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Meri Pearson, MPH, CIC: “Infection preventionists still need to do those active audits to make sure that they’re actually seeing what’s happening at the bedside.”
When COVID-19 struck, all health care systems in the United States and the world needed to improvise treatment and find ways to contain this deadly new pathogen. Piedmont Healthcare in Atlanta was no different. Meri Pearson, MPH, CIC, Piedmont’s infection surveillance manager, said that one of the main priorities for infection preventionists (IPS) at Piedmont was tracking COVID-19 at the facility—keeping tabs on how it might be spreading. The IP department teamed up with the business intelligence team to develop software that did just that—but so much more. Piedmont found that it could use the software to also track health care-acquired infections. “After we went live on this new program, we found that we had found 31% more colon surgical site infections [SSIs], and 50% more abdominal hysterectomy SSIs,” Pearson tells Infection Control Today®. The software means that IPs can spend less time documenting information manually and more time doing what they do best: fight infections. Pearson presented her findings last week at the annual conference of the Society for Healthcare Epidemiology of America.
Infection Control Today®:Thanks for joining us here at Infection Control Today®.
Meri Pearson, MPH, CIC: I’m really excited to be here to talk through what we did at Piedmont to make our lives a little bit easier. So, if you want to, I can go ahead and get into the background of why we decided to do this.
ICT®:Go ahead. Thank you.
Pearson: I feel like it’s important to take you back to where we started and where we are today. In 2016, Piedmont Healthcare, after some massive growth, we restructured our quality department. We went from a decentralized department to a centralized department for the quality department. What we did is we separated surveillance out from our quality programs that are more like at the local facilities to prevent infections. And we had a new strategic focus of zero patient harm by 2026. I think it’s important that I explained to you Piedmont is unique with our infection prevention program. We actually separate it into two different roles. We have this surveillance infection preventionist, which is my team, where we actually sit remote. We do all the surveillance for the system, for all 11 hospitals and look at all patient harm. And then we’ve got our local infection preventionists that actually sit at the local facilities and are doing more boots-
on-the-ground prevention efforts. And I think it’s important to explain this to you why we kind of unraveled this whole automation that we got into. We’ve got this structure that’s unique to Piedmont. And then we ended up getting a new infection surveillance program in 2018 that we started using. Prior to our new infection control software that is integrated with our EMR, we used a homegrown surveillance software that didn’t directly link with our EMRs or electronic medical records. And so that was an issue, because not only was our data delayed. The software often malfunctioned. Results are not in real time, which can be a problem with early identification and isolating patients that are infectious. It also was an issue in regard to CLASBIs [central line-associated bloodstream infection] and trying to find a secondary source because, of course, time is of the essence. And really lastly with this is that we could not upload our data directly to the NHSN [National Healthcare Safety Network]. We actually had to partner with a third party to upload this data. This new software we got in 2018. It is integrated with our EMR. We can actually upload data directly to NHSN. We also get results in real time, which is really great for early identification of infections, like we mentioned. And now the surveillance team are actually putting all that data and abstracting pertinent information—such as procedure abstraction—that’s used to calculate the surge, and what type of criteria they met for an infection. The reason we need to explain all that is because prior to this, we had a surveillance tool that did not link with the chart. So fast forward to COVID-19. That was just a huge thing for everybody in health care. What do we do with this? We have a lack of resources. We’re having to do more with less. During the beginning of COVID, our BI [business intelligence] team worked on this dashboard for COVID. Essentially, they were trying to figure out how we could track patients in-house. Make sure we did early identification, isolation. Making sure we do the appropriate testing and whatnot. But in this software, there was a new functionality to where you could not only pull data automatically from the EMR, but you could also input data directly into this dashboard, such as risk factors for the patient. Several other things that you could put in. So that triggered our thought, well, could we essentially automate how we do our HAI [health care-acquired infections] drilldowns, which were essentially a manual process at the time to look for risk factors for what contributed to the infection. That might be something like: Did they follow the insertion and maintenance bundle for the central line for the CLABSI? Did they follow the bundle for the C diff? Are they on laxatives? Essentially, the standard work. They’re drilling down to what went wrong. What can we do better next time. And that was completely manual by the local IPs, however, the SNA [social network analysis] data. IPs are already abstracting much of that data in the current new infection control software. We’re essentially doing double work. Why not pull that data out of our EMR into this dashboard, so that it can be automated. Basically, that’s kind of where it all began, and the background to where previously, before we got our new software, when we had the homegrown system, this was not possible to do. That is what led to us actually automating this process. I'll stop there and let you kind of digest all that.
ICT®: How will this look on the ground for infection preventionists in one of those 11 hospitals? What’s the difference in their routine?
Pearson: One, we have more time for rounding. So essentially, when you’re going to have all this automated…. So previously, the manual process of doing these drawdowns for all 11 hospitals is time intensive. You’re literally abstracting things from the chart, when really, we could use that time to be preventing infections, right? Also, what’s helpful about this tool is that you can quickly identify trends which, previously, we didn’t really have a great way to do that because we used a spreadsheet that … unfortunately it was a spreadsheet that only one person could be in at a time. As of now the data automatically pulls from the chart, more than one person could be in there, and you can quickly identify trends and opportunities to where we need to focus our efforts. And that really wasn’t so possible before, because a lot of it was manual work before. And there were accidental deletions in this spreadsheet. Some other kind of issues that happen when you’re sharing a spreadsheet among the 11 hospitals. Now a lot of this work is automated, to where essentially we’re going to get back to the basics of preventing those infections, and then identifying quickly what we could do to improve, especially those trends.
ICT®: So, again with the before and after. I’m an infection preventionist. I’m working at one of the 11 hospitals in the Piedmont Healthcare System. I go into a patient’s room, who may or may not have an HAI. What would happen in that before scenario? And what would happen in the after scenario, after you got the new software in?
Pearson: I guess for the before they might have, during COVID, they might have not been able to round us frequently, I would say, because resources were tied up in other areas. I feel like now the after would be we have more focused areas to figure out what went wrong and prevent by doing those environment of care round central audits and what not to where we’ve freed up a lot of resources that we didn’t have before. And we can also target those units that might be struggling and need more focused attention on what are the barriers. Like why did several patients on this unit not get a CHG [chlorhexidine gluconate] bath that we do daily at Piedmont? Why aren’t we getting that on that unit? What can we do to help you make sure you have what you need so our patients can get a bath and prevent future harm? So essentially, you’re just reducing the time that we spent on a task previously, especially during COVID. When you know some of these drilldowns kind of took the backburner because we had other pressing issues. Now a lot of this is just automatically going to pool to where you can quickly see what’s going wrong and how to fix it.
ICT®: If a doctor or nurse doesn’t note something, the system will pick that up?
Pearson: Really, it’s important that we are using all the data that is documented by those frontline staff, so the nurses, the physicians—if they didn’t really document, that would be a problem. But let’s say a problem that we also often identify in health care is that they might be following standard work. But as one of our leaders used to say, “The meat doesn’t match the sauce.” You might have documented that something happened, but it didn’t necessarily happen at the bedside. That’s another thing, which I guess is the limitation with any of these tools. Infection preventionists still need to do those active audits to make sure that they’re actually seeing what’s happening at the bedside, and how we can prevent future infections what are the barriers, what’s working well and what’s not working well.
ICT®: And, as you say, COVID-19 drove these changes?
Pearson: We put it into place during COVID. This is all that from stemmed. Because, again, we were creating this dashboard for COVID and that’s when we determined that there are these new functionalities within this software that we have. That this would make our vision possible. If it wasn’t for COVID, we might have not even thought to do this, honestly. But because we were so resource strapped, we were trying to work smarter and not harder by using technology. We’ve done that with a lot of our dashboards and other essential functionality to where we’re constantly trying to think of things to where technology can work in our favor to cut down on a lot of the manual work that we do. We also have other dashboards that are useful that we regularly use to see how we're performing. So not just this, which is why we figured it was possible. But we just needed to try it out to see if it actually can be done and the data be pulled into this. All the IPs have access to the EMR because we are making sure patients are isolated. We own these infection headers, which essentially, are used for frontline staff to know: “OK. This patient’s on contact. They have C diff. I need to make sure that I’m wearing the appropriate isolation, in addition to signs outside the room.” But we want to make sure whatever’s in our EMR matches what we’re doing.
ICT®: And this helps spot trends?
Pearson: So essentially, before, as I said, when we’re aggregating our infections, so your CAUTIS [Catheter-associated urinary tract infections], your CLASBIs, your MRSAs [Methicillin-resistant Staphylococcus aureus]; we wanted that in a—essentially—repository so that we could look for trends. But previously, we were just using a simple spreadsheet. So now we have something that is automatically pulling the data into this meaningful dashboard to where you’re taking a lot of those manual drilldowns that IPs were doing into one place automatically. I think it’s important that you lean on your partners. I know, especially for infection prevention, at least for a lot of the surveillance team, we really rely on our business intelligence and our clinical intelligence teams, because they have such skillsets that can help make these useful dashboards for us that make sense out of things. In addition to of course, like you mentioned, our EVS [environment services] partners and stuff, but for this the focus of this presentation [at the annual conference of the Society for Healthcare Epidemiology of America], we wanted to share what we had done at Piedmont, so then maybe other facilities that have similar software could implement something similar to where they could essentially save time, work smarter, not harder, because these resources are out there, and it can be done. You just have to have those partners help you do the work. And that’s what we did in this case because a lot of what the business intelligence team did was over my head, but it’s like I told them what we wanted to do, and they were able to make it happen.
ICT®: Is there something that you want to add that I neglected to ask you about?
Pearson: We’re going to continue to try and think outside the box. I think the one thing I do want to mention that’s a kind of a sidebar is, as I mentioned, in 2018 when we went live on this new software program for infection prevention. It’s actually a more robust enhanced software system to detect patient harm. We did feel at this point, we were finding all patient harm. And previously we were not, because as I mentioned, we were using a culture-based only surveillance system. We actually looked at analysis. After we went live on this new program, we found that we had found 31% more colon surgical site infections [SSIs], and 50% more abdominal hysterectomy SSIs. I think it’s important that those who are just only on culture-based surveillance systems realize they could be missing potential patient harm. I understand that at Piedmont we’re fortunate that we do have these resources to have this technology. But I will say we did write an SBR [situation-background-assessment-recommendation] to the NHSN to request that they revise how they risk-stratify facilities, because that’s not currently in their NHSN patient safety annual surveys. We really want to make sure that we’re being compared fairly against other hospitals across the nation who have other enhanced software systems like this because that’s not currently being done. So NHSN definitely said they would consider doing that and revising it for us, which we really appreciate. I just wanted to plug that as well.
ICT®: Are you more concerned that because of this software, because you’re getting so good at finding problems, that it might make Piedmont seem less effective than other hospital systems?
Pearson: That’s exactly right. Because you know, when you are looking at surveillance, when you start to look for something, of course, you’re going to find more. And that’s exactly what we found with our situation when we got this more robust surveillance system. We had to explain to our physicians or surgeons: “You aren’t doing worse per se than you were before. We were just not detecting this patient harm, because we were just looking at cultures.” And as a reminder, per NHSN, culture-based surveillance misses between 50% to 60% of surgical site infections. Think about all those hospitals that are not looking at it from the standpoint that we are. I think that was something that was challenging. We had to explain to our local leadership and physicians, but now we do truly feel like we can get to zero patient harm because we are actually finding all the harm and finding what we can do better. I think it’s a win for us, but we do want to make sure that this is considered in their risk adjustment for the SSI model.
\This interview has been edited for clarity and length.