Read Patient Safety Action Group (PSAG) Newsletter, July 2, 2009 text version

A Message from

Voices of Our Patients

Kudos to the Staff of B7I

This is a letter of thanks to you. Your clinical and professional performance on Tuesday night 5/12 was outstanding. The critically injured and gravely ill young man was supported by your clinical expertise, teamwork and never give up attitude. You worked diligently all night long and displayed the ultimate in compassion and devotion to a job that you do so well. The patient's mother expressed the following... "I am very thankful to all the nurses, doctors and everyone else who worked all night, they never gave up on my son." Indeed, no one gave up and total support was provided to this patient. Thank you and it was a pleasure working with you to provide the best possible patient care in Bliss 7ICU. Sincerely, Robert Brautigam, MD Karyn Butle, MD Cathy Yavinsky, RN, MS Manish Tandon, MD Sue Williamson, RN, MHA John Mah, MD

Letter reprinted with permission from the authors.


Sa fety

Action Group

July 2, 2009

Year 2; No. 26

Staff Recognized with Full Circle Award for Introducing PreThickened Liquids to Safeguard Patients with Difficulty Swallowing

On June 29, 2009 five members of the Department of Rehabilitation ­ Speech Therapy were honored for successfully introducing new products into Hartford Hospital that will help prevent aspiration pneumonia in patients with difficulty swallowing (dysphagia). The idea of using pre-thickened liquids to accommodate difficulties swallowing is not a new one, but what is particularly notable is that this team has persisted over several years in studying the issue and has used data in supporting their conclusions that pre-thickened liquids would be safer and more cost-effective and, at the same time, would improve workflow for staff and caregivers (see following article).

Jeff Flaks, Dick Gallagher, Jamie Roche, MD, Janice Cannon, Dave Fichandler, Sylvia Reis-Fisher, Elizabeth Conlon and Elliot Joseph.

L to R:

Pre-Thickened Liquids are Coming to Hartford Hospital in June 2009!

Dysphagia and Aspiration Pneumonia are major health concerns facing not only Hartford Hospital but the American health care system. It has been estimated that some 2.8 million patients were at risk of aspiration pneumonia nationally and that number continues to grow. Aspiration pneumonia adds an average of ten additional days to an inpatient hospital stay, and increases the total cost of care by an average of $78,653 per incidence as well as the hospital costs by $6,950. In fact, The Joint Commission (TJC) has stated that as many as 50 percent of patients with a stroke will develop dysphagia and 37 percent of those patients will develop

pneumonia. Additionally, as of October 1, 2008, the costs related to nosocomially acquired aspiration pneumonia are no longer a covered expense. Current management of patients with known dysphagia and/or who are at risk for aspiration pneumonia is to place them on a dysphagia diet. Liquid and food consistencies are individually adjusted to accommodate swallowing deficiencies. This is a manual process that must occur at every meal using Thicken UP© for liquids and historically this process has been managed at the bedside by nursing staff, patients and their caregivers.

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We want to hear from you. Just hit "reply" and write your thoughts. If you do not have access to e-mail, you can send your comments or suggestions via the inter-hospital mail. Address the envelope to the Patient Safety Action Group. (Please include your name and department if you would like a response from PSAG.) Useful ideas win awards!

Page 2 July 2, 2009

As an opportunity to evaluate the accuracy and effectiveness of this system, a snapshot review was designed to look at compliance with the consistency of liquids delivered. Inpatients were selected from within Hartford Hospital during a six week time frame in February and March. Patients were identified electronically by their dysphagia diet status. The results revealed: · 74percentofpatientswere receiving the incorrect

consistency of liquids · 49percentofpatientsreceived liquids that were too thin or unthickened · 22percentofpatientsreceived no liquids at all As a result of these findings, the leadership of both Rehabilitation and Food & Nutrition Services developed a plan to improve compliance with liquid management through implementing pre-thickened liquids.

quality of life. From an operational perspective, pre-thickened liquids provide a safe, standardized method of liquid delivery and reduce the burden placed on Food & Nutrition and the bedside nursing staff.

Throughout the coming weeks, please look for additional information on the nursing units about the roll out of pre-thickened liquids. If you have questions about the products or delivery, please contact Janice In addition to compliance, preCannon in Food & Nutrition Services thickened liquids will greatly improve @ x 52697. If you have questions patient safety by reducing the about education and training, risk of aspiration pneumonia and please contact Sylvia Fisher in the dehydration thus leading to greater Department of Rehabilitation-Speech outcomes, patient satisfaction and Therapy Services @ x 52462.

Catheter Acquired Urinary Tract Infections (CAUTI) Reduced by 40 Percent

Hospital-acquired UTIs account for approximately 40 percent of all hospital-acquired infections. They result in incidences of bacteremia, septicemia, death, and frequently serve as a source for antibiotic resistant organisms such as VRE, MRSA, and multi-drug resistant gram-negative rods. UTI rates have been reported to range from 1.3 percent to 3.1 percent per 100 admissions. Most of these infections are CAUTIs. In 1992 a well designed case control study (Clausen et al) showed a cost difference of $3,803 between patients who acquired catheter associated UTI vs. patients who did not. Due to health care cost inflation since that time, current costs may approach $5,000. Hospital acquired infections are gaining increased attention by the public, by the media, and by payers. In 2008, CMS issued a rule change that disallows payment for hospital acquired catheter-associated urinary tract infection. use of Foley catheters. The recently completed audit shows a 40.7 percent reduction in CAUTI. The chosen time frames for this project were as follows: Baseline surveillance (Endemic CAUTI level) Number of months: 3 Time frame start: August 1, 2007 Time frame end: October 31, 2007 Evaluation surveillance (Rate using Bardex-IC® product) Number of months: 3 Time frame start: August 1, 2008 Time frame end: October 31, 2008 Patient care days were used as the denominator for CAUTI rate calculation. Rates are expressed as number of CAUTIS per 1000 patient care days.

Standard Catheter Group Bardex-IC® Group

Silver alloy and hydrogel-coated Foley Total Cases Meeting CAUTI Definition 159 93 catheters have been shown to reduce the Patient Days Denominator 43,077 42,394 occurrence of CAUTI when measured against non-silver coated Foley catheters. Hartford CAUTI Rate (per 1000 patient days) 3.69 2.19 Hospital switched to silver coated catheters in Rate Difference N/A 40.7% 2008. The Bard company (the manufacturer) Thank you to Bard for the audit, to the Infection Control agreed to sponsor a before and after audit to see if the department and the CAUTI team for leading the switch switch to silver-coated catheters reduced the incidence to silver coated catheters, which has led to a decrease in of CAUTI. The Hartford Hospital CAUTI team concomithe inappropriate use of Foley catheters. tantly introduced measures to decrease inappropriate

We want to hear from you. Just hit "reply" and write your thoughts. If you do not have access to e-mail, you can send your comments or suggestions via the inter-hospital mail. Address the envelope to the Patient Safety Action Group. (Please include your name and department if you would like a response from PSAG.) Useful ideas win awards!


Patient Safety Action Group (PSAG) Newsletter, July 2, 2009

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Patient Safety Action Group (PSAG) Newsletter, July 2, 2009