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Hospitals improved poor Leapfrog scores with a series of interventions. One strategy involved an ultraviolet sterilization system.
• Expect some resistance to adopting best practices.
• Retained surgical items also were targeted.
• Clinicians may drift away from established policies and procedures.
Two hospitals in Wisconsin undertook a concerted effort to improve patient safety after receiving a “C” from The Leapfrog Group, raising their scores to an “A” over two years.
Hospital Sisters Health System (HSHS) Sacred Heart Hospital in Eau Claire, and St. Joseph’s Hospital in Chippewa Falls, both received the top rating recently from The Leapfrog Group, a national nonprofit healthcare ratings organization that assigns letter grades to hospitals nationwide based on performance in preventing medical errors, infections, and other harm.
The Leapfrog Hospital Safety Grade uses 27 measures of publicly available hospital safety data to assign grades to more than 2,600 U.S. hospitals twice per year. The grades are assessed by patient safety experts and are peer-reviewed.
The hospitals both scored a “C” in 2015 and an “A” in the spring of 2017, says Tammy Lampro, MT, MBA, CQE(ASQ), patient safety officer at both hospitals. That improvement required several interventions, she says.
“The grade is based on how each hospital performs against the other hospitals across the nation at that time, so it is a bit of a moving target. You can’t say this was the level to achieve in 2015 and carry that forward, because everyone else is improving at the same time,” Lampro says. “We’re always looking to improve our processes and be better every day, so this was an opportunity to look at what could be changed.”
The hospitals targeted several areas in which patient safety could be improved. One was reducing the incidence of retained surgical items (RSIs), so the hospitals adopted the NoThing Left Behind program (http://www.nothingleftbehind.org), particularly the rigorous sponge accounting process.
“This was a more thorough, standardized process than what we were doing before, and we now have a policy that if the count is off we always do an X-ray and make sure it is not in the patient,” Lampro explains. “The Leapfrog data gives you a starting place to see what happened and then you have to investigate to see what object was retained and how you could prevent that from happening in the future. It’s root-cause analysis and continuous process improvement, with your past experience as a guide to where you should devote time and resources.”
Another effort involved reducing hospital-acquired infections (HAIs) such as catheter-associated urinary tract infections (CAUTIs), central line-associated bloodstream infections, and surgical infections. The hospitals made an effort to follow the established best practices for reducing these infections, including not leaving catheters in any longer than necessary.
Following the best practices to the letter every time, every day was the goal, Lampro says.
“Every hospital runs into the tendency to drift away from the process, so you have to accept that and have a system in place to discourage that and spot it when it happens. You also have to stay on top of training new people when they come in,” Lampro says. “That’s a constant management challenge.”
Implementing best practices is not always an easy task, Lampro says. The hospitals found that although a best practice may be accepted by the clinical community, your own clinicians may still want to know why it is better than what they are currently doing.
“We addressed that partly by bringing people into the process early, helping them understand what we’re moving to and exactly what it entails. A lot of times, resistance comes from just not fully understanding what someone is asking you to do, and you can dispel that by showing them,” Lampro says. “For example, the CAUTI best practices call for a kit you use with the cleaning products and everything else you need. Before we adopted it, we talked to everyone involved to really get their engagement up front, and we piloted it on some areas before we moved forward in a bigger way.”
The hospitals also eliminated unnecessary traffic in the OR and improved cleaning processes in the hospital, says Sue Galoff, RN, MHA, infection prevention manager at HSHS Sacred Heart and St. Joseph’s hospitals. One of the cleaning process improvements was the addition of an ultraviolet light sterilization system.
The system uses short-wavelength ultraviolet (UVC) light to kill or inactivate microorganisms on surfaces in the room, explains Steven Wheeler, CHESP, director of environmental services at HSHS Sacred Heart and St. Joseph’s hospitals. The light destroys nucleic acids and disrupts the DNA of microorganisms, leaving them unable to perform vital cellular functions.
A large, randomized trial led by Duke Health found that UVC machines can cut transmission of four major superbugs by a cumulative 30%. The trial included more than 21,000 patients at nine hospitals in the Southeast, including three Duke University Health System hospitals, a Veterans Affairs hospital, and small community healthcare settings. It focused on patients staying overnight in a room where the previous patient was known to have an infection from a drug-resistant organism: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Clostridium difficile, and Acinetobacter. (An abstract of the study is available online at: http://bit.ly/2k3s3B8.)
“We started with our C. difficile isolation rooms because it is effective on the C. diff spores, but our ultimate goal is to do it with every single discharge so we have that added assurance that any HAIs are taken care of,” he says.
The cost of the UVC system was significant, so they had to make the case that the patient safety improvements would be worth the expense both in the savings of real dollars from fewer HAIs and in the less tangible benefits to patient care. UVC systems are available for hospital use from several manufacturers, and a single unit can cost around $90,000.
“It also is a time-consuming process, so it adds to the turnaround time for that room. That means we have to make sure we’re using best practices for the procedure and maximizing the amount of time we have to clean the room and add that disinfection time,” Wheeler says. “Sometimes, it is not enough to have the technology and tell people to use it. You have to put some thought into the best ways to use it efficiently.”
The UVC operates on line of sight, so the unit must be activated in more than one spot in a room to make sure everything has been covered. For a typical patient room, the sterilization requires three placements for five minutes each.
“It took us a while to work that into our bed turnaround process and figure out how to be effective with it,” Wheeler says. “For instance, we figured out that we could save time by shooting the bathroom first, putting the unit in the bathroom with the door closed while the housecleaner cleans the rest of the room. We wanted to reduce the HAIs without unnecessarily holding up the process of making that bed available to the next patient.”
The hospitals also had to add new staff positions in environmental services to accommodate the extra steps for cleaning.
The investment in the technology and additional staff were justified by the reduction in infections that the hospital is seeing, Galoff says.
“If you’re an organization looking at where to start improving patient safety, targeting based on data is a good strategy. The data leads you to look at where you should focus, and for us that was the C. diff area,” she says. “A lot of work goes into all of these processes, but you can start small, with pilot projects and then expanding to your most vulnerable areas and finally going as wide within the organization as you want.”
• Sue Galoff, RN, MHA, Infection Prevention Manager, Hospital Sisters Health System Sacred Heart Hospital, Eau Claire, WI, and St. Joseph’s Hospital, Chippewa Falls, WI. Email: email@example.com.
• Tammy Lampro, MT, MBA, CQE(ASQ), Patient Safety Officer, Hospital Sisters Health System Sacred Heart Hospital, Eau Claire, WI, and St. Joseph’s Hospital, Chippewa Falls, WI. Email: firstname.lastname@example.org.
• Steven Wheeler, CHESP, Director of Environmental Services, Hospital Sisters Health System Sacred Heart Hospital, Eau Claire, WI, and St. Joseph’s Hospital, Chippewa Falls, WI. Email: email@example.com.
Financial Disclosure: Author Greg Freeman, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Terrey L. Hatcher and Nurse Planner Maureen Archambault report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Consulting Editor Arnold Mackles, MD, MBA, LHRM, discloses that he is an author and advisory board member for The Sullivan Group and that he is owner, stockholder, presenter, author, and consultant for Innovative Healthcare Compliance Group.