Download Patient safety and harm

Methods for Improvement
Where are the Ideas?
David I Gozzard
Quality Improvement Fellow
Health Foundation
National Leadership
and Innovation Agency
For Healthcare
Asiantaeth Genedlaethol
Arweiniad ac Arloesoldeb
dros Ofal Iechyd
An International Movement of
Movements?
The Entire UK Is Engaged
3
England
• Cause
• To make the safety of patients
everyone’s highest priority
• Aim
• No avoidable death and no
avoidable harm
• Interventions
• Leadership for safety
• Reducing harm from deterioration
• Reducing harm in critical care
National Leadership
• Reducing harm and
in perioperative
Innovation Agency
For Healthcare
care
Asiantaeth Genedlaethol
• Reducing harm
from ac
high
risk
Arweiniad
Arloesoldeb
dros Ofal Iechyd
medicines
Scotland
• 5.5 million people
• Scottish Patient
Safety Programme
• 37 acute hospitals
•
•
•
•
•
Critical care
Peri-op
Medicines
General ward
Leadership
• Aims
• 15% reduction in
mortality
• 30% reduction in
adverse events
Denmark
•
•
•
5.5 million inhabitants
Health care is a public task
5 regions that are responsible for
health care
Operation Life:
• 38 hospital units
•
•
•
•
•
•
•
Rapid Response Systems
AMI Bundle
Medication Reconciliation
Ventilator Bundle
Central Line Bundle
Surviving Sepsis Campaign
Aims
•
Save 3000 lives during campaign
period
 All regions present at campaign
start
 Cover 75% of discharges
www.operationlife.dk
6
Canada
• 33 million people
• 10 interventions + 2
pilots
• 1035 teams enrolled
• 80% of acute care
hospitals enrolled
• All regional health
organizations
outside of Quebec
enrolled
Aim
• Reduce adverse
events by 40-100%
dependent upon
intervention
www.saferhealthcarenow.ca
Japan
“PARTNERS for Patient Safety”
National Campaign for Patient Safety in Japan
National Leadership
and Innovation Agency
For Healthcare
Asiantaeth Genedlaethol
Arweiniad ac Arloesoldeb
dros Ofal Iechyd
http://kyodokodo.jp/
Wales
• 3 million people
• 1000 Lives Campaign
• All Hospitals, Primary Care
and Ambulance services
•
•
•
•
Leadership
Critical Care/Rapid response
Medicines
Healthcare associated
infection
• Surgical care
• General medical and surgical
care
• Aims
• To save 1000 lives, and
• Avoid 50,000 cases of harm
in 2 years from April 2008
www.1000livescampaign.wal
100,000 Lives Campaign
• Deploy Rapid Response Teams…at the first sign of patient
decline
• Deliver Reliable, Evidence-Based Care for Acute
Myocardial Infarction…to prevent deaths from heart
attack
• Prevent Adverse Drug Events (ADEs)…by implementing
medication reconciliation
• Prevent Central Line Infections…by implementing a series
of interdependent, scientifically grounded steps
• Prevent Surgical Site Infections…by reliably delivering the
correct perioperative antibiotics at the proper time
• Prevent Ventilator-Associated Pneumonia…by
implementing a series of interdependent, scientifically
grounded steps
5 Million Lives Campaign
The Platform
 Reduce Surgical Complications – Adopt “SCIP”
 Prevent Harm from High Alert Medications
 Prevent MRSA Infections
 Reduce Readmissions from Congestive Heart
Failure
 Prevent Pressure Ulcers
 Get Boards on Board
Reducing Surgical Complications
The Goal:
Reduce surgical complications by 25
percent by December 2008 by
reliably implementing the changes
in care recommended by the
Surgical Care Improvement Project
(SCIP)
Four Key Interventions
Surgical Site Infection Prevention
Beta Blockers for Patients on Beta
Blockers prior to Admission
Venous Thromboembolism Prophylaxis
Ventilator-Associated Pneumonia
Prevention
Reduce Surgical Site Infections
1. Appropriate use of antibiotics
2. Appropriate hair removal
3. Postoperative glucose control (major cardiac
surgery patients cared for in an ICU)*
4. Perioperative normothermia (colorectal
surgery patients)*
* These components of care are supported by clinical trials and
experimental evidence in the specified populations; they may
prove valuable for other surgical patients as well.
Beta Blockade
The American College of Cardiology / American
Heart Association Task Force on Practice
Guidelines: “Beta blockers should be continued
in patients undergoing surgery who are
receiving beta blockers to treat angina,
symptomatic arrhythmias, hypertension, or
other ACC/AHA Class I guideline indications”
(ACC/AHA Practice Guidelines. JACC. 2006;
47(11); 2342-2355).
What Does the Evidence Tell Us?
In a study of 140 patients who received beta
blockers preoperatively, eight patients had
their beta blockers discontinued
postoperatively and mortality was 50 percent,
compared to mortality of 1.5 percent in the
other 132 patients who had beta blockers
continued (odds ratio 65.0, P<.001).
(Shammash JB, Trost JC, et al. Am Heart J.
2001;141(1):148-153)
Venous Thromboembolism
Prophylaxis (VTE)
• Deep vein thrombosis (DVT) is estimated to
occur in 10 to 40 percent of general surgical
patients when prophylaxis is not provided.
• In a study cited by the American College of
Chest Physicians (ACCP), autopsies of surgical
patients who died within 30 days
postoperatively revealed that 32 percent had
had a PE and it was the cause of death for
most (Lindblad B, Eriksson A, Bergqvist D. Br
J Surg. 1991;78:849-852).
Tips for Getting Started
• Develop standard order sets for prophylaxis
• Develop protocols for providing prophylaxis
automatically, based on surgical procedure
• Provide education and training for staff on
the importance of VTE prophylaxis
• Educate patients preoperatively about the
prophylaxis they will receive and steps they
can take to reduce risk
Ventilator-Associated Pneumonia
• According to SCIP, “postoperative pneumonia
occurs in 9 – 40% of patients and has an
associated mortality of 30 - 45%”
• Hospital mortality of ventilated patients who
develop VAP is 46 percent
(Ibrahim EH, Tracy L, Hill C, et al. Chest.
2001;20(2):555-561)
• VAP prolongs time spent on the ventilator,
length of ICU stay, and length of hospital stay
after discharge from the ICU
(Rello J, Ollendorf DA, Oster G, et al. Chest.
2002;22(6):2115-2121)
Four Key Changes
 Elevation of the head of the bed to
between 30 and 45 degrees
 Daily “Sedation Vacation” and daily
assessment of readiness to extubate
 Peptic ulcer disease (PUD)
prophylaxis
 Deep vein thrombosis (DVT)
prophylaxis (unless contraindicated)
Reducing Harm from High-Alert
Medications
The Goal:
Reduce harm from high-alert
medications by 50% by December
2008
What Are High-Alert Medications?
High-alert medications are more likely to
be associated with harm that is both
more common and likely to be more
serious:
• Anticoagulants
• Insulin
• Narcotics
• Sedatives
What Does the Evidence Tell Us?
Several studies have identified adverse drug events
as the single most frequent source of health care
mishaps, continually placing patients at risk of injury.
-Rozich JD, Haraden CR, Resar RK. Adverse drug event
trigger tool: A practical methodology for measuring
medication-related harm. Qual Saf Health Care. 2003;12:194200.
-Bates DW, Boyle DL, Vander Vliet VM, et al. Relationship
between medication errors and adverse drug events. J Gen
Intern Med. 1995;10:199-205.
-Bates DW, Cullen DJ, Laird NM, et al. Incidence of adverse
drug events and potential adverse drug events: implications
What Does the Evidence Tell Us?
Warfarin and insulins caused:
• One in every seven estimated adverse drug events
treated in emergency departments
• More than a quarter of all estimated
hospitalizations
In the elderly, insulin, warfarin, and digoxin were
implicated in:
• One in every three estimated adverse drug events
treated in emergency departments
• 41.5% of estimated hospitalizations
Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency department
visits for outpatient adverse drug events. JAMA. 2006;296:1858-1866.
What Does the Evidence Tell Us?
Review of events in an adverse drug reaction database of
317 preventable ADEs, “…suggested that three highpriority preventable ADEs accounted for 50% of all reports:
(1) overdoses of anticoagulants or insufficient monitoring
and adjustments (according to laboratory test values)
were associated with hemorrhagic events,
(2) overdosing or failure to adjust for drug-drug interactions
of opiate agonists was associated with somnolence and
respiratory depression, and
(3) inappropriate dosing or insufficient monitoring of insulins
was associated with hypoglycemia.”
Winterstein AG, Hatton RC, Gonzalez-Rothi R, Johns TE, Segal R. Identifying clinically
significant preventable adverse drug events through a hospital's database of adverse
drug reaction reports. American Journal of Health-System Pharmacy. 59;18:1742-1749.
Prevent MRSA Infection
The Goal:
Reduce methicillin-resistant
Staphylococcus aureus (MRSA)
bloodstream infection by
December 2008
Focus on “getting to zero”
A Vision For The Future?
MRSA in Denmark
100%
Rosdahl VT et al. Infect Control Hosp Epidemiol 1991;12:83-88.
90%
80%
70%
60%
50%
MRSA Bloodstream Infections
40%
30%
20%
10%
0%
1960
1995
1965
1970
1975
1980
1985
1990
Or This?
MRSA in the UK
What Does the Evidence Tell Us?
• Rational Interventions Should Target Modes of
MRSA Transmission
• Person-person via hands of health care
providers – by far the most important
• Personal equipment (e.g., stethoscopes, PDAs)
and clothing
• Environmental contamination
• Airborne transmission
• Carriers on the hospital staff
• Rare common-source outbreaks
Prevent Infection and Colonization
• Colonized patients comprise the reservoir for
transmission (“colonization pressure”).
• High rates of MRSA colonization complicate
empiric antibiotic therapy (e.g., vancomycin).
• Colonized patients have a high rate of MRSA
infection.
• Nearly 1/3 develop infection, often after discharge
• Colonization is long-lasting, and patients can
transmit MRSA to patients in other health care
settings (e.g., nursing homes), as well as to
family members.
Five Key Interventions
 Hand hygiene
 Decontamination of the environment
and equipment
 Active surveillance cultures (ASCs)
 Contact precautions for infected and
colonized patients
 Compliance with Central Venous
Catheter and Ventilator Bundles
Tips: Hand Hygiene
• Single most important intervention, especially
after and before patient contact
• Compliance rates of 40-50% no longer are
acceptable
• Hold staff accountable
• Encourage patients and families to remind caregivers
to practice hand hygiene
• Alcohol hand rubs have made hand hygiene much
easier
• Rapidly kill bacteria (except Clostridium difficile
spores)
• Surprisingly gentle on hands
• Not a substitute for soap and water when hands are
grossly soiled
Tips: Decontamination of
Environment and Equipment
• Use dedicated equipment for
colonized/infected patients
• For general patient care, use alcohol wipes for
stethoscopes and other personal equipment when
leaving the bedside
• Put environmental services personnel on the
team
• Clean and disinfect the environment carefully,
especially “high touch” areas
• Use an environmental cleaning checklist
• Trust and verify
Tips: Active Surveillance
• Perform active surveillance cultures (ASCs) to
detect colonized patients on admission
• Necessity of ASCs per se in controlling MRSA is
controversial
• But “knowledge is power” – clinical cultures miss many
colonized patients and vastly underestimate the magnitude of
the problem
• ASCs on admission, followed by testing weekly and/or at
discharge, is necessary to document the extent of
transmission and the success of control measures
• Successful programs combine ASCs with reliable
implementation of other interventions
• Controversy regarding ASCs for high-risk areas (ICUs)
vs. entire hospital
• Flag colonized patients when discharged
Reduce Re-admissions from
Congestive Heart Failure (CHF)
The Goal:
Reduce the 30-day re-admission rate
of patients discharged with the
diagnosis of CHF by 50% by
December 2008
What Is “Congestive Heart Failure?”
• A clinical syndrome resulting from a
structural or functional cardiac disorder
that impairs the ability of the heart (the
ventricles) to fill with or eject blood
• Characterized by
• Shortness of breath (dyspnea) and fatigue
(exercise intolerance)
• Fluid retention – trouble lying flat, swelling
(edema) of dependent parts of the body
(especially the legs)
What Does the Evidence Tell Us?
• Measuring left ventricular systolic (LVS) function is a
critical step in determining who needs specific
treatment (left ventricular ejection fraction (LVEF) <
40%)
• Numerous clinical trials demonstrate that drugs that
help the ventricles pump more effectively reduce
symptoms, readmissions, and mortality
• Angiotensin-converting enzyme (ACE) inhibitors
• Angiotensin receptor blockers (ARBs)
• Beta blockers
• Patients with atrial fibrillation (AF) tend to form blood
clots in the heart and are at increased risk for stroke
• Anticoagulation reduces the risk of stroke
ACC/AHA Guideline, Circulation 2005;112:154-235
What Does the Evidence Tell Us?
• CHF patients have a higher risk of hospitalization
and mortality due to pneumonia
• Influenza and pneumococcal immunizations both are
effective in reducing the risk of pneumonia,
hospitalizations, and mortality (ACIP recommended)
• Smoking is a risk factor for poor outcomes in CHF
• Smoking cessation programs initiated in the hospital
can help patients quit smoking, as least in the short
term
• Discharge planning, including a good “hand off,”
probably reduces short-term re-hospitalizations
and puts the patient and ambulatory providers on
the right track for better longer-term outcomes
Seven Key Interventions
 Left ventricular systolic (LVS) heart
function assessment
(CMS,JCAHO,ACC,AHA)
 ACE inhibitor or ARB at discharge for CHF
patients with systolic dysfunction
(LVEF<40) (CMS,JCAHO,ACC,AHA)
 Anticoagulant at discharge for CHF
patients with chronic/recurrent atrial
fibrillation (ACC,AHA)
Seven Key Interventions
 Influenza immunization (ACIP)
 Pneumococcal immunization (ACIP)
 Smoking cessation counseling
(CMS,JCAHO,ACC,AHA)
 Discharge instructions that address all of the
following: activity level, diet, discharge
medications, follow-up appointments,
weight monitoring, and what to do if
symptoms worsen (CMS,JCAHO,ACC,AHA)
Hospital performance on all interventions is sub-par
(54% on the discharge component, 2005 CMS data)
Other Interventions to Consider
• Beta blocker therapy for patients who have
minimal or no evidence of fluid overload or
volume depletion (AHA,ACC)
• Well supported by randomized controlled trials
• If started at discharge (as recommended by AHA Get
With The Guidelines-HF):
• Insures patient is started on therapy and hastens attainment
of therapeutic levels
• Requires close monitoring and follow-up post-discharge
• Discharge “contract”
• Statin for patients with/at risk for coronary
artery disease
• Spironolactone
(certain high risk patients)
Prevent Pressure Ulcers
The Goal:
Reduce the incidence of
hospital-acquired pressure
ulcers by December 2008
Focus on “getting to zero”
What Does the Evidence Tell Us?
• Risk is predictable
• age immobility, incontinence, poor nutrition, sensory
problems, circulation problems, dehydration and poor
nutrition
• Skin integrity can deteriorate in hours
• frequent assessment prevents minor problems from
becoming major ulcers
• Wet skin is more vulnerable to skin disruption and
ulceration
• But dry skin is a risk factor as well
• Continual pressure, especially over bony
prominences, increases risk
• Pressure-relieving surfaces work
Reddy et al., JAMA 2006;296:974-84
Six Key Interventions
 Conduct a pressure ulcer admission risk
assessment for all patients
 Reassess risk for all patients daily
For all patients identified as being at risk for
pressure ulcers:
 Inspect skin daily
 Manage moisture: keep the patient dry;
moisturize dry skin
 Optimize nutrition and hydration
 Minimize pressure: ensure that patients are
turned every two hours; use pressure-relieving
surfaces
Conduct a Pressure Ulcer Admission
Risk Assessment; Reassess Daily
• Use visual cues in admission documentation for
completion of skin and risk assessment
• Standardize risk assessment tool/check list
across the institution
• Incorporate action steps linked to risk
• Use multiple methods to visually identify
patients at risk
• Stickers on chart, visual cues on door and bed
• Post compliance rates to motivate staff
• Improve processes to ensure risk assessment is
conducted within 4 hours of admission and daily
• Assess surgical patients
Inspect Skin Daily
• Required for high-risk patients
• Skin integrity can deteriorate in a
matter of hours
• Always look at sacrum, back, buttocks,
heels, and elbows every time the patient
is assessed
Manage Moisture
• Cleanse skin at time of soiling and at routine
intervals
• Watch for excessive moisture due to perspiration
and wounds
• Use gentle cleansing agent
• Use moisturizers for dry, fragile skin
• Provide under-pads that wick moisture away
from skin
• Keep kit of needed supplies at bedside for atrisk incontinent patients
Optimize
Nutrition/Hydration
• Respect patient’s dietary preferences
• Involve dietician, use supplements as
needed
• Monitor hydration
• Offer water (when appropriate) whenever
patient is turned
Minimize Pressure
• Turn/reposition patient at least every 2 hours
• Use alerts and cues to remind staff to turn patient
• Protect skin when turning patient (use lift devices or
“drawsheet,” heal and elbow protectors, sleeves and
stockings; do not “drag”)
• Use pillows and cushions strategically
• Use static and/or dynamic pressure-relieving support
surfaces
• Static surfaces include well-designed mattresses, mattress
overlays filled with water, air, gel, foam, or a combination of
these
• Dynamic surfaces include devices that vary pressure beneath
the patient, reducing duration of pressure at any given skin
site
Engage Leadership and
Governance
The Goal:
Boards in all hospitals will spend at least
25% of their meeting time on quality
and safety issues
Full Board will have a conversation with
at least one patient (or family member
of a patient) who sustained serious
harm at their institution within the last
year
What Does the Evidence Tell Us?
• Outcomes are better in hospitals where:
• The Board spends >25% of its time on quality and
safety
• The Board receives a formal quality measurement
report
• There is a high level of interaction between the
Board and medical staff on quality strategy
• Senior executive compensation is based in part on
quality and safety performance
• The CEO is identified as the person with the greatest
impact on QI, especially when so identified by the QI
Executive
Vaughn T, Koepke M, Kroch et. al. J of Patient Safety 2:2-9
Six Things That Boards Can Do
 Set a specific aim to reduce harm this year and
make an explicit, public commitment to
measurable quality improvement (e.g.,
reduction in unnecessary mortality or harm)
 Select and review progress towards safer care
as the first agenda item at every Board meeting
• Get data on harms and hear stories; put a “human
face” on data
 Establish and monitor a small number of
organization-wide “role up” measures that are
updated continually and are transparent to the
entire organization and its customers
Six Things That Boards Can Do
 Commit to establish and maintain an
environment that is respectful, fair, and just for
all who experience pain and loss from avoidable
harm
• Patients, their families, and staff at the sharp end of
error
 Develop the capability of the Board
• Learn how the “best in the world” Boards work with
executive and MD leaders to reduce harm
• Set an expectation for similar levels of
education/training for all staff
 Oversee the effective execution of a plan to
achieve the Board’s aims to reduce harm,
including executive team accountability for clear
quality improvement targets