This presentation was for 150 or so Dept of VA Patient Safety managers with and for whom I worked at VA Central Office while they worked at the VA Medical Centers and Network offices. The main items of interest are the preliminary work that I was describing from the periphery of the then developing VA MRSA Prevention Program, which was quite successful and led by Dr. Rajiv Jain (and published in NEJM: http://www.nejm.org/doi/full/10.1056/NEJMoa1007474#t=abstract). Also of interest is the wide-ranging work that VA NCPS led on the follow up on an OIG report that identified problems in some of VA's operating rooms. Also of interest is slide 36 where I present some interesting data on VA's reduction in unadjusted inpatient mortality - this hasn't been widely publicized or published to my knowledge. The second to last slide refers to the fact that the day after the meeting I was going to the Grand Canyon and planning to hike to the bottom one day and out the next day. That turned out to be a great experience.

1. 1
AHRQ PIPS, MRSA,
and OIG on PS in VHA ORs
(05-00379-91)
Noel Eldridge, MS
National Center for Patient Safety
National Patient Safety Managers’ Conference
3/20/07
202 273-8878

2. 2
It’s nice
to get a
break
away
from the
office!

3. 3
What is he talking about?
I. “Partnerships for Implementing Patient
Safety” projects funded and managed by
the Agency for Healthcare Research and
Quality
II. The new VHA Program to prevent
Methicillin-Resistant Staphylococcus
aureus in VA patients, and
III. The VA Office of Inspector General Report
on Patient Safety in the Operating Room in
VHA Facilities (Report # 05-00379-91)

4. 4
I. AHRQ PIPS Projects

5. 5
PIPS Program Overview
 17 Projects Implementing Evidence-Based
Interventions
 Generalizable, Realistic, Replicable & Sustainable
 PIPS Project Teams - PI 20%, Multi-Disciplinary, Sharp-
End
 PIPS Goals
 Assist sharp-end users in implementing
interventions
 Provide information for implementation (both
what works & what does not!)
 Provide toolkits to put interventions into
practice

6. 6
PIPS Program Timeline
 Patient Safety Intervention Implementation Activities
 July 2005 – July 2006
 AHRQ Site Visits & PIPS Presentations
 Presentations/Posters at AHRQ PS Conference: June 2006
 PIPS Projects Analysis & Evaluation Activities
 July – November 2006
 AHRQ PIPS Technical Assistance Workshop &
Presentations October 25-26, 2006
 PIPS Toolkit & Website Development & Refinement
 November 2006 - June 2007
 PIPS Toolkits & Evaluations Available July 2007

7. 7
Focus of PIPS Projects
 Discharge & Transitions
 3 PIs: Jack, Noskin,
Williams
 Deep Vein Thrombosis
and/or Anticoagulation
 2 PIs: Maynard, Zierler
 Medication Reconciliation
and Safety
 9 PIs: Fairbanks, Jack,
Jones/Mueller,
Leonhardt, Levett,
Muller, Noskin, Sirio,
Williams
 Simulation
 2 PIs: Guise, Patterson
 Team Training &
Communication
 4 PIs: Daugherty,
Fairbanks, Noskin,
Sirio
 Workflow & Processes
 4 PIs: Burdick,
Landrigan, Maynard,
Speroff

8. 8
PIPS Toolkits
Minimum Guidance for Maximum Flexibility
 Identify Problem
 Define & Measure the Intervention
 How (and How Not) to Implement the Intervention
 Results: Evidence-Based Patient Safety Tools
 Website
 CD/Video
 “How To” Guide & Checklist
 Training Materials – Online Training, Workbooks
 Data Analysis & Tracking Spreadsheets
 Poster & PowerPoint Presentations

9. 9
PIPS Program: Next Steps
 17 PIPS Representatives at National Patient
Safety Foundation (NPSF) Congress - May 2-4, 2007,
DC
 3 Presenting in Research Track Session
 14 “Meet the Experts” in Exhibit Hall
 AHRQ Marketing & Rollout Plan in Development
 Plan to Conduct National Call(s) for VHA Patient
Safety Managers and other VHA Personnel in
July/August 2007

10. 10
Take Home Message:
AHRQ PIPS projects
 17 AHRQ PIPS Projects Near Completion
 Most are on Topics Relevant to VHA
 NCPS Plans to Organize National Calls
focusing on Toolkits in July – August 2007

11. 11
II. MRSA Program

12. 12
Why a New Program & this
New Program?
 MRSA is a Growing Problem in US
Healthcare, Including VHA Facilities
 The VA Pittsburgh Healthcare System has
Demonstrated Good Results (reduced
MRSA rates and transmission of MRSA)
that Appear Replicable
 Related JCAHO Finding from 2006 Surveys
 7 of 33 (21%) VAMCs received RFIs for Hand
Hygiene

13. 13
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
'50 '60 '78-'82 '83-'87 '88-'92 '93-'97 2000
Denmark, Finland and
the Netherlands ( <1%).
USA: This MRSA trend accompanies a 36% rise in the overall
national nosocomial infection rate from 1975 to 1995.
Percent of Staph Aureus Resistant to Methicillin is Rising in the USA
…But has been Controlled in Denmark, Finland and the Netherlands
(Source: CDC NNIS data)
PercentofStaphAureusResistanttoMethicillin
VHA 2006

14. 14
VAPHS (4-West Surgical Ward)
Nosocomial MRSA Infection Rate
Fig 1. MRSA Infections/1000 BDOC - 4W Surgical Ward
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
24 Mo. Pre FY02 FY03 FY04 FY05
Intervention begun

15. 15
VAPHS (Surgical Intensive Care
Unit) MRSA Infection Rates
Fig. 2. MRSAInfections/1000 BDOC - SICU
0
1
2
3
4
5
6
24 Mo Pre FY04 FY05
Intervention begun

16. 16
Four Basic Aspects of MRSA
Program from VA Pittsburgh
Healthcare System
1. Hand Hygiene
2. Active Surveillance Cultures
3. Contact Isolation
4. Cultural Transformation
from within

17. 17
VAPHS MRSA Bundle:
1. Hand Hygiene
 Before and after every patient
contact
 BEST: Alcohol hand sanitizer
 Still must wash hands if visibly
soiled
 Monitor: peer data collection
 (Standard Methods being Developed)

18. 18

19. 19
Hand Hygiene Questions
Which of these do/does the VHA Directive/ Joint
Commission NPSG/ CDC Guideline Require?
 Keeping Natural Fingernails Short (<4mm free edge)?
 No Artificial Fingernails on Anyone Who Does Direct
Patient Care?
 Providing Pocket-sized Alcohol-based Hand-rub to
Staff?
 Providing Facial Tissues (“Kleenex”) to Staff?
 Different Practices in a Norovirus Outbreak?
 Decontaminate Hands Before and After Gloving?

20. 20
VAPHS MRSA Bundle:
2. Active Surveillance Cultures
 Nares Swabs
• Admission
• Discharge or Transfer
• CTB is considered discharge
 Open wounds

21. 21
Active Surveillance Cultures?
 VA-wide Application of Active
Surveillance?
 VAMCs with low baseline MRSA
Bloodstream Infection Rates May
be Able to Opt Out of Some
Aspects of Active Surveillance

22. 22
Implement Action Plan as submitted
Facility review of FY06 Baseline MRSA BSI (Bloodstream Infections) rate
Baseline MRSA BSI rate =
# unique nosocomial episodes (>48 hrs) MRSA BSIs
# Acute care Bed Days of Care
Small facilities that do not have a single case of BSI should consult MRSA Program Office for
assistance in determining an appropriate measurement tool.
Directive 2007-002
Methicillin-Resistant
Staphylococcus aureus
(MRSA) Initiative
MRSA Bundle
1Active Surveillance
Cultures
2Aggressive Hand Hygiene
3Contact Precautions for MRSA-
colonized patients
4Cultural change
Targeted Active Surveillance for
high-risk units
Based on internal assessment
Apply to Taskforce for Exemption
from Active Surveillance Cultures
Active Surveillance Exemption
Not Approved
Implementation of Full MRSA Bundle,
including Active Surveillance Cultures
(Admission/Discharge)
NOTE:
Review Exemption criteria:
•Strong Action Plan*
•Reduce infection rate by 20% in FY07
Reassess 6 months after implementation: has goal to reduce
nosocomial MRSA BSIs by 20% or to ZERO been achieved?
No
MRSA BSI Rate <median, maintains Contact Precautions for patients MRSA-
INFECTED or colonized based on clinical culture AND components 2 & 4 of
MRSA Bundle are fully implemented
MRSA BSI Rate >median
Single case of VRSA in last 12mos., or
at any time during surveillance
No. Facility must implement full MRSA
Bundle with active surveillance
Facility Choice
x 1000
( )
Active Surveillance Exemption
Approved
Yes. Facility may choose approach

23. 23
VAPHS Bundle:
3. Contact Isolation &
4. Cultural Transformation
 Contact Isolation– all MRSA+ patients
• HH, Gown, Glove
• Designated or Disinfected Equipment
 Cultural Transformation from Within
• Staff – own and operate solutions
• Leaders - Set direction, create freedom and
opportunities for staff to co-create and implement
solutions, remove barriers

24. 24
Take Home Message:
VHA MRSA Program
 MRSA Program has New Interventions and
Requirements, and New Funding (Planned)
 Some Aspects will Vary by VAMC
 Currently 17 Beta Sites at VAMCs
 Some Methods Still Being Developed
 e.g., standard measurement methods for some
processes
 MRSA Program has Potential to Focus and
Improve Various VHA and VAMC-wide
Efforts to Prevent Infections

25. 25
III. OIG Report on Patient
Safety in the Operating
Room
www.va.gov/oig/54/reports/VAOIG-05-00379-91.pdf

26. 26
Purpose of OIG Review
 To “determine whether”:
1. “facility leaders established and implemented
effective policies, procedures, and guidelines to
ensure patient safety in the OR”;
2. “facility leaders established surgical improvement
program and identifies potential problem areas
needing improvement; and
3. “there was coordination between Supply, Processing,
and Distribution (SPD) and the OR”
Eight (8) VAMCs Visited by OIG Staff

27. 27
Summary of Findings
 Issue 1: Compliance with
VHA Directives, AORN
Guidelines, & JCAHO
Standards
 Issue 2: Surgical
Performance
Improvement Program
 Issue 3: SPD
Coordination with the OR

28. 28
Accentuating the Negative
 Ensuring Correct Surgery
 We found that …two (of 8) facilities… had policies that only
addressed side/site verification.
 We found that two (of 8) facilities… had incident or near miss
incorrect surgery events in fiscal year (FY) 2005.
 The first facility reviewed the event of the wrong site surgery and
determined that (a) the surgeon did not possess the consent form
when the site was marked, (b) the nurse circulator did not mention the
variance between the marked site and the consent, and (c) a time-out
briefing with the informed consent was not performed.
 At the second facility, a patient had the wrong eye anesthetized
(blocked)…The incident was reviewed and monitors were developed
and implemented to ensure the correct site was identified and
marked.
 Related JCAHO Finding from 2006 Surveys
 12 of 33 (36%) VAMCs received RFIs for “Universal Protocol” (11
Time-outs and 1 Mark Operative Site).

29. 29
Accentuating the Negative
 Disclosure of Adverse Events
 We found that three (of 8) facilities failed to document
disclosure of adverse surgical events.
 At one facility, two patients had to return to surgery with
partially retained drains. (no record of disclosure)
 At a second facility, the surgeon administered a regional
block into the wrong eye. (no record of disclosure)
 In the third facility, we reviewed three surgery-related
deaths that involved delay in diagnosis or treatment…
(no record of disclosure)

30. 30
Other Topics Reviewed
 Preventing Retained Surgical Items (VHA Directive 2006-030)
 Environment of Care
 HVAC (e.g., air exchanges)
 Equipment Management (preventive maintenance schedules)
 Anesthesia Cart Security (e.g., unmarked filled syringes)
 Resident Supervision
 Morbidity and Mortality Peer Review (Directive 2004-054)
 Mortality Assessment (Directive 2005-056)
 Credentialing and Privileging
 Availability of Supplies
 Missing, Broken, and Incorrect Instruments
 Contaminated Surgical Instruments

31. 31
Who Can Make this Better?
 I don’t think that we can’t fix
this from VACO
 No thousand mile
screwdriver
 We don’t know how
 Different places, Different
Problems, Different
Solutions
 Do you and your colleagues
know how?
 Let us know how we can help
 Especially re communicating
non-optional aspects

32. 32
Who Needs to Participate in a
Time-out in the Operating Room?
 Everyone in the Operating Room?
 Attending Surgeon?
 Anesthesia Provider?
 Circulating Nurse?
 Surgical Nurse?
 Do Midline Sites Need to be Marked?
 How About Out-of-OR?
 Is a time-out required for thoracentesis?

33. 33
Summary of VHA Follow-ups
 Plan to Require Check of Local Policies, Processes
and Practices (OR and Management), & Aspects of
the Physical Environment
 Paper Reviews (e.g., policies and committees w/minutes)
 Observations
 Pre-operative Processes (marking sites, “time-outs”…)
 Intra-operative Processes (counting sponges…)
 Environment of Care/Engineering/Equipment, etc.
 Method for Reporting Results to VACO is TBD
 No Plan for a New Mandatory Standardized
Checklist to be Used for Every Surgical Case

34. 34
Thanks for Examples of OR
Checklists from VISNs and VAMCs
 Carol Bills, VISN 23
 Christine Carlin, San
Diego
 Sandra Hart, Danville (IL)
 Kerry Inhofe, Oklahoma
City
 Tanya Kotar, Milwaukee
 Patricia Lingenfelter,
Baltimore
 Karen Pierce, Loma
Linda
 Phyllis Trainor,
Providence
 Edith Villaruz, Los
Angeles
 Medical Team Training
Program Sites
 And Anyone I missed

35. 35
Take Home Message:
OIG report on PS in VHA ORs
 OIG Review Found Variation in Processes
 Some were disturbing (e.g., marking “Ace bandage”)
 VHA Follow-up will Focus on Local Policies and
Self-Assessments (Observation) of Processes
 Details of Reporting to VACO Not Yet Defined
 You Should Read This Entire Report
 NCPS-led Medical Team Training Program
Focusing on Some of Same Process Issues
 NSQIP Data has Demonstrated Morbidity and
Mortality Improvements in VA Surgical Patients

36. 36
Some Context: Good News
VA & US Inpatient
Discharges and Mortality
50
60
70
80
90
100
110
120
130
140
150
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
1998=100
VA Discharges
VA Mortality
US Discharges
US Mortality
1995-1998 (Pink Oval):
● US discharges and mortality
flat
● VA discharges down 28% and
mortality up 14%
1999 to Date (Yellow Oval):
● US discharges up (8% thru
2003) and mortality down (14%
thru 2004)
● VA discharges flat (down 2%
thru 2006) and mortality down
(35% thru 2006)
VHA Inpatient Mortality
(Unadjusted) is Down 35%

37. 37
Enjoy the Conference!

38. 38
Wish me luck!