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Clinical Transformation, Part II


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This month's community call is part two in a series on Clinical Transformation. The presentations will highlight how Clinical Transformation affects outcomes AND the bottom-line of health care organizations. The presentation will provide a proof point on how Clinical Transformation has a direct Return on Investment (ROI) for both the patient and the provider organization.

This topic is both clinical and administrative in nature and will likely be useful to physicians, nurses and others interested in outcomes, as well as health care CIOs, CFOs and administrators.

Please feel free to forward this invitation to any colleagues or associates who you believe would find this topic of interest or would like to participate in the discussion.

What: Clinical Transformation (Part II)
- Clinical Transformation
- a Blueprint
- in Practice
- Transformation Working Group Update
- Review of status
- Framework for Planning
- Discussion
- Open Project Updates
- OpenVista/GT.M Integration
- CCD/CCR collaboration
- Tip of the month

When: March 26, 12:30 - 2pm Pacific
Where: Dial-in: (888) 346-3950 // Participant Code: 1302465
Web conference:

The community calls are listed on the event calendar ( and we will update each month's call as the agenda is solidified.

Details and Recording available here:

Published in: Health & Medicine
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Clinical Transformation, Part II

  1. 1. Clinical Transformation, Part II March 2009 Community Call
  2. 2. Presenters • Edmund Billings, MD - CMO • Jeff Parker, RN, BsBA - Clinical Informatics Manager • Janine Powell - Sr. Director of Client Services • Debbie Daspit - Director of Product Management • George Lilly - CCD/CCR Developer • Adam Waterbury - GT.M Product Manager • Ben Mehling - Director of Ecosystem Operations
  3. 3. Agenda • Clinical Transformation – A Blueprint – In Practice • Transformation Working Group Update – Status Update – Framework for Planning – Discussion • Open Project Updates – OpenVista/GT.M Integration – CCD-CCR Project • Tip of the Month
  4. 4. Clinical Transformation, a Blueprint 5 Million Lives Project Example: The Central Line Bundle Edmund Billings, MD
  5. 5. 5
  6. 6. Central Line 6
  7. 7. Central Line: Subclavian 7
  8. 8. Preventing Catheter-Related Bloodstream Infections • Central venous catheters (CVCs) are being used increasingly in the inpatient and outpatient setting to provide long-term venous access. • CVCs disrupt the integrity of the skin, making infection with bacteria and/or fungi possible. • Infection may spread to the bloodstream and hemodynamic changes and organ dysfunction (severe sepsis) may ensue, possibly leading to death. • Approximately 90% of the catheter-related bloodstream infections (CR-BSIs) occur with CVCs. 8
  9. 9. Preventing Catheter-Related Bloodstream Infections • 48% of intensive care unit (ICU) patients have central venous catheters, accounting for about 15,000,000 central- venous-catheter-days per year in ICUs. • Approximately 5.3 central line infections occur per 1,000 catheter days in ICUs. • The attributable mortality for such central line infections is approximately 18%. • Thus, probably about 14,000 deaths occur annually due to central line infections. Some estimates put this figure as high as 28,000 deaths per year. • In addition, nosocomial bloodstream infections prolong hospitalization by a mean of 7 days. Estimates of attributable cost per bloodstream infection are estimated to be between $3,700 and $29,000. 9
  10. 10. References 1. Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med. 2000;132(5):391-402. 2. Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1994;271:1598-1601. 3. Saint S. Chapter 16. Prevention of intravascular catheter-related infection. Making health care safer: a critical analysis of patient safety practices. AHRQ evidence report, number 43, July 20, 2001. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32:2014-2020. 4. Soufir L, Timsit JF, Mahe C, Carlet J, Regnier B, Chevret S. Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: a matched, risk-adjusted, cohort study. Infect Control Hosp Epidemiol. 1999;20(6):396-401. 10
  11. 11. Care Bundles • Care bundles, in general, are groupings of best practices with respect to a when applied together result in substantially greater improvement. The science supporting each bundle component is sufficiently established to be considered the standard of care. • Evidence-based interventions result in better outcomes than when implemented individually. 11
  12. 12. Central Line Bundle 12
  13. 13. Central Line Bundle The central line bundle has five key components: 1. Hand hygiene 2. Maximal barrier precautions 3. Chlorhexidine skin antisepsis 4. Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters 5. Daily review of line necessity, with prompt removal of unnecessary lines • Compliance with the central line bundle can be measured by simple assessment of the completion of each item. • The approach has been most successful when all elements are executed together, an “all or none” strategy. 13
  14. 14. Central Line Bundle 14
  15. 15. Central Line Bundle Results Berenholtz SM, Pronovost PJ, Lipset PA, et al. Eliminating catheter-related bloodstream infection in the intensive care unit. Critical Care Medicine. 2004;32:2014-2020. 15
  16. 16. Model for Improvement The model has two parts: 1. Three fundamental questions that guide improvement teams to 1. Set clear aims, 2. Establish measures that will tell if changes are leading to improvement 3. identify changes that are likely to lead to improvement. 2. The Plan-Do-Study-Act (PDSA) cycle to conduct small-scale tests of change in real work settings — by planning a test, trying it, observing the results, and acting on what is learned. This is the scientific method, used for action- oriented learning. 16
  17. 17. Model for Improvement • Implementation: After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team can implement the change on a broader scale — for example, test medication reconciliation on admissions first. • Spread: After successful implementation of a change or package of changes for a pilot population or an entire unit, the team can spread the changes to other parts of the organization or to other organizations. Model for Improvement on 17
  18. 18. Get Started 1. Select the team and the venue. It is often best to start in one ICU. Many hospitals will have only one ICU, making the choice easier. 2. Assess where you stand presently. What precautions are taken presently when placing lines? Is there a process in place? If so, work with staff to begin preparing for changes. 3. Contact the infectious diseases/infection control department. Learn about your catheter-related bloodstream infection rate and how frequently the hospital reports it to regulatory agencies. 4. Organize an educational program. Teaching the core principles to the ICU staff will open many people’s minds to the process of change. 5. Introduce the central line bundle to the staff. 18
  19. 19. Metrics Rate Total no. of CR-BSI cases x 1000 = CR-BSI per 1000 catheter days No. of catheter days Compliance # with ALL 5 elements of central line bundle = reliability of compliance # with CVCs on the day of the sample Track and Scoreboard Overtime Rate & Compliance 19
  20. 20. Track Overtime: Rate & Compliance 20
  21. 21. Automation Helps Knockdown Barriers 1. Fear of change – “It works and its proven” – It’s the reason to use the system 2. Communication breakdown – “Its built in” – The system supports compliance 3. Physician and staff “partial buy-in” – “I thought I was doing better than that” – Measuring performance is compelling 21
  22. 22. The Form: Specs 22
  23. 23. The Form: Prep 23
  24. 24. The Form: During 24
  25. 25. The Form: After 25
  26. 26. Ongoing Daily Review • Daily review for necessity and prompt removal of unnecessary lines: • The ICU patient with a central line will be reviewed daily, with a notation on the daily goals sheet or medical record indicating the continued need for the central line. • Routine replacement should be avoided, and all lines should be removed as early as possible. 26
  27. 27. Clinical Transformation, in Practice Jeff Parker, Midland Memorial Hospital
  28. 28. Outcomes • Central line days in ICCU averaged over the past year = 178 month. • We have scored 100% on bundle compliant forms. • We use maximum barrier kits.
  29. 29. Quality Improvement: Order Sets • Using the in place order sets, the physician with a mere click or two can order all the necessary orders for central line placement – including X-rays for placement, flushes, with an order that staff can start using when placement is confirmed. In the old days, we would have to call the physician as most did not write the orders out in the detail we have with the electronic record.
  30. 30. Quality Improvement: Chart Availability • Radiology immediately can view the order and can check the patients record for a signed consent, what the H&P shows, and the patients overall medical condition prior to them ever actually seeing the patient. • The physician can view the X-ray immediately from any location within the hospital, from his home or office.
  31. 31. Quality Improvement: Efficiency • Often, the chest X-ray is done within minutes of inserting the central line, allowing the use of the central line to be started much more quickly than was previously possible – which could be a crucial five minutes if it’s a unit patient.
  32. 32. Quality Improvement: Measuring and Compliance • The electronic record has made it possible to easily audit charts and monitor for central line compliance.
  33. 33. Transformation Working Group Janine Powell & Debbie Daspit
  34. 34. Community Collaboration • Organized Collaboration - Just getting started.. – Work as a Group – Divide and Conquer option • Collaboration Dependences – Values – Interpretation – Understanding – Workflow – Distribution of information • Framework as a collaboration path to design and document and distribute strategies and content – Core Measure Reporting – “Never Event” Prevention – Performance Improvement
  35. 35. Clinical Transformation Framework sample
  36. 36. Admitted Patient Triggers
  37. 37. Emergency Visit Triggers
  38. 38. Orders/Standing Orders Triggers
  39. 39. Design and Documentation Example
  40. 40. Open Development Projects George Lilly & Fay Struble Adam Waterbury
  41. 41. OpenVista/GT.M Integration Project Adam Waterbury
  42. 42. Get Involved Code is available on Launchpad Not production ready; for developers only Bugs are in Launchpad You can help! File a bug Comment on a bug with suggestions Create a branch and fix a bug yourself Not sure how to get started? Post on with your interests; we'll find something for you!
  43. 43. Opensource CCR and CCD support for VistA based systems Project Update March 26, 2009 by George Lilly * This project has been funded in part with Federal funds from the National Institutes of Health, under Contract No. HHSN268200425212C, “Re-engineering the Clinical Research Enterprisequot;.
  44. 44. Collaborators Individuals Organizations Kevin Peterson George Lilly WorldVista Mike Schendel Christopher Anderson HP Fay Strubel Nancy Anthracite KRM Thomas Sullivan Lee Castonguay Medsphere Chris Uyehara Duane DeCorteau Robert Morris University David Whitten Emory Fry Sequence Managers Greg Woodhouse Sam Habiel University of Minnesota JohnLeo Zimmer Jose Lacal John McCormack Ben Mehling Dennis Menor Ken Miller
  45. 45. Topics Definition Purpose Snapshot Highlight Contributors
  46. 46. Definition: The Continuity of Care Record (CCR) is a machine readable and human readable ASTM XML standard data set of a person's clinical status
  47. 47. The CCR dataset has many intended purposes including the exchange of medical records, synchronization with clinical repositories, and the transformation into clinical messages Exchange of medical records: Between two EHR systems (VistA<->VistA and VistA<->Other) With a Personal Health Record (PHR) – like Google Health or MS HealthVault Synchronization with clinical repositories: For clinical decision support For research and clinical trials – as with the Electronic Primary Care Research Network (ePCRN) Transformation into clinical messages XSLT transformation into a Continuity of Care Document (CCD) For use the the National Health Information Network (NHIN) For CCHIT Certification For HIPAA Claims Attachments Transformation into XML Web Service messages for ePrescribing
  48. 48. CCR/CCD PROJECT SNAPSHOT 3/26/2009 Picklist Web File CCD Transformation Processing Service ePCRN Connection CCR Batch Parameters Template Proccessing ePrescription XML Fileman Parameters Support Lab Date Limits CCR Meds Date Limits Fileman Template File Checksums Processor Menu Vitals Date Limits Template Import Options Codes XPath Library XML RPC Variables RPC MUMPS Temporary Globals Fileman CCR Elements Export Import (Accessioning) Family History Advance Directives Lab Results Vital Signs Alerts/Allergies Procedures Support Payers Medications Problems Actors Medication Advisories (ePrescribing) Encounters Functional Status Immunizations Alerts/Allergies Plan of Care Medical Equipment Social History GTM GTM Cache GTM GTM Cache WorldVistA OpenVistA FOIA VistA RPMS EHR Legend Planned In Development Testing In Production Recent Change
  49. 49. Recently, we demonstrated the transformation of our CCRs into level 2 CCDs thanks to an XSLT transformation contributed by Ken Miller
  50. 50. Tip of the Month Ben Mehling
  51. 51. Start a new Blog Post
  52. 52. Create a Personal Blog
  53. 53. Setup your Blog
  54. 54. Write a new post
  55. 55. Blogs