Transcript 2010 - Hadassah Medical Center

Clinical Quality & Safety
A Progress Report
October 4, 2010
Mayer Brezis, MD MPH
Professor of Medicine
Center for Clinical Quality & Safety
(I) Ventilator-Associated Pneumonia
(VAP)
(II) Medication Reconciliation
(Med-Rec)
(III) Follow Up
on a few other projects
Ventilator-Associated Pneumonia
(VAP)
Project aim: reduce VAP incidence at Hadassah
Inna Apelbaum, Nurit Katz, Dr. Philip Levine, Dr. Shmulick Benenson,
Carmela Shwartz, Prof. Colin Block, Lois Gordon, Prof. Mayer Brezis
General Intensive Care, Unit for Infection Control and
the Center for Clinical Quality and Safety
VAP Prevention:
Recommendations Rated
With High Level of Evidence
ICHE 2008
Summary for 2009 survey
1. The incidence of VAP at Hadassah is higher
than what is reported in the literature.
2. The adherence to guidelines for VAP prevention
is lower than desirable.
3. How can adherence to guidelines be improved?
 Elevating the head of the bed between 30o- 45o
 Hand hygiene by staff before and after contact
with ventilator, patient and patient’s belongings
 Oral hygiene including brushing
 Discontinuation of sedation once a day
‫‪Intervention‬‬
‫‪Findings discussed with staff‬‬
‫‪Review of guidelines at staff meetings‬‬
‫‪Emails‬‬
‫‪Signs‬‬
‫‪Posters‬‬
‫‪Buttons‬‬
‫‪Screensaver‬‬
‫ביצוע היגיינת ידיים במים וסבון או בתמיסת אלכוהול‬
‫ראש המיטה מורם בין ‪30o- 45o‬‬
‫לפני ואחרי שנוגעים במכשיר‬
‫ההנשמה‪ ,‬במטופל וחפציו‬
‫טיפול פה כל משמרת בתמיסת כלורהקסידין עם צחצוח שיניים‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫צנרת ההנשמה נקייה מהפרשות ולכלוך הנראה לעין‬
‫‪Re-evaluation scheduled for early 2010‬‬
Survey results
Periods of observation:
Pre Intervention:
February – March 2009
Post Intervention:
February – March 2010
2009
Department
Mean
ventilation
days/pt.
Ventilation days N of ventilated
during period patients during
(observed for
observation
processes)
period
ICU A
ICU B
Neurosurgical ICU
12
11
16
449 (187)
175 (78)
195 (86)
32
19
11
Medical ICU
Total
10
12
220 (81)
1039 (432)
17
79
Intern. Medicine A
Intern. Medicine B
Intern. Medicine C
Neurology
Total
11
10
9
14
11
212 (79)
139 (55)
238 (106)
29 (13)
618 (253)
17
13
25
2
57
2010
Department
Mean
ventilation
days/pt.
Ventilation days N of ventilated
during period patients during
(observed for
observation
processes)
period
ICU A
12
128 (58)
11
ICU B
Neurosurgical ICU
8
4
73 (34)
23 (11)
9
6
Medical ICU
Total
6
7
84 (41)
308 (144)
13
39
Intern. Medicine A
Intern. Medicine B
13
9
50 (23)
64 (29)
4
7
Intern. Medicine C
Neurology
9
9
57 (25)
80 (33)
9
9
Total
9
251 (110)
29
Adherence to VAP prevention guidelines
Department
ICU A
ICU B

% Head of bed ≥ 30o % Ventilator
2009
2010 ()
2009
59
62
74
58
40
75
Neuro ICU
Medical ICU
Total
32
54
53%
91*
41
55%
68
72
72%
Medicine A
Medicine B
36
37
78*
69**
71
68
Medicine C
37
52
69
Neurology
Total
62
39%
70
68%*
92
75%
for stable patients only
* p<0.001 ** p<0.01
Adherence to hand hygiene (nurses)
Department
ICU A
ICU B
Neuro ICU
Medical ICU
Total
Medicine A
Medicine B
Medicine C
Neurology
Total
Hands washed
before contact (%)
2009
2010
Hands wash
after contact
2009
20
35
33
30
86*
76*
55
54
52
39
91
91
82
35
33%
85*
75%*
47
47%
93
91
29
27
26
23
28%
35
34
36
30
34%
39
37
38
62
39%
5
62
68
4
58
* p<0.001 ** p<0.01
Hand hygiene (respiratory technicians)
Department
ICU A
ICU B
Neuro ICU
Medical ICU
Total
Medicine A
Medicine B
Medicine C
Neurology
Total
Hands washed
before contact (%)
2009
2010
Hands wash
after contact
2009
20
12
13
8
26
23
27
58
59
45
5
6
6
11
11%
39
29%*
55
54%
7
63%
10
9
9
15
10%
26
34
32
27
30%*
48
46
47
38
47%
6
6
7
6
66
* p<0.001 ** p<0.05
Diagnostic criteria for VAP
Rates of VAP: 2009 & 2010
ICUs
43
Medicine
24
Total
67
Percent developing VAP
827
15
35%
296
5
21%
1123
20
30%
VAP cases/1000 ventilation days
18 ‰
17 ‰
18 ‰
41
711
13
19
383
7
60
1094
20
32%
18 ‰
37%
18 ‰
33%
18 ‰
Department
Patients observed
Ventilation days
Cases of VAP
Patients observed
Ventilation days
Cases of VAP
Percent developing VAP
VAP cases/1000 ventilation days
Mean cases/1000 ventilation days in literature* 11‰ (95%CI, 10-13)
* Chest 2008 (before interventions, down by 50% after interventions)
Rate of VAP per 1000 ventilation days
Adherence to VAP Guidelines
2009
% Head of bed ≥ 30o N
% Ventilator
tubing
clean of
of
days
Rate
Department Department
2009
2010 () observed
2009
VAP ‰
ICU A
62
ICU
A
ICU B
40
594
19
ICU B
Neuro ICU
91*
Medical ICU Neuro ICU
41
176
17
Total
53%
55%
%
Medical ICU
57
18
Medicine A
78*
Total
827
18 ‰
Medicine B
69**
Medicine C

52
62
70
Medicine
A
Total
39%
68%*
Medicine
B
for stable patients only
* p<0.001
Medicine C
Neurology
Total
Neurology
2010
N of days Ra
observed VA
252
2
124
53
282
2
711
18
92
84
5%
108
** p<0.01
104
0
296
24
9
19
17 ‰
48
75
95
165
383
2
1
2
1
18
Summary & Discussion:
VAP at Hadassah
1. Adherence to VAP prevention guidelines has
somewhat improved but remains lower than
desirable.
2. The incidence of VAP remains higher than that
reported in the literature.
3. Reactions from teams:
• “We don’t believe your data”
• “We need to look into this issue”
• “You lie and mislead”
• “We should have a checklist to increase
adherence to guidelines”
• “Our patients are sicker”
• “We need more staff”
• “We should introduce a protocol of daily
sedation cessation”
• “We need more equipment”
• “We will build an algorithm for VAP diagnosis”
Ventilator-Associated Pneumonia
Last VAP
SICU: Jan. 1, 2008
CICU: January 15,
2010*
*Prior to 1/15/10, the last
CICU VAP was on 3/24/08, or
621 days
VAP: The Beginning (2001)
• Do we have a problem?
• IHI Conference: VAP Prevention Bundle
• BUDAS: Bed up, Ulcer prophylaxis, DVT
prophylaxis, Anemia, Sedation wake-up
• VAP Workgroup: Critical Care Medical Director,
Infection Control, CNS, Respiratory Therapy
–
–
–
–
–
Consistent definition for VAP
Policies & procedures
Equipment & supplies
Intensivists
Education of RNs & RTs
VAP Initiatives (2002-2004)
• BUDAS
• Intensivist Co-Attending Model
• Multidisciplinary Rounds
– Reviewed components of BUDAS
– Reinforced education
• Education of ICU RNs & RTs
• Hand cleanser dispensers
• Monthly compliance review by Critical Care
Medical Director
• Critical Care Committee
– Informed physicians of EBP changes
Compliance with BUDAS
Process Improvements (2004)
• Daily multidisciplinary rounds (7 days a week)
• Chart documentation
Multidisciplinary Rounds
Pt seen with:
• Physician contracting
{ }Nursing { }Pharmacy { }Rehab Services
{ }Resp Therapy { }Nutrition { }MSW
Pt summary:
PUD Y N NA
NA
HOB Y N NA
NA
New Findings:
Goals:
Recommendations:
Pharmacy
Nutrition
Other
Follow up:
DVT
Y N
Sed WU
Y N
Cycles of Improvement
2005 Reported BUDAS compliance by individual
component
2006 Improved oral care, added chlorhexidine rinse
2007 Opened MCR with best practices from PVH
Switched to oral gastric tubes
2008 Reinforced standard procedure, chlorhexidine has
to be after toothbrushing, storage of Yankauer,
deep oralpharyngeal suctioning
2009 Introduced silver-coated endotracheal ETT (IHI 5
Million Lives Campaign)
New approach: Root cause analysis for each VAP
Lessons Learned
• Small incremental improvements based on audit data,
literature & outcomes
• Education, education, education
– Posters, case studies, self-learning packets, face to face
• Physician engagement
– Partner with physician champion
• Staff engagement
– Engage staff in solving problem
– Post rates in each ICU
– Rates = reflection of THEIR practice
Medication Reconciliation
Roni Cohen, B.Sc., Inbal Yifrach-Damari, M.Sc.*
Dr. Meir Frankel, Prof. Mayer Brezis
Hadassah-Hebrew University Hospital, Jerusalem, Israel
* Clinical Pharmacist, Hadassah Pharmacy Services
PhD student, School of Pharmacy, Hebrew University
With Help From Joint Commission International
Medication Errors
 Medication errors are the fourth leading cause of death or
major permanent loss of function in hospital patients.
 The majority of problems with patient safety occur during the
transition from one care setting to another.
 Ambulatory-hospital lack of communication is responsible for
50 % of medical errors.
 To improve patient safety, the Joint Commission on
Accreditation of Healthcare Organizations now recommends a
procedure designed to minimize errors.
What is Medication Reconciliation?
Obtaining a complete and accurate list of each
patient’s medications.
Documenting EVERY change:
Before the patient moves on, the physician must
decide about each drug:
CONTINUE
DISCONTINUE
This way, no drug is forgotten!
Drugs include: ‘over-the-counter’ medications, topical medications,
eye drops, vitamins, herbal medications and ‘occasional’ medications.
Methods for current project
 Over 100 adult patients admitted to the ER, on at least
5 regular drugs, underwent medication reconciliation.
 Review of medications with patient, family, primary
physician and/or database of HMOs (sick funds).
 After 24-48 hours, we checked the list of medications
prescribed to the patient by the ward staff.
 Our list was then compared with the list in the ward.
 If any discrepancy was observed
or an error was suspected, the
staff was approached to clarify
the reason for the change.
Overall Errors
In 97% of our patients, an error / intervention was found
on admission, during hospitalization or at discharge.
On average: 7 mistakes / interventions per patient
Pharmacological interventions
in 85%
Med-Rec interventions
in 87%
On average: ≈ 3 mistakes / interventions per patient, of any kind
Medication Errors on Hospitalization
At least one error was found in 73% of the patients
Enalapril and ramipril
were both prescribed
in the ward.
11%
5%
11%
Antiepileptic drug, taken at
home, was not continued in the
ward.
5%
19%
19%
65%
65%
Captopril was prescribed to a
patient only once a day
(instead of 3 times a day).
Unexplained discrepancies in medication
Unexplained
in medication
Doublediscrepancies
treatment / contraindications
Double treatment / contraindications
Hydralazine was written
for no reason.
Wrong dosage /frequency /route
Wrong put
dosage
/frequency
/routepharmacy
Medication
on hold
- not in Hadassah
Medication put on hold - not in Hadassah pharmacy
Medication Errors at Discharge
At least one error was found in 65% of the patients
“Pain killers as needed”
11%
6%
Combination of nortriptyline
11%
& citalopram
17% 6%
Propafenone
prescribed once a day
(instead of 3 times a day).
17%
10%
56%
56%
Levothyroxine
(eltroxin) omitted from
discharge letter.
10%
Alendronate
omitted from discharge letter.
Unexplained medication discrepancies
Medications on hold during hospitalization - not included in discharge letter
medication
discrepancies
WrongUnexplained
dosage /frequency
/route
Medications on hold during hospitalization - not included in discharge letter
Double treatment / contraindications
Wrong dosage /frequency /route
Unclear instructions on discharge letter
Double treatment / contraindications
Severity of Medication Errors
On
Hospitalization
At
Discharge
39%
47%
46%
45%
13.5%
7.5%
1.5%
0.5
Telephone Interviews
At least one error / problem was found in 23% of the patients!
● Nearly all patients had visited primary care
physician after discharge.
● 25% of patients were not aware of a
change in medication.
● On occasion, an error noted during
admission was continued after discharge.
Clinical Pharmacist Service
In 85% of patients:
• Apply correct indications and
contra-indications (≈18%).
• Adapt dosage to kidney or
liver function (≈15%).
• Drug-Drug Interaction (≈37%).
• Correct administration:
discharge, over 50% of
patients were not taking
medications correctly.
After
Polypharmacy
On Medication-Reconciliation Elsewhere
Survey of 100 patients at the Mayo Clinic: Inpatient
Medication Reconciliation in an Academic Setting
American Journal of Health-System Pharmacy 2007
Number of medication discrepancies decreased
from 3 per patient in phase 1 to 1.8 per patient in
phase 2 (p = 0.003)
Survey of 180 patients at Brigham and Women’s
Hospital, in Boston: Classifying and Predicting Errors
of Inpatient Medication Reconciliation. J Gen Intern
Med 2008. Average of 1.5 error per patient with
potential for harm.
Solutions included development of special software
for adapting prescription to the patient’s provider
preferred medications outside hospital.
Discussion
• Avoidable mistakes in medications are very common.
About 1% can be life threatening.
• Drug lists, in the community and in hospitals, are not
updated and often fail to reflect the medications that
the patient actually takes.
• A correct medical history can identify errors and can
sometimes even shed new light on the cause of
hospitalization.
• Critical changes in medications made during
hospitalization are often not implemented after
discharge.
Solutions to Reduce Errors
 At the individual level: have patient bring his/her bag of
drugs and carefully review them with him/her.
 A clinical pharmacist is very useful, as shown in literature:
improvement in outcomes, ↓errors, cost of care & LOS.
 Devise a computerized table for medication reconciliation
for each patient at each transfer of care provider.
Medication
Aspirin
Furosemide
Continue

Discontinue
Why?

hypokalemia
 Improve IT for transfer of information between Hadassah
and outside providers on admission and on discharge.
 Monitor quality for continuity of care by measuring quality
of handovers within Hadassah wards and with outside.
(III) Follow Up on a Few Other Projects
Involvement
of Physician’s
family during
 Family’s Involvement
during
Rounds
physician’s rounds: conclusion
After discussion of survey findings, a new policy was enacted by the Division of
Medicine to allow
one relative
be present during
physician’s
round. This policy
A majority
oftopatients,
relatives,
nurses
was also suggested to other departments by Ein Kerem Director, Dr. Y. Weiss.
and physicians:
• support the idea
 Checklist to reduce central lines infections
• think it improves communication
Major project
Hadassah
showed
a 65% reduction
in central lines infections with
• at
and
relieves
family’s
anxiety
the use of a checklist (as shown by Pronovost et al, NEJM 2006).
Observations
presence
of relatives
Despite this success,
checklist hasshow
not been
adopted in routine
work in any unit.
round
does
not
affectofits
duration
We are tryingduring
to introduce
at least
routine
recording
insertion
in the chart. To
help overcome inertia, we proposed to the Ministry of Health to publish guidelines
Findings are consistent with literature
with mandatory use and documentation of a checklist. The guidelines were
and suggest need for change in policy
prepared based in part on Hadassah experience and their publication is pending.
(III) Follow Up on a Few Other Projects
Leadership for Quality & Safety
A survey on leadership at Hadassah,* showed that 70% of
departments heads and 80% of head nurses, thought it
would be appropriate to use as criteria for appointment
(or re- appointment) of a department head, presentation of
initiatives on clinical quality & safety.
Such a policy is worthwhile to consider as it would
enhance participation of clinical heads in quality & safety
and facilitate implementation of improvement initiatives
such as on VAP and central line infections.
* Dr. Nurit Porat. The Relationship between the Leadership Style of Hospital
Department Head, Cooperation with Head Nurse, and Climate of Quality and Patient
Safety in General Hospital. PhD thesis, BGU, 2010.
(III) Follow Up on a Few Other Projects
 Disruptive Behavior
Disruptive Behavior
“Do you have disruptive behavior at Hadassah?”
Mark Chassin, MD, MPP, MPH
Professor of Medicine & VP for Excellence
Mount Sinai School of Medicine
President of the Joint Commission
Joint Commission now
requires hospitals to have a
written code of conduct and a
process for enforcing it
Survey of Disruptive Behavior at Hadassah
Last year exposure to intimidating behavior (%)
Refuses to answer
questions/calls
Arrogant tone
Impatience to answer
questions
Strong verbal insult
Threatening body
language
“Just do it”
Physical violence
Frequently or
Very frequently
Sometimes
9
18
22
9
9
8
0
30
48
41
16
15
16
3
Rarely
or Never
Didn’t
answer
60
1
32
1
36
1
73
2
76
1
75
97
1
0
Data from 100 MDs & nurses, at Departments of Medicine & Surgery
at Ein Kerem and Mt Scopus Hadassah Hospitals
(III) Follow Up on a Few Other Projects
 Disruptive Behavior
Hadassah Quality and Safety Committee has proposed to adopt a code of conduct
and a policy for enforcing it with an institutional committee to handle disruptive
behavior, using review of cases, sanction for recidivism and education.
Despite several reminders, our suggestion has not been followed.
 Rapid Response Teams (RRT’s)
RRT’s have been shown in some studies to reduce need for coding, morbidity and
mortality. Efficacy may depend on local institutional culture. In a survey of
intensive care experts and anesthesiologists (N=32), nearly half thought RRT’s
might be efficacious at Hadassah. A working team from the Quality and Safety
Committee has proposed to run a pilot project with several departments.
Members of this Committee have commented that the death of a woman from
bleeding after a C/S could have been averted by a RRT.
The suggestion to run a pilot has not been followed.
(III) Follow Up on a Few Other Projects
 Transparency
Recent studies suggest that an open disclosure policy after
a medical error is useful to restore trust, reduce anger and
liability costs and to enhance safety improvement efforts.
A Better Approach to Medical Malpractice Claims?
The University of Michigan Experience
“…an honest, principle-driven approach to claims is
better for all those involved—the patient, the healthcare
providers, the institution, future patients, and even the
lawyers”
“Do you believe a disclosure policy
could work in your department?”
 Survey of members of the Quality & Safety Committee:
9/10 senior clinicians and department heads responded yes,
some reported they already work according to a policy of
full disclosure. These were from pediatrics, medicine,
obgyn and hemato-oncology.
 Survey of 43 department heads:
15 responded yes, 8 of them added they already work
according to a policy of full disclosure. These were from
pediatrics, pediatric surgery, medicine, and hematology.
2 responded no; 5 asked for more time; the remainder
have not replied.
 Based on these preliminary observations, a policy of
disclosure appears worthwhile to consider at least with
some wards and with the development of a support team in
collaboration with RM.
Conclusion
Quality and safety initiatives, such as
VAP or medication reconciliation, show
opportunity for significant improvement.
To enhance participation by clinicians,
quality initiatives could be used as
criteria for appointment (or reappointment) of departments heads.