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A Lean Surveillance Transformation
Poster Abstracts / American Journal of Infection Control 40 (2012) e31-e176
in the use of the marker for monitoring 35 rooms per quarter. A spreadsheet was created, which calculates cleaning compliance rates by room, by housekeeper and by HRO. A toolkit was assembled to troubleshoot communication gaps and to assist housekeeping staff in ensuring that all rooms were cleaned daily. Results: Three hospitals piloted the project. 40 pre-and 40 postmeasurements using the marker were obtained. Post-measures were completed on the 7 HRO objects that showed the greatest opportunity for improvement; data analysis demonstrated improvement from 77% to 83%. The remaining 9 hospitals implemented the process during the last quarter of 2010. Pre- and postintervention comparison revealed 17% improvement in cleaning for all objects combined. The measures were monitored by the project team for 2 quarters. Quarter 2 2011 “clean” percentage showed little change (81.6%) compared with the post intervention measure (80.4%); however, Quarter 3 showed a 10% increase in cleaning of the 14 HRO (91.8%). Lesson Learned: A standardized cleaning policy, process and measurement system is an effective way to improve cleaning. Use of a fluorescent marker to assess room cleanliness resulted in improved cleaning of objects and surfaces that may harbor organisms and contribute to hospital-acquired infections. Exact reasons for the increase in compliance between Quarter 2 and 3 are unknown, but increased scrutiny and attention may have been given to the process when initial results were below the goal of 90% clean on all 14 HROs. Monitoring and reporting results to Infection Prevention and to the housekeeping management reporting chain can be effective in maintaining continued interest in such a project.
Presentation Number 12-176 Reducing Blood Culture Contamination in the Emergency Department Marie Hodgins RN, BScN, CIC, Director, Infection Control and Employee Health, Harlingen Medical Center; Ms. Deborah L. Meeks RN, MSN, CCRN, Director, Emergency Department, Harlingen Medical Center Issue: Our hospital's Emergency Department had a blood culture contamination rate ranging from 2-4 times the national average. Contaminated blood cultures lead to increased length of stay, increase cost and unnecessary antibiotic use with the associated problems of pressure toward antimicrobial resistance and increased risk of C. difficile associated disease. Project: Our emergency department does not have the volume to justify a dedicated phlebotomist, so in the interest of optimizing turn-around time, the ED nurses and CNAs are responsible for phlebotomy. This project was a joint effort of the Infection Preventionist, the Emergency Department Director and the Emergency Department Clinical Manager. We began by interviewing the staff and observing current blood culture collection practices. Wide variation and some alarmingly creative approaches were noted. Staff stated these practices were intended to prevent an additional “stick” and to save supplies and time. We created an inservice which focused on the adverse impact of contaminated blood cultures, the rationale for each recommended step in the process, and the opportunities for contamination presented by current rogue practices. We implemented an observation form to evaluate each individual's technique and provided real time feedback to individuals when a sample they drew resulted with a contaminant. The rate did not improve as expected. We observed again and
e135
determined that the skin prep was rarely being performed correctly. We re-inserviced with a real time demonstration of a full 30 second prep and full 30 second drydown. Individuals were observed in clinical practice using the same observation checklist, but with emphasis on correct duration of skin prep. This resulted in a dramatic improvement in our contamination rate. Results were communicated and celebrated. Results: Our monthly blood culture contamination rate ranged from 6.6-8.6% in the four months prior to intervention. It actually got worse immediately following the first inservice reaching 10%. After the timing of the prep was addressed definitively, in dropped down to a sustained at a rate of 2.1-3.3% in the last 6 months.
Lesson Learned: Careful planning and oversight is required to facilitate change. Planning considerations include: -Understanding what is motivating current behavior -Persuading individuals of the value of the proposed change -Reviewing the literature to determine which potential strategies are most likely to be impactful -Measuring both processes and outcomes -Revising strategies as indicated -Providing individualized, timely performance feedback, not just aggregate results -Celebrating success.
Presentation Number 12-177 A Lean Surveillance Transformation Mari Driscoll RN, CIC, Infection Preventionist, Lehigh Valley Health Network; Ms. Deborah Fry MT(ASCP), MBA, CIC, Manager Infection Control and Prevention, Lehigh Valley Health Network; Ms. Terry Lynn. Burger MBA, BSN, RN, CIC, NE-BC, Director Infection Control and Prevention, Lehigh Valley Health Network Issue: The demands facing Infection Preventionists today have grown exponentially. They are challenged with increasing public reporting requirements, more stringent regulatory requirements, expanding scopes of practice (inpatient and outpatient), zero tolerance for healthcare associated infections and mounting pressures from value based pay for performance programs. Therefore it is important to closely examine how Infection Preventionists structure their daily activities to assure effective surveillance is achieved and adequate time is available to invest in the multitude of other project responsibilities. Project: The Infection Control and Prevention department team members gathered for several sessions to identify opportunities to improve patient safety and enhance their value to patients. The objective of the activity was to create standard work processes for surveillance and documentation and eliminate waste in their daily routine. The team utilized several lean methodology tools to streamline work flow. They followed a 6S approach to organize their work spaces, completed a process map to illustrate the
APIC 39th Annual Educational Conference & International Meeting j San Antonio, TX j June 4-6, 2012
e136
Poster Abstracts / American Journal of Infection Control 40 (2012) e31-e176
mechanics of their daily work load and created an A3 analysis to guide them through the activity. The format of the A3 included the following: background, current conditions, ideal state, gap analysis, proposed countermeasures, metrics and timelines and follow-up and feed forward. Results: The current state demonstrated a lack of standard work, redundancy in data entry, employee dissatisfaction, lack of time for professional development, excessive travel, numerous nonvalue added distracters, unused human potential and lack of infection preventionist visibility. The goals of the ideal state was to become more efficient, more organized, more standardized, to decrease expenses, improve employee satisfaction, improve efficiency and patient safety. A number of countermeasures were implemented. Work processes were streamlined and standardized. All data entry forms were made electronic. Additional staffing resources were obtained. Electronic devices were purchased including individual laptops, iphones and iPads. Work assignments were redistributed. After the countermeasures were implemented waste was reduced and employee satisfaction and workflow efficiency were immediately improved. Since some of the countermeasures were recently implemented the impact on healthcare associated infections and patient safety is currently being evaluated. Lesson Learned: Going to the Gemba is an expression utilized in lean methodology which means going to where the work is done. This exercise illustrates how critical it is to success. It is imperative to involve all members of the team when a process improvement change is needed. Energy and enthusiam drives results. The A3 and process map information helped to justify and support all additional resources that were requested. Infection Preventionists are finally getting the attention and support they have always needed. Therefore it is necessary to assure those resources are utilized in the most efficient and effective way. In a financial atmosphere forecasting diminishing funding and pay for performance driving reimbursement, it is essential that infection control programs are designed to maximize efficiency to help achieve the best outcomes for the organization and for the patient.
Presentation Number 12-178 Clinical Attributes of Non Ventilator-Associated Hospital-Acquired Pneumonia Barbara Quinn MSN, RN, ACNS-BC, Clinical Nurse Specialist, Sutter Medical Center, Sacramento; Dr. Dian Baker PhD, APRN-BC, Associate Professor, School of Nursing, California State University Sacramento; Dr. Carol Parise PhD, Research Scientist, Sutter Health Sacramento-Sierra Region Background/Objectives: Objectives: To describe the incidence and risk factors of patients with non ventilator-associated pneumonia (non-VAP HAP). Background: Numerous studies have reported the incidence and prevention of ventilator-associated pneumonia (VAP); conversely, non-VAP HAP is an underreported and unstudied area, with potential for measureable nurse-sensitive outcomes. With the National Healthcare Safety Network focus on VAP, hospitals are required to monitor VAP; however, there are currently no requirements to monitor non-VAP HAP. The limited studies available indicate that non-VAP HAP is an emerging factor in prolonged hospital stays, patient morbidity, and increased cost of $40,000 for each case. Understanding the incidence and determining patients most at risk of this hospital-acquired infection is essential to provide optimal patient care.
Methods: Non-VAP HAP data were obtained from a large, urban hospital's electronic integrated medical management system. Inclusion criteria for this observational descriptive study were all adult discharges between January 1, 2010 and December 31, 2010, coded pneumonia- not present on admission and meeting the Centers for Disease Control and Prevention's (CDC's) definition for HAP. Descriptive statistics including means (SD) and percents were used to determine the age, gender, length of stay, primary diagnosis for admission, common risk factors, common chronic morbidities, and disposition upon discharge. Results: A total of 24,482 patients comprising 94,247 patient days were eligible for study inclusion. 194 cases were coded as HAP and 115 (59%) met the CDC definition. The infection rate per 100 patients and per 1,000 patient-days was found to be 0.47 and 1.22, respectively. The mean age of patients was 66 +14.45 and 54% of the patients were male. The mean length of stay was 27 +30.48 days. Most HAP episodes were detected outside of the ICU (62%). Cardiac disease was the most frequent primary diagnosis (18%), followed by sepsis (14%) and cancer (10%). The most common risk factors for HAP were >6 medications (90%), central nervous system depressants (78%), and acid blocking medications (76%). Notable chronic co-morbidities were cardiac disease (40%), chronic obstructive pulmonary disorder (33%), and diabetes (27%). The most frequent disposition upon discharge was home (39%) and other nursing facilities (32%); 29% of the HAP patients expired. Conclusions: This study confirms that non-VAP HAP occurs in a large, urban hospital and should be monitored. Coded databases may not be the most accurate method of surveillance for this hospital-acquired infection. HAP results in an extended length of stay and occurrs most frequently in elderly, male patients with other chronic conditions. Mortality among these patients is high; however, most patients are discharged directly to home or to an extended care facility. More research is needed to understand and design nursing interventions to prevent non-VAP HAP iatrogenic disease.
Presentation Number 12-179 Successful Nurse-driven Improvement Team Raises Postpartum Tdap Rates and Surpasses Target Goal Tamara Persing RN, BSN, MS, CIC, Director Infection Prevention & Control, Geisinger Health System; Holly Barbella RN, MSN, MBA, CIC, Operations Manager, WHSL, Geisinger Health System; Kimberly Cawley Rohrer RNC-OB, Administrative Team Coordinator, Geisinger Health System; Megan West King MSN, RN, Coordinator, Perinatal Education, Geisinger Health System; Leslie Laam MS, Quality & Operations Auditor, Geisinger Health System; Jami Marks RN, BSN, Operations Manager, Inpatient Women's Health, Geisinger Health System; Ruth Nolan RN, PhD.c, Vice President Women's Health Service Line, Geisinger Health System; Ruth Nolan RN, PhD.c, Vice President Women's Health Service Line, Geisinger Health System; Andrea Wary RN, M.Ed, Director of Urology Operations, Geisinger Health System; Stephanie Wohrach RNC-OB, CBC, CCE, CLSS, Clinic Nurse Supervisor Women's Health, Geisinger Health System Issue: The death of an infant from pertussis within the state in 2010 raised the awareness of the healthsystem to improve Tdap immunization rates. Postpartum Tdap immunization is recommended by the Advisory Council for Immunization Practice (ACIP) to reduce the risk of transmitting pertussis to their infants. Initial attempts to immunize unvaccinated patients in 2009 at a large teaching facility
APIC 39th Annual Educational Conference & International Meeting j San Antonio, TX j June 4-6, 2012
in the use of the marker for monitoring 35 rooms per quarter. A spreadsheet was created, which calculates cleaning compliance rates by room, by housekeeper and by HRO. A toolkit was assembled to troubleshoot communication gaps and to assist housekeeping staff in ensuring that all rooms were cleaned daily. Results: Three hospitals piloted the project. 40 pre-and 40 postmeasurements using the marker were obtained. Post-measures were completed on the 7 HRO objects that showed the greatest opportunity for improvement; data analysis demonstrated improvement from 77% to 83%. The remaining 9 hospitals implemented the process during the last quarter of 2010. Pre- and postintervention comparison revealed 17% improvement in cleaning for all objects combined. The measures were monitored by the project team for 2 quarters. Quarter 2 2011 “clean” percentage showed little change (81.6%) compared with the post intervention measure (80.4%); however, Quarter 3 showed a 10% increase in cleaning of the 14 HRO (91.8%). Lesson Learned: A standardized cleaning policy, process and measurement system is an effective way to improve cleaning. Use of a fluorescent marker to assess room cleanliness resulted in improved cleaning of objects and surfaces that may harbor organisms and contribute to hospital-acquired infections. Exact reasons for the increase in compliance between Quarter 2 and 3 are unknown, but increased scrutiny and attention may have been given to the process when initial results were below the goal of 90% clean on all 14 HROs. Monitoring and reporting results to Infection Prevention and to the housekeeping management reporting chain can be effective in maintaining continued interest in such a project.
Presentation Number 12-176 Reducing Blood Culture Contamination in the Emergency Department Marie Hodgins RN, BScN, CIC, Director, Infection Control and Employee Health, Harlingen Medical Center; Ms. Deborah L. Meeks RN, MSN, CCRN, Director, Emergency Department, Harlingen Medical Center Issue: Our hospital's Emergency Department had a blood culture contamination rate ranging from 2-4 times the national average. Contaminated blood cultures lead to increased length of stay, increase cost and unnecessary antibiotic use with the associated problems of pressure toward antimicrobial resistance and increased risk of C. difficile associated disease. Project: Our emergency department does not have the volume to justify a dedicated phlebotomist, so in the interest of optimizing turn-around time, the ED nurses and CNAs are responsible for phlebotomy. This project was a joint effort of the Infection Preventionist, the Emergency Department Director and the Emergency Department Clinical Manager. We began by interviewing the staff and observing current blood culture collection practices. Wide variation and some alarmingly creative approaches were noted. Staff stated these practices were intended to prevent an additional “stick” and to save supplies and time. We created an inservice which focused on the adverse impact of contaminated blood cultures, the rationale for each recommended step in the process, and the opportunities for contamination presented by current rogue practices. We implemented an observation form to evaluate each individual's technique and provided real time feedback to individuals when a sample they drew resulted with a contaminant. The rate did not improve as expected. We observed again and
e135
determined that the skin prep was rarely being performed correctly. We re-inserviced with a real time demonstration of a full 30 second prep and full 30 second drydown. Individuals were observed in clinical practice using the same observation checklist, but with emphasis on correct duration of skin prep. This resulted in a dramatic improvement in our contamination rate. Results were communicated and celebrated. Results: Our monthly blood culture contamination rate ranged from 6.6-8.6% in the four months prior to intervention. It actually got worse immediately following the first inservice reaching 10%. After the timing of the prep was addressed definitively, in dropped down to a sustained at a rate of 2.1-3.3% in the last 6 months.
Lesson Learned: Careful planning and oversight is required to facilitate change. Planning considerations include: -Understanding what is motivating current behavior -Persuading individuals of the value of the proposed change -Reviewing the literature to determine which potential strategies are most likely to be impactful -Measuring both processes and outcomes -Revising strategies as indicated -Providing individualized, timely performance feedback, not just aggregate results -Celebrating success.
Presentation Number 12-177 A Lean Surveillance Transformation Mari Driscoll RN, CIC, Infection Preventionist, Lehigh Valley Health Network; Ms. Deborah Fry MT(ASCP), MBA, CIC, Manager Infection Control and Prevention, Lehigh Valley Health Network; Ms. Terry Lynn. Burger MBA, BSN, RN, CIC, NE-BC, Director Infection Control and Prevention, Lehigh Valley Health Network Issue: The demands facing Infection Preventionists today have grown exponentially. They are challenged with increasing public reporting requirements, more stringent regulatory requirements, expanding scopes of practice (inpatient and outpatient), zero tolerance for healthcare associated infections and mounting pressures from value based pay for performance programs. Therefore it is important to closely examine how Infection Preventionists structure their daily activities to assure effective surveillance is achieved and adequate time is available to invest in the multitude of other project responsibilities. Project: The Infection Control and Prevention department team members gathered for several sessions to identify opportunities to improve patient safety and enhance their value to patients. The objective of the activity was to create standard work processes for surveillance and documentation and eliminate waste in their daily routine. The team utilized several lean methodology tools to streamline work flow. They followed a 6S approach to organize their work spaces, completed a process map to illustrate the
APIC 39th Annual Educational Conference & International Meeting j San Antonio, TX j June 4-6, 2012
e136
Poster Abstracts / American Journal of Infection Control 40 (2012) e31-e176
mechanics of their daily work load and created an A3 analysis to guide them through the activity. The format of the A3 included the following: background, current conditions, ideal state, gap analysis, proposed countermeasures, metrics and timelines and follow-up and feed forward. Results: The current state demonstrated a lack of standard work, redundancy in data entry, employee dissatisfaction, lack of time for professional development, excessive travel, numerous nonvalue added distracters, unused human potential and lack of infection preventionist visibility. The goals of the ideal state was to become more efficient, more organized, more standardized, to decrease expenses, improve employee satisfaction, improve efficiency and patient safety. A number of countermeasures were implemented. Work processes were streamlined and standardized. All data entry forms were made electronic. Additional staffing resources were obtained. Electronic devices were purchased including individual laptops, iphones and iPads. Work assignments were redistributed. After the countermeasures were implemented waste was reduced and employee satisfaction and workflow efficiency were immediately improved. Since some of the countermeasures were recently implemented the impact on healthcare associated infections and patient safety is currently being evaluated. Lesson Learned: Going to the Gemba is an expression utilized in lean methodology which means going to where the work is done. This exercise illustrates how critical it is to success. It is imperative to involve all members of the team when a process improvement change is needed. Energy and enthusiam drives results. The A3 and process map information helped to justify and support all additional resources that were requested. Infection Preventionists are finally getting the attention and support they have always needed. Therefore it is necessary to assure those resources are utilized in the most efficient and effective way. In a financial atmosphere forecasting diminishing funding and pay for performance driving reimbursement, it is essential that infection control programs are designed to maximize efficiency to help achieve the best outcomes for the organization and for the patient.
Presentation Number 12-178 Clinical Attributes of Non Ventilator-Associated Hospital-Acquired Pneumonia Barbara Quinn MSN, RN, ACNS-BC, Clinical Nurse Specialist, Sutter Medical Center, Sacramento; Dr. Dian Baker PhD, APRN-BC, Associate Professor, School of Nursing, California State University Sacramento; Dr. Carol Parise PhD, Research Scientist, Sutter Health Sacramento-Sierra Region Background/Objectives: Objectives: To describe the incidence and risk factors of patients with non ventilator-associated pneumonia (non-VAP HAP). Background: Numerous studies have reported the incidence and prevention of ventilator-associated pneumonia (VAP); conversely, non-VAP HAP is an underreported and unstudied area, with potential for measureable nurse-sensitive outcomes. With the National Healthcare Safety Network focus on VAP, hospitals are required to monitor VAP; however, there are currently no requirements to monitor non-VAP HAP. The limited studies available indicate that non-VAP HAP is an emerging factor in prolonged hospital stays, patient morbidity, and increased cost of $40,000 for each case. Understanding the incidence and determining patients most at risk of this hospital-acquired infection is essential to provide optimal patient care.
Methods: Non-VAP HAP data were obtained from a large, urban hospital's electronic integrated medical management system. Inclusion criteria for this observational descriptive study were all adult discharges between January 1, 2010 and December 31, 2010, coded pneumonia- not present on admission and meeting the Centers for Disease Control and Prevention's (CDC's) definition for HAP. Descriptive statistics including means (SD) and percents were used to determine the age, gender, length of stay, primary diagnosis for admission, common risk factors, common chronic morbidities, and disposition upon discharge. Results: A total of 24,482 patients comprising 94,247 patient days were eligible for study inclusion. 194 cases were coded as HAP and 115 (59%) met the CDC definition. The infection rate per 100 patients and per 1,000 patient-days was found to be 0.47 and 1.22, respectively. The mean age of patients was 66 +14.45 and 54% of the patients were male. The mean length of stay was 27 +30.48 days. Most HAP episodes were detected outside of the ICU (62%). Cardiac disease was the most frequent primary diagnosis (18%), followed by sepsis (14%) and cancer (10%). The most common risk factors for HAP were >6 medications (90%), central nervous system depressants (78%), and acid blocking medications (76%). Notable chronic co-morbidities were cardiac disease (40%), chronic obstructive pulmonary disorder (33%), and diabetes (27%). The most frequent disposition upon discharge was home (39%) and other nursing facilities (32%); 29% of the HAP patients expired. Conclusions: This study confirms that non-VAP HAP occurs in a large, urban hospital and should be monitored. Coded databases may not be the most accurate method of surveillance for this hospital-acquired infection. HAP results in an extended length of stay and occurrs most frequently in elderly, male patients with other chronic conditions. Mortality among these patients is high; however, most patients are discharged directly to home or to an extended care facility. More research is needed to understand and design nursing interventions to prevent non-VAP HAP iatrogenic disease.
Presentation Number 12-179 Successful Nurse-driven Improvement Team Raises Postpartum Tdap Rates and Surpasses Target Goal Tamara Persing RN, BSN, MS, CIC, Director Infection Prevention & Control, Geisinger Health System; Holly Barbella RN, MSN, MBA, CIC, Operations Manager, WHSL, Geisinger Health System; Kimberly Cawley Rohrer RNC-OB, Administrative Team Coordinator, Geisinger Health System; Megan West King MSN, RN, Coordinator, Perinatal Education, Geisinger Health System; Leslie Laam MS, Quality & Operations Auditor, Geisinger Health System; Jami Marks RN, BSN, Operations Manager, Inpatient Women's Health, Geisinger Health System; Ruth Nolan RN, PhD.c, Vice President Women's Health Service Line, Geisinger Health System; Ruth Nolan RN, PhD.c, Vice President Women's Health Service Line, Geisinger Health System; Andrea Wary RN, M.Ed, Director of Urology Operations, Geisinger Health System; Stephanie Wohrach RNC-OB, CBC, CCE, CLSS, Clinic Nurse Supervisor Women's Health, Geisinger Health System Issue: The death of an infant from pertussis within the state in 2010 raised the awareness of the healthsystem to improve Tdap immunization rates. Postpartum Tdap immunization is recommended by the Advisory Council for Immunization Practice (ACIP) to reduce the risk of transmitting pertussis to their infants. Initial attempts to immunize unvaccinated patients in 2009 at a large teaching facility
APIC 39th Annual Educational Conference & International Meeting j San Antonio, TX j June 4-6, 2012