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Hospital Quality Improvement Projects

Community Acquired Pneumonia

Project Name: Community Acquired Pneumonia Core Measure Performance Improvement

Time Frame: January 2013-present

Background: Improving the care of patients with community-acquired pneumonia, has been the focus of healthcare organizations across the country for many years. Efforts to improve outcomes for patients with pneumonia are important because pneumonia, along with influenza, is the 9th leading cause of death in the United States. Community-Acquired Pneumonia affects approximately 4 million Americans each year, accounting for more than 1 million hospital discharges, and more than 50,000 deaths. (Murphy and Xu) According to National Hospital Discharge Survey data, there were 1.1 million hospital discharges and 5.8 million days of care for patients with pneumonia in 2010. In addition to the clinical impact, the economic burden associated with CAP is substantial at greater than $17 billion annually. Despite the availability of recommended treatment guidelines, CAP continues to present a significant burden on adults. Furthermore, given the aging population clinicians can expect to encounter an increasing number of adult patients with CAP. (Stanton)

Core measure performance is critical for Rutland Regional Medical Center for several reasons:

  • Measures are nationally recognized, evidence-based best practices;
  • We are committed to provide our patients with those best practices;
  • Performance is publicly reported;
  • Excellent performance is one measure of our Vision to be the Best Healthcare System in New England;
  • Performance is tied to Medicare reimbursement through the Value-Based Purchasing Program

Currently, our CAP core measure compliance is inconsistent fluctuating between the 10th and 95th percentile as measured against the MIDAS national database of over 500 hospitals. One of our organization-wide Quality Goals is to improve our core measure compliance to the 50th percentile or better by the end of the fiscal year and to the 75th percentile or better within 5 years. Our ultimate goal is to be 100% compliant with all measures.

Project Aim:Our organization-wide quality goal is to improve compliance with core measure performance to the 50th percentile or better by the end of fiscal year 2013. Our ultimate goal is to be 100% compliant with all measures. 

Description: Beginning in January, the Performance Improvement department led a cadre of teams to improve performance on all core measures, including Community Acquired Pneumonia.  The improvement team for CAP included physicians, pharmacy, nursing and performance improvement.  Using Rapid Problem Solving methods the team analyzed and identified opportunities and implemented solutions to improve care.  Analysis identified timing of blood cultures and antibiotic selection as the greatest opportunities for improvement; therefore, interventions were targeted to improve these functions.  


  1. Provided education for all ED staff regarding the timing of blood cultures and initiation of antibiotics;
  2. Developed visual aids to prompt appropriate timing of blood cultures;
  3. Developed a Community Acquired Pneumonia Antibiotic Selection Algorithm based on IDS guidelines to facilitate appropriate antibiotic selection  (Mandell, Wunderink and Anzueto) 


  1. Core PN3b – Blood culture in ED prior to initial antibiotic
  2. Core PN6 – Antibiotic selection for ICU/non-ICU patients
  3. Core Pneumonia All-or-None Bundle

Results: At the onset of this project, our compliance with Community Acquired Pneumonia core measures was variable. Performance measures for blood culture timing and antibiotic selection ranged from 89 to 100 percent. By May 2013, our team completed education around blood culture timing and the CAP Antibiotic Selection Algorithm was complete. The final algorithm was presented through the sections of Emergency Medicine and Hospitalists. Following implementation, immediate improvement was noted.  To date our measures reveal 100% compliance without variation.        


Community Pneumonia Graph


Contact information:           

Denise Simpson, MSA, CIC, CPHQ
Performance Improvement Manager   

Works Cited

Mandell, LA, et al. "Infectious Diseases Society of American/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults ." Supplement Article. 2007.

Murphy, SL and J. Kochanek, DK Xu. "Deaths: Final Data for 2010." National Vital Statistics Reports . 2013.

Stanton, MW. "Improving treatment decisions for patients with community-acquired pneumonia." n.d.

Congestive Heart Failure (CHF) Readmissions Reduction

Project Name:

Congestive Heart Failure (CHF) Readmissions Reduction

Timeframe: June 2011-Present

Description: Hospital readmission rates are under close scrutiny by payers and policymakers including the federal government because of the high costs involved (and therefore high potential for savings). In addition to the costs, patient readmission rates are increasingly being used to measure quality of care, are being publicly reported, and soon will be directly tied to some of the financial programs being put into place as part of national healthcare reform. Many patient readmissions to hospitals represent good care such as those that are part of a course of treatment planned in advance by the patient and their physician, or those that are done in response to trauma or a sudden acute illness unrelated to the patient’s original hospital admission. However, sometimes hospital readmissions are avoidable and that is the focus of this Team: to find ways to reduce avoidable hospital readmissions for patients with congestive heart failure for a minimum of 30 days after their hospital stay.

Background: In 2011, the Vermont Association of Hospitals & Health Systems (VAHHS) asked all Vermont hospitals to come together and work on a common goal; to collaborate as one group to share ideas, successes, and best practices so that all organizations and our patients could benefit from each other’s experience. The topic chosen was to reduce avoidable 30-day readmission rates for patients with congestive heart failure (CHF). CHF is a long-term (chronic) condition in which the heart can no longer pump enough oxygen-rich blood out to the rest of the body, especially when the patient exercises or is active. It may affect on the right side or only the left side of the heart, but more often both sides of the heart are involved. As the heart’s ability to pump blood is lost, the blood may back up in other areas of the body and fluid builds up in the lungs, liver, gastrointestinal tract, and the arms and legs. This is congestive heart failure.

Most Vermont hospitals, including Rutland Regional Medical Center (RRMC), agreed to participate in the state-wide collaborative. As RRMC began to analyze its 30-day readmissions for CHF patients, currently averaging between 20-24%, we quickly realized that we needed to involve other more regional organizations and physicians in our improvement efforts. We invited the three local skilled nursing facilities, two home health agencies, Cardiologists, primary care physicians, office coordinators, and others to partner with RRMC to improve the care coordination amongst all of our organizations for the benefit of our patients. These other organizations agreed to participate and we have been working together as a collaborative with the shared goal of reducing avoidable admissions for these patients. Our analysis of our CHF patients being readmitted, along with a literature search and best practice ideas sharing from other organizations working on CHF, led us to the establish of the project goals- the areas where we felt we could make the biggest impact to help our patients.

Project Goals:
1. Complete analysis of all CHF patient 30-day readmissions from 2009-2011 to identify opportunities for improvement to reduce avoidable admissions.
2. To collaborate with other area health care providers and facilities to develop communication processes that cross organizational boundaries for the benefit of improving patient care and coordination.
3. To implement evidence based best practices when evaluated as appropriate for our hospital, community and patient population.
4. Overall measure to be used to gauge success on the project: Medicare 30-day all cause readmission rate. Current monthly rate averages in the 20-24% range.

1. Jointly develop standardized clinical protocol for managing CHF patients in the community setting and determining the clinical criteria to be used for sending a patient to the hospital.
2. Improve the coordination and communication between the hospital, skilled nursing facilities, home health agencies, and physician practices so that when patients are admitted and then discharged from the hospital to another organization, we improve the ‘transitions of care’.
3. Evaluate the potential for more patients to receive Home Health if they are eligible and would benefit from those services.
4. Develop a standard of the clinical terms and advice given to patients as they are treated and cared for by/at the different facilities participating in this CHF collaborative. Develop a standard, effective patient journal to empower and encourage the patients to better self-manage.
5. Provide a follow up telephone call to each CHF patient within 1-3 days after hospital discharge. This will be done to help answer any questions the patient may have, and to help ensure the patient understands and follows their discharge plans including getting prescriptions filled, dietary & other behavioral modifications, regular weight checks, follow up appointments with their physician and similar activities.
6. Ensure the patient has a good understanding and an accurate list of the medications that he/she is taking. This list is also shared with others caring for the patients to ensure medication safety.
7. For those patients with advanced stages of CHF, it may be beneficial to have palliative care discussion and advice with a nurse or patient’s doctor so that the patient’s wishes and best interests are known and factored into the care decision making practices.

Measures: Congestive Heart Failure Readmission Rates (with 30 days).

Results: In FY 2013, the readmission rate for heart failure patients over the age of 64 years in 2013 was 17.6%.


Contact for project: Darren Childs, Director, Quality Improvement Services, Rutland Regional Medical Center, 160 Allen Street, Rutland, VT 05701. Telephone 802.747.3704.

Perioperative Eradication of Staphylococcus aureus

Project Name: Perioperative Eradication of Staphylococcus aureus (S. aureus)

Project Aim: To eradicate perioperative S. aureus colonization in order to reduce the risk of surgical site infections for patients undergoing elective total joint procedures.

Time Frame:   December 2009-ongoing

Background: Surgical Site Infections (SSI) are an infrequent but serious complication of total joint arthroplasty. According to National Healthcare Safety Network, infection rates for knee arthroplasty range from 0.58 to 1.6 percent and hip arthroplasty infection rates are between 0.67 and 2.4 percent. Orthopaedic surgical site infections cause substantial morbidity, prolong hospital stay, lead to readmission and increase healthcare costs. Carriers of S. aureus are two to nine times more likely to acquire S. aureus surgical site infections than non carriers (Spencer, M. 2008). Thus, interventions designed to eradicate nasal carriage preoperatively will decrease surgical site infections. 

Description: RRMC and Vermont Orthopaedic Clinic have implemented a program to eradicate S. aureus colonization in patients undergoing elective total joint procedures. This was the first eradication program of its kind in the State of Vermont. The process is managed during the perioperative period by the surgeon, case manager, pre-op nurses, and infection prevention nurse. 

The methods used are adapted from New England Baptist Hospital (NEBH) in Boston who performs over 6000 orthopaedic procedures each year.  Following implementation, NEBH reported 78% eradication of MRSA prior to surgery and demonstrated a 50% reduction in surgical site infections due to S. aureus.4

All joint replacement patients are provided five 4% Chlorhexidine sponges and instructed on usage. The eradication protocol we follow identifies the presence of S. aureus for both the Methicillin Sensitive Staphylococcus aureus (MSSA) as well as Methicillin Resistant Staphylococcus aureus (MRSA) by nares culture. Patients with S. aureus receive a five day treatment course of Mupirocin antibiotic ointment. They also receive additional preoperative antibiotic prophylaxis with Vancomycin, or another antibiotic with activity againt MRSA.

The surgical site infection rate for orthopaedic clean cases at Rutland Regional Medical Center is low. Our clean case infection rate through the 3rd quarter of 2013 is 0.3% which is lower than the comparative rate. This project is part of our commitment to work toward zero infections. 


% of Patients Undergoing Elective Joint Replacement with MRSA colonization

% of Patients Undergoing Elective Joint Replacement with MSSA colonization

# of successful preoperative eradication of MRSA colonization

Surgical Site Infection rate – Total Hip, Total Knee


Since 2009, our perioperative S. eradication program has screened 1576 patients. We measure success of the eradication program in the following ways:

  • Perioperative eradication in MRSA positive patients
  • Reduction in Surgical Site Infections

Following this protocol we have successfully eradicated MRSA from  88% of our patients during the perioperative period. Of the 42 positive patients, 32 had follow-up screens prior to surgery and 28 demonstrated eradication. Ten patients were eliminated from the study due to: inability to follow protocol, insufficient time prior to surgery, or cancellation of surgery.


Staphylococcus screening and Infections December 2009 – August 2013


Number of Patients

Number of Infections


All patients cultured




MRSA Identified




MRSA identified and eradicated




MRSA identified, not eradicated




MRSA Identified,

Unable to complete protocol




MSSA Identified



MSSA - 3,

Other - 1

No Staph aureus Identified



MRSA - 4

MSSA - 5

Other - 2


Hip and Knee Arthoplasty Infection Rates

Hip and Knee 

Contact information:           

Nancy Meszaros, BSN, RN, CIC

Infection Prevention


Denise Simpson, MSA, CIC, CPHQ

Performance Improvement



Institute for Healthcare Improvement (2013) Preventing infection after hip and knee replacements (Reprinted from Healthcare Executive) retrieved from

Sept/Oct 2013 68-70

Nalini Rao MD, FACP, PSHEA, Barbara Cannella RN, Lawrence S. Crossett MD, A.J. Yates Jr MD, Richard McGough III MD. "A Preoperative Decolonization Protocol for Staphylococcus aureus Prevents Orthopaedic Infections." Clin Orthop Relat Res (2008): 1343-1348.

NHSN annual report; Data summary for 2006-2008. American Journal of Infection Control 2009; 37:783-805 retrieved from

Spencer, M.,  Gulcyznski, D., Davidson, S., Richmond, J., at New England Baptist Hospital, Boston, Mass.   Abstract 118 “Eradication of Methicillin Sensitive Staphylococcus aureus and Methicillin Resistant Staphylococcus aureus Before Orthopedic Surgery.”  18th Annual Scientific Meeting of the Society for Healthcare Epidemiology of America (SHEA), April 5-8, 2008

phoneCall 802.775.7111 for more information about a service or to make an appointment.

Reducing Hospital Admissions for Congestive Heart Failure Patients

A collaborative of health care providers in Rutland, Vermont is working to help patients with Congestive Heart Failure (CHF) stay out of the hospital. 
Watch the Video >>

Rutland Regional Medical Center
160 Allen Street
Rutland, VT 05701

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