Methodology to Reduce Healthcare Associated Infections at a Large Multi-Hospital Health System

Abstract

BACKGROUND In this changing landscape of healthcare, Infection Prevention (IP) programs need to demonstrate their value to their institutions. One way to do this is through the reduction of healthcare associated infections (HAI). This improves patient outcomes and can also provide value through the avoidance of hospital acquired condition (HAC) penalties. METHODS The reduction of HAIs at the system level of a 151-hospital health system became a top priority necessitating a structured approach. Beginning in January 2017, clear expectations of what is submitted to the National Healthcare Safety Network (NHSN) and reporting deadlines were defined. Next, HAI targets were established. Data is accessed from NHSN by the analytics department via Group Administrator rights. Analysis of standardized infection ratios (SIR), standardized utilization ratios (SUR) and Cumulative Attributable Differences (CADS) relative to system targets is conducted. Follow-up with hospitals having the highest CADS begins with a discussion with the IP team. Then, collaboration and feedback with the local team continues and efforts are escalated up to and including the C-suite and may culminate in a site visit if needed. The role and engagement of the Chief Quality Officer (CQO) is critical throughout the process. RESULTS Since establishing this methodology, the HAI outcomes have approved in six of the eight categories. In the past year (October?2017-September 2018) Clostridium difficile reduced 12%, central line associated bloodstream infection (CLABSI) 16%, catheter?associated urinary tract infection (CAUTI) 11%, abdominal hysterectomy surgical site infections (SSI) 46%, colon surgery SSI?19% and hip arthroplasty SSI 15%. In addition, HAC penalties were reduced. CONCLUSIONS This methodology has been very effective in reducing the HAIs across the health system. Also, the feedback from the stakeholders is positive because it results in collaboration and often brings needed attention to an area they have been struggling with.