Agents of Change

INFECTION CONTROL practitioners must sort through a vast amount of information in order to maintain a current base of knowledge. From standards and guidelines to cutting-edge, evidence-based initiatives to vendor claims and information, potential tools and solutions abound. Creating effective and workable protocols is something that challenges each healthcare facility; those that undertake this effort successfully benefi t from the dedication and diligence of many healthcare workers.

Saint Joseph Hospital

Denver-based Saint Joseph Hospital, part of Exempla Healthcare, has seen benefi ts from addressing infections through a variety of initiatives and mechanisms. For the last few years, Saint Joseph has participated in the Surgical Care Improvement Project (SCIP). SCIP is a national quality partnership of organizations interested in improving surgical care by significantly reducing surgical complications. With regard to reducing surgical site infections (SSIs), SCIP suggests a number of interventions, including appropriate use of prophylactic antibiotics, appropriate hair removal, perioperative glucose control for major cardiac surgery patients, and perioperative normothermia for colorectal surgery patients, all of which are actively used at Saint Joseph.

Infection control is involved with all aspects of this auditing, chart reviews, attending all the surgical section meetings, and reporting on how were doing with all of these outcome measures to our Special Care Committee, says Robin Meinberg, RN, MSN, COHN-S, infection prevention specialist at Saint Joseph Hospital. Were very proud of how were doing with most of these initiatives; in terms of administering the antibiotics within one hour, for 2005 we were at about 93 percent, which was pretty good because nationally it was only about 69 percent. Were also doing very well with out antibiotic selection; we were at 95 percent overall for 2005, and nationally it was about 88 percent. Meinberg notes that work remains to be done in terms of discontinuing antibiotics within 24 hours. The orthopaedic surgery section is concerned that theres not a lot of evidence base to that, so were only at 70 percent on that outcome measure, although its still better than the national average, which is about 65 percent.

Our overall SSI rate has been decreasing since October 2005, she continues. We set very high goals for ourselves at Saint Joseph Hospital and we strive to be the best in all areas of infection rates and other patient safety initiatives. Were pretty happy with the fact that our SSIs have been decreasing. Our overall rate right now is around 1 percent. We do about 1,000 surgeries per month, and for our three-hospital system we do all the high-risk surgeries. Nationally, 2 percent to 5 percent is what a lot of other facilities are showing for post-op infections. Weve been as low as .69 percent in the past three months, so were very excited about that.

While her facility has experienced success with SSI rates, it remains an important focus. The simultaneous application of several different approaches continues to be key. Were working closely with the surgeons to expand the use of chlorhexidine surgical cleanser for our patients, Meinberg says. Were also going to do something new this year where well report individual SSI rates to each doctor. Normally we report their section rates (i.e., cardiovascular, OB-GYN, etc.), on a whole, but we want to do it individually to doctors so they can see how they compare to other doctors in their field. I think that will really help people once they see whats going on with their rates.

Hand hygiene has been a significant focus of Saint Josephs infection control efforts as well. We want to be at 100 compliance 100 percent of the time. Thats very difficult, Meinberg concedes. We do have some areas where were at 100 percent, and we have some areas that we need to work on. We just instituted the Its OK to Ask program; there are other partners in your care programs out there for hand hygiene, but we are very committed to empowering our patients and have them become active and informed members of the healthcare team. We just had our annual safety fair for employee education, and we focused on making hand hygiene instruction an integral part of their patient education program.

We did our own study with auger plates showing that alcohol hand gel is actually more effective than soap and water for cleaning your hands, and the staff was pretty impressed with that, Meinberg continues. Were adding more alcohol dispensers as many as we can while staying within our fi re code. We have a publication that we hand out to patients suggesting how they can help make healthcare safer; we want patients to be more informed and to help us reduce the hospital infection risk. Thats our big goal this year in infection control is to really promote hand hygiene for patients and visitors, so they really take part and are able to ask a physician or nurse to clean their hands, and have the staff members not feel threatened by that. We know that hand washing will decrease our rates even more.

Patients have responded very favorably to this approach. They love it, Meinberg observes. We began the program on two high-risk floors oncology and the transitional care unit. With the oncology unit, on the first day that we rolled it out I met with every patient on the floor. They got a brochure about the program, we hung signs over all the hand gels dispensers that said it was OK to ask, and patients were very impressed that we were doing this for them. I wasnt surprised at that reaction. Staff members werent quite so enthusiastic at first. The staff was a little leery initially.

They were worried that they would get defensive, that patients would be confronting them all of the time; they werent comfortable with this. Eventually, through the staff education program and the safety fair, really explaining to the staff what our purpose was and why we wanted to do this, that apprehension went away. The physicians were a little concerned as well; some thought this would create a barrier between them and their patients. This is still not their favorite thing, but theyre coming around. Now its kind of becoming a way of life, and thats what we want hand hygiene to be. We want it to be so ingrained in our culture that it will happen 100 percent of the time.

The drive to decrease infection rates also involved the creation of quality control measures in the sterile processing department (SPD). We were really lucky one of our OR managers decided to take a new path in her career and took over the SPD, Meinberg says. This move prompted Meinberg and her colleague in infection control to take an active look at the processes in the SPD. We developed an infection control audit tool where we would go into the department once a month and interview staff; we would have them show us all of the documentation and explain the procedure for disassembling and examining equipment, etc. just going through the whole process with them.

We also had the manager actually bring in the manufacturers of the sterilizers to go through all of the preventative maintenance with her and spend a lot of time reeducating staff. We had a problem in our SPD where there was a malfunction with one of the washers; somehow the soap wasnt getting into the washer like it was supposed to. We found out that there was a huge container of soap that no one was really tracking, and it was such a huge container that it was hard to tell if the soap was decreasing in level. The manager instituted a different control so that the washer wont even function without soap in it; we put an alarm on the system that would let us know if there was no soap.

Just little things like that, and just really spending more time the OR educators did a great job spending so much time in there with the staff, so they would really understand just how important their job was to the whole surgery process. When we instituted these changes, it was around September 2005, and since then we have seen a drop in infection rates. We dont think its one thing; its not just SCIP, its not just ChloraPrep®, and its not just the SPD quality control, but a combination of these.

Saint Josephs commitment to undertaking many different infection control efforts involves a significant educational component. We dont just take one approach; we take several, Meinberg explains. For instance, we had a physician who was very concerned that there was a spike in C. difficile, so we did a major infection control newsletter and blitz on C. diff education. It reached everyone because it went out through e-mail, voice mail, face-to-face new employee orientation, and individual inservices out on the floors in certain areas that were higher risk for C. diff. We try to attend as many physician meetings as we can and we participate in resident training as well, where we focus on hand hygiene and other things related to infection control. We take a variety of approaches because were a pretty large hospital were licensed for 500 beds and we have more than 2,000 employees. Its difficult to reach everybody the same way, so we try to spend a lot of time out in the units face to face, and setting up formal inservices as well.

Centra Health

As a result of implementing preventive measures to reduce central line-associated blood stream infections (BSIs), Centra has been able to realize an estimated annual cost savings of $110,000 in its two intensive care units (ICUs).

It all started back in 2002, and that was a very specific effort for our medical intensive care unit, says Kathy Bailey, RN, CIC, director of infection control at Lynchburg, Va.-based Centra Health. This effort was part of VHA Inc.s Transformation of the ICU (TICU) project, which involves a series of interactive meetings, conference calls, and coaching aimed at helping organizations meet their clinical, operational, and fi nancial goals. Design components include:

• Clinical performance 

• Patient and family satisfaction 

• Work force 

• Leadership 

• Teamwork 

• Design 

• Technology integration 

• Financial management 

Bailey notes that the initial step in addressing central line-related issues involves making sure that the line is necessary and that it is removed as soon as possible. If a central line is deemed necessary, the subsequent focus is on the use of appropriate barriers on line insertion, and appropriate care for the line during the entire time that it is in place. That was really our first attempt to look at barriers for insertion, because we know that there is practice evidence that if full barriers are used including masks, gloves, gowns, head covering for the inserter, and then masks for anyone in the room that greatly reduces the risk of infection, she continues. Weve been looking at that in our medical ICU since 2002. In 2004, we took a different approach in our surgical intensive care unit we participated in a VHA project called Healthcare-Associated Infection Reduction Collaborative.

That was specific to our surgical ICU, where we didnt really focus on the line insertion, but on nursing care of that line. Once the line was in place, the nurses would do appropriate dressing changes, they would perform hand hygiene with the dressing changes, determine whether or not the dressing was occlusive, and if it remained occlusive until the next dressing change (if not, it would be changed). Also, when they accessed the line for medication administration or blood draws, they would use appropriate technique.

In 2005, Centra enhanced its existing efforts to combat central line-related BSIs by becoming involved in the Institute for Health Improvement (IHI)s 100,000 Lives Campaign. At that point we went hospital-wide, Bailey explains. We went back to the barriers on insertion, and we included our anesthesiologists, who place a lot of lines for our surgical patients. At this point, an important step was taken to ensure and monitor compliance. Beginning in July 2005, we asked that there be an observer of every central line insertion at our facility. There had to be a nurse or someone in the room assisting, and they would document compliance with the central line bundle. We were looking at hand hygiene, the barriers, the need for the line, and ChloraPrep as a skin antiseptic. We felt as if that had a huge impact on our decrease in central-line BSIs, because it is known to be such a good skin antiseptic. Prior to Centras surgical ICU project in 2004, ChloraPrep had been included for insertion in the insertion kit, but it had not been included it in the dressing change kit. Thats one thing that came out of that SICU project in 2004 we realized that we werent providing the best skin antiseptic agents for our dressing changes. We did a trial in our SICU, and as a result of the outcome they have now gone hospital wide with ChloraPrep as our skin antiseptic both for insertion and for dressing changes.

Were headed toward 100 percent compliance with that central line bundle, Bailey continues. The line insertion observation is a system that weve consistently done everywhere except our emergency department (ED). Weve had a lot of discussion with our ED physicians and we feel that theyre certainly aware of the bundle elements and that theyre following that as close as they can given the emergent, trauma situations, but given the nature of the ED, we just have not been successful in getting those observation forms turned in, through no fault of theirs; its just not the place to try and add another form.

Hospital-wide central line-related BSI rates declined by 26 percent from 2004 to 2005 at Centra. Even with this success, Bailey considers this infection control effort to be a work in progress. Theres always something new and something better; some different way of looking at things, she says. Right now were looking at possibly trialing a new dressing. We feel that, particularly with our critical care patients, its difficult for those dressings to remain occlusive, and so were looking for the best dressing that will stay in place for the longest period of time so that the line site wont have access to the potential contaminants that it might if the dressing were open.

Education and training were, of course, critical to the success of Centras central line initiatives. As far as line insertion, thats the easiest piece because we have physicians who have line-insertion privileges, and those numbers are small; were talking about our intensivits, our anesthesiologists, and a few other surgeons, Bailey comments. I would say there are 20 or fewer physicians who have line insertion privileges. From the nursing perspective, care of the lines, it was more difficult because of the sheer number of nursing staff members. Weve utilized our IV team in this approach; weve actually had the IV team observe every central line in the hospital on a daily basis. If, say, a dressing is non-occlusive at the time the IV team nurse sees it, she doesnt correct it herself; she goes to that patients nurse and explains that the dressing is no longer occlusive, so that nurse is made aware of the situation theres kind of a one-on-one education process that occurs between the IV nurse and the patients nurse.

The other approach that we have on the infection rate side of things, each unit manager is given a rate of infection each quarter for their specific unit, Bailey continues. This is based on the number of infections related to the number of central line days for that unit. We calculate a rate of infection based on the best denominator possible, because the patients who have the lines are the patients who have the risk, not the patients who might have something like a peripheral IV. We use central line days as a denominator for our infection rates, and that information is sent back to the people who can really make the difference. So if, say, for the first quarter of this year, if we see that a certain unit has two central line infections, that information is going to go directly back to that unit and they are going to be given specific information on the patients who have those infections and be asked to look into that to see how the infections occurred, and see if they have any suggestions on prevention for the next time around. The other thing about the education piece is that when we started with the insertion observation, we werent near 100 percent; we were seeing some outliers and some physicians who maybe used barriers but didnt use all of the barriers maybe they didnt use head protection or a gown for example. If there was one element that was omitted, we communicated directly with that inserting physician and it wasnt too long before we were approaching 100 percent compliance.

Fort Sanders Regional Medical Center

Instituting principles to address ventilator-associated pneumonia (VAP) saved an estimated six lives and $280,000 in related costs at Knoxville, Tenn.-based Fort Sanders Regional Medial Center, part of Covenant Health. Gregory P. LeMense, MD, pulmonary specialist, notes that although no baseline to data was available to gauge initial progress and change in terms of VAP rates, significant improvement was evident from the start. Having the head of the bed elevated all the time, making sure that we had appropriate ulcer prophylaxis and deep vein thrombosis (DVT) prophylaxis; we were focusing on all the elements in the TICU ventilator bundle. That was really the main early initiative and thats where we saw the drop; within the first two months, and then consistently after that point, we saw a very obvious drop in VAP. 

Despite these efforts, the facility began to see an increase in VAP rates in late 2005. This forced us to sit down and look at everything that was going on in the ICU, LeMense recalls. Ultimately, it was found that adequate oral care was not always being performed on ventilated patients. We made a strong push through nursing to do oral care twice every shift on a regular basis, and we actually had a way that we could document the use of the equipment, so we could be sure that it was being done. Again, within a month of initiating that, we saw rates drop again, back to where they had been before, so thats a newer initiative that wasnt part of that TICU program. LeMense adds that the subsequent establishment of a baseline VAP rate has been helpful. If that baseline goes up, were able to start troubleshooting and determine what the problem is.

Catheter-related BSIs also became an area of focus at Fort Sanders. Efforts to reduce these infections saved an estimated four lives and $235,200. That was something we really initiated here, the move toward using full barrier precautions and using chlorhexidine instead of Betadine, LeMense says. A lot of our central lines are put in by anesthesia, and there really was not any quality control. There wasnt anyone who was using full barrier precautions up until a couple years ago. What we did as an internal quality control was start to track all line insertions in the ICU. It was piloted in the ICU and now its done almost everywhere in the hospital. Its very basic fi ve questions that the nurse would complete as soon as the line insertion was done.

He notes that the observing nurse would identify the group that the physician was affiliated with instead of the individual physician. That way we werent head hunting for a specific doctor, but we looking for which group put the line in, and if they did it with full barrier precautions, the type of prep that they used Betadine or chlorhexidine what type of line they used, and where they put it, LeMense continues. There wasnt any outcome tied to that, but we tracked that for two years and were able to maintain a very consistent record of which group was putting it in and where they were putting it in. Any time we had a line infection, we could go back because we had the data on the patients insertion, and fi nd out what was done, whether it correlated to using Betadine instead of chlorhexidine, or to a specific physician group.

This approach yielded results almost instantly. Basically this impacted human nature; as soon as everybody knew we were tracking this, the rate of full barrier and chlorhexidine use, which was initially less than 50 percent for both, was 95 percent within one month, LeMense states. We didnt really sit down and educate all the doctors; I spent two meetings with the medical staff and said, These are the current initiatives, and were going to track this. So once they knew they were being tracked, everyone immediately changed their practice. As soon as we started seeing 95 percent utilization of chlorhexidine or higher (some months it was 100 percent), our infection rate immediately went down. Thats been very easy to maintain as long as they see those tracking sheets on the carts, they know that its still being tracked, and its basically become convention that everybody does it.

VHA is Transforming the Hospital Operating Room
New Program Targets Clinical, Financial, Cultural Factors Infl uencing Surgical Success

For the first time, a hospital organization is attempting to change the traditional hospital operating room (OR) to reduce surgical complications, improve patient safety, and reduce the money hospitals lose every year due to ineffi ciency in the surgical area. VHA Inc., a national hospital alliance, has introduced a new program, titled, Transformation of the Operating Room (TOR).

VHAs Transformation of the Operating Room will help hospitals make systemic, smart changes clinically, operationally and culturally, says Peter Plantes, MD, vice president at VHA. Until hospitals implement the steps necessary for change, they will continue to unnecessarily lose patients lives and millions of dollars.

To improve surgical care, the VHA program focuses on helping hospitals reduce surgical site infections, adverse cardiac events, deep vein thrombosis, and reduce postoperative ventilator-associated pneumonia.

To do this, hospitals should monitor and control glucose levels, establish fi rmer guidelines about the timing and dosages of antibiotic and anticoagulant administration, and eliminate the practice of shaving body hair around surgical sites.

We know that patients whose blood sugars are kept within a normal range are much less likely to develop complications. Even a short period of high glucose levels can cause a long-term impairment of the bodys defenses against infection. Research also shows that having defi nite start/stop times for antibiotic administration helps patients avoid infections and reduces overuse of antibiotics, which contributes to the development of drug resistance. Furthermore, if necessary, clipping of body hair is strongly advised over shaving which leads to micro-abscess development in the surgical field. VHA knows how to help hospitals make these changes in their processes and cultures, says Plantes.

National data indicates that surgical site infections cost hospitals an extra $3,152 per incident and extend hospital stays. Postoperative ventilator-associated pneumonia occurs in nine percent to 40 percent of patients and has a mortality rate between 30 percent and 46 percent. Potential savings from the reduced hospitalization due to post-operative pneumonia is $22,000 to $28,000 per admission.

Another problem, says Plantes, is that most hospitals do not have methods in place to measure how much money they make or lose in the OR. Thats because they dont have common measurement systems. For example, hospitals have different defi nitions for when a surgical case begins. Some hospitals start the clock when the physician or patient arrives others, when the first cut is made. TOR will change this by setting formulas and uniform calculations that hospitals can use to compare improvements with other hospitals across town or across the country.

VHA has committed physicians, nurses and leadership from its headquarters and 18 offices across the country to develop this one-of-a-kind program. Currently it is piloting the program in 16 hospitals. The program focuses on improving clinical areas that have been targeted by government initiatives.

We are working with VHA to conduct trial components of this program, says Faith Schaffer, director of perioperative services, Deaconess Billings Clinic, Billings, Mont. Educating both staff and physicians and implementing sustainable change will be challenging, but the results will help to set measurable controls to create a safer OR and get all hospital ORs talking the same language.