True, the campaign against infection may be experiencing renewed vigor due to Medicare’s refusal to reimburse for certain infections, but let’s never forget that those in the trenches battling infection really do care about providing a safe environment for their patients and staff. Battling infection can be a tough, frustrating, thankless job. You have to want to be there.

There’s one characteristic shared by many infection control professionals that in other people might be annoying but in them is a virtue: They’re never satisfied. Good isn’t good enough. Better is just that, better. What they really strive for is excellence. They’re always looking for ways to make their facility’s and patients’ situations better, more efficient, less costly, but mostly, safer. Let’s look at some of those infection control professionals who are continuously striving for excellence and examine what they have done to make their environments safer.

How they did it: At Jennie Edmundson Hospital, they found that involving multiple departments and disciplines was an important part of attacking the problem. "The issue was addressed by physician and nurse representatives from patient safety, infection prevention, and the ICU," said Love, "and our potential solution started in our Clinical Quality Value Analysis Committee."

BD Q-Syte Luer Access Split Septum is a needleless connector with a straight, unobstructive fluid path

They had been using bundles since 2005, noted Love. "When the infection rate spiked again, in August 2007, we immediately started looking for solutions." Current processes include employing recommendations of the CDC’s "Guideline for Prevention of Intravascular Device-Related Infections," and other evidence-based practices. Elements of their catheter-insertion bundle include a checklist, to document that all components of the bundle (caps, gowns, masks, and gloves; BioPatch [Ethicon, Inc, division of Johnson & Johnson, Sommerville, NJ] antimicrobial dressing with chlorhexidine; chlorhexidine [ChloraPrep, Cardinal Health, Leawood, KS]) are used for skin prep before insertion. The need for a central line is reviewed daily, removing it when feasible. Despite having these elements in place, the CR BSI rate was unacceptable," said Love.

"I knew that there were reported increases in BSIs temporally associated with a change from split-septum technology to mechanical valves." After review of the literature, a search began for a device that met their criteria: easy to clean the access surface; presence of clear housing, so that incomplete flushing is not masked; and high flow rates. They eliminated devices that had a gap around the device plunger, which has the potential to harbour bacteria, and those that had internal device mechanisms, which may obscure the fluid path. "We identified a device that met our criteria and gained approval for a trial of the device from our Physician Quality and Infection Prevention Committee. The new needleless device we selected is a closed luer access, split-septum device, BD Q-Syte Luer Access Split Septum (Becton, Dickinson and Company, Franklin Lakes, NJ)."

Results: The new device was introduced into the ICU in November 2007. The CR BSI rate quickly decreased to 0 in the ICU and has been maintained to date. "The decrease to 0 in the ICU prompted the use of this device for all central lines in our facility in January 2008," said Love. "As of January 2009, the ICU rate remains 0 and the house-wide rate has decreased 67%, from 4.06 infections per 1,000 catheter-days to 1.38 infections per 1,000 catheter-days."

Sage CHG Cloths are rinse-free for maximum infection prevention

How they did it: Patients were educated on how to use the CHG cloth (Sage 2% CHG Cloth, Sage Products Inc, Cary, IL) when they arrived at the hospital. The patient washed himself or herself for approximately 30 seconds, from jaw bone to toes, allowing the body to air-dry. The prepackaged cloths were warmed prior to use to decrease risk of hypothermia. No lotion, moisturizers, or makeup were allowed, as was no shaving of the operative site. Patients were required to sign the instruction form to verify that they had read the instructions and had used the cloths accordingly. Rhee noted: "Signed patient forms were forwarded to Infection Control for review and data collection. No other SSI prevention measures were implemented during this time."

Results: "Rates of SSI were measured 10 months prior to implementation of the preoperative skin preparation protocol and 10 months post-implementation," said Rhee. "There were a total of 25 SSIs in the 10 months prior to institution of the protocol and 11 SSIs during the 10 months after institution. The SSI rate went from the historical rate of 2.1% in the 10 months pre-implementation to 0.7% in the 10 months post-implementation. Despite higher skin-antisepsis product cost, the decreased number of SSIs resulted in cost savings of $348,923 in the 10-months post-intervention."

How they did it: The project was kicked off in July 2008 with a statewide MRSA Summit. Hospitals; long-term, behavioral, correctional, and ambulatory-care facilities; the department of public health; law enforcement; athletic facilities; and schools participated. "A shared challenge requires shared vision. The summit helped us develop a statewide roadmap for success in elimination of MRSA transmission."

"Following the summit, a web-accessible toolkit was developed that builds on the idea of bundling prevention activities that promote hand hygiene, use of Isolation Precautions, and environmental cleaning and disinfection. Toolkit elements include the evidence basis for the interventions; specific examples on which to base interventions, including sample policies, checklists, and forms; tools for monitoring performance; the ability to input results from one outcome and two process measurements; and, the ability to benchmark those outcomes among other Kentucky hospitals."

Cardinal’s ChloraPrep antiseptic system minimizes direct hand-to-patient contact, helping reduce risk of cross-contamination

"Since one of the outcomes involved the need to ensure correct blood-culture results, a sample policy outlined proper skin disinfection focusing on use of a chlorhexidine-alcohol combination. A video, funded in part by Cardinal Health (Dublin OH), provided step-by-step visual instruction on the elements of correct blood-culture collection procedures and covered key activities, including use of Cardinal Health’s ChloraPrep antiseptic system and the example of an effective process for skin disinfection. This product was chosen for its 2% chlorhexidine/70% isopropyl alcohol formulation, as well as the applicator, which minimizes the opportunity for contamination of the prepared skin and helps reduce organisms that may be present on the patient’s skin, including MRSA."

Results: Standardization and networking have kept participates engaged and resulted in improved patient outcomes, said Carrico. "Common obstacles, such as variation of isolation signs and outcome measurements that were difficult to obtain by infection preventionists, were confronted. Artificial barriers, such as the perceived inability to standardize isolation signage and procedures, environmental challenges, and observational monitoring capabilities, were addressed. Cohesion among the participants has emerged as a secondary benefit. The result has been an improvement in the safety of patients through a demonstration of the power that occurs when people experiencing the same problems come together and work collectively to remove obstacles."

Although improvement rates cannot be shared yet, Carrico noted that "100% of the hospitals are participating in this collaborative, and 100% are submitting data. They are monitoring hand-hygiene compliance and environmental-cleaning compliance as the process measures and incidence of invasive MRSA infection (BSI) as their outcome measure. The results are positive to the point that there is already discussion of expanding the collaborative to other settings (eg, long-term care) and developing other outcome metrics that look at incidence of urinary tract infection and Clostridium difficile infection, and adding process measures such as central-line insertion, adherence with Isolation Precautions, and antimicrobial stewardship."

How they did it: "While documenting the results for instrument flash sterilization, we simultaneously began to take a more in-depth review of any inconsistent workflow processes, as well as the effectiveness of our sterilization processes. This review included physical monitors: cycle times, documentation, and record keeping; biological and chemical indicators; potential for sterilization process failures: wet loads, rate of recall, and corrective action; vendor management and control guidelines: acquisition to disposition of instruments, drop-off times, etc."

This information was used to create a performance-improvement matrix that would help provide base lines and define the appropriate timeline to drive all process improvements, both operational and financial, explained Schuler. "A holistic approach was developed to utilize process mapping to identify redundant and non-value processes to our workflow, particularly with flash-sterilization log-documentation protocol. The departments included in this process were OR, central processing, central stores, supply chain management, and infection control."

"Our education coordinators worked to ensure that staff competencies and professional education opportunities were developed and requirements were met. The education included resource validation, stakeholder input, hardware interface, instrument tracking, and monitoring of equipment."

Getinge’s T-DOC Instrument Tracking and Asset Management System provides instrument traceability and inventory management. It enhances process quality assurance through real-time logging of washer-disinfector and sterilizer-cycle parameters.

Review, education, and reinforcement of sterilization standard operating procedures enabled them to standardize surgeon sets and workflow methods. "A project was initiated to look at our eye-instrument–set flash rate in January 2008," said Schuler. "By July 2008, we were able to document a 95% decrease in overall flash sterilization of eye -instrument sets simply through workflow and process changes. Since July 2008, we have purchased additional eye sets to offset any flash sterilization. Additional instrument purchases were made for instrument sets with high utilization and high flash-rate percentages. Tracking data was done through our instrument tracking system. We developed and enforced vendor guidelines for the systematic management of the loaner instrumentation and implants from acquisition to disposition."

A crucial step was gaining support from surgeons for zero flash sterilization. "Our facility is working with the surgeons and stakeholders to come up with alternative solutions related to the scheduling of back-to-back cases. Block scheduling increases the likelihood that the same sets will be needed, which does not always allow for optimal time to reprocess instrument and implant sets."

"The development of Sterility Assurance Program in the Operating Core areas will provide 24-hour coverage of autoclave and sterilizer operations, and will be implemented in May 2009," continued Schuler. "The purpose of this program will be to eliminate flash sterilization and increase compliance with no-flash policy. The hope is that this program will promote knowledge and efficiency to improve job performance and OR satisfaction, create higher levels of cooperation and communication between departments, and implement uniform sterilization testing for all equipment." Each month, members of a subcommittee, comprised of OR and central processing personnel, meet with the infection control department to talk about cases where flash sterilization was used. This helps in identifying ways to decrease the need to flash sterilize.

Results: "We have seen significant decreases in our overall flash sterilization of instrument sets," said Schuler. "The average rates of flash sterilization have decreased from 26% to 4% from June 2007 to January 2009. In 2009, Sanford USD Medical Center has the lowest infection rate we have seen at the hospital in years. We believe that heightened awareness and improvements to department processes have definitely aided in the reduction of the overall rate."