Do No Harm

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Do No Harm

• Gaston Memorial Hospital
• Gastonia, NC

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Gaston Memorial Hospital

• 435 Bed Not-for-Profit Community Hospital
• Gastonia, NC
• Magnet Hospital
• Emergency Department Visits 2008 87,803
• Stroke Admissions 2008 464
• Adjusted Admissions 2008 49,104

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National Quality Forum DefinitionNever Events

• Never events are errors in medical care that
  are clearly identifiable, preventable, and
  serious in their consequences for patients, and
  that indicate a real problem in the safety and
  credibility of a health care facility.

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GMH Involvement in 5 Million Lives from Harm

• Commitment to all initiatives associated with 5
  Million Lives
• Use of Global Trigger Tool
• Board Development of Harm AIM Statement
• Involvement in Patient Safety Study in N.C.

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GMH Global Trigger ToolSeverity Level (Jan.
07-Jun. 07)
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GMH Global Trigger Tool (Jan-07 Mar-09)
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Hospital Readiness of Never Events

• Obtain Baseline Data (October 2007)
• Identify Vulnerabilities/ Including Financial
  Impact.
• Organize Quality Action Teams
• Monitor Monthly
• Develop PDSA Strategies

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Quest

• Incorporate Harm Events into monthly
  vulnerability list for baseline data
• Implement Action Teams
• Develop PDSA Cycles for improvement
• Evaluate effectiveness.

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What Did We Discover?

• Documentation Opportunities
• Clinical Strategies
• Concurrent Evaluation
• Using Safety Surveillor Alerts

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Action Team

• Clinical Areas
• Nursing
• Physicians
• Finance
• Medical Records Professional Coders
• Senior Administration

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Deep Vein Thrombosis/Pulmonary Embolism

• 140,010 cases (IPPS FY 07)
• Cost 50,037 per hospital stay
• 
  www.ahrq.gov/qual/nqfpract.htm

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Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)

• The goal is to ensure 100 compliance with the
  SCIP initiatives and expand to non-surgical
  patients
• Develop screening tool for all admissions to GMH
• Provide DVT prophylaxis for all order sets
  presently in place.
• Review all forms with DVT prophylaxis for
  consistency and standardization
• Screen all admissions for DVT prophylaxis needs

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Catheter-Associated Urinary Tract Infection
(CA-UTI)

• 12,185 (IPPS FY 2007)
• Cost 44,043/hospital stay
• CA-UTI is the most common nosocomial infection
• CA-UTI accounts for up to 40 of nosocomial
  infections
• CA-UTI increases length of stay by 1-3 days.

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Catheter Associated UTI

• Institute whole-house surveillance for UTIs
• Taskforce of RNs (Unit Based Councils) from all
  units to develop strategies to reduce CA-UTIs.
• Emergency Department developed insertion criteria
  for urinary catheters
• Nursing Protocols for Indwelling Urinary Catheter
• Includes daily review of necessity for catheter
• Lists criteria for catheter placement and
  retention
• Measures to take to facilitate voiding after
  catheter removal
• Educational CBL Nursing Protocol and UTI
  Prevention
• All Patients admitted to hospital with foley
  catheter have automatic urine cultures
• Urinary Catheter Prevalence Studies started. Did
  they meet insertion criteria. Was the Catheter
  secured appropriately
• 2.92/1,000 device days National Average

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Pressure Ulcer Stages III and IV

• 257,412 cases (IPPS FY 2007)
• Cost 43,180 per hospital stay

www.ahrq.gov/qual/nqfpract.htm
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Pressure Ulcers

• RN completes SAFER (Simplified Assessment Form
  for Evaluation Risk) on Admission
• Photograph wounds upon admission
• Each Unit has a SWAT (Skin Wound Assessment Team)
• SAFER triggers automatic Consult Food and
  Nutritional Services for any score of 2 or more.
  
• SAFER triggers automatic Wound Consult for any
  score of 1 or greater
• Wound nurse will complete a (POA) pressure ulcer
  sheet and place under the MD order section of the
  chart
• Wound team continues to follow the patient weekly
  until discharge for reassessments.

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Vascular Catheter Infections

• 29,536 Cases (IPPS FY 2008)
• Cost 103,027 per hospital stay

www.ahrq.gov/qual/nqfpract.htm
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Vascular Catheter Infections

• Adapt guidelines for I.H.I. central line bundle.
• Trend reports are shared with specific units and
  physicians to ensure compliance
• Central Line Improvement Project (CLIP) team
  reviews all data, develops strategies and
  implements as appropriate.
• Added the usage of BioPatch protective disk to
  all vascular catheters.
• IV Team rounds on all patients with central lines
  daily and changes the dressing every 7 days (or
  PRN) per policy
• If vascular catheter infection appears to be Not
  POA, Clinical Documentation Specialist will query
  physician for confirmation of POA

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Falls and Trauma, Hospital Acquired Injuries

• Includes
• Fractures
• Dislocations
• Intracranial Injuries
• Burns
• Electric Shock
• Crashing Injuries
• 193,566 cases (IPPS FY 2007)
• Cost 33,894/ hospital stay

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CMS proposing to add or remove categories of HACs
at this time

• 813.46 Torus fracture of ulna
• 813.47 Torus fracture of radius and ulna

www.ahrq.gov/qual/nqfpract.htm
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Fall Prevention Program

• Originally initiated in 2003
• Assessment Tool (MORSE scale)
• Environmental assessment
• Signage
• Bed alarms
• Chair alarms
• Patient/family education
• Identification of high-risk medications
• Focus on activity/toileting
• Initiation of rounding
• Development of the NICHE program to focus on
  assessment and treatment of the elderly
  population

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Is It Just About the Money?

• Expand to include all patients
• Pull Report for all Quest Harm Events
• Pull Report from all events identified by
  National Quality Form (NQF) Serious Reportable
  Events

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Outcome

• Development of comprehensive strategies to
  decrease harm
• Decreased exposure to financial impact from POA
  indicators
• Ability to apply knowledge to other clinical
  areas Example DVT, Glycemic Control
• Continued work at GMH toward protecting lives
  from harm.