1. Clinical Quality & Safety Center for Clinical Quality & Safety
A Progress Report
October 4, 2010
Mayer Brezis, MD MPH
Professor of Medicine
Center for Clinical Quality & Safety
מי צריך לקבוע מה היא איכות: מטפל? מטופל?, מנהל? מבטח? משרד בריאות? עתונאי? שופט? 1 1

2. (I) Ventilator-Associated Pneumonia (VAP)
(II) Medication Reconciliation (Med-Rec)
(III) Follow Up on a few other projects 2 2

3. Ventilator-Associated Pneumonia (VAP)
Project aim: reduce VAP incidence at Hadassah
Inna Apelbaum, Nurit Katz, Dr. Philip Levine, Dr. Shmulick Benenson, Carmela Shwartz, Prof. Colin Block, Lois Gordon, Prof. Mayer Brezis
General Intensive Care, Unit for Infection Control and the Center for Clinical Quality and Safety

4. 4

5. Recommendations Rated With High Level of Evidence
VAP Prevention:
Recommendations Rated With High Level of Evidence
ICHE 2008

6. Summary for 2009 survey
The incidence of VAP at Hadassah is higher than what is reported in the literature.
The adherence to guidelines for VAP prevention is lower than desirable.
How can adherence to guidelines be improved?
Elevating the head of the bed between 30o- 45o
Hand hygiene by staff before and after contact with ventilator, patient and patient’s belongings
Oral hygiene including brushing
Discontinuation of sedation once a day

7. Intervention Findings discussed with staff
Review of guidelines at staff meetings s
Signs
Posters
Buttons
Screensaver
Re-evaluation scheduled for early 2010

8. Periods of observation: Pre Intervention:
Survey results
Periods of observation: Pre Intervention:
February – March 2009
Post Intervention:
February – March 2010

9. 2009 ICU A 12 449 (187) 32 ICU B 11 175 (78) 19 Neurosurgical ICU 16
Department
Mean ventilation days/pt.
Ventilation days during period (observed for processes)
N of ventilated patients during observation period
ICU A 12
449 (187) 32
ICU B 11
175 (78) 19
Neurosurgical ICU 16
195 (86)
Medical ICU 10
220 (81) 17
Total
1039 (432) 79
Intern. Medicine A
212 (79)
Intern. Medicine B
139 (55) 13
Intern. Medicine C 9
238 (106) 25
Neurology 14
29 (13) 2
618 (253) 57

10. 2010 ICU A 12 128 (58) 11 ICU B 8 73 (34) 9 Neurosurgical ICU 4
Department
Mean ventilation days/pt.
Ventilation days during period (observed for processes)
N of ventilated patients during observation period
ICU A 12
128 (58) 11
ICU B 8
73 (34) 9
Neurosurgical ICU 4
23 (11) 6
Medical ICU
84 (41) 13
Total 7
308 (144) 39
Intern. Medicine A
50 (23)
Intern. Medicine B
64 (29)
Intern. Medicine C
57 (25)
Neurology
80 (33)
251 (110) 29

11. Adherence to VAP prevention guidelines
% Head of bed ≥ 30o
% Ventilator tubing clean
Department
2009
2010 ()
2010
ICU A 59 62 74 88
ICU B 58 40 75 85
Neuro ICU 32
91* 68 82
Medical ICU 54 41 72
Total
53%
55%
72%
85%*
Medicine A 36
78* 71 83
Medicine B 37
69**
Medicine C 52 69 80
Neurology 70 92 79
39%
68%*
75%
81%
 for stable patients only
* p< ** p<0.01

12. Adherence to hand hygiene (nurses)
Hands washed before contact (%)
Hands washed after contact (%)
Department
2009
2010
ICU A 35
86* 54
91*
ICU B 33
76* 52
Neuro ICU 30 55 39
82**
Medical ICU
85* 47
93*
Total
33%
75%*
47%
91%*
Medicine A 29 57
Medicine B 27 34 37
62**
Medicine C 26 36 38
68**
Neurology 23 62 48
28%
34%
39%
58%*
* p< ** p<0.01 12 12

13. Hand hygiene (respiratory technicians)
Hands washed before contact (%)
Hands washed after contact (%)
Department
2009
2010
ICU A 12 26 58
ICU B 13 23 59 62
Neuro ICU 8 27 45 63
Medical ICU 11 39 55 71
Total
11%
29%*
54%
63%**
Medicine A 10 48 65
Medicine B 9 34 46
Medicine C 32 47 72
Neurology 15 38
10%
30%*
47%
66%*
* p< ** p<0.05 13 13

14. Diagnostic criteria for VAP

15. Rates of VAP: 2009 & 2010 2009 2010 Total Medicine ICUs 67 24 43 1123
Department 67 24 43
Patients observed
1123
296
827
Ventilation days 20 5 15
Cases of VAP
30%
21%
35%
Percent developing VAP
‰ 18
17 ‰
18‰
VAP cases/1000 ventilation days
2009 60 19 41
Patients observed
1094
383
711
Ventilation days 20 7 13
Cases of VAP
33%
37%
32%
Percent developing VAP
‰ 18
18 ‰
VAP cases/1000 ventilation days
Mean cases/1000 ventilation days in literature* 11‰ (95%CI, 10-13)
2010
* Chest (before interventions, down by 50% after interventions)

16. Rate of VAP per 1000 ventilation days
2009
2010
Department
N of days observed
Rate of VAP ‰
ICU A
594 19
252 24
ICU B
124 8
Neuro ICU
176 17 53
Medical ICU 57 18
282 21
Total
827
18 ‰
711
Medicine A 84 48
Medicine B
108 9 75 13
Medicine C
104 95
Neurology
165
296
17 ‰
383 16 16

17. Summary & Discussion: VAP at Hadassah
Adherence to VAP prevention guidelines has somewhat improved but remains lower than desirable.
The incidence of VAP remains higher than that reported in the literature.
Reactions from teams:
“We don’t believe your data”
“You lie and mislead”
“Our patients are sicker”
“We need more staff”
“We need more equipment”
“We need to look into this issue”
“We should have a checklist to increase adherence to guidelines”
“We should introduce a protocol of daily sedation cessation”
“We will build an algorithm for VAP diagnosis”

18. Ventilator-Associated Pneumonia
Saving Lives with Baldrige & IHI, Session D3 & E3
Ventilator-Associated Pneumonia
Last VAP
SICU: Jan. 1, 2008
CICU: January 15, 2010*
*Prior to 1/15/10, the last CICU VAP was on 3/24/08, or 621 days
2003 – 3 VAPS each; 2004 – 4 & 3; & 1; 2006 – 2 & 5, 2007 – 3 & 1, 2008 – 1 each ;
Graph path: R:\MCR_CRITICAL_CARE\QUALITY\09_IHI\BUDhAS\Annualized Graphs
Do we want to add the events noted on the previous slide to show we continue to work on improvement despite a low rate??

19. Saving Lives with Baldrige & IHI, Session D3 & E3
VAP: The Beginning (2001)
Do we have a problem?
IHI Conference: VAP Prevention Bundle
BUDAS: Bed up, Ulcer prophylaxis, DVT prophylaxis, Anemia, Sedation wake-up
VAP Workgroup: Critical Care Medical Director, Infection Control, CNS, Respiratory Therapy
Consistent definition for VAP
Policies & procedures
Equipment & supplies
Intensivists
Education of RNs & RTs
Conference attendance December EBM and “how’s” to roll out. Applied Baldrige opportunities. Ideas generated from conference, creating a systematic plan. Discuss the story of BUDAS pneumonic creation.

20. Saving Lives with Baldrige & IHI, Session D3 & E3
VAP Initiatives ( )
BUDAS
Intensivist Co-Attending Model
Multidisciplinary Rounds
Reviewed components of BUDAS
Reinforced education
Education of ICU RNs & RTs
Hand cleanser dispensers
Monthly compliance review by Critical Care Medical Director
Critical Care Committee
Informed physicians of EBP changes
Utilized PDCA, Focus: patient care , Multiple cycles of improvement, small steps
Implementation: 2002 into 2004, year to solidify process; contracting with physicians, daily rounding. It took about a year to really solidify the rounding process. It was a big change in culture and there were many details to work out.

21. Saving Lives with Baldrige & IHI, Session D3 & E3
Compliance with BUDAS
BUDAS compliance 100% in both units since March of 2008
Pathway to graph: R:\MCR_CRITICAL_CARE\QUALITY\CICU and SICU Data\BUDdAS\2007 BUDhAS Data (2009 BUDhAS Data has monthly compliance graphs)

22. Process Improvements (2004)
Saving Lives with Baldrige & IHI, Session D3 & E3
Process Improvements (2004)
Daily multidisciplinary rounds (7 days a week)
Chart documentation
Physician contracting
Chart documentation for The Joint Commission (rolled out 2004 after 2003 site visit)

23. Saving Lives with Baldrige & IHI, Session D3 & E3
Cycles of Improvement
Reported BUDAS compliance by individual component
Improved oral care, added chlorhexidine rinse
Opened MCR with best practices from PVH
Switched to oral gastric tubes
Reinforced standard procedure, chlorhexidine has to be after toothbrushing, storage of Yankauer, deep oralpharyngeal suctioning
Introduced silver-coated endotracheal ETT (IHI 5 Million Lives Campaign)
New approach: Root cause analysis for each VAP
Each year we have continued to make incremental improvements to improve outcomes. Our VAP rates have actually been very good since 2006, but we have continued to work to push the rate as low as possible and recently we have achieved a rate of zero. We did not think that would be possible in the beginning of our journey.

24. Saving Lives with Baldrige & IHI, Session D3 & E3
Lessons Learned
Small incremental improvements based on audit data, literature & outcomes
Education, education, education
Posters, case studies, self-learning packets, face to face
Physician engagement
Partner with physician champion
Staff engagement
Engage staff in solving problem
Post rates in each ICU
Rates = reflection of THEIR practice
Engagement on two levels:
Physician – share story of ownership (education at start up, incrementally and during rounds, new ideas for improvements) and monthly data
Staff – now see this as their practice, their responsibility

25. Medication Reconciliation
Roni Cohen, B.Sc., Inbal Yifrach-Damari, M.Sc.* Dr. Meir Frankel, Prof. Mayer Brezis
Hadassah-Hebrew University Hospital, Jerusalem, Israel
* Clinical Pharmacist, Hadassah Pharmacy Services PhD student, School of Pharmacy, Hebrew University
With Help From Joint Commission International 25

26. Medication Errors
Medication errors are the fourth leading cause of death or major permanent loss of function in hospital patients.
The majority of problems with patient safety occur during the transition from one care setting to another.
Ambulatory-hospital lack of communication is responsible for 50 % of medical errors.
To improve patient safety, the Joint Commission on Accreditation of Healthcare Organizations now recommends a procedure designed to minimize errors. 26

27. What is Medication Reconciliation?
Obtaining a complete and accurate list of each patient’s medications.
Documenting EVERY change: Before the patient moves on, the physician must decide about each drug:
CONTINUE
DISCONTINUE
This way, no drug is forgotten!
Drugs include: ‘over-the-counter’ medications, topical medications, eye drops, vitamins, herbal medications and ‘occasional’ medications. 27

28. Methods for current project
Over 100 adult patients admitted to the ER, on at least 5 regular drugs, underwent medication reconciliation.
Review of medications with patient, family, primary physician and/or database of HMOs (sick funds).
After hours, we checked the list of medications prescribed to the patient by the ward staff.
Our list was then compared with the list in the ward.
If any discrepancy was observed or an error was suspected, the staff was approached to clarify the reason for the change. 28

29. Overall Errors
In 97% of our patients, an error / intervention was found on admission, during hospitalization or at discharge.
On average: 7 mistakes / interventions per patient
Pharmacological interventions
in 85%
Med-Rec interventions
in 87%
On average: ≈ 3 mistakes / interventions per patient, of any kind 29

30. Medication Errors on Hospitalization
At least one error was found in 73% of the patients
Enalapril and ramipril were both prescribed in the ward.
Antiepileptic drug, taken at home, was not continued in the ward.
Captopril was prescribed to a patient only once a day (instead of 3 times a day).
Hydralazine was written for no reason. 30

31. Medication Errors at Discharge
At least one error was found in 65% of the patients
“Pain killers as needed”
Combination of nortriptyline & citalopram
Levothyroxine (eltroxin) omitted from discharge letter.
Propafenone
prescribed once a day (instead of 3 times a day).
Alendronate omitted from discharge letter. 31

32. Severity of Medication Errors
On Hospitalization
At Discharge
39%
47%
46%
45%
13.5%
7.5%
1.5%
0.5 32

33. At least one error / problem was found in 23% of the patients!
Telephone Interviews
At least one error / problem was found in 23% of the patients!
Nearly all patients had visited primary care physician after discharge.
25% of patients were not aware of a change in medication.
On occasion, an error noted during admission was continued after discharge. 33

34. Clinical Pharmacist Service
In 85% of patients:
Apply correct indications and contra-indications (≈18%).
Adapt dosage to kidney or liver function (≈15%).
Drug-Drug Interaction (≈37%).
Correct administration: After discharge, over 50% of patients were not taking medications correctly.
Polypharmacy 34

35. On Medication-Reconciliation Elsewhere
Survey of 100 patients at the Mayo Clinic: Inpatient Medication Reconciliation in an Academic Setting American Journal of Health-System Pharmacy 2007 Number of medication discrepancies decreased from 3 per patient in phase 1 to 1.8 per patient in phase 2 (p = 0.003) Survey of 180 patients at Brigham and Women’s Hospital, in Boston: Classifying and Predicting Errors of Inpatient Medication Reconciliation. J Gen Intern Med Average of 1.5 error per patient with potential for harm. Solutions included development of special software for adapting prescription to the patient’s provider preferred medications outside hospital.

36. Discussion
Avoidable mistakes in medications are very common. About 1% can be life threatening.
Drug lists, in the community and in hospitals, are not updated and often fail to reflect the medications that the patient actually takes.
A correct medical history can identify errors and can sometimes even shed new light on the cause of hospitalization.
Critical changes in medications made during hospitalization are often not implemented after discharge. 36

37. Solutions to Reduce Errors
At the individual level: have patient bring his/her bag of drugs and carefully review them with him/her.
A clinical pharmacist is very useful, as shown in literature: improvement in outcomes, ↓errors, cost of care & LOS.
Devise a computerized table for medication reconciliation for each patient at each transfer of care provider.
Improve IT for transfer of information between Hadassah and outside providers on admission and on discharge.
Monitor quality for continuity of care by measuring quality of handovers within Hadassah wards and with outside.
Medication
Continue
Discontinue
Why?
Aspirin 
Furosemide
hypokalemia 37

38. (III) Follow Up on a Few Other Projects
Family’s Involvement during Physician’s Rounds
After discussion of survey findings, a new policy was enacted by the Division of Medicine to allow one relative to be present during physician’s round. This policy was also suggested to other departments by Ein Kerem Director, Dr. Y. Weiss.
Checklist to reduce central lines infections
Major project at Hadassah showed a 65% reduction in central lines infections with the use of a checklist (as shown by Pronovost et al, NEJM 2006).
Despite this success, checklist has not been adopted in routine work in any unit. We are trying to introduce at least routine recording of insertion in the chart. To help overcome inertia, we proposed to the Ministry of Health to publish guidelines with mandatory use and documentation of a checklist. The guidelines were prepared based in part on Hadassah experience and their publication is pending. 38 38

39. (III) Follow Up on a Few Other Projects
Leadership for Quality & Safety
A survey on leadership at Hadassah,* showed that 70% of departments heads and 80% of head nurses, thought it would be appropriate to use as criteria for appointment (or re- appointment) of a department head, presentation of initiatives on clinical quality & safety.
Such a policy is worthwhile to consider as it would enhance participation of clinical heads in quality & safety and facilitate implementation of improvement initiatives such as on VAP and central line infections.
* Dr. Nurit Porat. The Relationship between the Leadership Style of Hospital Department Head, Cooperation with Head Nurse, and Climate of Quality and Patient Safety in General Hospital. PhD thesis, BGU, 2010. 39 39

40. (III) Follow Up on a Few Other Projects
Disruptive Behavior 40 40

41. Disruptive Behavior “Do you have disruptive behavior at Hadassah?”
Mark Chassin, MD, MPP, MPH
Professor of Medicine & VP for Excellence
Mount Sinai School of Medicine
President of the Joint Commission
Joint Commission now requires hospitals to have a written code of conduct and a process for enforcing it

42. Survey of Disruptive Behavior at Hadassah
Last year exposure to intimidating behavior (%)
Didn’t answer
Rarely or Never
Sometimes
Frequently or Very frequently 1 60 30 9
Refuses to answer questions/calls 32 48 18
Arrogant tone 36 41 22
Impatience to answer questions 2 73 16
Strong verbal insult 76 15
Threatening body language 75 8
“Just do it” 97 3
Physical violence
Data from 100 MDs & nurses, at Departments of Medicine & Surgery at Ein Kerem and Mt Scopus Hadassah Hospitals

43. (III) Follow Up on a Few Other Projects
Disruptive Behavior
Hadassah Quality and Safety Committee has proposed to adopt a code of conduct and a policy for enforcing it with an institutional committee to handle disruptive behavior, using review of cases, sanction for recidivism and education.
Despite several reminders, our suggestion has not been followed.
Rapid Response Teams (RRT’s)
RRT’s have been shown in some studies to reduce need for coding, morbidity and mortality. Efficacy may depend on local institutional culture. In a survey of intensive care experts and anesthesiologists (N=32), nearly half thought RRT’s might be efficacious at Hadassah. A working team from the Quality and Safety Committee has proposed to run a pilot project with several departments. Members of this Committee have commented that the death of a woman from bleeding after a C/S could have been averted by a RRT.
The suggestion to run a pilot has not been followed. 43 43

44. (III) Follow Up on a Few Other Projects
Transparency
Recent studies suggest that an open disclosure policy after a medical error is useful to restore trust, reduce anger and liability costs and to enhance safety improvement efforts. 44 44

45. A Better Approach to Medical Malpractice Claims
A Better Approach to Medical Malpractice Claims? The University of Michigan Experience
“…an honest, principle-driven approach to claims is better for all those involved—the patient, the healthcare providers, the institution, future patients, and even the lawyers” 45 45

46. “Do you believe a disclosure policy could work in your department?”
Survey of members of the Quality & Safety Committee:
9/10 senior clinicians and department heads responded yes, some reported they already work according to a policy of full disclosure. These were from pediatrics, medicine, obgyn and hemato-oncology.
Survey of 43 department heads:
15 responded yes, 8 of them added they already work according to a policy of full disclosure. These were from pediatrics, pediatric surgery, medicine, and hematology.
2 responded no; 5 asked for more time; the remainder have not replied.
Based on these preliminary observations, a policy of disclosure appears worthwhile to consider at least with some wards and with the development of a support team in collaboration with RM. 46 46

47. Conclusion
Quality and safety initiatives, such as VAP or medication reconciliation, show opportunity for significant improvement.
To enhance participation by clinicians, quality initiatives could be used as criteria for appointment (or re- appointment) of departments heads. 47 47