Continuous Quality Improvement

Through Continuous Quality Improvement (CQI), we can measure, analyze and improve quality on a continuous basis. Middlesex Hospital chooses areas for CQI based on a number of factors, including a high volume of cases, high–risk cases, or those that may present specific problems.

CQI teams at Middlesex Hospital then identify areas where there are opportunities to improve care:

Safe Order Project

A collaborative effort involving Middlesex Hospital, its IRMA subsidiary, and Anthem Blue Cross/Blue Shield, this helps to decrease medication errors caused by misinterpretation of a physician’s order or by transcription of an incomplete or illegible order. Now, to qualify as a “safe order” all orders must contain the following information or meet the following criteria: date, time, legibility, name of drug written out with no abbreviations, dosage amounts and frequency, no abbreviation of “units” and no use of trailing decimals. This new policy requires that physicians review all medication orders with a registered nurse, a pharmacist or unit secretary.

Infection Reduction Initiative

Another collaboration with IRMA and Anthem Blue Cross/Blue Shield is to reduce the number of infections in hospitalized patients caused by resistant bacteria. The project focuses on excellence and diligence in hand–washing and isolation techniques as well as on reducing the number of central IV catheter line infections (and subsequent blood stream infections), by using better insertion techniques and more careful monitoring. The most recent outcomes of this project are displayed in the charts below.

Safe Medical Gas Use

Middlesex Hospital has performed an extensive proactive inventory and analysis of all medical gases used facility wide in order to ensure patient and staff safety.

Patient Identification Quality Improvement Team

This team ensures that patients are appropriately identified prior to any treatment or test; that all patients who should have an ID bracelet have it on; and that the information is accurate. Two forms of identification are used to verify the correct identity of each patient (for example, the patient’s name and medical record number which are listed on the patient’s identification bracelet).

Medical Abbreviations

In order to prevent medical errors due to improper or problematic medical abbreviations, a list of 17 unacceptable abbreviations NOT to be used in any written communication in the medical record was developed, based on the most common problematic abbreviations as published by the Institute for Safety in Medical Practices. These abbreviations cannot be used in any written communication in the medical record.

Pharmacy Intervention Program

Every medication order written by a physician is reviewed by a pharmacist. If the pharmacist identifies any problem with the order (for example, dose exceeds limit or serious drug interactions are present), the physician is contacted to correct the order. These occurrences are tracked over time for patterns or trends.

Medication Errors Per 10,000 Dispensed Doses

The medication error rate at Middlesex Hospital has historically been quite low, ranging from 1.1 to 1.7 errors for every 10,000 doses of medication given to patients. Still, Middlesex continuously strives to further decrease the chance that a medication error will occur. The Safe Order Project, initiated in April of 2003, has further reduced that rate. In calendar year 2003, there were only 0.7 errors per 10,000 medication doses given. This represents an approximate reduction of 50% to an already low number or errors.

Middlesex Hospital Central Line Related Bloodstream Infections Critical Care Unit

In 2002, there were 10 CCU central line related bloodstream infections and the infection rate was 5.7 infections/1000 device days. Between January and September 2003, there were three central line related bloodstream infections and the rate dropped to 2.2 infections/1000 device days.

Middlesex Hospital Peripherally Inserted Central Catheters (PICC) Related Bloodstream Infections Among All Patients

In 2002, there were 19 PICC related bloodstream infections and the infection rate was 4.0 infections/1000 device days. Between January and September 2003, there were five PICC related bloodstream infections, and the rate dropped to 1.5 infections/1000 device days.

Behavioral Health Unit

In response to the increase in severity of behavioral health patients’ conditions and the lack of long–term care facilities for these patients in Connecticut, areas being evaluated to improve safety include: the physical layout of the unit, criteria for appropriateness of admission to the unit, new policies and procedures for high–risk issues such as aggressive behavior and restraints. Outside consultants have been hired to analyze these and other issues, both on the unit and in the Hospital’s Emergency Department.

Pain Management

Middlesex Hospital has voluntarily participated in a nationwide Post–Operative Pain (POP) Management Quality Improvement Project. The primary goal of the project was to assist hospitals in improving the management of acute post-operative pain through the development of assessment standards, updated policies and procedures, staff and patient education regarding pain management and quality monitoring.

Six key quality indicators were the focus of the intervention, including:

• The intensity of pain is assessed and documented with a numeric or verbal descriptive rating scale
• Pain intensity is documented at frequent intervals
• Pain is treated by a route other than intramuscular
• Pain is treated with regularly scheduled medications
• A balanced approach is used to treat pain
• Pain is treated with non–pharmacologic interventions in addition to medications

The following are some highlights from the study results:

Method	Middlesex	Mean Score (for all hospitals in study
Charts with documentation of physician use of a numeric or descriptive scale for pain	69.9%	34%
Charts with documentation by an R.N.	99.3%	73%
Pain intensity is documented at frequent intervals. (Number of Documented Pain Ratings Per Patient Per 24 Hours)	11.8%	8.0%
Pain is treated with medications and other, non-medication approaches (i.e., deep breathing, Reiki, repositioning of patient, massage, backrub, etc.)	90.1%	39.0%

Overall, 88.6% of the Middlesex patients in the study expressed satisfaction with how well their pain was managed.