Grady Health System Infection Prevention & Control August 13, 2014 Mary Cole, RN, MSN, CIC

Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

CLABSI Prevention Activities Feb Insertion bundle, CHG dressing, standardized carts, unit audits March 2011 Unit based CVC Champions May 2011 Cross audits to other areas July 2011 Enhanced MD education, credentialed after CBL, proctored insertions Sept alcohol port protectors SICU Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

CLABSI Prevention Activities, cont. Oct 2011 Alcohol port protectors MICU Nov Alcohol port protectors Med/Surg Feb CUSP MICU/SICU June 2012 Alcohol port protectors ED/Radiology, blood culture collection limited to phlebotomy (ED and in-patient)

CLABSI Prevention Activities, cont. March 2013 needle free adaptors and alcohol port protectors for vascath (dialysis) April 2013 CUSP for Burns, Neuro, and Intermediate Care July 2013 PICC Team (nurses) at bedside Oct 2013 Neutral valve for IV ports to prevent backflow

Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

CAUTI Prevention Activities Upgraded foley tray & added securement device CAUTI Champions, monthly meetings and conduct RCAs Purchased additional bladder scanners to decrease re-insertion of foleys Regular agenda item for CUSP teams Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

CAUTI Prevention Activities, cont. On-going work with ED and OR to decrease foley usage Nurse driven foley removal protocol Increased various sizes of condom caths MD and nurse daily justification in EMR Infection Prevention & Nursing conduct weekly audit of bundle compliance with report to Executive Leadership

Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

SSI Prevention Activities SUSP team with Executive Leadership SSI surveillance all COLO,HYST, CARDS, CABG, FUSN, HIPS, KNEES IP presence in OR, monitoring a minimum of 4 procedures per week for HYST/Colon. Findings are reviewed in SUSP RCA completion for all SSIs by OR, MDs, reviewed in SUSP. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

SSI Prevention Activities, cont. Mandatory training of all staff and MDs on surgical site prep CHG bath night before and morning of surgery in addition to nasal and oral prep for all surgeries below the neck, track compliance Work with IT to add this to pre-op orders Currently working to isolate separate instruments for skin closure for COLO and HYST

Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

CRE Prevention Activities MDRO designation in header of EMR Orange bracelet on MDRO patients IP receives E mail alert MDRO lab identification MDRO admissions are followed daily by IP EVS reports quarterly to ICC on ATP monitoring and UV disinfecting activities Participated in recent CRE collaborative with GA DPH and CDC. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

Essentials to success Active involvement from Executive leaders, MDs, and front-line staff Partnership with IT Partnership with EVS Be persistent!

Questions? Thank you