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

In This Issue: 

• News from CMS: Final Rule Establishes Rural Emergency Hospitals as Medicare Provider 
• 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 
• Best Practices Corner
• Success Stories

Final Rule Establishes Rural Emergency Hospitals as Medicare Provider 
In November 2022, CMS published a final rule effective January 1, 2023, establishing initial policies for Rural Emergency Hospitals as a new Medicare provider type enacted in the Consolidated Appropriations Act of 2021. Learn More
 

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
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 September 27 Session  | View Session 1 Presentation 

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:

• 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. 

Building Reliable Sepsis Mortality Prevention Practices: How Does Your Organization Measure Up?

Thursday, September 14
This session will feature examples from the field to highlight practical strategies for the early identification and response to sepsis, including an innovative approach using the Sepsis Honor Roll self-assessment as a driver to measure improvement. Additionally, Windham Hospital in Connecticut will share tools and resources to successfully facilitate the implementation of bundles and increase staff knowledge and expectations. 
Register Here

Back to Basics, A CAUTI Reduction Journey 
Recorded August 10, 2023
This event discussed 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. It also featured a discussion about best practice bundle development, components, challenges and successes. View Presentation

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

Managing Xylazine Exposure in Opioid Overdose Patients
In North Carolina and nationwide, the veterinary sedative xylazine is increasingly detected in the illicit opioid drug supply and opioid overdoses. Toxicology data from major U.S. regions where xylazine testing was conducted found that xylazine-involved overdose deaths increased nearly 20-fold between 2015-2020.
The NC Department of Health and Human Services (NC DHHS) recently released guidance to help clinicians understand the health impacts of xylazine exposure and appropriately manage patients exposed to the sedative through illicit drug use. Learn More

Antibiotic Stewardship

Study: Antimicrobial Residual Drug Error in the Intensive Care Unit
As with all medications, delays in or underdosing of antimicrobials can result in unnecessarily long hospital stays. A study published by ScienceDirect found that discarded antibiotic vials in the intensive care unit (ICU) contained residual drugs remaining in the vial (median 3.7% error). This finding suggests patients may not be receiving the full prescribed dose. Read Study

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

Adverse Drug Events

Study: Anticoagulation-Associated Adverse Drug Events in Hospitalized Patients Across Two Time Periods 
Anticoagulants are high-risk medications in both outpatient and inpatient settings. A study published by the American Journal of Medicine compared two time periods, both before and after the implementation of anticoagulant safety programs, to assess changes in type, severity, root cause, and outcomes of adverse events in hospitalized patients. Despite numerous changes in procedures and technology, adverse events increased in the post-implementation period. Read Study

Study: Medication Reconciliation for Patients After Discharge From Intensive Care Unit to Hospital Ward 
Medication reconciliation is used when a patient moves from one level or location of care to another to ensure they receive the appropriate medications. A retrospective study published by Science Direct reviewed completed medication reconciliations of adult patients transferring from the intensive care unit to the ward. Nearly one in five had an error requiring physician changes to the order. Of those errors, 19% were high-alert medications, most notably low-molecular-weight heparin. Read Study

Hospital-Acquired Infections (HAIs)

September is Sepsis Awareness Month
September is Sepsis Awareness Month. Every September, health care providers, the public and organizations raise awareness of sepsis, the leading cause of death in U.S. hospitals. Sepsis is a public health crisis, taking a life every two minutes. That is 270,000 lives lost to sepsis every year in the United States, more than lives lost to opioid overdoses, breast cancer and prostate cancer combined. 

The key to saving lives is T.I.M.E. For every hour treatment is delayed, the risk of death increases by as much as 8%. T.I.M.E. is a memory aid developed by the Sepsis Alliance to help individuals remember the signs and symptoms of sepsis and the urgent need for medical treatment when they are present. 

T.I.M.E. stands for: 
T – TEMPERATURE that’s abnormal 
I– Signs of an INFECTION 
M – MENTAL DECLINE 
E – Feeling EXTREMELY ILL 

This September, take the T.I.M.E. to join Alliant HQIC in raising sepsis awareness and saving lives. Learn More 

CDC Sepsis Core Elements 
The CDC’s Hospital Sepsis Program Core Elements are essential to improve sepsis outcomes in hospitals by outlining structural and procedural components required to support the care of patients with sepsis. Learn More

NHSN Survey 
Infection control directors or persons in charge of infection prevention and control (IPC) in acute care hospitals are invited to participate in a study examining the impact of COVID-19 on healthcare-associated infections and update recommendations for Infection Prevention and Control Department Staffing and Resources in acute care. 

This national study, “Prevention of Infections Through Appropriate Staffing (PITAS),” is led by experts from Thomas Jefferson University and Rutgers University. The study is funded by the Agency for Healthcare Research and Quality (R01HS029023) and has been approved by the Thomas Jefferson University IRB. Access the Survey 

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

Speaking Up for Safety
A study by the University of Washington School of Medicine concluded that speaking up for patient safety within clinical environments occurs within a power hierarchy, making leaders’ inclusive behaviors essential for creating a psychologically safe culture. Training should target established and new leaders to cultivate verbal skills and habits to motivate health professionals on the team to step up, speak up and learn from their speaking up. Read More

Readmissions/Care Transitions

CMS QSO Memo: Requirements for Hospital Discharges to Post-Acute Care Providers 
The CMS QSO memo describes the information that should be shared during transitions of care. Information to be shared between facilities during transitions includes skin tears, pressure ulcers, bruising, or lacerations (e.g., surgical site(s), skin conditions noted upon hospital admission and/or acquired during hospitalization), including orders or instructions for cultures, treatments, or dressings. Alliant Health Solutions HQIC created a handoff tool to assist hospitals in including this information during transitions of care. Download Handoff Tool | View Memo

Study: Relationship Between In-Hospital Adverse Events and Hospital Performance on 30-Day All-Cause Mortality and Readmission for Patients With Heart Failure
Unplanned hospital readmission and 30-day all-cause mortality rates are indicators of hospital safety. A study published by the Patient Safety Network analyzed the association of these two indicators with in-hospital adverse events (AE) for patients admitted with heart failure. Results suggest patients with heart failure admitted to hospitals with high rates of 30-day all-cause mortality and readmission are at increased risk for in-hospital AE. The authors describe several possible explanations for these findings. Read More 

Health Equity

New Z Code Infographic Now Available 
The Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH) released a new Z code infographic entitled Improving the Collection of Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes (2023). This resource aims to assist providers with understanding and using Z codes to improve the quality and collection of health equity data. Using social determinants of health, Z codes can enhance quality improvement activities, track factors that influence people’s health, and provide further insight into existing health inequities. Download Infographic

Z codes are a set of ICD-10-CM codes used to report social, economic, and environmental determinants known to affect health and health-related outcomes. Nine broad categories of Z codes represent various hazardous socioeconomic, and environmental conditions. Z codes can be used in any health setting and by any provider as a tool for identifying a range of issues related to education and literacy, employment, housing, ability to obtain adequate amounts of food or safe drinking water, and occupational exposure to toxic agents, dust, or radiation.
For more information, review the journey map: Using SDOH Z Codes Can Enhance Your Quality Improvement Initiatives,

Patient and Family Engagement

New Model Enhances Care Coordination and Increases Support for Caregivers 
CMS recently announced a new voluntary nationwide model, the Guiding an Improved Dementia Experience (GUIDE) Model, which aims to support people living with dementia and their unpaid caregivers. The agency is accepting letters of interest for the GUIDE Model through September 15 and will release a GUIDE Request for Applications for the model this fall. The model will launch on July 1, 2024, for eight years. Learn 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

Best Practices Corner

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St. Mary’s Good Samaritan Foundation Collaborates With Community To Address Growing Health Care Needs 
St. Mary’s Good Samaritan Foundation Board Chair Becky Smith recently led a meeting with local physicians, community leaders, and representatives from St. Mary’s Health Care System in Greensboro, Georgia, and its parent ministry, Trinity Health, to assess the evolving health care needs of the community. Read More

Emanuel Medical Center Celebrates Sepsis Awareness Month 
In honor of Sepsis Awareness Month, Emanuel Medical Center in Swainsboro, Ga., designed a T-shirt with an important message. The shirt says kNOw Sepsis on the front, and TIME is key: Temperature, Infection, Mental decline, Extremely ill.  SUSPECT SEPSIS? SAY SOMETHING! on the back. All Emanuel staff members will receive a shirt as part of the hospital’s efforts to ensure everyone understands that recognizing sepsis is the first step in preventing sepsis mortality.

Success Stories

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Intermountain Health: Opioid Stewardship Health System Perspective 

Intermountain Health reduced the number of opioid tablets prescribed to patients in acute pain by 3.8 million in 2018 and nearly 13 million cumulatively through June of 2023, reducing the risk of opioid dependency and misuse in Utah. In the early 2000s, the opioid epidemic hit the state of Utah and saw opioid overdose deaths increasing. By 2016, Intermountain Health reviewed data and determined there was a steady increase in both the number and rate of all drug overdose deaths (top yellow line in the graph) and opioid-specific overdose deaths (bottom yellow line in the graph).  As a health system, Intermountain determined there was an opportunity to reduce opioid addiction and the availability of opioid tablets by focusing on our prescribers’ practices within the health system.

Goals/Objectives:
Intermountain Health started opioid stewardship work in 2016 with a deep review of the available data around opioid prescribing and opioid overdose death count and rates (particularly prescription). It included both state-level and internal system data around opioid prescribing practices. The opioid stewardship goals addressed include:

1. Reduce the quantity of opioid tablets prescribed by 40% (2017- 2019)
2. Reduce the co-prescribing of opioids and benzodiazepines by 10% (2018 –2019)
3. Reduce the potency of opioids prescribed (2020–2021)
4. Increase naloxone co-prescribing with any opioid prescription (2022 –present)

In addition, Intermountain Health was the first health care organization in Utah to offer formal opioid-free surgery for patients. (More information can be found here.)

Dr. David Hasleton stated in 2019, “We knew these would be lofty goals, and we’re encouraged by the reduction in opioid tablets and the success of our other opioid-reduction efforts.  We knew these were the right steps to take.  We’re continuing our focus to implement appropriate evidence-based opioid treatments, provide alternative forms of pain control for our patients and educate providers and the public about the safe use of opioid medications.”

PLAN:
Intermountain Health developed a team of key behavioral health, physician, community health and other leaders to look at the available data and develop a plan to address and improve opioid stewardship within the health system. They were given the name Opioid Tiger Team (OTT).  This team spearheaded the development of goals and the actions taken to achieve the goals, and is still in existence today.  The team brought together key leaders who could provide valuable insight and effect change. As part of Intermountain Health’s commitment to this work, in 2021, 10 of the Intermountain Health critical access and rural facilities partnered with Comagine Health under the CMS-funded Hospital Improvement initiative (prime awardee: Alliant Health).
 The Plan, Do, Study, ACT (PDSA) cycle occurred with each of the four goals listed above. 

I. Reduce the quantity of opioid tablets prescribed by 40% (2017 through 2019)

• Creation of the OTT, as discussed above
• Design and establish a data analytics dashboard and designation of a data analyst for the project
• Establishment of data baseline, find target providers and service lines
• Educate providers
• Change opioid prescription defaults in the electronic health record

Cumulative opioid pills prescribed 2018 – 2023 (to date)

II.    Reduce the co-prescribing of opioids and benzodiazepines by 10% (2018–2019)

• Establish baseline performance
• Identify low-performing providers and service lines
• Educate providers
• Implement an electronic health record (EHR) alert

III.    Reduce the potency of opioids >= 90 Morphine Milligram Equivalents (MME)/Day (2020 – 2021)

• Provider to patient opioid risk consultation
• Provider resources on opioid management and safety
• Removal of high MME order sentences from the orders catalog
• EHR alert for high MME doses and other risks 

IV.    Increase naloxone co-prescribing with any opioid prescription (2022–present)

• Service line leadership education and buy-in
• Provider education tools
• Electronic health record changes

DO:    
The early implementation phase was to develop and implement provider education for each goal.  The outcomes of the education were measured for impact.

STUDY:
Analysis of data changes showed minimal change in provider prescribing practices from education alone.  Following education, the OTT moved into making changes to the EHR, such as changing the standing order catalog, removing favorites with high pill counts and instituting EHR alerts when certain prescribing thresholds are met.  

ACT TO HOLD THE GAINS:
The biggest contributor to the changes Intermountain Health saw in prescribing practices has consistently been when EHR alerts were implemented.  The OTT continues to monitor all four Opioid Stewardship goals and acts to make changes when needed to keep the positive momentum moving forward.

Oregon Hospital Improves Use of Prescription Drug Monitoring Program (PDMP) 

Lake Health District Hospital, a 24-bed critical access hospital in Lakeview, Oregon, implemented steps to improve the safe use of opioids in their facility. Alena Acklin, process and quality improvement coordinator, focused on the Prescription Drug Monitoring Programs (PDMPs) as an important step to improve opioid prescribing practices. As part of this work, the team focused on the practice of checking PDMP data when applicable. Promoting Interoperability Program has “query PDMP” as one of the measures. Read More

When the project began, the hospital was not meeting the measure requirements and experienced difficulty convincing providers of the importance of checking PDMP provided to their patients. Alena and the team focused on the following interventions:

•  Identified a nurse champion who educated each provider and confirmed that the system was working for them
•  Integrated the PDMP into the Cerner system and created a monitoring system to review compliance by the provider
•  Provided follow-up to providers who demonstrated less than 100% compliance
•  Shared an “achievement dashboard” via whiteboard, which created competition among the providers 

The efforts of the Lake Health District Hospital Team are having a positive impact. As of August 2023, the hospital achieved 67% compliance with the PDMP and has now spread the work to the outpatient clinic environment. As of April 2023, the Relative Improvement Rate (RIR) for ADE Opioids was 100%, with no events in the past year and a 38.89% RIR for Opioid Dose at Discharge. Congratulations, Lake Health District Hospital!

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.

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-TO3-HQIC--4445-09/06/23