Provider Focus
April 2015
UPHDM Duodenoscope Safety Plan for CRE
Recently there have been national reports of CRE (Carbapenem resistant Enterobacteriaceae) transmission to patients related to contaminated ERCP scopes.
- In response to these reports, UPHDM has developed a multi-step safety plan, including the following
- Inform patients undergoing procedures using duodenoscopes that there is a risk of patient-to-patient bacterial transmission as part of the consent process
- Document the specific duodenoscope used in a procedure to aid in identification in the event of an exposure
- A competency assessment for all staff who reprocess duodenoscopes was completed in March 2015 and will be reassessed annually
- This assessment focuses on critical control points recommended by the CDC, manufacturer, and national standards
- As an additional safety measure, we plan a validation culture survey to be conducted over 8 weeks
- Each ERCP scope will be cultured once every other week for 8 weeks
- The culturing will follow the CDC Interim Sampling and Culturing Methods
- The culturing will provide baseline data to guide decisions in the future
- If a scope is contaminated with CRE or another organism of high concern, or contains unacceptable CFU(colony forming units) of low-concern organisms, it will be reprocessed and re-cultured, and will not be used until it has been proven to be free of the contaminating organism
- As per CDC guidance, we are not using non-culture methods such as ATP bioluminescence assays until processes have been developed to interpret and document results and action steps as needed
No duodenoscope related infections have been identified at UPHDM, but all measures are being implemented to minimize the risk of CRE or any infection associated with ERCP scopes.
Critical Care Medical Directors
We are happy to announce the appointment of two Critical Care Medical Directors. Dr. Sheryl Sahr a Surgical Intensivists and Trauma Surgeon from the Iowa Clinic will lead the Surgical Intensive Care component of Critical Care at Iowa Methodist Medical Center. Dr. Jason Mohr a Medical Intensivists and Pulmonologist with the Iowa Clinic will lead the Medical Intensive Care component of Critical Care at Iowa Methodist and Iowa Lutheran Medical Centers.
UnityPoint Health Des Moines prides itself as a patient focused-physician driven organization. As we continue to strive to provide best outcome for every patient every time. We have identified a need for Critical Care Medical Directors who can dedicate leadership time to the improvement of processes and care in our Critical Care units. We are confident with Drs. Sahr and Mohr leadership we will continue our journey from a good Critical Care to a Great Critical Care Service.
Over the next 90 days the Critical Care leadership team will develop a Strategic Plan for the future of Critical Care at UnityPoint Health Des Moines. We will be reaching out broadly for input from all stakeholders. We are excited to embark on the next chapter in our Critical Care Service. Please welcome Drs. Sahr and Mohr in their new roles.
CMS’s 5-Star Ratings for HCAHPS
A new star-rating system based on 11 facets of patient experience was released recently from CMS. Nationally, 251 hospitals received a 5-star rating from CMS with 11 being in Iowa. The average rating for Iowa hospitals was 3.8. While no UnityPoint Hospitals received a 5-star rating, IMMC and ILH earned a 4-star rating. UPH Affiliates of Meriter, Fort Dodge, Cedar Rapids, and Peoria also received 4-star ratings.
Read the full article here:
Quality in Action
Directions in Quality: Never Events Revisited. What Are They Again?
By Janice McCullough, Clinical Quality
In 1999, the Institute of Medicine, (IOM) released its report To Err is Human, which identified that up to 98,000 deaths occur in U.S. hospitals each year as a result of a medical errors. This revelation put patient safety in the national spotlight. The National Quality Forum (NQF) is a not-for-profit; nonpartisan, membership-based organization that works to lead national collaboration to improve health and healthcare quality through measurement.
In 2002, NQF created a list of Serious Reportable Events (SRE’s) or “Never Events” in reference to medical errors deemed preventable in most cases. The 28 events in the list represent largely preventable, grave errors and events of concern to the public and healthcare providers and warrant careful investigation. The list has been reviewed and updated since that time, most recently in 2011.
Never Events include the following items:
SURGICAL OR INVASIVE PROCEDURE EVENTS
- Wrong surgical or other invasive procedure performed on a patient intraoperative or immediately postoperative/post-procedure death in an ASA Class 1 patient.
PRODUCT OR DEVICE EVENTS
- Patient death or serious injury associated with:
-The use of contaminated drugs, devices, or biologics provided by the health-care setting.
-The use or function of a device in patient care, in which the device is used or functions other than as intended.
-Intravascular air embolism that occurs while being cared for in a healthcare setting.
PATIENT PROTECTION EVENTS
- Discharge or release of a patient/resident of any age, who is unable to make decisions, to someone other than an authorized person.
- Patient death or serious injury associated with patient elopement (disappearance).
- Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting.
CARE MANAGEMENT EVENTS
- Patient death or serious injury associated with:
-A medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration).
-A fall while being cared for in a healthcare setting. Patient death or serious injury associated with unsafe administration of blood products.
- Patient death or serious injury resulting from:
-The irretrievable loss of an irreplaceable biological specimen.
- Failure to follow up or communicate laboratory, pathology, or radiology test results.
- Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting.
- Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy.
- Any Stage 3, Stage 4, and unstageable pressure ulcer acquired after admission/presentation to a healthcare setting.
- Artificial insemination with the wrong donor sperm or wrong egg.
ENVIRONMENTAL EVENTS
- Patient or staff death or serious injury associated with:
-An electric shock in the course of a patient care process in a healthcare setting.
-A burn incurred from any source in the course of a patient care process in a healthcare setting.
-The use of physical restraints or bedrails while being cared for in a healthcare setting.
- Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or are contaminated by toxic substances.
RADIOLOGIC EVENTS
- Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area.
POTENTIAL CRIMINAL EVENTS
- Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider.
- Abduction of a patient/resident of any age.
- Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting.
- Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting.
These events were added to our Sentinel Event policy # UPHDM091 in 2012. Be familiar with these types of events. Report them in our RL Solutions Event and Feedback occurrence reporting program so investigation can occur. Document the facts of the event clearly but do not document that you have entered the incident in the RL Solutions system. Identifying why something happened will help us take steps to prevent reoccurrence. Remember,
We are all responsible for keeping patients safe!
Quality in Motion: RL Solutions Monthly Featured Forms
By Janice McCullough, Clinical Quality
Keep watching for the Monthly Featured Form in Quality in Action. Each month, you will be provided with information about a specific form in the RL Solutions Event and Feedback program. This month’s forms:
Directions in Quality: DNV Surveys for 2015
By Jan Freese, Accreditation Specialist
Det Norske Veritas (DNV) teams will conduct back-to-back accreditation surveys at Iowa Lutheran Hospital and Iowa Methodist Medical Center during May and June 2015. DNV survey black-out dates (when surveyors are not to come) are June 15-19, 2015. We requested both surveys close together by the same DNV core team to allow better coordination of the surveys and prevent duplication of survey activities that include the same persons. The following interviews and reviews will include both CMS providers (ILH and IMMC/MWH) during the ILH survey. Each hospital will receive a separate accreditation report of findings because the hospitals have separate CMS provider numbers.
Sessions that will include reports from both ILH & IMMC/MWH: Leadership, Medical Staff, Human Resources, Medication Management, Infection Prevention, Medical Records review, Environment of Care/Physical Environment, Performance Improvement/ISO, Patient Rights/Patient Complaints/ Grievances, and Discharge Planning/Utilization Management.
DNV will verify that the corrective actions that we implemented for non-conformances in 2014 have been sustained. DNV survey teams visit all UPHDM hospitals yearly. Department self-assessment survey preparation tools will be sent to the Management Team within the next few weeks.
Quality in Motion: Healthwise: Patient Education Materials
By Carla Orr, Nurse Champion, Healthwise Implementation Team
UnityPoint Health has chosen Healthwise to be the standard platform for all patient education materials across affiliates. The Healthwise product meets the goals of delivering consistent health content and patient education across the entire organization regardless of discipline.
The emergency departments will go-live with Healthwise on April 30th when the contract expires with ExitCare, the current patient information platform. Training for the emergency departments begins April 24th. The remaining areas, including Home Health Care and the UPH Clinics, begin training June 17 with a go-live date of June 23.
Healthwise can be accessed in several ways. Clinicians will be able to access Healthwise for patient instructions from within Epic. Suggested patient education will automatically be generated from the problem list and added to the After Visit Summary. Patients will be able to access the Healthwise knowledgebase through the MyUnityPoint patient portal as well as through the UnityPoint Health’s external website. A video library will also be available for patient use. The knowledge-base contains more than 8,000 health topics including health conditions, symptoms, medications, medical tests, and wellness and prevention.
Patient education materials from Healthwise are evidence based, written at a 4th-6th grade reading level, and usually 1 to 3 pages in length. Education materials are available in both English and Spanish. Healthwisealso offers patient instruct-tions for the most common diagnoses in 10 additional languages.
This is a great time for departments to review any “home grown” educational materials. The Patient Education Committee is completing a gap analysis to identify what we have that are “home grown” versus what is available in Healthwise. Please notify Cheri Miller . if your area has any “home grown” patient education materials you are currently using as soon as possible (ASAP)! Be sure to list the name, any form numbers and where it may be located, i.e., Print Center, DocuCenter, etc. for follow up. This affects all disciplines that are involved with patient education at UPH-DM, both inpatient, ambulatory and outpatient services.
Continued below…
Infection Prevention: Myths about Immunizations
By Infection Prevention
Dr. Shawn Spooner Recognized by Iowa State University
Dr. Shawn Spooner has traveled the world and touched thousands of people’s lives.
His work as a doctor in the U.S. Navy for nine years took him from California to South Korea, Chicago, and Afghanistan. He delivered more than 200 babies while in residency. He was the surrogate support system for new moms whose husbands were deployed to another country.
For two years, Spooner was the only doctor in the small, isolated Naval base in Chinhae, South Korea, serving the medical needs of 500 sailors, their families, and the nearby U.S. Pacific Fleet by himself.
Read the full story here:
Annual Perinatal Conference at St. Luke’s
The 41st annual Perinatal Conference will be held at St. Luke’s on May 27. The event will take place in the Institute for Health Education Auditorium. The purpose of the conference is to enhance patient outcomes by providing current information on obstetrical and newborn care practices for perinatal healthcare professionals. Obstetricians, pediatricians, neonatologists, family physicians, physician assistants, nurse, nurse practitioners, midwives and other allied health professionals interested in prenatal and perinatal care are encouraged to attend.
Speakers include: Paul J. Eastman, M.D., F.A.C.O.G., Paul W. Espositio, M.D. Alfred Fleming, M.D., F.A.C.O.G., Bonnie J. Lees, M.D., Phillip N. Rauk, M.D. and Jean Rhodes, PhD, CNM, IBCLC.
View the event brochure here: