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Partnership for Patients includes 10 focus areas:(With Current RHQN Strategies for helping CAHs)
1. PfP: Cultural Transformation 2. Leadership Engagement
CEO and Trustee Summit May 2nd or 3rd.
Current activities:Hospital Survey of Patient Safety Culture (HSOPS)-
Second group of 7 CAHs now taking the Survey.Just Culture, Executive WalkRounds and TeamSTEPPS
Communication tool training (currently Flex funded)
RHQN Root Cause Analysis and Taste of Lean classes
3. PfP: Preventable Readmissions within 30 days
Goal:Reduce preventable readmission from 2010 benchmark by 20% to end of 2013.
See RHQN Best Practice calls with Whitman in the past on RHQN website. Also focus of future Best Practice calls.
4. PfP:
Reduce
Hospital Acquired Infections (HAI) and
Hospital Acquired Conditions (HAC)
by 40% from 2010 to end of 2013.
3. PfP: Infection Prevention Measures (HAI) Safe Table on April 11th.Encourage all to come to the Safe Tables. Sometimes works best for two to come because you have support when you go home and want to implement something1) CAUTI- On Survey, 20 CAHs indicated they have a CAUTI Bundle. 3 asked for support. February Best Practice Call Fran Petersen, Lourdes : Nurse Initiated Foley Catheter removal-on RHQN Website. 2) Surgical Site Infections- RHQN will follow WSHA lead with CAH Best Practice discussions3) VAP-Not applicable in many facilities. Others indicated on the RHQN Survey that they had Ventilator Bundle and QI monitoring. 4) CLABSI- 15 CAHs indicated on the Survey that you have CLABSI Bundles. 4 CAHs indicated it is not applicable. 4 asked for support.
PfP: Hospital Acquired Conditions (HAC)1) VTE- On Survey, 15 indicated they had a VTE Prevention and Treatment Protocol. Only 7 CAHs had QI projects to monitor and improve VTE rates. 5 did not and 7 asked for support. 2) Obstetrical Adverse Events-Working with CAHs who have challenges implementing the ACOG Guidelines for 39 weeks. Best Practice Sharing on-going. 3) Pressure Ulcers-April 25th-WSHA Web-conference and RHQN to follow4) Falls-10 CAHs report on QBS. 6=less than 5%. See 4/25 WSHA Web-conference. 5) Adverse Drug Events….27 CAHs indicated they track Adverse Events with 22 having a QI project in this area. We will work especially with the 7 who did not indicate they have a program in place. Also, we will bring Best Practices to you in the future.
RHQN Best Practice Call:Partnership for Patients (PfP)
focus: VTE
April 10, 2012Facilitated by
Bev McCullough, RN, MBA, CPHQ
VTE: DVT& PE: Alphabet Soup
Venous Thromboembolism (VTE):Deep Vein Thrombosis of the lower
leg (DVT)Clot dislodges from DVT, travels to
the lungs and becomes a Pulmonary Embolism (PE)
Implementing a VTE Protocol
The “QI Basics”: “8 Steps for Effective Change”
Explain the Urgency Leadership buy-in, Physician Champion, engaged
team Have a shared vision Communicate to others: The “elevator speech” Remove barriers: empower to create change Choose well: Implement in one area, do “small tests of
change” and then Celebrate Keep improving: PDSAs, Measure, Monitor, SPREAD Sustain
VTE: The Urgency
“Pulmonary Embolism is the third most common cause of hospital-related death and it is the most common preventable cause of hospital-related death.”*
*http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/venous-thromboembolism/
VTE: CMS Measures
SCIP-VTE-1 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis ordered
SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery
VTE: Making the Case
Meaningful Use:2012 –Eligible CAHs seeking to
demonstrate Meaningful Use are required to electronically submit aggregate CQM numerator, denominator, and exclusion data to CMS or the States.
VTE: Making the Case
Meaningful Use for Hospitals:VTE prophylaxis w/in 24 hrs. of arrivalIntensive Care Unit VTE prophylaxisAnticoagulation overlap therapyPlatelet monitoring on unfractionated
heparinVTE discharge instructionsIncidence of potentially preventable
VTE
VTE: Making the Case: TJC measures: CMS 2013
VTE-1* Venous Thromboembolism Prophylaxis VTE-2 Intensive Care Unit Venous Thromboembolism
Prophylaxis VTE-3* Venous Thromboembolism Patients with
Anticoagulation Overlap Therapy VTE-4 Venous Thromboembolism Patients Receiving
Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol
VTE-5 Venous Thromboembolism Discharge Instructions
VTE-6* Incidence of Potentially-Preventable Venous Thromboembolism
VTE: Making the Case: The CAH National Measures Brief
VTE prophylaxis
VTE patients with anti-coagulation overlap therapy
Incidence of potentially preventable VTE
VTE Implementation
The “QI Basics”: “8 Steps for Effective Change”
Explain the Urgency Leadership buy-in, Physician Champion, engaged
team Have a shared vision Communicate to others: The “elevator speech” Remove barriers: empower to create change Choose well: Implement in one area, do “small tests of
change” and then Celebrate Keep improving: PDSAs, Measure, Monitor, SPREAD Sustain
Choose a VTE Protocol
Standardized processes The key to reliability All patients, Every time
Example:1. Wells Risk Assessment Tool2. D-Dimmer blood test3. Menu of appropriate prophylaxis
options4. Screening for pharmacological
contraindications
Wells Score
1-Active Cancer 1=Paralysis, paresis, or recent plaster immobilization of lower
extremities 1=Recently bedridden > 3 days or major surgery within 4 weeks 1=Localized tenderness along the deep venous system 1=Entire leg swollen 1=Calf swelling > 3 cm vs asymptomatic leg* 1=Pitting edema greater in symptomatic leg 1=Collateral superficial veins (not varicose) -2=Alternative dx as likely or greater than deep-vein thrombosis
Wells Scoring
High >=3Moderate 1 or 2Low 0
Modify by adding one point if there is a previously documented DVT
Likely=>2Unlikely=<1
Wells Scoring
High >=3Moderate 1 or 2Low 0
Modify by adding one point if there is a previously documented DVT
Likely=>2Unlikely=<1
D-Dimer Test
A blood test of a fibrin degradation product, present in the blood after a blood clot is degraded by fibrinolyis.
Combined with the Wells clinical decision rule it has @ 99% predictive value for VTE.
Choose a VTE Protocol
Standardized processes Are the key to reliability All patients, Every time
Example: 1. Wells Risk Assessment Tool 2. D-Dimmer blood test
3. Menu of appropriate prophylaxis options4. Screening for pharmacological
contraindications
Menu of Treatment Options
Pharmacological prophylaxis reduces the incidence of asymptomatic and symptomatic DVT and PE by 50-65%*
Resources:Society of Hospital Medicine http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE
/VTE_Home.cfm http://www.hospitalmedicine.org/ResourceRoomRedesign/
RR_VTE/PDFs/SAMPLEVTEPROTOCOLS.pdf
Getting to 100%
Situational Awareness and "Measure-intervention"—
Identify patients on no anticoagulation-Put on the daily checklist.
Empower nurses to place mechanical prophylaxis.
Contact MD if no anticoagulant in place and no obvious contraindication: Template note, text page, etc.
Back up these interventions: Physicians can not "shoot the messenger."
Create Highly Reliable Strategies
Desired Action is the Default (You have to Opt-Out if you don’t do it)
Desired Action is Prompted by a reminder or decision aide
Desired Action is Standardized into a process (a deviation feels weird)
Desired Action is Scheduled to occur at known intervals
Responsibility for the Desired Action is Redundant (Example: The clerk or pharmacist is empowered to halt processing of an admission order set that has not prophylaxis selected)
Implementing a VTE Protocol
The “QI Basics”: “8 Steps for Effective Change”
Explain the Urgency Leadership buy-in, Physician Champion, engaged
team Have a shared vision Communicate to others: The “elevator speech” Remove barriers: empower to create change Choose well: Implement in one area, do “small tests of
change” and then Celebrate Keep improving: PDSAs, Measure, Monitor, SPREAD Sustain
RHQN Website:http://www.rhqn.org/Select “Resources”:
User Name: RHQN
Password: Quality1
Or contact:Bev McCullough, RN, MBA,CPHQ
206-216-2862