CSR Hospital Compass Newsletter December 2009 A quarterly newsletter for CSR members in more than 740 member organizations across the United States Volume 4, Number 4 Edited by Maureen Burger Countdown to the New Year … Are You Prepared for Organization-wide Implementation of National Patient Safety Goal 7? Karen M. Caywood, RN, MBA Consultant, Joint Commission Resources Healthcare-associated infections (HAIs) rank in the top ten leading causes of death in the United States. To assist acute care hospitals in focusing and prioritizing efforts to implement evidence-based practices for prevention of HAIs, the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America Standards and Practice Guidelines Committee created a concise compendium of recommendations for the prevention of common HAIs. The Joint Commission developed specific standards for National Patient Safety Goal (NPSG) 7 that require organizations to implement evidence-based practices for prevention of healthcare-associated infections by January 1, 2010. The NPSG includes many of the prevention strategies that are included in the compendium. Reference websites where the compendium may be accessed are: • http://www.apic.org • http://www.shea-online.org/about/compendium.cfm • http://www.cdc.gov/ncidod/dhqp/HAI_shea_idsa.html NPSG 7 requires that organizations perform periodic risk assessments for Multidrug-Resistant Organism (MDRO) acquisition and transmission, central line–associated bloodstream infections, and surgical site infections. These risk assessments may be included in the organization-wide infection control annual risk assessment or may be separate risk assessments, as determined by the organization. Based on the results of the risk assessments, there is a responsibility to educate, as appropriate, both staff and licensed independent practitioners (LIPs) about the organization’s policies and practices relative to prevention of HAIs. This education should be relative to the role of the individual in the organization. For example, education of the LIPs may include appropriate antibiotic use for MDRO or prevention of SSI, while the education for the environmental services staff members may include appropriate processes and products for equipment and supply cleaning and disinfection. Consider including in the education information regarding methods to reduce risk associated with intrinsic patient related SSI factors such as age, glucose control, obesity, smoking cessation, and immunosuppressive medications. When applicable, patients, and their families as needed, must be educated regarding prevention of central line-associated and surgical site infections. This education should begin prior to the procedure, if at all possible. Those patients who are colonized or infected with an MDRO must be education about health care–associated infection strategies. Suggested content for MRDO education includes: • What are characteristics of the organism? • How is the organism transmitted? • How can we prevent transmission? • What–if any–treatment is required? 1 CSR HOSPITAL COMPASS NEWSLETTER December 2009 (continued on page 2) (continued from page 1) Patient education information sheets have been developed and co-sponsored by JC, APIC, SHEA, CDC, AHA, and IDSA. The complimentary information sheets may be accessed at http://www.sheaonline.org/about/compendium.cfm. They are available in both normal and large print and also in large-print Spanish Translation for the following: • MRSA • C-Difficile • Catheter-associated UTI • Catheter-associated Bloodstream Infections • SSI • Ventilator-associated Pneumonia Surveillance methodology for HAIs within an organization may change over time, based on the periodic risk assessments. Targeted surveillance may be appropriate for MDRO and SSI, while CLABSI surveillance must be organization-wide. Well-designed MDRO surveillance will ensure early case identification and early detection of outbreaks. Surgical site infection surveillance may be targeted to high risk patient populations and/or high risk surgical procedures. Surgical site infection rates must be measured for the first 30 days following procedures that do not involve inserting implantable devices and for the first year following procedures involving implantable devices. The surveillance must be an active process, such as postoperative surgeon surveys via email, phone, or snail mail. Information related to post discharge SSI surveillance may be found in the CDC’s “Guideline for Prevention of Surgical Site Infection.” More Tips for Prevention of HAI: MDRO • Consider screening for high risk populations upon entry to the organization • Monitor antibiotic usage for appropriateness • Monitor compliance with transmission-based precautions • Monitor hand hygiene compliance • Consider discontinuing contact precautions only with approval of the Infection Preventionist CLABSI • Monitor compliance with use of the standardized list for insertion of central lines and ensure that the list is being used to drive the insertion process - not being used only for documentation purposes. If the standardized list is used from the Electronic Medical Record (EMR), ensure the list is available via computer at the bedside at the time of insertion. • Empower staff to “halt the line” and stop the insertion process if there is any break in technique or protocol • Consider attaching the standardized insertion list and patient education handout to the central line kit • If EMR is available, consider bar code scanning patient education handouts and implementing documentation of patient education via bar code scanning technology • Consider an infection rate definition that may not be cumbersome for data collection, yet will enable trending and identification of concerns • (critical care definition may = # CLABSI / # line days, while noncritical care definition may = #CLABSI / # total patient days) • Post scoreboards for staff applicable to their units or departments and include comparisons to their peers • Post results of PI monitoring (hand hygiene compliance, compliance with contact precautions) • Develop a standardized process and/or algorithm to evaluate all central venous catheters routinely in an effort to remove nonessential catheters • Consider a central line order set that is initiated upon insertion and includes an intervention for periodic evaluate of the need for the central line For example, address necessity algorithm every other day (even, odd) and document continued necessity or contact physician for appropriate orders (continued on page 3) 2 CSR HOSPITAL COMPASS NEWSLETTER December 2009 (continued from page 2) • Verify documentation of the use of insertion checklist, dressing dated, dressing occlusive on weekly rounds by the Infection Preventionist or during interdisciplinary weekly or biweekly rounds SSI • Encourage anesthesia “ownership” for administration of preoperative antibiotics • Utilize pre-printed order sets to guide preoperative antibiotic selection • Associate surgery end time with postoperative antibiotic orders • Consider documentation as a medication error when the antibiotic has been continued beyond 24 hours post surgery end time, unless the need is justified via documentation in the medical record. • Incorporate procedures and proceduralists with trends into SSI surveillance processes. Healthcare-associated infections continue to be preventable events with complex—yet proven—solutions. As we prepare for the New Year, is your organization prepared to prevent healthcare-associated infections? CSR AHRQ Hospital Survey on Patient Safety Culture Nanne M. Finis RN MS Executive Director, Consulting Services Joint Commission Resources As you know, The Joint Commission requires that hospitals measure the culture of safety within the organization using valid and reliable tools (LD.03.01.01, EP 1). The AHRQ Hospital Survey on Patient Safety Culture is a valid and well-established survey instrument that assesses a hospital’s patient safety culture and can be used to track changes in patient safety culture over time and evaluate the impact of patient safety interventions. The AHRQ survey tool is available at no charge to the organization, but you may want to consider using a vendor to manage data collection, data analysis, report generation, and most importantly, action plan design. Joint Commission Resources can provide assistance for you! Product Components • • • • Web-based survey via an online link to the AHRQ survey A report of survey results, including comparison to the 2009 AHRQ benchmarks An Excel file of your raw data Interpretation and consultation with a JCR patient safety consultant Features and benefits of the product • • • • • • Efficient online administration Ability to handle paper-based surveys (organization enters data into JCR-provided Excel file) Clear report with graphical displays to show performance Virtual summary and assistance from experienced experts with understanding results Provides a framework for taking action Helps leaders and staff communicate about organizational challenges Typically organizations request a summary of a hospital which is considered “one report.” The all inclusive fee for one report is $3,000.00. The CSR 15% discount is not applicable to this product. Customized reports and other additive services will be priced separately. Identical services for ambulatory care and long term care settings will be available in 2010. Below is the link to JCR's web where the service is highlighted. http://jcrinc.com/Consulting/AHRQ-Culture-Survey-Administration-Analysis-Interpretation/1733/ 3 CSR HOSPITAL COMPASS NEWSLETTER December 2009 CSR Networking Blogs for CSR Members – What a Hit! The CSR website is chock full of valuable information and tools only for CSR members. Due to popular demand, the website is now hosting blogs to help you connect with others, discuss hot topics, and explore concerns out there in the field. Each topic is hosted by a CSR content expert, and the topics are driven by your input. New topics include 2010 Home Care Survey Changes, the Accreditation Manager Plus (AMP), and a new one on Medication Reconciliation. Lots of folks are viewing the sites, not too many of you are leaving your thoughts, comments, or concerns. Come on and join in – the value of a blog is in the people who participate! Bookmark this exciting link so you can keep up with the latest information, news, and issues! http://www.jcrinc.com/CSR-Member-Blogs/ CSR Restraint Rumors This summer brought the latest revisions in the restraint standards from the Joint Commission (PC.03.05.01 – 19). Hospitals have been busy reviewing and revising their policies on the use of restraints, and there has been lots of information and some misinformation being shared. Here are a few pieces of misinformation and some clarifications that may help you relax and enjoy the New Year. Rumor #1. PC.05.05.17 EP 1 CMS requires 4 hours per person per year for restraint training. CMS has not stated that a 4 hour per person per year restraint training should occur. The organization determines the length of the training based on the needs of the population they are serving, level of staff competency and the educational topics that need to be covered. Rumor #2. PC.03.05.05 EP 6 MD must do face-to-face eval every 24 hours for non-violent/self-destructive restraints. Orders for restraint used to protect the physical safety of the non-violent, non-self destructive patient are renewed in accordance with hospital policy. The organization determines when the physician would evaluate the patient in this type of restraint. Patient safety, the type of restraint and patient assessment would be considered. Rumor #3. PC.03.05.05 EP 6 For hospitals that use Joint Commission accreditation for deemed status purposes: Orders for restraint used to protect the physical safety of the nonviolent or non–self-destructive patient are renewed in accordance with hospital policy. The org has order that says "restrain per clinical guidelines" and the MD states in the order the reason for the restraints (clinical behaviors). Rumor has it that the MD must also include a time limit. Orders are renewed per hospital policy. By stating restrain by clinical guidelines, the organization would have to have the clinical guidelines approved by the Medical Staff and each individual episode would need a physician order for the restraints. The order needs to have a time limit. It cannot be an unlimited time in restraints. The clinical guideline would need to be specific to the behavior that necessitates the use of restraint. See next rumor. Rumor #4. PC.03.05.05 EP 2 (PRN orders). An org uses clinical guidelines for restraint use based on presence of endotracheal tubes, invasive lines, etc. Would this be perceived as a PRN order since it is not based on patient behavior at the time of the order? Yes—not every patient with a line or tube (such as endotracheal tube) needs to be restrained. The use of restraint needs to be based on patient behavior and an individual order needs to be obtained for each episode. The organization should review how they define a clinical guideline and how they are using clinical guidelines. CSR 4 CSR HOSPITAL COMPASS NEWSLETTER December 2009 A Little Infection Control Humor... Safe Health Design In the last issue of CSR Compass, Leo Gehring discussed how healthcare construction can be the biggest challenge of your career. Making sure that patients are safe in either new or a renovated space is always the goal, making sure we accomplish the goal can be difficult. Just recently an organization asked when is a good time to bring in a Life Safety Code specialist to walk the new constructed areas and identify any issues. The answer to this question is really at the beginning of the process – in order to prevent costly construction change orders. Another organization relates how the LSC surveyor described a list of deficiencies as the result of “value engineering”. Regardless of where you are in your construction program, there are experts available from JCR to help in the process. This new service is aimed to assure that patients are safe in the physical environment in which care occurs or will occur as renovation or new construction is planned, executed, and reviewed. The JCR consultants use a unique and customized blend of Standards-based design (incorporates elements of the Joint Commission standards into the built environment) and Evidence-based design features and expertise. The principle focus of evidence based design is to offer a “process of decision making concerning the built environment on credible research to achieve the best possible outcomes”. Standardsbased design incorporates accreditation standard elements into the facility design planning proactively versus retroactively impacting construction costs. Want to read more? http://www.jcrinc.com/Consulting/Patient-Safe-Design/1475/ CSR Be Careful What You Wish For... In a perfect world, I could go to one place to find all the regulations that govern hospitals in the US and my state. I dream of a day when I can open my email to find daily alerts of new information I need to meet my regulatory compliance activities. Well dream no more! E-dition Compliance Monitor™ is an online web-based library of health care industry regulations, organized and linked to relevant chapters of The Joint Commission standards. With E-dition Compliance Monitor, hospital leaders and staff can stay on top of requirements from The Joint Commission and regulatory bodies such as the Center for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services, Food and Drug Administration (FDA), Occupational Safety and Health Administration (OSHA) and state regulators in one easy-to-access location. Click on the link for more features and pricing. http://www.jcrinc.com/monitor/ CSR 5 CSR HOSPITAL COMPASS NEWSLETTER December 2009 For the Record There are some new standards/EPs in the Record of Care Chapter for hospitals that add some new requirements for operating rooms. RC.02.01.03 EP 15 requires that the organization maintain an operating room register/log or be able to produce a post-operative summary that contains the same data elements as required in the register/log. The functional issue for the organization is whether they can produce the information in a concise manner within a short time interval and in a usable format. You may want to touch base with your OR management team to determine how you would assess compliance with this element of performance. Some other issues concern RC.02.01.03 EP 7 that requires a progress note be entered into the medical record before the patient is transferred to the next level of care (usually a postanesthesia care unit or ICU). The brief note is required whenever the full operative note (usually dictated) is not done on completion of the operation or high risk procedure. The standard does not state who should fill out the data elements of the progress note (it has always been understood that it is the MD responsibility to complete and sign the note), so if you have push-back from surgeons, this may be an issue for your Medical Staff bylaws/procedures. Even if the same information is available in the nursing record, the MD must still complete a post-operative progress note. Finally, if the nurse would act as scribe and complete the elements of the post-operative progress note, the MD would have to sign and date the note – the nurse cannot attest that that MD had read and approved the note. Compliance with this standard is best monitored by chart audits conducted in the designated recovery area for operations and high risk procedures. Last but not least, PC.03.01.07 EP 7 and 8 requires that a postanesthesia evaluation is completed and documented by an individual qualified to administer anesthesia no later than 48 hours after surgery or a procedure requiring anesthesia services, following medical staff approved policies and procedures. CMS issued revised interpretative guidelines on December 11, 2009 that further clarify the expectations for post-anesthesia evaluations. The 48 hour time frame begins when the patient is moved into a designated recovery area. The postanesthesia evaluation may take place in the recovery area as long as the patient is able to participate in the evaluation. The postanesthesia evaluation for outpatients must be done prior to discharge. You may want to review the policies and procedures that describe anesthesia services at your organization to determine if the postanesthesia evaluation process has been approved by your medical staff and meets the intent of the standards. In addition, you may want to add the postanesthesia evaluation to your perioperative tracer as a way to monitor compliance. CSR 6 CSR HOSPITAL COMPASS NEWSLETTER December 2009