PSC Newsletter 2008 Summer
Transcript of PSC Newsletter 2008 Summer
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HAND HYGIENE:A PRIORITY FOR THE MILITARY HEALTH SYSTEM
SUMMER 2008 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY
INSIDE: More About MSRA Infection Reduction Across the MHS
SUMMER 2008
Patient Safety Survey Update6Summer Reading Picks5
Varied Strategies Employed to Reduce MSRA Infections
The reduction of methicillin-resistant
Staphylococcus aureus(MRSA) infec-
tion is a universal priority across thespectrum of healthcare today. Although
long recognized as major contributing fac-tors, improving hand hygiene and environ-
mental decontamination have proven to bevexing problems. Standardization of thesepractices has been oddly resistant to wide-
spread, effective intervention, despite therelative ease of strategies such as increased
hand-washing and use of alcohol-basedhand rub products.
Collaborative efforts by the Center for Dis-ease Control (CDC), the World HealthOrganization (WHO), the Institute forHealthcare Improvement (IHI) and The
Joint Commission have combined to high-light the risks associated with MRSA and
the specific steps that healthcare organiza-tions can and must take to reduce those
risks. Both the CDC and WHO have pub-lished hand hygiene guidelines (see:http://www.cdc.gov/handhygiene an d
http://www.who.int/patientsafety/information_centre/guidelines_hhad/en/index.html).
The Joint Commission has expanded
National Patient Safety Goal #7A to includethe WHO hand hygiene guidelines. Begin-ning in 2008, organizations are required to
be compliant with either the WHO or CDCguidelines. (http://www.jointcommission
.org/PatientSafety/NationalPatientSafetyGoals/08_hap_npsgs.htm). The IHI Five
Million Lives Campaign counts reducingMSRA infections as one of its goals. Among
a list of helpful information and tools, aPowerPoint presentation outlining impor-
tant data, interventions and strategies isavailable on the IHI website: www.ihi.org/IHI/Programs?Campaign/MRSAInfection.htm.
Military Treatment Facilities (MTFs),
providers and staff across the Military
Health System have been active in theirefforts to reduce MRSA infections. Featured
in the pages of this Summer Newsletter is acall to even greater personal responsibility
for infection control. The creativity shownby Tripler Army Medical Center, and the
breath of efforts at the Naval Health ClinicAnnapolis, highlighted herein, illustrate therange of strategies employed by the DoD
MTF Infection Preventionists and PatienSafety Managers to protect patients from
preventable infections.
Revised Call for Patient Safety Awards3
Tripler AMC Infection Control & Epidemiology Program Manager Stephen Yamada and GuyDickinson, Lead Medical Support Assistant, Adult Medicine Clinic, demonstrate how patientsreturn their hand hygiene data cards to the hand-fan receptacle.
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2 SUMMER 2008 PATIENT SAFETY
Like most hospitals across the nation, TriplerArmy Medical Center has long had a hospi-tal-wide program in place to encourage hand
hygiene among its providers. Unlike most
hospitals however, Tripler reexamined theirestablished efforts. They wondered how theycould be sure hand hygiene practices were
being followed in areas like the out-patientclinic where monitoring hand washing prac-tices are notoriously difficult. Their ques-
tions led to a unique patient-centered moni-toring system. With patients as active part-
ners in infection control Tripler has not onlyimproved its own compliance with hand-
hygiene goals, it has developed an improve-ment model that can be adopted across theMilitary Health System and beyond.
Recognizing that the out-patient setting pres-
ents a particularly challenging venue forhand hygiene monitoring with its multiple
encounters in separate examination rooms,COL Michael Brumage, then Chief of theDepartment of Preventive Medicine, led a
team effort to devise a completely new mon-itoring system. Thinking well outside the
established box, the team, comprised of COLBrumage, Stephen Yamada, Infection Control
& Epidemiology Program Manager, and JoanGodich, Infection Control Nurse, recognized
that patients provided an untapped resource.Together they developed a process utilizingpatients as monitors of clinic hand-washing
practices. The process was piloted in theAdult Medicine Clinic in January 2007.
Each patient was given a 3 x 5 card when
they registered in the clinic. Side 1 of thecard included a simple explanation of theproject and a brief set of instructions. Side 2
of the card included lines for the clinicname, the date, what health care provider
was being observed (doctor, nurse, other),and a simple yes or no check line as to
whether hand hygiene was performed.Patients were asked to drop their completedcards in a special receptacle, easily recogniz-
able by its hand-fan motif.
Results of the pilot project showed that patientobservations of hand-washing practices were
generally similar to staff observations. Howev-er, the increased reliability of objective patientreports added value to the pilot data. Addi-
tionally, a welcome unintended consequenceof the patient monitoring was noted. Physi-cian hand hygiene compliance rates improved
at Tripler during the course of the pilot project
and from December 2007 to May 2008 haveconsistently exceeded 95 percent.
No longer a pilot project, the patient handhygiene partnership at Tripler continues andhas expanded to other out-patient clinics
Obstetrics, Medical Specialties, Schofield Bar-racks Family Practice and Tripler Family
Practice. The Infection Control Service hastaken leadership of the partnership, providing
data cards, collecting and aggregating dataand reporting feedback on a monthly basis.Internally the feedback has been appreciated
and used to great advantagethe ObstetricsDepartment adopted hand hygiene as a per-
formance improvement project and achievednearly 100 percent compliance.
In an effort to share what it believes tounique, cost-effective and easily repliimprovement strategy, Tripler has prod
the impressive hand hygiene poster repr
herein. The poster, exhibited at vapatient-safety conferences, won an awardHawaii Patient Safety Conference in M
2008. Triplers hand hygiene partnershunder consideration by the Joint Commifor inclusion as a best practice in an upc
ing monograph on hand hygiene. Elegaits simplicity, Triplers initiative proves
even good practices can be improvedthat our patients can be powerful partne
our efforts to keep them safe.
For more information, please con
Stephen Yamada, Infection ControlEpidemiology, Department of Preve
Medicine, Tripler Army Medical C([email protected]).
TRIPLER ARMY MEDICAL CENTERJOINS HANDS FOR CLEAN HANDS
Patients Enlisted as Partners in Creative Hand Hygiene Pilot Effort
Award-winning Poster from Tripler AMC depicting its innovative partnership with patients to mtor hand-washing in out-patient settings.
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PATIENT SAFETY SUMMER 2008 3
Feedback and Suggestions Based on Your ReportingNEWS FROM THE PATIENT SAFETY CENTER
Healthcare associated or hospital acquired
nfections (HAI) were responsible for 394,129dditional hospital days at a cost of $3.5 bil-ion in 2005 in one statePennsylvania. Mul-
iplied by 50 states, plus the federal healthcareystems such as DoD and the VHA, the annu-
l cost of HAI in the U.S. is measured in manyillions of dollars and millions of excess hos-
pital days. HAI Reduction is not only a U.S.ssue, it is a global challenge.
HAI is also largely a preventable tragedy.
National and international organizationsdedicated to public health (World Health
Organization, Centers for Disease Control),quality improvement (Institute for Health-are Improvement), accreditation (The Joint
Commission), and federal healthcareDepartment of Defense and Veterans
Healthcare Administration) all have initia-ives to reduce HAI. While differing in
mphasis they have a common threadwash your hands between patients.
The DoD Patient Safety Program websitehttp://dodpatientsafety.usuhs.mil/) recently
aunched a section devoted to hand hygiene.The introduction to hand hygiene includes
he following:
The observations of Oliver Wendell Holmes in843 and, Ignaz Semmelweis in 1846 concern-ng the development of puerperal fever
hrough cross contamination by the unwashedhands of healthcare providers provided some
of the earliest evidence as to the importance ofppropriate hand hygiene. Semmelweis was
ble, though the mandatory use of a chlorineolution as an antiseptic hand-wash by physi-ians and students between patient contacts,
o significantly reduce maternal mortalityates. Medical historians believe that the use of
ungloved and unwashed fingers to probe theullet wound of James Garfield, the 20th US
President, after an assassination attempt, andhe resulting infection was a proximate cause
of his death.
Hand hygiene is currently widely acceptedas the single most important interventionfor preventing transmission of pathogens
in healthcare facilities. Although there is a
substantial literature to support this, theadherence by healthcare personnel varieswidely, in part related to setting and
required frequency. The introduction ofwaterless alcohol based antiseptic gels thattake less time than traditional hand-wash-
ing, and in the majority of cases are lesstraumatic to the hands than the repeated
use of soap and water, has helped improvecompliance. However a clear understand-
ing of the use and limitations of theseagents is required as they are not effectiveagainst Clostridium difficile and some
viruses and must be applied appropriately.Most importantly, sustained improvement
in hand hygiene behavior requires a long-term educational program with reinforce-
ment, peer acceptance, and continuedinstitutional commitment.
The Joint Commission has made handhygiene a priority issue in its NationalPatient Safety Goals. Knowledge of andcompliance with the hand hygiene guidelines
are a major component of the recentlyreleased goals for 2009 to implement best
practices to facilitate the prevention of multi-ple drug resistant organisms infections withan emphasis on methicillin-resistant Staphy-lococcus aureus[MRSA] and Clostridium dif-
ficile-associated disease along with best prac-
tices for the prevention of catheter-associatedbloodstream infections.
Goal 7: Reduce the risk of healthcare-associ-ated infections.
Requirement 7A: Comply with current
World Health Organization (WHO) HandHygiene Guidelines or Centers for Disease
Control and Prevention (CDC) handhygiene guidelines.
Rationale for Requirement 7A: Compli-ance with the WHO Hand Hygiene Guide-
lines or CDC hand hygiene guidelines willreduce the transmission of infectious
agents by staff to [patients], therebydecreasing the incidence of healthcareassociated infections.
Another excellent website is that developedby (HCA) Hospital Corporation of America(http://www.hcahealthcare.com/) which has
a section devoted to MRSA. Their material
are publically available and, while targetingMRSA, are widely applicable to all HAI.
Hand hygiene is the essential core compo-nent of all HAI reduction program. Handhygiene is not everybody'sresponsibilityitis your responsibility.
WASH YOUR HANDSIts YOUR Responsibility
Geoffrey Rake, M.D.Director, DoD Patient Safety Center
REVISED CALL FOR PATIENT SAFETYAWARD SUBMISSIONS
Deadline is November 7, 2008
The Office of the Chief Medical Officer
(OCMO) at TRICARE Management Activ-
ity (TMA), sponsor of the Department of
Defense (DoD) Patient Safety Awards, is
calling for submissions for the 2008
Patient Safety Awards. Now in its sixth
year, the Patient Safety Award recognizes
efforts designed to improve the care deliv-
ered within the Military Health System.
Please note that this years time-frame has
changed. The deadline for awards sub-
missions is November 7, 2008. However,
since the awards will be presented at the
annual Military Health System (MHS)
Conference, whose date has yet to be
finalized, the award submission deadline
may be subject to further adjustment
The formal awards Announcement and
Application Guide can be found on the
Patient Safety website: http://dodp
atientsafety.usuhs.mil/patientsafetyawards
. The seven-page Guide includes an
explanation of the award categories, the
application process and requirements,
instructions for the components to be sub-
mitted, and an example scoring guide
and sheet.
Please continue to check the Patient Safe-
ty website for further announcements
regarding Award submission deadline
changes.
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The shipboard terminology ship, ship-
mate, self was based on sailors com-mitment to placing their common
welfare ahead of their own in order to sur-
vive at sea. This mentality was as critical tothose onboard the USS Forestall as it was onUSS Cole. The same commitment is needed
to combat Methicillin-resistant Staphylococ-
cus aureus(MRSA) as well as other commu-
nicable diseases.
According to CDC, nearly 90 million people
in the U.S. carry naturally occurring bacteriastaph on their skin and nose.Over 2 millionof these carriers have MRSA, the mutated
form of staph that is resistant to many antibi-otics. Serious MRSA infections occur inapproximately 94,000 persons each year and
are associated with approximately 19,000deaths. Of these infections, about 86% are
healthcare-associated (HA-MRSA) and 14%are community-associated (CA-MRSA).
Deadly MRSA infections are preven
with personal protective measures. Thwhere you come in! What would you
you saw smoke coming from the
engine room? You would report it! Wwould you do if critical watertight intewas lost? You would secure it! This same
tude taken towards combating diseaseensure your safety as well as that of your
and shipmates.
4 SUMMER 2008 PATIENT SAFETY
Experiences and Suggestions From the FieldPATIENT SAFETY IN ACTION
Article from Trident Newspaper Outlines Annapolis Collaborative
SHIPMATES NEEDED TO FIGHT MRSA
Graphic representation of the collaborative effort between the Naval Academy and Naval Health Clinic Annapolis to reduce MRSA rates amonmidshipment by enhancing hand hygiene practices.
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PATIENT SAFETY SUMMER 2008 5
CA-MRSA is found in settings where the fiveCs (crowding, frequent skin-to-skin contact,uts or abrasions, contaminated items and
urfaces, lack of cleanliness) increase the risk
f spread. These settings include schools,military units, and athletic venues. CA-MRSA is most often spread through direct
ontact with contaminated skin, sharedlothing, towels, personal hygiene items orraining equipment. Prolonged person-to-
erson contact and lapses in personalygiene can create ideal conditions for CA-
MRSA transmission.
The following are personal protective meas-res for you and your shipmates in the battlegainst MRSA:
Check your skin routinely. Report unusu-
al cuts or wounds, abscesses, boils, orother pus-filled lesions to medical for an
evaluation.
Keep skin infections covered with a clean
dressing and avoid swimming, whirlpools,& saunas, contact sports, and other close
contact activities. Medical recommenda-tions for activity restrictions should be
taken seriously to prevent potential spreadof the infection.
Thoroughly wash your hands with soapand water a minimum of 5 times per day,
including before meals and after toileting.An alcohol-based hand sanitizer serves as a
great alternative when soap and water isnot readily available.
Take adequate showers daily or more fre-quently as necessary. Shower immediately
following physical activity.
Do not share personal items such as tow-els, wash cloths, razors, bar soap, other toi-
letries, or clothing such as undergarmentsand athletic jerseys with others.
Do not reuse soiled clothes or towels.Launder these items daily with detergent
and hot water.
Disinfect athletic areas and sports equip-ment at least weekly using a commercialdisinfectant (look for EPA-approved, hos-
pital-grade germicide on the productlabel) or a fresh (daily mix) solution of 1part bleach to 100 parts water (1 table-
spoon bleach in 1 quart of water). Bleach
solution must be left on surfaces for atleast 5 minutes to achieve maximum dis-infection.
Wipe surface of sports equipment and ath-letic gear prior to use with a clean dry
towel. Use sanitary wipes if available toclean equipment before use.
Use a towel or clothing as a barrier
between the skin and shared equipment.
Disinfect commonly touched or soiled sur-
faces in your living quarters on a regularbasis using an EPA-registered product effec-
tive against Staph: http://www.epa.gov/.Follow label instructions for use.
Launder clothing, towels, and sheets inwater with laundry detergent at hottest
suitable temperature. Dry in a dryer athottest suitable temperature. Avoid line
drying your clothing.
a. Launder uniforms on a regular basis. If
laundering once weekly, recommendchanging uniform at least mid-week to
ensure cleanliness. Uniforms may needmore frequent laundering/changingdepending on the temperature and activi-
ty. Be a friend and tell your shipmate ifhe/she needs to change his/her uniform!
b. Launder used towels, athletic gear daily.
These easy and practical personal protectivemeasures were put to the test over the courseof plebe summer 2007. In a collaborative
effort between Naval Health Clinic Annapo-lis and Naval Academy leadership, these
measures as well as other education andinfection prevention initiatives were imple-
mented to improve hygiene and control theincidence of CA-MRSA infections amongplebe midshipmen. MRSA prevention edu-
cation sessions were provided to plebes,training cadre, and the medical staff. Hand-
washing was emphasized, and hand sanitizerwas made readily available in the mess hall
and as issue in medical welcome aboardpackages for plebes. In addition, showeringtimes were increased to 35 minutes in
length, weekly antiseptic showers wereencouraged, and weekly environmentacleaning of plebe personal spaces and gea
was recommended. These efforts con
tributed to an 83% drop in the incidence ofMRSA wound infections as well as a 71%reduction in lost physical training time
among Plebes.
These observations support the premise tha
education and enhanced hygiene are reasonable strategies to help control the incidence
of skin infections that are easily spreadthrough close contact with individuals
and/or contaminated objects. Monitoring oMRSA cases and considerations for contin-ued improvement are ongoing at Nava
Health Clinic Annapolis.
Article reprinted with permission oTrident Publications and the United States
Naval Academy, Annapolis, Maryland.
Experiences and Suggestions From the FieldPATIENT SAFETY IN ACTION
SUMMER READING PICKS
The Best Practice Charles Kenny
IHI highly recommends this first ever docu-
mentation of health care's quality move-
ment for anyone interested in understand-
ing today's efforts to transform health care.
Joint Commission Alert: Behaviors That
Undermine A Culture of Safety
This Alert by the Joint Commission
addresses intimidating and disruptive
behaviors among health care profession-
als, describing such actions as a serious
threat to patient safety and the overall
quality of care.
http://www.jointcommission.org/Sen-
tinelEvent/SentinelEventAlert/sea_40.htm.
2009 Patient Safety GoalsAccess the official, approved 2009 Patient
Safety Goals and helpful solutions for
meeting them at http://psnet.ahrq.gov/
resource.aspx?resourceID=8135&sour-
ceID=1&emailD=16003
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The first phase of the 2008 MHS PatientSafety Culture survey concluded on May 182008 with the completion of data collec-
tion. There were 72,478 raw responses sub-
mitted by MHS facility personnel for a rawresponse rate of 58%. Phase 2, data clean-ing and validation, has been completed.
Data cleaning removes invalid surveys fromthe total. Reasons for removal are respon-dents who straight-lined all their responses
or did not answer any of the survey ques-tions. After data cleaning there were 70,837
validated responses for an overall 57%response rate MHS wide. When the survey
was given initially in 2005/2006 the MHSresponse rate was 53%. The graph includedat right shows the number of validated
responses by Services as well as the overallMHS responses. The graph also compares
the 2008 survey results with the results
from the 2005/2006 survey. In the currentsurvey, the Air Force had a 69% response
rate followed by the Navy with 53% and theArmy with a 52% response rate.
The response to this survey was exception-al. Thirty-five facilities came in at over 85%
response rates with twenty-eight of those
over 90%. Only six facilities MHS-widecame in at less than 40% response rates.We anticipate survey analysis to be com-
pleted by August with reporting distributedby mid-September.
The DoD Patient Safety Program staffthanks all of you who took the time to par-
ticipate in the survey and the Service repre-sentatives for their help in ensuring maxi-
mum participation. Special recognition goesto Ms Kristi Yarcho, Air Force survey POC,for the outstanding 69% showing in the Air
Force. We look forward to your impressionson the culture of patient safety in the MHS.
374 MDG, Yokota AFB Shares Patient BoardThe Patient Board pictured above was devel-oped by Capt Brian Smith, NC, USAF to helpimprove hand-offs while including the patientin the process. Located in the patients room,the Patient Board has proven to be a usefulreminder about the current plan of the day toboth the patient and the health care team.Feedback has been positive for this HIPAA-approved tool. Patients appreciate the trans-parency the board has brought to their careplans. They report feeling more a part of theirplanning. Nurses have found that the boardhelps them avoid mistakes that come frommisplacing or losing paper checklists. Formore information, contact Scott Chittenden,Patient Safety Manager at the 374th MDG.([email protected])
TeamSTEPPS Modules On-LineTeamSTEPPS modules for the Fundamentalsand Essentials courses are now available onthe Patient Safety website. This is exciting
news for TeamSTEPPS trainers, who can nowimmediately access all course materials any-where in the world where internet serviceexists. The modules include slides and sup-porting video clips, which play right inside theslide and are accessed with a simple click onthe screen. The screen shot pictured above isfrom the Team Structure module in the Funda-mentals course. It captures a moment on thevideo clip which presents a team failure roleplay scenario. To access TeamSTEPPS modulesgo to http://dodpatientsafety.usuhs.mil/teamsteppsmodules.
Published quarterly by the Department of Defense(DoD) Patient Safety Center to highlight the progress
of the DoD Patient Safety Program.
DoD Patient Safety ProgramOffice of the Assistant Secretary
of Defense (Health Affairs)
TRICARE Management ActivitySkyline 5, Suite 810, 5111 Leesburg Pike
Falls Church, Virginia 22041703-681-0064
PATIENT SAFETYPROGRAM NEWSLETTER
Forward comments and suggestions to:DoD Patient Safety Center
Armed Forces Institute of Pathology1335 East West Highway, Suite 6-100
Silver Spring, Maryland 20910Phone: 301-295-7242
Toll f ree: 1-800-863-3263DSN: 295-7242 Fax: 301-295-7217
E-Mail: [email protected]: http://dodpatientsafety.usuhs.mil
E-Mail to editor: [email protected]
DIVISION DIRECTOR,PATIENT SAFETY PROGRAM
COL Steve Grimes
DIRECTOR, PATIENT SAFETY CENTERGeoffrey Rake, MD
DIRECTOR, CENTER FOR EDUCATIONAND RESEARCH IN PATIENT SAFETY
Eric S. Marks, MD
DIRECTOR, HEALTHCARE TEAMCOORDINATION PROGRAM
Ms. Heidi King
SERVICE REPRESENTATIVESARMY
LTC Anthony BohlinNAVY
Ms. Carmen BirkAIR FORCE
Lt Col Anne Coyne
PATIENT SAFETY PROGRAM NEWSLETTER EDITORPhyllis M. Oetgen, JD, MSW
6 SUMMER 2008 PATIENT SAFETY
Patient Safety: All Day, Every Day Across the MHS
PATIENT SAFETY PHOTO ALBUM
MILITARY HEALTHSYSTEM (MHS)Patient Safety Culture Survey Update
80,000
60,000
40,000
20,000
008 Validated Results
Air Force
Army
Navy
MHS
Patient Safety Culture Survey
24,077
26,577
20,183
70,837
22,016
21,689
18,843
62,548
05-06 Validated Results
SEND YOUR PHOTOS TO NEWSLETTER EDITOR at [email protected]