Healthcare-associated Infections

IHC, in cooperation with infectious disease specialists from across the state, has developed the following Healthcare-associated Infection Toolkit. The toolkit consists of outcomes measures, standardized reporting format, and tools to improve performance related to healthcare-associated infections.

We would like to thank those individuals and organizations who have shared their materials and who have agreed to serve as mentors. Please contact IHC if your organization would like to contribute materials to this toolkit.

Case for Change

Healthcare-associated infections (HAIs) are a major public health problem in the United States. According to the 2005 Healthcare Infection Control Practices Advisory Committee (HICPAC) Report, hospitals account for an estimated 2 million infections, 90,000 deaths, and $4.5 billion in excess healthcare costs annually.(1)

Public Reporting – Since 2002, several states have enacted legislation that requires healthcare organizations to publicly disclose HAI rates. Advocates for mandatory reporting of HAIs believe that making more information publicly available will enable consumers to make more informed choices about their healthcare and improve overall quality. However, others have expressed concern that the reliability of public reporting systems may be compromised by institutional variability in the definitions used for HAIs, and/or in the methods and resources used to identify HAIs. In either case, there is insufficient evidence on the merits and limitations of an HAI public reporting system.(2)

Changing measures – Industry measurement of HAIs is undergoing widespread reevaluation. Several factors, including advances in medicine, have rendered previous methods of measurement obsolete. Several national organizations are working to identify new measures, standardize definitions, and focus improvement efforts where they will be most effective. The 2005 HICPAC Report recommended tracking and reporting the following rates:

Influenza vaccination coverage among healthcare personnel;
Central line-associated bloodstream infections, and,
Surgical site infections following selected operations.(2)

IHC Efforts – Following HICPAC recommendations, the Iowa Healthcare Collaborative (IHC) has developed a strategy to reduce HAIs in Iowa. IHC will develop and deploy a set of consistent, evidence-based measures across the state. Implementation of these uniform metrics will decrease institutional variability in interpretation and use. IHC also hopes the formation of these metrics will improve public access to HAI information. We believe that a provider-led exercise in self-reporting will accelerate clinical improvement and the spread of best practice in HAI.

IHC has produced this toolkit for healthcare providers in the state. It provides detailed information about IHC’s 2007 HAI reporting initiative and practical applications to improve performance.

References:
(1) Guidance on Public Reporting of Healthcare-Associated Infections, Recommendations of the Healthcare Infection Control Practices Advisory Committee (Feb. 28, 2005)
(2) Am J Infection Control 2005; 33:217-26.

Project Description

Objectives

In September of 2005, IHC began this effort to reduce Healthcare-Associated Infections. The objectives:

Increase awareness about HAIs among providers and the public.
Convene a discussion in the Iowa healthcare community to standardize definitions and metrics around infection reporting.
Promote public reporting of HAI information in Iowa.

Project Team

IHC convened a Work Group that includes:

Infectious Disease Specialists from the health systems across the state
State Epidemiologist
Infection control practitioners (ICPs)
Hospital management
Specialists in performance improvement
The state Quality Improvement Organization, the Iowa Foundation for Medical Care

Metrics

The 2006 measures set represents existing measures taken from the CMS data set:

SCIP 1 - Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision
SCIP 3 - Prophylactic Antibiotic Discontinued Within 24 Hours After Surgery End Time
PN 2 - Pneumococcal Vaccination

New measures will be added to the 2007 Iowa Report. These are described in greater detail in the Tools section of this toolkit. New measures IHC plans to include:

Healthcare Worker Influenza Vaccination Rate
Central Line Infection Rate in the Intensive Care Unit
CABG Surgical Site Infection Rate
Hip Arthroplasty Surgical Site Infection Rate
Hysterectomy Surgical Site Infection Rate
Colon Surgery Surgical Site Infection Rate

Selection Process

Through a series of meetings, surveys, and work days, the Project Team has:

Reviewed both the status of the industry and the research community with regard to HAIs.
Adopted the 2005 Report prepared by the Healthcare Infection Control Practices Advisory Committee (HICPAC) on public reporting as the foundational document.(2) The National Quality Forum’s 30 Safe Practices were also used to design next steps.
Selected readily available HAI-related CMS data to include in the 2006 Iowa Report.
Surveyed the state ICP community about Immunization of Healthcare Workers, Device-Related Infections, and Surgical Site Infections to determine reporting opportunities.
Worked to stay congruent with national initiatives currently underway including the Surgical Care Improvement Project, the Institute for Healthcare Improvement’s 100,000 Lives Campaign, the National Quality Forum’s re-write of the 30 Safe Practices, and work by the CDC and others.
Engaged the Iowa Infection Control and Epidemiology and Consultation Program as partners in this project.
Defined a set of metrics for 2007 in healthcare worker immunization, central line infection, and selected surgical site infection to be added to the HAI section of the 2007 IHC Iowa Report.

Timeline

This project is designed to promote voluntary hospital reporting of a set of evidence-based measures on an annual basis beginning in 2007. It is expected that this reporting will continue into the foreseeable future.

The third quarter of 2006 has been dedicated to preparing materials to educate the ICP community and hospitals about the 2007 reporting initiative. During this phase, a web-based data reporting vehicle and this toolkit were prepared.
The fourth quarter of 2006 is designated for education and preparation for reporting. A series of conference calls with providers and the ICP community are planned to discuss the reporting set and procedures. This toolkit will be promoted and expanded. The web-based reporting vehicle will be available for trial reporting.
The formal measurement period for 2007 will occur from January 1, 2007 – June 30, 2007. Data will be reported to the website on a monthly basis. Final information for this six-month sample must be submitted by September 1, 2007, to be included in the 2007 Iowa Report.
Measurement will continue on a monthly basis. Beginning with the 2008 Iowa Report, information will be presented for 12 month reporting periods.

Project Status

The HAI Work Group has designed metrics, engaged the ICP community, built this toolkit, and endorsed public reporting. They will continue to meet to direct and advance this project. Currently, attention is focused on execution of this strategy. The work of this group will be presented at the IHC Annual Meeting in November. Data will be reviewed to prepare reporting formats that bring the most benefit to the state. Finally, it is expected that IHC will introduce new metrics and expanded reporting as the project advances.

References:
(2) Am J Infection Control 2005; 33:217-26.

Tool Kit

The Toolkits section provides applications designed to help providers better execute this project. In each area, there is a formal definition of what is being measured. Where available, sample policies, signage, monitoring techniques, and implementation tools are included. The toolkit is designed to change and expand as new information becomes available. This section presents toolkits in four areas of focus:

Influenza Vaccination Among Health Care Workers
Central Line Infection Rates
Surgical Site Infection Rates
Hand Hygiene in Health Care

Influenza Vaccination Among Health Care Workers

Introduction

Influenza vaccination of Health Care Workers (HCWs) is an important staff and patient safety issue. The national rate of influenza vaccination of HCWs is approximately 40 percent and widely acknowledged to be unacceptably low. HCWs are at great risk to acquire and transmit influenza to patients, their families, and the community in general. Vaccination decreases the disease burden on HCWs, reduces absenteeism, and helps maintain the health care workforce during influenza epidemics. The Centers for Disease Control and Prevention advocates an aggressive approach to HCW vaccinations.

Influenza vaccination is an annual campaign at most Iowa hospitals. Our evaluation shows that hospitals are very aggressive at administration of the vaccinations through out the facility and the community. At-risk populations are identified and targeted by administration. Accurate tracking mechanisms for estimates of true effectiveness do not exist. This problem has been complicated in recent years by the variable availability of influenza vaccine, forcing rationing.

The Iowa Healthcare Collaborative is encouraging Iowa's hospitals to improve rates of HCW influenza vaccination by participating in a multi-year statewide project. We recognize vaccine availability will have dramatic effects on these numbers, but feel accurate tracking will improve both our effectiveness and the vaccine supply. The employee vaccination target with this measurement technique is 95%.

2007 Reporting Metric

Definitions

Numerator

(number of employees vaccinated) + (number of total employees, defined as those individuals receiving a paycheck from October 1st through March 31st of the following year)
The committee elected to recommend vaccination to all hospital employees for the following reasons:
- It is acknowledged that while some employees do not have direct patient contact, patients are often exposed to employees indirectly.
- Un-immunized employees place the hospital at risk for staffing shortages in the event of an epidemic.
- This committee also considered those employees with contraindications to vaccination. The committee elected not to include this population in the numerator. The infrequent incidence of true contraindication would not justify the administrative cost of measurement. Recognizing this exempt population, the target vaccination rate was set at 95% rather than 100%.
- It is important to include both employees that received vaccinations on-site as well as those who were vaccinated at other locations.

Denominator

(number of total employees, defined as those individuals receiving a paycheck from October 1, 2006, through March 31, 2007)
Influenza vaccination is a common practice given on an annual basis.

The measurement period was selected to coincide with the beginning of vaccine availability and the end of influenza season.
The committee decided to focus only on employees at this time and not immediately pursue efforts to measure vaccination rates of other hospital populations including volunteers and students who do not receive a paycheck.

Reporting Period

Sample Signage

Influenza Poster (PDF 20KB)

Implementation

Immunization of Health Care Workers Toolkit
IHC has created a toolkit that provides guidance, resources, and success stories in the immunization of health care workers.

Surgical Site Infections

Introduction

Surgical Site Infections (SSIs) are the second most common type of adverse event occurring in hospitalized patients.(3) While nationally the rate of SSIs average between 2 and 3 percent for clean cases, an estimated 40-60% of these infections are preventable.(4) A medical record review of 34,133 charts performed under the auspices of the Centers for Medicare & Medicaid Services (CMS) demonstrated a significant opportunity for improvement in SSI prevention.(5) Considerable national attention has been focused on this area through CMS, Joint Commission for Accreditation of Healthcare Organizations, National Quality Forum, and Institute for Healthcare Improvement through the 100,000 Lives Campaign.

IHC is encouraging Iowa's hospitals to decrease SSI rates by participating in a multi-year statewide reporting project. This project aligns with other national initiatives. Participation includes sharing of best practices for effective SSI prevention and the reporting of select SSI rates.

Infection Control Practitioners agreed that the National Nosocomial Infections Surveillance System (NHSN) should be the reporting set to allow national benchmarking. In the beginning of this SSI rate reporting project, hospitals will share SSI rates for a few select procedures. Procedures selected to be reported in the 2007 Iowa Report include:

Coronary Artery Bypass Grafts
Colon Surgery
Hip Arthroplasty
Hysterectomy (both abdominal and vaginal).

Currently, some Iowa hospitals are monitoring SSI rates under CMS criteria, while others are using NHSN criteria. To include as many Iowa hospitals as possible, this 2007 Iowa Report will allow hospitals to report using either NHSN ICD 9 codes or the CMS ICD 9 codes. These will be presented as separate sections in the Iowa Report.

References:
(3) Brennan, N Engl J Med. 1991; 324:370-376
(4) 2006 IHI Getting Started Kit for Surgical Site Infection
(5) Bratzler, Arch Surg. 2005; 140:174-182

2007 Reporting Metric

Definition

Numerator:

The number of surgical site infections
- Procedures selected to be reported in the 2007 Iowa Report include:
  - Coronary Artery Bypass Grafts
  - Colon Surgery
  - Hip Arthroplasty
  - Hysterectomy (both abdominal and vaginal).
- NOTE: Report infection in the month that the surgery was performed.
Surgical Site Infections are defined as the following:
- (View Definitions) (PDF 15KB)

Denominator:

The number of procedures in specified ICD-9-CM categories (Though NHSN criteria are preferred, hospitals may choose to report in either NHSN or CMS reporting sets in 2007)

(View Sets) (PDF 12KB)

Reporting Period

The reporting period is from October 1st through March 31st of each successive year. The final numerator and denominator values are due to IHC by May 15th following the closing of the reporting period, to be included in the Iowa Report.

Measurement will continue on a monthly basis. Beginning with the 2008 Iowa Report, information will be presented for 12 month reporting periods.

Tricks for Implementation

IHI 100,000 Live Campaign Toolkit (WEBSITE)
Guidelines for Prevention of Surgical Site Infection, 1999 (PDF 274KB)
IHC Health Care Worker Survey on Surgical Site Infections (PDF 13KB)
SCIP Core Measure Reporting by Hospital Type (PDF 13KB)

Central Line Infections

Outcomes measures should be chosen for reporting based on the frequency, severity, and preventability of the outcomes and the likelihood that they can be detected and reported accurately.(2) An outcome measure meeting these criteria mentioned in the HICPAC Report is Central Line Infections (CLI).(2) The specific criteria will be central line-associated, laboratory-confirmed primary bloodstream infections (CLA-LCBI) in intensive care units (ICU).

2007 Reporting Metric

Definitions
Definitions from the National Health Safety Network (NHSN) (previously National Nosocomial Infections Surveillance System or NHSN) will be used.

Numerator:

Number of central line bloodstream infections

Laboratory-confirmed bloodstream infection must meet at least one of the following criteria and have occurred in the ICU or within 48 hours of leaving the ICU: (6)

Criterion 1:

Patient has a recognized pathogen cultured from one or more blood cultures and
Organism cultured from blood is not related to an infection at another site.

Criterion 2:

Patient has at least one of the following signs or symptoms: fever (>38°), chills, or hypotension and at least one of the following:

Common skin contaminant (e.g., diphtheroids, Bacillus sp., Propionibacterium sp., coagulase-negative staphylococci, or micrococci) is cultured form two or more blood cultures drawn on separate occasions.
Common skin contaminant (e.g. diphtheroids, Bacillus sp., Propionibacterium sp., coagulase-nagative staphylococci, micrococci) is cultured from at least one blood culture form a patient with an intravascular line, and the physician institutes appropriate antimicrobial therapy.
Positive antigen test on blood (e.g. Haemophilius influenzae, Streptococcus pneumoniae, Neisseria meninitidis, or group B Streptococcus) and signs and symptoms and positive laboratory results are not related to an infection at another site.

Note: The patient is followed for 48 hours after transfer to another unit. If a BSI develops within that 48 hour period, the original unit is "credited" with the infection.
Flowchart (PDF 115KB)

Denominator:

Number of central line catheter days

Central line days are the total number of days of exposure to the central line by all of the patients in the ICU during the selected time period. (6)

Example: On the first day 5 patients had one or more central lines in place; 4 had central lines on day 2; and 2 had central lines on day 3; Adding the number of patients with central lines on days 1 through 3, we would have 5+4+2= 11 central line days for the first three days.
Note: Add the number of patients with central lines NOT the number of central lines.

Central line:

A central line: an intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring. The following are considered great vessels for the purpose of reporting central-line days in the NHSN system: Aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins, and common femoral veins.
- Note: An introducer is considered an intravascular catheter.
- Note: Neither the location of the insertion site nor the type of device may be used to determine if a line qualifies as a central line. The device must terminate in one of these vessels or in or near the heart to qualify as a central line.
- Note: Pacemaker wires and other non-lumened devices inserted into central blood vessels or the heart are not considered central lines, because fluids are not infused, pushed, nor withdrawn through such devices.
- Flowchart (PDF 119KB)

Intensive Care Unit (ICU)

An ICU is a hospital unit that provides intensive observation, diagnostic, and therapeutic procedures for adults who are critically ill. An ICU excludes bone marrow transplant units and nursing areas that provide step-down, intermediate care, or telemetry only.
For reporting purposes, organizations will combine the rates of any Med ICUs, Surgery ICUs, or combined Med/Surg ICUs and report infection rates as a whole under the heading of "Med/Surg ICU."
Note: When reporting infection rates, NICUs, PICUs, Burn Units, and stand-alone coronary care units will not be included. However, if coronary patients are a part of Med and/or Surg ICUs, this patient population will still be included. The Central Line Infection Work Group believed that the inclusion of some coronary care patients in already-mixed ICUs would not significantly affect the reported infection rates.

Frequently Asked Questions

GNYHA/UHF Quality Improvement Collaborative
Central Line Associated Bloodstream (CLAB) Infections
These Frequently Asked Questions were developed by the Missouri Department of Health and Human Services in conjunction with CDC.

If a patient in an ICU has a temporary (Quinton) or tunneled (ASHE) hemodialysis catheter, is that device counted as a central line in the central line days? 5/20/2005
If a line meets the definition, then it is a central line and should be counted. The only exception to this would be an implanted device that is not used. In this situation, the line would only be counted beginning on the first day it is accessed (e.g., physician orders that the port-a-cath be flushed). Then it would be counted every day thereafter.
Do central lines include the following: implantable-ports, non-tunneled TLC, Swan Ganz catheter, tunneled-Broviac, Groshong, Quinton, Hickman, ASHE catheter, PICC, and umbilical lines? If yes, would they be counted in central line days for that unit? 5/20/2005
Yes to all of the above if they meet the definition. Central lines are not defined by type of device.
Is a dialysis catheter considered a central line since it isn't used for infusion? 5/20/2005
A dialysis catheter is considered a central line if it meets the definition of a central line. It is used for infusion of the patient's own blood.
Are permanent shunts and balloon pumps considered central lines? 5/20/2005
Yes, if they meet the definition of a central line. Central lines are not defined by type of device.
If a patient is admitted to the ICU with a central line in place, is it counted in the central line days? 5/20/2005
It must first be determined if it meets the definition of a central line. If it meets the definition and it is accessed, then it is counted (e.g., a patient is admitted with a central line that is not being used; the physician comes in on day three and flushes the line; the day of the flush is considered the first central line day).
Please clarify the last sentence of the definition for CLAB infection that reads, "If the time interval was longer than 48 hours, there must be compelling evidence that the infection was related to the vascular access device." 5/20/2005
This means only that if the time interval between the removal of the line and the onset of bloodstream infection (BSI) is greater than 48 hours, the BSI should not be considered central line-associated unless there is evidence that it was related to the device.
What if: a patient had a central line inserted in the ICU; 6 days later the patient has a positive blood culture; and the patient meets the definition for laboratory confirmed bloodstream infection (LCBI). Would this patient be counted as a CLAB infection? 5/20/2005
If the line was not discontinued, it would be counted as a CLAB. If the line were to be discontinued on day 4 or earlier, it would not be counted as a CLAB.
How do you determine which unit to "credit" with a bloodstream infection (BSI)? E.g., on May 2 patient is in the medical ICU; on May 3 patient is transferred to the coronary ICU; symptoms develop on May 4. Which unit is "credited"? 5/20/2005
The patient is followed for 48 hours after transfer to another unit. If a BSI develops within that 48 hour period, the original unit is "credited" with the infection.
In the laboratory confirmed bloodstream infection (LCBI) definition, it refers to "appropriate antimicrobial therapy" under Criterions 2 and 3. What is appropriate? 5/20/2005
This is not defined. If an antibiotic is appropriate for the microorganism identified (e.g., not resistant or used for that microorganism) then it is appropriate.
What should be done if a device-day is not counted? 5/20/2005
Days should not be skipped. If days are not recorded (say on the weekend), then the staff should be interviewed and charts reviewed to determine what the counts were at the appropriate time.
The following two questions/situations relate to an ICU patient undergoing dialysis: 6/8/2005

a. A patient with a dialysis catheter is in one of the ICUs under surveillance for CLABs. If this patient's dialysis catheter is only accessed in the dialysis center, are the central line days for this patient counted in the ICU's central line day count?
No, in this instance, the central line days would not be counted in the ICU central line day count.

b. A patient with a dialysis catheter is in one of the ICUs under surveillance for CLABs. Someone from the dialysis center comes to the ICU to perform the dialysis. Will the central line days for this patient be counted in the ICU's central line day count?
Yes, in this instance, the central line days would be counted in the ICU central line day count.

Reporting Period

The formal measurement period for 2007 will be January 1, 2007, through June 30, 2007. Data will be reported to the website on a monthly basis. Final information for this six month sample must be submitted by September 1, 2007, to be included in the 2007 Report.
Measurement will continue on a monthly basis. Beginning with the 2008 Report, information will be presented for 12 month reporting periods.

Sample Policies

Iowa Health-Des Moines CVC Placement Policy

Tricks for Implementation

IHI 100,000 Live Campaign Toolkit (WEBSITE)
Guidelines for the Prevention of Intravascular Catheter-Related Infections (WEBSITE/PDF)
Use of ATB Impregnated Lines

References:
(6) Am J Infect Control 2004; 32:470-85
(7) Horan TC, Gaynes RP. Surveillance of nosocomial infections. In: Hotpital Epidemiology and Infection Control 3rd ed., Mayhall CG, editor. Philadelphia:Lippincott Williams & Wilkins, 2004:1659-1702.

Hand Hygiene

For centuries, hand washing with soap and water has been considered a measure of personal hygiene, but the link between hand washing and the spread of disease has only been established in the last 200 years. Currently, hand hygiene is considered the most important measure for preventing the spread of pathogens in the healthcare setting.

Guidelines

WHO guidelines on Hand Hygiene in Health Care (PDF 4.33MB)
CDC Guideline For Hand Hygiene In Health Care Settings (PDF 402KB)
Genesis Medical Center Hand Hygiene Policy (PDF 23KB)
Genesis Medical Center Hand Hygiene Coordinator Duties (PDF 12KB)

Sample Signage

Hand Hygeine (PDF 17KB)
CDC Materials to Promote Hand Hygiene in your Healthcare Facility (WEBSITE)
U.S. Dept. of Veterans Affairs Hand Hygiene Posters (WEBSITE)

Alcohol-Based Hand Rubs

Waterless Hand Gel Flowsheet (PDF 23KB)
Waterless Hand Antiseptic Evaluation (PDF 9KB)
Hand Hygiene Resource Center's - Selecting The Right Alcohol Based Hand Rub (PDF 26KB)

Monitoring Techniques

Hand Hygiene Resource Center's – Hand Hygiene Monitoring Tool (PDF 20KB)
Genesis Medical Center – Hand Hygiene Observation Tool (PDF 12KB)

Resources

Waverly Health Center, Waverly, Iowa - Hand Hygiene Management Team (PDF 258KB)
Waverly Health Center, Waverly, Iowa - Jeopardy Hand Hygiene (PDF 41KB)
Waverly Health Center, Waverly, Iowa - Hand Hygiene Compliance (PDF 69KB)
Waverly Health Center, Waverly, Iowa - Germ Buster Orientation (PDF 441KB)

Success Stories

Clarinda Regional Health Center, Clarinda, IA
Our most successful campaign was entitled "Germ Warfare" with a military theme. I heard about it at a national APIC meeting. We had different things for each day, but the most memorable was when National Guard Soldiers in uniform came to our facility and went to each dept and used certain "tactics" (push-ups, etc..) to get the point across about hand washing.

It was fun and our CEO, who was previously in the Army, was speechless for the first time when they interrupted one of his meetings. Luckily, it worked and I didn't get fired. We decorated the hall with a manikin in uniform and had camouflage and signs around the hospital. Attached are some other things which might be helpful.
- "Fight the good fight-wash your hands" was posted in the hallway-(Camouflage paper and tanks, flags etc.. for signs found at a scrap booking store. )
- We took pictures of employee's hands and had a contest on whose hands were whose.
- We also had a contest where each department was encouraged to come up with a "jingle" to sing when washing hands.
- Crossword puzzles,
- Handing out dum-dum suckers "Don't be a dum-dum- wash your hands"
- Have the infection control team bring in their baby pictures and have people guess who they are
- Culturing employee hands spontaneously (with permission :-))
- We also had the local preschool participate by discussing hand hygiene and drawing around their hands on a large poster stating "Clarinda Preschool Washes Their Hands, too". We posted it in our hallway. Many employees had children or grandchildren in that preschool, so it was even more special.
Maggie Brown, RN, BS
Clarinda Regional Health Center
Genesis Medical Center Success Story
Our outpatient Dialysis unit was noting an increase in the number of blood stream infections several years ago. While creating an action plan, several infection control issues were discovered. Those issues included a lack of waterless hand rinse, and low compliance amongst staff with regards to hand hygiene.

A fellow non-nurse employee accompanied her father each week to his dialysis sessions. The infection control staff recruited this individual, "Debbie" to do hand hygiene observations. "Debbie" was educated and given concrete instructions on how to complete and record these observations. These observations were then relayed to the infection control staff.

Unfortunately, our hand hygiene compliance was a meager 38%. Six one-hour in-services were completed with the staff that provides hands on patient care. The observations continued during and after the education sessions. We began to see an increase in hand hygiene compliance to 80%. The staff knew they were being observed but did not know who was the observer. Unfortunately, "Debbie’s" father passed away a year after this journey began.

With the goal of achieving at least 90% hand hygiene compliance the infection control staff recruited the charge nurses to do the observations. The differences in the observations were that the staff being observed was recorded. The infection control staff in turn provided the nurse manager with names of the staff who were non-compliant. The manager counseled those individuals and a few were placed in disciplinary action status.

We are happy to report that today our outpatient dialysis unit has maintained 92% hand hygiene compliance for the past 2 years. The charge nurses continue to do observations one week every other month with a goal of achieving at least 100 observations. The number of blood stream infections also has decreased over time.

Lisa Caffery, BSN, MS,RN,BC,CGRN,CIC
Genesis Medical Center