They demonstrate that there isn’t necessarily only one way to achieve a goal and that sometimes it doesn’t even take money to hit the mark. What it does take, however, is the desire to improve performance, willingness to put on the thinking caps, exercising a little elbow grease, and arriving at a common understanding of what’s needed and why. Multidisciplinary teamwork is a recurring theme in these success stories.

Take these stories as a personal challenge. Make it your goal to stamp out infection in your facility. Get ready, get set, get inspired!

Surgical-site infection (SSI) is an enormous problem any way you measure it. The Institute for Healthcare Improvement tells us, "Postoperative infection is a major cause of patient injury, mortality, and health care cost. An estimated 2.6 percent of nearly 30 million operations are complicated by surgical site infections (SSIs) each year... Each infection is estimated to increase a hospital stay by an average of 7 days and add over $3,000 in charges."¹

How they did it:
Halsey M. Bagg, Director, Cardiac Services, told HPN that their community hospital chose a multidisciplinary approach to reduce postoperative CT SSI and LOS. The Cardiac Quality Improvement Team included members of the infection control (IC) department, CT operating room (OR), and CT intensive care unit (ICU), as well as the MVHI educator, a pharmacist, the quality-assurance nurse, a perfusionist, an endocrinologist, and the CT surgeons.

MVHI used a "bundled" approach that emphasized the following:

• Improved use of antibiotics, ie, administration within 30 minutes prior to cut time, re-dosing with operations exceeding 3 hours, and adjustment of dosage according to patient’s weight

• Back-to-the-basics practices, ie, review of aseptic technique; no artificial nails, no unrestrained hair, no excessive jewelry; good handwashing techniques; restriction of access to the CT OR and ICU; changing to Triseptin (Healthpoint Ltd.) body wash and scrub; and creation of a step-down unit

• Silver-impregnated dressings (Acticoat, Smith & Nephew)

• Screening all CT surgery patients for methicillin-resistant Staphylococcus aureus (MRSA)

• Control of glucose, using a modified Portland Protocol, pre-, intra-, and postoperatively

• Application of mupirocin (Glaxo-SmithKline) to the nares of all patients pre- and postoperatively

Results:
Whereas LOS and rate of SSI took a dive, profit took a big leap. In 2005, LOS dropped to 9.95 days versus 11.15 in 2004. Rate of SSI dropped from 4.7 in 2004 to 0.0 in 2006. Profit per case rose from $356 in 2004 to $791 in 2005. "The cost of implementation was minimal compared to cost-avoidance, which is conservatively estimated at over $250,000. More
importantly, many patients avoided life-threatening sternal wound infections," noted Bagg.

How they did it:
Maureen Spencer, RN, M.Ed, CIC, Infection Control Manager, explained: "The team evaluated procedures, practices, and facility design, and prioritized action plans to institute changes and IC measures. Issues included traffic control, surgical attire, cleaning of the OR, processing of instruments, air-handling system and laminar flow, surgical hand scrub, Joint Commission on the Accreditation of Healthcare Organization Surgical Infection Prevention core measures, postoperative dressings, antibacterial suture material, and education. An important component included consistent and timely collaborative communication at monthly staff meetings."

Results:
The rate of orthopedic SSI took a plunge during the 4-year project, with some procedures demonstrating zero infections in 2006. At the beginning, in FY03, there were 63 infections in 8,837 cases (0.7). FY04 showed some improvement at 60 infections in 9,669 cases (0.6). The next 2 years showed significant improvement, with FY05 having 49 infections in 9,216 cases (0.5) and FY06 having 46 in 8,986 cases (0.5). In FY06 there were zero infections in 853 total hip replacements with zero risk index and only 1 infection in 848 total knee replacements with zero risk index.

"The importance of a team approach to IC, especially in the OR," noted Spencer, "is key to the success of the program. Intent for a zero infection rate created hospitalwide support. Program components must include consistent communication, networking, creative marketing, education, and, most importantly, administrative support."

How they did it:
VHA member CHN chose a framework based on Plan-Do-Study-Act (PDSA) improvement cycles, redesigning their system using evidenced-based practices to improve the quality of patient care. Their multidisciplinary team included senior leadership, OR staff, a surgeon champion, an epidemiologist, an endocrinologist, clinical educators, respiratory therapy, and a designated data collector, with the IC nurse as project leader.

Manning explained that, "A formal budget was not developed, but CMS recommended one full-time employee (FTE) be devoted to the 13-month project. Our team used all members to maintain data collection, analysis, reporting, and education. Clinical education and feedback required at least 40 hours per week at $35 per hour. A few members at a time attended four national learning sessions to support networking and collaboration with other facilities at a cost of $500 each."

The following initiatives were put in place, with the expectation of 100% compliance in every patient: Use of prophylactic antibiotics consistent with guidelines; administration of antibiotic within 0 to 60 minutes of cut time; discontinuation of antibiotic within 48 hours after surgery; control of glucose in all patients at <200mg/dL perioperatively through 48 hours; removal of hair by clipping.

Redesigned workflow reduced variation in timing and increased use of appropriate antibiotic. Preoperative orders were standardized, and administration was assigned solely to anesthesia, with all patients now receiving antibiotic in the OR. Education, computerized documentation forms, standardization of personnel performing hair removal, removal of all razors from the OR, and purchase of an adequate number of clippers aided in achieving compliance with clipping.

Glucose control became the primary focus of the project for two reasons: Monitoring had the most impact on their work, and the connection between glucose control and infection prevention was a new concept, so staff were resistant to treating nondiabetic patients. Education resulted in overwhelming support in meeting this goal. Revised preoperative orders included obtaining an HgbA1C and an endocrinologist consult for patients undergoing CABG and valve procedures. Order sets for insulin infusion were standardized, and a single order set was developed.

Methods used to gain support and collaboration included physician dinners, to facilitate networking; one-on-one education; monthly feedback of data; and ongoing requests for staff input.

Results:
Work redesign significantly improved patient care and reduced the infection rate by half the first year (2.4% in 2001 to 1.4% in 2002). For the past 4 years, rates remain at or below the NNIS median benchmark of 2.4%. Avoidance of four infections during that year saved approximately $324,072.

"The Collaborative Project is no longer a project but a way of life," enthused Manning. "Hard work paid off with tangible results. Creating and redesigning work processes that are durable and reproducible allowed the initiatives to become ingrained into everyday practice."

Overpowering Resistant-organisms

Resistant organisms continue to present a major threat to health and healthcare economics. There was a time when hospitals were fairly content just to try holding the numbers down. The current focus on patient safety and evidence-based practices has fostered the movement to eradicate resistant organisms.

How they did it:
Maureen Spencer, RN, M.Ed, CIC, Infection Control Manager, described the route NEBH chose to achieve their goal to eradicate MRSA and MSSA: "Administrative support was elicited from the Senior Vice President of Patient Care Services to fund an eradication program that included nasal screens obtained with rapid PCR [polymerase chain reaction] technology, which enables a 2-hour turnaround for results. The program required two additional FTEs and a budgetary cost of approximately $400,000. The board of trustees and administration approved the program, which was implemented in July 2006."

Results:
From July 17, 2006, through November 30, 2006, 1,901 patients were screened; 446 (23%) were positive for MSSA, and 82 (4%) were positive for MRSA. The nares of both MSSA and MRSA patients were treated with 2% mupirocin (Bactroban, GlaxoSmithKline) ointment for 5 days, and MRSA-positive patients were instructed to bathe with 2% chlorhexidine scrub (BactoShield, STERIS Corp.) for 5 consecutive days prior to surgery. "Repeat nasal screens on MRSA patients revealed greater than 60% eradication," said Spencer. "Since implementation, there have been no MRSA infections in patients who screened positive for MRSA and who were treated with vancomycin for surgical prophylaxis. Compared to the same time period in FY05, there is a 66% reduction in SSIs due to S aureus."

"We successfully implemented an MSSA and MRSA eradication program in an orthopedic-specialty hospital for all inpatient surgical procedures during the pre-surgical screening process. It allowed for early identification of nasal carriers of MRSA, who now receive surgical prophylaxis with vancomycin. We have documented a reduction in S aureus infections, with significant cost savings to the institution. It is estimated that an SSI costs approximately $25,000. In comparing these two time periods, we have five fewer infections at a cost savings of $125,000. We anticipate further reduction as the year continues."

How they did it:
Hoffmeister explained: "SAHC started by reviewing and revising IC practices, educating staff on the need to return to basic principles of IC, and launching an attack on hand hygiene, environmental disinfection, and recognition and screening of admissions for resistant organisms. Whereas the project is ongoing, the major work required 3 years."

SAHC also initiated use of several products that they believe cut specific hospital-acquired infection (HAI) rates: BioPatch Antimicrobial Dressing (Johnson & Johnson, Advanced Sterilization Products Division, Ethicon Inc.); Avagard D Instant Hand Antiseptic (3M Health Care); CaviCide surface disinfectant and CaviWipes (Metrex Research Corporation); Hype-Wipe Disinfecting Towel with Bleach and Bleach-Rite Disinfecting Spray with Bleach (Current Technologies Inc.); Bardex I.C. Silver-Coated Latex Foley Catheter (Bard Medical Division); Bard StatLock I.V. Catheter-Stabilization Devices (Venetec International, Division of Bard Inc).

Results:
SAHC experienced a 70% to 100% decrease in the rates of the following HAIs after implementing these measures and products:

• Central-line (CL)—associated primary hospital-acquired bloodstream infections decreased-from NNIS benchmarking for the 25th percentile in 2001 to less than 0.1 infections per 1,000 device-days, both housewide and in ICUs, by 2005 after the introduction of BioPatch Antimicrobial Dressing in all insertion and dressing change kits; the use of StatLock securement device for all CL and peripherally inserted central venous catheters; a strong program encouraging use of Avagard D Instant Hand Antiseptic; and strongly encouraging the use of CaviCide and CaviWipes for equipment and environmental cleaning.

• Ventilator-associated pneumonia decreased from 2001 to date by over 80%, also due in part to increased awareness for hand hygiene and environmental cleaning using the above products.

• MRSA, and vancomycin-resistant enterococcus (VRE) rates fell 70% to 80%, whereas community-acquired MRSA and VRE cases in the same time frame (2001-2006) increased by 100% to 300%. Use of these products had a direct relationship on these rate decreases.

• Rates of hospital-acquired Clostridium difficile decreased after introduction of Hype-Wipe Disinfecting Towel with Bleach and Bleach-Rite Disinfecting Spray with Bleach for environmental and equipment cleaning in patient rooms with C difficile, whereas our community has experienced a marked increase in C difficile.

"We now hope to see a decrease in the incidence of Foley catheter-related urinary tract infections with a targeted campaign for adherence to IC principles in the insertion and maintenance of Foley catheters and the use of StatLock securement devices for all indwelling urinary catheters," noted Hoffmeister.

How they did it:
VHA member Medcenter One also chose the multidisciplinary-team route. The team was comprised of representatives from the departments of IC, anesthesia, ICU, education, and infectious disease. Over a period of 2 years, the team reviewed their old practices, beginning with reviewing and implementing CDC’s "Guideline for Prevention of Intravascular Device-Related Infections," and implemented new evidence-based practices. Prevention strategies approved by the Quality Council and the Medical Staff Executive Committee included the following:

• Wearing of sterile caps, gowns, masks, and gloves when inserting a CL, enforced through development of a documented checklist for tracking sterile technique

• Using BioPatch (Johnson & Johnson) antimicrobial dressing with chlorhexidine

• Development of the Central Line Care Quick Reference Sheet

• Using chlorhexidine (ChloraPrep, Enturia Inc., formerly Medi-Flex) for skin prep before insertion of CL

• Use of a CL with an antimicrobial coating (Cook Spectrum catheter, Cook)

Results:
"By using the practices as stated, our facility has had two quarters in a row with zero central bloodstream infection in the ICU setting in 2004 and 2005," said Barnum.

Hopefully, these stories will inspire you to find new ways to reduce infection at your facility. Some of these stories were accomplished with new funds, but some show that reviewing and revising current practices and products may be all that’s needed. Stay abreast of the issues, think long and hard about how procedures and practices could be performed better to reduce infection, then roll up your sleeves and get to work. Next time, it may be your story that inspires others to raise the bar at their facilities.

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