The trusted source for
healthcare information and
State-sponsored programs help PA hospitals reduce HAIs
Facility-specific initiatives complete picture of impressive QI efforts
In quality improvement circles, certain states have gained a reputation for excellence, and recent statistics out of Pennsylvania seem to indicate that this particular state's reputation is well deserved. A new report issued by the Pennsylvania Department of Health (DOH) shows a decline of 12.5% for overall health care-associated infection (HAI) rates at the state's acute care hospitals in 2009.
One of the reasons for this improvement is the number of programs Pennsylvania makes available to its hospitals. For example:
On the 'CUSP'
Pennsylvania hospital quality leaders recognize the value of initiatives such as CUSP. "Pennsylvania has been at the forefront of IHI bundling programs and CUSP, which is a Hopkins program," notes Omar Rahman, MD, medical director of the adult ICU stroke trauma unit at Geisinger Medical Center in Danville, PA. "They were part of a cohort of states that took the bold move to get onboard with what are extremely important issues. In the era of health care reform, addressing HAIs is essential."
Rahman's ICU is part of the CUSP program. "We have a team that I lead, and we have interactive meetings with all participants state hospitals as well as those outside the state," he explains. "We started with regular weekly meetings, and now we still meet monthly to share ideas and safety initiatives."
Every CUSP team has a clinical leader (in this case, Rahman). "Then, the program asked us to include well-known nurses who lead by example; we have five," he says. "We also included our quality assurance person [the ICU has its own], and we included an executive member of administration, so each executive team member can help facilitate resources."
Rahman says he began participating in the CUSP program in July 2009, with the initial steps being education, orientation, and getting the teams together. "With Geisinger being a large academic institution with multiple ICUs, this was a decentralized process," he explains. "Each ICU was asked to create a team and implement CUSP guidelines, keeping in mind the uniqueness of each unit."
The basic goal, he continues, is to improve the safety culture. "For decades we have been trying to treat patients and fix sickness, but this new culture is moving toward an era of not letting anything else happen to the patient," Rahman notes.
The CUSP strategy, says Rahman, is multi-faceted, and focused on improving the culture through the ongoing education of nurses, doctors, and residents. "It occurs on several different levels group sessions, PowerPoint presentations, and one-on-one sessions with each of the 110 nurses," Rahman shares. "I've also e-mailed them regularly telling them why we're doing what we're doing, and sharing current data. We also have visual aids such as posters, monthly listings of current infection rates a dashboard that shows how many lines we used and how many infections we got." In other words, he adds, staff can sit in the break room, look at the wall, and see all the information they need.
Rahman says he actually had a head start on CUSP because about 18 months earlier, he had started a program of his own to change the culture of the unit and make it more quality- and safety-friendly. "We came up with the idea of a verbal rounding checklist where the doctor, nurse, and respiratory therapist will go over every single patient on every single day," he shares. These discussions include most of the unit's quality and safety goals and many National Patient Safety Goals. "We discuss why the patient needs a central line, why a Foley catheter is needed, whether or not they are on a DVT program, whether code status is designated, if we've met with the family, the patient's mobility status those things frequently overlooked in ICU patients that can lead to complications," he says. "We made a rule that doctors cannot round unless a nurse is present, and we have 100% compliance with that, after having 33% compliance a year earlier."
In addition, he says, the unit improved its rates of sores, the number of times lines were left in the body, and discussion of code status and advanced directives.
"When CUSP came along, we were happy it was something we were kind of already doing," says Rahman. He notes that before the unit joined, despite the fact that its rate of line days was going down, infection rates were still higher than the national average. "Although CUSP started last July, the changes weren't implemented until last December, after the education process," he notes. "Still, in 2009 our infection rate was 4.1 infections per 1,000 line days; our most current rate was 1.9 per 1,000 line days." In terms of absolute numbers, he says, there were 17 last year and a total of four so far this year. "We're obviously moving in the right direction; we want to achieve a zero rate by the end of this year," he asserts.
Among the specific benefits of CUSP, Rahman continues, was the suggestion that the unit create a checklist. "We now have a checklist as we put a line in; if there's a problem, we interrupt and stop the process," he says. "Our next venture is to have the checklist done electronically." As for those regular meetings, says Rahman, "there's never been a meeting where we did not add new a strategy."
A different approach
The approach taken to CUSP by Greensburg, PA-based Excela Health demonstrates how different facilities can customize their own initiatives. "We're participating at our Westmoreland ICU in conjunction with HAP," says Denise Addis, RN, MSN, CPHQ, Excela's chief quality officer. "Our goal is to improve our culture of safety within the ICU and reduce our central line-associated bacteremia, or CLAB rate, using the bundle from IHI. And, because our CLAB rate is so low in all our organizations, we decided to also reduce sepsis by implementing what is now called the sepsis bundle, which is just starting to get legs nationally."
At the outset, says Addis, the AHRQ patient safety survey was implemented, which is a requirement of the project. "Another thing we've done is encourage staff to identify one defect a week and then work on that as a team," she shares. "It could be as simple as where supplies are located, or how communication occurs."
In addition, she says, the unit has instituted multidiscipline rounding led by an intensivist. "We have a 24/7 intensivist program at Westmoreland, which we know improves outcomes, and we have developed a daily report sheet that allows everyone to know the plan of care and expectations for every patient," says Addis.
A representative from the Josie King Foundation provided an educational seminar to Excela's physicians, caregivers, and the community on how they could work together to improve patient safety.
In 18 months, Addis says, staff participation has been good. "They participate every day in rounds," she notes. Since the facility's CLAB rate was already very low, "our main benefit has been teamwork." The sepsis bundle, she adds, was implemented only a month ago.
CUSP is not the only state program benefitting Excela, says Addis. "I would say the resource of the patient safety liaison of the Patient Safety Authority has put us more in touch with the national literature," she says. "And they have a website board where you can post questions and get a response from the authority. We use them very much as advisors; they've been invaluable in triggering us to look proactively at identifying opportunities rather than reactively after things happen."
Excela and other Pennsylvania systems and facilities have been participating in a number of initiatives beyond those offered by the state, notes Addis. For example, she says, "Hand hygiene is a No. 1 priority, and we've most recently been given more structure around compliance through the H1N1 scare. It allowed more attention to be placed on hand washing and put everyone on a level playing field because we all can relate to the flu, as opposed to other more technical microorganisms (i.e., MRSA)."
While the outbreak did not match the expectations, she continues, "It allowed us to increase education, observational opportunities (compliance) and force the hand of [administration] to put in more hand-washing stations," says Addis. "We did a lot of community outreach with physician offices, providing them with resources on hand washing and prevention."
As for compliance, says Addis, she used "secret shoppers" future medical and nursing students to observe compliance while appearing to do another task. "We also required every department to monitor hygiene compliance two to four times a year by direct observation," she notes. "We empowered both staff and physicians to step up and tell someone they did not wash their hands, and we empowered patients or guests and taught them that they also needed to stop caregivers who were not washing their hands." In addition, creative slogans such as "Boo to the flu!" have been used and T-shirts given out to publicize the effort. Addis says compliance rates have steadily increased and are now around 80% well above the national average.
Another initiative Excela is participating in is "Quality Blue," a pay-for-performance program sponsored by Highmark Blue Cross Blue Shield. "Highmark incentivized organizations to reach best practice outcomes for projects based on national standards and best practices," says Addis. "We reached max reimbursement and outcomes at all campuses in the latest fiscal year, as we did the year before. It's a good way to get an organization to do best practices when it is clearly established what a best practice is."
In fiscal year 2010, she adds, Excela is working on surgical repair infection prevention; MRSA; UTIs; and CLAB, "and we continue work on the ventilator-associated pneumonias [VAPs]."
Piggybacking on success
Speaking of VAPs, Rahman says he is using lessons learned from his VAP initiative in the current CUSP efforts. "We want to achieve what we did with VAP," he asserts. "In 2006, we started aggressively, and have brought it down to almost zero; in the last two to three years we've only had two infections, and in 2008-2009, we had 12 months where we had none."
The key to this success, he says, "was that we not only set up a committee to look at the IHI bundle and make sure we were compliant, but we used our EMR and innovative IT tools to make sure compliance was being done."
Most hospitals, he says, will commit to processes such as providing good oral care or having the head of the bed elevated, "but we ensured it; oral care had to be electronically documented through a pharmacy order," Rahman explains. "This was a big step, because it meant care was standardized. Second, we only use a specialized endotracheal tube it's now the only one used in the hospital."
Ongoing education is also crucial, he continues. "When we have a case, we sit down with infection control, analyze it in depth, and see what the breakdown was," says Rahman. These discussions led to the discovery that "99% of the time" the patient was either not getting the right tube or not receiving proper mouth care. "If the cause was nurse care, we addressed it with the nurse; if it was the system, we addressed it with the supply department," he adds.