Patient Safety: Healthcare- Associated Infection

Quality Improvement Activities

For questions and comments, please contact:
Sarah Keehner,
Quality Improvement Director
(203) 285-1214

Heather Camilleri, CCHT
Quality Improvement Coordinator
(203) 285-1224
QIA Facilities:

List of facilities

participating in the Bloodstream Reduction QIA


List of facilities  participating in Long Term Catheter Reduction QIA


For Facilities involved in LTC reduction QIA.
Please be aware of the dates associated with each activity.

Provide: Input Key Facility Staff Contact Information into the Patient Safety: Long Term Catheter Reduction   by Friday, March 2, 2018. One contact form per facility. 

DISCUSS: Talk with dialysis team members and patients to identify root causes of barriers decreasing LTC use

Complete: The 5 Why's RCA tool by Friday, March 9, 2018 to determine root causes for a minimum of two identified barriers. 
Resources :
The CDC has launched the Clean Hands Count campaign to promote proper hand hygiene for both patients and provides. Listed below are links for poster, fact sheets and training materials for both patients and staff. 


Please take a moment to give us feedback regarding the resources below. Let us know if you believe these will be helpful in the facility and if patients utilize them.
Resource Assessment

Blood Stream Reduction
Dear Provider,
Thank you to all the facilities that have completed the 5- Why's RCA tool provided in the project inclusion newsletter. If you have not completed and submitted the RCA tool please do so by the end of February.
The top identified barriers that the Network would like facilities to focus on during the month of  March are: 
  1. Facilities being  held responsible for all positive blood  cultures 
  2. Nurses are rushed and not preforming proper hand hygiene 
  3. Patient personal hygiene  
  4. Long Term Catheter rates greater than 15%
Each facility should have at least one staff member enroll and complete all training available in the National Healthcare Safety Network (NHSN). This will ensure that all bloodstream infection and any event of puss, redness or swelling is accurately documented in NHSN. Facilities should enter data in NHSN on a monthly basis. 
The Centers for Disease and Control and Prevention states that the nation is currently experience one of worst cold and flu season in a decade. Flu season usually peaks sometime in March but can still spread easily among immune compromised dialysis patients. Practicing good  hand hygiene is the best way to prevent the spread of disease. The CDC estimates the proper hand hygiene with soap and water could:
  • Reduce diarrheal disease-associated deaths by 50%
  • Reduce the risk of a respiratory infection by 16%    
During March all facilities involved in the Patient Safety Quality Improvement Activity (QIA) Project must use the CDC hand hygiene audit tool to preform a minimum of 30 hand hygiene audits. The facility can audit any staff member that enters and exists the treatment area, administrators, social workers and dietician should all be practicing good hand hygiene as well. Along with the patient, who must also wash their hands when entering and existing the treatment area. Any staff member can preform these audits.  All audits must be entered in to NHSN by the end of the March.
Project Activities
  • Implement CDC core interventions
  • Complete NHSN training
  • Partner with the CDC Making Dialysis Safer Coalition
  • Appoint a patient ambassador to help with patient audits
Long Term Catheter Reduction
Facilities that had a 15% LTC in use rate as of June 2017 are required to work with the Network to reduce the facilities use of LTC by at least 2% but July 2018. Facilities participating in this project will be asked to complete a Key contact form once a project lead has been established. Each facility will also be required to perform a root cause analysis on why they continue to have high catheter rates.
Project Activities
  • Designate a vascular access coordinator
  • Complete a Key Contact form for the facility
  • Complete the 5- Why's RCA tool to identify barriers associated with LTC removal
Health Information Exchange  

A Health Information Exchange (HIE) platform is vital for  communication between the dialysis facilities and the hospital. Facilities are able to see when blood cultures are being drawn on their patients and the results of the culture before the patient returns to the facilities. If a patient test positive for a BSI after being hospitalized for more than 48 hours then the hospital is then required to claim the BSI and the burden does not fall back onto facilities. For this reason alone dialysis facilities should actively enroll in a HIE.

Independent facilities can enroll in an HIE on their own, but large dialysis organizations should speak with their corporations about the process of enrolling. 

The Network has chosen Mass HIway as the HIE for facilities in this project to enroll in. For more information click the following link to get to Mass HIway Website. 

We Want to Hear from YOU!
Please contact the Quality Improvement Department if you have questions, comments, or specific barriers that you would like to address.  Let us know if you have identified any best practices that you would like to share with the community.