with hospital-acquired infection rate reduction - … hospital-acquired infection rate reduction....
TRANSCRIPT
115 General Session Thursday January 26
Win Big With Hospital-Acquired Infection
Rate Reduction
Nancy Dunton PhD FAAN Catima Potter MPH Vincent Staggs PhD
lowastNational goal for more than a decade lowast High cost of care lowast Low quality
lowast Agency for Health Care Research amp Quality finds lowast Little progress on quality of care lowast Declining patient safety
Improvement in Patient Safety
2
lowast Catheter-Associated Urinary Tract Infections (CAUTI)
lowast Central Line-Associated Blood Stream Infections (CLABSI)
lowast Ventilator-Associated Pneumonia (VAP)
Story of Success on Hospital-Acquired Infections (HAI)
3
lowast There are about 17 million HAIs reported annually
lowastHAI are the 5th leading cause of death in US hospitals lowast ~100000 deathsyear
lowast Treatment costs $17- $20 billion annually lowast Much of which is not reimbursed
HAI Significance
4
lowast VAP is leading cause of death among patients who acquire HAI (IHI)
lowast 46 of patients who acquire VAP die in the hospital
lowast Compared with 32 of ventilated patients who do not acquire VAP
VAP Deadly
5
lowast If best practices in infection control were applied to all US hospitals reduction in
lowast CLABSI could save 5520-20239 lives annually
lowast VAP could save 13667-19782 lives annually
Prevention Saves Lives
6
lowast ldquoHospitals make impressive progress in driving down certain infections in critical care units through implementing CDC prevention strategiesrdquo CDC Director Thomas Frieden MD MPH 10192011
lowast 33 reduction in CLABSI since 2008 amp lowast 7 reduction in CAUTI
CDC Breaking News
7
CLABSI in critical care units CAUTI throughout hospital
Structure Process Outcomes
Why Have HAI Improved Follow Donabedianrsquos QI Model
8
1 National policy influence
2 National dissemination of best practices
3 Patient populations
4 Nursing workforce characteristics
Structural Factors
9
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
10
lowastNational Healthcare Safety Network (NHSN) lowast Established 2005mdashIntegration of CDC surveillance
activities
lowast NHSN standardized definitions of hospital acquired infection and methods of data collection
lowast Develop and disseminate prevention bundles
lowast Encouraged mandated public reporting
Leadership of CDCrsquos NHSN
11
lowastOctober 2008mdashCenters for Medicare amp Medicaid Services (CMS) no longer reimbursed hospitals for certain preventable hospital-acquired conditions
lowast Including HAI
CMS Value-Based Purchasing
12
lowast Krein et al (2011) found that the majority of non-federal hospitals reported moderate or large increases in the priority of prevention activities for HAI
lowast 58 reported increase in preventing CLABSI
lowast 54 reported increase in preventing VAP
lowast 65 reported increase in preventing CAUTI
Hospital Prevention Activities Related to CMS Non-Payment Rule
13
National Policy Initiatives National Dissemination
of EBP Change in Patient Populations
Nursing Workforce Characteristics
14
lowastMost but not all HAI preventable with evidence-based practices (Umscheid 2011) lowast 65-70 of CLABSI preventable lowast 55 of VAP preventable
Process Elements
15
lowast Responsibility for performing procedures that can result in infection eg
lowast Insertion and removal of urinary catheters
lowast Observation and maintenance of central lines
lowast Observation and maintenance of ventilators
Nurses Have Critical Role in HAI Prevention
16
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowastNational goal for more than a decade lowast High cost of care lowast Low quality
lowast Agency for Health Care Research amp Quality finds lowast Little progress on quality of care lowast Declining patient safety
Improvement in Patient Safety
2
lowast Catheter-Associated Urinary Tract Infections (CAUTI)
lowast Central Line-Associated Blood Stream Infections (CLABSI)
lowast Ventilator-Associated Pneumonia (VAP)
Story of Success on Hospital-Acquired Infections (HAI)
3
lowast There are about 17 million HAIs reported annually
lowastHAI are the 5th leading cause of death in US hospitals lowast ~100000 deathsyear
lowast Treatment costs $17- $20 billion annually lowast Much of which is not reimbursed
HAI Significance
4
lowast VAP is leading cause of death among patients who acquire HAI (IHI)
lowast 46 of patients who acquire VAP die in the hospital
lowast Compared with 32 of ventilated patients who do not acquire VAP
VAP Deadly
5
lowast If best practices in infection control were applied to all US hospitals reduction in
lowast CLABSI could save 5520-20239 lives annually
lowast VAP could save 13667-19782 lives annually
Prevention Saves Lives
6
lowast ldquoHospitals make impressive progress in driving down certain infections in critical care units through implementing CDC prevention strategiesrdquo CDC Director Thomas Frieden MD MPH 10192011
lowast 33 reduction in CLABSI since 2008 amp lowast 7 reduction in CAUTI
CDC Breaking News
7
CLABSI in critical care units CAUTI throughout hospital
Structure Process Outcomes
Why Have HAI Improved Follow Donabedianrsquos QI Model
8
1 National policy influence
2 National dissemination of best practices
3 Patient populations
4 Nursing workforce characteristics
Structural Factors
9
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
10
lowastNational Healthcare Safety Network (NHSN) lowast Established 2005mdashIntegration of CDC surveillance
activities
lowast NHSN standardized definitions of hospital acquired infection and methods of data collection
lowast Develop and disseminate prevention bundles
lowast Encouraged mandated public reporting
Leadership of CDCrsquos NHSN
11
lowastOctober 2008mdashCenters for Medicare amp Medicaid Services (CMS) no longer reimbursed hospitals for certain preventable hospital-acquired conditions
lowast Including HAI
CMS Value-Based Purchasing
12
lowast Krein et al (2011) found that the majority of non-federal hospitals reported moderate or large increases in the priority of prevention activities for HAI
lowast 58 reported increase in preventing CLABSI
lowast 54 reported increase in preventing VAP
lowast 65 reported increase in preventing CAUTI
Hospital Prevention Activities Related to CMS Non-Payment Rule
13
National Policy Initiatives National Dissemination
of EBP Change in Patient Populations
Nursing Workforce Characteristics
14
lowastMost but not all HAI preventable with evidence-based practices (Umscheid 2011) lowast 65-70 of CLABSI preventable lowast 55 of VAP preventable
Process Elements
15
lowast Responsibility for performing procedures that can result in infection eg
lowast Insertion and removal of urinary catheters
lowast Observation and maintenance of central lines
lowast Observation and maintenance of ventilators
Nurses Have Critical Role in HAI Prevention
16
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast Catheter-Associated Urinary Tract Infections (CAUTI)
lowast Central Line-Associated Blood Stream Infections (CLABSI)
lowast Ventilator-Associated Pneumonia (VAP)
Story of Success on Hospital-Acquired Infections (HAI)
3
lowast There are about 17 million HAIs reported annually
lowastHAI are the 5th leading cause of death in US hospitals lowast ~100000 deathsyear
lowast Treatment costs $17- $20 billion annually lowast Much of which is not reimbursed
HAI Significance
4
lowast VAP is leading cause of death among patients who acquire HAI (IHI)
lowast 46 of patients who acquire VAP die in the hospital
lowast Compared with 32 of ventilated patients who do not acquire VAP
VAP Deadly
5
lowast If best practices in infection control were applied to all US hospitals reduction in
lowast CLABSI could save 5520-20239 lives annually
lowast VAP could save 13667-19782 lives annually
Prevention Saves Lives
6
lowast ldquoHospitals make impressive progress in driving down certain infections in critical care units through implementing CDC prevention strategiesrdquo CDC Director Thomas Frieden MD MPH 10192011
lowast 33 reduction in CLABSI since 2008 amp lowast 7 reduction in CAUTI
CDC Breaking News
7
CLABSI in critical care units CAUTI throughout hospital
Structure Process Outcomes
Why Have HAI Improved Follow Donabedianrsquos QI Model
8
1 National policy influence
2 National dissemination of best practices
3 Patient populations
4 Nursing workforce characteristics
Structural Factors
9
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
10
lowastNational Healthcare Safety Network (NHSN) lowast Established 2005mdashIntegration of CDC surveillance
activities
lowast NHSN standardized definitions of hospital acquired infection and methods of data collection
lowast Develop and disseminate prevention bundles
lowast Encouraged mandated public reporting
Leadership of CDCrsquos NHSN
11
lowastOctober 2008mdashCenters for Medicare amp Medicaid Services (CMS) no longer reimbursed hospitals for certain preventable hospital-acquired conditions
lowast Including HAI
CMS Value-Based Purchasing
12
lowast Krein et al (2011) found that the majority of non-federal hospitals reported moderate or large increases in the priority of prevention activities for HAI
lowast 58 reported increase in preventing CLABSI
lowast 54 reported increase in preventing VAP
lowast 65 reported increase in preventing CAUTI
Hospital Prevention Activities Related to CMS Non-Payment Rule
13
National Policy Initiatives National Dissemination
of EBP Change in Patient Populations
Nursing Workforce Characteristics
14
lowastMost but not all HAI preventable with evidence-based practices (Umscheid 2011) lowast 65-70 of CLABSI preventable lowast 55 of VAP preventable
Process Elements
15
lowast Responsibility for performing procedures that can result in infection eg
lowast Insertion and removal of urinary catheters
lowast Observation and maintenance of central lines
lowast Observation and maintenance of ventilators
Nurses Have Critical Role in HAI Prevention
16
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast There are about 17 million HAIs reported annually
lowastHAI are the 5th leading cause of death in US hospitals lowast ~100000 deathsyear
lowast Treatment costs $17- $20 billion annually lowast Much of which is not reimbursed
HAI Significance
4
lowast VAP is leading cause of death among patients who acquire HAI (IHI)
lowast 46 of patients who acquire VAP die in the hospital
lowast Compared with 32 of ventilated patients who do not acquire VAP
VAP Deadly
5
lowast If best practices in infection control were applied to all US hospitals reduction in
lowast CLABSI could save 5520-20239 lives annually
lowast VAP could save 13667-19782 lives annually
Prevention Saves Lives
6
lowast ldquoHospitals make impressive progress in driving down certain infections in critical care units through implementing CDC prevention strategiesrdquo CDC Director Thomas Frieden MD MPH 10192011
lowast 33 reduction in CLABSI since 2008 amp lowast 7 reduction in CAUTI
CDC Breaking News
7
CLABSI in critical care units CAUTI throughout hospital
Structure Process Outcomes
Why Have HAI Improved Follow Donabedianrsquos QI Model
8
1 National policy influence
2 National dissemination of best practices
3 Patient populations
4 Nursing workforce characteristics
Structural Factors
9
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
10
lowastNational Healthcare Safety Network (NHSN) lowast Established 2005mdashIntegration of CDC surveillance
activities
lowast NHSN standardized definitions of hospital acquired infection and methods of data collection
lowast Develop and disseminate prevention bundles
lowast Encouraged mandated public reporting
Leadership of CDCrsquos NHSN
11
lowastOctober 2008mdashCenters for Medicare amp Medicaid Services (CMS) no longer reimbursed hospitals for certain preventable hospital-acquired conditions
lowast Including HAI
CMS Value-Based Purchasing
12
lowast Krein et al (2011) found that the majority of non-federal hospitals reported moderate or large increases in the priority of prevention activities for HAI
lowast 58 reported increase in preventing CLABSI
lowast 54 reported increase in preventing VAP
lowast 65 reported increase in preventing CAUTI
Hospital Prevention Activities Related to CMS Non-Payment Rule
13
National Policy Initiatives National Dissemination
of EBP Change in Patient Populations
Nursing Workforce Characteristics
14
lowastMost but not all HAI preventable with evidence-based practices (Umscheid 2011) lowast 65-70 of CLABSI preventable lowast 55 of VAP preventable
Process Elements
15
lowast Responsibility for performing procedures that can result in infection eg
lowast Insertion and removal of urinary catheters
lowast Observation and maintenance of central lines
lowast Observation and maintenance of ventilators
Nurses Have Critical Role in HAI Prevention
16
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast VAP is leading cause of death among patients who acquire HAI (IHI)
lowast 46 of patients who acquire VAP die in the hospital
lowast Compared with 32 of ventilated patients who do not acquire VAP
VAP Deadly
5
lowast If best practices in infection control were applied to all US hospitals reduction in
lowast CLABSI could save 5520-20239 lives annually
lowast VAP could save 13667-19782 lives annually
Prevention Saves Lives
6
lowast ldquoHospitals make impressive progress in driving down certain infections in critical care units through implementing CDC prevention strategiesrdquo CDC Director Thomas Frieden MD MPH 10192011
lowast 33 reduction in CLABSI since 2008 amp lowast 7 reduction in CAUTI
CDC Breaking News
7
CLABSI in critical care units CAUTI throughout hospital
Structure Process Outcomes
Why Have HAI Improved Follow Donabedianrsquos QI Model
8
1 National policy influence
2 National dissemination of best practices
3 Patient populations
4 Nursing workforce characteristics
Structural Factors
9
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
10
lowastNational Healthcare Safety Network (NHSN) lowast Established 2005mdashIntegration of CDC surveillance
activities
lowast NHSN standardized definitions of hospital acquired infection and methods of data collection
lowast Develop and disseminate prevention bundles
lowast Encouraged mandated public reporting
Leadership of CDCrsquos NHSN
11
lowastOctober 2008mdashCenters for Medicare amp Medicaid Services (CMS) no longer reimbursed hospitals for certain preventable hospital-acquired conditions
lowast Including HAI
CMS Value-Based Purchasing
12
lowast Krein et al (2011) found that the majority of non-federal hospitals reported moderate or large increases in the priority of prevention activities for HAI
lowast 58 reported increase in preventing CLABSI
lowast 54 reported increase in preventing VAP
lowast 65 reported increase in preventing CAUTI
Hospital Prevention Activities Related to CMS Non-Payment Rule
13
National Policy Initiatives National Dissemination
of EBP Change in Patient Populations
Nursing Workforce Characteristics
14
lowastMost but not all HAI preventable with evidence-based practices (Umscheid 2011) lowast 65-70 of CLABSI preventable lowast 55 of VAP preventable
Process Elements
15
lowast Responsibility for performing procedures that can result in infection eg
lowast Insertion and removal of urinary catheters
lowast Observation and maintenance of central lines
lowast Observation and maintenance of ventilators
Nurses Have Critical Role in HAI Prevention
16
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast If best practices in infection control were applied to all US hospitals reduction in
lowast CLABSI could save 5520-20239 lives annually
lowast VAP could save 13667-19782 lives annually
Prevention Saves Lives
6
lowast ldquoHospitals make impressive progress in driving down certain infections in critical care units through implementing CDC prevention strategiesrdquo CDC Director Thomas Frieden MD MPH 10192011
lowast 33 reduction in CLABSI since 2008 amp lowast 7 reduction in CAUTI
CDC Breaking News
7
CLABSI in critical care units CAUTI throughout hospital
Structure Process Outcomes
Why Have HAI Improved Follow Donabedianrsquos QI Model
8
1 National policy influence
2 National dissemination of best practices
3 Patient populations
4 Nursing workforce characteristics
Structural Factors
9
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
10
lowastNational Healthcare Safety Network (NHSN) lowast Established 2005mdashIntegration of CDC surveillance
activities
lowast NHSN standardized definitions of hospital acquired infection and methods of data collection
lowast Develop and disseminate prevention bundles
lowast Encouraged mandated public reporting
Leadership of CDCrsquos NHSN
11
lowastOctober 2008mdashCenters for Medicare amp Medicaid Services (CMS) no longer reimbursed hospitals for certain preventable hospital-acquired conditions
lowast Including HAI
CMS Value-Based Purchasing
12
lowast Krein et al (2011) found that the majority of non-federal hospitals reported moderate or large increases in the priority of prevention activities for HAI
lowast 58 reported increase in preventing CLABSI
lowast 54 reported increase in preventing VAP
lowast 65 reported increase in preventing CAUTI
Hospital Prevention Activities Related to CMS Non-Payment Rule
13
National Policy Initiatives National Dissemination
of EBP Change in Patient Populations
Nursing Workforce Characteristics
14
lowastMost but not all HAI preventable with evidence-based practices (Umscheid 2011) lowast 65-70 of CLABSI preventable lowast 55 of VAP preventable
Process Elements
15
lowast Responsibility for performing procedures that can result in infection eg
lowast Insertion and removal of urinary catheters
lowast Observation and maintenance of central lines
lowast Observation and maintenance of ventilators
Nurses Have Critical Role in HAI Prevention
16
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast ldquoHospitals make impressive progress in driving down certain infections in critical care units through implementing CDC prevention strategiesrdquo CDC Director Thomas Frieden MD MPH 10192011
lowast 33 reduction in CLABSI since 2008 amp lowast 7 reduction in CAUTI
CDC Breaking News
7
CLABSI in critical care units CAUTI throughout hospital
Structure Process Outcomes
Why Have HAI Improved Follow Donabedianrsquos QI Model
8
1 National policy influence
2 National dissemination of best practices
3 Patient populations
4 Nursing workforce characteristics
Structural Factors
9
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
10
lowastNational Healthcare Safety Network (NHSN) lowast Established 2005mdashIntegration of CDC surveillance
activities
lowast NHSN standardized definitions of hospital acquired infection and methods of data collection
lowast Develop and disseminate prevention bundles
lowast Encouraged mandated public reporting
Leadership of CDCrsquos NHSN
11
lowastOctober 2008mdashCenters for Medicare amp Medicaid Services (CMS) no longer reimbursed hospitals for certain preventable hospital-acquired conditions
lowast Including HAI
CMS Value-Based Purchasing
12
lowast Krein et al (2011) found that the majority of non-federal hospitals reported moderate or large increases in the priority of prevention activities for HAI
lowast 58 reported increase in preventing CLABSI
lowast 54 reported increase in preventing VAP
lowast 65 reported increase in preventing CAUTI
Hospital Prevention Activities Related to CMS Non-Payment Rule
13
National Policy Initiatives National Dissemination
of EBP Change in Patient Populations
Nursing Workforce Characteristics
14
lowastMost but not all HAI preventable with evidence-based practices (Umscheid 2011) lowast 65-70 of CLABSI preventable lowast 55 of VAP preventable
Process Elements
15
lowast Responsibility for performing procedures that can result in infection eg
lowast Insertion and removal of urinary catheters
lowast Observation and maintenance of central lines
lowast Observation and maintenance of ventilators
Nurses Have Critical Role in HAI Prevention
16
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
Structure Process Outcomes
Why Have HAI Improved Follow Donabedianrsquos QI Model
8
1 National policy influence
2 National dissemination of best practices
3 Patient populations
4 Nursing workforce characteristics
Structural Factors
9
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
10
lowastNational Healthcare Safety Network (NHSN) lowast Established 2005mdashIntegration of CDC surveillance
activities
lowast NHSN standardized definitions of hospital acquired infection and methods of data collection
lowast Develop and disseminate prevention bundles
lowast Encouraged mandated public reporting
Leadership of CDCrsquos NHSN
11
lowastOctober 2008mdashCenters for Medicare amp Medicaid Services (CMS) no longer reimbursed hospitals for certain preventable hospital-acquired conditions
lowast Including HAI
CMS Value-Based Purchasing
12
lowast Krein et al (2011) found that the majority of non-federal hospitals reported moderate or large increases in the priority of prevention activities for HAI
lowast 58 reported increase in preventing CLABSI
lowast 54 reported increase in preventing VAP
lowast 65 reported increase in preventing CAUTI
Hospital Prevention Activities Related to CMS Non-Payment Rule
13
National Policy Initiatives National Dissemination
of EBP Change in Patient Populations
Nursing Workforce Characteristics
14
lowastMost but not all HAI preventable with evidence-based practices (Umscheid 2011) lowast 65-70 of CLABSI preventable lowast 55 of VAP preventable
Process Elements
15
lowast Responsibility for performing procedures that can result in infection eg
lowast Insertion and removal of urinary catheters
lowast Observation and maintenance of central lines
lowast Observation and maintenance of ventilators
Nurses Have Critical Role in HAI Prevention
16
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
1 National policy influence
2 National dissemination of best practices
3 Patient populations
4 Nursing workforce characteristics
Structural Factors
9
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
10
lowastNational Healthcare Safety Network (NHSN) lowast Established 2005mdashIntegration of CDC surveillance
activities
lowast NHSN standardized definitions of hospital acquired infection and methods of data collection
lowast Develop and disseminate prevention bundles
lowast Encouraged mandated public reporting
Leadership of CDCrsquos NHSN
11
lowastOctober 2008mdashCenters for Medicare amp Medicaid Services (CMS) no longer reimbursed hospitals for certain preventable hospital-acquired conditions
lowast Including HAI
CMS Value-Based Purchasing
12
lowast Krein et al (2011) found that the majority of non-federal hospitals reported moderate or large increases in the priority of prevention activities for HAI
lowast 58 reported increase in preventing CLABSI
lowast 54 reported increase in preventing VAP
lowast 65 reported increase in preventing CAUTI
Hospital Prevention Activities Related to CMS Non-Payment Rule
13
National Policy Initiatives National Dissemination
of EBP Change in Patient Populations
Nursing Workforce Characteristics
14
lowastMost but not all HAI preventable with evidence-based practices (Umscheid 2011) lowast 65-70 of CLABSI preventable lowast 55 of VAP preventable
Process Elements
15
lowast Responsibility for performing procedures that can result in infection eg
lowast Insertion and removal of urinary catheters
lowast Observation and maintenance of central lines
lowast Observation and maintenance of ventilators
Nurses Have Critical Role in HAI Prevention
16
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
10
lowastNational Healthcare Safety Network (NHSN) lowast Established 2005mdashIntegration of CDC surveillance
activities
lowast NHSN standardized definitions of hospital acquired infection and methods of data collection
lowast Develop and disseminate prevention bundles
lowast Encouraged mandated public reporting
Leadership of CDCrsquos NHSN
11
lowastOctober 2008mdashCenters for Medicare amp Medicaid Services (CMS) no longer reimbursed hospitals for certain preventable hospital-acquired conditions
lowast Including HAI
CMS Value-Based Purchasing
12
lowast Krein et al (2011) found that the majority of non-federal hospitals reported moderate or large increases in the priority of prevention activities for HAI
lowast 58 reported increase in preventing CLABSI
lowast 54 reported increase in preventing VAP
lowast 65 reported increase in preventing CAUTI
Hospital Prevention Activities Related to CMS Non-Payment Rule
13
National Policy Initiatives National Dissemination
of EBP Change in Patient Populations
Nursing Workforce Characteristics
14
lowastMost but not all HAI preventable with evidence-based practices (Umscheid 2011) lowast 65-70 of CLABSI preventable lowast 55 of VAP preventable
Process Elements
15
lowast Responsibility for performing procedures that can result in infection eg
lowast Insertion and removal of urinary catheters
lowast Observation and maintenance of central lines
lowast Observation and maintenance of ventilators
Nurses Have Critical Role in HAI Prevention
16
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowastNational Healthcare Safety Network (NHSN) lowast Established 2005mdashIntegration of CDC surveillance
activities
lowast NHSN standardized definitions of hospital acquired infection and methods of data collection
lowast Develop and disseminate prevention bundles
lowast Encouraged mandated public reporting
Leadership of CDCrsquos NHSN
11
lowastOctober 2008mdashCenters for Medicare amp Medicaid Services (CMS) no longer reimbursed hospitals for certain preventable hospital-acquired conditions
lowast Including HAI
CMS Value-Based Purchasing
12
lowast Krein et al (2011) found that the majority of non-federal hospitals reported moderate or large increases in the priority of prevention activities for HAI
lowast 58 reported increase in preventing CLABSI
lowast 54 reported increase in preventing VAP
lowast 65 reported increase in preventing CAUTI
Hospital Prevention Activities Related to CMS Non-Payment Rule
13
National Policy Initiatives National Dissemination
of EBP Change in Patient Populations
Nursing Workforce Characteristics
14
lowastMost but not all HAI preventable with evidence-based practices (Umscheid 2011) lowast 65-70 of CLABSI preventable lowast 55 of VAP preventable
Process Elements
15
lowast Responsibility for performing procedures that can result in infection eg
lowast Insertion and removal of urinary catheters
lowast Observation and maintenance of central lines
lowast Observation and maintenance of ventilators
Nurses Have Critical Role in HAI Prevention
16
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowastOctober 2008mdashCenters for Medicare amp Medicaid Services (CMS) no longer reimbursed hospitals for certain preventable hospital-acquired conditions
lowast Including HAI
CMS Value-Based Purchasing
12
lowast Krein et al (2011) found that the majority of non-federal hospitals reported moderate or large increases in the priority of prevention activities for HAI
lowast 58 reported increase in preventing CLABSI
lowast 54 reported increase in preventing VAP
lowast 65 reported increase in preventing CAUTI
Hospital Prevention Activities Related to CMS Non-Payment Rule
13
National Policy Initiatives National Dissemination
of EBP Change in Patient Populations
Nursing Workforce Characteristics
14
lowastMost but not all HAI preventable with evidence-based practices (Umscheid 2011) lowast 65-70 of CLABSI preventable lowast 55 of VAP preventable
Process Elements
15
lowast Responsibility for performing procedures that can result in infection eg
lowast Insertion and removal of urinary catheters
lowast Observation and maintenance of central lines
lowast Observation and maintenance of ventilators
Nurses Have Critical Role in HAI Prevention
16
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast Krein et al (2011) found that the majority of non-federal hospitals reported moderate or large increases in the priority of prevention activities for HAI
lowast 58 reported increase in preventing CLABSI
lowast 54 reported increase in preventing VAP
lowast 65 reported increase in preventing CAUTI
Hospital Prevention Activities Related to CMS Non-Payment Rule
13
National Policy Initiatives National Dissemination
of EBP Change in Patient Populations
Nursing Workforce Characteristics
14
lowastMost but not all HAI preventable with evidence-based practices (Umscheid 2011) lowast 65-70 of CLABSI preventable lowast 55 of VAP preventable
Process Elements
15
lowast Responsibility for performing procedures that can result in infection eg
lowast Insertion and removal of urinary catheters
lowast Observation and maintenance of central lines
lowast Observation and maintenance of ventilators
Nurses Have Critical Role in HAI Prevention
16
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
National Policy Initiatives National Dissemination
of EBP Change in Patient Populations
Nursing Workforce Characteristics
14
lowastMost but not all HAI preventable with evidence-based practices (Umscheid 2011) lowast 65-70 of CLABSI preventable lowast 55 of VAP preventable
Process Elements
15
lowast Responsibility for performing procedures that can result in infection eg
lowast Insertion and removal of urinary catheters
lowast Observation and maintenance of central lines
lowast Observation and maintenance of ventilators
Nurses Have Critical Role in HAI Prevention
16
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowastMost but not all HAI preventable with evidence-based practices (Umscheid 2011) lowast 65-70 of CLABSI preventable lowast 55 of VAP preventable
Process Elements
15
lowast Responsibility for performing procedures that can result in infection eg
lowast Insertion and removal of urinary catheters
lowast Observation and maintenance of central lines
lowast Observation and maintenance of ventilators
Nurses Have Critical Role in HAI Prevention
16
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast Responsibility for performing procedures that can result in infection eg
lowast Insertion and removal of urinary catheters
lowast Observation and maintenance of central lines
lowast Observation and maintenance of ventilators
Nurses Have Critical Role in HAI Prevention
16
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
CAUTI Prevention
lowast Avoid unnecessary urinary catheters
lowast Insert catheters using aseptic technique
lowast Maintain catheters based on recommended guidelines
lowast Review catheter necessity daily against criteria
17
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
CLABSI Prevention
lowast Hand hygiene lowast Maximal barrier precautions
upon insertion lowast Chlorhexidine skin antisepsis lowast Optimal catheter site
selection lowast Avoidance of femoral vein
lowast Daily review of line necessity with prompt removal of unnecessary lines
18
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
VAP Prevention
lowast Elevation of the head of the bed
lowast Daily ldquosedation vacationsrdquo and assessment of readiness to extubate
lowast Peptic ulcer disease prophylaxis
lowast Deep venous thrombosis prophylaxis
lowast Daily oral care with chlorhexidine
19
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast Recent upsurge in efforts to prevent HAIs (Flanagan 2011)
lowast Education to increase awareness lowast Infection control professionals CDC IHI
lowast Systems redesign
lowastHospitals reported lowast Hand hygiene most frequent initiative lowast Most frequent challengemdashsustaining behavioral change
Dissemination amp Adoption of Prevention Activities
20
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast Awards given by Department of Health amp Human Services and Critical Care Societies Collaborative
lowast 2011 Awardees lowast Mercy Hospital Coon Rapids MI lowast Chidrenrsquos Hospital and Clinics of Minnesota
MinneapolisSt Paul lowast St Joseph Mercy Hospital Ann Arbor MI lowast Riverside Methodist Hospital Columbus OH
Award Winning Hospitals Reduce or Eliminate HAIs
21
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast Attitude Change lowast ldquoWe get angry when wersquore not at 0 It energizes usrdquo
lowast Multidisciplinary Teams lowast Generally chaired by staff nurses lowast Unit-based Patient Champions
lowast Regular Team Meetings lowast Sometimes daily lowast Huddle boards where staff ask ldquowhy did that infection
occur and what can we do to prevent this in the futurerdquo
What Did They Think Worked
22
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast Long journey to change culture lowast One winner said nearly a decade
lowast Hard to keep ldquoeye on ballrdquo lowast For VAPmdashculture change needed to adopt light
sedation lowast High sedation patients have more PSTD than light
sedation patients
lowast Physicians who donrsquot buy into prevention bundlesmdash ldquocookbook medicinerdquo
What Were Their Obstacles
23
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast Talk it up
lowast Find champion to promote change who is really excited about it
lowast Post signs in break roomsmdashhow many days since the last HAI
lowast Responsibility has to be with bedside nurse
What Is Their Advice
24
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowastMedical Center of the Rockies Loveland CO lowast Saturated education strategy
lowast Cook Childrenrsquos Medical Center Ft Worth TX lowast Real-time feedback on infection-free days lowast Hired 2 RNs dedicated to line insertion and dressing
changes
NDNQI Monographs Stories of Sustained Improvement
25
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
National Policy Initiatives National Dissemination of EBP
Change in Patient Populations
Nursing Workforce Characteristics
26
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowastHospitalized patients now more acutely ill
lowast APACHE scores amp nursing acuity scores not related to HAI in multivariate models (Cho et al 2003))
lowast Patient acuity is related to use of devices that may lead to HAI
Patient Populations
27
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
National Policy Initiatives National Dissemination of EBP Change in Patient Populations
Nursing Workforce Characteristics
28
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
Factors Related to LOWER HAIs
lowastHigher staffing lower CLABSI amp VAP (Stone 2007 amp 2008 Cho 2003)
lowastHigher skill mix lower CAUTI amp VAP (Needleman et al 2002)
Nursing Research Literature On Nursing Workforce amp HAI
29
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
Factors Related to HGHER HAIs lowastMore overtime related to higher CAUTI
(Stone 2007)
lowastMore agency staff higher HAI (Stone 2008)
lowastHigher float staff higher CLABSI (Stone 2008)
Nursing Research
30
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast Sufficient RN staffing important
lowast Nurses not well oriented to critical care or the unit team (float or agency) may not provide high quality care lowast Or units that need float or agency may have
quality problems that lead to turnover or absenteeism
lowast Under pressure of increased workload (short staffing or overtime) clinicians may not be complying with infection control measures
Interpretation of Literature
31
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
NEW Analysis of HAIs
Using NDNQI Data
32
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
AMCs Teaching Non-Teaching
CAUTI 346 195 134 CLABSI 167 131 096 VAP 566 193 128
HAI Rates Higher in Academic Medical Centers
33
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
Magnet Non- Magnet
CAUTI 198 191 CLABSI 130 119 VAP 165 247
Similar HAI Rates for Magnets and Non-Magnets
34
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
1 What characteristics of the nursing workforce related to CAUTI CLABSI and VAP rates
2 What is the relationship between mandated public reporting and CLABSI
Research Questions
35
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast Large Sample
lowastNational Coverage
lowastHigh data quality
Value of NDNQI Data
36
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast Adult critical care units that submitted HAI data to NDNQI for 2010 and participated in the RN Survey
lowast Compared with all NDNQI hospitals lowast More large hospitals lowast More academic medical centers (AMCs) amp
teaching facilities lowast More Magnet facilities
Sample
37
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
CAUTI CLABSI VAP
Hospitals 354 420 409
Adult CC Units 619 750 730
Sample Sizes
38
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast CAUTI CLABSI VAP
lowastData collected using NHSN standardized definitions lowast Infection determined with laboratory test X-
rays or clinical symptoms lowast Infection not present on admission lowast Infection occurred in patient with a device or
within 48 hours of discontinuance of device
Dependent Variables
39
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast Required State Reporting (CLABSI only)
lowast Hospital Characteristics lowast Teaching status lowast Staffed bed size lowast Magnet status
lowast Unit Staffing Characteristics lowast RN HPPD lowast RN hours from Agency staff lowast RN Certification
Independent Variables
40
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowastHierarchical Poisson regression
lowast Random term included to account for clustering of units within hospitals
lowastDevice Days used as exposure variable
Analytic Design
41
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast Confirmed beneficial effect of RN HPPD on CLABSI
lowastDid not find a beneficial effect of RN HPPD on VAP
lowast Confirmed deleterious effect of Agency RNs on VAP
NDNQI Analysis amp Previous Research
42
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowastDemonstrates for first time the beneficial effect of specific RN certifications on HAI
New from NDNQI Analysis
43
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast Sample restricted to NDNQI hospitals participating in the RN Survey
lowastNDNQI hospitals are more likely to be AMCs larger Magnets and not-for-profit than non-NDNQI hospitals
lowastMethodology measures association not causation
Study Limitations
44
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
What Have We Learned About Reductions in HAI
45
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast Policy Effects lowast Some evidence of the beneficial effect of
mandated reporting lowast Effectiveness of CMS non-payment rule
merits additional investigation
lowastWidespread adoption of prevention practices lowast Multiple organizations disseminating lowast Aided by on site infection control staff
National Policies and EBP Dissemination
46
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowastHigher RN HPPD associated with lower CLASBI amp CAUTI rates
lowastMore certified RNs on CC units
lowastDetrimental effect of Agency on VAP
Nurse Staffing
47
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
Looking Forward Can the HAI Lessons be
Translated to Other Outcomes
48
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowastNational Policies to promote prevention lowast Solid EBP guidelines lowastMultiple organizations disseminating EBP lowastOn-site infection control personnel lowast Critical care units more likely others to
have higher RN HPPD and higher RN certification rates
For HAI the ldquoStars Were Alignedrdquo
49
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
Potential Reducing Hospital Acquired Pressure Ulcers
Have
lowast Solid EBP
lowast CMS non-payment for HAPU III amp IV
May Lack lowast Equivalent EBP
dissemination campaign
lowast Sufficient RN HPPD
lowast Unit-based RNs wrelevant certifications
lowast Hospital counterpart to investigative infection control staff
50
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
Potential Reducing Falls
Have lowast CMS non-payment for
serious injury falls
May Lack lowast Solid EBP
lowast Multi-organization dissemination campaign
lowast Sufficient RN HPPD
lowast A relevant certification
51
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
lowast Great to see progress on HAI lowast Delighted that there are so many drivers and
supports for improvement in HAI
lowast HAI experience may be a guide as to ldquowhat it takesrdquo
lowast Thankful that you in the audience collect the data used for looking at relationships between staffing characteristics and outcomes
Closing Thoughts
52
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
Thank You for Your Commitment to
Safe Patient Care
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
-
54
References lowast Centers for Disease Control and Prevention Health care-associated Infections Declined in 2010 Available at
httpwwwcdcgovmediarelsease2011p1019_healthcare_infectionshtml Accessed October 31 2011 lowast Cho SH Ketefian S Barkauskas VH et al The effects of nurse staffing on adverse events morbidity mortality and medical
costs Nurse Res 200352(2) 71ndash9 lowast Coffin SE Klompas M Classen D et al Strategies to prevent ventilator-associated pneumonia in acute care hospitals
Infect Control Hosp Epidemiol 2008 29(Suppl 1)S31ndash40 lowast Duncan J Montalvo I and Dunton N (2011) NDNQI Case Studies in Nursing Quality Improvement Silver Spring MD
American Nurses Association lowast Gould C Umscheid CA Agarwal RK Kuntz G Pegues DA Healthcare Infection Control Practices Advisory Committee
Guideline for prevention of catheter-associated urinary tract infections 2009 Infection control and hospital epidemiology 2010-0431319-326
lowast Flanagan M Welsh CA Kiess C Hoke S Doebbeling BN A national collaborative for reducing health care‒associated infections current initiatives challenges and opportunities American journal of infection control 2011-1039685-9
lowast 5 Million Lives Campaign Getting Started Kit Prevent Central Line Infections How-to Guide Cambridge MA Institute for Healthcare Improvement 2008 (Available at wwwihiorg)
lowast Klevens R Edwards JR Richards CL Jr Horan TC Gaynes RP Pollock DA Cardo DM Estimating health care-associated infections and deaths in US hospitals 2002 Public health reports (1974) 2007-03122160-166
lowast Krein SL Kowalski CP Hofer TP Saint S Preventing Hospital-Acquired Infections A National Survey of Practices Reported by US Hospitals in 2005 and 2009 Journal of general internal medicine JGIM 2011-12-06
lowast Needleman J Buerhaus P Mattke S Nurse-staffing levels and the quality of care in hospitals The New England journal of medicine 2002-05-303461715-22
lowast OGrady NP Alexander M Burns LA Dellinger EP Garland J Heard SO Lipsett PA Masur H Mermel LA Pearson ML Raad II Randolph AG Rupp ME Saint S Healthcare Infection Control Practices Advisory Committee Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Am J Infect Control 2011 May39(4 Suppl 1)S1-34
lowast Stone P Pogorzelska M Kunches L Hirschhorn LR Hospital staffing and health care-associated infections a systematic review of the literature Clinical infectious diseases 2008-10-0147937-944
lowast Stone PW Mooney-Kane C Larson EL Horan T Glance LG Zwanziger J Dick AW Nurse Working Conditions and Patient Safety Outcomes Med Care 2007 Jun45(6)571-578
lowast Umscheid C Mitchell MD Doshi JA Agarwal R Williams K Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infection control and hospital epidemiology 2011-0232101-114
lowast US Department of Health and Human Services HHS Recognizes Progress Toward Eliminating Healthcare-Associated Infections httpwwwhhsgovashnews20110502ahtmlsource=govdelivery Accessed November 9 2011
- Win Big With Hospital-Acquired Infection Rate ReductionNancy Dunton PhD FAANCatima Potter MPH Vincent Staggs PhD
- Improvement in Patient Safety
- Story of Success onHospital-Acquired Infections (HAI)
- HAI Significance
- VAP Deadly
- Prevention Saves Lives
- CDC Breaking News
- Why Have HAI ImprovedFollow Donabedianrsquos QI Model
- Structural Factors
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Leadership of CDCrsquos NHSN
- CMS Value-Based Purchasing
- Hospital Prevention ActivitiesRelated to CMS Non-Payment Rule
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Process Elements
- Nurses Have Critical Role in HAI Prevention
- CAUTI Prevention
- CLABSI Prevention
- VAP Prevention
- Dissemination amp Adoption of Prevention Activities
- Award Winning HospitalsReduce or Eliminate HAIs
- What Did They Think Worked
- What Were Their Obstacles
- What Is Their Advice
- NDNQI MonographsStories of Sustained Improvement
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Patient Populations
- National Policy InitiativesNational Dissemination of EBPChange in Patient PopulationsNursing Workforce Characteristics
- Nursing Research Literature On Nursing Workforce amp HAI
- Nursing Research
- Interpretation of Literature
- NEWAnalysis of HAIsUsing NDNQI Data
- HAI Rates Higher in Academic Medical Centers
- Similar HAI Rates forMagnets and Non-Magnets
- Research Questions
- Value of NDNQI Data
- Sample
- Sample Sizes
- Dependent Variables
- Independent Variables
- Analytic Design
- NDNQI Analysis amp Previous Research
- New from NDNQI Analysis
- Study Limitations
- What Have We Learned About Reductions in HAI
- National Policies and EBP Dissemination
- Nurse Staffing
- Looking ForwardCan the HAI Lessons be Translated to Other Outcomes
- For HAI the ldquoStars Were Alignedrdquo
- Potential Reducing Hospital Acquired Pressure Ulcers
- Potential Reducing Falls
- Closing Thoughts
- Thank You for Your Commitment to Safe Patient Care
- References
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