Leadership in nursing Discussion

Reprinted with permission from Journal of Nursing Care Quality, 2012;27(2):99-108. J Nurs Care Qual Vol. 27, No. 2, pp. 99–108 c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright  Using the Agency for Healthcare Research and Quality Patient Safety Indicators for Targeting Nursing Quality Improvement Patricia A. Zrelak, PhD, RN, NEA-BC, CNRN; Garth H. Utter, MD, MSc; Banafsheh Sadeghi, PhD, MD; Joanne Cuny, MBA, RN; Ruth Baron, BScN, RN; Patrick S. Romano, MD, MPH Quantifying the critical impact nurses have on the prevention and early recognition of potential complications and adverse events, such as those identified by the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSI), is becoming increasingly important. In this paper, we describe how the AHRQ PSI may be used to identify nursing-specific opportunities to improve care based on data from the national AHRQ PSI validation pilot project. Key words: administrative data, adverse event, central line–related bloodstream infection, deep vein thrombosis, hospital-acquired conditions, nursing-sensitive indicator, patient safety indicator, postoperative respiratory failure, pressure ulcer, quality improvement, sepsis T HE AGENCY for Healthcare Research and Quality (AHRQ) patient safety indicators (PSI) are a set of hospitalization quality indicators that take advantage of readily avail- Author Affiliations: Center for Healthcare Policy and Research (Drs Zrelak, Utter, and Romano and Ms Baron), University of California, Davis; Departments of Surgery (Dr Utter), Internal Medicine (Drs Sadeghi and Romano), and Pediatrics (Dr Romano); and Physician Consortium for Performance Improvement Measure Testing and Quality Improvement (Ms Cuny), American Medical Association, Chicago, Illinois. Supported by the US Agency for Healthcare Research and Quality contract 290-04-0020. The authors declare no conflict of interest. Correspondence: Patricia A. Zrelak, PhD, RN, Center for Healthcare Policy and Research, UC Davis Medical Center, 2103 Stockton Blvd, Ste 2224, Sacramento, CA 95817 (pazrelak@ucdavis.edu). Accepted for publication September 10, 2011. Published online before print: November 2, 2011. DOI: 10.1097/NCQ.0b013e318237e0e3 able administrative data.1 The PSIs identify 18 potentially preventable adverse events and complications that patients may experience through contact with the health care system. Leadership in nursing Discussion

Events identified by the PSIs collectively impart a picture of patient safety within a hospital and may represent occurrences amenable to system-level change. Medical records identified as having a PSI of interest may then be reviewed for opportunities for improvement, such as issues related to nursing care. OBJECTIVE The aim of this article is to evaluate opportunities for improving nursing care related to the AHRQ PSIs identified through detailed review of a national sample of medical records of patients identified as having at least 1 event of interest, as part of the AHRQ PSI validation pilot project and a related collaboration with the University 99 JONA • Vol. 43, No. 10 • October Supplement 2013 S51 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 100 JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2012 HealthSystem Consortium (UHC). Information about the accuracy (criterion validity) of the PSIs, based on the same review process, has been published elsewhere.2-5 METHODS This study was approved by the federal Office of Management and Budget and by the institutional review board at the University of California, Davis. University HealthSystem Consortium provided permission to use data submitted by member organizations. Data collection procedures complied with the Health Insurance Portability and Accountability Act Privacy Rule provisions for disclosure of protected health information without subject authorization to a public health authority [45 CFR 164.512(b)]. Participating hospitals This was a retrospective, multifacility, cross-sectional chart abstraction study. Two groups of hospitals participated. The first group consisted of 47 nonfederal hospitals, representing 29 states and various hospital types, that responded to a call for volunteers through the AHRQ Quality Indicator technical support listserve. These hospitals reviewed records that met criteria for PSI 13 (postoperative sepsis) or PSI 7 (selected infections due to medical care; now known as central line–related bloodstream infection or CLRBSI).4,5 The second group included 34 academic medical centers affiliated with UHC, identified through the UHC listserve. Their staff reviewed medical records meeting criteria for PSI 12 (postoperative deep vein thrombosis or pulmonary embolus or DVT/PE); PSI 11 (postoperative respiratory failure); and/or PSI 3 (decubitus ulcer; now known as pressure ulcer).2,3 Instrument development Evidence-based data abstraction instruments and corresponding guidelines, available at http://qualityindicators.AHRQ.gov/ validationpilot.aspx, were developed by study investigators based on a literature review S52 and input from national experts. Group 1 instruments were pretested at hospitals in Sacramento, California. Final abstraction tools included questions about demographic characteristics, verification of the reported events, patient-level risk factors, preventive measures, evaluation and treatment, and patient outcomes. Instruments used by group 2 were developed similarly, except a national steering committee was formed for each PSI, and pretesting occurred within UHC. Data collection Group 1 hospitals applied a modified version of the AHRQ PSI Windows software version 3.1 (March 12, 2007), provided by the authors, to extract concurrent probability samples of records that met criteria for each PSIs under study between October 1, 2005, to March 31, 2007. Leadership in nursing Discussion

Sampling targets included 240 cases nationally and 30 cases per hospital for each PSI. The overall number of abstracted records often fell short of the target because some hospitals had no qualifying or retrievable cases. For group 2, the UHC coordinating center, using the public use version of the same AHRQ software, prepared the sample list for each study hospital with targets ranging between 30 and 60 cases per PSI per facility. For both groups, if after answering an initial set of questions, the patient did not appear to qualify for the targeted PSI event, the abstractor was allowed to exit the abstraction process. Criteria for each PSI are defined in the AHRQ PSI Technical Specifications (currently available at http:// www.qualityindicators.AHRQ.gov/Modules/ PSI_TechSpec.aspx).1 Abstractors for each group were trained via Web-based teleconferences. Group 1 abstractors used a paper tool, which was submitted to study staff for data entry. Group 2 entered their data into an online database. Ongoing support was provided by e-mail, listserve, and telephone. Statistical analysis SAS, version 9.1 (Cary, North Carolina), was used to perform descriptive analyses. Proportions were calculated for categorical data and JONA • Vol. 43, No. 10 • October Supplement 2013 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Using AHRQ PSI for Targeting Nursing Quality Improvement averages for continuous data. Only records found to have the PSI of event of interest were included in the results. RESULTS Participating hospitals reviewed a total of 2293 PSI events. Cases per indicator are as follows: CLABSI (n = 130), sepsis (n = 67), respiratory failure (n = 548), DVT/PE (n = 314), and hospital-acquired pressure ulcers (HAPU) (n = 1234).2-5 Central line–related blood stream infection At the time of the study, this indicator included all vascular device types, although most confirmed events were related to central venous catheters (CVC) (n = 72), followed by peripheral intravenous (n = 13) and arterial lines (n = 3). Peripherally inserted central catheters represented 30% of the infected nontunneled CVCs. For short-term nontunneled CVCs, the internal jugular site was responsible for 34% of the events followed by the subclavian (25%) and femoral (11%) sites. Femoral catheters had the shortest mean time to infection (5.7 ± 3.4 days) compared to internal jugular (10.0 ± 6.1 days) and subclavian lines (11.7 ± 8.4). Abstractors were frequently unable to find documentation of line type (peripheral vs central) (n = 24), CVC insertion site (n = 12), and CVC insertion or removal dates (n = 12). Total parenteral nutrition was used in 29 (36%) cases. Abstractors found no documentation regarding the presence or absence of symptoms in 73 cases. Postoperative deep vein thrombosis/pulmonary embolus This PSI targets surgical cases that develop a postoperative DVT or PE. Leadership in nursing Discussion

Only 42% of the surgical cases received American College of Chest Physicians guideline–directed venous thromboembolism prophylaxis before or on the day of surgery.6 The elapsed time from documentation of clinical signs of DVT and/or PE (eg, leg swelling, tenderness, or a palpable venous cord for DVT; new dyspnea, chest JONA • Vol. 43, No. 10 • October Supplement 2013 101 pain, or oxygen desaturation for PE) to the diagnosis or diagnostic evaluation was greater than 1 day in 21% of DVT and 17% of PE cases. The initiation of treatment was delayed, defined as greater than 1 day from diagnosis, in 20% of DVT and 17% of PE cases. Postoperative sepsis This PSI targets previously uninfected patients who develop sepsis after an elective surgical procedure. In a large number of cases (n = 28; 17%), the abstractor was unable to identify bacteremia, septicemia, sepsis, or systemic inflammatory response syndrome from the medical record and in some cases, may have incorrectly assumed that sepsis was absent based on “negative blood cultures” alone (according to their abstraction notes). When hair removal is necessary, clipping and depilatory creams have been found to result in fewer surgical site infections when compared to razors.7,8 Among the 67 confirmed cases, only 12 cases had documented hair removal, and razors were used in 3 cases (25%). Preoperative intravenous (IV) antimicrobial prophylaxis should be given within 1 hour of incision to maximize tissue concentration (2 hours are allowed for vancomycin and fluoroquinolones).9,10 In all but 3 cases in which antibiotics were ordered, administration of the antibiotic occurred within 1 hour of the operative start time. In each of these cases, antibiotics were administered within 15-minutes of the 1-hour standard. Pneumonia (54%), CLABSI (46%), and urinary tract infections (12%) were the most common infections (not mutually exclusive) associated with the septic episode. Optimal antimicrobial prophylaxis (defined as antimicrobials administered within 1 hour of surgery and stopped within 24 hours of incision time) occurred in 77% in those with urinary tract infections, 83% of those with surgical site infections, 88% of those with CLRBSI, and 100% of those with pneumonia.11,12 Perioperative hypothermia (temperature < 96.8◦ F) has been associated with increased risk of infection and sepsis.8,10 Among confirmed cases of sepsis, 7 of 31 and 11 of 32 had a S53 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 102 JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2012 temperature lower than 96.8◦ F in the operating room and postanesthesia care unit, respectively. In 11.8% of cases, the abstractor was unable to find a recorded intraoperative temperature, and in 17.6% of cases, the abstractor reported use of a different temperature scale between perioperative care settings. Postoperative respiratory failure This PSI is intended to capture cases of respiratory failure following an elective operation. General anesthesia was associated with 787 of the 834 procedures (94.4%) performed in the 548 records with at least 1 episode of postoperative respiratory failure. More than three-fourths (80.2%) of study patients developed respiratory failure within the first week after surgery, with 22.5% reintubated on the same day as surgery. The most common reasons for postoperative reintubation were hypoxemia, hypoventilation, and/or hypercapnia (69.8%), followed by airway protection (20.5%). Of 834 procedures evaluated, explicit documentation of preoperative oxygen saturation was missing in 287 cases (34.4%), although 80.6% of cases had an American Society of Anesthesiologists physical status classification of III or IV (indicating severe systemic disease). In 323 procedures (38.7%), there was no documentation of a PaO2 < 60 mm Hg or a PaCO2 > 45 mm Hg at any time in the postoperative period. For patients who had a postoperative PaO2 < 60 mm Hg, the median time from the end of the surgical procedure to the first postoperative event was 50 hours (range; 10 minutes to 42.1 days). Leadership in nursing Discussion

 For patients who presented postoperatively with a PaCO2 > 45 mm Hg, the median time to the first postoperative event was 20 hours (range, 7 minutes to 42.1 days). An order or protocol for breathing exercises was not apparent in 31% of cases. Pressure ulcer This measure targets HAPU; it excludes patients with a length of stay of 4 days or less, pa- S54 tients admitted from nursing homes and other acute care facilities, and patients who are particularly susceptible to pressure ulcers due to paralytic conditions. Of the 1234 confirmed HAPU cases, we found that 96.5% had a skin assessment and 80.9% had PU risk assessment completed on the date of or the date following admission. There were 152 HAPU cases with an emergency department (ED) length of stay greater than 24 hours, of which 80.9% had documentation of a first skin assessment completed prior to ED departure. For cases admitted to a preoperative holding area for greater than 24 hours prior to admission, 87.2% had a first skin assessment before departure to another inpatient unit. Twenty-five percent of HAPU cases were not assessed for pressure ulcer risk within the 2 days prior to the diagnosis. Only 3.6% (median hospital performance) of HAPU cases included documentation of the location, dimensions, exudate, and site when the ulcer was first recognized, and only 3.5% (median hospital performance) of cases had these characteristics documented at discharge. Staging, which is important for deciding on nursing interventions and treatment, was initially documented in 64.3% of HAPU cases (including ulcers documented as stages 1-4 or unstageable). Stage 3, 4, and unstageable ulcers represented 20.1% of HAPU cases on diagnosis. Only 13.3% of new HAPUs were stage 1 when first recognized. Physicians documented the presence of a HAPU in less 50% of all cases. Staging was documented in 58% (496/850) of HAPU cases at discharge. Height or weight was missing from 20.6% of HAPU cases, despite a median length of stay of 26 days (range, 5-319). Excluding ambulatory patients, those with a Braden score greater than 18 (low risk), or those with a documented contraindication to turning, less than half (49.1%) of bed-bound patients were turned or repositioned at least every 2 hours in the 2 days prior to being diagnosed with a HAPU, although most (61.5%) were located in an intensive care unit on the day of diagnosis. JONA • Vol. 43, No. 10 • October Supplement 2013 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Using AHRQ PSI for Targeting Nursing Quality Improvement DISCUSSION Potential nursing opportunities to improve care relevant to the AHRQ PSIs are 103 summarized in the Table. Common trends across indicators were lack of documentation of an accurate and timely patient assessment, lack of adherence to national Table. Summary of Potential Nursing Opportunities as Identified From AHRQ Patient Safety Indicator Pilot Project Patient Safety Indicator Central line–related blood stream infection (CLRBSI) Postoperative deep vein thrombosis or pulmonary embolus (DVT/PE) Postoperative sepsis Postoperative respiratory failure Nursing Opportunities Improve site selection to avoid the femoral vein for central venous catheter placement (if possible). Evaluate opportunities to reduce infection related to total parenteral nutrition. Improve documentation of catheter type, insertion site, insertion date and time, and removal date and time. Document reasons for catheter placement, ongoing need, and removal. Provide nursing education related to identification and documentation of signs and symptoms of CLRBSI and associated interventions. Use AHRQ patient safety indicators to monitor CLRBSI in all acute care units (not restricted to the intensive care unit). Provide timely implementation of American College of Chest Physicians directed guidelines for prevention of DVT/PE. Improve processes of care related to improved recognition of PE/DVT (eg, leg swelling, tenderness, and/or palpable venous cord and new dyspnea, chest pain, and acute oxygen desaturation). Improve processes of care to facilitate earlier treatment of PE/DVT. Evaluate opportunities to use alternative to razors, such as clippers or depilatory agents, when hair removal is necessary. Leadership in nursing Discussion

Administer preoperative IV antimicrobial prophylaxis within 1 hour of incision time to maximize tissue concentration (2 hours are allowed for the administration of vancomycin and fluoroquinolones). Improve perioperative temperature management to include use of the same measurement scale between hospital units (Celsius or Fahrenheit, but not both) and achievement of normothermia as appropriate for individual surgery (eg, temperature >36.0 C following colorectal surgery). Evaluate opportunities to improve early recognition of sepsis and implementation of early goal directed therapy. Evaluate further opportunities to prevent infection of lungs, blood stream, urinary tract, and surgical site. Employ strategies to reduce postoperative pulmonary complications in patients with the following risk factors: poor ASA status, general (vs regional) anesthesia, prolonged duration of anesthesia (>2 hours), and abdominal, renal, urologic, orthopedic, or emergency surgery. Improve documentation of preoperative and postoperative respiratory assessments to include oxygen saturation/pulse oximetry. Evaluate opportunities to reduce incidence of postoperative respiratory failure such as protocols to increase incentive spiratory use and breathing exercises. Review opportunities to prevent other complications and earlier recognition of impending respiratory failure. (continues) JONA • Vol. 43, No. 10 • October Supplement 2013 S55 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 104 JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2012 Table. Summary of Potential Nursing Opportunities as Identified From AHRQ Patient Safety Indicator Pilot Project (Continued) Patient Safety Indicator Pressure ulcer (PU) Nursing Opportunities Accurately assess for and document PU present on admission. Increase frequency and accuracy of skin and PU risk assessments. Increase number of patients assessed for skin or PU risk in pre-hospital holding areas and in emergency department. Include height, weight, and nutrition as part of initial and ongoing assessments for skin, PU risk, and PU. Aim for earlier recognition of PU and improve on completeness of PU assessments including PU stage. Take proactive measures to prevent PU such as turning and repositioning patients, especially in high risk patients. Take steps to ensure that physicians are aware of their patients’ PU risk and status. Abbreviation: ASA, American Society of Anesthesiologists. standard … Leadership in nursing Discussion