admin – Page 27 – PatientCareLink

Norwell VNA Fights Readmissions

A program at the Norwell VNA and Hospice that targets patients with Heart Failure (HF) has proven successful in reducing hospital admissions and readmission.

The Norwell model relies on two foundational elements: (1) a strong clinical commitment to chronic care management using a wide-ranging team of providers and the patient, and (2) early intervention using telehealth technology.

All of Norwell's patients with a history of heart failure are entered into its care management program, but are managed differently depending on the severity of their illness. All interventions consist of two teams - the telehealth team and the home healthcare team coordinating care.

The telehealth team includes a nurse practitioner, three registered nurses on a rotating schedule, and one technician to manage the telehealth equipment. The home health team includes the home health nurse, the agency's medical director, occupational and physical therapists, case managers, home health aides, nutritionists, and medical social workers.

Readmission programs also rely heavily on case management personnel at area hospitals, a patient's primary care physician, patients themselves, and patients' families

A key element of the Norwell program is "front-loading" visits to high-risk patients during the first week of care. Within the first 24 and 48 hours, two visits are made to conduct initial assessments, set up the telehealth equipment, and involve the patients in their own care.

The telehealth technology provides real-time information to the care team to support their decision making and helps patients recognize the signs and symptoms that may indicate their heart failure is worsening. For example, it can provide a comparison to the prior day's weight. (A patient with congestive heart failure that gains weight quickly - 2 to 3 pounds in 24 hours - is retaining water and is at risk for rehospitalization.) The telehealth system can also provide daily health status assessment and education. Based on the patient's responses, the telehealth equipment helps the patient connect their daily behaviors to their health status.

The Norwell VNA's care management program combined with the telehealth technology successfully reduced the organization's overall acute care hospitalization (ACH) rate from 25% to 20% as reported in Home Health Compare. The ACH rate for just heart failure patients in the program was 19%. Of the 115 people enrolled in the heart failure program, 22 were re-hospitalized, and the most prevalent reasons for those hospitalizations were falls and shortness of breath (dyspnea).

This publication from the Alliance for Home Health Quality & Innovation gives more information about Norwell VNA and Hospice's successful program.
The Norwell VNA and Hospice's initiative is just one of the many programs underway in Massachusetts and throughout the U.S. to reduce hospital readmissions. MHA has played a role in coordinating many of those efforts within the state, which include: STAAR (STate Action on Avoidable Rehospitalizations); Potentially Preventable Readmissions (PPR) Project with 3-M; MOLST (Medical Orders for Life-Sustaining Treatment); and Project BOOST (Better Outcomes for Older Adults through Safe Transitions).

Partners Study on Falls Featured in JAMA

Reducing falls and the injuries that arise from such falls is a major goal of Massachusetts hospitals, which report their falls data through PatientCareLink. And our hospitals are developing the best practices, innovative strategies, and measurement tools that other states are using to address the issue.

In the Vol. 304, No. 17, November 3, 2010, issue of JAMA - the Journal of the American Medical Association - researchers from Partners HealthCare System, Brigham and Women's Hospital, Harvard Medical School, and Massachusetts General Hospital, report on whether a fall prevention tool kit using health information technology decreases patient falls in hospitals.

JAMA is available through subscription only, but the Abstract text below, outlines the key points of the study:

Fall Prevention in Acute Care Hospitals
A Randomized Trial

Patricia C. Dykes, RN, DNSc; Diane L. Carroll, RN, PhD, BC; Ann Hurley, RN, DNSc; Stuart Lipsitz, ScD; Angela Benoit, BComm; Frank Chang, MSE; Seth Meltzer; Ruslana Tsurikova, MSc, MA; Lyubov Zuyov, MA; Blackford Middleton, MD, MPH, MSc

JAMA. 2010;304(17):1912-1918. doi:10.1001/jama.2010.1567
Context Falls cause injury and death for persons of all ages, but risk of falls increases markedly with age. Hospitalization further increases risk, yet no evidence exists to support short-stay hospital-based fall prevention strategies to reduce patient falls.

Objective To investigate whether a fall prevention tool kit (FPTK) using health information technology (HIT) decreases patient falls in hospitals.
Design, Setting, and Patients Cluster randomized study conducted January 1, 2009, through June 30, 2009, comparing patient fall rates in 4 urban US hospitals in units that received usual care (4 units and 5104 patients) or the intervention (4 units and 5160 patients).

Intervention The FPTK integrated existing communication and workflow patterns into the HIT application. Based on a valid fall risk assessment scale completed by a nurse, the FPTK software tailored fall prevention interventions to address patients' specific determinants of fall risk. The FPTK produced bed posters composed of brief text with an accompanying icon, patient education handouts, and plans of care, all communicating patient-specific alerts to key stakeholders.

Main Outcome Measures The primary outcome was patient falls per 1000 patient-days adjusted for site and patient care unit. A secondary outcome was fall-related injuries.

Results During the 6-month intervention period, the number of patients with falls differed between control (n = 87) and intervention (n = 67) units (P=.02). Site-adjusted fall rates were significantly higher in control units (4.18 [95% confidence interval {CI}, 3.45-5.06] per 1000 patient-days) than in intervention units (3.15 [95% CI, 2.54-3.90] per 1000 patient-days; P = .04). The FPTK was found to be particularly effective with patients aged 65 years or older (adjusted rate difference, 2.08 [95% CI, 0.61-3.56] per 1000 patient-days; P = .003). No significant effect was noted in fall-related injuries.

Conclusion The use of a fall prevention tool kit in hospital units compared with usual care significantly reduced rate of falls.

Trial Registration clinicaltrials.gov Identifier: NCT00675935

Author Affiliations: Partners HealthCare System (Drs Dykes and Middleton, Ms Benoit, and Messrs Chang and Meltzer), Brigham and Women's Hospital (Drs Dykes, Hurley, Lipsitz, and Middleton, and Ms Tsurikova), Harvard Medical School (Drs Dykes, Lipsitz, and Middleton), and Massachusetts General Hospital (Dr Carroll and Ms Zuyov), Boston.

Patient Falls

The National Quality Forum (NQF) defines a fall as an unplanned descent to the floor (or extension of the floor e.g., trash can or other equipment) with or without injury to the patient.

Partners: Coordinating Care for High-Risk Patients

The results are in from Partners HealthCare's Medicare demonstration project that was conducted at Massachusetts General Hospital (MGH).

In August, 2006, the Centers for Medicare and Medicaid (CMS) funded the MGH and the hospital's physician organization to launch the Care Management Program at MGH, one of six demonstration projects nationwide. During the three-year demonstration, the MGH developed new strategies to improve the way health care is delivered to its most vulnerable high risk patients - those with multiple health conditions and chronic disease.

The program integrates nurse care coordinators into primary care practices to coordinate each patient's medical and psychosocial needs. It focuses on the sickest patients because 10 percent of Medicare patients represent nearly 70 percent of Medicare spending.

Here's the results: Hospital readmissions dropped 20 percent, and emergency room visits dropped 13 percent for patients enrolled in the program. Patients and caregivers rated it highly. And the program resulted in annual net savings of 7 percent among enrolled patients after accounting for the management fee paid by CMS to MGH. Over the first three years, MGH invested more than $8 million to operate the program, but the return on investment is high; for every dollar spent, the program saved $2.65 in health care costs.

In 2009, CMS renewed the MGH program for another three years (only three of the original demonstration projects were renewed) and expanded it to two more Partners hospitals, Brigham and Women's and North Shore Medical Center. To date, the Care Management Program has enrolled almost 5,000 patients and is expected to involve more than 8,000 total patients over the next few years.

MetroWest’s Readmission Intervention Strategies

In 2011, MetroWest HomeCare & Hospice, in partnership with MetroWest Medical Center, initiated a strategic and evidence based effort to reduce their emergent care visits and acute care hospitalization rates.

The effort was initiated with the formation in November 2011 of MetroWest's Re-Admission Intervention Strategy Council (RISC). The RISC includes representatives from management, nursing, rehabilitation, palliative care, and a heart failure nurse specialist. In addition, RISC invites specific expertise - for example, social worker, wound nurse, physician specialists - when needed to address particular issues. The Council took a multi-disciplinary approach to reducing unnecessary re-hospitalizations, improving quality of care and optimizing patient outcomes. In the beginning, RISC met every other week and eventually was decreased to a monthly meeting. Often special projects or educational programs require additional time of some RISC members.

Together these efforts have proven successful in reducing overall acute care hospitalization rates. In June 2012, only six months into RISC, MetroWest Home Care's readmission percentile ranked 46th in the state and 55th in the nation, according to CMS's Home Health Compare and CASPER reporting system. In May 2013, after all RISC initiatives had been implemented, MetroWest was ranked in the 4th percentile for the state and the 6th percentile for the nation. These numbers have been maintained.

The goals of RISC include:

Use data collection and analysis to identify any trends in hospital transfers;
Increase team awareness of patients who return to the hospital, especially repeat visitors;
Use of Case Conferences and Plan of Care modifications to keep patients at home;
Reduce hospital re-admissions and improve patient quality outcomes.

To identify trends, RISC developed a user-friendly data collection tool tracking patients transferred to the hospital. Based on the data collected and analyzed, RISC developed a dashboard to illustrate key trends, summarizing the primary reasons for hospitalization, risk factors, and which hospitalizations might be preventable based on the documentation, and why. For example, if a heart failure patient who does not follow the plan of care with weights, and whose Lasix dose was not adjusted accordingly, is re-hospitalized, then that re-hospitalization would be considered potentially avoidable through better medication management at home. An RISC Nurse Specialist completes the OASIS Transfer Assessment and reviews the clinical documentation. The whole RISC team presents data and cases at regular meetings of the hospital's Quality Council.

As a result of the RISC analyses, MetroWest's RISC has implemented a host of interventions and strategies to meet its readmission reduction goals:

Created the Patient at Increased Risk for Transfer (PIRT) Alert Process, which identifies a patient that has been transferred to the hospital more than once in a 60-day episode. The PIRT Alert is communicated at time of transfer to the clinical managers and clinicians who have been involved with the patient's case so timely follow up and interventions can be implemented.
Created and implemented Heart Failure & COPD Management Programs, in which high-risk patients for re-hospitalization with heart failure or chronic respiratory diagnoses are identified at intake for program protocol. Patients on program receive a specialized schedule of visits - such as medication intensive visit and case manager continuity - all of which are tracked for compliance and presented at RISC meetings. All patients in this program receive a program booklet as a teaching guide; cardiac and respiratory nurse and physician specialists contributed to the content of the final programs.
Developed a specialized education program called the "RISC Think Tank" which introduces the RISC initiatives to all staff and provides them with tools and strategies to reduce avoidable re-hospitalizations. The RISC Think Tank is given at least annually and includes presentation of actual patient cases and informal open discussion to engage staff in sharing of new ideas and/or strategies.
Created a collaborative nursing and therapy wound management program with 1.5 CEU accreditation.
Developed tri-fold colorful and easy to read Patient & Family Guides (for e.g. Bladder Health, Dehydration Prevention, and Constipation.)

RISC continues to meet to review trends and discuss innovative strategies to keep patients at home and out of the hospitals.

Reducing Surgical Site Infections at New England Baptist Hospital

By John C. Richmond, MD and Maureen Spencer, RN, M.Ed, CIC

This article is reprinted from the August 2010 First Do No Harm newsletter produced by the Quality and Patient Safety Division of the Massachusetts Board of Registration in Medicine

A post-operative infection can be a devastating complication for any patient. This is particularly true in elective orthopedic surgery, where the patient typically chooses to undergo the procedure in the anticipation of decreased pain and improved function. Deep infection following orthopedic surgery may drastically alter the outcome. The national benchmark from the CDC for orthopedic surgery is 1.25%.

At the New England Baptist Hospital (NEBH) more than 90% of our surgeries are elective orthopedic procedures and as part of our continuous improvement process, we have embraced the goal of reducing surgical site infections (SSI's) to zero. This report outlines a major step forward in that journey.

Staphylococcus aureus is considered the most important pathogen in terms of SSI. Epidemiologic studies have demonstrated that most cases of SSI are caused by strains of S. aureus that are brought into the hospital environment by patients themselves, i.e. most patients who develop S. aureus SSI are carriers of the strains causing infection. The anterior nares may be the most common niche for S. aureus among carriers, and multiple studies have established that nasal carrier status is a significant risk factor for the development of S. aureus SSI.

In July of 2006, we began screening the nares of all patients scheduled for inpatient orthopedic surgery at NEBH. Rapid screening of preoperative patients utilizing a polymerase chain reaction (PCR) based diagnostic test was used to identify methicillin-resistant S. aureus (MRSA) carriers. Standard microbiologic culture methods were used to identify methicillin-sensitive S. aureus (MSSA) strains. Patients testing positive for either MRSA or MSSA were treated with intranasal 2% mupirocin ointment applied to the interior of each nares twice daily for five days and a daily 2% chlorhexidine shower wash for five days. PCR was then repeated to confirm eradication of the MRSA carrier state.

By the end of 2007, with the S. aureus identification and elimination program fully functioning, our overall orthopedic infection rate had been reduced from an already low 0.51% to 0.43%. This, however, was not the case with certain spine procedures (laminectomy and microdiscectomy), where the infection rate had actually increased to 1.34%. We put together a team from our infection control unit and our spine surgery and research divisions to investigate this anomaly. At that time, many of our spine surgeons were utilizing peridural methylprednisolone to reduce post-operative pain and adhesions. While this treatment has established benefits, corticosteroids are immunosuppressive and are known to be associated with septic arthritis if used intra-articularly during arthroscopy.

In order to identify the potential risk factors for SSI following lumbar spine procedures, a retrospective case-control study was performed, reviewing almost 6000 lumbar spine procedures, which had been done at NEBH between 2005 and 2007. A multivariate logistic regression analysis was carried out. This revealed that the use of peridural methylprednisolone was associated with a nearly 7 fold increased risk of infection (95% confidence interval 1.8-25.8). When this information was conveyed to our spine surgeons, they immediately discontinued the routine use of peridural methylprednisolone. Simultaneously the use of high dose (6+ mg) intravenous dexamethasone given intra-operatively by anesthesia to help with post-operative nausea and vomiting was also decreased to 4 mg.

Over the 2 years 2008-2009, the infection rate following lumbar laminectomy and microdiscectomy at NEBH fell to zero and our continued S. aureus identification and eradication program has lead to a reduction in our overall infection rate to 0.31%, highlighting how a focused infection eradication program, in conjunction with a superior infection control unit, can be successful in minimizing the risk of SSI.

-- Dr. Richmond is Chair of the NEBH Department of Orthopedic Surgery. Ms. Spencer is NEBH Infection Control Manager and holds national Certification in Infection Control (CIC).

Southcoast Health System: Reducing the Use of Safety Sitters

Southcoast Health System’s well thought-out program to reduce patient “sitters” – the individuals who spend time with patients to ensure that they do not fall and injure themselves – makes sense financially for the system, but has its genesis in improving patient safety and strengthening the caregiving team.

“They’re not just sitting there. They are now interacting with the patients” says Joyce Dolin, R.N., the director of patient services at Southcoast. “So we changed the name.”

But the changes go far beyond the two new titles – Patient Care Observer and Therapeutic Assistant. Southcoast, which is the parent of Charlton Memorial Hospital (Fall River), St. Luke’s Hospital (New Bedford), and Tobey Hospital (Wareham), instituted a whole new program of re-training, clustering of fall risk patients, more coordinated handoffs between caregivers, plus new equipment, and a new “culture” among the observers and assistants and the other caregivers with which they work.

ASSESSING THE ISSUE

Southcoast hospitals each had their own fall prevention team, but beginning in 2009, hospital officials put together a falls team across the entire system. They also hired a consultant, assessed all the numbers at the various-sized hospitals, reviewed new equipment, assessed alarm systems, and more, ultimately coming up with a multi-pronged plan.

“An overriding goal was to move away from the use of restraints – which are used as a last resort,” says Karen Pehrson, psychiatric clinical nurse specialist at Southcoast. “So we had to see what was out there, while reducing the amount of sitters, which was a tall order.”

NEW EQUIPMENT

The falls team looked at acquiring a new form of patient beds that are constructed very low to the floor; they’re about six inches high with a two-inch pad next to them, so if patients roll off the beds, they only have a four-inch fall. But re-fitting 750-beds in the entire Southcoast system proved to be very capital-extensive and not necessary for all patients, so the beds are used on select patients.

Southcoast then looked at various alarm systems before finally settling on one manufactured by Posey Healthcare Products.

“Their alarm is very clear so you can hear them outside of the room, plus they don’t need to be reactivated,” Pehrson said. “Every time you add another layer of decision making, you add another layer of potential error, which is why Posey’s auto-reactivation capabilities appealed to us.”

Plus the new alarm, which warns patients that they may be at risk of falling, is able to be recorded in the patient’s native language, using the voice of a relative or loved one.

And rather than use restraints to stop, say, an elderly, mentally-impaired patient from pulling out their IV (a common occurrence at hospitals), Southcoast uses a knit sleeve which runs over the thumb and almost up to the shoulder. It not only covers the IV site, but elders like it because it is warm and protects frail elbows as well. Southcoast is also experimenting with a “freedom splint,” a large blue, plastic balloon arm covering that gives people a large range of motion but, again, prevents damage to the IV area.

Patients with dementia are also outfitted with an activity apron, which contains many zippers, buttons, Velcro tabs, and more to occupy those patients who have a need to be busy.

“Some people are very fidgety and their attention is turned to the apron,” Dolin says. “For those with dementia, it’s good to redirect their attention.”

Other patient safety and fall preventers include torso support that holds patients upright in their chairs. It’s not a restraint because they can easily release themselves – at which point they hear a recorded voice reminding them they may be at risk.

“It’s all about finding humane ways to give people reminders and cues,” Pehrson said. “You don’t restrain people just because they are at risk of a fall”.

NEW SAFETY ZONES

Aside from the use of new equipment, Southcoast began to coordinate how high-risk fall patients are served in the hospital. First, they clustered patients so that one observer could watch four people at once. But gradually they took their concept to the next level, creating “safety zones,” which are two semi-private rooms (four patients) staffed by personnel who are trained in dementia and psychiatric issues. A brochure developed through the hospital’s education department explains the safety zone to patients and their families.

Admissions criteria was created for the safety zone and patients are reassessed every shift to see if they still should be located there.

Attempts are made to make patients in the safety zone as comfortable as possible, meaning Southcoast attempts to find out from family members the person’s daily routines. What time do they usually go to bed and get up? When do they eat? Do they play cards? By keeping patients to a familiar routine and surrounding them with familiar touchstones, such as pictures of family, the patient feels less compelled to move around and risk a fall.

One of the biggest fall risks is the transition from one area of the hospital to another, so Southcoast assessed the entire handoff hierarchy. Like other hospitals, Southcoast uses the “red slipper” logo on charts (and actually provides them to patients) so everyone, from nurses, to patient transporters, to technicians in the radiology department, knows that a patient is a fall risk.

IT’S ABOUT THE PEOPLE

Even though Southcoast reconsidered the equipment it uses, the places in the hospitals where fall risks are clustered, and more, the biggest change – and the one that goes to the heart of care at the hospitals – involves the people it hires as Patient Care Observers and Therapeutic Assistants.

“In the past we had unlicensed people with only three hours of training serving as sitters,” says Karen Pehrson. “This wasn’t good enough. People dealing with patients who have drug and alcohol issues, or who are suicidal, really need more in-depth training.”

Southcoast surveyed the literature from Chief Nursing Officers and others throughout the U.S., and developed two new job descriptions – Patient Care Observers for those who have a high-risk of falls, and Therapeutic Assistants for those dealing with patients with psychiatric or drug abuse problems.

“People are not always adept at dealing with both populations,” Dolin notes.

Patient Care Observers (PCO) are given 8.5 to 9 hours of classroom training. They learn a great deal about elders, about Alzheimer and dementia. “We do role playing where they have to intervene with someone who is escalating,” Pehrson says. “We want them to I.D. an escalating situation and know how to diffuse it.” The PCOs can help someone from bed to chair or from chair to bathroom but they don’t handle any blood or fluids. However, Pehrson says they are taught core emergency skills – CPR, how to recognize stroke symptoms and, most importantly, how to get help fast.

“I’ve seen our people do wonders by just using a soothing voice to really keep patients safe,” Dolin says.

Training for the Therapeutic Assistants is the same for the first five hours of the classroom but then they focus on behavioral issues and psychiatric patients.

“These are much more aggressive types of behaviors,” Pehrson says, and it takes a different type of personality.

One of the training exercises Southcoast does is to put the TAs in full four-point restraint so that they can “experience that situation and have compassion for what it is like for patients,” Pehrson says. “We don’t want them to stigmatize people because they have a brain disorder.”

THE RESULTS

Southcoast’s fall rate per 1,000 patient days fell from 3.01 to 2.98 – a small drop but a drop nonetheless. “Plus there’s better patient care,” Dolin notes.

The system’s next steps are to try to find flexibility between the PCO and TA positions so that one can fill in for the other at peak times. (There’s a peak time for elder care, during flu season, for example, and even a peak time for suicides around the holidays, the hospital has found.)

But no matter who they work with, or at what times, the PCOs and TAs are making a difference, Southcoast’s Pehrson says. “When our observers and TAs have compassion for patients, it’s really good to see what they can do. It’s not so much what you do with your hands to help someone, but what you do with your whole person. They really get the message that they are a key part of the caregiving team. They have an important role,” she says.

–by John LoDico

Spaulding Rehab Cape Cod Reduces Adverse Drug Events

ADEs are defined as injuries resulting from the use of a drug. They result in increased morbidity and mortality, prolonged hospitalizations, and higher costs of care. All hospitals, as a condition of their accreditation, must have medication reconciliation programs in place. These programs assure that at each point of care the medications listed in a patient's medical record are cross-checked with an external list of medications obtained from a patient, hospital, or other provider.

But reconciliation programs are merely a first step in a hospital's medication error reduction programs. Spaulding's effort on Cape Cod adds a series of layers over the basic cross-check of medications.

"The first level is 'intervention' - when the pharmacy steps in and acts before the problem reaches the patient. Our pharmacy has led this change," said Linda Melillo, director of patient experience and quality & compliance. "The second level is 'administration' - when the administration of a drug to a patient causes harm. We've been able to reduce both our interventions and administration errors significantly."

The Massachusetts Hospital Association (MHA) is serving as a Hospital Engagement Network (HEN), which is coordinating the efforts of hospitals to reduce inpatient harm by 40% and readmissions by 20% by focusing on 10 targeted safety areas - including reducing adverse drug events. Spaulding Rehab's 61% reduction in ADEs betters the HEN goal of 40%.

Jim Blackwell, RPH, the pharmacy manager at Spaulding Rehab Cape Cod, recently walked through a typical example of how a drug order is written and processed and the problems that can arise.

First, a physician enters the order through a Computerized Physician Order Entry (CPOE) system. CPOEs eliminate the oftentimes hard-to-read handwriting that led to problems. Spaulding Rehab has its core hospitalists on staff who are familiar with CPOE; but when an outside doctor covers on a weekend or off-shift, that physician (a "moonlighter" in hospital lingo) may not be familiar with Spaulding's CPOE. Special attention is given to moonlighter prescriptions.

Once the pharmacy receives the prescription, it reviews it, checking it closely with the patient's transfer paperwork. This step is not as easy as it may sound, Blackwell says, because a patient may have a list of medications he took at home, and another list of medications that were administered in the hospital while at-home medications were suspended.

"Sometimes the discharge summary doesn't reflect entirely what the patient has been taking," says Blackwell. "After we review all the discharge documents, we'll converse with the doctor to discuss any possible drug interactions."

Melillo and Blackwell say that prescriptions entered into the CPOE and the Electronic Medical Record (EMR) can alert the pharmacy to drug interactions and to obvious transcription errors, such as assigning 1000 mg as opposed to 100 mg. But one of the biggest potential problems the hospital faces, and which the electronic systems do not catch, concerns medication orders that are written but which are not administered immediately. For example, a prescription order may be put into the system after 6 p.m. because a patient is in transfer. The computer may default the dose to the next day - 6 a.m. - meaning the patient misses the nightly dose. It's up to the pharmacy team to catch that.

Another factor, Blackwell says, involves a patient's kidney function. The average age of the hospital's patients is 74 and oftentimes their renal system is compromised. Because the majority of medicines are excreted through the kidneys, if the renal function is poor, the medicine is not excreted and it can cause adverse effects; sleeping medications will cause prolonged drowsiness, or the next dose of a medication is administered when the first dose has not yet left the body.

"We often go into the patients profile when the labs are drawn so we can assess the renal function and look at their medications and we know which ones may need to be changed to stop a problem from developing," Blackwell says.

ADMINISTRATION ERRORS
Those interventions are key, but problems can also arise during the administration of the medication, Melillo says.
Nurses administering drugs can be caring for patients that are taking 15-20 medications at once. The system they use requires them to scroll through a series of screens to get the patient's record, drug dosage, record of administration, and more.
"Errors happen when you bypass the computer system, when you 'click through' the screens and prompts," Melillo says. "Also, as we've mentioned, the computer system doesn't catch everything. Sometimes people can get away from using their knowledge and rely on the computer instead, like relying on a spell checker to catch all misspellings."

Because medication administration errors occur at hospitals, Spaulding Rehab Cape Cod formed a Medical Management Committee to work on the issue, leading to the creation of a peer-review panel based on the Ongoing Professional Practice Evaluation model that physicians use.

"Anyone who made an error has to attend the review to help us troubleshoot the system," Melillo said. "It helped us turn the corner."

As one would imagine, anyone who makes a mistake during the course of his or her work - especially when that work involves caring for an ill person - is troubled by it, and may feel apprehensive about admitting error. But the Spaulding system, like many such systems in healthcare, is non-punitive, meaning the system does not exist to mete out punishment but rather to identify why errors occurred and then to fix the systems that led to the error.

"I've been here for 10 years and I let them know - whether it be a pharmacist, RN, respiratory therapist, or another - I let them know that it's not a punitive system," Blackwell says. "Our improvement, in fact, shows an exceptional level of teamwork to help us identify underlying problems and reduce errors."

Thomson Reuters Top 10 Health Systems of 2011

Thomson Reuters Research Identifies Top 10 U.S. Health Systems:

Thomson Reuters released its third annual study identifying the top 10 U.S. health systems based on quality of care, efficiency, and patient satisfaction. [Including Cape Cod Healthcare, Hyannis, MA; CareGroup Healthcare System, Boston, MA; and Partners Healthcare, Boston, MA]. Compared with their peers, the Thomson Reuters 10 Top Health Systems saved more lives, caused fewer medical complications, made fewer medical errors, followed recommended standards of care more closely, released patients half a day sooner on average, and scored better on patient satisfaction surveys.

Tufts’ CLABSI Team Scores Remarkable Success

Anyone who has ever been near a hospital emergency room - due to their own illness or that of a family member, or friend - probably has seen saline solutions or medications delivered intravenously. A catheter is inserted into the arm, a saline bag is hung on a nearby pole, and the "IV drip" delivers fluid quickly and effectively.

But for more serious cases, when a mere drip is not enough, or when the drugs being administered are so caustic they can damage smaller veins, clinicians have to insert a central line into the patient - and that involves entering the jugular vein, or the vein in the chest below the collarbone, or the large vein in the groin.

Any foreign object such as a catheter inserted into a patient may present a pathway for pathogens to enter the body, and large central lines that terminate close to the heart and that remain in the body for long periods of time are no exception. Staphylococcus aureus and Staphylococcus epidermidis sepsis are serious, potential consequences of central line insertions; nearly 13,000 such "central line-associated bloodstream infections" (CLABSIs) occur each year in the U.S., sometimes resulting in fatalities and always resulting in additional cost per patient, ranging up to $40,000 by some estimates.

But the number of CLABSIs is dropping rapidly across the U.S. because of the efforts that hospitals have undertaken.

At Tufts Medical Center (Tufts MC) in downtown Boston, the small team that was assembled to reduce, or eliminate, CLABSI has had remarkable success. Since 2010, through a daily effort that has involved the hospital's most senior leadership, nurses at the bedside, and assistive personnel, Tufts Medical Center reduced central line-associated bloodstream infections by 80%. In some of its units, Tufts MC has had 600 and 800 CLABSI-free days - that's zero infections for every day a patient has had a central line inserted into his or her body. The hospital's CLABSI rate of 0.69 per 1000 central line days is far below the national average.

Dorothy DiDomenico, R.N., BSN, a professional development manager at Tufts MC, says 100% of cardiac thoracic inpatients have a central line, which demonstrates how important they are to keeping patients alive. Yet the first line of defense against CLABSI is to evaluate each line each day to determine the risk/benefit of its use.

THE SIX KEY STEPS

Tufts MC, like many other hospitals in Massachusetts and throughout the U.S., is basing its improvement efforts on the CUSP: Stop BSI initiative, which uses a "comprehensive unit-based safety program" (CUSP) to stop bloodstream infections. Teams follow a bundle of six steps and then focus on changing the culture of a hospital to address a particular infection problem. Under CUSP, traditional hierarchies are broken down, teamwork is encouraged, and everyone has an equal role in ensuring high-quality, safe patient care.

The basis of the program originated with the Michigan Health & Hospital Association's Keystone Center teaming up with patient safety leaders at Johns Hopkins Medicine to implement the CUSP culture-change model, along with the bundle of proven clinical strategies. The Michigan model had such tremendous success that the Agency for Healthcare Research and Quality funded the Health Research & Educational Trust of the American Hospital Association to expand the program across the country - including Massachusetts where the Massachusetts Hospital Association coordinated the effort.

"Many places throughout the country are doing the same things we're doing - following the same 'bundle' of best practices," says Erik Garpestad, M.D., director of the Medical Intensive Care Unit at Tufts Medical Center "But we found additional best practices, the steps doctors and nurses were taking within their units to achieve better outcomes."

The six main parts of the best-practice bundle are:

Remove unnecessary central lines. Assess the need for a central line every day. Does the patient really need the line? Can other ways of introducing medications be used? And once it's used, how quickly can a central line be removed?
Wash hands prior to inserting central lines. A seemingly obvious step, but one that all hospitals have to stay on top of. Touching one patient, sheet, cup, or pen after your hands are washed means you have to wash your hands again.
Central Line cart. Each area in the hospital has a cart specifically designed with all the items needed for central line insertion. This ensures all items necessary are readily available.
Use maximal barrier precautions during line insertion. That is, don't just cover the neck area if you're inserting a line into the jugular vein; rather, cover the entire body so that if an end of the line flops down during insertion, it doesn't hit the patient's skin but rather lands on a sterile cloth. Barrier precautions also include caps, masks, sterile surgical gowns, and sterile gloves for the operators.
Clean skin with chlorhexidine. It's an antiseptic that simply has proven far more effective than other substances such as rubbing alcohol.
Avoid the femoral site when inserting lines. Of the three places to insert a central line - jugular, subclavical, or femoral - the latter has the potential to be the most unclean and susceptible to soiling. Sometimes, however, it is the only recourse.

Dr. Garpestad says, "We interviewed everyone to see how they maintained the central line, and when we found one practice that was proven to work well, we were able with hospital leadership's encouragement to roll it out in other parts of the hospital."

The best example of how Tufts MC found and disseminated best practice involves the hospital-wide educational roll-out to all providers on how to keep the central lines' "ports" or "hubs" sterilized.

Therese Hudson-Jinks, R.N., MSN, Tufts MC's Chief Nursing Officer and V.P. of patient care services, says, "Whenever we administer fluid or medications through the central line, we 'scrub the hub', meaning we really clean that port in a certain, prescribed way for at least 15 seconds. We don't swipe it with alcohol - we scrub it." In an effort to keep unused ports clean and ready for use, Tufts MC rolled out alcohol swab-caps, which are protective caps that have alcohol soaked gauze inside of them and that are placed on unused ports on central venous catheters. "In a 'small test of change' the alcohol swab-caps were used on two of our high risk floors with notable decreases in CLABSI rates," Hudson-Jinks says. "Now capping as well as scrubbing is standard operating procedure throughout Tufts Medical Center."

Hudson-Jinks says, "We formed a small team to ensure that we weren't just meeting the bundled care goals but that we were also engaging the community on the steps we were taking." Because administrators and others throughout the hospital were involved in the CLABSI-fighting effort, the team had the support to make the changes it needed.

For instance, when it became apparent that the best way to determine if a vein was a good candidate for a central line was to view it with a portable ultrasound machine, hospital administration budgeted for additional ultrasounds so that they could be readily available. Because each nurse involved in central lines had to be trained in new protocols, money for that education effort was found. When the team discovered that the length of the central line may affect infection rates (the shorter the length exposed outside of the patient, the less chance pathogens would use it as a ladder into the body), other units adopted the shorter-lengths, when possible.

The team also determined that having a cart in close proximity to the patient fully loaded with everything needed for an insertion (lines, antiseptic, syringes, gowns and gloves, etc.) eliminated the need for a clinician to leave the room to get a piece of equipment from a supply closet. (If someone leaves the room, they leave the sterile area and increase the chance for infections.)

"If you were to view the insertion of a central line it would look like an operating room," says Susan Murray, R.N., MPH, infection preventionist. "Everyone is gowned and gloved." And one of the first steps in ensuring the cart is placed properly in the patient's room.

Central lines are inserted by M.D.s, but a physician assistant or nurse practitioner can also be certified to perform the procedure. An R.N. is nearby maintaining the checklist and electronically tracking the fulfillment of each step; that nurse monitors the physician and has the authority to enforce a halt if a step is not met. (In very rare instances when a central line is needed ASAP to save the life of a patient, sterile procedures are maintained but the checklist may have to be skipped. "If you don't follow the checklist for whatever reason, the line comes out within 24 hours," Murray says.)

Even the bandaging that covers the central line insertion is applied following a strict procedure.

"We have one way to apply the dressing and R.N.s have to demonstrate competency in that area," says Chief Nurse Hudson-Jinks. "There's a methodology for applying the dressing because you don't want too much of the line exposed and you don't want it pulling away from a patient."

Even though Tufts Medical Center has achieved tremendous success, the core CLABSI-fighting team at the hospital doesn't feel as though it has reached its goal. That's because there is no finish line in the fight against infections. The goal is simply to never waiver from proven strategies for fighting infections, while testing new improvements that come along.

"You have to remain humble," says Dr. Garpestad when discussing Tufts MC's improvement numbers.

Says Murray, "We analyze each time a patient gets an infection, performing a root-cause analysis. Even the way we discuss our work now is different. We don't say, 'We had an infection' but rather 'We have a patient with an infection.' We always keep in mind that it's our patients who are affected by what we do."

Two Hospitals are Co-Winners of Betsy Lehman Patient Safety Award

A Focus on Infection Prevention

Two hospitals within the UMass Memorial Health Care system each received the 2009 Betsy Lehman Patient Safety Recognition Award from the Betsy Lehman Center for Patient Safety and Medical Error Reduction, a program established under the Executive Office of Health and Human Services and housed within the Massachusetts Department of Public Health. UMass Memorial Medical Center and Marlborough Hospital were this year's co-winners.

The 2009 award focused on organizations/healthcare facilities that best demonstrated the promotion of a culture of safety in the reduction of healthcare associated infections. In addition to the primary awards, Certificates of Merit were given to Lahey Clinic's Infection Control Program, Massachusetts General Hospital and the Central Line Infection Reduction Workgroup, and Children's Hospital Boston's Neonatal Intensive Care Unit.

The Betsy Lehman Patient Safety Recognition Award was established in 2005 to recognize leadership and innovation in patient safety including public awareness, education and promotion of systems-based solutions through the implementation of best practices.

Marlborough Hospital's Achievement

At Marlborough Hospital, an interdisciplinary task force of physicians, nurses, managers, and members of the quality, infection control and radiology departments worked diligently evaluating processes, policies and equipment to integrate a series of health care "best practices" to completely eliminate central line blood stream infections in hospitalized patients. For the past 13 months, there were no central line infections at the hospital. The hospital also adopted innovative programs to ensure high levels of performance in critical efforts such as increasing hand hygiene compliance, improving inpatient pneumococcal and influenza vaccination rates, and distribution of appropriate antibiotics to prevent pneumonia in intensive care unit patients.

"We are honored to receive the distinguished Betsy Lehman award," said John Polanowicz, CEO and president of Marlborough Hospital. "We are a community hospital where many talented, highly skilled and compassionate clinical leaders are committed to outstanding quality and safety outcomes for our patients. I thank everyone for their great work and know this will propel us forward to even greater achievements."

UMass Memorial Medical Center's Achievement

UMass Memorial Medical Center's award was presented in recognition of the Division of Cardiac Surgery's accomplishments in building a culture of safety, reducing health care associated infections, enhancing data monitoring resulting in implementation of evidence-based best practices, and focusing on innovative system-based solutions to support ongoing improvement in quality and patient safety. The division has consistently demonstrated lower mortality and infection rates than the state average, and has maintained zero percent incidences of postoperative mediastinitis, a life-threatening health care-associated infection, since 2007.

"By focusing on safety, data and communication, we have established a vision of zero tolerance to any outcome that does not put patient safety first," said Stanley Tam, MD, chief of Cardiothoracic Surgery at UMass Memorial Medical Center.

"Our cardiac surgery team has been recognized as one of the best in the nation and our whole Medical Center continues to set the bar for excellence in quality outcomes and patient safety," said Walter Ettinger, MD, MBA, president of UMass Memorial Medical Center.

This year marks the first occasion that the primary award winners were members of the same health care system. "We are extremely proud to be recognized by the Betsy Lehman Center," said John O'Brien, president and CEO of UMass Memorial Health Care. "Improving quality, safety and the patient experience is paramount throughout the hospitals and physician practices of our system. I thank and congratulate everyone associated with these programs which make such a positive impact to our patients."

About the Betsy Lehman Center

The Betsy Lehman Center was formed in 2002, with the goal of improving patient safety and reducing medical errors through coordinating state agency initiatives, promoting ongoing collaboration between the public and private sectors, coordinating state and federal safety programs, and promoting patient safety through educating both health care providers and patients. The center is named for Betsy Lehman, a Boston Globe reporter who died in 1994 as the result of a chemotherapy overdose. Go to www.mass.gov/dph/betsylehman for more information.

###

Fall Prevention in Acute Care Hospitals A Randomized Trial