Clinical Transformation, Part II

March 2009 Community Call

Presenters

• Edmund Billings, MD - CMO

• Jeff Parker, RN, BsBA - Clinical Informatics Manager

• Janine Powell - Sr. Director of Client Services

• Debbie Daspit - Director of Product Management

• George Lilly - CCD/CCR Developer

• Adam Waterbury - GT.M Product Manager

• Ben Mehling - Director of Ecosystem Operations

Agenda

• Clinical Transformation– A Blueprint

– In Practice

• Transformation Working Group Update– Status Update

– Framework for Planning

– Discussion

• Open Project Updates– OpenVista/GT.M Integration

– CCD-CCR Project

• Medsphere.org: Tip of the Month

Clinical Transformation, a Blueprint5 Million Lives Project Example: The Central Line Bundle

Edmund Billings, MD

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http://www.ihi.org/IHI/Programs/Campaign/

Central Line

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Central Line: Subclavian

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Preventing Catheter-Related Bloodstream Infections

• Central venous catheters (CVCs) are being used increasingly in the inpatient and outpatient setting to provide long-term venous access.

• CVCs disrupt the integrity of the skin, making infection with bacteria and/or fungi possible.

• Infection may spread to the bloodstream and hemodynamic changes and organ dysfunction (severe sepsis) may ensue, possibly leading to death.

• Approximately 90% of the catheter-related bloodstream infections (CR-BSIs) occur with CVCs.

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Preventing Catheter-Related Bloodstream Infections

• 48% of intensive care unit (ICU) patients have central venous catheters, accounting for about 15,000,000 central-venous-catheter-days per year in ICUs.

• Approximately 5.3 central line infections occur per 1,000 catheter days in ICUs.

• The attributable mortality for such central line infections is approximately 18%.

• Thus, probably about 14,000 deaths occur annually due to central line infections. Some estimates put this figure as high as 28,000 deaths per year.

• In addition, nosocomial bloodstream infections prolong hospitalization by a mean of 7 days. Estimates of attributable cost per bloodstream infection are estimated to be between $3,700 and $29,000.

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References

1. Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med. 2000;132(5):391-402.

2. Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1994;271:1598-1601.

3. Saint S. Chapter 16. Prevention of intravascular catheter-related infection. Making health care safer: a critical analysis of patient safety practices. AHRQ evidence report, number 43, July 20, 2001. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32:2014-2020.

4. Soufir L, Timsit JF, Mahe C, Carlet J, Regnier B, Chevret S. Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: a matched, risk-adjusted, cohort study. Infect Control Hosp Epidemiol. 1999;20(6):396-401.

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Care Bundles

• Care bundles, in general, are groupings of best practices with respect to a when applied together result in substantially greater improvement. The science supporting each bundle component is sufficiently established to be considered the standard of care.

• Evidence-based interventions result in better outcomes than when implemented individually.

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Central Line Bundle

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Central Line Bundle

The central line bundle has five key components:

1. Hand hygiene

2. Maximal barrier precautions

3. Chlorhexidine skin antisepsis

4. Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters

5. Daily review of line necessity, with prompt removal of unnecessary lines

• Compliance with the central line bundle can be measured by simple assessment of the completion of each item.

• The approach has been most successful when all elements are executed together, an “all or none” strategy.

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Central Line Bundle

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Central Line Bundle Results

Berenholtz SM, Pronovost PJ, Lipset PA, et al. Eliminating catheter-related bloodstream

infection in the intensive care unit. Critical Care Medicine. 2004;32:2014-2020.

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Model for Improvement

The model has two parts:

1. Three fundamental questions that guide improvement teams to

1. Set clear aims,

2. Establish measures that will tell if changes are leading to improvement

3. identify changes that are likely to lead to improvement.

2. The Plan-Do-Study-Act (PDSA) cycle to conduct small-scale tests of change in real work settings — by planning a test, trying it, observing the results, and acting on what is learned. This is the scientific method, used for action-oriented learning.

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Model for Improvement

• Implementation: After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team can implement the change on a broader scale — for example, test medication reconciliation on admissions first.

• Spread: After successful implementation of a change or package of changes for a pilot population or an entire unit, the team can spread the changes to other parts of the organization or to other organizations.

Model for Improvement on www.IHI.org

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Get Started

1. Select the team and the venue. It is often best to start in one ICU. Many hospitals will have only one ICU, making the choice easier.

2. Assess where you stand presently. What precautions are taken presently when placing lines? Is there a process in place? If so, work with staff to begin preparing for changes.

3. Contact the infectious diseases/infection control department. Learn about your catheter-related bloodstream infection rate and how frequently the hospital reports it to regulatory agencies.

4. Organize an educational program. Teaching the core principles to the ICU staff will open many people’s minds to the process of change.

5. Introduce the central line bundle to the staff.

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Metrics

Rate

Total no. of CR-BSI cases

No. of catheter days

Compliance

# with ALL 5 elements of central line bundle

# with CVCs on the day of the sample

Track and Scoreboard Overtime

Rate & Compliance

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x 1000 = CR-BSI per 1000 catheter days

= reliability of compliance

Track Overtime: Rate & Compliance

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Automation Helps Knockdown Barriers

1. Fear of change

– “It works and its proven”

– It’s the reason to use the system

2. Communication breakdown

– “Its built in”

– The system supports compliance

3. Physician and staff “partial buy-in”

– “I thought I was doing better than that”

– Measuring performance is compelling

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The Form: Specs

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The Form: Prep

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The Form: During

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The Form: After

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Ongoing Daily Review

• Daily review for necessity and prompt removal of unnecessary lines:

• The ICU patient with a central line will be reviewed daily, with a notation on the daily goals sheet or medical record indicating the continued need for the central line.

• Routine replacement should be avoided, and all lines should be removed as early as possible.

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Clinical Transformation, in Practice

Jeff Parker, Midland Memorial Hospital

Outcomes

• Central line days in ICCU averaged over the past year = 178 month.

• We have scored 100% on bundle compliant forms.

• We use maximum barrier kits.

Quality Improvement: Order Sets

• Using the in place order sets, the physician with a mere click or two can order all the necessary orders for central line placement – including X-rays for placement, flushes, with an order that staff can start using when placement is confirmed. In the old days, we would have to call the physician as most did not write the orders out in the detail we have with the electronic record.

Quality Improvement: Chart Availability

• Radiology immediately can view the order and can check the patients record for a signed consent, what the H&P shows, and the patients overall medical condition prior to them ever actually seeing the patient.

• The physician can view the X-ray immediately from any location within the hospital, from his home or office.

Quality Improvement: Efficiency

• Often, the chest X-ray is done within minutes of inserting the central line, allowing the use of the central line to be started much more quickly than was previously possible –which could be a crucial five minutes if it’s a unit patient.

Quality Improvement: Measuring and Compliance

• The electronic record has made it possible to easily audit charts and monitor for central line compliance.

Transformation Working Group

Janine Powell & Debbie Daspit

Community Collaboration

• Organized Collaboration - Just getting started..– Work as a Group

– Divide and Conquer option

• Collaboration Dependences – Values

– Interpretation

– Understanding

– Workflow

– Distribution of information

• Framework as a collaboration path to design and document and distribute strategies and content – Core Measure Reporting

– “Never Event” Prevention

– Performance Improvement

Clinical Transformation Framework sample

Admitted Patient Triggers

Emergency Visit Triggers

Orders/Standing Orders Triggers

Design and Documentation Example

Open Development Projects

George Lilly & Fay Struble

Adam Waterbury

OpenVista/GT.M Integration Project

Adam Waterbury

Get Involved

� Code is available on Launchpad

� Not production ready; for developers only

� Bugs are in Launchpad

� You can help!

� File a bug

� Comment on a bug with suggestions

� Create a branch and fix a bug yourself

� Not sure how to get started?

� Post on Medsphere.org with your interests; we'll find something for you!

Opensource CCR and CCD supportfor VistA based systems

Project Update

March 26, 2009by

George Lillyglilly@glilly.net

* This project has been funded in part with Federal funds from the National Institutes of Health, under Contract No. H HSN268200425212C, “Re-engineering the Clinical Research Enterprise".

CollaboratorsOrganizations

WorldVista

HP

KRM

Medsphere

Robert Morris University

Sequence Managers

University of Minnesota

Individuals

� George Lilly

� Christopher Anderson

� Nancy Anthracite

� Lee Castonguay

� Duane DeCorteau

� Emory Fry

� Sam Habiel

� Jose Lacal

� John McCormack

� Ben Mehling

� Dennis Menor

� Ken Miller

� Kevin Peterson

� Mike Schendel

� Fay Strubel

� Thomas Sullivan

� Chris Uyehara

� David Whitten

� Greg Woodhouse

� JohnLeo Zimmer

Topics

� Definition

� Purpose

� Snapshot

� Highlight

� Contributors

Definition: The Continuity of Care Record (CCR) is a machine readable and human readable ASTM XML standard data set of a person's clinical status

The CCR dataset has many intended purposes including the exchange of medical records, synchronization with clinical repositories, and the transformation into clinical messages

Exchange of medical records:� Between two EHR systems (VistA<->VistA and VistA<->O ther) �

� With a Personal Health Record (PHR) – like Google He alth or MS HealthVault

Synchronization with clinical repositories:� For clinical decision support � For research and clinical trials – as with the Elect ronic

Primary Care Research Network (ePCRN) �

Transformation into clinical messages� XSLT transformation into a Continuity of Care Docum ent (CCD) �

� For use the the National Health Information Network (NHIN) �� For CCHIT Certification� For HIPAA Claims Attachments

� Transformation into XML Web Service messages for eP rescribing

CCR/CCD PROJECT SNAPSHOT 3/26/2009

Payers

Advance Directives

Support

Functional Status

Problems

Alerts/Allergies

Lab Results

Medications

Family History

Medical Equipment

Immunizations

Procedures

Encounters

Plan of Care

Recent Change

Vital Signs

Social History

Actors

Export

TestingPlanned In ProductionIn DevelopmentLegend

Import (Accessioning)�Alerts/Allergies

Medication Advisories(ePrescribing)�

OpenVistA WorldVistAEHR FOIA VistA RPMS

GTM GTM

GTM

Cache

GTM

Cache

Fileman CCR Elements

MUMPS Temporary Globals

CCRTemplate

CCRProcessor

File WebService

XPath Library

Template File

Template Import

Parameters

Lab Date Limits

Meds Date Limits

Vitals Date Limits

PicklistProcessing

BatchProccessing

XML RPC Variables RPC

Checksums

CCD Transformation

ePrescription XMLSupport

FilemanMenu

Options

Fileman Parameters

ePCRNConnection

Codes

Recently, we demonstrated the transformation of our CCRs into level 2 CCDs thanks to an XSLT transformation contributed by Ken Miller

Medsphere.org Tip of the Month

Ben Mehling

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