Healthcare-Associated Infections (HAI) Quality Improvement Activity 2017 Project Kickoff Webinar
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%
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 Respond to calendar invites even if you aren t attending, we want you to be there but it is ok to say no!
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.
Collaboration at all levels DaVita Fresenius Medical Care Independent Facilities Facility Administrators Facility Infection Managers Centralized Infection Managers (CIM) Clinical Services Support (CSS) Regional Operating Directors (ROD) Directors Clinical Services Senior Director Clinical Services Medical Directors Clinic Managers Regional Quality Managers (RQM) Director of Operations Regional Vice Presidents Medical Directors Assistant Nurse Managers Clinic Managers Vascular Access Coordinators Facility Administrators Dialysis Program Administrators Regional VP of Operations Clinical and Regulatory Managers Medical Directors
HAI Background Regardless of the management modality for kidney failure, the risk for acquiring an infection is high. Infection is a leading cause of death in incident patients in their first year of dialysis, ranging from 6.3% in month one to 10.4% in month ten. 1 Overall, in prevalent patients on dialysis, 9.5% of the deaths are caused by infections. 2 Further, dialysis center surveys conducted by CMS in 2014 found problems in infection control activities. 4 Of the 1,928 centers surveyed, 33.6% were cited as being out of compliance for wearing gloves and hand hygiene, and 30.1% were cited for being out of compliance for cleaning and disinfecting surfaces and equipment. ESRD patients have compromised immune system Majority of patients have dialysis treatments three times per week 6 needle punctures per week OR Access via an external catheter with the tip located in the right atrium of the heart. 1, 2 Weinhandl, E., Constantini, E., Everson, S., Gilbertson, D., Li, S., Solid, C., Collins, A. (2014). Peer kidney care initiative 2014 report: Dialysis care and outcomes in the United States. American Journal of Kidney Diseases, 65(6, Suppl. 1), S1 S140. 3 Ball, L., George, C., Duval, L., Hedrick, N. (2016). Reducing blood stream infection in patients on hemodialysis: Incorporating patient engagement into a quality improvement activity. International Society for Hemodialysis, 20: S7 11. 4 Payne, G. (2015, June 17). Update: CMS surveys and QIP measures. Lecture presented at Florida Renal Administrators Annual Meeting in Naples Beach Hotel & Golf Resort, Naples, FL.
Why invest in Project WipeOut? Catheter related bloodstream infections (CRBSIs) equate to 10% to 20% of all HAIs 1. CRBSIs are the most common cause of nosocomial bacteremia and possess a mortality rate of 25% resulting in an increased length of hospital stay and high treatment costs 2. Patients dialyzed through catheters are 2 to 3 times more likely to be hospitalized for infection and die of sepsis than patients who dialyze with a graft or fistula 3. Given these statistics patients dialyzing via catheters have a higher risk of acquiring a bloodstream infection from their vascular access. Several efforts to expand HAI prevention efforts including coordination of HAI reporting metrics across multiple national agencies, changes in financial incentives by CMS, and federal funding for expansion of state based HAI prevention programs outline the need to improve infection prevention practices. Real world example: http://www.fmqaimedia.com/ncc/videos/5/ 1, 2 Bianco, A., Coscarelli, P., Nobile, C., Pileggi, C., & Pavia, M. (2013). The reduction of risk in central line associated bloodstream infections: Knowledge, attitudes, and evidence based practices in health care workers. American Journal of Infection Control, 41(2), 107 112. 3 Boyce, J. (2012). Prevention of Central Line Associated Bloodstream Infections in Hemodialysis Patients. Infect Control Hosp Epidemiol Infection Control & Hospital Epidemiology, 33(9), 936 944. 4 Lincoln, M. (2011). Preventing catheter associated bloodstream infections in hemodialysis centers: The facility perspective. Nephrology Nursing Journal, 38(5), 411 415.
AIM : Better Care for the Individual through Patient and Family Centered Care Patient Safety: Healthcare associated Infections Sepsis
Project Logistics QIA Project Lead Details Bloodstream Infections/Sepsis Lori Finch, MS, RN, CNN 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 1st & 2 nd quarter 2016 data (January June 2016) Re measurement: Combined 1 st & 2 nd quarter 2017 data (January June 2017)
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%
Bloodstream Infections QIA FACILITIES' NUM (# OF EVENTS) QIA FACILITIES' DENOM (PATIENT MONTHS) QIA FACILITIES' BSI RATE/100 PATIENT MONTHS QIA FACILITIES REPORTING NETWORK BSI RATE/100 PATIENT MONTHS PERIOD 2014Q1 122 12,409 0.983 65 0.715 2014Q2 141 13,325 1.058 65 0.700 2014Q3 124 13,203 0.939 65 0.694 2014Q4 123 13,230 0.930 65 0.620 2015Q1 89 13,500 0.659 67 0.526 2015Q2 124 13,600 0.912 68 0.627 2015Q3 140 13,753 1.018 68 0.679 2015Q4 119 13,591 0.876 68 0.621 2016Q1 165 13,611 1.212 68 0.560 2016Q2 162 13,797 1.174 68 0.509 2016Q3 120 12,880 0.932 66 0.565 National BSI Rate/100 patient months: 0.64 Jan Jun 2016 BSI Rate/100 patient months = 1.19 (165+162)/(13,611+13,797)* 100 = 1.19 Jan Jun 2017 BSI Rate/100 patient months GOAL = 1.19*0.95 = 1.13 Source: NHSN
Bloodstream Infections 1.4 BSI RATE OVER TIME BSI RATE/100 PATIENT MONTHS 1.2 1.0 0.8 0.6 0.4 0.2 1.13 1.212 1.174 0.932 0.0 2014Q1 2014Q2 2014Q3 2014Q4 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 TIME PERIOD QIA FACILITIES NETWORK JAN JUN 2017 QIA GOAL NATION Source: NHSN Note: Jan Jun 2017 QIA Goal (1.13) represents a 5% relative reduction from the Jan Jun 2016 BSI rate of 1.19
Access Related Bloodstream Infections QIA FACILITIES' NUM (# OF EVENTS) QIA FACILITIES' DENOM (PATIENT MONTHS) QIA FACILITIES' BSI RATE/100 PATIENT MONTHS QIA FACILITIES REPORTING NETWORK BSI RATE/100 PATIENT MONTHS PERIOD 2014Q1 100 12,409 0.806 65 0.600 2014Q2 119 13,325 0.893 65 0.599 2014Q3 101 13,203 0.765 65 0.575 2014Q4 93 13,230 0.703 65 0.494 2015Q1 71 13,500 0.526 67 0.427 2015Q2 100 13,600 0.735 68 0.515 2015Q3 119 13,753 0.865 68 0.553 2015Q4 87 13,591 0.640 68 0.473 2016Q1 122 13,611 0.896 68 0.369 2016Q2 133 13,797 0.964 68 0.364 2016Q3 101 12,880 0.784 66 0.451 National BSI Rate/100 patient months: 0.49 Jan Jun 2016 Access Related BSI Rate/100 patient months = 0.93 (122+133)/(13,611+13,797)* 100 = 0.93 Jan Jun 2017 Access Related BSI Rate/100 patient months GOAL = 0.93*0.95 = 0.88 Source: NHSN
Access Related Bloodstream Infections 1.2 ACCESS RELATED BSI RATE OVER TIME BSI RATE/100 PATIENT MONTHS 1.0 0.8 0.6 0.4 0.2 0.88 0.896 0.964 0.784 0.0 2014Q1 2014Q2 2014Q3 2014Q4 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 TIME PERIOD QIA FACILITIES NETWORK JAN JUN 2017 QIA GOAL NATION Source: NHSN Note: Jan Jun 2017 QIA Goal (0.88) represents a 5% relative reduction from the Jan Jun 2016 BSI rate of 0.93
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.
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
Project Methodology AIM MEASURE CHANGE Decrease bloodstream infections in project dialysis facilities NHSN Bloodstream Infections Rate Table 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 3 patient engagement cycles (Early February, April, June) At initiation of this project prior to ANY additional infection education is completed (Early February) At the mid point of the quality improvement activity (April 2017) 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, April, 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 Interventions in place Hand hygiene Observations Staff education and competency Catheter/ vascular access care observations Catheter hub disinfection Patient education/ engagement Surveillance and feedback using NHSN Catheter reduction Chlorhexidine for skin antisepsis Prevention of and reduction in the incidence of BSIs Antimicrobial Ointment
NHSN Prevention Process Measures CDC Core Intervention Hand hygiene Observations 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 Core Interventions Logistics Chlorhexidine for skin antisepsis: Povidone iodine (preferably with alcohol) or 70% alcohol are alternatives for patients with chlorhexidine intolerance. Catheter hub disinfection: If closed needless connector device is used, disinfect connector device per manufacturer s instructions.
CDC Core Interventions Logistics Antimicrobial Ointment CDC recommends using povidone iodine ointment or bacitracin/gramicidin/polymyxin B ointment at the hemodialysis catheter exit site after catheter insertion and at each hemodialysis session Bacitracin/gramicidin/polymyxin B ointment is not currently available in the United States. Triple antibiotic ointment (bacitracin/neomycin/polymyxin B) is available and might have a similar benefit but studies have not thoroughly evaluated its effect for prevention of bloodstream and exit site infections. Single antibiotic ointment have also been studied (e.g., mupirocin) however, concerns exist about development of antimicrobial resistance and their ability to cover the spectrum of potential pathogens (e.g., gram negative and gram positive bacteria) that can cause bloodstream infections in dialysis patients.
CDC Core Interventions Logistics Antimicrobial Ointment (cont.) Another important consideration is that ingredients in antibiotic and povidone iodine ointments may interact with the chemical composition of certain catheters. Therefore, before any product is applied to the catheter, first check with the catheter manufacturer to ensure that the selected ointment will not interact with the catheter material. Catheter Manufacturers Antiseptic & Antimicrobial Compatibility Chart
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
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 Date to be determined 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 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