Making “Infection-Free” Happen:
Across, Down & Up; An Update
August 13, 2014
Pranavi Sreeramoju, MD, MPH
Associate Professor, Medicine-Infectious Diseases, UT Southwestern
Chief of Infection Prevention, Parkland Health and Hospital System, Dallas, TX
Email: Pranavi.sreeramoju@utsouthwestern.edu
+ HAI Reduction at Parkland: FY09 to FY13
-60.0%
-80.0%
-100.0%
-75.5%
-90.3%
-38.2%
-49.0%
52.8%
C.difficile
associated
diarrhea of
Hospital Onset
-40.0%
VRE Hospital
Onset BSI
-20.0%
MRSA
Hospital Onset
Bloodstream
Infections
0.0%
SSIHysterectomy
20.0%
% Change in Rate in FY2013 compared
to Baseline Rate in FY2008
0.0%
VAP - adult
ICUs
40.0%
CLABSI - ICUs
60.0%
+ HAI Reduction at Parkland: FY09 to FY13
Rate of Known HAI through IC Surveillance
CLABSI - ICUs (per 1000 catheter-days)
Ventilator Associated Pneumonia - adult ICUs (per 1000
ventilator-days)
SSI-Hysterectomy (% of procedures)
MRSA Hospital Onset Bloodstream Infections (Infection per
10,000 patient-days)
VRE Hospital Onset BSI (Infection per 10,000 patient-days)
C.difficile associated diarrhea of Hospital Onset (Infection
per 10,000 patient-days)
FY09 FY13 %Change
5.3
1.3
-75.5%
14.4
3.4
1.4
2.1
-90.3%
-38.2%
0.98
0.5
0.5
0.5
-49.0%
0.0%
3.6
5.5
52.8%
+
Project RITE: FY2013 to FY2016

‘Reduce Infections Together in Everyone’

A Texas 1115 Waiver Program for Quality Transformation at
Parkland

Executive Sponsors: Ron Laxton, RN, PhD and Chris Madden, MD,
MBA

Project Lead: Pranavi Sreeramoju, MD, MPH

Project Managers: Herron Mitchell, Nancy Baez, David Huffman,
and Joanne Muturi
+
AIM Statement (1 of 2)
Compared to FY2013 baseline rates at Parkland,
•
FY2015 and FY2016 - 20% per year reduction in
Central Line Associated Bloodstream Infection
(CLABSI) in ICUs, Wards, and outpatients
•
FY2015 and FY2016 - 20% per year reduction in
Catheter Associated Urinary Tract Infection
(CAUTI) in ICUs, and Wards
+
AIM Statement (2 of 2)
Compared to FY2013 baseline rates at Parkland,
•
FY2015 and FY2016 - 8% per year reduction in SSI
occurring after seventeen types of procedures.
•
Improve adherence to 3-hour and 6-hour Sepsis
Management Bundle for patients admitted with
Sepsis in the Emergency Department
+
Our Interventions
1.
Reduce Variation in Processes of Care and
Standardize Curriculum and Training
2.
Engage Clinicians & Stakeholders
3.
Have Bi-weekly Learning Sessions
4.
Train At Least 500 Champions in Process
Improvement Methodologies
5.
Participate in Regional Collaborative
+
Results Thus Far vs. FY13
10.0%
5.6%
0.0%
CLABSI
CAUTI
-10.0%
Rolling 12-Month
Goal by FY16
-30.0%
-50.0%
Sepsis
Mortality
-4.3%
-15.4%
-20.0% -12.4%
-40.0%
SSI
-36.0%
-36.0%
-40.5%
+
Positive Deviance Trial
+
Project Outputs

English/Spanish Flashcards - Teach
Patients How to Participate in their
Care

Hand Hygiene Video - Teach Patients
How to Perform Hand Hygiene

Infection Prevention Skills Checklist: 64
items

Name for the study
+
Outcome Data
# of Patient-days of Care
# of HAI (Primary Outcome)
Intervention Group
6-month
9-month
Baseline
Intervention
9-month FollowPeriod
Period
Up Period
9144
14841
15095
43
48
34
Control Group
6-month
9-month
9-month
Baseline
Intervention
Follow-Up
Period
Period
Period
9564
14339
14652
43
41
46
Rate of HAI per 1000 Patient-days
# of CLABSI
# of CAUTI
# of HAP
# of CDI
4.70
9
11
8
15
3.23
11
7
11
19
2.25
6
7
15
6
4.50
8
10
13
12
2.86
7
8
15
11
3.14
7
10
17
12
# of HAI associated with complications
occurring during same admission within 28
days (Secondary Outcome)
8
17
8
15
10
7
0.87
1.15
0.53
1.57
0.70
0.48
3
2
0
0
0
0
5
5
13
8
6
4
15
6
10
6
6
3
Rate of HAI associated with complications
per 1000 patient-days
# HAI associated with permanent loss of
organ or organ system
# HAI associated with transfet to higher
level of care
# HAI associated with Death
+
Summary of Positive Deviance Trial

Intervention may have accelerated reduction of HAI

Culture of Safety decline not seen in Intervention Wards

Social networks revealed that the ward manager, charge nurse,
ward clerk were predominantly the ‘go-to’ people for infection
prevention work

Staff turnover was high during study period due to
organizational situation

Look for the Publication
+
What Others can Learn from Us: 2013

Ensure that the program meets the highest of regulatory standards , e.g.,
TJC, CMS

Perceptions matter a great deal

Optimize technical solutions first

Leverage intrinsic motivation

Learn from the frontline employees and stakeholders if your challenges
are adaptive in nature
+
What Others can Learn from Us: 2014

Regulatory not done yet: Mock Surveys, Corporate Integrity Agreement,
Quality Review Organization

Perceptions still matter a great deal

Past performance will haunt (e.g., HAC reduction program due to late start
with CAUTI reduction, hemodialysis-associated CLABSI)

1115 Waiver Program is a blessing

Keep At It
Antimicrobial Stewardship
1, 2014
Patient Safety Summit
2013