Transcript Nancy`s show - Tift Regional Medical Center

PI CME in a
Community Hospital
Nancy Carrier, RN, BSN
Quality Support
Tift Regional Medical Center
Tifton, GA
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About Tift Regional Medical
Center (TRMC)
 Located in South Central Georgia
- Combined service area population 250,400 (12 counties)
- Governed by Hospital Board Authority
- State accredited CME provider
 Staff
- 120 physicians on staff representing 15
specialties
- 1,600 employees
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About TRMC
 191 licensed beds
- 176 acute care
- 15 skilled nursing
 2010 Volume
- 1,093 deliveries
- 48,833 ER patients
- 12,244 inpatients
- 110,412 outpatients
- 7,595 surgical cases
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4
Medical staff structure
Hospital Authority
Medical Executive
Committee
Quality Council
Clinical Monitoring
Committee
Infection Control
Committee
MRSA PI/CME
Department of
Medicine
Department of
Surgery
Department of
Peds
Department of
OB
Department of
Family Practice
Emergency Room
Department
Critical Care
Committee
Cardiovascular
Committee
Gastrology
Committee
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Hospital structure
Hospital Authority
CEO
QM Director
CNO
HR Director
CFO
Outreach &
Development
VPMA
Joint Commission
Resources
CME
Case Management
Work Smart
Infection Control
Health Plus
Clinics
Quality Management
PI / CME
Physician Services
Recruitment
Liaison
COO
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CME Program
 CME Committee (working committee)
 Very active and committed Director
 CME - monthly
 RSS Activities (4)
 Other Activities:



Physician case based research (PoC)
Enduring CME
PI CME
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PI CME
 Started in 2007 with first project on
Sepsis
 Developed a model for all future projects
 Change happens when physician driven
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Pre-op MRSA screening & intervention
before elective total joint
replacements (TJR)
 Needs identified by Infection control and
discussed in the Department of Surgery
medical staff meeting
 Back ground research done
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Needs Assessment
 The MRSA Risk assessment for 2008
revealed an increase in SSI with MRSA
 Orthopedic statistics were the highest
 Increase in community acquired MRSA
in area
 Patients colonized with MRSA are at risk
for developing a SSI following an ortho
procedure & have a 3.4 x higher risk of
death and 2 x greater hospital costs.
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Define the “GAP”
 Pre –op patients colonized with MRSA
are not identified
 Only patients with acute infections are
cultured
 No decolonization guidelines for patients
 No formalized educational support
resource
 Pre op antibiotic selection not consistent
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Close the GAP
 Research Best Practice – evidenced
based
 Identify national performance measures
How do you do this?
Where do you go to get this information?
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Evidence based
Performance Measures
(examples)
 Physician Quality Reporting Initiative
(PQRI)
 Physician Consortium for Performance
Improvement (PCPI)
 Institute for Healthcare Improvement
(IHI)
 CDC
 National Organizations
 Evidenced based literature research
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MRSA
 CDC & Surgical Care Improvement
Project (SCIP) Guidelines
 SHEA (Society for Healthcare Epidemiology of America)
 IDSA (Infectious Diseases Society of America)
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Goals & Objectives
 Screen 100% of patients scheduled for elective
total joint replacements for MRSA during their
pre op assessment
 All colonized patients will complete a
decolonization protocol before surgery


2% mupirocin ointment to nose bid x 5 days pre-op
4% chlorohexidine gluconate body wash x 5 days pre-op
 Colonized patients will be screened again prior
to surgery
 Colonized patients will be placed in Contact
Precautions upon admission
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Goals & Objectives
 Patient Outcomes


Surgical site infections will decrease in
total joint patients
Reduce use of Vancomycin for surgical
prophylaxis
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PI CME – 1st steps
 This PI CME project started in March,
2009
 Planning started

CME & QI brainstorming
 IC and the Ortho group requested to
“take on the challenge”
 Provide background information &
literature
 Needed to identify champion

IC Committee chair
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Project leader / physician
champion
 Physician
 Passion for the project
 Finalize team members identified to participate
 Invited physicians to participate by letter
 Follow up with a phone call
 Want cross section representation of all
departments involved when ever possible
We may affirm absolutely that nothing great in the
world has ever been accomplished without passion.
-- Georg Hegel
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Adding Support Staff
 Laboratory
 OR
 Day Surgery and Assessment nurses
 Ortho nurses
 Infection Preventionist
 Orthopedic PAs
 Pharmacy
 QI/ Data analysist
 CME
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Initial kick-off meeting
Provide a meal for the initial meeting






Overview of QI / PI CME activity
Establish ground rules
 Peer protection
 Confidentiality
Expected time frame
What commitment would involve
 Required to sign letter of commitment
Educational backup
 Literature & articles
 Web sites
 Grand rounds and 1:1 time with expert
Benefits of participants
 Become resources for peers
 Develop guidelines they would be measured against
 CME Credit
 Several free lunches / dinners
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Next Steps
 Letter of Commitment
 Confirmation of goals
 Schedule of future meetings
 Reading Assignment


SHEA/IDSA Practice Recommendation,
“Strategies to Prevent Transmission of
MRSA in Acute Care Hospitals” Oct 2008
CDC “Management of Multidrug-Resistant
Organisms” 2006
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Meeting Calendar
 Dinner Kick-off and assignments
 Sub-Committee report back
 Guideline draft presented / approved
 Guideline roll-out
 Possible Grand Rounds
 Final Meeting / Wrap-up
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Letter of Commitment
You are being asked to participate in a Performance Improvement study at TRMC that involves improving pre-op MRSA screening
& treatment of patients who are scheduled for elective Total Joint Replacements.
This form provides you with information about the expectations of the study and encourages commitment of about 6 months
participation. --------_is the Director of this project and is available to answer any questions that may arise.
Please review the following information and if you agree to participate, please sign in the appropriate sections.
Name:
Practice Specialty:
Dr
Title:
Purpose:
Pediatrics
phone:
e-mail
Pre-op MRSA screening & treatment for elective Total Joint Replacements
To develop protocols designed to decrease the incidence of SSI by MRSA, including active surveillance cultures to identify patients
colonized with MRSA and decolonization of patients with MRSA prior to surgery.
Benefits:
Improve patient care by decreasing the incidence of SSI in elective Total Joint Procedures caused by MRSA.
Cost:
No cost will be accrued to you for participating; however, there will be a time commitment.
Compensation: You will not receive payment for participating. Up to 20 CME credits will be awarded commiserate with your participation. Educational
opportunities will be provided and any expenses incurred such as travel will be reimbursed.
Privacy
Information will be shared that must remain confidential. The information discussed in this group will be peer protected through the IC
Confidentiality: committee
Expectations: We will ask your commitment to reading all literature provided, to attend any planned CME conference, and participate in the project as
outlined. Periodic evaluations will be provided for you to complete, including a summary at the end of the designated time frame of the project.
Monthly meeting time will be set. We understand that your time is important. We will start and stop on time. You may be asked to review data collection
summaries to validate the results. All HIPAA sensitive information and peer review must remain confidential.
You have been informed about this project’s purpose, benefits and expectations and have been given the opportunity to ask questions. By signing,
you voluntarily agree to participate in this project.
_______________________________________
Signature
__________________
Date
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Unless commitment is made, there are only promises
and hopes; but no plans.
-- Peter F. Drucker
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CME credit
 Give overview of the PI/CME process
 Explain Stages A, B & C
 Review the evidenced based
performance measures
 Review their commitment and
documentation required to be awarded
credit
 Answer all questions
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Stage A
Learning from current practice
performance assessment
 The team Physicians review patient data
 May request additional information
 Objectives for PI CME activity are defined
 Public reporting
 Review current practice and make recommended
changes in physician practice (hospital-wide)
 Develop P&P as needed

Standardize educational materials
 Develop Stage A measures
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MRSA Screening
Performance Measures
Goal
Indicator
Definition
100%
Percent of population screened
Number of patients cultured/number of
planned total hips and knees
100%
Percent compliant with
decolonization protocol
Number of colonized patients who completed
decolonization protocol/number of colonized
patients
100%
Effective decolonization
Number of negative follow up screens/number
completing decolonization
< 1%
Surgical Site Infection (SSI)
rate for total hips and knees
Number of SSIs/total number of hips and
knees
100%
Patient Education on MRSA
screening
Number of patients receiving
education/number of patients screened
Percent of populations
colonized with MRSA
Number of positive initial screens/total number
of patients screened
Establish
TRMC
Prevalence
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Stage B
Learning from the application
of PI to patient care
 Develop
guidelines for identifying patients
colonized with MRSA and steps to take to
initiate decolonization procedures
 Provide surgical and orthopedic staff education
 Provide patient education
 Standardize educational materials for patients
 Develop discharge planning tools for patients
 Develop checklists
 Write policies and procedures
 Review antibiotic practices
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Stage B interventions
 Development of new guidelines

Committee approval
 Staff education
 MRSA
 Pre-op assessments and scheduling
 Nasal swabbing
 Medications used
 Documentation requirements
 Patient education
 MRSA booklet
 Pre op & post op instructions
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Building patient & hospital
interest
Living with MRSA
This is really
serious! I need to
do something
about this now!
Learning how to control the spread of
Methicillin-Resistant Staphylococcus Aureus (MRSA)
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There is a simple, painless nasal swab test for a potentially dangerous pathogen called Staphylococcus aureus, also known as
MRSA (Methicillin-resistant Staphylococcus aureus). This test identifies people who are potential reservoirs of infection. You can
carry MRSA in your nose or on your skin without displaying symptoms. Approximately 1 in 5 people carry MRSA. An approach
called Active Surveillance Culturing could reduce MRSA infections in hospitals by more than 70 percent.
Total Joint Replacement Pre-Operative Screening Protocol
People who harbor these bacteria in their nose, or on their skin, are called “carriers,” or are “colonized” with the bacteria.
MRSA colonized patients are at higher risk for developing MRSA infections after surgery at their surgical site.
During your pre-op assessment, the nurse will use a Q-tip swab to collect a culture from your nose to determine if you are an
MRSA carrier.
If you test positive for MRSA, someone will contact you with further instructions prior to your surgery.
Your doctor will order a nasal ointment to be applied to your nose twice a day for 5 days just prior to your surgery.
Since this bacteria could also be living on your skin, it is very important that you bathe once a day using the Hibiclens body wash
for 5 days just before your surgery.
Hibiclens can be purchased from your local Pharmacy without a prescription.
We are very committed to providing you the best care possible.
It is very important that you follow these instructions to
minimize the risk of complications after surgery.
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Stage C
Learning from the evaluation of
the PI effort

Final chart reviews began one month after
guidelines were completed and interventions
were implemented

Analyze chart reviews
 Review
compliance with new guidelines
 Implementation success
 Determine opportunities for improvement
Do something. If it works, do more of it. If it doesn't, do something else.
-- Franklin D. Roosevelt
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Final meeting with participating
physicians
 Project
physicians review their individual data
 Guidelines
 Complete
are reviewed & edited as needed
final evaluation & credit request
forms
 AWARD
CME CREDIT!
 Develop
plan to communicate changes &
educate
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Continuing Medical Education
Credit Request for
Performance Improvement Activity
TRMC pre-op MRSA screening & treatment for elective
total joint replacements
April, 2009
Stage C
Activity: please check areas you have completed, respond to the questions and sign


I completed the implementation plan for the Performance Improvement CME project for
MRSA Initiative
I evaluated the progress made through implementation of this plan
Please describe below whether the intervention (Individual Action Plan)
you implemented improved your department practice/performance in
those areas identified. If not, please provide an explanation as to why.
Factors such as systems failures or other barriers to success should be
included……..
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Results from activity
Goal
Indicator
Results
100%
Percent of population screened
100%
100%
Percent compliant with
decolonization protocol
92%
100%
Effective decolonization
92%
< 1%
Surgical Site Infection (SSI) rate
for total joint replacements
0.67%
100%
Patient Education on MRSA
screening
100%
Establish
TRMC
Prevalence
Percent of populations colonized
with MRSA
17%
All this data has been
collected since 5/18/09
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Barriers Identified

Determining benefit of
active surveillance
screening

Monitoring compliance
with decolonization

Follow up on decolonization
failures
Availability of 4%
chlorohexidine gluconate
Compliance with Contact
Precautions


 This was a learning
curve that soon was
overcome
 This was based on
patient report so was out of
our control
 A discharge instruction sheet
was designed
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Benefits

Pre-op showers with
4% chlorohexidine gluconate for all
total joint patients
 Improved compliance with
Contact Precautions
 Standardized patient
education on MRSA
 Developed discharge
instructions for patients colonized
with MRSA
 Appropriate use of
Vancomycin as a pre-op antibiotic

 TRMC now uses all 4% chloro-




hexidine gluconate showers for
ALL surgeries not just joints
Staff education and awareness
on Ortho unit
MRSA booklet providing
standardized education
P&P developed
Marketing tools and posters
 Decrease in Vancomycin use
improving resistance rates
SSI rate decreased (>50%
through 2010)
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Recommendations

Continue MRSA
screening for total joints
and extend to other
procedures
 Consider 4% chloro –
hexidine gluconate for all preop showers
 Investigate all surgical
site infections and observe for
any trends or common links
 Any implants such as
hernia mesh as well as
all spinal implants.
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Final Discussion & Roll Out
 Presentation to Quality
Council
 General Surgeon
Education
 Cost analysis
 Final report from Infection
Control
 CME credits
 Adjournment
 Physician champion & IC presented
findings to the hospital Quality
Council then to the Board
 This data will be presented at the
Department of Surgery. Even though
the hernia infection rate is <1.5%, there
is always room for improvement
 IC will work on a cost analysis for
prevention costs as compared to
infection costs (selling point for admin)
 All implants must be followed for
infections for 12 months. At the end of
this time, IC will report a final infection
rate.
 20 Category one credits will be
awarded
 Great Job!
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Tips for engaging physicians
 Recruit a strong physician leader
 Follow the “ground rules” established in
your first meeting
 Keep within the time frames agreed
upon
 Make sure it is physician driven
 Feed them!
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Lessons learned
 Administrative support
 Committed medical leader
 Buy-in from medical staff participating in project
 Preparations for each meeting

(pre-meeting meetings)
 Clear expectations
 Defined budget
 Food
 Celebrate success
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Advice for other CME providers
 Utilize your Resources

(QI loves this stuff!)
 Excitement with success!
 Share your success with peers
 Be prepared for the time commitment
 Strong non-medical leader
 CME Director backing
 Record keeping
 Facilitate CME compliance
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Comments from the MRSA
Physician Champion
 It IS doable
 Recommend a strong support team
 The Physician champion will coordinate
with the support staff to keep everyone
working in the same direction
 Be available by phone or e-mail; it will
save on overall time commitment and
meetings
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Just play! Have fun. Enjoy the game!
-- Michael Jordan
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