Denise Murphy, RN, BSN, MPH, CICDenise Murphy, RN, BSN, MPH, CICVice President, Quality and Patient Safety Vice President, Quality and Patient Safety

Main Line Health SystemMain Line Health SystemPhiladelphia, PA USAPhiladelphia, PA USA

April 2010April 2010Nice, FRNice, FR

Disclosures 2010Disclosures 2010

CDC International Meeting on Healthcare Associated CDC International Meeting on Healthcare Associated Infections (Decennial); CDC Healthcare Infection Control Infections (Decennial); CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) Practices Advisory Committee (HICPAC)

AHSRM/APIC/Chartis Insurance: Patient Safety Tour facultyAHSRM/APIC/Chartis Insurance: Patient Safety Tour facultyAPIC International Conference and Education Meeting APIC International Conference and Education Meeting

faculty; APIC Consulting, Inc. Boardfaculty; APIC Consulting, Inc. BoardNPSF/APIC Patient Safety Awareness Webinar facultyNPSF/APIC Patient Safety Awareness Webinar facultyTMIT faculty for IHI International Conference and TMIT faculty for IHI International Conference and

Educational MeetingEducational MeetingNational Quality Forum (NQF) Patient Safety Advisory National Quality Forum (NQF) Patient Safety Advisory

CommitteeCommittee2

ObjectivesObjectives

Discuss the scope of the problem created by healthcare Discuss the scope of the problem created by healthcare associated infections (HAIs) globallyassociated infections (HAIs) globally

Discuss impact of HAIs: clinical, financial and societalDiscuss impact of HAIs: clinical, financial and societalEmphasize the role of culture related to Emphasize the role of culture related to

reduction/elimination of preventable harmreduction/elimination of preventable harmOutline what top performers are doing to eliminate HAIs Outline what top performers are doing to eliminate HAIs

3

HAIs: Scope of the ProblemHAIs: Scope of the ProblemAt any time, over 1.4 million people worldwide suffer from At any time, over 1.4 million people worldwide suffer from

healthcare associated infections (HAI) healthcare associated infections (HAI)

Prevalence survey in 55 hospitals in 14 countries in Europe, Prevalence survey in 55 hospitals in 14 countries in Europe, Eastern Mediterranean, South-East Asia and Western Pacific Eastern Mediterranean, South-East Asia and Western Pacific showed average of 8.7% of hospital patients had HAIsshowed average of 8.7% of hospital patients had HAIs

In England, 9% inpatients have HAI at any time, equivalent In England, 9% inpatients have HAI at any time, equivalent to at least 100,000 infections a year*to at least 100,000 infections a year*

Tikhomirov E. WHO Programme for the Control of Hospital Infections. Tikhomirov E. WHO Programme for the Control of Hospital Infections. ChemiotherapiaChemiotherapia, 1987, , 1987, 3:148–151.*Management and Control of HAI in Acute NHS Trusts in England. Feb 3:148–151.*Management and Control of HAI in Acute NHS Trusts in England. Feb 20002000

FOR MORE INFO...

Impact of HAI in the U.S.Impact of HAI in the U.S.At least 1.7 million HAI in US hospitals (2002*)At least 1.7 million HAI in US hospitals (2002*)

155,000 deaths; 99,000 attributable to the infection**155,000 deaths; 99,000 attributable to the infection**

0 100000 200000 300000 400000 500000 600000 700000 800000

HAI

Accidents

Chronic LungDisease

Cancer

Heart Disease

*Klevens RM et al., 2007; ** National Vital Statistics Reports, Deaths: Injuries 2002

FOR MORE INFO...

Beyond Death….Beyond Death….One HAI leads to risk for multiple HAIsOne HAI leads to risk for multiple HAIsExcess LOS increases risk for other patient safety Excess LOS increases risk for other patient safety

events (e.g., mevents (e.g., medication errors, fall, pressure ulcers)edication errors, fall, pressure ulcers)MDROsMDROsSocietal costsSocietal costs

Loss of trustLoss of trust Increased legislation and litigationIncreased legislation and litigation

Personal loss: productivity, sense of well being, Personal loss: productivity, sense of well being, impact on family and caregiversimpact on family and caregivers

Why Target Elimination of HAI?Why Target Elimination of HAI?

Too many people are dying Too many people are dying or are harmed by HAI.or are harmed by HAI.

Theresa Marie MurphyTheresa Marie Murphy1927-20011927-2001

8

U.S. DHHS* Steering Committee on U.S. DHHS* Steering Committee on Healthcare Associated Infection ReductionHealthcare Associated Infection Reduction

CHARGE:CHARGE: Develop a Coordinated Strategy Develop a Coordinated Strategy

National goals for reduction will target:National goals for reduction will target:Catheter-associated urinary tract infectionsCatheter-associated urinary tract infectionsCentral line-associated blood stream infectionsCentral line-associated blood stream infectionsSurgical Site infectionsSurgical Site infectionsVentilator-associated pneumoniaVentilator-associated pneumoniaMRSAMRSAClostridium difficileClostridium difficile

NOTE: Tier one - focus on hospitals; tier two - out of hospital care and NOTE: Tier one - focus on hospitals; tier two - out of hospital care and additional types of HAIadditional types of HAI

*Department of Health and Human Services*Department of Health and Human Services

9

Recommendations: Recommendations: Prevention and ImplementationPrevention and Implementation

Many goals call for at least 50% reduction over 5 yearsMany goals call for at least 50% reduction over 5 yearsUse and improve metrics needed to assess progressUse and improve metrics needed to assess progressPrioritize existing prevention strategies (CDC HICPAC Prioritize existing prevention strategies (CDC HICPAC

guidelines) – guidelines) – setset National performance standardsNational performance standards

DHHS Challenge to LeadersDHHS Challenge to Leaders

Identify specific actions to fix broken processes and Identify specific actions to fix broken processes and systems AND to address staff behavior/compliancesystems AND to address staff behavior/compliance Responsible parties to drive each tactic or step Responsible parties to drive each tactic or step Timelines and resources to complete actionsTimelines and resources to complete actions Briefings to senior leadersBriefings to senior leaders Make performance transparent: scorecardsMake performance transparent: scorecards Watch for barriers in each step of implementationWatch for barriers in each step of implementation

Financial Impact of HAIFinancial Impact of HAI

Attributable Costs2005 US$

Excess Length of Stay (Days)

Infection Type Mean Min Max Mean Min Max

Ventilator associated pneumonia

22,875 9,986 54,503 9.6 7.4 11.5

CABG-associated SSI 17,944 3,592 26,668 25.7 20 35

Central line associated bloodstream infection

18,432 3,592 34,410 12 4.5 19.6

Catheter associated urinary tract infection

1,257 804 1,710 - - -

Perencevich EN, et al. Infect Control Hosp Epi, October 2007 (Studies from 1999-2005)Perencevich EN, et al. Infect Control Hosp Epi, October 2007 (Studies from 1999-2005)

FOR MORE INFO...

Comparison of Economics – Patients with/without Central Line Associated Bloodstream Infection

N = 20N = 20 PatientPatient

Admit diagnosisAdmit diagnosis Respiratory failureRespiratory failure Respiratory failureRespiratory failure

AgeAge 7171 7575

PayerPayer Medicare + commercialMedicare + commercial Medicare + commercialMedicare + commercial

Revenue $Revenue $ 20,79220,792 20,41720,417

Expense $Expense $ 19,50119,501 37,07537,075

Gross margin $Gross margin $ +1,291+1,291 -16,658-16,658

Costs attributable to BSI Costs attributable to BSI 13,69613,696

LOS (days)LOS (days) 1010 1515

Shannon et al. Shannon et al. Amer J Med QualityAmer J Med Quality Nov/Dec 2006; pgs 7S-16S Nov/Dec 2006; pgs 7S-16S

FOR MORE INFO...

Foreign object retained after surgery;Foreign object retained after surgery;Air embolism;Air embolism;Blood incompatibility;Blood incompatibility;Stages III and IV pressure ulcers;Stages III and IV pressure ulcers;In-hospital falls and trauma; In-hospital falls and trauma; Catheter-associated urinary tract infection (UTI);Catheter-associated urinary tract infection (UTI);Vascular catheter–associated infection;Vascular catheter–associated infection;Surgical site infection—mediastinitis after CABGSurgical site infection—mediastinitis after CABG

* Center for Mediicare and Medicaid Services; Source: McNair et al. Health Affairs 2009:28(5):1485-93.* Center for Mediicare and Medicaid Services; Source: McNair et al. Health Affairs 2009:28(5):1485-93.

FOR MORE INFO...

Preventable Complications No Preventable Complications No Longer Covered by CMS* Longer Covered by CMS*

Business SolutionBusiness Solution: Focus on Length of Stay: Focus on Length of Stay

Know the financial impact of HAI and medical Know the financial impact of HAI and medical errors and the attributable excess length of stay errors and the attributable excess length of stay

Realize how many additional patients can be Realize how many additional patients can be admitted into beds not occupied by patients admitted into beds not occupied by patients with an HAIwith an HAI

Calculate added revenue from reducing Calculate added revenue from reducing infections (not costs saved)infections (not costs saved)

*Ward EJ, Healthc Financ Manage. 2006 Dec;60(12):92-8

FOR MORE INFO...

Clinical SolutionClinical Solution: Focus on Implementation of : Focus on Implementation of and Compliance with Infection Prevention and Compliance with Infection Prevention

BundlesBundles (see appendix) (see appendix)

CLABSICLABSICAUTICAUTIVAPVAPSSISSIMDROMDRO

Cultural and Administrative SolutionsCultural and Administrative Solutions: :

Setting the theoretical goal of elimination of HAIs – Setting the theoretical goal of elimination of HAIs – not even 1 HAI is acceptable; not even 1 HAI is acceptable;

Setting expectations that infection prevention and control Setting expectations that infection prevention and control measures will be applied consistently by all health care measures will be applied consistently by all health care workers, 100% of the time;workers, 100% of the time;

Creating a safe environment for health care workers to Creating a safe environment for health care workers to pursue 100% adherence, where they are empowered to hold pursue 100% adherence, where they are empowered to hold each other accountable for infection prevention;each other accountable for infection prevention;

Ensuring resources and leadership support as the foundation Ensuring resources and leadership support as the foundation to successfully implement prevention measures;to successfully implement prevention measures;

FOR MORE INFO...

Warye K, Murphy DM. Am J Infect Control 2008;36:683-4.Warye K, Murphy DM. Am J Infect Control 2008;36:683-4.

Cultural and Administrative Solutions:Cultural and Administrative Solutions:

Transparency and continuous learning allow for mistakes to Transparency and continuous learning allow for mistakes to be openly discussed without fear of penalty;be openly discussed without fear of penalty;

Prompt investigation of HAI’s of greatest concern to the Prompt investigation of HAI’s of greatest concern to the patients, the organization and/or community; drilldown into patients, the organization and/or community; drilldown into root and contributing causes.root and contributing causes.

• View problems and solutions from a human factors View problems and solutions from a human factors perspective (People, Tools, Work, Environment)perspective (People, Tools, Work, Environment)

Providing real time data to front-line staff for the purpose of Providing real time data to front-line staff for the purpose of driving improvement.driving improvement.

FOR MORE INFO...

Warye K, Murphy DM. Am J Infect Control 2008;36:683-4.Warye K, Murphy DM. Am J Infect Control 2008;36:683-4.

Complementary Improvement StrategiesComplementary Improvement Strategies

© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. © 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Used with Permission.Used with Permission.

FallsFallsPressure UlcersPressure UlcersPatient SatisfactionPatient Satisfaction……and on, and on…and on, and on…

Central LineCentral LineInfectionsInfections

HandHandHygieneHygiene

Surgical SiteSurgical SiteInfectionsInfections

Codes OutsideCodes Outsidethe ICUthe ICU

Culture

““Clinical Bundle”Clinical Bundle”

Process DesignProcess Design Behavioral AccountabilityBehavioral Accountability

““People Bundle”People Bundle”

VAP PreventionVAP Prevention

1. Elevation of the head of 1. Elevation of the head of the bed to between 30 the bed to between 30 and 45 degreesand 45 degrees

2. Daily “sedation vacation” 2. Daily “sedation vacation” and assessment of and assessment of readiness to extubatereadiness to extubate

3. Peptic ulcer disease 3. Peptic ulcer disease (PUD) prophylaxis(PUD) prophylaxis

4. Deep venous thrombosis 4. Deep venous thrombosis (DVT) prophylaxis (DVT) prophylaxis (unless contraindicated)(unless contraindicated)

Who has gotten to ZERO HAI?Who has gotten to ZERO HAI?

CT ICU Primary Bloodstream Infection Rates CT ICU Primary Bloodstream Infection Rates

2006 - 2008

00

2

4

6

8

JanJanFebFebMarMarAprAprMayMayJunJunJulJulAugAugSepSepOctOctNov Nov DecDecJanJanFebFebMarMarAprAprMayMayJunJunJulJulAugAugSepSepOctOctNov Nov DecDecJanJanFebFeb

20062006 20072007 20082008

BS

I R

ate

(p

er 1

000

lin

e d

ay

s)

BS

I R

ate

(p

er 1

000

lin

e d

ay

s)

RateRate MeanMean NHSNNHSN

Source: Barnes Jewish Hospital Source: Barnes Jewish Hospital Epidemiology Epidemiology and Infection Prevention and Infection Prevention DepartmentDepartment

Mercy Hospital ICU

Ventilator Associated Pneumonia (VAP)

Quarterly

0

1

2

3

4

5

6

7

8

Baseline1Q-2Q03n=3/499

3Q03n=1/203

4Q03n=0/261

1Q04n=2/302

2Q04n=0/343

3Q04n=0/203

4Q04n=0/150

1Q05n=1/241

2Q05n=1/281

3Q05n=0/201

4Q05n=0/187

1Q06 n=0/316

2Q06n=0/331

3Q06n=0/313

4Q06n=0/347

1Q07n=0/331

2Q07n=0/324

3Q07n=1/287

4Q07n=0/333

1Q08n=0/259

2Q08n=1/325

3Q08n=1/352

VAP Rate

NNIS Benchmark

May04- Suction and oral care education.

Aug05 - Hilo evac tubes in use.

Feb08 - BAL/PBS for susp VAP

Trish M. Perl, MD, MSc, Trish M. Perl, MD, MSc, Johns Hopkins Hospital, Baltimore, MDJohns Hopkins Hospital, Baltimore, MD

And the Hospital Epidemiology DepartmentAnd the Hospital Epidemiology Department

Jerome E. Granato MD MBA, Medical DirectorJerome E. Granato MD MBA, Medical DirectorJoy Peters, RN MSN MBA, Nursing DirectorJoy Peters, RN MSN MBA, Nursing DirectorCoronary Care Unit, Coronary Care Unit, Allegheny General Hospital, PAAllegheny General Hospital, PAAnd Cheryl Herbert, Manager, ICAnd Cheryl Herbert, Manager, IC

CL

AB

SI/

1,0

00 L

ine

Day

sC

LA

BS

I/1

,000

Lin

e D

ays

Process Extinction

Education Programs

Cultural Shift?

Process Standardization

Allegheny General Hospital CCU Allegheny General Hospital CCU Central Line Associated BacteremiaCentral Line Associated Bacteremia

2002 Through April 20072002 Through April 2007

0

1

2

3

4

5

6

7

8

9

Jul 02

Mar 07

Johns Hopkins Medical InstitutionCLABSI for All Adult ICU’s

2001 –2009

Main Line Health System – Phila, PAMain Line Health System – Phila, PA

Mark Ingerman, MD and Connie Cutler,Mark Ingerman, MD and Connie Cutler,Medical Director and System Director,Medical Director and System Director,Main Line Health System’s Adult Critical Care UnitsMain Line Health System’s Adult Critical Care UnitsSuburban Philadelphia, PASuburban Philadelphia, PA

2

3

4

2

0 0 0 0 0 0 0 0 0 0 0 0 00

0.5

1

1.5

2

2.5

3

3.5

4

4.5

CRBSI

Incidence of CRBSI in PICC LinesIncidence of CRBSI in PICC LinesHouse-Wide; January 2005-March 2009House-Wide; January 2005-March 2009

2

3

4

2

0 0 0 0 0

1

0 0 0 0 0 0 00

0.5

1

1.5

2

2.5

3

3.5

4

4.5

CRBSI

Incidence of CRBSI- Incidence of CRBSI- all CVCall CVCHouse-Wide; January 2005- March 2009House-Wide; January 2005- March 2009

Sophie Harnage RN,BSN Sophie Harnage RN,BSN Clinical Manager Infusion Services Clinical Manager Infusion Services Sutter Roseville Medical Center Sutter Roseville Medical Center Roseville, CARoseville, CA

Sutter Roseville Medical Center, Roseville, CaliforniaSutter Roseville Medical Center, Roseville, California

Targeting Zero – Global ChallengeTargeting Zero – Global Challenge

““An intervention conducted over two years at a 450 bed hospital in An intervention conducted over two years at a 450 bed hospital in Pratumthani, Thailand involved 2,412 patients with urinary catheters. Pratumthani, Thailand involved 2,412 patients with urinary catheters. A nurse-driven intervention involving A nurse-driven intervention involving daily assessmentdaily assessment of of appropriateness of catheter use and reminders to physicians about appropriateness of catheter use and reminders to physicians about importance of catheter removalimportance of catheter removal resulted in resulted in

fewer urinary catheter days (11d vs. 3 days), fewer urinary catheter days (11d vs. 3 days), lower UTI rates (23.4/1,000 catheter days vs. 3.5/1,000)lower UTI rates (23.4/1,000 catheter days vs. 3.5/1,000) lower hospitalization (16 d vs. 5 d) lower hospitalization (16 d vs. 5 d) lower costs ($3,739 vs. $1,378.).” lower costs ($3,739 vs. $1,378.).”

We realized a 73% reduction in catheter utilization and We realized a 73% reduction in catheter utilization and decreased UTI 85%.”decreased UTI 85%.”

““An educational intervention, using the An educational intervention, using the WHAP VAP modulesWHAP VAP modules, was also , was also conducted at Thammasart Univiversity Hospital - conducted at Thammasart Univiversity Hospital - VAP was reduced 59%.VAP was reduced 59%.

Submitted by Anucha Apisarnthanarak, MD Submitted by Anucha Apisarnthanarak, MD and the Thammasart University VAP intervention team and the Thammasart University VAP intervention team

Targeting zero is Targeting zero is culture changeculture change – – takes timetakes time

Strong Sr. Leader support: Strong Sr. Leader support: Champions/multidisciplinary teamsChampions/multidisciplinary teams

IHI’s bundle approach/EBMIHI’s bundle approach/EBMTransparency/data feedbackTransparency/data feedbackAnalysis – real timeAnalysis – real timePersonalize HAIPersonalize HAICommunication!Communication!Celebrate successCelebrate successPlan to sustain the gainsPlan to sustain the gains

Critical event analysisCritical event analysisDaily assessment of device Daily assessment of device

use/reminders to removeuse/reminders to removeBuilding in reliabilityBuilding in reliabilityHuman Factors trainingHuman Factors trainingBoard involvementBoard involvementIPC Liaisons “Link Nurses”IPC Liaisons “Link Nurses”Weekly Executive ReportWeekly Executive ReportWeb-based educationWeb-based educationEmpowered staff Empowered staff

STOP THE LINESTOP THE LINE

What’s Standard?What’s Standard? What’s Different?What’s Different?

Teams who have gotten to zero HAI…Teams who have gotten to zero HAI…

SummarySummaryLeaders must:Leaders must:

Educate themselves and their teams about the total impact of HAI.Educate themselves and their teams about the total impact of HAI.Must BELIEVE that zero HAI is an achievable imperative and sustainable Must BELIEVE that zero HAI is an achievable imperative and sustainable

for long periods of time. They must set and actively support that goal.for long periods of time. They must set and actively support that goal.Understand HOW to achieve zero and what is required to sustain that Understand HOW to achieve zero and what is required to sustain that

performance.performance.Set cultural and behavioral expectations: Set cultural and behavioral expectations: 100% compliance with 100% compliance with

evidence based measures to prevent infection is expected from every one, evidence based measures to prevent infection is expected from every one, for every patient, every day.for every patient, every day.

Provide the environment, equipment, human and financial resources Provide the environment, equipment, human and financial resources to reduce HAI to zero. to reduce HAI to zero.

Ensure that when even Ensure that when even one HAIone HAI occurs, it should trigger immediate occurs, it should trigger immediate concern and a drilldown into potential causes (process breakdown, concern and a drilldown into potential causes (process breakdown, new equipment, slip in compliance, lack of knowledge, etc.)new equipment, slip in compliance, lack of knowledge, etc.)

Educate their communities about more than the Educate their communities about more than the riskrisk for HAI, but also for HAI, but also efforts targeted at prevention. Then market successful reductions.efforts targeted at prevention. Then market successful reductions.

““Never forget that a small group of people can change Never forget that a small group of people can change the world. It is the only thing that ever has…”the world. It is the only thing that ever has…”

- Margaret Mead- Margaret Mead

APPENDIX:APPENDIX:

Table of “What Top Performers in Patient Table of “What Top Performers in Patient Safety are Doing”Safety are Doing”

Main Line Health System’s: Main Line Health System’s: - Clinical Bundles - Clinical Bundles - Culture of Safety (People Bundle) - Culture of Safety (People Bundle)

What Top Patient Safety What Top Patient Safety Performers Are DoingPerformers Are Doing

Culture of zero preventable Culture of zero preventable harm/highest quality careharm/highest quality care

Reliability engineered into Reliability engineered into processes (cues, forcing processes (cues, forcing functions, human factors)functions, human factors)

Just Culture of Safety, Service Just Culture of Safety, Service ExcellenceExcellence

Standardized processes (e.g., Standardized processes (e.g., order sets)order sets)

Transparency and rapid Transparency and rapid feedback systemfeedback system

Technology enabled QPS and Technology enabled QPS and serviceservice

Medical staff fully engagedMedical staff fully engaged Real time analysis of eventsReal time analysis of events

Front line empoweredFront line empowered Certification for risky Certification for risky proceduresprocedures

Clear expectations set for safe Clear expectations set for safe behaviorsbehaviors

Strong measurement/analysisStrong measurement/analysis

Reciprocal accountability Reciprocal accountability Organized spread of learningOrganized spread of learning

Commitment to teamworkCommitment to teamwork Effective PI framework and Effective PI framework and toolstools

Formal, standard Formal, standard communication systemcommunication system

Dedicated, skilled facilitatorsDedicated, skilled facilitators

Evidence-based measures Evidence-based measures (bundles)(bundles)

PI oversight functionPI oversight function

Systems approach to problem Systems approach to problem solvingsolving

Simulation Simulation

• Appropriate Appropriate criteria-based utilizationcriteria-based utilization of central line of central line• Line site choice (internal jugular<subclavian<PICC): Line site choice (internal jugular<subclavian<PICC): avoid femoral siteavoid femoral site• Hand hygieneHand hygiene• Central line carts or kits (cabinet in Interventional Radiology)Central line carts or kits (cabinet in Interventional Radiology)• Chlorhexidine gluconate to cleanse site before insertionChlorhexidine gluconate to cleanse site before insertion• Full barrier precautions for insertionFull barrier precautions for insertion• Protect line integrity: do not use for blood draws! Protect line integrity: do not use for blood draws! • Scrub the hub before all necessary usageScrub the hub before all necessary usage• Daily assessment of need for central lineDaily assessment of need for central line• Drill down on use of PICC lines and using central line for blood drawDrill down on use of PICC lines and using central line for blood draw• Timely feedback about outcomes (rates) and process (bundles)Timely feedback about outcomes (rates) and process (bundles)• Review of each case by BSI prevention PI teamReview of each case by BSI prevention PI team• Comprehensive Unit-based Safety Program (CUSP) collaborativeComprehensive Unit-based Safety Program (CUSP) collaborative

Standardization of component locations in carts or kitsStandardization of component locations in carts or kitsObservation of central line insertions and use of checklistObservation of central line insertions and use of checklistEngagement of senior leadershipEngagement of senior leadership

Evidence-based Prevention Measures and Best PracticeEvidence-based Prevention Measures and Best Practice

MLHS Central line-associated Bloodstream MLHS Central line-associated Bloodstream Infection (CLABSI) PreventionInfection (CLABSI) Prevention

MLHS Catheter-associated Urinary Tract MLHS Catheter-associated Urinary Tract Infection (UTI) PreventionInfection (UTI) Prevention

• Hand HygieneHand Hygiene• Appropriate criteria-based Foley catheter insertionAppropriate criteria-based Foley catheter insertion• Nurse-driven Foley catheter removal protocolNurse-driven Foley catheter removal protocol• Evaluation of silver-coated catheters Evaluation of silver-coated catheters • Rounds with daily assessment of need for catheterRounds with daily assessment of need for catheter• Point prevalence survey on documentationPoint prevalence survey on documentation• Education for residents and nurses on insertion techniqueEducation for residents and nurses on insertion technique• Review of each case by UTI prevention PI teamReview of each case by UTI prevention PI team• CMS CMS SSurgical urgical CCare are IImprovement mprovement PProject requirement to roject requirement to remove on first or second post-op day (or document why remove on first or second post-op day (or document why catheter is necessary)catheter is necessary)

Evidence-based Prevention Measures and Best PracticeEvidence-based Prevention Measures and Best Practice

MLHS Ventilator-associated Pneumonia MLHS Ventilator-associated Pneumonia (VAP) Prevention(VAP) Prevention

• Hand HygieneHand Hygiene• Daily weaning assessments, “sedation vacation” in standing ordersDaily weaning assessments, “sedation vacation” in standing orders• Elevate head of bed (HOB) at least 30 degrees Elevate head of bed (HOB) at least 30 degrees • High-low evacuation endotracheal tubes for subglottic suctionHigh-low evacuation endotracheal tubes for subglottic suction• Oral care every 2 hours by nursing or respiratory therapyOral care every 2 hours by nursing or respiratory therapy• Chlorhexidine gluconate oral rinse twice/dayChlorhexidine gluconate oral rinse twice/day• Mandatory documentation fields for HOB and mouth care in Mandatory documentation fields for HOB and mouth care in electronic documentationelectronic documentation• Feedback to caregivers when opportunity for mouth care is missedFeedback to caregivers when opportunity for mouth care is missed• No routine vent circuit changesNo routine vent circuit changes• Emphasis on minimal opening of vent circuitsEmphasis on minimal opening of vent circuits• Ambulate as early as possible or investigate mobility optionsAmbulate as early as possible or investigate mobility options• Review of each case by VAP prevention PI teamsReview of each case by VAP prevention PI teams

Evidence-based Prevention Measures and Best PracticeEvidence-based Prevention Measures and Best Practice

• NO RAZORS; if hair must be removed, use clippersNO RAZORS; if hair must be removed, use clippers• CHG wipe (skin antiseptic) for hip/knee surgery patientsCHG wipe (skin antiseptic) for hip/knee surgery patients• Use of CHG/alcohol skin prepUse of CHG/alcohol skin prep• Pre-operative prophylactic antibiotic choice and timingPre-operative prophylactic antibiotic choice and timing• Post-operative discontinuation of prophylactic antibioticPost-operative discontinuation of prophylactic antibiotic• Meeting with surgical specialty group when cluster identifiedMeeting with surgical specialty group when cluster identified• Normothermia (normal body temperature) Normothermia (normal body temperature) • Infection prevention rounds in surgical suitesInfection prevention rounds in surgical suites• Review of each case by SSI prevention PI teamsReview of each case by SSI prevention PI teams

MLHS Surgical Site Infection MLHS Surgical Site Infection (SSI) Prevention(SSI) Prevention

Evidence-based Prevention Measures and Best PracticeEvidence-based Prevention Measures and Best Practice

1.1. Leaders make safety a visible and vocal priorityLeaders make safety a visible and vocal priority2.2. We have zero tolerance for reckless behaviorWe have zero tolerance for reckless behavior3.3. Management sets clear expectations around safe(ty) behaviorsManagement sets clear expectations around safe(ty) behaviors4.4. Staff understand their accountabilityStaff understand their accountability5.5. Managers hold staff accountable 100% of the timeManagers hold staff accountable 100% of the time6.6. Staff speak up about risk without fearStaff speak up about risk without fear7.7. Peers observe, coach and hold one another accountable for safetyPeers observe, coach and hold one another accountable for safety8.8. Staff are equipped with critical thinking skills and apply them when Staff are equipped with critical thinking skills and apply them when

safety is at risksafety is at risk9.9. Our patients and our workforce are surrounded by safe systems and Our patients and our workforce are surrounded by safe systems and

processes enabling them to prevent harmprocesses enabling them to prevent harm10.10.Staff proactively engage patients and families in their healthcareStaff proactively engage patients and families in their healthcare

MLHS Culture of Safety ( “People Bundle”)MLHS Culture of Safety ( “People Bundle”)

BEST PRACTICE and BEST PRACTICE and MLHS CULTURE OF SAFETY GOALSMLHS CULTURE OF SAFETY GOALS