Winchester Hospital — Reducing IV-associated bloodstream infection

Executive Treatment Urged to Drive Down Infection Rates

By Jane Sherwin

Culture change requires top leadership to get engaged, collaborate with staff

Reducing catheter-related bloodstream infections remains a challenge for many hospitals. In a recent survey by the Association for Professionals in Infection Control and Epidemiology, 40 percent of respondents said their hospitals had been targeting CRBSI reduction for up to 10 years, but nearly half said CRBSI's are at least somewhat problematic at their facility and fewer than one in five reported zero infections.

Hospitals that have reduced their CRBSI rates to zero or near-zero use a straightforward five-step checklist developed by the Michigan Health & Hospital Association and Johns Hopkins University. The Hopkins checklist, as it is commonly referred to now, includes simple steps such as hand washing by all staff, but usually calls for a cultural shift toward greater equality among team members. And that requires executive commitment.

"To succeed in using the checklist, senior management needs to get visibly involved," says Gina Pugliese, R.N., vice president of the Premier Safety Institute. Pugliese suggests making scheduled rounds to the front lines to observe and offer support to staff as needed, especially in cases where physicians may resist the new process. In-house publicity is also important.

Kay Deackoff, infection prevention specialist at Winchester Hospital in Massachusetts, says the hospital went 37 months without a single ICU IV-associated bloodstream infection. "CRBSI reduction is discussed regularly at all leadership meetings and findings are cascaded to the staff level," she says. "Leaders and staff alike are empowered to make changes and implement strategies whenever appropriate for improved patient care."

South Carolina's Georgetown Hospital System reduced catheter-related infections by about five cases annually to near zero. Roy Gilbreath, M.D., vice president of medical affairs, says that CRBSI rates are followed monthly by both the hospital board and the quality council. The board delegated CRBSI reduction oversight to its harm-reduction committee.

Most implementation costs are for redesigning a process: meetings, training and monitoring for compliance, Pugliese says. Costs will vary with the size and complexity of the hospital. Gilbreath estimates Georgetown's first-year equipment expenditures at about $20,000, with half of that recurring yearly, compared with an industry estimated average cost of $30,000 per case.

The American Hospital Association is working with state associations and collaborative groups to support hospitals in CRBSI reduction. Nancy Foster, the AHA's vice president for quality and patient safety, points to the On the CUSP: Stop BSI initiative led by the Health Research and Educational Trust. HRET recently announced the availability of $5.8 million to support CUSP participants. The funds are part of an Agency for Healthcare Research and Quality grant that HRET administers.

This article 1st appeared in the September 2010 issue of HHN Magazine.

Winchester Hospital’s Hand-Hygiene Competency

An estimated 85 percent of hospital-acquired infections are due to organisms carried on the hands of personnel. As a result, Winchester Hospital has launched a hospital-wide hand hygiene competency for all employees in an effort to save patients from avoidable harm.

The competency includes reciting three opportunities for hand hygiene, communicating three infection prevention strategies (staying home if you are ill, coughing or sneezing into your elbow or sleeve, and hand hygiene), and demonstrating proper hand hygiene technique with either soap and water or alcohol-based hand gel.

To kick off the competency assessment, the hospital's senior management team had their hand hygiene practices reviewed by Pam Linzer, infection prevention specialist at Winchester Hospital. Every employee's hand hygiene competency is being assessed in their department and evaluated by a champion of Winchester Hospital's Environment of Safety Committee, a Nursing Quality Council representative, or an infection prevention champion selected within their department.

Last year, Winchester Hospital's Medical/Infectious Diseases Unit Performance Improvement Team set a goal to reduce all hospital-acquired infections due to multidrug resistant organisms (MRSA, CDIFF, VRE, or ESBL) by 50 percent (eight or more cases). Whereas 21 percent of unit employees were observed complying with hand hygiene in December 2008, the unit reached 100 percent compliance by March 2009. The monthly statistics have not fallen below 85 percent since that time.

The team achieved this goal through employee feedback, which suggested adding more Purell dispensers, making the dispensers more visible, adding wipe holders to the unit, and posting flyers about the importance of hand hygiene.
The second phase of the process, which began in April 2009, focused on the isolate practices and compliance. That month, employees of the Medical/Infectious Diseases Unit were observed complying with the use of gowns and gloves when entering a marked isolation room 50 percent of the time. Four months later, compliance had soared to 80 percent. The program is being rolled out to other units in the hospital.

Thanks to the great efforts of this team, Winchester Hospital has become a safer place for our patients and employees.

Winchester Hospital: A Focus on Outcomes

Like all hospitals, Winchester Hospital has its share of preventable harm events and, like all hospitals, it is constantly striving to improve. In 2008, Winchester Hospital experienced 108 preventable harm events in five categories: serious medication errors; surgical site infections; ventilator-associated pneumonia; falls with serious injury; and central line-associated bloodstream infections. At the close of 2010, this number had dropped to four. The goal for 2011 is zero. Winchester's passion for improvement inspired leaders at the Institute for Healthcare Improvement (IHI) to invite hospital leaders and staff to share these results at an international webinar. A team of health care leaders from Denmark that participated in the webinar subsequently sent staff members to visit Winchester Hospital to learn first-hand from our performance improvement efforts.

This article details some of Winchester Hospital's remarkable achievements.

Winchester’s Hospital to Home Care for Joint Replacement Patients

Hospital to Home Care for Elective Joint Replacement Patients

Providing high-quality post-acute care to patients recovering from an illness or injury is a critical component of the healthcare delivery system. The Medicare fee-for-service payment method has historically limited the incentive to promote integrated post-acute care where providers work together to determine the most appropriate and cost-effective care setting and then collaborate to achieve a smooth care transition.

However, a partnership between the Winchester Hospital Joint Program, Excel Orthopedics, and Winchester Home Care via a private health information exchange is changing that. Winchester Home Care is taking on reform of the current system with an integrated post-acute care management model for patients who undergo elective joint replacements.

The program was launched in 2013 with the intent of:

Breaking down post-acute care silos, and replacing them with a collaborative approach around identifying which patients are appropriate for each post-acute care setting.
Reducing rehabilitation stays and increasing the rate of discharges to home after elective joint replacement surgery.
Creating a post-acute care system that is more patient centered and that reduces the need for emergent care and rehospitalization.

An initial team identified technology (including a mechanism to communicate patient information via a secure system) and education (of all parties, including the patient) as central to the project's success.

The project launch was aided by a grant of $75,000 from The Massachusetts eHealth Institute that supported efforts to improve communication and enhance the efficiency of workflow between the orthopedic practice, pre-admission testing, and home care. In the planning phase of the eHealth project implementation, the home care team worked to begin the shift towards enabling more patients to go directly home from their surgical inpatient stay. The Mass HIway was used beginning in May 2014 and provided a seamless approach to communicating information, eliminating the manual processes set up during the implementation phase.

Critical to the effort was the identification of patients who are appropriate for discharge directly home versus a transfer to a skilled nursing facility. One of the mechanisms used to determine this for some patients is RAPT (Risk Assessment and Prediction Tool), developed by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. This tool helps determine whether a patient is a suitable candidate for an integrated program, which enables the patient to be discharged from a hospital directly to their home.

In addition, the use of a secure electronic communication system triggers a process by which an increased number of patients are enrolled in Winchester Hospital pre-surgical education (Joint Class). By increasing the number of participants in this Joint Class, patients are better educated on their options for post-acute care, with an emphasis on the option of going directly home with services after their inpatient stay. The added feature of having this secure electronic communication is that upon discharge from home care, certain clinical documents can be sent to the orthopedic office, allowing the surgeon to review the patient's progress with recovery.

The team was able to shift significantly the percentage of patients who were discharged home from their surgical inpatient stay versus discharge to a skilled rehab facility. This shift began during the planning phase for the Mass HIway implementation project and, to date, reflects a 30% increase in these patients receiving their post-surgical care at home.

According to Karen Keaney, director of Winchester Home Care, "This program has resulted in a significant increase in patients' electing to receive their post-hospitalization services in the home care setting as compared to a rehabilitation facility. Our patients have benefited from the partnership between the orthopedic practice, hospital, and home care as evidenced by excellent clinical outcomes, and, most notably, a zero readmission rate for patients admitted directly to home care from inpatient surgical hospitalization."

From Multiple Angles, Readmission Rate are Decreasing

A variety of different measures all point to one inescapable fact: readmissions of Medicare patients at Massachusetts hospitals are steadily decreasing, according to a new MHA analysis.

Statistics over the past decade show that Massachusetts hospitals, as well as hospitals nationwide, over the past decade at first had incremental improvements in readmissions before experiencing a significant drop beginning in 2012. The improvements may be due to the increased focus on the issue that hospitals undertook in response to Medicare readmission penalties that the federal government instituted in recent years.

The data shows that readmissions held steady for about seven years and then beginning in 2012, and continuing in 2013, readmissions declined distinctly. (The 2012-to-2013 decrease was slower than the 2011-to-2012 decrease, however.)

Another measure, which focuses on "all-cause" readmissions and not just those confined to heart attack, heart failure, and pneumonia patients, shows Massachusetts readmissions dropping 1.9% in 2013 versus 2012.

Yet another source of data - "Medicare 30-day unadjusted all cause readmission measures for fee-for-service beneficiaries of all ages" - was developed by CMS to help target geographic variation in care. MHA's analysis of this data showed Massachusetts readmission rates went from 8.1% above U.S. rates in 2008 to 2.3% above in 2013. Readmissions per 1,000 beneficiaries dropped for five consecutive years in both Massachusetts and the U.S., and at a continuously acclerating pace. Readmissions and readmissons per 1,000 beneficiaries dropped more than 20% from FFY 2007 to FFY 2013 in both Massachusetts and the U.S.

David Smith, MHA's Senior Director, Health Data Analysis & Research, says, "The decline in Medicare readmissions may have been caused by care improvements - such as better case management, improved care transitions, and coordinated care practices - that were incentivized by payment reforms such as the Medicare Readmission Reduction Program."

In 2013, MHA's Board of Trustees challenged all hospitals to reduce readmission rates by 20% over the next three years, and MHA has been leading the effort to bring providers together to share strategies of what works to reduce re-hospitalizations.

But lowering readmissions is not always easy. Patients move from one setting of care to another or to one set of care providers to another during an episode of illness. As patients and families navigate across new care settings and among different care providers, they often encounter communication challenges and confusion around who is clearly accountable for their care. This can lead to medical errors, duplication, increased costs and, sometimes, higher rates of re-hospitalization.

Scholarship has also demonstrated that hospitals serving socioeconomically disadvantaged populations incur more readmission penalties than other hospitals. Because poorer people may find it hard to fill prescriptions, adhere to complex post-hospital care regimens, and travel to outpatient clinics, their chances for readmissions increase. Reducing funding to hospitals that serve the poor creates a situation, according to recent studies, whereby access to care for the poor is reduced.

Brigham’s DASH Initiative Reduces Readmissions

The percentage of patients admitted to a hospital with a mental health condition - either as a primary or a secondary diagnosis - is rising and often these patients experience delirium, alcohol withdrawal and suicide harm (DASH), which put them at an increased risk for higher-than-average readmission rates.

In a new report in the July 2015 edition of The Joint Commission Journal on Quality and Patient Safety, clinicians at Brigham and Women's Hospital (BWH) describe the implementation and effectiveness of a hospital-wide clinical improvement initiative for acute care patients at risk for DASH and demonstrate its effectiveness in reducing readmission rates.

The population-based effort implemented across all departments at BWH enhanced screenings for DASH. These screenings were accompanied by the adoption of new care management guidelines to effectively address patients who were identified as being at risk for these conditions.

"Patients with a DASH diagnosis can be found anywhere in the hospital, so it was important to include our entire patient population in our efforts," said Barbara E. Lakatos, DNP, PCNS-BC, APN, program director of the Psychiatric Nursing Resource Service at BWH and the lead author of the paper. "If not appropriately identified and treated, delirium can lead to negative outcomes and poor quality of life for those affected."

The care improvement process consisted of the development of guidelines; implementation/rollout; integration into practice; and ongoing practice development and evaluation. In 2009, an interprofessional task force comprised of hospital leadership, physicians, nurses, and other healthcare professionals conducted a literature review to identify existing evidence-based assessment tools focused on DASH symptoms and also reviewed existing hospital policies and best practices to guide the new hospital-wide program.

After screening and care guidelines were developed, Lakatos and her colleagues embarked on a hospital-wide effort to integrate them into the clinical workflow in 2010. Training videos, resource manuals and role-playing workshops were developed and assessment tools were embedded into nursing and medical workflows in stages, starting with pilot units and later being adopted across the entire hospital.

"Whenever a patient was identified as high risk for DASH, we convened an interdisciplinary care team for a discussion about the best approach for that patient," said Adam C. Schaffer, MD, hospitalist at Brigham and Women's/Faulkner Hospitals and co-author of the report. "Although we established guidelines, the approach for each patient was personalized and directed by the collaborative care team with consideration of the patients' individual health history and symptoms."

An assessment of the DASH population at BWH was conducted pre- and post-program implementation (from FY 2010 to FY 2013) to measure its effect. All inpatients were included with the exception of neonatal and hospice patients. This assessment showed the volume, average length of stay, clinical service line, discharge location and 30-day admission rate of DASH patients. Lakatos and her colleagues found that while the DASH population increased by one percent from 2012 to 2013, the 30-day readmission rate decreased by nine percent from 2010 to 2013.

David Gitlin, MD, chief of the division of medical psychiatry at Brigham and Women's/Faulkner Hospitals and co-author of the paper, said, "A key reason for these positive results is that our DASH program was embedded in the clinical culture at the Brigham. Successful implementation and sustainability in other organizations will similarly require aligning with processes and resources already in place."

Cambridge Health/Hallmark Health Reduce Readmissions

Cambridge Health Alliance (CHA) and Hallmark Health, in collaboration with Somerville Cambridge Elder Services and Mystic Valley Elder Services, are among the top performers in an innovative national pilot program to reduce hospital readmission rates.

The four organizations, known collectively as the Mystic Valley Community-Based Organization, joined 71 other community-based organizations (CBOs) across the U.S. in the Centers for Medicare & Medicaid Services (CMS Community Care Transitions Project (CCTP) in 2012.

According to early findings by the CCTP, the Mystic Valley group reduced 30-day readmission rates in certain high-risk patient populations by nearly nine percent over a two-year period, ranking among the best improvements nationally.

The CHA component of the project, known as the Hospital-to-Home Program, includes both CHA’s Cambridge and Whidden Hospitals. At both hospitals, transition facilitators meet with patients before discharge to learn about their healthcare needs and assess their home care requirements. This is followed up with home visits from a transition facilitator or a nurse practitioner within 48 hours of discharge. Ongoing phone calls allow the team to further monitor patients’ health. Hallmark Health uses a similar “health coach”/transition facilitator model, and sends hospital nurse practitioners to visit with newly discharged patients in the home or other care settings, such as a nursing home or rehabilitation facility. Nurse practitioners can write prescriptions and adjust medications and treatment plans in collaboration with the patients’ primary care providers.

“Between the transition facilitators and the nurse practitioners we are able to identify indicators that could eventually lead to a readmission and take immediate corrective action,” said Cheryl Warren, MS, RN, chief clinical integration officer at Hallmark Health. “The new teams can assess social and physical triggers and make adjustments to medications and treatments in real time in the patients’ home or care facility, keeping patients home, healthy and well cared for.”

“We have learned that providing excellent health care necessitates supporting our patients in their homes and community,” said Rich Balaban, MD, medical director of CHA’s Hospital-to-Home Program. “Our partners have enabled us to extend our reach so that together, we now provide a broad range of community-based medical and home care services. We are proud of the progress we have made and the many lives we have improved.”