Judy Prescott, RN, BSN, CIC, Manager, Epidemiology; William Sutker, MD, Medical Director, Epidemiology; Cristie Columbus, MD, Asst. Medical Director; Irving Prengler, MD, Chief Medical Officer; Janette Brown, RN, BSN; Fidelina Valencia, RN, BSN; Allen Peden, RN; Connie Izzo, RN, Epidemiology Nurse, Baylor University Medical Center, Dallas, TX
Issue: Even with substantial evidence that hand hygiene reduces the incidence of infections, healthcare workers (HCWs) compliance to recommended hand hygiene practices remains low. With reimbursement to hospitals affected when infections develop after admission, there is renewed attention to infection prevention. The leadership of this large 14 facility system decided to face the challenge of improving HCWs hand hygiene compliance rates.
Project: Beginning in January 2008, a system-wide team of leaders chaired by two physicians was selected. Along with the President of the system, physician and hospital leaders from all facilities were selected to champion the hand hygiene efforts. The AIM statement was “To increase the System hand washing compliance from the current rate to 85% by the end Jun 2009 and 95% by the end of Jun 2010, thereby contributing to a projected 10% decrease in the number of healthcare associated MRSA infections, urinary tract infections(UTIs), and central venous catheter blood stream infections (BSI) by the end of Jun 2009 and 20% by the end of Jun 2010.”. Three sub-teams were selected to develop and implement public relations, education, and metrics initiatives. The public relations team developed a sophisticated messaging that included signage, ongoing articles in publications and avenues of communication across the system, and a video message from the President to employees and patients. The education team developed a mandatory online learning module for all employees. The metrics team developed a process to monitor compliance consistently and developed a report comparing hand hygiene compliance by facility.
Results: Since Jan 2008, the system hand hygiene compliance rate has improved from 76.74% to 87.28%. The central line BSI rate has decreased from 3.39/1000 central line days to 0.36/1000 central line days. A process has been developed to include MRSA and UTI data.
Lessons Learned: Moving a large system in the same direction must be planned carefully and attention to detail is imperative. The support from the top leadership in this system has moved the importance of hand hygiene to the top of the initiative list. They wholeheartedly supported the hand hygiene efforts because it is the right thing to do for our patients.
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