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Nancy Carrier, RN, BSNQuality Support
Tift Regional Medical Center Tifton, GA
PI CME in a Community Hospital
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About Tift Regional Medical Center (TRMC) Located in South Central Georgia
- Combined service area population - 250,400 (12 counties)
- Governed by Hospital Board Authority- State accredited CME provider
Staff
- 120 physicians on staff representing 15 specialties
- 1,600 employees
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About TRMC
191 licensed beds
- 176 acute care- 15 skilled nursing
2010 Volume
- 1,093 deliveries
- 48,833 ER patients
- 12,244 inpatients
- 110,412 outpatients
- 7,595 surgical cases
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Medical staff structureHospital Authority
Medical Executive Committee
Department of Medicine
Department of Surgery
Department of Peds
Department of OB
Department of Family Practice
CardiovascularCommittee
Emergency RoomDepartment
GastrologyCommittee
Critical Care Committee
Quality Council
Clinical MonitoringCommittee
Infection Control Committee
MRSA PI/CME
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Hospital structure
Hospital Authority
CEO
QM Director CNO HR Director CFOOutreach & Development
VPMA COO
CME
Work Smart
Joint CommissionResources
Case Management
Infection ControlHealth Plus
Clinics
Quality Management PI / CME
Physician ServicesRecruitment
Liaison
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CME Program CME Committee (working committee) Very active and committed Director CME - monthly RSS Activities (4)
Other Activities: Physician case based research (PoC) Enduring CME PI CME
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PI CME
Started in 2007 with first project on Sepsis
Developed a model for all future projects
Change happens when physician driven
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Pre-op MRSA screening & intervention before elective total joint replacements (TJR)
Needs identified by Infection control and discussed in the Department of Surgery medical staff meeting
Back ground research done
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Needs Assessment
The MRSA Risk assessment for 2008 revealed an increase in SSI with MRSA
Orthopedic statistics were the highest Increase in community acquired MRSA
in area Patients colonized with MRSA are at risk
for developing a SSI following an ortho procedure & have a 3.4 x higher risk of death and 2 x greater hospital costs.
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Define the “GAP”
Pre –op patients colonized with MRSA are not identified
Only patients with acute infections are cultured
No decolonization guidelines for patients No formalized educational support
resource Pre op antibiotic selection not consistent
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Close the GAP
Research Best Practice – evidenced based
Identify national performance measures
How do you do this?
Where do you go to get this information?
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Evidence basedPerformance Measures (examples) Physician Quality Reporting Initiative
(PQRI) Physician Consortium for Performance
Improvement (PCPI) Institute for Healthcare Improvement
(IHI) CDC National Organizations Evidenced based literature research
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MRSA
CDC & Surgical Care Improvement Project (SCIP) Guidelines
SHEA (Society for Healthcare Epidemiology of America)
IDSA (Infectious Diseases Society of America)
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Goals & Objectives
Screen 100% of patients scheduled for elective total joint replacements for MRSA during their pre op assessment
All colonized patients will complete a decolonization protocol before surgery 2% mupirocin ointment to nose bid x 5 days pre-op 4% chlorohexidine gluconate body wash x 5 days pre-op
Colonized patients will be screened again prior to surgery
Colonized patients will be placed in Contact Precautions upon admission
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Goals & Objectives
Patient Outcomes
Surgical site infections will decrease in total joint patients
Reduce use of Vancomycin for surgical prophylaxis
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PI CME – 1st steps
This PI CME project started in March, 2009
Planning started CME & QI brainstorming
IC and the Ortho group requested to “take on the challenge”
Provide background information & literature
Needed to identify champion IC Committee chair
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Project leader / physician champion
Physician Passion for the project Finalize team members identified to participate Invited physicians to participate by letter Follow up with a phone call Want cross section representation of all
departments involved when ever possibleWe may affirm absolutely that nothing great in the world has ever been accomplished without passion.-- Georg Hegel
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Adding Support Staff
Laboratory OR Day Surgery and Assessment nurses Ortho nurses Infection Preventionist Orthopedic PAs Pharmacy QI/ Data analysist CME
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Initial kick-off meetingProvide a meal for the initial meeting Overview of QI / PI CME activity Establish ground rules
Peer protection Confidentiality
Expected time frame What commitment would involve
Required to sign letter of commitment Educational backup
Literature & articles Web sites Grand rounds and 1:1 time with expert
Benefits of participants Become resources for peers Develop guidelines they would be measured against CME Credit Several free lunches / dinners
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Next Steps
Letter of Commitment Confirmation of goals Schedule of future meetings Reading Assignment
SHEA/IDSA Practice Recommendation, “Strategies to Prevent Transmission of MRSA in Acute Care Hospitals” Oct 2008
CDC “Management of Multidrug-Resistant Organisms” 2006
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Meeting Calendar
Dinner Kick-off and assignments Sub-Committee report back Guideline draft presented / approved Guideline roll-out Possible Grand Rounds Final Meeting / Wrap-up
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Letter of Commitment
You are being asked to participate in a Performance Improvement study at TRMC that involves improving pre-op MRSA screening & treatment of patients who are scheduled for elective Total Joint Replacements.This form provides you with information about the expectations of the study and encourages commitment of about 6 monthsparticipation. --------_is the Director of this project and is available to answer any questions that may arise. Please review the following information and if you agree to participate, please sign in the appropriate sections.
Name: Practice Specialty: PediatricsDr phone: e-mail
Title: Pre-op MRSA screening & treatment for elective Total Joint ReplacementsPurpose: To develop protocols designed to decrease the incidence of SSI by MRSA, including active surveillance cultures to identify patients colonized
with MRSA and decolonization of patients with MRSA prior to surgery.
Benefits: Improve patient care by decreasing the incidence of SSI in elective Total Joint Procedures caused by MRSA.Cost: No cost will be accrued to you for participating; however, there will be a time commitment.Compensation: You will not receive payment for participating. Up to 20 CME credits will be awarded commiserate with your participation. Educational
opportunities will be provided and any expenses incurred such as travel will be reimbursed.Privacy Information will be shared that must remain confidential. The information discussed in this group will be peer protected through the ICConfidentiality: committee
Expectations: We will ask your commitment to reading all literature provided, to attend any planned CME conference, and participate in the project as outlined. Periodic evaluations will be provided for you to complete, including a summary at the end of the designated time frame of the project.Monthly meeting time will be set. We understand that your time is important. We will start and stop on time. You may be asked to review data collection summaries to validate the results. All HIPAA sensitive information and peer review must remain confidential.
You have been informed about this project’s purpose, benefits and expectations and have been given the opportunity to ask questions. By signing, you voluntarily agree to participate in this project.
_______________________________________ __________________Signature Date
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Unless commitment is made, there are only promises and hopes; but no plans.
-- Peter F. Drucker
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CME credit
Give overview of the PI/CME process Explain Stages A, B & C Review the evidenced based
performance measures Review their commitment and
documentation required to be awarded credit
Answer all questions
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Stage A Learning from current practice performance assessment The team Physicians review patient data
May request additional information Objectives for PI CME activity are defined
Public reporting Review current practice and make recommended
changes in physician practice (hospital-wide) Develop P&P as needed
Standardize educational materials
Develop Stage A measures
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MRSA ScreeningPerformance Measures
Goal Indicator Definition
100% Percent of population screened Number of patients cultured/number of planned total hips and knees
100% Percent compliant with decolonization protocol
Number of colonized patients who completed decolonization protocol/number of colonized patients
100% Effective decolonization Number of negative follow up screens/number completing decolonization
< 1% Surgical Site Infection (SSI) rate for total hips and knees
Number of SSIs/total number of hips and knees
100% Patient Education on MRSA screening
Number of patients receiving education/number of patients screened
Establish
TRMC
Prevalence
Percent of populations colonized with MRSA
Number of positive initial screens/total number of patients screened
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Stage B Learning from the application of PI to patient care
Develop guidelines for identifying patients colonized with MRSA and steps to take to initiate decolonization procedures
Provide surgical and orthopedic staff education Provide patient education Standardize educational materials for patients Develop discharge planning tools for patients Develop checklists Write policies and procedures Review antibiotic practices
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Stage B interventions
Development of new guidelines Committee approval
Staff education MRSA Pre-op assessments and scheduling Nasal swabbing Medications used Documentation requirements
Patient education MRSA booklet Pre op & post op instructions
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Building patient & hospital interest
Living with MRSA
This is really serious! I need to do something about this now!
Learning how to control the spread of Methicillin-Resistant Staphylococcus Aureus (MRSA)
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There is a simple, painless nasal swab test for a potentially dangerous pathogen called Staphylococcus aureus, also known as MRSA (Methicillin-resistant Staphylococcus aureus). This test identifies people who are potential reservoirs of infection. You can carry MRSA in your nose or on your skin without displaying symptoms. Approximately 1 in 5 people carry MRSA. An approach called Active Surveillance Culturing could reduce MRSA infections in hospitals by more than 70 percent.
Total Joint Replacement Pre-Operative Screening ProtocolPeople who harbor these bacteria in their nose, or on their skin, are called “carriers,” or are “colonized” with the bacteria. MRSA colonized patients are at higher risk for developing MRSA infections after surgery at their surgical site. During your pre-op assessment, the nurse will use a Q-tip swab to collect a culture from your nose to determine if you are an MRSA carrier. If you test positive for MRSA, someone will contact you with further instructions prior to your surgery.Your doctor will order a nasal ointment to be applied to your nose twice a day for 5 days just prior to your surgery.Since this bacteria could also be living on your skin, it is very important that you bathe once a day using the Hibiclens body wash for 5 days just before your surgery. Hibiclens can be purchased from your local Pharmacy without a prescription.We are very committed to providing you the best care possible.
It is very important that you follow these instructions to minimize the risk of complications after surgery.
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Stage C Learning from the evaluation of the PI effort
Final chart reviews began one month after guidelines were completed and interventions were implemented
Analyze chart reviews Review compliance with new guidelines Implementation success Determine opportunities for improvement
Do something. If it works, do more of it. If it doesn't, do something else.-- Franklin D. Roosevelt
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Final meeting with participating physicians
Project physicians review their individual data
Guidelines are reviewed & edited as needed
Complete final evaluation & credit request forms
AWARD CME CREDIT!
Develop plan to communicate changes & educate
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Continuing Medical Education Credit Request for Performance Improvement Activity
TRMC pre-op MRSA screening & treatment for elective
total joint replacements
April, 2009
Stage C
Activity: please check areas you have completed, respond to the questions and sign
I completed the implementation plan for the Performance Improvement CME project for MRSA Initiative
I evaluated the progress made through implementation of this plan
Please describe below whether the intervention (Individual Action Plan)
you implemented improved your department practice/performance in
those areas identified. If not, please provide an explanation as to why.
Factors such as systems failures or other barriers to success should be
included……..
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Results from activity
Goal Indicator Results
100% Percent of population screened 100%
100% Percent compliant with decolonization protocol
92%
100% Effective decolonization 92%
< 1% Surgical Site Infection (SSI) rate for total joint replacements
0.67%
100% Patient Education on MRSA screening
100%
EstablishTRMCPrevalence
Percent of populations colonized with MRSA
17% All this data has been collected since 5/18/09
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Barriers Identified
Determining benefit of active surveillancescreening
Monitoring compliance with decolonization
Follow up on decolonizationfailures
Availability of 4% chlorohexidine gluconate
Compliance with ContactPrecautions
This was a learning
curve that soon was
overcome This was based on
patient report so was out of
our control A discharge instruction sheet
was designed
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Benefits
Pre-op showers with 4% chlorohexidine gluconate for alltotal joint patients Improved compliance with Contact Precautions Standardized patient education on MRSA Developed discharge instructions for patients colonizedwith MRSA Appropriate use of Vancomycin as a pre-op antibiotic
SSI rate decreased (>50% through 2010)
TRMC now uses all 4% chloro-hexidine gluconate showers for ALL surgeries not just joints
Staff education and awareness on Ortho unit
MRSA booklet providing standardized education
P&P developed Marketing tools and posters
Decrease in Vancomycin useimproving resistance rates
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Recommendations
Continue MRSA
screening for total joints
and extend to other
procedures Consider 4% chloro –
hexidine gluconate for all pre-
op showers Investigate all surgical
site infections and observe for
any trends or common links
Any implants such ashernia mesh as well as all spinal implants.
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Final Discussion & Roll Out Presentation to QualityCouncil
General SurgeonEducation
Cost analysis
Final report from Infection Control
CME credits
Adjournment
Physician champion & IC presentedfindings to the hospital QualityCouncil then to the Board This data will be presented at the Department of Surgery. Even though the hernia infection rate is <1.5%, there is always room for improvement IC will work on a cost analysis forprevention costs as compared toinfection costs (selling point for admin) All implants must be followed forinfections for 12 months. At the end ofthis time, IC will report a final infection rate. 20 Category one credits will be awarded Great Job!
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Recruit a strong physician leader Follow the “ground rules” established in
your first meeting Keep within the time frames agreed
upon Make sure it is physician driven Feed them!
Tips for engaging physicians
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Lessons learned
Administrative support Committed medical leader Buy-in from medical staff participating in project Preparations for each meeting
(pre-meeting meetings)
Clear expectations Defined budget Food Celebrate success
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Advice for other CME providers
Utilize your Resources (QI loves this stuff!)
Excitement with success! Share your success with peers Be prepared for the time commitment Strong non-medical leader CME Director backing Record keeping Facilitate CME compliance
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Comments from the MRSA Physician Champion
It IS doable Recommend a strong support team The Physician champion will coordinate
with the support staff to keep everyone working in the same direction
Be available by phone or e-mail; it will save on overall time commitment and meetings
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Just play! Have fun. Enjoy the game! -- Michael Jordan
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