Driver Diagrams Healthcare Associated Infection Prevention OHA HEN 2.0

Healthcare Associated Infection Prevention AIM Primary Drivers Secondary Drivers Change Ideas Reduce HAI by 40% Basic Infection Prevention Practices Hand hygiene Cleaning of environment and equipment Aseptic technique Develop checklists to use when evaluating cleaning practices Directly observe room cleaning and provide immediate feedback Use agar slide cultures to provide an easy method of quantifying viable microbial surface contamination Utilize swab cultures to demonstrate effectiveness or opportunities Utilize ATP Bioluminescence to measure organic debris as a surrogate marker for biological contamination Provide feedback on effectiveness of cleaning, hand hygiene and aseptic technique Include competency training infection prevention Organism Specific Practices (MRSA, C. diff, etc.) Identification of colonization with active surveillance Decolonization Develop policies/processes for identification of colonization Work collaborative with Laboratory to document surveillance activities Use evidence-based, best practices for decolonization (see C. diff Driver Diagram for more detail)

Healthcare Associated Infection Prevention AIM Primary Drivers Secondary Drivers Change Ideas Reduce HAI by 40% Surgical Site Infection Prevention Antibiotics (selection, time, d/c) Appropriate hair removal Normothermia (colorectal) Glycemic control (cardiac) Surgical Safety Checklist Skin Antisepsis Antimicrobial Prophylaxis Senior leader part of improvement team Engage front line workers in project early and often Audit staff compliance with measures and provide regular feedback Assure new physicians, nurses and ancillary staff receive bundle information Include SSI bundle elements in annual competencies/tie to individual performance Obtain glucometer for every anesthesia station Develop a team (surgeon, anesthesiologist, endocrinologist, nurses) Adopt standardized, evidence based algorithms and monitor compliance Adopt standard checklist as prompt and for documentation Conduct 3 pauses (pre-induction, pre-incision, prior to exit) for verbal confirmation of all checklist items Include SCIP measures on beta blockers, VTE and VAP prevention, peri-operative normothermia, including standardized processes pre- and intra-operative Develop standardized order set for preadmission skin cleansing with CHG, including process for distribution and patient education Use appropriate hair removal process only if hair with interfere with surgery (clip v shaving) Consider MRSA screen and decolonization (mupirocin/CHG) Follow SCIP measures as to appropriate antibiotic, timing and discontinuation

Healthcare Associated Infection Prevention AIM Primary Drivers Secondary Drivers Change Ideas Reduce HAI by 40% Device-Related Infections - Central Line Bundle Equipment and Supply Availability Promote Culture of Safety Around CVLs Adaptive Changes Standardized Insertion Process Standardized Maintenance Process Create central line insertion cart with necessary supplies to promote best practices Develop process for convenient access to supplies for best practices (central line dressing change kits, cap change kits If at or near rate of 0, consider other supply-supported interventions, e.g. CHG site dressing, CHG bathing, disinfection caps Learn and adopt team and communication skills Adopt policies which combine individual accountability with a blame-free, patient-centered approach to error Assure policies/processes are in place to reduce risk to individuals confronting colleagues/reporting breaches, over senior level support for staff "stopping the line" when breaches in policy occur Senior leader as part of improvement team Engage front line workers early and often Adopt and imbed evidence based insertion bundle Audit insertion bundle compliance Provide compliance feedback/review outliers Interdisciplinary daily review of line necessity Adopt and imbed evidence based maintenance bundle Audit maintenance bundle compliance Provide compliance rate feedback/tie to individual performance

Healthcare Associated Infection Prevention AIM Primary Drivers Secondary Drivers Change Ideas Reduce HAI by 40% Device-Related Infections - Ventilator Bundle Peptic Ulcer Disease Prophylaxis VTE Prophylaxis Spontaneous Awakening (SAT)/breathing (SBT) Trials Promote Culture of Safety Around CVLs Adaptive Changes HOB Elevation Standardized Oral Care Include PUD prophylaxis in ventilator order sets (H2 blockers preferred) Engage pharmacy to ensurePUD compliance Include VTE prophylaxis in ICU admission order sets Engage pharmacy to ensure VTE compliance Use sedation protocol, goal directed sedation therapy Perform daily assessments of readiness to wean/extube, coordinate with lower sedation levels Embed SAT/SBT into ventilator order sets Learn and adopt team and communication skills Adopt policies which combine individual accountability with a blame-free, patient centered approach to error Assure policies/processes are in place to reduce risk to individuals confronting colleagues/reporting breaches, overt senior level support for staff "stopping the line" Senior leader as part of improvement team Engage front line workers in project early and often Visual cues for easy monitoring of HOB elevation Provide compliance feedback/review HOB elevation outliers Perform brushing of teeth twice daily Provide oral care Q2-4 hours with antiseptic swab Consider CHG rinse (0.12%) at least daily Provide compliance rate feedback on oral care/tie to individual performance

Healthcare Associated Infection Prevention AIM Primary Drivers Secondary Drivers Change Ideas Reduce HAI by 40% Device-Related Infections - CAUTI Strategies Adaptive changes Avoid urinary catheterization when possible Equipment/supply availability Promote culture of safety around Urinary Catheters Adopt and imbed policy based on evidence based bundle Audit compliance with bundle/review outliers Provide compliance feedback, tie to individual performance Develop process for convenient access to supplies for best practice, e.g. insertion kits, "add-a foley" kits If at or near a rate of 0, consider other interventions, e.g. CHG bathing, hydrogel, silver or antimicrobial coated catheters Learn an adopt team and communication skills Adopt polices which combine individual accountability with a blame-free, patient centered approach to error Assure policies/processes are in place to reduce risk to individuals confronting colleagues/reporting breaches, errors, overt senior level support for staff "stopping the line" Senior leader as part of improvement team Engage front line staff in project early and often Adopt and imbed policy regarding medical indications for urinary catheterization Audit utilization compliance with policy/review outliers Provide compliance feedback/tie to individual performance Adopt and embed policy regarding EBP insertion technique Audit technique policy compliance Provide insertion compliance rate feedback/tie to individual performance Standardized insertion process Standardized maintenance process Insertion competency training Catheter maintenance protocols and competency training Nurse-directed catheter removal protocols Alternatives to indwelling cahteters Protocols for management of postop urinary retention Implementation of stop orders 48-72 hrs after insertion Reminders/alerts requiring documentation for continued use

Healthcare Associated Infection Prevention AIM Primary Drivers Secondary Drivers Change Ideas Reduce HAI by 40% Antimicrobial Stewardship Audit antimicrobial use prospectively and provide direct feedback to the provider Restrict antimicrobial formulary and require preauthorization for antimicrobial prescription and/or administration Monitor Healthcare Effectiveness Data and Information Set (HEDIS) performance measures for pharyngitis, upper respiratory infections, acute bronchitis and antibiotic utilization Target specific infections, e.g. UTI (second most common bacterial infection leading to hospitalization Adopt guidelines for management of community-acquired pneumonia using a shorter course of therapy (John Hopkins study) Evaluate the use of antimicrobials among patients with CDI and provide feedback to medical staff and facility leadership Educate prescribing clinicians regarding the appropriate selection, dose, timing, and duration of therapy with antimicrobials Focus efforts on reducing use of certain antibiotic classes that have higher risk for CDI, e.g. cephalosporins, clindamycin, and fluroquinolones Eliminate redundant combination therapy Develop multidisciplinary standardized order sets incorporating local microbiology and resistance patterns Develop antimicrobial order forms to facilitate implementation of practice guidelines Ensure all orders have dose, duration and indications documented Obtain cultures before starting antibiotics Streamline or de-escalate empirical antimicrobial therapy based upon culture results Optimize antimicrobial dosing based upon individual patient characteristics, infection-causative agents, site of infection, and drug characteristics Consider an "antibiotic timeout" (ie. reassessing antibiotic therapy after 48-72 hours. Source Document: C. DIfficile Infection (CDI) Change Packet, Preventing Clostridium difficile transmission and infection; prepared by American Hosppital Associate and HRET (Health Research & Educational Trust)

Healthcare Associated Infection Prevention AIM Primary Drivers Secondary Drivers Change Ideas Reduce HAI by 40% Antimicrobial Stewardship continued Develop a systematic plan for parenteral-to-oral conversion of antimicrobials based upon patient condition Develop clinical criteria and guidelines to promote the switch from parenteral to oral agents as soon as possible Use healthcare information technology, e.g. electronic medical records, to improve antimicrobial decision-making Develop computer-based surveillance to target antimicrobial interventions, track resistance patterns, and identify HAIs and adverse drug events Implement collaboration between the clinical microbiology laboratory and the infection prevention department to optimize surveillance and investigation of outbreaks Determine if antimicrobials that increase risk for CDIs are discontinued or de-escalated when CDI is suspected