Germ warfare goes viral
Environmental Services pros share success stories
by Susan Cantrell, ELS
the good fight means to stay the course, to persevere, to be faithful to the
truth. The truth is that healthcare workers and environmental service
workers are fighting the good fight against hospital-acquired infections (HAIs)
every day. It is not easy work. It can be messy and smelly and thankless. It
can be monumentally frustrating, because often there are no quick fixes
while patients’ lives hang in the balance—but—they persevere until they
figure out what works. Lives will be saved.
Some examples of those who have fought the
good fight follow. These infection-prevention success stories represent
those who are willing to go the extra mile, those who are willing to stick
their neck out, those who are willing to think out of the box. Take heart.
The good fight is being fought with more and more successes.
Using hospital surfaces
to battle infections
Copper Development Association
New York, NY
A multiyear study was conducted in the
medical intensive care units (MICUs) at three hospitals: Memorial Sloan
Kettering Cancer Center in New York City, the Medical University of South
Carolina, and Ralph H. Johnson VA Medical Center, both located in
Charleston, South Carolina. The purpose was to demonstrate the effect of
antimicrobial copper alloy touch services on three pathogens and relate it
to reduced HAIs.
Antimicrobial copper touch surfaces in an ICU room at
Ralph H. Johnson VA Medical Center, Charleston, SC.
How they did it:
Harold T. Michels, PhD, PE, Senior Vice President, Technology and
Technical Services, Copper Development Association Inc., described the
problem and their approach to improvements. "A multiyear study was conducted
to determine the impact of inherently antimicrobial copper alloy touch
surfaces on three microbes found in healthcare facilities: methicillin-resistant
Staphylococcus aureus (MRSA); vancomycin-resistant enterococci; and
Acinetobacter baumannii, assessing principally whether a lower microbial
bioburden would reduce the number of HAIs."
"Microbial burden values on hospital
surfaces were collected for 21 months. Patient infection data were collected
from July 12, 2010, to June 14, 2011," said Michels. "Results from the
project firmly established that the built environment represents a
substantial risk.1 The baseline microbial burden on frequently touched
surfaces in close proximity to MICU patients routinely exceeded a value
believed to represent a risk for the acquisition of infectious agents, 2.5
The study’s results were astounding. "After an intervention, where
inherently antimicrobial copper alloys replaced existing plastic, metal,
wood, and painted materials on 6 high-touch surfaces, sampling showed a
median reduction in burden of >99.9%," said Michels. "This observation is
significant in that antimicrobial copper surfaces were able to maintain
bacterial burdens below levels set for terminal cleaning during the routine
course of patient care. In addition to this marked reduction in microbial
burden, a significant reduction in HAIs was observed in rooms with
copper-clad surfaces, representing a relative-risk reduction to the rate of
HAIs of greater than 50% (N=564, 95% confidence interval, P=0.00003).2 This
signifies the first time a continuously active material placed in the built
environment facilitated a simultaneous reduction to both microbial burden
and the rate with which HAIs are contracted. The bulk of this research has
This work was supported by the U.S. Army
Medical Research and Materiel Command under Contract No. W81XWH-07-C-0053.
Any opinions, findings, and conclusions or recommendations expressed in this
material are those of the author(s) and do not necessarily reflect the views
of the U.S. Army Medical Research Acquisition Activity.
Persistence in hand
Baptist Memorial Hospital
North Mississippi, Oxford, MS
Baptist Memorial Hospital, North
Mississippi, a 217-bed regional hospital, needed "to determine if using
persistent products would reduce HAI rates and healthcare costs," said Betty
A. von Kohn, RN, BSN, CNOR, CIC. "Current healthcare guidelines require
frequent sanitizing, but it is not persistent or long-acting. This allows
transmission of germs between normal cleaning, sanitizing, and disinfecting.
The objective of this study was to determine if using a persistent
antimicrobial hand-sanitizing lotion and surface disinfectant would bridge
any gaps and reduce HAIs and healthcare costs."
How they did it: The study, which took
place in 2011, is a before and after comparison of nosocomial infection
markers (NIMs) rate, as reported by
MedMined (a CareFusion company,
Birmingham, AL) surveillance technology. Three months’ (April to June) NIMs
rate before Germ Pro [use] was compared to 3 months
(August to October)
during Germ Pro use," said von Kohn. "July was not used for the comparison,
because project approval and in-service training were done in July."
Staff were instructed to continue observing
CDC hand-hygiene guidelines. Then they turned the program up a notch.
"Healthcare workers were instructed to apply Germ Pro Hand Sanitizing Lotion
at start of their workday and to reapply every 4 hours. Placement of Germ
Pro Lotion at the time clocks makes using the lotion quick and easy," noted
von Kohn. "Staff really liked the lotion. [It] was reported to heal cracked
hands and to be nonsticky. Employee Health reported a reduction in hand
Hand Sanitizing Lotion
"Environmental-service employees were
instructed to apply Germ Pro Surface Disinfectant to high-touch points after
terminal discharge cleaning in patient rooms and monthly in common areas.
Germ Pro did not replace any products or sanitizing practices. They were
used in addition to all current guidelines."
Results: "The study determined product
effectiveness and cost-benefit analysis," said von Kohn. "A 43% reduction of NIMS validated the theory that using a persistent antimicrobial sanitizing
lotion and surface disinfectant can fill the gaps in surface disinfecting
and hand hygiene," said von Kohn. "Patient safety is greatly improved, while
realizing significant cost savings."
The following numbers illustrate Baptist
Memorial’s success: MRSA rate reduction, 53.8%; quantity of NIMS reduced,
62; cost per NIM, $4,055; 3-month cost savings, $251,410. Projected annual
savings is $1,005,640, and estimated annual cost is $20,000. Here’s the
kicker: "One week’s savings pays for both persistent products for the entire
year," noted von Kohn.
"The data validated the importance of the
role of Germ Pro’s hand sanitizing lotion and surface disinfectant in
infection prevention and the role high-touch surfaces play in transmission.
The trial has been a positive measure for our facility, as we promote a
safer environment for staff, patients, and visitors," said von Kohn.
Increasing hand-hygiene compliance
Greenville Hospital System
University Medical Center
Greenville Hospital System (GHS) University
Medical Center is a 5-campus, 1,268-bed health system ranked among the
nation’s top 50 hospitals in U.S. News & World Report’s America’s Best
Hospitals, 2012-2013. Heather McLarney, Vice President Marketing,
Charlotte, NC, explained the hospital’s goal: "The GHS Infection Prevention
Team, with the support of the organization’s leadership, initiated a highly
focused effort to improve hand-hygiene compliance systemwide. The study
began in December 2009. It was published in April 2011."
How they did it: As is the case with many
successful infection-prevention efforts, this one began with teamwork.
"Realizing the importance of staff involvement to the success of the
program, the first effort was to hold a contest among employees to create a
campaign theme," explained McLarney. "The winning slogan was ‘Germ Warfare:
Join the Battle.’ The team created employee communications and tools related
to hand hygiene using this motto."
GMS hand-hygiene–compliance reports
The team enlisted yet more help. "The team
also recognized that they needed a physician advocate on their side,"
explained McLarney, "and approached Tom Diller, MD, Vice President of
Quality and Patient Safety, who enthusiastically agreed to support their
efforts. Kevin Gilroy, MD, a hospitalist with a passion for hand hygiene,
was appointed the physician leader for the hand-hygiene team."
"The team also participated in a study with
Elaine Larson, PhD, Columbia University School of Nursing. The HOW2
Benchmark Study established the expected numbers of hand-hygiene
opportunities in various types of units in different hospital settings,
based on the WHO’s Five Moments for Hand Hygiene standard. This breakthrough
study was published in the American Journal of Infection Control in April
2011.5 This study was used to create the algorithms in the DebMed GMS [Group
Monitoring System], being used at GHS to monitor compliance rates
electronically. It allows GHS to create a culture of safety based on
collaboration and working as a team, rather than singling out individuals."
McLarney summarized the three main efforts
leading to their success. "The keys to the GHS team’s success were getting
frontline staff involved, using a scientific approach to data analysis that
was credible, and engaging physicians to champion the initiative. "
Reduction in infections, costs,
and hand-hygiene compliance was significant. Central-line—associated
bloodstream infections (CLABSIs) were reduced by 60%. It was estimated to
have saved more than $3 million this past year. More than 50% reduction in
ventilator-associated pneumonia rates also saved nearly $3 million this past
year. They created an interactive hand-hygiene program, based on data
collection and identifying barriers to compliance, which resulted in
improved hand-hygiene compliance from 50% to over 90%, per direct
Reducing CLABSIs and increasing hand-hygiene compliance
Children’s Hospital of Atlanta
Wava Truscott, Director Medical Sciences
and Clinical Education,
Kimberly-Clark Health Care, Roswell, GA, explained
the goal was to involve everyone at Children’s Hospital of Atlanta, from
front-line staff to executive committees to home health agencies to
patients’ families, in an effort to reduce infections among pediatric
patients significantly. "The campaign started at the 529-bed healthcare
organization in 2006, with the goals of reducing systemwide and unit-level
CLABSIs and increasing hand-hygiene compliance," stated Truscott.
How they did it: "The vascular access,
performance improvement, and infection-prevention teams were first enlisted
to develop a campaign to increase awareness, educate, and reduce harm to
their patients. A key strategy was to enable clinicians and nonclinicians to
recognize that they play an instrumental role in the prevention of
"The Bloodstream Infection Task Force was
created," said Truscott, "with key stakeholders across the continuum of
care. They adopted evidence-based CLABSI prevention bundles and practices
supported by national quality organizations such as Child Health Corporation
of America and the Institute of Healthcare Improvement. The
infection-prevention and quality team also initiated change by helping to
create tools for real-time CLABSI data monitoring and analysis, first
piloting and then rolling out a ‘BSI huddle,’ a strategy to improve
communication among the various staff members. A vital underpinning of this
initiative was ongoing education of clinicians and non-clinicians about
their roles in preventing CLABSIs."
Children’s Hospital of Atlanta received Kimberly-Clark's 2010 HAI
Watchdog Award for "Best in Class" for hospitals with >300 patient
"Early on, for example, the team engaged
the hospital’s medical staff governing body and the medical executive
committee to support physician practice changes such as hand-hygiene and
sterile-barrier guidelines during line insertion. Area home health agencies
are periodically invited to an educational session on central-venous–line
care. A ‘Days Since Last Infection’ sign is displayed in each unit as a
daily visual reminder to staff. To reinforce the importance of proper hand
hygiene, a cornerstone of any CLABSI reduction initiative, the hospital’s
communication department created a ‘Foam Up’ education campaign that
targeted physicians, staff, and, most importantly, patient families."
"Children’s Hospital also worked closely
with vendors like Kimberly-Clark," said Truscott. Kimberly-Clark is well
known for their educational programs for both patient and provider. Their
tools on HAIs are available at
Results: "Since the launch of this
initiative in 2006," said Truscott, "Children’s has reduced its BSI rates by
76%, resulting in more than 816 avoided BSIs, with a cost avoidance of over
$37 million. As of September 2012, 2 of the critical-care units at
Children’s have celebrated more than 900 and more than 1,100 days each
without a CLABSI. Hand-hygiene rates increased from 35%, now consistently
remaining above the 95% target and currently at 98.3%, evidence that hand
hygiene has become engrained in the culture of safety."
"Children’s has been recognized for its
work in reducing CLABSIs as a recipient of the 2010 HAI Watchdog Award for
‘Best in Class’ for hospitals that have more than 300 patient beds," said
Truscott. Kimberly-Clark created the HAI Watchdog Awards (www.haiwatchdog.com)
specifically to recognize clinicians making a difference in reducing and
preventing the spread of HAIs.
Reducing BSIs related to peripheral IVs
"Methodist Hospitals–Northlake Campus, a
507-bed community hospital, sought to reduce BSIs in its central and
peripherally inserted central catheter (PICC) lines and, notably, also in
its peripheral intravenous (PIV) lines," explained Michelle DeVries, MPH,
CIC, Senior Infection Control Officer. "Hospitals usually focus BSI
reduction efforts on central catheters; yet, PIVs, which also carry BSI
risk, are the most common lines. Guidelines now permit longer dwell times,
which make the risk greater."
How they did it: "An audit revealed a
potential cause of Methodist’s BSIs: improper manual disinfection of IV
connectors. Nurses were complying with the mandated practice, but few if any
were performing it correctly," said DeVries, "risking IV-line
"With the support of the infection-control
and nursing-administration departments, bedside nursing staff were consulted
about the issue and suggested that two different device solutions be tried,"
explained DeVries. "The first was an evidence-based disinfection cap (SwabCap
by Excelsior Medical, Neptune, NJ). The device dispenses isopropyl alcohol
when twisted onto the connector hub’s threads and protects the hub from
contamination between line accesses. Its design addresses multiple problems
with the technique for manually disinfecting hubs. The second device was a
disinfecting cleaner with a friction scrub design."
SwabCap, Excelsior Medical
"The Materials Management Department
consented to a trial of both devices in the health system’s three intensive
care units (ICUs), with nurses choosing the winner," said DeVries. "After
the trial, they selected the disinfection cap."
"Over the next 3 months, each of the ICUs
reported zero BSIs. This data, plus positive response by staff, led to the
hospital adopting the cap for use housewide, with materials management
Results: "The infection rate for both PIVs
and central lines has dropped substantially since the disinfection cap was
implemented, with a statistically significant reduction in overall and
During the 13-month pre-intervention
period, PIVs plus central lines experienced a BSI rate of 0.1 per 100
patient-days. In contrast, during the 13-month post-intervention period, the
BSI rate dropped to 0.04 per 100 patient-days, a 60% reduction (P<0.000001).
For central lines only, during the 13-month
pre-intervention period, the BSI rate was 0.09 per 100 patient-days. During
the 13-month post-intervention period, the BSI rate dropped to 0.03 per 100
patient-days, a 67% reduction (P<0.000001).
For PIVs only, during the 13-month
pre-intervention period, the BSI rate was 0.09 per 100 patient-days. During
the 13-month post-intervention period, the BSI rate dropped to 0.04 per 100
patient-days, a 56% reduction (P=0.11).
"The PIV-only BSI rate reduction is
associated entirely with cap use," noted DeVries, "because the cap was the
only new intervention for PIVs. During the post-intervention period, the
PICC team became more involved in line monitoring and dressing changes,
which conceivably contributed to the BSI drop in those lines."
Assuring environmental cleanliness
"Hygiena is a microbiology and life science
company that serves industrial food processors, healthcare institutions,
sanitation suppliers, life-science researchers, and the general public,"
said Lauren Roady, Marketing Manager.
"Our rapid ATP cleaning verification system
is used throughout hospitals to measure cleaning effectiveness and improve
overall cleanliness. With offices in the US, UK, China, India, and over 100
distributors worldwide, Hygiena products span the globe," said Roady. "Our
SystemSURE Plus ATP Cleaning Verification System, used with UltraSnap ATP
tests, was implemented at North Tees (470 beds) and Hartlepool (220 beds)
hospitals in the UK in 2008."
How they did it: "ATP cleaning verification
was implemented in an effort to improve overall facility cleanliness and
universal reduction in HAIs. Clostridium difficile infection rates were
tracked as an indicator of HAI rates and overall facility cleanliness,"
"North Tees and Hartlepool Hospitals
implemented ATP monitoring using the Hygiena SystemSURE Plus luminometer and
UltraSnap ATP swabs." Testing is routinely used throughout both hospitals
for monitoring of cleanliness of patient rooms after terminal cleaning; for
training of cleaning staff; for protocol and process training of
environmental services staff; to demonstrate effective hand-washing
techniques; for performance management; and ATP monitoring results are used
as proof of cleaning-staff performance.
SystemSURE Plus ATP Cleaning Verification System, with UltraSnap ATP,
from Hygiena USA
Roady emphasized the need for teamwork.
"Cleaning improvements and infection reductions are a cooperative effort
between facilities, nursing, and infection-control staff members.
monitoring in the facilities, a project champion was assigned to each
facility. This monitoring officer is independent from nursing and
environmental-services staff and reports to department managers if
corrective action is required, ie, poor cleaning is discovered."
"On a monthly basis, reports are produced
and circulated in a cross-functional team meeting of nursing, facilities,
and infection-control staff. This meeting opens up discussion on all
cleaning and maintenance related issues, as well as suggestions for
Results: "From April 2007 to March 2008,
the facilities shared a total of 210 post-48 hour C difficile cases, or
9.934 infections per 10,000 occupied bed-days," said Roady. "From April 2009
to March 2010, the facilities shared a total of 136 post-48 hour C diff cases, or 6.054 infections per 10,000 occupied bed-days. This is a 35%
reduction in C diff cases in just 2 years."
"Not only has the facility sustained
reduced infection rates since the implementation of ATP monitoring, but
cleanliness levels have also improved. Cleaning scores are rated as ‘pass,’
‘caution,’ or ‘fail’ with Hygiena’s ATP Cleaning Verification system. Since
2008, the hospitals have seen a 20% increase in pass cleaning scores,
indicating improvements in cleaning practices and personnel performance.
Their successes have influenced the adoption of Hygiena ATP monitoring
systems in a national health system in Scotland."
Preventing pressure ulcers
Tempe (AZ) St. Luke’s Hospital
St. Luke’s Medical Center
Two facilities participated in this program
to reduce incidence of pressure ulcers: Tempe St. Luke’s Hospital, an 87-bed
full-service hospital, and St. Luke’s Medical Center, a 226-bed,
state-of-the-art hospital in Phoenix, Arizona.
How they did it: Kathy Berry, FNP, MSN,
BSN, CWON, St. Luke’s Medical Center, Phoenix, and St. Luke’s Tempe,
described their mission: "The two hospitals in this study had prevalence
rates of 38.2% (St. Luke’s Medical Center) and 14.8% (Tempe St. Luke’s
Hospital), whereas the National Database of Nursing Quality Indicators
benchmark standard is 9.6%. We started this campaign to reduce the
prevalence of pressure ulcers in April 2012. We are continuing it today
and into the future. It is now part of our everyday patient care."
Berry explained their approach: "The first step was forming a
multidisciplinary team consisting of the administration chief nursing
officer (CNO), materials-management director and manager, housekeeping
director and manager, CNO acute-care and all managers, education director,
infectious-disease director, rehab director, acute-care wound, ostomy, and
continence nurse." The second step was developing a skin formulary. The
third step was setting up a baseline pressure-ulcer prevalence.
Medline’s Pressure Ulcer Prevention Program incorporates education,
training, products, and program management.
"The 2 directors in charge of this program
set a goal of reaching the national benchmark or being below the national
benchmark in 4 months’ time," said Berry. "Data were collected at both
hospitals by 2 nurses with expertise in wound care. All patients in both
hospitals, on 1 day, were examined and pressure ulcers counted."
Other steps included seeking support from
Medline’s Pressure Ulcer Prevention Program (PUPP) and working with hospital
administration to get support and resources. "Following consultation with
Medline and hospital administration, the following key steps were
identified," said Berry: reassess risk for all patients daily; inspect skin
of at-risk patients daily; manage moisture; optimize nutrition and
hydration; and minimize pressure.
"Education and product changes were made.
Medline Remedy advanced skin-care products [were used] on all floors, and
hospitals began use of Ultrasorb dry flow pads." Berry described some of the
educational changes: mandatory requirement of all nursing staff to complete
three pressure-ulcer prevention modules on Medline University, Medline’s
free online education resource (www.medlineuniversity.com); measurement and
documentation of wounds, wound management, and prevention of pressure
ulcers; new nurse orientation that includes a 1-hour lecture on
pressure-ulcer prevention, given by a wound nurse; a skin-and-wound quick
Next, they evaluated the effects of the
product and educational changes. "Post-PUPP implementation prevalence data
were collected again," said Berry. "These data were collected by the same
two nurses as the pre-PUPP data. Again, all patients in both hospitals, on 1
day, were examined and pressure ulcers counted."
"We have seen a sustained
significant reduction in the prevalence rates of pressure ulcers at both
hospitals for almost a year now. For both hospitals combined, the prevalence
went from 30.15% to 0.85% after we implemented our initiative. For St.
Luke’s Medical Center, the prevalence of pressure ulcers dropped to 0% from
38.2% after implementing PUPP. For Tempe St. Luke’s Hospital, the prevalence
dropped from 14.89% to 2.38% after implementing the PUPP program."
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