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NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2

NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2. Speaker. Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD Medical Legal consultant 5447 Fawnbrook Lane Dublin, Ohio 43017 sdill1@columbus.rr.com 614 791-1481. 2. 2. NQF 34 SAFE PRACTICES.

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NQF 34 Patient Safety Practices for Hospitals 2010 Part 2 of 2

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  1. NQF 34 Patient Safety Practices for Hospitals 2010Part 2 of 2

  2. Speaker Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD Medical Legal consultant 5447 Fawnbrook Lane Dublin, Ohio 43017 sdill1@columbus.rr.com 614 791-1481 2 2

  3. NQF 34 SAFE PRACTICES • Released in 2003, updated 2006, 2009 and April 2010 • These should followed in all healthcare facilities • All clinical care settings to reduce risk of harm to patients • A roadmap to preventing harm • States 10 years after IOM report, To Err Is Human, uniformly reliably safety in healthcare has not been achieved

  4. Culture 2010 NQF Report Culture SP 1 • CHAPTER 2: Creating and Sustaining a Culture of Patient Safety • Leadership Structures & Systems • Culture Measurement, Feedback and Interventions • Teamwork Training and Team Interventions • Identification and Mitigation of Risks and Hazards Team Training & Team Interv. ID Mitigation Risk & Hazards Structures & Systems Culture Meas., F.B, & Interv. CHAPTER 1: Background • Summary, and Set of Safe Practices Consent & Disclosure Consent & Disclosure • CHAPTER 3: Informed Consent & Disclosure • Informed Consent • Life-Sustaining Treatment • Disclosure Disclosure Informed Consent Life-Sustaining Treatment Workforce CHAPTERS 2-8 : Practices By Subject • CHAPTER 4: Workforce • Nursing Workforce • Direct Caregivers • ICU Care Nursing Workforce Direct Caregivers ICU Care • CHAPTER 5: Information Management & Continuity of Care • Critical Care Information • Order Read-back • Labeling Studies • Discharge Systems • Safe Adoption of Integrated Clinical Systems including CPOE • Abbreviations • CHAPTER 7: Healthcare-Associated Infections • Hand Hygiene (Safe Practice 19) • Influenza Prevention (Safe Practice 20) • Central Line Associated Blood Stream Infection Prevention (SP 21P • Surgical Site Infection Prevention (Safe Practice 22) • Care of the Ventilated Patient (Safe Practice 23) • Multidrug-Resistant Organism Prevention (Safe Practice 24) • Catheter-Associated Urinary Tract Infection Prevention (SP 25) Information Management & Continuity of Care Critical Care Info. Order Read-back Labeling Studies Discharge System CPOE Abbreviations Medication Management • CHAPTER 6: Medication Management • Medication Reconciliation • Pharmacist Role • Standardized Medication Labeling & Packaging • High-Alert Medications • Unit-Dose Medications Med Recon. Pharmacist Central Role High Alert Meds Std. Med Labeling & Pkg Unit Dose Medications • CHAPTER 7: Hospital-Acquired Infections • Prevention of Aspiration and Ventilator-Associated Pneumonia • Central Venous Catheter-Related Blood Stream Infection Prevention • Surgical Site Infection Prevention • Hand Hygiene • Influenza Prevention Hospital Acquired Infections Asp +VAP Prevention Hand Hygiene Influenza Prevention Central V. Cath BSI Prevention Sx Site Inf. Prevention • CHAPTER 8: • Evidence-Based Referrals • Wrong-Site, Wrong Procedure, Wrong Person Surgery Prevention • Perioperative Myocardial Infarct/Ischemia Prevention • Pressure Ulcer Prevention • DVT/VTE Prevention • Anticoagulation Therapy • Contrast Media-Induced Renal Failure Prevention Condition & Site Specific Practices Evidence- Based Ref. Anticoag. Therapy DVT/VTE Prevention Press. Ulcer Prevention Wrong-site Sx Prevention Periop. MI Prevention Contrast Media Use

  5. Safe Practice 19 Hand Hygiene • Comply with current Centers for Disease Control (CDC) and Prevention Hand Hygiene Guidelines • TJC has NPSG.07.01.01 to comply with CDC or WHO 2009 guidelines • TJC published document in 2009 on Measuring Hand Hygiene Adherence: Overcoming the Challenges and this is an important document • IHI publishes “How-to Guide: Improving Hand Hygiene. A Guide for Improving Practices among Health Care Workers” • Very important issue in reducing HAI

  6. TJC Hand Hygiene NPSG.07.01.01 • Comply with current CDC or WHO hand hygiene guidelines and has 3 EPs, • EP1 Implement a program that follows categories 1A, 1B, and 1C on one of the above, • EP2 Set goals for improving compliance with hand hygiene guidelines, • EP3 Improve compliance with hand hygiene guidelines based on established goals,

  7. CDC Hand Hygiene Recommendations • CDC published guidelines Oct 25, 2002 at www.cdc.gov/handhygiene • In CDC MMWR Recommendations and Reports, • Report available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm or go to www.cdc.gov • Also new admission video on hand hygiene • Hand hygiene interactive training class • Monitored during infection control tracer by TJC

  8. Hand Hygiene • WHO Guidelines on Hand Hygiene in Health Care; Clean Hands are Safer Hands at www.who.int/patientsafety/events/05/HH_en.pdf • Good website for children on importance of washing hands with colorful posters, puzzles, and quiz AT http://www.microbe.org/washup/Wash_Up.asp • Henry the Hand at henrythehand.com • Toolkits and posters at http://www.health.state.mn.us/handhygiene/materials.html • Clean your hand campaign at www.npsa.nhs.uk/cleanyourhands/resources

  9. Safe Practice 19 Hand Hygiene • Implement the CDC requirements with Category I requirements or WHO • Encourage compliance with category II • Ensure that all staff know what is expected of them with regard to hand hygiene • Ensure compliance with hand hygiene

  10. TJC NPSG FAQ

  11. Safe Practice 20 Influenza Prevention • Comply with current Centers for Disease Control and Prevention (CDC) recommendations for influenza vaccinations for healthcare personnel • and the annual recommendations of the CDC Advisory Committee on Immunization Practices for individual influenza prevention and control. • CDC has website at www.flu.gov

  12. www.cdc.gov/mmwr/preview/mmwrhtml/00050577.htm

  13. 20 Flu Prevention • Healthcare workers with direct patient contact should be immunization against the flu • Unless contraindicated • Patients should be immunized as per current CDC recommendations • P&P on above along with flu program should be in place • Document immunization status of all employees • Implement CDC recommendations for flu prevention and control

  14. 20 Flu Prevention • Educate staff on benefits of flu vaccine • Offer flu vaccine annually to all eligible healthcare personnel at no cost • Use strategies such as flu cart, access during shift, modeling etc • Also a TJC requirement • CMS allows protocols for flu and pneumovac for patients

  15. SP 21 Central Line -Associated Bloodstream Infection Prevention • Take actions to prevent central line-associated bloodstream infection (CLABSI) by implementing evidence-based intervention practices. • 2011 CDC guidelines on recommendations • Hospital Quality Reporting Program for ICU and NICU to CDC National Healthcare Safety Network (NHSN) • Made popular by IHI How to Kit on central line bundle • Keystone project showed wisdom of using checklist • TJC 2011 NPSG • Pa Patient Safety Authority has a toolkit on CLABSI risk reduction at http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/clabsi/Pages/home.aspx

  16. CDC Resources • Has many resources on preventing catheter associated blood stream infection • Device association module • Central line insertion practices training course • Many resources on MDRO and CDAD • Note TJC requires the use of a checklist and need to place the checklist in the medical record or most hospitals have a checkbox that says central line checklist used

  17. CDC Website

  18. Keystone Project Changes Everything

  19. Pa Patient Safety Toolkit

  20. www.ihi.org

  21. Revised How to Kit Central Lines

  22. Safe Practice 21 Central Lines • Educate staff about central line-associated bloodstream infection (CLABSI) prevention who insert or maintain lines • Use checklist • Perform hand hygiene before you insert or manipulate • Avoid using femoral vein for access in adults • Use maximal sterile barrier precautions (mask, gloves, sterile gown, and cap by all involved in procedure)

  23. Safe Practice 21 Central Lines • Use CHG alcohol if over two months of age and allow to dry • Use protocol to disinfect catheter hubs, needless connectors and injection ports before accessing ports • Remove nonessential catheters • Perform surveillance and report data to nursing and medicine • Use standardized protocol for nontunneled CVCs in adults and adolescents as changing transparent dressings every five to seven days

  24. TJC NPSG Central Lines 07.04.01 • Implement best practices to prevent central line associated bloodstream infections, • 13 EPS • IHI has how to guides and other resources at www.ihi.org (Keystone project) • EP1 Educate staff and LIPs involved in procedures about HAI, central line infection and importance of prevention • Must do education in orientation and annually and if procedure added to your job

  25. TJC NPSG Central Lines • Note that under reform law hospitals with ICUs or NICU must report central lines infections on the CDC National Healthcare Safety Network (NHSN) 2. Educate patients and families before inserting central line about central line associated bloodstream infection prevention (BSI), as needed 3. Implement P&Ps to reduce risk of BSI that meet regulatory and evidenced based standards

  26. Central Lines 07.04.01 • P&P need to meet the regulatory requirements • Need to be aligned with the CDC requirements • And professional standards of care (APIC, AORN, SHEA, etc.) • 4. Conduct periodic risk assessments for central line infection, measure BSI (blood stream infection) rate, and monitor compliance with best practices and how effective the prevention efforts are • Need to do risk assessment conducted in the time frames defined by the hospital • Surveillance is hospital wide and not targeted

  27. TJC NPSG Central Lines 5. Provide CLAI (central line associated infection) rate data and prevention outcome measurement to staff and LIPs and clinicians 6. Use a catheter checklist and standard protocol for central line insertion 7. Perform hand hygiene before catheter insertion or manipulation 8. Do not put in femoral vein unless last resort for adult patients 9. Use standardized supply care or kit for central lines

  28. TJC NPSG Central Lines 10. Use standardized protocol for maximum sterile barrier precautions during insertion 11. Use antiseptic for skin prep in patients during insertion that is cited in the scientific literature or endorsed by professional organizations 12. Use standardized protocol to disinfect catheter hubs and injection ports before accessing • Such as wipe vigorously for 15 sections and let dry • Surveyor will ask to see the protocol or P&P 13. Evaluate all central lines routinely and remove none essential catheters

  29. Safe Practice 22 Surgical Site Infection • Surgical site infection prevention • Take actions to prevent surgical-site infections by implementing evidence-based intervention practices. • Safe Practice 22 is currently under ad hoc review by an expert panel. • This practice will be updated in the coming months to reflect the review decision. • CDC has guidelines • TJC has 2011 NPSG

  30. Four Changes to TJC 2011 NPSG

  31. July 1, 2010 Changes • NPSG.03.05.01 EP 6:  A written policy addresses baseline and ongoing laboratory tests that are required for anticoagulants • NPSG.07.04.01 EP 11:  Use an antiseptic for skin preparation during central venous catheter insertion that is cited in scientific literature or endorsed by professional organizations (such as chlorahexidine alcohol and not povidone iodine but this specific wording removed)

  32. July 1, 2010 Changes • NPSG.07.05.01 EP 7:  Administer antimicrobial agents for prophylaxis for a particular procedure or disease according to methods cited in scientific literature or endorsed by professional organizations • NPSG.07.05.01 EP 8: When hair removal is necessary, use a method that is cited in scientific literature or endorsed by professional organizations (Such as clippers and not razors but this language removed)

  33. Proposed TJC NPSGs for 2012 • TJC is seeking comments on NPSGs for 2012 • Looking at two proposed additions • Ventilator-associated pneumonia (VAP) • Has seven elements of performance • Catheter-associated urinary tract infections (CAUTI) • Has four elements of performance • Comment period ended January 27, 2012

  34. TJC 2011 NPSG Surgical Site Infections • Implement best practices to prevent surgical site infections (SSI) • There are 8 EPs • 1. Educate hospital staff and LIPs involved in procedures about HAI, surgical site, and the importance of prevention • Educate during orientation, annually, and if added to your job

  35. Surgical Site Infections 2. Educate patients and families, who are undergoing surgical procedures, about preventing surgical site infections (SSI) 3. Implement P&P to reduce SSI that meet regulations and evidenced based practice (such as the CDC and other professional organizations) 4. Conduct periodic risk assessments for SSI, select measures using best practices or evidence based guidelines and monitor compliance with them and how effective they are

  36. Surgical Site Infections 5. Measure surgical site infection rates for the first 30 days following a procedure that does not involve inserting implantable devices • Measure for the first year procedures involving implantable devices • Need to follow evidence based guidelines • Surveillance may to targeted to certain procedures based on hospital risk assessment 6. Provide process and outcome data on SSI to stakeholders etc, such as the SS infection rate

  37. Surgical Site Infections • Antimicrobial agents for prophylaxis are administered according to methods cited in the scientific literature or endorsed by professional organizations • Still want to be sure that prophylactic antibiotics are administered timely in the operating room and rebolused when indicated • When hair removal is necessary, use a method that is cited in the scientific literature or endorsed by professional organizations

  38. Safe Practice 23 Care of the Ventilated Patient • Take actions to prevent complications associated with ventilated patients: • specifically, ventilator-associated pneumonia (VAP), venous thromboembolism, peptic ulcer disease, dental complications, and pressure ulcers • VAP bundle also an IHI initiative • TJC NPSG 2011 standard

  39. 23 Care of the Ventilated Patient • Educate healthcare workers on daily care of ventilated patient and complications such as VAP, VTE, PUD, dental complications, and pressure ulcers • Implement P&P on disinfection and sterilization of respiratory equipment • Active surveillance for VAP and maintain data • Educate patients and families about prevention measures

  40. 23 Care of the Ventilated Patient • Use checklist and standardized protocol • Hand hygiene • Regular antiseptic oral care • HOB 30-45 degrees • Daily assessment of readiness to wean and sedation interruption • Use weaning protocols • Implement PUD prophylaxis (still controversial) • VTE prophylaxis unless contraindicated

  41. Safe Practice 24 MDRO Prevention • Implement a systematic multidrug-resistant organism (MDRO) eradication program built upon the fundamental elements of infection control, • an evidence-based approach, • assurance of the hospital staff and independent practitioner readiness, • and a re-engineered identification and care process for those patients with or at risk for MDRO infections. • Also a TDC NPSG for 2011 and CMS CoP requirement

  42. 24 MDRO Prevention • Includes but is not limited to • Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) , and Clostridium difficile (C-diff) • Multidrug-resistant gram-negative bacilli, such as Enterobacter species, Klebsiella species, Pseudomonas species, and Escherichia coli (Ecoli), and vancomycin-resistant Staphylococcus aureus, should be evaluated for inclusion on a local system level based on organizational risk assessments

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