WINNIPEG, April 2 /CNW/ - Four new interventions to improve patient
safety will be launched at a National Conference in Winnipeg today, as part of
the Safer Healthcare Now! (SHN) campaign and its partner campaign in Quebec -
Together, Let's Improve Healthcare Safety. The SHN campaign was initially
launched in April 2005, with six interventions to reduce death and injury to
patients in acute-care settings. Two of the four new interventions will focus
on residents in facilities providing long-term care and two pilot projects
will be undertaken specific to reducing potential adverse drug events in home
care and paediatric settings.
"One of the primary goals of the campaign is to evolve and spread
evidence-based safety initiatives into every relevant healthcare organization
in Canada," says Philip Hassen, Chair of the Safer Healthcare Now! National
Steering Committee and CEO of the Canadian Patient Safety Institute (CPSI),
the campaign secretariat. "An advisory panel of widely recognized patient
safety and quality experts were consulted on patient safety target areas and
their input shaped the direction for the next phase of the campaign."The new interventions will focus on:
- Falls in long-term care - reduce the number of falls and injury from
falls for residents in facilities providing long-term care.
- Adverse drug events in long-term care - implement medication
reconciliation to prevent adverse drug events (ADEs) in long-term
care settings.
- Antibiotic resistant organisms (AROs): Methicillin-resistant
Staphylococcus aureus (MRSA) - implement a series of evidence-based
guidelines to prevent harm from antibiotic resistant organisms,
specifically MRSA.
- Venous thromboembolism (VTE) - implement evidence-based best practice
guidelines to ensure that general surgery and hip fracture surgery
patients receive the appropriate thromboprophylaxis to prevent deep
vein thrombosis (DVT) and pulmonary embolism (PE).
In addition, two pilot projects will be implemented and lessons learned
will be use to determine best practices and ways of approaching quality
improvement for safer healthcare in the following two areas:
- Prevent adverse drug events through medication reconciliation in home
care. Unique challenges exist when conducting medication
reconciliation within diverse community care settings. This work will
identify successful processes and systems to facilitate medication
reconciliation in home care settings. The Victorian Order of Nurses
Canada and the Institute for Safe Medication Practices (ISMP Canada)
will co-lead this study.
- Prevent adverse drug events related to high-risk medications in
paediatrics. Members of the Canadian Association of Paediatric Health
Centres (CAPHC) and ISMP Canada, in partnership with the Canadian
Patient Safety Institute (CPSI), Canadian Council on Health Services
Accreditation (CCHSA) and the REISS (Research, Exchange and Impact
for System Support) Study Group will work together to develop a
national action plan to address high-risk medication delivery across
the paediatric continuum of care.As the next phase of the SHN campaign is rolled out, teams are now
signing up to participate and the 'Getting Started Kits' identify tools and
resources to help them implement the new interventions. The process and
measures for the new interventions align explicitly with the Canadian Council
on Health Services Accreditation required standards for healthcare
organizations.
"Patient safety is everyone's concern and healthcare professionals across
Canada are committed to providing a better quality of care for their
patients," adds Hassen. "We thank the intervention leads for their commitment
and leadership in developing the direction for new interventions. Working
together, we can in fact reduce the number of needless deaths and injuries
resulting from preventable adverse events."
ISMP Canada will lead the interventions on Medication Reconciliation,
expanding on the process developed with acute-care teams. "Medication
reconciliation is an effective process to reduce adverse drug events and
potential harm associated with the miscommunication of medication information
as patient/clients/residents transfer among healthcare settings," says Marg
Colquhoun, Project Leader, ISMP Canada. "Medication reconciliation is about
reducing medication discrepancies, potential adverse drug events, duplication
of work and confusion across the system. It is a critical process that will
help to ensure medication safety for patients."
The Falls intervention will be implemented using a collaborative
methodology, led by the Registered Nurses' Association of Ontario (RNAO) and
co-sponsored by the Western Leadership Group. "This team-based quality
improvement approach to implementing the RNAO best practice guideline for
falls prevention can improve safety in facilities providing long-term care,"
says Dr. Irmajean Bajnok, Director, International Affairs and Best Practice
Guidelines Programs, RNAO. "Injuries from falls compromise health and quality
of life for older persons. Collectively we can use knowledge, skills and
experience to develop a falls strategy to reduce the number of falls and
injuries from falls."
Dr. Michael Gardam of the University Health Network in Toronto will lead
implementation of the MRSA intervention initiative. "We know how to control
MRSA, but it is one thing to know how to do something and a much more
difficult task to actually put knowledge into practice and affect change,"
says Dr. Gardam. "To fight the spread of germs involves everyone: staff,
patients and visitors. It takes a change in attitude and a cultural shift from
that of commonplace to one of intolerance."
Dr. William Geerts, an international expert in thromboembolism, along
with Sunnybrook Health Sciences Centre in Toronto, a national leader in
patient safety, will lead the VTE intervention. "The use of thromboprophylaxis
has unequivocally been shown to reduce deep vein thrombosis and pulmonary
embolism, contributors to longer hospital stays and increased costs to our
healthcare system," says Dr. Geerts. "We need to eliminate the gaps in the
provision of this key patient safety intervention."
The four new interventions will augment the six interventions of the SHN
campaign initially introduced in 2005. Acute-care teams can continue to
sign-up for these interventions, work toward full implementation, and
measure/report results:- RRT - Implement Rapid Response Teams - prevent deaths in patients who
are progressively failing outside the ICU through the intervention of
specially trained teams of health professionals. (Led by the Canadian
ICU Collaborative.)
- AMI - Improved care for Acute Myocardial Infarction - consistently
implement protocols for heart attack patients along the continuum of
care that are known to reduce complications and deaths. (Led by
Theresa Fillatre, SHN Atlantic Node Leader.)
- Med Rec - Implement Medication Reconciliation - implement medication
reconciliation to prevent adverse drug events (ADEs) and potential
harm by creating the Best Possible Medication History (BPMH) for
patients in acute care hospitals and using it during admission,
transfer, or discharge. (Led by ISMP Canada.)
- CLI - Prevent Central Line Infections - implement a series of
interdependent, scientifically grounded steps to reduce
catheter-related bloodstream infections. (Led by the Canadian ICU
Collaborative.)
- SSI - Prevent Surgical Site Infections - implement a series of
protocols known as the 'SSI bundle' to reduce the frequency of
infections and deaths in SSI. (Led by Marlies van Dijk, SHN Western
Node Leader)
- VAP - Prevent Ventilator-Associated Pneumonia - implement the "VAP
bundle' of practices to prevent VAP infections and deaths. (Led by
the Canadian ICU Collaborative.)About Safer Healthcare Now!
The Safer Healthcare Now! campaign is the largest healthcare quality
improvement initiative underway in Canada to reduce the number of deaths and
injuries related to preventable adverse events. Currently, over 830 teams,
representing more than 220 hospitals, health regions and other healthcare
delivery organizations are implementing one or more of the initial six
targeted interventions. The Quebec campaign, launched in April 2006, works in
collaboration with the SHN campaign. To date, 46 teams are part of the
"Together, Let's Improve Healthcare Safety" campaign in Quebec.
For more information on the SHN campaign, visit the website
www.saferhealthcarenow.ca or www.soinsplussecuritairesmaintenant.ca.
Editor's Note: Video footage for each of the four new Safer Healthcare
Now! Interventions is available on the homepage of the Safer Healthcare Now!
website: www.saferhealthcarenow.ca.-------------------------------------------------------------------------
BACKGROUNDER
-------------------------------------------------------------------------Expanding the Safer Healthcare Now! campaign - Phase II
The Safer Healthcare Now! campaign is a pan-Canadian initiative developed
to reduce the number of deaths and injuries in hospitals related to
preventable adverse events. Over 830 teams, representing more than 220
hospitals, health regions and other healthcare delivery organizations are
currently implementing one or more of six targeted leading practice
interventions to improve patient safety. Interim results show that the
implementation of the six healthcare interventions, the pillars of the
campaign, can reduce injuries or deaths related to preventable adverse events.
The initial six acute-care interventions will continue. As Phase II of the
Safer Healthcare Now! campaign is launched, four new interventions will be
added, two of them focusing on long-term care settings.
MRSA - Preventing harm from antibiotic-resistant organisms
Methicillin-resistant Staphylococcus aureus (MRSA) is a micro-organism
that has developed a resistance to antibiotics. MRSA is currently the most
clinically significant antibiotic-resistant organism (ARO) in Canada.
MRSA is hardy. The bacteria can live up to six weeks on environmental
surfaces and is easily transmitted by skin-to-skin contact and touching shared
items. Through the implementation of evidence-based strategies, healthcare
providers can reduce MRSA transmission and infections.
About 220,000 Canadians develop hospital-acquired infections each year
and about 8,000 die from them annually. It costs more to treat MRSA infections
than to prevent them. Estimated costs for treating and isolating patients with
MRSA infections was $82 million in 2004 and that could reach $129 million by
2010. Total cost per infected MRSA patient averages $12,216, for prolonged
hospitalization, special control measures, expensive treatments and extensive
surveillance.The five key components of evidence-based infection control practices that
form the basis of successfully reducing MRSA transmission include:
1. An aggressive hand hygiene program.
2. A systematic program for cleaning and decontamination of the
environment and equipment.
3. Use of precautions for contact with any patient that is infected with
MRSA (requires healthcare workers to wear gloves, gowns, and in some
cases masks when in the room or bed space of MRSA patients).
4. Selected MRSA screening surveillance cultures on admission and at
other times during hospitalization if indicated.
5. Surveillance and reporting of MRSA infection rates to frontline
workers and hospital leadership.The Canadian Council on Health Services Accreditation (CCHSA) now
requires healthcare organizations to provide their MRSA rates as part of the
accreditation process. This intervention provides the framework for a MRSA
strategy and tools to measure its effectiveness.
Dr. Michael Gardam of the University Health Network in Toronto, Ontario
will lead implementation of the MRSA intervention initiative. Some national
stakeholders supporting the intervention include: Community and Hospital
Infection Control Association (CHICA - Canada), Canadian Committee on
Antibiotic Resistance (CCAR) and the Public Health Agency of Canada (PHAC).
VTE - Preventing venous thromboembolism
Venous thromboembolism (VTE) comprises both deep vein thrombosis (DVT)
and pulmonary embolism (PE). DVT occurs when a blood clot forms inside a vein
deep in the leg, causing leg pain and swelling. A blood clot in a leg vein can
grow, break off, and travel to the lungs. This may result in shortness of
breath or chest pain, and in some cases, can cause a patient's death. Clots
that travel to the lungs are called pulmonary emboli.
Patients who develop VTE are also at risk of recurrent thromboembolic
events of about 10 to 30 per cent at five years. Within 10 years, some 30 to
50 per cent of patients with DVT will develop post-thrombotic syndrome with
chronic leg swelling, discomfort and possible leg ulcers.
VTE is one of the most common and preventable complications of
hospitalization. The rate of hospital-acquired VTE, if thromboprophylaxis is
not used, is 10 to 40 per cent after general surgery and 40 to 60 per cent
after hip surgery.
There are several hundred randomized trials that demonstrate
unequivocally that thromboprophylaxis is effective in the prevention of DVT,
PE and fatal PE. It is also safe and inexpensive. More than 25 published
evidence-based clinical practice guidelines are also readily available.
With all of this evidence, how well do Canadian hospitals adhere to the
guidelines?
In a national survey of Canadian hospitals, 86 per cent reported that
they routinely provided thromboprophylaxis to hip fracture patients, and only
33 per cent report that they routinely provide thromboprophylaxis to patients
undergoing major general surgery. Post-operative VTE has been associated with
an excess length of hospital stay of five days and a doubling of the cost of a
hospital stay. The 30-day case fatality rate for DVT is five per cent and
33 per cent for PE.
Through this intervention, hospital teams will engage in quality
improvement initiatives to increase the use of thromboprophylaxis for adult
patients (18+) undergoing major general surgery (open abdominal), or hip
fracture surgery and adherence to evidence-based thromboprophylaxis will be
measured over time. Participating teams will identify consecutive eligible
major general surgical and/or hip fracture patients and will start appropriate
thromboprophylaxis 24 hours after surgery-end-time and continue it until
discharge, or at least 10 days after surgery for hip-fracture patients.
The American College of Chest Physicians (ACCP) sponsors what are
generally considered to be the most comprehensive and most utilized
evidence-based guidelines on the prevention of VTE. The "ACCP Guidelines" are
peer reviewed, revised every three years and have become the international
reference standard for thromboprophylaxis. This guideline process has been
chaired by Dr. William Geerts, from the University of Toronto, for the past
10 years. The ACCP guidelines will be used as a basis for "appropriate
thromboprophylaxis" developed for this intervention.
Dr. Geerts, an international expert in venous thromboembolism, along with
Sunnybrook Health Sciences Centre in Toronto, Ontario are leading this
intervention.
Falls - reduce falls and prevent harm resulting from falls in long-term
care
Falls and injury from falls are critical issues in healthcare safety.
Almost half of all elderly residents in facilities providing long-term care
fall every year. Some 40 per cent of admissions to facilities providing
long-term care, such as nursing homes, are the direct result of a fall. One in
three of those who fall develop serious injuries. Those who fall are at higher
risk for future falls and injury.
The Falls intervention is designed around a Breakthrough Series
Collaborative, which brings a unique perspective to quality improvement.
Facilities providing long-term care will enroll teams of five to seven staff
in the learning collaborative and for the next 12-months, these teams will
implement evidence-based change interventions in their local practice. The
teams will be supported through learning sessions, regular facilitated
teleconferences and networking with other Improvement Teams and national
experts in falls prevention. A proven effective approach to practice change
will be utilized, including three specific learning sessions interspersed with
action periods that follow the quality improvement cycle of Plan-Do-Study-Act
(the PDSA cycle).
Teams enrolled in the Collaborative will look at four main areas where
caregivers can make a difference, related to falls and injury from falls in
older persons. These are awareness of risk, prevention of falls, falls
intervention and reduction of injuries. The goal is to reduce falls and fall
injuries by 40 per cent in participating sites.
This national intervention is led by the Registered Nurses' Association
of Ontario (RNAO) and co-sponsored by the Western Leadership Group. It is
based on a team approach with full engagement of regulated and unregulated
care providers including, nurses, personal support workers, physiotherapists,
physicians, occupational therapists, pharmacists and the ministries leading
provincial falls prevention initiatives. The Falls Collaborative also aligns
with the CCHSA Required Organizational Practice on the prevention of falls in
conjunction with the mitigation of resulting injury.
Medication reconciliation in long-term care
Medication reconciliation is an effective process to reduce adverse drug
events (ADEs) and potential harm associated with changes in or the loss of
medication information as patients/clients/residents transition or transfer
among healthcare settings (community or hospital). One of the interventions
launched during Phase I of the SHN campaign focused on medication
reconciliation in acute care. Resources, processes, tools and infrastructure
have been developed to expand the use of medication reconciliation into
continuing care or long-term care settings.
The medication reconciliation process identifies and resolves
discrepancies in drug regimens at transitions of care. The ultimate goal of
medication reconciliation is to prevent adverse drug events by eliminating all
undocumented intentional discrepancies and unintentional discrepancies.
The need for LTC medication reconciliation is demonstrated through a 2006
review of the transfer of information from an acute care hospital to a
long-term care facility that found 22 per cent of transfers had no formal
summary of information; legible summaries were available only 56 per cent of
the time; secondary diagnoses were missing from 30 per cent of transfers; only
51 per cent had allergies documented; and clarification of information was
difficult because identification of the hospital physician was only legible
41 per cent of the time and phone numbers only 33 per cent of the time. The
conclusions from this study were that major errors of omissions and
commissions occur frequently with potential for serious departures from
intended or appropriate management resulting in unnecessary rework and
inefficiencies.
The Best Possible Medication History (BPMH) forms the basis of medication
reconciliation in both acute and long-term care. The BPMH documents all
medications that a resident is currently taking, even though it may be
different from what was actually prescribed. At each interface of care when
the resident is being transferred from one healthcare facility/service to
another, the BPMH should be compared to the resident's medication orders.Medication reconciliation in long-term care will involve a formal process
of:
1. At admission, obtaining a complete and accurate list of each
resident's current and pre-admission medication - including name,
dosage, frequency and route (BPMH).
2. Using the BPMH to create admission orders or comparing the list
against the resident's admission orders, identifying and bringing any
discrepancies to the attention of the prescriber for resolution.
3. Any resulting changes in orders are documented and communicated to
the relevant providers of care and resident or family member wherever
possible.The Institute for Safe Medication Practices (ISMP) Canada will lead this
intervention, building upon their experience in medication reconciliation for
acute care. In the first 18 months of the SHN campaign, medication
reconciliation teams in acute-care showed success in reducing unintentional
discrepancies almost 50 per cent, after 13 months of data submission.
Phase I of the SHN campaign - the initial six interventions
The first phase of the campaign established that a better quality of care
and improved patient outcomes are achievable. Efforts to spread implementation
of these interventions and measure results will continue. Following are the
six interventions under Phase I of the campaign and early results reported in
March 2007, for these interventions:- RRT - Implement Rapid Response Teams - prevent deaths in patients who
are progressively failing outside the ICU through the intervention of
specially trained teams of health professionals.
Rapid Response Teams (RRTs) bring critical care expertise to staff
outside the ICU. The measures for this intervention are: Codes per
1,000 discharges, percentage of codes outside ICU and utilization of
RRT. Early results indicate that RRTs are a challenge to implement
due to the need to identify, mobilize and fund expert staff and
ultimately build knowledge and support across the organization.
- AMI - Improved care for Acute Myocardial Infarction - consistently
implement protocols for heart attack patients that are known to
reduce complications and deaths. Canada is a leader in establishing
and disseminating standards of care in cardiology resulting in the
reduction of harm or adverse events. Close to 75 per cent of all
participating hospitals were administering ASA on arrival and
prescribing ASA, Beta Blockers and ACE inhibitors at discharge to
90 per cent of their AMI patients - an indication of how well
entrenched these indicators are in the cardiology communities across
the country. Teams administering thrombolytic agents within
30 minutes of arrival in 90 per cent of their patients reached only
7.3 per cent at baseline, whereas over 42 per cent of the teams had
met the goal after implementing the Safer Healthcare Now!
intervention. The percentage of teams providing counseling for
smoking cessation to all eligible patients increased from 40 to
almost 85 per cent in Phase 1.
- Med Rec - Implement Medication Reconciliation - prevent adverse drug
events (ADEs) and potential harm by gathering a comprehensive
medication list upon admission to hospital and reconciling any
discrepancies between the list and medication orders. The rate of
undocumented intentional discrepancies fell from a baseline rate of
over 1.0 per patient to .68 per patient within Phase 1. The rate of
unintentional discrepancies reported a sustained reduction over time
from almost 1.2 per patient at baseline to close to 0.6 per patient.
- CLI - Prevent Central Line Infections - implement a series of
interdependent, scientifically grounded steps to reduce
catheter-related blood stream infections. Central line infections
(CLI) account for 90 per cent of catheter related infections and the
mortality for central line-blood stream infections (BSI) is
approximately 20 per cent. The intervention measures include: central
line-associated blood stream infection (BSI) rate per 1000 central
line days (Target: 50 per cent reduction), central line insertion
bundle compliance and central line maintenance bundle compliance. The
overall national mean for the Central Line-associated BSI rate per
1000 CLI days was reduced from a baseline of 5 to a sustained rate of
0.3 to 0.8 in Phase I. Of the teams reporting data, 75 per cent
reached the national goal of (less than)1.9 CLI-BSI per 1000 CLI
days.
- SSI - Prevent Surgical Site Infections - implement a series of
protocols known as the 'SSI bundle' to reduce the frequency of
infections and deaths from SSI. Surgical complications, including
surgical site infections, were the most frequent type of adverse
event reported in the 2004 Canadian Adverse Event Study. Baseline
data collected indicated that 32.7 per cent of teams reported
administering prophylactic antibiotics within 60 minutes of the
surgical incision in at least 75 per cent of their surgical patients,
which increased to 75 per cent of teams following implementation of
the Safer Healthcare Now! intervention. The rate of discontinuation
of the prophylactic antibiotics within 24 hours post-operatively in
at least 75 per cent of surgical patients increased from
36.9 per cent at baseline to 64.6 per cent following implementation
of the intervention.
- VAP - Prevent Ventilator-Associated Pneumonia - implement the 'VAP
bundle' of practices to prevent VAP infections and deaths.
Ventilator-associated Pneumonia is the leading cause of death among
hospital acquired infections and substantially increases the
likelihood of mortality for ventilated patients. There are two
measures - the VAP rate per 1,000 ventilator days and the
implementation of the four evidence-based "bundle" elements. For the
first measure, the majority of teams had implemented the four bundle
elements. Half of the teams reporting data achieved the national goal
of seven VAP per 1,000 ventilator days. The overall national mean for
the VAP rate per 1,000 ventilator days was reduced from a baseline of
20 to five in Phase I.About the Safer Healthcare Now! campaign and the Quebec campaign -
Together, Let's Improve Healthcare Safety!
In 2004, The Canadian Adverse Events Study (Baker and Norton, et al)
concluded that one in 13 patients in Canadian healthcare facilities
experiences some type of adverse event. It is estimated that between 9,000 and
24,000 patients die each year from preventable adverse events. The Safer
Healthcare Now! campaign was established in 2005 to ensure that evidence-based
practices known to improve patient outcomes are consistently implemented. The
Quebec campaign: Together, Let's Improve Healthcare Safety! was launched in
Quebec in April 2006, and collaborates with the SHN campaign. The campaigns
are modeled on the Institute for Healthcare Improvement's (IHI) 100,000 Lives
campaign in the United States (www.ihi.org).
Several organizations committed to patient safety support the campaigns,
including the Institute for Safe Medication Practices (ISMP) Canada, the
Canadian Association of Paediatric Health Centres (CAPHC), the Canadian
Intensive Care Unit (ICU) Collaborative and the Canadian Patient Safety
Institute, the campaign secretariat. In addition, over 70 related
organizations have endorsed the campaign by becoming partners, including the
Canadian Medical Association, Canadian Nurses Association, Canadian Institute
for Health Information, Canadian Council for Health Services Accreditation,
other health professional associations and regulatory agencies, provincial
health ministries and health regions. For a full list of partners, visit the
website www.saferhealthcarenow.ca /or www.soinsplussecuritairesmaintenant.ca
For further information: Jim Durham, Director Communications, Canadian
Patient Safety Institute, T: 1-866-421-6933, C: (780) 862-8127; Kelly Bowman,
Communications Officer, Canadian Patient Safety Institute, T: 1-866-421-6933,
C: (780) 288-3847
