I came to work this week with new energy and excitement! For the last many months, I’ve started each Monday wondering if The Joint Commission would arrive and each week, I would feel both disappointment that they didn’t come, as well as a bit of relief—knowing the stress that survey week often brings.  

But once the surveyors arrived, our months-long preparation and hard work was rewarded. We left a positive impression on the surveyor team, who noted it was clear we have a wonderful team of people who are passionate about being here. On top of that, our final report showed zero condition level findings and no need for a resurvey. Every Joint Commission survey provides the opportunity for improvement and we have some, and we will work together to address them. Rarely, though, does a hospital hear the great praise that we heard last week. We heard about how you welcomed the surveyors, how you are constantly focused on the quality of care and safety of our patients through consistent practices, how you work so well together, and overall, what a great team of people you are. I speak for the entire leadership team when I say that this is no surprise to us and that we are so proud of how you handled the survey and for what you do each and every day for our patients and for each other. 

We have faced many obstacles during these last three years, and I know how challenging it has been for each of you.   I am grateful that you have chosen to remain a part of this great team and that you come to work each day focused on helping people. 

I ask that—as you start this new month in this new year—you take a moment to reflect on all the good you and your colleagues have done. I hope that this fills you with the same great energy, excitement, and gratitude that I feel.    

You make a difference! 

-Theresa Brennan, MD 

The Ethics Consult Service (ECS) is a free clinical resource for UI Health Care personnel who feel they have reached the limits of their own ability to address an ethical question or problem. The ECS is designed to identify and/or clarify ethical problems in the care of a particular patient and promote discussion. The ethics consultant may make recommendations or share resources with those requesting the consult.  

Requests for an ethics consult are especially encouraged when:  

• You want to discuss important ethical dimensions of a patient’s care 
• A patient’s care raises unusual, unprecedented, or very complex ethical issues 
• You need help making an ethically-significant decision 
• Efforts by the patient, family, and professional staff to resolve an ethical problem have stalled 

With five trained ethics consultants providing 24/7 coverage, An ethics consult can be requested by paging #2922. These consultants can provide guidance about how to place an Epic order for a formal ethics consult if indicated. The ECS reviews all cases with the interdisciplinary Ethics Working Group and reports to the Chief Medical Officer.

Questions? Contact bioethics@healthcare.uiowa.edu  

First, I hope you were all able to enjoy the holiday and spend time with your loved ones. For those of you who were here caring for patients, thank you so much. Thanksgiving is a time for us to reflect on the many things we are grateful for. I’ve said it before and I’ll say it again, what makes our UI Health Care team amazing is each and every one of you and what you do every day. Because of you, I’m confident we can meet any challenge, and I have great hope for our future.  

For many years, we have struggled to efficiently use our time and our patient’s time during their inpatient stay, and it’s an issue that is not unique to this organization. When we compare ourselves to other health systems across the country, we commonly refer to the Length of Stay Index (LOSI). The LOSI allows us to look at the time it takes us to care for the patient and discharge them based on the patient’s diagnosis. 

This is an area of focus for many reasons: 

• It is a challenge drawing focus from health care organizations across the country. 
• UI Hospitals & Clinicshas experienced sustained high patient volume year over year. 
• Given our high census, we need open beds to provide care to the next patient who needs us, so we must also focus on an early discharge when it is safe and feasible. 

But perhaps the most important reason to focus on length of stay is that it’s the right thing to do for our patients.  If you or a loved one has ever been hospitalized you know  that waiting for discharge can be a difficult experience for the patient and their family. This waiting period is sometimes the last impression our patients have of us on the day of discharge, making it even more important that we try to make it as efficient and easy a process as possible.  

In order to provide high quality and efficient care for our patients and their families, we must: 

• Have strong collaboration and communication across our multi-disciplinary teams 
• Start thinking about and discussing discharge planning when the patient is admitted 
  • Think about the expected day of discharge (ask about it in huddles, and wrench it into your EPIC dashboard)  
  • Know the plan of care for the day and proactively think about the plan of care for each day until discharge 
    • What do we need to accomplish for the patient to prepare for a safe discharge? 
    • Do all members of the team know the plan and what is needed for discharge? 
• Tell the patients and their families when we anticipate discharge and confirm it the day prior whenever possible 
• Discuss with the patient and family the expectation of the 1100 discharge time 
  • If their ride home will be later in the day, let them know they will be sent to our discharge lounge—if they qualify—to await their ride. 
• Engage our nurse navigators early and schedule the follow-up appointments early in the patient’s stay 
• Engage our social workers early if the patient has potential needs for medical equipment at home, or a post-acute facility stay (SNF, rehab, etc.) 
• Complete what you can before the day of discharge (discharge summary, patient education, consults, imaging, prescriptions, final labs, etc.) 
• Prioritize the patients who are going home that day 
  • Physicians should first round on those patients who we anticipate going home that day and write the discharge order by 0930. 
  • Nurses should complete the discharge tasks as soon as the order is written 
• Tell us the barriers that prevent patients from discharging  
  • Are there delays in tests/procedures being completed? 
  • Are consults pending? 
  • Do you feel empowered to escalate concerns and delays? 
  • What are the system challenges? 
    • Remember to put these into the BlindSpots portal so we can look at how these challenges may be overcome. 

We know that a patient’s status may change, and we cannot always predict when they will be healthy and able to discharge, but for those we can predict, let’s do everything we can to be ready. 

By decreasing our patient’s length of stay, not only are you helping your present inpatients, but you are improving access for patients  in our Emergency Department, operating rooms, ambulatory clinics, and outside hospitals who need our help. Lastly, when a patient is efficiently prepared for a safe discharge, you save time for yourself and your colleagues. 

Please keep your eyes open for more communication on length of stay and early discharge as we work to continue improving these processes. We look forward to continuing this journey with all of you! 

Blog contributors: 

• Ami Gaarde, MBA, BSN, RN, OCN, Director, Nursing and Patient Care, Care Coordination (Adult) 
• Theresa Brennan, MD, Chief Medical Officer 
• Evelyn Kinne, MHA, Quality and Operational Improvement Engineer, Office of the Chief Medical Officer 

This blog is part of an ongoing series focused on introducing the current quality initiatives. Thank you to the Quality Improvement Program team for sharing their important work with us, and thank you for taking the time to learn more about the vital work that goes on to improve the care we provide to our patients.   

Learn more about the other initiatives by viewing the introduction to this series and previous topics.

Why do some people need a urinary catheter? 

Urinary catheters are used for urinary drainage or as a means to collect urine for measurement. Indications for catheterization are as follows: 

• Urinary retention  
• Urine output measurement in ICU patients 
• During surgery to evaluate fluid status  
• During and following specific surgeries of the genitourinary tract 
• Hematuria associated with clots  
• Neurogenic bladder  

Although urinary catheters provide many patient benefits, there are also associated risks. Due to these risks, urinary catheters should be removed as soon as the benefits no longer outweigh the risks. 

Epidemiology 

According to the Centers for Disease Control and Prevention (CDC), between 15 to 25% of hospitalized patients receive urinary catheters during their hospital stay. Bacteriuria (positive bacteria in urine) in patients with indwelling catheters occurs at a rate of approximately 3 to 10% per day. Of those with bacteriuria, 10 to 25% develop symptoms of urinary tract infection (UTI). In the U.S., based on surveillance data reported to the CDC National Healthcare Safety Network (NHSN), the incidence of CAUTI in 2012 was 1.4 to 1.7 per 1,000 catheter days in inpatient adult and pediatric medical/surgical floors. This means if all the patients at UI Hospitals & Clinics had a urinary catheter today, between one and two of them will develop a CAUTI. 

The duration of catheterization is an important risk factor for CAUTI and is a major target of prevention efforts. Other risk factors include female sex, older age, diabetes mellitus, bacterial colonization of the drainage bag, and improper catheter care.  

Issues with CAUTI 

Health care-associated infections cost U.S. hospitals an estimated $40 billion each year. CAUTIs are among the most common types of health care-associated infections. Research suggests CAUTIs are highly preventable and that perhaps as many as 50 to 70% of these episodes can be prevented. Complications associated with CAUTI result in increased length of stay, patient discomfort, excess health care costs, and contribute to increased mortality. The estimated total U.S. cost per year for CAUTI is $340–450 million. Since October 2008, the Centers for Medicare & Medicaid Services no longer reimburses costs associated with hospital acquired CAUTI.  

How do we prevent CAUTI? 

In general, the most important aspects of CAUTI prevention are avoidance of unnecessary catheterization, use of sterile technique when placing the catheter, proper catheter care, and removal of the catheter as soon as possible.  

The need for a urinary catheter should be evaluated for every patient, every day by both physicians and nurses. It is important to insert catheters only for appropriate indications and leave them in place only if needed. The catheter should not be kept solely for the convenience of patient care. It is also important to consider using alternatives to indwelling urethral catheterization in selected patients when appropriate, such as external catheter or intermittent catheterization. If intermittent catheterization is used, perform it at regular intervals to prevent bladder overdistension. We can use a bladder scanner to assess urine volume in patients undergoing intermittent catheterization and reduce unnecessary catheter insertions. 

Proper technique during catheter insertion is critical. Health care personnel must perform hand hygiene immediately before and after insertion. We need to use aseptic technique and sterile equipment, and properly secure indwelling catheters after insertion to prevent movement and urethral traction.

Ideal catheter care is also instrumental to CAUTI prevention. Meatal care (cleaning around the catheter) once per shift and after every bowel movement is essential. In addition, daily bathing with chlorhexidine is necessary and is reported to reduce CAUTIs.  

The way a urine culture is collected also has a significant impact on CAUTIs. For instance, urine cultures should never be obtained from a catheter that has been in place for more than 24 hours, because urine cultures collected from an existing catheter will almost always come back positive but may not be clinically significant. Once a CAUTI is suspected urinary catheters should be removed and urine specimens should be obtained from either a newly placed urinary catheter or via intermittent catheterization 

CAUTI reduction initiative 

In August 2022, a multidisciplinary CAUTI committee, led by Karen Brust, MD, hospital epidemiologist, was formed in an effort to reduce CAUTI across UI Hospitals & Clinics’ adult units. Members of the CAUTI committee provided feedback on contributing factors from the perspective of leaders and bedside nurses. Their feedback provided a foundation for potential future data collection and process improvement. The discussions and work of the CAUTI initiative led by Brust also aligned with another CAUTI committee led by the Department of Nursing Services and Patient Care. Since its initiation, the nursing-led committee reviewed and updated existing protocols and policies related to CAUTI. The group identified opportunities for additional guiding documents, specifically for bladder scanning and intermittent catheterization protocol, which is actively being developed. The team collaborated with clinicians to understand the current process of ordering urine cultures and how urine specimens are collected after an order is placed. The results of these conversations revealed variation in practice by the ordering provider and the nurse collecting the urine sample. This led to the ongoing development of an “ideal state” for both actions with recommendations brought to the clinical and nursing informatics teams.

Blog contributors:
-Karen Brust, MD, Clinical Associate Professor of Internal Medicine, Infectious Diseases, Hospital Epidemiologist
-Takaaki Kobayashi, MD, MPH, Clinical Assistant Professor or Internal Medicine, Infectious Diseases

Citations: 

• Agency for Healthcare Research and Quality. Overview | Agency for Healthcare Research and Quality (ahrq.gov) 
• Cather-associated urinary tract infection. Centers for Disease Control and Prevention. Catheter-associated Urinary Tract Infections (CAUTI) | HAI | CDC 
• UPTODATE: placement and management of urinary bladder catheters in adults. Placement and management of urinary bladder catheters in adults – UpToDate 

This blog is part of an ongoing series focused on introducing the current quality initiatives. This month, we are featuring the work being done to reduce injuries resulting from falls. Thank you to the Quality Improvement Program team for sharing their important work with us, and thank you for taking the time to learn more about the vital work that goes on to improve the care we provide to our patients.  

Learn more about the other initiatives by viewing the introduction to this series and previous topics.   

What is the problem 

A cesarean delivery is the most common major surgical procedure performed in the United States, with well over one million procedures performed each year. Unfortunately, postoperative surgical site infections (SSIs) and wound complications affect approximately 10% of these deliveries across the nation. A number of risk factors for these SSIs have been identified, some of which are inherent characteristics of that particular pregnancy and cannot be changed. However, there are evidence-based strategies that have been shown to reduce the risk of post-cesarean infections and wound complications, including processes such as administering appropriate antibiotic prophylaxis within 60 minutes of the surgical skin incision and using chlorhexidine-alcohol solutions for skin antisepsis.   

What is a surgical site infection after cesarean section 

According to the Centers for Disease Control and Prevention, cesarean SSIs are defined as superficial or deep incisional infections—or infections involving organs/spaces—that occur within 30 days of surgery. In general superficial SSIs involve only the skin and subcutaneous tissue of the incision, while deep incisional SSIs involve the deeper soft tissues of the incision such as the fascial or muscle layers. Organ space SSIs involve any other part of the patient’s anatomy that was entered at the time of surgery. At UI Hospitals & Clinics, the Program of Hospital Epidemiology monitors and tracks surgical site infections.  

Core team  

In fall 2020, a multidisciplinary core team consisting of representatives from the Departments of Nursing, Obstetrics and Gynecology, Anesthesia, Pharmacy, Hospital Epidemiology and the Quality Improvement Program came together to begin reviewing the current performance data and identifying opportunities for improvement.  

Metrics being tracked 

In addition to comprehensively reviewing each reported cesarean delivery SSI, we conduct periodic observations in the operating room (OR) to ensure recommended best practices—such as having a surgical debrief after each case that includes discussing the wound classification, urgency of the delivery, and quantified blood loss—are being completed. We monitor compliance with a variety of evidenced-based process metrics, including the following: 

• Administration of appropriate antibiotic prophylaxis within 60 minutes before skin incision 
• Maintenance of maternal normothermia  

• Hair removal using clippers instead of razors before entering the OR prior to surgery 
• The use of chlorhexidine-alcohol solutions for skin antisepsis, except in emergency cesarean deliveries where povidone-iodine is recommended  
• The use of chlorhexidine vaginal preparation 
• Redosing of antibiotics if the duration of the procedure exceeds 2 half-lives of the drug or there is excessive blood loss during the procedure (>/= 1500 mL) 

What is the team doing to improve metrics  

Upon review of UI Health Care’s cesarean section SSI trends, a significant number were found to be superficial SSIs, for which expanded efforts on skin antisepsis and antibiotic prophylaxis were identified as improvement opportunities. The core team facilitated an adjustment to the antibiotic prophylaxis regimen to expand the indications for azithromycin use and implemented an expanded use of daily chlorhexidine gluconate (CHG) bathing for select patient populations. The pre-operative abdominal skin preparation process prior to a cesarean delivery has been adjusted based on recommended best practices to enhance skin antisepsis. A review of the literature concerning cesarean delivery incisional wound care was conducted, and there is now a standard preferred dressing that is recommended for use. A standard script for post-operative wound care education instructions was created and each patient who undergoes a cesarean section delivery receives a follow-up phone call after discharge.  

Recommendations for prophylactic antibiotics for patients with chorioamnionitis during labor who deliver by cesarean were reviewed and order sets were updated. These changes are all intended to help mitigate the likelihood that superficial SSI occurs.      

There have been multiple other improvement steps taken as a result of this project, including the purchasing of new surgical instruments, expanded staffing of Environmental Services personnel to assist with routine cleaning of the labor and delivery ORs and creation of a best practice alert to help identify pregnant women with a self-reported penicillin or cephalosporin allergy who may benefit from referral to the Allergy Clinic for further allergy testing so that appropriate antibiotics can be used when indicated at the time of delivery.   

The multidisciplinary core team that has been focused on this work has been integrated into the Obstetrics Quality & Safety Committee who will continue to oversee this important work for the organization moving forward.   

Blog contributors:
-Noelle Bowdler, MD, Clinical Professor of Obstetrics and Gynecology, Physician Value Officer
-Derek Zhorne MD, Clinical Associate Professor of Pediatrics, Associate Chief Medical Officer

Team, 

As you know, we’re preparing to soon welcome a group of Joint Commission surveyors between now and September. I hear a lot from different groups about being “Joint Commission ready.” While this is absolutely important—as their survey provides us with a benchmark of our hospitals and clinics’ quality and safety standards—the real question we should ask ourselves is, “Are we patient ready?” 

Our protocols and policies are not in place for the Joint Commission. They exist—and we follow them—because it’s the right thing to do for our patients and visitors to keep them safe. If we’re diligent and mindful of maintaining a safe environment day in and day out, a visit from the Joint Commission becomes just another week. 

With that in mind, we should all be taking a proactive approach to patient-readiness, each and every day.  

How do we do this? I encourage you to review the host of resources available to us from our Quality and Safety teams. Resources—from quick tips to downloadable fact sheets—can be found on The Loop to help us all be patient (and Joint Commission) ready.  

Thank you for all you do. 

Theresa Brennan, MD, FACC 
Chief Medical Officer 

This blog is part of an ongoing series focused on introducing the current quality initiatives. This month, we are featuring the work being done to reduce injuries resulting from falls. Thank you to the Quality Improvement Program team for sharing their important work with us and thank you for taking the time to learn more about the vital work that goes on to improve the care we provide to our patients.   

Patient falls are a challenging problem to solve since there is no one-size-fits-all approach to reducing falls and preventing injuries. All health care team members (e.g., provider, nursing, therapy, transport teams, etc.) have the ability—and responsibility—to make a difference in the safety of our patients. A fall event typically occurs unexpectedly, but many of these falls can also be anticipated through the completion of a thorough fall risk assessment. 

 What risk factors are patients assessed for? 

The fall risk assessment is completed to assess for multiple risk factors including:  

• Elimination: Most common activity contributing to falls 
• Mobility/Ambulation: Gait, unsteadiness, weakness, assistive devices, etc. 
• Mental Status: Delirium is a major risk factor for falling and is preventable. 
• Sensory/Communication Deficit: Neuropathy, vision, hearing, etc.  
• Medications: Cardiac and central nervous system medications 
• Last fall: Including admission due to a fall or a fall during hospitalization 
• Age-related risk 
• Nursing judgment: Alcohol withdrawal, encephalopathy, impulsivity, impaired judgment, etc. 

Fall prevention interventions are multifactorial and individualized. Recognizing what makes your specific patient population unique and using the information obtained from the fall risk assessment to understand your patient’s fall risk factors will aid in initiating appropriate fall prevention strategies.  

 What is a fall with injury? 

We have standard definitions that are provided to us by the National Database of Nursing Quality Indicators (NDNQI) to ensure a standard process in defining a patient fall and the level of injury. A patient fall event is defined as a “sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface (e.g., a counter), on another person, or on an object (e.g., a trash can).” The NDNQI further defines the injury levels by providing a framework of examples including but not limited to: 

•  No injury: Resulted in no signs or symptoms of injury as determined by post-fall
• Minor injury: Resulted in application of ice or dressing, cleaning of a wound, limb elevation, topical medication, pain, bruise or abrasion 
• Moderate injury: Resulted in suturing, application of steri-strips or skin glue, splinting, or muscle/joint strain 
• Major injury: Resulted in surgery, casting, traction, required consultation for neurological (e.g., basilar skull fracture, small subdural hematoma) or internal injury (e.g., rib fracture, small liver laceration), or patients with any type of fracture regardless of treatment, or patients who have coagulopathy who receive blood products as a result of a fall 
• Death: The patient died as a result of injuries sustained from the fall (not from the physiological events causing the fall) evaluation” 

 Core Team: 

There is a monthly multidisciplinary Fall Prevention Committee that consists of nursing leaders, staff nurses, nursing assistants, physical therapists, occupational therapists, a pharmacist, and a provider. We are also developing a task force consisting of a smaller core team that will review the data on current themes with opportunities for patient falls and quick decision-making for opportunities in fall prevention, as well as the correlation of other patient factors to their fall risk.   

 Metrics being tracked: 

In addition to the total number of patient falls each month, we also monitor the number of assisted falls and falls that result in an injury within Tableau. Each quarter, we also submit our data on total patient falls and falls with injury to the NDNQI. We use this data from the NDNQI to benchmark against other academic medical centers and other comparative units (down to the unit level), allowing for fair comparison for each unit/clinic that submits data to the NDNQI. Inpatient and ambulatory/non-inpatient falls and falls with injury are monitored and shared each month (data is through the month of May 2022). 

What is the team doing to improve metrics? 

Generally, patient falls are multifactorial, which is why a thorough fall risk assessment and understanding of how each risk factor impacts the patient’s risk of falling is important. In some instances, the fall risk assessment may have been completed just to “check the box,” ultimately missing the correlation between risk factors and the appropriate fall prevention interventions. 

Reinstituting post-fall huddles is one way UI Health Care is working to improve metrics. Additionally, the post-fall huddle form was redone, including the development of an electronic version. The updated form is broken down by risk factor to assist staff with making the connections and linking appropriate interventions with the patients identified risk factors. The team is continuing to work with various departments to assist staff with making the connections between risk factors, interventions, and hardwiring practices that will promote routine use of patient-specific strategies for fall prevention.  

Patient fall events have been an ongoing national concern that has resulted in The Joint Commission’s sentinel event definition in January 2021. Any patient fall that results in a major injury or death (as defined above) is now reported to the Joint Commission as a sentinel event.  

So, as we continue our work reducing falls and preventing injuries for our patients, it’s important to remember that change doesn’t happen overnight. We encourage you to make short-term attainable goals that are specific for your area that include realistic components that will help you hit those milestones. Understand what the top three risk factors/causes are for patient falls in your area, build a plan with your team with realistic interventions, and implement those interventions to  minimize those identified risks. A good rule of thumb is to start with the primary risk factor and continue to build as you make progress.  

Focus areas for improvements 

• Education for thorough and accurate fall risk assessment 
• Education on connecting risk factors with appropriate interventions 
• Complete a multidisciplinary post fall huddle (paper or electronic version) after every fall to learn from fall event 

This blog is part of an ongoing series focused on introducing the current quality initiatives. This month we are featuring the work being done to improve Central-Line Associated Blood Stream Infections (CLABSIs). Thank you to the Quality Improvement Program (QuIP) team for sharing your important work with us and thank you to our readers for taking the time to learn more about the vital work that goes on to improve care for our patients here within UI Health Care. To learn more about the other initiatives please check out the introduction and previous topics. 

—Theresa Brennan, MD 

Why do some patients need central lines? 

Reliable vascular access is necessary for the safe and effective care of hospitalized patients. Central lines are often necessary for many patients requiring acute or long-term venous access treatments. Central lines have many benefits and are indicated for longer dwell times when compared to peripheral vascular access. When determining appropriate venous access, expert teams use evidence-based practice guidelines to aid in decision making for vascular access devices. Key clinical indications must be considered, which include length of treatment, indication for vascular access, need for vessel preservation, and the nature of the infusate. Although central lines provide many patient benefits, there are also associated risks. Due to these risks, central lines should be removed as soon as the benefits no longer outweigh the risks.  

What causes a Central-Line Associated Bloodstream Infection (CLABSI)? 

CLABSI is a bloodstream infection where germs enter the blood through a central line. It occurs when the patient’s line becomes contaminated. This can happen at the time the line is being placed and the skin is not adequately cleaned. It can happen when dirty health care worker’s hands (or gloves) contact the line. Or it can occur when medications are being introduced through contaminated lumens.  

CLABSI is the most expensive hospital-acquired infection and adds approximately $46,000 per event. Furthermore, it impacts length of stay by 10.4 days, and mortality can be high, with approximately 1 in 4 patients (23.8%) dying as compared to similar patients without a CLABSI. CLABSIs occur less frequently than they used to but nationwide, they still impact 41,000 patients annually.  

How do we prevent CLABSIs?  

At the most basic level, CLABSIs are prevented by ensuring correct and sterile insertion of a central line, proper care of the line, and prompt removal when no longer needed. Accessing and maintaining the line requires health care workers to interact with the device, dressings, and patient’s skin around the line, and each interaction comes with some risk of infection. Reducing the amount of time that a patient has a central line decreases the risk of contamination. All members of the care team have a role in maintaining sterility of the device and site and in reducing the amount of time a patient has a line inserted. 

Foundational practices by care team members actively caring for a patient’s central line make a significant difference in keeping the device and site clean. Implementing effective hand hygiene and following best practices for insertion, removal, dressing changes, and blood culture collection are important in preventing contamination. Further, bathing with chlorhexidine gluconate soap keeps the bacterial load on a patient’s skin to a minimum.  

Members of the patient’s care team who do not directly interact with their central lines also have a role in preventing CLABSIs. For example, when a patient is admitted with a previously placed central line, documenting the insertion date enables accurate calculation of line days. Epic reporting can then display this timeframe, prompting the care team to review whether that line is still needed. Additionally, when a patient’s environment is contaminated, it is more likely that the contamination will spread to their central line. This is most notable in pediatric patients who are smaller and more active. Further, if a patient is experiencing signs of a CLABSI, timely, properly obtained cultures will allow clinical and epidemiology experts to identify the bacteria and better understand the circumstances to improve in the future. 

CLABSI reduction initiative 

In December 2020, an interprofessional CLABSI committee was formed to reduce CLABSIs across adult and pediatric units within UI Health Care. Currently co-chaired by Karen Brust, MD, hospital epidemiologist, and John Swenning, BSN, RN, MBA, CENP, director of ISS Nursing, this initiative team monitors CLABSI trends in our institution, investigates changes needed to align with best practices, and implements proven CLABSI reduction strategies.  

Upon review of UI Hospitals & Clinics CLABSI trends, a significant number of CLABSIs were found to be associated with peripherally inserted central catheters (PICCs). After researching evidence-based recommendations, the team pilot and implement chlorhexidine-coated PICCs for all eligible adult patients. Chlorhexidine is an antimicrobial that provides another layer of protection in preventing line contamination. During the trial period, more than 550 coated PICCs were placed in eligible adult patients. This trial included extensive data tracking, educational content development, and policy expansion. Combined with basic infection prevention bundle elements, the introduction of chlorhexidine-coated PICCs has significantly decreased PICC CLABSIs. In patients who are not immunocompromised, only one patient in the trial developed a CLABSI from September 2021 to February 2022. Comparatively, the institution averaged three adult CLABSIs per month prior to this trial. With organizational recognition of trial success, the team has begun a similar process to implement chlorhexidine-coated central venous catheters (CVCs). 

Another identified opportunity to reduce CLABSIs, was to improve compliance with scheduled central line care and maintenance bundle elements. This includes routine dressing changes, tubing changes, and needleless access device changes. A small workgroup was tasked to build a dashboard that gives frontline staff and unit leadership real-time information about patients with central lines that require those bundle elements to be completed. With quick access to this information, they are in the best position to call out missed bundle elements and concerns during rounding. “Nurse-first” rounding is being used in many areas, and this workbench report will be an asset to all participants.  

The central line dashboard will be rolled out in the coming weeks starting with units that have the highest utilization of central lines and then continuing to remaining areas. Look for more information regarding house-wide implementation by the end of this fiscal year. 

Everyone can help prevent CLABSIs by focusing on proper insertion, appropriate care and maintenance of central lines, and early removal.   

Blog contributors:
-Kathryn Trautman, MSN, RN, CMSRN, Nursing Practice Leader, Adult Vascular Access
-Mary Beth Hovda Davis, MSN, RN, VA-BC, Nursing Practice Leader, Pediatric Vascular Access
-Karen Brust, MD, Hospital Epidemiologist
-Jill Furgason, MPH, PMP, CPHQ, Sr. Project Manager
-Dominica Rehbein, MHA, MPH, PMP, Sr. Project Manager

This month I wanted to write about our work on modifying the discharge huddle process and the purpose. 

I like to think of the patient’s hospitalization as a journey, similar to any road trip you would plan. You would pack your car with your bags and fill the tank with gas. Your bags would have clothes and shoes for all weather conditions, just in case. You may plan to stop along the way to see different sites, pick up souvenirs, take pictures and eat at a restaurant you have heard so much about. Armed with a spare tire in the trunk, extra cash, and maybe an umbrella, you hope for a smooth trip, but are prepared for the unexpected. You have an expectation of the day and potentially time that you will arrive at your destination. Most of the time, this journey is uneventful, but occasionally, things come up. As you are driving, on your way, your “check engine” light comes on and you have to find a service station. With this detour, how do you get back on track?  

This journey is analogous to the patient’s journey through their hospitalization. We prepare for the patient’s need by having the right people available to care for them, the right testing and procedural access, the right meds, etc.—all of these we have at the ready for that patient and their potential needs, just as we have done to pack our car. All patients have an expected length of stay for the diagnosis for which they present. Many of us, including the patient, do not know what that expected date of discharge should be, and that date may change based on the diagnoses that patient comes in with and acquires during their hospitalization. However, the unexpected may occur: they have a complication, their course is slower or faster than expected, they need help when going home, etc. What do we do as health care providers to make sure this patient gets back on track and discharged on time, as expected, safely?  

The first is to make sure everyone on the team knows what is going on and what to expect. This communication should result in the team working together better and should eliminate some duplication of efforts. This need for this communication is the purpose of the discharge huddle. We know not everything goes as planned, so we prepare the best we can for each patient during their hospitalization. We schedule procedures, order consults, labs and imaging ahead of time. We prepare them for post-acute treatment needs, like skilled care and rehab and home health care, and schedule any follow-up appointments as necessary. We send prescriptions for their medications to the patient’s pharmacy. We do all of this to have a safe and efficient discharge for the patient. 

Communicating and planning with our teams each and every day about each of our patients makes the journey through the hospitalization more effective, more satisfying, and safer. And when unexpected delays occur, we can quickly resolve them and get our patients back on track by working together as a great team.  

Discharge planning truly begins at admission. It is important to discuss the discharge plan each day of hospitalization to ensure timely discharge. 

—Theresa Brennan, MD, Chief Medical Officer

We all have a role to play in preventing hospital acquired pressure injuries, or “HAPI.” These injuries harm patients, prolong the hospital stay, and are costly. With teamwork and attention to proven strategies, nearly all HAPIs can be prevented. 

How does a HAPI impact our patients? In addition to an extended length of stay, HAPI’s can lead to sepsis and may require surgical intervention. 

HAPI definition and stage descriptions: Pressure injuries are damage to the skin and/or underlying soft tissue related to positional pressure on a bony prominence or external pressure from a medical device. Medical device related pressure injuries often take on the shape of the device. Pressure injuries can occur due to a high amount of pressure over a short period of time or a low amount of pressure over a long period of time. They can range from an area of redness on intact skin to deep cavernous wounds with exposed bone and are often painful. 

How are HAPIs monitored at UI Hospitals & Clinics? Our performance is monitored through two primary methods. Our PSI-03 CMS reportable event is captured exclusively through physician documentation. The staging and determination of present on admission (POA) status are both required documentation per coding guidelines. Effective Feb. 15, 2022, providers are now able to use the dot phrase .PRESSUREINJLIP in their note to incorporate wound nursing documentation. Providers then have an attestation statement to complete.  

This change will help to standardize and accurately reflect the correct stage of HAPI. Additionally, the wound and ostomy nursing team completes Riskonnect events to monitor HAPI performance. 

Fiscal year 2022 HAPI reduction initiative 

Beginning in July 2021, Greg Schmidt, MD, professor of internal medicine, associate chief quality officer, and Nick Poch, DNP, RN, MBA, VA-BC, interim director of Centralized Function, Interim associate chief quality officer, have been co-chairing the organizational HAPI reduction initiative for UI Hospitals & Clinics. During the past nine months, much work has focused on improving documentation tools in Epic, reporting tools for frontline staff and leaders to proactively identify high-risk HAPI patients, and identification of HAPI reduction tools such as the HoverTech Q2 Roller designed to provide consistent and adequate sacral pressure relief. Additionally, effective March 1, 2022, all VoalteOne nursing phones have the Rover application capable of uploading images directly into the patient’s medical record. 

Stages of pressure ulcers  

• Stage 1 Non-blanchable erythema of intact skin: Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. 
• Stage 2 Partial thickness skin loss with exposed dermis: The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible.  
• Stage 3 (PSI-03 reportable event to CMS): Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, or bone are not exposed. 
• Stage 4 (PSI-03 reportable event to CMS): Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occur. 
• Unstageable (PSI-03 reportable event to CMS): Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. 
• Deep tissue injury: Persistent non-blanchable deep red, maroon, or purple discoloration; Intact or non-intact skin with localized area of persistent, non-blanchable, deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precedes skin color changes. Discoloration may appear differently in darkly pigmented skin. 

You can see further information on the staging system for pressure injuries in this guide with definitions and illustrations. Stage 3, 4 and unstageable pressure injuries determined by physician documentation coding are reported to CMS for the PSI-03 Quality Performance Metric. 

Plans for future improvements  

• Organization-wide use of four eyes skin assessment on admission and transfer 
• Education on device-related pressure injuries 
• Education and monitoring of consistent and effective turning  

Key Points 

• Everyone on the health care team has a role in pressure injury prevention 
• When documenting in a note, use .PRESSUREINJLIP 
• Consult wound ostomy care nurses (Inpatient Consult Wound Ostomy Nurse – Adult) when you are concerned about any skin breakdown  
• Complete and document a full body skin assessment with a colleague (four eyes skin assessment) upon admission and transfer 
• Use the Rover application on the VoalteOne phones to capture and upload images when any skin injury is identified 
• Refer to this guide for further information on the NPIAP staging system for pressure injuries 

Blog contributors:
– Julia Langin, MSN, RN, CMSRN, CWON, Nursing Practice Leader, Adult Wound and Ostomy/Quality, Nursing Centralized Functions
– Nick Poch, DNP, RN, MBA, VA-BC, Interim Director of Centralized Function, Interim Associate Chief Quality Officer, Department of Nursing
– Greg Schmidt, MD, Professor of Internal Medicine, Associate Chief Quality Officer