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2006 Malcolm Baldrige National Quality Award Reipient

February 2008 Premier Safety Share

Dear Colleague:

This month we are featuring a number of infection related stories about preventing Clostridium difficile and urinary tract infections; bloodstream infections using CHG; improving hand hygiene; CMS reimbursement rule; and preventing influenza transmission with a humorous video. Also, visit our new Web site on healthcare-associated infections and MRSA.

Gina Pugliese, editor
Vice President, Premier Safety Institute





Bloodstream infection rates reduced with chlorhexidine bathing

A recent study found that daily cleaning of patients in a medical intensive care unit with chlorhexidine gluconate (CHG) impregnated cloths compared to soap and water baths was effective in reducing the rate of primary bloodstream infections (BSI). This clinical trial was a 52-week, two-arm, crossover design in a 22-bed medical intensive care unit (MICU), which is comprised of two geographically separate, similar 11-bed units of a public teaching hospital in Chicago. The study population included 836 MICU patients. During the first of two study periods (28 weeks), one hospital unit was randomly selected to serve as the intervention unit in which patients were bathed daily with 2 percent CHG-impregnated washcloths (Sage 2 percent CHG cloths; Sage Products Inc, Cary, IL); patients in the concurrent control unit were bathed daily with soap and water. After a two-week washout period at the end of the first period, cleansing methods were crossed over for 24 more weeks.

Patients in the CHG intervention arm were significantly less likely to acquire a primary BSI (4.1 versus 10.4 infections per 1,000 patient days; incidence difference, 6.3 [95% confidence interval, 1.2-11.0]). The incidences of other infections, including clinical sepsis, were similar between the units. Protection against primary BSI by CHG cleansing was found to be apparent after five or more days in the MICU.

Compared with soap and water, CHG cleaning resulted in a persistent, several log reduction in the density of microbial skin colonization, representing a low microbial load. This 12-month clinical trial, bathing MICU patients daily with a no rinse, 2 percent CHG-impregnated cloth, resulted in a 61 percent relative decline in the incidence of primary BSIs. The researchers note that primary BSIs were reduced by improving a required, routine patient care activity (i.e., patient bathing) without introduction of additional actions.

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First study showing rapid response teams result in dramatic drop in both hospital-wide mortality and non-ICU code rates

In a recent study measuring mortality and cardiopulmonary arrest rates, researchers found after the addition of a rapid response team (RRT), the monthly mortality rate decreased by 18 percent, and cardiopulmonary arrests rates declined by almost 72 percent. The authors estimated that 33 children's lives were saved over a 19-month period. The significant differences may be due in part to the case mix and the longer study period after intervention.

Other research has shown that the employment of a RRT decreases mortality and cardiopulmonary arrests outside of the intensive care unit (ICU) in adult inpatients. The study, "Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a Children's Hospital," found that the implementation of an RRT was associated with a statistically significant reduction in hospital-wide mortality rates and code rates outside of the pediatric ICU setting.

Researchers at Lucile Packard Children's Hospital and the Stanford University School of Medicine measured the before and after hospital-wide mortality rates and respiratory and cardiopulmonary arrests rates outside of the ICU setting. The ICU-trained RRT, consisting of a pediatric intensive care physician, an intensive care nurse, an intensive care respiratory therapist and a nursing supervisor, was called when patients experienced acute changes in vital signs, such as heart and respiratory rates, blood pressure or consciousness. RRTs remain in the hospital around the clock and respond within five minutes after being called. The RRT may be called due to a change in the patient's status, a change in breathing, blood oxygen content or blood pressure, but many calls result because a parent or nurse simply felt that something was different about the child. RRTs provide additional respiratory support, administer additional or different intravenous fluids or may transfer a child to the intensive care unit for more intensive monitoring. After the RRTs were added, the monthly mortality rate and rate of cardiopulmonary arrests decreased significantly, as noted earlier.

One reason for the success of the RRTs may be the long time frame of the study, as well as a greater proportion of high-risk children. The authors suggest that the focus of future research should be on repeating these findings in other pediatric inpatient settings, efficient ways to implement rapid response teams, as well as evaluating the cost-effectiveness of RRT implementation.

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Hospital boards benefit from safety dashboards that track improvement in system-wide measures

Hospital boards should primarily focus on whether their system-wide measures show they are improving, according to a recent discussion of how hospitals and their hospital board members can benefit using patient safety dashboards. This white paper safety dashboards from the Institute for Healthcare Improvement (IHI), "Reducing harm to patients: Using patient safety dashboards at the board level" and published by Healthcare Executives, describes the importance for hospital boards to set clear expectations and goals, as well as monitoring those goals, for reducing patient harm. Referencing IHI's white paper, "Seven Leadership Leverage Points," Leadership authors Pugh and Reinertsen state that a hospital board should first try to improve a few whole system measures such as in clinical quality, patient satisfaction, financial performance, and organizational effectiveness. These whole system measures can be described as "dashboards." One example the authors give is "to reduce the inpatient mortality rate by 20 percent within 2 years."

The authors stress the need for the hospital boards to focus on the system measures rather than get caught up in the increasingly large number of detailed clinical and improvement measures. They recommend changing the way quality and clinical information is presented to hospital boards. Separate dashboards such as quality control, patient safety, and improvement projects should be presented first, followed by overall system measures. The measures should be presented in two ways. The first should answer the question of how you compare to other hospitals; the second should answer the question of whether or not you are improving. The board’s main focus should be on the second question of whether they are improving. Additional recommendations include the setting of interim targets or goals for certain measures when needed and keeping the presentation format simple. Board-level patient safety measures should lead to discussions about strategies and resources needed to see improvements.

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Education critical to implement 2008 CMS hospital-acquired conditions rule

A new CMS policy taking effect in October 2008, in which Medicare will no longer pay for the extra cost of treating eight conditions acquired in the hospital, is part of an effort to push hospitals to improve medical quality and enhance patient safety while maintaining costs.

CMS changes reduces payment
The Centers for Medicare and Medicaid (CMS) develops Conditions of Participation (CoP) and Conditions for Coverage (CfC) that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. CoP and CfC are the minimum health and safety standards that providers and suppliers must meet in order to be Medicare and Medicaid certified and receive reimbursement.

A new CMS rule, the FY2008 Inpatient Prospective Payment System (IPPS) Final Rule, issued in August 2007, will take effect beginning October 1, 2008. The rule denies additional payment for eight hospital-acquired conditions (HAC) for cases in which one of the selected HAC was not present on admission. The eight conditions selected for implementation include three hospital-associated infections (HAIs), catheter-associated urinary tract infections, vascular catheter-associated (central-line associated) blood stream infections, and the surgical site infection, mediastinitis, after coronary artery bypass surgery (CABG). The remaining five selected conditions are considered "serious reportable events." They include: pressure ulcers, air embolism, blood incompatibility, object left in patient after surgery, and patient falls (i.e., consequences of falls such as fractures). These five HACs are included in the National Quality Forum’s list of 28 adverse events that are serious and largely preventable. At the present time nationwide, almost 1,300 hospitals and many insurers have agreed to waive all costs directly associated with many of the 28 events defined by the NQF. Successful implementation of this new CMS rule is likely to increase more private payers to follow in their footsteps regarding non-payment for these conditions.

Staff education critical to successful documentation and reimbursement
The new CMS action to reduce reimbursement for these eight HAC provides healthcare organizations with opportunities to educate their staff on the importance of patient assessment and documentation. Education should focus on training staff, particularly attending physicians on distinguishing between hospital and community-acquired conditions coded as present on admission (POA). Education should also include reinforcement of the need for adherence to known infection prevention measures – not just for the selected infections, but for all types of infections. Education also is important for medical record coders, who use the physician documentation of existing conditions to assign POA codes that distinguish hospital from community-acquired conditions.

Unintended consequences
There is some concern among healthcare providers that several of the CMS HACs, such as patient falls or pressure ulcers, are not always preventable or accurately found on admission. Penalizing hospitals may also discourage them from reporting. Regarding the three infection-related HACs, AMA CEO Michael D. Maves, MD, MBA, wrote in a letter to Medicare that denying payment for healthcare-associated conditions "could have significant unintended consequences" such as discouraging facilities from admitting patients with comorbidities who are more susceptible to infection. Healthcare leaders caution that implementation of the CMS rule should proceed slowly with a small number of clearly definable conditions. CMS, in conjunction with the Centers for Disease Control and Prevention (CDC), held a public HAC "Listening Session" on December 17, 2007, that described the background and issues related to successful implementation of the HAC and POA indicators. Participants’ concerns included present-on-admission (POA) coding that needs to be more reliable before Medicare stops paying for certain conditions such as MRSA and Clostridium difficile, which are being evaluated by CMS for inclusion in 2009.

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Clostridium difficile and hand hygiene techniques: Update and commentary

Clostridium difficile (C. difficile) is an emerging pathogen affecting healthcare systems and the community at large with a significant health and cost burden. Other challenges related to control of this pathogen include acquisition (community- or facility-acquired), treatment, transmission risks, and control measures such as hand hygiene.

Recent articles (ref 1) address the increasing challenge of measuring the disease burden and costs related to C. difficile infection (CDI), including treatment, surveillance for location of acquisition, tracking epidemic strains, frequency of reoccurrence and the dilemma of how to prevent CDI. Regardless of the source of CDI, hand hygiene is among the most important strategies to prevent cross transmission within a healthcare setting. The Premier Safety Institute recently interviewed Russ Olmsted, MPH, CIC, an expert microbiologist and epidemiologist at St. Joseph-Mercy Health System, MI, who answered some questions regarding the controversy surrounding the use of alcohol-based hand rubs (ABHR) with patients with CDI.

Does the use of an alcohol-based hand rub facilitate the transmission of C. difficile?
Olmsted: This question continues to surface, but I remain unconvinced that the use of alcohol-based hand rub (ABHR) facilitates cross transmission of C. difficile based on currently available, published literature. Boyce (ref 2) was not able to demonstrate an association between hand-rub and the incidence of Clostridium difficile infection CDI. Most concern over hand hygiene technique remains theoretical or contained in unpublished abstracts at recent meetings. Dr. L. Clifford McDonald (ref 3) has been the CDC point person on investigations of CDI and this quote from his recent review in CID seems a logical position from which to base policy at any particular facility:

"...Because alcohol does not eradicate C. difficile spores, there has been concern that widespread use of alcohol-based hand sanitizers for health care worker hand hygiene has had a role in recent increases in CDAD rates. However, there are data from a number of health care facilities demonstrating that overall CDAD rates tend to either decrease or remain the same after the introduction and increased use of alcohol-based sanitizers as the primary mode of hand hygiene in the care of all patients, including those with CDAD [Boyce JM 2006]. Nonetheless, if a health care facility is experiencing an outbreak of CDAD, it is prudent for health care workers to wash their hands with soap and water rather than using an alcohol-based hand sanitizer after glove removal [CDC Hand Hygiene Guideline, 2002]..." (2)

Another scientist who has conducted extensive study of the epidemiology of CDI has also recently reviewed this issue and offers very similar guidance:

"Alcohol-based hand sanitizers are highly effective against non–spore-forming organisms, but they do not kill C. difficile spores or remove C. difficile from the hands… A recent study found that the reduction in spore counts after applying any of three alcohol-based hand gels was significantly lower than after handwashing with chlorhexidine gluconate (P<0.009). A mean of 30 percent of the inoculum of C. difficile spores remaining on contaminated hands after the use of alcohol-based gel was transferred to a second volunteer by handshaking [Leischner J. Abstract LB-29. ICAAC, 2005]

Chandler (ref 2) notes that the state of Oregon surveyed the efficacy of various components of CDI prevention programs in licensed acute care hospitals over several years. Of 50 hospitals responding, all promoted the use of alcohol-based gels or foams for hand cleansing. Thirty nine percent identified a specific agent for hand hygiene. However, the only infection control policy significantly associated with an increasing incidence of CDI was the absence of a specific definition of diarrhea, a marker of consistency of criteria for C. difficile testing.

Even the most recent description of a stepwise use of CDI prevention interventions for a facility-wide outbreak [peak incidence of 10.0/1,000 discharges to 3.0 in 2007 YTD] by Muto (ref 2) does not clearly attribute a change in hand hygiene technique for those with CDI to the reducing of their CDI rate. In fact, the authors even acknowledge the following in their discussion of the theoretical concern about ABHR and CDI: "...this would not explain the spread of CDI in our hospital, because use of ABHR was not implemented at our facility until after the onset of the CDI outbreak…" Last, Johnson (ref 2) demonstrated some time ago that an emphasis on preventing contamination of hands with vinyl exam gloves was very effective in interrupting cross transmission of C. difficile. Most recently Rupp et al (ref 2) studied the impact of enhancing the use of ABHR in two different medical ICUs. The incidence of CDI dropped significantly in one but increased in the other.

Should ABHR dispensers be removed the rooms of patients with CDI?
Olmsted: My assessment of the evidence does not suggest a need to remove ABHR from rooms occupied by patients with CDI. The concern I have is for our overall goal to improve hand hygiene by all personnel and there is reasonable evidence that the use of ABHR facilitates an improvement. Removal of this product may undermine confidence in use of this class of hand cleaning agent and result in less use for other organisms of concern, including multi-drug resistant organisms such as MRSA, Vancomycin-resistant Enterococcus and extended spectrum beta-lactamases (ESBL) producers. The logistics of managing the removal of dispensers and subsequent replacement is onerous; it not only increases the complexity of hand hygiene, it also sends a mixed message to personnel as has been identified by Gay (ref 2) and others. Enhancing hand hygiene as an overall goal is the most important issue regardless of the technique employed plus the fact that increased adherence with hand hygiene offsets the potential drop in efficacy of hand rubs against C. difficile spores.

Can we expect to see additional recommendations clarifying this issue?
Olmsted: The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) have a guideline, "Detection and Prevention of Clostridium difficile-Associated Disease in Acute-Care Hospitals," expected to be released in Spring 2008. Infection preventions experts and other colleagues should keep an eye out for publication of this guideline, but I suspect the recommendations will be consistent with the opinion leaders quoted earlier.

Do you have any additional containment recommendations?
Olmsted: One area we have addressed at our facility and for which there is accumulating evidence, is use of dilute bleach for disinfection of surfaces around the patient. Gerding (ref 2). We have implemented use of this product in collaboration with Environmental Services.

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Surveyed hospitals: Only 10-30 percent use successful CA-UTI prevention practices

A recent national survey of urinary tract prevention infection practices revealed that more than 50 percent of hospitals did not have a monitoring system for patients with indwelling catheters and greater than 70 percent did not monitor the duration the catheter was in place.

VA study
Ann Arbor VA researchers conducted a national survey in order to characterize the current practices in use in hospitals today to prevent hospital-associated UTIs. Results of the survey sent to infection control specialists in over 700 hospitals nationwide yielded a response rate of 72 percent. Hospitals included Veterans Affairs (VA) hospitals as well as non-federal hospitals.

Survey results
The survey indicated that monitoring practices across VA and non-VA hospitals were similar. Over 50 percent of hospitals did not have a monitoring system for patients with indwelling catheters, greater than 70 percent did not monitor the duration the catheter was in place, and almost 30 percent of reporting hospitals did not have any CA-UTI surveillance. Prevention practices included 30 percent of hospitals reporting the use of antimicrobial urinary catheters and portable bladder scanners, 14 percent reported using condom catheters in men, with only nine percent using catheter reminders and suprapubic catheters.

Important findings
The findings indicate that despite evidence that links indwelling catheters to UTIs, only a small minority of hospitals actually track their hospitalized patients with indwelling catheters and there are no common widely used strategies to prevent hospital acquired UTIs. The two most commonly reported prevention practices – use of antimicrobial catheters and bladder ultrasounds – were used in fewer than one-third of surveyed hospitals.

VA hospitals were more likely to use bladder scanners but less likely to use antimicrobial catheters. Another important finding: less than 10 percent of hospitals used urinary catheter reminders despite the evidence indicating the success of this practice. In an accompanying editorial, Lindsay Nicolle, MD, reinforces the idea that to optimize patient safety, monitoring the use of and duration of indwelling urinary catheters is necessary. "There seems no reasonable argument against expecting facilities to collect, distribute, and act on this information for indwelling urethral catheters," Dr. Nicolle stated.

UTI in post-op, older patients
In another recent study that monitored postoperative indwelling urinary catheters in older patients, researchers found those patients have poorer outcomes. The main purpose of this study was to characterize the relationship between the extended postoperative use of indwelling urinary catheters and outcomes for older patients who have undergone cardiac, vascular, gastrointestinal, or orthopedic surgery in skilled nursing facilities, and to describe patient and hospital characteristics associated with the extended use of indwelling urinary catheters. Twenty three percent of more than 170,000 Medicare patients over the age of 65 included in the study were discharged to a skilled nursing facility with and indwelling catheter in place. These patients were found to have a higher risk of re-hospitalization for UTIs and death within 30 days than those patients who did not have catheters. Patients from hospitals in the northeastern or southern regions of the United States had a lower likelihood of having an indwelling urinary catheter, compared with hospitalized in the western region. This disparity led researchers to conclude that there are geographic variations in practice that should be the focus of further study.

The use or non-use of preventive practices for hospital acquired UTIs may soon have major implications for all hospitals. The Centers for Medicare and Medicaid (CMS) has decided that for all discharges occurring on or after October 1, 2008, hospitals will not receive reimbursement for cases in which certain hospital acquired conditions (HAC) were not present on admission. This includes the additional costs associated with treating hospital acquired CA-UTIs.

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Hand hygiene adherence improves with alcohol-based hand gels

Researchers from a large university studying the use of alcohol-based hand gel for hand hygiene over a two-year period found a significant and sustained improvement in the rate of hand hygiene compliance.

The study compared two critical care units. One used an alcohol-based hand rub (ABHR) for hand hygiene and the other did not. After one year, the units reversed their hand hygiene method. Results of the surveillance found that during the time the combination of hand hygiene education and the use of ABHR was available, there was a significantly greater adherence to hand hygiene policy (up to 76 percent) compared to the time when only regular soap was available (37 percent).

Although compliance to hand hygiene improved dramatically when ABHR was used, researchers did not observe a change in the HAI rates associated with increased hand hygiene; this finding was anticipated. The researchers point out that the current HAI rates in these units were already extremely low and the ability to detect a further reduction would have required a much larger study of ICU infection.

An additional significant finding in this study was the importance of education. In the unit where the ABHR was not initially provided, education alone resulted in a significant and sustained improvement in hand hygiene compliance, most notably among nursing staff. Researchers also observed that as the activity level in the units increased, hand hygiene compliance decreased regardless of whether the ABHR was available. This has important implications for healthcare facilities as they plan for staffing or providing care during a situation of mass casualties or an epidemic. Cultures from the hands of nurses also reinforced the finding that nail length and jewelry influenced the amount of microbial flora on the hands.

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Safety Tools

AHRQ DVD – Free tool for designing hospitals for patient safety

A free DVD from the Agency for Healthcare Research and Quality, "Transforming Hospitals: Designing for Safety and Quality," reviews evidence-based hospital design and how it increases patient and staff satisfaction and safety, quality of care, employee retention, and results in a positive return on investment. Key concepts of evidence-based design in a hospital include single-patient rooms, the use of noise reducing construction materials, easily accessible workstations, and improved layout for patients and staff. Patient safety issues addressed are falls, hospital-associated infections and medical errors. The DVD also presents cases of three hospitals that have incorporated evidence-based design elements in their construction and renovation. Review the summary that describes the available resources on the DVD. To order the DVD, go to

Additional information on safer building designs is available on the Premier Safety Institute Web site under Green, Safer Building Designs.

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Humorous DVD – Video encourages proper coughing, sneezing techniques

Diseases are spread by poor coughing and sneezing techniques. Most people put their hands in front of their mouths and noses to stop germs from getting into the air. Unfortunately, this technique puts the germs on their hands. The germs are then spread to telephones and doorknobs and many other surfaces, where the next user then acquires. This five-minute video was designed by three Maine hospitals to encourage people to cough and sneeze according to the infection control guidelines put forth by the Centers for Disease Control and Prevention (CDC). It is aimed at the common citizen. The message is serious, but it is presented with humor in such a way that it engages the viewer's attention for a full five minutes while the message is repeated in interesting new ways. The DVD, "Why Don’t We Do It in Our Sleeves?" can be previewed at and ordered at

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Family toolkit – Reference tools and guide for managing the flu at home

A home care influenza toolkit, published by Montgomery County's Advanced Practice Center, is designed to help people manage influenza at home. This simple toolkit, "Stay At Home Toolkit for Influenza," includes checklists on what to keep in the home, tips on how to recognize flu signs and symptoms, instructions on using thermometers, isolating the sick, making disinfectant with bleach, and cleaning potentially contaminated areas, a personal care log to help caregivers track observations and action, guidelines for those returning to work after recovering from flu, and items to keep on hand for pets for disaster preparedness. This user-friendly guide is meant for family reference.

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NIH tool kit – Online health information for seniors

A set of free, easy-to-use training programs developed by the National Institute on Aging is designed to help seniors find accurate, up-to-date health information online. The "Toolkit for Trainers"( uses two National Institutes of Health Web sites ( and as models for the lessons. Each model includes a lesson plan, student handouts, and glossary of computer and Internet terms. The course can be delivered in nine, 90-120 minute sessions or customized to meet students’ needs.

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FDA – Downloadable medication safety videos; e-updates on safety reports

The latest FDA medication safety-related videos, including some developed in cooperation with ISMP, are now available free for viewing or downloading on the ISMP Web site The videos added from October include warnings about Vincristine errors, luer misconnection, and how the use of a disposable straw with Exactacain, a local anesthetic spray, may pose a safety risk to patients. November videos highlight side effects of codeine in nursing mothers, avoiding mix-ups with Amphotericin B formulations, and warnings for Rocephin use with any IV product that contains calcium.

Because pressing issues such as defective product recalls are issued with such frequency, the ISMP recommends that its members stay apprised of these notices by signing up for the FDA's electronic updates from its "Safety Information & Adverse Event Report Program." Here's how to do it: Proceed to and click "Join the E-List" in the upper right corner. You'll receive timely safety information on drugs and other medical products regulated by the FDA.

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AHRQ toolkits – 17 patient safety resources indexed by setting, topic and Joint Commission patient safety goals

The Agency for Healthcare Research and Quality (AHRQ) has developed a series of toolkits designed to help reduce medical errors. These 17 toolkits, "Patient Safety at the Point of Care," range from checklists to help reconcile medications when patients are discharged from the hospital to processes to enhance effective communication among caregivers and with patients, to toolkits to help patients taking medications, and can be adapted to most healthcare settings. AHRQ has organized the same toolkits but in multiple groups as shown for easy location. Go to

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Web-based educational tools – Infection prevention case studies

The ALFA Institute of Biomedical Sciences Educational Portal at contains medical education material on topics that include pediatric infections, zoonoses, infectious diseases, internal medicine, dermatology, upper and lower respiratory infections, surgical infections, antimicrobial resistance, clinical research tools, biomedical databases, critical care and sepsis, cardiovascular infections, nosocomial infections, hepatitis B virus, orthopedic infections, OB/GYN infections and urogenital infections.

The Academy of Infection Management ( has a selection of case studies that can be used as interactive case-based learning tools. The case studies include the specialties of surgery, pediatrics, ICU, and pneumonia. Specific topics include patient outcomes related to antibiotic usage and healthcare associated infections

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Editorial team
  • Gina Pugliese, RN, MS editor
  • Judene Bartley, MS, MPH, CIC, associate editor
  • John Hall, BSJ, contributor
  • Judith Luca, RN, BSN, contributor
  • David Huntley, BA, Web master
Premier Inc., 2006 Malcolm Baldrige National Quality Award recipient

Serving 2,000 U.S. hospitals and more than 51,000 other healthcare sites, the Premier healthcare alliance and its members are transforming healthcare together. Owned by not-for-profit hospitals, Premier operates one of the leading healthcare purchasing networks and the nation's most comprehensive repository of hospital clinical and financial information. A world leader in helping healthcare providers deliver dramatic improvements in care, Premier is working with the United Kingdom's National Health Service North West and the Centers for Medicare and Medicaid Services to improve hospital performance. Premier's Safety Institute provides publicly available safety resources and tools to promote a safe healthcare delivery environment for patients, workers, communities and the environment. Headquartered in San Diego, Premier has offices in Charlotte, N.C., Philadelphia, and Washington.

Safety Share © 2008 Premier, Inc.

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