MDRO’s Break-out Session April 2017 Regional Meetings

Knoxville

EVS

  • ATV Cleaning of all C.Diff rooms and randomly in all other patient rooms
  • During tracer activities they discuss wet time and why and terminal cleaning training/competency especially related to isolation patients
  • Investigating cleaning products with less “wet time”
  • Use of Clorox healthcare bleach product and also “Fusion” due to decreased wet time and allows use of bucket/rag method for cleaning. Fusion has a two minute kill time
  • In-house washing machines changed and now have added bleach dispenser
  • Use of disposable dedicated toilet scrubbers
  • Use of disposable mop heads
  • Clean bathrooms twice daily in CDI patients
  • EVS stickers/tape on door during/after cleaning
  • CHI Memorial and Johnson City Medical Center using UV technology
  • Cleaning of PT equipment
  • EVS cleaning of common areas
  • Changing curtains after CDI patient transferred/discharged
  • Placement of booster heater to heat water to 185 degrees to kill organisms on mops/cloths
  • Use of dedicated cleaning cloths/mop strips for CDI rooms
  • Cleaning of mobile equipment frequently – included discussion of placing flat packages of bleach based cleaning cloths directly to gurney’s, wheelchairs, etc. for ease in obtaining/using cleaning cloths after use with every patient

Hand Hygiene

  • Hand washing audits
  • Formed front-line steering committee (no more than 10-15) comprised of nursing, infection control, EVS, PT, RT, etc.

Formulated action plan

Identified at least 85 areas/points in facility with inadequate access to hand foam/gel or sink/soap for handwashing

Began use of CDC posters directed both to staff and to patients

Process initiated for ensuring needed materials for hand hygiene were always available i.e. dispensers filled, fresh batteries in dispensers, etc.

Lapel pins given to leads (champion hand pins)

In process to make every employee at facility an auditor

  • Secret shoppers
  • Identified respected physician champion to follow-up with physicians who fall out with handwashing initially and chronic issues taken to Quality Committee which is physician led
  • Patient education campaign

Provided small bottles of hand sanitizer on admission

Educational materials

20 count wipe packs kept at the patient’s bedside

Pop-up wipe canisters used by dietary when passing meal trays to allow patients to clean their hands before eating

  • Cover hand foam dispensers with hair bonnet to increase hand washing in CDI patient rooms
  • Leader rounding daily to improve staff washing in and out of patient rooms
  • Signage to include effective slogans identified and/or tested by staff i.e “keep it foamy”, “got soap?” (fun), and “you could kill him with your bare hands” (emotional)
  • Staff accountability with scripting i.e. Dr. Waters needs to see you, hand check, have you seen Hanna Washington?, high five, and Dr. Hands is on the phone for you. Also non-verbal signals i.e. hold up both hands to non-verbally say “I’ve washed my hands but didn’t see you wash yours”

Appropriate Testing

  • Physician education related to community verses hospital acquired infections made inroads into tests ordered, documentation, etc.
  • Patient safety week slogan “If the stick stands, the test is banned!” related to CDI testing
  • C.Diff testing order with no specimen within 24 hours then test cancelled. Test can be re-ordered but same rule applies
  • Diarrhea decision tree
  • Hard stop for repeated specimens or for inappropriate specimens

Education

  • PPE demonstrated to all visitors as applicable
  • Use of chocolate syrup on gloves during staff education to demonstrate appropriate/in-appropriate donning/doffing of PPE
  • Use of spray adhesive on gloved hands then placed down in small Styrofoam balls to demonstrate spore adhesiveness and how hard to get rid of them (need for adequate handwashing to eliminate CDI spores)
  • Use of glow germ on gloves as contaminate to demonstrate wrist contamination during in-appropriate removal of gloves

Memphis

EVS

  • Use of tele-tracking to allow continuous updates for appropriate cleaning of all isolation rooms
  • Use of dedicated toilet brushes
  • Use of fluorescent powder to spot check terminal cleaning effectiveness
  • Currently discussing use of disposable shower curtains
  • Use of disposable curtains in rooms
  • Use of special enteric precaution signage to increase EVS awareness
  • Isolation type noted at top of EPIC screens
  • CDI patients added to daily safety huddles
  • Track # of patients with MDRO’s in facility shared daily
  • Track # of rooms treated with UV cleaning as well as the turnaround time from discharge to terminal cleaning completion
  • Decrease cross contamination with patients being treated by P.T. as the physical therapist sees isolation patients toward the end of the shift
  • Decrease OR contamination by putting isolation patients toward end of shift for their cases if possible

Hand Hygiene

  • Use of new electronic documentation process/tool available both on laptops and hand held devices to audit hand hygiene compliance
  • Specific hand hygiene training for new hires
  • Specific hand hygiene training for nursing
  • Use of badge buddies
  • Monthly memo’s to department heads with hand hygiene compliance rates for their departments
  • Internal competition to improve hand hygiene rates via audit tool results
  • Foam in and foam out and are you washing your hands correctly via compliance monitoring. IP does stop with on the spot training to staff not washing hands correctly by asking why they didn’t use correct technique or what happened to prompt you not to wash your hands
  • Implementation of electronic foam dispensers in ED – identified who owns refilling dispensers with soap and replacing batteries as needed and where located should need arise in between checking use

Antibiotic Stewardship

  • Antibiogram recommendations shared with physicians face-to-face in meetings
  • Antibiogram recommendations shared with physicians via posting in dictation rooms
  • Multiple facility antibiograms produced based on area of facility patients are admitted to for appropriate treatment i.e. NICU/trauma/med-surg/ICU

Nashville

EVS

  • Direct observations
  • UV lights post cleaning to determine if residual areas of contamination exist
  • Use of disposable curtains
  • Use of color-coded isolation cards i.e. brown = CDI; green = MRSA; blue = TB
  • Use of color-coded door caddy’s for isolation patients i.e. yellow, red = CDI
  • Use of container over the hand foam container in isolation rooms to promote use of hand washing
  • Hold isolation rooms for 24 hours prior to admitting another patient into that room whenever possible
  • Use of portable ATP monitor for real time swabbing for organic matter after cleaning CDI patient rooms

PPE

  • Use of Hershey’s kisses to remind staff of CDI, appropriate stool samples, etc.
  • Use of a brown “stool” Halloween costume to remind/educate staff re: appropriate CDI practices
  • Tour of laundry facility demonstrated auto folding machine and lack of proper decontamination

Hand Hygiene

  • Secret shoppers including family members
  • Compliance is built into part of employee evaluations
  • Hand hygiene team meets monthly by unit/provider/etc.
  • Provide hand gel holders for badge holders
  • Uses Hershey’s kisses to remind staff of CDI and need for appropriate hand washing as placed into their hands
  • Written thank you notes individual staff members to embed best practices related to hand hygiene
  • Demonstrate appropriate hand hygiene then staff and patients allowed to mimic to determine skill/knowledge of proper handwashing techniques
  • Use of table tents to remind about hand washing and appropriate steps on patient over bed table

Appropriate Testing

  • Lab rejects specimen as inappropriate if not within certain timeframe
  • Lab rejects specimen if stool does not form to the container that it is in
  • Infection preventionist can remove a patient from isolation without lab test
  • After isolation is discontinued, patient gown, etc. changed and patient moved to a “clean” room
  • If inappropriate specimens sent to the lab for testing the lab has been empowered to reject them
  • Addressing inappropriate testing related to laxative use
  • Addressing timing related to testing
  • Infection preventionist consult generated in EMR if 3 stools within shift occur
  • Use of a diarrhea decision tree
  • Use of a nurse driven protocol
  • Education to providers includes discussions related to inappropriate testing “teachable moments”
  • Physician modules available at SHEA
  • Use of physician newsletter every other month to add information related to CDI and antibiotic stewardship