Cornerstone Specialty Hospitals Little Rock (Ark.) faced a crisis. In 2019, the rate of hospital-acquired infections significantly exceeded the hospital’s own targets and national benchmarks. Dissatisfied with these results, Cornerstone focused on the causes of these HAIs, formed a team to improve the hospital’s results, developed a Model for Enhancement, Advancement and Improvement and implemented multiple changes — which produced significant results.
To learn how Cornerstone Specialty Hospitals Little Rock lowered HAI rates, Becker’s Hospital Review recently spoke with two Cornerstone clinical leaders: Kiacie Farmer, BSN, RN, chief nursing officer; and Toi Grimm, RN, director of quality management.
They described this hospital’s disappointing HAI results in 2019 and the steps taken to transform the environment and decrease HAIs in 2020 and 2021.
Falling short of targets and benchmarks
Cornerstone in Little Rock is a 30-bed long-term acute care unit comprising 19 high-observation beds and 11 mixed medicalsurgical beds. The Little Rock facility is one of 18 Cornerstone Specialty Hospitals.
Ms. Farmer characterized 2019 as “a pretty rough year with hospital-acquired infections.” The hospital had 12 catheterassociated urinary tract infections, resulting in a CAUTI rate of 2.75 against a target of 1.0 and a national benchmark of 2.0. Cornerstone in Little Rock also had five central line-associated bloodstream infections, resulting in a CLABSI rate of 1.21, compared to a target of 1.0 and a national benchmark of 1.0.
The low point came in September of 2019 when this hospital had four CAUTIs in one month, causing the hospital’s leaders to conclude that changes were essential.
Understanding the reasons why
Before deciding on changes, Cornerstone shared the hospital’s HAI data with the staff and formed a team to focus on reducing HAIs. This team first focused on understanding the reasons why the hospital’s HAIs were so high. Team members spoke with and listened to staff and conducted a deep dive on the HAIs.
This team found Cornerstone lacked standard practices. “We did not have good, standard processes for the staff,” Ms. Grimm said. Everyone was kind of doing their own thing.” For example, some staff members were using chlorhexidine gluconate when giving baths, and other staff members saw use of CHG as optional. When CHG was used, it was used inconsistently, with some staff members using a few drops and others using half a bottle. Ms. Grimm reported that some staff members told her, “Well, it just depends on the patient.”
The team also found many infections were related to using diapers and to catheters remaining inserted longer than necessary.
Creating consistent standards
Cornerstone Specialty Hospitals Little Rock set a goal of creating a culture of patient safety by developing and implementing standard practices. It termed its efforts the Model for Enhancement, Advancement and Improvement to Lower HAIs. These practices included adopting guidelines the Agency for Healthcare Research and Quality for line care and eliminating the use of diapers. Standards were created for weekly dressing changes and for tubing changes.
Cornerstone also decided to replace patient baths using soap and water with baths using 4 percent CHG. Cornerstone developed specific guidelines for the use of CHG as part of baths. The guidelines specified:
- Use foam pump to place CHG directly onto the skin
- Use wet wash cloths to spread the CHG
- Use a different wet wash cloth to rinse
- Do not dilute
- The liquid CHG should no longer be in use
- One foam bottle should last three to five baths
“It wasn’t a guessing game anymore,” Ms. Farmer said. “Standardizing the process as well as the product became a secondary goal.”
Driving and sustaining organizational change
Developing consistent guidelines and practices was the first step, but the key to success was having those practices implemented and sustained on an ongoing basis. The most important elements of driving change at Cornerstone were:
- Education. The practices were communicated to staff in multiple ways including through materials, signage, reminders and huddles. “The key piece was education,” Ms. Grimm said, such as “just explaining how it [the CHG foam] should be utilized on every patient every day.” There was also staff reeducation on the central line dressing change process.
- Sharing data. At some facilities, only the managers see data on infection rates, but Cornerstone decided to share its data with the entire staff. “We communicate with the staff and keep the HAI data at the forefront; every day and every month we discuss our results,” Ms. Grimm said.
- Staff incentives. Staff received rewards for achieving certain HAI goals. These rewards included group lunches, sweets or clothing. While reducing HAIs is a serious topic, having incentives engaged the staff and kept the process fun.
- Monitoring and auditing. Cornerstone engaged in continuous audits. “Staff tend to do what you inspect, not what you expect,” Ms. Farmer said. With that in mind, constant inspection is essential. One form of inspection involved unexpected peer-to-peer audits where one staff member observes and audits a peer, with no prior notice. “The staff would audit their peers,” Ms. Farmer said. “After the audit is completed, we all return to the nurse’s station and we review the results. It was a good way to keep the staff accountable.”
The changes at Cornerstone also included educating patients, who at times can resist change. It was important to convey to patients the importance of safety and cleanliness to prevent infections.
Achieving outstanding results
This combination of efforts has paid off. In 2020, Cornerstone Little Rock’s CAUTI rate was 0.78 against a target of 2.0 and the CLABSI rate was 0.25 against a target of 1.0. On both of these important measures, Cornerstone is now outperforming national benchmarks. “We have pretty much sustained what we’re doing . . . and so far, we’re doing pretty good this year [2021],” Ms. Grimm said.
Coping with COVID-19
Cornerstone’s focus on HAIs during 2020 coincided with heightened attention on safety and cleanliness due to COVID-19. “COVID just raised the awareness with staff,” Ms. Grimm said. “It made them extra careful when taking care of patients.” She believes that implementing the Model for Enhancement, Advancement and Improvement during this period proved to be good timing because the staff was so focused.
Also, implementing this model during COVID showed staff anything is possible. “We can always say to our staff, ‘Look, if we did this in the midst of a pandemic, we can do anything,’” Ms. Grimm said. She added, “We did not sit back and use COVID as an excuse. This allowed us to keep our patients safe and keep infections down.”
Conclusion
Cornerstone Specialty Hospitals Little Rock shows it is possible to make and sustain significant changes to practices and processes, leading to dramatic improvement in HAI results. The keys are determining consistent practices and engaging the entire staff in the change process through education, communication, incentives and monitoring.
Ms. Grimm offered advice to other acute care hospitals that may be facing infection challenges, summarizing, “The leadership team has to get the bedside staff involved. I think our biggest accomplishment is having the bedside staff engaged. We have had team meetings on their days off, we provided lunch, they came and sat down and we discussed what they were doing at the bedside. The bedside staff has to be involved. They have to know the results, at least monthly, to make a change.”
Ms. Farmer noted that in 2019, the Little Rock facility “was in the hot seat” during Cornerstone’s monthly and quarterly corporate meetings. But now that the Little Rock team is meeting its targets, “We’re the star child.”
These results exhibit what is possible at any facility that has strong leadership, clear focus, consistent practices and specific measures, along with education, team work and monitoring.