Operationalizing an Infection Prevention Program

Elaine Crittenton, RN, Director of Infection Prevention, Employee Health and Wellness Katherine Steele, RN, Infection Preventionist Carteret General Hospital , Morehead City, NC

As in nursing and other healthcare professions, true success is dependent not only upon intellectual understanding and technical expertise, but upon the art of care-giving and compassion. There is a true art to being an infection preventionist!

Basic Rules Regarding Infection Prevention

No harm should occur to a patient as a result of an HAI! Infection prevention MUST be an organizational-wide goal! Senior administration must be onboard, providing necessary resources and supporting goals. Target ZERO is an admirable goal Infection prevention is everyones responsibility, including patients, visitors, vendors and all healthcare providers

Identify Obstacles to an IP Program

Infection prevention is a non-revenue producing cost center
Soft dollars vs. Hard dollars
Soft = savings from infections prevented based on historical data from your facility Hard = money expected for services provided

Identify Obstacles to an IP Program

Overburdened Staff
Infection preventionists are frequently given other responsibilities in addition to IP activities ALL to be accomplished in 40 hours per week!!!
Employee Health Multiple Committee Memberships and Meetings Quality Division Responsibilities Environment of Care Oversight Construction and Renovation Oversight Provision of Education to Staff, Physicians, Community, etc.

Identify Obstacles to an IP Program

Lack of understanding (and resentment) of the Infection Preventionists role across the hospital
The IP is just the Chief Cootie Counter Shes just a nurse I dont have time for infection control Why do you want or need to know that? Another clipboard nurse You dont understand how busy we are

Identify Obstacles to an IP Program

Limited Resources Do You.
Still live in the paper world without electronic tools? Live in the hybrid paper and electronic world doing double duty? Function without electronic surveillance tools? Struggle to get support from administration or other department? Feel theres not enough hours in the day for the lone wolf IP?

SOHow do you build a successful infection prevention program???

Be Prepared for a Baptism by Fire, and

Learn Your Facility Study Your Facilitys Organizational Chart Develop Relationships With Key Individuals Study the Flow of Information Get Engaged with the Hospitals Safety Committee, Employee Health and Education Departments Befriend Fellow Hospital Departments Be Prepared to Work Long Hours and Be Tested

Knowledge is Power and Consistency is Key!!!

Learn the regulatory standards for your deeming agency, CMS, state and local health departments. Be sure your IP policies mirror the regulations Remember the strongest regulation wins. Keep policies up-to-date and list all supporting references on respective policy They are your defense. Learn what your facilitys biggest IP problems are and plan to tackle those first, but also look for an easy win. Once armed, be prepared to prove your credibility!

Infection Prevention Initial Assault

Most Significant Issue = MRSA 2000 SHEA Decennial Hot Topic was MRSA Plan was revealed for NC and VA to partner in an active surveillance program which came to be known as the Problem Pathogen Partnership (PPP) 57% of our staph aureus isolates were MRSA! Quickest Opportunity for a Win = VAP Numbers were small 8-bed mixed Critical Care Unit Pulmonologist visionary, active on the IC Committee Willing and eager cardiopulmonary manager and staff

Initiation of Protocols
Make sure information is shared across the organization Present facts, NOT perceptions Strive for transparency Eliminate SILOS and TURF ISSUES Then PDSA Plan, Do, Study, Act

Results of Our Early Efforts

The PPP began at CGH in May 2002 and continues. We rarely have transmission of MRSA in our hospital, with no MRSA transmission in 2007. We were recognized for our efforts in changing our culture by the University of Wisconsin in a comparative publication. The VAP team reviewed all current literature regarding care of the mechanically ventilated patient. Our pulmonologist was our greatest champion easy to work with, supportive and well respected by his peers. We developed and implemented a ventilator bundle in 2000 which drastically reduced our VAP incidence. These two wins helped IP gain credibility and promoted interest throughout the organization in patient safety, cost savings, and collaboration. Then came IHI and the 100,000 Lives Campaign.

Overview of the 100,000 Lives Campaign December 2004 The names of the patients whose lives we save can never be known. Our contribution will be what did not happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken, and work completed, and books read, and symphonies heard, and gardens tended that, without our work, would never have been.
Donald M. Berwick, MD, MPP Former President and CEO Institute for Healthcare Improvement

We invite you to join a campaign to make healthcare safer and more effective to ensure that hospitals achieve the best possible outcomes for all patients.

JOIN FORCES
IHI presented opportunities to collaborate and benchmark on three infection prevention targets, CLABSI, SSI and VAP.
Administration saw value in this approach and supported participation. IHI provided tools, such as bundles and staff education, to assist in the organization and operationalization of the effort.

WINS
Significant improvement was seen in all three targets. VAP rates were initially reduced by half and we currently average one per year Central line insertions were reduced by two thirds, CLABSIs were almost entirely eliminated. Over the past 23 quarters only 7 CLABSIs have occurred. PICC lines are largely preferred at this time. SSI reduction was also noted and SCIP efforts assisted with this effort. We did have a brief spike in the first half of 2008 when our SSI rate climbed to 2.13. It has steadily declined since that time with a last quarter SSI rate of .28%! This success fueled the desire to do more

Hospital Staff Response

Everyone looks forward to the regular reporting of Infection Prevention statistics. Staff requested education at staff meetings and wanted to know more about all aspects of infection prevention. Natural leaders emerged and formed a group we call Infection Control Representatives. They are unit-based, have a formal job description and meet with us every other month. We ask for a year commitment to maintain continuity. The IC Reps are also our Secret Shoppers that monitor hand hygiene and PPE compliance monthly.

Employee Orientation
Each new employee must attend a comprehensive orientation where we stress: Development of an interactive relationship with all employees to provide resources and guidance in infection prevention and to promote a culture of safety Importance of hand hygiene compliance in the healthcare setting Prevention of health acquired infections, CLABSIs, CAUTIs, SSIs, VAPs, etc. Bloodborne pathogen education introduction to the hospitals engineering and work practice controls and exposure control Transmission based precautions: Contact Precautions, Special Enteric/Contact Precautions, Droplet Precautions, Airborne Infection Isolation Precautions, Special Airborne Isolation Precautions, and Protective Isolation (Neutropenic) Precautions

Transmission Based Precautions (Signs are laminated with disease processes listed on the back)

Hand Hygiene Effectiveness Demonstrated in Employee Orientation

KEEP IT FRESH!
Be proactive NOT reactive Find new ways to deliver old information Keep your sense of humor and share it with others

Memorable IP Activities
1000 hand-shaped cookies to launch our mandatory hand hygiene policy in 2006
Skits with an infection prevention theme during IP week with inhouse education credit Fall Festival for International Infection Prevention week, paired with quality with in-house education credit Ice cream cart, going from unit to unit, asking IP questions and rewarding correct answers.

International Infection Prevention Week National Healthcare Quality Week Fall Festival

Keep it Real and Make it Personal

Hospital staff and medical staff will respond best to your facilitys data. Present HAI cases in a Grand Rounds format or during multidisciplinary rounds. This gives a chance to drill down to determine where the problem occurred. We now have a formal review through our safety initiative and just culture. We report life-threatening infections as serious safety events. Ours is a small town, so often the event is very personal to someone on our staff.

COLLABORATE
Todays infection prevention environment provides many challenges and many opportunities to build your program and your practice. You will quickly recognize your worth to your facility and, hopefully, they will too! Take every opportunity to share your successes and keep the value of your program high. Collaborate as much as possible. While the requirements of a formal collaborative may seem daunting, there are always incredible benefits to joining such as: ~ Networking with peers ~ Access to valuable tools ~ Staying on schedule with data collection and reporting ~ Help changing your facilitys culture, if needed ~ Access to experts on evidence based practice ~ The opportunity to mentor others

COLLABORATIVE COMPONENTS In-person meetings Teleconferences Comprehensive toolkit Secure on-line data collection Collaborative website List serve Open office-hours calls Technical support

Internal Partnerships
Environmental Services The environment is a significant concern for IP and is being closely evaluated during surveys. We are partnering with EVS in environmental monitoring using an ATP device and this information will be reported quarterly. This is a great teaching tool for EVS staff.

Internal Partnerships
Materials Management Purchasing can be a boon or bust for infection prevention programs. Some devices that engineer risk out of invasive procedures can be significantly more expensive than standard products. The purchasing department can be a major ally when they see the whole picture, the breadth and depth of the IP program. This relationship was essential in obtaining a medicated central line, a silver coated indwelling catheter, hand hygiene stations, and other supportive products. IP is always called to the table when products are being evaluated. Money is NOT always the determining factor in decision making.

Internal Partnerships
Engineering/Facilities Maintenance Friends or Foes? Key players in environment of care issues. Teach them the importance of the IPs presence in project planning Make it easy for them -- policies, ICRAs, facility upkeep Help them see the IP in a positive light, not an intrusive one

Internal Partnerships
Education Resource to extend IP capabilities Help with employee IP performance Integrate IP with orientation, including documentation requirements, to facilitate reports needed for IP measures Assist with development of educational tools for patients and families Survey staff and plan requested/needed educational offerings

Internal Partnerships
Risk Management Expect the Unexpected! Assist with Investigation of serious safety events and near misses Assist with improving the safety culture of the facility Partners with IP in times of disaster , i.e., hurricanes, tornadoes, floods, etc. Supports unpopular IP decisions such as restriction of visitation Partners with IP for regulatory compliance

Internal Partnerships
Quality Eliminate redundancy Collects data for various quality measures, some of which is useful to IP Assists with the link between departments which is need for collaborative participation Usually manages the required reporting of core measures, etc. to CMS may help with NHSN requirements Another watch dog to keep compliance on track

Internal Partnerships
Information Technology Your new best friend Keep them informed of IP requirements, especially regarding mandatory reporting Garner their buy-in to IP needs so you will be fairly represented in IT purchases and upgrades Be sure any hospital-wide system is IP friendly and that EMR and surveillance software will interface properly, providing surveillance benefit Keep your equipment current and ask for classes if your computer skills need polishing

Potential External Partners

IHI http://www.ihi.org Partnership For Patients

http://partnershipforpatients.cms.gov/getinvolved/getinvolved.html CMS

HENS Hospital Engagement Networks State Hospital Association State APIC chapter National APIC Regional Collaboratives

CAUTI Catheter-Associated Urinary Tract Infection

How many Foley catheters are inserted in the Emergency Department at CGH?

October 2010
510 Foley Catheters were inserted at CGH

202 Foley Catheters were inserted in the E.D.

Why care about CAUTIs?

CAUTI is associated with increased morbidity and mortality. It is the second most common cause of bloodstream infections. 12% to 25% of hospitalized patients will have a Foley inserted and half of those are placed without meeting appropriate criteria. A patients risk for developing a CAUTI is approximately 3% to 7% each day that the Foley remains inserted. Studies show 40% of attending doctors, caring for patients with unnecessary Foley catheters, were not aware that the Foleys remained in place.

CARTERET GENERAL HOSPITAL REDUCES FOLEY CATHETER INSERTIONS

F O L E Y C A T H E T E R S I N S E R T E D

2010
250 202 200

153 150

155

149 141 131

126
113

123

ED OR ALL OTHER UNITS

100

44%
50
reduction

26%
reduction

0 Oct-10 Nov-10 Dec-10

CGH ED Reduces Foley Catheter Insertions 2011 Average reduction of 56%

F O L E Y C A T H E T E R S I N S E R T E D

202 Foleys inserted Oct 2010

200

150

113 102 100 85 75 61 50 64 72 94

70%
reduction

103 92 94

103

50%
reduction

44%
reduction

0 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11

3,651

3,510

10 9

Catheter Associated UTI Rates

8.58

Infections/Line Days X 1000

8 7

E D E d u c a t i o n N o v 2

6.96

6
5 4 3 2 1 0

5.5

1.07

Partnership For Patients Video

http://media.healthcarecommunities.org/HC/PFP/Videos/Reducing_CAUTI.wmv

Hand and Environmental Hygiene

ICT presents highlights from the OnSite brief exploring how Carteret General Hospital in Morehead City, N.C. boosted its hand hygiene and environmental hygiene efforts

As we say at the coast.Red sky at night, sailors delight Happy sailing to all fellow IPs!.....................Elaine and Kathy