HAI/SEPSIS LAN AND QIA REPORT DANY ANCHIA, RN, CDN QUALITY - - PowerPoint PPT Presentation
Friday y NETWORK 14 October r 27, 2017 HAI/SEPSIS LAN AND QIA REPORT DANY ANCHIA, RN, CDN QUALITY IMPROVEMENT COORDINATOR OBJECTIVES Network Mission HAI LAN Overview CDCs Making Dialysis Safer for Patients Coalition
DANY ANCHIA, RN, CDN QUALITY IMPROVEMENT COORDINATOR
C.4.1.B. Participate in the ESRD NCC HAI LAN The ESRD NCC HAI LAN has two primary purposes. The first is to improve information communication across care settings, with emphasis on communication between hospitals and dialysis centers caring for the same ESRD patients. The second is to increase awareness of and implementation of CDC Core interventions Include: QIN-QIO(s), HIINs, state/local health departments, State Survey Agencies, long-term care facilities, hospitals, ALL dialysis facilities including regional leadership, and patient representatives to support communication and the BSI QIA
Network 14 is a partner of this coalition. Our commitment includes the following goals and activities:
Use Coalition messages and materials to publish editorials, blogs, articles, and/or
Launch a social media campaign featuring Coalition messages Place the Coalition button, materials and resources on our website, www.esrdnetwork.org Link to the CDC Core Interventions and Guidelines and Coalition materials and resources from our Website Promote the Coalition’s purpose and material through the Network 14 HAI LAN Participate in Coalition calls and webinars to obtain the newest infection prevention information for CDC and dialysis experts Promote and use CDC continuing education (CE) course/training for health care providers in the Network Provide Coalition materials to patients and encourage them to speak up about infection prevention Promote the use of CDC Core Interventions and Guidelines in our Infection Detection Quality Improvement Activity which is focused on decreasing bloodstream infections Deliver presentations to interested parties Facilitate sharing of bloodstream infection prevention experiences among Network facilities
The Making Dialysis Safer for Patients Coalition aims to:
through promotion, dissemination, and use of audit tools, checklists, and other resources;
bloodstream infection prevention through educational efforts; and
Coalition participants.
To Join you can go to the following website: https://www.cdc.gov/dialysis/coalition/
Gro roup # # Fac In Inter erventi entions ns A: Facilities with a LTC rate =/>15% at baseline 74 (75) (75)
Network facility notification of facility LTC rate of >15% at
Facilities will be monitored for detection of untoward trends with their LTC rate. An untoward trend is defined as a focus facility with a LTC of 15% or more for 3 consecutive months. Should this occur, the facility will be required to update/develop an action plan and have Medical Director sign off on it. Monthly coaching calls are required for all facilities in Group A as well as LTC Monthly Reports.
B: Facilities with LTC rate > 10% at baseline but no greater than 15% 166 (165)
Complete a facility specific root cause analysis via survey monkey in order to identify the most common reason(s) for LTC use. Facilities with LTC rates >10% will be monitored
untoward trend (i.e., reach 15% or more for 3 consecutive months), interventions for the facility will be developed including moving facility into Group A and initiation of one-
facilities in group B otherwise. LTC Monthly Reports required.
Gro roup # # Fac In Inter erventi entions ns Bloodstream Infection (BSI) QIA Crossover 48 Facilities enrolled on both QIAs will still complete interventions required for both QIAs. Rationale: These facilities will benefit from being involved in both the CORE QIA and BSI QIA interventions as reducing catheter use leads to a reduction in catheter infections All Facilities Site visits: Will be conducted anytime and as needed. i.e., facility has compliance issues or needs onsite support and guidance. Update: 6 site visits completed in May (South Texas, Houston, and Tarrant County) followed up by post-visit letter and a MD VA Self-Assessment. VA Newsletter: Fax blast, email, webpage.
Total
ne coaching hing call lls complet pleted ed fro rom Feb 21-Au August gust 2017 Questi stions ns & Is Issues ues Ad Address ssed d
role
then get one ASAP
includes percentage of AVFs, AVG, and CVCs <=> 90 days
for VA
initiation of permanent access pre-dialysis (i.e., in the hospital before patient gets discharged to be admitted to their facility)
Reduction Toolkit
IDT, Clinical Specialist and ROD
clinic VA Managers
S EPTEMBER 2 016 B ASELINE DATA I SSUED 1 2/15/16
15.2 .26 14.7 .71 14 14.30 .30 14.05 .05 13.9 .97 13.6 .66 13.6 .61 13.5 .55 13.9 .97 14 14.0 .07 15.0 .09 14.92 .92 14.75 .75 14.58 .58 14.4 .41 14 14.2 .24 14.0 .07 13.9 .90 13.7 .73 13.5 .56 13.3 .39 13.2 .24 12.00 .00 13.00 .00 14.00 .00 15.00 .00 16.00 .00 Sep- Sep-16 16-O
Feb Mar Mar Apr pr May May Jun un Jul ul Aug ug Sep Sep
% Long g Term Catheter r Rate te
LTC TC Cohort t 240 Faciliti ties es with >10 10% at baseline Goal = 2 2% reducti uction
LTC R LTC Rat ate 2017 Goal Goal DIF and IQI DB starts with Dec 2016 for monthl hly y 15.1 .18 14.69 .69 14.6 .6 14.5 .54 13.92 .92 13.58 .58 13.9 .91 14.05 .05 14.1 .19 14.02 .02 14.00 .00 13.92 .92 13.60 .60 15.0 .01 14.85 .85 14.68 .68 14.5 .51 14.35 .35 14.18 .18 14.0 .01 13.85 .85 13.68 .68 13.5 .51 13.35 .35 13.1 .18
12 13 14 15 16
Se Sep-1 p-15 Oct Nov Nov Dec Jan Jan-1
Feb Feb Mar Mar Apr pr May May Jun Jun Jul Jul Aug ug Se Sep % Long g Term Catheter r Rate te
Last t Year ar 2016
LTC TC Cohor
t 233 Faciliti ties with >10% LTC TC at baseline
LT LTC R C Rat ate 201 2016 Go 6 Goal Intervention Period
Inte tervent ntion
Period
No Data ta
*2015 rates
B A S E D O N D ATA F R O M A U G U S T 2 01 6
Phase 1
Sustainability Plan submitted in 2016
Network 14 Phase 2 – RCA & Data Errors
and Root Cause Analysis
CROWNWeb/data corrections based on RCA Phase 3 – Interventions & Resources
and Available Resources (Vaccination Discussion Groups, RCA, Awareness Campaigns, Data Validation Tools, etc.)
due to the Network Phase 4 – Verify and Sustain Improvements
Sustainability Initiatives
mean rate at re-measurement compared to previous year
an oversampling to account for possible attrition (Total number
Interventions: Monthly CDC activities and education over the nine core interventions for BSI Prevention
review and share
facility utilized tools
March 12-18 Shared facility’s BSIs and other dialysis events rates with patients using the CDC’s Conversation Starter
April 24-28 Discussed facility’s policy for chlorhexidine or alternative use with patients
May 5 Used the CDC’s Conversation Starter to share with patients important hand hygiene practices
(links to the CDC’s Clean Hands Count Campaign site)
60% 4% 16% MAY World Hand Hygiene Day APRIL Patient Experience Week MARCH Patient Safety Awareness Week
Pa Patie ient nt Choice ice by Monthly hly Ac Activ ivit ity
N = 114 BSI QIA Facilities
36% 34% 32% 31% Handouts Patient Education (one to one, groups) Inservice/Homeroom Bulletin Board
Top p Educa cation tion Met ethods
d during ing World ld Hand Hygie iene ne Day
N = 114 BSI QIA Facilities
CDC’S CONVERSATION STARTER TO PREVENT INFECTIONS IN DIALYSIS PATIENTS
HOW USEFUL WOULD THE CDC'S CONVERSATION STARTER BE FOR OTHER FACILITIES TO USE?
Answered: 98 Skipped: 2
HOW LIKELY ARE YOU TO RECOMMEND THE USE OF THE CDC'S CONVERSATION STARTER TO A COLLEAGUE OR FACILITY STAFF?
Answered: 97 Skipped: 3
AS A RESULT OF REVIEWING THE CONVERSATION STARTER WITH YOUR PATIENTS… WERE THEY MORE LIKELY TO ASK FOLLOW UP QUESTIONS ABOUT OTHER TOPICS OR CONCERNS?
Answered: 55 Skipped: 0
WERE THEY MORE LIKELY TO BE ENGAGED IN THEIR CARE?
Answered: 45 Skipped: 10
WILL YOU CONTINUE USING THE CDC’S CONVERSATION STARTER WITH YOUR PATIENTS AFTER THE NETWORK’S BSI PROJECT HAS ENDED?
Answered: 44 Skipped: 11
CDC Resources: https://www.cdc.gov/dialysis/coalition/resource.html
Background
as those that occurred on the 1st and 2nd day of hospital admission
facility
Goals of NHSN Data Quality QIA
between the hospitals and dialysis facilities
Culture (PBC) rate as expressed by the number of PBC’s by a dialysis facility reported to NHSN that occurred on the 1st or 2nd day of hospital admission
Domain: Support for facility Data Submission to NHSN QIA Components
hospitals during a period of 5years
the project
United States Renal Data System. 2016 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2016. https://www.usrds.org/2016/view/v2_05.aspx
twice per year and 30% are re- hospitalized within 30 days of discharge
per patient year
attributed to hospitalization
hospital who either were rehospitalized or died within 30 days of discharge, by kidney disease status as of 2014
Pro roportion tion of hem emodialysis ialysis patien ients ts wit ith cause se-spe pecif cific ic Re Re-hospitaliz spitalization tions s wit ithin in 30 days ys of dis ischarg harge, , by cause se of
index x hospita
lizatio ion, , 20 2014
2016 Annual Data Report, Vol 2, ESRD, Ch 5
38 38
Data Source: Data Source: Special analyses, USRDS ESRD Database. Period prevalent hemodialysis patients, all ages, 2014,
principal ICD-9-CM codes. See Vol. 2, ESRD Analytical Methods for principal ICD-9-CM diagnosis codes included in each cause of hospitalization category. Abbreviations: CVD, cardiovascular disease; ESRD, end-stage renal disease; rehosp, rehospitalization; VA, vascular access..
Dialysis Facilities
Improvement
Hospitals
Management Staff Collaboration
Distribution Platform
Community
Coordination Meetings for Healthcare Providers
7 5 7 11 11 12 12 8 1 8 10 10 4 20 20 8 6 8 7 7 5 9 8 3 12 12 11 11 5 4 18 18 12 12 13 13 17 17 10 10 4 5 10 15 20 25 Staffing issues: Short staffed, stress, turnover, Not enough staff who are… Time constraints Lack of staff training on how to retrieve information from the hospital/ ED Lack of follow-up from dialysis facility on getting information from the… Lack of follow-up from dialysis facility on getting information from the… Lack of staff knowledge regarding the DE protocol and application of the… Not following protocol and/or no protocol General misconception that reporting guidelines for NHSN and… Language barrier Cultural differences Patient/Family unaware of importance of communicating transitions of… There is no protocol for hospital/ ED record retrieval process There is no protocol for asking and documenting the patients about… No tracking system for monitoring PBC and reporting in NHSN No process for validating the data reported to NHSN There is no clear designation of NHSN roles for facility personnel Lack of incentives for communicating with hospital and ED staff Not involving patients in the design, development and implementation of… Individual dialysis staff access to NHSN through SAMS registration… There is a learning curve for NHSN application of NHSN Dialysis Events… Reporting is time consuming Lack of facility data validation into NHSN No / limited access to hospital electronic medical records (EMR) Retrieval of information from EMR is difficult Key information of PBC and specifically the day of collection following the… No designated hospital personnel to contact to retrieve information on PBC No or limited knowledge of the role and responsibilities of different… No/limited knowledge of the structure and function of the hospital EMR FACILITY FACTORS PATIENT FACTORS ORGANIZATIONAL FACTORS NHSN FACTORS HOSPITAL FACTORS
Number er of R Respons nses es Root
es
Root
e Analy lysis
N = 22
18 18 12 12 13 13 17 17 10 10 4 5 10 15 20 No / limited access to hospital electronic medical records (EMR) Retrieval of information from EMR is difficult Key information of PBC and specifically the day of collection following the hospital admission is not routinely… No designated hospital personnel to contact to retrieve information on PBC No or limited knowledge of the role and responsibilities of different departments in hospital No/limited knowledge of the structure and function of the hospital EMR
Number er of R Respons nses es Root
es
Hospital al Factor
N = 22
20.6 22.4 29.1 21.6
5 10 15 20 25 30 35
Baseline (1/16- 6/16) Interim (7/16- 12/16) Final (1/17-6/17) Goal
Perc rcen ent Perc rcen ent t Posit itive Blo lood
ltur ure Rate as identified on 1st or 2nd day of hospitalization Data Source: NHSN, N=22 facilities
CTSE- Council of State and Territorial Epidemiologists
Website
Transitions of Care toolkit
0care%20toolkit%202017%20FINAL.pdf
esrdnetwork.org Access many resources here
Evaluation https://www.surveymonkey.com/r/5HJSYCY