The August 2023 issue of the Hospital Quality Improvement Newsletter features the latest insights and resources.

In This Issue: 

• News from CMS: Care Compare and Provider Data July 2023 Data Refresh
• Upcoming and Previous Educational Events
• Expert Insights and Resources on:
  • Behavioral Health and Opioid Stewardship
  • Antibiotic Stewardship
  • Patient Safety
  • Readmissions/Care Transitions
  • Patient and Family Engagement
  • Health Equity
  • Violence Prevention 
• Public Health Emergency
• Best Practices Corner
• Success Stories

Care Compare and Provider Data Catalog July 2023 Data Refresh for Hospitals 
The Centers for Medicare & Medicaid Services (CMS) Care Compare website provides consumers with information on over 100 quality measures for over 4,000 hospitals nationwide, including Veterans Administration (VA) medical centers and Department of Defense (DoD) military hospitals. 
The Overall Hospital Quality Star Rating summarizes data from existing measures on Care Compare for each hospital to allow users to easily compare hospitals. Patients and caregivers can also compare hospitals’ performance for many common conditions. 

Data Updates - On July 26, 2023, CMS updated data for hospitals on the Care Compare and Provider Data Catalog websites. 
 
Hospital of Quality Improvement Contractor (HQIC) Environmental Safety Assessment
Alliant HQIC is interested in learning more about specific topics related to your hospital safety operations. Please take our five-minute survey. Your responses will help us determine the best tools and resources. 
The survey should be completed by only one person per hospital. The deadline is Friday, August 4, 2023. Click HERE to complete the survey or visit https://bit.ly/HQICEnvironmentalSafetyAssessment.

Educational Events

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Upcoming Learning and Action Network (LAN) Events

Health Equity Strategy Series: How to Make It Work for Your Hospital
Tuesday, August 29, at 1 p.m. ET and Wednesday, September 27, at 2 p.m. ET
Do you want to learn how to meet CMS and The Joint Commission (TJC) health equity requirements and improve patient outcomes for your community? Join Alliant Health Solutions and Tift Regional Medical Center - Southwell for an interactive two-part series in which we break down exactly what your health equity action plans and next steps should include.

Learning Objectives:

• Explain CMS and The Joint Commission (TJC) mandatory health equity requirements 
• Illustrate a framework and best practice examples to identify health disparities, collect and analyze REaL and health-related social needs data, implement interventions, and establish community partnerships
• Discuss how a 181-bed hospital started on its health equity journey, overcame challenges and made it work for its patients and community

After you register for the sessions, you will receive a confirmation email that includes two resources to help you prepare for the session. Please be sure to complete the pre-work prior to attending the sessions.

Register Here for the August 29 Session | Register Here for the September 27 Session 


The Core Elements for Antibiotic Stewardship in Action
Antibiotic stewardship is the effort to measure antibiotic prescribing; to improve antibiotic prescribing by clinicians and use by patients so that antibiotics are only prescribed and used when needed; to minimize misdiagnoses or delayed diagnoses leading to underuse of antibiotics; and to ensure that the right drug, dose and duration are selected when an antibiotic is needed. The CDC originally released the Core Elements of Hospital Antibiotic Stewardship in 2014 to measure and improve how antibiotics are prescribed by clinicians and used by patients. Since then, hospitals across the country have successfully implemented the interventions outlined by the Core Elements. Join us to learn directly from your peers across the country in this multi-session series. The series will culminate with timely information from the CDC and antibiotic stewardship and medication safety subject matter experts. View Agenda

Series Dates:

• August 29: Leadership Commitment + Accountability - Register Here 
• September 19: Pharmacy Expertise + Action - Register Here 
• October 24: Tracking + Reporting + Education - Register Here

Past Learning and Action Network (LAN) Event

How to Rebuild, Reengage and Reenergize Your Patient and Family Advisory Council (PFAC) 
Recorded on July 25
In recent months, hospitals have begun to reengage their Patient and Family Advisory Councils (PFACs) after the adverse impact that the COVID-19 pandemic had on their health care systems, including the ability to have in-person PFAC meetings. As a result, some hospital PFACs are even better and stronger than ever before. Wills Memorial Hospital, a 25-bed critical access hospital in Washington, Georgia, presented on the rebuilding and reenergizing of their PFAC, identifying and prioritizing several key areas of concern, and implementing projects based on the greatest need. 
View Recording | View Presentation 

Community of Practice (CoP) Call

CMS hosts CoP calls on the second Thursday of each month at 1 p.m. ET | 12 p.m. CT | 11 a.m. MT | 10 a.m. PT. The calls are open to all Alliant HQIC hospitals. 

Back to Basics, A CAUTI Reduction Journey 

Thursday, August 10
Catheter-associated urinary tract infections (CAUTI) are among the most common types of healthcare-associated infections. Research suggests that CAUTIs are highly preventable. The Agency for Healthcare Research and Quality (AHRQ) states that complications associated with CAUTI include longer lengths of hospital stays, patient discomfort, excess health care costs and increased mortality. This event will discuss how the University of Texas Medical Branch used its Journey to Zero program to reduce its rate of CAUTIs using a back-to-basics and best practice bundle approach. This event will also feature a discussion about best practice bundle development, components, challenges and successes.
Register Here

Innovative Approaches to Addressing Health Equity and Social Determinants in Rural Communities
Recorded July 13, 2023
Access the event recording and presentation slides on the Quality Co-Op.

Monthly Office Hours-IP Chat

Office Hours-IP Chats are quarterly networking events to build knowledge, share experience and provide support for hospital infection preventionists. The Office Hours-IP Chats are hosted by Amy Ward, MS, BSN, RN, CIC, FAPIC.The next Office Hours-IP Chats will take place on:

• Wednesday, October 25, from 2-2:30 p.m. ET

To schedule a one-on-one meeting with Amy, please let your quality advisor know. Questions? Contact Amy Ward at amy.ward@allianthealth.org.

Expert Insights & Resources

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Alliant HQIC Online Portal
Access the Alliant HQIC portal to view your assessments and measurement data, and chat with other HQIC-enrolled hospitals to share best practices, barriers and solutions. Download Portal Instructions to Get Started

Updated Patient Safety Coaching Packages
Updated coaching packages with best practice interventions and resources are now available on the HQIC website. View Coaching Packages

Behavioral Health & Opioid Stewardship

New COE-NF Resources 
The Center of Excellence for Behavioral Health in Nursing Facilities (COE-NF) provides mental health and substance use training, customized technical assistance and resources to certified Medicare and Medicaid nursing facility staff who care for residents with a variety of behavioral health conditions at absolutely no cost.
Interested in learning more? Visit the Website 
Want to request assistance? Submit an Online Request, or call the Center at (844) 314-1433

Chronic Opioid Use: An Interactive Case History
This article discusses how to apply the updated CDC Clinical Practice Guideline for Prescribing Opioids for Pain in patients already on opioid therapy for chronic pain. Read More

Antibiotic Stewardship

Large Urban Hospital Reduces CAUTI, CLABSI, and Clostridioides difficile Rates
An urban hospital in California worked with Health Services Advisory Group, a CMS HQIC, to successfully decrease its catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and Clostridioides difficile (C. diff) standardized infection ratios (SIRs). Read More

Core Elements of Antibiotic Stewardship
CDC’s Core Elements of Antibiotic Stewardship offer providers and facilities a set of key principles to guide efforts to improve antibiotic use and, therefore, advance patient safety and improve outcomes. These frameworks complement existing guidelines and standards from key healthcare partner organizations, including the Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, American Society of Health System Pharmacists, Society of Infectious Diseases Pharmacists, and The Joint Commission. 
Resources:

• Core Elements of Hospital Antibiotic Stewardship Programs
• Implementation Resources for Hospitals 
• Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals

Nonadherence With Guidelines Associated With Cardiac Surgery Infection
Nonadherence to the Society of Thoracic Surgeons’ (STS) postoperative cardiac surgery guidelines is associated with adverse events, according to an AHRQ-funded study in the Journal of Thoracic and Cardiovascular Surgery. STS guidelines include timing of first dose of antibiotics, weight-adjusted dosing, redosing of antibiotics and choice of certain drugs. Researchers’ review of more than 2,800 records from 2016 to 2021 indicated that 38 percent of patients received care that did not follow at least one aspect of the guidelines. Failure to comply with the antibiotic timing and weight-adjusted dosing guidelines was associated with higher rates of postoperative infection, sepsis and mortality after cardiac surgery. Most providers comply with postoperative guidelines from The Joint Commission’s Surgical Care Improvement Project, but the STS guidelines have received less attention, the authors said. Access the Abstract

Adverse Drug Events

Prevalence of Potentially Inappropriate Medication Prescribing in Nursing Homes
Potentially inappropriate medication (PIM) prescribing in older adults is common and can lead to medication-related harm. This retrospective study published of Medicare beneficiaries estimated that the prevalence of PIM use was 77% among long-stay nursing home residents (defined as >101 consecutive days in a nursing home). The most common PIMs were benzodiazepines, antipsychotics, and insulin. Read Study 

Medication Reconciliation for Patients After Discharge From Intensive Care Unit to Hospital Ward 
A study published by ScienceDirect aims to determine whether the transition of care from the intensive care unit to the ward would pose a high risk for reconciliation errors. The study’s primary outcome was to describe and quantify the discrepancies and reconciliation errors. Secondary outcomes included classification of the reconciliation errors by type of medication error, therapeutic group of the drugs involved and grade of potential severity. Read Study 

Hospital-Acquired Infections (HAIs)

Infection Prevention Resources
Check out updated NHSN resources such as the IP NHSN Training Checklist and NHSN Survival Guide as well as IP training resources. View Resources

Patient Safety

IHI Podcast: What Happened to Patient Safety?
IHI’s new podcast, Turn on the Lights, features Sue Sheridan of Patients for Patient Safety US sharing how she strives for transparency and champions the patient's role in developing solutions. IHI President and CEO Kedar Mate and IHI President Emeritus and Senior Fellow Don Berwick explore actions being taken to bring patient safety to the forefront. Listen Now

Readmissions/Care Transitions

How To Create a My Medicines List 
It can be hard to keep track of medicines. A My Medicines List can remind you when, how, and how much medicine to take. Here are step-by-step instructions to create a My Medicines List for yourself, a family member, a friend, or anyone you take care of. View Instructions 

Toolkit for Improving Surgical Care and Recovery 
The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical Care and Recovery (ISCR) Toolkit helps hospitals improve patients' surgical experience by adopting enhanced recovery practices. Enhanced recovery practices are evidence-based processes that are supported by multidisciplinary teams and span the continuum of perioperative care. Hospitals can use the toolkit to apply the evidence for enhanced recovery within the proven principles and methods of AHRQ's Comprehensive Unit-based Safety Program (CUSP) to prevent complications such as surgical site infections, venous thromboembolism, and urinary tract infection and improve perioperative safety culture. View Toolkit

HIE Integration Cuts ED Visits and Hospital Readmissions 
Health Information Integration and meaningful utilization can decrease emergency department visits and unplanned 30-day patient readmission by 10-13%. Patient wait times can also be decreased, resulting in increased patient satisfaction. Unfortunately, it’s not enough to just connect an EHR to an HIE but rather establish training and workflows to support data sharing and use at the point of care. Learn More

Health Equity

AHRQ Stats: COVID-19 Visits and Age-Related Disparities in 2020
In 2020, 3.8% of civilian, noninstitutionalized Americans had a COVID-19-related medical visit or prescribed medicine purchase. Adults between the ages of 18 and 64 were more likely to receive treatment for COVID-19 (over 4.5%) than children ages 5–17 (1.5%). Learn More

Study: Geographic Health Disparities More Common in U.S. 
Canada, the Netherlands and Norway have fewer geographic health disparities than the United States, according to a study published in JAMA Network Open that evaluated 11 developed nations in the categories of care affordability, care access and socioeconomic risk factors. The researchers noted disparities in five of 10 indicators within those categories for the United States, giving it the lowest mean number, with chronic conditions and mental health conditions highlighted as notable concerns. Read More

Violence Prevention

New Survey Sheds Light on Workplace Violence in Health Care Settings 
A new survey polled clinical health care workers, health care administrative workers, and health care security personnel and found that 40% of health care workers experienced workplace violence in the past two years. At a time when several states are upping the penalties for assaulting health care workers, and there is currently legislation before Congress that would give health care workers the same legal protections against assault and intimidation as aircraft and airport workers, current data can arm health care leaders in advocating for change on behalf of their employees. Read More

Public Health Emergency

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Perspective: Towards a Stronger Post-Pandemic Nursing Workforce 
An article in the New England Journal of Medicine provides a snapshot of the nursing workforce crisis induced by the COVID-19 pandemic. An estimated 100,000 RNs left the workforce in 2021, but there are indications the workforce has rebounded. Additionally, it is projected that by 2035, there will be an expansion of the RN workforce; however, health care delivery organizations, nurses, educators, and policymakers will have to take action to enable RNs to adapt to changes in care delivery. The article provides an integrated approach to developing and sustaining the nursing workforce, including initiatives such as increasing nursing education capacity, tracking and disseminating best practices, and gathering data about attrition, reentry, and their patterns and causes. Read Article
 

Best Practices Corner

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How to Build Your Improvement Team 
A recent article in Becker’s Clinical Leadership & Infection Control, Physician leader: An often poorly defined term, discussed how clinical leadership is about more than just a title. The same is true when building an effective improvement team, which requires knowing what to look for in potential team members, which skills they should possess, etc. including the right people on an improvement team is critical to a successful improvement effort,  Read Article | Learn More

Wellstar West Georgia Medical Center Receives Primary Stroke Certification 
Offered in collaboration with the American Heart Association/American Stroke Association, achieving Primary Stroke Center (PSC) Certification means Wellstar West Georgia Medical Center in LaGrange, Georgia, is making exceptional efforts to foster better outcomes. Read Article 
 

Success Story

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Utah Critical Access Hospital Focuses on Assessment of Social Determinants of Health to Reduce Readmissions 

Like many hospitals, Kane County Hospital, a 25-bed critical access hospital in Kanab, Utah, had an increase in patient readmissions during the COVID-19 pandemic. Chief Nursing Officer Julia Sbragia, DNP, CNS, RN, was hired in 2022. Upon the first meeting with the Alliant HQIC partner, she reviewed the data and established the hospital's improvement priorities. One of the first actions was completing a gap analysis of their current processes surrounding discharge planning and readmission review. As a result, a decision was made to hire someone to serve in a dual role, including patient education and discharge planning.
 

Over the next few months, the new discharge planner, Nicole Ramirez RN, MSN, worked with the Alliant HIQC partner to identify the requirements for admission risk assessment, assess health equity and social determinants of health, discharge follow-up, and readmission review. 

Nicole implemented a revised readmission risk admission assessment, including an assessment of social determinants of health using The PRAPARE Screening Tool - PRAPARE, utilization review based on InterQual criteria, and ongoing discharge planning. She also focused on other elements that impact readmissions, like antibiotic utilization review, opioid use disorder, and a new 100% readmission review process based on reports developed in the electronic medical record system.

Nicole is also developing internal educational resources and discussing the potential to implement a diabetic educator position for the Native American population, which has a high rate of diabetes. View Reference

Kane County Hospital is a small critical access hospital serving approximately 8,000 people in a community with scarce resources. The team continues identifying and implementing additional community resources for their patients, such as telehealth services. As a result of the work of the team, the readmission rate has decreased over time, with several months of zero readmissions.

Mobile Infirmary (AL) Improves Sepsis Bundle Compliance and Reduces Sepsis Mortality 

Mobile Infirmary in Mobile, Alabama, is the largest non-governmental hospital in Alabama, with 669 licensed beds and 14 beds at Saraland Freestanding Emergency Department. In early 2016, a multidisciplinary committee was initiated to focus on the sepsis core measure and compliance after identifying the need for some improvement. 

The committee approved nurse/pharmacy/ provider education, order sets, and best practice alerts in the EMR. All involved staff and physicians received extensive sepsis education at the beginning of the sepsis initiative, as well as ongoing education. The nurse-driven process started in May 2016, accompanied by a sepsis checklist for ED staff. This checklist guides the staff through the process and recommends antibiotics, which is useful when discussing the sepsis screening and findings with the physician.  

The nurse-driven process allowed the nurse to order the lactic acid and blood cultures without a physician's order. With the nurse-driven process, sepsis compliance increased. In January 2017, Mobile Infirmary hired a dedicated Rapid Response Team (RRT), a resource to the Emergency Room for sepsis screening and ran the Inpatient Code Sepsis process. See the  RRT team photo below.

A Point of Care (POC) testing lactic acid was initiated to decrease turnaround time. Before POC testing, the turnaround time was three hours to obtain results. Now, results are available within three minutes, dramatically impacting the timing of patient antibiotic administration. The RRT also receives best practice alerts for any ER patient with SIRS. They follow these patients in real time through the ER process. The Rapid Response RN will alert the charge nurse if the patient requires additional steps. If the patient does not meet the sepsis core measure in the ER but is diagnosed with a source, they follow them for the next twenty-four hours in case they meet inpatient sepsis criteria. If they meet the criteria, RRT will initiate the process. In addition, the RRT has a dedicated hospital phone that allows providers and staff members to communicate directly with them about the sepsis core measure requirements. In 2019, Mobile Infirmary implemented the Modified Early Warning System (MEWS) to assist with sepsis and decrease ICU code blues.

Currently, Mobile Infirmary has a sepsis checklist utilized mostly by the Emergency Department staff, which allows the nurse to check off bundle elements as it occurs and a resource for handoff. The Rapid Response Team manager runs a best practice advisory report daily to monitor compliance. If non-compliance is found, it is reported to the unit manager to educate staff. The hospital has ongoing education annually. Sepsis compliance and metrics are discussed in all medical staff committees so that our providers are involved with compliance.

For the first three and half years of our process, multidisciplinary team meetings attended by nursing, physicians, lab, IT, pharmacy, quality and RRT were held monthly to discuss any sepsis fall outs and opportunities for improvement. Since COVID, the hospital changed its follow-up on fall outs to a more real-time conversation or at least within 24-48 hours of the patient being in the hospital.

Currently, the Core Sepsis Bundle compliance is 78%. The challenge continues to be fluid resuscitation. Mobile Infirmary has done a significant amount of provider education related to resuscitation and continuous monitoring, and education remains a focus for continued success.  

As of March 2023, the sepsis mortality rate exceeds the 42-month (March 2024) goal of a 9% reduction with a relative improvement rate (RIR) of 16.79%. Nine patient lives were saved for a cost savings of $519,498. Congratulations to the team for their dedication to improving patient care and saving lives.

This material was prepared by Alliant Health Solutions, a Quality Innovation Network–Quality Improvement Organization (QIN – QIO) under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication Number: 12SOW-AHS-QIN-QIO TO3-HQIC--4219-08/01/23