Ready and able

Ascension’s successful infection prevention journey prepared us well for the COVID-19 pandemic

“In everything we do now, we do it as one Ascension. Never has that been more evident than during our response to the COVID-19 pandemic.” — JOSEPH R. IMPICCICHE, JD, MHA, PRESIDENT AND CHIEF

EXECUTIVE OFFICER, ASCENSION

As Ascension President and CEO Joe Impicciche noted in his “Welcome” column in the summer 2020 Good Day Ascension, the agility and innovation that characterized Ascension’s response to the COVID-19 pandemic were rooted in our journey as a unified ministry, as well as a 10-year effort involving clinicians and others from across the ministry, including representatives from Ascension Medical Group and the medical staff, nursing, infection preventionists (IPs), pharmacy, clinical professional development, The Resource Group, Medxcel and TouchPoint.

“Thanks to the tremendous work of our clinicians over the past decade-plus, we were well positioned to respond to the pandemic,” Joe said.

Alongside their colleagues on the medical staff and in nursing, Ascension IPs worked tirelessly to develop isolation precautions, discharge and home care instructions for all care settings, screening protocols, and guidelines for critical staffing workflows.

In collaboration with The Resource Group and vendor partners, they developed solutions for securing and maintaining supplies of needed personal protective equipment for front-line clinicians.

With support from clinical professional development associates, they provided ongoing education and training for front-line caregivers on managing patients with COVID-19.

The Infection Prevention team at Ascension St. John Hospital in Detroit at a conference before social-distancing and mask-wearing measures were put in place, from left (standing), Debi Hopfner, MSN, RN, CIC; Rebecca Battjes, MPH, CIC; and Jennifer Madigan, MPH, CIC; and (sitting), Michelle Flood, MSN, RN, CIC, FAPIC; and Tamika Anderson, MPH, MLS(ASCP)cm .

Like a majority of Ascension associates, IP team members worked long hours without time off from the beginning of the pandemic. A quote from pastor and author Robert H. Schuller became the IP team’s motto during its weekly calls: “Tough times pass, but tough people last.”

Each step in the evolution of Ascension’s infection prevention journey helped prepare the ministry for the unprecedented challenge of COVID-19.

STEP 1. Hospital Engagement Network In 2011, Ascension was one of just five healthcare systems selected to participate in the two-year CDC Partnership for

KEEPING OUR HEROES SAFE

Break the chain of infection

INFECTIOUS AGENT

Bacteria Viruses Fungi Parasites Diagnose and treat Antimicrobial stewardship

SUSCEPTIBLE HOST Any person, especially those receiving healthcare Immunize Treat underlying disease Health insurance coverage Educate patients

PORTAL OF ENTRY

Broken skin/incisions

Respiratory tract

Mucous membrane

Catheters and tubes Perform hand hygiene Wear PPE

Practice personal hygiene Apply first aid Remove catheters and tubes

CHAIN OF INFECTION

MODE OF TRANSMISSION Droplet/airborne Ingestion Contact (direct or indirect) Inhalation Perform hand hygiene Wear PPE Food safety RESERVOIR

Dirty surfaces and equipment People Water Animals/insects Soil (earth) Clean, disinfect, sterilize Follow infection prevention policies Pest control

PORTAL OF EXIT

Open wounds/skin Splatter of body fluids Aerosols Perform hand hygiene Wear PPE Control aerosols and splatter Practice respiratory etiquette Dispose of waste

Clean, disinfect, sterilize Isolate

Patients campaign as a Hospital Engagement Network (HEN); 69 of our hospitals piloted a broad set of initiatives designed to increase clinical quality and safety. In 2013, the Ascension HEN was one of six chosen for the Leading Edge Advanced Practice Topics (LEAPT) program, which addressed additional areas for improvement. By the close of the federal program, physicians, nurses, and allied health and quality professionals from 98 Ascension hospitals led various process improvement initiatives and were able to achieve significant results. Ascension evaluated the different infection prevention practices at its hospitals to identify opportunities for improvement. The evaluation results were published in the American Journal of Infection Control in 2013. In addition, Ascension was the first system to establish a process to improve the utilization of urinary catheters in emergency departments, which led to a reduction in placement of urinary catheters by one-third. The effort was adopted nationally by other systems and state hospital associations. During the HEN work, topics addressed included septic shock, Clostridium difficile (C. diff) infections, central line-associated bloodstream infections and antimicrobial stewardship. All these areas of focus are associated with a risk of significant morbidity, mortality and cost to hospitalized patients.

Mohamad G. Fakih, MD, MPH, FIDSA, FSHEA, Chief Quality Officer, Clinical & Network Services, Ascension, at the time served as the HEN Physician Advisor for Infection and supported the implementation of the efforts to reduce infection harm across the System. The successful implementation of evidence-based interventions for these conditions improved the quality and length of patients’ lives: 3,461 injuries, infections and adverse events avoided and 291 lives saved.

STEP 2. New clinical decision tool to support infection prevention To support optimizing the performance of the infection preventionist, clinical associates from across the ministry

came together to choose a new tool designed to streamline the clinical workflow around infection prevention. The result: implementation of Ascension’s Infection Control Surveillance and Medication Management (ICSMM), a web-based clinical monitoring and performance reporting system that automates previously manual processes and enhances collaboration among IPs, pharmacists, medical staff and nursing.

By pulling in patient data from multiple systems, including pharmacy, laboratory, radiology, surgery and microbiology, ICSMM provides decision support and facilitates early recognition of infections and real-time interventions that produce better patient outcomes.

STEP 3. The challenge of H1N1, Ebola and other emerging pathogens Ascension has faced multiple emerging pathogens and pandemics. In 2009, we addressed pandemic preparedness for H1N1, from personal protective equipment to vaccination and measures to reduce exposure. Over the years, infection preventionists addressed — with System support — their readiness to identify and mitigate emerging pathogens.

Another example of System-led support was meeting Ebola head-on in 2015. Our industry-leading work on establishing strategies to overcome the risks of this lethal pathogen reflected the strength of having System support. The preparedness efforts were summarized in a paper by Dr. Fakih; former Chief Quality, Safety and Nursing Officer Ann Hendrich, PhD; and then-Director of Clinical Excellence Michelle Heavens (now serving as Vice President, Operations, Clinical & Network Services): “Ebola as a Test for Emerging Pathogen Preparedness: The Critical Role of Health Systems in Ensuring Support” — in the June 2015 issue of Infection Control & Hospital Epidemiology.

STEP 4. National engagement on antimicrobial stewardship Also in 2015, due to the rising threat of antibiotic resistance resulting from unnecessary antibiotic use, antimicrobial stewardship in the United States became a national priority. The White House developed The National Strategy for Combating Antibiotic-resistant Bacteria (CARB), which called for hospitals and healthcare systems to implement antimicrobial stewardship programs (ASPs).

Ascension answered the call by establishing its first Center of Excellence (COE) for Antimicrobial Stewardship and Infection Prevention under Dr. Fakih’s leadership as Senior Medical

Associates at Ascension Medical Group Via Christi on Murdock Immediate Care in Wichita, Kansas, from left, Laura Black, PA; Tammy Munyon, PA (sitting); Tami Walock, RN; Kealan Pavlak, RN; Kelli Kirkbride, RN; and Chalese Araiza, RN.

Director. The Ascension COE implemented local ASPs at every hospital, co-led by a physician and pharmacist, to ensure compliance with evidence-based antimicrobial use, optimal testing for infections and standardized disease management processes.

System-wide antimicrobial stewardship efforts resulted in 8.2% reduction in FY16 in total systemic antibiotic use, including 40% reduction in the quinolone class of antibiotics. Ascension was recognized in the CDC’s “2017 Antibiotic Use in the United States Progress and Opportunities” as a model large system that had achieved swift progress in antimicrobial stewardship by implementing CDC core elements in its hospitals.

Ascension’s successful approach also was summarized in the paper “Health Systems Can Play a Pivotal Role in Supporting Antimicrobial Stewardship” in Clinical Infectious Diseases, in 2016. Key factors to success were leadership accountability, building a structure at the System and local levels, and having clear goals to achieve.

“Ascension’s approach is unique, especially with its implementation in a very large number of hospitals in 24 states, with diverse patient populations and variable hospital sizes, from very small to tertiary care teaching hospitals,” Dr. Fakih said at the time. “Our work is a true reflection of

the great teamwork among our physicians and pharmacists, which resulted in the positive patient care outcomes across our System, and our System-wide pioneering work is making a big difference to combat antimicrobial resistance.”

STEP 5. Focus on sepsis In 2016, new sepsis definitions and early warning signs were released and a task force with expertise in sepsis determined that healthcare practitioners required improved clinical prompts and diagnostic approaches to facilitate earlier identification. The elevated risk of mortality and the urgency of taking immediate action when treating all stages of sepsis eventually drove the development of the Surviving Sepsis campaign.

Ascension responded with renewed energy around early detection and implementation of standardized protocols for managing sepsis. In 2018 Ascension sponsored a formal awareness campaign that directly engaged more than 41,000 front-line caregivers.

For the first time in Ascension’s history, a campaign to enhance clinician awareness was paired with a public awareness campaign. Benefiting from input by Ascension’s national Person and Family Advisory Council, Ascension developed a robust suite of materials to engage patients and their family members in monitoring their loved ones for early signs of sepsis. The campaign resulted in 170 fewer deaths due to sepsis and an overall lower cost of care.

STEP 6: Preventing central line-associated bloodstream infections An initiative that ran parallel and in union with the sepsis campaign was standardization and optimization around our care of central lines in order to decrease central line bloodstream infections. This effort pulled together experts from across the System to standardize policy, education and products used for central lines. The result was a sustained and stunning 38% reduction in infection rates.

STEP 7: Mitigating the COVID-19 pandemic Fast-forward to 2020 and the advent of the novel coronavirus known as COVID-19. Building on the infrastructure, protocols and engagement levels already in place from previous efforts, as well as our Mission-inspired Transformation Design Team initiatives, Ascension caregivers were more ready than many industry peers for the surge that came over them.

BREAKING THE CHAIN

Now, the team has one more forward-looking project to complete: the launch of a comprehensive myLearning eModule, “Breaking the Chain of Infection.”

“Breaking the Chain of Infection” addresses what we as individuals and as a team can do to break the chain of infection to deliver healthcare in a safe and healthy workplace. This new, 15-minute module, intended for all associates, especially those in clinical roles, discusses the six common occurrences through which germs are passed from person to person and provides suggested practices by which each of us can break that chain of infection.

Lisa Sturm, MPH, CIC, FAPIC, Senior Director for Infection Prevention, Quality, Clinical & Network Services, Ascension, said she likes the concept “as it ties it all together and shows that the best approach to prevention of infections is the multipronged approach, and that there is typically never one ‘solution’ to prevent all infections.”

“We, as humans, have to outsmart them every step of the way,” she said. The ‘Chain’ is important because it visually shows how each step is important, whether that is removing their reservoir (e.g., cleaning/disinfection), blocking their route (e.g. face masks), or staying healthy ourselves (e.g., vaccines, etc.).

“I remain positive we can beat COVID-19 by consistently implementing all of the elements of the ‘Chain of Infection,’ and teaching our associates and patients these principles as well.”

Lisa noted that it was Amy Wilson, DNP, RN, CPHQ, Senior Vice President, Clinical Operations, Ascension, who encouraged her to develop the module after seeing a version produced by the Association for Professionals in Infection Control and Epidemiology on a slide Lisa presented.

“It does not matter if it is COVID, MRSA, VRE or C. diff; we owe it to our patients and our community to break the chain of infection, and it starts individually with each one of us,” Amy said. “And the truth is it was never about us; it has always been about protecting others and doing what’s best for our patients.”

“Front-line clinicians’ engagement as champions of the work has proven to be a key factor in Ascension’s success. Ascension’s agility and team-based approach to care let us produce some great work during the pandemic,” said Richard Fogel, MD, Chief Clinical Officer, Clinical & Network Services. “Now it’s up to us to sustain these efforts for the long term.”