30 things you can do to eliminate infections
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This article kicks off the 2006 version of H&HN’s Save Lives Now series. The series, begun in 2005, outlines relatively low-cost and simple steps that hospitals can take to eliminate preventable deaths among patients. This year’s series focuses on nosocomial infections, and draws on the expertise of numerous health care leaders and patient safety organizations.
In addition to the 30 steps enumerated in this article, each issue of H&HN through the end of this year will present an additional strategy. The follow-up articles will appear in the InBox section of the magazine.
We also want to hear from readers who have undertaken effective steps to reduce infections in their hospitals. Go to our Web site and click on Save Lives Now. Then click on the link to share your story.
Each year, more than 2 million people acquire an infection during a hospital stay and about one in 20 of them die as a result. Experts estimate that up to 30 percent of these infections are preventable. Richard Shannon believes it’s much higher. “As many as 90 percent of hospital-acquired infections could be prevented in a year’s time if hospitals paid better attention to hygiene and standardized how intensive care unit patients receive care,” asserts Shannon, chair of the department of medicine at Allegheny General Hospital in Pittsburgh.
To be sure, the pressure is mounting on hospitals to find ways of not just reducing, but eliminating infections. As of early August, 14 states have laws requiring hospitals to report infection rates. Ohio Gov. Bob Taft has stated that he would sign a disclosure bill by the middle of the month. While the reporting mechanisms vary, they all provide for public disclosure of hospital infection rates. This, coupled with pressure from the Joint Commission on Accreditation of Healthcare Organizations, the Leapfrog Group, Consumers Union and others is making infection control an issue for hospital C-suites, says Donald Goldmann, M.D., senior vice president at the Institute for Healthcare Improvement. “It’s getting attention because there are now some consequences associated with things like hand washing,” he says.
In Pennsylvania, for instance, data show significant bottom-line costs to hospitals and payers. The Pennsylvania Health Care Cost Containment Council, which was given legislative authority to collect hospital infection data in 2004, estimates that insurance companies pay up to seven times more for the care of infected patients than for those who don’t contract infections in the hospital. In 2004, the council tallied 11,688 hospital-acquired infections in Pennsylvania. They were associated with 1,793 deaths, approximately 205,000 extra hospital days and $2 million in additional hospital costs.
Part of the problem for hospitals is that there are usually multiple ways for patients to get an infection. That makes controlling them much more difficult. When patients undergo surgery or are put on ventilators, they are more vulnerable to infections from their own bacteria or from that carried on the hands of health care workers. Hospitals with successful infection control programs recommend a systematic approach. “You have to make the effort bigger than the individual doctor,” says Howard Nadworny, director of the infection control program at St.Vincent Hospital, Erie, Pa.
Research has identified specific interventions and strategies to dramatically reduce the most common types of infections, from simple hand washing to using “bundles” of best practices. This article outlines 30 low-cost and relatively simple things you can do to reduce infections at your hospital.
Routinely cleaning hands properly is a simple—and obvious—concept that is frustratingly difficult to institutionalize. Some estimates suggest that improving hand hygiene could eliminate up to 50 percent of hospital-acquired infections.
1. Educate Employees: Hospitals should educate employees about proper hand hygiene, have senior doctors model that behavior and verify that employees do it correctly. Effective hand washing requires workers to coat their hands completely and rub them for at least 15 seconds. Consider live demonstrations using fluorescent dye. Some organizations use timers. A 2003 study by the Centers for Disease Control & Prevention and Chicago’s Northwestern Memorial Hospital showed that if a senior doctor did not wash his or her hands while making rounds, staffers, including nurses, residents and medical students, washed their hands just 10 percent of the time.
2. Use alcohol-based hand rubs: Alcohol-based rubs reduce bacteria and viruses on hands, require less time to use and cause less irritation and dryness than using soap and water. Long accepted in Europe, particularly Germany, this strategy is relatively new to hospitals in the United States. But the use of alcohol-based sanitizers got a big push in 2002 when the CDC updated hand hygiene guidelines based on decades of research. “Alcohol-based rubs are now the preferred method [with a few exceptions], and it’s been a paradigm shift for hospitals,” says Barbara Soule, R.N., practice leader for infection prevention services at the Joint Commission Resources Inc., a JCAHO subsidiary.
3. Itrack and monitor hygiene: A review of 34 studies showed that health care workers practiced good hand hygiene only 40 percent of the time. The Association for Professionals in Infection Control and Epidemiology cites numerous strategies that hospitals use to monitor compliance. At Forum Health Hillside Rehabilitation Hospital in Warren, Ohio, staff members from all departments and all shifts observe 10 situations that call for hand washing. Using index cards preprinted with “Yes” or “No,” a staff member documents whether colleagues wash their hands when they should. Those being observed are not identified. The observers’ names are entered in a drawing for a small prize. Other hospitals monitor the levels of alcohol-based sanitizers to get an idea of how frequently staff are using them.
4. Involve employees: Involve staff in creating hand hygiene policies, as well as in choosing and testing alcohol-based rubs. Compliance at the Mayo Clinic improved sharply after employees were allowed to test different alcohol rubs with strong emollients.
5. Don’t forget ancillary staff: Most hospitals target their hand hygiene programs to nurses and physicians, but there are plenty of other hospital employees who enter patient rooms, touch surfaces and sometimes even patients. Extend hand hygiene education to housekeepers, lab technicians and patient transport crews.
Age and obesity are patient risk factors for surgical site infections, or SSIs. Sources of infection include the patient’s own bacteria, cross contamination, the surgeon’s hands, airborne contamination and devices such as drains and catheters. SSIs cause about 40 percent of hospital-acquired infections, and nearly 3 percent of patients develop an SSI after surgery. Patients are five times as likely to be readmitted to the hospital if infection develops after surgery.
6. Give Antibiotics within one hour of surgery: Administering prophylactic antibiotics within one hour before cutting the skin can prevent surgical site infections (two hours for vancomycin). But timing them and determining who gives them is an issue because multiple caregivers are involved and operating room schedules are often in flux. “Most surgeons aren’t aware when an antibiotic is given,” Nadworny says. “They write the order and simply assume the antibiotics are given.” Hospitals should designate exactly which clinician will administer the antibiotics. St. Vincent Hospital gives preanesthesia nurses that responsibility. IV bags are hung up while the patient is still in the patient room, and the antibiotics are administered as the patient is wheeled to the operating room, 20 to 40 minutes before surgery. Other hospitals designate anesthesiologists to do the task.
7. Warm the patient: Keeping the patient warm during surgery significantly reduces his or her chance of getting an infection. When a patient’s body temperature falls below 96.8 degrees during surgery, the body’s immune functions are impaired and blood vessels narrow, which increases the risk of infection. There are multiple ways to keep the patient warm; some include specialized gel packs, forced-warm-air blankets, and having the patient wear hats and booties perioperatively. Additional tactics include warming the room prior to surgery and giving surgical staff the ability to control the OR temperature.
8. Clip, don’t shave: For decades, clinicians have known they should clip, not shave the area of the patient’s body to be operated on. Shaving produces microscopic cuts on the skin, where bacteria can enter. “This keeps coming up as an issue every five years or so, usually when infection rates are low and infections can’t be directly linked to shaving,” Nadworny says. “A new crop of physicians decides they’d rather shave the hair. They think, ‘I’ve never had a problem, so what’s the big deal?’” Remove razors from the room and use clippers to remove hair right before surgery. In addition, counsel patients not to shave prior to surgery. Establish protocols for hair removal, and if shaving is absolutely necessary, do it immediately before surgery.
9. Control the patient’s blood sugar: Diabetes and hyperglycemia, or high blood sugar, are well-known risk factors for surgical site infections. Experts believe that patients who have better blood glucose control before surgery also maintain lower blood sugar levels after surgery, which reduces their risk of infection. Organizations should institute glucose testing for selected patients to screen for undiagnosed hyperglycemia and diabetes; design standardized protocols to monitor blood sugar during and after surgery; and assign someone to be responsible and accountable for blood glucose monitoring and control in surgical patients.
Fifteen percent of patients on ventilators develop pneumonia. Nearly 26,000 people die from ventilator-associated pneumonia each year. Certain procedures, such as endotracheal intubation and tracheostomy increase the risk of acquiring pneumonia. Ventilators and nebulizers also can cause pneumonia.
10. Practice good oral hygiene: Train nurses to provide good oral hygiene to ventilated patients. Infections are caused when bacteria in patients’ mouths travel to their lungs. At Memorial Hospital, a 477-bed hospital in Colorado Springs, Colo., VAP rates dropped nearly 70 percent—from 11.33 per 1,000 device days in 2001 to 3.44 per 1,000 device days in 2003—after the hospital implemented an oral hygiene protocol.
11. Remove tubes promptly: Endotracheal (mouth to trachea) and nasogastric (nose to stomach) tubes are necessary to help some patients breathe, be fed and have the contents of their stomachs checked. Unfortunately, intubation dries the patient’s lower respiratory tract and provides entry for microbes. Moreover, many endotracheal tubes create an insufficient seal in the trachea, which allows microbes to migrate into the patient’s lungs. Remove nasogastric and endotracheal tubes as soon as possible.
12. Go up 30 degrees: Patients are less likely to get a ventilator-associated infection when they recline at an angle rather than lying flat on their backs. Ideally, the patient’s head should be elevated between 30 and 45 degrees. This step is one of several best practices in what’s known as the ventilator “bundle,” which includes evaluating patients daily to see if they can be extubated, a daily “sedation vacation,” and deep vein thrombosis and peptic ulcer disease prophylaxis. In January 2004, St. Luke’s Hospital, Jacksonville, Fla., adopted the ventilator bundle and slashed its rate of VAP from between six and nine VAP incidents per 1,000 ventilator days to 0.72 per 1,000 ventilator days. Meanwhile, the overall length of ICU stay dropped from an average of 5.7 days to 4.6 days.
Forty percent of hospital-acquired infections are urinary tract infections, which are caused mainly by indwelling catheters followed by genito-urinary procedures.
13. Use silver-alloy-coated catheters or no catheter at all: Each year, more than 5 million hospital and nursing home patients have urinary catheters inserted, and each year, more than 1 million of those patients get an infection. But according to the CDC, as many as 20 percent of patients may not need to be catheterized at all. Try to avoid inserting urinary catheters whenever possible, but if absolutely necessary consider catheters coated with a silver alloy, which has anti-infective properties. Although more expensive than standard catheters, they’ve been shown to significantly reduce the risk of UTI in cases where patients are catheterized for two to three weeks. However, given their higher cost and the general overuse of catheters, the recommendation of silver-alloy-coated catheters is still somewhat controversial, Goldmann says.
14. Remove catheters quickly or use alternatives: An indwelling catheter is a pipeline for bacteria and puts the patient at significant risk for a hospital-acquired infection. If indwelling catheters are absolutely required, set a time limit for use and make sure the catheter has a closed drainage system. Remove the catheter as soon as possible. External, condom-style catheters, which are appropriate for certain male patients, carry a lower risk of infection.
Forty-eight percent of ICU patients have central venous catheters, which deliver medications, fluids and nutrients to patients. But CV catheters are the greatest source of bloodstream infections, causing about nine out of 10 infections. The Institute for Healthcare Improvement says bloodstream infections kill 500 to 4,000 patients in the United States every year. Patients with bloodstream infections are hospitalized seven days longer and each infection costs an extra $3,700 to $29,000. Common sources of infection include contaminated antiseptics used to clean the patient’s skin and the hands of health care personnel.
15. Use line carts: Sterile materials are imperative for patients with central lines, but in the chaotic hospital environment, it’s easy for those materials to go astray. “I’ve seen nurses hoard bandages in a locked drawer so they’d have what they needed the next time they were on shift,” Shannon says. Place a tailored package or cart of materials directly at the bedside of every patient who needs a central line so that ICU personnel always have easy access to sterile materials. Several hospitals in New York state, including Good Samaritan Hospital Medical Center, North Shore–Long Island Jewish Medical Center, Long Beach Medical Center and Southside Hospital, placed line carts beside the beds of patients who required central lines. This step, along with some additional protocols, reduced the hospitals’ central line infections by 50 percent, from five per 1,000 days to two and a half per 1,000 days.
16. Keep sterile: Because they pose such a high infection risk, central line procedures demand the utmost sterile conditions. Accidents or mishaps that can compromise safety are fairly common, experts say. Clinicians should be fully gowned and gloved when inserting central lines, the patient’s skin must be cleaned with appropriate disinfectants, and the patient must be covered with a full-sized drape. Hospital staff and patients should wear face masks. Community Medical Center, Scranton, Pa., has seen no infection cases in 273 days (from January 2005 through early August 2006), in part because it required staff to wear face masks.
Removing gowns, gloves and masks properly is also important. Health care workers tend to put on gloves, gowns and masks correctly, but remove them the wrong way, Soule says. For example, instead of using the ear loops to remove a face mask completely, a nurse might use one ear loop to partially remove it, but then grab the mask itself to take it off. Touching the face mask in this fashion compromises its sterility, and could spread germs to the nurse and then to others.
17. Use PIC lines: Because the majority of patients with tubes or catheters are not in the ICU, peripherally inserted central catheters, known as PIC or PICC lines, can be a good alternative for many patients. PIC lines are inserted into a peripheral vein, then advanced through larger veins toward the heart, and they pose fewer risks than femoral or internal jugular lines.
From patient bed handrails to bathrooms to computer keyboards, hospitals teem with bacteria, some of it harmful to patients. Basic cleanliness can go a long way toward reducing infections. Involve housekeeping staff in infection control efforts.
18. Don’t skimp on supplies: Nothing will undermine a hand hygiene program like empty hand rub or soap dispensers. Maintain sinks and soap dispensers; keep paper towels stocked. And make sure to include properly sized gloves.
19. Enforce good housekeeping: Is the water used to mop the floor dark with dirt? Are computer keyboards cleaned or disinfected regularly? What about the patient rooms and the bathrooms? Set and maintain good housekeeping standards. Chlostridium difficile, a bacteria common in health care settings, can be spread through surface contact. Experts like Soule and Nadworny believe much of infection control is labor intensive and consists not so much of big steps, but of many little steps that add up.
20. Make hand rub dispensers ubiquitous: Place alcohol-based hand rub dispensers and boxes of clean gloves next to each patient’s bed and near the door to each patient’s room. Put dispensers in the hallway. Place them so that just by walking down the hall, clinicians will see the dispensers and stop to clean their hands.
Controlling infections involves more than implementing clinical interventions or protocols—it requires an organziational perspective. Hospitals need to understand their specific infection control issues, how to communicate infection data quickly and effectively and how to ensure that infection control policies are appropriate for their specific circumstances. They also need to monitor patients and vaccinate staff.
21. Understand your current conditions: “Observe, observe, observe,” Shannon says. “See all the barriers that people face. Understand the things that can go wrong and actually listen to health care workers.” Shannon spent eight hours a week for four weeks observing the two ICUs he oversees at Allegheny General. He learned that variation in processes was common, that health care workers are accustomed to chaos and that consequently, staff wasted precious time looking for supplies that they could have used to provide patient care. If you don’t know what’s happening in your environment, you can’t really understand what needs fixing.
22. Build a business case: Hospitals bear the financial brunt of infections; a typical hospital pays anywhere from $600,000 to $1.2 million per year for patients’ extended length of stay and additional medical procedures and medications. Experts estimate that a central line infection costs about $24,000, ventilator-associated pneumonia costs $26,000 and an MRSA (methicillin-resistant staphylococcus) infection costs $13,000. A 2003 study using national data and adjusted for DRG, sex, race, age and co-morbidity, calculated the average cost of infection incurred during medical care was $38,656. In two years, Allegheny General saved $4.3 million in operating performance by reducing errors, Shannon says. “You need to have a hard look at the hospital economics associated with infections,” he says.
23. Investigate in real time: Too often the process of analyzing infection data takes months. In a typical scenario, the infection control specialist will collect data over a three-month period before sharing it with the quality committee. But after three months, the context is lost, experts say. Complicating matters, there is variation in how quickly some infections develop. A central line infection, for example, develops within hours and is relatively easy to track, but ventilator-associated pneumonia takes three to four days to develop. Investigate infections immediately, for example within 24 hours for fevers.
24. Communicate quickly and effectively: Head off errors by improving communication between caregivers and those involved in infection control, including microbiology, the laboratory and clinical staff. “Having a computer system is not enough,” the IHI’s Goldmann says. “Just because the results are in the computer system doesn’t mean physicians will look at it in a timely way.” The lab needs to know who they should call with results. Staff on the wards need to know who is accountable for results. Clinicians also need real-time feedback of key data, at least on a monthly basis. “You won’t be motivated to change if you don’t know you have a problem,” Goldmann says.
25. Standardize your processes: A hospital’s infection control guidelines are often too general, failing to spell out explicit steps. Variation in processes such as central line insertions are common. A typical hospital may have six to eight different ways that physicians put on gowns and gloves, four or five insertion kits and three or four ways the patient is draped and prepped. This makes it impossible to identify where things go wrong and how to improve them. Hospitals should standardize processes and put in systems to ensure all steps are executed reliably and accurately. “It doesn’t matter what it is, whether it’s Six Sigma, or lean methods, or whatever process a hospital wants to use, as long as it is a system,” Goldmann says.
26. Speak plainly: Too often, the language of infection control obscures the problem and its severity. To say that you have 49 infections, with a central line rate of 10 per 1,000 line days is not nearly as effective as saying there were 49 infections in 37 human beings, half of whom died. “When you put it that way, people say ‘Whoa!’ The intent is well-intentioned, but when you share infection data, many people have no idea what you’re saying,” Shannon says. Transform data into information that people can understand and use.
27. Harness the power of numbers: IHI promotes the use of care “bundles.” A bundle is a grouping of best practices, each of which improves care when individually applied, but when practiced together leads to substantial improvement in reducing infection. “It’s very hard to link single interventions to data on infections, and consequently it’s difficult to get doctors to do them consistently,” Nadworny says. It is only when all of the interventions are applied that improvement accelerates.
28. Get infection control expertise: The guideline for acute care hospitals is to employ an infection control practitioner for every 150 to 200 beds, but not every hospital can meet that goal. “The bottom line is you have to assess your risk for infection to your patients and staff,” Soule says. “Take into account surveillance data, environmental issues, your incidence of MRSA (methicillin-resistant staphylococcus aureus), employee health, your incidence of needlesticks. Design your program around your priorities.” Smaller and rural hospitals can benefit from the expertise of an infection control practitioner if they partner with other hospitals.
29. Monitor patients for antibiotic-resistant bacteria: Antibiotic-resistant bacteria is a serious and growing problem. Hospitals spend $1.3 billion each year on infections caused by so-called “superbugs” like MRSA , which are resistant to most, if not all, antibiotics. For example, some staph infections acquired during hospital stays are resistant to all antibiotics except vancomycin, considered to be the drug of “last result,” and a growing number of strains are even resistant to vancomycin. If detected early, people with these bacteria can be given antibiotic therapy, which will interrupt the spread of resistant bacteria to other individuals. Monitor the patients at your facility to detect and stop the potential spread early.
30. Vaccinate staff: Each year, flu causes 36,000 deaths and 200,000 hospitalizations. Unvaccinated health care workers can spread infection to patients, yet fewer than 40 percent are immunized each year. Beginning in 2007, the Joint Commission on Accreditation of Healthcare Organizations will require that hospitals vaccinate staff against influenza in order to be accredited.
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This article first appeared in the September 2006 issue of H&HN magazine.