Reducing Hospital-Acquired Infections in a Long-Term Acute Care Hospital

Windy Hill Hospital
Marietta, Georgia, USA


The team from Windy Hill Hospital is a participant in IHI’s Learning and Innovation Community on Reducing Hospital-Acquired Infections.

Dwayne Hooks, MN, RN, FNP-BC, Team Sponsor
Karen Nightingale, Administrative Support
Sally Williams, BS, RN, CIC, Project Leader
Deborah Smiler, MSN, RN, Project Facilitator/PI Coach, Performance
Shalyn Self, RN, MBA, Information System/Data Resource  
James Daniel, MD, Medical Consult
Gail Sikora, MT (ASCP), Admission Surveillance Cultures (ASC) Team Leader
Elizabeth Sanders, RN, ACS Team Member
Jeff Batcher, RN, BSN, ASC Team Member
Charlene Mitchell, RN, BSN, ASC Team Member
Cheri Romero, BS, OT/L, Contact Precautions Team Leader
Karee Grier, MA, LD, RD, Contact Precautions Team Member
Jamie Redmond, Contact Precautions Team Member
Luann Land, RT(R)(M), Hand Hygiene Team Leader
Mireille Gervais, Hand Hygiene Team Member
Sandy Luxama, Hand Hygiene Team Member
Terri Baugher, RN, Central Line Bundle Team Leader
Kathy Baker, BS RN, Central Line Team Member
Kim Cate, RRT, BS, Ventilator Bundle Team Leader



Reduce hospital-acquired infections (HAIs) caused by methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and Clostridium difficile (C. diff) by 50 percent in the Long-Term Acute Care Specialty Center within 12 months by focusing on prevention of infections and transmission, using admission surveillance cultures (ASC) and hand hygiene.



  • Percent of patient encounters with appropriate hand hygiene
  • Percent of patients with Clostridium difficile-associated disease
  • Rates of occurrence of MRSA and VRE infection per 1,000 patient days
  • Percent of appropriate patients with admission surveillance culture collected
  • Percent of admission surveillance culture specimens that are positive

  • Hand hygiene education: Hospital-wide education was provided, starting with managers and then spread to all staff.
  • Data collection process update: Instead of using a manual process for recording hand hygiene observations, an electronic system was developed.
  • Foam sanitizer tested: The current product being used was a gel-based hand sanitizer and a foam product was tested. Staff preferred the foam.
  • Soap and water wash for C. diff: Because C. diff is a spore-forming bacteria alcohol is not effective at killing the spores and hands must be washed with soap and water. Pink stickers were used as reminder cues for staff to use soap and water when caring for patients with C. diff.
  • Contact Precautions log instituted: An electronic log of all patients placed in Contact Precautions (Isolation Log) was established and made accessible to multiple users.
Active Surveillance Cultures
  • Assessed risk on admission: A preadmission assessment was completed by our case managers to determine if the patient had a history of VRE or MRSA.
  • Admission surveillance cultures: If a patient was found to have a negative VRE or MRSA history, admission surveillance cultures were collected by the nursing staff (nasal swabs for MRSA and rectal swabs for VRE). 
  • Laboratory verifies collection of screening culture when patient is admitted: A daily list of new admissions was sent to the lab. If screening cultures were not received and there was no reason noted, the lab followed up with the nursing staff to trigger the cultures. 








Summary of Results / Lessons Learned / Next Steps

The results realized by our facility are substantial and motivating. We experienced greater than a two-fold increase in our hand hygiene adherence through education, direct observations, and improving the reporting system for our observations. 
In addition to the increased focus on routine hand hygiene practices, special emphasis was placed on increasing the use of soap and water when caring for patients with C. diff, with the fluorescent pink stickers noting “wash with soap and water” on the Contact Precautions signs of patients with Clostridium difficile-associated disease (CDAD). 
During the same time period (August to September 2007) that we experienced an improvement in hand hygiene, we also see a signal that HAIs related to MRSA (bloodstream infection and ventilator-associated pneumonia) and VRE (bloodstream infection and urinary tract infection) may also be decreasing. To prevent further risk of transmission, we instituted an Active Surveillance Culture program. For the last six months of our program we have had an 88 percent to 100 percent rate of specimen collection on patients with no reported history of MRSA and/or VRE. Of these patients 25 percent to 67 percent had positive ASC. These patients are identified early in their admission and other patients and staff are protected from exposure and possible transmission.
Other Action Focus Groups [improvement teams] that were in operation during this time were working on implementing the Ventilator Bundle, the Central Line Bundle, Contact Precautions and Environmental. Actions from these Action Focus Groups complimented and strengthened the highlighted actions of the Hand Hygiene and ASC Focus Groups.
Lessons Learned:
  • Keep the tests of change small
  • Limit the number of initiatives started at any given time
  • Involve multiple disciplines in the changes to increase the success of the change initiative
  • Trial and error showed that a better protocol and a procedure were needed, with clear roles and responsibilities defined, in order to have success with active surveillance
Points of Celebration:
  • Many more employees are on board and tuned in to their role in reducing HAIs
  • Multiple disciplines have been involved in improvement
  • There is still a sense of energy for continuing this important work
  • Medical staff continue to show interest in the projects
  • Greater need for infection prevention support and education due to staff turnover
  • Gathering baseline data to get started was challenge ― often baseline data had not been considered until the project started
  • Timely data reporting from team members
  • Problems with the electronic hand hygiene database
  • Abandoned an Environmental Action Group due to staff turnover and shortage
Next Steps:
  • Continue regular performance feedback to staff
  • Broad staff education with a focus on new precautions signage
  • Formalize a patient and family infection prevention and precautions education program, including “Speak Up”
  • Locate isolation caddies hospital-wide
  • Focus on environmental issues, including cleaning equipment
  • Complete ASC protocol
  • Examine associations between C diff. active disease and ASC


Contact Information

Henrietta Hardnett, MSN, RN,
Infection Prevention Coordinator
Windy Hill Hospital


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