NY Nurses Help Hospitals Realize Better Outcomes, Lower Health Care Costs Through AACN CSI Program

Small teams of nurses at seven New York hospitals have improved patient care and saved their hospitals millions of dollars by participating in a training program conducted by the American Association of Critical-Care Nurses (AACN).

The New York hospitals were the sixth cohort in the program. So far 42 hospitals nationwide have participated in the AACN Clinical Scene Investigator (CSI) Academy, a 16-month nursing leadership and innovation training project that has improved patient outcomes and saved hospitals more than $28 million annually.

In the New York cohort, groups of four nurses from each hospital chose a treatment area they wanted to address, such as preventing hospital-acquired infections and falls or standardizing protocols to assessing delirium or mobilizing ventilated patients, reports Nurse.com.

At North Shore University Hospital, nurses focused on reducing catheter-associated urinary tract infections (CAUTIs) in the intensive care unit (ICU), because their unit had the highest rate in the state’s health system. Interventions included education efforts for patients, staff, and families on the importance of earlier removal of the catheter, and a focus on hygiene practices. After implementing the changes, the hospital achieved more than six months without a CAUTI, a significant improvement from not having a single CAUTI-free month before the academy. The reduction in infections saved $112,000 for the hospital.

At NYU Langone Medical Center nurses wanted to establish a consistent approach to treating and assessing delirium in the medical ICU. They collaborated with the care team, including the IT department, which developed a way to incorporate delirium assessment into electronic health records. Innovations also included an assessment checklist for delirium printed on mousepads, which eliminated the need to search for the tool. The Center estimates it will save between $3.3 million and $5.5 million as a result of the changes.

Nationwide, the CSI Academy has trained 163 nurses to address clinical challenges such as hospital-associated infections, pressure ulcers, delirium, early mobility, falls, and patient handoffs. Project materials developed by each team, including plans, data collection tools, practice resources and references in a searchable online database, are available on the AACN website at www.aacn.org/csiprojects.

The INQRI Blog featured previously released data from the Academy from regional groups working in Massachusetts and North Carolina and overall progress in the program.

CLASBIs Rates Improved When Hospitals Implement Airline Industry Approach

Hospitals around the country are reducing central line associated bacterial infections (CLASBIs) by taking a “plane crash” instead of a “car crash” approach in their efforts, according to a VOX special report.

The theory is that car companies see accidents as unavoidable, no matter how much work goes into prevention. The aviation industry, however, treats each crash as potentially preventable and investigates how it could have been prevented. A similar divide exists among hospitals when it comes to treating CLASBIs central line infections, Vox reports.

While some hospitals view the infections as bad but inevitable, other hospitals “see each central line infection as a failure that requires investigation and better preventive techniques in the future.” And many of these “plane crash” hospitals are reducing infections, in part by empowering nurses and giving them the tools to prevent infections.

Peter Pronovost, a critical care physician at Johns Hopkins University in Baltimore, created a simple five-item checklist that centers on cleanliness when inserting central lines, and changing the dressing, and implementing changes such as centralized stock carts. But one of the most significant changes the hospital implemented was to instruct nurses to “call out” doctors who were not following checklists. Within three months, CLASBIs decreased by 50 percent, and they decreased by 70 percent after six months.

Hospitals in Michigan and California Follow Suit

After hearing of the success at Johns Hopkins, the Michigan Hospital Association implemented a similar the protocol at about 60 hospitals in the state, and realized a 70 percent decrease within three months. Similarly, Roseville Medical Center in California implemented its own version of Pronovost’s checklist and also gave an 18-nurse vascular access team exclusive responsibility for inserting and monitoring central lines. For seven years after the new program was instituted, Roseville did not have a single central line infection.

When the hospital’s seven year streak broke in 2014, Roseville decided to investigate. The investigation revealed that subcontracted nurses who treated dialysis patients, but who were not part of the central line team, were responsible for the infections. As a result of the findings the hospital now requires annual competency checks for contract nurses who manage central lines.

“The Roseville response mirrors what airlines do at a moment of crisis: analyze the situation and implement new policies that could prevent the same type of problem in the future.”

Reducing CLASBIs was the focus of an INQRI-funded study led by David Thompson and Jill Marsteller. Their study, involving 45 intensive care units in 35 hospitals in 12 states, tested a nurse-led intervention that used a bundle of evidence-based practices to reduce infections. The intervention was successful in significantly reducing infections and also highlighted the importance of promoting a culture of safety and communication. It also established that nurses should play a central role in quality improvement interventions.

The full VOX article is available here.

Study Finds Patients Admitted to Hospitals on Weekends are at Greater Risk for “Never Events”

Falls and infections are more common among patients admitted to hospitals on weekends, according to a new study conducted by researchers at the University of Southern California and published in the British Medical Journal. The research team analyzed data from more than 350 million hospital admissions from 2002 to 2010. Even though the vast majority (81 percent) of the admissions were on weekdays, there were more complications in patients admitted on weekends (5.7 percent of complications compared with 3.7 percent for patients admitted on week days). The most common kinds of hospital-acquired infections among patients admitted on weekends were pressure ulcers and catheter-associated urinary tract infections.

The research team could not determine whether the higher proportion of complications were due to lower staffing rates on weekends or patients with more urgent treatment needs being admitted during those times.

These findings are consistent with a body of research showing that patients admitted during off-peak hours (like evenings and weekends) experienced more health problems, and were less likely to survive in-hospital cardiac arrest, and that newborns born on weekends were more likely to die than babies born during the week.

An INQRI-funded study led by Patti Hamilton and Gretchen Gemeinhardt found that nurses’ “off-peak” work environments play a significant role in the increased patient mortality during these time periods.  In particular, the researchers found that nurses who participate in hospital plans that allow them to work only weekend shifts for full pay and benefits are less familiar with their institutions’ initiatives and priorities that govern policies, procedures, principles and regulations for providing care, because those initiatives and priorities are stressed more during peak periods.

AACN Academy Shows Value of Investing in Nurse Leadership Development

After participating in a 16-month leadership and innovation training program, nurses at 42 hospitals nationwide went on to direct quality initiatives that improved patient outcomes and saved more than $28 million annually.

The AACN Clinical Scene Investigator (CSI) Academy is a 16-month leadership and innovation training program for staff nurses delivered by the American Association of Critical-Care Nurses (AACN) that seeks to empower nurses as clinician leaders and catalysts for change.

The CSI Academy trained 163 nurses to address clinical challenges such as health care associated infections, pressure ulcers, delirium, early mobility, falls, and patient handoffs. The nursing teams saw great success, according to AACN, significantly reducing many common hospital errors.

Regional groups working in Indiana, Massachusetts, New York, North Carolina, Pennsylvania and Texas showed progress in decreasing:

• Intensive care unit (ICU) and progressive care unit lengths of stay by one day; 
• Days on mechanical ventilation by 14 percent or approximately one day;
• Health care-acquired infections and ICU complications by 50 percent;
• Patient falls by 50 percent;
• Pressure ulcers by 40 percent;
• Catheter-associated urinary tract infections by 70 percent; and
• Confusion Assessment Method for the ICU (CAM-ICU) positive scores by 14 percent

“These outcomes solidly reaffirm the value of investing in bedside nurses’ leadership development,” AACN CEO Dana Woods said in a statement. “Our program evaluations confirm that dedicated time for nurses to apply their skills in leading organizational and behavioral change was vital to achieving the program’s impressive results.”

AACN provides project materials from each team, including plans, data collection tools, practice resources and references in a searchable online database, which can be accessed at www.aacn.org/csiprojects.

INQRI Blog featured previously released data from the Academy from regional groups working in Massachusetts  and North Carolina.

New Study Finds Benefits to Increasing Nurse-Physician Collaboration

Healthcare-associated infections (HAIs) decreased when collaboration between nurses and physicians working in critical care increased, according to a new study published in the April issue of Critical Care Nurse (CCN).

In critical care units in which nurses reported a more favorable perception of nurse-physician collaboration, researchers found lower rates of ventilator-associated pneumonia (VAP) and central line-associated bloodstream infection (CLABSI).

Researchers for the study, including Christine Boev, performed a secondary analysis of nurse surveys conducted in four specialized intensive care units (ICUs) over a five year period. The resulting article, “Nurse-Physician Collaboration and Hospital-Acquired Infections in Critical Care,” shows the association between nurses’ perception of their working relationships with physicians and the rates of VAPs and CLASBSIs.

“Our findings suggest that raising the quality of collaboration and communication among nurses and physicians has the potential to improve patient safety,” Boev said in a statement. “Efforts to prevent healthcare-associated infections must include interventions to improve nurse-physician collaboration.”

Boev, an assistant professor at the Wegmans School of Nursing, St. John Fisher College, suggested multidisciplinary daily patient rounds and shared simulation training to improve collaboration.

Reducing CLASBIs was the focus of an INQRI-funded study led by David Thompson and Jill Marsteller. Their study, involving 45 intensive care units in 35 hospitals in 12 states, tested a nurse-led intervention that used a bundle of evidence-based practices to reduce infections. The intervention was successful in significantly reducing infections and also highlighted the importance of promoting a culture of safety and communication. It also established that nurses should play a central role in quality improvement interventions.

The CCN article abstract and full-text PDF is available at: http://ccn.aacnjournals.org/.

Nurse Team Reduces CAUTI Infections Through EHR Tool

A nurse-led initiative at a Missouri hospital used Electronic Health Records (EHRs) to reduce the number of catheter-associated urinary tract infections (CAUTIs) by 25 percent in its facilities, Becker’s Health IT & CIO Review reports.

Eileen Phillips, an RN at the University of Missouri Health System, led a team of nurses in reviewing literature on infections. The team then developed a list of appropriate, evidence-based indications for catheter use, and included a step in their EHRs that required nurses to document the reasons for use of a catheter. This led to a decrease in use of catheters and contributed to the subsequent 25 percent drop in infections.

The nursing team also began an educational and communications campaign called “CAUTIon: Zero Infections Ahead” that used web-based modules, posters, rewards systems, weekly quizzes, and staff meetings to highlight best practices for catheter use.

"This could not have occurred without first reducing our utilization, which is why the EHR task has helped so much," Phillips said in a blog post Q&A on Cerner’s website. "In 2013, our catheter utilization was 33 percent, and in 2014, utilization decreased to 25 percent, which is a 24 percent overall decrease. I am really happy with the progress we have made so far."

Reducing central line infections was the focus of an INQRI-funded study led by David Thompson and Jill Marsteller. Their study, involving 45 intensive care units in 35 hospitals in 12 states, tested a nurse-led intervention that used a bundle of evidence-based practices to reduce infections. The intervention was successful in significantly reducing infections and also highlighted the importance of promoting a culture of safety and communication. It also established that nurses should play a central role in quality improvement interventions.

Preventing Hospital Acquired Infections among Elderly ICU Patients Reduces Death Risk, Saves Money

Elderly patients who develop hospital-acquired infections (HAIs) while in intensive care units (ICU) are approximately 35 percent more likely to die within five years than other patients, according to a new study co-authored by INQRI grantee Patricia Stone.

The most common HAIs are bloodstream infections caused by central lines and pneumonia caused by ventilators, reports Advanced Healthcare Network for Nurses. Decreasing the incidents of these two HAIs alone could increase the odds that ICU patients survive, and reduce health care costs by more than $150,000, according to Stone’s study.

Stone and her colleagues examined outcomes for 17,537 Medicare patients over a five year period and found that while 57 percent of all the elderly ICU patients had died, nearly 80 percent of patients who developed HAIs during their ICU stays died.

"Any death from preventable infections is one too many," Stone tells Advanced. "We've known for decades what works to prevent infections and save lives. Now, our study shows just how much money can be saved by investing in prevention."

The paper, "A decade of investment in infection prevention: A cost-effectiveness analysis," was published in the January 2015 issue of the American Journal of Infection Control and was funded by the National Institute of Nursing Research.

Reducing central line infections was the focus of an INQRI-funded study led by David Thompson and Jill Marsteller. Their study, involving 45 intensive care units in 35 hospitals in 12 states, tested a nurse-led intervention that used a bundle of evidence-based practices to reduce infections. The intervention was successful in significantly reducing infections and also highlighted the importance of promoting a culture of safety and communication. It also established that nurses should play a central role in quality improvement interventions.

Patricia Stone’s INQRI-funded project: “The Impacts of Nurse Staffing, Skill Mix, and Experience on Quality and Costs in Long-Term Care” examined whether there is a causal relationship between nursing input and patient outcomes in long-term care (LTC) facilities.

The full Advanced article is available here.

New Guidance Shows Importance of Evidenced-Based Best Practices in Hygiene

A new guidance published in the August issue of Infection Control and Hospital Epidemiology emphasizes the importance of proper hand hygiene to prevent the spread of health care-associated infections, reports Health Canal. RWJF Health & Society Scholars program alumna Allison Aiello and her colleagues developed the guidance, which includes a series of evidenced-based best practices for optimal hand hygiene in health care settings. The guidance encourages increased availability and acceptability of certain soap and alcohol-based rubs and the development of a system to empower health care personnel to create a personalized hygiene system that gives them a way to track their progress.

The recommendations include developing a multidisciplinary team in which representatives from administrative and unit-level leadership work together to establish a hand hygiene program that best fits each institution. The program should include clear performance targets and an action plan for improving adherence, according to the guidelines.

An INQRI-funded study published last year in Critical Care Medicine found that a nurse-led intervention combining a “bundle” of evidence-based practices with a comprehensive safety program dramatically reduced the mean rate of health care-associated infections. The study was conducted by David Thompson and Jill Marsteller associate professors at Johns Hopkins University in the School of Medicine and Bloomberg School of Public Health, respectively, and by J. Bryan Sexton now at the Duke University Health System Patient Safety Center.

Study Finds Weekly Emails Can Empower Nurse Leaders to Help Curb Hospital Acquired Infections

Incorporating hospital leaders into weekly email reports empowered nurses to better fight infections at Jackson Memorial Hospital (JMH) in Miami. As a result the hospital was finally able to curb the spread of the highly resistant organism Acinetobacter baumannii, which it had been battling for 20 years with little success, HealthLeaders Media reports. Acinetobacter baumannii can cause a variety of infections, ranging from pneumonia to wound infections.

When the medical director of infection control began sending weekly emails about infection rates to hospital executives and nurse leaders, things changed. According to a study published in the American Journal of Infection Control, for about a year the director sent weekly emails to the hospital leadership that were copied to staff. The emails:

• Described and interpreted the findings of the preceding week's bundle of interventions;
• Relayed the number and location of new carbapenem-resistant A. baumannii acquisitions;
• Described environmental findings, including culture results and ultraviolet markers (as indicators of cleaning); and
• Included maps of the units showing the location of patients and objects that had tested positive to the organism and weekly action plans.

This information provided a roadmap for how the bacteria moved through the unit and empowered nurses to take action, according to the study. Charge nurses used print outs of the emails to pre-plan patient placement within the unit. The maps and culture results also showed who was spreading the organisms and individuals who did not clean properly were appropriately disciplined.

Including the C-suite in this effort made everyone more accountable, and sharing the infection information helped everyone feel like they were making a difference, Elizabeth Davidson, nurse manager of the surgical intensive care unit at JMH told HealthLeaders Media. Having the weekly emails and directives from the hospital leadership empowered nurses on the unit speak up if they saw someone breaking protocol, such as failing to wash their hands or not cleaning patient rooms properly.

"The nurses became very, very territorial about their patients," Davidson said. "They would really have zero tolerance for a physician, perhaps, that would violate any kind of infection-control practice. They also got much pickier about their rooms being cleaned."

As a result, infections rates began to drop, according to the study, and as of December 2013, the number of new acquisitions of carbapenem-resistant A. baumannii was down to one per month hospital-wide, even after the weekly emails stopped.

Utilizing a nurse-led intervention to reduce central line-associated bloodstream infections was the focus of an INQRI-funded study led by David Thompson and Jill Marsteller. Their study, involving 45 intensive care units in 35 hospitals in 12 states, tested a nurse-led intervention that used a bundle of evidence-based practices to reduce infections. The intervention was successful in significantly reducing infections and also highlighted the importance of promoting a culture of safety and communication. It also established that nurses should play a central role in quality improvement interventions.

Rates of Infections, Falls, Pressure Ulcers, Other Hospital Acquired Conditions Drop

Hospitals saw a nine percent decrease in harms experienced by patients from 2010 to 2012, according to a new report from the U.S. Health and Human Services Department (HHS). There were reductions in adverse drug events, falls, infections, pressure ulcers, and other areas, estimated to have prevented nearly 15,000 deaths and 560,000 cases of patients being harmed in hospitals.

The HHS report also shows that the incidences of hospital-acquired infections dropped from 145 per 1,000 discharges in 2010 to 132 per 1,000 discharges in 2012, resulting in 560,000 few incidents in two years, FierceHealthcare reports. Falls and trauma declined 14.7 percent and pressure ulcers fell 25.2 percent.

In addition to lives saved, the reduction in harm to patients saved $4.1 billion according to the report, which credits factors such as diverse public-private partnerships, active engagement by patients and families, and new tools provided by the Affordable Care Act (ACA), with the improvement. In 2011, under the ACA, HHS launched the Partnership for Patients, a nationwide public private initiative to keep patients from being harmed in hospitals and heal without complication. The Partnership shares best practices with more than 3,700 hospitals enrolled in the initiative.

INQRI grantees have conducted a number of studies into how nurses can lead efforts to reduce medical errors and patient harm, including:

• Reducing central line-associated bloodstream infections was the focus of an INQRI-funded study led by David Thompson and Jill Marsteller. Their study, involving 45 intensive care units in 35 hospitals in 12 states, tested a nurse-led intervention that used a bundle of evidence-based practices to reduce infections. The intervention was successful in significantly reducing infections and also highlighted the importance of promoting a culture of safety and communication. It also established that nurses should play a central role in quality improvement interventions.
• The INQRI funded project “Interdisciplinary Mobility Team Approach to Reduction of Facility-Acquired Pressure Ulcers” developed a sustainable, system-wide program for pressure ulcer prevention that enhances mobility of long-term care (LTC) residents. The primary goal, under nursing's leadership, was to reduce LTC facility-acquired pressure ulcer incidence by 50 percent using a cost-effective innovative program to increase resident active or passive movement. The team, which developed and implemented a program that involved using musical cues to remind residents to move or staff to help residents move, was led by Tracey Yap, a nurse researcher, and Jay Kim, an engineer.
•  INQRI grantee Patti Dykes worked with a team to develop the Falls: Tailoring Interventions for Patient Safety (Falls TIPS) online tool kit to educate patients and families about how they can work with nurses and other providers to prevent falls. The toolkit was developed based on the Fall TIP: Validation of Icons to Communicate Fall Risk Status and Tailored Interventions to Prevent Patient Falls study, which involved developing and validating a set of icons designed to communicate fall risk status, and developing tailored interventions to prevent patient falls in hospitals.

The full HHS report is available here.

Infections Drop by nearly 20 Percent with Reduced Blood Transfusions

Reducing the amount of red blood cell (RBC) transfusions performed in hospitals can also reduce infection rates, according to a new study published in the Journal of the American Medical Association.

Researchers from the University of Michigan and the University of Rochester School of Medicine and Dentistry studied 18 clinical trials, comparing those which restricted use of blood transfusions with a more liberal transfusion strategy. They found that incidence of health care-associated infections was 11.8 percent in the restrictive group and 16.9 percent in the liberal group.

The study shows that RBCs can be a more costly and dangerous treatment method than previously believed, according to the researchers.

"Many people are beginning to accept that we can make a difference--despite being taught in medical school that blood transfusions 'might help and can't hurt,'" Neil Blumberg, professor at the University of Rochester School of Medicine and Dentistry tells HealthCanal. "What we've found is actually the opposite, that it can hurt and it rarely helps."

An INQRI-funded study published last year in Critical Care Medicine found that a nurse-led intervention combining a “bundle” of evidence-based practices with a comprehensive safety program dramatically reduced the mean rate of infections. The study was conducted by David Thompson and Jill Marsteller associate professors at Johns Hopkins University in the School of Medicine and Bloomberg School of Public Health, respectively, and by J. Bryan Sexton now at the Duke University Health System Patient Safety Center.

One in Five Health Care Facilities Falling Short on Hand Sanitizer

This post first appeared on the Robert Wood Johnson Foundation Human Capital Blog.

In a time of progress against hospital-acquired infections, a new nurse-led study offers a reminder of the work that remains to be done. The study finds that approximately one in five U.S. health care facilities fails to place alcohol-based hand sanitizer at every point of care, missing an opportunity to prevent the spread of infectious diseases.

A research team jointly led by Laurie Conway, RN, MS, CIC, a PhD student at the Columbia University School of Nursing, and Benedetta Allegranzi, MD, of the World Health Organization (WHO), surveyed compliance with WHO hand-hygiene guidelines at 168 facilities in 42 states and Puerto Rico. Just over 77 percent reported that alcohol-based sanitizer was continuously available at every point of care. They also found that only about half of the hospitals, ambulatory care, and long-term care facilities had allocated funds for hand-hygiene training.

“When hospitals don’t focus heavily on hand hygiene, that puts patients at unnecessary risk for preventable health care-associated infections,” Conway said in a news release. “The tone for compliance with infection control guidelines is set at the highest levels of management, and our study also found that executives aren’t always doing all that they can to send a clear message that preventing infections is a priority.”

Read the study in the American Journal of Infection Control.

Interdisciplinary Team Approach Needed to Battle HAIs Effectively

Nurse-led, interdisciplinary team-based approaches are needed to effectively prevent hospital-acquired infections (HAIs), according to a new study led by former INQRI grantee Patricia Stone. Neither nurses alone, nor the presence of infection-prevention policies, are enough to keep HAI rates down, HealthLeaders Media reports.

The study was published by Columbia School of Nursing, where Stone is Centennial Professor of Health Policy, and is featured in the American Journal of Infection Control. Among the findings:

• Central line-associated bloodstream infections (CLABSI): 92 percent of ICUs had a policy for an insertion checklist, but only 52 percent of the health care professionals were seen to adhere to that policy;
• Ventilator-associated pneumonia: 74 percent of ICUs had a ventilator bundle checklist, but only 52 percent of those treating patients adhered to it; and
• Catheter-associated urinary tract infection: 27 percent of ICUs had a policy for a nurse-assisted catheter insertion, but only 22 percent were seen to observe that practice.

"Some of these things are really [linked to] nursing," Stone tells HealthLeaders. “But just because HAIs are a nursing-sensitive outcome, doesn't mean that nurses alone bear the responsibility for them. It takes a team, it takes top leadership, it takes everyone on the same page. It's not just a nursing problem."

However, nurse leaders can and should take the lead on making sure that an interdisciplinary team is adhering to infection prevention policies, and establishing such policies when needed. This can include ensuring that nurses have carts for central line insertion and resources like portable bladder ultrasounds. Strong policies, interdisciplinary checks and balances, and leadership are all needed to battle HAIs, according to the study.

Reducing CLABIs was the focus of an INQRI-funded study led by David Thompson and Jill Marsteller. Their study, involving 45 intensive care units in 35 hospitals in 12 states, tested a nurse-led intervention that used a bundle of evidence-based practices to reduce infections. The intervention was successful in significantly reducing infections and also highlighted the importance of promoting a culture of safety and communication. It also established that nurses should play a central role in quality improvement interventions.

Patricia Stone’s INQRI-funded project: “The Impacts of Nurse Staffing, Skill Mix, and Experience on Quality and Costs in Long-Term Care” examined whether there is a causal relationship between nursing input and patient outcomes in long-term care (LTC) facilities.