Clinical Quality & Safety A Progress Report October 4, 2010

1. Clinical Quality & Safety A Progress Report October 4, 2010 Mayer Brezis, MD MPH Professor of Medicine Center for Clinical Quality & Safety

2. (I) Ventilator-Associated Pneumonia (VAP) (II) Medication Reconciliation(Med-Rec) (III) Follow Up on a few other projects

3. Ventilator-Associated Pneumonia(VAP) Project aim: reduce VAP incidence at Hadassah Inna Apelbaum, Nurit Katz, Dr. Philip Levine, Dr. Shmulick Benenson, Carmela Shwartz, Prof. Colin Block, Lois Gordon, Prof. Mayer Brezis General Intensive Care, Unit for Infection Control and the Center for Clinical Quality and Safety

5. VAP Prevention: Recommendations Rated With High Level of Evidence ICHE 2008

6. Summary for 2009 survey • The incidence of VAP at Hadassah is higher than what is reported in the literature. • The adherence to guidelines for VAP prevention is lower than desirable. • How can adherence to guidelines be improved? • Elevating the head of the bed between 30o- 45o • Hand hygiene by staff before and after contact with ventilator, patient and patient’s belongings • Oral hygiene including brushing • Discontinuation of sedation once a day

7. InterventionFindings discussed with staff • Review of guidelines at staff meetings • Emails • Signs • Posters • Buttons • Screensaver Re-evaluation scheduled for early 2010

8. Survey results Periods of observation:Pre Intervention: February – March 2009 Post Intervention: February – March 2010

9. 2009

10. 2010

11. Adherence to VAP prevention guidelines  for stable patients only *p<0.001 ** p<0.01

12. Adherence to hand hygiene (nurses) *p<0.001 ** p<0.01

13. Hand hygiene (respiratory technicians) *p<0.001 ** p<0.05

14. Diagnostic criteria for VAP

15. Rates of VAP: 2009 & 2010 2009 2010 * Chest 2008 (before interventions, down by 50% after interventions)

16. Rate of VAP per 1000 ventilation days

17. Summary & Discussion: VAP at Hadassah • Adherence to VAP prevention guidelines has somewhat improved but remains lower than desirable. • The incidence of VAP remains higher than that reported in the literature. • Reactions from teams:

18. Ventilator-Associated Pneumonia Last VAP SICU: Jan. 1, 2008 CICU: January 15, 2010* *Prior to 1/15/10, the last CICU VAP was on 3/24/08, or 621 days

19. Do we have a problem? IHI Conference: VAP Prevention Bundle BUDAS: Bed up, Ulcer prophylaxis, DVT prophylaxis, Anemia, Sedation wake-up VAP Workgroup: Critical Care Medical Director, Infection Control, CNS, Respiratory Therapy Consistent definition for VAP Policies & procedures Equipment & supplies Intensivists Education of RNs & RTs VAP: The Beginning (2001)

20. BUDAS Intensivist Co-Attending Model Multidisciplinary Rounds Reviewed components of BUDAS Reinforced education Education of ICU RNs & RTs Hand cleanser dispensers Monthly compliance review by Critical Care Medical Director Critical Care Committee Informed physicians of EBP changes VAP Initiatives (2002-2004)

21. Compliance with BUDAS

22. Daily multidisciplinary rounds (7 days a week) Chart documentation Physician contracting Process Improvements (2004)

23. Reported BUDAS compliance by individual component Improved oral care, added chlorhexidine rinse Opened MCR with best practices from PVH Switched to oral gastric tubes Reinforced standard procedure, chlorhexidine has to be after toothbrushing, storage of Yankauer, deep oralpharyngeal suctioning Introduced silver-coated endotracheal ETT (IHI 5 Million Lives Campaign) New approach: Root cause analysis for each VAP Cycles of Improvement

24. Small incremental improvements based on audit data, literature & outcomes Education, education, education Posters, case studies, self-learning packets, face to face Physician engagement Partner with physician champion Staff engagement Engage staff in solving problem Post rates in each ICU Rates = reflection of THEIR practice Lessons Learned

25. Medication Reconciliation Hadassah-Hebrew University Hospital, Jerusalem, Israel Roni Cohen, B.Sc., Inbal Yifrach-Damari, M.Sc.* Dr. Meir Frankel, Prof. Mayer Brezis * Clinical Pharmacist, Hadassah Pharmacy Services PhD student, School of Pharmacy, Hebrew University With Help From Joint Commission International

26. Medication Errors • Medication errors are the fourth leading cause of death or major permanent loss of function in hospital patients. • The majority of problems with patient safety occur during the transition from one care setting to another. • Ambulatory-hospital lack of communication is responsible for 50 % of medical errors. • To improve patient safety, the Joint Commission on Accreditation of Healthcare Organizations now recommends a procedure designed to minimize errors.

27. What is Medication Reconciliation? Obtaining a complete and accurate list of each patient’s medications. CONTINUE DISCONTINUE Documenting EVERY change: Before the patient moves on, the physician must decide about each drug: This way, no drug is forgotten! Drugs include: ‘over-the-counter’ medications, topical medications, eye drops, vitamins, herbal medications and ‘occasional’ medications.

28. Methods for current project • Over 100 adult patients admitted to the ER, on at least 5 regular drugs, underwent medication reconciliation. • Review of medications with patient, family, primary physician and/or database of HMOs (sick funds). • After 24-48 hours, we checked the list of medications prescribed to the patient by the ward staff. • Our list was then compared with the list in the ward. • If any discrepancy was observed or an error was suspected, the staff was approached to clarify the reason for the change.

29. Overall Errors In 97% of our patients, an error / intervention was found on admission, during hospitalization or at discharge. On average: 7 mistakes / interventions per patient Pharmacological interventions in 85% Med-Rec interventions in 87% On average: ≈ 3 mistakes / interventions per patient, of any kind

30. Medication Errors on Hospitalization At least one error was found in 73% of the patients Enalapril and ramipril were both prescribed in the ward. Antiepileptic drug, taken at home, was not continued in the ward. Captopril was prescribed to a patient only once a day (instead of 3 times a day). Hydralazine was written for no reason.

31. Medication Errors at Discharge At least one error was found in 65% of the patients “Pain killers as needed” Combination of nortriptyline & citalopram Levothyroxine(eltroxin) omitted from discharge letter. Propafenone prescribed once a day (instead of 3 times a day). Alendronateomitted from discharge letter.

32. Severity of Medication Errors

33. Telephone Interviews Nearly all patients had visited primary care physician after discharge. 25% of patients were not aware of a change in medication. On occasion, an error noted during admission was continued after discharge. At least one error / problem was found in 23% of the patients!

34. Clinical Pharmacist Service • In 85% of patients: • Apply correct indications and contra-indications (≈18%). • Adapt dosage to kidney or liver function (≈15%). • Drug-Drug Interaction (≈37%). • Correct administration: After discharge, over 50% of patients were not taking medications correctly. Polypharmacy

35. On Medication-Reconciliation Elsewhere Survey of 100 patients at the Mayo Clinic: Inpatient Medication Reconciliation in an Academic SettingAmerican Journal of Health-System Pharmacy 2007 Number of medication discrepancies decreased from 3 per patient in phase 1 to 1.8 per patient in phase 2 (p = 0.003) Survey of 180 patients at Brigham and Women’s Hospital, in Boston: Classifying and Predicting Errors of Inpatient Medication Reconciliation. J Gen Intern Med 2008. Average of 1.5 error per patient with potential for harm. Solutions included development of special software for adapting prescription to the patient’s provider preferred medications outside hospital.

36. Discussion Avoidable mistakes in medications are very common. About 1% can be life threatening. Drug lists, in the community and in hospitals, are not updated and often fail to reflect the medications that the patient actually takes. A correct medical history can identify errors and can sometimes even shed new light on the cause of hospitalization. Critical changes in medications made during hospitalization are often not implemented after discharge.

37. Solutions to Reduce Errors • At the individual level: have patient bring his/her bag of drugs and carefully review them with him/her. • A clinical pharmacist is very useful, as shown in literature: improvement in outcomes, ↓errors, cost of care & LOS. • Devise a computerized table for medication reconciliation for each patient at each transfer of care provider. • Improve IT for transfer of information between Hadassah and outside providers on admission and on discharge. • Monitor quality for continuity of care by measuring quality of handovers within Hadassah wards and with outside.

38. (III) Follow Up on a Few Other Projects • Family’s Involvement during Physician’s Rounds • After discussion of survey findings, a new policy was enacted by the Division of Medicine to allow one relative to be present during physician’s round. This policy was also suggested to other departments by EinKerem Director, Dr. Y. Weiss. • Checklist to reduce central lines infections • Major project at Hadassah showed a 65% reduction in central lines infections with the use of a checklist (as shown by Pronovost et al, NEJM 2006). • Despite this success, checklist has not been adopted in routine work in any unit. We are trying to introduce at least routine recording of insertion in the chart. To help overcome inertia, we proposed to the Ministry of Health to publish guidelines with mandatory use and documentation of a checklist. The guidelines were prepared based in part on Hadassah experience and their publication is pending.

39. (III) Follow Up on a Few Other Projects • Leadership for Quality & Safety • A survey on leadership at Hadassah,* showed that 70% of departments heads and 80% of head nurses, thought it would be appropriate to use as criteria for appointment (or re- appointment) of a department head, presentation of initiatives on clinical quality & safety. • Such a policy is worthwhile to consider as it would enhance participation of clinical heads in quality & safety and facilitate implementation of improvement initiatives such as on VAP and central line infections. • * Dr. NuritPorat. The Relationship between the Leadership Style of Hospital Department Head, Cooperation with Head Nurse, and Climate of Quality and Patient Safety in General Hospital. PhD thesis, BGU, 2010.

40. (III) Follow Up on a Few Other Projects • Disruptive Behavior

41. Disruptive Behavior “Do you have disruptive behavior at Hadassah?” Mark Chassin, MD, MPP, MPH Professor of Medicine & VP for Excellence Mount Sinai School of Medicine President of the Joint Commission Joint Commission now requires hospitals to have a written code of conduct and a process for enforcing it

42. Survey of Disruptive Behavior at Hadassah Last year exposure to intimidating behavior (%) Data from 100 MDs & nurses, at Departments of Medicine & Surgery at Ein Kerem and Mt Scopus Hadassah Hospitals

43. (III) Follow Up on a Few Other Projects • Disruptive Behavior • Hadassah Quality and Safety Committee has proposed to adopt a code of conduct and a policy for enforcing it with an institutional committee to handle disruptive behavior, using review of cases, sanction for recidivism and education. • Despite several reminders, our suggestion has not been followed. • Rapid Response Teams (RRT’s) • RRT’s have been shown in some studies to reduce need for coding, morbidity and mortality. Efficacy may depend on local institutional culture. In a survey of intensive care experts and anesthesiologists (N=32), nearly half thought RRT’s might be efficacious at Hadassah. A working team from the Quality and Safety Committee has proposed to run a pilot project with several departments. Members of this Committee have commented that the death of a woman from bleeding after a C/S could have been averted by a RRT. • The suggestion to run a pilot has not been followed.

44. (III) Follow Up on a Few Other Projects • Transparency • Recent studies suggest that an open disclosure policy after a medical error is useful to restore trust, reduce anger and liability costs and to enhance safety improvement efforts.

45. A Better Approach to Medical Malpractice Claims? The University of Michigan Experience “…an honest, principle-driven approach to claims is better for all those involved—the patient, the healthcare providers, the institution, future patients, and even the lawyers”

46. “Do you believe a disclosure policy could work in your department?” • Survey of members of the Quality & Safety Committee: • 9/10 senior clinicians and department heads responded yes, some reported they already work according to a policy of full disclosure. These were from pediatrics, medicine, obgyn and hemato-oncology. • Survey of 43 department heads: • 15 responded yes, 8 of them added they already work according to a policy of full disclosure. These were from pediatrics, pediatric surgery, medicine, and hematology. • 2 responded no; 5 asked for more time; the remainder have not replied. • Based on these preliminary observations, a policy of disclosure appears worthwhile to consider at least with some wards and with the development of a support team in collaboration with RM.

47. Conclusion Quality and safety initiatives, such as VAP or medication reconciliation, show opportunity for significant improvement. To enhance participation by clinicians, quality initiatives could be used as criteria for appointment (or re- appointment) of departments heads.