Your Resource for HQIC Highlights and Learning Opportunities | Oct. 2021
Preventing CLABSI
Central line-associated bloodstream infections (CLABSIs) result in thousands of deaths each year and billions of dollars in added costs to the U.S. healthcare system.1 Experts agree that these infections are preventable when providers adhere to fundamental infection control principles, which includes the avoidance of indwelling device placement. If a central line is required, select an appropriate site (avoid femoral access), ensure insertion techniques meet best-practice recommendations, validate that maintenance expectations are being met, and prioritize prompt removal of unnecessary devices, whenever possible.

The guidance in The Flash section below explores device utilization at the facility and unit-level, explains how the National Healthcare Safety Network (NHSN) data can be used to target units with higher incidence of infection, and shares tools that assess factors that contribute to increases in CLABSI events.

HSAG HQIC certified infection preventionists are available to assist if you have any questions or need additional support. You can contact them through your Quality Advisor or email
It Figures—Data and Performance
View your hospital's CLABSI data by visiting the Quality Improvement Innovation Portal (QIIP) and selecting the Measure Category of HAI, then Device Associated.

The ratios in the table below indicate that, overall, HSAG HQIC CLABSI rates are moving in the wrong direction. This mirrors what the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS) are seeing on a national level. You can find tools and resources to assist your facility in The Flash section of this newsletter and plan to attend the October 19 HSAG HQIC webinar, "CLABSI Reduction Efforts During the COVID-19 Pandemic." You may also reach out to your HSAG HQIC Quality Advisor or email for further assistance.
The Flash: Resources
CLABSI Tools and Resources
HSAG HQIC, the CDC, and CMS offer several CLABSI tools to assist your hospital.
HSAG HQIC Document: Targeted Assessment for Prevention (TAP) Strategy
Download the single-page TAP Strategy overview to get started on using data for action.
Webinar: NHSN Acute Care Mapping and Leveraging the TAP Strategy
This presentation for HSAG HQIC covers details on using NHSN. View the webinar recording, slides, and NHSN checklist.
Resource: CLABSI TAP Implementation Guide
This guide includes links to example resources for healthcare-associated infection (HAI) prevention.
Resource: NHSN SUR—A Guide to the SUR
This guide for SUR, the primary summary measure used by NHSN to compare device utilization, explains how to calculate and interpret SURs in NHSN, with specifics for central line, urinary catheter, and ventilator.
Education: The Standards, Approaches, and Tactics for Infection Control & Prevention (StAT) Learning Series for Hospital Clinical Staff and Leaders
Released by CMS, this training is designed for hospital clinical staff, infection control leaders, and hospital administrators.
Critical Communication
Quality During Crisis
Hospitals have historically faced situations, such as hurricanes, fires, and mass traumas, necessitating implementation of crisis standards of care. These catastrophic events were typically infrequent and localized. However, the current COVID-19 pandemic has led to a national shortage of inpatient beds, critical supplies, and frontline staffing—causing wide-spread, prolonged use of crisis standards of care. Analysis of patient outcomes measures during the pandemic are beginning to reveal significant increases in HAIs, medical device-related pressure injuries, and falls.

To keep patients safe, even during crisis standards of care, hospitals must prioritize and commit to maintaining key patient safety best practices. This template is designed to assist hospitals in identifying and communicating these practices to maintain and ensure patient safety, even during times of crisis.
Events and Education
HSAG HQIC Quality and Safety Series
The Quality and Safety Series is designed to assist your organization in its quality improvement (QI) journey, from planning and preparation to sustaining gains.

Offered on the 2nd and 4th Tuesdays of the month, these 30-minute-or-less "quickinars" are bite-size learning presentations that review the key skills necessary for you to function in the QI role or for other staff members who are participating in a QI initiative. The quickinars are intended as a basic foundation for the novice or as a skills refresher for the expert.
Quality and Safety Series 7: Cause-and-Effect (Fishbone) Diagramming
Tuesday, October 12, 2021, 2–2:30 p.m. ET
Quality and Safety Series 8: Strengths, Weaknesses, Opportunities, Threats (SWOT) Analysis
Tuesday, October 26, 2021, 2–2:30 p.m. ET
Disparities: Using Area Deprivation Index (ADI) as a Predictor of Readmission
Thursday, October 14, 2021, 2–3 p.m. ET
Learning Objectives:
  • Define and understand social determinants of health (SDOH).
  • Examine the burden of social determinants on healthcare quality.
  • Recognize how cultural and linguistic differences can manifest as SDOH.
  • Discuss possible interventions to address SDOH, including involving patients and their families in decisions during transitions of care. 

Amber E. Johnson, MD, MS, MBA, FACC

One continuing education unit available.*
CLABSI Reduction Efforts During the COVID-19 Pandemic
Tuesday, October 19, 2021, 2–3 p.m. ET
Learning Objectives:
  • Develop a comprehensive central-line bundle rounding tool to help prevent the incidence of CLABSI.
  • Illustrate ways to keep the focus on CLABSI prevention when there are competing priorities.
  • Outline the quality turnaround framework that was used to identify, plan, and correct quality concerns within a healthcare facility.
  • Evaluate the work of a team using the Plus/Delta debrief model.

Caroline Gill Rifold, RN, BSN

One continuing education unit available.*
Using Medication-Assisted Treatment (MAT) in the Emergency Department (ED)
Tuesday, November 2, 2021, 2–3 p.m. ET
Learning Objectives:
  • Review the impact of the opioid crisis and patients with opioid use disorder (OUD) on the ED.
  • Discuss the importance of beginning MAT in the ED.
  • Identify the evidence-based framework of the California Bridge program used to lower barriers of implementing MAT in the ED for patients with OUD.

Andrew A. Herring, MD

One continuing education unit available.*
HSAG Opioid Stewardship Program
Join HSAG in an action-based “quickinar” series to provide tactics, strategies, and information needed for a successful opioid stewardship program (OSP).

The 11 opioid stewardship quickinars in the series are short, 30-minute webinar presentations beginning October 21 and running until May 2022.
October Topics:
OSP Quickinar Kickoff: Introduction to Opioid Stewardship and Quickinar Format  
Thursday, October 21, 2021, 1:30 p.m. ET
OSP Assessment Overview
Thursday, October 28, 2021, 1:30 p.m. ET
World Thrombosis Day Webinar
Tuesday, October 12, 2021, 11 a.m. ET
Co-hosted by the CDC and the International Society on Thrombosis and Haemostasis World Thrombosis Day campaign.

  • General Thromboprophylaxis (Alex Spyropoulos, MD, FACP, FCCP, FRCPC)
  • Thromboprophylaxis in Special Cases (Prof. Beverley Hunt, MD, OBE)
  • Thromboprophylaxis and Cancer (Alok A. Khorana, MD, FACP, FASCO)
  • Q&A Session (Moderated by Claire McLintock, MD)
*Continuing Education: Health Services Advisory Group, Inc., is the CE provider for this event. Provider approved by the California Board of Registered Nursing, Provider Number 16578, for 1 contact hour. There is no charge to attend this event. You must attend the live event to earn CE credit.
This material was prepared by Health Services Advisory Group (HSAG), a Hospital Quality Improvement Contractor (HQIC) under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication No ZS-HQIC-XT-10062021-01