St. John’s Regional Health Center1235 East Cherokee

Springfield, Missouri 65804

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 26th, 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

4.04

1.34

0.00

2.73

0.00 0.00 0.00

1.42 1.35 1.40

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.000.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

May

-07

Jun-

07

Jul-0

7

Aug-0

7

Sep-0

7

Oct-0

7

Nov-0

7

Dec-0

7

Jan-0

8

Feb-

08

Mar

-08

Apr-0

8

May

-08

Jun-

08

Jul-0

8

Aug-0

8

Sep-0

8

Oct-0

8

Nov-0

8

Dec-0

8

Jan-0

9

Ra

te

Days since last MRSA infection on 7C/3BAs 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.

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

5/1

/2007

6/1

/2007

7/1

/2007

8/1

/2007

9/1

/2007

10/1

/2007

11/1

/2007

12/1

/2007

1/1

/2008

2/1

/2008

3/1

/2008

4/1

/2008

5/1

/2008

6/1

/2008

7/1

/2008

8/1

/2008

9/1

/2008

10/1

/2008

11/1

/2008

12/1

/2008

1/1

/2009

pe

rce

nt

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.

2-19-09

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

417-820-3322 Diana.Henderson@mercy.net

• Judy Walker, BSN, MHSA, Director Infection Prevention

417-820-7069 Judy.Walker@mercy.net