2008 Summer Nursing Conference
Arizona Geriatrics Society
“PREVENTING BAD THINGS (HARMS) THAT
COULD HAPPEN DURING ACUTE ILLNESS”
Howard Pitluk, MD, MPH, FACS
Vice President & Chief Medical Officer
Health Services Advisory Group
(and recovering vascular surgeon)
Objectives:
• Define the Quality Improvement Organization’s role in Patient Safety for
Medicare beneficiaries
• Demonstrate the evidence for addressing the process covered in the 9th
Scope of Work Patient Safety Theme
• Challenge participants to make patient safety improvement part of their
care goals
DISCLOSURE
Howard Pitluk, MD, MPH, FACS does not have a significant financial interest or other
relationship with manufacturer(s) of commercial product(s) and or provider(s) of
commercial services discussed in the presentation.
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
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88
2008 Summer Nursing Conference
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Slide 1
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Preventing Bad Things (Harms)
That Could Happen
During Acute Illness
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___________________________________
Howard Pitluk, MD, MPH, FACS
V/P Chief Medical Officer
Health Services Advisory Group, Inc.
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Arizona Geriatrics Society
August 22, 2008
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Slide 2
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Slide 3
The Health Care Challenge
We know that for every unnecessary death there is
much more error, injury, and pain.
We know that the nation has a great deal of progress
yet to make in reducing adverse drug events,
infection, and surgical complications.
CMS, The Joint Commission, IOM, etc., are serious
about completely transforming the U.S. health care
system.
We know that there is great will and optimism
among leaders and frontline providers of care.
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
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89
2008 Summer Nursing Conference
Slide 4
Arizona Geriatrics Society
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How Many Injuries (Harms) in the
United States?
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37 Million Hospital Admissions
(Source: The AHA National Hospital Survey for 2005)
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X
40 Injuries per 100 Admissions
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(Source: IHI “Global Trigger Tool” Guiding Record Reviews)
=
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15 Million Injuries (Harms) per Year
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Slide 5
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Definition of Medical Harm
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Unintended physical injury resulting from or
contributed to by medical care (including the absence of
indicated medical treatment), that requires additional
monitoring, treatment or hospitalization, or that results
in death.
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Such injury is considered harm whether or not it is
considered preventable, whether or not it resulted from
a medical error, and whether or not it occurred within a
hospital.
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For more information, please reference detailed FAQs at www.ihi.org/campaign.
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Slide 6
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The 5 Million Lives Campaign
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IHI is asking hospitals participating in
the Campaign to prevent 5 million
incidents of medical harm over the next
two years.
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
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90
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Slide 7
Arizona Geriatrics Society
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The 5 Million Lives Campaign
Campaign Objectives:
Avoid 5 million incidents of harm over the next
24 months;
Enroll more than 4,000 hospitals and their
communities in this work;
Strengthen the Campaign’s national infrastructure
for change and transform it into a national asset;
Raise the profile of the problem – and hospitals’
proactive response – with a larger, public
audience.
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Slide 8
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The Platform
Deploy Rapid Response Teams…at the first sign of
patient decline.
Deliver Reliable, Evidence-Based Care for Acute
Myocardial Infarction…to prevent deaths from heart
attack.
Prevent Adverse Drug Events (ADEs)…by
implementing medication reconciliation.
Prevent Central Line Infections…by implementing a
series of interdependent, scientifically grounded steps.
Prevent Ventilator-Associated Pneumonia…by
implementing a series of interdependent, scientifically
grounded steps.
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Slide 9
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The Platform
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Prevent Pressure Ulcers... by reliably using
science-based guidelines for their prevention.
Reduce Methicillin-Resistant Staphylococcus
aureus (MRSA) Infection…by reliably
implementing scientifically proven infection control
practices.
Prevent Harm from High-Alert Medications...
starting with a focus on anticoagulants, sedatives,
narcotics, and insulin.
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
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91
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Slide 10
Arizona Geriatrics Society
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The Platform
Reduce Surgical Complications... by reliably
implementing all of the changes in care recommended
by the Surgical Care Improvement Project (SCIP).
Deliver Reliable, Evidence-Based Care for
Congestive Heart Failure…to reduce readmissions.
Get Boards on Board….Defining and spreading the
best-known leveraged processes for hospital Boards of
Directors.
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Slide 11
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CMS 9th Scope of Work
Patient Safety Theme
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Pressure Ulcers
Physical Restraints
SCIP
MRSA
Drug Safety
Poorly Performing Nursing Homes
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Slide 12
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What is a Pressure Ulcer?
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Defined as an area of localized damage to
the skin and underlying tissue caused by
pressure, shear, friction, and/or a
combination of these.
Commonly referred to as bed sores,
pressure damage, pressure injuries, and
decubitus ulcers.
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
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Slide 13
Arizona Geriatrics Society
Why are Pressure Ulcers Important?
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An estimated 4%–10% of patients admitted
to an acute hospital develop a pressure ulcer.
Major cause of sickness, reduced quality of
life, and morbidity.
Associated with a 2–4-fold increase in risk of
death in older people in intensive care units.
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Substantial financial costs.
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Slide 14
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Key Priorities for Implementation
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Initial and ongoing assessment of risk
Initial and ongoing pressure ulcer
assessment
Pressure ulcer grade should be recorded
using a classification system
All pressure ulcers graded 2 and above
should be documented as a local clinical
incident
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Slide 15
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Key Priorities for Implementation
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All patients vulnerable to pressure ulcers
should, as a minimum, be placed on a highspecification foam mattress.
Patients undergoing surgery require highspecification foam theatre mattresses.
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
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Slide 16
Arizona Geriatrics Society
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Classification of
Pressure Ulcer Severity
Grade 1 − non-blanchable erythema of intact skin.
Discoloration of the skin, warmth, edema, induration or
hardness can also be used as indicators, particularly on
individuals with darker skin.
Grade 2 − partial thickness skin loss involving epidermis or
dermis, or both. The ulcer is superficial and presents clinically
as an abrasion or blister.
Grade 3 – full thickness skin loss involving damage to or
necrosis of subcutaneous tissue that may extend down to, but
not through, underlying fascia.
Grade 4 – extensive destruction, tissue necrosis, or damage to
muscle, bone, or supporting structures with/without full
thickness skin loss.
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Slide 17
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Slide 18
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Key Priorities for Implementation
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Patients with a grade 1–2 pressure ulcer
should:
As a minimum provision be placed on
a high-specification foam mattress/
cushion, and
Be closely observed for skin changes.
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
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94
2008 Summer Nursing Conference
Slide 19
Arizona Geriatrics Society
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Key Priorities for Implementation
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Patients with grade 3–4 pressure ulcers should:
As a minimum provision be placed on a highspecification foam mattress with an alternating
pressure overlay, or
A sophisticated continuous low-pressure
system, and
The optimum wound healing environment
should be created by using modern dressings.
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Slide 20
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Prevention and Treatment of
Pressure Ulcers
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Assess and record risk
People
vulnerable
to pressure
ulcers
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Patient with
pressure ulcer
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Assess pressure ulcer
Re-assess
Re-assess
Prevent pressure ulcer
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Treat pressure ulcer and
prevent new ulcers
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Assess and Record Risk
Slide 21
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Risk factors include:
Pressure
Shearing
Friction
Level of mobility
Sensory impairment
Continence
Level of consciousness
Acute, chronic and
terminal illness
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Comorbidities
Posture
Cognition,
psychological status
Previous pressure
damage
Extremes of age
Nutrition and hydration
status
Moisture to the skin
Reassess on an ongoing basis
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
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95
2008 Summer Nursing Conference
Slide 22
Arizona Geriatrics Society
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Skin Assessment
Assess skin regularly – inspect most vulnerable areas
Frequency – based on vulnerability and condition of patient
Encourage individuals to inspect their skin
Look for:
Persistent erythema
Non-blanching
hyperemia
Blisters
Localized heat
Localized edema
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Localized induration
Purplish/bluish
localized areas
Localized coolness if
tissue death occurs
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Slide 23
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Assessment of Pressure Ulcer
Assess:
Cause
Site/location
Dimensions
Stage or grade
Exudate amount and type
Local signs of infection
Pain
Wound appearance
Surrounding skin
Undermining/tracking,
sinus or fistula
Odor
Record:
Document:
- Depth
- Estimated surface area
Grade
Support with photography
and/or tracings
Document all pressure
ulcers graded 2 and above
as a clinical incident
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Initial and ongoing ulcer assessment is
the responsibility of a registered healthcare
professional
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Slide 24
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Treatment of Pressure Ulcers
Consider preventive measures, positioning,
self-care, nutrition, and pressure-relieving
devices.
Create an optimum wound-healing environment
using modern dressings.
Consider oral antimicrobial therapy in the
presence of systemic and/or local clinical signs
of infection.
Consider referral to a surgeon.
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
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96
2008 Summer Nursing Conference
Slide 25
Arizona Geriatrics Society
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Positioning
Consider mobilizing, positioning, and
repositioning interventions for all patients.
All patients with pressure ulcers should actively
mobilize, change position/be repositioned.
Minimize pressure on bony prominences and
avoid positioning on the pressure ulcer.
Consider restricting sitting time.
Aids, equipment, and positions – seek specialist
advice.
Record using a repositioning chart/schedule.
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Slide 26
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Self-Care
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Teach individuals and caregivers how to
redistribute individual’s weight.
Consider passive movements for patients
with compromised mobility.
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Slide 27
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Nutrition
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Provide nutritional support to patients with an
identified deficiency
Decisions about nutritional
support/supplementation should be based on:
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– Nutritional assessment
– Patient preference
– Expert input (dietitian/specialists)
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
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2008 Summer Nursing Conference
Slide 28
Arizona Geriatrics Society
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Pressure Relieving Devices
− Risk assessment pressure
ulcer assessment (severity) if
present
− Location and cause of the
pressure ulcer if present
− Availability of caregiver/
healthcare professional to
reposition the patient
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- Skin assessment
- General health
- Lifestyle and abilities
- Critical care needs
- Acceptability and comfort
- Cost consideration
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Consider all surfaces used by the patient.
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Patients should have 24-hour access to pressurerelieving devices and/or strategies.
Change pressure-relieving device in response to altered
level of risk, condition, or needs.
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Slide 29
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Referral to Surgeon
Failure of previous
conservative
management
interventions
Level of risk
Patient preference
Ulcer assessment
General skin
assessment
General health status
Competing care needs
Assessment of
psychosocial factors
regarding the risk of
recurrence
Practitioner’s
experience
Previous positive effect
of surgical techniques
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Slide 30
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Implementation for Clinicians
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Be familiar with hospital guidelines.
Facilitate an integrated approach to the
management of pressure ulcers across the
hospital community interface.
Ensure continuity of care between shifts.
Ensure your local risk-assessment tool
incorporates all risk factors.
Access training on a regular basis.
Give patients and caregivers information.
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
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98
2008 Summer Nursing Conference
Slide 31
Arizona Geriatrics Society
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Implementation for Clinicians
Ensure that you have an understanding of what
the different modern dressings are, their
objectives, and application.
Know how to access pressure-relieving devices –
24 hour access.
Pressure ulcers Grade 2 and above – document as
a ‘local’ clinical incident.
Place documentation aids in patient charts.
31
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Slide 32
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Implementation for Managers
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Ensure an integrated approach to the
management of pressure ulcers across the
hospital community interface.
Ensure appropriate equipment is available.
Develop or review local guidelines for pressure
ulcer prevention and management – are they in
line with this guidance?
Include in induction for new staff and provide
opportunities for retraining on a regular basis.
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Slide 33
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Implementation for Managers
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Ensure standardization and availability of
modern dressings on all wards and across
healthcare settings.
Put in place a system for staff to access pressurerelieving devices in a timely manner – 24 hour
access for secondary care.
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Monitor, audit, and review progress.
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
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Arizona Geriatrics Society
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Slide 34
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Prevention and Control of
Healthcare-Associated
Methicillin-Resistant
Staphylococcus aureus
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Slide 35
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Slide 36
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Most Invasive MRSA Infections
Are Healthcare-Associated
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n=8,987
In the U.S. in 2005 there
were:
– 94,360 invasive MRSA
infections
– 18,650 associated deaths
14%
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86%
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Community-Associated
Healthcare-Associated
Source: ABCs Population-based Surveillance System, Klevens et al. JAMA 2007
36
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
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100
2008 Summer Nursing Conference
Slide 37
Arizona Geriatrics Society
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MRSA as a Healthcare Pathogen
Has emerged as one of the predominant
pathogens in healthcare-associated infections.
Treatment options are limited and less effective
– higher morbidity and mortality.
High-prevalence major influence on unfavorable
antibiotic prescribing, which contributes to
further spread of resistance.
37
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Slide 38
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MRSA as a Healthcare Pathogen
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Adds to overall S. aureus infection burden
Represents a failure to contain transmission
of drug-resistant bacteria:
– A marker for our ability to contain
transmission of important pathogens in
the healthcare setting.
– Learning how to successfully control
MRSA is likely to have benefits that
extend to other pathogens (MDRO).
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Slide 39
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Campaign to Prevent Antimicrobial Resistance in Healthcare Settings
Key Prevention Strategies
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Prevent infection
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Diagnose and treat
infection effectively
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Use antimicrobials wisely
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Prevent transmission
Clinicians hold the solution!
39
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
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101
2008 Summer Nursing Conference
Slide 40
Arizona Geriatrics Society
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Most Healthcare-Associated
Invasive MRSA Infections Have
Their Onset Outside of the
Hospital
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28%
14%
59%
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Community-Associated
Healthcare-Associated (community-onset)
Healthcare-Associated (hospital-onset)
40
Source: ABCs Population-based surveillance System, Klevens et al. JAMA 2007
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Slide 41
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Regional Spheres of Influence
Within Spectrum of Inpatient
Care
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NH 2
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Nursing
Home 1
Hospital A
Nursing
Home 3
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Hospital B
Nursing
Home 4
Hospital c
41
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Slide 42
How Best to prevent MRSA
Transmission in Healthcare Settings?
Controversial subject
– Standard precautions versus standard
plus barrier (i.e., contact
precautions)?
– Should contact precautions be used
only on those identified by clinical
cultures?
• Due to “iceberg effect,” many
colonized patients are
unrecognized based on clinical
cultures alone
• Should active surveillance be
used to identify carriers?
42
– If so, in what settings?
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
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102
2008 Summer Nursing Conference
Slide 43
Arizona Geriatrics Society
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CDC Guidance On Management of
Multidrug-Resistant Organisms
(MDROs) in Healthcare Settings
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First Tier: General Recommendations
For All Acute Care Settings
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If endemic rates not decreasing, or
if first case of important organism
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Second Tier: Intensified Interventions
43
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Slide 44
CDC MDRO Guidance (Acute Care)
First Tier: General Recommendations For All
Acute Care Settings
Administrative engagement
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– Make MDRO prevention and control an
organizational patient safety priority
– Implement a multidisciplinary process to monitor
and improve healthcare personnel (HCP)
adherence to recommended practices
– Feedback on facility and patient-care unit trends
in MDRO incidence and adherence measure
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Education and training of personnel
44
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Slide 45
CDC MDRO Guidance (Acute Care)
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First Tier: General Recommendations For All
Acute Care Settings
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Judicious use of antimicrobial agents
Standard precautions for all patients
Contact precautions for patients known to be
infected or colonized (masks not routinely
recommended)
Monitoring of trends over time to determine
whether additional interventions are needed
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45
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
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103
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Slide 46
Arizona Geriatrics Society
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CDC MDRO Guidance
(Acute Care)
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Indications for moving to second tier
– First case or outbreak of an epidemiologically
important MDRO
– When endemic rates of a target MDRO are not
decreasing despite implementation of and
correct adherence to the first-tier measures
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46
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Slide 47
CDC MDRO Guidance (Acute Care)
Second Tier: Intensified Interventions For
Acute Care Settings
Active surveillance cultures from patients at risk
on admission to high-risk area and at periodic
intervals to assess transmission.
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– Contact precautions until surveillance culture
known to be negative
– Administrative engagement/correction of systems
failures
– Education and training of personnel/adherence
monitoring
– Judicious use of antimicrobial agents
47
– Monitoring of trends
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Slide 48
CDC MDRO Guidance (Acute Care)
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Second Tier: Intensified Interventions For
Acute Care Settings
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Cohorting of staff to care of MDRO patients only
Enhanced environmental measures
Consult with experts on case-by-case basis
regarding decolonization therapy for
patients/staff.
If transmission continues despite full
implementation of above, stop new admissions to
the unit.
48
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
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104
2008 Summer Nursing Conference
Slide 49
Arizona Geriatrics Society
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MDRO Module
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Multidrug-Resistant Organism (MDRO) and
Clostridium difficile-Associated Disease (CDAD)
Module
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49
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Slide 50
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MDRO Module
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Organisms Monitored:
-Methicillin-Resistant Staphylococcus aureus (MRSA)
(option w/ Methicillin-Sensitive S. aureus (MSSA)
___________________________________
-Vancomycin-Resistant Enterococcus spp. (VRE)
___________________________________
-Multidrug-Resistant (MDR) Klebsiella spp.
-Multidrug-Resistant (MDR) Acinetobacter spp.
___________________________________
-Clostridium difficile-Associated Disease (CDAD)
Protocol available online at:
http://www.cdc.gov/ncidod/dhqp/nhsn_MDRO_CDAD.html
50
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Slide 51
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Conclusions
The burden of MRSA remains high in U.S.
healthcare settings.
Community-associated MRSA (CA-MRSA)
infections are emerging rapidly, but most MRSA
infections are still healthcare-associated
Epidemic strains of MRSA originally
community-associated have emerged as important
causes of hospital-acquired infections,
MRSA infections and transmission can be
prevented, even in endemic settings in the U.S.
Effective control programs must be multifaceted,
with broad institutional commitment.
51
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___________________________________
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
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105
2008 Summer Nursing Conference
Slide 52
Arizona Geriatrics Society
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Preventing Medication Errors
Related To Prescribing
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Where Do Errors Occur?
___________________________________
Prescribing
Transcribing
Dispensing
Administering
___________________________________
39%
11%
12%
38%
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52
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Slide 53
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Medication Prescribing Process
Components: Communication
___________________________________
Written Prescription Orders
Medication Ordering Systems
Electronic Order Transmission
Dosage Calculations
Verbal Orders
___________________________________
___________________________________
___________________________________
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
53
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Slide 54
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Written Medication Orders:
Illegible Handwriting
___________________________________
16% of physicians have illegible handwriting.1
Common cause of prescribing errors.2, 3, 4
Delays medication administration.5
Interrupts workflow.5
Prevalent and expensive claim in malpractice
cases.3
1. Anonymous. JAMA 1979; 242: 2429-30; 2. Brodell RT. Arch Fam Med 1997; 6:
296-8; 3. Cabral JDT. JAMA 1997; 278: 1116-7; 4. ASHP. Am J Hosp Pharm
1993; 50: 305-14; 5. Cohen MR. Medication Errors. Causes, Prevention, and Risk
Management; 8.1-8.23.
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
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Arizona Geriatrics Society
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Slide 55
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Slide 56
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Illegible Handwriting:
Error Prevention
___________________________________
Prescribers’ Obligation
Write/Print More Carefully
Computers
Verbal Communications
___________________________________
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56
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Slide 57
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57
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
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Slide 58
Arizona Geriatrics Society
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Written Medication Orders:
Complete Information
___________________________________
Patient’s Name
Patient-Specific Data
Generic and Brand Name
Drug Strength
Dosage Form
Amount
Directions for Use
Purpose
Refills
___________________________________
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Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
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Slide 59
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Written Medication Orders:
Do Not Use Abbreviations
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Drug names
“QD” or “OD” for the word daily
Letter “U” for unit
“µg” for microgram (use mcg)
“QOD” for every other day
“sc” or “sq” for subcutaneous
“a/” or “&” for and
“cc” for cubic centimeter
“D/C” for discontinue or discharge
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
Jones EH. Clev Clin J Med 1997; 64: 355-9.
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Slide 60
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Written Medication Orders:
Weights, Volumes, Units
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Use metric system
Avoid apothecary system
Confusion With Apothecary System
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1/200 grain (0.3 mg) ≠ 1/100 grain (0.6 mg) + 1/100
grain (0.6 mg)
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Cohen MR. Medication Errors. Causes, Prevention, and Risk Management ; 8.1-8.23.
Cohen MR. Am Pharm 1992; NS32: 26-8.
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
© 2008 Arizona Geriatrics Society. All Rights Reserved
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Arizona Geriatrics Society
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Written Medication Orders:
Decimals
Avoid whenever possible1
– Use 500 mg for 0.5 g
– Use 125 mcg for 0.125 mg
Never leave a leading decimal point “naked” 1, 2, 3
– Haldol .5 mg → Haldol 0.5 mg
1.
Cohen MR. Medication
Never use a terminal zero
Errors. Causes,
Prevention, and Risk
Management; 8.1-8.23.
– Colchicine 1 mg not 1.0 mg
2.
Jones EH. Clev Clin J
Med 1997; 64: 355-9.
3.
Cohen MR. Am Pharm
Space between name and dose1,3
1992; NS32; 32-3.
– Inderal40 mg → Inderal 40 mg
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Slide 62
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Look-alike and Sound-alike
Drug Names
Accupril®
Accutane®
Alprazolam
Lorazepam
Cardene®
Cardura®
Flomax®
Fosamax®
Lamisil®
Lomotil®
Nizoral®
Neoral®
Plendil®
Prilosec®
Zantac®
Zyrtec®
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USP Quality Review. www.usp.org/reporting/review/qr66.pdf accessed on February 6, 2001.
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Slide 63
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Medication Prescribing Process:
Electronic Prescribing
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Computer with 3 Interacting Databases
– Drug History
– Drug Information/Guidelines Database
– Patient-Specific Information
Avoids
–Illegible Prescriptions
–Improper Terminology
–Ambiguous Orders
–Incomplete Information
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Schiff GD. JAMA 1998; 279: 1024-9.
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
© 2008 Arizona Geriatrics Society. All Rights Reserved
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2008 Summer Nursing Conference
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Arizona Geriatrics Society
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Computerized Prescribing
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Photograph of prescriber order entry
computer screen courtesy of AllScripts
Healthcare Solutions
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Slide 65
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Dosage Calculations:
Error Prevention
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Avoid calculations
Cross-checking
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65
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
ISMP Medication Safety Alert 1996; 1 (15).
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Slide 66
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Verbal Orders:
Error Prevention
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Avoid when possible
Enunciate slowly and distinctly
State numbers like pilots
(i.e., “one-five mg” for 15 mg)
Spell out difficult drug names
Specify concentrations
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
© 2008 Arizona Geriatrics Society. All Rights Reserved
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Slide 67
Arizona Geriatrics Society
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Patient Education
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Educate patients about their medications.
Purpose of each medication.
Name of drug, dose, how to take, etc.
Provide patients with understandable written
instructions.
Lack of involving patients in check systems.
Inform patients about potential for error with
drugs known to be problematic.
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Slide 68
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Surgical Care Improvement Project
(SCIP)
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Slide 69
SCIP Measures
SCIP-Inf 1: Prophylactic antibiotic received within one hour
prior to surgical incision
SCIP-Inf 2: Prophylactic antibiotic selection for surgical
patients
SCIP-Inf 3: Prophylactic antibiotics discontinued within 24
hours after surgery end-time (48 hours for cardiac patients)
SCIP-Inf 4: Cardiac surgery patients with controlled 6 a.m.
postoperative serum glucose (< 200 mg/dL)
SCIP-Inf 5: Postoperative wound infection diagnosed
during index hospitalization
SCIP-Inf 6: Surgical patients with appropriate hair removal
SCIP-Inf 7: Colorectal surgical patients with immediate
postoperative normothermia
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
© 2008 Arizona Geriatrics Society. All Rights Reserved
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2008 Summer Nursing Conference
Slide 70
Arizona Geriatrics Society
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SCIP Measures
SCIP-Card 1: Non-cardiac vascular surgery
patients with evidence of coronary disease who
received beta-blockers during perioperative
period
SCIP-Card 2: Surgical patients on a beta-blocker
prior to arrival that received a beta blocker
during the perioperative period
SCIP-Card 3: Intra- or postoperative acute
myocardial infarction (AMI) diagnosed during
index hospitalization and within 30 days of
surgery
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Slide 71
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SCIP Measures
SCIP-VTE 1: Surgical patients with recommended
venous thromboembolism prophylaxis ordered
SCIP-VTE 2: Surgery patient who received appropriate
venous thromboembolism prophylaxis within 24 hours
prior to surgery to 24 hours after surgery
SCIP-VTE 3: Intra- and postoperative pulmonary
embolism (PE) diagnosed during index hospitalization
and within 30 days of surgery
SCIP-VTE 4: Intra- and postoperative deep vein
thrombosis (DVT) diagnosed during index
hospitalization and within 30 days of surgery
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Slide 72
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SCIP Measures
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SCIP-ESRD 1: Permanent hospital ESRD
vascular access procedures that are autogenous
AV
SCIP-Global 1: Mortality within 30 days of
surgery
SCIP-Global 2: Readmission within 30 days of
surgery
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
© 2008 Arizona Geriatrics Society. All Rights Reserved
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2008 Summer Nursing Conference
Slide 73
Arizona Geriatrics Society
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SCIP Measures
SCIP-Resp 1: Ventilated surgery patients with
documentation of Head of Bed (HOB) elevated
SCIP-Resp 2: Patients diagnosed with (VAP)
postoperative ventilator-associated pneumonia
SCIP-Resp 3: Documentation of stress ulcer
disease (SUD) prophylaxis
SCIP-Resp 4: Surgical patients on a ventilator who
were placed on a ventilator weaning protocol†
73
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Slide 74
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HSAG Mission
___________________________________
To positively affect the quality of health
care by providing information and
expertise to those who deliver and those
who receive health services.
___________________________________
___________________________________
To help make a better health care system.
___________________________________
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Slide 75
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HSAG Partners
60+ Acute Care Hospitals
5 Critical Access Hospitals
140+ Nursing Homes
64 Medicare-Certified Home Health Agencies
4000+ Primary Care Physicians
8 Medicare Advantage Plans
Pharmaceutical Companies
750,000 Medicare Beneficiaries, their
Families & Caregivers
___________________________________
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___________________________________
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
© 2008 Arizona Geriatrics Society. All Rights Reserved
113
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Slide 76
Arizona Geriatrics Society
___________________________________
Contact Information
___________________________________
Howard C. Pitluk, MD, MPH, FACS
Vice President/Chief Medical Officer
Health Services Advisory Group
1600 East Northern Avenue, Suite 100
Phoenix, AZ
602.665.6143
[email protected]
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Slide 77
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All Medicare beneficiaries have the right to appeal their
discharge from a hospital, skilled nursing facility, home
health agency, or comprehensive outpatient rehabilitation
facility. For more information, go to
http://www.hsag.com/azmedicare or call 1.800.359.9909.
___________________________________
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___________________________________
www.hsag.com
This material was prepared by Health Services Advisory Group, the Medicare Quality
Improvement Organization for Arizona, under contract with the Centers for Medicare
& Medicaid Services (CMS), an agency of the U.S. Department of Health and Human
Services. The contents presented do not necessarily reflect CMS policy.
Publication No. AZ-8SOW-1C-073108-01
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the
Arizona Geriatrics Society.
© 2008 Arizona Geriatrics Society. All Rights Reserved
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