www.ohiokepro.com

Vol. 2 No. 2

Spring/Summer 2004

s Cleveland Clinic's

Conference
Identifies Key
Elements of
Patient Safety
Page 8

s Ohio KePRO to

Review Charts of
Long-Term Acute
Care Hospitals
Page 9

s Order Influenza

Vaccine Now!
Page 9

s Antimicrobial

Prophylaxis for
Surgery--Duration
of Therapy
Page 10

Rock Run Center, Suite 100
5700 Lombardo Center Drive
Seven Hills, Ohio 44131-2545
1.800.385.5080

Respiratory Therapists Making
Great Strides in Increasing
Smoking Cessation Advice Rates

Providing smoking cessation advice to Medicare patients hospitalized for acute myocardial infarction,

hear t failure, and pneumonia is a high priority for the Centers for Medicare & Medicaid Services (CMS)

7th Scope of Work (7th SOW). Recent surveillance data -- inpatient data collected and abstracted by the

clinical data abstraction center (CDAC) for the purpose of monitoring the quality of care in each state (which

is shown in the accompanying graph) -- indicate there is much to be done by Ohio hospitals to reach the

goal of advising all smokers hospitalized with heart disease or pneumonia to stop smoking.

Adult Smoking Cessation Advice Given-- Percentage of Medicare Patients Eligible
for and Receiving Smoking Cessation Counseling/Advice in the Acute Care Setting.

s 1st Quarter 2002 s 3rd Quarter 2003

100%

Target 100%

90%

Percentage   of   Patients   Receiving   Recommended   Care

80%

70%

60%

50%

40%

30%

20%

10%

0%

46.7%

57.1%

17.7%

40.0%

33.3%

44.4%

Hear t Failure

I

  t is estimated that 70%
  of smokers want to quit. ¹
Hospitalization provides the
ultimate teachable moment.
Patients are more likely to
listen to smoking cessation
advice when they are expe-
riencing the negative health
consequences attributed
to this habit. Also, while
hospitalized, patients interact
with several healthcare
professionals who can provide
resources, reinforce the quit

smoking message, and offer
support to patients who want
to quit.

Unique position
Respiratory therapists are in
a unique position to dispense
smoking cessation advice. They
are called on daily to evaluate
and administer physician-
ordered treatments for
smoking-related respiratory
diseases.

Respiratory therapists in
Ohio are attracting national
attention for their leadership
in advancing inpatient

smoking cessation programs.
Respiratory therapists are
trained and licensed to give
smoking cessation advice.
They have incorporated this
task into their daily work
and used their standardized
charting protocols to ensure
easy, accurate and complete
documentation.

2

The following programs

highlight the spectacular

achievements of respi-

rator y therapists in our

state. Ohio KePRO urges

all hospitals to learn more

from these trendsetters

and begin actively

engaging respiratory

professionals in this vital

aspect of care.

St. Vincent Charity
Hospital, Cleveland
One of the most efficient
programs is conducted
at St. Vincent Charity
Hospital in Cleveland. The
program is relatively new,
but has made a significant
impact. Developed by a
team of physicians,
respiratory therapists,
information technologists,
and quality improvement
specialists, this program
resulted in an increase in
smoking cessation counseling
and documentation from a
baseline of 35% to 92% in a
3-month period. According
to Craig Myers, RRT, PA-C,
RN, Manager of Respiratory

Therapy for the hospital,
smoking cessation counseling
and documentation was
also chosen as a quality
improvement project for
the Respiratory Therapy
Department. Preparing
respiratory therapists for
this role involved a specially
developed program of edu-
cation provided by Joseph
Sopko, MD, Director,
Department of Medicine, and
Berta Briones, MD, MBA,
FCCP, FAASM, Medical
Director of Respiratory
Therapy. Paula Gordos, RN,
MSN, Outcomes Specialist,
provides data abstraction
and analysis for the program.

Highlights of the
program include:
 · Identification of a smoker
   on admission by nurses.
 · Automated referral to
   the Respiratory Therapy
   Department via the
   electronic medical record
   as a result of the
   admission assessment.
 · A visit to the patient
   within 24 hours by the
   respiratory therapist,
   who then provides the
   accompanying hospital-
   developed intervention
   card to the patient.
 · Documentation of the
   intervention in the
   electronic medical record.

Where can I get more information?
s There are many resources available to support you as you prepare to quit smoking.
 A few are listed below for when you actually quit.
Ohio KePRO               American Heart Association  American Lung Association
Tel: 1-800-MEDICARE        Tel: 1-800-242-1793        Tel: 1-800-586-4872 or
(1-800-633-4227)         (call center) or             1-212-315-8700
Internet: www.ohiokepro.com  1-800-242-8721           Internet: www.lungusa.org
                        Internet: www.americanheart.org

St. Vincent Charity Hospital
Cardiac Rehab
2351 E. 22nd Street
Cleveland, OH 44115
Tel: 216-363-2693
Internet: craig.myers@csauh.com

Feedback from patients indicates that they appreciate
the brevity of the material and the positive approach
presented in the stages of recovery. One patient reported,
"nobody has ever told me this in this way before."

TIME SINCE LAST CIGARETTE

20 minutes

HEALING THAT OCCURS

Blood pressure, pulse, and temperature return to normal.

It's time to quit smoking

8 hours

Carbon monoxide levels drop. Oxygen levels increase to normal.

24 hours

Chance of heart attack begins to decrease.

48 hours

Ner ve endings repair. Ability to smell and taste is enhanced.

2 weeks to 3 months

Circulation improves. Walking becomes easier and lung function improves up to 30%.

1-9 months

Coughing, sinus congestion, fatigue and shortness of breath decrease.
Cilia in the lungs regenerate, improving handling of secretions. Energy increases.

1 year

Risk of coronary heart disease is one-half that of a smoker.

5 years

Risk of lung cancer drops by one-half. Stroke risk lessens. Risk of cancer of the mouth
and throat is one-half that of a smoker.

10 years

Lung cancer death rate corresponds to that of non-smokers. Precancerous cells are replaced.
Risk of mouth, bladder, throat, kidney and pancreatic cancer decreases.

15 years

Risk of coronary heart disease equals that of a non-smoker.

Chart adapted courtesy of St. Vincent Charity Hospital

A partnership of The Sisters of Charity of St. Augustine Health System & University Hospitals Health System ­ 2351 East 22nd Street, Cleveland, Ohio 44115

 Publication No. 4020-OH-017-4/2004. This material was prepared by Ohio KePRO under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S.
Department of Health and Human Services (DHHS). The contents presented do not necessarily reflect CMS policy. For more information, please call 1-800-MEDICARE (1-800-633-4227),
                                                    or visit CMS's Web site at www.medicare.gov.

Why should I quit smoking now?
s Your health is important! Smoking can cause many health
  problems such as heart disease, respirator y/breathing
  problems, strokes and cancer.
s You will cut the risk of lung cancer, as well as many types of
  cancers, heart disease, stroke and other lung/breathing
  diseases.
s Ex-smokers have fewer days of illness, fewer health
  complaints, less bronchitis and pneumonia than current
  smokers do.
s You will save money -- a pack-a-day smoker, paying $2.00
  or more per pack will save more than $700/year.

How can I quit smoking?
  Get ready to quit
   q Pick a day. Encourage a friend to quit smoking with you
   so you can succeed together.
   q When do you smoke? F ind the "routines" in your daily
   life that you often do while smoking.
   q Change your routines -- move the cigarettes, smoke only
   in certain places.
   q When you want a cigarette, wait a few minutes.
   q Switch to a brand of cigarettes that you don't like.

s

s

On the day you quit...
q Get rid of your cigarettes and hide your ashtrays!
q Change your routines!
q Car r y things to put in your mouth such as gum, hard
 candy, or toothpick.
q Reward yourself at the end of the day for not smoking.
q Exercise.
q When you feel tense -- tr y to keep busy.
q Eat regular meals.
q Star t a money jar with the money you save by not
 buying cigarettes.
q Let others know you quit smoking so they can offer
 their support.
q If you slip and smoke, don't be discouraged -- tr y to
 quit again!

Can my doctor help me?
s YES! If you need more information,
  or additional tools to help you,
  talk with your doctor.

MetroHealth Medical Center, Cleveland
One of the earliest programs using respiratory therapists was
developed at MetroHealth Medical Center in Cleveland. Peg
Mitchner, BS, RRT, Manager of Pulmonary Services, and Sherry
Williams, MD, MHS, Medical Director of Pulmonary
Rehabilitation, obtained funding 2 years ago from the national
tobacco settlement to develop and implement an eight-stage
outpatient program. About a year ago, MetroHealth Medical
Center launched its inpatient smoking cessation program,
which is supported by the Respiratory Therapy Department.

At MetroHealth Medical Center, respiratory therapists do
smoking cessation counseling on all patients referred to them
by physicians for respiratory treatments. As part of the initial
assessment of the patient, a respiratory therapist takes a
smoking history and, if applicable, asks if the patient wants
help to stop smoking. Smoking cessation information is
provided regarding the outpatient program, and the intervention
is documented in the education record.

Ms. Mitchner has encountered no significant barriers in
the system. Respiratory therapists are evaluated on their
compliance with implementing this standard of smoking
cessation counseling and documentation. Their interventions
complement those provided by the nursing staff.

The American Lung Association's Freedom From Smoking
program is taught by trained facilitators in the outpatient
smoking cessation classes. Highlights of the low-cost program
at MetroHealth include nicotine cessation products for those
who qualify, educational sessions on nutrition and exercise, a
quality of life survey given at session one and after completion
of the program, a buddy system for participants, and a
celebration upon completion of the program.

(Continued on page 4)

3

Respiratory Therapists (Continued from page 3)

"correspondence course" version for those who do not have
Internet access or prefer not to take the course online.

St. Rita's Medical Center, Lima
The program at St. Rita's Medical Center incorporates another
important feature of smoking cessation counseling and
documentation--a follow-up period after discharge. The patient
is identified on admission, seen on the second day of his or
her inpatient stay by a respiratory therapist, and follow-up is
done one week post-discharge. Phone follow-up is also conducted
at 1, 3, 6, 9, and 12 months. Unique to this program is the
involvement of the pharmacy department, especially in the
outpatient phase.

According to Linda Dodge, RRT, Smoking Cessation Educator
and ABG Lab Coordinator at St. Rita's Medical Center, referral
rates are high due to the use of computerized systems to
identify smokers. Physicians are also very supportive of the
smoking cessation and documentation program. Integrated
progress notes and teaching records are used to document
counseling sessions. This program has achieved an 84% rate
of compliance in meeting smoking cessation performance
measures for patients hospitalized for acute myocardial
infarction, heart failure, and pneumonia.

A patient who completed the program reports that she
successfully quit due to the counseling and advice provided to
her. She felt that "someone really cared" whether or not she
quit and that this "made a huge difference" in her attitude.

On the inpatient side, smokers are noted in the initial nursing
assessment when admitted to the hospital. A referral is made
to either Bailey or Crumrine, who then see the patient and
offer him or her this smoking cessation program that can
begin while the patient is in the hospital or when he or she
returns home.

In developing the program, Bailey and Crumrine worked
closely with the Marketing Department's Web designer. The
respiratory therapists compiled the program's content and the
designer developed the site: www.ftmc.com/stopsmoking.
Upon its launch on the hospital's established homepage, the
site received excellent media coverage including a full-page
story in the local newspaper's health section and a front-page
article in a regional business publication.

During its first year, the program has "graduated" 30 students
and more than 600 individuals have accessed the site to take
the Nicotine Dependency Test. As one patient reports, "I like
that the program is done at your own speed and in your own
home." Another says, "I took the carbon monoxide test
recently and received a score of nonsmoker."

Fisher-Titus Medical Center, Norwalk
Respiratory therapists at Fisher-Titus Medical Center have
taken traditional smoking cessation techniques into the 21st
century with their Web-based smoking cessation program.
Developed just one year ago by Kim Bailey, RRT, CPFT, and
Denise Crumrine, RRT, the unique site has proved to be very
successful both in the inpatient setting and as a community
outreach tool.

The interactive, self-paced program uses many of the same
methods as traditional programs: five modules, incentives for
completion, peer support through an online message board,
and personal feedback via e-mail or phone calls from the
respiratory therapists. The two have even developed a

4

Lakewood Hospital, Lakewood
Mary Ann Marsal, RRT, RCP, Assistant Manager of the
Respiratory Therapy Department at Lakewood Hospital, reports
that referrals come to their department in different ways.
Initially, they found patients through physician referrals for
respiratory treatments. All patients ordered respiratory
therapy are asked about their tobacco use by the respiratory
therapist initiating the treatment. If the patient currently
uses tobacco, or has quit in the past year, they are offered
smoking cessation literature.

According to Kay Yantz, BS, RRT, Pulmonary Health and Wellness
Coordinator, respiratory therapists approach tobacco users with
advice to quit and an offer of cessation support. Eighty percent of
these patients do not have a pulmonary diagnosis and the majority
is not being seen for respiratory therapy. Literature developed
by the U.S. Department of Health and Human Services, You Can
Quit Smoking, is given to the patients along with the contact
information for the Health Center's smoking cessation staff.
The intervention is documented in the patient's medical record.

The second method of referral is a more proactive approach
and is in the early stages of development. Tobacco users are
identified by nursing staff as part of the admission process on
each unit. The nurse can offer the patient smoking cessation
literature, or can request that a respiratory therapist meet with
the patient. Physicians also write orders for smoking cessation
consults by respiratory therapists. All of these interventions
are documented in the interdisciplinary education record.

The smoking cessation literature distributed by Lakewood
Hospital includes a You Can Quit Smoking brochure by the
U.S. Department of Health and Human Services/Agency for
Healthcare Research and Quality and a pamphlet describing
the free services offered by the Ohio Tobacco Quit Line.
Information regarding the American Lung Association's
Freedom From Smoking program (FFS) and Nicotine
Anonymous meetings held at the hospital is included.

Wyandot Memorial Hospital, Upper Sandusky
Wyandot Memorial Hospital nurses identify all smokers on admission.
Patients are then given an initial packet of smoking cessation
information, and respiratory therapists follow-up with more in-depth
counseling. Denise Orwick, RRT, BBA, Supervisor of Respiratory
Services, notes that there are three points of contact with patients
who smoke: on admission, the second or third inpatient day, and
once again prior to discharge. Interventions are documented in the
multidisciplinary education forms and in the nurses' notes. The
hospital has achieved excellent compliance with CMS's smoking
cessation and documentation measures with rates of 90% or higher.

The FFS program consists of eight sessions and is offered four
times a year through a grant from the Cuyahoga County
Comprehensive Partnership for Tobacco Reduction. The
sessions are facilitated by a respiratory therapist who is a
former smoker, or by a registered nurse who is a graduate
of the FFS program. The Nicotine Anonymous meetings are
open to anyone with a desire to quit using nicotine and those
who graduated from the FFS program who feel they need
continued support.

Lutheran Hospital, Cleveland
The program at Lutheran Hospital in Cleveland is approaching
100% compliance with CMS's smoking cessation and docu-
mentation quality measures. Originally set up to track certain
diagnoses, the program now allows respiratory therapists to
identify each and every smoker who is admitted to the hospital.
According to Mark D. Babic, RRT, Supervisor of Respiratory
Care, not only are these patients approached about quitting
smoking, the do not smoke message is conveyed to all
inpatients. Information given to patients includes literature
from the American Lung Association and a referral to
Lakewood Hospital's outpatient program. Documentation of
these interventions takes place on the interdisciplinary
education sheets.

Blanchard Valley Regional Health Center, Findlay
At Blanchard Valley Regional Health Center, respiratory
therapists are involved in giving tobacco cessation advice to
patients who acknowledge tobacco use during the admission
assessment conducted by nursing. Cardiac rehabilitation staff
perform this function for patients admitted with cardiovascular
diagnoses, which is about 9% of the tobacco users.

Galion Community Hospital, Galion
As patients are admitted to Galion Community Hospital, the
admitting nurse determines their smoking status. A referral is
then made to respiratory therapy. Within the first or second
day, a respiratory therapist sees the patient. Documentation
of these sessions takes place in the progress notes through the
use of stickers.

Linda Hooks, LPN, RRT, Manager, Pulmonary Services, reports
that outpatient classes are held three or four times each year.
The program offered is from the American Lung Association,
and support for the program comes from the Tobacco Use
Prevention and Control Foundation.

Ashtabula County Medical Center, Ashtabula
Ashtabula County Medical Center has developed a smoking
cessation program that incorporates the American Lung
Association's Freedom From Smoking, according to Jeff Leonard,
RRT, RCP, MBA, Director of Rehabilitation and Cardiopulmonary
Services. The program was developed by an interdisciplinary
team headed by Mr. Leonard and comprised of staff members
from Cardiopulmonary Rehabilitation Services, Obstetrics,
Nursing, Quality Management, Pharmacy and Case Management.

The first session will be conducted in June and is being offered
to both patients and employees. Initiatives are underway to
offer an outreach program to area schools as well.

(Continued on page 6)

5

Respiratory Therapists (Continued from page 7)

Cleveland Clinic Health System-East Region Hospitals
The Cleveland Clinic Health System--East Region Hospitals
launched their inpatient quit smoking program in April 2004
with the objective of advising/counseling all hospitalized
cigarette smokers to quit. Ronald R. Gambino, RN, BSN, MPA,
Regional Coordinator of the Cardiopulmonary Rehabilitation
Department, leads this effort in collaboration with Daniel
Sutton, Regional Director, MPA, BS, RRT, RCP, Cardiopulmonary
Services, Cyndi Shelton, RT, Quality Coordinator/
Cardiopulmonary Services, and respiratory therapists or
RNs in each of the participating hospitals.

respiratory therapy. In addition to the education offered by
the respiratory therapists, the patient is given an informational
brochure developed as a teaching aid that includes a list of
community resources and relevant Web sites for follow-up
after discharge. Documentation of the intervention is noted
in the respiratory therapy treatment record.

University Hospitals Health System-Richmond Heights Hospital
Heather Blazek, RRT, Cardiopulmonary Services Manager at
UHHS Richmond Heights Hospital, is in the early stages of
developing a program for inpatient smoking cessation counseling.
Preprinted education sheets are given to those patients referred
to respiratory therapists for physician-prescribed treatments.
These are comprehensive materials on smoking cessation
and resources. Documentation occurs on the education log,
which is a permanent part of the medical record.

Southwest General Health Center, Middleburg Heights
At Southwest General Health Center in Middleburg Heights,
Bonnie Weston, MA, RRT, Director of Pulmonary Rehabilitation,
reports Southwest's program involves an inpatient and out-
patient effort. Nurses provide information to patients routinely
and staff in Pulmonary Rehabilitation see patients referred
to them by physicians. At this time, a smoking cessation
questionnaire is completed and a copy is placed on the patient's
chart. This copy provides the physician with pharmacological
suggestions. Patients are given additional information and
placed on a mailing list for future programs. These interventions
are documented in the patient education form.

Nurses, respiratory therapists and other healthcare professionals
are being educated through in-services and self-instructional
learning packets. All healthcare professionals are expected
to offer a brief smoking cessation intervention by sending a
clear and personal health-related message advising patients to
quit smoking. Furthermore, patients are given an internally
developed 3x5 "quit card" that includes smoking cessation
resources from the CCHS-East Hospitals, the American Lung
Association and information on the Ohio Tobacco Quit Line.
Documentation occurs in one or both of the following:
Multidisciplinary Teaching Tool form and/or Respiratory
Therapist-Driven Protocol, which become part of the patient's
medical record.

In addition to this newly developed effort in inpatient smoking
cessation counseling, CCHS-East offers an outpatient program,
Smokeless in Cleveland. This community quit smoking
program meets once per week for a total of four 1-hour sessions.
About one-third of the graduates are smoke-free at 6 months.

The Bellevue Hospital, Bellevue
The Bellevue Hospital has implemented a new protocol
related to smoking cessation counseling. An order to offer
smoking cessation education has been added to the preprinted
orders for certain diagnoses. This triggers a referral to
Cardiopulmonary Services for smoking cessation intervention.
Terry Webb, RRT, and Certified Smoking Cessation
Counselor, has trained respiratory therapists to educate
patients in smoking cessation techniques. Cardiopulmonary
Services offers information to all patients with the designated
diagnoses and continues to educate any patient prescribed

Weston has established several avenues to promote this
program including physician education, hospital newsletter
articles, and advertisements in community newspapers.
Plans are underway to present a series of four American
Cancer Society Fresh Start programs to promote the Great
American Smokeout later this year.

University Hospitals Health System, Bedford Medical Center
Karla Balasko, RRT, Manager of the Cardiopulmonary
Department, sees only patients referred to her by physicians
ordering bronchodialators. This is in addition to interventions
offered by nursing staff. She takes advantage of the treatment
time by having an informal discussion with the patient related
to smoking cessation. She is working to develop a referral
system that would involve nursing staff once the initial
assessment is complete.

Mercy Hospital of Tiffin
Matt Schlagheck, MBA, RRT, Manager of Cardiopulmonary
Services, has been instrumental in obtaining funding for their
outpatient program from the Ohio Tobacco Use Prevention
and Control Foundation. This program offers the American
Lung Association's Word of Mouth program to youth in the
community.

Inpatient efforts begin with the admitting assessment. Once
the patient is identified as a smoker, there is a standing
protocol that automatically triggers a referral to respiratory
therapy. This new intervention started with heart failure
patients and will be spread to patients with acute myocardial
infarction and pneumonia patients in the future.

6

An educational packet is provided to the patient that contains
literature on smoking cessation and resources for outpatient
programs. The information is reviewed with the patient by the
respiratory therapist, and this intervention is then documented
in the special education check sheet and the interdisciplinary
progress notes. Schlagheck is carefully monitoring this early
stage of program implementation in order to identify ways
to improve the process.

Successful by design

It is clear from reviewing these smoking cessation

programs that they are successful by design. Among

the most consistent processes are identification of

EMH Regional Healthcare System, Elyria
At EMH Regional Healthcare System, smokers are identified
on admission and entered into the database. According to
William Bursley, RPFT, RCP, Supervisor of Electro-Diagnostic
Services, respiratory therapists become involved with smoking
cessation as physicians refer their patients for respiratory
treatments or by RNs who take the initial patient history.
Both RNs and respiratory therapists provide education and
resources to these patients such as the American Lung
Association's Quit Line and a referral to their outpatient
program.

EMH Regional Health System has invested in training a team
of 15 professionals to teach the American Lung Association's
Freedom From Smoking program. The team consists of
respiratory therapists and RNs from cardiac/pulmonary
rehabilitation, occupational medicine, the sleep lab, and
several inpatient units. Both respiratory therapists and RNs
make referrals to the program as they encounter appropriate
candidates from their inpatient stays. Since its inception in
the fall of 2003, pulmonologists have been the most avid
supporters of this intervention, making referrals from their
outpatient practices. The team is now looking for ways to
enlist the support of other physician groups.

smokers on admission, an electronic mechanism to

notify respiratory therapists of patients' status, a

multidisciplinar y approach to program development,

and a clearly identified procedure for documentation.

In addition, many of these programs have received funding
from outside sources. The eagerness of respiratory therapy
managers who have embraced smoking cessation counseling
as a quality improvement project and involved their departments
in leading these efforts offers all Ohio hospitals great examples
of successful programs. Ohio KePRO project leaders will
continue to seek examples from hospitals initiating these
programs and offer statewide conference calls as a forum
for sharing ideas.

Funding Sources for Smoking Cessation Counseling

Ohio Tobacco Use, Prevention and Control Foundation ­
www.standohio.org

Marymount Hospital, Garfield Heights
Smoking cessation kits are given to every patient at Marymount
Hospital who is a known smoker. These kits contain information
on pharmacy aids, quitting "cold turkey," hypnosis resources,
and other options including the American Lung Association's
program conducted at Marymount. Kits are given out by nurses
or volunteers who document on a master checklist. This
checklist is a permanent part of the medical record.

The Cleveland Foundation ­ www.clevelandfoundation.org

The Robert Wood Johnson Foundation ­ www.rwjf.org

These are just a few of the many funding resources available.
For additional resources, please contact Ohio KePRO at
1-800-385-5080 or www.ohiokepro.com

According to Mary Glauser, Community Relations Manager,
1 of every 3 people in their service area is a smoker. Providing
both an inpatient and outpatient program therefore assists
in reaching a wide audience. Three respiratory therapists
have been trained to teach the American Lung Association's
program, according to Leslie Svoboda, BA, RRT, Manager,
Respiratory Department at the hospital. This program started in
March 2004 and has received good community support. s

Additional Smoking Cessation Information

August 2, 3, 4: Ohio Society For Respiratory Care Annual
Meeting, Columbus, Ohio. Craig Myers, RRT, PA-C, RN,
Manager of Respiratory Therapy, St. Vincent Charity
Hospital, Cleveland, to speak on Smoking Cessation.

      --Barbara G. Stiebeling, RN, MSN, and
Mona Wendell, RN, BA, MBA, Project Leaders

Ohio KePRO held a smoking cessation conference on
April 27, 2004, featuring three respiratory therapy-led
smoking cessation programs for hospitals in the state
par ticipating in the American Heart Association's Get
With The Guidelines. ^SM Watch for additional programming
offered to all hospitals in upcoming months.

7

Cleveland Clinic Health System's Conference
Identifies Key Elements of Patient Safety

The 1999 publication of the Institute of Medicine's

(IOM) report To Err is Human: Building a Safer Health

System, brought the problem of healthcare errors

to the forefront of American consciousness and

represented an important step forward in

identifying patient safety as a national priority.

I

 n addition to raising our
 collective awareness, the
report laid the foundation for
a broad-based approach to
combating healthcare errors.
It emphasized the critical
importance of identifying
healthcare errors as the result
of systems failure, thereby
requiring a change in focus
from individual fault toward
system-based solutions. A
national goal for a 50% error
reduction over the next 5
years was set.

Ohio KePRO is committed
to the promotion of patient
safety through its quality
improvement projects and
activities. Toward that goal,
members of Ohio KePRO's
Acute Care Services Team
enthusiastically responded
to an invitation from the
Cleveland Clinic Health
System to exhibit at its
Patient Safety Conference.

Cleveland Clinic Health
System's Patient
Safety Conference
The single most important
objective of the Cleveland
Clinic Health System's
Patient Safety Conference
was to discuss strategies to
eliminate harm to patients,
according to Deborah Nadzam,
PhD, FAAN, Director of the

Cleveland Clinic Health
System's Quality Institute.
Dr. Nadzam discussed the
Cleveland Clinic Health
System's Strategies for Patient
Safety. This comprehensive
program focuses on the
following seven strategies:

1. Promotion of safety.

2. Increased reporting of
  adverse events and
  error-prone processes.

3. Increased communication
  about safety issues.

4. Increased learning from
  analysis of reported
  adverse events.

5. Focused process redesign.

6. Promotion of appropriate
  applications of technology.

7. Focused education
  about safety activities.

Creating a Just Culture
Culture affects the way
people hear every message,
how they interpret facts,
how they allocate priorities,
and therefore, how they
perform. Thus, culture is a
powerful influence on the
performance of a healthcare
system. In the case of

Rosann Pasko, MS, Marketing Intervention Specialist, staffs Ohio KePRO's
booth at the recent Cleveland Clinic Health System's Patient Safety Conference.

ensuring safe care for all
patients, the development
of a just culture is perhaps
the most important indicator
of success.

Mr. Marx's comprehensive
description of just culture,
titled Patient Safety and the
"Just Culture:" A Primer for
Health Care Executives, can
be downloaded for free at
www.mers-tm.net/support/
Marx_Primer.pdf

David Marx, JD, a nationally
known human error manage-
ment consultant to hospitals,
regulators, and air carriers, was
the keynote speaker at the
conference and addressed
this critical component of
patient safety. Mr. Marx's
presentation titled "Patient
Safety and the Just Culture"
emphasized the healthcare
system's overemphasis on
disciplining employees.

Ohio KePRO's exhibit
Barbara G. Stiebeling, RN,
MSN, Acute Care Services
Project Leader and Rosann
Pasko, MS, Marketing
Intervention Specialist,
staffed Ohio KePRO's exhibit.
The booth drew many visitors
from the conference. There
was high interest in
comparison data charts
that showed how hospitals in
Ohio are doing at eliminating
the errors of omission
associated with the treatment
of patients with acute
myocardial infarction, heart
failure, and community-
acquired pneumonia. There
was also intense interest in
the online rebroadcast of
the Ohio KePRO/Ohio
Hospital Association's
statewide introduction to
the Agency for Healthcare
Research and

Mr. Marx's presentation
provided an overview of each
the following characteristics
of patient safety and a just
culture:
 · An expectation that
   errors will be reported
   (transparency).
 · No expectation of
   perfection.
 · Accountability for
   choosing to take risk.
 · Expectations set at a
   system level.
 · Expectation that system
   safety will improve.

(Continued on page 11)

8

OHIO KEPRO TO
REVIEW CHARTS OF
LONG-TERM ACUTE
CARE HOSPITALS

Order
Influenza
Vaccine Now!

Beginning in January 2004, Long-term Acute Care Hospitals (LTACs) were added

to the random selection of chart review. LTACs provide extended medical and

In order to ensure the

rehabilitative services to their patients. They usually follow the hospital-within-

availability of influenza

vaccine for administration

hospital model and must adhere to strict Centers for Medicare & Medicaid

early in the fall 2004,

Ser vices (CMS) regulations defining their relationship to the hospital in which

physicians and providers

they are located. LTACs' target patients are those who are clinically complex and

should order supplies of

have multiple acute or chronic conditions. These patients often have multiple

influenza vaccine imme-

comorbidities and are probably less stable than patients admitted to other

diately if they have not

already done so.

post-acute settings.

T

(PPS). 42 CFR parts 412, 413 and 476
establish a PPS for Medicare payment of
inpatient hospital services furnished by
LTACs. The transition was to be complete
by October 2003.

There are two major changes that affect
payment under PPS. Under TEFRA, the LTAC
could assign more than one principal diagnosis
code and the beneficiary's liability commenced
the day after issuance of a hospital issued
notice of noncoverage (HINN). Under PPS,
the LTAC may assign only one principal
diagnosis code per discharge and must allow
two days for post-discharge planning. As
always, the beneficiary has the same appeal
rights with regard to HINN issuance.

Since January 2004, Ohio KePRO has reviewed
14 LTAC charts including higher weighted
DRGs. If you have any questions or would like
to learn more about the reviews we perform,
please visit Ohio KePRO's Web site:
www.ohiokepro.com. s

Last year, large numbers of
cases of influenza began to
appear in October, and activity
was widespread.

Anticipation of increased
demand for vaccine in fall
2004 makes it imperative that
physicians and providers who
care for Medicare beneficiaries
and others at high risk for
complications from influenza
begin to prepare for the 2004-
2005 influenza season now.

While the recently enacted
Medicare Prescription
Drug, Improvement and
Modernization Act of 2003
changed the Medicare pay-
ments for many covered
drugs and biologicals, the
basis for Medicare payment
of influenza vaccine will
continue to be 95% of the
average wholesale price. s

9

Antimicrobial Prophylaxis for
Surger y­Duration of Therapy

Surgical site infections (SSIs) are the second most common cause of nosocomial infections, accounting for

17% of all hospital-acquired infections. ^1,2 Two to five percent of all patients undergoing clean extra-abdominal

operations and up to 20% of patients undergoing intra-abdominal operations will develop an SSI. ³

T

   here are several concepts that guide the understanding of
   principles of antimicrobial prophylaxis to prevent SSIs. First,
microbial contamination that results in the development of an SSI
almost always occurs during the interval between operative
incision and closure. ^4,5 Second, most if not all wounds are
contaminated with microbes during the operation. ⁶ Despite near
universal contamination, the majority of wounds heal without
infection, providing evidence that host defenses have dealt with
the contaminating organisms. Finally, the combination of the
fibrin matrix within the wound, along with continued
inflammation, edema, and relative lack of blood flow in the
tissue immediately adjacent to the postoperative wound create
barriers that prevent systemically administered antimicrobials
from penetrating the wound space after closure. ⁷

Widespread agreement
There is widespread
agreement that antimicrobial
prophylaxis should be initiated
within the hour prior to the
operative incision to achieve
serum and tissue levels
sufficient to reduce microbial
contamination of the wound.
In 1961, Burke demonstrated
that administering systemic
antimicrobials just prior to
experimental skin incisions

contaminated with
Staphylococcus aureus
resulted in SSI rates that
were identical to those of
uncontaminated incisions. ⁴
He also demonstrated that
delaying antimicrobial
administration until 3 hours
after the experimental

incisions resulted in no
reduction of the SSI rate. ⁴
Similarly, other investigators
have demonstrated that
delayed administration of
the first antibiotic dose 3-4
hours after the incision is
essentially no better than
giving the patient a placebo
for reducing the incidence
of SSIs. ^8-10

Because SSIs are largely the
result of intraoperative wound
contamination, administration
of antibiotics beyond wound
closure has not been shown
in most studies to provide
additional benefit. Many
studies comparing single-dose
preoperative prophylaxis to
multiple-dose prophylaxis
have not shown benefit of the
additional doses. ^{3,7,11-14,15-17}
Prolonged use of prophylactic
antimicrobials has been
associated with the emergence
of resistant bacterial
strains, and excess use of
antimicrobials can contribute
to secondary infections such

as those caused by
Clostridium difficile. ^18-20
There is no evidence that
continuation of prophylactic
antimicrobials until all drains
are removed will lower SSI
rates. ^21,22 Based on published
evidence, a panel of experts
in surgical infection preven-
tion, hospital infection
control, and epidemiology
developed a national quality
improvement performance
measure recommending that
antimicrobial prophylaxis
should be discontinued
within 24 hours of the end
of surgery.

In summary, SSIs are the
result of a variety of factors
including bacterial contam-
ination of the wound during
the operation, virulence of
the contaminating organisms,
adjuvant factors within the
surgical wound, and the host
defenses of the patient.
Antimicrobials administered
prior to incision in doses that
achieve adequate serum and

tissue levels throughout the
operation prevent SSIs.
Antimicrobials administered
after wound closure offer
little benefit in the prevention
of SSIs and promote
antimicrobial resistance.

10

 9. Polk HC Jr, Lopez-Mayor JF. Postoperative
   wound infection: a prospective study of
   determinant factors and prevention. Surgery.
   1969;66:97-103.
10. Stone HH, Hooper CA, Kolb LA, et al.
   Antibiotic prophylaxis in gastric, biliary, and
   colonic surgery. Ann Surg. 1976;184:443-451.
11. Page CP, Bohnen JM, Fletcher JR, McManus AT,
   Solumkin JS, Wittman DH. Antimicrobial
   prophylaxis for surgical wounds. Guidelines
   for clinical care. Arch Surg. 1993;128:79-88.
12. Dellinger EP, Gross PA, Barrett TL, et al.
   Quality standard for antimicrobial prophylaxis
   in surgical procedures. Infectious Diseases
   Society of America. Clin Infect Dis. 1994;
   18:422-427.
13. American Society of Health-System
   Pharmacists. ASHP therapeutic guidelines on
   antimicrobial prophylaxis in surgery. Am J
   Health-Syst Pharm. 1999;56:1839-1888.
14. Antimicrobial prophylaxis in surgery.
   Med Lett Drugs Ther. 2001;43:92-97.
15. Meijer WS, Schmitz PI, Jeekel J. Meta-analysis
   of randomized, controlled clinical trials of
   antibiotic prophylaxis in biliary tract surgery.
   Br J Surg. 1990;77:283-290.
16. Kreter B, Woods M. Antibiotic prophylaxis
   for cardiothoracic operations. Meta-analysis
   of thirty years of clinical trials. J Thorac
   Cardiovasc Surg. 1992;104:590-599.
17. McDonald M, Grabsch E, Marshall C, Forbes
   A. Single- versus multiple-dose antimicrobial
   prophylaxis for major surgery: a systematic
   review. Aust N Z J Surg. 1998;68:388-396.
18. Harbarth S, Samore MH, Lichtenberg D,
   Carmeli Y. Prolonged antibiotic prophylaxis
   after cardiovascular surgery and its effect on

   surgical site infections and antimicrobial
   resistance. Circulation. 2000;101:2916-2921.
19. Eggimann P, Pittet D. Infection control in
   the ICU. Chest. 2001;120:2059-2093.
20. Hecker MT, Aron DC, Patel NP, Lehmann MK,
   Donskey CJ. Unnecessary use of antimicrobials
   in hospitalized patients: current patterns of
   misuse with an emphasis on the antianaerobic
   spectrum of activity. Arch Intern Med. 2003;
   163:972-978.
21. Borecki P, Schein M, Rucinski JC, Wise L.
   Antibiotic administration in patients
   undergoing common surgical procedures in
   a community teaching hospital: the chaos
   continues. World J Surg. 1999;23:429-433.
22. Polk HC Jr, Christman AB. Prophylactic
   antibiotics in surgery and surgical wound
   infections. Am Surg. 2000;66:105-111.
23. Surgical Infection Prevention Project
   Description. Available at http://www.medqic.org/
   content/nationalpriorities/topics/
   projectdes.jsp?topicID=461. Accessed
   December 8, 2003. s

  --Dale W. Bratzler, DO, MPH, Principal
                   Clinical Coordinator,
Oklahoma Foundation for Medical Quality.

Reprinted with permission.

Cleveland Clinic Health
System's Conference
(Continued from page 8)

If you know a colleague who would like to receive his or her
own copy of Quality Matters, please pass this form along to them.

Quality's (AHRQ) Web M&M,
(www.webmm.ahrq.gov), the popular
patient safety Web site designed
for physicians.

If you missed the live presentation
of the AHRQ Web site tour, you can
link with it by visiting Ohio KePRO's
Web site at www.ohiokepro.com/providers/
events.asp. The morbidity and mortality
cases contributed by practicing physicians
each month to the AHRQ Web site help
medical professionals recognize that most
cases of preventable patient harm are
functions of overly complicated
processes of care with an inadequate
focus on error proofing. Each module
contains an actual case submitted by
practicing physicians with expert
commentary addressing issues of
patient safety and medical errors.
Free CME is offered. s

--Rosann Pasko, MS, Marketing
        Intervention Specialist

11

Acute Care Services Team
Margaret M. Toth, MD
David A. Bitonte, DO, MBA, FAOCA
Rita Bowling, RN, MSN, MBA, CPHQ
Jennifer Bitterman, RHIA, MBA
Tammera D. Caine, MS, CPHQ
Meghan Harris, MS
Lynn Mistovich, RN

Donna Moore, RN, MBA, CPHQ
Diane Oye, RN, BA
Karl E. Peters
Rosann Pasko, MS
Barbara G. Stiebeling, RN, MSN
Amanda Stroupe, MPH
Mona D. Wendell, RN, BA, MBA
Alina S. Wilkinson, MA

Medical Editor:
Margaret M. Toth, MD

Executive Editor:
Suzana C. Iveljic, MBA

Editor:
Rober t A. Feigenbaum, MS

Associate Editor:
Barbara G. Stiebeling, RN, MSN

Publication No. 4020-OH-004-6/2004. This material was prepared by Ohio KePRO under a contract with the Centers for Medicare & Medicaid Services (CMS),
an agency within the U.S. Department of Health and Human Services (DHHS). The contents presented do not necessarily reflect CMS policy.

Ohio KePRO Provider QIC Line--Your Quality Improvement Connection: 1-800-385-5080 · www.ohiokepro.com · hospital@ohqio.sdps.org