Evidence-Based Practice Drives Improvement

By Kelly M. Pyrek

Teamwork and a multi-modal approach to infection prevention and control were the driving forces behind positive change and improved patient outcomes at several institutions that were honored in late 2014 by the Fine Foundation and the Jewish Healthcare Foundation (JHF). The Fine Awards for Teamwork Excellence in Health Care recognized frontline workers in the greater Pittsburgh, Pa. area who elevate and disseminate best practices in infection control - a quality measure that influences whether providers receive incentive payments or incur penalties from the Centers for Medicare and Medicaid Services (CMS).

"Infection control prevents unnecessary pain, expense and death," says Milton Fine, chairman of the Fine Foundation. "Working together with the energy, the creativity and the enthusiasm that we celebrate, we can reach clarity, sanity and effectiveness in our healthcare."

"The recent Ebola outbreak in Africa, and isolated cases in the U.S.," says JHF president and CEO Karen Wolk Feinstein, PhD, "has raised public awareness of the need to control infection, but this certainly is not a new issue - healthcare-associated infections (HAIs) have been a major threat to patient safety since there was health care. We do, however, know that most HAIs can be prevented through strict adherence to evidence-based practices - JHF's Pittsburgh Regional Health Initiative (a regional health improvement collaborative that is an operating arm of the foundation) has demonstrated that quite successfully in a number of settings. Progress has been made in HAI prevention; but there is still much room for improvement.

Fine Awards winners, chosen by a national panel of experts, were required to demonstrate evidence of sustainable quality improvement. Let's take a look at the initiatives of three winners in the infection prevention category.

Allegheny Health Network/Allegheny Valley Hospital
The Platinum Award winner is Allegheny Health Network/Allegheny Valley Hospital for their initiative, "Eliminating Hospital-Acquired Clostridium difficile Infections." Allegheny Valley Hospital (AVH) in Natrona Heights, Pa. is a 228-bed hospital that serves as an inpatient facility and offers a broad spectrum of programs, including medical and surgical services, inpatient psychiatric care and geriatric psychiatric care, cardiology, orthopedics and cancer care. It is part of the group of Allegheny Health Network of hospitals.

Front row: Esther Atwood, AVH vice president of patient care services and chief nursing officer; Diane Lang, AVH infection preventionist; Renee Mackenzie, AVH clinical pharmacist; Gwyn Weil, AVH director of quality; Sheila Fine.­ Back row: Russ Livingston, chairman of the AVH board of directors; Margaret Meals, MD, AVH chief medical officer; Milissa Hammers, nurse manager of AVH Orthopedics; Karen Feinstein, president and CEO of Jewish Healthcare Foundation; and Milton Fine, chairman and president of The Fine Foundation. Photo by Renee Rosensteel 

Gwyn Weil, RN, BSN, director of medical staff performance improvement for Allegheny Valley Hospital and Allegheny Health Network, de-scribes the scope of her institution's challenges regarding C. difficile infections: "Clostridium difficile infection (CDI) is one of the most common hospital-acquired infections and has been steadily on the rise over the last decade based on the CDC statistics.  As a result of this national trend and our own increase in the CDI rate to 15.6 in fiscal year 2009, AVH identified CDI prevention as a priority quality objective and ramped up efforts starting with the assembly of a multidisciplinary team to lead efforts to reduce/eliminate the risk and incidence of CDI. There is a high volume of high-risk and/or immuno-suppressed patients from our cancer program and our SNF population. Additionally, there was no focused team effort focusing on the CDI problem."

Weil says that they conducted an extensive literature review to establish current evidence-based best practice standards in CDI prevention. "These standards were divided into 'core' and 'supplemental' strategies based on the level of evidence," she says. "Core strategies had high levels of scientific evidence and demonstrated feasibility. Supplemental strategies had some scientific evidence and variable levels of feasibility. A gap analysis was completed to compare our current activities against the core and supplemental best practice. The CDI team conducted a thorough risk assessment to identify the most significant issues based on the gap analysis, patient populations and analysis of CDI data from each nursing unit. A written action plan was established, implemented and is updated on an ongoing basis to reflect changes in best practice and internal findings."

Armed with this knowledge, Allegheny Valley Hospital also identified opportunities for improvement in areas such as environmental cleaning, hand hygiene, and C. diff testing, as well as education of patients, families and employees throughout the facility.
The first core strategy, environmental disinfection, included the following actions and initiatives, according to Weil:
• Established a systemwide environmental cleaning subcommittee which is chaired by the infection preventionist from AVH.
• Practices include daily and terminal room cleaning using bleachcontaining disinfectant, but the facility has recently converted to a peracetic acid-based disinfectant due to the effect that the bleach agent was having on equipment and mattresses.
• Cubicle curtains are washed during the terminal room cleaning process for isolation rooms.
• All pull cords in the patient rooms were changed from cloth cord to a plastic cord to improve the ability to clean.
• Implemented microfiber mop heads which are changed after cleaning each patient room.
• Multiple and ongoing education of the environmental services staff to reinforce adequacy of daily and terminal room cleaning with focus on hightouch surfaces and bathroom.
• Room cleaning inspections were implemented with immediate staff feedback.

AVH also developed a "bag it, tag it, rag it" protocol, in which all equipment is cleaned and tagged before it is delivered to the next user to indicate that it has been disinfected properly. If the equipment is too large to be bagged, staff will tag it with a 'clean' label; a piece of equipment that is not bagged or tagged, is assumed by staff to be dirty, so they "rag it" using disinfectant wipes.

The second core strategy, according to Weil, is hand hygiene compliance and included the following actions and initiatives: 
• Implemented a system-wide multi-disciplinary Clean Hands Collaborative  
• Completed a hospital-wide assessment of the locations of all hand sanitizer dispensers and installed additional dispensers to ensure that all healthcare workers had access to alcohol-based hand sanitizer at all points of patient care. Since alcohol-based sanitizer does not kill C. difficile, the dispensers were labeled “Not for Use With Patients With C. diff.” The facility changed the policy that if a sink was not readily available, alcohol-based sanitizer could be used before exiting room to an area where soap and water could be used. 
• Implemented new CDI teaching materials for patients/families which addresses hand hygiene. Weil says, "We developed a new, more patient/family friendly education tool which includes general information about C. diff, importance of hand hygiene and also conveys information about treatment, preventing transmission and what a positive C. diff patient needs to do once discharged to home."  
• New hand hygiene reminder posters were developed and placed throughout all patient-care areas.  Posters are exchanged with new versions every six months. Some hand hygiene reminder posters were developed for non-patient-care areas such as break rooms that provided a much more direct message to employees.
• Hand hygiene compliance monitoring was ramped up using a “secret shopper” process in the patient-care areas. Auditing is also completed by the unit managers and coordinators as well as the Safety Rounding Team.  The facility also implemented the iScrub app on the orthopedic unit. The Clean Hands Team is currently assessing other options for monitoring hand hygiene.
• Incorporated hand hygiene compliance of physicians and allied health professional in OPPE. Also, the chief medical officer promptly addresses any non-compliance issues with physicians and allied health
• Hand hygiene compliance data is aggregated and graphed by department for review, action and display in each patient-care area.   
• Unit and personal hand hygiene pledges were initiated.

Surveillance was critical to AVH's success, Weil says, adding, "Surveillance is a key component of a successful CDI program. Our facility uses Theradoc® Infection Control Assistant to identify and confirm CDI cases in real time, spots trends, speed up interventions, simplify reporting and provides views to help understand transmission of pathogens between patients. Testing is also a key component of a CDI program. AVH introduced Cepheid RT-PCR testing for CDI in March 2012. The PCR test is much more sensitive and specific and provided us with a shorter turnaround time for results. Positive results are reported immediately to the nursing unit and infection preventionist. A new C. difficile testing protocol was also implemented in conjunction with the new PCR testing to ensure the appropriateness and adequacy of the specimen."

Weil adds, "It's well known that antibiotic utilization is probably a primary contributor to patients developing C. diff. Pharmacy has played a huge role in this collaborative effort to reduce C. diff in our institution. Our pharmacy monitors all antibiotic use within the hospital so our goal is to have patients who need antibiotics on the most appropriate antibiotic for the shortest amount of time necessary."

AVH was able to reduce the C. diff infection rate from almost 15.6 percent to below 2.58 percent. Weil attributes their success to communi-cation and follow through: "We used a number of forums to ensure implementation of CDI best practices throughout the hospital including unit-based education, our annual Performance Improvement Fair, communications from AVH's CDI Team, participation in webinars and visual aids such as posters. Practices pertaining CDI prevention are monitored regularly through the unit managers, the Safety Rounding Team and daily rounding by Infection Prevention. A weekly and monthly Quality Scorecard which includes hospital-acquired CDI cases and rate is widely disseminated and posted in each department so every employee has regular access to our performance. There is a monthly nursing unit-based scorecard distributed that breaks down the occurrences by department. The Infection Control, Performance Improvement, Medical Quality, Operat-ing Room and Pharmacy & Therapeutics Committees are also forums where CDI strategies are discussed and conveyed. There has been a high level of interest and support from the hospital and health system’s leadership regarding this initiative."

Weil adds, "AVH's CDI team works in collaboration with the AHN CDI Collaborative, both sharing and receiving CDI reduction strategies.  AVH also participated in a state-wide CDI Collaborative through Quality Insights of Pennsylvania (QIP) and received an award from QIP for the great-est state-wide reduction in CDI in May 2014. We were invited to share our CDI practices and success factors at a QIP-sponsored webinar."

Cultivating teamwork and collaboration among the various stakeholders to address C. diff required that AVH have a team leader that is ex-perienced in process improvement and driving change, as well as possess clarity on the role and expectations of all team members. The institution also had to
demonstrate that each team member's viewpoint and input was valued, Weil says. 

Weil provides the following advice to other institutions wishing to improve patient outcomes and reduce their infection rates:
• Establish a team with key stakeholders i.e., nursing, pharmacy, infection control, environmental services, laboratory, education; set expec-tations for consistent participation.
• Communicate importance of initiative and impact to patients
• Identify and implement core prevention strategies
• Monitor adherence, on an ongoing basis, to core prevention strategies
• Complete a root cause analysis of each CDI case to identify improvement opportunities
• Communicate results
• Celebrate successes

St. Clair Hospital
The Gold Award winner was St. Clair Hospital located in Pittsburgh, Pa. for the initiative, "Surgical Site Infection Prevention." Bob Kovatch, MPT, MBA, director of orthopedics at St. Clair Hospital, explains that the institution identified the need for some standardization among its operative processes along the entire spectrum of preoperative, intraoperative and postoperative. "Based on our own research and the recommendations of an onsite consultant and working with our own surgeons and clinical staff, we were to develop a preoperative optimization process initiative."

Pictured left to right: Laura Morris, senior infection preventionist; Marge Mignogna, manager of the 6E medical-surgical nursing unit; Bob Kovatch, director of the orthopedic service line (and team leader); Steven Colodny, MD, infectious disease; Diane Puccetti, director of perioperative services; Bonnie Widenor, chief CRNA; Milton Fine, chairman of The Fine Foundation; Sheila Fine, of the Fine Foundation; Karen Wolk Feinstein, president and CEO of Jewish Healthcare Foundation.

Kovatch continues, "Generally speaking, standardization reduces the opportunity for error. Decreasing variability in the care delivered to pa-tients within a defined criteria set will minimize the chance that an essential step will be inadvertently missed, leading to an unfavorable out-come. This is important with any patient population since any error or omission has the potential to have an impact] on clinical outcomes."

A key component to cultivating change at St. Clair's Hospital was involving patients in SSI prevention efforts. "Patients play a key role in the ultimate success of any surgical procedure. There are things they can and should be doing to help minimize their risk of infection, such as completing all pre-operative screening and employing the skin preparation regimen at home before they even enter the hospital for surgery. Patients must be educated on what they can do, exactly how to do it, and why it is important. They must be given both the knowledge and the resources to accomplish their part in SSI prevention. Absent of these things, patients may be less likely to follow-through on doing their part. That is why St. Clair Hospital partners with our physician offices in providing not only education, but also the tools necessary to accomplish their role, such as the antiseptic wipes to be used at home." 

The process starts with the surgeon discussing with the surgical patient the best ways to minimize infection, including preoperative skin cleansing with antiseptic wipes the night before and the day of surgery. The process continues with surgical patients being screened to ensure that their lab values are where they need to be, that they have optimized their nutrition, and they have no infection present (indicated by a negative urine culture).

The information is compiled on a form (called a 'green sheet' by staff) that becomes part of the patient's medical record and referred to on the day of the surgery. "This information is reviewed with the patient in holding before they go in for the surgery and it's also presented to the surgeon," Kovatch explains. "The information is also retained in a database; if there are areas that need to be addressed we can track and trend by each of the components on the green sheet and trend for overall compliance as well."

St. Clair Hospital also standardized its intraoperative procedures (including prep, draping, positioning the patient, hair removal, etc.), as well as addressed traffic coming in and out of the operating room.

"Another way to reduce SSIs is to make sure that the traffic in and out of the OR is at a minimum," says Kovatch. Whenever a room is set up and during surgery, red straps are deployed across the door -- it's a strong visual aid and a reminder that people cannot access this room. "The red strap was a highly beneficial yet inexpensive measure to help reduce traffic, and ultimately to help reduce the risk of SSI," Kovatch says.  "The cost savings in terms of labor efficiency alone have covered the expense of the straps many, many times over. Although the dollar value attached to labor efficiency due to decreased traffic as a direct result of the straps is admittedly difficult to quantify, intuitively we can draw that connection.  Furthermore, if even one SSI is prevented due improved traffic control in the OR, then certainly there has been a positive ROI for this initiative."

Kovatch adds, "Another effective yet relatively low-cost process improvement for traffic control was our transition to disposable scrubs to be worn in the OR. All outside vendors now must sign in and obtain the disposable scrubs, enabling us to more effectively manage OR traffic to appropriate levels."  

Even with a highly competent and well-trained staff in the OR, St. Clair Hospital requires employees to review and sign a pledge each year as a condition of employment. "It never hurts to revisit and get back to the basics of what staff were trained on from the start," Kovatch says. "Understanding the 'why' is critical to gaining buy-in, and ultimately compliance. Providing our staff with clinical evidence supporting the actions required of them not only enhances credibility, but also fosters an attitude of acceptance and support, and ultimately leads to higher coopera-tion and compliance. St. Clair was successful in basing the components of our employee pledge in sound evidence, thereby gaining acceptance with very minimal, if any, pushback from staff."

Before the initiatives were put into place, St. Clair Hospital's infection rate for total hip replacement was at 3.1 per 100 cases; for fiscal year 2014 it was 0.4 per 100 cases. In the knee replacement population, previously it was 1.5 per 100 cases, now it is .7 per 100 cases.

Kovatch attributes this kind of success to buy-in from the various stakeholders involved.

"Physicians must understand the value of the extra steps they are being asked to take in the pre-operative preparation process," Kovatch says.  "Each of the components of our pre-op optimization initiative is rooted in peer-reviewed literature, with sound supporting data. Further-more, they have been vetted through our own multi-disciplinary (including physicians) internal review process. This thorough review ensures that not only will the surgeons be supportive, but that they will champion compliance among the various members of their office staff who will help keep the gears oiled and the wheels turning on a day-to-day basis." 

Kovatch continues, "But beyond the physician office, there is an expansive network of hospital staff who are essential to making this initia-tive work.  From registration, to pre-op holding, the operating room, PACU, and then the nursing units, staff in each area are attuned to the extra steps we take to ensure our patients’ risk of infection is minimized. And of course above it all, our board of directors and senior leadership team are supportive, helping to remove any barriers to the program’s success."

A multi-modal approach is credited for the SSI rate decrease that St. Clair Hospital experienced post-intervention, says Kovatch, who adds, "We recognize that SSIs are multi-factorial in their etiology.  It is very difficult, if not impossible, to point to any one thing and say with certainty, 'that caused this infection.' That is why we have endorsed a multi-modal approach to SSI prevention. We may never be able to single out any given part of our process as being the one thing that made the difference, but there seems little doubt that collectively all these measures have contributed to our outcomes having shown significant improvement. This also underscores why is so important that we implement each individu-al component of the multi-modal approach which has been shown in the literature to be valid. Combined, they comprise a very effective risk-mitigating care model." 

It's not enough to understand the clinical imperatives of SSI prevention; Kovatch acknowledges that the business case for infection preven-tion for SSIs is critical to process improvement. "As our healthcare environment continues to evolve, providers at all levels are becoming more aware of financial influences on care delivery and value," he explains. "Managing costs becomes increasingly relevant in a landscape of diminishing reimbursement dollars and increased competition for performance/outcome-based payments. It is indeed helpful for clinical staff to understand the financial implications of our clinical outcomes because doing so can provide context for the processes we have chosen to implement (or not implement). Again, as with anything, understanding the 'why' helps improve compliance."

Children’s Hospital of Pittsburgh
The Silver Award winner is Children’s Hospital of Pittsburgh, Pa. for the initiative "Creating a Culture of Excellence in Central Line Care." Teresa Mingrone, RN, MSN, NICU programmatic nurse specialist, explains that in 2009, the NICU moved to a new building -- a move with unin-tended consequences. "We actually were expecting to see a decrease," Mingrone says. "In a brand-new building, we thought there wouldn't be a lot of germs running around but what we saw was the exact opposite."

Front row left to right: Teresa Mingrone, Terri Roberts, Margaret Lamouree, Bonnie Landgraf, all of CHP, and JHF president and CEO Karen Wolk Feinstein. Back row left to right: Cindy Valenta, Diane Hupp, Wilma Powell, all of CHP, and Milton and Sheila Fine, of The Fine Foundation.

Previously, the NICU was in one large open room, but the NICU was transitioned to a configuration of private rooms. "Although we antici-pated that we would see a decrease in infections when we moved into single rooms that is not what occurred," confirms Margaret Lamouree, unit director of the NICU at Children’s Hospital of Pittsburgh. "Immediately following the move we actually saw an increase in central line rates. We believe this increase was due to the increased amount of personal belonging that were being brought into the private rooms. On occasions parents were observed reaching into their purse, grabbing their cell phones and handling other belongings while they were holding their baby. These observations prompted us to launch a parent education campaign about the importance of parent and visitor handwashing and also high-lighted the need to re-educate about re-washing after they touched any item in room and before touching the patient."

Lamouree continues, "Within our hospital, we care for many patients who require central lines due to a critical illness or injury or for long-term nutrition. This is especially true in our NICU where we care for many infants who have intestinal failure as a result of complications of prematurity, intestinal anomalies and other complex medical conditions. In infants the short distance between the central line site and sources of contamination, such as the diaper area, stomas or tracheostomy sites can significantly increase the risk of contamination and infection."

Because handwashing is such a cornerstone of safety in the NICU setting, Children’s Hospital of Pittsburgh conducted a series of education campaigns aimed at increasing hand hygiene awareness. Signage was posted in the family waiting rooms, at the entrance to the unit and in every patient room. A brochure about the importance of handwashing and proper handwashing technique also was given to all first-time visitors to the NICU.

"A handwashing video from the CDC was added to our patient/family education channel and we asked all families to view the video within 24 hours of their child’s admission to the NICU," says Mingrone. "Our attending physicians/fellows and NNPs incorporated hand hygiene into their discussions with families; once a family was educated about hand hygiene a hand symbol was placed on the patient’s door. These hand symbols generated additional discussion among families and served as a visual reminder to wash before entering a room. A friendly contest was held between our two NICU medical teams to determine which team had the most hand hygiene discussions with the families. Families were invited to participate in the contest and received points for performing good handwashing and helping to educate other visitors." 

"To increase transparency related to hand hygiene compliance we developed a simple Hand hygiene report card which we post in both public areas of the NICU, with the results of both staff and family/visitor hand hygiene compliance," Lamouree adds. "Although most of these activities were aimed at family and visitors, by engaging the staff in educating families, it helped raise awareness and compliance for all levels of employees."

In concert with hand hygiene improvement efforts, Children’s Hospital of Pittsburgh launched a CLABSI-prevention bundle. Says Lamouree, "The central line bundle we developed addressed four specific areas of care: insertion, ongoing care and maintenance, accessing lines and line removal. Key elements were proper gowning and draping for insertion as well as the need to allow adequate drying time for prep solutions, positioning lines so that the hubs were 'up and away' from the diaper area, the importance of occlusive dressings, scrubbing the hub and dry times before accessing ports, minimizing the number of times ports are accessed by clustering bloods draws and prioritizing which med are administrated through the central line vs a peripheral line, and the need to remove lines as soon as possible if they are no longer needed for care."

Nurse practitioners routinely insert PICC lines in the NICU, and at Children’s Hospital of Pittsburgh they perfect their skills in a simulation lab. As part of the exercise they review a procedural checklist that addresses core components such as hand hygiene, PPE and maintenance of ster-ile technique throughout the procedure. A key component of line care is scrubbing the hub, particularly for a prescribed amount of time -- 15 seconds.

"Along with education it is important to incorporate time to practice the associated clinical skills," Mingrone says. "Having staff scrub the hub in simulation and timing them was helpful. Most staff found it eye-opening and underestimated the 15 seconds scrub duration. Showing the demo of glow germs at 5, 10 and 15 seconds helped staff to visualize the importance of the 15 seconds. Today, staff watch the clock or recite the ABC’s to ensure 15 seconds on the scrub. Simulation training is also very helpful for teaching new clinicians appropriate gowning, prepping, draping and sterile technique for line insertion."

Mingrone says that during rounds, the NICU teams engage in daily discussions about the need for the line for each patient. "Our clinical leaders are responsible for various aspects of monitoring lines and dressings," she says. "They check the condition of the dressings and to see if there is a date on the dressing and to make sure it has been changed per our policy of every seven days."

"Discussing central line care and hand hygiene every day was vitally important to changing in our unit's culture," says Lamouree. "Daily discussions and holding all levels of staff equally accountable provided a clear message about the importance of this issue. Daily discussions also serve to reinforce the message, we know that families as well as newer staff can be overwhelmed by the volume of new information they receive in one day, involving parents in the discussions on rounds helps to empower the families and help them to partner with the medical team."

Beverly Brozanski, MD, medical director of the NICU at Children’s Hospital of Pittsburgh, says that prior to this initiative, the CLABSI rate was 1.29 per 1,000 central line days over a 12-month period. "Upon closer examination of our data we noted that was wide variability;  sometimes achieving  four or five consecutive months without a central line infections and then seeing spikes up to three to five  CLABSIs per 1,000 line days in a single month," Brozanski says. "This inconsistency confounded us and prompted us to dig deeper into our data and the consistency of our practices."

The interventions that Children’s Hospital of Pittsburgh put into place helped drive the CLABSI rate to 0.5 per 1,000 line days. "Identifying best practices and then making them the standard of care is essential to decreasing the central line infections," Lamouree emphasizes. "This cannot be a one-time educational effort. In large units such as ours there is a constant influx of new families, and new personnel within the hospital (staff, students, residents, consultants, etc.), so ongoing learning activities are needed to maintain heightened awareness. We communicate every month about our handwashing and CLABSI rates, we celebrate our successes (usually with food) and challenge our staff to help us achieve even better results. Using a root cause analysis method to investigate all CLABSI has been helpful in identifying areas that need re-education as well as previously unrecognized factors that may contribute to infection risk. Data gathered from these investigations are leading us to explore additional best practices which we can incorporate into our bundles as we strive to reach zero."