© 2019, Telligen, Inc.

This material was prepared by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. This material is for informational purposes only and does not constitute medical advice; it is not intended to be a substitute for professional medical advice, diagnosis or treatment. 12SOW-QIN-QIN-12/26/19-3552

© 2018, Telligen, Inc.

Gina Anderson, RN, BSN

Senior Quality Improvement Facilitator

Sepsis Prevention: Three Part Series - Part One

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Zoom Chat Function

Open Chat

To open chat, hover over the bottom of the meeting screen

and click on the chat icon

Be sure to enter your name, title, and organization into the

chat box

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▪ In chat type in the following:

– Organization name and state

– How many are in your group?

▪ Be engaged

▪ Limit multitasking

▪ Come prepared

▪ Be ready to share – use chat or press *6 to speak verbally

Sepsis Prevention Series: Part One

Housekeeping

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Agenda

Topic Who Time

Introduction Gina 5 minutes

Presentation – Sepsis Overview

and Hand Hygiene

Gina 35 minutes

Discussion/Questions Everyone 15 minutes

Next Steps/Action Period Gina 5 minutes

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▪ Understand the impacts of sepsis

▪ Identify measures to prevent sepsis

▪ Recognize hand hygiene as the number one prevention strategy

▪ Implement a program to improve hand hygiene compliance

▪ Provide tools to utilize during the action period

Objectives

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CMS 483.80 Infection Control

▪ The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

▪ (a) Infection prevention and control program. The facility must establish an infection prevention program (IPCP) that must include, at a minimum, the following elements:

▪ (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes

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CMS Infection Control (continued)

2) Written standards, policies, and procedures for the program, which must include, but are not limited to:

▪ 1. A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility;

▪ 2. When and to whom possible incidents of communicable disease or infections should be reported

▪ 3. Standard and transmission-based precautions to be followed to prevent spread of infections;

▪ 4. When and how isolation should be used for a resident; including but not limited to:

– The type and duration of the isolation, depending upon the infectious agent or organism involved, and

– A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.

▪ 5. The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and

▪ 6. The hand hygiene procedures to be followed by staff involved in direct resident contact.

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▪ Sepsis is the body's systemic inflammatory response to

an infection – bacterial, viral or fungal

▪ Sepsis happens when an infection you already have triggers a chain reaction throughout your body

▪ Sepsis is serious, overwhelming, and sometimes life-threatening

▪ Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death

Sepsis is:

https://www.cdc.gov/sepsis/what-is-sepsis.html

https://www.mayoclinic.org/diseases-conditions/sepsis/symptoms-causes/syc-20351214

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▪ Sepsis is a toxic response to an infection

▪ Sepsis occurs when your body starts to attack itself rather than the infection

▪ You must have an infection to have sepsis, but the infection isn’t always identified

Why Does Sepsis Occur?

https://www.sepsis.org/sepsis-in-the-news/what-is-sepsis-what-it-is-and-what-it-isnt/

This Photo by Unknown Author is licensed under CC BY-ND

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▪ When a resident is hospitalized with a primary diagnosis of

infection, the mortality rate can reach as high as

▪ Infections account for up to half of nursing home resident

to the hospital and cost between

$670 million to $2 billion each year

▪ Sepsis begins outside of the hospital for nearly of patients

▪ Sepsis is the leading cause of hospital

Infection and Sepsis Facts

http://www.cdc.gov/vitalsigns/sepsis/index.html

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Among adults with Sepsis:

▪ 35 percent had pneumonia or respiratory infection

▪ 25 percent had a urinary tract infection

▪ 11 percent had a GI infection

▪ 11 percent had a skin infection

Sepsis Facts:

http://www.cdc.gov/vitalsigns/sepsis/index.html

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▪ Many survivors of sepsis recover completely

▪ Consequences may include:

– Physical impairment

– Sepsis-induced inflammation and cardiovascular risk

– Sepsis-induced immunosuppression

– Long-term morbidity

– Loss – limb, self-esteem

Long Term Consequences of Sepsis

https://www.cdc.gov/sepsis/life-after-sepsis/index.html

This Photo by Unknown Author is licensed under CC BY-ND

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▪ A number of infections, if caught early, may be treated in the nursing home

▪ Transfer to a hospital emergency department can cause problems including translocation trauma and colonization with drug resistant bacteria

Early Identification is Key

https://www.cdc.gov/media/releases/2017/p0831-sepsis-recognition-treatment.html

“The only way to prevent sepsis is to prevent infections from occurring in the first place.”

https://www.sepsis.org/news/what-is-sepsis-what-it-is-and-what-it-isnt/

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Critical Element Pathways▪ Form-20053 Dining

▪ Form-20054 Infection Prevention and Control

▪ Form-20056 Med Administration

▪ Form-20061 Environmental

▪ Form-20062 Sufficient and Competent Staff

▪ Form-20066 Kitchen

▪ Form-20068 Urinary Catheters or UTI

▪ Form-20078 Pressure Ulcers

▪ Form-20123 Hospitalizations

Sepsis Prevention is Linked to the CEPs

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

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▪ Prevent infections by following infection control practices including:

– Hand hygiene

– Catheter removal

– Ensuring patients receive recommended vaccines

▪ Educate your patients and their families

▪ Initial screening by the nursing care staff is critical to determine if there are any sites for infection

Prevention Strategies

https://www.cdc.gov/sepsis/education/hcp-resources.html

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Infection Prevention

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Hand hygiene is one of the most important ways to prevent the spread of infections

Prevention Strategy and Hygiene

https://www.cdc.gov/sepsis/prevention/index.html

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The most common mode of pathogen transmission is hands

▪ Infections acquired in healthcare

▪ Spread of antimicrobial resistance

Full adherence to hand hygiene standards is performed less than 40% of the time

An Uncomfortable Truth

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3249958/

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▪ Confirm staff has access to hand hygiene standards of practice

▪ Confirm hand hygiene performed appropriately for situations

Guidance to Surveyors for LTCF

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

Did staff implement appropriate hand hygiene?

This Photo by Unknown Author is licensed under CC BY

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▪ Before and after contact with a resident

▪ Before donning gloves

▪ Before performing an aseptic task

▪ Before meals

▪ After contact with blood, bodily fluids, visibly contaminated surfaces or objects in the resident’s room

▪ After removing personal protective equipment (gloves, gown, facemask)

▪ After using the restroom

▪ When hands are visibly dirty

When to Perform Hand Hygiene

World Health Organization 5 Moments for Hand Hygienehttp://www.who.int/gpsc/5may/background/5moments/en/

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The rubbing hands together for 15-20 seconds with soap and water, followed by

rinsing under a stream of water

Hand Washing

Guideline for Hand Hygiene in Health-Care Settings https://www.cdc.gov/handhygiene/providers/guideline.html

CDC fight Germs. Wash Your Hands! video https://www.cdc.gov/cdctv/healthyliving/hygiene/fight-germs-wash-hands.html

This Photo by Unknown Author is licensed under CC BY-SA-NC

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▪ A 60-95 percent ethanol or isopropyl alcohol containing preparation base designed for hand application to reduce the number of viable microorganisms

▪ Benefits to promote hand hygiene adherence:

– Less time

– More effective

– Greater decrease of bacteria on hands than soap and water

Alcohol Based Hand Rub

This Photo by Unknown Author is licensed under CC BY

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Use Soap and Water▪ When hands are visibly dirty

▪ After known or suspected exposure to C-diff if your facility is experiencing an outbreak or higher endemic rates

▪ After known or suspected exposure to patients with infectious diarrhea during norovirus outbreaks

▪ Before eating

▪ After using the restroom

▪ If exposure to Bacillus anthracis is suspected or proven

Use an ABHR▪ For everything else

Soap and Water vs. Alcohol Based Hand Rub (ABHR)

https://www.cdc.gov/handhygiene/providers/guideline.html

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▪ Handwashing agents cause skin irritation and dryness

▪ Sinks are inconveniently located, or lack of sinks

▪ Lack of soap and paper towels

▪ Too busy/insufficient time

▪ Understaffing/overcrowding

▪ Patient needs to take priority

▪ Perceived low risk of acquiring infection from patients

What Keeps Us From Adherence?

http://www.idpublications.com/journals/pdfs/jhi/jhi_mostdown_1.pdfhttps://apic.org/resources/topic-specific-infection-prevention/hand-hygiene/

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Mitigation Steps to Your Hand Hygiene Program

Accessibility of hand hygiene

Facility policy

Staff training and competency

evaluation

Staff performance

Provide feedback

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Assess the Accessibility of Hand Hygiene

▪ Soap, water and paper towels are available in all resident care areas

▪ ABHR is available in all resident care areas (place outside of each resident room/pocket sized containers)

▪ Other supplies necessary for standard precautions (i.e. gloves)

Step One

This Photo by Unknown Author is licensed under CC BY-SA-NC

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Assess Facility Policy

▪ Make improved hand hygiene an institutional priority!!

▪ Policies promote use of alcohol-based hand rub over soap and water in most clinical situations

▪ Should follow evidenced based guidance (CDC Hand Hygiene Guidelines)

Step Two

This Photo by Unknown Author is licensed under CC BY-SA

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Assess Staff Training and Competency Evaluation

▪ All personnel receive training and competency validation on HH at the time of employment

▪ All personnel received training and competency validation on HH within the past 12 months

Step Three

This Photo by Unknown Author is licensed under CC BY-NC

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Hand Hygiene Training

CDC Hand Hygiene Traininghttps://www.cdc.gov/handhygiene/providers/training/index.html

Wash Your Hands: It Just Makes Sense https://www.youtube.com/watch?v=M8AKTACyiB0

Hand Hygiene and Glove Usage https://www.youtube.com/watch?v=9R8fHo6WfzY&feature=youtu.be

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Hand Hygiene Competency

https://www.hse.ie/eng/about/who/healthwellbeing/infectcont/sth/resources/hhassess/knowledge-assessment-and-competency-tool-2014.pdf

https://spice.unc.edu/wp-content/uploads/2017/03/Hand-Hygiene-Competency-SPICE.pdf

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Assess Staff Performance

▪ The facility routinely audits adherence to HH (monitors and documents)

▪ Performance is recorded

▪ Audits occur with all staff and all shifts for several activities

▪ Report of performance are provided to the QAPI committee to assist with necessary support

Step Four

This Photo by Unknown Author is licensed under CC BY

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▪ Directly observing

▪ Measuring product use

▪ Conducting surveys

Methods for Measuring Hand Hygiene

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Reporting both process and outcome measures to the QAA and QAPI team for hand hygiene practices

▪ Examples of process measures: – Compliance with educational program

– Compliance with documentation of hand hygiene audits

– Compliance with documentation of compliance with timing

▪ Examples of outcome measures:– Rates of hand hygiene compliance

– Rate of sepsis occurrences secondary to health-related infections

– Readmission rates secondary to health-related infections or sepsis occurrences

Internal Reporting

https://www.cdc.gov/infectioncontrol/guidelines/cauti/implementation-audit.html

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Rate Equation Examples

Prevalence rates

(# of residents with infections) / (# of residents) X 100

= _____% of infections per # of residents

Calculation of infection rates

(# of infections) / (avg. # of resident census) X (days in the month) X 1000 =____infections per 1000 resident days

Compliance/performance rates

(# times practice is performed correctly) / (# of opportunities to perform the practice) X 100 =___% of compliance rate

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Monitoring Tool

Download from the

App Store

https://vinci.cs.uiowa.edu/scrubwatch/iscrub.php

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Entering Observations

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Provide Feedback

▪ Provide feedback to personnel regarding their HH performance

▪ Provide just-in-time training for staff not following the policy

▪ Results from step four and five incorporated back into step three

Step Five

39https://www.vumc.org/handhygiene/23196

Vanderbilt Health Receives National Designation for Excellence in Infection Prevention https://www.newswise.com/articles/vanderbilt-health-receives-national-designation-for-excellence-in-infection-prevention

8 Ways Vanderbilt UMC Raised Hand Hygiene Compliance https://www.beckershospitalreview.com/quality/8-ways-vanderbilt-university-medical-center-raised-hand-hygiene-compliance.html

Hand washing: How one hospital achieved nearly 100% compliancehttps://www.healthcarebusinesstech.com/hospital-hand-washing/

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Hand Hygiene Saves Lives

This Photo by Unknown Author is licensed under CC BY-NC

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Questions

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▪ Meet as a team – determine a time to meet one or two times per

week for discussion during action periods of the three-part series

▪ Review steps one through five of the handouts – determine

areas that need mitigation in gaps recognized

▪ Download the iScrub App – use this to monitor staff

performance during the action period as noted in step four

▪ Monitor 10 or more hand hygiene performances by sepsis series part two – determine who will do the ongoing monitoring

▪ Seek new opportunities - promote hand hygiene to residents,

their families, volunteers, and your staff using the resources provided in the slides

▪ Be prepared to share your action items during Sepsis Series part 2

Next Steps for Action Period

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Hand Hygiene Resources

▪ Telligen Hand Hygiene resources https://www.telligenqinqio.com/?s=hand+hygiene

▪ Change Package Attachment 4 https://telligenqinqio.com/resource/national-nursing-home-

quality-care-collaborative-change-package/

▪ Hand Hygiene in Healthcare Settings https://www.cdc.gov/handhygiene/

▪ CDC Hand Hygiene: 5 Facts https://www.cdc.gov/handhygiene/patients/index.html

▪ Wash Hands Posters https://www.cdc.gov/handwashing/posters.html

▪ The Safety Stand-Down: a technique for improving and sustaining

hand hygiene compliance among health care personnel https://psnet.ahrq.gov/resources/resource/32190/The-safety-stand-down-a-technique-for-improving-and-

sustaining-hand-hygiene-compliance-among-health-care-personnel

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▪ CMS Hand Hygiene Video https://www.cms.gov/Outreach-and-Education/Medicare-

Learning-Network-MLN/MLNProducts/MLN-Multimedia-Items/2017-06-28-Infection-Control.html

▪ Dirty Hands Can Be Scary http://www.dirtyhandscanbescary.com/

▪ How To Guide: Improving Hygiene http://www.ihi.org/resources/Pages/Tools/HowtoGuideImprovingHandHygiene.aspx

▪ Hand Hygiene Observation Training Toolkit http://atomalliance.org/wp-

content/uploads/2016/06/Hand-Hygiene-Observation-Training-Toolkit.pdf

▪ Measuring Hand Hygiene Adherence: Overcoming the Challenges https://www.jointcommission.org/topics/hai_hand_hygiene.aspx

Hand Hygiene Resources Continued

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▪ Sepsis Among the Elderly Toolkit https://www.telligenqinqio.com/resource/our-work/sepsis/sepsis-resources/sepsis-among-the-elderly-toolkit/

▪ Telligen Sepsis Resources https://www.telligenqinqio.com/?s=sepsis

▪ Test Your Knowledge: Sepsis Quiz https://www.telligenqinqio.com/our-work/care-

coordination/sepsis-quiz/

▪ CHA Sepsis Training Suite https://cha.com/quality-patient-safety/sepsis/cha-sepsis-training-

suite/

▪ Stop Sepsis Now https://atlanticquality.org/initiatives/sepsis-initiative/

▪ The Rory Staunton Foundation for Sepsis Prevention https://rorystauntonfoundationforsepsis.org/

▪ Sepsis Alliance https://www.sepsis.org/itsabouttime/

▪ Agency for Healthcare Research and Quality https://www.ahrq.gov

Sepsis Resources

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– January 8 @ 11:00am - 11:30am CST/10:00am – 10:30am MST https://www.telligenqinqio.com/event/community-coalition-kickoff-events/

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▪ Sepsis Prevention: Three Part Series – Part 2– February 4 @ 1:30pm - 2:30pm CST/12:30am – 1:30pm MST

https://www.telligenqinqio.com/event/sepsis-prevention-in-your-nursing-home-three-part-series-2/

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Telligen QI Connect™ Team

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Thank You!

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Please complete the evaluation coming to you by email!

Gina AndersonSenior Quality Improvement Facilitator

gina.anderson@telligen.com515-223-2127