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Posted October 24, 2013
All Children’s Hospital Undertakes Multiple Initiatives to Ensure High Quality of Care for Patients

Achieving excellent healthcare quality and safety is a vital measure of a top-notch hospital - and an array of measures at All Children's help ensure that patients receive the best care possible.

The results are certainly hard to beat in the most fundamental ACH initiative: hand-washing compliance.

ACH frequently scores a 100 percent compliance rate among its caregivers and is never beneath 95, according to Vice President of Medical Affairs and Chief Safety Officer Brigitta Mueller. Furthermore, the hospital ranks higher than any other in the Johns Hopkins system and is among the best in the country.

That high standing is especially noteworthy in the midst of National Healthcare Quality Week, which mirrors the top priority placed on quality and safety by All Children's President and Vice Dean Jonathan Ellen, M.D.

"You can look nationwide - it's hard to get 100 percent," remarked Dr. Mueller, who joined ACH in early September. "When I first heard about our scores, I thought, 'Is that really true?' It is - and it's very impressive."

ACH Vice President and Chief Nursing Officer Hella Ewing underscores the significance of ACH's high compliance rate:

"So many organizations have variation in their compliance - they'll be good with in-patient but won't be good in their outpatient areas. Or the physicians won't be compliant with it, but the front-line nursing staff and other clinicians are. We don't have that issue. We audit the entire team - in-patient and out-patient.  We do more than 800 audits monthly in this organization and we have a team that's trained to do the audits, so they all do it the same way and you get less variation in the process.

"Our goal is zero, always. Because when we think of it not as a rate but as a child, we don't want to cause harm to even one patient. And that patient is a child."

All Children's uses the World Health Organization definition of the five instances when a caregiver should wash his or her hands.

  • Before patient contact
  • Before an aseptic, sterile procedure
  • After handling body fluids
  • After patient contact
  • After contact with patient surroundings

"In comparison, many hospitals are in the 50-to-60 percent range," Dr. Mueller said. "So our scores are really good. It's the result of a lot of education and buy-in in from the staff. It just becomes a habit. You go into a room and you use your Purell Hand Sanitizer or wash your hands. You observe the isolation signs. The other important thing is that people feel free to speak up if they see somebody who forgot to do it. You might forget, and we need to remind each other. That's another thing we're really emphasizing, because we're all here for the kids."

"I'm very in favor of teaching the parents and patients to speak up as well," she added. "If you're not sure whether your provider has washed his or her hands, ask them to do it again. It's all about protecting the child."

Another important push on the healthcare quality front: striving to avoid central line associated blood stream infections (CLABSI). The problem can occur when a child has a catheter implanted to draw blood or provide medication and it comes infected.

"The line is plastic, so bacteria can cling to it and cause the infection," she explained. "Sometimes, as we access these lines, if we're not very careful, we can introduce bacteria just by contaminating the site. So there are many different initiatives - from cleaning the cap where you go in through to making sure the skin is clean where they do the insertion, to making sure these catheters don't stay in longer than they need to."

The HEM-ONC unit at ACH, which has had particularly good results, recently became plugged in to the National Association of Children's Hospitals and Related Institutions to learn what other hospitals are doing, and provide guidance to other hospitals.

"Maybe we're doing something that's very good and they can learn from us," Dr. Mueller said. "Thirty-five hospitals participate and on a monthly basis they share results. The ones that do very well present what they think made a difference."

In addition, twice-a-year workshops allow representatives from the various hospitals in the collaborative to share approaches that can ultimately benefit the entire organization.

All the efforts are guided by one central premise:

"In the pediatric environment, and even with adults, the No. 1 thing that we can do is convey to staff that there is the potential of harming patients unintentionally, and that we can prevent that harm," Ewing said. "There are systematic things we've put in place here at All Children's and have been able to sustain and have seen a tremendous decrease in our infection rate, especially related to our central line infections and urinary tract infections induced by catheter. And all of that plays into standardizing the approach to care."

For instance, Ewing credits the PICU nursing staff with implementing a procedure to reduce infection rate: a checklist system similar to what is used in the military.

"With every patient they ask the same question as a team," she said. "They're not thinking about it and reading it. As a team, they vocalize the questions. And we saw a drop overnight, literally, from a unit that struggled with their central line infections to go to zero - and now sustain that for months, well over 200 days. They did it by implementing that one intervention, asking questions like, 'Does this patient even need a line?' If they don't have a line, they won't get an infection. Or, 'Do we still need the IV antibiotics?' (as opposed to oral).

"There are about 13 questions they're up to that look at the patient overall the same way, each one. The reason the PICU has been successful - and why we're spreading its approach through the entire organization - is because the entire team has to stop, listen and answer the questions 'yes' or 'no.' It's not just a nurse going through a check-list in her mind."

Being part of the Hopkins system adds an additional layer of oversight to ensure quality and safety, explains Dr. Mueller. Every hospital in the system is held accountable to its numbers. And when agreed-upon goals are not reached, hospital leaders may have to meet with the Hopkins quality control board in Baltimore to explain why. If problems persist, then a meeting with the overall Hopkins board would take place to find a solution.

Another major initiative, driven by the nursing staff, is to reduce patient falls.

Ewing explains that in looking at the situation, the problem was particularly prevalent with oncology patients. "We have a lot of adolescents with cancer who are very independent - first, because they're teenagers, and it's the only control they have," she said. "They tend to want to get up by themselves. They want privacy on levels that the younger kids don't care about. So they tend to fall more often."

That prompted the nursing staff on 7 South to begin the "Save a Fall, Call" program, which has had a tangible impact on reducing the number of falls.

"We're very good nationally in our fall rate - we do an exceptional job," Ewing said. "We hadn't been sustaining it but now we are. So we were sitting in a meeting and somebody asked, 'Why have we been seeing the rates drop?' It turned out that 7 South, which had the highest rate of falls, was doing its intervention. They were doing things to educate and raise awareness, and involve the families on a much different level than anywhere else in the organization. When they dramatically decreased and eliminated their falls in most months, that affected the whole organization.

"The reality is that kids are going to fall. It's in their DNA. But we don't want falls with injuries - and that's our big focus."

That has led to the organization-wide roll out of the "Humpty Dumpty" falls program, coordinated by 12 different front-line leaders with the goal of raising awareness throughout All Children's. It's just one more measure at a hospital dedicated to ensuring quality and safety for every child in its care.