Infection Prevention… Strategies for Success Mairead Hickey, PhD, RN, FAHA Chief Nursing Officer and Senior Vice President Patient Care Services Brigham and Women’s Hospital

Discuss the role of the Chief Nurse in Infection Prevention and related “culture charges” Present strategies that have worked at BWH Review samples of infection prevention data Review BWH Balanced Scorecards

Role of CNO in Infection Prevention Create/support a culture of improvement… Demonstrate a commitment to change and improvement based on evidence Communicate and stay engaged Provide resources and remove barriers Celebrate successes

What does this look like at BWH? Multipronged Approach… CNO – CMO Leadership RN – MD – Infection Prevention Leadership triads at a unit level Unit-based champions Nursing Quality Committee ICU Committee: MD – RN leaders Review monthly data Develop/standardize ICU protocols And more

Hand Hygiene and VRE Improvement Project Unit Example: Hand Hygiene and VRE Improvement Project

Unit Example: When we looked at unit hand hygiene rates, we saw much variability and rates below 90% compliance.

Action Team Brainstorming Ideas: What are the defects? Unit Example: Action Team Brainstorming Ideas: What are the defects? I can’t find the Purell I have to walk all around the unit to find a laundry basket If I have to change gloves in the room, new ones aren’t available How is the BP cuff cleaned between patients? I didn’t know the impact HCAI had on Patients These yellow gowns do not provide enough protection Ideas from the team included:

What Happened? High Reliability Concepts (Roger Resar) Unit Example: What Happened? High Reliability Concepts (Roger Resar) Process versus outcome Standardization Identification of Defects Daily Huddle What went wrong? What went right? What would you change? As part of the process, we pulled from the high reliability concepts. What is getting in the way of performing hand hygiene, can we standardize expectations, can we resolve issues identified? We agreed to standardize the need for hand hygiene before entering the room & encouraged everyone to give feedback if others were not performing to this level. We met daily Monday through Friday for a quick 15-minute huddle with any staff available on the unit.

Measures Implemented after Huddles Unit Example: Measures Implemented after Huddles Infection Control In-services New Precaution Gowns Laundry Hampers in each room BP cuffs & Stethoscopes for each Patient Bed Glove box holders in each room Reminder Cards on outside of door to use Purell May Purell on the inside of the door in patient room June Dirty tray holder on unit* July As a result of the huddle, the following measures were implemented. We can honestly say that staff initially were resistant the huddle concept and believed ideas raised would take a long time to fix. By working as a multidisciplinary team (housekeeping, unit secretary, PCAs, RNs, MDs, Ops manager link with engineering and materials management) we were able to get ideas in place quickly and evaluate whether it worked or did not work. In May, we saw a decline in rates after patient contact. Staff joked that if they had Purell on the inside of the door it would make it easier to perform hand hygiene. Within a few days, Purell was installed on the inside of the door and the rates improved.

Unit Example: Identified need for Purell As you exit the room

Was This Initiative Sustainable? Unit Example: Was This Initiative Sustainable? Hand Hygiene FY2008 84% FY2009 88% FYTD (Feb) 2010 94% VRE Rates/1,000 line days FY2008 4.7 FY2009 2.2 FYTD (as of Feb) 2010 1.9 Initially after the huddles ended, 6B did have a reduction in hand hygiene rates. We uncovered staff needed further education surrounding need to perform hand hygiene as a final step. At times, staff would Purell, put on gloves & then be called to phone or desk & not re-do hand hygiene. Once this re-education was completed, rates raised & were sustained. We believe the grassroots effort helped to change the unit culture and ability to provide feedback to each other. In addition, identifying and fixing defects in the environment in a way to make hand hygiene easy had a tremendous impact on the sustainability of the work.

Infection Control Data on the BWH Balanced Scorecard