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 everyone’s 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 Preventionist’s role across the hospital

• The IP is just the “Chief Cootie Counter”

• She’s “just a nurse”

• “I don’t have time for infection control”

• “Why do you want or need to know that?”

• Another “clipboard” nurse

• “You don’t 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 there’s not enough hours in the day for the “lone wolf” IP?

SO…How do you build a successful infection prevention program???

Be Prepared for a Baptism by Fire, and…

• Learn Your Facility

• Study Your Facility’s Organizational Chart

• Develop Relationships With Key Individuals

• Study the Flow of Information

• Get Engaged with the Hospital’s 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 facility’s 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, CLABSI’s 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 hospital’s 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 in-house 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 facility’s 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

Today’s 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 facility’s 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 IP’s 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/get-involved/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 patient’s 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.

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CGH ED Reduces Foley Catheter Insertions

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202 Foleys inserted Oct 2010

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ED Education Nov 2

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, sailor’s delight Happy sailing to all fellow IPs!.....................Elaine and Kathy