St. John’s Regional Health Center 1235 East Cherokee Springfield, Missouri Diana Henderson, BSN, CPHQ, Executive Director Quality Judy Walker, BSN, MHSA, Director Infection Prevention February 19, 2009

St. John’s is a tertiary hospital and Level 1 trauma center 33,255 Discharges 30,688 Surgeries 81,177 Emergency Department Visits

How we started… Institute for Healthcare Improvement (IHI) Reducing Health Care Associated Infections Collaborative – April 26 th, 2007 Focus: MRSA Pilot Unit: –7C Surgical Unit – general surgery, trauma, ENT, Urology, Plastics, Medical overflow –Average daily census: 26

Team Members Ronnie Brownsworth, MD, Sr. VP Medical Management Service Lynn Smith, VP Performance Improvement Ravi Nerella, MD, Hospitalist and Physician Champion Judy Walker, BSN, MHSA, Nursing Director 7C Surgical Unit Patti Reynolds, BSN, Infection Control Supervisor Diana Henderson, BSN, CPHQ, Executive Director Quality Brenda Huddleston, RN, Quality Improvement Analyst

Our Journey… Set an aim Quantifiable measurement Plan, Do, Study, Act (PDSA) –1 nurse, 1 doctor, 1 patient Share successes and failures – Failure is an opportunity to learn Spread changes PLAN DO STUDY ACT

Improvement Methods Utilized Interdisciplinary Team –Include Physician and Administrative Leadership champion Failure Mode Effects Analysis (FMEA) conducted on hand hygiene Bi-monthly conference calls with IHI faculty Co-worker surveys Huddle with frontline staff regarding test of change Transparency of data

Outcome Goal Decrease MRSA infections from Health Care Associated Pneumonia (HAP), Blood Stream Infections (BSI), and Surgical Site Infections (SSI) by 30% on 7C Surgical Unit within one year by focusing on prevention of transmission. We will ensure that our work contributes to designing processes that enhance the quality improvement infrastructure and sustains results.

Infection Reduction Strategies Reliable hand hygiene Contact precautions for colonized patients Appropriate room cleaning/disinfection Active surveillance cultures on admission Dedicated equipment for colonized patients

7C/3B Surgical Unit Rate of Occurrence of MRSA Surgical Site Infections (SSI), Blood Stream Infections (BSI), & Health Care Associate Pneumonia (HAP) per 1000 patient days

Days since last MRSA infection on 7C/3B As of February 12, 2009

7C/3B Surgical Unit Survey Healthcare workers thought they did not cause infection Handwashing agents cause irritation and dryness Sinks are inconveniently located/lack of sinks Lack of soap and paper towels Alcohol-based handrubs are inconveniently located Too busy/insufficient time Understaffing/overcrowding Patient needs take priority Low risk of acquiring infection from patients

A picture is worth a thousand words! Hand Stethoscope

Hand Hygiene Changes Culture select co-workers’ hands quarterly Strategic placement of hand hygiene dispensers Provide alcohol-based handrub for patients on bedside table Encourage patients and their families to remind healthcare workers to practice hand hygiene –“It’s Okay To Ask” button with scripting –“It’s Okay To Ask” sign hung in all patient rooms –“It’s Okay To Ask” banner hung on nursing unit Monitor healthcare workers' adherence with hand hygiene practices and provide feedback –Positive reinforcement –Physician to physician conversations regarding non-compliance –Director of Nursing (DON) address frontline co-worker/ancillary staff non-compliance

Hand Hygiene Changes Infection Prevention Specialist (IPS) attends monthly staff meetings –Personalizing infections Hands up campaign “Hands up” is the standard phrase or action to use if you observe another co-worker NOT performing hand hygiene when appropriate.

7C/3B Surgical Unit Percent of patient encounters with compliance for hand hygiene

Contact Precaution Changes Educate co-workers to complete hand hygiene before donning personal protective equipment (PPE) Floor stock isolation kits standardized with dedicated equipment Computer forcing function that designates type of isolation on diet orders Identify isolation patients by placing a sticker on patient menu and placing in designated area Assign daily monitoring of isolation holder supplies

Contact Precaution Changes Provide patient with isolation precautions frequently asked questions (FAQ) pamphlet Visual aid placed on isolation holders as a reminder to encourage hand hygiene Ticket to ride

Appropriate Room Cleaning and Disinfection Changes Identify clean equipment with “door knocker” tag High touch cleaning checklist provided to co- workers Three step process to notify environmental services that isolation room needs terminal cleaning which includes laundering privacy curtain –Verbally notify environmental service of isolation status –Document isolation status in environmental service log book –Isolation sign removed by environmental service Judy W

Adult ICUs, Pediatric ICU, and Burn Unit Active Surveillance Cultures (ASC) at Admission Educate co-workers on MRSA active surveillance process Standing order for obtaining MRSA cultures and isolation if applicable Monitor ASC compliance and colonization rates by unit

Keys to Success Hand Hygiene must be a priority Personalizing infections Senior Leadership support Physician Champion Involve and seek input from frontline co-workers Monitor adherence with recommended hand hygiene practices and provide feedback Transparency of data Encourage patients and their families to remind healthcare workers to practice hand hygiene

Contact Information Diana Henderson, BSN, CPHQ, Executive Director Quality Judy Walker, BSN, MHSA, Director Infection Prevention