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.

Building a Team to Reduce CLABSI and CAUTI

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

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.

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.

Training and the Culture of Learning: Health Equity Resource Series

American Hospital Association (AHA) Institute for Diversity and Health Equity (IFDHE)

To support hospitals and health systems starting from different points on their journey to achieve health equity, the AHA’s Institute for Diversity and Health Equity (IFDHE) is releasing a series of toolkits to share evidence-based practices to inform organizational next steps for the following topics:

  • Data collection, validation, stratification and application of patient information to address disparate outcomes
  • Cultural humility and implicit bias training and education
  • Diversity and inclusion in leadership and governance roles
  • Sustainable community partnerships focused on improving equity

Each toolkit is designed to be informative, whether organizations have already deployed health equity tactics and strategies or if they are at the early stages of implementation. Each helps lay the groundwork for an in-development equity roadmap to support hospitals’ and health systems’ efforts toward achieving high-quality, equitable care for all. This toolkit focuses on training and education strategies and approaches to encourage cultural humility and overcome implicit bias.

Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guidelines )

European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance

(Updated 05/21/24) In 2019, a full set of Clinical Practice Guidelines were developed, by the European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guidelines, The International Guideline and can be purchased for a fee. In addition, a Quick Reference Guide (QRG), which provides a summary of the recommended guidelines can be downloaded for no charge.

Pressure Injury Prevention and Treatment in the Acute Care Setting (6 Modules)

Hospital and Healthsystem Association of Pennsylvania (HAP)

  1. Overview: Pressure Injury Prevention and Treatment in the Acute Care Setting
  2. Overview: Pressure Injury Prevention and Treatment in the Acute Care Setting: It Takes a Village
  3. Overview: Pressure Injury Prevention and Treatment in the Acute Care Setting: Prevention of Pressure Injuries
  4. Overview: Pressure Injury Prevention and Treatment in the Acute Care Setting: Treatment of Pressure Injuries
  5. Overview: Pressure Injury Prevention and Treatment in the Acute Care Setting: Measuring Performance
  6. Overview: Pressure Injury Prevention and Treatment in the Acute Care Setting: Process Improvement

Note: In 2019, a full set of Clinical Practice Guidelines were developed, by the European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guidelines, The International Guideline and can be purchased for a fee. In addition, a Quick Reference Guide (QRG), which provides a summary of the recommended guidelines can be downloaded for no charge.

Please refer to the most updated guidelines for clinical practice.

Citation: European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019.

Partnering with Patients and Families During the COVID-19 Pandemic

American Institutes for Research (AIR) and IPRO Hospital Quality Improvement Contractor (HQIC)

The American Institutes for Research (AIR) and the IPRO HQIC hosted the March 2021 Patient and Family Engagement (PFE) webinar, titled Partnering with Patients and Families During the COVID-19 Pandemic.

During this 45-minute interactive event, the AIR team provided an overview of five PFE best practices and described how engaging patient and families can help both patients and clinical staff address the emergency. The event featured real-world examples of how hospitals are partnering with patients and families during the COVID-19 pandemic.

Webinar Materials:

March 30: Partnering with Patients and Families During the COVID-19 Pandemic IPRO QIN-QIO

VTE & VTE/COVID-19 Resources

North American Thrombosis Forum (NATF)

The North American Thrombosis Forum is dedicated to saving lives through education and prevention. A major part of this is helping healthcare professionals stay up to date on the latest research in the rapidly changing field of thrombosis. Through educational events and informative articles geared specifically towards clinicians, NATF provides clinicians with the information they need to best treat their patients. Topics covered include thrombosis, stroke prevention, atrial fibrillation, diabetes, cardiovascular-related illnesses, and more. Check back regularly for important updates on everything from the development of new medications to the release of novel research.

Managing the Risks of Direct Oral Anticoagulants

The Joint Commission: Sentinel Event Alert

While DOACs offer ease of use to patients, stopping bleeding events in patients on DOACs is more complicated, requiring different strategies than those for patients on warfarin (Coumadin®) and heparin. Unlike the more widely available reversal agents for warfarin and heparin, reversal agents for DOACs are lesser known and may not be available in every care setting. Also, some DOACs have no FDA-approved reversal agent at this time. Therefore, bleeding complications can be severe if these patients are not assessed according to guidelines on the management of DOACs. Intracranial hemorrhage is the most serious emergent bleeding risk.

In response to an increase in adverse events related to these widely prescribed medications, this alert provides guidance on the safe use and management of DOACs to all medical practitioners and health care organization leaders, particularly chief medical officers, pharmacists, emergency department clinicians, and quality and safety officers.

Anticoagulation FORUM: Numerous Resources and Expert Guidance

Anticoagulation FORUM

  • Education & Guidance
  • Webinars and Events
  • Centers of Excellence
  • Anticoagulation Stewardship

Established more than 25 years ago, the Anticoagulation Forum is the largest organization of its kind helping practitioners improve patient care by providing current and relevant information on best practices. The flagship program, the Anticoagulation Centers of Excellence, embodies our commitment to the clinical application of evidence-based practices and improved patient outcomes. Expert Guidance is provided by the Board of Directors, who are regularly relied upon for their expert opinion. Their contributions to research and guideline development have influenced all aspects of anticoagulation therapy.