The September 2021 issue of the Hospital Quality Improvement Newsletter featuring the latest insights and resources. Email not displaying correctly?
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This monthly newsletter highlights the latest insights, resources, and evidence-based best practices.
Our hope is that this newsletter makes it easy for you to stay on top of trends and allows you to provide the best possible care for those you work with and serve. 

​​​​​​Educational Events

Upcoming Learning and Action Network (LAN) Events

HQIC LAN: Exploring Sepsis Strategies: Part 2
Thursday, September 30 at 2 p.m. ET | 1 p.m. CT | 11 a.m. PT
Part 2 will focus on preventing sepsis-related harm and avoidable readmissions using effective care coordination and hand-off strategies to the next level of care provider.
Register Now 

View All Upcoming Events Here

Alliant To Host COVID Office Hours-IP Chat for Infection Preventionists Beginning Sept. 22 
Beginning September 22, Alliant will host COIVD Office Hours–IP Chat for Infection Preventionists and other healthcare providers to provide an opportunity to discuss the challenges and solutions of COVID patients in hospitals. The Office Hours–IP Chat will be held weekly and led by Alliant’s Infection Prevention Specialist Amy Ward, MS, BSN, RN, CIC, who will facilitate the open discussion and answer any questions. Questions? Email Amy Ward at Click Here to Join the COVID Office Hours-IP Chat
Past Learning and Action Network (LAN) Events

HQIC LAN: Exploring Sepsis Strategies: Part 1
Early Identification, Patient Family Engagement & Disparities in Care 

Recorded on August 24
Part 1 of a dynamic two-part LAN event featuring proactive strategies and tools for preventing all-cause harm related to sepsis and readmissions. Part 1 focused on the importance and impact of:

  • Understanding the interconnectedness of early identification, patient family engagement and disparities in care to enhance patient safety.
  • Learning how a sepsis screening tool was successfully implemented and achieved results in a 100-bed rural hospital using a multidisciplinary approach.
  • Hearing about a sepsis survivor’s experience and how early identification could have assisted with improving care delivery and patient outcomes.

Watch Recording View Slides 

HQIC Community of Practice Event: Opioid Stewardship 
Recorded on August 12
Improving Opioid Stewardship across the Surgical Continuum
Watch Recording

​​​​Did you find this LAN event useful?

If Yes, Click Below.

Click here if you attended the August LAN event and were able to "use tomorrow" what you heard during the webinar.
View All Previous LAN Event Recordings

Upcoming Partner Events

Decreasing Sepsis Mortality through Bundle Compliance 
Tuesday, September 14 at 12 p.m. ET | 11 a.m. CT | 9 a.m. PT (60 min.)
This webinar, a collaboration between the Compass and Convergence HQICs, features a focus on the SEP1 measure, and the connection to process reliability for the Hour 1 Bundle. Improved compliance with the Hour 1 Bundle is connected to reduced rates of sepsis mortality.
Learning Objectives:

  1. Review concepts and elements of Hour 1 Bundle.
  2. Summarize a case presentation of a 338-bed acute-care community hospital’s Sepsis Performance Improvement Program from 2016-2021, including the sepsis “war room” concept and the effectiveness of IP and ED sepsis alerts with real time sepsis tracking and SCIRT RNs.
  3. Demonstrate the link between process compliance to patient outcomes and decrease mortality.

Register Here

Sepsis Alliance Summit
Tuesday, September 14 through Thursday, September 16
The Sepsis Alliance is hosting its Sepsis Alliance Summit, presented by T2 Biosystems, in September. The event will feature three days of learning and inspiration for healthcare providers, managers, policy makers, and industry leaders.

Designed to explore an array of sepsis-related topics in healthcare, the Sepsis Alliance Summit will include expert presentations from clinicians, innovation experts and other influential leaders. The event will also incorporate panels that highlight sepsis recognition and care strategies across the continuum of care. Join sessions that are relevant to your practice and interests, and increase your sepsis knowledge and skills. Sessions will be recorded if you can’t attend. Register Here

Behavioral Health/Opioid Stewardship

Advancing Opioid Stewardship Strategies to Save Lives
The opioid epidemic has been challenging the public health crisis in communities across our country, and the COVID-19 pandemic has only exacerbated those challenges. It is critically important for hospitals to develop a Naloxone education and distribution program. With this type of program, hospital staff can provide Naloxone prescriptions and education to all patients, families, caregivers and friends discharged with an opioid prescription or at risk of overdose. Actively measuring and developing strategies to improve access to Naloxone could save lives. Additionally, hospitals should work with physicians and staff to address possible stigma towards opioid use disorder (OUD) patients. View AHA Opioid Epidemic Resources

Battling the Stigma of Addiction: On-Demand Learning for Substance Use Disorder 
Stigma continues to be one of the strongest negative influences on how we see and treat people with addiction. This four-part learning series from Superior Health Quality Alliance describes addiction as a chronic medical condition, offers strategies for combatting stigma, describes resources for treatment and discusses prevention strategies. While the intended audience is nursing assistants and caregivers for patients and residents in nursing homes, the material is relevant to everyone. Watch the Learning Series

Pain Assessment and Management Initiative (PAMI) at UF College of Medicine-Jacksonville 
The overall goal of PAMI is advancement of multimodal, safe pain management in healthcare systems to improve outcomes and reduce opioid risk. Multimodal management includes a variety of pharmacologic and non-pharmacologic interventions to address opioid stewardship, discharge planning and safe pain management.

Free educational materials on safe pain management practices for clinicians and patients are available on the PAMI website. These materials include:

  • Pain Management and Dosing Guide
  • Discharge Planning Toolkit for Pain
  • Patient Educational Videos
  • Non-pharmacologic & Distraction Toolkit/Toolbox
  • Communication cards in Spanish and Creole with pain terms

Access Educational Materials

Patient Safety​​​​​

Adverse Drug Events

Study Shows Prevalence of Adverse Drug Events in Mental Health Settings 
Adverse drug events (ADE) can occur in any healthcare setting. Using retrospective record reviews from three mental health hospitals, clinical pharmacists confirmed that ADEs were common and nearly one-fifth of those were considered preventable. Read the Article

Venous Thromboembolism 

Trends in Venous Thromboembolism Anticoagulation in Patients Hospitalized with COVID-19
A COVID-19 study addresses the frequency with which patients hospitalized with COVID-19 are treated with venous thromboembolism (VTE) prophylactic- and treatment-dose anticoagulation and the association of anticoagulation with in-hospital and 60-day mortality. Read the Article

Antibiotic Stewardship

The Role of Oral Antibiotics in Bacterial Bloodstream Infections 
IV antibiotics are generally the mainstay of treatment for bloodstream infections due to their high bioavailability and fast peak plasma levels. However, the ideal administration route of any medication achieves serum concentrations sufficient to produce the desired result without any unwanted effects. Oral therapy offers several benefits with similar outcomes, and the decision to treat a patient with oral antibiotics should be based on current evidence and patient, pathogen and drug characteristics. Read the Article

StAT Learning Series 

StAT Learning Series for Hospital Clinical Staff and Leaders 
The Centers for Medicare & Medicaid Services (CMS), with input from the Centers for Disease Control and Prevention (CDC) and other stakeholders, developed the StAT Learning Series for hospital clinical staff and leaders. StAT stands for Standards, Approaches and Tactics for Infection Control & Prevention. This online, mobile-friendly, self-paced training is intended for hospital infection control leaders, frontline hospital staff and hospital administrators. The StAT Learning Series offers the latest tools and techniques, along with refreshed best practices for a new era of infection prevention and control. Each self-paced learning module is approximately 15 minutes long. Access the StAT Learning Series for Hospital Clinical Staff and Leaders

FDA Recall 

FDA Expands Recall of Eco-Med Ultrasound Gels and Lotions
The U.S. Food and Drug Administration (FDA) issued updated information regarding Eco-Med ultrasound gels and lotions, expanding the limited voluntary recall issued on August 4, 2021, to include all ultrasound gels and lotions manufactured by Eco-Med Pharmaceutical, Inc. The FDA requests healthcare providers and healthcare facilities to immediately stop using and discard all Eco-Med manufactured ultrasound gels and lotions due to the concern for contamination with Burkholderia cepacia complex bacteria. Email with any questions or concerns. Read More


Patient Surveillance System Helps Reduce Sepsis-Related Mortality by 53%
As with many hospital, for Tift Regional Medical Center in Tifton, Ga., the incidence of sepsis is much higher in the intensive care unit and the emergency department than in other parts of the hospital. The hospital found a way to re-energize its attack on sepsis in these areas to improve its nurse protocols and overall bundle compliance, and reduce the human and financial costs. Read the Article

NHSN Reporting 

Report Healthcare Associated Infection Data to NHSN Every Month   
All enrolled hospitals are highly encouraged to report Healthcare Associated Infection data to the National Healthcare Safety Network (NHSN) database every month so meaningful data analysis and opportunities for improvement can be identified. Contact Alliant Quality’s Infection Prevention Specialist, Amy Ward, at with any questions or technical assistance needs. NHSN Monthly Reporting Checklist

Patient and Family Engagement 

Video Highlights the Signs and Symptoms of Sepsis        
Every two minutes, someone in the United States dies of sepsis. But, if caught early, sepsis is highly treatable. MedStar Health, based in Maryland, developed a short video with patient and family advisors about the signs of sepsis. Watch Here

Health Equity

Racial/Ethnic Disparities in the Incidence and Mortality of Sepsis
There are many racial, ethnic and socioeconomic disparities related to sepsis. The Sepsis Alliance created a fact sheet that includes the following sepsis disparities:

  • Black and other nonwhite people have nearly twice the incidence of sepsis as whites.
  • Non-Hispanic black children admitted to an emergency room are less likely to be treated for sepsis than non-Hispanic white children.
  • Native Hawaiians have almost twice the burden of sepsis mortality compared to whites.
  • Black children are 30% more likely than white children to develop sepsis after surgery.
  • Children with severe sepsis or septic shock who are black or Hispanic are about 25% more likely to die than non-Hispanic white children.
  • Adults below the poverty line have more than three to four times the risk of dying of sepsis compared to adults whose family income is at least five times the poverty line.

Download the Fact Sheet

How to Proactively Address Health Equity Issues 
Proactively addressing health equity involves leveraging social determinants of health (SDoH) which requires proper measurement and interpretation of available SDoH data. It is a complex problem due to the variety of structured/semi-structured/unstructured data sets coming from multiple sources, the lack of standardization in data collection and processing, and the need to capture a large number of demographic, environmental and socioeconomic metrics. Read More

​​Readmissions/Care Transitions​​​​

Sepsis Survivors are at High Risk for Readmission 
Sepsis is the second highest reason for readmission in Medicare patients. When readmission rates for pneumonia are combined with sepsis, it is the most common reason for readmission in Medicare patients. Review your sepsis survivors for readmission risk. Co-morbidities such as malignancy, diabetes, autoimmune disorders, heart failure, chronic lung, liver or kidney disease and management of those conditions, as well as inadequate discharge follow-up and access to healthcare, are all associated with increased risk of 30-day readmission. For more information and details on sepsis readmission risk factors and prevention see:

AHRQ Guide Helps Patients Care for Themselves After Discharge 
The AHRQ created the "Taking Care of Myself: A Guide for When I Leave the Hospital" that providers can give to patients at discharge to help them care for themselves when they leave the hospital. Download the Guide

COVID-19 Care

FDA Recalls N95 Respirators Manufactured by Shanghai Dasheng
The FDA is alerting health care facility risk managers, procurement staff and health care personnel to stop using certain N95 respirators manufactured by Shanghai Dasheng Health Products Manufacturing Co., Ltd. (Shanghai Dasheng). The CDC’s National Institute for Occupational Safety and Health (NIOSH) revoked all respirator approvals issued to Shanghai Dasheng because the company did not implement, maintain and control a quality management system. All previously authorized Shanghai Dasheng respirators are no longer authorized for emergency use as a result of the loss of NIOSH-approval. Read More 

Overcoming Quality Improvement Challenges in the Global 
The COVID-19 pandemic continues to present unique challenges to quality improvement efforts within health care organizations. Healthcare systems are required to maintain established standards while ensuring consistent compliance utilizing evidence-based practices. The quality teams at Cleveland Clinic developed sustainable new guidelines to direct the care of COVID-19 patients with suspected or confirmed infection, in addition to creating innovative interventions aimed at protecting caregivers. Access the Cleveland Clinic Initiatives

Alliant is a Strategic Partner in the National COVID-19 Resiliency Network (NCRN) 
The National COVID-19 Resiliency Network works to continue mitigating the impact of COVID-19 on racial and ethnic minority, rural, and disproportionately impacted populations, especially in light of recent surges in cases across the country and the recent FDA approval of the Pfizer COVID-19 vaccine. We are excited to provide newly developed social media videos and animated graphics designed to continue to increase COVID-19 vaccinations. They are accessible at the links below:  

Hugs: English | Spanish

Home Stretch: English | Spanish

Myths vs. Facts: English | Spanish

The National COVID-19 Resiliency Network Call Center is available to help with the identification of COVID-19 information, services and resources in communities. Call 1-877-904-5097 Monday-Friday between 9 a.m.-9 p.m.

COVID-19 Vaccine Resources

Immunization Action Coalition Provides Weekly News and Updates  
The Immunization Action Coalition (IAC) provides information, updates and resources for vaccinators. Their newsletter includes new and updated vaccine information sheets in 14 languages. View the IAC August Newsletter

Immunocompromised Medicare Patients Can Receive an Additional COVID-19 Dose at No Cost 
In response to the Food and Drug Administration’s (FDA) recent action that authorizes an additional dose of the COVID-19 vaccine for immunocompromised individuals, CMS is assuring people with Medicare who qualify for an additional dose that they can receive it at no cost. Medicare will pay for administering an additional dose of COVID-19 vaccines consistent with the modified FDA emergency use authorization announced in August. View the FDA Announcement | CMS COVID-19 Provider Toolkit

Alliant Quality COVID-19 Vaccine Resources
Curated resources and best practices to support long-term care facilities, clinics, providers and staff as they navigate vaccine distribution. Alliant Quality COVID-19 Vaccine Resources

Best Practices

South Alabama Hospital Celebrates No Infections Even as Line Days Tripled 
Group photo of staff at North Baldwin Medical CenterWhile most hospitals lament thatGroup photo of staff at the North Baldwin Medical Center in South Alabama their infection rates, particularly CLABSI, have gone up during the pandemic, one hospital in south Alabama has had no infections (CAUTI or CLABSI) even though they tripled their line days.

According to the staff at North Baldwin Medical Center (photo at right) in Bay Minette, Ala., they continued their nurse-driven protocol for foley removal. They ensured they stayed focused on maintaining the lines and foleys. In addition, they implemented alternate foley devices for females and are working on a male option. 

The hospital’s emergency department is working hard not to insert catheters, and the hospitalist program, which is fully engaged, works with nurses to ensure consistency of care. The hospital has daily safety huddles each morning to discuss infections and other safety issues. An interdisciplinary team also meets daily to discuss each patient, particularly those at most risk, and the CEO personally visits all patients. 

Hospital Heroes​​​

Emory mobilizes vaccination events in Atlanta-area communities 
In an effort to increase Georgia’s COVID-19 vaccination rates, Emory Healthcare began sponsoring vaccination events in neighborhoods around the Atlanta metro area. One recent effective strategy was to set up a table in front of the Emory Hillandale Hospital with a sign that said: “Meet the Doctors.” Emory physicians Augustine Conduah and Victoria Green were onsite to answer questions from those still hesitant to get a vaccine. Read More

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Hospital Quality Improvement Project Collaborators

For more information about Alliant Quality, visit the website:

For questions or information about free technical assistance, please contact: 

Donna Cohen, Director, Quality Projects

Karen Holtz, Training and Education Lead, Hospital Quality

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This material was prepared by Alliant Quality, the quality improvement group of Alliant Health Solutions (AHS), the Medicare Quality Innovation Network - Quality Improvement Organization for Alabama, Florida, Georgia, Kentucky, Louisiana, North Carolina, and Tennessee, 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 document 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 or that product or entity by CMS or HHS. AHSHQIC-TO3H-21-1060-09/01/21
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