Never Event Mitigation By Tele Icu Care
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Never Event Mitigation By Tele Icu Care






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Never Event Mitigation By Tele Icu Care Never Event Mitigation By Tele Icu Care Presentation Transcript

  • Never Event Mitigation ICU - TeleICU Collaborate Elizabeth Cowboy, MD Cheryl Donelan, RN
  • What is a Never Event
    • National Quality Forum (NQF), “never events” are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients
    • Indicates a real problem in the safety and credibility of a health care facility
  • How it began
    • In 1999, the Institute of Medicine (IOM) estimated 98,000 deaths a year.
    • In 2003 Minnesota law requires hospitals to report “never events” to web-based Patient Safety Registry. 
    • 2004, New Jersey law required hospitals to report adverse events to the state and to patients’ families
    • In 2005 Connecticut and Illinois law required hospitals and ambulatory surgery centers to report 24 “never events”
  • Federal Action
    • In 2005 the Deficit Reduction Act represents allowed CMS starting October 1, 2008 to begin to adjust payments for hospital-acquired infections. 
  • Never Events 10.1.2008
    • Patient falls
    • Pressure ulcers
    • Urinary tract infections
    • Vascular-catheter-associated infections
    • Mediastinitis
    • Air emboli
    • Removal of objects left in the body during surgery
    • Injury caused by use of incompatible blood products
    • Inadequate glycemic control
    • Surgical site infections
    • Deep vein thrombosis and pulmonary embolism
  • Three Step IHI Model
    • Prevent failure
      • a breakdown in operations or functions
    • Identify and Mitigate failure
    • Redesign the process based on the critical failures identified
  • TeleICU Partnership to Prevent Air Embolism Elizabeth Cowboy, MD (eCare Medical Director), Robin Simmons, RN (eCare Nurse Manager), Beryl Silkey, ScM (Research Scientist), Kelly Nebergall, BSB (Administrative Analyst), Cheryl Donelan, RN, MSN (Cardiology Service Line Director) and Shannon Miller, RN, BSN, CCRN (CTICU Charge Nurse) CONCLUSION eCare partners monitoring, mentoring and intervening capabilities resulted in prevention of a total of three potential cases of air embolism during the first two months of use. According to IHI and ACCN, occurrence prevention requires identification and mitigation of possible stress points which redesign the process based on the critical failures identified. Cost avoidance of an estimated $80,000 per case or $240,000 for the 3 teaching in non-reimbursable patient care costs under the new CMS Never Events rule. This partnership complies with the 2009 Office of Inspector General policies and fulfills the Tax Relief and Health Care Act of 2006 LESSONS LEARNED Performance requiring continuous operational reliability despite complex interrelated patterns among people Increase the consistency that appropriate care is delivered to each patient outcome involves being a continual learning organization. VCHS is committed to Zero Never Events. Clinical quality and patient safety requires never-ending vigilance. www.hcca/ 888-580-8373 CHALLENGE Central venous lines (CVL) are being placed in a majority of ICU patients for infusion of complex medications, rapid delivery of blood products and for monitoring of central venous pressures. In order to prevent infections, CVLs are removed once it is determined they are no longer required. Often, the CVL is removed during the patient’s ICU stay. In May 2008, a sentinel case of air embolism was attributed to removal of a CVL while patient was in a sitting position. This triggered Via Christi Regional Medical Center to re-educate all ICU RNs. CTICU and SICU nursing leadership requested the eCare RNs to partner with the bedside care team for ongoing education, quality assurance and to prevent all future occurrences. SOLUTION The eCare partners reviewed existing policies concerning CVL removal. It was determined that the Trendelenburg position (ACCN) policy required at the time the case occurred, was appropriate. Reviewed timing of removal with and without mechanical ventilation. The eCare RNs completed mandatory inservice within 14 days. Full awareness and understanding of the CVL removal policy. The Central Venous Access Removal Quality Monitoring Tool© (CVAR-QM) was piloted in SICU and CTICU. Each time a CVL was removed, the bedside RN called the eCare partner to document performance of the procedure and to provide coaching to prevent improper technique. RESULTS A total of 47 CVL removals were documented during the first 2 months of ICU eCare Team monitoring. The eCare Team identified, educated and intervened in 3 separate cases to ensure appropriate agreed upon procedures were followed. An eCare ICU Intensivist conducted an informal survey of 50 nurses in multiple ICUs at VCRMC that revealed individuals who remained unaware of the AACN guidelines and compulsory procedures for the CVL removal. The nursing directors determined that this warranted system wide expansion of the eCare partnering monitoring, coaching and intervention to all ICUs. This collaboration is fully backed by the MEC, Clinical Quality & Patient Safety and Chief Medical Officer. VISICU Users Conference • November 5 - 7, 2008 Via Christi Health System ( is a 5-hospital, 1,118 bed not-for-profit health system. The e ICU ® Program services 5 hospitals and 143 beds within VCHS and 1 hospital with 6 beds outside of VCHS; for a total of 149 beds across Kansas. eICU ® is a registered trademark of VISICU, Inc.
  • Rounding tool N Y Is pt in Tredenenburg & CVL pull sheet completed to reduce risk of Air Emboli? N Y Is artline being used for hemodynamic monitoring? N Y Is CVL required for Pressors, TPN, or blood transfusion? Gown, glove, hat, mask, full body drape and subclavian or IJ site N Y Was sterile technique used on placement with optimal site possible? Vascular-catheter-associated infections? N Y Is the Foley cath medically required and removal plan to prevent UTI ? N Y Are nutritional and positioning precautions instituted to prevent Pressure Ulcers? N Y Have all precautions been instituted to prevent Patient Falls?
  • Rounding tool N Y Has your eCare Partner been notified of daily goals or orders requested? N Y Has the physician been notified of concerns to be addressed? T>100.4or<96.8, HR>90, RR >20 or CO2<32,WBC<4,000 or>12,000 or >10% bands N Y Is Sepsis Screening Tool been completed if there are signs of Sepsis ? N Y If patient has Acute MI are B blocker, Ace Inhibitors, Aspirin and EF measurement instituted? N Y Is sedation Holiday and Weaning protocols been instituted to decrease VAP ? N Y Is HOB at 30*, GI and DVT prophylaxis ongoing to prevent VAP? N Y Is mechanical or medical therapy ongoing to prevent DVT and pulmonary embolism? N Y Would pt benefit from Insulin protocol to avoid Inadequate Glycemic Contro l? N Y Pt identity double verified to prevent Transfusion Incompatible Blood Products?
  • Never Events MS-DRG with Cost Estimates
    • Patient falls 800-829 $33,894
    • Pressure ulcers Stage III IV 707.00 $43,180
    • Urinary tract infections 590.11 $33,894
    • Vascular-catheter infections 999.31 $103,027
    • Mediastinitis 36.10 $299,237
    • Air emboli 999.1 $71,636
    • Injury caused by use of incompatible blood products 999.6 $50,454
    • Inadequate glycemic control 250.30 $35,215
    • Deep vein thrombosis and pulmonary embolism
    • 453.40 $50,937
    • Ventilator-Associated Pneumonia 997.31 $135,795 or phone 202-690-6145