Objectives Identify the regulatory programs rewarding or penalizing - - PDF document

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 1

“Treating HAI as Plane Crashes instead of Car Accidents”

Progressing toward Zero Harm

Christopher Schmidt, ARNP, MSN, CEN

Chief, Quality and Patient Experience

Objectives

 Identify the regulatory programs rewarding or penalizing

hospitals for performance specific to Hospital Acquired Infections (HAI)

 Recognize the importance of realtime monitoring and

intervention (Code Rush) specific to HAI

 Recognize the technological initiatives which aided

Flagler Hospital in improving facility overall HAI scores

 Discuss Flagler Hospital’s use of technology to improve

institution wide hand hygiene compliance

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 2  Opened 1890, private, NFP

335-bed acute-care community hospital serving Northeast Florida.

 St Johns County only Hospital  Member, Coastal Community

Health

 ACO, First Coast Health

Alliance

335 Beds 335 Beds 55,000 Inpatient Days 55,000 Inpatient Days 59,000 ER Visits 59,000 ER Visits 16,000 Surgical Cases 16,000 Surgical Cases 141,000 Radiology Exams 141,000 Radiology Exams 1,100,000 Lab Tests 1,100,000 Lab Tests 1,550 Babies Born 1,550 Babies Born

A Focus on Clinical Excellence

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 3

$700K

$700K

HAC National Performance

6

Flagler Hospital Score: 6.94

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 4

The Road to Zero Harm

• Strong Leadership Support and Involvement
• Emphasis on safety as an organizational priority
• Adequate Financial Resources
• Allow time and incentive for key players involvement in

the Change process

• Allow time for the project to work
• Thinking outside of the box

Strengths

• Interprofessional team
• Leadership, Physician and Nursing personnel, Medical

Informatics, Infusion team, Quality Improvement personnel, Education

 reviews gap analysis on HAI process and formulate action plans to

be in line with best practices.

 Able to leverage technology to better assist in providing

transparency and clinical decision making

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 5

Weaknesses

• Lack of time and resources
• Always looking at the past, waiting for reports
• Addressing some problems creates others (CPOE)
• Physician/nursing buy in for new protocols and

equipment.

HAI Rates

Project Measure Start Date End Date Baseline Rate Hospital Target 9/2018 CAUTI CAUTI Rate - all except NICUs 1/15 12/15 0.65 0.52 CAUTI Rate - ICUs except NICUs 1/15 12/15 0.83 0.66 Catheter Utilization -all except NICUs* 1/15 12/15 29.22 23.38 Catheter Utilization -ICUs except NICUs* 1/15 12/15 51.32 41.06 C.difficile

• C. diff Rate Facility-wide-all except NICUs (per 10,000)

1/14 12/14 10.79 8.63 CLABSI CLABSI Rate - All 1/15 12/15 0.76 0.61 CLABSI Rate - ICUs 1/15 12/15 0.69 0.55 Central line utilization - All* 1/15 12/15 25.13 20.10 Central line utilization - ICUs* 1/15 12/15 41.22 32.98 MRSA Hospital-onset MRSA bacteremia events 1/14 12/14 0.05 0.04 Sepsis Sepsis Post-op Rate 12/15 9/16 10.85 8.68 Hospital-Onset Sepsis Mortality Rate 12/15 9/16 164.95 131.96 Overall sepsis mortality 12/15 9/16 73.06 58.45 SSI SSI rate, colon surgeries* 1/14 12/14 3.57 2.86 SSI rate, abdominal hysterectomy* 1/14 12/14 0.00 0.00 SSI rate, knee surgeries* 1/16 9/16 1.48 1.18 SSI rate, hip surgeries* 1/16 9/16 3.61 2.89 VAE Ventilator-associated condition rate 4/15 3/16 1.53 1.22 Infection-related ventilator-associated condition rate 4/15 3/16 1.53 1.22

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 6

HAI SIR rate

Project Measure Start Date End Date Baseline Rate Hospital Target 9/2018

CAUTI CAUTI SIR - all except NICUs (NHSN only)** 1/15 12/15 0.69 0.55 CAUTI SIR - ICUs except NICUs (NHSN only)** 1/15 12/15 0.80 0.64 C.difficile

• C. diff SIR - all except NICUs (NHSN only)** ^^

1/15 12/15 1.14 0.91 CLABSI CLABSI SIR - all (NHSN only)** 1/15 12/15 0.93 0.74 CLABSI SIR - ICUs (NHSN only)** 1/15 12/15 0.79 0.63 MRSA SIR: MRSA bacteremia (NHSN only)** ^^ 1/15 12/15 1.17 0.94 SSI SSI SIR, colon surgeries (NHSN only)** 1/15 12/15 1.69 1.35 SSI SIR, abdominal hysterectomy (NHSN only)** 1/15 12/15 0.00 0.00 SSI SIR, knee surgeries (NHSN only)** 1/17 1/17 0.00 0.00 SSI SIR, hip surgeries (NHSN only)** 1/17 1/17 0.00 0.00

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 7

Code Rush

• Conducting real time Root Cause Analysis (RCA) of HAI

to identify underlying causes of the incident to ensure an effective solution can be identified and implemented before another incident occurs.

Tenerife , Canary Islands 1977 Worst Commercial Aviation Disaster in History Objective: Predict patients at higher risk for developing CLABSI; intervene before CLABSI can

• develop. Based on a literary review of risk factors for

CLABSI development, CMIO created an algorithm identifying patients that would benefit from close monitoring and early intervention. Since Implementation, 0 CLABSI in 11 months.

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 8

This reports all patients that may have a catheter in place. The order allows nursing floors, logistics and supervisors to correct documentation errors, obtain an order for the Foley if one was not place and to place the Foley if it was ordered. Process necessary to ensure documentation is accurate for another notification system alerting physicians within their progress note that a Foley has been in place for 3 days and to either discontinue or document why Foley is still necessary.

Addressing Sepsis

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 9

• Data demonstrates reduced C.Diff rates by 50% since 2013

Clostridium difficile (C.diff.)

17

National Benchmark = 0.965 FH Average Rate = 1.283

CDIFF Report

Report lists patients who have an order for C. Diff stool test, but not collected. Often Often times C. diff test ordered on admission but stool not collected and sent for analysis until after 3rd day. This would occur for various reasons, but if collected beyond the 3rd day, patient reported as HAC instead of POA.

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 10

CDIFF (CDI) Dashboard

• Pharmacists review dashboard daily which includes

patients with active CDI or suspected CDI (test pending):

• Contact Precautions and Isolation
• De-escalation or discontinuation of broad spectrum antibiotics
• Discontinuation of antacid therapy or switch PPI to H2 blocker
• Appropriate treatment of CDI based on severity of infection

CDI Pharmaceutical Prevention Implementation

• Development of CDI Treatment and Testing Order Sets
• Probiotics are an orderable option on order sets containing

high risk antibiotics

• Removed PPIs and H2 blockers from Admission Order Sets
• Prescriber Led Review at 72 hours for discontinuation or de-

escalation of antibiotics

• Automatic antimicrobial discontinuation at 7 days unless
• therwise specified by provider
• Prospective Audit and Feedback of Target Antimicrobials
• Removal of Antimicrobials from Applicable Post-Op Order Sets

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 11

Antimicrobial Stewardship Other techniques to reduce HAC

 Infra Red Technology  Hand Hygiene

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 12

25% 25% 26% 26% 29% 34% 38% 39% 38% 45% 56% 57% 57% 63% 64%

0% 25% 50% 75% Sep '16 Oct '16 Nov '16 Dec '16 Jan '17 Feb '17 Mar '17 Apr '17 May '17 Jun '17 Jul '17 Aug '17 Sep '17 Oct '17 (To Date) Oct 23rd 2017 Sep 2016 – Oct 2017

Hand Hygiene Compliance 152% Improvement Over Baseline

2017 Facility Goal: 70%

HAI Improvement

Project Measure Baseline Rate Average Rate Hospital Target 9/2018 All State Baseline Percent Improved

CAUTI CAUTI Rate - all except NICUs 0.65 0.56 0.52 1.00

14%

CAUTI Rate - ICUs except NICUs 0.83 0.88 0.66 1.16

• 6%

Catheter Utilization -all except NICUs* 29.22 28.99 23.38 19.15

0.8%

Catheter Utilization -ICUs except NICUs* 51.32 57.03 41.06 55.81

• 11%

C.difficile

• C. diff Rate Facility-wide-all except NICUs (per 10,000)

10.79 8.57 8.63 6.94

21%

CLABSI CLABSI Rate - All 0.76 0.21 0.61 0.92

72%

CLABSI Rate - ICUs 0.69 0.00 0.55 0.89

100%

Central line utilization - All* 25.13 15.79 20.10 19.50

38%

Central line utilization - ICUs* 41.22 32.95 32.98 41.98

20%

MRSA Hospital-onset MRSA bacteremia events 0.05 0.00 0.04 0.07

100%

Sepsis Sepsis Post-op Rate 10.85 5.09 8.68 10.07

53%

Hospital-Onset Sepsis Mortality Rate 164.95 174.31 131.96 117.76

• 6%

Overall sepsis mortality 73.06 76.17 58.45 148.85

• 4%

SSI SSI rate, colon surgeries* 3.57 3.42 2.86 4.29

4%

SSI rate, abdominal hysterectomy* 0.00 3.23 0.00 1.47

• 100%

SSI rate, knee surgeries* 1.48 1.72 1.18 0.77

• 16%

SSI rate, hip surgeries* 3.61 1.95 2.89 1.44

46%

VAE Ventilator-associated condition rate 1.53 0.79 1.22 6.43

49%

Infection-related ventilator-associated condition rate 1.53 0.40 1.22 2.03

74%

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 13

HAI SIR Improvement

Project Measure Baseline Rate

SIR

Hospital Target 9/2018

CAUTI CAUTI SIR - all except NICUs (NHSN only)** 0.69 ^Den. < 1 0.55 CAUTI SIR - ICUs except NICUs (NHSN only)** 0.80 ^Den. < 1 0.64 C.difficile

• C. diff SIR - all except NICUs (NHSN only)** ^^

1.14 0.92 0.91 CLABSI CLABSI SIR - all (NHSN only)** 0.93 ^Den. < 1 0.74 CLABSI SIR - ICUs (NHSN only)** 0.79 ^Den. < 1 0.63 MRSA SIR: MRSA bacteremia (NHSN only)** ^^ 1.17 0.00 0.94 SSI SSI SIR, colon surgeries (NHSN only)** 1.69 ^Den. < 1 1.35 SSI SIR, abdominal hysterectomy (NHSN only)** 0.00 ^Den. < 1 0.00 SSI SIR, knee surgeries (NHSN only)** 0.00 ^Den. < 1 0.00 SSI SIR, hip surgeries (NHSN only)** 0.00 ^Den. < 1 0.00

Questions…

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 14

HAI Improvement

Measure Rates October 23, 2017 Project Measure Baseline Rate (BL) Average Rate Progress Hospital 9/2018 Target ADE ADEs - excessive anticoagulation* 3.77 0.48 87.3% 3.02 ADEs - hypoglycemia* 6.62 4.45 32.8% 5.30 ADEs - opioids* 0.51 0.25 51.0% 0.41 CAUTI CAUTI Rate - all except NICUs 0.65 0.56 13.8% 0.52 CAUTI Rate - ICUs except NICUs 0.83 0.88

• 6.0%

0.66 Catheter Utilization -all except NICUs* 29.22 28.99 0.8% 23.38 Catheter Utilization -ICUs except NICUs* 51.32 57.03

• 11.1%

41.06 C.difficile

• C. diff Rate Facility-wide-all except NICUs (per 10,000)

10.79 8.57 20.6% 8.63 CLABSI CLABSI Rate - All 0.76 0.21 72.4% 0.61 CLABSI Rate - ICUs 0.69 0.00 100.0% 0.55 Central line utilization - All* 25.13 15.79 37.5% 20.10 Central line utilization - ICUs* 41.22 32.95 20.1% 32.98 Falls Falls w/Injury 0.79 0.47 40.5% 0.63 MRSA Hospital-onset MRSA bacteremia events 0.05 0.00 100.0% 0.04 Pressure Ulcers Pressure ulcer rate, stage 3+ 4.17 1.82 56.4% 3.34 Pressure ulcer prevalence, stage 2+* 0.52 0.25 51.9% 0.42 Readmissions Readmissions - 30 day all cause* 10.36 11.63

• 12.3%

9.12 Readmissions - Medicare* 14.76 16.39

• 11.0%

12.99 Sepsis Sepsis Post-op Rate 10.85 5.09 53.1% 8.68 Hospital-Onset Sepsis Mortality Rate 164.95 174.31

• 5.7%

131.96 Overall sepsis mortality 73.06 76.17 4.3% 58.45 SSI SSI rate, colon surgeries* 3.57 3.42

• 4.2%

2.86 SSI rate, abdominal hysterectomy* 0.00 3.23 >100% 0.00 SSI rate, knee surgeries* 1.48 1.72

• 16.2%

1.18 SSI rate, hip surgeries* 3.61 1.95 46.0% 2.89 VAE Ventilator-associated condition rate 1.53 0.79 48.4% 1.22 Infection-related ventilator-associated condition rate 1.53 0.40 73.9% 1.22 VTE Post-operative VTE or DVT 13.51 6.23 53.9% 10.81