Removing Unnecessary Contact Isolation Precautions

Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium that can be transmitted via skin-to-skin contact and may cause severe infections.  BMC has a policy to place MRSA-colonized patients on contact isolation precautions.  An estimated 15-30% of colonized patients clear within 90 days giving us the opportunity to reduce the need for private rooms, improve staff and patient satisfaction by reducing need for protective gear, minimize “isolation precaution fatigue”, and save an estimated $6.4 million/year by removing unnecessary MRSA precautions.

Eligible MRSA positive adults for rescreening are those:

1. With no positive MRSA PCR or culture in the prior 90 days, and
2. Who do not have an active antibiotic order.

A Best Practice Advisory Logic has been introduced to Admission Order Sets to facilitate removal MRSA precautions in eligible patients.  This logic looks at patients  previously identified as MRSA positive to begin a re-screening process at admission.  The order is two-step testing, once on the day of the order and the second 48 hrs later if the first test is negative.

If both screens/cultures come back negative, please e-mail DG-Infection Prevention and isolation precautions will be removed.

PLEASE ONLY DE-SELECT ORDERS if patient is currently on antibiotics.

Resident Corner Fall ’19

STARS Candy Rounds by Swetha Ramachandran, MD and the QIPS Residents

As part of the internal medicine residency program at BMC, there is a Quality Improvement and Patient Safety (QIPS) pathway for residents who are interested in identifying patient safety issues and improving outcomes using quality improvement methodologies. This year the residents in the QIPS pathway are working to promote resident participation in quality improvement initiatives.

To achieve this goal, we have started weekly patient safety rounds where a QIPS resident will touch base with medicine teams in person to inquire about patient safety issues that the teams have encountered in the hospital. With these weekly rounds, we hope to increase resident STARS reporting and patient safety awareness.

Additionally, each week a STARS report will be reviewed by a QIPS resident with the aim of improving recurrent systems issues as well as providing feedback to the reporting provider. As a group, the QIPS pathwa

y residents are excited and motivated to make changes that will improve patient care and streamline hospital processes.

BMC Joins the Age-Friendly Health System Community

To better support older adults and improve their health outcomes, health systems must put in place comprehensive, coordinated evidenced-based models that better deliver care to the growing aging population.

In September 2018, BMC joined John A. Hartford Foundation-Institute for Healthcare Improvement’s (IHI) Age-Friendly Health System Community in spreading age-friendly care with the goal of reaching 1,000 US hospitals and 1,000 medical practices by December 2020.

BMC is working towards a comprehensive approach to implementing best practices under the 4Ms (What Matters, Medication, Mentation, and Mobility) for each patient 65+ admitted to the hospital.

BMC is well on its way to becoming an Age-Friendly Health System!

Success of New Hyperglycemia Crisis Management Guideline

In AY2018 the Endocrine Subcommittee of the Pharmacy and Therapeutics Committee rolled out changes to the longstanding BMC Hyperglycemic Crisis Management Guideline, which had been in use for more than a decade.  A QI project done the prior year had shown higher rates of hypoglycemia (blood glucose (BG) <70) in patients after up-titration of the insulin infusion drip, in particular to doses of >0.14 unit/kg/hour of insulin.  These patients had a 3-fold higher rate of hypoglycemia, and in 60% of patients treated at this dose needed to have the drip stopped to prevent hypoglycemia (Figure 1).

Led by Dr. Sara Alexanian the Director of Inpatient Diabetes Program and Quality Leader in the Section of Endocrinology, a multidisciplinary group including en

docrine, pharmacy, nursing and IT came together to create an updated guideline.  The process included reviewing  primary literature supporting current hyperglycemic crisis management, review of national standards as well as protocols at outside institutions.  Based on this review a new guideline was developed.  Major changes included:

1. Removal of default increases in the insulin infusion rate, and
2. An updated insulin titration algorithm based on solid published evidence.

Subsequently there were several months of ED and ICU nursing education, including - in-services by endocrine and pharmacy, as well as a required Health Stream course.   The new guideline was rolled out in September 2019.

Three months after the release of the new guideline, a chart review was done on the 40 patients who were treated with the new algorithm compared to 35 patients on the prior protocol. There was a 60% reduction in hypoglycemia (26% on the prior protocol down to 10% on the new protocol, Table 1).  Furthermore the total episodes of hypoglycemia decreased with the new protocol, as did the number of times the drip needed to be stopped to prevent hypoglycemia.  Further analysis showed that despite the lower rates of hypoglycemia, there was no significant increase in the time to DKA resolution.

The multidisciplinary  workgroup continues to engage with nursing to improve the guideline.  Based on feedback, new changes include making minor adjustments to the insulin titration algorithm and making the transition to dextrose-containing fluids a default in the order set to ease nursing work-flow.  Furthermore, when substantial discrepancies occur between the ED and ICU weights, the nurse will be prompted to adjust the infusion dose appropriately for weight obtained on admission to the ICU. These changes are expected to go live in the fall 2019 with the hope of reducing hypoglycemic events further!