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Some healthcare professionals are achieving the seemingly impossible in their departments—zero infections. It used to be unheard of, thought to be the stuff of which pipe dreams were made. Not so anymore. It’s happening. Healthcare Purchasing News talked with several healthcare professionals who shared their infection-prevention success stories. Their stories surely will make you want to push harder for successes of your own. Here’s how they did it.

Ultrasite Needle-Free IV System from B Braun Medical

Cathy Wishba, RNC, MS, neonatal clinical consultant, Intensive Care Nursery, Adventist Hinsdale Hospital, Hinsdale, IL, noticed an increase in central-line (CL)—associated bloodstream infections (BSIs) in the neonatal intensive care unit (NICU) on occasion over a year’s time, from November 2005 to November 2006. "We track CL-associated BSI rates through quarterly audits. In comparing our facility’s rate of infection to the national benchmark of 0 to 20 infections per 1,000 CLs, we found that we were spiking above the benchmark at times. We had spikes of 60 infections per 1,000 CLs; so 60% of our lines were becoming infected during certain months."

Wishba worked with the infection control department to resolve the issue. "We already had the Ultrasite Needle-Free IV System (B Braun Medical, Inc, Bethlehem, PA) in stock, but we weren’t using them on our CLs. After I researched how and why the Ultrasite valve may help in decreasing infections, we began using it for CLs in the NICU. At about the same time, I also implemented another product, ChloraPrep (Enturia, Leawood, KS), incorporating it into our policy. I also changed our policy to be very specific on how to place the Ultrasite CLs, how to clean them, and how often to change them. Educating staff on these changes was accomplished through one-on-one meetings, staff meetings, inservices, and written educational materials. The importance of handwashing was reinforced during these activities, too."

Striving for excellence paid off in spades. The changes implemented quickly achieved amazing results. "The NICU had no CL infections from January 2007 to June 2007. For 6 months, we had 0 infections, a 60% drop," Wishba told HPN. "We estimated that 6 infections were averted at a cost of $46,000 each; so, from January 2007 to June 2007, we saved nearly $300,000."

Kimberly-Clark’s BAL-CATH System

Kimberly-Clark’s Ballard Trach Care Closed Tracheal Suction System

Kimberly-Clark’s MICROCUFF Endotracheal Tube

Michael Hewitt, RRT-NPS, FAARC, director of respiratory care services, Memorial Hermann Texas Medical Center, Houston, TX, had been seeing ventilator-associated pneumonia (VAP) rates and bounce backs to his facility’s intensive care units (ICUs) at rates higher than acceptable. Memorial Hermann is a 1,000-bed, level-1 trauma and referral center that has approximately 4,000 new ventilator cases per year.

"We decided to be more proactive," said Hewitt. "In April 2006, we modified a VAP bundle program that was already in place." The respiratory staff began to treat all patients as if they were going to get sick, with the goal of warding off VAP before it found a toehold. "We started treating all vented patients with increased sigh breathing and vibratory therapy," explained Hewitt.

"We use the Ballard Trach Care Closed Suction System (Kimberly-Clark, Roswell, GA)," continued Hewitt, "which allows us to get the secretions out of the airway without disconnecting the ventilator. Traditionally, you have to disconnect the ventilator, but any time the circuit is disrupted, the opportunity for infection is increased and alveolar derecruitment occurs. We also use the Bal-Cath System (Kimberly-Clark) for nonbronchoscopic bronchoalveolar lavage. It’s a nicely designed catheter that extends deeper into the lungs for a sample that can help determine if any specific organism is present, allowing for more accurate antibiotic coverage. Another advantage is that our therapists can do this test themselves instead of having to wait for the doctor to come and perform a more expensive, but no more beneficial, test with a bronchoscope. We are now also incorporating Kimberly-Clark’s MicroCuff Endotracheal Tube to help decrease the potential for microaspiration. Traditional cuff technology is suspected to contribute to microaspiration, increasing the chance for VAP."

Hewitt mentioned other tools they employed against VAP: "We also use the Vest Airway Clearance System (Hill-Rom, Batesville, IN), which wraps around the patient and inflates to apply vibratory therapy. This device effectively mobilizes secretions, quite often before they are evident in the RTT or suspected via chest x-ray or other specific signs of lung infection. We also use another therapy, post extubation, that delivers positive pressure and vibratory therapy: MetaNeb CPEP (Comedica, Dallas, TX). This device provides medicated aerosol combined with continuous positive pressure and vibratory therapy to assist expanding the airways and mobilizing secretions. This device has helped decrease the number of ICU bounce backs related to pneumonia, atelectasis, and secretions."

The results of instituting the VAP bundle are impressive. Bouncing back of patients to the ICU has decreased, overall mortality rate has decreased, length of stay has decreased, and cost of care has decreased. Hewitt told HPN: "We have reduced the length of stay in surgical and orthopedic trauma patients that are off the ventilator by almost 4 days. Number of patients returning to the ICU with pneumonia is almost zero, whereas we once saw about a 3% to 4% bounce back (for the entire hospital). In the last 16 months, our VAP bundle and proactive approach has reduced VAP rates by 48%."

BD GeneOhm MRSA Assay

Jackie Whitaker, RN, MS, CIC, infection control director and National Patient Safety Goal administrator, University Community Hospital, Tampa, FL, is another who believes strongly in the value of being proactive, attacking an issue before it becomes a big problem. In this case, methicillin-resistant Staphylococcus aureus (MRSA) was her target. "I want essentially to nip it in the bud, to identify patients as early as possible upon admission" stated Whitaker.

Whitaker’s facility uses BD GeneOhm MRSA assay (BD, Franklin Lakes, NJ), a rapid-testing methodology, to screen for MRSA upon patient admission. "We have screened patients on admission in the recommended categories for the past 10 years, but this rapid test made it more efficient. Patients’ nares are swabbed upon admission, and now we know in an hour or two instead of a day or two whether the patient is carrying MRSA."

Identifying MRSA-positive patients upon admission meant that patients could be placed correctly from the get-go. "The rapid assay really reduced the time patients spent in isolation. It allows proper placement of the patient the first time," said Whitaker.

"Our ICPs started monitoring results of the rapid MRSA tests, that is, how many tests were run compared to how many results were positive," continued Whitaker. Monitoring the results revealed astounding news. "We started tracking the dollars associated with being able to take a patient out of isolation earlier. At $500 saved per day, we saved $170,000 in the first month by taking patients out of isolation that didn’t need to be there. The flip side is patient outcomes. We had been averaging two MRSA infections per 1,000 patient-days; now we’re running 0.8 MRSA infections per 1,000 patient-days, a reduction of more than 50%. We’re saving about $2 million per year."

Whitaker wasn’t content to stop there. She’s on a campaign to educate staff as to the link between transmission of multidrug-resistant organisms (MDROs) and handwashing compliance. "We also track all MDROs. We’re tying in outcomes for each unit with their activities. This year we’re correlating our outcomes with handwashing compliance. At the end of January, I’ll do an educational session with our clinical leadership to show how outcomes correlate with the number of times nurses are washing their hands per patient-day on their unit. I have just set the benchmark. Handwashing compliance benchmarks are set based on acuity of patient care. Medical units are set at 80 hand washes per patient-day; ICUs are set at 125 hand washes per patient-day. This information is compared with outcome indicators, tracked by nursing unit, and the level is set based on the outcome indicators tracked per nursing unit. Over the last 2 years, I have noted patterns for some of the units and, as a result, instituted measures that will increase compliance with handwashing."

Whitaker, who serves on Medline Industries’ advisory board, said that Medline (Mundelein, IL) will soon release new tools designed to improve handwashing compliance. The Hand Hygiene Compliance Kit (available only through Medline reps; they are not for sale and individual items are not available) will include a training manual, rewards program, communication placards, infection control cost calculator, competency evaluation, infection-protection cost calculator, and a patient and family education pamphlet. Another product, The Competency Validation Kit, is comprised of a portable ultraviolet light, Visirub (fake germs for demonstration purposes), and Sterillium Comfort Gel alcohol-based hand rub. "Our unit patient-safety officers can take this kit to all their departmental meetings to demonstrate proper handwashing, then show individuals whether they’ve removed all the germs from their hands."

Medline Industries’ UV light and Visirub shows users whether they have performed handwashing effectively.	Medline’s Hand Hygiene Compliance Kit

The best-case scenario is to prevent an infection situation from developing in the first place. Robert Garcia, PharmD, director of pharmacy and materials management, Advocate Trinity Hospital, Chicago, IL, is a believer. He stated his position clearly: "It’s all about assurance that we’re doing the best we can for patients."

One of the measures his pharmacy department has taken to assure a cleaner environment for patients is disposable liners for medication bins. Medication carts have a bin for each patient’s medication, and the carts are wheeled from patient room to patient room. Sometimes medicine may be spilled, or perhaps a nurse may fail to follow hand-hygiene protocol, which presents the potential for the medication cart to be contaminated.

The Joint Commission International Center for Patient Safety’s document "Infection Control in Medication Storage Bins," (Patient Safety 2005;5:11) suggests considering the use of bin liners, saying, "Although the risk of contaminants still exists with bin liners, it is significantly reduced. . . . Disposable liners provide a consistent, convenient, and cost-effective method for maintaining clean bins."

Garcia explained how Advocate Trinity Hospital began using disposable plastic medication bin liners: "In 2006, one of our pharmacy personnel saw Health Care Logistics’ (Circleville, OH) Daschner bin liners at a conference and thought it had potential to help ensure that we’re maintaining good infection control practices. It seemed to be a cleaner way of taking care of patients’ medications. We placed a small order and piloted the bin liners to see how the nurses, the infection control department, and we as pharmacy personnel felt about it. We’d read a lot about MRSA outbreaks at other institutions, and we wanted to make our patients’ environment as healthful as possible. The nurses agreed it was a good idea to use the Daschner bin liners. The ability to easily change the liners whenever there was a spill of any sort made it very convenient for nurses while at the same time contributing to a safer, cleaner environment."

"We haven’t performed any studies to see how it might have reduced infection, we just know it’s the right thing to do," said Garcia. "It’s all about assurance that we’re doing the best we can for our patients. The amount spent on Daschner bin liners is negligible compared to costs that could be saved by avoiding potential infections. We want to keep the medicines we’re giving to our patients as clean and healthful for them as we can make it. It makes us feel better to know we’re doing the right thing."

Daschner Bin Liners from Health Care Logistics.

Readers who would like to examine HCL’s bin-liner study, "An Evaluation of Medication Drug Bins as a Potential Source of Nosocomial Pathogens," can email their request to hcl@healthcarelogistics.com.