presentation at 2007 annual meeting of va patient safety managers and officers
DESCRIPTION
This presentation was for 150 or so Dept of VA Patient Safety managers with and for whom I worked at VA Central Office while they worked at the VA Medical Centers and Network offices. The main items of interest are the preliminary work that I was describing from the periphery of the then developing VA MRSA Prevention Program, which was quite successful and led by Dr. Rajiv Jain (and published in NEJM: http://www.nejm.org/doi/full/10.1056/NEJMoa1007474#t=abstract). Also of interest is the wide-ranging work that VA NCPS led on the follow up on an OIG report that identified problems in some of VA's operating rooms. Also of interest is slide 36 where I present some interesting data on VA's reduction in unadjusted inpatient mortality - this hasn't been widely publicized or published to my knowledge. The second to last slide refers to the fact that the day after the meeting I was going to the Grand Canyon and planning to hike to the bottom one day and out the next day. That turned out to be a great experience.TRANSCRIPT
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AHRQ PIPS, MRSA, and OIG on PS in VHA ORs
(05-00379-91)
Noel Eldridge, MSNational Center for Patient Safety
National Patient Safety Managers’ Conference3/20/07
202 273-8878
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It’s nice to get a break away from the office!
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What is he talking about?
I. “Partnerships for Implementing Patient Safety” projects funded and managed by the Agency for Healthcare Research and Quality
II. The new VHA Program to prevent Methicillin-Resistant Staphylococcus aureus in VA patients, and
III. The VA Office of Inspector General Report on Patient Safety in the Operating Room in VHA Facilities (Report # 05-00379-91)
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I. AHRQ PIPS Projects
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PIPS Program Overview
17 Projects Implementing Evidence-Based Interventions Generalizable, Realistic, Replicable & Sustainable PIPS Project Teams - PI 20%, Multi-Disciplinary,
Sharp-End
PIPS Goals Assist sharp-end users in implementing
interventions Provide information for implementation
(both what works & what does not!) Provide toolkits to put interventions into
practice
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PIPS Program Timeline
Patient Safety Intervention Implementation Activities July 2005 – July 2006
AHRQ Site Visits & PIPS Presentations Presentations/Posters at AHRQ PS Conference: June 2006
PIPS Projects Analysis & Evaluation Activities July – November 2006
AHRQ PIPS Technical Assistance Workshop & Presentations October 25-26, 2006
PIPS Toolkit & Website Development & Refinement November 2006 - June 2007
PIPS Toolkits & Evaluations Available July 2007
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Focus of PIPS Projects
Discharge & Transitions 3 PIs: Jack, Noskin,
Williams Deep Vein
Thrombosis and/or Anticoagulation 2 PIs: Maynard, Zierler
Medication Reconciliation and Safety 9 PIs: Fairbanks, Jack,
Jones/Mueller, Leonhardt, Levett, Muller, Noskin, Sirio, Williams
Simulation 2 PIs: Guise,
Patterson Team Training &
Communication 4 PIs: Daugherty,
Fairbanks, Noskin, Sirio
Workflow & Processes 4 PIs: Burdick,
Landrigan, Maynard, Speroff
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PIPS Toolkits
Minimum Guidance for Maximum Flexibility
Identify Problem Define & Measure the Intervention How (and How Not) to Implement the Intervention Results: Evidence-Based Patient Safety Tools
Website CD/Video “How To” Guide & Checklist Training Materials – Online Training, Workbooks Data Analysis & Tracking Spreadsheets Poster & PowerPoint Presentations
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PIPS Program: Next Steps
17 PIPS Representatives at National Patient Safety Foundation (NPSF) Congress - May 2-4, 2007, DC 3 Presenting in Research Track Session 14 “Meet the Experts” in Exhibit Hall
AHRQ Marketing & Rollout Plan in Development
Plan to Conduct National Call(s) for VHA Patient Safety Managers and other VHA Personnel in July/August 2007
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Take Home Message:AHRQ PIPS projects
17 AHRQ PIPS Projects Near Completion Most are on Topics Relevant to VHA NCPS Plans to Organize National Calls
focusing on Toolkits in July – August 2007
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II. MRSA Program
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Why a New Program & this New Program? MRSA is a Growing Problem in US
Healthcare, Including VHA Facilities The VA Pittsburgh Healthcare System has
Demonstrated Good Results (reduced MRSA rates and transmission of MRSA) that Appear Replicable
Related JCAHO Finding from 2006 Surveys 7 of 33 (21%) VAMCs received RFIs for Hand
Hygiene
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
'50 '60 '78-'82 '83-'87 '88-'92 '93-'97 2000
Denmark, Finland and the Netherlands ( <1%).
USA: This MRSA trend accompanies a 36% rise in the overall national nosocomial infection rate from 1975 to 1995.
Percent of Staph Aureus Resistant to Methicillin is Rising in the USA…But has been Controlled in Denmark, Finland and the Netherlands
(Source: CDC NNIS data)P
erce
nt o
f Sta
ph
Au
reu
s R
esis
tan
t to
Met
hic
illin VHA 2006
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VAPHS (4-West Surgical Ward) Nosocomial MRSA Infection Rate
Fig 1. MRSA Infections/1000 BDOC - 4W Surgical Ward
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
24 Mo. Pre FY02 FY03 FY04 FY05
Intervention begun
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VAPHS (Surgical Intensive Care Unit) MRSA Infection Rates
Fig. 2. MRSA Infections/1000 BDOC - SICU
0
1
2
3
4
5
6
24 Mo Pre FY04 FY05
Intervention begun
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Four Basic Aspects of MRSA Program from VA Pittsburgh Healthcare System
1. Hand Hygiene
2. Active Surveillance Cultures
3. Contact Isolation
4. Cultural Transformation from within
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VAPHS MRSA Bundle:1. Hand Hygiene
Before and after every patient contact
BEST: Alcohol hand sanitizer Still must wash hands if visibly
soiled Monitor: peer data collection
(Standard Methods being Developed)
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Hand Hygiene Questions
Which of these do/does the VHA Directive/ Joint Commission NPSG/ CDC Guideline Require?
Keeping Natural Fingernails Short (<4mm free edge)? No Artificial Fingernails on Anyone Who Does Direct
Patient Care? Providing Pocket-sized Alcohol-based Hand-rub to
Staff? Providing Facial Tissues (“Kleenex”) to Staff? Different Practices in a Norovirus Outbreak? Decontaminate Hands Before and After Gloving?
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VAPHS MRSA Bundle: 2. Active Surveillance Cultures
Nares Swabs• Admission• Discharge or Transfer• CTB is considered discharge
Open wounds
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Active Surveillance Cultures? VA-wide Application of Active
Surveillance? VAMCs with low baseline MRSA
Bloodstream Infection Rates May be Able to Opt Out of Some Aspects of Active Surveillance
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Implement Action Plan as submitted
Facility review of FY06 Baseline MRSA BSI (Bloodstream Infections) rateBaseline MRSA BSI rate =
# unique nosocomial episodes (>48 hrs) MRSA BSIs # Acute care Bed Days of Care
Small facilities that do not have a single case of BSI should consult MRSA Program Office for
assistance in determining an appropriate measurement tool.
Directive 2007-002
Methicillin-Resistant Staphylococcus aureus (MRSA) Initiative
MRSA Bundle
1Active Surveillance Cultures
2Aggressive Hand Hygiene3Contact Precautions for MRSA-colonized patients4Cultural change
Targeted Active Surveillance for high-risk units
Based on internal assessment
Apply to Taskforce for Exemption from Active Surveillance Cultures
Active Surveillance Exemption Not Approved
Implementation of Full MRSA Bundle, including Active Surveillance Cultures
(Admission/Discharge)
NOTE:Review Exemption criteria:
Strong Action Plan*Reduce infection rate by 20% in FY07
Reassess 6 months after implementation: has goal to reduce nosocomial MRSA BSIs by 20% or to ZERO been achieved?
No
MRSA BSI Rate <median, maintains Contact Precautions for patients MRSA-INFECTED or colonized based on clinical culture AND components 2 & 4 of
MRSA Bundle are fully implementedMRSA BSI Rate >median
Single case of VRSA in last 12mos., or at any time during surveillance
No. Facility must implement full MRSA Bundle with active surveillance
Facility Choice
x 1000( )
Active Surveillance ExemptionApproved
Yes. Facility may choose approach
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VAPHS Bundle:3. Contact Isolation &
4. Cultural Transformation
Contact Isolation– all MRSA+ patients• HH, Gown, Glove• Designated or Disinfected Equipment
Cultural Transformation from Within• Staff – own and operate solutions
• Leaders - Set direction, create freedom and opportunities for staff to co-create and implement solutions, remove barriers
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Take Home Message:VHA MRSA Program
MRSA Program has New Interventions and Requirements, and New Funding (Planned)
Some Aspects will Vary by VAMC Currently 17 Beta Sites at VAMCs Some Methods Still Being Developed
e.g., standard measurement methods for some processes
MRSA Program has Potential to Focus and Improve Various VHA and VAMC-wide Efforts to Prevent Infections
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III. OIG Report on Patient Safety in the Operating
Room
www.va.gov/oig/54/reports/VAOIG-05-00379-91.pdf
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Purpose of OIG Review To “determine whether”:
1. “facility leaders established and implemented effective policies, procedures, and guidelines to ensure patient safety in the OR”;
2. “facility leaders established surgical improvement program and identifies potential problem areas needing improvement; and
3. “there was coordination between Supply, Processing, and Distribution (SPD) and the OR”
Eight (8) VAMCs Visited by OIG Staff
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Summary of Findings
Issue 1: Compliance with VHA Directives, AORN Guidelines, & JCAHO Standards
Issue 2: Surgical Performance Improvement Program
Issue 3: SPD Coordination with the OR
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Accentuating the Negative Ensuring Correct Surgery
We found that …two (of 8) facilities… had policies that only addressed side/site verification.
We found that two (of 8) facilities… had incident or near miss incorrect surgery events in fiscal year (FY) 2005. The first facility reviewed the event of the wrong site surgery and
determined that (a) the surgeon did not possess the consent form when the site was marked, (b) the nurse circulator did not mention the variance between the marked site and the consent, and (c) a time-out briefing with the informed consent was not performed.
At the second facility, a patient had the wrong eye anesthetized (blocked)…The incident was reviewed and monitors were developed and implemented to ensure the correct site was identified and marked.
Related JCAHO Finding from 2006 Surveys 12 of 33 (36%) VAMCs received RFIs for “Universal Protocol”
(11 Time-outs and 1 Mark Operative Site).
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Accentuating the Negative
Disclosure of Adverse Events We found that three (of 8) facilities failed to document
disclosure of adverse surgical events.
At one facility, two patients had to return to surgery with partially retained drains. (no record of disclosure)
At a second facility, the surgeon administered a regional block into the wrong eye. (no record of disclosure)
In the third facility, we reviewed three surgery-related deaths that involved delay in diagnosis or treatment… (no record of disclosure)
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Other Topics Reviewed Preventing Retained Surgical Items (VHA Directive 2006-030) Environment of Care
HVAC (e.g., air exchanges) Equipment Management (preventive maintenance schedules) Anesthesia Cart Security (e.g., unmarked filled syringes)
Resident Supervision Morbidity and Mortality Peer Review (Directive 2004-054) Mortality Assessment (Directive 2005-056) Credentialing and Privileging Availability of Supplies Missing, Broken, and Incorrect Instruments Contaminated Surgical Instruments
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Who Can Make this Better?
I don’t think that we can’t fix this from VACO No thousand mile
screwdriver We don’t know how
Different places, Different Problems, Different Solutions
Do you and your colleagues know how? Let us know how we can help Especially re communicating
non-optional aspects
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Who Needs to Participate in a Time-out in the Operating Room?
Everyone in the Operating Room? Attending Surgeon? Anesthesia Provider? Circulating Nurse? Surgical Nurse? Do Midline Sites Need to be Marked? How About Out-of-OR?
Is a time-out required for thoracentesis?
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Summary of VHA Follow-ups
Plan to Require Check of Local Policies, Processes and Practices (OR and Management), & Aspects of the Physical Environment Paper Reviews (e.g., policies and committees w/minutes) Observations
Pre-operative Processes (marking sites, “time-outs”…) Intra-operative Processes (counting sponges…) Environment of Care/Engineering/Equipment, etc.
Method for Reporting Results to VACO is TBD No Plan for a New Mandatory Standardized
Checklist to be Used for Every Surgical Case
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Thanks for Examples of OR Checklists from VISNs and VAMCs
Carol Bills, VISN 23 Christine Carlin, San
Diego Sandra Hart, Danville (IL) Kerry Inhofe, Oklahoma
City Tanya Kotar, Milwaukee Patricia Lingenfelter,
Baltimore
Karen Pierce, Loma Linda
Phyllis Trainor, Providence
Edith Villaruz, Los Angeles
Medical Team Training Program Sites
And Anyone I missed
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Take Home Message:OIG report on PS in VHA ORs
OIG Review Found Variation in Processes Some were disturbing (e.g., marking “Ace bandage”)
VHA Follow-up will Focus on Local Policies and Self-Assessments (Observation) of Processes Details of Reporting to VACO Not Yet Defined
You Should Read This Entire Report NCPS-led Medical Team Training Program
Focusing on Some of Same Process Issues NSQIP Data has Demonstrated Morbidity and
Mortality Improvements in VA Surgical Patients
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Some Context: Good NewsVA & US Inpatient Discharges and Mortality
5060708090
100110120130140150
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
1998
= 1
00
VA Discharges
VA Mortality
US Discharges
US Mortality
1995-1998 (Pink Oval): ● US discharges and mortality flat ● VA discharges down 28% and mortality up 14%1999 to Date (Yellow Oval):● US discharges up (8% thru 2003) and mortality down (14% thru 2004)● VA discharges flat (down 2% thru 2006) and mortality down (35% thru 2006)
VHA Inpatient Mortality (Unadjusted) is Down 35%
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Enjoy the Conference!
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Wish me luck!