UASCA Annual Educational Conference

1. UASCA Annual Educational Conference Utah Department of Health November 1, 2007 November 1, 2007 Draft

2. Presentation Objectives • To inform audience about national trends in patient safety • (Marc Babitz, MD) • To inform audience about the Utah Patient Safety Initiative • (Iona M. Thraen) • To engage Ambulatory Surgical Care Centers in the Utah Patient Safety Initiative • All

3. National Patient Safety Environment Marc Babitz, MD Director of Health Systems Improvement UDOH November 1, 2007 Draft

4. National Patient Safety Environment • Institute of Medicine (IOM) Report – “To Err is Human” • Retrospective chart review methodology • Colorado/Utah, New York • Findings • Colorado/Utah– 2.9% of hospitalizations had adverse events • 6.6 % of adverse events lead to death • New York – 3.7% of hospitalizations had adverse events • 13.6% of adverse events lead to death • Total predicted deaths due to adverse events • 44,000 – 98,000 per year • 8th leading cause of death – more than breast cancer or AIDS.

5. Types of Adverse Events

6. Types of Adverse Events

7. Adverse Event (AE) Rate by Specialty

8. Preventability of AE by Specialty

9. Healthcare Acquired Infections (HAIs) • Myth – Infections occur and cannot be prevented (a by-product of day to day operations) • The Facts (costs) • It is estimated that 2 million hospital patients develop HAIs a year • Rates of HAI have increased in the US between 1975 and 1995 by 36% • As many as 100,000 deaths and up to $3.5 billion in costs can be attributable to HAIs

10. HAIs • Pennsylvania is the first state to compare mortality rates, costs, and additional hospital days due to HAIs • Unadjusted mortality rate of 15.4% in those with HAI versus 2.4% without • Two billion additional charges • 205,000 additional hospital days

11. HAIs • Surgical Wound Infections • Three types of procedures were studied between Oct 1, 2004 and Sept 30, 2005 • Circulatory (n = 65, 940) • Neurological (n = 6706) • Orthopedic (n = 107,825) • Patient specific factors were a significant determinant of risk of surgical wound infections

12. AE Rates and Patient Risk factors • Circulatory (3.7 AE/1000 cases) • Patient severity • Diabetes • Chronic renal failure • Obesity • Neurological (7.2 AE/1000 cases) • Age • Orthopedic (4.2 AE/1000 cases) • Patient severity • COPD • Diabetes • Obesity

13. Hospital Factors • When hospital factors AND patient risks were included, prediction of rates improved. • Different hospital specific practices and environments improved prediction of infections by 23-33%.

14. Hospital Components to improving HAIs • Key components • Surveillance • A Control program that includes: • Trained infection control physician • Infection control nurse • System for reporting infection rates (post discharge follow-up by ASC – not left to outpatient MD) • Processes to identify risk factors to predict, intervene and measure effects

15. Concluding Remarks • The is an increasing public demand for HAI information • Our goal is to respond constructively • We do this by having a improvement focus as well as a public accountability focus • Therefore we need the following: • Surveillance measures that are consistent, safe, and support improvement • Process measures that meet public accountability needs. • Active participation by the industry to build consensus driven measures and improvement strategies

16. References • Bogner, S.B., Human Error in Medicine, Institute for the Study of Medical Error, 1994. • Hollenbeck, C.S., Lave, J.R., Zeddies, T., Pei, Y., Roland, C.E. Sun, E.F., “Factors associated with Risk of Surgical Wound Infections”, American Journal of Medical Quality, 2006: 21:29. • Institute of Medicine, To Err is Human, National Academy Press, 2000. • Nash, D.B., “Hospital-Acquired Infections: Raising the Anchoring Heuristic”, American Journal of Medical Quality, 2006: 21:5. • Peng, M.M., Kurtz, S., Johannes, R.S., “Adverse Outcomes from Hospital Acquired Infection in Pennsylvania Cannot be Attributes to Increase Risk upon Admission”, American Journal of Medical Quality, 2006: 21:17. • Rosenthal, M.M., Sutcliffe, K.M. Medical Error: What do we know, what do we do?, Josey Passey, 2002.

17. Utah Patient Safety Initiative Iona M. Thraen, ACSW Patient Safety Director

18. Utah Patient Safety Participants • Patient Safety Steering Committee • HealthInsight • IASIS • IHC • MountainStar • PCMC • UDOH • UHA • UHSC • UMA

19. Participants and Structure

20. Initial Patient Safety Rules • October 2001 • Sentinel Events - Initiation of 8 general categories for reporting • Deaths related to clinical service • Wrong patient/site surgery • Suicide • Loss of function not related to underlying condition • Patient abductions • Discharge of infant to wrong family • Rape • Intentional injury • Adverse Drug Events • Analyzed from hospital discharge data

21. Lessons Learned - Deaths as a result of Adverse Events • Using the 2000 IOM report methodology estimated at the lower end, a death rate due to adverse events would equal 1.3/1000 admissions • Utah had 268,652 hospital discharges in 2005 • A conservative estimate of 350 deaths would be due to adverse events • Average # SE reported is between 30-40/year – a tenfold under-reporting

22. Sentinel Events Hospitals/Ambulatory Surgical Centers

23. Sentinel Events

24. Ambulatory Surgical Centers Sentinel Events by Years

25. Ambulatory Surgical Centers Sentinel Events by Type

26. Utah Wrong Site Surgery InitiativeC³ Correct Patient, Correct Procedure, Correct Site

27. Misadventures Rate of Misadventures per 100 Inpatient Discharges in Utah Acute Care Hospitals, 1999-2004 Data Notes Adverse event ICD-9-CM codes can be in any of up to 9 reported diagnosis codes including ecode(s).ICD-9-CM codes: E870-E876, 998.2, 998.4, 998.7. Utah Adverse Event Classes, 2001 Version. Data Sources Utah Inpatient Hospital Discharge Data, Office of Health Care Statistics, Utah Department of Health; 

28. AHRQ - PSIs

29. AHRQ-PSIs

30. Adverse Events – Inpatient Hospitalizations

31. Adverse Drug Events – Inpatient Hospitalizations

32. Wrong Patient/Site SurgeriesC³ • Wrong Patient/Site Surgeries • Types of events included: wrong knee surgery, wrong finger digit, wrong back disk, wrong sided hip surgery, wrong patient for circumcision, etc. • Users group established in 2002 as a collaborative between Utah Department Of Health, Utah Hospital Association, Utah Medical Association, and Health Insight. The Sentinel Event users group developed a survey instrument to inventory how patients were identified and marked. Results indicated wide variability ranging from yes/no, X marks the spot, X means no – do not operate here, X/O, happy faces, stickers with scissors, physician initials, patient initials, etc. • SE Users group worked to establish consensus standard – C³ or C-Cubed Standard for Correct Patient, Correct Procedure, Correct Site • C³ Standard agreed to by hospitals and ad published 11/6/05 • All physicians (approximately 7500) who are renewing their licenses through DOPL were sent a letter with a copy of the C³ standard with their renewal letter in November 2005.

33. Adverse Drug Events • Anti-Coagulants/Insulin - UHA • Adverse Drug Effects User Group Publications • The Advese Drug Effects (ADE) User Group was established to develop ways to identify events and ultimately reduce harm from the use of medications. This section is dedicated to the dissemination of ADE group projects and analyses that organizations might use for evaluating potential issues or events in their own systems • Medication Reconciliation (in progress) • http://www.uha-utah.org

34. Adverse Drug Events Prescription Drug Overdoses

35. Adverse Drug Events Prescription Drug Overdoses

36. Prescription medication overdose deaths* by implicated medicationUtah 1997-2005

37. Healthcare Associated Infections • Users group established 2006 • Rules written and undergoing administrative rule process • WEB site established for reporting • Focus of Rule • Central Line Infections • Employee influenza immunizations in hospitals and nursing homes

38. Sentinel Event Rule Revisions • Ten fold under-reporting as compared with IOM methodology • Consistency with national standards – National Quality Forum, JCAHO, CMS • Need for more quantitative analysis than qualitative • WEB reporting format • Ability to establish statewide trends and conduct interventions • You cannot improve what you don’t measure!

39. Sentinel Event Rule Revisions • Checklist/WEB entry • Expanded list – see rule/form • Quantitative analysis • Regular feedback • Revisions as needed

40. Future Directions • Request for UDOH funding ($250,000) • Integration of patient safety into existing public health surveillance • Peri-natal mortality review (started) • Pediatric mortality review • Trauma • Others • Geriatric trauma • Others • Multiple surveillance systems (voluntary reporting, clinical indicators, administrative data analysis, chart review) • http://health.utah.gov/psi

42. Utah wants you!!