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Change is never easy, and that was true for Norma Atienza, RN, MPA, CIC, when she arrived at Saint Clare's Health System in Denville, N. J, to become the director of clinical quality and epidemiology. In this role, she was asked to make some changes that would affect patient care and the work habits of employees. "We were all new in the department when I came to the facility in 2004. We knew where we wanted to head; we just had to decide how to get there," says Atienza. What the department wanted to do was make a significant change in the rate of methicillin-resistant Staphylococcus aureus (MRSA) infections in its inpatient population.

In 1992, the CDC published a report from the National Nosocomial Infections Surveillance system that indicated a significant increase in resistant S. aureus infections from 1975 through 1991. The rates continued to rise, and the data from the NNIS on patients in intensive care from 1995 to 2004 showed that the trend was 60% MRSA of the S. aureus infections (Jt Comm J Qual Saf. 2007; 33:12).

"We knew there was a problem here and at hospitals throughout the country," Atienza says, "We looked at our own rates and then we started to develop strategies that would help us make a difference," she says. "Although it would take time to make a measurable difference, we had to plan a program that would make a real change in our practices."

After Atienza and her colleagues made changes, they gained national attention when they submitted the results of their work to the Institute for Healthcare Improvement. "At the end of 2003, our infection rate was 0.84, with 72 MRSA cases," Atienza says. "By the end of 2007, the infection rate was 0.29, with 22 MRSA cases. In 2004, we had a low handwashing compliance rate of only 72%, but with hard work and creative innovations, our compliance rate was up to 91.3% by the end of 2007."

5 Million Lives

The current IHI 5 Million Lives Campaign is built upon the success of the earlier 100,000 Lives Campaign. The new campaign asked hospitals to improve the care they provide to protect patients from an estimated 5 million incidents of medical harm within a 24-month period, which ends on December 9, 2008. According to the IHI, the campaign represents a continuation of the largest improvement effort in recent history by the healthcare industry.

The interventions focus on practices that can prevent harm from high-alert medications, reduce surgical complications, prevent pressure ulcers, deliver evidenced-based care for CHF, persuade boards of directors to make changes, and reduce MRSA infections by implementing scientifically proven infection control practices (www.ihi.org/ihi/Programs/campaign/campaign.htm).

An All-Out Effort

Atienza knew that these changes needed time and had to be a collaborative effort. "We knew that we had to make changes in practice, that we had to educate our staff, and that everyone from administration to environmental services needed to be involved. Our IT people helped to get the necessary tracking information into patients' medical records," she says. Atienza and the two RNs in her department realized that the staff needed to know more about the infection. "We held classes, went to staff meetings, and taught staff as we made our rounds," Atienza says. Information was provided on the hospital's internal Internet, and they offered programs with CEUs to make it more enticing.

"We have a great relationship with our Infectious Disease director, who is our link to the medical staff," Atienza adds. "We planned educational programs for the physicians and included information in medical grand rounds and the medical staff newsletters."

The team reviewed the way that rooms were cleaned; environmental staff was evaluated on cleaning and went through a comprehensive educational session on the importance of a clean environment. Discharge rooms are terminally cleaned, and curtains are changed in the rooms where there have been patients in isolation.

The campaign to increase handwashing compliance was carried out by interdisciplinary teams of "handwashing secret agents," who were asked to perform 20 observations a month on a unit. Statistics were collected for data analysis; units with low compliance rates received reports; non-handwashing employees were given tickets as reminders to be compliant; and compliance was also considered in annual employee evaluations. Additional alcohol dispensers were installed in high-traffic areas to improve compliance.

"We instituted more stringent isolation procedures than were required by state regulations," Atienza adds. "Besides our patients in critical care, we expanded our MRSA nasal screening population to more high-risk populations, including those coming through the ED from nursing homes, inpatients on hemodialysis, and patients who wwere previously positive for MRSA. We screen patients in orthopedics preoperatively and those on surgical units who are being discharged to a nursing home or rehab facility."

For patients who are found to be MRSA-colonized, there are specific educational handouts, in both English and Spanish, that explain the facts about MRSA and why they will be in isolation while in the hospital. Treatment for these patients is still a topic up for debate, according to Atienza. "We do require employees to decolonize so they can come back to work," she says. "However, whether patients should be treated is decided on an individual basis. Treatment for employees includes nasal Bactroban, Hibiclens showers, and treatment with oral antibiotics: either Rifampin, Doxycycline, or Bactrim DS, for five days."

After three years, their patience and hard work have been rewarded. Saint Clare's was among the organizations cited by IHI as an Innovation Challenge winner for successful strategies in reducing MRSA infections. Atienza says, "It takes time to make changes in practice. Every year we come up with new ways to get the information out there."

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Carol Nelke Dunbar, APRN, is a contributing writer for Nursing Spectrum. To comment, e-mail editorNJ@nursingspectrum.com.