Methods for Improvement Where are the Ideas?

1. Methods for ImprovementWhere are the Ideas? David I Gozzard Quality Improvement Fellow Health Foundation

2. An International Movement of Movements?

3. The Entire UK Is Engaged

4. England Cause To make the safety of patients everyone’s highest priority Aim No avoidable death and no avoidable harm Interventions Leadership for safety Reducing harm from deterioration Reducing harm in critical care Reducing harm in perioperative care Reducing harm from high risk medicines

5. 5.5 million people Scottish Patient Safety Programme 37 acute hospitals Critical care Peri-op Medicines General ward Leadership Aims 15% reduction in mortality 30% reduction in adverse events Scotland

6. Denmark • 5.5 million inhabitants • Health care is a public task • 5 regions that are responsible for health care Operation Life: • 38 hospital units • Rapid Response Systems • AMI Bundle • Medication Reconciliation • Ventilator Bundle • Central Line Bundle • Surviving Sepsis Campaign • Aims • Save 3000 lives during campaign period • All regions present at campaign start • Cover 75% of discharges www.operationlife.dk

7. Canada • 33 million people • 10 interventions + 2 pilots • 1035 teams enrolled • 80% of acute care hospitals enrolled • All regional health organizations outside of Quebec enrolled Aim • Reduce adverse events by 40-100% dependent upon intervention www.saferhealthcarenow.ca

8. Japan “PARTNERS for Patient Safety” National Campaign for Patient Safety in Japan http://kyodokodo.jp/

9. 3 million people 1000 Lives Campaign All Hospitals, Primary Care and Ambulance services Leadership Critical Care/Rapid response Medicines Healthcare associated infection Surgical care General medical and surgical care Aims To save 1000 lives, and Avoid 50,000 cases of harm in 2 years from April 2008 Wales www.1000livescampaign.wales.nhs.uk

10. 100,000 Lives Campaign • Deploy Rapid Response Teams…at the first sign of patient decline • Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack • Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation • Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps • Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time • Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps

11. 5 Million Lives Campaign The Platform • Reduce Surgical Complications – Adopt “SCIP” • Prevent Harm from High Alert Medications • Prevent MRSA Infections • Reduce Readmissions from Congestive Heart Failure • Prevent Pressure Ulcers • Get Boards on Board

12. Reducing Surgical Complications The Goal: Reduce surgical complications by 25 percent by December 2008 by reliably implementing the changes in care recommended by the Surgical Care Improvement Project (SCIP)

13. Four Key Interventions • Surgical Site Infection Prevention • Beta Blockers for Patients on Beta Blockers prior to Admission • Venous Thromboembolism Prophylaxis • Ventilator-Associated Pneumonia Prevention

14. Reduce Surgical Site Infections • Appropriate use of antibiotics • Appropriate hair removal • Postoperative glucose control (major cardiac surgery patients cared for in an ICU)* • Perioperative normothermia (colorectal surgery patients)* * These components of care are supported by clinical trials and experimental evidence in the specified populations; they may prove valuable for other surgical patients as well.

15. Beta Blockade The American College of Cardiology / American Heart Association Task Force on Practice Guidelines: “Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA Class I guideline indications” (ACC/AHA Practice Guidelines. JACC. 2006; 47(11); 2342-2355).

16. What Does the Evidence Tell Us? In a study of 140 patients who received beta blockers preoperatively, eight patients had their beta blockers discontinued postoperatively and mortality was 50 percent, compared to mortality of 1.5 percent in the other 132 patients who had beta blockers continued (odds ratio 65.0, P<.001). (Shammash JB, Trost JC, et al. Am Heart J. 2001;141(1):148-153)

17. Venous Thromboembolism Prophylaxis (VTE) • Deep vein thrombosis (DVT) is estimated to occur in 10 to 40 percent of general surgical patients when prophylaxis is not provided. • In a study cited by the American College of Chest Physicians (ACCP), autopsies of surgical patients who died within 30 days postoperatively revealed that 32 percent had had a PE and it was the cause of death for most (Lindblad B, Eriksson A, Bergqvist D. Br J Surg. 1991;78:849-852).

18. Tips for Getting Started • Develop standard order sets for prophylaxis • Develop protocols for providing prophylaxis automatically, based on surgical procedure • Provide education and training for staff on the importance of VTE prophylaxis • Educate patients preoperatively about the prophylaxis they will receive and steps they can take to reduce risk

19. Ventilator-Associated Pneumonia • According to SCIP, “postoperative pneumonia occurs in 9 – 40% of patients and has an associated mortality of 30 - 45%” • Hospital mortality of ventilated patients who develop VAP is 46 percent (Ibrahim EH, Tracy L, Hill C, et al. Chest. 2001;20(2):555-561) • VAP prolongs time spent on the ventilator, length of ICU stay, and length of hospital stay after discharge from the ICU (Rello J, Ollendorf DA, Oster G, et al. Chest. 2002;22(6):2115-2121)

20. Four Key Changes • Elevation of the head of the bed to between 30 and 45 degrees • Daily “Sedation Vacation” and daily assessment of readiness to extubate • Peptic ulcer disease (PUD) prophylaxis • Deep vein thrombosis (DVT) prophylaxis (unless contraindicated)

21. Reducing Harm from High-Alert Medications The Goal: Reduce harm from high-alert medications by 50% by December 2008

22. What Are High-Alert Medications? High-alert medications are more likely to be associated with harm that is both more common and likely to be more serious: • Anticoagulants • Insulin • Narcotics • Sedatives

23. What Does the Evidence Tell Us? Several studies have identified adverse drug events as the single most frequent source of health care mishaps, continually placing patients at risk of injury. -Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger tool: A practical methodology for measuring medication-related harm. Qual Saf Health Care. 2003;12:194-200. -Bates DW, Boyle DL, Vander Vliet VM, et al. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10:199-205. -Bates DW, Cullen DJ, Laird NM, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;274:29-34. -Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA. 1997;277:312-317.

24. What Does the Evidence Tell Us? Warfarin and insulins caused: • One in every sevenestimated adverse drug events treated in emergency departments • More than a quarter of all estimated hospitalizations In the elderly, insulin, warfarin, and digoxin were implicated in: • One in every threeestimated adverse drug events treated in emergency departments • 41.5% of estimated hospitalizations Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency department visits for outpatient adverse drug events. JAMA. 2006;296:1858-1866.

25. What Does the Evidence Tell Us? Review of events in an adverse drug reaction database of 317 preventable ADEs, “…suggested that three high-priority preventable ADEs accounted for 50% of all reports: (1) overdoses of anticoagulants or insufficient monitoring and adjustments (according to laboratory test values) were associated with hemorrhagic events, (2) overdosing or failure to adjust for drug-drug interactions of opiate agonists was associated with somnolence and respiratory depression, and (3) inappropriate dosing or insufficient monitoring of insulins was associated with hypoglycemia.” Winterstein AG, Hatton RC, Gonzalez-Rothi R, Johns TE, SegalR.Identifying clinically significant preventable adverse drug events through a hospital's database of adverse drug reaction reports.American Journal of Health-System Pharmacy. 59;18:1742-1749.

26. Prevent MRSA Infection The Goal: Reduce methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection by December 2008 Focus on “getting to zero”

27. A Vision For The Future? MRSA in Denmark 100% Rosdahl VT et al. Infect Control Hosp Epidemiol 1991;12:83-88. 90% 80% 70% 60% 50% MRSA Bloodstream Infections 40% 30% 20% 10% 0% 1960 1965 1970 1975 1980 1985 1990 1995

28. Or This? MRSA in the UK

29. What Does the Evidence Tell Us? • Rational Interventions Should Target Modes of MRSA Transmission • Person-person via hands of health care providers – by far the most important • Personal equipment (e.g., stethoscopes, PDAs) and clothing • Environmental contamination • Airborne transmission • Carriers on the hospital staff • Rare common-source outbreaks

30. Prevent Infection and Colonization • Colonized patients comprise the reservoir for transmission (“colonization pressure”). • High rates of MRSA colonization complicate empiric antibiotic therapy (e.g., vancomycin). • Colonized patients have a high rate of MRSA infection. • Nearly 1/3 develop infection, often after discharge • Colonization is long-lasting, and patients can transmit MRSA to patients in other health care settings (e.g., nursing homes), as well as to family members.

31. Five Key Interventions • Hand hygiene • Decontamination of the environment and equipment • Active surveillance cultures (ASCs) • Contact precautions for infected and colonized patients • Compliance with Central Venous Catheter and Ventilator Bundles

32. Tips: Hand Hygiene • Single most important intervention, especiallyafter and before patient contact • Compliance rates of 40-50% no longer are acceptable • Hold staff accountable • Encourage patients and families to remind caregivers to practice hand hygiene • Alcohol hand rubs have made hand hygiene much easier • Rapidly kill bacteria (except Clostridium difficile spores) • Surprisingly gentle on hands • Not a substitute for soap and water when hands are grossly soiled

33. Tips: Decontamination of Environment and Equipment • Use dedicated equipment for colonized/infected patients • For general patient care, use alcohol wipes for stethoscopes and other personal equipment when leaving the bedside • Put environmental services personnel on the team • Clean and disinfect the environment carefully, especially “high touch” areas • Use an environmental cleaning checklist • Trust and verify

34. Tips: Active Surveillance • Perform active surveillance cultures (ASCs) to detect colonized patients on admission • Necessity of ASCs per se in controlling MRSA is controversial • But “knowledge is power” – clinical cultures miss many colonized patients and vastly underestimate the magnitude of the problem • ASCs on admission, followed by testing weekly and/or at discharge, is necessary to document the extent of transmission and the success of control measures • Successful programs combine ASCs with reliable implementation of other interventions • Controversy regarding ASCs for high-risk areas (ICUs) vs. entire hospital • Flag colonized patients when discharged

35. Reduce Re-admissions from Congestive Heart Failure (CHF) The Goal: Reduce the 30-day re-admission rate of patients discharged with the diagnosis of CHF by 50% by December 2008

36. What Is “Congestive Heart Failure?” • A clinical syndrome resulting from a structural or functional cardiac disorder that impairs the ability of the heart (the ventricles) to fill with or eject blood • Characterized by • Shortness of breath (dyspnea) and fatigue (exercise intolerance) • Fluid retention – trouble lying flat, swelling (edema) of dependent parts of the body (especially the legs)

37. What Does the Evidence Tell Us? • Measuring left ventricular systolic (LVS) function is a critical step in determining who needs specific treatment (left ventricular ejection fraction (LVEF) < 40%) • Numerous clinical trials demonstrate that drugs that help the ventricles pump more effectively reduce symptoms, readmissions, and mortality • Angiotensin-converting enzyme (ACE) inhibitors • Angiotensin receptor blockers (ARBs) • Beta blockers • Patients with atrial fibrillation (AF) tend to form blood clots in the heart and are at increased risk for stroke • Anticoagulation reduces the risk of stroke ACC/AHA Guideline, Circulation 2005;112:154-235

38. What Does the Evidence Tell Us? • CHF patients have a higher risk of hospitalization and mortality due to pneumonia • Influenza and pneumococcal immunizations both are effective in reducing the risk of pneumonia, hospitalizations, and mortality (ACIP recommended) • Smoking is a risk factor for poor outcomes in CHF • Smoking cessation programs initiated in the hospital can help patients quit smoking, as least in the short term • Discharge planning, including a good “hand off,” probably reduces short-term re-hospitalizations and puts the patient and ambulatory providers on the right track for better longer-term outcomes

39. Seven Key Interventions • Left ventricular systolic (LVS) heart function assessment (CMS,JCAHO,ACC,AHA) • ACE inhibitor or ARB at discharge for CHF patients with systolic dysfunction (LVEF<40) (CMS,JCAHO,ACC,AHA) • Anticoagulant at discharge for CHF patients with chronic/recurrent atrial fibrillation (ACC,AHA)

40. Seven Key Interventions • Influenza immunization (ACIP) • Pneumococcal immunization (ACIP) • Smoking cessation counseling (CMS,JCAHO,ACC,AHA) • Discharge instructions that address all of the following: activity level, diet, discharge medications, follow-up appointments, weight monitoring, and what to do if symptoms worsen (CMS,JCAHO,ACC,AHA) Hospital performance on all interventions is sub-par (54% on the discharge component, 2005 CMS data)

41. Other Interventions to Consider • Beta blocker therapy for patients who have minimal or no evidence of fluid overload or volume depletion (AHA,ACC) • Well supported by randomized controlled trials • If started at discharge (as recommended by AHA Get With The Guidelines-HF): • Insures patient is started on therapy and hastens attainment of therapeutic levels • Requires close monitoring and follow-up post-discharge • Discharge “contract” • Statin for patients with/at risk for coronary artery disease • Spironolactone (certain high risk patients)

42. Prevent Pressure Ulcers The Goal: Reduce the incidence of hospital-acquired pressure ulcers by December 2008 Focus on “getting to zero”

43. What Does the Evidence Tell Us? • Risk is predictable • age immobility, incontinence, poor nutrition, sensory problems, circulation problems, dehydration and poor nutrition • Skin integrity can deteriorate in hours • frequent assessment prevents minor problems from becoming major ulcers • Wet skin is more vulnerable to skin disruption and ulceration • But dry skin is a risk factor as well • Continual pressure, especially over bony prominences, increases risk • Pressure-relieving surfaces work Reddy et al., JAMA 2006;296:974-84

44. Six Key Interventions • Conduct a pressure ulcer admission risk assessment for all patients • Reassess risk for all patients daily For all patients identified as being at risk for pressure ulcers: • Inspect skin daily • Manage moisture: keep the patient dry; moisturize dry skin • Optimize nutrition and hydration • Minimize pressure: ensure that patients are turned every two hours; use pressure-relieving surfaces

45. Conduct a Pressure Ulcer Admission Risk Assessment; Reassess Daily • Use visual cues in admission documentation for completion of skin and risk assessment • Standardize risk assessment tool/check list across the institution • Incorporate action steps linked to risk • Use multiple methods to visually identify patients at risk • Stickers on chart, visual cues on door and bed • Post compliance rates to motivate staff • Improve processes to ensure risk assessment is conducted within 4 hours of admission and daily • Assess surgical patients

46. Inspect Skin Daily • Required for high-risk patients • Skin integrity can deteriorate in a matter of hours • Always look at sacrum, back, buttocks, heels, and elbows every time the patient is assessed

47. Manage Moisture • Cleanse skin at time of soiling and at routine intervals • Watch for excessive moisture due to perspiration and wounds • Use gentle cleansing agent • Use moisturizers for dry, fragile skin • Provide under-pads that wick moisture away from skin • Keep kit of needed supplies at bedside for at-risk incontinent patients

48. Optimize Nutrition/Hydration • Respect patient’s dietary preferences • Involve dietician, use supplements as needed • Monitor hydration • Offer water (when appropriate) whenever patient is turned

49. Minimize Pressure • Turn/reposition patient at least every 2 hours • Use alerts and cues to remind staff to turn patient • Protect skin when turning patient (use lift devices or “drawsheet,” heal and elbow protectors, sleeves and stockings; do not “drag”) • Use pillows and cushions strategically • Use static and/or dynamic pressure-relieving support surfaces • Static surfaces include well-designed mattresses, mattress overlays filled with water, air, gel, foam, or a combination of these • Dynamic surfaces include devices that vary pressure beneath the patient, reducing duration of pressure at any given skin site

50. Engage Leadership and Governance The Goal: Boards in all hospitals will spend at least 25% of their meeting time on quality and safety issues Full Board will have a conversation with at least one patient (or family member of a patient) who sustained serious harm at their institution within the last year