Webinar: NYC center maps success in fighting infection
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In an Institute for Healthcare Improvement (IHI) webinar yesterday, Koll described how his organization has used the IHI Improvement Map in its efforts to prevent catheter-associated urinary tract infections (CAUTI) and clostridium difficile (c.diff) infection.
The Improvement Map is an online tool that helps facilities prioritize, implement and manage quality improvement initiatives and “get everyone on the same page,” said Maureen Bisognano, IHI president and CEO. “There’s never been more urgent need to save time, to reduce waste and focus more squarely on effective outcomes and care for patients.”
Beth Israel, based in Manhattan, includes a tertiary care facility in Manhattan and a community hospital in Brooklyn, and is a teaching hospital affiliated with Albert Einstein College of Medicine, with more than 1,000 beds combined, Koll said.
Using the Improvement Map, Beth Israel modified models of success in its efforts to lower CAUTI and c. diff. “We rely on existing technology and limited additional resources. Usually, we have to deal with what we have,” he said.
Koll’s group started by getting hospital-specific data—with sobering results. A point prevalence study found that 17 percent of patients had a Foley catheter, and of those patients, 16 percent had a CAUTI, he said. By comparison, 0.8 percent of patients had other device-related infections, such as central-line associated blood infections or ventilator-associated pneumonia. “The other thing we found was that about 20 percent of patients in our ICU did not have a valid indication for a Foley catheter, which meant there was a significant amount of unnecessary use,” Koll said.
Armed with data, the team went to work. “Our hospital is sort of in between paper and computers: We do have a computer ordering system and nursing notes are documented on the computer, [but] physician notes are documented the old-fashioned way, in the chart. So we looked at what would be acceptable criteria for a Foley catheter, and incorporated that into the computer system.” Now, Foley catheter use is limited to patients that meet one of these seven criteria, he said. In addition, a renewal order is required. Every three days, a screen pops up and prompts the physician to reorder Foley, and it has to meet one of those indications or use is discontinued.
Beth Israel also came up with an education programs for its 8,000-plus employees, according to Koll. “We try to harness the energy of front-line staff” by partnering with the workers’ union and building an infection prevention coach program, training all staff to be advocates for infection prevention.
Goals for the initiative included:
1. Valid indication for Foley catheter placement. The goal was to implement criteria on the computer system within 30 days, which was achieved.
2. Renewal prompts to make caregivers think about reason for catheter use. “We were able to decrease utilization of Foley catheters on average by three days. Two-thirds of units now have no Foley CAUTI for six months or greater,” said Koll.
3. An associated reduction in multi-drug resistant e.coli and CLF.
4. Cost reduction. “This is a patent safety initiative—the most important thing is morbidity and mortality, but finances are important because infection prevention is a cost center,” he said. “We were able to save the medical center $320,000 in prevention of these infections over a year.”
Beth Israel’s c.diff. initiative involved developing a prevention bundle of hand hygiene (washing with soap and water), contact precautions, having readily available gowns and gloves and using them appropriately, building alerts about patients who need precautions and what the precautions are.
All staff were educated to look for visual queues in the form of “traffic light signals” in email—red, green or yellow, depending on the precautions needed—for each patient. This has helped maintain its prevention measures hospitalwide, Koll said.
The results have been significant: Prior to the initiative, the infection rate for c.diff was eight patients per 10,000 patient days at Beth Israel’s Petrie Division tertiary care hospital; the improvement effort brought that down to two per 10,000 patient days. At the Kings Highway Hospital, the results were even more notable: from a rate of 25 per 10,000 patient days down to five per 10,000 patient days.
In terms of cost effectiveness, “we needed $200,000 in additional resources” to switch from rectal thermometers to temporal artery thermometers as part of the initiative, but the overall effort has resulted in more than $1 million of savings, said Koll.
His advice for other facilities: Don’t ignore the time needed to implement an initiative. In the case of Beth Israel, these efforts were moderately challenging, and the organization saved some time by using practices that have been successful in other places. “It makes people realize they’re not alone” in their quality improvement and patient safety efforts, Koll said.