Vol. 7 Issue 21
Inside Infection Control
Nurses are employing innovative infection control approaches to combat hospital-acquired infections and save lives
To say American's are aware of the risk of hospital-acquired infections is perhaps an understatement. In recent months, Readers Digest, Time Magazine, Newsweek and U.S. News and World Report all have featured stories about drug-resistant organisms, inadequate handwashing and perioperative mistakes leading to infections.
But being aware of hospital-acquired infections and actually doing something about them often are two different things. With that in mind, ADVANCE recently spoke with nurses at several facilities across the country who are promoting best practices in infection control.
Perhaps the most popular proponent of best practices in infection control is The Institute for Healthcare Improvement (IHI). The Cambridge, MA-based, not-for-profit organization, founded in 1991, offers healthcare facilities infection control related products and services and serves as a clearinghouse of best practices through its 100K Lives Campaign. More than 2,700 hospitals have joined the campaign, which aims to save 100,000 lives by eliminating hospital-acquired infections through the implementation of changes proven to prevent avoidable deaths.
The campaign is initially focused on six separate interventions, including deploying rapid response teams, delivering reliable evidence-based care for acute MI and preventing adverse drug events, central-line infections, surgical site infections and ventilator-associated pneumonia (VAP). More information on the campaign is available online at www.ihi.org.
IHI recommends a "bundle approach" to combat hospital-acquired infections, said Elaine Lyons, MSN, RN, epidemiology/ infection control nurse at Long Island Jewish Medical Center in New Hyde Park, NY. Backed by solid research findings, the recommendations within each IHI bundle address specific risk factors for different hospital-acquired infections.
"The central line infection bundle, for example, calls for whole-body drapes, masks and gowns during line insertion," Lyons said. "So we've made kits that the nurse just has to grab and take into the room, which makes it easy to comply with best practices."
Penny Takizawa, MS, RN, CIC, epidemiology coordinator at El Camino Hospital in Mountain View, CA, is committed to making adoption of the IHI bundles as painless as possible for the nursing staff.
"For example, we've created a checklist of requirements that comes out with every central line kit," she said. "We also did a lot of education with the nurses and the physicians, and we made it clear that they must follow these procedures or they can't put in the line."
At Miami (FL) Children's Hospital, Dorothy Thomas, BSN, RN, CIC, director of infection control, is concentrating on eliminating device-related bacteremia in the pediatric population.
"There used to be a mindset that if you had a critically ill patient it was not unusual for that patient to develop a central line infection," she said. "Today, the thinking is to go for a zero-percent infection rate."
With that goal in mind, Thomas said, nurses at the hospital are following practice bundles that specify what type of dressing and skin prep to use in specific situations. Then they make sure the procedure is followed correctly.
Timothy Sheard, MA, BSN, RN, assistant director of infection control at Downstate Medical Center in Brooklyn, NY, is conducting a small trial of bactericidal dressings for central venous and arterial line catheters, trying to eliminate infections at insertion sites.
"I'm not sure that will be possible with the very vulnerable patients we have," he said, "but we'll be trying these dressings for a couple of months in some areas, and then we'll look to see if our infection rates are down."
Staff education coupled with regular follow-through is very important to combating hospital-acquired infections, Sheard added.
"We taught staff on our surgical units that the head of the bed should be elevated a minimum of 30 degrees for patients on ventilators, unless that's contraindicated. The beds actually have a scale that we read, and then we report the results weekly and monthly to the head nurse and medical director," he explained. "It's been very successful virtually 100 percent compliance and our VAP rate is almost zero."
Gathering Data, Sharing Results
At Sutter Medical Centers in Sacramento, CA, Janet Frain, RN, CIC, CPHQ, CPHRM, director of integrated quality services, gathers quality-assurance data remotely to help eliminate incidences of hospital-acquired infections.
"Nurses and physicians can remotely monitor the care of patients in our ICUs via cameras and physiological monitoring equipment. So when they're monitoring a patient who is on the ventilator-associated pneumonia bundle, for example, they can actually see into the patient's room and determine if the head of the bed is elevated more than 30 degrees," Frain said. "This is a different way of using resources and a way that technology can assist us in monitoring quality of care."
Dennis Duquette, BA, RN, cardiac outcomes coordinator at Portsmouth (NH) Regional Hospital, emphasized the importance of sharing outcome data with nursing staff.
"As part of our plan to reduce surgical-site infections, we asked the nurses to adapt a glucose control process that is extremely intensive, with hourly monitoring and adjusting insulin drips," Duquette said. Nurses were then shown data reflecting how much the facility's surgical-site infection rate in diabetic patients had decreased. "So they could see the tangible effects of the extra work they were doing."
Visibility, Accessibility & Reward
Infection control practitioners who spoke to ADVANCE stressed the importance of their maintaining a presence throughout the hospital so nursing staff know who to turn to if they are ever unsure about an infection control protocol or just have a question.
"We have found it's best to be exceptionally accessible and visible to the nursing staff," said Janine Chapman, BSN, RN, CIC, infection control nurse at Ochsner Clinic Foundation in New Orleans. "Often, I'll be talking with one nurse and there will be two or three others standing around, not necessarily participating in the conversation, but certainly listening to the message."
Providing nursing staff with positive feedback about their efforts to eliminate infections also is very important.
"Nurses respond to educational programs and active, regular surveillance with timely feedback and positive reinforcement," said Shear, who rewards staff for extra efforts toward infection control with tokens of appreciation, such as calculators and flashlights from drug company sales reps, for example. "I like to reward staff," he said, "whether it's a ward clerk who disinfects a keyboard or a nurse or assistant who wipes down the bed rail."
But if nurses are to be in the vanguard of new infection control practices, they must be empowered to enforce changes, Lyons said.
"Nurses are going to play a very large part in the implementation of the '100K Lives' measures," she said. "We're giving them the authority to stop the central line insertion procedure if the physician isn't following the protocol, for example."
To increase the nursing staff's comfort level with the more extensive use of gowns, masks and drapes during procedures at Miami Children's Hospital, Takizawa produced a videotape on the proper use of personal protective equipment. The video reminds nurses "to take off their gloves first, then their gown, and then to cleanse their hands," she explained. "After that, they are told to remove their goggles and mask by pulling down off their face and to never pull the equipment up over their eyes."
Cordelia Alfaro, MA, RN, CNA, CPHQ, an infection control practitioner at Nashoba Valley Medical Center in Ayer, MA, feels collaboration between nurses and physicians is integral toward the goal of eliminating hospital-acquired infections.
"We belong to an SIP (surgical infection prevention) program that's nationwide, and we have instituted more physician participation in sitting and actually reviewing records," Alfaro said. "We have one physician who became a real champion and he talks with other physicians to increase their understanding."
Proactive Patient Involvement
When it comes to enhancing communication with patients, nursing staff at Dana-Farber Cancer Institute (DCFI) and Brigham and Women's Hospital in Boston are supported by patient family advisory committees.
"As a result, infection control is able to obtain timely and direct feedback from the committee members," said Susan O'Rourke, BSN, RN, CIC, infection control practitioner at DCFI.
Alfaro also expressed appreciation for the input she receives through the patient safety awareness committee. For example, after a committee requested different types of precaution cards that would be easier for patients and visitors to understand, nursing staff came up with a number of creative ideas.
"We made some [precaution cards] in the shape of a stop sign and color-coded them to match the type of infection, such as pink signs for airborne infections," she said. "We cued them pictorially on what they should be looking for, and also put laminated posters on the elevators to draw attention to the campaign."
Alfaro and her colleagues also created prep sheets for patients in the pre-procedure area. "We've made changes, such as stopping at-home preps before procedures, and replacing razors with clippers," she said. "We share those goals with our patients so they'll be partners with us in proactive infection control."
Anticipating the Future
Gina Schultz, RN, CIC, infection control practitioner at Provena St. Joseph Medical Center in Joliet, IL, shared a sobering view of infection control in the near future.
"There are no really great antibiotics on the horizon, so we have to go back to the antibiotics that we already have, prescribe them wisely and teach patients to use them properly to reduce the incidence of resistant strains," she emphasized.
Shear agree, and he added that in order to be successful, infection control measures must involve a collaboration of healthcare professionals and the public they serve.
"We have to warn the public that bacteria are always two steps ahead of us, and that all hospitals worldwide are seeing increasing incidence of panresistant bacteria," he said, "especially in critical care, which has the sickest patients and the most devices that violate basic barriers."
Sandy Keefe is a regular contributor to ADVANCE.
Back to Basics
Hand hygiene remains best weapon against spreading infections, nurses tell ADVANCE
While infection control nurses across the country gladly shared their newest strategies for reducing hospital-acquired infections with ADVANCE, virtually every practitioner interviewed emphasized that basic hygiene measures still offer the most protection to their vulnerable patient populations.
"If you could get all your staff to practice handwashing, infection precautions, proper cleaning techniques for equipment, and disinfection of the items that go in and out of patient rooms, those are the simplest things that would make for the best outcomes with nosocomial infections," said Gina Schultz, RN, CIC, infection control practitioner at Provena St. Joseph Medical Center in Joliet, IL.
The FROG Campaign
At Children's Hospital of Orange County (CHOC) in Orange, CA, infection control/epidemiology manager Wendi Gornick, MS, CIC, acknowledged that healthcare providers do know the importance of handwashing but said they get busy and distracted in the clinical setting.
"We did a couple of things we thought would be kind of fun and creative to gently remind them," Gornick said. "We came up with the acronym FROG, which stands for 'friction rubs out germs,' and designed a little frog sitting on a bar of soap surrounded by bubbles," she explained. "When families see the stickers and ask about the frog, it creates a teachable moment that the nurses can use to discuss hand hygiene."
Families also receive an infection control booklet in a child's admission packet, along with a coupon for a bottle of handwashing gel. "The family can hand the coupon to the nurse," Gornick said, "which offers a perfect opportunity to teach hand hygiene."
Penny Takizawa, MS, RN, CIC, El Camino Hospital in Mountain View, CA, finds patients want to be partners in hand hygiene.
"As the epidemiology coordinator, I get a lot of calls from patients asking me, 'How are you going to protect me from an MRSA infection during my hospital stay?'" she said. "We provide antimicrobial gel to our patients, and we tell them that they have the right to ask their caregivers, 'Have you cleansed your hands before taking care of me?'"
Schultz includes hand hygiene information in a television guide handed out to patients on admission. It includes a reminder that patients can take an active role in their own safety during hospitalization. "That message makes patients aware that they can ask staff if they've cleansed their hands," she said.
To personalize the hand hygiene awareness message, Schultz developed a poster campaign with photos featuring different staff members washing their hands. She then observed handwashing practices among staff and gave chocolates as a reward to those who washed and Dum-Dum lollipops to those who didn't follow protocols.
Janine Chapman, BSN, RN, CIC, infection control nurse, Ochsner Clinic Foundation, New Orleans, went to bat for the nursing staff when the state fire marshal banned alcohol-based hand washes. She testified before the Louisiana legislature to get a bill prohibiting those products overturned.
"Then we told the nurses: 'Look, we listened to you, we testified on your behalf, and we empowered you to make these decisions about your own practice," Chapman told ADVANCE. "So when you tell us what we can do to reduce infections in our patients, we will listen!'"
Chapman also collaborated with the facility's NICU nurses to present a paper about the impact of a handwashing campaign on outcomes in their unit.
"They shared with their peers at an international epidemiology conference," she said, "and then we published their success in our internal newsletter, which sent the message that bedside nurses can lead the way in infection control."
– Sandy Keefe, MSN, RN