When a score of zero is a good thing

No HAIs for years at Shore Health

Imagine going more than two years — nearing three — without a single hospital-acquired infection (HAI) in your intensive care unit (ICU). Imagine that not just one ICU, but multiple units in multiple hospitals were routinely making it months, and even years, without a single infection that could cause harm to a patient and have financial repercussions for the hospital. That's exactly what is happening at Shore Health System in Maryland, where Robert Carroll, MBA, CPHQ, MHP, the director of performance measurement and improvement, and Julie Bryan, RN, director of infection prevention, have presided over some amazing results from a top-down determination to "make zero happen."

The attitude a few years back was that infections are just something that happens, says Carroll. And while the rates in the system weren't awful, Carroll and some others felt that zero was achievable, and not just for a minute or a day, but for extended periods of time. "Nine months was the initial goal," he says. As of the middle of July, one ICU had gone more than 1,000 days since the last ventilator-associated pneumonia (VAP) infection; another had made it 888 days. Central line-associated blood stream infections (CLABSI) have been absent for over 740 days in one unit, and 950 in the other; catheter-associated urinary tract infections (CAUTI) had disappeared for 500 days in the first unit, and 811 in the second.

But more than just ICUs, this program has spread throughout both hospitals and a home health agency in the system. Estimated savings to the system are more than $1 million, Carroll estimates.

And nothing they did was out of the ordinary. It was all based on literature reviews of best practices, says Bryan, and a lot of education. Just about every unit has gone at least one year without bugs, and enjoyed a lunchtime celebration for making it to that mark without CAUTI or CLABSI (VAP rates are only measured in the ICU). And the goal remains the same — not no infections, but doing everything that they know prevents infections every single time.

Carroll says that leadership allowed them to build a strong team who went out and did 50 structured interviews with people throughout the organization — nurses, physicians, staff at every level. "We asked them what they thought were the strengths and weaknesses and what they saw as the problems in infection control."

He says that by interviewing every stripe of stakeholder, the team made it immediately clear that this wasn't a single unit, department, or class of employee issue, but everyone's.

They collected data related to infections and made sure to share it with everyone. Carroll says that was a key to getting buy-in. "We knew we had achieved a culture change when departments started reacting to the data we gave them." The biggest problem with sharing information was figuring out how to show the data to each department in a way that made sense to them. "Initially we did what most infection control teams do: We showed them the rates per 1,000 patient days or patient device days." That wasn't speaking to them, so they changed it to absolute numbers of infections and the number of days since the last one.

If it was in the literature as something that reduced HAI, Shore Health tried it. If there were new bundles or different products that were touted as helping, they did a trial to see if it would work for their patients in their hospitals. If those bundles or products worked in the pilot unit, they were rolled out systemwide. Checklists, protocols, and computer reminders were developed, implemented, and used. And while they don't have a culture of blame at Shore Health, the Target Zero program and infection rates are used as part of staff performance goals.

Bryan says that there is a lot of electronic monitoring of the practices they developed and implemented, and the system even engaged patients and families as watchdogs, encouraging them to ask providers if they washed their hands. Hand-washing rates have been over 90% for nearly three years now, much of that time over 95%.

"People were telling us this was impossible," Bryan recalls. "But the literature says if we change our practices, we can decrease infections. So we plowed ahead." It helped that both hospitals are Magnet-recognized facilities. "Nurses here have a big focus on quality, and they have a framework in place for them to work to improve safety and improve quality. This played right into what we wanted to do."

Indeed, believing in the possibility is one of the key elements that Carroll says led to the program's success. Another part was making it fun. To that end, the program was launched with the chief nursing officer running around the hospital dressed as a giant bug. The team asked employees to come up with 100 ideas to reduce infections in 100 days. It actually took just 58 days, and every single idea was followed up on. "We admitted that we don't know all the right or best things," Carroll says. "We need to know from front-line staff what they know that we don't, what they see that we can't."

Some of the ideas were used, but some — like decolonizing each patient room using expensive techniques — were just too impractical, he says. But everyone who participated in the 100 ideas project was recognized and his or her name was included in a prize drawing.

The hospitals started a "catch you in the act" program where people who were caught washing their hands had their names entered for a drawing. "We did things constantly to keep this effort at the front of everyone's mind," says Bryan.

And when an infection does occur, it is studied rigorously, she says, to make sure that they understand what happened. For example, the last CLABSI infection they had on a particular unit ended up being the result of inadequate training of weekend staff on dressing changes. A mini root-cause analysis led to the discovery, and improved training led to a new no-infection streak.

While he thinks any organization can aspire to zero and develop a program that works, he doesn't think everything they did will translate to other facilities — the two hospitals are relatively rural and serve a population of about 150,000. "These were our problems, and we solved them our way. It's an ambitious project that doesn't have an end. You can't copy and paste it to fit you; it's all local."

That said, he does have some advice that he's eager to give: Take a page from the book of the marketing geniuses at Shore Health. They kept the Target Zero program in front of the entire hospital community's eyes with regular stories in newsletters, puzzles, posters, and prize patrols. "Keeping them engaged means we get a lot of good ideas — not just for this project either, but for others. I don't have to ask for input anymore. They want to be part of our efforts."

For more information on this topic, contact:

• Robert Carroll, MBA, CPHQ, MHP, Director of Performance Measurement and Improvement, Shore Health System, Easton, MD. Email: rcarroll@shorehealth.org

• Julie Bryan, RN, Director of Infection Prevention, Shore Health System, Easton, MD. Email: jbryan@shorehealth.org.