10th SOW Wrap-Up
Karline Roberts & William Gardiner
July 24, 2014
Overview
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Project began August 1, 2011
58 hospitals participated
4 face to face LAN meetings
24 webinars
CUSP Training
CAUTI workgroup call series
Handwashing for Life visits
ATP monitoring
Countless site visits
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Tools
•HAI Resource Guide
•RCA Tool Kit
•CLABSI Video
•CLABSI Maintenance
Bundle
•Excel Audit tool for
CLABSI & CAUTI
•CLIP monitoring form
•Hand washing pins
•PowerPoint templates for
CLABSI, CAUTI, CDI
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More Tools
•CAUTI Posters – 3
•CAUTI Screen Savers
•Foley Insertion Checklist
•CAUTI Patient Brochure
•CAUTI Pocket Card
•Patient Hand washing Brochure
•CDI Bundle
•CDI Tool Kit
•SSI Pocket card
•Antibiotic Selection Pocket
cards
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IPRO website
http://qio.ipro.org/hospitals-hai/about-thisproject/prevention-tools-and-resources-for-healthcareprofessionals
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Advisory Committee Members
•Brian Koll, MD – Mt. Sinai Beth
Israel Medical Center
•Zeynep Sumer - GNYHA
•Ghinwa Dumyati, MD - University
of Rochester
•Mary Ann Magerl - Vassar
Brothers
•Kathi Mullaney - Metropolitan
Hospital
•Christina Ostwald - Mount St.
•Hillary Jalon - United Hospital Fund
•Mary Manfredo – Oneida Hospital
•Mary Therriault - HANYS
•Carol VanAntwerpen
•David Calfee, MD - New York
Presbyterian/Weil Cornell Center
•Peggy A. Hazamy –DOH
•Donna Armellino - North Shore
Hospital System
Mary's
•Mary Jane Milano - Regional
Hospital Association
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CLABSI Relative Improvement
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CLABSI SIR
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CLIP
Adherence was consistently well over 90%
No CLIP for 11th SOW!!!
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CAUTI Relative Improvement
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CAUTI SIR
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Standardized Urinary Catheter Utilization
Rate (SDUR)
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CDI Relative Improvement
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CDI SIR
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10th SOW Overview - Barriers and Successful Interventions
Antimicrobial Stewardship
Barriers:
a. Lack of administrative support
b. Lack of an ID physician
c. Lack of a clinical pharmacist
d. Overwhelmed ID physician
e. Lack of running and/or distribution of an (annual) antibiogram
f. Lack of formulary restrictions
g. Lack of agreement in what constitutes an acceptable program
h. Not knowing where to start
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Lack of budgetary resources
Successful Interventions:
a. Starting with one intervention with gradual expansion, once support is demonstrated
b. The lab culture not only contains the susceptibility results but also contains the price of the
antibiotics, so practitioners can equate the cost of therapy.
c. Selected antibiotics require an ID consult
d. Antibiograms are run (annually, biannually) and distributed to practitioners via pocket cards
e. Antibiogram is on the back of the antibiotic order sheet.
Catheter Related Urinary Tract Infections (CAUTI)
Barriers:
a. Lack of administrative support or a physician champion
b. Lack of demonstrated competency for insertion and maintenance of foley catheters
c. Receipt of patients with foley catheters already in place
d. Lack of a daily reminder system to remove the foley.
e. Lack of appropriate reasons for foley insertion
a. Lack of clinician understanding of what is considered “appropriate”
f. Lack of delivery of the urine specimen to the laboratory in a timely manner or proper
refrigeration
g. Manual daily foley counts
h. Inability to capture foley counts in the EMR
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Foleys are addressed on rounds, but an ordering practitioner does not participate. This hinders
an order being written and carried out.
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Lack of a root cause analysis for each infection.
k. Lack of a nurse-driven protocol and need for a cultural change for acceptance of the nurse
driven protocol. (reluctance to remove a catheter without an ‘order’)
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Lack of a renewal timeframe
m. Lack of a good female alternative
n. Noncompliant patients disrupting device
o. Lack of clinical and surveillance definition consensus.
p. Increasing frequency of yeast (mainly Candida spp.), which may not be a true infection
q. Lack of IP presence on product evaluation committees and purchasing committees
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What’s Next?
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11th SOW begins August 1st
Introductory webinar will be held on August 6th
Conditions are: CLABSI, CAUTI, CDI, VAE
5 Year Project
Work to be done in ICU and non-ICU units
QIOs required to report to CMS the hospitals that
continue work from 10th to 11th SOW
• New MOA will need to be signed
• Work will be done in a community collaborative
setting
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Questions
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This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract
with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human
Services. The contents do not necessarily reflect CMS policy. 10SOW_NY_AIM7.1-14-08
For more information
Karline Roberts
Director
(518) 320-3508
Karline.roberts@hcqis.org
William Gardiner
Senior QI Specialist
(518) 320-3505
William.gardiner@hcqis.org
IPRO CORPORATE HEADQUARTERS
1979 Marcus Avenue
Lake Success, NY 11042-1002
IPRO REGIONAL OFFICE
20 Corporate Woods Boulevard
Albany, NY 12211-2370
www.ipro.org
Template 1/13/2012