Under the Microscope

A microscope is being aimed at healthcare-associated infections, and hospitals are responding.

In 2008, the Centers for Medicare and Medicaid Services began denying payments to hospitals for certain conditions that occur during a hospital stay and were not present at admission, including certain healthcare-associated infections (HAIs).

And starting in January 2011, hospitals have been mandated to share data on central line-associated bloodstream infections, or CLABSIs, on the publicly available Hospital Compare website.

It’s part of a growing trend toward transparency to help ensure hospitals take every possible measure to reduce the incidence of HAIs, which kill nearly 100,000 U.S. patients, sicken 1.7 million and cost U.S. hospitals up to $34 billion every year.

Studies, such as one published by the Center for Evidence-Based Practice at the University of Pennsylvania, show the most common ICU HAIs are actually preventable.

Up to 70 percent of CLABSIs and catheter-associated UTIs – and up to 55 percent of ventilator-associated pneumonias (VAP) – can be prevented if the correct policies and protocols are followed.


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Simple Measures

It’s all about simple measures in most cases.

The University of Pennsylvania Health System took a lesson from the automotive manufacturing industry in attacking CLABSIs.

It incorporated the Toyota Production System, which helps reduce variation in practice and streamline and improve care, along with checklists to guide line insertion and maintenance, electronic infection surveillance and leadership initiatives.

The change was jump-started at the bedside, when the chief nursing officer at Penn met with shared governance leadership to set reasonable goals for reducing infections.

“When the person at the bedside providing care has a stake in the percent reduction of HAIs, and when the leader of the institution comes to the bedside nurse, that shared governance person, and wants that insight, that’s very empowering for staff and creates buy-in from all the critical care nurses,” said Robin Strauss, MSN, ACNS, BC, CVN, WCC, a clinical nurse specialist in the cardiovascular ICU at Penn.

Nurses also worked closely with an external consultant to identify the number of steps they were taking in the care and maintenance of central lines. Any variations among units or nurses were noted, which became launching points for discussion and streamlining, all set in evidence-based practice.

“With everyone doing the same thing all the time, the results were better and there was improvement,” Strauss said.

The results were impressive, with CLABSIs falling by more than 90 percent from 2007 to 2010.

Leading the Way

Massachusetts General Hospital has already taken the initiative to publish data on HAIs on its own quality and safety website and, since 2008, the hospital has bested national rates set by the National Healthcare Safety Network for CLABSIs.

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MRSA UP CLOSE: This scanning electron micrograph depicts numerous clumps of methicillin-resistant Staphylococcus aureus bacteria. courtesy CDC/Jeff Hageman

Like Penn, Mass General instituted a checklist to help streamline the process and ensure all nurses were following the same procedure in caring for CLABSIs.

Using the prevention bundle established by the CDC, which calls for hand hygiene, using full barrier precautions during the insertion of the central line, cleaning of the skin with chlorhexidine, avoiding placing lines in legs if possible, and early line removal, the hospital also worked to standardize kits and supply carts, and incorporated a monitor, or observer, to ensure sterile techniques were being followed.

“We also acknowledged that there are times in emergent situations, for example in the ER during cardiac arrest, when a line must be placed emergently, without the ability to create a sterile field,” said Paula Wright, RN, CIC, director of the infection control unit at Mass General. “We developed a system to identify those lines, and as soon as the patient is stable, to replace it.”

The hospital is now shifting its focus to ensuring lines are assessed every day to see if they can come out and to ensure consistent care.

“Also, within the critical care group, we inform the ICU as soon as we identify a CLABSI and they try to look back as best they can to see if anything contributed to it, to learn and share information,” Wright said.

“It’s a team huddle in real time, to think about how it might have been prevented.”

Bundling VAP Care

The “bundle” has become the last word in preventing HAIs; and in preventing VAP, there’s no exception.

Both Penn and Mass General follow a VAP bundle that combines several tactics, including elevation of the head of the bed and regular oral care. “VAP prevention is all about keeping secretions out of the lungs,” Wright said.

As with CLABSIs, bundling care helps ensure consistency. “It’s about making the VAP bundle sacrosanct,” Strauss said, “then auditing it to make sure it’s working.” Data is collected electronically at Penn so there is “tremendous transparency” on any current infections and recommended strategies and treatments, according to Strauss.

Previously documented just on the flow charts, Mass General is also collecting data on compliance to the VAP bundle in its electronic nursing documentation system. “We get the data back to critical care, so we can see if compliance is as good as we think it is,” Wright said.

According to Chris Ranjo, BSN, RN, NEBC, nurse manager of the critical care unit at Penn, again, it all comes down to the nurses. “They are the champions of this,” she said. “The nurses on the floor take ownership on improving VAP, and they bring information back to the unit. That’s the most important thing, it coming from each other and wanting to improve.”

Hospital recognition of their achievements adds to the ownership. When Ranjo’s unit achieved a zero percent VAP rate over 750 days and earned a celebration and a silver medal from hospital administration, nurses began immediately planning for 1,000 days VAP free and a gold medal. “There was a lot of talk and energy on the floor,” Ranjo said. “They want that achievement.”

Removing Risk for UTIs

Simply put, UTIs won’t happen in the ICU if a patient doesn’t have a catheter. Standardized processes help get the catheter out as soon as possible, by ensuring nurses perform daily checks to see if a patient still requires a catheter. Some hospitals have automated reminders established for both nurses and physicians. It’s a huge change from the past.

“For years, we left the Foley in all the time,” said Ranjo. “It’s a big practice change to say we don’t need the Foley in ICUs.”

Basic education on standardized practices also ensures everyone is on the same page.

“We did something called the ‘unit of horrors,'” Strauss said. “We identified suboptimal scenarios and walked through what was wrong, and did a return demo of catheter insertion and removal. If you’re not a new nurse, a lot of times, you don’t get to ever practice that after nursing school . having that hands-on return demo was really helpful.”

These practices helped Penn reduce its UTI rates by 65 percent in the medical ICU, by 35 percent in the trauma ICU and by 18 percent in the heart and vascular ICU in the past fiscal year.


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Hand Hygiene

Another relatively simple measure – hand hygiene – helps prevent the spread of antibiotic-resistant bacteria in the ICU. Yet compliance with hand hygiene standards is still at or below 50 percent, according to recent studies.

Why so low? Part of the issue may be the time involved. It’s estimated nurses could spend up to 30 minutes per hour washing their hands with soap and water according to guidelines. But an easy solution is alcohol-based rubs, which take only seconds and are better for the skin.

Mass General has had “a very strong hand hygiene program over the past 10 years,” Wright said. “That’s our primary effort to ensure we don’t bring bugs to the patient.”

The program provides education, ensures availability of alcohol hand rubs, conducts surveys and provides feedback, enlists local champions, promotes awareness through posters and publicity, sets goals, and encourages patient and visitor involvement – all with a goal of achieving 100 percent compliance.

In 2007, a modest hospitalwide bonus was awarded if the hospital achieved its targets. And since 2009, Mass General has had a hand hygiene compliance rate of greater than 90 percent both before and after contact with the patient.

In addition, infection control also works with local pharmacies to manage antibiotic stewardship to ensure antibiotics are being used appropriately.

Culture Change

With reimbursements now directly tied to how well hospitals prevent the rise of HAIs, hospitals and hospital ICUs have become increasingly transparent in the mechanisms they use to reduce this incidence. A widespread culture change has been the result. ICUs with the lowest HAI rates report that instead of working in silos, sister ICUs in the same hospital system now share data and information so they can benefit from each others’ knowledge and experiences. Even further, bedside nurses are empowered to play an active role in reducing HAIs.

“Years ago, the data was just given to you, if it was given to you at all,” Ranjo said. “Now, all of the nurses can speak to the data on the floor, it’s posted for all to see. . In the nursing professional practice model, it’s a pyramid, and at the top of the pyramid is well-crafted patient care, and that’s what we’re striving for in all these initiatives that we do, that we’re providing the best care we can for these patients.”

Danielle Wong Moores is a frequent contributor to ADVANCE.

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