HCA Healthcare, LifePoint Health and other HealthTrust members tackle hospital-acquired infections
At the end of 2017, the Centers for Medicare & Medicaid Services (CMS) released the latest data on its Hospital Acquired Condition (HAC) Reduction Program. As the name suggests, the aim of the program is to reduce hospital-acquired conditions like methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C. diff.) and catheter-related urinary tract infections. CMS is assessing a 1 percent penalty this fiscal year on all hospitals (about 750 in all) that fall in the bottom quartile of the total HAC score distribution.
According to an analysis by Kaiser Health News, 336 hospitals that lost money a year ago were spared in 2017. That means more than 400 hospitals are facing another round of penalties. Improved patient safety is its own reward for the large number of HealthTrust members actively working to standardize infection prevention best practices across their hospitals. Read on to learn from two of them.
All Hands On Deck
The network of HCA hospitals and care sites is vast, stretching across the United States and to the United Kingdom. Despite its widespread geographic reach, it has a unified, focused battle plan against C. diff. The C. diff bacterium is highly contagious and potentially lethal. Left unchecked, it can spread quickly, wreaking havoc in patient rooms and hospital corridors. Older patients or those with multiple chronic conditions are particularly at risk. According to the Centers for Disease Control and Prevention (CDC), almost 10 percent of patients 65 and older who contract healthcare-associated C. diff don’t survive.
Given these sobering statistics, HCA set out to lower the rate of this infection among inpatients. After three years of collaboration among medical, surgical, radiology, nursing, environmental and pharmacy departments, in 2016 HCA rolled out a toolkit detailing a specific set of procedures for combating C. diff at its hospitals. The collaborative effort has already paid off: From 2015 to 2017, the incidence of C. diff infections dropped by 20 percent in HCA hospitals systemwide. “It was a project requiring leadership and coordination from many stakeholders across all of the departments that impact infection prevention,” says Jackie Blanchard, assistant vice president of infection prevention at HCA. “Without stakeholders, you don’t have buy-in. Without buy-in, you don’t have results. That is a lot of upfront work, but it benefits us in the long run.”
Zeroing in on Antibiotic Stewardship
Last year, the CDC reported that C. diff rates in the United States are on the decline, dropping 9 to 15 percent between 2011 and 2014, after year-over-year increases the previous decade. It attributed the improvements to antibiotic stewardship and more rigorous cleaning standards for hospitals, which are two areas of emphasis in HCA’s toolkit.
To dramatically reduce the spread of C. diff, hospital staff limits the number of antibiotics prescribed to patients. Antibiotics can upset the balance of bacteria in the intestines, allowing C. diff to run rampant, damaging the lining of the intestinal wall. This causes symptoms such as severe diarrhea, abdominal pain and fever. Early detection and isolation is another priority. New patients exhibiting the telltale bowel symptoms of C. diff are isolated even before screening test results come back to eliminate any risk of the infection spreading to other patients. Staff is extra vigilant about cleaning and disinfecting all surfaces and scrupulously follow good hygiene practices. “Hospital staff must also wear gowns and gloves when entering the room, and visitors are encouraged to do the same,” Blanchard says.
LifePoint Health, a Brentwood, Tennessee-based system of 71 hospitals across 22 states, has devised a comprehensive, data-driven approach to protecting patients from infections. “Our focus on infection prevention has grown tremendously over the years,” says Tracy Louis, infection prevention director. “We have found that collaborative learning and sharing best practices among the different facilities net the greatest reductions in infection rates.”
Transparency also is key for LifePoint Health. Its facilities are able to monitor the number of infections occurring within specific units of the hospital through the use of the CDC’s National Healthcare Safety Network database as well as case mix administrative claims data. Hospital leaders, including the hospital infection preventionist, monitor and analyze this electronic data for opportunities to improve processes and patient outcomes.
All LifePoint hospitals utilize a data-driven approach to improving quality and patient outcomes. Each facility has access to its own infection surveillance and billing data to determine how many days it has successfully prevented specific types of infections. The hospitals share this information across units in a variety of ways, including posting on message boards, internal newsletters, electronic screensavers and daily communication. “Visually displaying the number of infections keeps the staff engaged,” says Cindy Chamness, vice president, quality operations.
LifePoint hospital infection preventionists utilize a number of communication tools to optimize their effectiveness as leaders and subject matter experts in infection prevention. The LifePoint intranet, specific specialty email distribution lists, and collaborative learning in a web-based environment provide opportunities for infection preventionists to communicate with peers at other LifePoint hospitals and affiliates. “This allows best practice sharing between LifePoint hospital staff and brings a sense of support and camaraderie to the infection prevention community,” Louis says.
The key to reducing infections is standardizing care, says Angie Mitchell, RN, director of nursing services at HealthTrust. “If a patient comes into the emergency room, are the practices going to be the same as the ones in the intensive care unit? Are the clinical and housekeeping staff using the same cleaning agent? When you have a variance in care, it opens up a gap to get or spread an infection.”
To standardize care, hospitals often use bundles—a specific set of evidence-based practices, usually endorsed by the CDC or a professional organization, which have been shown to improve patient care and clinical outcomes. Multiple studies support the use of bundles in reducing infection rates. A 2016 review published in Lancet Infectious Diseases found that central line-associated bloodstream infections in ICUs decreased from 6.4 per 1,000 catheter-days to 2.5 per 1,000 catheter-days after implementation of central-line bundles. A 2015 meta-analysis published in Surgery found that the use of a bundle during colorectal surgery resulted in a lower surgical site infection rate—7 percent versus 15 percent in patients where the bundle wasn’t used.
Some hospital systems take the extra step of assembling supplies into kits to standardize infection prevention best practices. LifePoint hospitals, for example, provide staff with central line dressing kits containing two pairs of gloves. “It’s a simple reminder to change out gloves,” Louis says. “It makes it easier to do the right thing.” Standardizing both supplies and processes makes a hospital safer for everyone. As Mitchell says, “You want to know that no matter where patients go, whether the third or sixth floor, the process of caring for them is the same.”
The Simplest Method
Of course, the most effective method of controlling infections is also the simplest—encouraging doctors, nurses, techs, housekeepers and everyone else who comes into contact with patients to wash their hands before entering and after leaving hospital rooms. “Even in our admissions materials, we invite patients and family members to remind caregivers to wash their hands to further increase accountability,” Chamness says.
There are also high-tech ways to remind healthcare providers to wash their hands, including monitors with sensors that indicate movement of the lever that releases soap. Some are tied to an employee’s hospital badge and measure the amount of alcohol on the person’s hands. “The light turns green, and it will capture the hand hygiene before and after the employee goes into a patient’s room,” Mitchell explains. But there’s a catch: “They aren’t perfect, and many of them can be tricked or fooled,” she adds. “When you read the clinical commentaries, these sensor devices are most effective if they are accompanied by positive culture change in the facility. All of the widgets in the world aren’t going to compel caregivers to hold up their end of the deal unless they’re committed and encouraged to do so.”
A non-technology option is to use employee surveillance—stationing an unobtrusive person near a sink, she says. The person will observe and record which employees wash their hands thoroughly and who rushes through the process or walks by the soap dispenser. HealthTrust consults its advisory boards when making decisions about supplies designed to reduce the chances of infection. Before putting such items as disinfectant wipes and antimicrobial dressings on contract, it wants to ensure all relevant research is thoroughly explored.