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Nurses' Unlikely Infection Control Tool Quashes HAI

 |  By Alexandra Wilson Pecci  
   May 13, 2014

Nursing leaders at a Florida hospital finally found an infection control method that helped arrest a stubborn problem with hospital-acquired infections. It took them 20 years.

For years, clinical staff at Jackson Memorial Hospital in Miami did everything they could think of to curb the spread of the highly resistant organism Acinetobacter baumannii (also known as Iraqibacter) with little luck.

But a bundle of infection control interventions including hand-hygiene initiatives, multidisciplinary taskforce meetings, and isolation and cohorting "didn't really make much of a dent in the situation," Elizabeth Davidson, R.N. M.S.N., nurse manager of the surgical intensive care unit at JMH.

But after 20 years of trying different things, something unexpected finally worked: Weekly emails to the C-suite.

Between January 14, 2011, and March 30, 2012, Luisa S. Munoz-Price, MD, Jackson Memorial's medical director of infection control, sent weekly emails to the hospital leadership, including the C-suite of the hospital, the Quality and Patient Safety Division, and the nursing and medical directors of inpatient units, according to the study published in the American Journal of Infection Control.

"She was looking for a different way to attack the problem and get upper-level management involved," Davidson says. "She was trying to get a multidisciplinary approach in which there was accountability. That's why we had to reach out to the upper-level management."

The emails described and interpreted the findings of the preceding week's bundle of interventions; relayed the number and location of new carbapenem-resistant A. baumannii acquisitions; and described environmental findings, including culture results and ultraviolet markers (as indicators of cleaning).

The emails also included maps of the units showing the location of carbapenem-resistant A. baumannii-positive patients and objects, as well as weekly action plans, according to the study.

"They would give us a roadmap of how the bacteria was moving through our unit," Davidson says. "It was more specific. Instead of just talking about infection in your unit in general, we would pin it down to specific patients."

'We Were the Culprit'
Davidson says the data and action plans would trickle down from the leadership, adding that charge nurses had print-outs of the emails in their hands at all times, and used them every day to pre-plan things such as patient placement within the unit.

They also shared the email contents with the staff. For instance, the maps and culture results showed not only how the infection was spreading but who was spreading it. Although representatives from hospital wouldn't tell me whether anyone was fired for failing to clean properly, they did say that individuals were spoken to about their performance and appropriately disciplined, when needed.

"You could definitely make the connection that we were the culprit," Davidson says.

Starting with the C-suite made everyone more accountable, and sharing the infection information with staff helped them see how they personally were helping to prevent infections by performing certain interventions, such as completely wiping down surfaces. The environmental workers took the information especially seriously, Davidson says.

"We shared everything with them and they saw the rates drop… that momentum went a long, long way to convince people," she says. "If they believe that, that's true, if they believe that those interventions are making a difference, they're much more likely to carry them on."

Nurses and others did see the infection rates drop. According to the study, as of December 2013, the number of new acquisitions of carbapenem-resistant A. baumannii was down to one per month hospital wide, even after the weekly emails stopped.

Researchers examined data from an infection control electronic database from before, during, and after the study period (representing a total of 42 months) and found that there were 198 new infections during the 13-month period before the emails started, 168 in during the 14-month that the emails were being sent, and 72 in the 15-month period after the emails stopped.

'A Striking Decrease' in Infection Rates
According to the study, the emails stopped because "there were only scattered weekly acquisitions to report."

Other data, such as readmissions and money savings weren't addressed in the published study data.

"Weekly electronic communications were associated with a striking decrease in the rate of new acquisitions of A. baumannii at our institution probably because of a combination of education, communication, feedback, and peer pressure," the study says. "As brought up by one of the reviewers of this paper, this article is more management than science and entails organizational culture change."

The culture change aspect of the study results has been evident among nurses. For instance, having the weekly emails and directives from the hospital leadership helped nurses on the unit speak up if they saw someone doing something dangerous for infection control, such as failing to wash their hands or not cleaning the patient rooms properly.

"The nurses became very, very territorial about their patients," Davidson says. "They would really have zero tolerance for a physician, perhaps, that would violate any kind of infection-control practice. They also got much pickier about their rooms being cleaned."

It became acceptable and even expected for nurses to call their managers and request that someone from environmental services to re-clean a room that wasn't up to snuff. They weren't afraid to tell physicians to take off their lab coats or wash their hands before examining a patient, says Laura Harris, RN, BSN MS, Director of Critical Care at Jackson Memorial Hospital.

"It's almost like it became OK to say something out loud to someone, to hold someone accountable. That's not easy to do," Harris says. "It became easier the more people that did it."

Harris adds that Davidson was very vocal herself and set the example for staff nurses to have these kinds of conversations, too.

"You lead by example," Harris says.

Alexandra Wilson Pecci is an editor for HealthLeaders.

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