Improving Patient Safety, Clinical Quality and Unfunded Mandates: What ICPs Should Know

2. Improving Patient Safety, Clinical Quality and Unfunded Mandates: What ICPs Should Know APIC 2005 Baltimore, MD Denise Murphy, RN, BSN, MPH, CIC Chief Patient Safety and Quality Officer Barnes-Jewish Hospital at Washington University Medical Center St. Louis, MO

3. I LOVE CHANGE! Who Keeps Moving the Cheese? And WHY? • Institute of Medicine Reports on • Medical Errors (>100,000 lives lost annually) • Quality Chasm (Safety, • Government: • Center for Medicare and Medicaid Services (CMS) • Agency for Healthcare Research and Quality • CDC • Healthcare research • Medical malpractice claims • JCAHO sentinel event tracking • Consumer’s Union and other advocacy groups • Insurers: Pay4Performance • Industry: Leapfrog Group

4. What Should ICPs Know About Quality Initiatives • National Quality Forum, CMS, JCAHO and other agencies require patient safety and quality (PSQ) monitoring and reporting • tied to reimbursement • Consumers & payors demanding performance data • Non- and for-profit organizations driving quality improvement (e.g., IHI, VHA) • Infection prevention is included in improvement initiatives (local and national scorecards)

5. What are Hospitals Responsible for in Terms of Quality & Compliance • Indicators related to • Clinical Quality • Infection Prevention • Patient Safety • Operational Excellence and Customer Satisfaction • Reporting • Federal and State agencies, accreditation agencies, voluntary quality initiatives (AHA, IHI, etc.), insurers • Governance boards • Public reporting of hospital-acquired infections • Reporting of other/all adverse events: stay tuned!

6. Why Should ICPs Care? • We are experts in monitoring, reporting and driving interventions related to adverse outcomes • We are Quality Improvement and Patient Safety Professionals – organizational consultants, experts, and leaders in • identifying risk • mitigating and preventing adverse events • If we bring our expertise to required, highly visible PSQ activities, we demonstrate our value to healthcare executives!

7. ORYX/ CMS Core Measures -Current CMS/AHA & JCAHO Measures - Anticipated Best-in-Class 2004 NPSG Indicator Safety Culture1 Employee perception of management commitment to patient safety  x Employee willingness to report errors  x Patient Identification2 Surgical/procedural site ID compliance  x Surgical/procedural time-out compliance  x Patient rating of consistency of identification by care givers (survey)  x Medication Safety2 Compliance with "Do Not Use" abbreviation list  x Infection Control Trained medical direction in Infection Control x Antibiotic management program enhancements x Surgical patients receiving prophylactic antibiotic within standard x Hand hygiene policy and education x Reduce Catheter-related Bloodstream Infections in ICU (SIR < 1) x Reduce VAP Infections in ICU (SIR < 1) x Patient Identification Mislabeled/unlabeled lab specimens x Medication Safety Tall man lettering utilized at medication storage locations x WHAT IS BEING MEASURED and BY WHOM?

8. JCAHO Core Measures -Current JCAHO Core Measures - Future Best-in-Class 2005 CMS Annual Payment Update Indicator AMI Admission Treatment ASA within 24 hours of hospital arrival1 x x x Beta-blockers within 24 hours of hospital arrival1 x x x Cholesterol testing within 24 hours of hospital arrival x Discharge Treatment ACE-I/ARB prescribed at discharge for LV systolic dysfunction1 x x x ASA prescribed at discharge1 x x x Beta-blockers prescribed at discharge1 x x x Lipid-lowering agents prescribed at discharge x Reperfusion therapy within standard (Thrombolytic & PTCA)1 x x -Smoking cessation advice/counseling2 x x Inpatient mortality x Society of Thoracic Surgeons (STS) CABG ASA/antiplatelet prescribed at discharge x x Lipid-lowering agents prescribed at discharge x x ACE-I prescribed at discharge x Beta-blockers prescribed at discharge x x Exercise program and/or cardiac rehabilitation therapy prescribed at discharge x Smoking cessation advice/counseling x x

9. Indicator JCAHOCore Measures -Current JCAHOCore Measures - Future Best-in-Class 2005 CMSAnnual Payment Update CAP Antibiotic administration within 4 hours of hospital arrival1 x x x Admission Treatment Oxygenation assessment1 x x Initial selection of antibiotic x x Blood cultures before antibiotics2 x x Preventive Care x Smoking cessation advice/counseling (adult/pediatric)2 x x Pneumococcal vaccine screening and/or vaccination1 x x x Influenza vaccination3 x x CHF ACE-I prescribed at discharge1 x x x Antithrombotics Rx at discharge for patients with AFib x Discharge instructions2 x x LV function assessment1 x x x Smoking cessation advice/counseling (adult)2 x x PCI ASA/antiplatelet prescribed at discharge x

10. Indicator Best-in-Class 2005 CMS Annual Payment Update JCAHO Core Measures -Current JCAHO Core Measures - Future SIP (Surgical Infection Prevention) Duration of prophylactic antibiotics3 x x x Duration of prophylaxis3 x x x Selection of antibiotic3 x x x Other HCAHPS (patient satisfaction survey)4 x 1 Publicly reported Q4 2003, Q1 2004 (Sept 2002 discharges) 2 Publicly reported beginning Q1 2005 (Q2 2004 discharges) 3 Publicly reported Summer 2005 (Q3 2004 discharges) 4 Publicly reported Fall/Winter 2005 (Q1 2005 discharges)

11. Indicator NPSG Improve accuracy of patient identification Use 2 patient identifiers when taking blood, administering medications or blood products, providing any other treatments or procedures x Prior to the start of any surgical or invasive procedure, conduct a final verification process, or "time out", to confirm correct pt., procedure, site using active communication techniques x Improve the effectiveness of communication among caregivers To verify telephone or verbal orders, or critical test results, the person receiving the order must "read back" the complete order or test result after transcription x Standardize abbreviations, acronyms and symbols used throughout the organization, including list of abbreviations, acronyms and symbols not to use x Measure, assess, and take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver of critical test results & values x Improve the safety of using medications Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units x Standardize and limit the number of drug concentrations available in the organization x Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs x Eliminate wrong site, wrong patient and wrong procedure surgery Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents, (e.g., medical records, imaging studies) are available x Implement a process to mark the surgical site and involve the patient in the marking process x

12. Indicator NPSG Improve the safety of using infusion pumps. Ensure free flow protection on all general use and PCA intravenous infusion pumps used in the organization x Improve the effectiveness of clinical alarm systems Implement regular preventive maintenance and testing of alarm systems x Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within unit x Reduce the risk of healthcare-acquired infections Comply with current CDC hand hygiene guidelines x Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a healthcare-acquired infection x Accurately & completely reconcile medications across the continuum of care Develop a process for obtaining & documenting a complete list of patient's current medications upon admission and with any involvement of the patient x A complete list of the patient's medications is communicated to the next provider of services when it refers or transfers a patient to another setting, service, practitioner or level of care x Reduce the risk of patient harm resulting from falls Assess & periodically reassess each patient's risk for falling, including the potential risk associated with the patient's medication regimen x

13. INDICATOR Magnet Status *NDNQI Pressureulcer prevalence x x Pressure ulcer occurrence x x Nursing care hours provided per patient day x x Nursing staff satisfaction x x Falls occurrence x x Fall injury occurrence x x Patient satisfaction in relation to: x x - Nursing care - Pain management x x - Patient education x x - Overall care x x Skill mix of RN, LPN and unlicensed staff x x *National Database of Nursing Quality Indicators

14. Indicator ORYX/ CMS Core Measures -Current CMS/AHA & JCAHO Measures - Anticipated Best-in-Class 2004 Magnet/ NDNQI NQF Nursing-Sensitive Voluntary Consensus Standards X Death among surgical inpatients with treatable serious complications (failure to rescue) Pressure ulcer prevalence X x Falls prevalence X x Falls with injury X x Restraint prevalence (vest and limb only) X Urinary catheter-associated UTI for intensive care unit (ICU) patients X Central line catheter-associated blood stream infection rate for ICU and high-risk nursery (HRN) patients X x Ventilator-associated pneumonia for ICU and HRN patients x x Smoking cessation counseling for AMI x x Smoking cessation counseling for HF x x Smoking cessation counseling for pneumonia x x Skill mix (RN, LVN/LPN, UAP, and contract) x x Nursing care hours per patient day (RN, LPN, and UAP) x x Practice Environment Scale - Nursing Work Index x Voluntary turnover x

15. Indicator ORYX/ CMS Core Measures -Current CMS/AHA & JCAHO Measures - Anticipated Best-in-Class 2004 Magnet/ NDNQI JCAHO ORYX ICU Measures Ventilator-Associated Pneumonia (VAP Prevention – Patient Positioning) x x Stress Ulcer Disease (SUD) Prophylaxis x Deep Vein Thrombosis (DVT) Prophylaxis x x Central Line-Associated Primary Blood Stream Infection x x Risk-Adjusted ICU LOS by type of ICU x Risk-Adjusted Hospital Mortality for ICU Patients x

16. PROPOSED 2006 NATIONAL PATIENT SAFETY GOALS Goal #10: Reduce Influenza and Pneumonia Develop and implement protocols for administration and documentation of influenza and pneumonia vaccination. Goal # 13: Achieve and Maintain an Organization-wide Safety Culture Assess Culture of Safety and take action on results of assessment Encourage external reporting of adverse events Use external or expert information when designing new or modifying existing processes to improve PS and reduce risk for sentinel events Share lessons learned from root cause analysis conducted by the organization with all staff who provide relevant services or may be impacted by proposed solutions Increase awareness of and access to relevant patient safety literature and advisories for all organizational leaders and staff Goal #14: Involve Patients in their Own Care as a Patient Safety Strategy Provide appropriate patient education to guide patient’s awareness and involvement in their own care. (Assess health literacy level, language skills, ethnic and cultural factors) Provide copy of medications to each patient and assist them in tracking/reconciling medications. Implement comprehensive patient involvement program Engage patients in the process of transitions across the continuum of care, including a dialogue about their expectations and concerns about the next setting of care Encourage patient participation in organization’s committees that relate to planning or providing patient care services Define and communicate the means to report concerns about safety and encourage pts. to do so

17. PROPOSED 2006 NATIONAL PATIENT SAFETY GOALS Goal #16: Prevent Healthcare-Associated Decubitus Ulcers Assess and periodically reassess each patient’s risk for developing a decubitus ulcer (pressure sore) and take action to address any identified risks Identify patients who enter the organization with a decubitus ulcer and provide appropriate medical, physical and nutritional management to facilitate healing

18. What is Interventional Patient Hygiene? • Webster defines hygiene as the science and practice of the establishment and maintenance of health. • Interventional Patient Hygiene is a nursing action plan directly focused on fortifying the patients host defense through use of evidence-based care. • It works best with a protocol (action plan) and PIP (measurement)

19. So What Can ICPs Do? • KNOW the big picture of PSQ and where you and your program fit in • Position yourself as a leader in your organization’s PSQ program…you are a Patient Safety Leader! • Volunteeryour expertise to teams addressing other types of adverse outcomes of patient care • Data management, analysis and reporting • Intervention development • Education and literature interpretation • Evaluation of products and technologies • Science-based, cross-functional, multi-disciplinary approach to problem solving

20. Get involved…WHY? ICPs are Safety, Quality and Performance Improvement EXPERTS!

21. Now, it is my pleasure to introduce you to our session experts… Robert Garcia, BS, MMT(ASCP), CIC Deborah Trau, RN, 6 Sigma Black Belt to further address the role of infection prevention in improving patient safety and clinical quality

22. The Role of Oral and Dental Colonization on Respiratory Infection: Call for New Interventions in a Patient Safety World Robert Garcia, BS, MMT(ASCP), CIC The Brookdale University Medical Center, Brooklyn, New York

23. High Risk, High Morbidity, High Cost

24. VAP Facts • Mechanical ventilation increases risk of pneumonia 6-21 times (1% per day) • Attributable mortality is 27% and increases to 87% when etiologic agent is P.aeruginosa or Acinetobacter sp. • Length of stay with VAP is 34 days and 21 days without VAP Garcia R., A review of the possible role of oral and dental colonization on the occurrence of healthcare-associated pneumonia: Underappreciated risk and a call for interventions. Accepted for publication. AJIC 2005

25. 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 11: Isolate the pathogen Hospital-Onset Infection Rates in NNIS Intensive Care Units, 1990-1999 Type of ICU BSI* VAP* UTI* Coronary 43% 42% 40% Medical 44% 56% 46% Surgical 31% 38% 30% Pediatric 32% 26% 59% *BSI = central line-associated bloodstream infection rate VAP = ventilator-associated pneumonia rate UTI = catheter-associated urinary tract infection rate Source: National Nosocomial Infections Surveillance (NNIS) System.

26. 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Prevalence of Antimicrobial-Resistant (R) Pathogens Causing Hospital-Onset Intensive Care Unit Infections: 1999 versus 1994-98 Organism # Isolates % Increase* Fluoroquinolone-R Pseudomonas spp. 2657 49% 3rd generation cephalosporin-R E. coli 1551 48% Methicillin-R Staphylococcus aureus 2546 40% Vancomycin-R enterococci 4744 40% Imipenem-R Pseudomonas spp. 1839 20% * Percent increase in proportion of pathogens resistant to indicated antimicrobial Source: National Nosocomial Infections Surveillance (NNIS) System.

27. ICU Rates of VAP, NNIS Study, Jan 2002-Jun 2004 Pooled means: Medical – 4.9 Med-Surg – 5.4 Surgical – 9.3

28. Cost of VAP • Retrospective matched cohort study using data from large U.S. database • 9,080 patients; 842 with VAP (9.3%) • Patients with VAP had significantly longer duration of mechanical ventilation, ICU stay, and hospital stay. • VAP associated with increase of >$40,000 in mean hospital charges Rello J et al., Epidemiology and outcomes of VAP in a large US database. Chest. 2002;122:2115-2121.

30. HICPAC guidelines on preventing pneumonia • Issued 3/26/04 • Evidence-based • Expert review • Recommendations categorized www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm

31. HICPAC categories • Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies. • Category IB. Strongly recommended for implementation and supported by certain clinical or epidemiologic studies and by strong theoretical rationale. • Category IC. Required for implementation, as mandated by federal or state regulation or standard. • Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or by strong theoretical rationale. • No recommendation; unresolved issue. Practices for which insufficient evidence or no consensus exists about efficacy. Guideline for the Prevention of Intravascular-Associated Infections, CDC, 3/26/04.

32. What strategies have been advocated in preventing VAP?

33. Do not change routinely the ventilator circuit…Change the circuit when it is visibly soiled or mechanically malfunctioning. Cat. IA

34. Heat Moisture Exchanger No recommendation can be made for the preferential use of either HMEs or heated humidifiers…Unresolved issue.

35. No recommendation can be made about the frequency of routinely changing the in-line suction catheter of a closed suction system – Unresolved issue.

36. Photographs courtesy of D. Ryan In the absence of medical contraindications, elevate at an angle of 30-45° the head of the bed of a patient…receiving mechanically assisted ventilation…Cat. II

37. Stress Ulcer Prophylaxis • Theory has it that modifying stomach acid effects the bacterial colonization level • HICPAC: • No recommendation can be made for the preferential use of sucralfate, H2-antagonists, and/or antacids for stress-bleeding prophylaxis in patients receiving mechanically assisted ventilation (unresolved issue). • Livingston DH, Prevention of ventilator-associated pneumonia. Am J Surg. 2000;179(suppl 2A):12S-17S. • “After all of this time and study, it is likely that neither drug has any advantage in significantly maintaining gastric flora and reducing VAP.”

38. Selective Digestive Decontamination • Preventive decolonization on the theory that the gut is a major source of VAP • HICPAC: • No recommendation can be made for the routine selective decontamination of the digestive tract (SDD) of all critically-ill, mechanically ventilated, or ICU patients (unresolved issue). • 30+ studies to date • Eggimann P, Pittet D. Infection control in the ICU. Chest 2001;120:2059-2093: • “…This selective pressure on the epidemiology of resistance definitely precludes the systematic use of SDD for critically ill patients.”

39. Weaning • Duration, duration, duration!!! • Cook D, Meade M, Guyatt G, Griffith L., Booker L, Criteria for Weaning from Mechanical Ventilation. Evidence Report/Technology Assessment No. 23 (Prepared by McMaster University under Contract No. 290-97-0017). AHRQ Publication No. 01-E010. Rockville MD: Agency for Health Care Research and Quality. November 2002. • Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support. A Collective Task Force Comprised of Members of the American College of Chest Physicians, the American Association for Respiratory Care and the American College of Critical Care Medicine. Chest 2001;120:375S-395S.

40. Is there scientific evidence that links oropharyngeal and dental colonization with respiratory illness?

41. Prevention or Modulation of Oropharyngeal Colonization • HICPAC: • Oropharyngeal cleaning and decontamination with an antiseptic agent: develop and implement a comprehensive oral-hygiene program (that might include the use of an antiseptic agent) for patients in acute-care settings or residents in long-term-care facilities who are at high risk for health-care-associated pneumonia. Cat. II • Schleder B, Stott K, Lloyd RC, The effect of a comprehensive oral care protocol on patients at risk for ventilator-associated pneumonia. J Advocate Health 2002;4:27-30. • Yoneyama T, et al., Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc. 2002;50:430-3.

42. 1. Oral Cavity vs. Gastric Colonization • Prospective study of 86 mechanically vented ICU patients to assess relationship between oropharyngeal colonization and subsequent occurrence of pneumonia • Patients oral and gastric specimens were collected on admission and twice weekly • When pneumonia suspected, bronchoscopic specimens were taken with protected specimen brush • In 31 cases of pneumonia identified, DNA genomic analysis demonstrated that oropharyngeal colonization was the predominant factor in the development of pneumonia compared with gastric colonization. Garrouste-Orgeas M, et al., Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA analysis. Am J Respir Crit Care Med. 1997;156:164.

43. Acquired bacterial colonization: Location of the microorganisms in the 44 carrier patients OC = oropharyngeal colonization; GC = gastric colonization; BC = both OC/GC colonization Garrouste-Orgear M, et al., Am J Resp Crit Care Med 1997.

44. Oropharyngeal Rather Than Gastric Colonization: Further Support • Kerver AJ, et al., Colonization and infection in surgical intensive care patients – a prospective study. Intensive Care Med. 1987;13:347-51. • Bonten MJM, et al., Risk factors for pneumonia, and colonization of respiratory tract and stomach in mechanically ventilated ICU patients. Am J Resp Crit Care Med. 1996;154:1339-46. • Ewig S, et al., Bacterial colonization patterns in mechanically ventilated patients with traumatic head injury. Am J Resp Crit Care Med. 1999;158:188-98.

45. 2. Decontamination of the Oropharynx • Prospective, randomized, double-blind study of ICU patients to determine VAP while manipulating oropharyngeal colonization and without influencing gastric or intestinal colonization • 87 given topical antibiotics (study group), 139 given placebo (control group) • Results: • VAP in study group: 10% • VAP in control group: 27% Bergmans D, et al. Prevention of ventilator-associated pneumonia by oral decontamination. Am J Resp Crit Care Med. 2001;164:382-88.

46. Additional Studies and Reviews Using Antibiotic Pastes or Solutions • Rodriguez-Roldan JM, et al., Prevention of nosocomial lung infection in ventilated patients: use of an antimicrobial nonabsorbable paste. Crit Care Med. 1990;18:1239-42. • Pugin J, et al., Oropharyngeal decontamination decreases incidence of ventilator-associated pneumonia: a randomized, placebo-controlled, double-blind clinical trial. J Am Med Assoc. 1991;265:2704-10. • Bonten MJ, et al., Role of colonization of the upper intestinal tract in the pathogenesis of ventilator-associated pneumonia. Clin Infect Dis. 1997;24:309-19.

47. 3. Oral Decolonization: Use of Chlorhexidine • Prospective, randomized, double-blind, placebo-controlled trial testing the effectiveness of oral decontamination on nosocomial infection • 353 patients undergoing coronary bypass surgery • Used chlorhexidine gluconate (0.12%) as oral rinse to prevent nosocomial infections • Randomized to receive CHG or placebo • Results: • Overall reduction in nosocomial infections of 65% when using CHG • Respiratory infections were reduced 69% in CHG group DeRiso AJ II, et al., Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and non-prophylactic systemic antibiotic use in patients undergoing heart surgery. Chest 1996;109:1556-61.

48. 4. Link Between Oral Pathogens & Respiratory Infection • A review article • 6 articles cited as support for a relationship between poor oral health and respiratory infection • Bacteria from colonized dental plaque may be aspirated into the lower airway Scannapieco, FA., Role of oral bacteria in respiratory infection. J Periodontol. 1999;70:794-802

49. 5. Dental Plaque as a Bacterial Source of VAP • Study on dental plaque colonization and ICU nosocomial infections. • 57 patients studied • Results: • Dental plaque occurred in 40% of patients • Colonization of dental plaque was highly predictive of nosocomial infection • Salivary, dental, and tracheal aspirates cultures were closely linked Fourrier E, et al., Colonization of dental plaque: a source of nosocomial infections in intensive care patients. Crit Care Med. 1998;26:301-8.

50. Additional Evidence Linking Colonized Dental Plaque and Respiratory Infection • Scannapieco FA, et al., Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Crit Care Med. 1992;20:740-45. • Fitch JA, et al., Oral care in the adult intensive care unit. Am J Crit Care. 1999;8:314-18. • Sumi Y, et al., Colonization of denture plaque by respiratory pathogens in dependent elderly. Gerontolog. 2002;9:25-9. • Russel SL, et al., Respiratory pathogen colonization of the dental plaque of institutionalized elders. Spec Care Dentist. 1999;19:128-34.