Quality Measurement for Clostridium Difficile Infection: Turning Lemons into Lemonade

May 20, 2019

For this post, we asked one of our Department of Quality and Safety medical directors, Marc Pimentel, MD, MPH, CPPS, to discuss hospital-acquired health conditions, specifically quality measurement for Clostridium difficile (C. difficile), an infection that can occur in the hospital after receiving antibiotic medicine.

We use quality measures to drive improvements in caring for our patients — focusing our efforts on preventing patient falls, blood clots and infections. Quality measures, such as how often we wash our hands, help us focus efforts on our trouble spots. Quality measurement is not perfect, but what if a hospital’s measured rate of patients who get a C. difficile infection was off by 20–40 percent? Could we still use this quality measurement for improvement?

In an article published last year in BMJ Quality and Safety, Brigham Health experts wrote about how pursuing a seemingly imperfect measurement still led to improved care. During hospital stays, up to 15 percent of patients will have diarrhea, usually from medication side effects or their own illness.

For some of our patients, there’s another reason: C. difficile infection, which causes up to 20 percent of inpatient diarrhea, usually as a complication of receiving antibiotic medicine. When patients have diarrhea in the hospital, we often send a test for C. difficile in hopes of identifying a treatable cause for the diarrhea.

Unfortunately, the test (like most) is not perfect. Because C. difficile is part of the normal gut flora, at least one out of five patients will have a false-positive test result for C. difficile. Despite this issue, we still count every positive C. difficile result toward our infection rate to allow hospitals to compare their performance to each other, without having to review every single case. Unfortunately, this method of reporting can lead to artificially inflated rates of C. difficile infections in our quality measures.

A team at the Brigham took the time to understand all our care processes that contribute to our positive C. difficile tests. We found several items to address, such as our clinician education for proper testing and interpreting the results. After this and other efforts were performed, such as improving our room disinfection practices, we were able to reduce our measured infection rate by 30 percent, while improving the accuracy of our quality improvement data.

This work has led to more transparency and trust from our patients that we are ensuring delivery of high-quality care and their safety, always.

Promoting Opioid Safety for Student Athletes

March 6, 2019

Scott G. Weiner, MD, MPH, a medical director in the Department of Quality and Safety and director of the Brigham Comprehensive Opioid Response and Education (B-CORE) program at Brigham and Women’s Hospital, discusses promoting opioid safety for student athletes.

The opioid epidemic continues to take a record number of lives in this country — 47,600 people died from opioid-related overdoses in 2017 (1). It is staggering to see that the average U.S. life expectancy has declined over the past two years, which is attributed mainly to preventable deaths, such as those caused by drug overdose (2).

To ultimately solve the opioid epidemic, an important step is working to prevent new cases of opioid use disorder from occurring. I like the mantra: “keep patients opioid naïve whenever possible.” If you don’t start taking an opioid, then you can’t get hooked on one. Of course, I don’t advocate for undertreating pain, but multiple studies about conditions ranging from back pain (3) to hip replacement (4) demonstrate that non-opioid pain relievers like ibuprofen and acetaminophen work just as well as opioids for many types of acute pain. From a safety perspective, Brigham and Women’s Hospital has also demonstrated that, for inpatients, adverse reactions to opioids are quite common (5).

One of the most at-risk groups for developing an opioid use disorder is athletes. Think about it: Athletes are prone to injury, particularly at the elite level. Sometimes, despite better judgment, athletes want to do whatever it takes to get back to their sport, even when not completely healed. Several colleagues and I collaborated with athlete Alex White, an alumnus of Harvard University, who had suffered a sports-related injury while in school. We spoke to him about the mindset of an injured athlete amidst the opioid epidemic. Combine that desire with lenient opioid prescribing and a recipe for disaster is created. Athletes need to know the dangers of these opioids, the fact that non-opioids can work just as well as opioids, and — most importantly — that opioids only mask pain so the body thinks it’s healed.

The Brigham is grateful for a donation from two non-profit organizations, Hanging with Ted and the ADK Charities, to create a video (see below) for student athletes that educates them about opioid use. Our goal is to have student athletes and their families view the video and be prompted to talk to their physicians about how to safely take opioids if prescribed and discuss alternative pain-relief options. We encourage you to share the link widely with your network.

Alex White, the student athlete featured in the video, has experience with sports-related injuries, but has not personally experienced opioid misuse or dependency. An earlier version of this post incorrectly stated that Alex had struggled with opioid dependency.

Additional Resource:

References:

  • Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and Opioid-Involved Overdose Deaths – United States, 2013-2017. MMWR Morb Mortal Wkly Rep. 2018 Jan 4;67(5152):1419-1427.
  • NBC News. U.S. life expectancy falls for second straight year — as drug overdoses soar. Available at: https://www.nbcnews.com/storyline/americas-heroin-epidemic/u-s-life-expectancy-falls-second-straight-year-drug-overdoses-n831676
  • Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, Bijur PE, Gallagher EJ. Naproxen with Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA. 2015 Oct 20;314(15):1572-80.
  • Thybo KH, Hägi-Pedersen D, Dahl JB, Wetterslev J, Nersesjan M, Jakobsen JC, Pedersen NA, Overgaard S, Schrøder HM, Schmidt H, Bjørck JG, Skovmand K, Frederiksen R, Buus-Nielsen M, Sørensen CV, Kruuse LS, Lindholm P, Mathiesen O. Effect of Combination of Paracetamol (Acetaminophen) and Ibuprofen vs Either Alone on Patient-Controlled Morphine Consumption in the First 24 Hours After Total Hip Arthroplasty: The PANSAID Randomized Clinical Trial. JAMA. 2019 Feb 12;321(6):562-571.
  • Urman RD, Seger DL, Fiskio JM, Neville BA, Harry EM, Weiner SG, Lovelace B, Fain R, Cirillo J, Schnipper JL. The Burden of Opioid-Related Adverse Drug Events on Hospitalized Previously Opioid-Free Surgical Patients. J Patient Saf. 2019 Jan 21. [Epub ahead of print]

Continuous Quality Improvement: It’s a Bit Like “Groundhog Day”

A large, multi-ethnic audience in a movie theater, watching a movie, eating popcorn and drinking soda. The group of people are mixed ages, including children, teenagers, young adults, mid adults and mature men and women, families, friends and couples.In this piece, Jen Beloff, MSN, RN, APN, executive director of Quality and Safety at Brigham and Women’s Hospital, looks at how we use continuous quality improvement to identify and solve program and process challenges.

February 1, 2019

If you are working in a health care setting, you’ve undoubtedly heard of the term “Continuous Quality Improvement (CQI)” to describe the process of systematically identifying, delineating and analyzing a quality or safety problem, testing, implementing and learning from the process, and then repeating the process.

It’s a bit like the movie “Groundhog Day,” where Phil Connors, played by Bill Murray, repeatedly relives the same day, known as Groundhog Day, turning moments of monotony and at times hopelessness into opportunities for enlightenment and decisive action.

Despite being stuck in a perpetual time loop, Phil continuously learns from his daily observations and associated outcomes, and adapts his behavior and processes, sometimes leading to a different and often more positive outcome the next day.

The same can be said of introducing successful quality and safety improvement initiatives in health care. Creating a shared need and vision, gaining stakeholder support and implementing and sustaining improvement initiatives can often feel like you are waking up every morning in a perpetual time loop. This is partially because most quality and safety improvement initiatives will not be solved with one fix. Designing for continuous improvement and success means your work is never done. Some interventions simply won’t work, and that is perfectly OK.

Take, for example, Catheter-associated Urinary Tract Infection (CAUTI) prevention. In 2009, Brigham leadership and care providers formed a multidisciplinary taskforce charged with reducing the rate of infections related to urinary catheter devices. Over the last decade, the taskforce has implemented close to 50 interventions, such as back-to-basics education and the development of clinical-decision support. Some interventions were more successful than others, like eliminating yeast from the CAUTI definition and cancelling urine cultures for those patients with a negative urinalysis.

Just as Phil eventually learns to incorporate the knowledge gleaned from one day into the next, so too can quality improvement leaders. We strive to transform the monotonous and sometimes frustrating moments of quality and safety program implementation into moments of ingenuity and innovation, ultimately leading to better patient outcomes and experiences.

As I compare the 2009 and 2019 CAUTI Taskforce improvement plans, I can’t help but reflect on the fact that many of the initiatives are eerily similar. However, like Phil, I also know that tomorrow is a new day and that we will apply the lessons and successes of the past 10 years to advance the cycle of continuous quality improvement. Our CAUTI standardized infection rate at the Brigham is down 34 percent since we first started publicly reporting it in 2012 and I know through our efforts we will continue to improve.

 

-Jen Beloff, MSN, RN, APN, executive director, Quality and Safety

 

Reference:

“Groundhog Day.” Directed by Harold Ramos et al., Columbia Tri Star Home Video, 2002.

Scientific Update: Hand Hygiene

January 15, 2019

At Brigham and Women’s Hospital, we are fortunate to have unparalleled access to some of the best health care researchers in the world. Our quality and safety initiatives often involve top researchers, who not only help us design and evaluate our initiatives but keep us updated with the latest discoveries and inventions that are transforming health care. In this blog post, we highlight some of these latest research findings about hand hygiene.

According to the Centers for Disease Control and Prevention and the World Health Organization, performing improper hand hygiene is one of the main drivers for hospital-acquired infections. It is no surprise that Brigham and Women’s Hospital, like many other leading health care institutions in the nation, dedicates significant resources to measure hand hygiene compliance among staff and develop ways to improve it.

There are two major barriers to improving hand hygiene compliance: knowing how to encourage the correct behavior and measuring that the said behavior is working.

Here are a few examples of recent research related to hand hygiene:

 

-Hojjat Salmasian, MD, PhD, medical director, Data Science and Analytics

Sound the Alarm – Or Perhaps Not

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If you live or work in a city, you’re likely used to the everyday sounds of car horns honking, jackhammers drilling, sirens ringing and trains rumbling. If you’re like me, you may have developed the ability to tune out these noises without even knowing it. So how do we know which sounds we really need to pay attention to?

That’s the question being asked in hospitals. With so many audible alarms on patient units, clinicians can become desensitized and fail to respond when an emergency arises. And the constant noise of alarms certainly doesn’t make for a restful patient experience either.

In 2015, we found that up to 490 unique alarms sounded per patient bed per day in certain units at the Brigham. That’s roughly 20 alarms per hour. About 75 percent of them were non-critical.

To address this, we conducted a six-month pilot to reduce the number of audible alarms and ensure that alarms indicating an urgent medical need would be heard.

Here are a few examples of the changes we made:

  • Widened the parameters for the high and low heart rate alarm settings to decrease the number of alarms that do not require action from a care provider.
  • Tailored alarms to the needs of each patient care unit. For example, the needs of patients in the Medical Intensive Care Unit are very different from the needs of postpartum patients, and the alarms have been programmed accordingly.
  • Implemented nursing practice changes to reduce alarms caused by poor contact of the monitor with the patient’s skin, such as the monitors that measure oxygen levels or record the electrical activity of the heart.

These efforts resulted in a 70 percent reduction of alarms across the hospital, which made the hospital safer by improving the care team’s ability to hear critical alarms and increased patient satisfaction as well.

Since then, we have heard from providers who said the units were significantly less noisy, allowing them to hear the alarms sounding for a critically-important condition. Patients reported improved satisfaction due to fewer noises, less stress about what the alarms meant and fewer interruptions.

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