On this page you will find a selection of data showing the clinical outcomes of certain important areas of patient care, which is publicly reported to appropriate regulatory bodies.
The single most important way that we prevent the spread of infection is by the use of hand hygiene, which is the cleaning of the hands with either soap and water or an alcohol-based agent. We measure hand hygiene compliance in all clinical areas. Note that different hospitals measure hand hygiene performance differently, so that rates may not be directly comparable. BID–Needham's hand hygiene performance rate is calculated by measuring the direct observation of Hand Hygiene Compliance throughout the Hospital. Below are BID–Needham's most recent Hand Hygiene Compliance results.
Hand Hygiene Compliance:January–December 2013
*There are no national benchmarks for hand hygiene. BID–Needham's current internal goal is be above 90% due to potential inaccuracies in the measurement system. This goal will be increased to 100% over time.
BID–Needham constantly strives to improve our performance with Hand Hygiene Compliance. Specific steps we are taking include
- Making sure that soap and water, as well as alcohol-based hand cleaners are easily accessible
- Providing education to our employees
- Feedback to all units
Ventilator Associated Pneumonia
Ventilator Associated Pneumonia (VAP) is a serious lung infection that can develop in patients who are put on ventilators (a machine to help them breathe). As part of our dedicated infection prevention and monitoring efforts, we measure the rate of patients with healthcare-associated VAP infections in our Intensive Care Unit. Hospitals use different ways to calculate rates. We calculate our rates using 1000 catheter days as the denominator.
BID–Needham has maintained a rate of zero VAP infections since June 2011.
Doctors, nurses, and respiratory therapists can help to prevent VAP by implementing what is referred to by the Institute for Healthcare Improvement (IHI) as the "Ventilator Bundle". The Ventilator Bundle is a series of interventions implemented together for patients on ventilators. This is aimed at achieving considerably better patient outcomes than when such interventions are implemented on an individual basis. As such, in order to sustain our rate of zero VAP infections, our Intensive Care patients on ventilators receive the Ventilator Bundle.
The Ventilator Bundle includes
- Elevation of the head of the bed
- Daily removal of sedation medication
- Daily assessment of a patients' readiness to breathe off the ventilator.
- Medication to prevent stomach ulcers
- Preventing blood clots when a patient is bedridden
Central Line Bloodstream Infections
Central line-associated bloodstream infections (CLBSIs) continue to be one of the most deadly and costly hospital-associated infections in the United States. A central line is a device inserted directly into a major blood vessel to allow delivery of medications and fluids. Patients in ICUs may also have these lines placed to monitor their condition. Sometimes central lines can become infected. These infections can be very serious because they can lead to damage of other vital organs. As part of our dedicated infection prevention and monitoring efforts, we measure the rate of patients with CLBSIs in our Intensive Care Unit. Hospitals use different ways to calculate rates. We calculate our rates using 1000 catheter days as the denominator.
BID–Needham has maintained a rate of zero CLBSI infections since March 2008.
In order to sustain our rate of zero CLBSI infections, we take preventative measures to minimize risk of these infections by providing a special standardized insertion kit with a checklist attached, by standardizing the insertion and care of central lines, and by utilizing special strategies referred to by the IHI as the "CLBSI Bundle."
The key components of the IHI CLBSI Bundle are
- Hand Hygiene
- Maximal Barrier Precautions Upon Insertion
- Chlorhexidine Skin Antisepsis
- Optimal Catheter Site Selection, with Avoidance of the Femoral Vein for Central Venous Access in Adult Patients
- Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines
Medicare Readmissions within 30 Days
The Centers for Medicare and Medicaid (CMS) sets goal for hospitals with respect to readmission to the hospital of Medicare patients within 30 days of a prior hospitalization. Per CMS, hospitals must strive to fall below 16% readmission rate. BID–Needham met this target, achieving a 9.7% readmission rate for Medicare patients. Analysis of medical readmissions between April 2013 and December 2013 revealed the top two diagnoses/reasons for readmission were sepsis and heart failure. Action plans to address these areas are in development.
The Healthcare Quality Department tracks patient care issues related to medication and tries to identify trends in order to develop systematic solutions where possible. Over the last six months, we have tracked events related to medication safety and determined an error rate of 1.7%. This was calculated based on the number of medication events over the total number of medications dispensed. None of these events caused reportable harm. It is important to note that there are no national benchmarks set for medication errors. The following Medication Safety Initiatives are in process to improve our medication-related care
- A Safe Quiet Zone sign was placed on the door of the Medication Room and a red tape was placed on the floor signifying a Red Zone in front of the Pyxis (automated medication management system) as a visual so that nurses are not interrupted when getting medications. In addition, restocking of Pyxis is done earlier in the day to avoid disruptions.
- The maximum dose of Tylenol was reduced to 3gm per rolling 24-hour period because of our (aged) patient population. A program in Meditech (our electronic medical record-management system) now tracks cumulative 24-hour Tylenol dosing. In addition, a general maximum daily dose of numerous medications was initiated (i.e. benzodiazepines)
- Electronic medication administration (eMAR) went live November 2013 and has reduced the number of transcription errors, incorrect labels, and interpretation errors.
- The Bedside Medical Verification (BMV) implementation project was implemented in May 2014. This program uses a bar code system to positively identify the patient and connects the patient to the medication prior to dispensing, therefore preventing wrong medication administration.
Stroke Prevention and Management Efforts
In a collaborative effort with the Needham Fire Department, BID–Needham spearheaded an initiative aimed at improving stroke outcomes through reducing wait times for diagnostic testing for stroke patients. All code strokes are called in by Emergency Medical Services (EMS) on the way to the Emergency Department (ED). When patients arrive, they go straight to Radiology for a CAT Scan (CT) on the EMS stretcher after being quickly evaluated by an ED Attending Physician. This process has cut door-to-CT times from 50 minutes to 8 minutes for all patients arriving with concerning signs and symptoms of a stroke via Needham Fire Department. This has cut the door-to-CT time from 39 minutes to 12 minutes for those patients with strong suspicion of a stroke as determined by Needham Fire Department before reaching the ED.
Due to the success of this initiative, BID–Needham has implemented this process for all ambulance companies that service its patient population.
Further, over the past several years, BID–Needham has been consistently recognized for excellence in caring for patients suffering from strokes.