[Rapid Response Teams]
Rapid Response Teams Reduce Mortality Rates By 30% or More
By Barbara G. Stiebeling, RN, MSN, Quality Improvement Project Leader
Over the past year, hospitals across the nation have been at work implementing Rapid Response Teams (RRT) as part of the Institute for Healthcare Improvement’s (IHI) 100,000 Lives Campaign. The goal of this intervention is to “prevent deaths in patients who are progressively failing outside the ICU;” in essence, intervening early so that cardiac and respiratory arrests are averted and resuscitation is unnecessary. How is this accomplished? By bringing the expertise of highly trained professionals to the bedside—a powerful intervention, estimated to reduce mortality rates by 30% or more.
In Ohio, more than 50 acute care hospitals have implemented RRTs through the IHI campaign and have achieved some amazing successes.
Two of the earliest RRT programs were implemented at HMHP St. Elizabeth Health Center in Youngstown, Ohio, and HMHP St. Joseph Health Center in Warren, Ohio. According to Patricia Helm, RN, BSE, HMHP-PI/Accreditation Manager, the programs have been very successful relative to patient care and have been very well received by staff.
Following implementation in February 2005 largely due to the efforts of Bonnie Perratto RN, Sr. V.P Clinical Services, Larry Woods, DO, Director of Critical Care, and Stella Maiorana RN, Certified Nurse Practitioner, St. Elizabeth experienced 99 fewer deaths in 2005 than in the previous year, and codes were reduced by about half with the implementation of the RRT and other IHI Bundles. Written protocols are in place for both hospitals which define criteria for calling the RRT. Keys to success include their use of tracking logs, a single pager system and follow-up surveys for feedback on the conduct of each RRT.
Team members include physicians/senior medical residents, advanced clinical nurses, respiratory therapists, anesthesia staff and others. Any staff member can call the team and the overall perception by staff has been very positive. Benefits realized are that patients receive highly skilled assessments before a crisis occurs and staff on the units feel very supported by the team. It is a win-win experience for all involved. The challenges of establishing a successful RRT within the complexities of a teaching facility highlight the extent to which this program can serve as a model to others.
Another early program was established at UHHS Richmond Heights Hospital in April 2005 under the direction of Sharon Garretson RN, BSc (Hons), Manager ICU and SDU and Mary Beth Rauzi RN, MSN, Manager Learning Services. With the support of senior leaders Bill Lawrence, President, Janet Schuster RN, BSN, Director of Patient Care Services and Janice Meister RN, MBA, Director of Quality Outcomes, Case Management and Risk, this program attracted the attention of IHI and the team presented this program during an IHI teleconference in November 2005.
Education is key
Education is key to their success and a major component of this educational programming has been promoting positive relationships between the RRT members and division staff. The RRT team includes ICU nurses, respiratory therapists, interns and hospitalists, and is in place to serve the needs of anyone in the hospital, including visitors and staff members.
Based on an average of about 12 RRT calls per month, patients have been transferred to a higher level of care in 30% of the cases. Benefits to patients are undeniable: cardiac arrests have decreased an impressive 52% overall, with a decrease of 60% in the number of cardiac arrests occurring outside of the ICU, and mortality rates have decreased 32%. Enthusiasm runs very high at this community hospital…and these great results were achieved without adding any FTEs.
In October 2005, the Delmarva Foundation, the Quality Improvement Organization for Maryland and Washington, DC received funding from the Robert Wood Johnson Foundation to set up a learning action network in support of RRTs. Partner organizations include Ohio KePRO, the Maryland Patient Safety Institute, The Pittsburgh Regional Healthcare Initiative and the Association of American Medical Colleges. Twenty-five hospitals including up to 12 from Ohio will participate in this collaborative. As these hospitals learn from the experts and each other over the next year of the project, patients in Ohio are certain to benefit. Stay tuned. (Winter 2005-2006)
[Appropriateness of Care Measure]
A Patient-Centered Measure: Appropriateness of Care
By Barbara Stiebeling RN, MSN, Quality Improvement Project Leader
Transformational change is that which enables a provider to deliver care meeting the goals of safety, effectiveness, efficiency, timeliness, patient-centeredness and equity. It is fundamental, system-wide and must involve a commitment from senior leaders. In the 8th Statement of Work (8th SoW), the Centers for Medicare & Medicaid Services (CMS) has outlined four strategies for promoting transformational change in hospitals.
These four strategies include:
- Clinical performance measurement and reporting
- Process improvement
- Systems improvement
- Organizational culture change
A major focus of the 8th SoW is to measure care at the patient level rather than at the indicator level. Called the Appropriateness of Care measure, the goal is to provide all the care a patient is eligible to receive, based on the 10 publicly reported measures. These include five measures for acute myocardial infarction (AMI), two measures for heart failure (HF) and three measures for Pneumonia (PN). The Appropriateness of Care measure is a composite score of these 10 publicly reported measures.
Using the heart failure topic, a patient who is eligible for and receives care prescribed by both measures has received appropriate care according to the CMS definition. If the patient was only eligible to receive care prescribed by one heart failure measure, and does receive this measure, this would also meet the criteria for appropriate care.
Differences in the indicator-level and patient-level scores are illustrated by the simplified example below using the two publicly reported measures for heart failure. These are HF–2 (Assessment of Left Ventricular Function) and HF-3 (ACEI or ARB for Left Ventricular Systolic Dysfunction). In this example, you will see that for HF-2, the hospital provided this intervention to 7 out of a total of 10 eligible patients for a 70% rating on this measure. For HF-3, the hospital provided this intervention to 6 of these 10 eligible patients for a 60% rating on this measure. Looking at the column headed “Appropriate Care,” it is easy to see that while hospitals performed these interventions 60% or 70% of the time when they had opportunities to do so, only 30% of the patients in this population received both interventions for which they were eligible. In other words, only 30% of patients received appropriate care, or all that they were eligible to receive for heart failure care, based on the publicly reported measures.
| HF–2 Eligible | HF–2 Received | HF-3 Eligible | HF–3 Received | Appropriate Care | |
| Patient #1 | x | x | x | x | x |
| Patient #2 | x | x | x | ||
| Patient #3 | x | x | x | ||
| Patient #4 | x | x | x | x | x |
| Patient #5 | x | x | x | ||
| Patient #6 | x | x | x | ||
| Patient #7 | x | x | x | ||
| Patient #8 | x | x | x | x | x |
| Patient #9 | x | x | x | ||
| Patient #10 | x | x | x | ||
| 70% | 60% | 30% |
* This eligible patient received the appropriate care
Bringing this concept of appropriate care to hospitals will necessitate a systems approach to problem solving. Listed below are a few ideas to support this type of change:
- Recruit clinical and non-clinical staff for your patient care teams including at least one senior leader
- Evaluate patient care processes according to timeframes such as admission processes and discharge processes
- Encourage multiple and concurrent tests of change
- Consider how the hospital’s culture impacts each patient care issue. Choose strategies that address these issues broadly, impacting several issues at once.
Ohio KePRO will be working with a small group of hospitals on this measurement, however all hospitals will continue to receive their Appropriateness of Care measures as part of the quarterly Leadership Summary Reports. Periodically we will highlight the work of those hospitals making significant improvements in this patient-centered measure. (Winter 2005-2006)
[HIT]
Health Information Technology a Key to Patient Safety and Quality Improvement
By Patricia Nelson, RN, Quality Improvement Project Coordinator
Health Information Technology (HIT) has been identified as a key component in achieving national patient safety and quality improvement goals. The Centers for Medicare & Medicaid Services (CMS) includes HIT as one of four strategies directed toward ensuring every person receives the right care every time. In the hospital-based projects for the 8th Statement of Work (SoW), CMS determined HIT areas of focus to be Computerized Physician Order Entry (CPOE), Bar Code-Enabled Point of Care and Telehealth, or Telemedicine.
Ohio hospitals are positioning themselves to be leaders in patient safety and quality improvement through commitment to the Systems Improvement and Organizational Culture (SIOC) Identified Participant Group (IPG). Ohio KePRO is currently working with senior leaders of hospitals in this IPG to facilitate the completion of a readiness assessment designed to prepare hospitals for successful implementation of their HIT goals. Each hospital in the IPG will work with Ohio KePRO over the next three years to assess/reassess readiness to move forward on implementation of their selected HIT strategy. These hospitals will also provide a forum for sharing barriers and successes related to their implementation experiences.
Access the Ohio KePRO website at http://www.ohiokepro.com/providers/hospitals/sioc.asp to learn more about the SIOC IPG. (Winter 2005-2006)
[Expanded Measure Set]
By Mona Wendell RN, MBA, Quality Improvement Project Leader
Leadership is a critical element for successful implementation of hospital initiatives; however, all employees perform as “leaders” to achieve the objective of safe and appropriate healthcare delivery. During the 8th Statement of Work, CMS has identified specific projects that all Quality Improvement Organizations (QIOs) will address with a small group of hospitals in their respective states. In addition, the QIOs will work on statewide objectives with both Critical Access and Prospective Payment System (PPS) hospitals to improve patient care and close the quality gap. PPS statewide objectives are discussed below.
Reporting on the Expanded Measure Set
The Hospital Quality Alliance (HQA) is an initiative begun in 2002 and sponsored by a consortium of organizations headed by the American Hospital Association, whose objective was to encourage hospitals to voluntarily report their data on a starter set of ten quality measures. These included five acute myocardial infarction (AMI), two heart failure (HF) and three pneumonia (PN) measures. An expanded set of measures now exists, numbering twenty-two, which includes additional indicators for AMI, HF and PN as well as measures for Surgical Infection Prevention (SIP). It is CMS’ goal that all PPS hospitals report on this expanded measure set, and it is Ohio KePRO’s goal to assist hospitals in this process. Please find a copy of this expanded measure set on the Ohio KePRO Web site: http://www.ohiokepro.com/providers/hospital/fullsetmeasures.asp
Passing Validation
Hospitals have been working very hard to improve data abstraction in order to report valid data on the Hospital Compare Web site at http://www.hospitalcompare.hhs.gov/hospital/home2.asp. While great strides are being made, room for improvement still exists. The purpose of validation is to verify that hospital-abstracted data is accurate and can be replicated by the CMS Data Abstraction Center (CDAC). Hospitals that reach or exceed the 80% pre-determined threshold are considered to be supplying valid data for that sample of medical records.
A basic tool for ensuring accurate abstraction is the Specifications Manual for National Hospital Quality Measures found on the QNET Exchange Web site: http://qnetexchange.org/public/hdc.do?hdcPage=hosp_quality_manual. It is updated quarterly to correspond to any required changes. In addition to this tool, Karen Terlaak, RN, Ohio KePRO Quality Improvement Project Leader, is our in-house expert on abstraction and validation. Karen can be reached at 1-800-385-5080; e-mail: kgallagher@ohqio.sdps.org.
Dr. Keller, President and CEO of Southeastern Medical Center, in Cambridge, Ohio, reports that his hospital has experienced considerable success in consistent and valid data abstraction. He attributes this to a dedicated team that adheres unwaveringly to the abstraction criteria. The team includes:
- The assigned abstractor(s). When more than one abstractor is involved, inter-rater reliability testing is performed.
- The vendor who produces timely error reports regarding data entry discrepancies.
Dr. Keller and his team stress the importance of utilizing the QNET Exchange resources to achieve desired results. He has demonstrated that when leadership, culture and processes converge, extraordinary products and services are produced.
To obtain the full text for the Statewide initiatives go to:
http://www.ohiokepro.com/providers/hospital/statewide.asp (Winter 2005-2006)
[ROSC]
Survey Examines Hospital Safety Culture
By Dawn K. Knopp, RN, CPHQ, Quality Improvement Project Leader
Patient safety is a critical component of health care quality. As health care organizations continually strive to improve, there is a growing recognition of the importance of establishing a culture of safety.
Carolyn M Clancy, MD, Director of The Agency for Healthcare Research and Quality (AHRQ) states, “there has to be an environment or culture that encourages health professionals to share information about patient safety problems and actions that can be taken to make care safer, and that also supports making any changes needed in how care is delivered.”
During the 8th Statement of Work (SoW) both Critical Access Hospitals (CAH) and rural Prospective Payment System (PPS) hospital senior leaders are being encouraged to utilize the AHRQ Hospital Survey on Patient Safety Culture to assess and improve their organization’s safety culture in order to accelerate the rate of quality improvement and broaden its impact. Ohio KePRO has chosen to utilize the collaborative environment already in place, known as the Ohio Rural Hospital Flexibility Program Quality Improvement Work Group, to support the CAHs and rural PPS hospitals in their patient safety efforts.
The Hospital Survey on Patient Safety Culture examines safety culture from a hospital staff perspective. It emphasizes patient safety issues and error and event reporting. The survey measures seven unit-level, three hospital-level, and four outcome variables.
Unit-level variables
- Supervisor/Manager Expectations & Actions Promoting Safety
- Organizational Learning – Continuous Improvement
- Teamwork Within Units
- Communication Openness
- Feedback and Communication About Errors
- Non-punitive Responses to Error
- Staffing
Hospital-level variables
- Hospital Management Support for Patient Safety
- Teamwork Across Hospital Units
- Hospital Handoffs and Transitions
Outcome-variables
- Overall Perceptions of Safety
- Frequency of Event Reporting
- Patient Safety Grade (Unit Level)
- Number of Events Reported
Hospitals will be assisted to perform initial measurement and analysis, select and implement change models that require direct involvement from senior leaders, and re-measure for improvements.
To learn more about the AHRQ Hospital Survey on Patient Safety Culture please log on to http//www.ahrq.gov/qual/hospculture/ or contact your Ohio KePRO Project Leader. (Winter 2005-2006)
[Hospital Payment Monitoring Program]
Quality Improvement Plans are Effective Tools
By Martha Truby, BSEd, RHIA, Review Supervisor
The quality improvement plan (QIP) is a valuable tool used by the Ohio KePRO Review Department to work with hospitals to improve processes related to quality of care, utilization and medical necessity, and accurate and complete coding/DRG assignment. When one of these types of concerns is determined by our physician reviewers or identified as a pattern or trend, Ohio KePRO’s Quality Improvement Committee may request the hospital develop and submit a QIP addressing the issue.
Ohio KePRO will assist the hospital in developing, implementing, and monitoring their plan. We will also follow the outcome and effectiveness of the plan with the hospital, and recommend changes if the plan does not have the desired outcome.
An effective QIP contains the following elements:
- Measurable outcomes and goals
- Action steps to correct the quality concern
- Assignment of a person responsible to implement each step
- A time frame for initiating and completing the plan
- A method to evaluate the outcome or results
A typical QIP allows sufficient time for the provider to analyze the data, determine whether a problem exists, identify the root cause of the problem and develop an action plan. The timeframe for implementation of the plan varies, depending on the complexity of the issue and the processes involved.
Results and outcomes should be measured at intervals based on the processes addressed in the plan. An initial measurement should typically be completed fairly early during the plan to allow for corrections in the process. After that, the results are typically measured monthly, quarterly, or semi-annually. If the QIP has not produced the expected improvements, the hospital needs to develop and put in place an alternate plan.
At predetermined intervals, the Ohio KePRO Quality Improvement Committee requests the results of the hospital’s QIP monitoring. After successful completion of the QIP, we will send a letter to the provider indicating their expected goal has been reached, and we will no longer request their results. The hospital may choose to monitor the process on their own in order to ensure that improvements are maintained. (Winter 2005-2006)
[Validation]
By Karen Terlaak, RN, Quality Improvement Project Leader
Modifications to the Specifications Manual for National Hospital Quality Measures are an ongoing process. They include corrections and clarifications in response to questions and alignment discussions.
A brief summary of the changes to support October 1, 2005 discharges and forward are provided below:
An effective QIP contains the following elements:
Acute Myocardial Infarction (AMI):
A new data element, ARB Prescribed at Discharge, was added for collection of AMI-3, ACEI or ARB for LVSD. The current data element, ACEI or ARB Prescribed at Discharge, has been changed to ACEI Prescribed at Discharge. Changes have been made to Table 2.1
Heart Failure (HF):
A new data element, ARB Prescribed at Discharge, was added for collection of HF-3, ACEI or ARB for LVSD. The current data element, ACEI or ARB Prescribed at Discharge, has been changed to ACEI Prescribed at Discharge. Changes have been made to the Medications table found in Appendix C.
Surgical Infection Project (SIP):
Changes have been made in the following tables in Appendix A, ICD-9-CM Code Tables. Changes have been made to table 2.1, Antimicrobial Medications, in Appendix C, Medications.
Changes Affecting All Topics:
The following changes were made to the data element Discharge Status, based on changes made by the National Uniform Billing Committee (NUBC):
Value 03 --Definition changed to “Discharged/transferred to skilled nursing facility (SNF) with Medicare certification in anticipation of covered skilled care (Effective 2-23-05).”
Value 05 --Definition changed to “Discharged/transferred to another type of institution not defined elsewhere in this code list (Effective 2-23-05).”
Value 06 --Definition changed to “Discharged/transferred to home under care of organized home health service organization in anticipation of covered skilled care (Effective 2-23-05).”
Value 08 --“Discharged/transferred to home under care of a Home IV provider” will be discontinued effective 10-1-05.
A brief summary of the changes to support January 1, 2006 discharges and forward is provided below:
Pneumonia (PN):
The data element Antibiotic Allergy is listed on the analytic flowcharts.
AMI:
Data Element Thromdate and Thromtime have been modified to not require Thromadin as a parent question.
SIP:
The performance measure on duration of antimicrobial prophylaxis Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time has been changed for cardiac surgery to Prophylactic Antibiotics Discontinued Within 48 Hours After Cardiac Surgery End Time.
A brief summary of the changes to support April 1, 2006 discharges and forward is provided below:
Data Dictionary:
Admission Source Value 04 has been changed from Transfer from a hospital to “Transfer from a hospital (Different Facility*). *For transfers from hospital inpatient in the same facility see Code D.
Add Value “D”. “Transfer from Hospital Inpatient in the Same Facility Resulting in a Separate Claim to the Payer”.
Appendix C:
Table 1.1 New Aspirin and Aspirin-containing medications have been added.
Table 1.2 ACEIs: Add Quinarectic
Table 1.7 ARBs: Add Benicar HCT
Remember to check the public pages of QNet Exchange
at http://qnetexchange.org/public/
for important updates and reminders posted.
(Winter 2005-2006)
[Critical Assess Hospitals]
New Performance Measures Proposed for Critical Access Hospitals
By Donna Moore, RN, MBA, CPHQ, Quality Improvement Project Leader
Rural hospitals and critical access hospitals (CAH) face challenges that are unique to them, including limited resources, low patient volume, small staffs, and inadequate information technology. As part of the 8th Statement of Work (SoW), Quality Improvement Organizations (QIOs) including Ohio KePRO are working with rural hospitals and CAHs to promote transformational change through system processes relevant to the type of care provided by the facility.
Critical access hospitals in Ohio were trendsetters during the 7th SoW, with many reporting their data on Hospital Compare, even though they were not required to do so by the Medicare Modernization Act of 2003. Many also participated in the American Hospital Association’s voluntary reporting prior to passage of the new Medicare law, which mandated reporting on 10 quality measures in order for Prospective Payment System (PPS) hospitals to receive their full annual payment update. Unlike PPS hospitals, CAHs receive cost-based reimbursement.
New set of performance measures
A new set of rural performance measures directed towards the small hospital is being finalized. The Acute Myocardial Infarction (AMI) patient is often stabilized in the rural hospital prior to being transferred to a tertiary care facility; however, the CAH receives no credit for the initial care they provide due to a “transfer exclusion”. The result is a small denominator for the CAH on the current measures. By eliminating this “transfer exclusion” from the AMI measures, CAHs will be able to present a more accurate picture of the care they provide. The proposed AMI measures for the CAH are:
- ASA prescribed at arrival -- no transfer exclusion
- ASA prescribed at discharge
- ACEI or ARB for LVSD
- Beta Blocker prescribed at arrival—no transfer exclusion
- Beta Blocker prescribed at discharge
- Time to thrombolytics—no transfer exclusion.
Modifications include no transfer exclusion for ASA on arrival, beta blocker on arrival and time to thrombolytics. CAHs will face a new challenge, ensuring that patients receive timely, appropriate care as they are stabilized prior to transfer. Many are already investigating how they will meet these requirements. (Winter 2005-2006)
[SCIP]
Prevention of Venous Thromboembolism in the Surgical Patient
By Lynn Mistovich, RN, Quality Improvement Project Leader
During the 8th Statement of Work (SoW), hospitals across the country will be collecting data and making improvements in the area of surgery through participation in the Surgical Care Improvement Project (SCIP). SCIP consists of four modules that address the prevention of surgical site infection, cardiac complications, ventilator-associated pneumonia, and venous thromboembolism (VTE).
VTE is a known complication of surgery that carries a very high morbidity and mortality rate, particularly when undiagnosed. According to Heit et al., 2000, surgery was associated with over a 20-fold increase in risk of being diagnosed with VTE. Studies have shown that appropriately used thromboprophylaxis has a positive risk/benefit ratio and is cost effective.
Two process measures
There are two process measures in the SCIP VTE module:
- The first is surgical patients with recommended VTE prophylaxis ordered.
- The second is surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery.
In November 2004, the Seventh American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic and Thrombolytic Therapy was published. Dr. Wayne Geertz and his colleagues published the chapter on Prevention of VTE in Chest, 2004. It represents one of the most comprehensive reviews of literature on the prevention of VTE and contains nearly 800 references. The guideline was reviewed by a team of experts, including some of the authors, before it was designated as the guideline for this national measure.
For more information on SCIP, please contact Ohio KePRO’s Acute Care Services Team at 1-800-385-5080; e-mail: hospital@ohqio.sdps.org. (Winter 2005-2006)
[Immunization]
Adult Inpatient Influenza and Pneumococcal Vaccination Self-Study Continuing Education Course
This self-study module was developed by Florida Medical Quality Assurance in support of the Centers for Medicare & Medicaid Services’ (CMS) National Pneumonia Project and the inpatient influenza and pneumococcal vaccination indicators. This material would also be beneficial to other health care professionals working in nursing homes, home health, and community health. Please note: Vaccination Course (1.3 MB)
http://www.ifqhc.org/hospital/hospital_pne.html#Self%20Study%20Course
Ohio KePRO offers a variety of free tools and interventions on health literacy and pneumococcal vaccination, the Physician Office Toolkit, mammography postcards, brochures, booklets, and more. View Shopping Bag>>
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Newsletter: Quality Matters (Winter 2005-2006)
Calendar of Events
- February is Heart Month
- February 12-18, 2006
National Heart Failure Awareness Week
Visit www.abouthf.org for more information.
Acute Care Services Team
David A. Bitonte, DO, MBA, FAOCA
Rita Bowling, RN, MSN, MBA, CPHQ
Jennifer Bitterman, RHIA, MBA
Karen Terlaak, RN
Dawn Knopp, RN, BSN, CPHQ
Lynn Mistovich RN
Donna Moore, RN, MBA, CPHQ
Patricia Nelson, RN
Karl E. Peters
Rosann Pasko, MS
Liz Simpson
Barbara G. Stiebeling, RN, MSN
Mona D. Wendell, RN, BA, MBA
Medical Editor: David A. Bitonte, DO, MBA, FAOCA
Editor: Robert A. Feigenbaum, MS
Associate Editor: Barbara G. Stiebeling, RN, MSN
If you have a disability and need a document on this Web site to be provided to you in another format, please contact the Webmaster.
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