WORLDWIDE, healthcare-acquired infections (HAIs) are considered the most prevalent adverse event in healthcare organizations. Approximately 1 in 25 US patients and as many as 1 in 10 patients in low-income countries will develop an HAI during their hospital stay.1,2 In the US alone, these infections cost 6.5 billion dollars each year.2 They adversely affect patients' lengths of stay and their physical and emotional well-being, as well as overall morbidity and mortality in healthcare facilities.
This article discusses a performance improvement initiative to combat the incidence and impact of HAIs at the authors' hospital in upstate New York.
The US Department of Health and Human Services (HHS) oversees and ensures essential human services through Medicaid and Medicare.3 It also executes the requirements outlined in the Affordable Care Act for high-value healthcare focused on prevention, quality, efficiency, accountability, and patient safety and outcomes.4
Under the Affordable Care Act and the direction of HHS, the Centers for Medicare and Medicaid Services (CMS) authorizes payments to healthcare organizations according to compliance with the healthcare-acquired condition (HAC) reduction program.5 HACs are defined as “conditions that patients did not have when they were admitted to the hospital, but which developed during the hospital stay.”6 These include adverse drug reactions, falls, obstetrical adverse events, pressure injuries, venous thromboembolism, and HAIs.7
Healthcare facilities are required to report their performance in six quality measures to the CDC's National Health Safety Network (NHSN), including CMS recalibrated patient safety indicator 90 and the CDC's NHSN HAI measures such as central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), colon and hysterectomy surgical site infections (SSIs), methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, and Clostridium difficile infections (CDIs).5
Performance data are used to calculate the organization's HAC score. Reimbursements may be reduced for hospitals with a total score above 0.3687 or that fall within the lowest performing 25%.6,8 Additionally, the New York Department of Health listed the most common HAIs as CDIs followed by SSIs, CAUTIs, MRSA, CLABSIs, and carbapenem-resistant Enterobacteriaceae bloodstream infections.9
The authors' facility had been subject to payment reductions due to its HAC score. A performance improvement plan was launched to understand and lower its HAI rates. The hospital is a nonprofit, 286-bed Level II trauma center with three medical-surgical units, a surgical ICU, a CCU, an ED, an endoscopy unit, an OR, a postanesthesia care unit, and a same-day surgery unit. The infection prevention department includes a director, a part-time infection preventionist, and a full-time, certified infection preventionist.
Working with the other units, the infection prevention department addresses all HAIs at the hospital. For example, CDIs are tracked and assessed by the infection prevention department and an interdisciplinary team from the antibiotic stewardship committee. Similarly, SSIs are addressed by the surgical and infection prevention teams. However, a formal interdisciplinary process was not in place to address CLABSIs or CAUTIs. Although CLABSI and CAUTI rates were carefully assessed and documented by hospital administrators and the infection prevention department, frontline healthcare staff were often unaware of their unit's HAI rates, as well as the process for diagnosis and reporting, prevention strategies, and surveillance. This performance improvement project focused on developing an interdisciplinary team to address CLABSIs and CAUTIs.
HHS has developed several strategies to improve healthcare quality and patient safety, including engaging frontline providers, sharing best practices, expanding quality improvement efforts, and educating healthcare professionals.4 These goals aligned well with the performance improvement project at the authors' facility.
The overall project goal was to significantly decrease the hospital's CAUTI and CLABSI rates, ultimately aligning with the CDC goal of eliminating all HAIs.2 The frontline healthcare staff was engaged using evidence-based education practices to achieve a culture shift focused on patient safety to improve not only HAI rates, but also patient outcomes and overall healthcare quality. Education pertained to HAI surveillance, diagnosis, reporting, unit-specific infection rates, and the length of time the unit has been without an HAI.
A multidisciplinary team was assembled, consisting of nursing leadership, licensed independent practitioners, environmental services, an infection preventionist, and any other interdisciplinary team members involved in a patient's plan of care such as unit nurses providing direct care to increase staff knowledge of HAIs. The team conducted weekly meetings for several months to develop HAI prevention strategies. To guide the initiative, a plan-do-study-act (PDSA) methodology and worksheet was used.10
The multidisciplinary team conducted research on current evidence for best-practice strategies to prevent HAIs. Best practices have a positive impact on patient safety, satisfaction, outcomes, and needs.11 The frontline staff was then educated on assessing for staff, patient, and family adherence to transmission-based precautions in addition to standard precautions.12 Their education also focused on the need for hourly rounding on all patients, especially those on transmission-based precautions. Additionally, an infection preventionist was assigned to each nursing unit to assess patients and staff for adherence with best practices.
Before educating the frontline staff, infection preventionists learned how to use a bundle form and assess for adherence, as well as how overall data trends would guide the improvement plan. According to the Institute for Healthcare Improvement, “a bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices—generally three to five—that, when performed collectively and reliably, have been proven to improve patient outcomes.”13 Bundles allow for consistency in following interventions to improve patient outcomes.
Each infection preventionist used the bundle form during unit rounding and created a daily list of patients with indwelling urinary catheters or central venous catheters. The forms provided an opportunity to educate and collaborate on best practices for CAUTI and CLABSI prevention.
For example, the indwelling urinary catheter bundle included the appropriate rationale, as well as whether the tubing was secured and the drainage bag properly placed. Similarly, the central line bundle included the type of central line and its appropriateness for use, as well as whether the dressing was dry and intact and whether dressings and lines were dated according to hospital policy. (See Bundle elements.)
Education was crucial to the improvement plan, and collaboration with the multidisciplinary team made all the difference in addressing infection rates. An important staff educational effort focused on defining an HAI. For example, the occurrence of CAUTIs, specifically symptomatic UTIs, requires certain criteria. These include the presence of an indwelling urinary catheter for more than 2 calendar days before a CAUTI diagnosis is made. At minimum, one of the following signs and symptoms must also be present: fever, suprapubic tenderness, costovertebral angle pain or tenderness, urinary urgency, urinary frequency, and dysuria.
The rate of UTIs in older adults is expected to increase as the population ages.14 As such, the diagnosis, management, and prevention of these infections is crucial to the health of older adults.14 Older patients may not report symptoms such as frequency or urgency as unusual, so alternate signs such as falls, confusion, and restlessness should be investigated as indications of possible UTIs.15,16 When patients are immunocompromised, they are at an increased risk for infection and preventive measures are essential.17,18
The hospital implemented a nurse-driven protocol to permit nurses to remove unnecessary indwelling urinary catheters without a provider's order. Catheters were considered unnecessary unless ordered for an appropriate indication, as previously discussed.
At times, even when patients did not have the appropriate indication, the infection preventionists noted that nurses were uncomfortable removing indwelling urinary catheters without an order. It was often necessary to reeducate nurses on the removal of indwelling urinary catheters and to discuss alternatives such as an external urinary collection device when appropriate.
Daily rounding allowed for on-the-spot reeducation. For instance, environmental services (EVS) required education on how to clean the isolation rooms. The EVS staff completed terminal cleaning after patient discharge and collected culture specimens to monitor for any actively growing microorganisms that remained.19 Additionally, nursing knowledge varied regarding dressing changes for new central lines. The facility central line policy was reviewed and the staff reeducated.
The frontline staff was notably engaged and proudly verbalized indwelling urinary catheter or central line removals. After 6 months without an HAI, the unit had a pizza party to recognize their accomplishments and reinforce positive infection prevention practices.
Educational objectives were met and resulted in increased compliance with noninvasive urinary collection devices. Consequently, the use of indwelling urinary catheters decreased by 10% at the authors' facility in 2017 and by 20% in 2018. Because of the collaborative effort of the frontline staff and multidisciplinary team, several hospital units went without HAIs for extended periods. For example, each unit's HAI rates were tracked monthly. In 2017, there were 13 CAUTIs at a rate of 1 per 1,000 catheter days and 7 CLABSIs at a rate of 0.8 per 1,000 central line catheters. In 2018, there were 8 CAUTIs at a rate of 0.7 per 1,000 catheter days. Notably, the cardiovascular ICU had been without a CLABSI for more than 2.5 years and without a CAUTI for 9 months.
The performance improvement project empowered and engaged nursing staff to practice to the full extent of their license by following a nurse-driven urinary catheter removal protocol. This was evidenced in both positive staff response and bundle records, which showed increased adherence with HAI prevention strategies including transmission-based precautions. The staff reported a better understanding of HAI surveillance, diagnosis, reporting, regulatory standards, and unit rates.
HAI prevention is an ongoing process, and continued work is needed. The goal remains to improve patient outcomes by preventing HAIs and receiving the maximum reimbursement and incentives associated with low-to-no HAI rates. Although the facility has seen notable improvements, it struggles to sustain a rate of zero HAI occurrences per unit, but this goal is attainable with continued support from the multidisciplinary team, organizational leadership, and frontline staff. Moving forward, it may be beneficial to treat HAIs as never events, with occurrences leading to a case review, root cause analysis, and a PDSA action plan.20
The improvement initiative was essential in engaging and educating frontline unit and department staff to address and prevent HAIs. The hospital is committed to prevention strategies, as well as a culture of both quality care and patient safety. Effective multidisciplinary teamwork and daily rounding provided an opportunity to improve nursing practice and infection rates. As long as HAIs continue to burden healthcare, evolving performance improvement strategies will be vital.
The authors' facility incorporated bundle criteria based on CDC guidelines.
Indwelling urinary catheter bundle21
- Appropriate indications for use include accurate measurement of urine output, acute or chronic urinary retention or bladder obstruction, end-of-life care, open sacral or perineal wounds, and prolonged immobilization due to surgery or an unstable fracture
- Site condition has been assessed
- Indwelling urinary catheter care has been completed
- Drainage tube has been secured to the patient's bed
- Tamper seal is intact
- Drainage bag is below bladder, not on floor, and less than half full
- No dependent loop in tubing
- Sterile solution used for irrigation
- Urine output has been recorded.
Central line bundle22
- Appropriate indications for use include dialysis and apheresis, hemodynamic instability, irritant vesicant medication, limited or no vessels suitable for conventional peripheral access, long-term I.V. antibiotics, and parental nutrition
- Appropriate type of central line
- Site conditions have been assessed
- Signs of infiltration have been assessed
- Date of last dressing change is included
- Dressings are clean, dry, and intact
- Positive blood return
- Alcohol cap has been used
- All I.V. lines have been currently dated according to hospital policy.