Healthcare-Associated Infections (HAI) Quality Improvement Activity 2017 February Webinar
AIM : Better Care for the Individual through Patient and Family Centered Care Patient Safety: Healthcare-associated Infections Sepsis
Contact Housekeeping Keep your facility contact current for the project at all times If you are leaving your position, going on FMLA, or will be out for a period of time please let the Network know via email and let us know if a new contact will be available or who will be the interim contact Keep in mind when things are due for the project so the ball doesn t get dropped on deadlines If the facility is closed for any reason please notify the Network If you would like an additional staff member added to the email distribution please email me name and email address
Project Logistics QIA Bloodstream Infections/Sepsis Project Lead Lori Finch, MS, RN, CNN Details Reduce BSIs utilizing CDC interventions or state surveyor requirements At least 20% of facilities targeted based on 1 st and 2 nd quarter 2016 NHSN data In 3 rd quarter, Network determines which facilities to continue or replace Measure 5% reduction in pooled mean BSI rates Timeline Baseline: Combined 1 st & 2 nd quarter 2016 data (January-June 2016) Re-measurement: Combined 1 st & 2 nd quarter 2017 data (January-June 2017)
QIP PY 2019 Final Measure Domain Weighting Domain Weight Measures/Measure Topics Weight (Domain) Safety 15% NSHN BSl Clinical Measure NHSN Reporting Measure Reporting Measure 10% Mineral Metabolism, Anemia Management, Pain Assessment and Follow-Up, Clinical Depression Screening and Follow-Up, NHSN HCP Weight (TPS) Clinical Measure 75% Patient and Family Engagement/ Care Coordination Subdomain 42% ICH CAHPS Measure 26% 19.5% SRR Measure 16% 12% Clinical Care Subdomain 58% STrR Measure 12% 9% Dialysis Adequacy Measure 19% 14.25% Vascular Access Type Measure Topic 19% 14.25% Hypercalcemia Measure 8% 6%
Facility Selection Inclusion criteria: First- and second-quarter of 2016 BSI rate greater than 0.50/100 patient months. Why are facilities not selected using access-related BSI results? The overall BSI rate is the only BSI measure that was endorsed by the National Quality Forum (NQF). CDC submitted various BSI measures for consideration, including an access-related BSI measure, but NQF chose instead to only endorse the overall BSI measure therefore that is the measure that was adopted for the CMS ESRD QIP and also for the HAI QIA project in the statement of work.
2017 HAI Project Facilities 68 Dialysis Facilities Affiliation # Facilities DaVita 26 FMC 24 Independent 18 State # Facilities DC 3 MD 21 VA 35 WV 9 Total #BSI ~ Patients Baseline BSI Rate Goal BSI Rate Average catheter rate 327 4,568 1.19 1.13 12.82%
General Infection Control Root Cause Analysis Criteria # of Facilities reported yes Percentage Someone in charge of Infection Control 68 100% Dedicated Vascular access coordinator 61 90% Participate in National/Regional infection prevention initiatives 67 99% Initiative Focus: Catheter Reduction 39 57% Initiative Focus: Hand Hygiene 49 72% Initiative Focus: Improving culture of safety Initiative Focus: Improving general infection control 20 29% 24 29% Reuse dialyzers 9 13% Source: NHSN 2016 Practice Survey
BSI & LTC Rates > 10% DaVita FMC Independent Total Total meeting LTC goal 9 facilities 15 facilities 14 facilities 38 facilities 11/38 facilities The facilities above met the criteria for the Network 5 QIA LTC project too. We will have a separate call in March to discuss LTC reduction strategies & interventions. You will be notified in email if your facility is in this cohort and next steps.
Patient Engagement Deliverable for MARCH Select a patient or patients to work with nurses & technicians on this education Create a poster or bulletin board- patients need to understand the facility is in a project to reduce BSIs- goal is to get patients involved Poster or Bulletin Board must include: Patient involvement- examples: hand hygiene auditing; patient access infection control checklist results; # of days since the last infection in your facility; how many patients a washing their hands prior to treatment or washing their accesses and display the number going up every month Bulletin Board must be updated monthly with progress so patients see and understand the AIM of the project Creativity is KEY and should be a MAGNET for PATIENTS! Send a picture of the Bulletin Board or Poster to Lori Finch- lfinch@nw5.esrd.net by March 31 All project facilities posters/bulletin boards will be entered into Network ENGAGE project and facility winner will be announced at the October Network 5 Council Meeting
Conditions for Coverage The Network serves as a resource to dialysis facilities to improve their quality of care. CMS has set minimum requirements through the Conditions for Coverage (CFC), for ESRD facilities to participate in the Medicare program. The CFC requires dialysis facilities to participate in Network activities. In addition, the CFC category of patient safety outlines in detail CDCrecommended infection control requirements to help facilities strengthen their infection control procedures and adhere to best practices for HAI prevention. The Network has designed this QIA to build upon what the selected dialysis facilities have already implemented for infection prevention and strengthen these initiatives by providing resources and data monitoring. Failure to participate will result in the Network filing a complaint with the State Survey Agency. If a facility still continues to refuse, the COR will be notified.
HAI LAN HAI Learning and Action Network: Antibiotic Stewardship March 13, 2017 11:00am-12:00pm- Mandatory for BSI QIA facilities Speakers: Erika M. D Agata MD MPH & Deborah Smith MLT(ASCP), BSN, CIC, CPHQ will discuss her work on Combatting Antibiotic Resistant Bacteria Through Antibiotic Stewardship in Communities (CARB-TASC)
Project Methodology AIM MEASURE CHANGE Decrease bloodstream infections in project dialysis facilities Surveillance & Feedback & Staff education and competency Implement CDC Core Interventions RAPID CYCLE IMPROVEMENT First cycle set to deploy: Wednesday, February 1 st.
HAI/Sepsis Quality Improvement Activity 1 Patient Engagement 2 CDC Core Interventions 3 Data Validation
Patient Engagement Source: ESRD Network 13 https://www.hsag.com/en/esrd-networks/
Patient Engagement Requirements A patient survey will be used at three points of time throughout the project 2 patient engagement cycles- (Early February, End of June) At initiation of this project- prior to ANY additional infection education is completed At the completion of the quality improvement activity (June-2017) Complete as many patient access infection control checklists as possible Do NOT include patient s name on the form Do insert your CCN #- Medicare Provider number on the forms Send hard copies to Network 5 after completion: Feb, June Attention: Lori Finch Quality Insights-MARC Network 5 300 Arboretum Place Suite 310 Richmond, Virginia 23236
Patient Engagement Resources See MARC website for Patient Engagement Resources http://www.esrdnet5.org/ongoing-projects/bloodstream- Infections-QIA/Intervention-Resources.aspx#Education Patient Education and Engagement Engaging Patients in infection prevention Lifeline for a lifetime planning your vascular access CDC Key Areas for Patient Education Know the Facts about Infection How do you get an infection? 6 tips to prevent dialysis infections Patient Instructions for hand hygiene auditing
CDC Core Interventions Interventions to add Patient Interventions in place Hand hygiene Observations Staff education and competency Education/ Engagement Catheter hub disinfection Cath/vascular access care observations Surveillance and feedback using NHSN Catheter reduction Chlorhexidine for skin antisepsis Prevention of and reduction in the incidence of BSIs Antimicrobial Ointment
Project Methodology AIM MEASURE CHANGE Decrease bloodstream infections in project dialysis facilities Hand Hygiene & Patient Education Implement CDC Core Interventions RAPID CYCLE IMPROVEMENT First cycle set to deploy: March 1st.
Intervention Resources http://www.esrdnet5.org/ongoing-projects/bloodstream-infections-qia.aspx INFECTION PREVENTION CDC Audit Tools CDC Checklists to accompany audit tools CDC Recommended Staff Competencies CDC Key Areas for Patient Education WHO 5 Moments for Hand Hygiene WHO Hand Hygiene Why, How and When Brochure Protocol: Hand Hygiene and Glove Use Observations Protocol: Scrub-the-Hub for Hemodialysis Catheters CDC Sequence for removing PPE
NHSN Prevention Process Measures CDC Core Intervention Hand hygiene Observations Start March 1st Catheter/vascular access care observations Christie Lines from NHSN will host a Webinar Feb 7, 2017 to in service on entering audit data into NHSN
CDC Hand Hygiene Auditing Tool
PDSA worksheet for February Interventions Complete the worksheet Outlining how your facility Implemented the CDC Core Intervention For staff education & send electronically to lfinch@nw5.esrd.net By March 5.
Project Timelines by Month February March April May June PDSA-Cycle 1 PDSA Cycle-2 PDSA Cycle- 3 PDSA Cycle-4 PDSA Cycle-5 Patient Engagement Survey Surveillance & Feedback-NHSN Staff Education & Competency NHSN Webinar Feb 7 with Christie Lines Hand Hygiene Observations Patient Education Start Entering NHSN audit data- hand hygiene HAI LAN Webinar- March 13, 2017 1100-1200pm Complete the PDSA worksheet from February Intervention & send to Lori Finch by 3/5/17 Create patient engagement bulletin board and have monthly data updates- send picture to Lori Finch by 3/31/17 Catheter/vascular access care observations CVC connection & Disconnection CVC exit site care AVF/AVG Cannulation & Decannulation Catheter reduction Enter NHSN audit data Hand Hygiene CVC connect/disconnect CVC exit site care AVF/AVG cannulation & decannulation Chlorhexidine for skin antisepsis Catheter Hub disinfection Enter NHSN audit data Hand Hygiene CVC connect& Disconnect CVC exit site care AVF/AVG cannulation & decannulation Sustain all 8 interventions Submit QAPI Network Project sustainability Plan Enter NHSN audit data Hand Hygiene CVC connect& Disconnect CVC exit site care AVF/AVG cannulation & decannulation Final Patient Engagement Survey
Contact Us Mid-Atlantic Renal Coalition Lori Finch, MS, RN, CNN 300 Arboretum Place, Suite 310 Richmond, Virginia 23236 804.320.0004 EXT. 2710 lfinch@nw5.esrd.net www.esrdnet5.org