QAPI in Action: Pilot Leads to Infection Control and Prevention Success

As one of 20 facilities chosen to participate in the Clostridium difficile (CDiff) Reporting and Reduction Project pilot project beginning in July 2016, Aberdeen Health and Rehab in South Dakota has been successful in implementing effective infection control and prevention practices. What began as an invitation from the Great Plains Quality Innovation Network (QIN) and the South Dakota Department of Health (SD DOH) Health Acquired Infections (HAI) Program to participate in a pilot project led to the best practice of data review to identify high-impact change.

Administrator Megan Kleinsasser commented on the pilot project success, “We incorporated reviewing our infection rate and our CASPER quality measure report in our monthly QAPI meetings.  It is through our QAPI meetings that we prioritize improvement areas for performance improvement projects.  One of the areas of improvement we are working on is reducing CDiff infections in our facility.”

The national CDiff pilot project has five goals:

  1. Increase national CDiff surveillance data from 235 nursing homes currently reporting to 2300 nursing homes consistently reporting into CDC NHSN database
  2. Determine state/national CDiff baselines for nursing homes
  3. Once baselines are determined, identify reduction goals and implement interventions
  4. National and state CDI rates will show reduction rates by December 2018
  5. Nursing homes will receive education and tools on NHSN, CDiff principles and management and antibiotic stewardship

As of November 2016, Aberdeen Health and Rehab has been providing monthly reporting of CDiff infection data to the Centers for the Disease Control and Prevention’s (CDC) national database, National Healthcare Safety Network (NHSN).

“It was a difficult start jumping through all the technical requirements to allow us to report, but reporting has become a very simple routine now. Our director of nursing is well versed in surveillance of our infections and has included the staff in our infection control and prevention systems,” Kleinsasser stated.

The team approach, including staff and residents, resulted in additional benefits, including a site visit by a certified infection preventionist who offered valuable insight on best practices and areas of improvement.

“We have seen a decrease in CDiff infections and feel better prepared and confident in our infection control and prevention program,” shared Kleinsasser, who has engaged staff and is looking to duplicate their success with antibiotic stewardship.

She intends to participate in the SD DOH, HAI Program’s Antibiotic Consumption Pilot Project for nursing homes, which aims to increase understanding of antibiotic usage, identify specific antibiotic stewardship improvement areas and also aligns perfectly with the new CMS regulations regarding antibiotic stewardship.

Kleinsasser reflected, “My advice to nursing home colleagues is to take advantage of pilot projects when the opportunity presents itself.  Pilot projects typically provide extra education, resources and technical assistance that otherwise might not be so readily available.  As an administrator, I feel our facility is better prepared and equipped to meet the infection control and prevention standards in long-term care today.”