J.1(e)_QIN-QIO_Table_of_Evidence_Based_Interventions.docx

Attachment J.1(e)- QIN-QIO Table of Evidence Based Interventions

HHSM-500-2014-RFP-QIN-QIO

Tables of Evidence-Based Interventions

Evidence-Based Interventions for Multidimensional Programs to Improve Care Transitions

Care Transitions Intervention (CTI) Description: Care transitions coaches support patients by providing specific tools and teaching self-management skills to ensure their needs are met during the transition from the acute care setting to home.

Aim: Support patients and families; increase skills among healthcare providers; enhance the ability of health information technology to promote health information exchange across care settings; implement system level interventions to improve quality and safety; develop performance measures and public reporting mechanisms; influence health policy at the national level.

Resource: http://www.caretransitions.org

RCT

Coleman et al. (2006): Lower 30-day readmission; lower readmission at 90 days and 180 days.

Other support Coleman et al. (2004): Lower readmission for same diagnosis at 90 days and 180 days.

Bridging Nursing Support / Transitional Care Model Description: Multidisciplinary, comprehensive in-hospital planning and home follow-up. Transitional Care Nurses follow patients from the hospital into the home to provide services designed to streamline plans of care, interrupt patterns of frequent acute hospital and emergency department use and prevent health status decline.

Aim: Improve coordination and continuity of care; engage and activate patients, family members and caregivers.

Resource: http://www.transitionalcare.info/index.html RCTs Naylor et al. (1999): 45% reduction in readmission rate.

Naylor et al. (2004): Increased time to readmission/death; reduced readmission rate.

Better Outcomes for Older Adults through Safe Transitions (BOOST) Description: Toolkit for improving hospital discharge, including screening/assessment tools, discharge checklist, transition record, teach-back process, risk-specific Interventions and written discharge Instructions.

Aim: Reduce 30-day readmissions; improve patient satisfaction; improve information flow between hospital and outpatient physicians; ensure that high-risk patients are identified and specific interventions are offered to mitigate their risk; improve patient and family education practices to encourage use of the teach-back process around risk specific issues.

Resource: http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm

RCT

Preen et al. (2005): Improved QOL, involvement and satisfaction with discharge care.

Systematic review Kripalani, Jackson et al. (2007): Approaches to promoting effective transitions of care include “…improvements in communication between inpatient and outpatient physicians, effective reconciliation of prescribed medication regimens, adequate education of patients about medication use, closer medical follow-up, engagement with social support systems, and greater clarity in physician–patient communication.”

Kripalani, LeFevre et al. (2007): Deficient communication between hospital-based physicians and PCPs; need for improvements to discharge summaries and health information technology.

Other support Simon et al. (1998): PCP involvement in hospitalization associated with reduced problems with diagnostic tests, post-discharge activity and health habits.

van Walraven et al. (2004): Follow-up care with hospitalization physician associated with lower readmission rate, versus community physician or specialist.

Best Practices Intervention Package (BPIP): Transitional Care Coordination Description: Comprehensive manual for home health agency leadership and staff to identify tools and processes to improve patient transitions; focus on the four pillars, or conceptual domains, of patient transition; includes tools and resources for patients and staff, guidelines and podcasts Aim: Reduce avoidable acute care hospitalizations.

Resource: http://www.homehealthquality.org/hh/ed_resources/interventionpackages/default.aspx Health Quality Improvement National Campaign Esslinger (2008): Preliminary data demonstrate modest improvements in hospitalization rata among participating HHAs and worsening among non-participating HHAs.

Schade et al. (2009): Agencies w/ improvement more likely to report activities consistent with campaign and use of campaign interventions, regardless of participation status.

Interventions to Reduce Acute Care Transfers (INTERACT) Description: Toolkit for SNF personnel to reduce avoidable hospital admission. Three types of tools: 1) communication; 2) clinical care paths; and 3) advance care planning. Utilization specified for selected members of the care team.

Aim: Reduce transfers to acute care setting.

Resource: http://interact.geriu.org/ CMS Nursing Home Special Study Ouslander (2008): Higher hospitalization rates associated with larger facilities, more Medicaid and Medicare skilled care residents, lower percentage of Caucasian residents and higher percentage of residents with impaired decision making; 68% of hospitalizations were avoidable, per expert panel record review.

Transforming Care at the Bedside (TCAB) Description: Hospital interventions built around four themes: 1) safety and reliability, 2) care team vitality, 3) patient-centeredness and 4) increased value. Four core elements of the intervention: 1) enhanced admission assessment for post-discharge needs; 2) enhanced teaching and learning; 3) patient and family-centered handoff communication; and 4) early post-acute care follow-up.

Aim: Transform the care experience of patients in hospital medical/surgical units, as well as the experience of health care professionals who care for them.

Resource: http://www.ihi.org/IHI/Programs/StrategicInitiatives/TransformingCareAtTheBedside.htm Program evaluation Lorenz et al. (2008): Reductions in patient wait times; increase in patient and staff satisfaction by 30 percentiles; shortened turnaround for laboratory results; improvement of visitors' first impressions through new signage and a concierge program.

Re-engineered Discharge (RED) Description: Standardized discharge intervention; includes patient education, comprehensive discharge planning, post-discharge telephone reinforcement.

Aim: Minimize post-discharge hospital utilization.

Resource: http://www.bu.edu/fammed/projectred/index.html

RCT

Jack et al. (2009): Nurse discharge advocate support (follow-up appointments, medication reconciliation, patient education, individualized instruction booklet sent to PCP); telephone follow-up by clinical pharmacist (reinforce the discharge plan, review medications) associated with lower rate of post-discharge utilization overall; non-significant reduction in readmission rate.

The Bridge Model Description: A social work approach to care transitions. A licensed social worker meets with patients prior to discharge home from a hospital stay. A resource center is also created in the hospital setting, and the social worker helps to connect patient to resources in the community prior to leaving the hospital. The social worker follows up with patients at 2 days and 30 days following discharge to provide care coordination and help address issues that arise.

Aim: Support patients, increase health literacy, increase connection to resources, improve care coordination, improve self-management of conditions Resource: http://www.transitionalcare.org

RCT

· Altfeld et al. (2012): Intervention patients were more likely than usual care patients to have scheduled and completed physician visits by 30 days post discharge. EDPP social workers identified problems during the post-discharge telephone assessment in 300 (83.3%) intervention group participants.

Other Support Altfeld et al. (2012): 93 percent agreed or strongly agreed that Bridge meets previously unmet client needs;

Guided Care Description: An interdisciplinary model that places a specially trained nurse in medical practices to provide intensive care management to patients with complex health conditions, as well as provide support to medical providers and caregivers.

Aim: Support patients and families; increase communication; increase care coordination.

Resource: www.guidedcare.org

RCT

· Boult et al. (2013) Guided Care was associated with significantly higher participant ratings of the quality of care (difference = 0.27, 95 % CI = 0.08-0.45) and 29 % lower use of home care (95 % CI = 3-48 %).

· Boyd et al. (2010): Eighteen months after baseline, the odds that a GC recipient rated his or her aggregate quality of care as “high-quality” were twice as great (aOR=2.13, 95% CI=1.30, 3.50, p=0.003). GC recipients had significantly greater odds of rating two specific elements of their care as “high-quality”: coordination of care (aOR=1.80, 95% CI=1.12, 2.90, p=0.016) and decision support (aOR=1.49, 95% CI=1.05, 2.11, p=0.025).

· Marsteller et al. (2010): Compared with the physicians in the control group, those in the Guided Care group rated their satisfaction with patient/family communication and their knowledge of the clinical characteristics of their chronically ill older patients significantly higher (ρ <0.05 in linear regression models).

· Sylvia et al. (2008): GC group had lower unadjusted mean insurance expenditures, hospital admissions, hospital days, and emergency department visits (p _ 0.05). There were larger differences in insurance expenditures between the GC and UC groups at lower risk levels (at ACG-PM _ 0.10, mean difference _ $4340; at ACG-PM _ 0.6, mean difference _ $1304).

Other Support

· Wolff et al. (2010): GC caregivers reported the overall quality of their recipients' chronic illness care to be significantly higher (adjusted beta = 0.40, 95% confidence interval: 0.14-0.67).

GRACE

Description: Interdisciplinary care team collaborates to develop and implement individual care plans for low-income seniors. Nurse practitioners and social workers provide home visits and regular follow-up phone calls to patients to manage and coordinate patient care, and regularly communicate with primary care physician and other members of interdisciplinary team to keep plan on track and make modifications as necessary. Also includes written protocols for management of common chronic conditions.

Aim: Support patients and families; increase standardized care; improve communication between providers; provide individualized care planning.

Resource: http://medicine.iupui.edu/IUCAR/research/grace.aspx

RCT

· Counsell et al. (2007): The cumulative 2-year ED visit rate per 1000 was lower in the intervention group (1445 [n=474] vs 1748 [n=477], P=.03). In a predefined group at high risk of hospitalization (comprising 112 intervention and 114 usual-care patients), ED visit and hospital admission rates were lower for intervention patients in the second year (848 [n=106] vs 1314 [n=105]; P=.03 and 396 [n=106] vs 705 [n=105]; P=.03, respectively).

Other Support Boult et al. (2010): Discusses benefits of GRACE, CTI, and one other intervention.

Hospital to Home (H2H) Description: A post-discharge service that is designed to reduce preventable 30-day readmissions by addressing multiple common causes of readmissions among patients with CHF or AMI.

Aim: Improved care coordination; improved management of chronic conditions; improved medication management; increased patient activation.

Resource: http://h2hquality.org/AboutH2H/AboutH2H/tabid/168/Default.aspx Best Practices

· Wiggins et al. (2013): Best Practice to implement H2H for Patients with Heart Failure or Myocardial Infarction

Systematic Review

· Enderlin et al. (2013): Each model described can provide a framework for managing health conditions across settings of care in collaboration with the older client and his/her family. Benefits in utilizing the models during transitions include early recognition and resolution of changes in an older adult’s health status.

Other Support

· Cox et al. (2011): Thirty day hospital readmission rate to VUMC for 56 pilot patients 30 days after discharge was reduced from our previous readmission rate of 26.1% (2006-2009) to 14.2% (p50.03).

Cunningham et al. (2011): Decreased the readmission rate from 25.7% to 13.4%.

Table 1 B: Intervention Strategies to Improve Care Transitions

CROSS-SETTING CARE STANDARDIZATION

Enhanced information transfer at discharge Description: Improvements in timely transfer of medical information from the acute care setting to post-discharge healthcare providers.

Aim: Ensure that current, accurate health information is accessible to receiving providers.

Targeted drivers of readmission: Unreliable handover processes; poor information transfer.

Basis for recommendation: An element of formal multidimensional programs with strong evidence base; evidence linking deficient information transfer processes and adverse events.

Systematic review Kripalani, LeFevre et al. (2007): Deficient communication between hospital-based physicians and PCPs; need for improvements to discharge summaries and health information technology.

Cohort study Forster et al. (2003): 19% with adverse event following hospital discharge (of which 6% preventable, 6% ameliorable); primarily medication-related (66%) and procedure-related (17%); attributed to ineffective communication and inadequate information transfer; suggestions for improved discharge planning, drug therapy education, follow-up visit with hospitalist within a week of discharge and telephone follow-up with 5 days of discharge.

Other support Payne et al. (2002): Liaison between hospital and community personnel (“key worker”) improved communication and satisfaction; little evidence to support reduced readmission rates per se.

van Walraven et al. (2002): Non-significant association between discharge summary received by follow-up physician and lower readmission rate.

Follow-up care established at discharge Description: Arrangements – made prior to leaving the acute care setting – for the patient to receive appropriate follow-up care.

Aim: Ensure that patients receive proper post-acute follow-up care.

Targeted drivers of readmission: Unreliable handover process.

Basis for recommendation: An element of formal multidimensional programs with strong evidence base.

RCTs Naylor et al. (1999): 45% reduction in readmission rate.

Naylor et al. (2004): Increased time to readmission/death; reduced readmission rate.

Medication management Description: Activities to improve effectiveness of pharmacotherapy, including support of patient understanding of appropriate medication use and adverse events; adherence to medication regimens and detection of adverse events and over-/under-use.

Aim: Reduce medication errors leading to adverse events and readmission.

Targeted drivers of readmission: Insufficient support for patient and family self-management; unreliable handover process; poor information transfer.

Basis for recommendation: Evidence linking adverse drug events and higher healthcare utilization; an element of formal multidimensional programs with strong evidence base.

RCTs Crotty et al. (2004): More appropriateness of prescribing, better pain and lower hospital utilization.

Schnipper et al. (2006): Reduction in preventable adverse drug events.

Koehler et al. (2009): Reduced readmission/ED visit rates.

Systematic review Pellegrino et al. (2009): Potential benefit, but numerous challenges; need for randomized controlled trials.

Cohort Study Boockvar et al (2004): 86% with at least one drug alteration during hospitalization, primarily drug discontinuations; 20% incidence of alteration-attributed adverse drug events; 4.4% overall risk of adverse drug event per alteration; most adverse drug events occurred following return to SNF.

Other support Forster et al. (2003) above (Enhanced information transfer at discharge).

Lappe et al. (2004): Lower readmission rate after program implementation targeting discharge medications.

Coleman et al. (2005): 14% prevalence of ≥1 discrepancy; associated with multiple medications and CHF.

Plan of care Description: Collaborative development of a complete, accurate strategy for post-discharge care including history, situation, likely progression, patient/family preferences for end-of-life issues.

Aim: Consistent vision of medical and health support needs among caregivers, including the patient as self-caregivers.

Targeted drivers of readmission: Insufficient support for patient and family self-management; poor information transfer.

Basis for recommendation: An element of many formal multidimensional programs strong evidence base. AHRQ endorsement.

Government report AHRQ (2007): Plan of care is essential to care coordination.

Other support Per AHRQ (2007) report: Longest et al. (1994), Ziring et al. (1999), Kinsman et al. (2000), Wehr (2000), Gittell (2000, 2002), Cooley et al. (2003), Sprague et al. (2003), Safran et al. (2006).

Telemedicine Description: Remote monitoring and care delivery via telemonitoring (electronic or telephonic transfer of physiological data from home to healthcare provider) or regular telephone-based medical management.

Aim: Continued medical management following discharge.

Targeted drivers of readmission: Poor information transfer due to insufficient availability of health information; discontinuous care after discharge.

Basis for recommendation: Substantive positive evidence amid mixed results; promising strategy for patients living in remote locations.

Systematic reviews Chaudhry et al. (2007): Evidence base still developing; telephone-based interventions appear equally effective to more complex, and costly, interventions.

Clark et al. (2007): Reduced hospital admissions for CHF; reduced all-cause mortality; improved QOL.

Other support Jerant et al. (2001): Intervention of home telecare or nursing telephone calls resulted in non-significant reduction in hospital readmission charges.

Hersh et al. (2006): Significant gaps in the evidence base; need for well-designed and targeted research.

Telephone follow-up Description: Telephone calls made to the patient shortly after discharge from acute care setting to provide information, health education, symptom management, early monitoring of complications, reassurance and quality post-discharge care.

Aim: Address problems arising in the first few weeks following hospital discharge; address patients’ post-discharge questions and care needs.

Targeted drivers of readmission: Discontinuous care after discharge; insufficient support for patient and family self-management.

Basis for recommendation: Ease of implementation; an element of many formal multidimensional programs with strong evidence base.

Systematic review Mistaiaen & Poot (2006): Some effects favoring telephone follow-up; insufficient evidence to support/refute effectiveness.

RCTs Jerant et al. (2001) above (Telemedicine).

Schnipper et al. (2006) above (Medication management).

Jack et al. (2009): Nurse discharge advocate support (follow-up appointments, medication reconciliation, patient education, individualized instruction booklet sent to PCP); telephone follow-up by clinical pharmacist (reinforce the discharge plan, review medications) associated with lower rate of post-discharge utilization overall; non-significant reduction in readmission rate.

Electronic health record / electronic medical record Description: Databases and data access/reporting systems to standardize patient information available to providers across care settings.

Aim: Prevent medical errors by minimizing incomplete, inaccurate and conflicting information across care settings.

Targeted drivers of readmission: Poor information transfer.

Basis for recommendation: Evidence linking inadequate information transfer and complications that lead to unnecessary care; robust information exchange continues to be rare.

Congressional report MedPAC (2007): Efficiency and quality benefits of health information technology, especially electronic medical record (e.g., informed care decisions, real-time measures of quality).

Systematic reviews Chaudhry et al. (2006): Increased adherence to guidelines and protocols; decreased utilization.

Jha et al. (2006): Electronic health record used by 24% of physicians in ambulatory setting; computerized provider order entry used by 5% of hospitals.

SYSTEMIC ENHANCEMENTS (WITHIN SETTING)

Multidisciplinary team, multifaceted interventions Description: Collaboration among a multidisciplinary team, facilitating community treatment, collaborative care and shared primary specialty care Aim: Improve care coordination to reduce readmissions; integration of patients’ medical, pharmaceutical, psychosocial and spiritual needs at the time of discharge.

Targeted drivers of readmission: insufficient support for patient and family self-management; lack of standard, known processes.

Basis for recommendation: Strong evidence base; an element of formal multidimensional programs with strong evidence base.

See Table 1a: BOOST, INTERACT, RED, TCAB Systematic review McAlister et al. (2004): 27% reduction in CHF hospitalization rates; reduced all-cause mortality; enhanced self-care, follow-up monitoring (including telephone), access to CHF clinics were most efficacious; key elements of specially trained CHF nurses, patient education on CHF and ready access to CHF-trained clinicians.

RCTs Rich et al. (1995): 56% reduction in readmissions for CHF; non-significant reduction in all-cause readmissions.

Kasper et al. (2002): Fewer CHF hospitalizations and deaths among treatment group.

Meta-analysis Holland et al. (2005): Reduced all-cause and CHF hospitalization, notably for home and telehealth; reduced all-cause mortality.

Clinical protocols, best practices and regional guidelines Description: Establishment of congruence in practice standards within and across settings.

Aim: Ensure that in-setting care will be consistent with care in other settings.

Targeted drivers of readmission: Lack of standard, known processes.

Basis for recommendation: Strong evidence base (esp. medication management). Consistent with AHRQ patient safety goals; MedPAC recommendations.

See Table 1a: BPIP, TCAB Congressional report MedPAC (2007): Several recommendations in favor or empirically based guidelines in clinical practice.

Other support Lappe et al. (2004) above (medication management).

Orrick et al. (2004): Antibacterial therapy per Infectious Diseases Society of America guidelines associated with shorter hospital stay, lower cost of hospitalization.

Huffman (2005): Recommendations for implementation of best practices and linkage to patient outcome.

Dean et al. (2006): Hospitals implementing PNE guidelines had lower readmission rate.

Enhanced palliative care consultation/support Description: Improved assessment of palliative care needs and end-of-life preferences, including appropriate palliative and hospice care referrals. Support for advanced care planning.

Aim: Ensure common understanding of preferred medical treatments to reduce reliance on acute care services; consistent vision of medical and health support needs among caregivers, including the patient as self-caregivers.

Targeted drivers of readmission: Insufficient support for patient and family self-management; lack of standard, known processes; poor information transfer.

Basis for recommendation: Strong evidence base.

See Table 1a: INTERACT

RCT

Gade et al. (2008): Fewer ICU admissions on hospital readmission; longer hospice stays.

Observational study Levy et al. (2008): Lower likelihood of in-hospital death after implementation; 100% prevalence of advanced directive among those who died after implementation; increased likelihood of palliative care referral.

Other support Johnson et al. (2004): 68% use of guidelines, protocols or care pathways for symptom management (larger organizations reported greater use); lack of availability was top reason for non-use; medication management was most common resource.

Penrod et al. (2006): Palliative care associated with smaller likelihood of ICU admission and lower direct, ancillary inpatient costs.

Meier & Beresford (2008): Recognition of large overlap between palliative care and care transitions.

PATIENT, FAMILY & CAREGIVER SUPPORT

Education Description: Teachings and materials targeted toward patients, family members and other informal caregivers on topics of disease self-management, treatment options, expectations and available resources.

Aim: Enable patients to avoid unnecessary utilization of health services though accurate understanding of health medical needs; improve quality of self-care and management.

Targeted drivers of readmission: Insufficient support for patient and family self-management.

Basis for recommendation: Strong evidence base; an element of formal multidimensional programs with strong evidence base.

RCTs Rich et al. (1995) above (multidisciplinary team / multifaceted interventions)].

Krumholz et al. (2002): Lower readmission rate; lower risk of readmission, controlling for demographics.

Riegel et al. (2002): Lower CHF readmission rate at 3 and 6 months; fewer multiple readmissions.

Kimmelstiel et al. (2004): Fewer hospitalizations for CHF; fewer cardiovascular hospitalizations.

Koelling et al. (2005): Lower risk of readmission; lower cost of care.

Coleman et al. (2006): Lower 30-day readmission; lower readmission at 90 days and 180 days.

Meta-analyses Phillips et al. (2004): Lower readmission rate.

Mistiaen et al. (2007): Some evidence that educational interventions at discharge lower the risk of readmission.

Other support Coleman et al. (2004): Lower readmission for same diagnosis at 90 days and 180 days.

Coaching Description: Non-medical support for home-based self-management capability.

Aim: Improve competence in achieving personal health goals. Avoid inappropriate and unwanted medical interventions.

Targeted drivers of readmission: Insufficient support for patient and family self-management.

Basis for recommendation: Strong evidence base; an element of formal multidimensional programs with strong evidence base.

See Table 1a: CTI

RCT

Coleman et al. (2006) above (Education).

Other support Coleman et al. (2004): above (Education)

Personal health record (PHR) Description: Organizational tool for patients to track health care goals/concerns, medications, sign and symptom red flags, provider contact information and any other information relevant to healthcare self-management.

Aim: Provide reliable resource for patients to document key medical information and track health support needs.

Targeted drivers of readmission: Insufficient support for patient and family self-management; poor information transfer.

Basis for recommendation: An element of formal multidimensional programs with strong evidence base; widespread acceptance as a promising and inexpensive intervention.

See Table 1a: CTI, BPIP

RCT

Coleman et al. (2006) above (Education).

Other support Coleman et al. (2004) above (Education).

Kaelber et al. (2008): Need for additional PHR research to increase likelihood of PHR deployment and demonstrate beneficial effects on healthcare costs, quality and efficiency.

Community supports Description: Connecting patients and family members to non-medical community health support agencies and other entities (individuals, community groups, businesses); patient use of resources provided by community members.

Aim: Eliminate everyday barriers to self-management (e.g., lack of transportation).

Targeted drivers of readmission: Insufficient support for patient and family self-management.

Basis for recommendation: Strong evidence base; AHRQ recommendation.

Systematic review Naylor & Keating (2008): Recommendations made for family support, esp. needs assessment.

Other support AHRQ (2007): Review of evidence and recommendations on care coordination improvement - “Providers should also consider establishing communication links with community services and maintaining an inventory of these services.” (p.133)

*Some of Evidence-Based Interventions for HAI prevention and reduction: Central line-associated bloodstream infections (CLABSI), Catheter-Associated Urinary Tract Infections (CAUTI), Clostridium difficile infections (CDI) and Surgical site infections

Hand Hygiene

Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR). Hand hygiene should be performed before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained

Guidelines for the Prevention of Intravascular Catheter-Related Infections2 http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

Category IB

All relevant clinical staff at hospitals and surgical care settings. Executive staff is included to support and champion interventions.

Healthcare Worker Education and Training

Educate health-care workers regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection-control measures to prevent intravascular catheter-related infections. Periodically assess knowledge of and adherence to guidelines for proper insertion and maintenance of intravascular catheters.

Guidelines for the Prevention of Intravascular Catheter-Related Infections2 http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

Category IA

All relevant clinical staff at hospitals and surgical care settings. Executive staff is included to support and champion interventions.

Surveillance

A. Conduct surveillance in ICUs and other patient populations to determine CRBSI rates, monitor trends in those rates, and assist in identifying lapses in infection-control practices B. Express ICU data as the number of catheter-associated BSIs per 1,000 catheter-days for both adults and children and stratify by birth weight categories for neonatal ICUs to facilitate comparisons with national data in comparable patient populations and health-care settings C. Investigate events leading to unexpected life-threatening or fatal outcomes. This includes any process variation for which a recurrence would likely present an adverse outcome (13).

Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals

Jonas Marschall, MD; Leonard A. Mermel, DO, ScM, et al.

From the http://www.onthecuspstophai.org/uploads/BSImanualsTools/CLABSIelimination/Appendix_G_SHEA_IDSA_Recommendations.pdf A. Category 1IB B. Category 1IB C. Category 1C All relevant clinical staff at hospitals and surgical care settings. Executive staff is included to support and champion interventions.

Catheter Site Selection

Avoid using the femoral vein for central venous access in adult patients

Use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimize infection risk for nontunneled CVC placement

Guidelines for the Prevention of Intravascular Catheter-Related Infections2 http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf Category 1A

Category 1B All relevant clinical staff at hospitals and surgical care settings. Executive staff is included to support and champion interventions.

Adherence to central line insertion practices (CLIP)

Hand Hygiene (Category 1B)

Maintain Aseptic Technique (Category 1B)

Sterile gloves should be worn for the insertion of arterial, central, and midline catheters (Category 1A)

Use of maximal sterile barriers (Category 1B)

O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, et al. Guidelines for the Prevention of Intravascular-related . MMWR 2002;51(No. RR January, 2010 http://www.cdc.gov/nhsn/PDFs/pscManual/5psc_CLIPcurrent.pdf

Guidelines for the Prevention of Intravascular Catheter-Related Infections2 http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

Full updated guidelines for the Prevention of Intravascular-related available at http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

Comprehensive Unit-Based Safety Program (CUSP) Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008; 23 (2): 207-21 [PubMed]

All relevant clinical staff at hospitals and surgical care settings. Executive staff is included to support and champion interventions.

Appropriate Urinary Catheter Use

Insert catheters only for appropriate indications (see Table 2 for guidance), and leave in place only as long as needed.

Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment.

A system of alerts or reminders to identify all patients with urinary catheters and assess the need for continued catheterization

Guidelines and protocols for nurse-directed removal of unnecessary urinary catheters

Education and performance feedback regarding appropriate use, hand hygiene, and catheter care

Surgical Care Improvement Project

Prophylactic antibiotic received one hour prior to surgical incision

Prophylactic antibiotic selection for surgical patients

Prophylactic antibiotics discontinued within 24 hours after surgery end time (48h for cardiac surgery patients)

Cardiac surgery patients with controlled 6am postoperative serum glucose

Surgery patients with appropriate hair removal (clippers as opposed to use of razor) *Surgical Care Improvement Project Community Handbook; Delmarva Foundation for Medical Care [internet][cited 2010 December] Available at www.dcqio.org

GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009

Carolyn V. Gould, MD, MSCR 1; Craig A. Umscheid, MD, MSCE 2; Rajender K. Agarwal, MD, MPH 2,et al.

1 Division of Healthcare Quality Promotion Centers for Disease Control and Prevention Atlanta, GA 2 Center for Evidence-based Practice University of Pennsylvania Health System Philadelphia, PA 3 Division of Infectious Diseases David Geffen School of Medicine at UCLA Los Angeles, CA

All relevant clinical staff at hospitals and surgical care settings. Executive staff is included to support and champion interventions

CDI prevention Use of Contact Precautions Cleaning and Disinfection of Equipment and Environment Surveillance Healthcare Personnel, Patient and Family Education

Strategies to prevent Clostridium difficile infections in acute care hospitals.

Bibliographic Source(s) Dubberke ER, Gerding DN, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Coffin SE, Fraser V, Griffin FA, Gross P, Kaye KS, Klompas M, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. Strategies to prevent Clostridium difficile infections in acute care hospitals. Infect Control Hosp Epidemiol 2008 Oct;29 S uppl 1:S81-92.

Centers for Disease Control and Prevention Heathcare-associated infection tool-kit

Includes education material (Slide sets) outlining core and supplemental prevention techniques for HAIs

Strength of recommendation A Good evidence to support a recommendation for use B Moderate evidence to support a recommendation for use C Poor evidence to support a recommendation Quality of evidence I Evidence from x1 properly randomized, controlled trial II Evidence from x1 well-designed clinical trial, without randomization; from cohort or case-control analytic studies (preferably from 11 center); from multiple time series; or from dramatic results of uncontrolled experiments III Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports from expert committees note. Adapted from the Canadian Task Force on the Periodic Health Examination

Centers for Disease Control www.cdc.gov/resources/HAI/recoveryact/stateResources/toolkits.html

All hospital facilities including ICU and non-ICU wards

Evidence-Based Interventions For Improving Preventive Services Utilization with EHRs

Table 3: Surgical Infections: Timely Urinary Catheter Removal

· Daily reminders to physicians from nursing staff

· Formalized stop orders

Intervention Rating: A

Evidence-Based Interventions for National Nursing Home Quality Care Collaborative

National Nursing Home Quality Care Collaborative (NNHQCC) Description: The National Nursing Home Quality Care Collaborative is a fast paced, dynamic, data-driven quality improvement initiative focused on addressing system-wide issues and opportunities for improvement of healthcare acquired conditions in order to improve the overall quality of care for nursing home residents. Using a systems approach to support residents and families and increase skills among healthcare providers; and implement system level interventions to improve quality and safety.

Aim: The National Nursing Home Quality Care Collaborative Aim is to seek to ensure that every nursing home resident receives the highest quality of care. Specifically, the Collaborative will strive to instill quality and performance improvement practices, eliminate healthcare acquired conditions, and dramatically improve resident satisfaction.

Resource: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityImprovementOrgs/Current.html and www.healthcarecommunities.org.

NNHQCC Change Package:

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/NNHQCC-Package.pdf

Quality Assurance Performance Improvement (QAPI) Description: QAPI is a data-drive, proactive approach to improving the quality of life, care, and services in nursing homes. The activities of QAPI involve members at all levels of the organization to: identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions.

Aim: Use a systems approach to eliminate problems at the source and actively pursue quality by improving coordination and continuity of care, improving the work environment of caregivers, and developing a feedback and monitoring system to sustain continuous improvement.

Resource (URL is case sensitive): : http://go.cms.gov/Nhqapi

QAPI (URL is case sensitive): http://go.cms.gov/Nhqapi

CMS Partnership to Improve Dementia Care in Nursing Homes Description: On March 29, 2012, CMS launched an initiative to improve behavioral health and safeguarding nursing home residents from unnecessary antipsychotic drug use.

Aim: Creating a multidimensional approach including public reporting, raising public awareness, regulatory oversight, technical assistance/training and research to enhance person-centered care for nursing home residents, particularly those with dementia-related behaviors.

Resource: http://www.healthcarecommunities.org/DesktopModules/Bring2mind/DMX/Download.aspx?portalid=3&EntryId=62161

CMS Partnership to Improve Dementia Care in Nursing Homes: http://doh.sd.gov/news/documents/CMS_DementiaResources.pdf.

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Evidence-Based Interventions for Nursing Home Pressure Ulcer Reduction

Moderate to Excellent – Best practice summary, evidence grading Summary & grading of evidence from:

1. JBI information sheet, 1997[footnoteRef:2] [2: The Joanna Briggs Institute. Pressure Sores – Part II: Management of Pressure Related Tissue Damage. Best Practice: evidence-based practice information sheets for health professionals 1997;1(2):1-6.]

2. Clinical Practice Guidelines from the Royal College of Nsg & National Institute for Health & Clinical Excellence,2005[footnoteRef:3] [3: The management of pressure ulcers in primary and secondary care. A Clinical Practice Guideline, 2005 Royal College of Nursing and National Institute for Health and Clinical Excellence.]

Best practice sheet: PUs – management of pressure related tissue damage:

http://www.joannabriggs.edu.au/pdf/BP_Book_Vol12_3.pdf

PU Management Technical report:

http://www.joannabriggs.edu.au/pdf/TR_2008_4_3.pdf Recommendations (all w/moderate support):

· Optimal mgmt requires comprehensive & accurate assessment of wound history, etiology recurrence & characteristics

· Grade 1-2 PUs should be place on high specification mattress or cushion w/ pressure reducing capabilities w/ close observation of skin changes & documented repositioning regime

· If deterioration from 1-2 or if grade 3-4: alternating pressure or CLP system should be implemented

· Dressings (such as hydrocolloids) create an environment most optimal for wound healing

· Patients w/ PUs should actively mobilize, change position independently or be repositioned as clinically indicated

Moderate to Excellent - Best practice summary, evidence grading Summary & grading of evidence from 4 systematic reviews:

1. Pancorbo-Hidalgo, et al. 20061

2. Reddy, et al. 20065

3. Cullum, et al. 2004[footnoteRef:5] [5: Cullum NA, et al. Support surfaces for Pressure Ulcer Prevention. Cochrane Database of Systematic Reviews 2004, Issue 3.]

4. Langer, et al, 2003[footnoteRef:6] [6: Langer G, et al. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2003;(4):CD003216 ]

Additional Summary of Best Practice evidence including JBI[footnoteRef:7] [7: Pressure Ulcers –prevention of pressure related damage. Aust Nurs Journ. 2008 May;15(10):22-29.]

Best practice sheet: PUs – prevention of pressure related damage:

https://www.joannabriggs.edu.au/pdf/BP_Book_Vol12_2.pdf PU Prevention Technical report:

http://www.joannabriggs.edu.au/pdf/TR_2008_4_2.pdf Conclusions:

· PUs are in many cases preventable

· A targeted prevention approach less costly than one focused on treating already established ulcers

Limited – Hospital case study n=1 medical center w/ PU incidence rate of 9.4% at baseline

Aim: Implement a PU prevention protocol to PU incidence by 50% Skin breakdown prevention protocol

· Total skin assessment every 24 hrs

· Moisture mgmt for incontinence w/ dry flow pads, moisture barriers, skin sealants & fecal incontinence pouches

· Braden Scale on admission & every 24 hrs

· Pressure redistribution mattresses for all patients

· Low-air loss bed if Stage III or IV

· Scheduled audible reminders to turn patients

· Save Our Skins (SOS) prompts

· SOS champion for each unit

· PUs reported as “never events”

· “Lift team” rounds hospital every 2 hrs to help mobilize patients

· Monthly meeting of interdisciplinary team led by WOCN nursing

· Pt & family education

· Performance audits Outcomes:

· Hospital-acquired PUs from 9.4 to 1.5% in 5 yrs

· Implementation of comprehensive PU prevention program has demonstrated sustained improvements

· Evidence based care benefits noted:

· pt safety through care quality

· healthcare costs from pt complications

· Enhanced staff satisfaction from streamlined work processes & knowing they’re providing optimal pt care

Ongoing program targets:

· # PU cases

· Improving pt safety

· service quality

· Limiting complications due to hospital acquired PUs

· Reducing costs by >$3 million annually

Best practice summary and evidence grading Summary & grading of evidence from systematic review by Hodgkinson and Nay, 2005[footnoteRef:10] [10: Hodgkinson B and Nay R. Effectiveness of topical skin care provided in aged care facilities. Int J Evid Based Healthc 2005; 3(4):65-101.]

Best practice sheet – Topical skin care in aged care facilities:

http://www.joannabriggs.edu.au/pdf/BPISEng_11_3.pdf

Topical Skin Care Technical Report http://www.joannabriggs.edu.au/pdf/TR_2007_3_3.pdf ‘Best' evidence for practical clinical care suggests that:

· Disposable bodyworns will guard against skin deterioration

· No-rinse cleansers preferable to soap & water to PU & skin dryness, no evidence exists for use to prevent skin tears

· Sudocrem may skin redness over zinc cream alone

· No recommendation on safety of any intervention as safety was not evaluated in any included study

Best practice recommendations and evidence grading Summary & grading of evidence from systematic review of:

1. JBI, 2003[footnoteRef:12] [12: JBI Solutions, techniques and pressure in wound cleaning Best Practice 7(1) 2003. Issn: 1329-1874]

2. Fernandez et al. 2004[footnoteRef:13] [13: Fernandez R, et al. Effectiveness of solutions, techniques and pressure in wound cleansing. 2004 JBI Reports 2(7), 231-270]

Best practice sheet – Wound cleaning:

http://www.joannabriggs.edu.au/pdf/BPISEng_10_2.pdf

Wound Cleaning Technical Report http://www.joannabriggs.edu.au/pdf/TR_2006_2_2.pdf

· Potable tap water may be appropriate cleansing solution if saline not available

· Boiled & cooled tap water effective for cleansing in absence of saline

· Irrigation with 1% povidone-iodine is effective in infection rate in contaminated wounds.

· Pressures of 13 psi effective in infection & inflammation w/ lacerations & traumatic wounds.

· Showering patients does not impact infection & healing rates of postoperative wounds; may benefit patients w/feeling of well-being, health, cleanliness.

· Showering for cleaning ulcers & other chronic wounds should be undertaken with caution.

· Whirlpool therapy may pain & inflammation in surgical wounds & PU healing rate

· Soaking in 1 % povidone-iodine not effective in bacterial count

Moderate to Excellent – Literature review, note link w/citation below

Summary of 6 studies related to nutritional interventions (78 studies reviewed):

· Citation

· Setting

· Sample

· Design

· Results & conclusions

Aim: Review of literature to summarize existing evidence about treatments to PU healing.

Intervention topics assessed include:

· Nutrition

· Support surfaces

· Wound debridement

· Skin cleansers

· Hydrocolloids/wound dressings

· Other adjunctive therapies

· Topical agents, growth factors & skin equivalents

· Bacterial control

· Vacuum assisted closure

· Negative Pressure Wound Therapy (NPWT) Nutritional Intervention Results & Conclusions:

Bergstrom & Braden, 1990:

· Monitoring nutritional status & ensuring adequate intake may help prevent & heal PUs faster

· Patients w/out PUs & w/PUs that healed had higher caloric intake than those w/non-healing PUs

· Patients w/non-healing PUs had lower intake of zinc Breslow, et al 1993: dietary protein 61g protein/L

· in PU area was significantly correlated w/dietary protein intake & caloric intake

· protein intake wound healing Van Rijswijk & Polansky, 1994: good nutritional status at baseline healing time significantly Welch, et al. 1991: Indirectly demonstrates efficacy of nutrient supplements in the few PU patients included to promote in albumin & PU healing

Lee, et al. 2006[footnoteRef:15] [15: Lee SK, et al. Pressure Ulcer Healing with a Concentrated, Fortified, Collagen Protein Hydrolysate Supplement: A Randomized Controlled Trial. Adv Skin Wound Care. 2006 Mar;19(2):92-6.]

Excellent-

RCT

(Also reviewed by Cullum, 2008 & AHRQ/Horn) 23 NHs w/ 89 residents w/ 132 stage II, III or IV PUs (71 residents w/108 PUs at completion) randomized to:

· Intervention (n = 56 res; 44 residents at completion w/ 75 PUs)

· Control (n = 33 res; 27residents at completion w/33 PUs) Exclusions: (a) terminal diagnosis; (b) hospice care; (c) a protein-restricted diet due to renal insufficiency; (d) active metabolic or gastrointestinal diseases that might…