Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA

1. PI CME in a Community Hospital Nancy Carrier, RN, BSN Quality Support Tift Regional Medical Center Tifton, GA

2. About Tift Regional Medical Center (TRMC) • Located in South Central Georgia - Combined service area population - 250,400 (12 counties) • Governed by Hospital Board Authority • State accredited CME provider • Staff - 120 physicians on staff representing 15 specialties - 1,600 employees

3. About TRMC • 191 licensed beds - 176 acute care • 15 skilled nursing • 2010 Volume - 1,093 deliveries - 48,833 ER patients - 12,244 inpatients - 110,412 outpatients - 7,595 surgical cases

5. Medical staff structure

6. Hospital structure

7. CME Program • CME Committee (working committee) • Very active and committed Director • CME - monthly • RSS Activities (4) • Other Activities: • Physician case based research (PoC) • Enduring CME • PI CME

8. PI CME • Started in 2007 with first project on Sepsis • Developed a model for all future projects • Change happens when physician driven

9. Pre-op MRSA screening & intervention before elective total joint replacements (TJR) • Needs identified by Infection control and discussed in the Department of Surgery medical staff meeting • Back ground research done

10. Needs Assessment • The MRSA Risk assessment for 2008 revealed an increase in SSI with MRSA • Orthopedic statistics were the highest • Increase in community acquired MRSA in area • Patients colonized with MRSA are at risk for developing a SSI following an ortho procedure & have a 3.4 x higher risk of death and 2 x greater hospital costs.

11. Define the “GAP” • Pre –op patients colonized with MRSA are not identified • Only patients with acute infections are cultured • No decolonization guidelines for patients • No formalized educational support resource • Pre op antibiotic selection not consistent

12. Close the GAP • Research Best Practice – evidenced based • Identify national performance measures How do you do this? Where do you go to get this information?

13. Evidence basedPerformance Measures (examples) • Physician Quality Reporting Initiative (PQRI) • Physician Consortium for Performance Improvement (PCPI) • Institute for Healthcare Improvement (IHI) • CDC • National Organizations • Evidenced based literature research

14. MRSA • CDC & Surgical Care Improvement Project (SCIP) Guidelines • SHEA (Society for Healthcare Epidemiology of America) • IDSA (Infectious Diseases Society of America)

15. Goals & Objectives • Screen 100% of patients scheduled for elective total joint replacements for MRSA during their pre op assessment • All colonized patients will complete a decolonization protocol before surgery • 2% mupirocin ointment to nose bid x 5 days pre-op • 4% chlorohexidine gluconate body wash x 5 days pre-op • Colonized patients will be screened again prior to surgery • Colonized patients will be placed in Contact Precautions upon admission

16. Goals & Objectives • Patient Outcomes • Surgical site infections will decrease in total joint patients • Reduce use of Vancomycin for surgical prophylaxis

17. PI CME – 1st steps • This PI CME project started in March, 2009 • Planning started • CME & QI brainstorming • IC and the Ortho group requested to “take on the challenge” • Provide background information & literature • Needed to identify champion • IC Committee chair

18. Project leader / physician champion • Physician • Passion for the project • Finalize team members identified to participate • Invited physicians to participate by letter • Follow up with a phone call • Want cross section representation of all departments involved when ever possible We may affirm absolutely that nothing great in the world has ever been accomplished without passion.-- Georg Hegel

19. Adding Support Staff • Laboratory • OR • Day Surgery and Assessment nurses • Ortho nurses • Infection Preventionist • Orthopedic PAs • Pharmacy • QI/ Data analysist • CME

20. Initial kick-off meeting Provide a meal for the initial meeting • Overview of QI / PI CME activity • Establish ground rules • Peer protection • Confidentiality • Expected time frame • What commitment would involve • Required to sign letter of commitment • Educational backup • Literature & articles • Web sites • Grand rounds and 1:1 time with expert • Benefits of participants • Become resources for peers • Develop guidelines they would be measured against • CME Credit • Several free lunches / dinners

21. Next Steps • Letter of Commitment • Confirmation of goals • Schedule of future meetings • Reading Assignment • SHEA/IDSA Practice Recommendation, “Strategies to Prevent Transmission of MRSA in Acute Care Hospitals” Oct 2008 • CDC “Management of Multidrug-Resistant Organisms” 2006

22. Meeting Calendar • Dinner Kick-off and assignments • Sub-Committee report back • Guideline draft presented / approved • Guideline roll-out • Possible Grand Rounds • Final Meeting / Wrap-up

23. You are being asked to participate in a Performance Improvement study at TRMC that involves improving pre-op MRSA screening & treatment of patients who are scheduled for elective Total Joint Replacements. This form provides you with information about the expectations of the study and encourages commitment of about 6 months participation. --------_is the Director of this project and is available to answer any questions that may arise. Please review the following information and if you agree to participate, please sign in the appropriate sections. Name: Practice Specialty: Pediatrics Dr phone: e-mail Title:Pre-op MRSA screening & treatment for elective Total Joint Replacements Purpose: To develop protocols designed to decrease the incidence of SSI by MRSA, including active surveillance cultures to identify patients colonized with MRSA and decolonization of patients with MRSA prior to surgery. Benefits: Improve patient care by decreasing the incidence of SSI in elective Total Joint Procedures caused by MRSA. Cost: No cost will be accrued to you for participating; however, there will be a time commitment. Compensation: You will not receive payment for participating. Up to 20 CME credits will be awarded commiserate with your participation. Educational opportunities will be provided and any expenses incurred such as travel will be reimbursed. Privacy Information will be shared that must remain confidential. The information discussed in this group will be peer protected through the IC Confidentiality: committee Expectations: We will ask your commitment to reading all literature provided, to attend any planned CME conference, and participate in the project as outlined. Periodic evaluations will be provided for you to complete, including a summary at the end of the designated time frame of the project. Monthly meeting time will be set. We understand that your time is important. We will start and stop on time. You may be asked to review data collection summaries to validate the results. All HIPAA sensitive information and peer review must remain confidential. You have been informed about this project’s purpose, benefits and expectations and have been given the opportunity to ask questions. By signing, you voluntarily agree to participate in this project. _______________________________________ __________________ Signature Date Letter of Commitment

24. Unless commitment is made, there are only promises and hopes; but no plans. -- Peter F. Drucker

25. CME credit • Give overview of the PI/CME process • Explain Stages A, B & C • Review the evidenced based performance measures • Review their commitment and documentation required to be awarded credit • Answer all questions

26. Stage A Learning from current practice performance assessment • The team Physicians review patient data • May request additional information • Objectives for PI CME activity are defined • Public reporting • Review current practice and make recommended changes in physician practice (hospital-wide) • Develop P&P as needed • Standardize educational materials • Develop Stage A measures

27. MRSA ScreeningPerformance Measures

28. Stage B Learning from the application of PI to patient care • Develop guidelines for identifying patients colonized with MRSA and steps to take to initiate decolonization procedures • Provide surgical and orthopedic staff education • Provide patient education • Standardize educational materials for patients • Develop discharge planning tools for patients • Develop checklists • Write policies and procedures • Review antibiotic practices

29. Stage B interventions • Development of new guidelines • Committee approval • Staff education • MRSA • Pre-op assessments and scheduling • Nasal swabbing • Medications used • Documentation requirements • Patient education • MRSA booklet • Pre op & post op instructions

30. Building patient & hospital interest Living with MRSA • This is really serious! I need to do something about this now! • Learning how to control the spread of • Methicillin-Resistant Staphylococcus Aureus (MRSA)

31. There is a simple, painless nasal swab test for a potentially dangerous pathogen called Staphylococcus aureus, also known as MRSA (Methicillin-resistant Staphylococcus aureus). This test identifies people who are potential reservoirs of infection. You can carry MRSA in your nose or on your skin without displaying symptoms. Approximately 1 in 5 people carry MRSA. An approach called Active Surveillance Culturing could reduce MRSA infections in hospitals by more than 70 percent. Total Joint Replacement Pre-Operative Screening Protocol People who harbor these bacteria in their nose, or on their skin, are called “carriers,” or are “colonized” with the bacteria. MRSA colonized patients are at higher risk for developing MRSA infections after surgery at their surgical site. During your pre-op assessment, the nurse will use a Q-tip swab to collect a culture from your nose to determine if you are an MRSA carrier. If you test positive for MRSA, someone will contact you with further instructions prior to your surgery. Your doctor will order a nasal ointment to be applied to your nose twice a day for 5 days just prior to your surgery. Since this bacteria could also be living on your skin, it is very important that you bathe once a day using the Hibiclens body wash for 5 days just before your surgery. Hibiclens can be purchased from your local Pharmacy without a prescription. We are very committed to providing you the best care possible. It is very important that you follow these instructions to minimize the risk of complications after surgery.

32. Stage C Learning from the evaluation of the PI effort • Final chart reviews began one month after guidelines were completed and interventions were implemented • Analyze chart reviews • Review compliance with new guidelines • Implementation success • Determine opportunities for improvement Do something. If it works, do more of it. If it doesn't, do something else.-- Franklin D. Roosevelt

33. Final meeting with participating physicians • Project physicians review their individual data • Guidelines are reviewed & edited as needed • Complete final evaluation & credit request forms • AWARD CME CREDIT! • Develop plan to communicate changes & educate

34. Continuing Medical Education Credit Request for Performance Improvement Activity TRMCpre-op MRSA screening & treatment for elective total joint replacements April, 2009 Stage C Activity:please check areas you have completed, respond to the questions and sign • I completed the implementation plan for the Performance Improvement CME project for MRSA Initiative • I evaluated the progress made through implementation of this plan Please describe below whether the intervention (Individual Action Plan) you implemented improved your department practice/performance in those areas identified. If not, please provide an explanation as to why. Factors such as systems failures or other barriers to success should be included……..

35. Results from activity

36. Determining benefit of active surveillance screening Monitoring compliance with decolonization Follow up on decolonization failures Availability of 4% chlorohexidine gluconate Compliance with Contact Precautions This was a learning curve that soon was overcome This was based on patient report so was out of our control A discharge instruction sheet was designed Barriers Identified

37. Pre-op showers with 4% chlorohexidine gluconate for all total joint patients Improved compliance with Contact Precautions Standardized patient education on MRSA Developed discharge instructions for patients colonized with MRSA Appropriate use of Vancomycin as a pre-op antibiotic SSI rate decreased (>50% through 2010) TRMC now uses all 4% chloro-hexidine gluconate showers for ALL surgeries not just joints Staff education and awareness on Ortho unit MRSA booklet providing standardized education P&P developed Marketing tools and posters Decrease in Vancomycin use improving resistance rates Benefits

38. Continue MRSA screening for total joints and extend to other procedures Consider 4% chloro – hexidine gluconate for all pre- op showers Investigate all surgical site infections and observe for any trends or common links Any implants such as hernia mesh as well as all spinal implants. Recommendations

39. Presentation to Quality Council General Surgeon Education Cost analysis Final report from Infection Control CME credits Adjournment Physician champion & IC presented findings to the hospital Quality Council then to the Board This data will be presented at the Department of Surgery. Even though the hernia infection rate is <1.5%, there is always room for improvement IC will work on a cost analysis for prevention costs as compared to infection costs (selling point for admin) All implants must be followed for infections for 12 months. At the end of this time, IC will report a final infection rate. 20 Category one credits will be awarded Great Job! Final Discussion & Roll Out

40. Tips for engaging physicians • Recruit a strong physician leader • Follow the “ground rules” established in your first meeting • Keep within the time frames agreed upon • Make sure it is physician driven • Feed them!

41. Lessons learned • Administrative support • Committed medical leader • Buy-in from medical staff participating in project • Preparations for each meeting • (pre-meeting meetings) • Clear expectations • Defined budget • Food • Celebrate success

42. Advice for other CME providers • Utilize your Resources • (QI loves this stuff!) • Excitement with success! • Share your success with peers • Be prepared for the time commitment • Strong non-medical leader • CME Director backing • Record keeping • Facilitate CME compliance

43. Comments from the MRSA Physician Champion • It IS doable • Recommend a strong support team • The Physician champion will coordinate with the support staff to keep everyone working in the same direction • Be available by phone or e-mail; it will save on overall time commitment and meetings

44. Just play! Have fun. Enjoy the game! -- Michael Jordan