Building a Team to Reduce CLABSI and CAUTI

Prepared by the HAP Quality Initiatives Department
Healthcare Associated Infection Prevention Managers
September 2019

The purpose of this tool kit is to teach you the key elements that are essential in building a successful team to reduce central line associated bloodstream infections (CLABSI) and catheter associated urinary tract infections (CAUTI) on your unit. The tool kit will provide you with information on how to develop a team, assess your work practices, develop an action plan, implement changes, and evaluate your success.

Building a Team to Reduce
Surgical Site Infections

This material was prepared by The Hospital & Healthsystem Association of Pennsylvania. It is redistributed by the IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

The purpose of this toolkit is to lead hospitals through the key elements that are essential in building a successful team to reduce surgical site infections (SSI). The toolkit will provide information regarding how to develop a team, assess work practices, identify gaps, develop an action plan, implement changes, and evaluate success.

How Person and Family Engagement Can Help Hospitals Achieve Equity in Health Care Quality and Safety

This material was prepared by American Institutes for Research (AIR). It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

Person and family engagement (PFE) is central to the mission of PfP and is recognized as a promising mechanism to aid in achieving equity in quality and safety. The PfP 3.0 Strategic Vision Roadmap for Person and Family Engagement lays out six overarching strategies to guide
hospitals in meaningfully engaging patients and families and describes how to apply these strategies to the five PFE metrics,

Reliability Culture Implementation Guide

This material was prepared by Michigan Health & Hospital Association, Illinois Health and Hospital Association, Wisconsin Hospital Association, and Minnesota Hospital Association. It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

The Reliability Culture Implementation Guide combines the five principles of high reliability organizations (HROs) with elements of safety culture. The Reliability Culture Implementation Guide was created to provide resources for healthcare organizations, with an emphasis on safety culture, regardless of where they are in their high reliability journey. This guide is not a step-by-step
process, but rather a guide that helps facilities after completing an initial assessment.

Implementing Antimicrobial Stewardship
and C.difficile Prevention Toolkit

The Hospital and Healthsystem Association of Pennsylvania
Quality Initiatives Department Health Care Associated
Infection Prevention Managers
.

Antibiotics represent the greatest risk factor for the development of CDI. While appropriate for treatment of many infectious diseases, antibiotics are often overused and misused. Antibiotics disturb normal bowel flora and place the patient at risk of acquiring Clostridioides difficile colonization and/or infection. Antibiotic Stewardship Programs (ASP) have been shown to be an integral part of a CDI reduction program.

The purpose of this toolkit is help facilities incorporate evidence-based research into their practices and measure their effectiveness. Process and outcome measures will be collected and trended.

Person and Family Engagement
and Health Equity – Summary

This material was prepared by American Institutes for Research (AIR). It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

This is a summary table that describes the six strategies for engaging with patients and families in equitable and meaningful ways. Although the order of the strategies in the table is based on hospitals’ experiences, hospitals do not need to implement all six strategies at once, or in this order.

PfP Strategic Vision Roadmap for
Person and Family Engagement (PFE)

This material was prepared by American Institutes for Research (AIR). It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

The purpose of the revised Roadmap is to provide practical guidance to help the Hospital Improvement Innovation Networks (HIINs), hospitals, and other PfP partners achieve a shared vision of PFE and meet the five PFE metrics.

The Roadmap contains information about:
• definition and core principles of PFE;
• role of PFE in patient safety;
• the intersection of PFE and health equity;
• definition, intent, and benefits of each PFE metric, as well as tips and resources to help
meet each metric and hospital success stories; and
• six PFE strategies to meet the five PFE metrics.

Coronavirus/COVID-19Frequently Asked Questions

This material was prepared by American Institutes for Research (AIR). It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

As of February 2021, frequently asked questions in this document refer to the two vaccines available in the U.S. at the time of this publication. These vaccines were developed by Moderna and Pfizer. Both the Pfizer and Moderna vaccines require two separate doses, or shots, in order to be fully vaccinated.

Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities

Centers for Disease Control (CDC)

Provides information on the basic principles and interventions recommended for the prevention of Clostridioides (formerly known as Clostridium) difficile infection (CDI) in acute care facilities. The strategies are intended to facilitate implementation of CDI prevention efforts by state and local health departments, quality improvement organizations, hospital associations, and healthcare facilities. Core strategies for the prevention of CDI in acute care facilities include:

1. Isolate & Initiate Contact Precautions

2. Confirm CDC in Patients

3. Perform Environmental Cleaning

4. Develop Infrastructure

5. Engage the Facility Antibiotic Stewardship Program

Managing Acute Respiratory Failure in Small, Rural, and Critical Access Hospitals: Non-Invasive Ventilation & High-Flow Nasal Cannula

This material was developed by IPRO HQIC.

Due to medical-surgical nurses’ limited exposure to managing acute respiratory failure, nurses in rural and critical access hospitals do not always have a comfort level with non-invasive ventilation (NIV) equipment and/or High-Flow Nasal Cannula (HFNC). Managing this situation on medical-surgical floors within these smaller hospitals created a void, especially without access to specialty staff who have advanced clinical respiratory experience, lack of critical care beds, and/or the lack of respiratory therapy resources. This is especially true in rural and critical access hospitals, possibly exacerbating adverse events and potentially increasing health disparities (due to access of specialty care issues). This electronic tool provides digestible information to support the front-line in CPAP, BiPAP, and HFNC management.

Pressure Injury- Learning and Action Network (LAN) May 24th 2021

IPRO & Telligen Hospital Quality Improvement Contractors (HQICs)

The LAN included:

  • A presentation of aggregated results from the IPRO & Telligen HQIC Hospital Baseline Assessment specific to pressure injury
  • An interactive discussion with quality and performance improvement subject matter experts on pressure injury identification, prevention, and management.

Attendees had the opportunity to discuss:

  • Pressure injury challenges in small rural and critical access hospitals (in general and with COVID-19)
  • Approaches to overcome these challenges, including patient and family engagement and health equity strategies.

Hospitals left “in action” with a variety of strategies and 17 salient resources for the front-line to further efforts in All-Cause Harm (Pressure Injury) prevention and management.

COVID-19 Response Webinar Series

American Association of Colleges of Nursing (AACN)

On demand free webinars on numerous COVID-19 nursing related topics. to include:

  • Decision Making
  • Admissions
  • Clinical and Simulation Alternatives
  • Teaching and Online Education
  • Leadership
  • Public Health
  • Mental Health and Culture
  • Student Issues

COVID-19 Lessons Learned (whitepaper): A Resource for Recovery

Co-authored by Deloitte & Joint Commission Resources

The whitepaper catalogues a broad array of lessons learned identified during the period of March through August 2020. These lessons learned are based on discussions with a diverse group of health care leaders; assessments of readiness/preparedness efforts across national, regional and local stakeholders; and a review of public documents. The considerations in this whitepaper include observed best practices adopted by organizations throughout the COVID-19 response. For each health care domain and associated issues, it lays out specific actions that organizations have taken to address them and provides access to guidance and tools that health care leaders can use to create and enact their own plan to address these challenges. Some of the wide array of health care domains covered in this in-depth resource include:

  • Leadership
  • Emergency readiness and crisis response
  • Infection control
  • Patient safety and high reliability
  • Communications and change management

COVID-19 Resources for Hospitals

Patient Safety Movement

  • Activate incident command systems.
  • Ensure there is an adequate supply of PPE, ventilators, and other supplies and equipment.
  • Maintain ethical standards when allocating resources.
  • Have a plan for continued surge.
  • Ensure safe staffing levels.
  • Routinely analyze your facility’s risk.
  • Embrace continuous improvement and a culture of safety.
  • Establish safe discharge practices.
  • Ensure that proper cleaning protocols are implemented.
  • Continuously involve patients, family members, and members of the general public in conversations around improvement. 
  • Create a plan to resume normal operations.
  • Take care of your people, so they can better care for patients.