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1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital
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1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

Mar 26, 2015

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Page 1: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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Nancy Carrier, RN, BSNQuality Support

Tift Regional Medical Center Tifton, GA

PI CME in a Community Hospital

Page 2: 1 Nancy Carrier, RN, BSN Quality 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

Page 3: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 4: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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Page 5: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 6: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 7: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 8: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 9: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 10: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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.

Page 11: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 12: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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?

Page 13: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 14: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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)

Page 15: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 16: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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Goals & Objectives

Patient Outcomes

Surgical site infections will decrease in total joint patients

Reduce use of Vancomycin for surgical prophylaxis

Page 17: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 18: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 19: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 20: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 21: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 22: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 23: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 24: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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Unless commitment is made, there are only promises and hopes; but no plans.

-- Peter F. Drucker

Page 25: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 26: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 27: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 28: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 29: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 30: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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)

Page 31: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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.

Page 32: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 33: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 34: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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……..

Page 35: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 36: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 37: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 38: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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.

Page 39: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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!

Page 40: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 41: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 42: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 43: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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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

Page 44: 1 Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA PI CME in a Community Hospital.

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Just play! Have fun. Enjoy the game! -- Michael Jordan