Wanda Lamm, infection prevention coordinator at Nash Health Care Systems, credits a multistep approach the hospital implemented to reduce its MRSA infection rate by 84 percent over the past four years.

  • Team approach-multiple departments serve on team
  • Active monitoring of hand hygiene and use of personal protective equipment (PPE)
    • Deadlines set for submitting data, which is reported to all departments monthly
      • Data posted on communication boards monthly
      • Data presented during hospital and medical staff committee meetings, as well as to the Quality Leadership Council (comprising senior leadership and board members) quarterly
    • Goals set and an action plan required if the goals are not met
    • Campaigns to increase awareness and to reward good behavior
      • "I Got Caught" campaign-team members distributed pens with the slogan and gave positive reinforcement
      • Staff entered in a quarterly drawing for an additional prize pack
      • Winners had their picture taken and posted on hospital's intranet
    • Peer coaching to encourage hand hygiene and PPE
    • Town hall meetings where senior administration discuss data with staff
    • Corporate goal set for compliance with hand hygiene and PPE
      • Monetary reward offered if goal is met (hospital met goal in 2010)
  • Increase signage regarding hand hygiene
    • Screen savers
    • Signs in units
  • Increase access to waterless hand sanitizer
  • Increase access to disinfectant wipes by placing brackets or packs on mobile equipment
  • Change policy to require use of gown and gloves for entry into each contact isolation room
  • Place PPE organizers on the door of the isolation patient room
  • Expand the active surveillance program
    • Computerized screening assessment questions and automatically dropped orders for screens if answered "yes"
    • Switched screening methodology from standard culture to CHROMagar to provide a more rapid result
    • Changed policy on when to discontinue isolation and remove MRSA flags based on literature review
  • Focus on room and equipment cleaning
  • Implement performance improvement teams for reducing central line-associated bloodstream infections and ventilator pneumonia

Source: Nash Health Care Systems 

Return to related article:Nash Health Care Cuts MRSA Rate by 84 Percent 

Publication Date: Monday, March 21, 2011