6 X 11:30 AM Break Break Lunder 6 White 7 Gray 3 OR Break Lunder 7 X 12:00 PM Ellison 9 Blake 4 Break Break White 3 Ellison 8 Break X 12:30 PM Ellison 8 Ellison 4 Lunder 7 White 3 Break Ellison 9 Lunder 8 X 1:00 PM Ellison 7 Ellison 6 Lunder 8 Gray 3 OR Blake 10 Ellison 10 Lunder 9 X 1:30 PM Ellison 6 Ellison 7 Lunder 9 Gray 3 OR Blake 11 Bigelow 10 Lunder 10 X 2:00 PM Ellison 4 Ellison 8 Lunder 10 Travel Blake 12 Travel Travel X 2:30 PM Ellison 3 Ellison 9 Travel White 6 Blake 13 Gray 3 OR Bigelow 9 X 3:00 PM Ellison 1 Ellison 10 Blake 4 Bigelow 6 Travel Gray 3 OR Bigelow 7 X 3:30 PM Travel Ellison 11 Ellison 4 Bigelow 7 Lunder 1 White 3 Bigelow 6 4:00 PM White 6 Ellison 12 Ellison 3 Bigelow 9 Lunder 2 Blake 4 Blake 6 X 4:30 PM White 7 White 12 White 3 Bigelow 10 Lunder 3 Travel Blake 7 X 5:00 PM White 8 Ellison 13 Ellison 6 Bigelow 11 Lunder 4 Ellison 11 Blake 8 X 5:30 PM White 9 Ellison 16 Ellison 7 Bigelow 12 Lunder 6 Ellison 12 Blake 10 X 6:00 PM White 10 Ellison 17 Ellison 8 Bigelow 13 Lunder 7 Ellison 13 Blake 11 X 6:30 PM White 11 Ellison 18 Ellison 9 Bigelow 14 Lunder 8 White 13 Blake 12 X 7:00 PM White 13 Ellison 19 Ellison 10 Ellison 13 Lunder 9 White 12 Blake 13 X 7:30 PM Break Phillips 20 Ellison 11 Ellison 12 Lunder 10 White 11 Bigelow 13 X 8:00 PM Bigelow 14 Phillips 22 Ellison 12 Break Break Break Break X 8:30 PM Bigelow 13 Break Break Ellison 11 Travel White 10 Bigelow 14 X 9:00 PM Bigelow 12 Blake 13 Ellison 13 Ellison 10 White 13 White 9 Bigelow 12 X 9:30 PM Bigelow 11 Blake 12 Ellison 16 Ellison 9 White 12 White 8 Bigelow 11 X 10:00 PM Bigelow 10 Blake 11 Ellison 17 Ellison 8 White 11 White 7 Travel X 10:30 PM Bigelow 9 Blake 10 Ellison 18 Ellison 7 White 10 White 6 Ellison 1 X 11:00 PM Bigelow 7 Blake 8 Ellison 19 Ellison 6 White 9 Blake 6 Ellison 3 X 11:30 PM Bigelow 6 Blake 7 Phillips 20 Ellison 4 White 8 Blake 7 Ellison 4 X

Attachment EP 32 EO.s Page 1372 Go With the Flow PICC Flushing Education Initiative GENERAL: FLUSHING: Minimum

Attachment EP 32 EO.t Page 1373