Collaborative to Reduce Healthcare Associated Infections

1. Collaborative to Reduce Healthcare Associated Infections Alignment with National Initiatives

2. Joint Commission National Patient Safety Goals • 2008 NPSG Goal 7 Reduce the risk of healthcare-associated infections • Comply with WHO/CDC hand hygiene guidelines • Manage as sentinel events all identified cases of unanticipated death or permanent loss of function associated with a healthcare-associated infection

3. Joint Commission 2009 National Patient Safety Goals • 3 new requirements related to preventing healthcare-associated infections: • Multiple drug resistant organisms • Central line associated bloodstream infections • Surgical site infections • Align with Safety Center initiatives

4. Joint Commission 2009 National Patient Safety Goals • Prescriptive elements of performance based on CDC recommendations • One-year phase-in period with defined expectations for planning, development, testing at 3,6,9 months with full compliance by January 2010 • Each requires pilot testing in at least one unit by October 2009 • Each requires specific patient /family education

5. Joint Commission 2009 National Patient Safety Goals • Goal 7 07.03.01 NEW • Implement evidence based practices to prevent health care-associated infections due to multi-drug resistant organisms • MDRO risk assessments and surveillance • Staff and practitioner education • Educate patients and families who are infected or colonized • Measure/monitor MDRO prevention processes and outcomes including MDRO infection rates and compliance with evidence based guidelines • Evaluation of the education programs for staff • Share surveillance data with leaders, staff, LIPs • Lab-based alert system that identifies new MDRO patients and alert system for readmissions and transfers

6. Joint Commission 2009 National Patient Safety Goals • Goal 7 07.04.01 Implement evidence-based guidelines to prevent central line-associated bloodstream infections. • Policies and procedures aligned with evidence-based standards • Periodic risk assessments,measure CLBSI rates, monitor compliance with evidence-based guidelines • Share infection rates and compliance data with key stakeholders including leaders, staff, LIPs • Standard insertion protocol and checklist (Document) • Use bundles – standardized cart, hand hygiene, full barrier precaution, avoid femoral site, chlorhexidine prep • Use standardized protocol to disinfect catheter hubs and injection ports before accessing. (Document) • Evaluate need for catheter routinely and remove nonessential

7. Joint Commission2009 National Patient Safety Goals • Goal 7 07.05.01 Implement best practices for preventing surgical site infections • Implement policies and practices that meet regulatory requirements and align with evidence based standards (Document) • Conduct periodic risk assessments, select and monitor measures, monitor compliance with evidence based guidelines • SSI rates measured for the first 30 days post op and for first year if implantable device • Share SSI rate data and prevention outcome measures with leaders, staff and LIPs • Antibiotic prophylaxis according to evidence based standards • When hair removal necessary, hospital uses clippers or depilatories (no shaving)

8. Joint Commission2009 National Patient Safety Goals • Goal 13 Encourage patients active involvement in their own care as a patient safety strategy • EP 13.01.01 • Patient and family are educated on available reporting methods for concerns related to care, treatment, services and patient safety issues • Provide patient with information on infection control measures for hand hygiene, respiratory hygiene, and contact precautions according to patient condition on admission or as soon as possible (Document) • Surgical patients educated on hospital measures to prevent adverse events in surgery such as patient identification, prevention of SSI, marking the site (Document) • Hospital encourages patients/families to report concerns about safety

9. Joint Commission 2009 National Patient Safety Goals • Updates, changes and new requirements to other existing safety goals for • Medication Reconciliation • Transfusion errors • Universal Protocol for surgery and invasive procedures

10. CMS Hospital Public Reporting • 2008 27 measures reported including SCIP process measures • 2009 13 new measures • Most are calculated by CMS using Medicare administrative claims data versus clinical chart abstraction • AHRQ quality and patient safety indicators software

11. Medicare Hospital-Acquired Conditions • The Deficit Reduction Act of 2005 required CMS to identify at least two preventable complications of care that could cause patients to be assigned to a higher paying DRG. • 8 conditions adopted in CMS IPPS 2008 final rule: • Object left in during surgery • Air embolism • Blood incompatibility • Catheter associated urinary tract infections • Pressure ulcers • Vascular catheter associated infections • Mediastinitis after coronary artery bypass graft • Hospital-acquired injuries (including fractures, dislocations, intracranial injury, crushing injury, and burns)

12. Medicare Hospital-Acquired Conditions • 2009 CMS selected 2 additional hospital acquired conditions. Unless present on admission, if present these conditions will not result in a higher DRG complications payment rate. • Poor Glycemic control in certain conditions • Deep-vein thrombosis/pulmonary embolism following certain orthopedic surgery cases • Expanded SSI to include certain orthopedic and bariatric surgeries

13. Tennessee Statutes • Public Chapter 904 • Hospital reporting to CDC NHSN on central line bloodstream infection rates in ICU’s • First public report released after 12 months of data (Jan 2008-Jan 2009) • Public Chapter 999 Passed May 2008 • Requires local MRSA risk assessments by all licensed healthcare facilities (hospitals, nursing homes, ambulatory surgery) • Facilities to implement prevention and reduction strategies based on local risk. • Strategies align with CDC guidelines. MAY include active surveillance testing

14. Alignment with National Initiatives • IHI 5 Million Lives Campaign • QIO 9th Scope of Work • CDC and professional society guidelines • National Quality Forum Hospital Safe Practices

15. Alignment with National Initiatives • Keep Patients as our North Star • But use the synergy of alignment with other requirements and national initiatives to build greater focus for your teams, elevate your team’s efforts on the priority list within the system and get the resources needed for your work!