St. Luke’s Hospital, an Iowa Health System Affiliate team, participated in IHI’s Learning and Innovation Community on Reducing Hospital-Acquired Infections.

Team members:

• Dr. Tracy Reittinger, Medical Director, Transitional Care Unit
• Dee Cook, RN, Manager, Transitional Care Unit
• Jennifer Wedemeier, RN, Transitional Care Unit
• Mary Ann Osborn, RN, Chief Nursing Officer, Executive Sponsor
• Julie Sturbaum, RN, Program Manager, Infection Prevention and Control

To improve patient care by reducing infections from Clostridium difficile (C. diff) by 30 percent on the Transitional Care Unit (TCU) by April 30, 2008, by focusing on the prevention of transmission. 

Our efforts included reliable use of contact precautions, hand hygiene and room cleaning/disinfection, as well as the use of dedicated equipment. We predicted that these changes would also reduce infections from methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). Reducing our infection rate from all of these organisms is in line with our organization's strategic goals for 2007.

We sought to accomplish our aims by April 30, 2008. Our specific aims were to:

• Increase days between cases of C. diff to 30
• Increase days between cases of MRSA to 182

• Days between cases for Clostridium difficile infections
• Days between cases for MRSA infections
• Percentage of environmental cleanings completed appropriately
• Percentage of patient encounters with compliance for contact precautions
• Percentage of patient encounters with compliance for hand hygiene
• Percentage of patients with C. diff-associated disease
• Rate of occurrence of MRSA, bloodstream infection (BSI), and hospital-acquired pneumonia (HAP) per 1,000 patient days
• Rate of occurrence of VRE, urinary tract infection (UTI), and BSI per 1,000 patient days

Key changes implemented on the TCU included the following:

• We standardized times to restock isolation supplies on all shifts to ensure proper equipment. 
• We posted reminder signs for hand hygiene that included pictures of role models, informal leaders from the unit, and “patients,” in addition to humorous signs of various types. Signs were changed as frequently as every two weeks.
• We initiated “Secret Shopper” audits of hand hygiene and isolation compliance. Each staff person was asked to do five observations per shift. The results were posted at the end of the shift and aggregated for monthly rates. Data were presented to staff on the unit and to the managers of staff from other units that were observed.
• We “Bagged and Tagged” used commodes to clearly identify “dirty” equipment and ensure cleaning.
• A hand hygiene video was produced. This was a fun video featuring our CEO as “VRE” and other recognizable hospital figures in different roles. A checklist for daily and terminal room cleaning was developed and utilized by Environmental Services to audit cleaning.
• We displayed a large poster on the unit listing the physicians who were compliant with hand hygiene.

Summary of Results:

The results accomplished by implementing these changes were significant for our Transitional Care Unit. Compliance with hand hygiene improved from 66 percent in April 2007 to 94 percent in April 2008. While we did not meet our aim of achieving a 30 percent reduction in C. diff disease on the unit, we did meet our goal of 30 days between C. diff infections in March-April 2008. As of April 30, 2008, we have had zero MRSA bloodstream infections or hospital-acquired pneumonias for 193 days, and zero VRE bloodstream infections and urinary tract infections for 11 months. In addition, our VRE colonization incidence declined to a new low during the 12 months of this work.

Lessons Learned:

• A key factor in our success was having an excellent staff nurse champion and an engaged manager, executive sponsor, and medical director.
• Having front-line staff do “Secret Shopper” audits raised awareness about poor compliance with hand hygiene and isolation precautions. Providing feedback at the end of the shift regarding compliance helped staff see that it was not “the other guy” who was not cleaning his hands. This was really the tipping point in improving our compliance.
• Getting people to clean their hands is less about education and more about behavior modification and accountability. 
• We should have included an Environmental Services (EVS) person on our core team. Our tests of change related to EVS were not very successful, and we believe that if we had asked an EVS supervisor to travel with us to key meetings, buy-in would have increased.
• The success of this unit has motivated other units to set the same goals. It has also helped to sustain the changes on the TCU, as staff on that unit now feel like they are role models for the hospital on hand hygiene and contact precaution. The video we produced prominently features staff from this unit. They are now the ambassadors for hand hygiene every time someone watches that video.

Remaining Barriers:

• C. diff continues to rise on our pilot unit and in our hospital as a whole, despite good compliance with contact precautions and hand hygiene. We are exploring reasons for the increase.
• Our staff really has a hard time speaking up to their colleagues when they see them failing to comply with hand hygiene or contact precautions. This is a very difficult barrier and one on which we should have spent more time. 
• We still need to make alcohol-based hand sanitizers available in the hallways, in addition to just inside the patient rooms.

Next Steps:

• Install alcohol-based hand sanitizers in the hallways.
• Continue to work on the culture of safety so staff can feel more comfortable speaking up when they see someone not following infection prevention practices.
• Use results for the TCU to tie the act of hand washing with the outcome of reduced VRE colonization on the unit. As we spread these changes to other units, the success on the TCU helps staff to see that their actions do make a difference to patients in a very real way.
• Engage physicians as role models for compliance with hand hygiene and contact precautions.

Julie Sturbaum, RN
Program Manager, Infection Prevention and Control
St. Luke’s Hospital
sturbajr@crstlukes.com