What Zero Looks Like: Eliminating Hospital-Acquired Infections

​As much as public awareness of the problem has grown, most patients might still be surprised to learn that infections contracted during a hospital stay are a significant cause of death in the US. Medical professionals already know this sobering truth. When bacteria lurking on, for instance, a medical device, a bed rail, a bandage or a caregiver’s hands find their way into a patient’s body via a surgical wound, a catheter, a ventilator, or some invasive procedure, the disturbingly frequent result is a serious, sometimes devastating, infection.
A study by the Centers for Disease Control and Prevention (CDC) published in the March/April 2007 issue of the journal Public Health Reports, estimated that 1.7 million hospital patients ― 4.5 of every 100 admissions ― become infected each year, causing or contributing to the deaths of nearly 100,000 people. Survivors may endure years of follow-up treatment, multiple surgeries, even permanent disability. Standard-setters, including the CDC and The Joint Commission, have long demanded that hospitals actively pursue prevention, control, and investigation of hospital-acquired infections (HAIs). Yet, despite efforts to comply with these standards, the number of infections remains unacceptably high. The Centers for Medicare and Medicaid Services have begun to get more aggressive and ambitious about driving the numbers down, and as of October 2008, will no longer reimburse hospitals for the additional expense of treating certain HAIs.
Beginning in 2005 with its initial 100,000 Lives Campaign and now 5 Million Lives Campaign, and with the help of several scientific partners, the Institute for Healthcare Improvement (IHI) has targeted for prevention and reduction three HAIs ― ventilator-associated pneumonia (VAP), central line-related bloodstream infection (CLRBI), and surgical site infection (SSI) ― which, according to the CDC, account for an estimated 50 percent of all HAI-related deaths. Reducing methicillin-resistant Staphylococcus aureus (MRSA) is also being championed by the Campaign and the underlying principle behind each of the interventions is redesign of process and systems around a set (or “bundle”) of evidence-based procedures of care that must be followed reliably and scrupulously. 
Embedding a new approach often requires a major culture change but by early 2006, an emerging statistic caught everyone’s eye, says Joe McCannon, manager of the 5 Million Lives Campaign and an IHI vice president. Hospitals participating in the Campaign had not only significantly reduced their monthly HAI rates, in some months all the way down to zero, but “a surprising number were getting down to zero and staying there.”
One such hospital is Barnes-Jewish Hospital at Washington University Medical Center in St. Louis, Missouri’s largest teaching hospital with 1,228 beds. Denise Murphy, RN, MPH, CIC, Vice President for Safety and Quality, insists that, for change to stick, a hospital has to revamp its culture as well as its procedures. She says, “You have to get your mind and heart in the right place, too.” That place is not just zero infections but zero tolerance for non-compliance with proven prevention measures, says Murphy. A past president of the Association for Professionals in Infection Control and Epidemiology (APIC), Murphy says that many hospitals simply measure themselves against national averages, such as three infections per 1,000 patient days. “If hospitals do as well as or slightly better than their peers, they are satisfied.” That sets the bar way too low, she argues. “The right benchmark is always zero,” she insists, because “every infection is someone’s loved one. If you know the protocols required to avoid infection, if you follow them precisely every single time, then zero infections are possible. When you’re talking about something that can cost people their lives and zero is possible, no other benchmark makes sense.”
Murphy allows that some extremely vulnerable patients ― those with immune systems ravaged by chemotherapy, for instance ― may develop infections despite every precaution. “That provides an opportunity to investigate and, possibly, learn something new for the next time.” However, she rebuts the idea that superior infection prevention requires high-tech measures. “First, let’s get good at washing our hands before we order the HEPA filters and space suits.” She acknowledges that getting to zero can take years of concerted effort. Her hospital and its entire parent health system, BJC Healthcare, began sharpening its approach to HAIs in 1999 after an uptick in surgical site infections following coronary artery bypass grafts (CABG). “We dug into the details and found that, officially, good processes were in place but they had broken down or, in some places, were being ignored.” Staff re-education and greater accountability were part of the remedy but the hospital also decided to post large charts in the corridor of the operating rooms, tracking monthly SSIs with big black dots. “That helped keep all staff and physicians aware of our need to improve,” says Murphy.
At Barnes-Jewish, infection control and key clinical staff investigate each infection for root causes. “We don’t blame anyone,” says Murphy, “we look for poorly designed processes and try to fix them, and now staffers are upset when we have even one infection and that’s a good thing. Healthy discussions help to hard-wire the right prevention measures into patient care so people don’t have to keep it all in the front of their minds.” After much work on “culture and transparency,” says Murphy, “we now have nurses admitting to short-cuts and violating policies ― and they tell us why.”  When a CABG patient developed an infection and investigators could find no failures in care, the feeling among the staff was not relief, Murphy recalls. “If anything, they felt worse at not finding something they could correct.” That feeling of acute discomfort ― zero tolerance as a personal standard ― is a key motivator, she says, adding that it has to extend all the way up to senior leadership.
In January 2004 the rate of deep chest surgical site infections following CABGs got down to zero at Barnes-Jewish, and with some exceptions, has remained at zero for multiple months at a time ― the longest was a 15-month stretch from April 2005 to June 2006.
Meanwhile, in 2000, Murphy and her colleagues had turned their attention to central line-related bloodstream infections and discovered that not only was hospital policy inconsistent with CDC guidelines but, as with SSIs, it wasn’t being regularly followed. In addition to educating staff on new guidelines, Murphy began reporting monthly CLRBI rates at quality committee and staff meetings. Rates were posted in staff break rooms and the initials of the affected patients were included to personalize infection rates. The hospital also supports safety by engineering it into its equipment. For example, unlike most hospital supply carts, the ones brought bedside when a Barnes’ patient requires insertion of a central line, now have giant STOP signs affixed to one side. “We lodge the cart in the doorway so no one accidentally comes into the room to interrupt or distract the physician inserting the line.”
Since 2000, the average rate of CLRBIs in the six ICUs at Barnes-Jewish dropped from eight per 1,000 line days to just over two in 2007 and 0.38 so far in 2008. Between January 2007 and February, 2008, there were none at all in some ICUs. “Our goal for 2009 is 0.25,” says Murphy, who summarizes her strategy as:
  • Keep setting lower and lower goals;
  • Investigate each failure and learn from it;
  • Hold everyone accountable; and
  • Celebrate success.
Dozens of hospitals have reported to IHI that they’re able to sustain zero cases of CLRBIs or VAPs for one year, two years, or longer.
Mercy Hospital in Coon Rapids, Minnesota, falls into that category. Since 2003, this 267-bed community hospital has been able to reduce its rate of ventilator-associated pneumonia ― an infection that enters the body via a mechanical breathing tube ― to zero, sustaining that level for as long as two years. To achieve the reduction from a VAP rate that had previously reached as much as 6.5 VAPs per 1,000 patient days on the ventilator, the hospital introduced and adapted the Ventilator Bundle of procedures, which includes elevating the head of the patient’s bed by 30 to 45 degrees to avoid pooling of secretions and allow the patient’s lungs to expand more fully. “Putting the protocol in place helped our multidisciplinary staff perceive the project as a systemic change, not a one-time intervention to bring our numbers down, but we needed to make it responsive to our individual situation,” says Michelle Farber, RN, CIC, Infection Control Specialist. One example: “In response to staff suggestions, we reduced the minimum elevation from 45 degrees to 30 degrees to avoid creating pressure ulcers or simply patients sliding down. Then we had the clinical nurse specialist and two nurse champions monitor compliance for a few months until the change solidified.”
Examples of notable work to defeat HAIs is also now evident internationally ― in Canada, the UK, Japan, the Netherlands, Scandinavia, and Brazil.
In January 2005 Thammasat University Hospital, a 500-bed teaching hospital in central Thailand, began a three-year project to eliminate pandrug-resistant Acinetobacter baumannii (PDRAB), a Gram-negative bacteria intrinsically resistant to most antibiotics that is a significant source of HAIs in Thailand, particularly in ICUs. After an initial data analysis, a team led by Anucha Apisarnthanarak, MD, devised an action plan in the hospital’s three ICUs consisting of the following:
  • Gowns and gloves used during all patient care, plus scrupulous hand hygiene both before and after patient contact in all ICUs;
  • Screening for PDRAB upon ICU admission and every seven days until discharge;
  • Cohorting of colonized or infected patients; and
  • Sanitizing surfaces with 1:100 solution of sodium hypochlorite (later changed to detergents and ammonia due to the corrosive effect on skin and surfaces).
The hospital encouraged compliance using educational sessions, wall posters, and monthly feedback to staff. Infection control specialists monitored both caregivers and housekeepers as they went about their jobs. The result: four months ― two of them consecutive ― with zero colonization or infection. Overall, the rate was reduced from 3.6 cases per 1,000 patient days before the intervention to 0.85 cases at the end of 2007.
Since then, Apisarnthanarak and his team have continued the protocol, minus the active screening, and infection rates have remained stable. The effort, he says, shows that “in a resource-limited setting where there is not much technology, simple and easily implemented infection control can reduce even the most drug resistant microorganism.” 
IHI’s McCannon says that it’s reasonable to expect that zero infections will become a widely-accepted goal for hospital performance. “What we’re talking about here is reliability. Once you bundle the right activities into the physical and mental space of the caregivers, change happens and begins to spread. People want to do the right thing.”
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