The following is five examples of the numerous quality improvement initiatives that UVM Medical Center staff engaged in during 2014. For more information on these or other quality improvement initiatives, contact the James M. Jeffords Institute for Quality & Operational Effectiveness at UVM Medical Center at 802-847-0554.”

Act 53 Quality Improvement Initiatives 2015

In November 2014 the U.S. Department of Health and Human Services, the Association for Professionals in Infection Control and Epidemiology, and the Society for Healthcare Epidemiology of America recognized the University of Vermont Medical Centerwith the 2014 Partnership in Prevention Award for achieving sustainable improvements toward eliminating healthcare-associated infections (HAIs).

The UVM Medical Center has created a culture of safety that encourages collaboration across ranks and disciplines, involving C-suite leaders, healthcare providers, caregivers, infection prevention experts, quality improvement experts, environmental services staff, and a team of infection prevention advocates from across the hospital, ambulatory clinics, and dialysis centers. The initiatives described below were included in the award submission.

Title: Prevention of healthcare-associated infections; a multifaceted approach resulting in sustained reduction of healthcare-associated infection at UVM Medical Center

Time Frame:  2008 – October 2014
Description/Problem:
The prevention and reduction of healthcare-associated infections (HAIs) became a top priority for UVM Medical Center in 2008.  At that time the Centers for Disease Control and Prevention (CDC) estimated that one in 20 hospitalized patients developed a healthcare-associated infection.  In response the Department of Health and Human Services (HHS) developed the HHS Action Plan to Prevent Healthcare-Associated Infections providing a roadmap for HAI prevention in acute care hospitals.   Included in the plan were national 5-year prevention targets for eight measures ranging from 25 percent to 50 percent reduction.  UVM Medical Center critically reviewed our infection trends and chose five areas to focus attention.  These areas were all at or above the national rate of infection in 2008.
Five Priority Areas

  • Prevention of central-line associated bloodstream infections (CLABSIs) in the medical intensive care unit (MICU) by standardizing the insertion and care of all central venous catheters (CVCs)
  • Prevention of CLABSIs in the neonatal intensive care unit (NICU) by standardizing the insertion and care of all CVCs and improving environmental cleanliness
  • Prevention of central-line access-related bloodstream infections (CL-ARBs) in hemodialysis outpatients by staff engagement, monitoring of practices and outcomes, and implementation of CDC core recommendations
  • Implementation of evidence-based interventions to reduce surgical site infections (SSIs) with total knee and hip joint replacement
  • Implementation of evidence-based interventions to reduce SSIs in patients undergoing orthopedic spinal fusion surgery

Project Goals:

  • To significantly reduce the rate of healthcare-associated infections in five priority areas, using the CDC’s National Healthcare Safety Network (NHSN) metrics along with specific process measures to measure success,
  • To identify and develop strategies across the organization to support the implementation of evidence-based practices,
  • To implement evidence-based best practices, and
  • To sustain the reduction of infection.

Priority Area 1: Prevention of central-line associated bloodstream infections (CLABSIs) in the medical intensive care unit (MICU) by standardizing the insertion and care of all central venous catheters (CVCs)
Time Frame:  January 2009 – September 2014
Interventions:
A MICU project team was assembled:  A hospital epidemiologist, intensive care unit (ICU) physicians (medicine and anesthesia), infection prevention advocates, nurses, nurse educators, managers and director, purchasing value analysis team, VP of Quality, simulation lab physician leadership and educator, vascular access nurses. 
ICU physician leadership together with support from quality and the infection prevention team was essential to undertaking these interventions: 

  • Organization-wide standardization of catheter insertion kits containing all items necessary for insertion as recommended by CDC guidelines.
  • Developed and implemented an electronic health record (EHR)-based catheter insertion checklist for nursing and physician use
  • Use of bedside ultrasound-guided placement techniques
  • Simulation lab training of procedural insertion techniques and EHR documentation protocol for all MICU physicians, novice as well as established (June 2010). During the development of the simulation program, practice changes such as the use of closed-sleeve gloving and other sterile techniques were standardized
  • Multidisciplinary rounds, weekly case review, and discussion of infection prevention measures.  Staff engagement increased creating a culture of “targeting zero”; even one infection was felt to be too many.
  • Monthly data reported on hospital quality dashboard, available to the entire team and senior leadership
  • Annual report to the public via State mandated public reporting
  • Enhanced nursing education regarding care, maintenance and documentation for CVCs, including the “scrub-the-hub” technique and standardized dressing change protocol.  Annual competency implemented
  • Implementation of daily CHG bathing for all ICU patients

Results:
The clinical interventions and practice changes were implemented during the 18-months prior to July 2010.  The 18 month (8/10 – 1/12) post-implementation CLABSI rate dropped 77 percent, from a baseline value of 2.72 to 0.62 per 1,000 CVC line-days (p=0.02) and has been sustained at a lower rate.  The UVM Medical Center NHSN standardized infection ratio (SIR) has remained significantly below the national benchmark for 2011 - 2014. The MICU has not had any CLABSI since November 2013. That’s zero CLABSI for 17 months, more than 3,500 central line-days.
Baseline compliance with central line insertion process measures (prior to July 2010) were:  48 percent for use of EHR-based checklist by MD and observer, 65 percent for pre-procedure hand hygiene and full barrier draping, and 80 percent for CHG skin antisepsis. Post-implementation, there was 100 percent compliance for all three of these measures.


Priority Area 2: Prevention of CLABSIs in the neonatal intensive care unit (NICU) by standardizing the insertion and care of all CVCs and improving environmental cleanliness
Time Frame:  August 2011 – September 2014
Interventions:
The improvement work was supported by the NICU quality assurance committee.  Members include an infection preventionist, nurses, a medical director, nurse educators, a nurse manager, physicians (attending, fellows and residents) and a quality consultant.
Key drivers of this initiative were an active unit-based infection prevention advocate team and the NICU physician leadership.  An EHR-based catheter insertion checklist was developed and implemented for nursing and physician use.

  • Monthly discussion at the Quality Committee regarding infection data and infection prevention measures. This has increased staff engagement and created a culture of “zero” tolerance for preventable infections
  • Monthly data reported on hospital quality dashboard, available to the entire team and senior leadership
  • Weekly active surveillance testing for MRSA/MSSA and isolation of MRSA-positive infants.

Interventions in the NICU Starting October 2010:

  • Standardized practices and revised CVC policy:
    • Organization-wide standardization of CVC kits to be “all-inclusive”
    • EHR-based documentation checklist for CVC insertion; completed by physician and nurse-observer.
    • Daily assessment of CVC included in progress notes.
    • Electronic prompt in EHR automatically discontinues peripherally inserted central catheter when a baby reaches a specified feeding volume, indicating the line is no longer necessary.
    • Standard 24 hours line change done on the evening shift by experienced nurses.
    • Developed enhanced nursing education program and competency to include standard evidence-based practices, care, maintenance and documentation for CVCs; including the “scrub-the-hub” technique, flushing, stopping and starting infusions, and standardized dressing change protocol.

Environmental cleanliness:

  • Changed linen policy, allowing only hospital-laundered linen and infant clothing
  • Medication administration pumps sent to Central Sterile Reprocessing for cleaning and disinfection
  • Improved environmental cleaning at the bedside and throughout the NICU:  thorough wipe down of bedside, pumps, workstations-on-wheels, keyboards, etc., before beginning daily shift
  • Standardized diaper disposal: diapers placed in a rubber glove turned inside out and disposed of immediately or placed on a designated “dirty space”, i.e. the floor
  • Focused on “de-cluttering” the bedside of infant toys and extraneous items
  • Hand hygiene improvement dual initiative: Hand washing upon entering the NICU, applies to all and staff hand hygiene during care of the infant
  • Implemented Braden Q-scale skin assessment tool
  • Restricted visitation policy, allowing parents only

Results:
Following implementation, the infection rate dropped 100 percent, from the baseline rate of 2.11 per 1,000 CVC line-days to zero infections under the achievement period.  Following a period of 36 months without a CLABSI we had two cases during the past 12 months.  The most recent 12 month rate is 36 percent reduced from baseline (2.11/1000 CL days reduced to 1.35/1000 CL days). Team engagement and a strong culture of safety in NICU resulted in close scrutiny of practices and educational reviews. Compliance with hand hygiene for anyone entering the unit was 82 percent between 4/2011-7/2011. This process measure improved to 99 percent following the interventions (8/2011-4/2013). 


Priority Area 3: Prevention of central-line access-related bloodstream infections (CL-ARBs) in hemodialysis outpatients by staff engagement, monitoring of practices and outcomes, and implementation of Centers for Disease Control and Prevention core recommendations
Time Frame:  January 2009 – September 2014
Interventions:
At our six outpatient hemodialysis centers, where approximately 300 patients are treated, we began surveillance for CL-ARBs in late-2007 using CDCs NHSN Dialysis module definitions and methods. In 2009, we joined the CDC Dialysis Bloodstream Infection Prevention Collaborative. Starting in June 2009, a series of interventions based on the CDCs recommended Core Interventions for Dialysis BSI Prevention were made at each of our six outpatient centers.  Interventions included staff engagement and education to improve adherence to recommended practices and monthly feedback of rates. The CDC core interventions implemented include the following:

  • Standardized aseptic practices during catheter care and vascular access. Practices were monitored at some centers using an observation audit tool to educate and assess compliance
  • Education about appropriate hand hygiene and glove use along with compliance monitoring and reminding
  • Skin antisepsis with CHG /alcohol
  • Implementation of enhanced catheter hub disinfection/cleansing method.
  • Use of antimicrobial ointment at catheter exit sites
  • Participation in “Fistula First,” a patient education and catheter-reduction initiative
  • Patient education about infection prevention
  • An infection prevention advocate program was introduced in 2009; participants included one nurse and one technician from each center.  This group identified challenges and opportunities specific to practices at the chair side using open discussion and brainstorming sessions.  These individuals became true advocates, inspiring others to be compliant with essential evidence-based practices and supporting a culture of safety

Results:
The combined incidence of CL-ARBs at the six centers decreased from 4.8/100 patient-months during the baseline period (11/2007-5/2009) to 2.0 for the 12 months post-intervention (4/2011–3/2012), a 58 percent reduction (p<0.001).  All centers experienced a decrease in their incidence from baseline ranging from 19 to 100 percent reduction.  The second post-implementation period (4/2012 – 3/2013) continued with a sustained decline in the CL-ARB rate for four of the six centers; the combined incidence was 1.2/100 patient-months, a 75 percent reduction from baseline (p<0.001).   
For the most recent 12 months there has been an 83 percent reduction in CL-ARB rate from baseline.  The strong culture of infection prevention in our six dialysis centers enabled us to partner with the CDC on an innovative project trialing changes for environmental cleaning of the dialysis station.  This initiative resulted in increased staff and patient engagement along with improved processes.  Our findings supported the feasibility of CDC’s Dialysis Station Routine Disinfection recommendations leading to the spread of these recommendations to other dialysis facilities across the country.


Priority Area #4: Implementation of evidence-based interventions to reduce surgical site infections (SSIs) with total knee and hip joint replacement
Time Frame:   2008 – September 2014
Interventions:
The multidisciplinary collaborative team led by an orthopedic surgeon implemented a variety of evidence-based interventions that reduced variation in practice throughout the patient experience.  A series of preoperative and surgical care improvement initiatives was rolled out between 2008 and 2010. Regular meetings with the hospital epidemiologist were conducted to review infected cases, discuss current practices and review of evidence based practices.
Preoperative Improvement Initiatives:
The preoperative evaluation was standardized specifically for joint replacement patients.  The protocol focused on getting the patient ready for surgery in order to reduce the risk of infection. Initial identification and coordination of complex patients was done at the time of procedure booking, 6-12 weeks prior to surgery:

  • Hemoglobin:  if low, coordination with primary care physician to resolve prior to procedure
  • Hemoglobin A1c screening:  diabetic & pre-diabetic closely monitored with primary care physician
  • Dental evaluation with required follow-up if periodontal disease identified
  • MRSA/MSSA nares screening:  if PCR positive, mupirocin decolonization pre-operatively and change pre-op antibiotics to vancomycin plus cefazolin
  • Implementation of a risk-adjusted blood clot

Surgical Improvement Initiatives:

  • Prevention program
  • Use of the WHO Checklist prior to surgery
  • Reduction in OR traffic by placing a phone outside the room to prescreen entry.
  • Teamwork improvement to expedite cases and avoid delays.
  • Standardized dressing products (Mepilex) and adoption of the use of sterile hoods for surgical team. 

Results:
Practice changes were phased in during 2008 – 2010. The surgical infection rates dropped significantly and have been sustained.  We have had one hip infection in the past 24 months and the last knee infection was in November 2010. The surgical care improvement project (SCIP) process measures showed continued compliance following implementation of the initiatives during 2008-2010.


Priority Area #5: Implementation of evidence-based interventions to reduce SSIs in patients undergoing orthopedic spinal fusion surgery
Time Frame:  2008 – September 2014
Interventions:
Starting in 2010, a team led by an orthopedic surgeon implemented a series of interventions involving pre- and post-operative care and operating room practices to reduce variation in practice.

  • Preoperative patient education class, including infection prevention measures
  • Preoperative MRSA/MSSA nares screening/decolonization for non-anterior cervical discectomy and fusions, pre-op CHG bathing for all patients, and mupirocin and adjusted perioperative antibiotics for colonized patients
  • Surgeon-initiated “triple play” for complex cases; during long cases, a procedure pause every 3 hours to do the following:  antibiotic re-dose, glove change and wound irrigation
  • Vancomycin powder in wound prior to closure and use of Prevena silver impregnated dressing
  • Perioperative improvements including delayed opening/covering of implant trays until needed (for anterior/posterior cases) to minimize open to air time
  • Minimized traffic by establishing a “closed room” philosophy; phones installed outside of door, signs stating “Think before you go thru the door”, and minimized vendor and nursing flow
  • Ongoing monthly assessment of air quality including temperature, relative humidity, pressure balance and particle filtration
  • Improved verification of instrument cleaning processes in Central Sterile Reprocessing by routine use of adenosine triphosphate (ATP) monitoring of cleaned instruments
  • Improved cleaning/disinfection in the OR by enhancing education, use of microfiber mops and cloths, routine surface testing, use of an Environmental Services/ Operating Room communication log

Results:
The improvement initiatives that began in 2010 were fully implemented by late 2011. There has been a 62 percent reduction in SSI rate from baseline for the past 14 months (7.3/100 cases reduced to 2.8/100 cases).  The surgeon led multidisciplinary team continues to focus on implementation of best practices.  The surgeon led model for improvement used for our two orthopedic initiatives is being replicated for colon surgical procedures, a new priority area for 2015.