Coming Clean in the NICU
Monday July 15, 2002
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New Procedures Needed
Rebecca Dixon, RN, BSN, CIC, Inova Fairfax Hospital's infection control practitioner; Lori Richardson, RN, NP, chair of the infection control reduction committee; and Dr. John North, chair of neonatology, spearheaded the campaign. According to Dixon, "During the preplanning phase of the campaign, the committee reviewed studies and statistics, its literature, and the latest Centers for Disease Control and Prevention (CDC) guidelines on the approaches to handwashing and antisepsis and developed an action plan." The studies revealed that skin irritation from soaps, inaccessibility to supplies or sinks, and insufficient time to wash hands between every patient care contact were the main reasons given by healthcare workers for lack of handwashing compliance. Dixon notes that she observed brevity in handwashing practices by some of their NICU staff, who complained that the harsh antiseptics injured their skin. The committee decided to modify their handwashing practice to include a new waterless alcohol hand gel to reduce the trauma to the hands.
"One of the first steps the multidisciplinary team undertook was getting the NICU doctors and consultants to buy-in and support the handwashing campaign," says Dixon. Before the team got started on the education process, a memo was sent to NICU physicians and consultants advising them of the campaign, rules they must follow, and the importance of the campaign. The team then gave their presentation to the department of neonatology, physician assistants, nurse practitioners, the infection reduction committee, and the NICU education committee to gain their support.
"Real Time" Education
The process of educating all 150 nurses on the two 12-hour shifts began in January and took a month to complete. The informal sessions were given in a break room on the unit or at the bedside. Dixon notes that staff education on the night shift was more challenging for the instructors as the class sessions and bedside demonstrations took place between 12 AM and 2 AM - a more suitable time for staff. But despite the early hours, she found the experiences very rewarding. Nurses were able to share a lot of their concerns about infection control issues and practices. Drawings for $25 gift certificates were also offered to the nurses as part of the inservice program to make the sessions more lively and fun.
At the start of each educational session, each staff person was given a "Drown a Germ" sticker and written educational material. Without the staff's knowledge, each sticker had been covered with "glow germ," a fluorescent powder that lights up in a dark room under an ultraviolet light. Later they were taken to a dark room where much to the nurses' astonishment, the "glow germ" was visible on their faces, necks, hair and hands - demonstrating how easily one can spread germs inadvertently from contaminated hands without realizing it. Afterwards, the nurses washed their hands with both the waterless alcohol-base hand gel and an antimicrobial soap to demonstrate how proper handwashing removes germs. Later, the presentation was given to the NICU physicians, nurse practitioners, physician assistants, and consultants.
According to Dixon, the new handwashing protocol is based on the CDC's latest guidelines calling for the use of waterless alcohol products for almost all patient care encounters. When the hands become visibly soiled or contaminated they are to be washed with antimicrobial soap and water for 10 to 15 seconds.
Dixon notes that each NICU nurse does a two-minute scrub using Triclosan, a broad-spectrum antimicrobial skin care product at the start of each shift. Prior to the scrub, all jewelry including wedding bands must be removed and pinned to the scrub uniform. In between each patient encounter, hands not visibly soiled are to be washed with "Endure 300," an alcohol-based waterless antiseptic agent. Dixon also encourages staff members to wash their hands again with an antimicrobial soap and water after taking off gloves, when visibly soiled, or after 10 to 15 hand washes with a waterless alcohol product.
Key to a Successful Campaign
Monitoring and feedback are vital to improving handwashing compliance, Dixon says. While making weekly rounds to monitor staff compliance, she checks for inadequate cleaning supplies - a telltale sign that equipment is not being cleaned properly.
According to Dixon, the handwashing protocol is part of an educational process that begins in orientation and is ongoing in the NICU. She monitors monthly infection control reports for changes in the rate of infections. Dixon says she believes a combination of education and being visible and interactive with staff was key to a successful campaign in their NICU and made the extra effort by the multidisciplinary team well worth the time and challenges.
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