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STRATEGIES FOR SUCCESS

May 2013

Member Hospitals Share Their Stories

Member Hospitals Share Their Stories

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Acknowledgements

A special thank you to our contributing hospitals for their stories – and to all of our member hospitals for their collaborative efforts

to significantly reduce patient harm, “forty by twenty by 13.”

If you would like to share a success story around one of our ten measures, please contact us at partnership@wsha.org.

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Table of Contents

Reducing Readmissions……………………………………………………………………………………………………page 4 • Dayton General Hospital • Providence Sacred Heart Medical Center and Children’s Hospital • St. Elizabeth Hospital

Reducing Early Elective Deliveries………………………………………………………………………………….page 14

• Kadlec Regional Medical Center • MultiCare Good Samaritan Hospital • Yakima Valley Memorial Hospital and Evergreen HealthCare

Reducing Central Line-Associated Blood Stream Infections…………………………………………...page 23

• Kadlec Regional Medical Center • MultiCare Health Systems • Sunnyside Community Hospital

Reducing Ventilator–Associated Pneumonia………………………………………………….……………..page 30

• Kittitas Valley Community Medical Center

Reducing Cather-Associated Urinary Tract Infections…………………………………………………….page 33 • Legacy Salmon Creek Medical Center • Peace Health St. John Medical Center

Reducing Surgical Site Infection Rates……………………………………………………………………………page 38

• MultiCare Health System C-Sections • Skagit Valley Hospital Glycemic Control

Reducing Injuries Related to Falls………………………………………………………………………….………page 43

• PeaceHealth Ketchikan Medical Center

Engaging Patients and Families……………………………………………………………………………………..page 47 • Peace Health St. Joseph Medical Center • Providence Regional Medical Center

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REDUCING READMISSIONS • Dayton General Hospital • Providence Sacred Heart Medical Center and Children’s Hospital • St. Elizabeth Hospital

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Dayton General Hospital Reducing Readmissions

Dayton General Hospital is a 25-bed critical access hospital in the southeast corner of Washington State. With the closest metropolitan hospital nearly an hour away, the small community of Dayton is the primary health services provider for the 4,000 residents of Columbia County. They are also an excellent example of how a systematic, coordinated approach to care transitions can reduce readmissions rates.

“Being small can have its downfalls, but it also has its advantages,” said Courtney Gritman RN, Dayton General Hospital Quality Improvement Coordinator. “Because we have a small, strong community we know what resources are available and we can pool them. We know the patients’ socioeconomic backgrounds, and whether or not they have someone at home to care for them. And we can make sure they have what they need to recover when they go home.”

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Dayton’s readmission rates dropped from 25% to zero between the first quarter of 2010 and the third quarter of 2011. Gritman cites several factors in their reduced rates.

The most important of these is arranging the patients’ home care needs before they leave the hospital. “Most of our patients are elderly,” she explained. “If they do not have a family member at home, then we make sure they are going to either have some other caregiver in the home or look at other options for assistance.”

At Dayton, all members of nursing staff serve as discharge planners. They also play a key role in follow-up appointments, scheduling the appointment for the patient and in some cases, even accompanying the patient to their appointment.

Having swing beds in the hospital proved to be an advantage as well. Patients stay longer in the same room and bed, which means less chance of infection and better continuity of care. “With swing beds we have our patients for a longer period of stay so we can make sure they have care at home. It gives us the time to explore the options they have for assistance after they are discharged. And there is no transition of care because they have the same staff caring for them and not a whole new team.”

That continuity of care extends out into the community. Dayton General does not have a hospitalist. With a limited number of providers in Dayton, there is a good chance that the provider who cares for the patient in the hospital is either the patient’s regular physician or from the same group practice. The doctors know their patients and there is less opportunity for miscommunication due to patient hand-off between providers.

And last but not least, Gritman said a new computer system has improved the efficiency of medication reconciliations and reduced errors, allowing better communication between providers and pharmacists.

According to the 2010 Hospital Survey of Patient Safety Culture by the Agency for Healthcare Research and Quality, “Handoffs and Transitions” ranks the lowest of 12 domains of patient safety culture and “Information Exchange with Other Settings” ranks the second lowest on the medical office version of that survey. Dayton General’s success with readmissions supports the importance of continuity of care and communication in keeping patients from returning to the hospital.

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Providence Sacred Heart Medical Center and Children’s Hospital in Spokane

Reducing Readmission Rates At Providence Sacred Heart Medical Center and Children’s Hospital in Spokane, a successful discharge plan is the key to a successful discharge.

“Our discharge planning process has been a focus for us for about two years,” said Jeffery Liles, MD, Division Chief of Medicine and the Medical Director for Care Management at Providence Health Care in Spokane. “It’s the transitions of care that help reduce readmisssion rates. The way you find out what the potential problems might be during that transition process is through discharge planning.”

Since the first quarter of 2010, readmission rates have been gradually declining from 15.1 percent to 11 percent in the third quarter of 2012. Liles says that three things have helped them reduce their rates in the past two years:

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1. A proactive discharge planning process 2. Community partnerships 3. The Community-Based Care Transitions Program (CCTP) for partnering with transitions

agencies in the community. Liles said they recently received funding for this project through the Centers for Medicare and Medicaid “Bridging Care Through the Inland Northwest” program.

Sacred Heart’s discharge planning process begins with admission. The patient fills out an “Ease My Way” form that is designed to identify any barriers the patient or family might face after discharge and to address them if possible during the patient’s stay. “We try to look at all the ways a patient leaves the hospital. For each ‘at-risk’ patient you have to have a different strategy,” he explained. If potential problems are identified, the staff then has a “discharge huddle,” and works to resolve any barriers before the patient leaves the hospital.

The form also helps staff to “risk stratify” patients and identify those who might have the highest risk for readmission after discharge. Liles said they assign patients a color code: Blue means home without services. Yellow is home with services and green means the patient is going to a post-acute rehabilitation facility. Red patients are being discharged with palliative care services. They pay close attention to those going home without services and risk-stratify them further.

Liles said that another important component is partnering with community resources and agencies. Sacred Heart staff has worked with the home health services in their community to standardize care, using the work of Eric Coleman, MD, author of The Post-Hospital Follow-Up Visit: A Physician Checklist to Reduce Readmissions. Sacred Heart is also working with the Washington State University School of Nursing Homeless Respite Project which is funded through Catholic charities

“If people are going home with no home health we work with them to come up with a plan to meet their specific healthcare goals. The ability to reach out to home health agencies, nursing homes and the rural communities to work on communication and head off any problems becomes important. We work with them to identify these patients and make sure they have some kind of follow-up, medication reconciliation and doctor’s appointments.”

Much of their discharge planning work centers around the “Four Pillars” of patient-centered care: having a dynamic, patient-centered record, follow-up, and identification of red flags for their specific medical problems. For example, he said, if they know a high-risk Medicare patient is going home without home health services, they make sure to notify the local Area on Aging of Eastern Washington, which will provide the patient with a coach and follow them as well. Or if a patient is ambulatory but needing medications, they will work with the pharmaco-therapy clinic for community-based follow-up.

Liles has been involved in a discharge planning project to study how decreasing length of stay affects both the readmission rate and patient satisfaction. He said the findings have been surprising. “We have seen substantial cost savings from decreased lengths of stay without

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affecting quality or patient satisfaction. To me it is impressive that we have been able to do those things.”

He also credits the spirit of community collaboration for successful transitions and falling readmission rates in their area. “The fact that it has been multidisciplinary with social workers, doctors, nursing, community-based agencies and the University is so important to the success of this,” he said.

“When we look at the future of healthcare and bundled payments I think we are well prepared. We have things in place that give value added because we understand our patient population and the issues that need to be addressed before they even come into the hospital.”

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St. Elizabeth Hospital

Reducing Hospital Readmissions

Question: When is a hospital patient like an onion? Answer: When your hospital is working hard to prevent the patient’s readmission.

“From the moment a patient enters our hospital, we begin looking at all the risk factors, and peeling back the layers throughout the patient’s stay like an onion,” said Shelly Pricco, Director of Patient Care Services at St. Elizabeth Hospital in Enumclaw, Washington. “As the patient goes through the continuum of care, we identify each factor that could contribute to readmission and address it.”

For example, along with the patient’s health history and diagnosis, they look at the social factors such as whether the patient has someone at home to look after them once they are discharged, lifestyle factors and what community resources are available where the patient lives.

During the patient’s hospital stay and treatment, they continue to evaluate and identify risk factors that may emerge. Pricco said that St. Elizabeth approaches discharge planning as a specialty, with staff whose sole job, as she puts it, is a successful discharge. Their discharge process generally takes about two hours, but they make certain that the patient is prepared for

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the next phase in their recovery whether it is going home or to a long term care or assisted living facility. Their daily multi-disciplinary rounds include a case manager, and they have a charge nurse do discharge teaching for all acute care patients. They also make sure the patient has a follow-up appointment scheduled and St. Elizabeth will soon be adding patient follow-up calls to their process as well.

Pricco said that their recent efforts for reducing readmissions have focused on congestive heart failure (CHF) patients. “As soon as we identify them as CHF patients, we look at the risk factors and whether they are in the red, yellow or green areas (of the communication and follow-up table) and use strategies based on those factors. We won’t let them leave until we see that they can manage at home. And if we see there is a disconnect at home, we are going to give the caregiver education.”

Another key piece of their efforts has been working with the entire healthcare community to ensure smooth transitions. Pricco said that in the past year they have worked with a local cardiologist and clinic to identify a clinical pathway for CHF patients. This process will go live in January. They also organized a two-day work session with the community assisted living facility, long term care facility, and home health agency to discuss strategies for reducing readmissions.

Several important gaps were identified in the care transition process as a result. One of these was the discovery that the hospital needed to be providing more information and direction on the patients to the care facility. For example, Pricco said they had noticed a spike in readmissions of CHF patients from care facilities on day nine.

Upon further investigation and discussion they found the cause: The CHF patients were not being weighed on a daily basis unless the care facility staff was told to do so by the hospital. Because patients were not being weighed daily, the facility was not always catching when the

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patient was having issues until they were bad enough to be rehospitalized - usually the ninth day after discharge. “It was a real ‘Aha!’ moment for us,” she said.

They also discovered that although care facilities were following a no-salt added diet for the CHF patients, staff was not always aware of the sodium levels in processed foods. “If they open up a can of green beans and serve it to the patient, it would have too much sodium, even if they don’t add salt,” she explained. After sharing and discussion, the group was able to identify areas where they could improve the process, she added.

“By being in the same room, we were better able to understand where some of the gaps were – like the weighing and diet and getting medications sooner – and have conversations about them. We realized we need to have a clear plan and not just good communication, but communication at the right time in the continuum.”

Another area of focus that has netted some gains has been patient handoff from hospital to care facility. Pricco says they now do nurse-to-nurse and doctor-to-doctor. “This lets the transitional care staff get the patient’s story. Being able to say ‘Here is where the patient is struggling’ is so much more effective than just reading the discharge papers.”

Since implementing these strategies, St. Elizabeth has seen a gradual decline in readmissions from 19.1 percent in the second quarter of 2010 to 10.6 percent in the second quarter of 2011. There have been some bumps along the way, but Pricco said that currently their readmission rate as of October 2012 is 6.2 percent. Their most challenging population, CHF, is currently at 11.5 percent, still below the national average for all cause readmissions.

In summary, Pricco suggests that hospitals looking to reduce readmissions focus on three primary strategies to get the most traction: • Initiate discharge planning from the day of admission. • Have a case manager round every day regardless if you are medical or surgical. • Think of it as a continuum of care.

“We tell our patients, ‘When you end up back in the hospital we have somehow failed you.’ We want to use strategies that will remove some of the barriers for patients if we can, and that means stepping back and looking at the whole continuum.”

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REDUCING EARLY ELECTIVE DELIVERIES • Kadlec Regional Medical Center • MultiCare Good Samaritan Hospital • Yakima Valley Memorial Hospital

and Evergreen Healthcare

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Kadlec Regional Medical Center

Reducing Early Elective Deliveries

Change is rarely easy, especially when it comes to changing long-standing medical practices. So when Kadlec Regional Medical Center decided to implement the state’s initiative to reduce early elective deliveries in 2010, they knew they would be facing some tough challenges getting staff buy in. “Medicine is an art and a science,” said Melanie O’Brien, BSN, RNC Birth Center Manager. “Doctors want the freedom to practice their art in a way that lets them do what is best for each patient and that patient’s individual needs. Sometimes it is hard for them to tell a patient that even though the patient might feel there is a good reason to induce the baby before 39 weeks, they are now going to have to wait.”

O’Brien said their efforts began in 2010 after attending the WSHA meeting in Seattle and hearing Dr. Thomas Benedetti’s presentation on the initiative and the evidence against early inductions. “We started with extensive education by physician champions. Along with Dr. Benedetti, we knew that Dr. Roger Rowels had also had good success at Yakima Valley, so we enlisted his help as well.” A March of Dimes grant was used to fund part of their educational efforts. Along with conference calls and participation in the WSHA safe tables, Kadlec had Drs. Benedetti and Rowels speak at grand rounds.

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Kadlec’s next step was to develop a checklist based on The Joint Commission criteria for early induction. If a physician feels an early induction is indicated and the patient’s diagnosis doesn’t meet Joint Commission criteria, they then have to get approval from the department chair before the induction can be scheduled.

Data collection and sharing is another important part of their approach. “We provide quantitative data to the physicians on a quarterly basis at the Department of OB meeting,” O’Brien said. They also provide individual physician report cards noting ‘fall-outs’ for that specific provider over the course of the quarter. An especially effective component of the reporting process has been implementing the peer review process. “Each ‘fall-out’ case is assigned to a doctor who reviews it and presents it at the department meeting. The group then scores the case together and that score is reported on the physician’s evaluation. Ultimately, it could affect their re-credentialing.” She said they started the peer review and report process in July and have seen it make a significant impact on EED rates. “We met the state goal of <5% upon implementation of the peer review process in July. That gave us the boost we needed.”

Patient education efforts include the March of Dimes materials and encouraging the doctors to provide their patients with information on the risks of early delivery. “Expectant parents are hungry for information so we make sure to send the March of Dimes brochures on brain development out to the physician’s offices and place the posters in our triage rooms where the patients can see them. Kadlec is also in the process of implementing an informed consent

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specifically for both elective and medically indicated inductions to ensure patients get the necessary information on risks and benefits related to induction.” O’Brien said one of their challenges has been the diverse group of physicians with different approaches and cultures of practice. Of the 13 OBs who have active privileges at Kadlec, some are solo practitioners while others are part of group practices. Each comes with their own history, philosophy and culture about early elective deliveries. Communication between the different providers and the hospital charge nurses have been an issue at times she admitted. However, to facilitate communication and provide clarity, Kadlec is currently working with them to develop induction scheduling guidelines. “If the group can come to an agreement, it will provide better communication, more clarity and less tension,” she said. And because there are several hospitals in the tri cities area, collaboration between hospitals is critical. “If we are all working on this together, we are going to be more successful in making the change.”

Physician champions play a crucial role in Kadlec’s success, O ‘Brien said. “I’ve used both doctors Benedetti and Rowels as resources. I call them and say, ‘we have this case…. what would you do?’” She is also adding a second provider to the checklist signoff process to give them even more support when a doctor requests an induction that does not meet the criteria.

In the end, it all comes down to doing what is best for the patient, said O’ Brien. “There are a lot of ways to get to where we are now. We have made steady progress but now it is about working hard to sustain the trend.”

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MultiCare Good Samaritan Hospital

Reducing Elective Deliveries Prior to 39 Weeks Sometimes experience can be the best teacher. For the staff at MultiCare Good Samaritan Hospital, learning from another’s experience and building on their success proved a valuable strategy for reducing early elective deliveries (EED) in their maternity center.

“As a part of the MultiCare system, we had the advantage of having (MultiCare) Tacoma General ahead of us,” said Karen Baker RN, Director, Women and Children’s’ Service at MultiCare Good Samaritan Hospital in Puyallup. “We learned from their hard work and knew that what would work best for us at Good Samaritan was to implement the hard stop and saying ‘this is no longer acceptable.’” However, it wasn’t just about learning, it was also about teaching: Several months prior to implementing the hard stop, they spent time educating the staff and providers about the decision and the evidence behind it.

As they made the shift to the new guidelines, documentation became an important component in their strategy. Doctors were expected to document each patient scheduled for delivery prior to 39 weeks,

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including criteria and progression of labor. Before it could be scheduled, each case had to go through the medical director, Carrie Wong, MD, Medical Director of the MultiCare Mother Baby Center.

“We have a good medical director who is very involved,” explained Baker. “If someone wants to put a patient down for an early delivery, Dr. Wong reviews it and then has a one-on-one conversation with the physician. It was very helpful to have Dr. Wong go back to each physician and say, ‘I need to understand your criteria for this decision,’” Baker said.

Dr. Wong takes the process one step further by reviewing each case of EED and finding out where it did not meet the criteria. She then shares this information with the OB committee as well as the physician.

Wong and Baker both agree it took some time and effort to bring everyone on board. As Baker puts it, “It’s hard to change practice and practice has always been that anyone 37 weeks gestation is a term pregnancy.”

However with education and reinforcement of the evidence, that culture has shifted and since first quarter of 2011 their rate has dropped from 10.2 percent to 4.3 percent one year later. “It is a cultural adaptation for our docs,” said Wong, “So educating them is important. We took the hard stop approach because we felt that with education, it would take us quickly to where we wanted to be.”

Taking information back to the OB committee from the WSHA Safe Table trainings was also helpful, Baker said. “Most of the information we were able to bring to the physicians group was information we received from WSHA’s perinatal group and their Safe Tables trainings.” Wong also cited the WSHA information as helpful stating that, “We didn’t realize in the beginning we were making assumptions that everyone already knew what the criteria were and how to document. Sharing the acceptable list from WSHA, and the new diagnosis and criteria as they were added, helped educate the doctors on the appropriate circumstances for scheduling a delivery.”

Along with sharing best practices and data, rounds are used as another opportunity to educate staff, says Connie Kirkpatrick, PhD, MS, RN Administrator Quality Management. She said it was four basic steps:

1. Education and preparation of staff several months before the hard stop. 2. Reviewing C-sections that were scheduled for compliance to guidelines 3. Using rounds as an opportunity to talk about EED 4. Ongoing evaluation and education

And of course patient education is an important part of their strategy for success. This includes one-on- one during office visits, sharing the March of Dimes educational materials, and discussing the risks of EED during child birth education classes. Baker said they also present this information in post-delivery classes to reach parents who might have another child in the future. MultiCare uses social media as well to reach patients by posting information on the Mother Baby Center’s FaceBook page.

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Wong said that one challenge they encountered was telling mothers who are just a little beyond term that it is still important to wait. “There is so much in our society based on convenience,” said Dr. Wong. “The hardest was the 39 weeks plus 5 days…we tell them you need to wait. They don’t really like it but they buy it.”

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Yakima Valley Memorial Hospital and Evergreen Healthcare

Reducing Early Elective Deliveries

Individual hospitals have been able to achieve even lower rates for elective deliveries, some below two percent. Yakima Valley Memorial Hospital (YVMH) has 3,000 deliveries each year. During the baseline quarter, they reported a rate of 7.4% for elective delivery prior to 39 weeks. By Q4 2011, they had dropped their rate to 1.6%. Evergreen Healthcare began the effort with an early elective delivery rate of more than 10%, which was reduced to around 5% for much of 2011. In Q4 2011, they achieved their lowest rate to-date of 1.5%.

Both organizations credit their success to support from executive leadership, physician education, and policy changes that made it more difficult to schedule C-sections without medical indication. In Yakima, the hospital made a concerted effort to provide education to physicians inside and outside their organization. They also conducted outreach to area birth educators to help patients understand what to expect. Once they understood the evidence, both organizations found their physicians to be generally supportive of changing their practices. “It is critical to make the measures meaningful for the physicians. They need to understand the evidence around what practices mean for the patients. Making it

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tangible for them makes the difference,” said Angela Chien, MD, Evergreen Health Care. Both organizations empowered their schedulers to deny scheduling of an elective procedure based upon information received from the scheduling physician’s office. At YMVH, any physician who wants to do an induction or scheduled C-section must fill out a form. Schedulers were trained to review the form and if the request did not meet criteria, the scheduler was empowered to say they could not schedule it. If physicians protested, they had to take the request up to the physician executive for approval. To track their progress, both organizations are conducting chart reviews on all inductions and C-sections. If they are not medically indicated, they are reviewed by the medical director and a physician-to-physician consultation takes place. “The education and policies really eliminated the convenience factor. Physicians like that they can say to a patient, ‘I’m sorry, the hospital does not allow us to schedule elective deliveries.’ It has removed the conflict between patients and their physicians,” said Mickey Remmel, MSN, RNC Coordinator, Yakima Valley Memorial Hospital. Both organizations feel that the combination of physician education and policy change has made the reduction in elective deliveries prior to 39 weeks sustainable for their organizations. They are seeing the number of charts that need to be reviewed going down and the change seems to be part of regular practice behavior now.

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REDUCING CENTRAL LINE-ASSOCIATED BLOOD STREAM INFECTIONS • Kadlec Regional Medical Center • MultiCare Health Systems • Sunnyside Community Hospital

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Kadlec Regional Medical Center

Reducing Central Line-Associated Blood Stream Infections

Preventing Central Line Associated Blood Stream Infections (CLABSI) is part of the culture at Kadlec Medical Center. Building that culture started several years ago with a focus on infections in the Intensive Care Unit. The organization investigated every patient who ended up with an infection to determine if a line could be the source of the infection. When the central line bundle was released, the hospital immediately adopted it across the organization, not just in the ICU and Neo-natal Intensive Care Unit.

Key factors for staff adoption included having easy access to the supplies on carts located in each unit and continually consistent education. The entire team, including physicians, was held accountable for proper insertion process using Chlorahexadine, masking, and full body draping. A physician champion conducted peer education and education continues, even years after the bundle was released. “The bundles are so effective because they bring a consistency to your systems,” Kadlec Infection Preventionist Cat Johnson, RN said.

Kadlec found two areas that needed additional attention: lines placed in the emergency room and evaluation of the continued need for a line once it was placed. Lines placed during emergent situations are now replaced upon admittance. Evaluation of the need for lines is now included on the rounding checklist. In addition to evaluating if the line is needed, the rounding team also evaluates if the placement of the line is appropriate. If a line in the arm would work, lines are removed from areas more prone to infection.

“It’s become ingrained in our culture, and staff recognizes that the accesses we put in a patient put them at risk for infection,” Johnson said. “If you need it, you need it, but if you don’t, you don’t and you should remove it.”

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The most recent change Kadlec has made is to add a bio-patch at the insertion site. The Chlorohexadine impregnated disc helps decrease the bacteria load at the line insertion point, which helps prevent bacteria from moving into the line.

Using these strategies, Kadlec Regional Medical Center has successfully achieved and maintained a low rate of central line infections for several years. In fact, over the last three years, Kadlec has been able to lower their infection rates even as their number of central line days increased. “But,” Johnson said, “the work is never done.” The organization is dedicated to continuous education and process improvement and adopting the latest in evidenc- based practices to ensure they maintain the progress they have made in this area.

“There are so many opportunities for failure and one failure could mean the life of a patient,” Johnson said.

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MultiCare Health Systems

Central Line-Associated Blood Stream Infections

In 2005, MultiCare Health Systems took an important and effective first step in reducing central line infections in their patients: They implemented the CLABSI Insertion Bundle and over the next four years saw a significant reduction in infection rates, e.g. from 44 infections at Tacoma General in 2006 to six in 2010. But, said Jeanette Harris, Infection Prevention specialist at MultiCare Health Systems in Tacoma, Washington, this was an instance when “good” was not “good enough.”

After looking at the data, the infection control staff knew they could do better. “We had to develop new strategies to get to zero,” Harris said. “By implementing the first insertion bundle, we got rid of the low- hanging fruit and the mid-level hanging fruit and what we had left were the very, very tough patients.” These cases were generally high risk and often outpatients, such as oncology, who required central lines for long periods of time. Looking at the data in 2010, Harris said they found that most of the infections at this point were occurring more than four

days after insertion, and often in patients outside the ICU. “We decided it was everybody’s job to reduce infection, not just ICU, and so we put together a system-wide CLABSI Committee,” she explained. The committee, which meets monthly, developed a second “maintenance bundle” with an education component that included vendor educators working with staff in reviewing dressing techniques. The committee also added continuing staff education, as opposed to a “one-time” training.

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Other key components of the training were: • A “Scrub the Hub,” campaign, ensuring that the entrance point of the line was kept clean • A daily needs assessment, encouraging staff to remove the line as soon as possible • A daily dressing assessment empowering staff to change the dressings as often as needed • Hand hygiene • Daily use of Cholorhexidine wipes, working from the insertion site out.

Recently, they have changed the CHG procedure to follow the manufacturer’s recommended applications, starting from the chin and working down.

Harris said that in the next two years they continued an aggressive approach to reducing infection rates, and took a close look at individual cases. This resulted in additional strategies such as daily linen changes, extra precautions at femoral sites to prevent fecal contamination, and discussing with the physician the implementation of an ethanol or antibiotic lock. To further avoid contamination of the tubing, they implemented a practice of taping so that IV tubing went “north” and all other tubing went “south.” This resulted in a unique solution for pediatric patients – a specially modified cotton “onesie” that had snaps on the shoulder to hold the tubing in place.

Since the implementation of these practices, Harris said they have had no CLABSI infections. However, she added, it is an ongoing process that requires commitment from everyone involved. “You need dedicated people and buy-in from the staff. It’s something you just have to keep nibbling away at.”

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Sunnyside Community Hospital

Reducing Central Line-Associated Blood Stream Infections

Keeping CLABSI rates at zero is about keeping it simple, says Russ Neal, RN at Sunnyside Community Hospital in rural eastern Washington. Russ is the hospital’s Director of Quality Services, Risk Management, Employee Health and Infection Control. Since the first quarter of 2010, there has not been a single CLABSI at Sunnyside.

This 25-bed critical access hospital does not have a high volume of central lines, which means staff does not have as many opportunities to practice insertion skills. Neal said for that reason it is important to keep documentation simple, keep materials together and provide clear and concise instructions for

following the bundle. “We don’t do a lot, so when we do do one, we are careful to follow the protocol and policy step by step,” Neal explained. The bundle checklist, which is kept with the insertion kit, follows best practices such as proper hygiene and using alcohol for 30 seconds when drawing blood. In August of 2011, Neal said they began implementing use of a biopatch as part of their bundle. “After reading the data and talking to other hospitals, this seemed to be a gold standard,” he said.

Neal said it is also important to keep everything needed for

insertion in one place. “If you have to run around looking for things there is more chance for error.” At Sunnyside, they have a CLABSI kit in a box that includes all the materials needed along with the checklist. Each time the box is used, it is refilled and before it is put away, the person who filled it signs off with their name and the date.

Careful documentation is essential of course, and Neal says they keep this as simple as possible by incorporating everything into one form. This form, which is part of the patient’s EMR, incudes:

• Insertion and removal dates

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• Whether it is a new insertion or an assessment • The reason for the insertion • The catheter lot number and how much was left on the catheter • If hygiene was done • Dressing changes • Was education given

Everyone inserting or assessing the line must fill out the paperwork. Neal receives a print out and he follows each patient until they are discharged. “You want a form that will guide you and it must be as simple and foolproof as possible,” he said.

Because of the infrequency of central lines and PIC lines at their facility, Neal said education is very important too. Their physicians do central lines and contracted IV specialists do PIC lines. It is also part of their skills fair each year. “We’ve worked hard to get it as easy as possible, educating and reeducating the staff. And, keeping them as comfortable as possible doing it,” he explained. “Once the physicians have it down, then we can start training the nursing staff.”

There have been instances of someone not following the bundle. However, Neal found that transparency and accountability have been a good way to address this challenge. “When you are sitting at a meeting and showing data and saying there is one person who is not following the bundle 100%, they know who they are, even if we do not use names. The physicians are the ones who can change things, and that is why you have physician champions.”

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REDUCING VENTILATOR-ASSOCIATED PNEUMONIA

• Kittitas Valley Community Medical Center

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Kittitas Valley Community Medical Center

Reducing Ventilator–Associated Pneumonia In the past six years, Kittitas Valley Community Hospital’s Infection Control and Quality departments have seen many critical care patients, a number of staff turnovers, and changes in technology including the addition of electronic medical records. But one thing the 25-bed Critical Access Hospital in Ellensburg, Washington has not seen since 2007 is a single ventilator- associated pneumonia.

Mandee Olsen, Director of Quality and Risk Management, and Interim Infection Control Employee Health Coordinator, attributes their sustained zero rates to three primary approaches: including the bundle in the order sets, the use of 24–hour hospitalists, and proactive root cause analyses.

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“Our order sets include the bundle and are initiated into electronic care plans that cue daily intervention,” Olsen says. “So all of the bundle is on an electronic intervention or action list for the nurse every day. It allows them to just click right on it and chart what they are doing at the bedside with the patient.”

Like many hospitals, Kittitas has found that having 24-hour hospitalists available can help improve safety. However, Olsen said for them the key to maintaining zero VAP has been the addition of a hospitalist who is board certified in pulmonology. “The immediate expert care and consultation the hospitalist provides really helps to make sure we are weaning people off of the vent as quickly as possible,” Olsen said.

Sustaining low infection rates over a long period of time requires constant vigilance. Olsen said they have found an effective way to accomplish this it to treat near misses like an event and take a proactive approach to prevention. “Earlier this year we had a case we thought potentially could be a VAP, and we went ahead and did a full RCA on it. In doing the root cause analysis, we were able to identify that we needed some kind of education on proper suctioning and oral care techniques.”

Of course, Olsen added, none of this would be as effective if they did not have the support and engagement of leadership. “Our administration and board are very supportive. I don’t know how you get so lucky as to have senior leaders who are so passionate about quality and safety. If we have a root cause analysis for any event the administrators and CEO participate. It means a lot to staff that they are heard.”

And this leadership support extends beyond the hospital into the community. For example, their infection control meetings include the county’s public health officer as well as the local epidemiologist. “There is a lot of expertise in the local area and we have really tried to partner in our community,” Olsen explained.

Even after so many years without an event, Kittitas quality staff continues to evaluate and monitor the process. “We are still holding our breath that we can keep this zero as long as possible and we continue to look at our processes to make sure they are reliably taking place and not just assume that we are doing the right thing all the time – because we don’t need a VAP to make us realize that something has gone astray!”

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REDUCING CATHETER-ASSOCIATED URINARY TRACT INFECTIONS • Legacy Salmon Creek Medical Center • PeaceHealth St. John Medical Center

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Legacy Salmon Creek Medical Center Reducing Catheter-Associated Urinary Tract Infections

The first and most important step to any quality improvement process is increasing awareness, according to Jennifer Leger, RN, BS, NMS, and Infection Control Practitioner at Legacy Salmon Creek Medical Center.

“Sharing the data for our CAUTI rates with staff allowed us to recognize there was an issue and then put the need for heightened awareness front and center,” Ledger said.

Between 2009 and 2011 Legacy’s CAUTI rates dropped from 1.8 per 1000 to 0. Leger attributes the drop in catheter-related infections to increased attention on the problem and staff and patient education.

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Once the hospital’s Infection Control Committee identified the need for a change, they began sharing the data on a regular basis at their Quality Council Meetings. The IC practitioners met with the staff Best Practice Council and made education on the issue mandatory, focusing on a different area of UTIs at each meeting. Leger adds that the MHSN and CDC Best Practices for CAUTI was also an important tool in their improvement process. “These prompted us to stop using antibiotics to treat UTI’s and that has made a big difference,” she adds.

Involving managers and staff and increasing their awareness of the issue was another factor. Using a Best Practices Bundle for CAUTI, all staff received mandatory education and was required to sign off on the bundle’s best practice. “The number one bundle issue was ‘can that Foley be removed?’” she said.

Technology came into play in the improvement process as well when the adoption of a new EMR system provided a better tool for communication and continuity of care. “We started using EPIC this year and it allows us to E-chart and put important patient information out there on a banner bar where everyone can see it,” said Leger.

The IC staff also identified the need to educate patients and families. “We realized that patients sometimes come in obese and with poor hygiene. So changing patient behavior from the beginning is important.” Leger said that EPIC was useful as a patient education tool because it has a component prompting staff to remind patients to keep the Foley bag at a lower level and practice good hygiene to prevent infection.

Other strategies included changing the system of reporting so that nursing reports directly to quality control rather than administration and working with the ED staff upon admission to identify patients at risk for infection. For example, blood cultures are taken in the ED to identify any preexisting infections.

Leger sums it up by saying, “It’s that constant awareness, and involving managers and staff in making a conscious effort to improve that makes the difference.“

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PeaceHealth St. John Medical Center

Reducing Catheter-Associated Urinary Tract Infections When it comes to Catheter-Associated Urinary Tract Infections, removing Foley catheters as soon as possible made a huge improvement for Peace Health St. John Medical Center. The team really started focusing on CAUTI within the last year. They found their rates were naturally going down based on efforts to improve overall infection prevention, including hand hygiene efforts. The added focus accelerated improvement from 2.35 infections per 1,000 urinary catheter days down to 0.97. The improvement effort was headed by the hospital’s quality department and involved a multidisciplinary team with lots of staff involvement. The effort began on the surgical floors where the team found the main issue causing many of the infections seemed to be catheters that were being left in for too long. The team initiated a staff awareness campaign, exclaiming “Holy moley, get rid of that Foley!” The organization also adopted nurse-initiated catheter removal protocols.

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After experiencing initial success in the surgical unit, the initiative was launched to ICU and house-wide and similar success was achieved across the organization. PeaceHealth St. John is continuing to work toward zero CAUTIs with additional emphasis on proper insertion and line care. “The staff recognize that infection prevention doesn’t belong to one person, it is everyone’s job to do,” said Infection Preventionist Angie Dickson, RN. “It’s a cultural thing to change and we are getting there!”

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REDUCING SURGICAL SITE INFECTION RATES • MultiCare Health System C-Sections • Skagit Valley Hospital Glycemic Control

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MultiCare Health System Reducing C-Section Infection Rates

MultiCare Health System has had tremendous success in reducing their C-section infection rates at their main hospital campus, Tacoma General Hospital. They have developed a bundle for use with high risk patients. Based upon careful data mining, MultiCare determined that the patients with a higher body mass index (BMI) were at greater risk for infection after a C-section, said Jeanette Harris, RN, MultiCare Health System. The interventions in the high-risk bundle include:

• Pre-surgery site preparation. Using Chlorhexidine to clean the surgical site. As too much Chlorhexidine can result in skin breakdown, use either in a bath or immediately before surgery.

• Drapes. Carefully remove surgical drapes to ensure the skin is not compromised.

• In-hospital wound care. Keep the incision covered in the hospital and use negative

pressure to bolster wounds on high-risk patients. Use watertight bandage material that is see-through so mothers can bathe and providers can visualize the wound without removing the dressing. (“We found physicians and nurses were ‘peeking’ beneath the dressing and then sticking it back down, providing an opportunity to introduce infections. The see-through dressing solved this problem,” Harris said).

• Educate staff in hospital and outpatient clinics on dressing care and removal.

“We’ve produced a three-ring binder with loads of education material for the

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clinic staff and with a lot of pictures,” she said.

• Leaving staples intact. Allow more time for healing by waiting seven days to remove staples during a post-op follow-up visit rather than upon discharge. MultiCare is now moving to suturing instead of stapling wound closures.

• Appropriate removal of staples. Train staff in outpatient clinics to properly remove staples.

• Post-op patient education. Ensuring patients know how to care for their wounds

and identify the signs and symptoms of infection.

• Don’t place unnecessary urinary catheters. Some hospitals are preventing complications by not routinely placing urinary catheters during C-sections.

As a result of implementing these best practices, MultiCare has experienced a 75 percent reduction in the number of surgical site infections (SSI) C-sections. This bundle is being shared across the WSHA-HEN through the Safe Table Learning Collaborative and the development of resource documents.

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Skagit Valley Hospital Glycemic Control to Reduce Surgical Site Infections

At Skagit Valley Hospital, glycemic management is physician-led. Hospitalists, anesthesiologists and surgeons are tasked with managing patients’ glucose levels before, during and after surgery. Recently the hospital initiated a six-month project focused on improving management of high blood glucose levels in surgical patients.

Since physicians are central to their strategy, the project leaders engaged them from the start, inviting them to a kick-off dinner where they unveiled the project and its goals. This was followed by a 45-minute in-service for nursing staff. In introducing their program, Janice Whitman RN, MSN, Clinical Nurse Specialist at Skagit Valley Hospital said they emphasized studies such as the Portland Diabetic Project which demonstrates the link between hyperglycemia and wound infection in open heart surgery. “This study showed that patients who had blood glucose levels greater than 250 had six times the rate of infection,” she said. They also shared data from a study demonstrating that non-diabetic patients with hyperglycemia have higher morbidities including longer length of stay, higher admission rates to ICU, and greater chance of being discharged to transitional care rather than directly home. And the non-diabetic patients had higher mortality rates than diabetic patients. The study concluded that it is just as important to monitor the blood glucose levels non-diabetic as in diabetic patients. This monitoring can be facilitated by determining the HbgA1C for suspected undiagnosed hyperglycemia when the patient is admitted.

All surgical patients are susceptible to ‘stress hyperglycemia’ – a rise in blood glucose which results from the body’s reaction to stress. This elevation in blood glucose starts a chain reaction of inflammatory responses in the body, resulting in greater risk for infection, increased prothrombotic state, decreased would healing and impaired cardiac function, she explained. “Just one episode of a blood glucose greater than 200 mg/dL can result in a 54% increase in the risk of bloodstream infections, an increase in acute renal failure requiring dialysis, and a 50% increase requirement for blood transfusion. We want to manage this and never let the episode occur.”

• Whitman said they do not recommend using oral glycemic agents during hospitalization. Their current best practice is to use insulin infusion if the patient is not taking food or is unstable. When eating or receiving enteral nutrition or TPN, insulin is given by

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subcutaneous protocol. They follow the American Association of Clinical Endocrinology (AACE)/American Diabetes Association (ADA) target glucose treatment levels which are to:

1. Select patients at 110-140 mg/dL for intensive management.

2. Use the acute care standard for patients with levels between 110-180 mg/dL

Whitman said a key component of their strategy was developing guidelines for monitoring the blood glucose and giving insulin during surgery as indicated. Dosing may include IV insulin given through basal insulin with bolus doses during the procedure. Another effective strategy has been development of a transition algorithm from IV insulin to subcutaneous (basal and bolus) when blood glucose levels are in the range of 90-140, the insulin infusion rate is stable, and the patient is either eating or will be soon. Whitman says using these algorithms has reduced their incidence of hyperglycemia significantly. Staff is also educated to watch for signs of hypoglycemia and initiate treatment interventions.

Education is a primary focus throughout the hospital stay, especially for patients who are taking insulin for the first time. Any changes to the patient’s insulin regimen are communicated to the primary care provider. Discharge planning includes referrals to the primary provider, nutritionists, and inpatient and outpatient diabetes educators. Patients are given an education and resource packet and the necessary equipment for monitoring their blood glucose and any prescriptions needed. There is also follow-up with a confirmed appointment.

Overall, Whitman said, the project has been successful and physicians have been supportive. Expanded utilization of glycemic management protocols has now spread to all surgical and medical patients.

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Reducing Injuries Related to Falls • PeaceHealth Ketchikan Medical Center

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PeaceHealth Ketchikan Medical Center Reducing Injuries Related to Falls

When Lindsay Duckworth – Project Coordinator at in the Center for Healthcare Improvement at the PeaceHealth Ketchikan Medical Center – says their staff went on a fall expedition, she isn’t talking about an outing to see the autumn leaves.

“In 2009 we noticed our injury and fall rate was 2.4 per one thousand patient days. We identified falls as something we really needed to improve.” However, she explained, it was not for lack of trying. “We were doing a lot of interventions for falls, but no matter how many root cause analyses we did, we just could not break through. So we decided to participate in the Institute for HealthCare Improvement’s ‘Reducing Falls Incidence and Injury Expedition.’”

This intensive program included six sessions over a four-month period with regular reporting and calls every other week and homework assignments in between. But, Duckworth said, it proved to be worth the investment because, “The light bulb went off for us – we learned through the process that instead of focusing on reducing falls we should be reducing injuries and looking to

see if people were high-risk for injury rather than high risk for falls.”

PeaceHealth Ketchikan is a 25-bed critical access hospital in Alaska with a connected long term care unit. Duckworth said the culture prior to the IHI expedition was long term care staff wanting to have a balance between independence and safety, and leadership throughout the hospital who believed falls should be “never events” without a distinction between preventable and unpreventable falls.

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Making this paradigm shift required training and educating the nurse managers to think differently about assessing patients before an event occurred. Other measures which they implemented included:

• use of floor mats next to the patient’s bed • purchase of ultra-low beds for surgical patients • use of helmets and hip protectors on some patients. • one-on-one sitters assigned to patients upon admission • anti-tippers for wheelchairs • teach backs

They also implemented intentional hourly rounding by the nurses to monitor for factors that can sometimes put a patient at risk for falls such as ensuring regular toileting for the patient and ensuring the patient goes to the bathroom before taking pain medication.

Physical therapists are included as part of this strategy, receiving reports on at-risk patients and performing random room checks twice a week to see that interventions are in place. They then give feedback to the nursing staff. “It has been a good collaboration between nursing and physical therapy,” Duckworth said.

One of the biggest boosts to their improvement process has been reestablishing a multi-disciplinary falls team. This group is comprised of managers and caregivers from the medical/surgical department, physical therapy, long term care, the risk manager and the vice presidents of patient care and quality. They began meeting two times a month as they implemented changes and now meet monthly to review any events and look for opportunities

for improvements. Falls are categorized as either unanticipated, such as a heart attack, or anticipated but preventable.

In November of 2010, Duckworth said they set a goal to reduce the rate of falls that result in injury by 25% by December 31, 2011. As a result of their efforts, they reduced the rate of falls

in acute care and long term care combined by 39% in a year. Their acute care has seen a 75% reduction and long term care has continued to plummet.

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Duckworth said one of the challenges they have encountered is tracking their injury assessments in the patients’ EMR. “We do not have a method right now for capturing that in our medical records. But we are going to make it a part of our future update in the system.”

However, overall everyone is quite pleased with their results. A physical therapist on the multi-disciplinary team summed up their success by saying, “It’s been a fun project to work on. But what’s even better is we will never be done. Who can complain about being part of a committee that keeps coming up with ways to keep our patients safe?”

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Engaging Patients and Families • PeaceHealth St. Joseph Medical Center • Providence Regional Medical Center

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Patient and Family Engagement PeaceHealth St. Joseph Medical Center

How do you create a sustainable and successful Patient and Family Engagement program? According to Joni Och, Director for Healthcare Improvement at PeaceHealth St. Joseph Medical Center, in Bellingham, by making your patients partners.

“They are truly partners, not telling us what to do or complaining about what we can’t do. They come with an open heart, saying ‘I want to make it better, how can I help?’ without blaming.” she said.

The hospital’s efforts started as far back as 2002 when they received a Robert Woods Johnson grant called “Pursuing Perfection” to help them launch a patient and family engagement program. They asked several former patients to participate in some of their quality efforts around specific service lines. However, she said, they were loosely organized and it was not until the hospital established the position for a Patient Experience Coordinator that the program took off. “It was our PEC who took them under her wings and got them organized. We found that having a guide and a connector to the hospital is key.”

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From there the program expanded and Och says they now have an active and engaged advisory board, whose members make sure the patient’s voice is heard. “They are our sounding board whenever we are thinking about implementing something new. It’s about how are we communicating to our patients and how they are communicating to us.”

For example, Och relates how the advisory board shaped their approach to a hand hygiene campaign. “We were going to call it ‘Ask me if I gelled.’ But one of our patient advisors asked, ‘What kind of gel are you talking about? Hair gel?’ So at their suggestion we changed it to ‘Ask Me if I Washed My Hands.’ We completely changed the posters based on their suggestion. We have realized that often the things the patients are suggesting are so much simpler than the way we were approaching it.”

PeaceHealth also includes patients on their joint quality committee and patient safety council board. In addition they have developed a Patient Ambassador Program. Former patients volunteer to sit with current patients and talk to them about their experience. This is especially beneficial with patients who are frightened or frustrated she said.

All participants in the patient engagement program are hospital volunteers who must go through the standard volunteer program and interview process. Most are patients who have come to them with concerns or suggestions, but Och cautions that it has to be a good fit. “It is important to find patients who want to make it better, not just ones with a bad experience that want to complain.”

Och admits that engaging patients and families can be daunting in the beginning, but is well worth the effort. “The result of patients being on our boards is that they become more fully engaged in the health care system and what we can do for the community partners. Even our doctors have noticed this change in their patients.

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Providence Regional Medical Center Everett Patient and Family Engagement

Sometimes good things can come out of adversity. Providence Regional Medical Center Everett‘s patient and family advisory council started 8 years ago with one adverse event and one family who decided to turn tragedy into triumph. Since then it has grown to a formal program with as many as 60 members on a variety of safety committees.

In 2005, after a patient died due to incorrect insertion of a nasogastric tube, the family approached the hospital about starting a patient advisory group. “The family came to us and said, ‘we want to see some oversight for patient safety,’” explained Paula Bradlee, Director of Organizational Quality at the hospital. “We started with a small group who we recruited by advertising in the paper and slowly gained more individuals.”

It took two years to develop the program and begin the committee, according to Bradlee. In the beginning, the group’s focus was patient safety. They were charged mostly with reviewing documents, setting up a few focus groups and sitting on a couple of committees. “But we started talking more about patient-centered care and changed the name to ‘Patient Satisfaction and Patient Experience.’”

Now it is one of the hospital’s most important groups, and patient input is a driving force behind many of the hospital’s initiatives and programs – from job interviews to design of the hospital’s new Cymbaluk Medical Tower. Patient advisory members conduct new employee tours to physicians and staff and they have been involved in Six Sigma. “My expectation is that every time we have a group that meets, we will have a patient advisor. At one point we were up to 60 people so we divided it into a committee and a board,” she said.

Bradlee said they looked at a number of other patient advisory programs before developing theirs, including the University of Washington. They also sent family members, patients, physicians and nurses to the Institute for Family Centered Care in Bethesda, MD for training.

Leadership involvement and support has been key to the program’s success as well. In 2010, Bev Johnson, President of the Institute for Patient and Family Centered Care was the guest speaker at the hospital’s leadership retreat. At the end of her presentation, Dave Brooks, who was hospital CEO at the time, stood up and spoke. “Our patient advisory committee had been slowly evolving from 2005 to 2009. But when Dave spoke to our leadership and shared his expectation that the patient advisors would be all over the hospital and in all committees, it really took off,” Bradlee said.

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Although it has expanded beyond its origins, there is still a strong safety component to the advisory council. Three patient advisors sit on the Northwest Partnership Quality group and attend the weekly meetings. They talk about adverse events such as falls, and look at whether a mediation team is needed. If so, the patient advisors become involved in that team.

And the program continues to expand; they recently added mental health, women and children and a new Providence Medical Group Advisory board. They continue recruiting new members through brochures, patient grievances and the cardiac rehab department. This year they sent representatives to the Institute for Family Centered Care and Bradlee said the participants returned excited to be involved in the program. “It’s going to be a year where we are really going to see some momentum,” she said.

As for the family who initiated the program, they are no longer involved on the council due to time commitments, however, they remain connected. The father has been a patient at Providence several times over the past few years, and recently one of the daughters contacted Bradlee. “The daughter called me over a year ago asking if there were any positions in my department because she was so pleased with the work we had accomplished.”

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Washington State Hospital Association 300 Elliott Avenue West

Suite 300 Seattle, WA 98119

phone: 206.281.7211 fax: 206.283.6122

http://www.wsha.org/partnershipForPatients.cfm