This is International Infection Prevention Week. See our stories on the WHO launch of a world-wide hand hygiene campaign, and Pennsylvania hospitals' collaboration and success in reducing blood stream infections.
Also noteworthy - results from the CMS-Premier Hospital Quality Improvement Demonstration project as well as success stories from the top decile performers will be shared at regional performance improvement programs. See Tools for more information.
Please share this newsletter with your colleagues.
Gina Pugliese, editor
Vice President, Premier Safety Institute
- SCIP – A National Quality Partnership audio conference; Final measures released
- Multi-institutional collaboration results in 68 percent decline in central line associated bloodstream infections
- Hospital Quality Alliance and JCAHO core measure data show steady hospital improvement
- Influenza vaccination now required in LTC; CDC monitors vaccine supply
- Environmental safety success story – Hospitals reducing mercury
- Pharmacists suggest single entry for medication vials with latex as best practice
- Study finds women wash hands more; WHO launches worldwide hand hygiene campaign, 'Clean care is better care'
- Premier resources - Regional Performance Improvement forums, Rapid Improvement Web tool
- Educational module for physicians – Bioterrorism agents
- CDC slide set – Medical waste management teleconference
- Toolkit – Medication safety
- JCAHO Emergency planning guide
- NFID Children's vaccine education kit
- CDC revised recommendations – HIV post-exposure prophylaxis
Premier is pleased to be a supporting partnership organization in the CMS Surgical Care Improvement Project (SCIP), a national quality improvement project designed to improve surgical care in hospitals, and is offering a free program on October 26 at 2 p.m. (EST) for anyone interested in learning more about SCIP. Faculty for this program will include Dale Bratzler, D.O., M.P.H., clinical coordinator for the Oklahoma Foundation for Medical Quality, the support center for the SCIP Partnership, and David Hunt, M.D., F.A.C.S., medical officer, CMS Quality Improvement Group, and member of the SCIP Steering Committee.
During an interview, the faculty will discuss SCIP's objectives, the four modules and the final outcome and process performance measures, and how SCIP is aligned with other quality initiatives such as the 100,000 Lives Campaign.
A key feature of Advisor Live is the live question-and-answer period. A live recording and handouts will be available at no charge at the link below for this program and previously recorded Premier Informatics Advisor Live audio conferences.
Register for SCIP program at: https://www.premierinc.com/advisorlive.
Visit CMS' official SCIP web site at: http://www.medqic.org/scip.
Multi-institutional collaboration results in 68 percent decline in central line associated bloodstream infections
The Centers for Disease Control and Prevention (CDC) recently reported on the results of the Pittsburgh Regional Health Initiative (PRHI) multi-institutional infection control collaboration among 32 hospitals in southwestern Pennsylvania. The collaborative effort resulted in a 68 percent decline in bloodstream-associated infections (BSI) – from 4.31 to 1.36 – in the hospitals' 69 intensive care units during a four-year period.
The significant reduction in BSI rates for hospitals that participated in this regional patient safety intervention suggests coordinated infection control initiatives among healthcare facilities in a region might be an effective way to reduce catheter-associated events such as BSIs.
In 2000, the Pittsburgh Regional Health Initiative (PRHI) convened an advisory committee of regional infection control experts to discuss strategies for the prevention of healthcare-associated infections (HAI). In April 2001, this group initiated a regional infection control intervention with the goal of eliminating central line-associated BSIs in ICUs. The intervention was designed collaboratively and led by infection control professionals and medical staff from the participating hospitals. Participation was voluntary. The intervention was multifaceted, consisting of five components:
- Promotion of targeted, evidence-based catheter insertion practices (i.e., use of maximum sterile barrier precautions during insertion, use of chlorhexidine for skin disinfection before catheter insertion, avoidance of the femoral insertion site, use of recommended insertion-site dressing care practices, and removal of catheters when no longer indicated);
- Promotion of an educational module about central line-associated BSIs and strategies for their prevention;
- Promotion of standardized tools for recording adherence to recommended catheter insertion practices;
- Promotion of a standardized list of contents for catheter insertion kits that includes all supplies required to adhere to recommended insertion practices; and
- Measurement of central line-associated BSI rates and distribution of data to participating hospitals in confidential quarterly reports, allowing comparison of individual unit-specific rates with pooled mean rates from other participating ICUs in the region and pooled mean rates from all other U.S. hospitals participating in the National Nosocomial Infection Surveillance (NNIS) system, stratified by type of ICU.
Thirty-two hospitals in 10 southwestern Pennsylvania counties participated in the intervention, including 28 (72 percent) of the 39 acute care hospitals that provided intensive care services in the six-county Pittsburgh metropolitan statistical area. The median size of participating hospitals was 215 beds (ranging from 27-796 beds). Among the participating hospitals, 69 ICUs participated. Overall, the pooled mean rate of central line-associated BSIs per 1,000 central line days in participating ICUs decreased by 68 percent, from 4.31 to 1.36 (p<0.001) during April 2001 to March 2005. BSI rates among medical/surgical ICUs decreased by 67 percent, from 3.64 to 1.18 (p<0.001), and BSI rates among other ICU types decreased by 69 percent, from 4.72 to 1.47 (p<0.001). Similar decreases were observed when rates were analyzed for ICUs that reported data for all 16 study quarters.
Download the full story from MMWR Oct 14, 2005
(.doc) (63 KB)
Download the complete MMWR Oct 14, 2005 report (.pdf) (318 KB)
See related story in Premier Safety Share, August 2005: "New techniques dramatically decrease ICU infections in multiple states; initiatives support IHI's '100,000 lives' campaign."
Hospitals are showing steady improvement on clinical performance measures for acute myocardial infarction, heart failure, and pneumonia, according to data published from the Centers for Medicare and Medicaid (CMS) Hospital Quality Alliance program and the JCAHO core measures program. Hospitals with the lowest level of performance at baseline have shown the greatest improvement and some variation exists among type and location of hospital and across indicators.
JCAHO core measures show significant improvements
In July 2002, JCAHO implemented standardized performance ("core") measures that were designed to track the performance of accredited hospitals and encourage improvement in the quality of healthcare. In the July 21, 2005 issue of the New England Journal of Medicine, JCAHO performance data were reported from more than 3,000 participating hospitals for the period from 2002 to 2004. Of the 18 standardized and evidence-based measures, one measured clinical outcome (death in the hospital after acute myocardial infarction), and the other 17 measures assessed processes of care. Participating hospitals improved significantly (p <0.01) on 15 of the 18 measures for acute myocardial infarction (AMI) heart failure (HF), and pneumonia. For five measures, involving the use of aspirin and beta-blockers for acute myocardial infarction and oxygenation assessment for pneumonia, U.S. hospitals are approaching optimal performance, according to JCAHO. For 16 of the 17 process-of-care measures, hospitals with a low level of performance at baseline had greater improvements over the subsequent two years than hospitals with a high level of performance at baseline.
Hospital Quality Alliance shows steady improvement with variations among hospitals and measures
In the same issue of the New England Journal of Medicine, data from the first half of 2004 were reported for hospitals participating in the CMS Hospital Quality Alliance (HQA) program, which began as a voluntary public reporting program that was changed and linked with financial incentives for participation (market basket payment according to the Medicare Modernization Act of 2003). The HQA is the first national public reporting system that provides detailed performance data for each hospital. A total of 3,558 hospitals reported data on at least one stable measure (discharge data from at least 25 patients) out of a total of 10 measures/indicators of quality of care for three conditions – acute myocardial infarction (AMI), congestive heart failure (CHF) and pneumonia. Median performance scores were at least 90 percent for 5 of the 10 measures. Midwest and northeastern hospitals performed better, on average, than southern and western hospitals, in all clinical conditions; non-profit hospitals slightly but consistently outperformed for-profit hospitals. The performance scores on quality measures in one clinical condition had only a moderate ability to predict scores across all three conditions. Although a high score for AMI predicted a high score for CHF, a high score for AMI was only marginally better than chance at predicting a high score for pneumonia care. The authors concluded that the HQA national reporting system shows that performance varies among hospitals and across indicators. Data from the HQA program is now being reported to consumers on the CMS Hospital Compare Web site.
Implications of the performance data
Although both of these studies from JCAHO and HQA reported on several of the same measures, the specifications of each measure differed slightly until this year, making side-by-side comparisons difficult. In an accompanying editorial, Patrick Romano, M.D., of the University of California-Davis, points out that these two studies establish very high levels of adherence with evidence-based guidelines and are achievable with sufficient education of physicians and hospitals managers and sufficient attention from outside entities such as JCAHO and CMS. Experts from performance improvement would also add that redesigns of healthcare systems likely also played a major role. Romano also noted that despite the progress, the healthcare community still faces major challenges. Medical knowledge continues to expand every year, so practice guidelines and the measures of quality on which they are based require continual updating, he said. Moreover, he noted, quality measures that are not updated to reflect current research findings will lose their value, and sponsors will lose their credibility. Romano concludes that practitioners still have far to go in closing the 'quality chasm" that the Institute of Medicine recognized in 2001.
Download the JCAHO abstract (.doc) (25 KB)
Visit the CMS Hospital Compare web site at: http://www.HospitalCompare.hhs.gov.
Long-term care vaccination (LTC) mandatory
As of October 7, 2005, the Centers for Medicare and Medicaid (CMS) requires long term care (LTC) facilities to offer each resident annual influenza immunization and lifetime pneumococcal immunization. The goal of the rule is to increase immunization rates by requiring facilities to ensure that before offering the immunization, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of immunization. The facilities will be required to offer immunization unless medically contraindicated or the resident or the resident's legal representative refuses immunization.
In an earlier letter to CMS, representatives of the National Influenza Vaccine Summit, a coalition of public and private stakeholders involved in vaccine research, production, distribution, advocacy and administration, stated their approval of the rule modifications. The modifications clarified that a facility is not penalized if the patient or their representative refuses immunization or there are medical contraindications and that facilities would not be cited as out-of-compliance if they cannot get vaccine due to a shortage.
CDC updates and vaccine monitoring
The Centers for Disease Control and Prevention (CDC) addressed this year's influenza vaccine supply in the September 2, 2005, Morbidity and Mortality Weekly Report, "Update: Influenza Vaccine Supply and Recommendations for Prioritization During the 2005-06 Influenza Season." Four manufacturers are providing influenza vaccine to the U.S. population this year, and supplies include both trivalent inactivated influenza vaccine (TIV) and live attenuated influenza vaccine (LAIV). Priority groups will receive the TIV until October 24, 2005, after which all persons will be eligible for vaccination. CDC has also updated its influenza web page with a FAQ about vaccine supply and prioritization of vaccinees. On a recent clinical conference call, CDC responded to an expressed concern for supplies intended for the LTC healthcare worker population, given the new mandate for vaccinating LTC residents, by stating CDC would be closely monitoring the impact of the LTC requirement on supplies. The CDC has provided a slide set on its web site that summarizes priority groups and updates the current information and encouraged use of the influenza gallery of resources for patient and provider education.
NH CMS COP immunization (October 7, 2005) (.pdf) (202 KB)
CDC influenza update (.doc) (51 KB)
CDC influenza Q&A (.doc) (31 KB)
CDC web site slides http://www.bt.cdc.gov/coca/callsummary.asp
CDC "Gallery of resources" http://www.cdc.gov/flu/professionals/patiented.htm
The recently published "Making Medicine Mercury Free" report states that in the last 10 years, over 97 percent of surveyed hospitals are aware of the need for mercury reduction and have taken steps to address mercury safety, including labeling mercury-containing devices and shifting to mercury-free alternatives. Released by the American Hospital Association (AHA) and Hospitals for a Healthy Environment (H2E), the report outlines the historical uses of mercury in healthcare, health concerns associated with mercury, and the status of the industry's mercury elimination efforts.
Under a 1988 agreement with the Environmental Protection Agency agreement, the AHA and its American Society for Healthcare Environmental Services (ASHES) and American Society for Healthcare Engineering (ASHE) membership groups set goals to virtually eliminate mercury-containing waste from hospitals by 2005 and cut overall hospital waste in half by 2010. Medical devices commonly containing mercury include blood-pressure monitoring devices and thermometers. Survey results indicate that 80 percent of respondents have completely eliminated mercury thermometers, 73 percent have completely eliminated mercury sphygmomanometers, and 75 percent have completely eliminated other mercury items such as cantor tubes.
The remaining hospitals report having elimination plans in place all other mercury-containing products. The survey found 72 percent of hospitals have inventoried, labeled or replaced all mercury-containing devices, and 75 percent are recycling light fluorescent light bulbs. As part of the commitment to the 1988 agreement with the Environmental Protection Agency, 80 percent of hospitals reported having a waste reduction policy.
The report concludes with specific recommendations for continued mercury elimination and stresses as priorities ongoing outreach to facilities that have not made a commitment to phase out mercury, addressing mercury in chemicals, and ensuring that mercury containing items that are removed from service are not exported elsewhere, shifting the burden rather than solving the problem.
Download "Making Medicine Mercury Free" (.pdf) (147 KB)
Premier Safety Institute's Mercury Pollution Prevention resources
Mercury free products – See Premier Safety Institute's Environmental safety and product lists
Adopting a rule for a single entry for all medication vials regardless of the vial closure formulation is one of the recommendations suggested in a study in the September 2005 American Journal of Health-System Pharmacy. The study, "Administering pharmaceuticals to latex-allergic patients from vials containing natural rubber latex closures," discusses whether the dry natural rubber used in pharmaceutical vial closures creates a risk for the latex-allergic patients who receive parenteral medications. Most of the current research has focused on the allergenic content of natural rubber latex in exam and surgeon gloves. A prospective, controlled, human study to determine if a type 1 hypersensitivity reaction can be induced in a latex-allergic patient by administering a medication from a vial with a latex closure has never been possible because of safety concerns.
Researchers conducted a masked prospective clinical study with volunteers (12 latex-allergic, 11 non-allergic), who underwent skin testing from unidentified solutions. Each solution was from a vial with a different closure formulation. The study results indicated that natural rubber latex closures release allergenic latex proteins into solutions in quantities sufficient enough to cause positive skin test results in 41 percent of latex-allergic patients, but not in non-latex allergic patients. The authors also determined that the latex allergen can leach into the solution when the solution has direct contact with the natural rubber latex closure, and that an increase in the quantity of the latex allergen results from the puncturing of the vial. Researchers were unable to determine, however, if the amount of latex allergen that leaches into the medication during shipping and storage is sufficient to cause a systemic allergic reaction.
Study authors suggested that the FDA's Center for Devices and Radiological Health (CDER) should call for natural rubber labeling requirements for drug packaging that is similar to the one the FDA issued in 1997 for medical devices, including device packaging containing natural rubber that comes into contact with humans. The FDA rule covers medical gloves containing natural rubber latex. Additional recommendations include having an effective program that identifies latex allergic patients before they are administered any medications and have their medication labels indicate latex precautions to alert all staff. Study authors also hold that pharmacies should have a universal policy for parenteral medications that includes: adoption of the single stick rule, in which all medication vials are punctured only once, regardless of the vial closure formulation; withdrawing medication into a non-latex syringe; and observing the patient after the medication is administered. A latex allergic patient may need to be observed for up to two hours after medication administration. The hospital policy should be reviewed yearly to include updates and changes, study authors concluded.
Download commentary, "Administering pharmaceuticals" (.pdf) (82 KB)
See Premier Safety Institute's Latex allergies resources
Study finds women wash hands more; WHO launches worldwide hand hygiene campaign, 'Clean care is better care'
Observations of hand washing practices
Researchers from the American Society for Microbiology observed the hand washing practices of more than 6,300 individuals in public restrooms in four major cities and conducted a telephone survey in which more than 1,000 adults were asked about their hand washing habits. The observational study and telephone survey were conducted to highlight National Clean Hands Week. The Centers for Disease Control and Prevention (CDC) states that hand washing is the single-most important practice to prevent illness and spreading it to others. Study findings show that that only 83 percent of American adults wash their hands after using public restrooms, while 91 percent of them said they routinely washed their hands. Ninety percent of women and 75 percent of men were seen washing their hands.
Researchers noted that the "perception-reality gap" was larger among men, who reported washing their hands 88 percent of the time but were observed doing so only 75 percent of the time. Women claimed to wash 94 percent of the time and were seen doing so 90 percent of the time. The phone survey responses indicated that 84 percent of people wash their hands after using the bathroom at home, 77 percent before eating or handling food, and 73 percent after changing a diaper. The percentages of people who said they wash their hands after petting a dog or cat, touching money, or coughing and sneezing were 42, 21, and 32 percent, respectively.
WHO issues draft international guidelines for hand hygiene in healthcare
The World Health Organization recently released advanced draft guidelines for hand hygiene in healthcare settings as part of a new campaign to reduce healthcare-associated infections worldwide. The campaign notes that the emergence of life-threatening infections such as severe acute respiratory syndrome and the risk of a new flu pandemic "highlight the urgent need for efficient infection control practices in healthcare." The guidelines recommend washing hands with soap and water or an alcohol-based hand rub before and after direct contact with patients and other specified clinical situations, and urge healthcare providers and governments to make improved adherence to hand hygiene a priority. The guidelines integrate much of the current CDC Hand Hygiene guidelines, but include simple strategies that work in other cultures. This comprehensive guideline encompasses scientific background and makes recommendations to governments, administrators and the public. WHO plans to pilot test the feasibility of the recommended interventions in various healthcare settings in each of its six regions before issuing final guidelines.
For more survey information, go to http://www.washup.org/.
WHO draft hand hygiene guidelines (.pdf) (3 MB):
WHO new campaign Web site:
Premier Safety Institute's CDC Hand Hygiene guidelines
Regional Performance Improvement Forums and Collaborative Networking Meetings
The agenda at the regional forums and networking meetings includes results from the CMS-Premier Hospital Quality Improvement Demonstration project (how-to's and success stories from top decile performers), patient safety, managing length of stay, physician engagement, interactive working groups, and live demonstrations of the Rapid Improvement Program and Web portal).
For more information about these programs and a schedule and registration, visit:
Rapid Improvement Programs
On October 6, more than 400 individuals participated in a Web seminar to launch Premier's "Rapid Improvement Programs." Through a single Web portal, Premier provides a gateway to a dynamic community of experts, best practices, evidence-based knowledge, and implementation guidance to help hospitals realize rapid quality and financial performance improvement. The Rapid Improvement Program also has key findings and best practices from top performing hospitals in the first national pay-for performance pilot project with CMS. The program received an endorsement from the Institute for Healthcare Improvement (IHI).
A recently released Archives of Internal Medicine article describes improvements in a physician's ability to diagnose and manage diseases caused by bioterrorism agents. Such improvements were documented after the completion of an online pre-test that assessed physicians' baseline knowledge and ability to diagnose and manage potential cases of smallpox, anthrax, botulism, and plague. An educational module following the pre-test reviewed diagnosis and decision-making for patients presenting with anthrax, botulism, plague, smallpox, or a common disorder that has clinical overlap with these diseases. The educational module was followed by a post-test, which measured the module's effectiveness. Extra cases were presented to the physicians between the pre- and post-tests on each of the four potential bioterrorism agents. Improvement in results led the study's authors to conclude that the online education module may improve physician's diagnosis and management of diseases caused by these agents. The bioterrorism-education module is available for registered users on the Johns Hopkins Medicine's Internet Learning Center at: http://www.hopkinsilc.org.
The Clinician Outreach and Communication Activity (COCA) offered a program in Medical Waste Management on August 23, 2005. Lynne Sehulster, Ph.D, M(ASCP), of the Centers for Disease Control and Prevention (CDC) Division of Healthcare Quality Promotion presented materials addressing: identification of general categories of medical waste; regulations governing the management of medical waste; insight into how the recent influenza A (H2N2) situation revealed weaknesses in the current system of waste management; and understanding the importance of reinstating on-site capacity for medical waste treatment. PowerPoint® slides are available. (.ppt) (154 KB)
The South Carolina Hospital Association (SCHA) Patient Safety Committee has developed three tools to help consumers, healthcare facilities, and healthcare workers keep track of all personal medications. These tools can help consumers, hospital inpatients and outpatients, hospitals, nursing homes, physician offices, emergency medical workers, and pharmacists "stay on the same page" so that everyone knows all of the medications a person takes. The tools are:
- Universal Medication Form (UMF) – Consumers use this form to track hard copy or electronic medications.
- Patient Medication Brochure –Explains the use of the Universal Medication form and includes a brochure on "What You Need to Know about Your Medications."
- Medication Reconciliation Form (MRF) –A hospital form.
South Carolina's Emergency Medical Services (EMS) has endorsed the UMF form. Free registration is required for access. The form is used by parish nurses, the Governor's office, AARP, physician offices, and pharmacies.
Forms can be accessed at:
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has issued a step-by-step guide, "Standing Together: An Emergency Planning Guide for America's Communities," (.pdf) (1.3 MB) for small, rural and suburban communities to both prepare for and successfully respond to major local and regional emergencies such as hurricanes, floods, terrorist attacks, major infectious outbreaks, hazardous materials spills, or other catastrophic occurrences. This comprehensive planning guide provides 13 essential steps that local government and public health leaders can use to establish an effective community-based emergency management planning and response process. These steps acknowledge that small communities face a number of significant barriers to emergency readiness, such as uncertainty about who is responsible for planning, how to fund emergency readiness efforts, what exactly constitutes the planning and response processes, and how to coordinate with state and federal emergency management resources.
The National Foundation for Infectious Diseases' "Kids Need Flu Vaccine" initiative now includes a new patient education resource for physicians and healthcare providers. The new patient education resource kit includes a parental brochure, fact sheet and poster in both English and Spanish. The kit provides useful strategies to help physicians and providers improve pediatric influenza vaccination rates among high-risk children with chronic medical conditions, such as asthma or diabetes. It also facilitates the implementation of recommendations by the CDC, AAP and other leading organizations to vaccinate all infants and toddlers 6 through 23 months of age as well as household contacts and out-of-home caregivers of children between birth and 2 years. The materials were developed by NFID in collaboration with the American Academy of Pediatrics (AAP). The resources are free and available via NFID's Web site at: http://188.8.131.52/index1.html.
The U.S. Public Health Service has updated the recommendations for the management of healthcare personnel (HCP) with occupational exposure to blood and other body fluids that might contain human immunodeficiency virus (HIV). Published in the September 30, 2005 Morbidity and Mortality Weekly Report (MMWR) , the recommendations (.pdf) (267 KB) emphasize adherence to postexposure prophylaxis (PEP) regimens when indicated, expert consultation in managing exposures, follow-up to improve HCP adherence to PEP, and monitoring for adverse events, including seroconversion. Clinicians should consider occupational exposures as urgent medical concerns. The list of antiretroviral medications that can be considered for use as PEP has been modified and expanded. Emphasis should be placed on: prompt management of occupational exposures; the selection of tolerable regimens; attention to potential drug interactions involving drugs that could be included in HIV PEP regimens and other medications; consultation with experts for postexposure management strategies (especially determining whether an exposure has actually occurred) and selection of HIV PEP regimens; use of HIV rapid testing; and counseling and follow-up of exposed personnel.
- Gina Pugliese, RN, MS editor
- Judene Bartley, MS, MPH, CIC, associate editor
- John Hall, BSJ, contributor
- Judith Luca, RN, BSN, contributor
- Derek Kleckner, BA, Web master
Premier, Inc. is a healthcare alliance entirely owned by 200 of the nations leading not-for-profit hospital and healthcare systems. These systems operate or are affiliated with 1,500 hospital facilities and hundreds of other healthcare sites. Premier provides an array of resources supporting health services delivery, including clinical and operational comparative data applications for quality/safety performance improvement, group purchasing and supply chain services, and insurance programs. The Centers for Medicare and Medicaid Services (CMS) has recently partnered with Premier for a three-year quality incentive demonstration project. Participating hospitals using Premier’s Perspective Online ™ database can receive recognition and additional Medicare payment when they meet or exceed specific quality measures.