Presentation at 2007 Annual Meeting of VA Patient Safety Managers and Officers


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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: 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.

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  • A Short History of Methicillin-Resistant S. aureus (MRSA): 1950 – Penicillin effective against 100% of S. aureus strains. 1985 – Penicillin effective against less than 5% of S. aureus strains. 1992– 40% of S. aureus strains in U.S. hospitals are resistant to methicillin (MRSA) – vancomycin is the only available treatment. – First case of vancomycin-resistant staph. aureus identified. MRSA transmission is a global contagion. The US has the second highest MRSA rate in the world (only Japan has more). There were 2.1 million healthcare associated infections in the US in the year 2000. These infections are associated with over 90,000 deaths annually. MRSA accounts for 50% of these infections. Finland, Denmark and Holland have succeeded in holding <1% rates of MRSA by strict application of advanced infection control practices. In fact, when an American is admitted to a hospital in these countries he/she will be isolated until proven not to be a MRSA carrier.
  • Presentation at 2007 Annual Meeting of VA Patient Safety Managers and Officers

    1. 1. 1 AHRQ PIPS, MRSA, and OIG on PS in VHA ORs (05-00379-91) Noel Eldridge, MS National Center for Patient Safety National Patient Safety Managers’ Conference 3/20/07 202 273-8878
    2. 2. 2 It’s nice to get a break away from the office!
    3. 3. 3 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)
    4. 4. 4 I. AHRQ PIPS Projects
    5. 5. 5 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
    6. 6. 6 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
    7. 7. 7 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
    8. 8. 8 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
    9. 9. 9 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
    10. 10. 10 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
    11. 11. 11 II. MRSA Program
    12. 12. 12 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
    13. 13. 13 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) PercentofStaphAureusResistanttoMethicillin VHA 2006
    14. 14. 14 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
    15. 15. 15 VAPHS (Surgical Intensive Care Unit) MRSA Infection Rates Fig. 2. MRSAInfections/1000 BDOC - SICU 0 1 2 3 4 5 6 24 Mo Pre FY04 FY05 Intervention begun
    16. 16. 16 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
    17. 17. 17 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)
    18. 18. 18
    19. 19. 19 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?
    20. 20. 20 VAPHS MRSA Bundle: 2. Active Surveillance Cultures  Nares Swabs • Admission • Discharge or Transfer • CTB is considered discharge  Open wounds
    21. 21. 21 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
    22. 22. 22 Implement Action Plan as submitted Facility review of FY06 Baseline MRSA BSI (Bloodstream Infections) rate Baseline 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 Hygiene 3Contact Precautions for MRSA- colonized patients 4Cultural 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 implemented MRSA 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 Exemption Approved Yes. Facility may choose approach
    23. 23. 23 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
    24. 24. 24 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
    25. 25. 25 III. OIG Report on Patient Safety in the Operating Room
    26. 26. 26 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
    27. 27. 27 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
    28. 28. 28 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).
    29. 29. 29 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)
    30. 30. 30 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
    31. 31. 31 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
    32. 32. 32 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?
    33. 33. 33 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
    34. 34. 34 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
    35. 35. 35 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
    36. 36. 36 Some Context: Good News VA & US Inpatient Discharges and Mortality 50 60 70 80 90 100 110 120 130 140 150 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year 1998=100 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%
    37. 37. 37 Enjoy the Conference!
    38. 38. 38 Wish me luck!