Along with the Centers for Medicare and Medicaid Services’ mandated reporting of healthcare-associated infection (HAI) rates and multidrug-resistant organism (MDRO) events, there are state mandates that expand the surveillance requirements of infection preventionists (IPs). Some of these mandates include process measures for tracking compliance with evidence-based best practices for the prevention of HAIs. The methods for collecting data on these process measures include observations, manual collection forms completed by the care providers and electronic documentation.
An example of a state with mandated process measures is California, where public reporting includes compliance with an insertion checklist (Centers for Disease Control central line insertion practices, or CLIP, form) and a law that requires physicians to document the necessity of continuing a central line each day. In a recent paper, Quan et al.1 describes an integrated electronic health record (EHR) solution created by her team at the University of California Irvine Health to promote completion of the CLIP form, track central line days and identification of new line insertions and facilitate daily documentation of line necessity.
Initial efforts to comply with the state mandate for CLIP form documentation by relying on clinician initiative had limited success. The EHR solution created an electronic procedure note with checkboxes to confirm that all elements of maximal sterile precautions were followed and generated a narrative procedure note that could be edited by the inserter. For capture of line days and new insertions, electronic nursing documentation of the number of patients with a central line for every shift was replaced with more comprehensive e-flowsheets to allow for documentation of each line by insertion site, type of catheter and assessment of skin integrity. For new line insertions, the name of the inserter and the insertion unit were collected to allow for clinician-specific follow-up for CLIP forms. Daily documentation of line necessity was transitioned from paper mechanisms to e-progress notes that contained information from the electronic nursing flowsheet documentation for each central line.
The EHR solutions significantly increased CLIP form submission, increased the capture of line days by 35%, allowed for automated calculation of line dwell-times, and facilitated nearly 100% compliance with documentation of daily line necessity.
The authors cited 3 main reasons for the success of these EHR solutions: 1) they were built within the nursing and physician documentation to streamline workflow, 2) they required completion and 3) they provided feedback to the line inserters and nurses. The authors emphasize that the solutions increased the accuracy of line day capture, which decreased CLABSI rates, and significantly improved compliance with best practices for line insertion.
The monitoring of compliance with evidence-based practices that have proven efficacy for reducing HAIs is becoming important for healthcare organizations, not only due to regulatory requirements, but for identifying performance improvement initiatives to reduce HAI rates. Some infection prevention leaders are proposing process measures as new quality metrics. The incorporation of electronic documentation mechanisms into the daily practice activities of providers promotes compliance and the accuracy and efficiency of data collection.
1Quan KA, Cousins SM, Porter DD, O’Brien M et al. Electronic health record solutions to reduce central line-associated bloodstream infections by enhancing documentation of central line insertion practices, line days, and daily line necessity. Am J Infect Control 44 (2016): 438-43.