The letter was more than a patient complaint. It was a call to action: "Our son died in your hospital seven days ago. He caught an infection there as a result of his medical care while being treated for something else … leaving him a helpless ventilator-dependent quadriplegic and ending his short but unforgettable life among us all. In the week since his death, the days I live have small worth to me. I am numb now… ."
In October 2006, Victoria Nahum's 27-year-old stepson Josh survived a skydiving accident that broke his femur and fractured his skull. He did not, however, survive the Enterobacter aerogenes bacterial infection he acquired during treatment of the injuries. "One of the nurses in the hallway looked at me and said, 'These things just happen. It's just part of the delivery of care,'" recalls Nahum of Atlanta, who started the Safe Care Campaign three months later with her husband Armando Nahum to advocate for patient safety initiatives and raise awareness of health care-associated infections.
She wrote a letter to the hospital's leadership, hoping to spark a modicum of the outrage she felt not only for her own stepson, but also for the 1.7 million other people who get an HAI each year — including 99,000 people who, according to the Institute of Medicine, do not survive. HAIs come with an estimated $33 billion annual price tag. Experts say at least one in five infections is preventable.
A recent report from the Centers for Disease Control and Prevention shows health care providers have heeded calls to action and are focused on changing these numbers. In the last year, the number of people who acquired one or more of the four most common HAIs declined: Invasive methicillin-resistant Staphylococcus aureus (MRSA) infections dropped 18 percent; surgical-site infections declined 10 percent, while catheter-associated urinary tract infections decreased 7 percent. The largest drop was seen in central line-associated bloodstream infections, which fell 33 percent. The report also showed that hospitals and health systems are on track to meet nearly all of the national infection reduction and protocol adherence targets by the Health & Human Services' 2013 deadline.
"Hospitals are taking [HAIs] far more seriously," Nahum says. "Five years ago they told us these infections cannot be prevented. Then, they told us these things should be prevented. Since 2009, they've been saying they absolutely can be prevented."
Several hospitals and health systems have deployed especially successful interventions to tackle the HAIs highlighted by the CDC. The common threads in each of the hospital's success stories are: a multidisciplinary team dedicated to finding solutions; senior leaders who foster accountability as well as an alliance with care providers; vigilant adherence to infection prevention protocols; and, most importantly, a constant awareness that infection rates are more than just numbers — they are patients' lives.
Taking it personally
When a 28-day-old infant died of a MRSA infection, the recently retired president and CEO of Novant Health, Paul Wiles, decided that senior leaders — including himself — were as personally responsible as caregivers. The health system, based in Winston-Salem, N.C., launched an aggressive hand hygiene campaign at its seven hospitals, linking adherence outcomes to leadership compensation.
"We had always tried many hand hygiene campaigns from the bottom up with cute sign-up sheets and no accountability. We all patted each other on the back and that was it," says Jim Lederer, M.D., an infectious disease physician and Novant Health's vice president of clinical improvement. "But this was a top-down, board-approved hand hygiene program that became a long-term goal for the system."
A steering committee, comprising representatives from nursing, infection control, environmental services and medical affairs, set a goal to hit a 90 percent hand hygiene compliance rate over the following three years. Research showed a drop in hand hygiene compliance if caregivers had to go into the patient's private bathroom to use soap and water. "We moved to alcohol hand sanitizer, and we had to make sure we had sanitizers in the right place," primarily at the entrances and exits to patient rooms, he says. Making sure hand-sanitizing dispensers were filled at all times became a key responsibility for environmental services staff.
Two observers were hired to rotate throughout all of the hospitals' acute inpatient units, monitoring compliance, educating caregivers and environmental services staff, and documenting at least 2,000 hand hygiene observations each month. "Then, it was education, feedback, education, feedback," Lederer says — education for direct patient caregivers, leadership conferences, computer-based training modules and meetings between infection preventionists and nursing unit staff. Novant's marketing department also launched a $325,000 promotional effort, including cutouts of cartoon characters stationed around the hospitals reminding people about hand hygiene.
Each facility could see how other hospitals in the system were faring every month. The penalty for not reaching the 90 percent target was a forfeit of end-of-year bonuses from the director level up. "So if you're the leader of one facility and I'm the leader of another, I can say, 'Hey, what are you doing? I don't want to miss this goal,' " Lederer explained.
At the beginning of the campaign in 2005, Novant's MRSA infection rates were between 0.8 to 1 infections per 1,000 patient days. Since then, the system has maintained 60 to 70 percent fewer infections, down to 0.15 infections per 1,000 days. And the hand hygiene target has been increased to 95 percent.
"It's all well and good for leaders to send out a memo," Lederer says. "But then you have leaders like Paul Wiles who stand in front of nurses and say, 'I'm responsible for that death, and I hold you responsible as well.'"
Calling all nurses
The Centers for Medicare & Medicaid Services listed catheter-associated urinary tract infections as one of the HAIs that no longer would receive Medicare or Medicaid reimbursement as of October 2008. That gave hospitals an added incentive to reduce the infections, which can cost between $600 and $2,800 per person to treat. However, Sanjay Saint, M.D., associate chief of medicine at the Ann Arbor VA Medical Center and director of the VA/University of Michigan Patient Safety Enhancement Program, had been researching CAUTI occurrences long before. More than 30 percent of HAIs are actually urinary tract infections, and Saint's research found that caregivers tended to leave urinary catheters in much longer than necessary.
"Step No. 1 is recognition that this is a problem," says Saint, who also is a liaison to CDC's Healthcare Infection Control Practices Advisory Committee. "For our patients who are unable to advocate for themselves — which is often the case for people with urine catheters — do we really want them to have a catheter longer than necessary? It's almost a moral and ethical issue."
"Step 2," he adds, "was to build a team with key involvement from nurses."
The Ann Arbor VA's team was also multidisciplinary, with representation from managers, an infection preventionist and information technology specialists — the majority of whom happened to have a nursing background.
Putting nurses at the helm is key to preventing CAUTI occurrences because, even though physicians write the orders, nurses are most aware of which patients have indwelling catheters and can have them removed. Nurses are also the ones responsible for helping patients during bathroom visits, doing cleanup in cases of incontinence, particularly in an older, less mobile population, explains Sarah Krein, R.N., research health science specialist at the Ann Arbor VA.
After spending several months getting feedback from various departments, the hospital piloted a new policy for patients on one of the medical-surgical units in the spring of 2010. The new policy required daily assessment of whether patients had an indwelling catheter and a determination of whether the catheter was still medically necessary according to CDC guidelines. A specially designed template was created for nurses to notify the physician of each patient's catheter status and document the rationale for leaving it inserted or removing it. The new templates allowed the hospital to track catheter usage and urinary tract infections more accurately. The new protocol later was rolled out to the entire facility.
Eighteen months after implementing the protocol, the Ann Arbor VA decreased catheter usage by 50 percent. This led to a 45 percent drop in CAUTI rates.
"One of the common reasons given for why catheters are often left in is nursing convenience, so we needed to have nurses be part of the solution," Saint says. "Nurses want to do what's best for patients. That's their goal. That was why we did it."
Each one counts
Before June 2008, if clinicians or staff members at East Tennessee Children's Hospital, Knoxville, were asked about the hospital's rate of central line-associated blood stream infections (CLABSI), their responses might have been blank stares. They might not have known that 21 CLABSI infections had occurred in the neonatal intensive care unit or that the pediatric ICU had seven CLABSI infections that year, costing an estimated $40,000 each.
But several staff members, including Sheri Smith, R.N., the hospital's nursing director of critical care services, learned about effective CLABSI interventions at other facilities at the Tennessee Patient Safety Center, an initiative of the Tennesee Hospital Association. "I knew our patients were no sicker than [those at other hospitals]," Smith says.
In addition to educating staff members on CLABSI prevention standards, Smith worked with colleagues in the NICU, PICU, and medical nursing and clinical education departments to hold focus groups on every single infection. Nurses and physicians were asked to dissect each case to determine the cause and what could have been done differently. Staff members were invited to share their ideas on how central lines could be handled differently. "Every single time, we came away from that room with something we wanted to change," Smith says.
One of the biggest challenges with the focus groups was creating a safe place where everyone could share without fear of being penalized or blamed. It also involved changing the dynamics of how physicians and nurses interacted. Physician leaders like Joe Childs, M.D., vice president of medical services, urged nurses to take a bolder approach, whether reminding a physician about hand washing or stopping a procedure because a protocol was overlooked. He encouraged fellow physicians to be open to that. Both physicians and nurses signed a pledge to accept and give correction for not following prevention protocols, such as wearing isolation gowns and masks, thoroughly sterilizing patient rooms and constantly assessing if central lines were necessary.
Parents whose children went home with central lines were educated on proper protocols, says Chris Tolliver, clinical educator for medical services floors. "We wanted to enlist parents as partners," Tolliver says. "We needed to prevent infection within the facility, but we also needed to prevent patients from coming back in with one from home. We gave them avenues to meet the same criteria we were."
And then there was the promotional campaign that reminded all caregivers that the next patient infected could be their child.
In one year, CLABSI infections fell 85 percent. Today, even the receptionists likely know that the NICU had only one CLABSI infection in 2011, and that the last infection in the PICU was 530 days ago.
Patients in, infections out
Surgical-site infections can be more elusive than other HAIs, since most don't appear until weeks after discharge. But infection preventionists at New England Baptist Hospital in Boston found that the infections often start at home before the surgery.
Between 500,000 and 750,000 surgical-site infections occur each year in the United States. The hospital established a zero-tolerance policy that started in 2004 with an in-house study of colonized patients, the vast majority of whom needed orthopedic surgery. The study showed a link between postsurgical infections and patients whose presurgical nasal swab screenings were positive for organisms like S. aureus bacteria.
In February 2006, a new policy for surgical patients was implemented: Instead of only screening patients with a history of infection, all patients — a star athlete with an ACL tear or a 90-year-old with a broken hip — had to be screened for bacteria exposure, particularly MRSA, which is harder to treat, says Helen Miller-McDermott, R.N., New England Baptist Hospital's director of infection prevention and control.
If cultures from the nasal swab screenings were positive for MRSA or other infection-causing organisms, the patient was treated with an intranasal antibiotic for five days and an antiseptic to be used in the shower. Meanwhile, preadmission staff members called patients to ensure they were following the treatment plan before the follow-up screening.
If the second screening also was positive, the patient was put on contact precaution, requiring special sanitization protocols for the patient's room and protective gear for anyone coming in contact with the patient.
Before surgery, the patient was given a prophylactic antibiotic. The data coordinator flagged patients with positive cultures and distributed a weekly list of patients on contact precaution to all units.
The new protocol led to a 60 percent decline in surgical-site infections. The key, Miller-McDermott says, was the medical center's ability to get new protocols and resources deployed as soon as they were deemed viable.
"We have a lot of communication across all specialties and all levels," Miller-McDermott adds. "But we're not resting on our laurels. We're going to zero."
Kadesha Thomas is a freelance writer in Chicago.
"People are busy, and sometimes necessary supplies and precautions aren't available. If I'm putting in a central line, I don't want to search one place for gowns and another place for gloves. Many hospitals are creating kits, so everything is there and available at the bedside. In an emergent situation, it's get the cart, everything's there, let's go." — Diane Jacobsen, epidemiologist and director of the Institute for Healthcare Improvement
"One issue that we're clearly seeing is patients who develop complications after discharge. It's happening in the community at large. This is more of a public health problem, rather than just acute care or long-term care. Patients may go from acute care to long-term care to a nursing home, receiving care in various facilities. There's potential for cross transmission. As we move into accountable care organization models where we're worried about wherever the patient is, it clearly is more cost-effective to prevent infections." — Russ Olmsted, 2011 president of the Association for Professionals in Infection Control and Epidemiology and director of infection prevention and control services at St. Joseph Mercy Health System in Ann Arbor, Mich.
Top-down common goals
"With top-down approaches, you don't get engagement of the staff whom you're asking to do the work. There's no ownership — just another policy that came down from wherever. But if you go to a physician or staff person and say, 'Hey we're trying to do something better here. Can you give your opinion?' They'll tell you. It's not us against them; it's establishing a common goal." — Barbara Edson, R.N., vice president of clinical quality at the American Hospital Association's Health Research & Educational Trust