Goal of this HAI BSI QIA is a relative reduction in the pooled mean BSI rate by five percent (5%) from baseline (January-June 2016) to re-measure (January-June 2017) in targeted facilities.

Project Timeline (January 2017 - September 2017)

December 2016

The Network notified selected facilities of their participation in this activity.

January 2017

Kickoff Webinar: HAI BSI Reduction QIA webinar was held on January 4, 2017. The webinar introduced the project expectations and provided an overview on the use of a 5-Whys tool to identify Root Cause Analysis (RCAs).
5-Whys tool - This tool has recommended CDC interventions for facilities to select from based on their identified root cause(s) to implement as interventions. Network Staff provided further guidance about how to use the 5-Whys approach for evaluating the root cause of the infections identified during the first six months of 2016.
RCA Tool: Facilities were required to complete the RCA tool by January 18, 2017.
Poster: The Network provided the CDC's Put Together the Pieces to Prevent Infections in Dialysis Patients poster to launch QIA interventions. During the kick-off webinar the concept of using each piece as a focus area* for specified months was outlined.

*Network staff will trend what is reported related to the focus area each month.

February

February Collection Tool: facilities to report their successes, barriers, QAPI review for activities, and BSI rates.
Focus topic of the month: Catheter Care, Scrub the Hubs
Tools Provided: CDC Catheter Scrub-the-Hub Protocol, Catheter Exit Site Care Observation Tool, and the Catheter Exit Site Care Checklist.
Complete Audits: Facilities are required to complete 10 audits of each ( Scrub the Hub and Exit Site Care) and enter them into NHSN.
February HAI Learning and Action Network (LAN) meeting: Recording Slides

March – October

Using the monthly focus topics based on the CDC's Put Together the Pieces to Prevent Infections in Dialysis Patients poster each focus topic of the month resource will be sent out to facilities prior to the start of the implementation month as outlined below:
March – Reduce Catheters
Article on catheter reduction and a post-assessment for staff members to complete and submit to the Network for evaluation.
March Collection Tool (Deadline to submit)

April – Use Aseptic Technique
CDC Catheter Connection and Disconnection Observation Tool, Catheter Connection Checklist, and the Catheter Disconnection Checklist.
Facilities will be required to complete 10 audits using each tool and enter the results into NHSN.
 April Collection Tool

May – Perform Hand Hygiene, Change Gloves and Engage Patients
CDC Clean Hands Count Poster for Patients: Speak Up for Clean Hands.
Patient Infection Prevention Pocket Guide (English). The Spanish version will be provided upon request.
HAI LAN Conference Call/Webinar: May XX, 2017 2017

June – Disinfect the Dialysis Station
CDC Environmental Surface Disinfection in Dialysis Facilities handout and the Dialysis Station Routine Disinfection Observation Tool. Facilities will be required to complete 10 audits using each tool and enter the results into NHSN.

July – Track Infections
Educational resource highlighting the importance of tracking BSI rates.
Facilities will be required to complete a quiz and submit it to the Network for evaluation.

August –Follow Safe Injection Practices
CDC Injectable Medication Preparation-Administration Observation Tool and the Injectable Medication Preparation-Administration Checklist.
Facilities will be required to complete 10 audits using each tool and enter the results into NHSN.
HAI LAN conference call/webinar: August xx,2017
Focus on interventions taken from the Put Together the Pieces to Prevent Infections in Dialysis Patients poster distributed May - July i.e. Perform Hand Hygiene and Change Gloves, Disinfect the Dialysis Station and Track Infections.

September –Vaccinate Dialysis Staff and Patients
Educational resource highlighting the importance of vaccinating dialysis staff and patients as a precaution to reduce BSIs.
Facilities will be required to complete a quiz and submit it to the Network for evaluation.

October – 2017 QIA Wrap-up
Network staff will review NHSN reports to determine which facilities did not meet goal, and will continue into 2018 and those that met goal and will graduate out of the 2017 HAI BSI Reduction QIA.
Network staff will notify all facilities of their 2017 status upon the submission of the last facility report(s) due to the Network by October 15, 2017.

HAI Blood Stream Infection (BSI) QIA

For more information:

Project Lead
Jeanine Pilgrim
Quality Improvement Coordinator
(516) 209-5365
jpilgrim@nw2.esrd.net

Data Coordinator
John Cocchieri
Data Coordinator, Quality Improvement
(516) 209-5515
jcocchieri@nw2.esrd.net

Director
Carol Lyden, RN, BSN, MS, CNN
Director, Quality Improvement
(516) 209-5302
clyden@nw2.esrd.net