Ariana Longley

and 30 more

Executive Summary ChecklistIn order to establish a program to improve hand hygiene and reduce healthcare-associated infections (HAIs), the following implementation plan will require actionable steps. The following checklist was adapted from the WHO Hand Hygiene Self-Assessment Framework \cite{2010a} and based on research studies in which sustainable improvement was achieved \cite{Bouk_2016} \cite{Kelly_2016}\cite{Son_2011}\cite{Robinson_2014}.Gain commitment from senior  leadership to make hand hygiene compliance an organizational priority by setting clear requirements and an adequate budget for:Staff PerformancePerformance Measurement and Feedback that is timely and actionableAccountability for Performance Improvement at facility and unit leadership levels as part of an overall Organizational Hand Hygiene Guideline. Cascade this message to the entire organization on an on-going basis.        Ensure that alcohol-based hand rubs and soap are available as close to the point of care as is reasonable.Establish a hand hygiene team responsible for implementation of the Hand Hygiene Protocol.The protocol should include mandatory training for all healthcare workers (HCWs) upon hire and on-going at least once annually. Training to include:Proper technique for hand rubbing and soap and water washingIndications for hand rubbing vs soap and water washing (WHO or CDC Guideline)How to speak up when fellow HCWs do not comply (psychological safety is a vital condition of an effective safety culture)Education for patients, family members and visitors. Performance Evaluation and FeedbackIt is essential to measure hand hygiene compliance accurately and reliably using a validated method capable of capturing and reporting on 100% of all hand hygiene events such as an evidence-based electronic hand hygiene compliance system. Such systems have been shown to lead to sustainable improvement, reduced infections & costs and a positive impact on patient safety culture \cite{Bouk_2016} \cite{Kelly_2016}\cite{Michael_2017}\cite{Son_2011}.Measure hand hygiene compliance using an evidence-based, validated electronic hand hygiene compliance system. Provide performance feedback to unit leadership and frontline staff on a daily or weekly basis using evidence-based behavior change feedback models \cite{21775022}. Follow technology suppliers’ evidence-based recommendations for how to best implement technology and provide timely feedback to healthcare workers.Reminders in the workplace such as posters, brochures, leaflets, badges, stickers, etc. can be used provided they are consistent with the overall Hand Hygiene Protocol and any organizational wide campaigns to focus attention on the importance of hand hygiene. 
2f

Ariana Longley

and 30 more

Executive Summary ChecklistIn  order  to  implement  a  program  to  eliminate  central  line-associated  bloodstream  infections  (CLABSIs)  the following  implementation  plan  will  require  these  actionable  steps.  The  following  checklist  was  developed  by  Dr. Peter Pronovost, in 2001. This checklist reduces infections when inserting a central venous catheter (CVC) \cite{00025}.Commitment from hospital leadership to support a program to reduce and then eliminate CLABSIs.Implement   evidence-based   guidelines   to   prevent  the   occurrence  of   CLABSIs,   including:   insertion, maintenance, and standardized access procedures.Such  as:  Arrow  International®  PSI  with  Integral  Hemostasis   Valve/Side  Port  or  Pressure Injectable  Quad-Lumen  Central  Venous  Catheterization  Kit  with  Blue  FlexTip®,  ARROWg+ard Blue PLUS® Catheter and Sharps Safety FeaturesDoctors should:Perform a “time-out”Wash their hands with soap.Clean the patient’s skin with chlorhexidine antiseptic.Put sterile drapes over the entire patient.Wear a sterile mask, hat, gown and gloves.Put a sterile dressing over the catheter site.Develop  an  education  plan  for  attendings,  residents  and  nurses  to  cover  key  curriculum  pertaining  to  the prevention, insertion and maintenance of central lines.Encourage  continuous  process  improvement  through  the  implementation  of  quality  process  measures  and metrics.Standardize a central-line kit based on the needs of your facility, and implement technology that will have a significant return on investment (ROI) such as:Arrow International® PSI Kit with Integral Hemostasis Valve/Side Port or Arrow International® Pressure  Injectable  Quad-Lumen  Central  Venous  Catheterization  Kit  with  Blue   FlexTip®, ARROWg+ard Blue PLUS® Catheter and Sharps Safety Features.Efforts  should  be  focused  on  eliminating  all  blood  draws  from  central  access  catheters.  This  includes patient with longer-standing catheters (e.g. dialyses catheters).All CLABSIs should have a root cause analysis (RCA) completed by the unit where the infection occurred with  multidisciplinary  participation  including nursing,  physicians  and infection  prevention  specialists.  All learnings from the RCA should be implemented.The Performance GapEach  year  in  the  United  States  there  are  more  than  700,000  healthcare-associated  infections  (HAIs)  resulting  in 75,000 deaths and $28-$45 billion in extra health care costs \cite{Klevens_2007},\cite{00026}.Central  line-associated  bloodstream  infections  (CLABSIs)  are  amongst  the  most  commonly  occurring  HAIs  and have  a  mortality  rate  of  12-25%  (3).  An  estimated  41,000  patients in  US  hospitals  acquire  central  line-associated infections each  year \cite{21460264}.  Heavy  bacterial colonization at the insertion site, catheter placement in the  arm or leg rather than  the  chest,  catheterization  longer  than  3  days,  and  insertion  with  less  stringent  barrier  precautions  all significantly  increase  the  risk  of  catheter-related infection \cite{Mermel_1991}.  While  intensive  care  unit  (ICU)  patients  are  at  the highest  risk  for  CLABSIs,  central  venous  catheters  are  becoming  increasingly  utilized  outside  the  ICU,  exposing more  patients to  the risk.  In  fact, recent data  suggest that the  greatest numbers  of  patients  with  central  lines  are  in hospital  units  outside  the  ICU \cite{Vonberg_2006}.  While  central  line  use  is  increasing  outside  the  ICU,  since  2008  CMS  has implemented a policy  of reduced reimbursement for reasonably preventable hospital-acquired conditions, including CLABSI. This policy  change can represent a significant financial burden to the hospital because increased hospital costs due to CLABSI can be as much as $23,000 per case \cite{00026}.CLABSI  and  other  HAIs,  however,  are  largely  preventable.  Interventions  focusing  on  reducing  CLABSIs  in particular resulted in reductions ranging from 38 to 71%.3 Pronovost et al.  for example, observed a 66% decrease in CLABSIs after implementing a multi-component intervention in the ICUs  of 67 Michigan hospitals \cite{Pronovost_2006}. In a separate study  conducted  in  32  hospitals  in  Pennsylvania,  CLABSIs  decreased  by  68%,  following  targeted  interventions between  April  2001  and  March  2005 \cite{00027}.  Other  studies  have  shown  similar  reductions  in  CLABSI,  saving  lives  and dramatically reducing costs \cite{Rosenthal_2012},\cite{Hong_2013},\cite{Gozu_2011}.A  variety  of  guidelines  and recommendations have  been  identified  to  prevent  CLABSIs  including  those  published by  The  Healthcare  Infection  Control  Practices  Advisory Committee, \cite{21511081}.  The  Institute  for  Healthcare  Improvement (IHI)\cite{00028} and the Agency for Healthcare Research and Quality (AHRQ) \cite{00029}.Important  shared  components  of  these  recommendations  include:  implementing  a  method  to  detect  the  true incidence of CLABSI, including information technology to collect and calculate catheter days; providing adequate infrastructure  for  the  intervention  including  an  adequately  staffed  infection  prevention  and  control  program  and adequate  laboratory  support  for  timely  processing  of  samples;  implementing  a  catheter  insertion  checklist; monitoring  the  continued  need  for  intravascular  access  on  a  daily  basis;  and measuring  unit-  specific  incidence  of CLABSI as part of performance evaluations.It is estimated that the use of process change and technology to reduce CLABSI can save up to $2.7 billion per year while significantly improving quality and safety \cite{00026}. Closing the performance gap will require hospitals and healthcare systems  to  commit  to  action in the  form  of  specific leadership,  practice,  and  technology  plans,  examples  of  which are  delineated  below  for  utilization  or  reference.  This  is  provided  to  assist  hospitals  in  prioritizing  their  efforts  at designing and implementing evidence-based bundles for CLABSI reduction.Leadership PlanHospital  governance  and  senior  administrative  leadership  must commit  to  becoming  aware  of  major performance gaps in their own organization.Hospital  governance,  senior administrative  leadership, and clinical/safety  leadership must  close  their  own performance gap by implementing a comprehensive approach.Healthcare  leadership  must  reinforce  their  commitment  by  taking  an  active  role  in  championing  process improvement, giving their time, attention and focus, removing barriers, and providing necessary resources.Leadership  must  demonstrate  their  commitment  and  support  by  shaping  a  vision  of  the  future,  clearly defining  goals,  supporting  staff  as  they  work  through  improvement  initiatives,  measuring  results,  and communicating progress towards goals. Actions speak louder than words. As role models, leadership must ‘walk  the  walk’  as  well  as ‘talk  the  talk’  when  it  comes  to  supporting  process  improvement  across an organization.There are many types  of leaders within a healthcare organization and in order for process improvement to truly  be  successful,  leadership  commitment  and  action  are required  at  all  levels.  The  Board,  the  C-Suite, senior leadership, physicians, directors, managers, and unit leaders all have important roles and need to be engaged.Change management is a critical element that must be included to sustain any improvements. Recognizing the needs and ideas of the people who are part of the process—and who are charged with implementing and sustaining a new solution—is  critical  in  building  the  acceptance  and  accountability for  change.  A  technical  solution  without acceptance  of  the  proposed  changes  will  not  succeed.  Building  a  strategy  for  acceptance  and  accountability  of  a change  initiative  greatly  increase  the  opportunity  for  success  and  sustainability  of  improvements. “Facilitating Change,” the change management model The Joint Commission developed, contains four key elements to consider when working through a change initiative to address HAIs (Appendix A).In addition to the change management model leaders should:Include  fundamentals  of  change  outlined  in  the  National  Quality  Forum  safe  practices,  including awareness, accountability, ability, and action.Meet  with  ICU  team,  infection  control  staff,  quality  and  safety  leaders,  nurse  educators,  and  physician champions.Understand barriers (walk the process)Use 4E grid to develop strategy to engage, educate, execute and evaluateEngage: stories, show baseline dataEducate staff on evidenceExecute practice changeEvaluate feedback performance, view infections as defectsUse surveillance data to drive improvementMonitor and provide feedback of compliance with best practice over timePractice PlanUse of current evidence-based guidelines and/or implementation aids regarding the prevention of CLABSIs:InsertionCreate a standardized central line insertion kit or line cart that contains all needed supplies (see Technology Plan).Ensure insertion checklist is in your electronic medical record.Wear sterile clothing – gowns, mask, gloves and hair covering.Cover patient with a sterile drape, except for a very small hole where line goes in.Maintain strict sterile technique when placing the line.Hand  Hygiene  -  Perform  hand  hygiene  procedures,  either  by  washing  hands  with  conventional  soap  and water  or  with  alcohol-based  hand  rubs  (ABHR).  Hand  hygiene  should  be  performed  before  and  after palpating  catheter  insertion  sites  as  well  as  before  and  after  inserting,  replacing,  accessing,  repairing,  or dressing  an  intravascular  catheter \cite{Boyce_2002}.  Palpation  of  the  insertion  site  should  not  be  performed  after  the application of antiseptic, unless aseptic technique is maintained \cite{12517020}.Ultrasound guidance should be used for all non-emergent central line placements.For  directly  inserted  central  lines,  avoid  veins  in  arm  and  leg,  which  are  more  likely  to  get  infected  than veins in chest.Before commencing the procedure, perform a “time-out.”Position patient appropriatelyPrepare insertion sitePrepare  clean  skin  with  a  0.5%  chlorhexidine  preparation  with alcohol  before  central  venous  catheter and peripheral  arterial  catheter  insertion  and  during  dressing  changes.  If  there  is  a  contraindication  to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives.No iodine ointment - Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance.When inserting near the lungs, ensure line aspirates blood to ensure proper catheter placement.Apply a sterile dressing to the site.Prepackaged or filled insertion cart, tray or box – cart/tray/box that contains all the necessary supplies.Insertion checklist with staff empowerment to stop non-emergent procedure - include a checklist to ensure adherence to proper practices;Full sterile barrier for providers and patients - use maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile gloves, and a sterile full body drape, for the insertion of CVCs, PICCs, or guidewire exchange. Use a sterile sleeve to protect pulmonary artery catheters during insertion.Insertion training for all providers.MaintenancePerform daily assessments of need for line and remove when no longer needed.Daily discussion of line necessity, functionality and utilization including bedside and medical care team members.Discuss with the medical team continued necessity of line.Discuss with the medical team the function of the line and any problems.Discuss  with the medical team the frequency  of access and utilization of line. Consider bundling labs and line entries.Consider best practice is documentation that the discussion occurred in the medical record.Regular assessment of dressing to assure clean/dry/occlusive:Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled.Replace  dressings  used  on  short-term  central  venous  catheters  sites  according  to  CDC  or institution’s protocol.Daily CHG bathing and linen changes - Follow manufacturer recommendations for usagePerform weekly rounds.Send monthly data to team and leadership.Celebrate successPerform  in-depth  case  reviews  in  instances  where  infections  do  occur  (identify  the  risk(s)  that could’ve been avoided and modifications needed moving forward, if any).Utilize a systematic approach to review all hospital acquired CLABSIsStandardized Access Procedure 17Refer to Hand Hygiene details in APSS #2A.Disinfect cap before all line entries by scrubbing with an appropriate antiseptic and accessing the port only with sterile devices.Scrub the Hub: Alcohol (15 second scrub + 15 second dry) or CHG (30 second scrub + 30 second dry).Standardized dressing, cap and tubing change procedures/timing:Scrub skin around site with CHG for 30 seconds (2 minute for femoral site), followed by complete drying. (Note: there may be institutional preference for CHG use for infant < 2 months of age).Change crystalloid tubing no more frequently than every 72 hours.Change  tubing  used  to  administer  blood  products  every  24  hours  or  more  frequently  per  institutional standard.Change tubing used for lipid and TPN infusions every 24 hours.Document date dressing/cap/tubing was changed or is due for change.Consider  when  hub  of  catheter  or  insertion  site  are  exposed,  wear  a  mask  (all  providers  and  assistants) shield patient’s face, ETT or trach with mask or drape.In the Neonatal ICU:\cite{Miller_2010},\cite{Wheeler_2011},\cite{Milstone_2013},\cite{00030}A monthly report-out at team/quality committee and leadership meetings.Implement standardized central venous catheter (CVC) practices:Insertion checklistDaily assessmentElectronic health record prompt to remove catheter based on feeding volume24-hour catheter tubing change, experienced nurses onlyEnhanced nursing education and competency for CVC careEducationNursing education – care and maintenance bundleNeonatal ICU nursing education – enhanced and competency for CVC careCentral Line Simulation ProgramDevelop education for attendings, residents, nursesKey Curriculum Concepts – reinforcementHand hygieneAppropriate gowning and glovingKey Curriculum Concepts – newStandardized central line insertion best practiceUltrasound guided cannulationUpdated insertion checklistMaintaining sterile technique – immediate feedbackCentral Line Navigator documentationGeneral Medical EducationMD rounding navigators (removal prompt)Resident infection prevention trainingEvidence-based practice adherenceRemain current with new literature findings, e.g., “Guidelines for the Prevention of Intravascular Catheter-Related Infections” 2011 compendium by the CDC \cite{Miller_2010}.Patient education document (Figure 1).

Ariana Longley

and 30 more

Executive Summary ChecklistIn order to establish a program to eliminate  Catheter-associated Urinary Tract Infections (CAUTI) an implementation plan  with the following actionable steps must be completed. This checklist was adapted from the core prevention strategies recommended by the CDC \cite{gould2010catheter}.Hospital governance and senior  administrative leadership must champion efforts to raise awareness of the high  incidence of CAUTIs and prevention measures.Healthcare leadership must support  the design and implementation of standards and training programs on catheter  insertion and manipulation.Insert catheters only for  appropriate indicationsEnsure that only properly trained  persons insert and maintain cathetersInsert catheters using aseptic  technique and sterile equipmentMaintain unobstructed urine flowPerform  perineal care routinely for patients who have indwelling catheters to reduce  the risk of skin breakdown and irritationRemove catheters as soon as possibleFollowing aseptic insertion,  maintain a closed drainage systemSenior leadership must address  barriers, provide resources (budget/personnel), and assign accountability  throughout the organization.Select technology has shown early  success to reduce infections and/or positively enhance outcomes of patients and  providers in frontline CAUTI  prevention.The Performance GapUrinary tract infections are the most common nosocomial infection,  accounting for up to 40% of infections reported in acute care hospitals \cite{20004811}. There are an estimated 560,000 nosocomial UTIs annually in the United States  with an estimated cost of $450 million annually \cite{Klevens_2007}. Up to 80% of UTIs are associated with the presence of an indwelling  urinary catheter \cite{Apisarnthanarak_2007}.A catheter-associated urinary tract infection (CAUTI)  increases hospital cost and is associated with increased morbidity and  mortality \cite{15774051,18165672,19292664}. There are an estimated 13,000 deaths annually attributable to CAUTIs \cite{17357358}. CAUTIs are considered by the Centers for Medicare and Medicaid Services to  represent a reasonably preventable complication of hospitalization.  As such, no additional payment is provided to  hospitals for CAUTI treatment-related costs.Urinary catheters are used in 15-25% of hospitalized  patients \cite{10466554} and are often placed for inappropriate indications.  According to a 2008 survey of U.S. hospitals  >50% did not monitor which patients were catheterized, and 75% did not  monitor duration and/or discontinuation \cite{18171256}. The pathogenesis of CAUTIs may occur early at  insertion or late by capillary action, or occur due to a break in the closed  drainage tubing or contamination of collection bag urine \cite{11294737}. The source of the organisms may be endogenous (meatal, rectal, or vaginal colonization) or exogenous,  usually via contaminated hands of healthcare personnel during catheter  insertion or manipulation of the collecting system.Prevention strategies have been recommended by  HICPAC/Centers for Disease Control and Prevention \cite{20156062}. The Core Strategies are  supported by high levels of scientific evidence and demonstrated feasibility,  whereas the Supplemental strategies are supported by less robust evidence and  have variable levels of feasibility.Core  Prevention Measures include:Insert catheters only for  appropriate indicationsCompliance  with evidence-based guidelines e.g. Surgical Care Improvement Project (SCIP-Inf-9) requires  urinary catheter removal on Postoperative Day 1 (POD1) or Postoperative Day 2  (POD 2) with day of surgery being day zeroLeave catheters in-place only as  long as neededOnly properly trained persons insert  and maintain cathetersInsert catheters using aseptic  technique and sterile equipmentMaintain a closed drainage systemMaintain unobstructed urine flowHand hygiene and standard (or  appropriate) isolation precautions       Supplemental Prevention Measures Include:Alternatives to indwelling urinary catheterizationsPortable ultrasound devices to reduce unnecessary catheterizationsThe following practices are NOT recommended for CAUTI prevention (HICPAC guidelines):Complex urinary drainage systemsChanging catheters or drainage bags  at routine, fixed intervalsRoutine antimicrobial prophylaxisCleaning of periurethral area with  antiseptics while catheter is in placeIrrigation of bladder with  antimicrobialsInstillation of antiseptic or  antimicrobial solutions into drainage bagsRoutine screening for asymptomatic  bacteriuria (ASB)Prior  to the implementation of new preventive measures, an evaluation should assess  baseline policies and procedures with regard to CAUTI.  New policies and practices should be tracked  once implemented to ensure adherence and to remove any barriers to effective  change.Leadership PlanHospital governance and senior  administrative leadership must champion efforts in raising awareness around the  high incidence of CAUTIs and prevention measures.Healthcare leadership should support  the design and implementation of standards and training programs on catheter insertion  and manipulationSenior leadership will need to  address barriers, provide resources (budget/personnel), and assign  accountability throughout the organizationLeadership commitment and action are  required at all levels for successful process improvementPractice PlanReduce the use and duration of use  of urinary cathetersWhile there have been multiple  attempts to deploy antimicrobial catheters to reduce the rate of infection,  there is no literature to support that this technology has made a significant  impact.It has been estimated that 80% of  hospital-acquired UTIs are directly attributable to use of an indwelling  urethral catheter \cite{15175612} and studies have shown that there is a very high utilization in patients where  it was not indicated or for durations that may have been longer than clinically  necessary \cite{saint2000physicians}.Thus the greatest opportunities to  reduce the rate of UTI are 1) to place catheters only for appropriate  indications and 2) to limit the duration of catheter placement.Technology PlanSuggested practices and technologies  are limited to those proven to show benefit or are the only known technologies  with a particular capability. As other options may exist, please send  information on any additional technologies, along with appropriate evidence, to info@patientsafetymovement.org.Implement an anti-infective Foley catheter kit with enhanced components to  prepare, insert and maintain a safe urinary catheter. One standard kit that has  been effective:BARDEX® I.C. Advance Complete Care®  TraysMetricsTopic:Catheter-associated urinary tract infections (CAUTI)Rate of patients with CAUTI per 1,000 urinary catheter-days - all in-patient unitsOutcome Measure FormulaNumerator: Catheter-associated  urinary tract infections based on CDC NHSN definitions for all inpatient units \cite{centers2015urinary}Denominator: Total number of urinary catheter-days for all patients that have an urinary catheter in all tracked units*Rate is typically displayed as CAUTI/1,000 urinary catheter daysMetric RecommendationsIndirect Impact: All patients with conditions that lead to temporary or permanent incontinenceDirect Impact: All patients that require a urinary catheterLives Spared Harm:

Ariana Longley

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Executive Summary ChecklistIn  order  to  implement  a  program  to  eliminate  Clostridium  difficile  infection  (CDI)  the  following  implementation plan  will  require  the  actionable  steps.  The  following  checklist  was  adapted  from  the  core  prevention  strategies recommended by the CDC \cite{00015}.Hospital governance and senior administrative leadership must champion efforts in raising awareness to prevent and safely manage CDIImplementation of antimicrobial stewardship programs can prevent and/or minimize infection rates in healthcare settings. Refer to APSS #3A.Maintain contact precautions for duration of diarrheaComply with hand hygiene as described in APSS #2AClean and disinfect equipment and environment  Equipment such as blood pressure cuffs and pulse oximeters are frequently not cleaned between patients. Might be useful to include some examples of equipment to ensure routine cleaning.Use a laboratory-based alert system for immediate notification of positive test resultsImplement technologies that support proper surface cleaning and utilize as part of a defined environmental control best practice programSuch as Clorox® Healthcare Bleach Germicidal Wipes or Xenex® UV Light Disinfection System.Educate healthcare providers, housekeeping, administration, patients and families about CDIEncourage continuous process improvement through the implementation of quality process measures and metrics.All CDIs should have a root cause analysis (RCA) completed by the unit where the infection occurred with multidisciplinary participation including nursing, physicians and infection prevention specialists. All learnings from the RCA should be implemented.The Performance GapClostridium difficile (C. diff) is a spore-forming, Gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B \cite{00016}. It is a common cause of antibiotic-associated diarrhea (AAD), and it accounts for 15-25% of all episodes of AAD. Various diseases result from C. diff infection (CDI), including: pseudomembranous colitis (PMC), toxic megacolon, perforations of the colon, sepsis, and death (rarely).  The clinical symptoms include watery diarrhea, fever, loss of appetite, nausea and abdominal pain/tenderness.   Certain patient populations are at an increased risk for C. diff, including patients with: antibiotic exposure, proton pump inhibitors, gastrointestinal surgery/manipulation, long length stay in healthcare settings, a serious underlying illness, immunocompromising conditions and advanced age.Clostridium difficile is shed in feces.  Any surface, device, or material that becomes contaminated with feces may serve as a reservoir for the C. diff spores.  The spores are primarily transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item.  It is important to note that C. diff spores are not killed by alcohol-based hand rubs \cite{Oughton_2009},\cite{Jabbar_2010},\cite{18177221}. The WHO recommends washing hands with soap and water before gloving and after degloving \cite{00017}. CDI will resolve within 2-3 days of discontinuing the antibiotic to which the patient was previously exposed in approximately 20% of patients.  The infection can usually be treated with an appropriate course (about 10 days) of antibiotics. After treatment, repeat C. diff testing is not recommended if the patients’ symptoms have resolved, as patients may remain colonized.  The differences between C. diff colonization and infection are important to note:Clostridium difficile colonizationPatient exhibits NO clinical symptomsPatient tests positive for Clostridium difficile organism and/or its toxinMore common than Clostridium difficile infectionClostridium difficile infectionPatient exhibits clinical symptomsPatient tests positive for the C. diff organism and/or its toxinCommon laboratory tests used to diagnose C. diff infection include stool culture, molecular tests, antigen detection for C diff, toxin testing (tissue culture cytoxicity assay or enzyme immunoassay). The toxin is very unstable and degrades at room temperature, and may be undetectable within 2 hours after collection of a stool specimen. False-negative results occur when specimens are not promptly tested or kept refrigerated until testing can be done.Leadership PlanHospital  governance  and  senior  administrative  leadership  must  champion  efforts  in  raising  awareness  to prevent and manage CDIs safely.Healthcare  leadership  should  support  the  design  and  implementation  of  an  antimicrobial  stewardship programSenior leadership  will need  to  integrate  surveillance  and  metrics  to  ensure  prevention measures  are  being followedLeadership commitment and action are required at all levels for successful process improvementPractice PlanEstablish  and  consistently  implement  Clostridium  difficile  infection  (CDI)  prevention  guidelines  that  focus  on  the education  of  healthcare  providers,  patients,  and  families,  surveillance,  hand  hygiene,  contact  and  isolation precautions,  and  establishment  of  an  antimicrobial  stewardship  program \cite{00016},\cite{00017}. An  example  of  an  evidence-based approach  is  the  Association  for  Professionals  in  Infection  Control  and  Epidemiology  Guide  to  Preventing Clostridium difficile Infections. This Guide can be accessed online \cite{00018}.We have also listed key elements of CDI prevention below:SurveillanceImplement  a  facility-wide  CDI  surveillance  method  of  both  process  measures  and  the  infection rates to which the processes are linked.Hand Hygiene \cite{Oughton_2009}-\cite{00017}It  is  recommended  that  healthcare  providers  wash  hands  with  soap  and  water  before  donning gloves  and  following  glove  removal  when  caring  for  patients with  CDI.  No  agent,  including alcohol-based hand rubs, is effective against C. diff spores.Appropriate  use  and  removal  of  gloves  is  essential  when  caring  for  patients  with  diarrheal illnesses, like CDI.Contact/Isolation PrecautionsUse Standard Precautions for all patients, regardless of diagnosis.Place patients with CDI on Contact Precautions in private rooms when available.Perform hand hygiene and put on gown and gloves before entry to the patient’s room.Use dedicated equipment (blood pressure cuff, thermometer, and stethoscope).Remove gown and gloves and perform hand hygiene before exiting the room.Educate  the  patient  and  family  about  precautions  and  why  they  are  necessary  and  ensure  that visitors are properly attired in personal protective equipment.Environmental Infection PreventionUse EPA-approved germicide for routine disinfection during non-outbreak situations \cite{00019}.Ensure that personnel allow appropriate germicide contact time.Ensure   that   personnel   responsible   for   environmental   cleaning   and   disinfection   have   been appropriately trained.For routine daily cleaning of all patient rooms, address at least the following items:Bed,  including  bedrails  and  patient  furniture  (including  the  bedside  and  over-the-bed tables and chairs).Bedside commodes and bathrooms, including sink, floor, tub/shower, toilet.High-touch surfaces like call buttons and TV remotes.Communication  devices  such  as  walkie-talkies  used  by  nurses  to  communicate  with  the nursing station as well as personal cell phones carried by healthcare personnel.Antimicrobial Stewardship and CDIImplement a program that supports the judicious use of antimicrobial agents \cite{00020}.The  program  should  incorporate  a  process  that  monitors and  evaluates  antimicrobial  use  and provides feedback to medical staff and facility leadership.Technology PlanSuggested practices and technologies are limited to those proven to show benefit or are the only known technologies with  a  particular  capability.  As  other  options  may  exist,  please  send  information  on  any  additional  technologies, along with appropriate evidence, to info@patientsafetymovement.orgImplement technologies that support proper surface cleaning and utilize as part of a defined environmental control best practice programSuch as Clorox® Healthcare Bleach Germicidal Wipes or Xenex® UV Light Disinfection System.Implement technologies that support proper hand hygiene and utilize as part of a defined hand hygiene best practice program such as product utilization and staff movement tracking, sensor bracelets, alcohol sensing technologies.See APSS 2A for a list of hand hygiene technology suppliersMetricsTopic:Healthcare-associated Clostridium Difficile Infection Rate (CDiff)Rate of patients with a healthcare associated CDI per 1,000 patient daysOutcome Measure Formula:Numerator: Number of healthcare associated CDI based on CDC NHSN definitions \cite{00020}Denominator: Total number of patient days based on CDC NHSN definitions*Rate is typically displayed as Infections/1000 Patient DaysMetric Recommendations:Direct Impact:All hospitalized patients

Ariana Longley

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Executive Summary ChecklistIn order to establish a program  to reduce surgical site infections (SSIs) the following implementation plan  will require these actionable steps. The following checklist was adapted from  the core prevention strategies recommended by the CDC \cite{SSICDC2}.Hospital governance and senior administrative  leadership must champion efforts to raise awareness of the problem in their own  institution, in order to prevent and safely manage SSIs.Educate patients and families on SSI prevention.Implement surveillance and metrics to measure patient  outcomes.  The results of this monitoring  should be reviewed at periodic caregiver education sessions, such as “grand  rounds.” Pre-operative:Administer antimicrobial prophylaxis in accordance with  evidence-based standards and guidelines \cite{23461695}.Administer within 1 hour prior to incision (2 hours for  vancomycin and fluoroquinolones)Select appropriate agents on basis of:1.      Surgical Procedure2.      Most common SSI pathogens for the planned procedure3.      Known allergies or drug reactions of each specific  patient.4.      Published recommendationsDo not remove hair at the operative site unless it will  interfere with the operation.Use appropriate antiseptic agent and technique for skin  preparation, preferably an alcohol containing preparation \cite{27915053,28467526}If appropriate,  mechanically prepare patients for colorectal surgery by enema or cathartic  agents. Administer non-absorbable oral antimicrobial agents in divided doses on  the day before the operation \cite{27915053}Smoking cessation 4 to 6 weeks before surgery \cite{27915053}Intraoperative: Implement Maintain intraoperative and immediate postoperative normothermia \cite{27915053}Re-dose prophylactic antibiotics based on agent half-life or for every 1,500 mL blood loss \cite{27915053}Keep operating room (OR) doors closed during surgery  except as needed for passage of equipment, personnel, and the patient.  Ensure that interior of operating room is at  “positive pressure” relative to adjacent corridors. Use of an impervious plastic wound protector can prevent SSI in open abdominal surgery, particularly colorectal and biliary procedures \cite{27915053}Triclosan antibacterial suture use is recommended for wound closure in clean and clean-contaminated abdominal cases when available \cite{27915053}Change gloves before closure in colorectal cases \cite{27915053} Topical irrigation of the incision site, particularly in colorectal surgery \cite{25681239}Postoperative:Protect primary closure incisions with sterile dressing  for 24-48 hours post-opSupplemental oxygen (80%) is recommend in the immediate post-operative period \cite{27915053}Discontinue antibiotics within 24 hours after the  surgery end time (48 hours for cardiac patients), unless signs of infection are  present.The Performance GapThere are approximately 300,000 surgical site infections (SSIs) annually (17% of all HAI; second to UTI). SSIs occur in 2%-5% of patients undergoing inpatient surgery \cite{28077567}. The SSIs mortality rate is 3 %, with a 2-11 times higher risk of death versus other infections. Seventy-five percent of deaths among patients with SSI are directly attributable to the SSI. Long-term disabilities can result from SSIs and while studies have been done on mortality, no studies have been done on the life-altering long-term disabilities and associated financial burdens that can result from SSIs.A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place. Most patients who have surgery do not develop an infection. Some of the common symptoms of a surgical site infection include redness and pain around the surgical site area, drainage of cloudy fluid from the surgical wound, and fever.Surgical site infections can result in 7-10 additional postoperative hospital days due to an SSI. Direct costs can be between $3,000-$29,000 per SSI, depending upon the procedure and pathogen. On a national scale, direct and indirect medical costs combined can reach up to $10 billion annually \cite{28674667b}. These estimated costs do not account for the additional costs of rehospitalization, post-discharge outpatient expenses, and long-term disabilities.The pathogenesis of SSIs can be endogenous (patient flora, seeding from a distant site of infection) and exogenous (surgical personnel, OR physical environment and ventilation, tools, equipment, and materials brought to the operative field). Challenges exist in detecting SSIs such as the lack of standardized methods for postdischarge/outpatient surveillance due to an increased number of outpatient surgeries and shorter postoperative inpatient stays. Another challenge is the increasing trend toward resistant organisms which may undermine the effectiveness of existing recommendations for antimicrobial prophylaxis.Education and awareness of risk factors amongst healthcare workers, physicians and nurses followed by the implementation of standardized guidelines can minimize the incidence of SSIs in hospitals. Some key preventive measures include appropriate antimicrobial prophylaxis, preoperative identification and treatment of existing infections, proper site preparation methods (hair removal, skin site), maintenance of normothermia in the immediate postoperative period, and keeping OR doors closed during surgical procedures.Leadership PlanHospital governance and senior administrative leadership must champion efforts in raising awareness around the high incidence of SSIs and prevention measures.Healthcare leadership should support the implementation of standards on pre-, intra- and postoperative guidelines to minimize incidence of SSIs.Senior leadership will need to address barriers, provide resources, and assign accountability throughout the organizationHospital administration should implement surveillance and metrics to measure outcomes.Practice PlanPre-operative skin cleansingDevelop standardized process for pre-operative skin cleansing that includes the repeated use of chlorhexidine gluconate (CHG).Educate patients on how to appropriately apply the CHG prior to surgery, and about the risk that they might reduce the residual beneficial effects of the CHG if they apply lotions or deodorants after cleansing.Pre-operative screening for patients at risk for SSIDevelop a protocol to conduct nasal Staphylococcus aureus (SA) screening in patients undergoing cardiac and elective orthopedic surgery.Develop a protocol to attempt to decolonize SA carriers that includes intranasal Mupirocin.Educate patients and families on SSI preventionThe adverse effect of tobacco use on wound healing and the importance of ceasing tobacco use for a minimum of 1 month pre- and post-surgery.Importance of proper nutrition pre- and post-operatively to support competent immune response to infection.In patients with diabetes, the importance of ensuring their blood sugar is well controlled.Appropriate preoperative bathing and skin cleansing.Identify any skin irritation or hypersensitivity in prior surgical experiences, and any new skin conditions.Postoperative wound handling techniques and hand hygiene.Early signs of sepsisPeri-operative skin antisepsisUse preoperative skin antiseptic agents that have been FDA-approved or -cleared and approved by the health care organization’s infection control personnel; these should be used for all preoperative skin preparation. This preparation should significantly reduce microorganisms on intact skin, contain a non irritating antimicrobial preparation, be broad spectrum, be fast acting, and have a persistent effect.Develop standardized practices, guided by the product insert, for the peri-operative application of skin antiseptic agents that ensures an appropriate therapeutic dose covers and is maintained across the entirety of the skin surface.Educate perioperative personnel on the safe application and use of selected skin antiseptic agents, and the benefits of skin antisepsis to reduce the microbial burden on the skin prior to surgery.Proper hair removalRemove only hair that interferes with the surgical procedure.Clip hair at the surgical site using a single-use hair clipper, or with a clipper with removable head that can be disinfected between patients. Razors should not be used.Appropriate timing, selection, and duration of prophylactic antibioticsGlycemic controlImplement perio-operative glucose control, targeting blood glucose levels <200 mg/dLMaintenance of normothermiaUse warmed forced-air blankets preoperatively, during surgery, and in PACU.Use warmed fluids for IVs and flushes in surgical sites and openings.Technology PlanSuggested practices and technologies are limited to those proven to show benefit or are the only known technologies with a particular capability. As other options may exist, please send information on any additional technologies, along with appropriate evidence, to info@patientsafetymovement.orgConsider implementing technologies that actively clean and remove infectious contamination from the surgical incision such as:CleanCisionTM Wound Retraction and Protection System \cite{28846497}Consider implementing technologies that provide skin antiseptic activity such as:3M® Duraprep™ and Carefusion® Chloraprep™Consider implementing technologies that support intraoperative wound protection such as:Applied Medical® Alexis™ and 3M® SteriDrape™MetricsTopicColon Surgical Site Infection Rate (Colo SSI): Rate of patients with a Colon Surgical Site Infection per 100 NHSN colon operative proceduresNumerator: Colon surgical site infections based on CDC NHSN definitionsDenominator: Total number of colon operative procedures based on CDC NHSN definitions* Rate is typically displayed as SSI/100 Operative ProceduresMetric RecommendationsIndirect Impact:  All patients requiring a colon operative procedureDirect Impact: All patients requiring a NHSN colon operative procedureLives Spared Harm:Notes:To meet the NHSN definitions, infections must be validated using the hospital acquired infection (HAI) standards.Data Collection: 

Kenneth Rothfield

and 31 more

Executive Summary Checklist\(\)Achieving a culture of safety in a healthcare organization requires transformational change which is owned and led by the top leaders of the organization, including the board, encouraging accountability and transparency. Hospital boards and senior leaders must commit to compensation policies that ensure that safety performance is aligned with executive compensation.  It is a key responsibility of healthcare administrators to prepare the workforce to continually enhance their competencies around hazard and risk identification.  Organization-wide commitment to worker safety offers personal awareness building and assist all staff to embrace their personal role as safety officer.Transparency regarding the outcomes of care, both within and outside of the organization, facilitates improvement across the continuum of care.Understanding and implementing Just Culture is essential for transitioning from a culture of shame and blame to one of trust and respect. In a just culture, people are not punished for human errors, but are always held accountable for their decisions.Address unexpected outcomes with open disclosure and prompt resolution. If patient harm results from a preventable medical error, adopt the CANDOR (Communication and Optimal Resolution) Approach: apologize as soon as possible, pay for all care related to the preventable harm, seek a just resolution, and provide ongoing support for patients and families. Clinicians (the "second victims" of patient harm events) may require special attention and support \cite{27558861}.Create a standard of care where the clinicians speak with family members and explain what will be changed so this won't happen again and offer family members an opportunity to be involved and witness the change in procedure, etc.Creation of a reliable means to capture and analyze good catches/near-misses is a key to identifying and addressing processes and systems.Both safety culture and patient outcomes require continual assessment: “What is measured gets managed.”Create and maintain five components of a safety culture to achieve a high reliability organizationEstablish trustEstablish accountabilityIdentify unsafe conditionsStrengthen systemsAssess and continuously Improve the safety cultureDevelop a strong infrastructure ensuring:Budgets that allow for an adequate number and quality of patient safety professionalsImplementation and ongoing monitoring of a comprehensive patient safety program that is  approved by the Board of Trustees.Creation of an internal working group made up of quality improvement, nursing, risk  management, patient safety, patient advocacy and regulatory leaders.Develop a ‘Good Catch’ Program to recognize and reward staff for reporting near misses or  system issues.Integration of worker safety and patient safety strategies and resources.Safety Commitment and goal setting must include aspirations that all errors and incidents are preventable and that zero is the most important goal.Safety has to be personalized for behaviors to change or be sustained. Alignment of patient safety and worker safety activities is an important consideration for workers to be engaged and for reliability.Implement an electronic adverse event reporting system that allows for anonymous reporting, tracking, trending and response to aggregate safety data.Thoughtful and memorable internal branding must be implemented to keep safety expectations and aligned behaviors top of mind throughout an organization.  The best safety culture plans and priorities mean nothing if not communicated clearly, widely and repeatedly.The Performance GapDespite widespread efforts among healthcare organizations to improve patient safety and healthcare quality, preventable patient deaths still occur. It is estimated that there could be over 200,000 preventable patient deaths per year in U.S. hospitals alone, and up to one-third of patients unintentionally harmed during a hospital stay \cite{James_2013,Classen_2011}. Preventable medical harm ranks as the third leading cause of death in the United States \cite{Makary_2016}. Such events cause unnecessary human suffering and also waste billions of dollars annually.The confluence of continued preventable safety events, growing public vigilance, patient and provider/staff dissatisfaction, and payment systems that penalize poor outcomes serves as leverage to change how hospitals address quality and safety. However, even with this strong motivation and focused effort to improve safety and quality, evidence suggests that the risk of harmful error may be increasing.Respect: The Essential Foundation of Safety Culture

Paul Alper

and 28 more

Executive Summary ChecklistIn order to establish a program to improve hand hygiene and reduce healthcare-associated infections (HAIs), the following implementation plan will require actionable steps. The following checklist was adapted from the WHO Hand Hygiene Self-Assessment Framework \cite{world2013hand}.Commitment from Hospital governance and senior administrative leadership to address this major performance gap in their own organization by taking action.Mandate a hand hygiene protocol that is supported by hospital leadershipContinually monitor hand hygiene and post results - the goal is 100% compliance.System change to ensure that alcohol-based handrub is easily available, there is a continuous supply of clean running water and soap at each sink, and a budget to replenish alcohol-based hand rubs.Dedicated hand hygiene team dedicated to the promotion and implementation of optimal hand hygiene practice in the facility. Include patients and visitors in the overall plan.Mandatory training for all professional categories at commencement of employment, then ongoing regular training (at least annually)Educational resources easily available to all health-care workers (ex: WHO Guidelines on Hand Hygiene in Health-care: A Summary)System in place for training and validation of hand hygiene compliance observers.Dedicated budget that allows for hand hygiene trainingEvaluation and FeedbackWard infrastructure survey regarding availability of hand hygiene products and facilities  performed annually.Indirect monitoring of hand hygiene compliance through consumption of alcohol-based handrub  and soap.Direct monitoring of hand hygiene compliance through hand hygiene monitoring technologies.Immediate feedback to healthcare workers at the end of each hand hygiene compliance  observation session.Systematic feedback of data related to hand hygiene indicators and trends given monthly, as well  as every 6 months.Reminders in the workplace such as posters, brochures, leaflets, badges, stickers, etc.The Performance GapHand hygiene contributes significantly to keeping patients safe. While hand hygiene is not the only measure to counter HAI, compliance with it alone can dramatically enhance patient safety, because there is much scientific evidence showing that microbes causing HAI are most frequently spread between patients on the hands of health- care workers. Many patients may carry microbes without any obvious signs or symptoms of an infection (colonized or sub clinically-infected). Microbes have an impressive ability to survive on the hands, sometimes for hours, if hands are not cleaned. This clearly reinforces the need for hand hygiene, irrespective of the type of patient being cared for .Health-care facilities which readily embrace strategies for improving hand hygiene also prove more open to a closer scrutiny of their infection control practices in general. Therefore, the impact of focusing on hand hygiene can lead to an overall improvement in patient safety across an entire organization. The hands of staff can become contaminated even after seemingly ‘clean’ procedures such as taking a pulse, blood pressure, or touching a patient’s hand \cite{world2009guidelines}.Leadership PlanHospital governance and senior administrative leadership must commit to becoming aware of this major performance gap in their own organization.Hospital governance, senior administrative leadership, and clinical/safety leadership must close their own performance gap by implementing a comprehensive approach.Healthcare leadership must reinforce their commitment by taking an active role in championing process improvement, giving their time, attention and focus, removing barriers, and providing necessary resources.Leadership must demonstrate their commitment and support by shaping a vision of the future, clearly defining goals, supporting staff as they work through improvement initiatives, measuring results, allocating resources, and communicating progress towards goals. Actions speak louder than words. As role models, leadership must ‘walk the walk’ as well as ‘talk the talk’ when it comes to supporting process improvement across an organization.There are many types of leaders within a healthcare organization and in order for process improvement to truly be successful, leadership commitment and action are required at all levels. The Board, the C-Suite, senior leadership, physicians, directors, managers, and unit leaders all have important roles and need to be engaged.Practice PlanChange management is a critical element that must be included to sustain any improvements. Recognizing the needs and ideas of the people who are part of the process—and who are charged with implementing and sustaining a new solution—is critical in building the acceptance and accountability for change. A technical solution without acceptance of the proposed changes will not succeed. Building a strategy for acceptance and accountability of a change initiative greatly increase the opportunity for success and sustainability of improvements. “Facilitating Change,” the change management model The Joint Commission developed, contains four key elements to consider when working through a change initiative to address HAIs.Plan the Project:Build a strong foundation for change  by assessing the culture for change, defining the change, building a strategy,  engaging the right people, and painting a vision of the future. This should be  done at the outset of the project.Inspire People:Solicit support and active  involvement in the plan to reduce HAIs, obtain buy-in and build accountability  for the outcomes.Identify a leader for the HAI  initiative. This is critical to the success of the project.Understand where resistance may come  from.Launch the Initiative: Align operations and ensure the  organization has the capacity to change, not just the ability to change.Launch the HAI initiative with a  clear champion and a clearly communicated vision by leadership.Support the Change:The capacity to support change is  critical; therefore, all leaders within the organization must be a visible part  of the HAI initiative.Frequent communication regarding all  aspects of the HAI initiative will enhance the initiative.Celebrate success as it relates to a  reduction in HAIs or a positive change in HAI organizational culture.Identify resistance to the HAI initiative  as soon as it occurs.Hand hygiene improvement is not amenable to a “one size fits all” approach. It involves a complex set of interactions that requires an approach focused on measurement and understanding of root causes. The Joint Commission Center for Transforming Healthcare Targeted Solutions Tool (TST)® provides health care organizations this type of comprehensive approach and is proven to improve hand hygiene compliance \cite{joint2012joint}.Define hand hygiene protocolWho to follow hand hygiene:All personnel and visitors in  contact with or in the proximity of patients, including the patient.When to follow hand hygiene: Before patient contact, sterile  procedures.After body fluid exposure risk,  patient contact, contact with patient surroundings.How to follow hand hygiene:Hand wash with soap and water or  hand rub over all hand surfaces with alcohol-based formulation. Hand rub/hand wash for at least 15  seconds.Dry hands completely. Do not touch potentially  contaminated surfaces after hand washing procedure.Educate all staff on hand hygiene  procedure and implications of non-compliance. Train observers and just in time  (JIT) coaches.Measure current “baseline” adherence  to hand hygiene protocol with observers who sample and record compliance within  the hospital units. Observers should be a role or  individual that can maintain anonymity throughout the data collection process,  be in a position where they can secretly observe staff while performing their  regular job duties, not seem out of place during their time on the unit, and  collect data that is representative of the patient population.Twenty to thirty observations should  be collected each day over a two to three-week period utilizing a standardized  data collection form including observation number, date and time, staff role,  entry or exit to patient room, hand hygiene - yes or no, observable  contributing factor to non-compliance.Identify barriers to hand washing.Qualitative input from secret  observers as to observable contributing factors as to why hand hygiene protocol  was not followed.Direct interviews with noncompliant  caregivers by just-in-time (JIT) coaches within the hospital units to identify  non-observable factors as to why hand hygiene protocol was not followed.Collect data on barriers to hand  washing and calculate the hospital (or unit) baseline compliance, top  contributing factors to non-compliance at your hospital (or unit), and the  compliance by role(s).Analyze the data to identify root  causes of why non-compliance is occurring.The top causes (or contributing  factors) vary across units and hospitals, roles and shifts. Thus, it is crucial  that data is first collected and analyzed to identify the factors which  contribute to hand hygiene non-compliance in your area. In order to improve  hand hygiene, it is essential that solutions targeting the specific causes are  implemented.Not all causes are applicable to  your organization and often there are two or three major causes that need to be  addressed.For instance, if the unit identifies  that “improper use of gloves” is the top contributing cause of hand hygiene  non-compliance, then the following targeted solutions can be implemented:Detailed training for clinical staff  on proper use of gloves.Relocate glove dispensers.Implement standard work process for  hand washing between each patient room or patient care area when delivering  food trays.Implement standard work process for  daily room cleaning and educate all housekeeping personnel. Another example of a contributing  cause could be “frequent entry or exit.” If the unit finds that this is a top  contributing cause through the use of the TST, then the following solutions can  be implemented to improve hand hygiene:Implement standard work process for  hand washing after bringing mobile work machines (such as mobile vital signs  devices) into the patient room or care area but before patient  contact/interaction (such as taking patient’s vital signs). Create a standard “drop spot” for  meds and supplies within the patient room that enables nursing to set down meds  and supplies and perform hand washing. Implement computers and scanners at  every bedside to reduce the likelihood of cross-contamination between patients  when performing bar code medication administration.Implement standard work process for  room cleaning and educate all housekeeping staff.Create and implement a list of  supplies that will be kept within the patient care area.Measure progress and effectiveness  of change.Utilize the same data collection and  analysis tools and process utilized to calculate baseline in order to measure  progress and effectiveness.Identify the changes from baseline  performance for each unit, role, and shift, and identify the effectiveness of  implemented solution, any barriers to effectiveness, and any additional  solutions that need to be implemented. Note: The TST includes data  collection forms and provides analyses in the form of Pareto (and other) charts  that allows your organization to track improvement versus baseline data, to  observe HAI data in correlation to hand hygiene compliance rates, and to  benchmark against national results.Implement a plan to ensure that  gains are sustainable.The plan should include the  following action items:Designate someone to “own” the  process (for example, the dedicated leader or a unit manager). At least one  aspect of their job function should specify that data continue to be collected,  monitored and shared with healthcare personnel.Replicate the findings to another  area within your organization.Continue real time data collection  to improve data collection.Train new hand hygiene observers and JIT coaches, once per year to ensure that observers receive updated training on  an annual basis.Update the plan whenever changes  occur.The plan should be completed with  the process owner, which signals the transition of responsibility from the  project leader.The project leader will continue to  ensure that data is collected, entered and shared with staff at a frequency  determined by the group.Technology PlanThe recommendations of specific technologies or products herein are those of the Patient Safety Movement Foundation and do not necessarily represent the opinions of the Joint Commission Center for Transforming Healthcare or its affiliates. The Joint Commission Center for Transforming Healthcare was not consulted on, nor did it participate in the decision or choice of any specific product or technology, and as a matter of policy the Joint Commission Center for Transforming Healthcare does not endorse any specific technologies, equipment, or other products.There is emerging evidence that electronic hand hygiene compliance systems, when combined with appropriate staff feedback and multi modal action plans can lead to reduced infections and avoided costs. Visit http://www.ehcohealth.org/the-evidence/ for a list of scientific studies.Essential Criteria to ConsiderThe system must be:Capable of capturing 100% of all hand hygiene events (soap and sanitizer) electronically in real-time.Capable of reporting Hand Hygiene Compliance (HHC) based on the WHO 5 Moments for Hand Hygiene  at the Group, Unit, Ward or Department Level.\cite{Steed_2011}Validated for accuracy in at least one peer reviewed study.\cite{Diller_2014}Supported by scientific evidence of efficacy.Supported with a behavior and culture change tool kit.Consider an Electronic Monitoring System for Hand Hygiene Compliance to ensure an accurate and reliable data set from which real improvement can be driven, such as:Biovigil Hand Hygiene Compliance & Surveillance SystemDebMed: DebMed GMS (Group Monitoring System)GOJO Industries: GOJO SMARTLINK Hand Hygiene SolutionsHandGieneCorp: HandGiene HHMS (Hand Hygiene Monitoring System)HyginexHill RomHygreenIntelligentM: IntelligentM Smartband SystemProventix: nGageStanley Healthcare: Hygiene compliance monitoring systemUltraClenz: Patient Safeguard System (PSS)Versus: SafeHaven with Versus RTLS and Versus Advantages Hand Hygiene Safety (HHS) softwareMetricsTopicObserved Hand Hygiene ComplianceCompliance rate of hand hygiene by observationOutcome Measure FormulaBased on the “My five moments for hand hygiene” method.\cite{Sax_2007,Sax_2009} Moments defined as:Before patient contact,Before aseptic task,After body fluid exposure,After patient contact andAfter contacts with patient surroundings.The formula can be used to calculate hand hygiene compliance during all 5 moments. Moments 1 and 4, before and after patient contact are key calculations.Numerator: Number of hand hygiene actions performedDenominator: Number of hand hygiene actions required (hand hygiene opportunities)*Rate is typically displayed as Events/10,000 Adjusted Patient DaysMetric RecommendationsDirect Impact: All PatientsLives Spared Harm:\(Lives\ =\ \left(Compliance\ Rate_{measurement}\ -\ Compliance\ Rate_{baseline}\right)\ x\ Healthcare-associated\ Infection\ Rate\ _{baseline}\)Data Collection:  Direct observation of hand hygiene practices in identified clinical settings with one (or two) trained and validated observers. Observers will watch healthcare workers’ hand hygiene practices at the point-of-care. The observer openly conducts observations but the identities of the healthcare workers are confidential. Based on WHO Guidelines on Hand Hygiene in Healthcare (2009) and “Save lives, Clean Your Hands” campaign. (World Health Organization 2009)Appendix A“Facilitating Change,” the change management model The Joint Commission developed, contains four key elements to consider when working through a change initiative to address HAIs..Plan the Project:● Build a strong foundation for change by assessing the culture for change, defining the change, building a strategy, engaging the right people, and painting a vision of the future. This should be done at the outset of the project.Inspire People:● Solicit support and active involvement in the plan to reduce HAIs, obtain buy-in and build accountability for the outcomes.● Identify a leader for the HAI initiative. This is critical to the success of the project.● Understand where resistance may come from.Launch the Initiative:● Align operations and ensure the organization has the capacity to change, not just the ability to change.● Launch the HAI initiative with a clear champion and a clearly communicated vision by leadership.Support the Change:● The capacity to support change is critical; therefore, all leaders within the organization must be a visible part of the HAI initiative.● Frequent communication regarding all aspects of the HAI initiative will enhance the initiative.● Celebrate success as it relates to a reduction in HAIs or a positive change in HAI organizational culture.● Identify resistance to the HAI initiative as soon as it occurs.Appendix BThe Joint Commission Center for Transforming Healthcare Targeted Solutions Tool (TST)® helps organizations accurately measure their actual performance, identify their barriers to excellent performance, and direct them to proven solutions that are customized to address their particular barriers related to hand hygiene.The TST includes the following steps:Define hand hygiene protocolWho to follow hand hygiene:All personnel and visitors in contact with or in the proximity of patients, including the patient.When to follow hand hygiene:Before patient contact, sterile procedures.After body fluid exposure risk, patient contact, contact with patient surroundings.How to follow hand hygiene:Hand wash with soap and water or hand rub over all hand surfaces with alcohol-based formulation.Hand rub/hand wash for at least 15 seconds.Dry hands completely.Do not touch potentially contaminated surfaces after hand washing procedure.Educate all staff on hand hygiene procedure and implications of non-compliance.Train observers and just in time (JIT) coaches.Measure current “baseline” adherence to hand hygiene protocol with observers who sample and record compliance within the hospital units.Observers should be a role or individual that can maintain anonymity throughout the data collection process, be in a position where they can secretly observe staff while performing their regular job duties, not seem out of place during their time on the unit, and collect data that is representative of the patient population.Twenty to thirty observations should be collected each day over a two to three-week period utilizing a standardized data collection form including observation number, date and time, staff role, entry or exit to patient room, hand hygiene - yes or no, observable contributing factor to noncompliance.Identify barriers to hand washing.Qualitative input from secret observers as to observable contributing factors as to why hand hygiene protocol was not followed.Direct interviews with noncompliant caregivers by just-in-time (JIT) coaches within the hospital units to identify non-observable factors as to why hand hygiene protocol was not followed.Collect data on barriers to hand washing and calculate the hospital (or unit) baseline compliance, top contributing factors to non-compliance at your hospital (or unit), and the compliance by role(s).Analyze the data to identify root causes of why non-compliance is occurring.The top causes (or contributing factors) vary across units and hospitals, roles and shifts. Thus, it is crucial that data is first collected and analyzed to identify the factors which contribute to hand hygiene non-compliance in your area. In order to improve hand hygiene, it is essential that solutions targeting the specific causes are implemented.Not all causes are applicable to your organization and often there are two or three major causes that need to be addressed.For instance, if the unit identifies that “improper use of gloves” is the top contributing cause of hand hygiene non-compliance, then the following targeted solutions can be implemented:Detailed training for clinical staff on proper use of gloves.Relocate glove dispensers.Implement standard work process for hand washing between each patient room or patient care area when delivering food trays.Implement standard work process for daily room cleaning and educate all housekeeping personnel.Another example of a contributing cause could be “frequent entry or exit.” If the unit finds that this is a top contributing cause through the use of the TST, then the following solutions can be implemented to improve hand hygiene:Implement standard work process for hand washing after bringing mobile work machines (such as mobile vital signs devices) into the patient room or care area but before patient contact/interaction (such as taking patient’s vital signs).Create a standard “drop spot” for meds and supplies within the patient room that enables nursing to set down meds and supplies and perform hand washing.Implement computers and scanners at every bedside to reduce the likelihood of crosscontamination between patients when performing bar code medication administration.Implement standard work process for room cleaning and educate all housekeeping staff.Create and implement a list of supplies that will be kept within the patient care area.Measure progress and effectiveness of change.Utilize the same data collection and analysis tools and process utilized to calculate baseline in order to measure progress and effectiveness.Identify the changes from baseline performance for each unit, role, and shift, and identify the effectiveness of implemented solution, any barriers to effectiveness, and any additional solutions that need to be implemented.Note: The TST includes data collection forms and provides analyses in the form of Pareto (and other) charts that allows your organization to track improvement versus baseline data, to observe HAI data in correlation to hand hygiene compliance rates, and to benchmark against national results.Implement a plan to ensure that gains are sustainable.The plan should include the following action items:Designate someone to “own” the process (for example, the dedicated leader or a unit manager). At least one aspect of their job function should specify that data continue to be collected, monitored and shared with healthcare personnel.Replicate the findings to another area within your organization.Continue real time data collection to improve data collection.Train new hand hygiene observers and JIT coaches, once per year to ensure that observers receive updated training on an annual basis.Update the plan whenever changes occur.The plan should be completed with the process owner, which signals the transition of responsibility from the project leader.The project leader will continue to ensure that data is collected, entered and shared with staff at a frequency determined by the group.

Ariana Longley

and 30 more

Executive Summary ChecklistIn order to establish a program to reduce ventilator-associated pneumonia (VAP) the following implementation plan will   require   these   actionable   steps.   The   following   checklist   was   adapted   from   the   prevention   strategies recommended by the California Department of Public Health (CDPH) \cite{00001}, American Association of Critical Care Nursing \cite{adults}, the American Thoracic Society and Infectious Disease Societies of America \cite{2005}. Commitment from hospital leadership to support a program to eliminate VAP.Implement evidence-based guidelines to prevent the occurrence of VAP.Prevent aspiration of secretionsMaintain elevation of head of bed (HOB) (30-45 degrees) Avoid gastric over-distentionAvoid unplanned extubation and re-intubationUse cuffed endotracheal tube with subglottic suctioningMaintain the endotracheal tube cuff pressure at greater than 20 cmH20Encourage early mobilization of patients with physical/occupational therapyEnsure that patient is conscious and responsive prior to extubation.Reduce duration of ventilationConduct “ sedation vacations”Assess readiness to wean from ventilator dailyConduct spontaneous breathing trialsReduce colonization of aero-digestive tractUse non-invasive ventilation methods when possible (i.e. CPAP, BiPap)Use oro-tracheal over naso-tracheal intubationUse cuffed Endotracheal Tube (ETT) with subglottic suctioningPerform regular oral care with an antiseptic agentReduce opportunities to introduce pathogens into the airway Prevent exposure to contaminated equipmentUse sterile water to rinse reusable respiratory equipmentRemove condensation from ventilator circuitsChange ventilator circuit only when malfunctioning or visibly soiledStore and disinfect respiratory equipment effectivelyMeasure adherence to VAP prevention practices and consider monitoring complianceHand HygieneDaily sedation vacation/interruption and assessment of readiness to weanRegular antiseptic oral careSemi-recumbent position of all eligible patientsMonitor  ventilated  patients  for:  positive  cultures,  temperature  chart/log,  pharmacy  reports  of antimicrobial use, and change in respiratory secretionsWhen complications exist, raise them on top of the patient’s EHR problem list.Develop  an  education  plan  for  attendings,  residents  and  nurses  to  cover  key  curriculum  pertaining  to  the prevention of VAP.Encourage  continuous  process  improvement  through  the  implementation  of  quality  process  measures  and metrics and a monthly display through a dashboardThe Performance GapVentilator-associated pneumonia (VAP) is an infection that appears in the lungs when a patient is mechanically ventilated. Mechanically ventilated hospital patients are typically critically ill and treated in an intensive care unit (ICU). The infection develops after 48 hours or more of mechanical ventilation and is caused when bacteria reaches the lower respiratory tract via the endotracheal tube or tracheostomy; in addition, when airways are not properly maintained intubation may allow oral and gastric secretions to enter the lower airways \cite{00002a}.VAP is the leading cause of death associated with healthcare-associated infections (HAIs) \cite{00003}. In the US, a multi-state prevalence survey estimated the incidence of VAP in the US at 49,900 cases annually \cite{2014}. As  many  as  28%  of  all  patients  who  receive mechanical ventilation in the hospital will develop VAP and the incidence increases with the duration of mechanical ventilation.  The  crude  mortality  rate  for  VAP  is  between  20%  and  60%; and incidence  ranges  from  4% to  48% \cite{9735080}\cite{10194173}. Depending  on the  type  of  pneumonia the  mortality  rate  may vary; Pseudomonas and Acinetobacter are  associated with higher  mortality  rates  than  other  strains  of  bacteria \cite{Fagon_1996}. It  is  believed  that  when  antibiotic  therapy  is  delayed  or improperly dosed, mortality also increases. These factors are largely preventable.Patients who acquire VAP have significantly longer durations of mechanical ventilation, length of ICU stay as well as hospital stay \cite{Rello_2002}. In addition,  the  development  of  VAP  is  associated  with significant increase  in hospital  costs  and poor economic outcomes. VAP is associated with greater than $40,000 in mean hospital charges per patient.It is estimated that the use of process change and technology to reduce VAP can save up to $1.5 billion per year while significantly improving quality and safety \cite{00006}. Closing the performance gap will require hospitals and healthcare systems to commit to action in the form of specific leadership, practice, and technology plans, examples of which are delineated below for utilization or reference. This is provided to assist hospitals in prioritizing their efforts at designing and implementing evidence-based bundles for VAP reduction.Leadership PlanHospital governance and senior administrative leadership must champion efforts in raising awareness to prevent and manage VAP infections safely.Healthcare leadership should support the design and implementation of an antimicrobial stewardship program.Senior leadership will need to integrate surveillance and metrics to ensure prevention measures are being followed.Leadership commitment and action are required at all levels for successful process improvement.