Emerging Infectious Disease

By Angela Krile

According to a study published in the November 2010 New England Journal of Medicine, patient safety issues persist in hospitals across the country. The study concluded that, as a nation, we have made little progress since the Institute of Medicine’s landmark report in 1999, To Err is Human, which put a spotlight on patient safety issues that were the result of preventable medical errors. The November 2010 study, conducted from 2002 to 2007 in 10 North Carolina hospitals, found that harm to patients—complications from procedures or drugs and hospital-acquired infections—was still common, and the study’s lead author concluded that it was unlikely that other regions of the country had fared better.

However, Ohio hospitals have a different story to tell. Through the collaborative efforts of the Solutions for Patient Safety initiative, these hospitals have fared better, and in fact, have demonstrated results by significantly improving patient safety and eliminating unnecessary healthcare costs from the system. In January 2009, Ohio business leaders and healthcare providers launched Solutions for Patient Safety, a collaborative effort with the aspiration of making Ohio the safest place in the nation for healthcare.

The Cardinal Health Foundation, the Ohio Business Roundtable, the Central Ohio Hospital Council, the Ohio Hospital Association and the Ohio Children’s Hospital Association created this collaboration to improve quality and reduce costs of healthcare statewide. The partnership brought together 25 hospitals—17 Central Ohio hospitals and 8 children’s hospitals throughout the state—to reduce healthcare-associated infections (HAIs) and medication errors.

Solutions for Patient Safety was funded by a $1.5 million investment from the Cardinal Health Foundation. Funding was used to foster collaborative opportunities among the participating institutions, support improved data collection, provide for required technology and deliver training programs for clinicians and hospital leaders. The work took place in central Ohio general hospitals, corresponding with Cardinal Health’s headquarters location in Columbus, and in eight children’s hospitals from around the state.

“Cardinal Health is proud to be a founding sponsor and ongoing partner in this groundbreaking initiative that has and will continue to save lives—not only throughout Ohio, but across the nation,” said George S. Barrett, chairman and CEO, Cardinal Health. “The impressive results of the Solutions for Patient Safety initiative prove that true collaboration among healthcare leaders and clinicians can create meaningful transformation in patient care.”

The Goals

Over an 18-month period,

Central Ohio hospitals and children’s hospitals across Ohio worked together to:

• Set and meet specific error-reduction goals—measuring lives and costs saved;
• Gather baseline data;
• Identify sustainable and replicable processes to improve quality;
• Share best practices and learning across institutions; and
• Engage hospital leaders in promoting a culture of safety in their institutions.

Participating Central Ohio hospitals (17 hospitals) worked to:

• Reduce central line associated blood stream infections (CLABSI) hospital-wide by 50 percent, by June 2010.
• Significantly reduce healthcare-associated methicillin-resistant staphylococcus aureus (MRSA) infections by June 2010.

Ohio children’s hospitals (eight hospitals statewide) worked to:

• Reduce overall adverse drug events (ADE) by 33 percent by June 2010.
• Reduce surgical site infections (SSIs) in designated cardiac, neurosurgery and orthopedic procedures by 50 percent by June 2010.

Central Ohio Hospitals Take on MRSA and CLABSI

Baseline data collected in the collaborative suggests that prior to the start of the Solutions for Patient Safety project, an average hospital-onset MRSA was approximately 60 isolates per month, with the average additional cost for MRSA infections totaling approximately $25,000-$36,000 per case. The average CLABSI rate before the project began was approximately 25 cases per month, and the average additional cost for a CLABSI infection is approximately $3,700-$29,000 per case.

Most hospital projects to reduce CLABSI rates typically focused exclusively on Intensive Care Units (ICU). However, the collaborative made the decision to report CLABSI infection rates hospital-wide—ICU and non-ICU infections—and in doing so, discovered a patient population outside the ICU that warranted in-depth analysis and identification of additional interventions.

Through its collaborative efforts, Central Ohio hospitals achieved an 11 percent reduction in hospital-onset MRSA isolates (incidences of MRSA that occur anywhere on the patient, not just in the bloodstream), a 42 percent reduction in MRSA bloodstream infections and a 37 percent reduction of catheter-associated bloodborne infections.

As a result of this work, Central Ohio hospitals saved 14 lives, avoided 918 additional patient days in the hospital, and saved approximately $7.5 million per year in unnecessary healthcare costs.  Jeanne Emmons, BS, MT (AMT), the infection prevention director for Licking Memorial Hospital in Licking County, Ohio, noted that working with other institutions allowed her to leverage data for better results. “As a smaller operation with limited data on actual infections, having access to aggregate data when educating staff and physicians about best practices in preventing MRSA and CLABSI infections was very helpful,” said Emmons.

Best practices to ensure infection prevention success

Together, members of the collaborative identified opportunities for improvement in data collection to enable participants to achieve and sustain reductions in MRSA and CLABSI infections. Solutions for Patient Safety hosted two learning sessions for participating hospitals, which resulted in the creation of standardized definitions for data, outcomes and process measurements; and a unique data collection tool that eliminates data entry errors using an automated classification system.

Additionally, the Central Ohio hospitals identified processes, best practices and opportunities for increased collaboration among community and larger hospital systems, including:

1. Facilitating monthly quality improvement conference calls that create a forum for sharing best practice ideas, discussing barriers and possible solutions and collaborating toward rapid cycle improvements.
2. Conducting regular quality improvement coordinator site visits, focusing on clinical and technical assistance. The coordinator effectively evaluates the unique needs of each hospital within the collaborative, strengthening their contribution to the continuous efforts to reduce MRSA and CLABSI infections.

Another key process that contributed to the collaborative’s success was the hiring of five student nurse process observers (SNPOs) to conduct more than 12,000 observations to monitor compliance with proper hand hygiene practices, environmental decontamination processes and processes related to the insertion and maintenance of catheters. Through the SNPOs observations, two processes emerged as critical to significantly reducing infection rates for MRSA and CLABSI, hand hygiene and “hub” scrubbing.

First, hand hygiene emerged as the primary area of focus for the collaborative’s efforts to reduce MRSA infections, observing an inverse relationship between hand hygiene and incidence of MRSA. Since the beginning of hand hygiene data collection by the SNPOs in September, the rate of compliance with washing hands upon entering and leaving a patient’s room, even while wearing gloves, improved by more than 20 percent. And, participants noted that the observation and feedback process had a significant impact on compliance.

SNPOs also helped to identify a critical point of infection transmission for CLABSI related to the length of time the “hub” (access point in a catheter where fluids and medications are administered) is cleaned. While the hub was wiped before accessing the point of entry 98 percent of the time, the scrub was usually performed for a period of 15 seconds (the preferred threshold by medical standards) only 20 percent of the time.

As a result of this additional process measure and the group’s findings, it created a “Seconds Count” educational and reminder poster for wide distribution and use in the hospitals to encourage all clinicians to extend their scrub period to the full 15 seconds. The “Seconds Count” materials developed through the Solutions for Patient Safety efforts have been made available to hospitals throughout the state and nation via the Ohio Hospital Association Quality Institute Web site.

Even the SNPOs involved in the observations noted that the process had a significant impact on their awareness. “I honestly can say that this experience has allowed me to become more aware of the importance of hand hygiene and the use of isolation and sterility practices,” said Ashley Mitchell, SN. “What we observed within the hospitals seems so simple, but it is so overlooked. I know the days can get busy going in and out of patient rooms; if the medical staff could just slow down to take15 seconds to either wash their hands or put on the correct protective barriers, it could save lives.”

The Central Ohio hospitals will continue to work together to build upon these results. Specifically, participating hospitals have committed to continued hand hygiene monitoring by external observers, extending the hand hygiene project to other regions of the state, continuing internal audits to ensure ongoing improvement, and monitoring CLABSI through a statewide program that is part of a national initiative facilitated by the American Hospital Association, Michigan Hospital Association and Johns Hopkins.

Children’s Hospitals Reduce SSIs

Preliminary data on SSIs in Ohio’s children’s hospitals indicated there were approximately four infections per month across the state. The average additional cost per-case for hospital-based SSI is approximately $28,000. Through the Solutions for Patient Safety efforts, Ohio’s children’s hospitals achieved a 60 percent reduction in surgical site infections (SSIs) over a 12-month period of time. This reduction, coupled with a 34.5 percent reduction adverse drug events, allowed Ohio children’s hospitals to save 3,583 children from unnecessary harm and $5.3 million in unnecessary health costs. Clinicians at participating institutions were excited to see the tangible results of the collaboration. “In addition to saving the lives of our patients, this initiative has improved the quality of these lives and reduced the expense of caring for these children,” said Ed Shepherd, PhD, interim section chief of neonatology at Nationwide Children’s Hospital.

Best practices for SSI reduction success

The children’s hospitals identified standard processes that were used across the institutions during the collaborative project. These standards included a process to increase the reliability in the use of order sets—or the manner in which medication is ordered for each patient—to reduce opiate over-sedations; and the use of a unique bundle of care for all hospitals for each surgical procedure group, including no razors in the operating room, use of the most effective prep for surgery (i.e. chlorhexidine) and the appropriate timing for the administration of antibiotics.

Additionally, the children’s hospital collaborative created opportunities for participating institutions to build capacity for safety and quality improvement efforts by:

• Hosting five learning sessions for participating hospitals to learn about quality improvement process and share learning and best practices.
• Creating an integrated data management application designed specifically to support multi-center quality improvement initiatives. The application provides a single point of contact for informational, collaborative and data-related activities. The application’s tools allow for rapid feedback of performance data, preparation of progress reports over the Internet and communication among teams.
• Hosting monthly quality improvement webinars and conference calls on various quality improvement science topics.
• Conducting site visits from a quality improvement consultant to provide hands-on technical assistance to hospital improvement teams.

The process of identifying and sharing best practices was one of the key benefits for the clinicians involved.  “Being a part of the SSI team for the collaborative has allowed us to assess our strengths and weaknesses as well as share ideas and benchmark with other children’s hospitals,” said Debbie Hawk, RN, ONC, CNOR, RNFA, clinical coordinator of orthopaedic surgery, Akron Children’s Hospital. “This process has enabled us to utilize a standard, reliable process to help minimize surgical site infections and improve patient care. It has also allowed the operating room nurses, anesthesia care providers and surgeons to collaborate as a team on preventing SSIs. This team approach has now carried over to help improve other aspects of patient care in the operating room.”