Network, ZList

Employees Collaborate to Decrease Number of Hospital-acquired Infections

Each year, the network sets goals for key result areas, targeting specific areas of opportunity. In 2018, one key result area was decreasing the number of hospital-acquired infections—a challenge to health care systems nationwide.

Year-end stats are in, and the network far exceeded its goal. The original target was a 10 percent reduction and a stretch goal of 15 percent reduction for the following: central line associated blood stream infection (CLABSI), catheter associated urinary tract infection (CAUTI), methicillin-resistant staphylococcus aureus (MRSA), C. difficile infections, surgical site infections (SSI) (colon deep), ABD, HYSTER DEEP, LAMI, FUS, TOTAL KNEE, TOTAL HIP, and C. SEC. By the end of 2018, the network more than doubled its stretch goal, decreasing the number of hospital-acquired infections by 32 percent.

This was achieved with the help of five task forces that focused on a specific infection: CLABSI, CAUTI, MRSA, C difficile infections, and SSI (colon deep).

Each taskforce developed improvement strategies that aimed to decrease the cases of their specific infection.


  • Standardized surveillance elements to monitor insertion and maintenance practices
  • Implemented vascular access consult
  • Improved RN education with dressing change hands-in competency
  • Updated documentation/Epic to support practices
  • Evaluated and partially implemented products to enhance practice


  • Implemented a nurse-driven protocol for removal of indwelling urinary catheters
  • Implemented a new external female urinary catheter


  • Started provodone iodine swabs
  • Created central database for hand hygiene/isolation compliance collection
  • Identified areas of opportunity for hand hygiene in facilities
  • Created reminder for peer-to-peer hand hygiene encouragement (Clean Hands Against Microorganisms Prevail)

C. diff

  • Implemented case review form
  • Updated order panel
  • Updated testing protocols to streamline diagnosis and protect integrity of samples
  • Added a Best Practice Alert to Epic in the Emergency Department to ask physicians if they would like to order a C. diff test if the patient displays warning signs


  • Initiated work on the Enhanced Recovery After Surgery (ERAS) as well as the Perioperative Surgical Home
February 4, 2019