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It takes more than one method to bring a hospital's hand hygiene compliance rate above 90%. At Barnes-Jewish St. Peters (MO) Hospital (BJSPH), it was a matter of trial and error to reach its compliance goal.

"We started collecting hand hygiene observations back in 2004," says Kathleen Dougherty, RN, MSN, manager of professional practice and leadership development at BJSPH. "We wanted to see where we were with compliance for guidelines from the Centers for Disease Control and Prevention [CDC]."

Taking 100 observations per quarter, the organization found its hand hygiene compliance rate was 57%. Conversations began on how to reach the CDC goal. The 2004 numbers illustrated the need for increased compliance; the renewed awareness alone caused a significant jump in compliance in 2005.

"We got our rates up to 79% [in 2005]," says Dougherty. "This came about just based on a general heightened awareness of hand hygiene. We didn't have a pointed focus or implementation plan."

Although the jump was encouraging, it still did not bring the organization's compliance numbers to an acceptable level. But the organization was collecting data.

The facility has seen significant rates of improvement each year since this time—remaining over 90% and at times hitting 99% compliance in 2009.

Education and training
BJSPH is a member of BJC HealthCare, a 13-hospital system in Missouri. The hospitals share a center for healthcare quality and effectiveness, which works closely with all facilities to develop standards and practices to be used across the system.

"The center looks at regulations that relate to clinical quality and patient safety and assists with development of protocols and procedures to facilitate positive results," says Dougherty. The center knew hand hygiene compliance was about to explode on the national level. At the time, The Joint Commission (formerly JCAHO) was increasing its focus on this issue, and BJC wanted to be prepared.

"We also knew we'd be accountable to publish data [on hand hygiene compliance] on a regular basis," says Dougherty. Thus, in 2006, mandatory training was implemented. "Every employee was provided with training on hand hygiene in 2006," she says.

However, the increase in compliance was minimal, climbing to 80% that year. Simultaneous to the training, the organization started using hand hygiene auditors—essentially undercover agents looking for hand hygiene compliance—to act as observers.

"These auditors were on all shifts like secret shoppers," says Dougherty.

They came from all walks of hospital life—not just physicians and nurses, but secretaries, housekeepers, lab techs, and others.

When the numbers did not rise as much as expected, extra training was provided, additional auditors were trained, and compliance rates were reported at departmental meetings.

You've been spotted
"In 2007, we knew we had to do more, and we wanted to do more," says Dougherty. "We wanted to be at 90% hand hygiene compliance by the end of that year."

BJSPH increased the frequency of the audits to a minimum of 100 per month.

"Our point of view was if you increase your 'n,' you have a better chance of being successful," Dougherty explains.

In February 2007, after a brief discussion with a Joint Commission surveyor, BJSPH learned of the idea to use cards as a method of feedback during audits. The hospital took this idea and developed it further into a very simple but highly effective concept: "You've Been Spotted" cards.

These cards—adorned with a Dalmatian to support the "spotted" theme—come in two varieties. At a distance, they appear indistinguishable, but up close, the two varieties are unique.

For positive reinforcement, some of the cards are flagged for incidents in which the receiver has been spotted using good hand hygiene practices. These cards include a $2 coupon that's good in the hospital cafeteria or gift shop, which is enough for a cup of coffee or candy bar.

Receivers of multiple positive reinforcement cards can use them together to purchase lunch. Funding for these coupons came from the infection prevention budget.

On the spot
The second type of card reads, "We are putting you on the spot for not using hand hygiene."

The reason the cards look nearly identical is to prevent embarrassment for the people involved. It's impossible to tell from a few feet away whether you've received a positive or negative card.

"We needed something nonconfrontational," says Dougherty. "We wanted something with positive reinforcement, but also something to notify you if you got caught. We didn't want this to be a public display."

The dynamic is an interesting one, especially because the auditors can be from any area of the hospital hierarchy. For example, secretaries have had to give cards to physicians.

The introduction of the cards showed an increase in compliance, but not enough of a jump to be completely satisfactory. "We saw an increase that year. We made it to 90% one month, but for year-to-date we were at 86%," says Dougherty.

Posting names was the next step toward improvement. "We continued the positive rewards program, but . . . we started reporting both those who did well and those who needed to improve," explains Dougherty.

The good with the bad
There was much deliberation within the leadership team on the concept of posting names. Leaders made a conscious decision to hold everyone accountable while continuing to use the carrot instead of the stick, staying with positive reinforcement to motivate their employees to higher hand hygiene compliance.

To temper the negative reinforcement of posting names—which helped improve compliance as well—BJSPH implemented an additional, and very public, way of rewarding those who were spotted using proper hand hygiene processes.

"Any [month] we meet or exceed our goal, we will take the names of everyone who was recognized as doing a good job, put their names into a drawing, and have a 'hand hygiene hero' drawn in the cafeteria," says Dougherty.

The cafeteria is shared by staff members and guests, so the congratulatory ceremony, which includes the loud playing of Bonnie Tyler's 1980's hit "Holding Out for a Hero," can be witnessed not only by staff members, but also patients and their visitors. The winner of the drawing receives a $25 gift certificate, and in months in which the goal is exceeded, multiple names are drawn.

Winners' pictures are taken and posted throughout the building and even made into screensavers on hospital computers. The tactic has been well received by staff members, and when a winner is present in the cafeteria during the drawing, cheers have been known to break out.

Handling positive recognition is easy. Those spotted to be noncompliant can be more of a challenge.

Non-staff members are not immune to the card system. If a physician or advanced practice nurse is spotted not following hand hygiene protocol, the hospital's risk manager follows up with the independent practitioner separately.

It's not all "gotcha," either. BJSPH uses the "Just Culture" concepts, acknowledging human error, and the follow-up for noncompliance is not without managerial discretion. The factors leading up to an incident are taken into consideration when a noncompliant employee is spotted. "Managers are expected to hold staff accountable," says Dougherty.

To the program's benefit, the auditors have remained remarkably consistent over its duration. To keep the secret shopper concept fresh, the auditors don't continually work the same shifts or areas of the building. A fluid schedule allows the auditors to remain anonymous even as they keep their role year after year.

"We've sent the message that these patients belong to all of us," says Dougherty.

Although The Joint Commission's National Patient Safety Goals force many organizations to focus primarily on MRSA, central line-associated bloodstream infections, and surgical site infections, ventilator-associated pneumonia (VAP) is a high priority for anyone in the hospital setting.

Mortality rates alone force hospitals to take a critical look at prevention processes. VAP is the leading cause of death among hospital-acquired infections, according to the Institute for Healthcare Improvement (IHI). Hospital mortality of patients already ventilated who develop VAP is 46%, compared to 32% for those who are ventilated and do not develop VAP.

Just as most facilities have implemented central line and surgical site bundles, the IHI has published a ventilator bundle with four evidence-based practices:

• Elevation of the head of the bed
• Daily "sedation vacations" and assessment of readiness to extubate
• Peptic ulcer disease prophylaxis
• Deep venous thrombosis prophylaxis

A study published in the October 2009 American Journal of Infection Control focused on prevention of VAP in the intensive care setting. The study implemented interventions in three different phases to reduce the incidence of VAP in the ICU.

In the study's first phase, from March 2001 to December 2002, researchers evaluated the effectiveness of Centers for Disease Control and Prevention (CDC)-recommended evidence-based practices, including no routine changing of humidified ventilator circuits, periodically draining and discarding condensation collecting in the ventilator tubing, and changing the heat and moisture exchangers when they malfunctioned mechanically or became visibly soiled.

From January 2003 to December 2006, researchers intervened in the processes while performance monitoring was occurring at the bedside.

Finally, from January 2007 to September 2008, the researchers continued interventions and implemented the IHI bundle in addition to oral decontamination with chlorhexidine and the use of continuous aspiration of subglottic secretions (CASS) endotracheal tubes, says Alexandre R. Marra, PhD, lead author of the study and infectious disease physician for the ICU and medical practice division at Hospital Israelita Albert Einstein in São Paulo, Brazil.

The incidence density of VAP in the ICU per 1,000 days was reduced from 16.4 in phase one to 15.0 in phase two to 10.4 in phase three. The study noted that achieving a rate of zero VAP was possible only in phase three, when all interventions exceeded 95% compliance. In November 2009, the hospital celebrated one year without VAP.

"Our main reason for doing the study was to show that VAP prevention using the majority of evidence-based measures for controlling this hospital-acquired infection in the ICU is a difficult process that involves the accountability of many healthcare workers who care for ventilated patients," Marra says.

The initial results
The first phase of CDC evidence-based practices yielded disappointing results, particularly regarding compliance rates, Marra says.

"It was necessary to have a lot of discussions and changing ideas with the ICU team to make a better performance in our compliance rates," he says. The ICU team was composed of doctors, nurses, and respiratory therapists.

In early 2007, the hospital's CEO declared zero tolerance for VAP. Intervention measures continued, but with more intensity and urgency, Marra says. At that point, phase three was also initiated as an added measure.

Implementing all three phases at once
Although Marra's study gradually implemented each phase over the course of more than seven years, implementation of all three phases yields optimum results.

"Our recommendation is to begin using all the sources at the same time: VAP bundle, oral decontamination with chlorhexidine, and CASS endotracheal tubes," says Marra. "It is important to mention that VAP bundle is not a checklist, but a process that is necessary to intervene for improving compliance with these processes at the same time that performance monitoring is occurring at the bedside."

The intervention portion of the study was particularly beneficial. It's not enough to simply hand staff members a checklist. Working with ICU team members to ensure consistent and correct compliance is the only way to see improvements, Marra says.

"Our experience shows that it is not enough to control [head of the bed] or only to implement the IHI ventilator bundle, as some centers have advocated," says Marra. "We believe that by getting the involvement of all members of the ICU team, we ultimately had success in applying all these process measures over several years. We have an ICU nurse taking care of these processes every day and also a respiratory therapist giving support to us."

Although the ICU team at Hospital Israelita Albert Einstein has been able to sustain zero VAP rates for a full year, Marra recognizes the goal is ensuring continued compliance to achieve that rate.

"We are completely aware that we may not be able to sustain zero VAP rates indefinitely, but our goal is to sustain nearly perfect compliance with the ventilator bundle and maintain ICU team motivation for VAP prevention," Marra says.

Oral care: The most important phase
Evidence is mounting that in addition to the Institute for Healthcare Improvement's ventilator bundle, oral care is an important infection prevention process, according to a study published in the October 2009 American Journal of Infection Control.

Alexandre R. Marra, PhD, lead author of the study and infectious disease physician for the ICU and medical practice division at Hospital Israelita Albert Einstein in São Paulo, Brazil, says the last phase was the most important in significantly reducing VAP rates.

"I strongly believe, and I have no doubt, that the last phase was the most important," Marra says. "We got a decrease of more than 70% in our VAP rate in the ICU."

A study published in the September 2009 American Journal of Infection Control focuses on oral care to prevent VAP. Mercy Medical Center in Springfield, MA, initiated the following measures every four hours for mechanically ventilated patients:

• Brushing patients' teeth with cetylpyridinium chloride (changed to chlorhexidine gluconate in 2007) using a suction toothbrush
• Cleaning the oral cavity with suction swabs treated with hydrogen peroxide
• Applying mouth moisturizer
• Performing deep oropharyngeal suctioning
• Controlling secretions with suction catheters

Kathleen Hutchins, RN, MSN, lead author of the latter study, began research in 2004. By 2007, oral care intervention, coupled with the ventilator bundle, led to an 89.7% reduction in the VAP rate at Mercy.