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Colin Ward (Host): The University of Maryland Upper Chesapeake is in the midst of an ambitious plan to limit healthcare associated infections or HAIs. This fiscal year, Upper Chesapeake operating plan helps light the path to zero harm for our patients and their families. Today, on the Hero podcast, we will hear from those charged with drafting the plan for high quality care and how team members play a vital role in this important patient safety initiative.

Hello, I’m Colin Ward, Vice President of Population Health and joining me today, to discuss the operating plan and our goals for the next 12 months is Lyle Sheldon, the CEO of Upper Chesapeake going on now, what 30 something years?

Lyle Sheldon FACHE (Guest):  I just celebrated my 31^st anniversary here at the University of Maryland Upper Chesapeake Health and 24 as CEO.

Host:  So, when you started here, the Berlin Wall was still up, and Michael Jackson was just releasing albums left and right. Quite a change from those days.

Lyle:  And some of us were still in high school or college.

Host:  Some of us may have been. So, Lyle, as we get started here today, I think maybe we will start with the most basic question for folks that are listening. Is what exactly is an operating plan and how are they put together?

Lyle:  Every well-run organization needs to be focused on it’s mission, vision and values that drive what we do on an annual basis and strategically long-term. A key component of that is this idea of an operating plan which outlines for our board, for our medical staff, for our team members; what are the key organizational objectives that we want to try to accomplish in that upcoming year in front of us.

Host:  So, an operating plan that you have seen 30 years ago is probably looking a little bit different than one that you are seeing today and that you’ve helped craft today. So, why is there such a focus now on healthcare associated infections in an operating plan?

Lyle:  As we look at one of our key responsibilities in servicing our community; from a patient perspective, it falls into three broad categories. Don’t hurt me, heal me, be nice to me. And as we think about this idea of healthcare associated infections; that falls into the category of don’t hurt me. Because these are infections that theoretically are avoidable and preventable when patients are in our care.

Host:  And so are there – obviously there are internal forces here at play. We think we can do better in this arena. How about externally? Are there external forces that are pushing hospitals to focus on this?

Lyle:  I think what I would say is that when you look across the country, there tend to be a number of different service industries or professional industries that have put this high focus on reducing patient harm or reducing harm for their clients. You certainly have the aeronautical industry; you certainly have nuclear power and I think healthcare is finally fallen into that arena where really our responsibility is this notion of doing no harm for our patients. I think there’s an internal expectation amongst our team members an dour physicians that those things that are preventable or avoidable that we have control over; we should be working very, very diligently to minimize. I think there’s an external expectation from family members and patients in the community and society at large that when you come to the hospital, it should be a safe place and you shouldn’t come out with an infection or another complication that you didn’t have prior to your arrival.

Host:  And then too what you are describing really is high quality care then.

Lyle:  It’s high quality care and safe care. And I think it’s important to put those two together in the same sentence.

Host:  Great. So, Upper Chesapeake has an ambitious plan. We know that we’ve set goals around certain components of our operating plan relating to safe and high quality care. So, if we hit those targets and we do a good job here on this journey to zero harm; what will that mean for Upper Chesapeake and our patients?

Lyle:  As I think about that question, when you look at the leading causes of death here in the United States; first is heart disease, second is cancer, but the third leading cause of death across the United States is medical error. And the majority of those medical errors take place in the hospitals across the country. And the majority of those medical errors are avoidable or preventable. And so, when you put it into the context of what does that mean from a patient’s standpoint; it means fewer patients that are dying unnecessarily. It means fewer patients that are having some type of potentially debilitating injury that they would not have had while they were here. And I think those are the success factors that we are looking at. It’s really decreasing the risk for that patient while they are in our care at our hospitals.

Host:  Absolutely. All right thanks Lyle. We are just getting started here. When we come back, we are going to be joined by Dr. Leo Girio-Herrara. He is the Medical Director for Infection Prevention. You’re listening to the Upper Chesapeake Hero podcast. As we continue our discussion on the journey to zero harm, I’m pleased to be joined by Dr. Leo Girio-Herrara, Board-Certified Infectious Disease physician and the Medical Director of Infection Prevention at Upper Chesapeake. Thank you for joining us today.

Leonardo Girio-Herrara, MD (Guest):  Thank you for welcoming me.

Host:  As we get started, can you tell us what are healthcare associated infections?

Dr. Girio-Herrara:  Sure so, an HAI is essentially an infection that occurs in any particular patient as a complication of treatment whether it’s medical treatment, any procedure, anything that happened within the hospital walls that was not intended because of therapy.

Host:  I understand. And how did you come to be so interested in this component of healthcare because you’re trying to treat patients and then there’s this sort of secondary component about patients who may have some issues that have come up as part of that care?

Dr. Girio-Herrara:  So, one of the reasons that I really enjoy infectious diseases really is the range in acuity of disease so for example, within our field, we can see tropical related infections, whether it’s malaria, travelling diarrhea, within our just in general HIV, viral illnesses and within the hospital, many common infections like blood infections, pneumonia and then within that category there is the hospital acquired infections so there is such a large variety. Plus we also get to have a pretty significant impact on patients. They may be really sick from an infection but if we are able to see them quick and early enough and institute the right therapy; they can be feeling better hopefully within a day or two. So, the ability for us to impact their health is very palpable and very visible.

Host:  So, that brings some joy back to the work that you are trying to do.

Dr. Girio-Herrara:  Of course, yeah, yeah, absolutely.

Host:  Excellent. And so, walk us through. What are kind of the causes for healthcare associated infections and how do they sort of originate?

Dr. Girio-Herrara:  So, unfortunately, like many things in medicine, there are side effects or adverse reactions that happen with procedures or medicine related treatments. So, for example, antibiotics. When you have an infection, the whole point is to get on antibiotics to kill the bad bacteria. Well the antibiotic doesn’t discriminate, it will kill the bad bacteria but then it will also for example, kill some good bacteria that’s in your gut. And as it kills some good bacteria, it may cause an adverse reaction of an antibiotic induced diarrhea or C diff. That’s one of the common hospital acquired infections. And so it’s an unfortunate side effect of certain therapies. For example, people who need a Foley catheter to empty their bladder. It’s obviously providing a benefit, but it can also lead to infections of the urine.

So, hospital acquired infections happen because of therapies or treatments that we are doing to help the patient but as I mentioned at the beginning of this question; each intervention may have a side effect or an adverse reaction.

Host:  And so that’s probably something that most patients when they come to the hospital aren’t even thinking about. So, how can patients and families sort of be better advocates for themselves in the way that they seek care and avoid these HAIs.

Dr. Girio-Herrara:  Yeah, that’s a great question. I think patient advocacy is a big part of hospital acquired infection prevention. The biggest way to prevent one is for each patient or family member to be aware and realize that they have the power and the autonomy to ask those healthcare providers whether it’s a physician, a nurse, a tech, a case manager who is coming into the room; to ask them if they have washed their hands. That’s step one in what we do is when we come see a patient, we should be washing our hands with the alcohol rub and if the patient perhaps didn’t see this process, they could ask the question – a simple question, did you wash your hands. If the provider say yes, that’s great but if not, then you know, you are at least providing them with the opportunity to do that before having contact with the patient.

Host:  And that seems like a very simple thing, washing your hands. Does that have the biggest impact?

Dr. Girio-Herrara:  It does have a huge impact and it is a very simple step that can prevent a number of hospital acquired infections.

Host:  Why is it difficult for healthcare organizations then to get from providing excellent care for patients down to zero harm. It seems like every intervention has some inherent risk that comes with it as you described earlier. So, how come this remains a problem? There’s plenty of smart people in healthcare. Why is it so difficult to get to zero harm?

Dr. Girio-Herrara:  I think it’s that there are two components. Number one is the I think cultural change. I think maybe a decade or two decades ago, those adverse reactions that come with each therapeutic intervention were just granted by the medical field. So, we said okay, we’ll give an antibiotic, there’s a certain risk. It just happens. And there were no steps implemented to reduce the risk. So, we are changing that culture of expectation from the medical field. And then the second thing is as I mentioned, every intervention does have a side effect or an adverse reaction so, like with antibiotics the example I gave, you are killing the bad bacteria, but it also kills good bacteria and that puts you at certain risk.

So, what we’re trying to do is number one, making sure that our therapy is absolutely indicated and then try to have an effect on the other components that may be contributing to hospital acquired infections in order to overall reduce the risk of the hospital acquired infections and bring those numbers to zero which is our whole goal of zero harm.

Host:  And certainly the patients that we see now in a hospital and patients that are aging and have more chronic conditions, their medication regimen is much more complex than it was previously. Does that play into this as well? Does that make it more difficult for you as a provider and for the clinical team?

Dr. Girio-Herrara:  Case complexity continues to rise just because as healthcare improves and as interventions allow people to live longer, even with chronic conditions; then you are trying to manage different aspects of each patient’s health, so you do have to have an awareness of what’s going on and how therapeutic interventions intervene and interact with other physicians and other recommendations and other therapies as well.

Host:  So, you have an interesting vantage point here along the healthcare continuum. You see patients outside of the hospital in your clinic and you obviously consult on patients and follow patients in the hospital. So, are there things that clinicians within the hospital and clinicians and those that are outside of the hospital could do to potentially impact healthcare associated infections?

Dr. Girio-Herrara:  Yeah, I think so. I think from our perspective from the infectious disease perspective, one of the most important things is accurate diagnosing. So, you hear often in the outpatient setting when somebody has a upper respiratory infection, a URI and they end up on an antibiotic like a Z-Pak or another antibiotic for pneumonia, or for a bacterial infection. Accurate diagnosing means that if you know that 90% or greater of all URIs, upper respiratory infections are virus related you don’t need an antibiotic. So, again by establishing the right diagnosis it leads to the right therapeutic intervention which really for this viral URI would be just monitoring, no antibiotic and that way you are reducing and eliminating the risk of antibiotic induced side effects.

In other areas such as urinary retention, where many times we went to a Foley catheter chronically; we can now essentially self-cath the patients, reducing the risk. Or for example, in things like bacteriuria which means bacteria in the urine. Many of the times it is asymptomatic which means that the patient has no symptoms. So, if you have the right diagnosis of asymptomatic bacteriuria which means again, a patient with no symptoms; bad bacteria in the urine; the recommendation is monitoring with no antibiotics. That compared to somebody with a UTI or urinary tract infection where antibiotics are needed.

So, if you made the right diagnosis of asymptomatic bacteriuria for example, you are avoiding risk to the patient by providing them therapies that are not needed. So, I think in the outpatient setting, and in the inpatient setting, the right diagnosis and the right therapeutic intervention which sometimes means no intervention; is really important for the patients and for the prevention of hospital acquired infections.

Host:  And sometimes those patients come to the physician saying heh I just want an antibiotic.

Dr. Girio-Herrara:  That’s right. So, essentially, education of the patients and informing them of the right expectations because you are right, many patients say oh my neighbor got a Z-Pak when they had a runny nose, so why am I not getting one. So, I think the physician whether in the outpatient setting or the inpatient setting, if they have informed the patient that look, we don’t want to give you an adverse reaction or hospital acquired infection so let’s just monitor you for the next two, three, four days; I think they are going to feel comforted by the fact that number one, we are keeping them from adverse risks and number two, they are consulting with their physician in order to have the right care provided.

Host:  Excellent. Thank you Dr. Girio-Herrara for your time. We really appreciate it.

Dr. Girio-Herrara:  You’re welcome. Thank you so much.

Host:  When we come back, we will be joined by Dr. Fermin Barrueto to see where this journey will take us. You’re listening to the University of Maryland Upper Chesapeake Health Hero podcast. Welcome back to the Upper Chesapeake Hero podcast. I’m Colin Ward. And we’re learning more about healthcare associated infections and how impactful they are. And we want to hear more about Upper Chesapeake’s plan to eliminate them. So, joining us now is Dr. Fermin Barrueto, the Chief Medical Officer for Upper Chesapeake. Fermin, thanks for joining us.

Fermin Barrueto Jr., MD, MBA (Guest):  Thanks for having me.

Host:  So, healthcare associated infections are a national problem and there are strategies that can be put in place to combat this issue. How have we organized for success here at Upper Chesapeake?

Dr. Barrueto:  Well let me give you a couple of examples Colin. One of the biggest ones of course is our what we call bundles to handle hospital acquired infections and one particular bundle involves clostridium difficile diarrheal illness and antimicrobial stewardship which has an entire slew of processes that we are trying to improve our use of antibiotics use since that is what causes the disease and also the testing stewardship to make sure we diagnose the disease appropriately. And the combination of these two strategies helps us drive down C diff and where even just five or ten years ago our rates were double digits on a monthly basis; we have actually gone months at times at the whole hospital system without a single C diff case showing that these strategies are highly effective in decreasing these hospital acquired infections.

Host:  That’s great. And so, one of the things that Dr. Leo mentioned is the ability to properly diagnose and get the right treatments so that you are limiting the opportunity for that secondary, that bad benefit, side effect that comes with a particular medication or a particular treatment regimen.

Dr. Barrueto:  Right. So, you are referring to the false positives that can occur if we over test and as well as making sure that we target the therapy at the right patient.

Host:  So, our teammates, they obviously play a vital role in reducing healthcare associated infections; so what should they be focused on here as we move forward?

Dr. Barrueto:  So, of course we have team members across the spectrum. The one that unites us all and where every single team member that works inside the hospital and that can contribute and help us reduce hospital acquired infections is hand hygiene. We need to get to 100% every single –

Host:  What does that mean, hand hygiene?

Dr. Barrueto:  So, that is washing in prior to going into any patient room and washing out. Usually with the hand sanitizer that is located right outside the room. There are rare cases where you have to use soap and water and those are usually labelled with particular isolation rooms. But essentially, you are washing in before you go in, washing out coming out.

Host:  And that seems like a pretty easy thing to do.

Dr. Barrueto:  Right. You can be complacent, forget or the sanitizer is out. There’s a lot of different things that can poke a hole into this, but we have to understand whether you are going in delivering a food tray, you are going in to evaluate the patient, this is critical for our success for HAI.

Host:  So, in your role as Chief Medical Officer, you obviously work very closely with the medical staff here. What can the providers and nursing team members do to limit the risk for potential infection?

Dr. Barrueto:  So, for the nursing staff, I think there is a tremendous set of processes that are already in place. Some of them are very labor intensive. In fact, a lot of the things that we are doing in maintaining lines such as CLABSI or CAUTIs and taking that onto MRSA bacteremia; it’s very labor intensive to clean and bathe the patient in these chlorhexidine baths but we know that that decreases the incidence of MRSA bacteremia. Our increasing compliance of that process is going to help us drive down hospital acquired infections.

For the medical staff, the proper technique when you insert these central lines, or the catheters is critical so that that patient doesn’t develop that hospital acquired infection upon insertion. So, there’s insertion technique and then there’s maintenance of the hardware as well that are both key and critical to be able to prevent an HAI.

Host:  So, is it as a clinician, you’ve got to decide what does the patient have, what’s the appropriate treatment, use the proper technique and then maintain it and so all those steps need to fall in place and if any one of those things is not perfect, then you increase the risk for having an infection.

Dr. Barrueto:  Look at you Colin. I think you can get out on the floors and help us out man.

Host:  I just need your white coat. We’ve been talking a lot about infections but does the same sort of principle and strategy also apply to falls or other injuries that can be acquired in the hospital?

Dr. Barrueto:  Yeah, absolutely. In fact, a lot of these go back to the HRO principles that we are talking about, about becoming a highly engaged and reliable organization. Be it falls, procedures on the wrong side, all of these hospital acquired conditions really are – we can apply the same HRO principles, develop nice safe processes so that we can keep our patients free from harm when they come into the hospital. I think one of the biggest slides that I have seen, the biggest driver for me is knowing that if we took into account all medical errors in the United States and lumped them into one bucket; it would actually be the third leading cause of death in the United States. And I think when you tell a clinician that, it really drives home that we need to do better. We can do better.

Host:  So, it’s these little things everyday that if we are appropriately nailing these items, we can eliminate these in a big way.

Dr. Barrueto:  Yes, these are avoidable.

Host:  All right Dr. Barrueto. I appreciate it. I think I’ll stay off the floor for a little bit of time.

Dr. Barrueto:  I’ll try and pull you up.

Host:  Thank you again for joining us today. and we’ll be back with more in a moment. You’re listening to the Upper Chesapeake Hero podcast. Welcome back to the Hero podcast. Joined again by Lyle Sheldon, the Upper Chesapeake Chief Executive Officer and Lyle you are an avid cyclist. I think most people know that. You’ve even ridden portions of the Giro D’Italia Course in Italy. And it’s not uncommon for you to ride 100 miles in a weekend. So, tell us, can there be any parallels drawn between our journey to zero harm and the endurance and training required of riding in some of Europe’s premiere cycling events?

Lyle:  So, when you think about cycling like so many hobbies or interests that we have, are proficiency improves as we spend more time in preparation and or planning. And as I was preparing to do the legendary climbs of the Giro D’Italia and these are in the Dolomites in the great country of Italy, imagine a majestic mountain peak surrounded by snow capped visuals and going up a mountain that might be 8 or 10,000 feet above sea level. And you might have 48 switchbacks.

Host:  And that’s where you just keep turning as you go up the side of the mountain.

Lyle:  Just to back and forth up the mountain. Or to have a five mile climb that has your legs saying things that you didn’t know your legs could say to you, either in Italian or in English. And then knowing that you when you crashed did you have an opportunity to scream down the mountain at 55 to 60 miles an hour. But I put that in the context of me coming from sea level and preparing to ride where you have an elevation of that high and like our HAI journey, it was a lot of preparation. It’s the people, it’s the processes, and it’s the equipment that we have in place or that we had in place to train for those rides.

And in some regards, it’s no different than our journey towards zero harm with our health care associated infections. It’s a lot of work by a lot of people trying to make sure that we are putting together the systems, the processes, the attention to detail to make sure that we are minimizing the risk for our patients while they are hospitalized with us. And that’s what this context is of a journey towards zero harm. No healthcare associated infections and things in that particular category.

Host:  Well, it’s an ambitious goal for sure. And one that we can certainly achieve here at Upper Chesapeake, right?

Lyle:  Absolutely. We’ve got the confidence and you’ve heard some of my colleagues from the medical staff standpoint that have the same passion in this journey as I do.

Host:  Well thanks Lyle. Hope you’ve enjoyed listening to our new format for the Hero podcast. Our next episode will actually be released on November 5^th.

Lyle:  You mean dropped November 5^th, as the kids say.

Host:  That’s right as the kids say it will be dropped on November 5^th. So, thanks for joining us as we learn more about healthcare associated infections and thanks to our guests Dr. Leo Girio-Herrara and Dr. Fermin Barrueto and of course Lyle Sheldon. I’m Colin Ward. And we hope you will join us on the journey to zero harm.