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Quality Improvement Report Through September 30, 2012Lieberman Center for Health and Rehabilitation

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INTRODUCTIONWe are pleased to present the following Quality Improvement report for Lieberman Center for Health and Rehabilitation (LCHR). We have compiled data through the third quarter of 2012 for our Sub-Acute Unit (Haag Pavilion), Long Term Care Units, and Whole House. Included are outcomes directly related to patient care.

SUb-ACUTe HIgHlIgHTSSub-Acute RAteSIn the Sub-Acute Unit, emphasis is placed on rehabilitation. This requires a team approach with all disci-plines. Nursing provides hands-on care, skilled infusion administration, skilled treatments and monitoring of condition, along with communication with the patient’s physician and coordination of interdisciplinary interventions. Social Services staff works with the individuals and their families to achieve a successful dis-charge. This process is initiated at admission and evolves through the stay of the patient, providing emo-tional and psychological support and assistance in arranging for needed services at the time of discharge.

Rehabilitation OutcomesThe Therapy Department works primarily on the patient’s functional status. Efforts are directed at increasing strength, endurance, and balance. The three prime areas that are measured are transferring/toileting; dressing; and ambula-tion. This data is then used to determine the patients’ overall outcomes for improvement in functional ability.

The previous chart shows the overall outcomes for 2011 through the third quarter of 2012. The initial data point on the chart is the patient’s pre-morbid state, or how the patient functioned prior to his/her recent illness. It is a self reported parameter and is determined through interview with the patient and/or the pa-tient’s family/significant other. The second data point is determined by the skilled therapist at the time of the initial assessment which is performed within 24 hours of admission. The final data point is also deter-mined by the skilled therapist at the time of discharge from the therapy program. Note that the patient’s status is measured with the standardized functional tool of a scale of 0 to 7, with 0 = most dependent and 7 = independent. The average overall improved functional ability was 1 to 2 points on this scale.

Overall Rehabilitation Outcomes 2011 through the Third Quarter of 2012

1st Quarter 2011 2nd Quarter 2011 3rd Quarter 2011 4th Quarter 2011 1st Quarter 2012 2nd Quarter 2012 3rd Quarter 2012

Avg. Overall Pre-Morbid***

*** This is a subjective measure, based on the patients’ report of their functional ability prior to entering the hospital.

Avg. Overall at Admit Avg. Overall at Discharge

0

1

2

33 3 3 3 3

44 4

55 5 5 5 5 5

66 6 6 6 6 6 6

7

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Rehospitalizations of Sub-Acute Patients2011 was the first year that the rate of hospital readmissions from the Sub-Acute Unit was tracked. Initially the tracking was done for readmissions that occurred within 72 hours of admission to Lieberman. It was subsequently determined that the rate for readmissions within 30 days of admission to Lieberman should also be tracked. This process was started in July of 2011. These rates will take on increasing importance as a benchmark for improving quality of care and communication between health care providers, and will also play an important role in reimbursement.

In the first quarter of 2011 the average rate for re-hospitalizations from the sub-acute unit occurring within 72 hours of admission was 18 percent. This rate was reduced significantly throughout the year and at year’s end the average rate for the whole year was 11 percent. This improved trend has continued in 2012. The average rate through the third quarter of 2012 is 3 percent.

Per Cent of All Admissions to LCHR Sub-Acute Unit from a Hospital who are Readmitted to a Hospital within 72 Hours

Oct. 11 Nov. 11 Dec. 11 Jan. 12 Feb. 12 Mar. 12 Apr. 12 May. 12 June. 12 July. 12 Aug. 12 Sept. 12 Oct. 120

10%

20%

30%

40%

3%0%

7%

0%3%

7%

0%5%

6% 8%

0% 0%3%

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Several initiatives that have been implemented and are now a part of operations contribute to the im-proved trend. One is increased collaboration and communication among nurses, therapy staff, the nurse practitioner and the physiatrist on the Sub-Acute Unit team; another is the implementation of a more thor-ough screening prior to admission that makes it more likely that the patient is more stable clinically and is appropriate for admission to sub-acute level of care.

As stated above the data for readmission within 30 days was not collected until the last half of 2011. Be-low is a chart showing the 2011 data and the data for the first three quarters of 2012: • Theaveragereadmissionrateforthelastsixmonthsof2011was18%.• Throughthethirdquarterof2012theaveragerateis19%.• Theaveragerateforthe30dayreadmissionratenationallyforMedicarespecificbenefitis21.04%,as

reported by the Illinois Quality Improvement Organization.

Per Cent of All Admissions To LCHR Sub-Acute Unit from a Hospital who are Readmitted to a Hospital within 30 Days

10%16%

26%18%

28% 28%

15%10%

26% 25%

16%

4% 3%

0

20%

40%

60%

80%

100%

Oct. 11 Nov. 11 Dec. 11 Jan. 12 Feb. 12 Mar. 12 Apr. 12 May. 12 June. 12 July. 12 Aug. 12 Sept. 12 Oct. 12

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long-Term Care Readmission RatesIn reviewing the data used to calculate these rates, the following facts were identified. In the 10 months that were reviewed there were 20 readmissions to the hospital that occurred within 30 days. Of those 20, 11 were attributed to patients who were readmitted more than once. In all but one case, each of these patients hadaconditionthatwasirreversibleandalsoverysubjecttoacuteexacerbations.Thedecisiontocontinueaggressive treatment in these situations was due to religious tenets, cultural beliefs, and lack of understand-ing of clinical issues regarding an emotionally charged issue. LCHR continues to provide pastoral and social service counseling in conjunction with clinical education in an environment that respects the values of the patient and family. It is thought that in some situations this may influence the decisions regarding aggressive treatment in irreversible conditions; however, ethics demands that each patient/family have the ability to make their own autonomous decision. The Illinois Readmission rate for Medicare and Medicaid combined is 23.76%asreportedbytheIllinoisQualityImprovementOrganization.

WHOle HOUSe, lONg-TeRM CARe AND SUb-ACUTe DATAHeALtH SeRVIceS (NuRSING) RAteSIn the health services area, Lieberman Center for Health and Rehabilitation has concentrated on improv-ing outcomes in the following clinical areas: falls, major and minor injuries associated with falls, and house-acquired pressure ulcers. These areas were chosen because they are important indicators of quality of care and they pose potential regulatory and/or liability risks.

In mid-2006, systems were initiated for data collection and subsequent analysis of that data. This data was in turn translated into rates displayed on control charts. This first set of data was used as a baseline to determine if initiatives that were developed and implemented were achieving the desired results. This system also provided feedback that allowed appropriate alterations to be made when deemed necessary.

Lieberman Health & Rehabilitation 30 Day Rehospitalization Rate for Long-Term Care Residents

0

20%

40%

60%

80%

100%

13%

25%17%

22%

11%17%

9% 7%

19%9%

Jan. 12 Feb. 12 Mar. 12 Apr. 12 May. 12 June. 12 July. 12 Aug. 12 Sept. 12 Oct. 12

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FallsThe fall rate is calculated per 1000 patient days. A stringent criterion of how falls are counted has been employed. Forexample,ifanindividualis“eased”tothefloor,thatsituationisconsideredafall.Moreindepthinvestigationhas identified a number of challenges associated with Lieberman’s fall rates. These are: The facility’s strict restraint-freepolicy;thefacilityagedemographics--30%oftheresidentsarebetweentheagesof75to84,and40%are85 years old or older; and the acute confusional delirium often associated with hospitalization and transition to a sub-acuteunit.(Prevalenceofdeliriumpresentonadmissiontoacutecareis10%to15%¹and31%inICU².)Theincidencerateofnewonsetinacutecareis10%to40%,inpost-hipsurgery43%to61%and83%inmechanicallyventilated patients³. This tracking method enabled staff to note early on an increase in the fall rate in 2007, and a 3-step intervention process was quickly developed to curb this rise: Step one is increased education and aware-ness of front line staff; step two is aggressive investigation in trying to identify the root cause of each and every fall; and step three is the interdisciplinary development of interventions to address these causes. This process is implemented for each fall in an interdisciplinary team meeting five days a week. This has resulted in a decreasing trend in falls.

¹Fann,J.R.(2000).Theepidemiologyofdelirium:Areviewofstudiesandmethodologicalissues.Seminarsin Clinical Neuropsychiatry, 5, 64-74.²McNicoll,L.Piasani,M.A.,EtAl(2003)Deliriumintheintensivecareunit:Occurrenceandclinicalcourseinolderpatients.JournaloftheAmericanGeriatricsSociety,51,591-598.³Ely, E.W., Inouye, S.K., Et Al (2001).Delirium in mechanically ventilated patients: Validity and reliability of the confusion assessment method for the intensive care unit. Journal of the American Medical Associa-tion, 286, 2703-2710.

ThenextgraphillustrateshowthefluctuationintheSub-AcuteUnit’srateimpactstheWholeHouserate.Overall, the fall rate for Long-Term Care floors as a unit continues on a downward trend.

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2

4

6

8

10

12

14

16

18

20

12.5

15.814.1

10

6.16.9 7.3

10.3

6.5

9.7

5.2 5.3

7.8 8.3 8.17

5.8 6

Annual Mean Rate for Falls from 2007 through Third Quarter 2012

Rate per 1000 Patient Days

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Fall-related InjuriesThe major reasons for tracking these statistics are two-fold: 1) fall-related injuries are a serious health issue for the elderly population; and 2) they are an indication of the effectiveness of patient-specific fall preven-tion interventions that reduce risk and prevent/minimize falls and fall-related injuries. Injuries are first clas-sified as either major (e.g. fracture, subdural hematoma) or minor (e.g. bruise, skin tear). Note that the injury rate is calculated per 100 falls and the fall rate is calculated per 1, 000 patient days. The fall interven-tions that are being used appear to be reducing not only the falls but also the severity of resultant injuries, as evidenced by comparison of current rates to rates from previous years. The rate for minor injuries has increased, but the rate for major injuries has continued to decrease.

The current outcomes show that not only is the fall rate decreasing, but there is also a decrease in the severity of injuries resulting from falls. The graph below shows the trend of injuries, both major and minor, for the Whole House.

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2.5 2.6 2.20.4

10.6 10.6

2.9

11.5

9

7

12.714.8

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2

4

6

8

10

12

14

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Annual Mean Rate of Major & Minor Injury from June 2006 through 2011

Rate per 1000 Patient Days

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House-Acquired Pressure Ulcers Lieberman’s skincare policies include an ongoing in-service program on skin/wound management that involves the entire interdisciplinary team. In addition to the preventive measures that are in place, there is a wound care formulary, with treatment protocols including pain management, that have been very effective in wound management. A board certified podiatric surgeon and a wound specialty surgeon are on staff. They make weekly rounds and are active members of the wound management team. There is a process in place that allows for on-going analysis of outcomes that enables staff to take any necessary ac-tions to sustain and improve quality outcomes.

It has been Lieberman’s practice to count each pressure ulcer rather than each resident who has one or more pressure ulcers. This is a considerably stricter method of data collection as compared to the CMS Quality Measures that report a percent of residents with pressure ulcers. This methodology reflects the facility’s adherence to its patient-centered philosophy that assigns great importance to the prevention of pressure ulcers.Recent CMS literature has stated that the current methodology that is used by CMS will be changing and will reflect the methodology that is used at LCHR.

Thechartbelowshowsratetrendssince2006.Thehighestrateatanyonetimeoverthepastsixyearsis3.1 per 1000 patient days. The current year has been steadily trending downward. Note this is a preva-lence rate versus an incidence rate.

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1

2

3

4

2.8

2.8

1.8

3.1

2.1

1.31.4

3.12.4

1.5 1.8

.5

Annual Mean for Prevalence Rate for House Acquired Pressure Ulcers from 2007 through Third Quarter 2012

Rate per 1000 Patient Days

Note: Data is for each pressure ulcer, not each patient who acquired a pressure ulcer.

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INfectIoN coNtRoLHouse-Acquired InfectionsLieberman has used control charts for monitoring infection rates from a Whole House perspective since 2007.In2007theSub-AcuteUnitexpandedtoincludetheentirefourthfloor.Surveillanceactivitiesin2007 and 2008 suggested that there was an increased incidence of infection in the Sub-Acute Unit. This observation prompted the calculation and tracking of the nosocomial (house-acquired) rate for the Sub-Acute Unit and the Long-Term Care floors as a combined unit, as well as the Whole House. This was startedin2009.

With time and investigation into the various peaks shown in the rates, it was discovered that education was needed regarding identification of infections by the nursing staff on the units. The two prime areas for education were focused on the determination of why an antibiotic was prescribed to treat an infection orforprophylaxis,andtheutilizationofmorediscernmentwhendeterminingiftheinfectionmeetsthecriteria for house-acquired versus the infection being present on admission. This was of particular impor-tance in the Sub-Acute Unit.

The chart below shows the historical and current data.

Nosocomial Infection Rate

0123456789

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5.3

6.1

6.3 5.8 5.4

5.7

7.5

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87.5

5.76.6

7.88.9

Rate per 1000 Patient Days

Note: Method for Aggregating Data Evolved after 2008.

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House-Acquired Urinary Tract InfectionsSymptomaticurinarytractinfections(UTIs)arethemostcommoninfectionexperiencedbyresidentsofLong-Term Care facilities. Because of this, the nosocomial rates are tracked for each floor. It was not until aftertheSub-AcuteUnitwasexpandedtotheentirefourthfloorthattheUTIratefortheLong-TermCarefloors was calculated as one unit.

Overall the rates of both Long-Term Care floor and Sub-Acute Units have decreased and are fairly steady. Part of this is due to the discontinuation of routine follow up cultures after antibiotic treatment. This reflects current best practices as defined by CDC (Centers for Disease Control) and APIC (Association of Professions in Infection Control and Epidemiology, Inc.). Again this rate may have been a little lower if the identification of nosocomial UTIs on each unit, and specifically the STU, had been more discriminating in determining whether it was present on admission (i.e. presented with symptoms within 48 to 72 hours after admission) or if it truly was acquired at Lieberman.

Nosocomial UTI Rate

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3

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4.84.3

3.9 4.13.7

3.33 3.4

2.42.8

2.2 2.3

1.92.12.5

2.1

Rate per 1000 Patient Days

Note: Method for Aggregating Data Evolved after 2008.

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Multi-Drug Resistant Organisms The multi-drug resistant organisms (MDROs) that have been seen at Lieberman are Clostridium Difficile (C-Diff), Methicillin-Resistant Staphylococcus Aureus (MRSA), Vancomycin-Resistant Enterococcus (VRE) andExtendedSpectrumBetaLactamaseproducinggramnegativebacteria(ESBL).

In 2007 these specific organisms were tracked and control charts were used to determine the prevalence rate on each of the separate nursing units. After a full year’s data was aggregated it was determined that, because the rates were so low, the methodology of using point prevalence should be changed to period prevalence(usingonemonthastheperiod).Thiswasdonein2008.In2009,anotherslightchangewasmade in utilization of the data that was collected. Since the rates continued to remain very low for all of the Long Term Care floors, it was determined that it would be more informative to combine the numbers fortheseunitsforuseinacontrolchart.ThehigherprevalenceratesexistintheSub-AcuteUnitwiththemajority present on admission. Each unit’s infections are reviewed weekly and monthly so that if there is an increase in any one area, rapid investigation and interventions can be made.

Below is a graph of the annual mean for the prevalence rates per 1000 patient days for all MDROs for 2009throughthethirdquarterof2012fortheentirefacility. Asisevident,therehasbeenanincreaseintheoverallratefrom2009through2011andithasbeentrend-ing down in 2012. As stated above, this is most prevalent in the Sub-Acute Unit, where the majority of admissions occur. These admissions are primarily from the hospital. It’s important to note that the rates for the Long-Term Care floors have remained low, suggesting that appropriate measures have been taken topreventthespreadoftheseorganisms.Itisexpectedthattherewouldbesomeincreaseintherateinthese units due to the conversion of a proportion of the sub-acute patients to long-term care residents.

Multi-Drug Resistant Organisms (VRE, MRSA, ESBL, C-Diff) Annual Mean of Prevalence Rates

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3.3 3.6

4.3

2.6

1 0.81.4

0.9

0.70.90.40.7

Rate per 1000 Patient Days

(Period used = one month)

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For more information or to schedule a tour call847.929.3320 Lieberman Center for Health and Rehabilitation 9700GrossPointRoad Skokie, Illinois 60076 www.cje.net

CJE SeniorLife is a partner in serving our community, supported by the Jewish United Fund/Jewish Federation of Metropolitan Chicago. 12.2012.