Awards for HAI Control
At ATS 2011 Hospitals Recognized for HAI Reductions/Elimination
At the ATS 2011 International Conference, 10 hospitals were recognized for their success in achieving wide-scale reductions of healthcare-associated infections (HAIs). The hospitals were recommended by critical care experts from the Critical Care Societies Collaborative comprising the American Thoracic Society, American Association of Critical-Care Nurses, American College of Chest Physicians and the Society of Critical Care Medicine.
“Each year in the United States, there are two million HAIs in hospitals,” said Don Wright, MD, MPH, deputy assistant secretary of Health and Human Services. “These awards are part of our effort to make hospital care safer, less expensive and more reliable.”
The hospitals are among 37 that the HHS and the Critical Care Societies Collaborative are recognizing for eliminating/reducing ventilator-associated pneumonias (VAPs) or central line-associated blood stream infections (CLABSIs).
“These hospitals are vanguard organizations,” explained Dr. Wright, who also noted that those recognized were chosen from among 250 applicants. “It’s rare that preventive initiatives yield such rapid results.”
Following are brief summaries of the process and methods each hospital used to reduce VAP and/or CLABSI. Click the “learn more” link to read the applications hospitals submitted to the Critical Care Societies Collaborative.
Highland Hospital, Rochester, New York
Highland applied for recognition after 20 months without a single case of VAP. The hospital used a multidisciplinary and collaborative process to deter VAP, which involved patients and staff and focused on tracking and improvement. For staff, the effort comprised up-to-date standards, targeted goals, documentation prompts and educational programs. Staff representing the multidisciplinary healthcare team participated in a critical care retreat to discuss the general principles of VAP prevention, early mobility and sedation.
To sustain the achievement, the hospital publishes a VAP scorecard, believing that communication regarding outcomes is essential and reinforces the education program.
For patients, the hospital instituted a VAP bundle that included minimizing sedation, brushing teeth and cleaning mouth frequently, avoiding nasal intubation and ulcer and deep vein thrombosis prophylaxis. The hospital also educates patients and family members about VAP prevention.
North Shore-LIJ Health System, Long Island, New York
North-Shore-LIJ was recognized for greatly reducing healthcare-associated infections at 12 of its acute care hospitals and two long-term facilities. An infection prevention task force representing each of the facilities worked to standardize infection control practices, develop explicit policies and procedures, and educate staff on the importance of infection control protocols. It also selected and purchased patient care equipment associated with a lower risk of infection.
The program resulted in the establishment of a uniform “table of measures” with consistent definitions for ICU central line-associated bloodstream infection and ICU VAP across all facilities in the organization. The results of these interdisciplinary initiatives are statistically significant. From January 2004 to December 2010, the annual CLABSI index decreased from 3.25 to 0.95. The VAP index steadily decreased from 5.64 to 1.64. LEARN MORE
Rochester General Hospital, Rochester, New York
Rochester General Hospital reduced central line infections dramatically by recognizing the importance of evidence-based scientific data and by embracing cultural changes that that led to a safer intensive care. The plan of action included staff re-education of the Institute for Healthcare Improvement central line bundle, proper hand hygiene, maximum barrier precautions, selection of appropriate insertion site, chlorhexidine skin preparation and twice daily review of line necessity. In addition, the hospital placed a “Procedure in Progress” sign outside a patient’s room to alert staff not to enter during central line insertion and empowered nurses to halt any procedure if maximum barrier precautions were not maintained.
Since 2008, the total CLABSI rate has decreased from eight to only one in 2009 and zero in 2010. LEARN MORE
Rome Memorial Hospital, Rome New York
Rome Memorial Hospital’s success—zero CLABSIs for more than four years—with its initiative to reduce central line infections is grounded in its philosophy that what gets measured gets done. In 2007, the hospital invested in the MedMined™ Data Mining Surveillance System to provide clinicians with actionable data
The hospital also purchased a bundled kit that includes all items needed to insert a CVC using maximum barrier precautions. This equipment has proven effective in preventing infections at the hospital. The hospital then acquired vascular access ultrasound sound (US) and began U.S.-guided RN PICC insertions. The number of PICCs grew rapidly. The PICC nurses immediately began using maximal barrier precautions. The hospital adopted the use of a central line checklist,
following the model developed by Peter Provonost, MD, PhD, at Johns Hopkins University, which empowers the nurse to stop the CVC procedure and correct any violation of policy.
As the initiative evolved, there was greater emphasis placed on avoiding unnecessary central lines and removing catheters promptly as patients recover. LEARN MORE
St. Catherine of Siena Medical Center, Smithtown, New York
The implementation of this project, which reduced the incidence of VAP by 90 percent, not only helped to decrease VAP, but it also established a culture in which protocols became routine and resulted in positive outcomes. Among the practices instituted to reduce VAP: pre-packaged oral hygiene kits were utilized every four hours; chlorhexidine rinse was performed every 12 hours; bath in a bag replaced standard basins; and educating visitors on their responsibility for hand hygiene; Staff also performed daily assessments of the necessity for sedation, were ready to wean and created a flow sheet that ensured systematic employment of the elements and standardized handoff to the next shift.
The Plan-Do-Control-Analyze model was chosen to initiate the project. A documentation tool was created, which included all elements of the bundle. This gave a baseline to determine where deficiencies existed. Education was provided for physicians, nursing, respiratory therapy, radiology, environmental services and transporters. LEARN MORE
Stony Brook University Medical Center, East Setauket, New York
Stony Brook’s program to reduce central line infections began with a daily goal sheet, which serves as a prompt to evaluate the necessity of the central line to encourage early removal. The form is used in conjunction with multidisciplinary “lightning rounds,” developed as a method for ancillary staff to participate in the development and communication of appropriate, explicit daily goals. A central line insertion kit was also developed and a checklist was designed as a method for capturing the reliability of applying the insertion bundle elements. A dashboard was created with success metrics.
The hospital developed a standardized central line insertion credentialing program for its residents. A comprehensive online educational module was leased from Duke Medical Center and a competency checklist obtained from Henry Ford Health System was modified and applied at Stony Brook. This checklist is a step-by-step guide to the safe insertion of central lines, beginning with the obtaining of consent and ending with the safe disposal of sharps. The competency checklist is used as a coaching and educational tool for residents.
These combined efforts resulted in a 59-percent decrease in central line infections. LEARN MORE
Norman Regional Health System, Norman, Oklahoma
The Norman Regional Health System was recognized for its success in reducing ventilatorVAP and centralCLABSIs. The NRHS began its campaign in 2004 by embracing the Veterans Health Administration’s Transformation of Intensive Care Unit (TICU) project. As a part of the campaign, the NRHS adopted evidence-based practices for reducing infections and implemented a “rapid cycle” that facilitated evaluation and communication of interventions to reduce HAIs without the need to go through a formal hierarchy of command.
Although the TICU program formally ended in 2008, the changes in the NRHS continue to have lasting results: the hospital has reduced the VAP rate from 9.86 percent in 2004 to 0.84 in 2010, and reduced CLABSIs from six in 2004 to two in 2010.
The NRHS has presented its successes and challenges at a number of conferences and continues to share order sets and protocols with other facilities. LEARN MORE
Cook Children’s Medical Center, Fort Worth, Texas
Since 2006, the Cook Children’s Medical Center estimates that it has prevented 14 infant deaths in its level III NICU through the implementation of HAI-reducing procedures. Prior to the initiation of a bundle of interventions, the NICU had an above-average CLABSI rate. They used a model for improvement from the Institute for Healthcare Improvement, implementing bundles of interventions to help keep the project focused and directed. The hospital formed a multidisciplinary team that included the central line nursing team staff, physicians and infection control personnel. Citing the Pareto Principle—which states that 80 percent of a problem is driven by 20 percent of the causes—the team focused on development of a central line team, standardization of insertion practice for central lines, standardization of hub care and timely removal of central lines.
The hospital celebrated its milestones in success—100 CLABSI-free days; one CLABSI-free year— with staff, motivating and encouraging continued vigilance. They have presented this information at national nursing conferences and other organizations have turned to them for assistance.
In four years, CLABSIs have been reduced from 43 a year to zero; deaths from five to zero, and additional patient NICU days from 215 to zero. Through their successes and sharing of information, they have also begun to see success at other facilities as they implement components of their best practice effort. LEARN MORE
Baylor University Medical Center, Waco, Texas
In spring 2007, Baylor set the goal of reducing VAP rates to five percent and implemented a ventilator bundle order set and oral care protocol. By July 2007, their VAP rates were zero percent. However, despite their striking initial success, they found that the reduction was unsustainable and conducted audits to determine how to implement a longer-term plan for sustained change.
The finding that neither physicians nor patients were compliant with the changes they had made—namely, the ventilator bundle set for physicians and oral care for patients—presented a challenge to reinforce the practices and require compliance. Using education, staff reporting and pre-packaged oral care kits that encouraged patient to cooperate, they were able to create new protocols that encouraged communication and standardized care and reporting with accountability to clinical managers, clinical supervisors, and the office of patient safety.
Since November 2008, Baylor has had no cases of VAP in the medical ICU, and the hospital standardized mortality ratio has decreased from 1.2 in 2006 to less than 0.7 in 2010.
St. Luke’s Episcopal Hospital, Houston, Texas
St. Luke’s began efforts to reduce VAP and optimize treatment of ventilated patients in 1996. Since 1997, there has been a 95.3 percent decrease in the number of VAP patients and a 99.5 percent decrease in the VAP rate. The collaboration among administrators and healthcare workers that is the heart of St. Luke’s culture made the task easier. In the 1990s, collaborative practice teams were created to implement best practices and improve quality of care. One of these teams, comprising physicians, nurses, respiratory therapists, administrators, pharmacists, dieticians, infection control practitioners and financial analysts, was tasked with improving care of ventilated patients.
They introduced a “Pneumonia Protocol,” which was implemented in four phases beginning in 1996. Phase one included education and simple interventions to reduce VAP in cardiovascular surgery patients, including chart review and hand-washing. Each successive phase included reviewing the successes and challenges of the previous phase, and building on past protocols for increased success. The results speak for themselves: since 1996, the VAP rate declined from 8.2 per 1,000 patient days to 0.4. Both hospital and ICU length of stay have also decreased. St. Luke’s has shared its success in a number of national settings. LEARN MORE
