Improving Quality and Safety at SVMC

Contact Patient Safety
(802) 447-4054
100 Hospital Drive
Bennington, VT 05201
mac1@phin.org

Quality and safety has always been important in health care, but only recently have hospitals focused on improving the systems that doctors and nurses use to provide care. Read on to learn more about how SVMC is working to make our hospital the safest in the nation.

Reducing Hospital-Acquired Clostridium Difficle Infections

Project Goal: Reduce the rate of Clostridium Difficile Infections from 13.6 infections per 10,000 patient days to less than 5 infections per 10,000 patient days.

Background: Antimicrobial resistance is one of our most serious health threats. Infections from resistant bacteria are now very common. The loss of effective antibiotics will undermine our ability to fight infectious diseases and manage the infectious complications common in vulnerable patients such as patients who are undergoing chemotherapy, dialysis or surgery. Although C. difficile infections are not yet significantly resistant to the drugs used to treat them, most are directly related to antibiotic use. CDC estimates that in the United States, almost 250,000 people each year require hospital care for C. difficile infections. In most of these infections, the use of antibiotics was a major contributing factor leading to the illness. At least 14,000 people die each year in the United States from C. difficile infections. Many of these infections could have been prevented.

Intervention: All SVMC inpatient rooms are cleaned using the standard disinfectant procedures. For all rooms where a patient has had an infection, the room is again cleaned using an aerosol disinfection process. With this method, the disinfectant is vaporised into ultrafine droplets and blown into the air, and they are able to penetrate the entire room including hard to reach spaces.

Results: In the 27 months prior to the introduction of the aerosol disinfection, we averaged 13.6 infections for every 10,000 hospital patient days. The new program began in January 2014 as depicted by the vertical line in the chart below. In the 15 months since the hospital began using the aerosol disinfectant, the hospital-acquired
C. Difficile rate has been 3.73 infections for every 10,000 hospital patient days.

 

Reducing Catheter-associated Urinary Tract Infections

Project Goal: Reduce the amount of time that hospital patients have a urinary catheter.

Alternate Goal: Ensure that hospitalized SVMC patients have urinary catheters in place for the shortest possible time; reach the 90th percentile among US hospitals.

Background: A urinary tract infection (UTI) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney. UTIs are the most common type of healthcare-associated infection reported to the National Healthcare Safety Network (NHSN). Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine. Between 15-25% of hospitalized patients receive urinary catheters during their hospital stay. The most important risk factor for developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary catheter. Therefore, catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed.

Summary: Physicians and nurses worked together to ensure that only patients who met agreed-upon, evidence-based criteria for urinary catheter placement were catheterized. Typically this starts in the Emergency Department. The nursing staff then undertook an effort to better manage those patients with urinary catheters by building “triggers” in the patient’s electronic medical record. These triggers alert nurses on every shift to patients who have urinary catheters and requires them to assess whether or not the patient can have the catheter removed. In addition, physician orders were built and standardized that require the physician to ask that the urinary catheter be removed within 24 hours unless a medical reason is entered into the patient’s record. The hospital IT staff built a report that summarizes urinary catheter use each month so that the clinical staff can determine how well it is performing toward the goal.

Outcome: After 15 months with the new program in place, SVMC’s non-ICU medical-surgical patients use urinary catheters at a rate of 14%. This is below the national median of 18% and only slightly above the 90th percentile of 13%, based on an analysis of 872 hospital medical-surgical units (2012) by the National Healthcare Safety Network.

Contact: Wilma Salkin, RN Infection Control & Kathy Brandi, RN Clinical Nurse Specialist

 

Curbing Emergency Department Visits for Opioid Prescriptions

Background: At SVMC, we do everything possible to ensure that our patients have access to appropriate and effective pain relief. However, we also have a societal responsibility to curb the flow of opioid analgesics into the community that can be used for reasons other than legitimate medical purposes. Drug overdose deaths, driven largely from prescription drugs, are now the leading cause of injury death in the United States – surpassing motor vehicle crashes. This has recently been brought to a high level of awareness by Vermont’s governor Peter Schumlin. At SVMC, we have directed our efforts toward prescriber and patient education as a means of addressing this epidemic.

In order to study this problem, we decided first to look at a small cohort of patients who frequently visit the SVMC Emergency Department and who have received opioid analgesia. In 2013 there were 93 adults under the age of 40 who visited the ED more than 7 times, with at least one visit that involved prescription of opioid analgesic medications. This group of people became our study sample.

Project Goal: Our aim was to significantly reduce the number of ED visits and opioid analgesia prescriptions from this group of patients.
Intervention: Our Emergency Medicine physicians adopted a set of clinical guidelines to identify at-risk patients, implement a standardized approach to these patients, and optimize alternative pain control strategies. The new guidelines have been in place since March of 2013.

Results: In the 9 months following the initiation of the guidelines, the volume of patient visits from the study cohort dropped 43%. The volume of visits with opioid analgesics dropped 50%. This represents a 7% reduction in the rate of dispensing opioids to this group of patients.

Discussion: While this rate of reduction in opioid dispensing is not significant, statistically, it does represent an improving trend in the direction of curbing opioid prescriptions from the Emergency Department. There were 300 fewer tablets dispensed to this small group of patients this year as compared to last year.

Contact: Adam Cohen, MD Emergency Department