The IPCC program sought to enhance improvements led by Six Sigma project teams to improve rates of central line-associated bloodstream infections (CLABSIs), ventilator-associated pneumonias (VAPs), and Foley catheter-associated urinary tract infections (UTIs). We engaged staff in hand hygiene observations and immediate feedback and included the compliance data on our dashboard. We also developed strategies to better communicate about line maintenance and to address daily whether lines can be removed (see Improving Communication Systems where the Daily Goals Communication Sheet is discussed).
In addition to regularly conducted bundle audits and education, we put in place certain structures to ensure continuous monitoring and follow-up related to HAIs. All occurrences of an HAI are reviewed at the monthly mortalities and morbidities conference for Pediatric Critical Care Medicine. Posters with the number of days since each type of infection are kept up-to-date for everyone in the PICU to see. Each type of infection has an owner who is responsible for initiating the following steps for addressing a concern.
- Owner calls meeting of improvement team (comprised of Green Belts from original Six Sigma project team and/or nursing performance improvement committee members)
- Team reviews recent cases/deviations from process
- Team develops action plan
- Owner reports plan to advisory group
- Owner monitors execution of action plan and reports out to advisory group until satisfactorily completed
We placed high importance on several strategies for hand hygiene compliance as we saw a direct correlation between decreased infection rates and better hand hygiene compliance. We intended to send a clear message that this is everyone’s responsibility by sending a letter from the Chief of Staff and Chief Nursing Officer reminding faculty and staff of the no tolerance policy for not adhering to hand hygiene practices.
- Embedded staff observations with immediate feedback. We identified individuals already working in the PICU in various roles to regularly conduct observations, give immediate feedback for compliance or non-compliance, and report back to the program team to record on our dashboard. We provided an observation form (or the option of using the iPhone application iScrub) as well as a script to use with individuals who were non-compliant. Roles asked to complete observations included back-up attending physicians, advisory group members, and nursing infection control liaisons.
- Signage. Hand hygiene posters were displayed throughout the PICU and in the waiting room and restrooms. The posters were rotated monthly in order to make them more noticeable. In addition, signs were placed at the foot of each patient’s bed (“Hi, my name is ____. Please remember to wash your hands.”)
- Communication. We also worked with the Hospital Epidemiology department to distribute letters to praised performers and repeat offenders. One of these letters resulted in an invitation to present at a division’s grand rounds.
- Families. We encouraged parents and other family members of PICU patients to speak up if they believe any of the medical care providers did not wash their hands before entering their child’s room or before examining their child. Family educational materials were included in the PICU handbook and on the website.
Additional strategies included placing hand sanitizer bottles in convenient places, like the nurse’s cart and the ventilator, and routine follow-up conversations with staff caring for patients who obtain an HAI.
Results & Lessons Learned
During the two years, the VAP rate decreased by 65%; the CLABSI rate decreased by 28%; and the UTI rate decreased by 7%. The PICU went for over a year without a VAP during this timeframe. With our grant funds, we printed large banners that read, “Thank you for 377 VAP-free days in the PICU” and posted them outside the PICU entrances. The Performance Improvement & Patient Safety department sponsored a pizza party for PICU staff.
Despite increased awareness and several successes, we still see hand hygiene compliance below our target of 100% with a median of 75% over the last two and half years. We learned that constant vigilance is necessary to maintain awareness and enforce compliance. Regular nurse education is needed regarding the oral care kits specialized for pediatrics. In addition, we would like to do more to involve families in this process by interviewing them on a regular basis regarding staff compliance and creating our own video stories.