Hold – the – Gains Projects



Continuing to Save the Butts: Maintaining Excellence with New Staff

Carilion Medical Center

This project builds upon prior success in reducing the hospital acquired pressure ulcer (HAPU) rate at the CRMH 8 Mountain ICU, which was 18.6% in 2011 compared to the NDNQI benchmark of 7.0%.

The high rate was driven by patient obesity, prolonged immobility and lack of frequent re-positioning. 8 MICU installed a Turn and Assist Product (TAP) from Sage Products to aid re-positioning and educated staff on skin condition monitoring. The HAPU rate fell to 5.5% in 2012, 18% below the benchmark. The unit has since educated new staff, appointed two Wound Care Champions, installed new pressure relief mattresses on all beds and treats pressure ulcers as a Sentinel event.

The HAPU rate at 8 MICU is 2.53% for 2013.

Team members:

Donna Bond, R.N.

Jessica Hallam, R.N.

Lisha Osborne, R.N., team leader

Amanda Wolford, R.N.


Hospital Acquired Pressure Ulcer Prevention

Carilion Medical Center

CRMH had hospital acquired pressure ulcer (HAPU) rates above national benchmarks in 2009-10. Finding a lack of evidence-based treatment approaches, Wound Care Services partnered with Materials Management to analyze wound care products and reorganize the formulary.

The Wound Care Council developed education for staff, revised the data collection process and conducted regular HAPU education and quality events. HAPU rates dropped below benchmarks to 4.4% in 2011. Follow-on improvements have included HAPU education for residents, a patient follow-up process, a “highrisk of skin breakdown” patient list and an updated HAPU prevention policy.

HAPU rates fell to 1.2% in 2012 and 1.0% through June 2013.

Team members:

Kathy Chalflinch, R.N.

Rebecca Clark, Ph.D

Bonnie Cline

Maria Christofas

Kimberly Hall, R.N., team leader

Linda Hodges, R.N.

Doris Jones, R.N.

Betty Williams, R.N.


Let the Baby Lead the Way—NICU Ventilator Management

Carilion Clinic Children’s Hospital

The average number of ventilator days at the CMC NICU for neonates ≤ 28 weeks gestational age was 19.7- 23.5 in 2008-09, compared to a 15-19 day average at the Vermont Oxford Network.

The team implemented ventilator management protocols in 2010. These reduced average ventilator days to 13.1 in 2010 and 12.2 in 2011. The team has since implemented additional ventilator protocols along with a standard sedation guideline and modified protocols as needed based on observed outcomes. Average ventilator days for neonates ≤ 28 weeks gestational age dropped to 11 in 2012.

Ventilator charge per patient dropped from $4,000 in 2009 to $2,200 in 2012.

Team members:

Jason Bishop

Heidi Blaser

Amber Cromer, N.P.

Alva Daniels

Susan Gladfelter

Ann Heerens, M.D.

Wendy Jobe, R.N.

Jenny Lane

Gary Rambadt

Shari Toomey, team leader

Marie Williams, R.N.

Lori Wright, N.P.


OB/GYN Quality Program

Carilion Clinic OB/GYN

OB/GYN lacked a structured quality program that integrated safety, education, research, evidence-based practice and service culture in nursing and medical care activities. Fragmented improvement projects lacked common goals or oversight.

OB/GYN implemented a quality structure in 2009 to close these gaps and ensure outcome-driven communication, eliminate redundancy and align with Carilion Clinic’s quality framework. Specific improvements included multidisciplinary inpatient and outpatient quality committees for clinical practice issues, a multidisciplinary quality peer review process and annual perinatal deep dives.

OB/GYN has since implemented additional quality improvement and control features. These include the creation of new quality leadership positions, revisions to the peer review process, department-wide quality/safety indicators, three new evidence-based care protocols and a focused Medical Quality Deep Dive.

Team members:

Sharon Bass, R.N.

Christinne Canela, M.D.

Michelle Franklin, R.N.

Donna Sams, R.N.

Eric Swisher, M.D.

Kristi Thomas

Patrice Weiss, M.D., team leader



The Breast Choice: Improving Breast Milk Utilization in the NICU

Carilion Clinic Children’s Hospital

Breastfeeding rates in 2009 for infants weighing less than 1500 grams showed a large decline from initiation to discharge. Through research and process improvement strategies, the team was able to increase the percentage of infants receiving breast milk at discharge from 14% to 34.5%. This improvement to the NICU patients was not only sustained, but it was enhanced further in 2013.

Recently, the team was able to increase breastfeeding rates by leaving encouragement notes weekly at the baby’s bedside, posting breastfeeding rates on the NICU bulletin board, developing promotional pamphlets and increased staff awareness and the development of Dot the Drops campaign. Overall, these steps have led to an increase of 5.5% in breastfeeding rates from 2012 to 2013 year-to-date.

Team members:

Karen Binns-Loveman, M.D.

Lora Devault, R.N.

Kara Dickinson, R.N.

Lisa Dooley, R.N.

Dena Goldberg, Ph.D., team leader

Amy Kageals

Angela Kinzie

Sondra Masten-Daroshefski, R.N.

Mercedes Maxwell, R.N.

Julie Taylor, R.N.

Tracey Zadell, R.N.


Category Winner:


Pulling the Line on CLABSIs

Carilion Roanoke Memorial Hospital - NTICU

Interdisciplinary team (IDT) contributed to the lack of staff engagement and evidence-based practice for prevention of central line associated bloodstream infections (CLASBIs). Significant improvements to the IDT resulted in a CLASBI rate of 0 in fiscal year 2012, compared to 18.7 and 14.7 in May and September the year before.

To continue progress, there has been focused IDT education on evidence-based fever management and culturing techniques, daily goal board updates in patient rooms and adherence to the Comprehensive Unit Safety Program to sustain progress.

As a result, NTICU CLASBI rates of 1.46 in 2012 and 0 in 2013 are below the National Healthcare Safety Network pooled mean of 1.6 for like units. Results highlight the tremendous efforts of a dedicated NTICU IDT to sustain 20 out of 21 months CLASBI-free culture.

Team members:

Karen Baker, R.N.

Kathryn Booth, R.N.

Eric Bradburn, D.O.

Heather Bramblett, R.N.

Ellen Harvey, R.N.

Jason Hoffman

Kelli Loftus, R.N.

Terry Tilley, R.N., team leader