OUR EXPERIENCES Embedded Safeguards

Cincinnati Children’s implemented a bundle of interventions—a robust detection system to accomplish real-time awareness and analysis of all failures, microsystem-level process and outcome data, and standardized pediatric process bundles—to reduce rates of specific hospital-acquired conditions.

  • Better care: 85 percent reduction in ventilator-associated pneumonia; >50 percent reduction in catheter-associated bloodstream infections; 43 percent reduction in class I and II surgical site infections
  • Lower costs: $5.6 million saved per year

HCA conducted a multi-year effort to reduce central line-associated bloodstream infections (CLABSIs). This program incorporates the latest evidence-based recommendations, including insertion and maintenance practices, supply standardization of central-line kits, and competency training for all HCA physicians as part of their biannual credentialing.

  • Better care: Up to 200 lives saved; 57.4 percent decrease in hospital-acquired bloodstream infections within the ICU since 2006; 80 HCA facilities with zero hospital-acquired bloodstream infections
  • Lower costs: $17.5 million saved system-wide annually ($44,000 per case)

Kaiser Permanente established early-intervention protocols for diagnosing and treating community-acquired sepsis. Nursing, physician, informatics, and quality leaders translated existing guidelines into specific competencies, practices, and roles for the care delivery staff. Patient care protocols in the ED and ICU were changed to provide early-recognition and treatment-intervention opportunities.

  • Better care: Sepsis mortality reduced by over half; 3.5-day reduction in the length of stay for patients with a principal diagnosis of sepsis; ∼3-fold increase in the number of sepsis cases diagnosed

Partners HealthCare implemented pharmacy barcoding at Brigham and Women’s Hospital to reduce serious medication errors. Pharmacists barcode-scan all medications dispensed from the pharmacy to ensure that the medications match the physicians’ orders. Nurses at the bedside then scan the medications prior to administration to patients, and are alerted about possible errors.

  • Better care: 31 percent reduction in serious medication-administration errors; increased on-time medication availability on nursing units
  • Lower costs: $3.3 million in cumulative 5-year savings (costs recouped within first year)

Veterans Health Administration’s Methicillin-Resistant Staphylococcus Aureus (MRSA) Prevention Initiative was implemented in 2007 to decrease MRSA infections acquired at acute care facilities nationwide. The program focused on a bundle of evidence-based best practices known to prevent MRSAs and the leadership of a MRSA Prevention Coordinator (MPC) charged with overseeing implementation at each medical center.

  • Better care: 1,000 prevented MRSA infections and a 62 percent reduction in ICU MRSA rates nationwide from October 2007 to June 2010; currently, more than 70 percent of VHA facilities have zero MRSAs monthly


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