Taking advantage of public reporting: An infection composite score to assist evaluating hospital performance for infection prevention efforts.

BACKGROUND: The standardized infection ratio (SIR) evaluates individual publicly reported health care-associated infections, but it may not assess overall performance. METHODS: We piloted an infection composite score (ICS) in 82 hospitals of a single health system. The ICS is a combined score for central line-associated bloodstream infections, catheter-associated urinary tract infections, colon and abdominal hysterectomy surgical site infections, and hospital-onset methicillin-resistant Staphylococcus aureus bacteremia and Clostridium difficile infections. Individual facility ICSs were calculated by normalizing each of the 6 SIR events to the system SIR for baseline and performance periods (ICSib and ICSip, respectively). A hospital ICSib reflected its baseline performance compared with system baseline, whereas a ICSip provided information of its outcome changes compared with system baseline. RESULTS: Both the ICSib (baseline 2013) and ICSip (performance 2014) were calculated for 63 hospitals (reporting at least 4 of the 6 event types). The ICSip improved in 36 of 63 (57.1%) hospitals in 2014 when compared with the ICSib in 2013. The ICSib 2013 median was 0.96 (range, 0.13-2.94) versus the 2014 ICSip median of 0.92 (range, 0-6.55). Variation was more evident in hospitals with ≤100 beds. The system performance score (ICSsp) in 2014 was 0.95, a 5% improvement compared with 2013. CONCLUSIONS: The proposed ICS may help large health systems and state hospital associations better evaluate key infectious outcomes, comparing them with historic and concurrent performance of peers.

Avoiding potential harm by improving appropriateness of urinary catheter use in 18 emergency departments.

STUDY OBJECTIVE: Urinary catheters are often placed in the emergency department (ED) and are associated with an increased safety risk for hospitalized patients. We evaluate the effect of an intervention to reduce unnecessary placement of urinary catheters in the ED. METHODS: Eighteen EDs from 1 health system underwent the intervention and established institutional guidelines for urinary catheter placement, provided education, and identified physician and nurse champions to lead the work. The project included baseline (7 days), implementation (14 days), and postimplementation (6 months, data sampled 1 day per month). Changes in urinary catheter use, indications for use, and presence of physician order were evaluated, comparing the 3 periods. RESULTS: Sampled patients (13,215) admitted through the ED were evaluated, with 891 (6.7%; 95% confidence interval [CI] 6.3% to 7.2%) having a catheter placed. Newly placed catheters decreased from 309 of 3,381 (9.1%) baseline compared with 424 of 6,896 (6.1%) implementation (Δ 3.0%; 95% CI 1.9% to 4.1%), and 158 of 2,938 (5.4%) postimplementation periods (Δ 3.8%; 95% CI 2.5% to 5.0%). The appropriateness of newly placed urinary catheters improved from baseline (228/308; 74%) compared with implementation (385/421; 91.4%; Δ 17.4%; 95% CI 11.9% to 23.1%) and postimplementation periods (145/158; 91.8%; Δ 23.9%; 95% CI 18% to 29.3%). Physician order documentation in the presence of the urinary catheter was 785 of 889 (88.3%), with no visible change over time. Improvements were noted for different-size hospitals and were more pronounced for hospitals with higher urinary catheter placement baseline. CONCLUSION: The implementation of institutional guidelines for urinary catheter placement in the ED, coupled with the support of clearly identified physician and nurse champions, is associated with a reduction in unnecessary urinary catheter placement. The effort has a substantial potential of reducing patient harm hospital-wide.

First step to reducing infection risk as a system: evaluation of infection prevention processes for 71 hospitals.

BACKGROUND: Hospitals can better focus their efforts to prevent health care-associated infections (HAIs) if they identify specific areas for improvement. METHODS: We administered a 96-question survey to infection preventionists at 71 Ascension Health hospitals to evaluate opportunities for the prevention of catheter-associated urinary tract infection, central line-associated bloodstream infection, ventilator-associated pneumonia, and surgical site infection. RESULTS: Seventy-one (100%) infection preventionists completed the survey. The majority of hospitals had established policies for urinary catheter placement and maintenance (55/70, 78.6%), central venous catheter maintenance (68/71, 95.8%), and care for the mechanically ventilated patient (62/66, 93.9%). However, there was variation in health care worker practice and evaluation of competencies and outcomes. When addressing device need, 55 of 71 (77.5%) hospitals used a nurse-driven evaluation of urinary catheter need, 26 of 71 (36.6%) had a team evaluation for central venous catheters on transfer out of intensive care, and 53 of 57 (93%) assessed daily ventilator support for continued need. Only 19 of 71 (26.8%) hospitals had annual nursing competencies for urinary catheter placement and maintenance, 29 of 71 (40.8%) for nursing venous catheter maintenance, and 38 of 66 (57.6%) for appropriate health care worker surgical scrubbing. CONCLUSION: We suggest evaluating infection prevention policies and practices as a first step to improvement efforts. The next steps include implementing spread of evidence-based practices, with focus on competencies and feedback on performance.