IHIs 100,000 Lives Campaign How to get started

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IHIs 100,000 Lives CampaignHow to get started

• Washington Network
• Sharon I. Eloranta, MD

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(No Transcript)
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Deploy Rapid Response Teams

• Is anyone currently using RRTs?
• What is your experience?
• Purpose of RRTs
• History
• Who is on the team?

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Mortality Diagnostic
ICU admission
No
Yes
Yes
Comfort care only
No
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Mortality Diagnostic
ICU admission
No
Yes
Yes
Comfort care only
No
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What to do with the data

• Box 3 and 4
• Use Global Trigger Tool (www.ihi.org) to find
  evidence of adverse events
• Box 4
• Look for communication and planning failures, and
  failures to recognize a deteriorating
  conditionleading to failure to rescue
• Take these results to leadership

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Failure to rescue

• Franklin C, Mathew J Developing strategies to
  prevent in-hospital cardiac arrest analyzing
  responses of physicians and nurses in the hours
  before the event. Crit Care Med 1994 22(2)
  244-247
• 66 of patients show abnormal s/s within 6 hours
  of the event
• Increased/decreased HR, RR, MAP
• Altered mental status
• Chest pain
• In only 25 of cases was the physician notified

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Forming the Team

• Engage Senior Leader support
• Identify the best structure for the team
• Educate and train staff
• Establish criteria and mechanism for calling the
  team
• Have a structured documentation tool
• Develop feedback mechanisms
• Measure effectiveness

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Most important criterion

• If someone is worried about the patient!

Its always better to ask than to wait
Role of families and friends
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3 essential features of RRT members

• Available immediately, without competing
  responsibilities
• Onsite and accessible
• Possess critical care skills necessary to respond
  and assess patients

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Prevent ADEs Medication Reconciliation
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What Is Medication Reconciliation?

• Reconciliation A process of identifying the most
  accurate list of all medications a patient is
  takingincluding name, dosage, frequency, and
  routeand using this list to provide correct
  medications for patients anywhere within the
  health care system
• Requires comparing the patients list of current
  medications against the physicians admission,
  transfer, and/or discharge orders

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Why Is This Important?

• 50 of all medication errors and 20 of ADEs in
  the hospital are due to poor communication at
  handoffs.
• 42 of the orders reviewed in pediatric cancer
  setting needed to be changed.
• 30 of the time there were variances between
  medication orders and information from
  patient/guardian or prescription labels on the
  container.

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Sample Results

• 80 reduction in potential adverse drug events
  within three months of implementing medication
  reconciliation
• Michels RD, Meisel S. Am J Health-Sys Pharm.
  2003601982-1986.

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Sample Results

• 70 reduction in medication errors associated
  with reconciling medications in short seven-month
  period
• 15 reduction in ADEs
• Significant efficiency gains Time saved
• At admission (nurse) 20-25 min.
• Transfer from CCU 25-45 min.
• At discharge (pharmacist) 35-50 min.
• Rozich JD, Resar RK. JCOM. 20018(10)27-34.

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Reconciliation Process

• Three Basic Steps
• Verify
• Collect an accurate medication history.
• 2. Clarify
• Clarify any questions about drug/dose/
  frequency.
• 3. Reconcile
• Document why medication not ordered or changed.

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What Is Included on the Medication List?

• Current home meds / OTC / herbals, including
  dose, route, and frequency
• Time of last dose
• Source of the information
• Patient adherence medication schedule
• Sample Reconciliation forms available on
  www.ihi.org

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Models for Patient Medication History

• Nurse who completes the initial admission history
  and assessment also completes reconciliation
  form.
• Pharmacist/pharmacy technician can take the
  medication history and complete reconciliation
  order form.
• A physician can take the medication history as
  part of the intake process.

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Understanding the Current Process
Example provided by UMass Memorial
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Changing Culture

• Recognize that this is HARD
• Requires changing the way people do work
• Difficult task, but not impossible
• Use a proven change strategy such as the model
  for improvement and small tests of change
• Start with the admission process
• Have all stakeholders in agreement
  administration, physicians, pharmacists, nurses
• Teams without nurses have failed
• Involve the patient

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Improved Care for AMI
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National Support for AMI Improvement

• Institute of Medicine (IOM)
• CMS 7th and 8th Scope of Work
• Joint Commission Core Measure
• American Heart Association
• American College of Cardiology

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Seven Components of AMI Care

• The seven care components in the ACC clinical
  guidelines and measured by JCAHO and CMS
• Early administration of aspirin
• Aspirin at discharge
• Early administration of beta-blocker
• Beta-blocker at discharge
• ACE-inhibitor or angiotensin receptor blockers
  (ARB) at discharge for patients with systolic
  dysfunction
• Timely initiation of reperfusion (thrombolysis or
  percutaneous intervention)
• Smoking cessation counseling

www.acc.org/clinical/guidelines/stemi/index_pkt.pd
f 2/11/05 1150 ET
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Successful Implementation

• Hackensack University Medical Center (HUMC)
• Through their Cardiac Service Line, developed
  standardized processes for AMI care
• Composite score increased from 72 in the first
  quarter of 2003 to 91 by the fourth quarter of
  2003 (as calculated by CMS aggregate of the key
  measures).
• AMI inpatient mortality decreased from 7 to 5.2
  in the same time period.

• Hackensack University Medical Center AMI Report,
  Sept 10, 2004

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Successful Implementation

• McLeod Regional Medical Center
• Developed protocols based on the evidence
• Percent of patients who received perfect care
  (all AMI key measures) increased from 80 in
  January 2001 to 100 by November 2003.
• Average inpatient mortality rate for AMI has been
  4 for the past year, below the CMS reported
  average of 7 in 2003.

McLeod Regional Medical Center Storyboard for the
2004 IHI National Forum
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Sample Aim Team

• Aim
• Reduce inpatient AMI mortality by 40 through the
  implementation of all evidence-based care
  components by June 2006
• Team
• Chief of Cardiology
• Chief of Emergency Medicine
• Nursing Clinical Coordinator or Educator
• Case Manager
• Quality Improvement Representative

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Tips

• Segment the population by working only on those
  patients admitted through the ED to start.
• Start by designing for a homogeneous population
  and control as many variables as possible to test
  the design.
• Work on the timed measures separately they need
  a different design.
• Use small tests of change to test the design.
• Measure the process and if the science is right
  the outcomes will follow.

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Preventing Surgical Site Infections
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Impact of SSI
Pairs matched for procedure, NNIS index,
age General inpatient surgical population 22,
742 procedures included
Kirkland. Infect Control Hosp Epidemiol.
199920725. Prospective, case-controlled study
of 22,742 patients undergoing inpatient surgical
procedures between 1991- 1995.
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Where are we now?

• (Bratzler. Arch Surg. 2005140174-182.) In
  the area of appropriate antibiotic use, the
  medical record review found the following
• Appropriate antibiotic selection occurred in
  92.6 of cases
• Antibiotics were given within one hour of
  incision time to 55.7 of patients and
• Prophylactic antibiotics were discontinued within
  24 hours of surgery end time for only 40.7 of
  patients.

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Opportunity to Prevent Surgical Infections

• An estimated 40-60 of SSIs are preventable.
• Improper timing, selection, and duration of
  prophylactic antibiotics (occurs in as few as
  25-50 of operations)
• Appropriate Hair Removal
• Optimized Glucose Control
• Maintenance of Perioperative Normothermia

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Appropriate Antibiotic Selection

• Choose prophylactic antibiotics consistent with
  national guidelines
• Special cases
• Allergy (anaphylactoid) to ?-lactam antibiotics
• High rate of MRSA wound infections locally
• Recent prolonged course of antibiotics or ICU
  stay

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Perioperative Prophylactic AntibioticsTiming of
Administration
14/369
15/441
1/41
1/47
Infections ()
1/81
2/180
5/699
5/1009
Hours From Incision Note only 60 received
antibiotics within two hours of incision
Classen. NEJM. 1992328281.
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Timing of Antibiotics

• Most studies indicate that optimum timing for
  prophylactic antibiotic is within one hour of
  incision time.
• When cuff is used, make sure all antibiotic is
  infused prior to inflation of cuff.
• Note Because of the longer required infusion
  time, vancomycin, when indicated for beta-lactam
  allergy, should be started within 2 hours before
  the incision.

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Antibiotic ProphylaxisDuration

• Most studies have confirmed efficacy of ?12 hrs.
• Many studies have shown efficacy of a single
  dose.
• Whenever compared, the shorter course has been as
  effective as the longer course.
• There is no need to continue coverage beyond 24
  hours even if a patient has intravascular
  catheters, chest tubes or drains postoperatively.

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Hair Removal

• Appropriate
• No hair removal at all
• Clipping
• Depilatory use
• Inappropriate
• Razors

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Razor Use vs. Clipper UseCardiac Surgery

• Number Infected ()
• Shaved 990 13 (1.3)
• Clipped 990 4 (0.4)
• p lt 0.03

Ko. Ann Thorac Surg. 199253301.
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Diabetes, Glucose Control, and SSIsAfter Median
Sternotomy
Latham. ICHE. 2001 22 607-612.
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Hyperglycemia and Risk of SSI after Cardiac
Operations

• No increased riskElevated HgbA1cPreoperative
  hyperglycemia
• Increased riskDiagnosed diabetesUndiagnosed
  diabetesPost-op glucose gt 200 mg within 48h

Latham. Inf Contr Hosp Epidemiol.
200122607. Dellinger. Inf Contr Hosp Epidemiol.
200122604.
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Perioperative Normothermia

• Hypothermia reduces tissue oxygen tension by
  vasoconstriction.
• Hypothermia reduces leukocyte superoxide
  production.
• Hypothermia increases bleeding and transfusion
  requirements.
• Hypothermia increases duration of hospital stay
  even in uninfected patients.

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Local and Systemic Warming and SSI after Clean
Operations

• Local Systemic Control
• SSI 5 (4) 8 (6) 19 (14)
• Post-op antibiotics 9 (7) 9 (7) 22 (16)
• Hematoma 4 (3) 2 (1) 5 (4)
• Seroma 7 (5) 4 (3) 9 (7)

p lt 0.01
Melling. Lancet. 2001358876.
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Tips for getting started

• Many are already looking at the antibiotics
  measure due to CMS/JCAHO requirements.
• Campaign measures are exactly the same as the
  CMS/JCAHO ones!
• Use the MFI
• Use PDSAs
• Sample changes
• Remove razors from ORs
• Provide patients with Bair huggers or other
  warming devices preoperatively, intraoperatively
  and postoperatively
• Make antibiotic administration the responsibility
  of the anesthesiologist/anesthetist
• Standing orders for antibiotic choice and number
  of doses

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Model for Improvement

• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in an
  improvement?

Act
Plan
PDSA cycles
Study
Do
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Preventing Central Line Infections
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Incidence and Risk

• 48 of ICU patients have central venous
  catheters, accounting for 15 million central
  venous catheter-days per year in ICUs.
• The case fatality rate for catheter-related
  bloodstream infections approaches 20.

Mermel LA. Ann Int Med. 2000132 391-402. Soufir
L et al. Infect Control Hosp Epidemiol. 1999
Jun20(6)396-401.
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Incidence and Risk

• Studies that control for underlying illness
  severity give lower estimates of attributable
  mortality.
• These data suggest that attributable mortality is
  between 4 and 20.
• Thus, between 500-4,000 U.S. patients die
  annually due to bloodstream infections.

Pittet D et al. JAMA. May 25 1994271(20)1598-16
01. Soufir L et al. Infect Control Hosp Epidemiol
1999 Jun20(6)396-401.
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AHRQ-Sponsored Evidence Summary

• Attributable mortality is 4-20.
• Analyses of costs are very variable.
• Routine replacement does not reduce risk.
• Maximal barrier precautions reduce risk.
• CVCs coated with antiseptics or antibiotics might
  reduce risk but are expensive.
• Use of chlorhexidine skin prep reduces risk more
  than povidone-iodine.

Saint S. http//www.ahrq.gov/clinic/evrptfiles.ht
mptsafety
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Centers for Disease Control Guidelines

• Major areas of emphasis
• Education and training of providers who insert
  lines
• Maximal sterile barrier precautions
• Use of 2 chlorhexidine for skin antisepsis
• Avoid routine replacement, including replacing
  over a wire
• Consider antiseptic/antibiotic impregnated
  catheters if rate of infection remains high

OGrady NP. MMWR. Aug 9, 2002 51 RR10, 1-29.
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The Central Line Bundle

• is a group of interventions related to
  patients with intravascular central catheters
  that, when implemented together, result in better
  outcomes than when implemented individually.

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Central Line Bundle Elements

• Hand hygiene
• Maximal barrier precautions
• Chlorhexidine skin antisepsis
• Optimal catheter site selection, with subclavian
  vein as the preferred site for non-tunneled
  catheters in adults
• Daily review of line necessity with prompt
  removal of unnecessary lines

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But, Does It Work?

• ICUs that have implemented multifaceted
  interventions
• similar to the central-line bundle have nearly
  eliminated
• CR-BSIs.
• Berenholtz et al. Critical Care Medicine. 2004
  322014-2020.

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To Be Successful

• Set an aim Reduce the incidence of central
  line catheter-related bloodstream infections
  using the central line bundle.
• Set a goal The rate of CR-BSI will decrease
  by 50 in one year using the central line
  bundle.
• Plan well Adopt a change methodology that
• accelerates improvement such as The Model for
  Improvement.

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Starting the Project

• Is there a method in place now?
• Know your baseline performance
• Randomly select the records of 20 patients who
  had central lines placed. Apply the measures to
  them.
• Be sure to check compliance with the total bundle
  as well, the all or none goal.
• Educate ICU staff (using your own data).

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Helpful ChangesCentral Line Insertion

• Use line carts and kits or grab bags.
• Standardize insertion procedures.
• Store all equipment in the same place.
• Include central line insertion checklists in the
  kits or on the cart.

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Supportive Interventions

• Multidisciplinary Daily Rounds
• An opportunity to assess bundle-related issues
• Invite and encourage the family to join in.
• Daily Goal Sheets
• Critical tool for verifying necessity of lines
• Link to ventilator bundle items if doing both
  interventions

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Preventing Ventilator-associated Pneumonia
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Incidence and Risk

• Prospective single-center study over 22 months of
  888 patients on mechanical ventilation
• VAP occurs in up to 15 of patients receiving
  mechanical ventilation.
• Risk factors include tracheostomy, multiple
  central line insertions, re-intubation, and use
  of antacids.
• Mortality Hospital mortality for patients who
  develop VAP is 46, compared to 32 for patients
  who do not develop VAP.

Ibrahim EH et al. Chest 2001 120 555-561
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VAP Prolongs Care

• Large retrospective matched cohort study of risk
  factors and consequences of VAP
• Prolonged mechanical ventilation
• Prolonged ICU stay
• Prolonged post-ICU hospital stay
• Marked increase in cost of admission

Rello J. Chest. 20021222115-2121.
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How Large a Problem Is VAP?

• Attributable mortality of 20-33
• In one study, VAP accounted for 60 of all deaths
  due to hospital-associated infections
• Prolongs ICU stay by an average of 4.3-6.1 days
  and hospital stay by 4-9 days
• Excess cost of 40,000 per patient

Tablan OC. MMWR Recomm Rep. Mar 26 2004
53(RR-3) 1-179.
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The Ventilator Bundle

• .is a package of evidence-based interventions
  that, when implemented together for all patients
  on mechanical ventilation, has resulted in
  dramatic reductions in the incidence of
  ventilator-associated pneumonia.

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Do Bundles Work?

• Our Lady of Lourdes, Binghamton, NY
• As of 1/11/2005, this hospital had gone 290 days
  without a VAP. As of 2/28/2005, they have gone
  48 days.

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Ventilator Bundle Elements

• 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)

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To Be Successful

• Set an aim Improve the health and well-being of
  ventilated patients by reducing the VAP
  rate.
• Set goals Reduce VAP rate by 50 by April
  2006. Implement use of ventilator bundle with
  greater than 95 reliability.
• Plan well Adopt a change methodology that
• accelerates improvement such as The Model for
  Improvement.

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Engage Stakeholders

• Identify stakeholders in ventilator care
• 3 groups MDs, RNs, respiratory therapy
• Secure representation from each
• Facilitates physician buy-in
• Generates nursing support

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Starting the Project

• What is the current process?
• Know your baseline performance
• Randomly select 20 records of ventilated patients
  and apply your measures to them.
• Be sure to check compliance with the total bundle
  as well, the all or none goal.
• Educate ICU staff (using your own data).

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ICU Infrastructure Changes

• Request infection control practitioner to report
  VAP data monthly, not quarterly.
• Initiate an intensivist-directed program that
  uses a multidisciplinary approach.
• Encourage open visitation for ICU families.

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Summary

• Possible mechanisms of success
• .Does implementation of a standardized
  bundle of care result in better overall care?
• .Are the interventions synergistic?
• Dramatic reduction in VAP
• .More than could have been expected from the
  sum of the individual interventions

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You must be the change you wish to see in the
world. Mohandas Gandhi