“PREVENTING BAD THINGS (HARMS) THAT COULD · PDF filePoorly Performing Nursing Homes...

2008 Summer Nursing Conference Arizona Geriatrics Society

The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the

Arizona Geriatrics Society. 88

© 2008 Arizona Geriatrics Society. All Rights Reserved

“PREVENTING BAD THINGS (HARMS) THAT

COULD HAPPEN DURING ACUTE ILLNESS”

Howard Pitluk, MD, MPH, FACS Vice President & Chief Medical Officer

Health Services Advisory Group (and recovering vascular surgeon)

Objectives:

• Define the Quality Improvement Organization’s role in Patient Safety for

Medicare beneficiaries

• Demonstrate the evidence for addressing the process covered in the 9th

Scope of Work Patient Safety Theme

• Challenge participants to make patient safety improvement part of their

care goals

DISCLOSURE Howard Pitluk, MD, MPH, FACS does not have a significant financial interest or other

relationship with manufacturer(s) of commercial product(s) and or provider(s) of

commercial services discussed in the presentation.





Slide 1

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Preventing Bad Things (Harms) That Could Happen During Acute Illness

Howard Pitluk, MD, MPH, FACS

V/P Chief Medical Officer

Health Services Advisory Group, Inc.

Arizona Geriatrics Society

August 22, 2008

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The Health Care Challenge

� We know that for every unnecessary death there is

much more error, injury, and pain.

� We know that the nation has a great deal of progress

yet to make in reducing adverse drug events,

infection, and surgical complications.

� CMS, The Joint Commission, IOM, etc., are serious

about completely transforming the U.S. health care

system.

� We know that there is great will and optimism

among leaders and frontline providers of care.

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37 Million Hospital Admissions(Source: The AHA National Hospital Survey for 2005)

(Source: IHI “Global Trigger Tool” Guiding Record Reviews)

X

40 Injuries per 100 Admissions

=

15 Million Injuries (Harms) per Year

How Many Injuries (Harms) in the United States?

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Definition of Medical Harm

Unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment or hospitalization, or that results in death.

Such injury is considered harm whether or not it is considered preventable, whether or not it resulted from a medical error, and whether or not it occurred within a hospital.

For more information, please reference detailed FAQs at www.ihi.org/campaign.

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The 5 Million Lives Campaign

IHI is asking hospitals participating in

the Campaign to prevent 5 million

incidents of medical harm over the next

two years.

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The 5 Million Lives CampaignCampaign Objectives:

� Avoid 5 million incidents of harm over the next

24 months;

� Enroll more than 4,000 hospitals and their

communities in this work;

� Strengthen the Campaign’s national infrastructure

for change and transform it into a national asset;

� Raise the profile of the problem – and hospitals’

proactive response – with a larger, public

audience.

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The Platform

� Deploy Rapid Response Teams…at the first sign of

patient decline.

� Deliver Reliable, Evidence-Based Care for Acute

Myocardial Infarction…to prevent deaths from heart

attack.

� Prevent Adverse Drug Events (ADEs)…by

implementing medication reconciliation.

� Prevent Central Line Infections…by implementing a

series of interdependent, scientifically grounded steps.

� Prevent Ventilator-Associated Pneumonia…by

implementing a series of interdependent, scientifically

grounded steps.

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The Platform

� Prevent Pressure Ulcers... by reliably using

science-based guidelines for their prevention.

� Reduce Methicillin-Resistant Staphylococcus

aureus (MRSA) Infection…by reliably

implementing scientifically proven infection control

practices.

� Prevent Harm from High-Alert Medications...

starting with a focus on anticoagulants, sedatives,

narcotics, and insulin.

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Slide 10

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The Platform

� Reduce Surgical Complications... by reliably

implementing all of the changes in care recommended

by the Surgical Care Improvement Project (SCIP).

� Deliver Reliable, Evidence-Based Care for

Congestive Heart Failure…to reduce readmissions.

� Get Boards on Board….Defining and spreading the

best-known leveraged processes for hospital Boards of

Directors.

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Slide 11

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CMS 9th Scope of Work

Patient Safety Theme

� Pressure Ulcers

� Physical Restraints

� SCIP

� MRSA

� Drug Safety

� Poorly Performing Nursing Homes

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What is a Pressure Ulcer?

� Defined as an area of localized damage to

the skin and underlying tissue caused by

pressure, shear, friction, and/or a

combination of these.

� Commonly referred to as bed sores,

pressure damage, pressure injuries, and

decubitus ulcers.

6

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Slide 13

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Why are Pressure Ulcers Important?

� An estimated 4%–10% of patients admitted

to an acute hospital develop a pressure ulcer.

� Major cause of sickness, reduced quality of

life, and morbidity.

� Associated with a 2–4-fold increase in risk of

death in older people in intensive care units.

� Substantial financial costs.

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Key Priorities for Implementation

� Initial and ongoing assessment of risk

� Initial and ongoing pressure ulcer

assessment

� Pressure ulcer grade should be recorded

using a classification system

� All pressure ulcers graded 2 and above

should be documented as a local clinical

incident

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� All patients vulnerable to pressure ulcers

should, as a minimum, be placed on a high-

specification foam mattress.

� Patients undergoing surgery require high-

specification foam theatre mattresses.

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Classification of Pressure Ulcer Severity

� Grade 1 − non-blanchable erythema of intact skin.

Discoloration of the skin, warmth, edema, induration or

hardness can also be used as indicators, particularly on

individuals with darker skin.

� Grade 2 − partial thickness skin loss involving epidermis or

dermis, or both. The ulcer is superficial and presents clinically

as an abrasion or blister.

� Grade 3 – full thickness skin loss involving damage to or

necrosis of subcutaneous tissue that may extend down to, but

not through, underlying fascia.

� Grade 4 – extensive destruction, tissue necrosis, or damage to

muscle, bone, or supporting structures with/without full

thickness skin loss.

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Patients with a grade 1–2 pressure ulcer

should:

�As a minimum provision be placed on

a high-specification foam mattress/

cushion, and

�Be closely observed for skin changes.

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Slide 19

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Patients with grade 3–4 pressure ulcers should:

� As a minimum provision be placed on a high-

specification foam mattress with an alternating

pressure overlay, or

� A sophisticated continuous low-pressure

system, and

� The optimum wound healing environment

should be created by using modern dressings.

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Slide 20

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Prevention and Treatment of Pressure Ulcers

Assess and record risk

Prevent pressure ulcer

Assess pressure ulcer

Treat pressure ulcer and

prevent new ulcers

Patient with

pressure ulcer

Re-assess

People vulnerable

to pressure

ulcers

Re-assess

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Assess and Record RiskRisk factors include:

� Pressure

� Shearing

� Friction

� Level of mobility

� Sensory impairment

� Continence

� Level of consciousness

� Acute, chronic and

terminal illness

� Comorbidities

� Posture

� Cognition,

psychological status

� Previous pressure

damage

� Extremes of age

� Nutrition and hydration

status

� Moisture to the skin

Reassess on an ongoing basis

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Slide 22

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Skin Assessment

� Persistent erythema

� Non-blanching hyperemia

� Blisters

� Localized heat

� Localized edema

� Localized induration

� Purplish/bluish

localized areas

� Localized coolness if

tissue death occurs

�Assess skin regularly – inspect most vulnerable areas

�Frequency – based on vulnerability and condition of patient

�Encourage individuals to inspect their skin

�Look for:

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Slide 23

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Assessment of Pressure UlcerAssess:

� Cause

� Site/location

� Dimensions

� Stage or grade

� Exudate amount and type

� Local signs of infection

� Pain

� Wound appearance

� Surrounding skin

� Undermining/tracking,

sinus or fistula

� Odor

Record:

� Document:

- Depth

- Estimated surface area

� Grade

� Support with photography

and/or tracings

� Document all pressure

ulcers graded 2 and above

as a clinical incident

Initial and ongoing ulcer assessment is

the responsibility of a registered healthcare professional

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Treatment of Pressure Ulcers

� Consider preventive measures, positioning, self-care, nutrition, and pressure-relieving devices.

� Create an optimum wound-healing environment using modern dressings.

� Consider oral antimicrobial therapy in the presence of systemic and/or local clinical signs of infection.

� Consider referral to a surgeon.

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Slide 25

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Positioning

� Consider mobilizing, positioning, and repositioning interventions for all patients.

� All patients with pressure ulcers should actively mobilize, change position/be repositioned.

� Minimize pressure on bony prominences and avoid positioning on the pressure ulcer.

� Consider restricting sitting time.

� Aids, equipment, and positions – seek specialist advice.

� Record using a repositioning chart/schedule.

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Self-Care

� Teach individuals and caregivers how to

redistribute individual’s weight.

� Consider passive movements for patients

with compromised mobility.

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Nutrition

� Provide nutritional support to patients with an identified deficiency

� Decisions about nutritional support/supplementation should be based on:

– Nutritional assessment

– Patient preference

– Expert input (dietitian/specialists)

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Pressure Relieving Devices

� Consider all surfaces used by the patient.

� Patients should have 24-hour access to pressure-

relieving devices and/or strategies.

� Change pressure-relieving device in response to altered

level of risk, condition, or needs.

- Skin assessment

- General health

- Lifestyle and abilities

- Critical care needs

- Acceptability and comfort

- Cost consideration

− Risk assessment pressure

ulcer assessment (severity) if

present

− Location and cause of the

pressure ulcer if present

− Availability of caregiver/

healthcare professional to

reposition the patient

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Referral to Surgeon

� Failure of previous

conservative

management

interventions

� Level of risk

� Patient preference

� Ulcer assessment

� General skin

assessment

� General health status

� Competing care needs

� Assessment of psychosocial factors regarding the risk of recurrence

� Practitioner’s experience

� Previous positive effect of surgical techniques

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Implementation for Clinicians

� Be familiar with hospital guidelines.

� Facilitate an integrated approach to the management of pressure ulcers across the hospital community interface.

� Ensure continuity of care between shifts.

� Ensure your local risk-assessment tool incorporates all risk factors.

� Access training on a regular basis.

� Give patients and caregivers information.

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Implementation for Clinicians

� Ensure that you have an understanding of what the different modern dressings are, their objectives, and application.

� Know how to access pressure-relieving devices –24 hour access.

� Pressure ulcers Grade 2 and above – document as a ‘local’ clinical incident.

� Place documentation aids in patient charts.

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Implementation for Managers

� Ensure an integrated approach to the

management of pressure ulcers across the

hospital community interface.

� Ensure appropriate equipment is available.

� Develop or review local guidelines for pressure

ulcer prevention and management – are they in

line with this guidance?

� Include in induction for new staff and provide

opportunities for retraining on a regular basis.

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Implementation for Managers

� Ensure standardization and availability of

modern dressings on all wards and across

healthcare settings.

� Put in place a system for staff to access pressure-

relieving devices in a timely manner – 24 hour

access for secondary care.

� Monitor, audit, and review progress.

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Prevention and Control of Healthcare-Associated

Methicillin-Resistant Staphylococcus aureus

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Most Invasive MRSA Infections Are Healthcare-Associated

Healthcare-Associated

Community-Associated

Source: ABCs Population-based Surveillance System, KlevensKlevensKlevensKlevens et al. et al. et al. et al. JAMA JAMA JAMA JAMA 2007200720072007

14% 86%

n=8,987

� In the U.S. in 2005 there were:

– 94,360 invasive MRSA infections

– 18,650 associated deaths

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MRSA as a Healthcare Pathogen

� Has emerged as one of the predominant

pathogens in healthcare-associated infections.

� Treatment options are limited and less effective

– higher morbidity and mortality.

� High-prevalence major influence on unfavorable

antibiotic prescribing, which contributes to

further spread of resistance.

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MRSA as a Healthcare Pathogen

� Adds to overall S. aureus infection burden

� Represents a failure to contain transmission

of drug-resistant bacteria:

– A marker for our ability to contain

transmission of important pathogens in

the healthcare setting.

– Learning how to successfully control

MRSA is likely to have benefits that

extend to other pathogens (MDRO).

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Key Prevention Strategies

� Prevent infection

� Diagnose and treat

infection effectively

� Use antimicrobials wisely

� Prevent transmission

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Clinicians hold the solution!

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Most Healthcare-Associated Invasive MRSA Infections Have

Their Onset Outside of the Hospital

Healthcare-Associated (community-onset)

Community-Associated

14% 59%

28%

Healthcare-Associated (hospital-onset)

Source: ABCs Population-based surveillance System, KlevensKlevensKlevensKlevens et al. JAMA 2007et al. JAMA 2007et al. JAMA 2007et al. JAMA 2007

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Regional Spheres of Influence Within Spectrum of Inpatient

Care

Hospital A

Hospital B

Nursing Home 1

Nursing Home 4

NH 2

Nursing Home 3

Hospital c

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How Best to prevent MRSA Transmission in Healthcare Settings?

� Controversial subject

– Standard precautions versus standard plus barrier (i.e., contact precautions)?

– Should contact precautions be used only on those identified by clinical cultures?

• Due to “iceberg effect,” many colonized patients are unrecognized based on clinical cultures alone

• Should active surveillance be used to identify carriers?

– If so, in what settings?

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CDC Guidance On Management of Multidrug-Resistant Organisms (MDROs) in Healthcare Settings

First Tier: General Recommendations First Tier: General Recommendations First Tier: General Recommendations First Tier: General Recommendations For All Acute Care SettingsFor All Acute Care SettingsFor All Acute Care SettingsFor All Acute Care Settings

Second Tier: Intensified InterventionsSecond Tier: Intensified InterventionsSecond Tier: Intensified InterventionsSecond Tier: Intensified Interventions

If endemic rates not decreasing, orIf endemic rates not decreasing, orIf endemic rates not decreasing, orIf endemic rates not decreasing, orif first case of important organismif first case of important organismif first case of important organismif first case of important organism

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CDC MDRO Guidance (Acute Care)First Tier: General Recommendations For All

Acute Care Settings

� Administrative engagement– Make MDRO prevention and control an

organizational patient safety priority

– Implement a multidisciplinary process to monitor and improve healthcare personnel (HCP) adherence to recommended practices

– Feedback on facility and patient-care unit trends in MDRO incidence and adherence measure

� Education and training of personnel

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CDC MDRO Guidance (Acute Care)First Tier: General Recommendations For All

Acute Care Settings

� Judicious use of antimicrobial agents

� Standard precautions for all patients

� Contact precautions for patients known to be

infected or colonized (masks not routinely

recommended)

� Monitoring of trends over time to determine

whether additional interventions are needed

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CDC MDRO Guidance (Acute Care)

� Indications for moving to second tier

– First case or outbreak of an epidemiologically

important MDRO

– When endemic rates of a target MDRO are not

decreasing despite implementation of and

correct adherence to the first-tier measures

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CDC MDRO Guidance (Acute Care)Second Tier: Intensified Interventions For

Acute Care Settings

� Active surveillance cultures from patients at risk on admission to high-risk area and at periodic intervals to assess transmission.

– Contact precautions until surveillance culture known to be negative

– Administrative engagement/correction of systems failures

– Education and training of personnel/adherence monitoring

– Judicious use of antimicrobial agents

– Monitoring of trends

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CDC MDRO Guidance (Acute Care)Second Tier: Intensified Interventions For

Acute Care Settings

� Cohorting of staff to care of MDRO patients only

� Enhanced environmental measures

� Consult with experts on case-by-case basis regarding decolonization therapy for patients/staff.

� If transmission continues despite full implementation of above, stop new admissions to the unit.

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MDRO Module

Multidrug-Resistant Organism (MDRO) andClostridium difficile-Associated Disease (CDAD)

Module

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50

MDRO Module

Organisms Monitored:

-Methicillin-Resistant Staphylococcus aureus (MRSA)

(option w/ Methicillin-Sensitive S. aureus (MSSA)

-Vancomycin-Resistant Enterococcus spp. (VRE)

-Multidrug-Resistant (MDR) Klebsiella spp.

-Multidrug-Resistant (MDR) Acinetobacter spp.

-Clostridium difficile-Associated Disease (CDAD)

Protocol available online at:http://www.cdc.gov/ncidod/dhqp/nhsn_MDRO_CDAD.html

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Conclusions

� The burden of MRSA remains high in U.S. healthcare settings.

� Community-associated MRSA (CA-MRSA) infections are emerging rapidly, but most MRSA infections are still healthcare-associated

� Epidemic strains of MRSA originally community-associated have emerged as important causes of hospital-acquired infections,

� MRSA infections and transmission can be prevented, even in endemic settings in the U.S.

� Effective control programs must be multifaceted, with broad institutional commitment.

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Where Do Errors Occur?

Prescribing 39%

Transcribing 11%

Dispensing 12%

Administering 38%

Where Do Errors Occur?

Prescribing 39%

Transcribing 11%

Dispensing 12%

Administering 38%

Preventing Medication Errors Related To Prescribing

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Medication Prescribing Process Components: Communication

� Written Prescription Orders

� Medication Ordering Systems

� Electronic Order Transmission

� Dosage Calculations

� Verbal Orders

Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

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Written Medication Orders: Illegible Handwriting

� 16% of physicians have illegible handwriting.1

� Common cause of prescribing errors.2, 3, 4

� Delays medication administration.5

� Interrupts workflow.5

� Prevalent and expensive claim in malpractice

cases.3

1. Anonymous. JAMA 1979; 242: 2429-30; 2. Brodell RT. Arch Fam Med 1997; 6: 296-8; 3. Cabral JDT. JAMA 1997; 278: 1116-7; 4. ASHP. Am J Hosp Pharm1993; 50: 305-14; 5. Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

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Illegible Handwriting: Error Prevention

� Prescribers’ Obligation

� Write/Print More Carefully

� Computers

� Verbal Communications

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Written Medication Orders: Complete Information

� Patient’s Name

� Patient-Specific Data

� Generic and Brand Name

� Drug Strength

� Dosage Form

� Amount

� Directions for Use

� Purpose

� Refills


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Written Medication Orders: Do Not Use Abbreviations

� Drug names

� “QD” or “OD” for the word daily

� Letter “U” for unit

� “µg” for microgram (use mcg)

� “QOD” for every other day

� “sc” or “sq” for subcutaneous

� “a/” or “&” for and

� “cc” for cubic centimeter

� “D/C” for discontinue or dischargeCohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.Jones EH. Clev Clin J Med 1997; 64: 355-9.

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Written Medication Orders: Weights, Volumes, Units

� Use metric system

� Avoid apothecary system

Confusion With Apothecary System

1/200 grain (0.3 mg) ≠≠≠≠ 1/100 grain (0.6 mg) + 1/100

grain (0.6 mg)

Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.Cohen MR. Am Pharm 1992; NS32: 26-8.

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Written Medication Orders: Decimals

� Avoid whenever possible1

– Use 500 mg for 0.5 g

– Use 125 mcg for 0.125 mg

� Never leave a leading decimal point “naked” 1, 2, 3

– Haldol .5 mg → Haldol 0.5 mg

� Never use a terminal zero

– Colchicine 1 mg not 1.0 mg

� Space between name and dose1,3

– Inderal40 mg → Inderal 40 mg

1. Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

2. Jones EH. Clev Clin J Med 1997; 64: 355-9.

3. Cohen MR. Am Pharm1992; NS32; 32-3.

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Look-alike and Sound-alike Drug Names

USP Quality Review. www.usp.org/reporting/review/qr66.pdf accessed on February 6, 2001.

Zyrtec®Zantac®Prilosec®Plendil®Neoral®Nizoral®Lomotil®Lamisil®Fosamax®Flomax®Cardura®Cardene®LorazepamAlprazolamAccutane®Accupril®

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Medication Prescribing Process: Electronic Prescribing

� Computer with 3 Interacting Databases

–Drug History

–Drug Information/Guidelines Database

–Patient-Specific Information

� Avoids

–Illegible Prescriptions

–Improper Terminology

–Ambiguous Orders

–Incomplete Information Schiff GD. JAMA 1998; 279: 1024-9.

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Computerized Prescribing

Photograph of prescriber order entry computer screen courtesy of AllScripts Healthcare Solutions

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Dosage Calculations: Error Prevention

� Avoid calculations

� Cross-checking

Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.ISMP Medication Safety Alert 1996; 1 (15).

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Verbal Orders: Error Prevention

� Avoid when possible

� Enunciate slowly and distinctly

� State numbers like pilots

(i.e., “one-five mg” for 15 mg)

� Spell out difficult drug names

� Specify concentrations


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Patient Education

� Educate patients about their medications.

� Purpose of each medication.

� Name of drug, dose, how to take, etc.

� Provide patients with understandable written

instructions.

� Lack of involving patients in check systems.

� Inform patients about potential for error with

drugs known to be problematic.

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Surgical Care Improvement Project(SCIP)

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SCIP Measures

� SCIP-Inf 1: Prophylactic antibiotic received within one hour prior to surgical incision

� SCIP-Inf 2: Prophylactic antibiotic selection for surgical patients

� SCIP-Inf 3: Prophylactic antibiotics discontinued within 24 hours after surgery end-time (48 hours for cardiac patients)

� SCIP-Inf 4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose (< 200 mg/dL)

� SCIP-Inf 5: Postoperative wound infection diagnosed during index hospitalization

� SCIP-Inf 6: Surgical patients with appropriate hair removal

� SCIP-Inf 7: Colorectal surgical patients with immediate postoperative normothermia

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SCIP Measures

� SCIP-Card 1: Non-cardiac vascular surgery patients with evidence of coronary disease who received beta-blockers during perioperative period

� SCIP-Card 2: Surgical patients on a beta-blocker prior to arrival that received a beta blocker during the perioperative period

� SCIP-Card 3: Intra- or postoperative acute myocardial infarction (AMI) diagnosed during index hospitalization and within 30 days of surgery

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SCIP Measures

� SCIP-VTE 1: Surgical patients with recommended

venous thromboembolism prophylaxis ordered

� SCIP-VTE 2: Surgery patient who received appropriate

venous thromboembolism prophylaxis within 24 hours

prior to surgery to 24 hours after surgery

� SCIP-VTE 3: Intra- and postoperative pulmonary

embolism (PE) diagnosed during index hospitalization

and within 30 days of surgery

� SCIP-VTE 4: Intra- and postoperative deep vein

thrombosis (DVT) diagnosed during index

hospitalization and within 30 days of surgery

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SCIP Measures

� SCIP-ESRD 1: Permanent hospital ESRD

vascular access procedures that are autogenous

AV

� SCIP-Global 1: Mortality within 30 days of

surgery

� SCIP-Global 2: Readmission within 30 days of

surgery

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SCIP Measures

� SCIP-Resp 1: Ventilated surgery patients with

documentation of Head of Bed (HOB) elevated

� SCIP-Resp 2: Patients diagnosed with (VAP)

postoperative ventilator-associated pneumonia

� SCIP-Resp 3: Documentation of stress ulcer

disease (SUD) prophylaxis

� SCIP-Resp 4: Surgical patients on a ventilator who

were placed on a ventilator weaning protocol†

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HSAG Mission

To positively affect the quality of health care by providing information and expertise to those who deliver and those who receive health services.

To help make a better health care system.

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HSAG Partners

� 60+ Acute Care Hospitals

� 5 Critical Access Hospitals

� 140+ Nursing Homes

� 64 Medicare-Certified Home Health Agencies

� 4000+ Primary Care Physicians

� 8 Medicare Advantage Plans

� Pharmaceutical Companies

� 750,000 Medicare Beneficiaries, their

Families & Caregivers

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Contact Information

Howard C. Pitluk, MD, MPH, FACS

Vice President/Chief Medical Officer

Health Services Advisory Group

1600 East Northern Avenue, Suite 100

Phoenix, AZ

602.665.6143

[email protected]

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www.hsag.com

This material was prepared by Health Services Advisory Group, the Medicare Quality

Improvement Organization for Arizona, under contract with the Centers for Medicare

& Medicaid Services (CMS), an agency of the U.S. Department of Health and Human

Services. The contents presented do not necessarily reflect CMS policy.

Publication No. AZ-8SOW-1C-073108-01

All Medicare beneficiaries have the right to appeal their

discharge from a hospital, skilled nursing facility, home

health agency, or comprehensive outpatient rehabilitation

facility. For more information, go to

http://www.hsag.com/azmedicare or call 1.800.359.9909.

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