Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care

Abstract

Background: An academic safety-net hospital leveraged the federally funded state Delivery System Reform Incentive Payment programme to implement a hospital-wide initiative to reduce healthcare-associated infections (HAIs) and improve sepsis care.

Methods: The study period was from 2013 to 2017. The setting is a 770-bed urban hospital with six intensive care units and a large emergency department. Key interventions implemented were (1) awareness campaign and clinician engagement, (2) implementation of HAI and sepsis bundles, (3) education of clinical personnel using standardised curriculum on bundles, (4) training of key managers, leaders and personnel in quality improvement methods, and (5) electronic medical record-based clinical decision support. Throughout the 5-year period, staff received frequent, clear, visible and consistent messages from leadership regarding the importance of their participation in this initiative, performing hand hygiene and preventing potential regulatory failures. Several process measures including bundle compliance, hand hygiene and culture of safety were monitored. The primary outcomes were rates of central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI) and sepsis mortality.

Results: From 2013 to 2017, the hospital-wide rates of HAI reduced: CLABSI from 1.6 to 0.8 per 1000 catheter-days (Poisson regression estimate: -0.19; 95% CI -0.29 to -0.09; p=0.0002), CAUTI from 4.7 to 1.3 per 1000 catheter-days (-0.34; -0.43 to -0.26; p<0.0001) and SSI after 18 types of procedures from 3.4% to 1.3% (-0.29; -0.34 to -0.24; p<0.0001). Mortality of patients presenting to emergency department with sepsis reduced from 9.4% to 2.9% (-0.42; -0.49 to -0.36; p<0.0001). Adherence to bundles of care and hand hygiene and the hospital culture of patient safety improved. Results were sustained through 2019.

Conclusion: A hospital-wide initiative incentivised by the Delivery System Reform Incentive Payment programme succeeded in reducing HAI and sepsis mortality over 5 years in a sustainable manner.

Keywords: health policy; healthcare quality improvement; infection control; nosocomial infections; patient safety.

Figure 1

Trends in outcomes of healthcare-associated infections and sepsis mortality during the initiative. The following are the Poisson regression estimates for trend in reduction for each outcome over the 5-year period, the 95% CIs and the p values: CAUTI: estimate −0.34 (−0.43 to −0.26), p<0.0001; CLABSI: estimate −0.19 (−0.29 to −0.09), p=0.0002; SSI: estimate −0.29 (−0.34 to −0.24), p<0.0001; sepsis mortality: estimate −0.42 (−0.49 to −0.36), p<0.0001. CAUTI, catheter-associated urinary tract infection; CLABSI, central line-associated bloodstream infection; SSI, surgical site infection.

Figure 2

Volume of alcohol hand sanitiser purchased per month and hand hygiene adherence in the health and hospital system during different time periods in the hospital system. DPMO is defects or failures per million opportunities. Sigma level is a measure of how much the process varies from perfection: a level of six is perfect. Numbers corresponding to each peak of volume purchased in the graph represent the following events: 1: CMS regulatory survey; 2: beginning of health and hospital system response to negative findings of regulatory survey; 3 and 4: anticipation of follow-up CMS survey; 5: occurrence of Ebola virus infection in the local community; 6: opening of new hospital facility; and 7: opening of new subspecialties clinic facility. CMS, Centers for Medicare and Medicaid Services; HAI, healthcare-associated infection.