PICU paves way for Clean In, Clean Out campaign

Several years ago, Pediatric Intensive Care Unit (PICU) leadership implemented changes that led to a dramatic improvement in its hand hygiene compliance rates. The PICU effort was so successful that it became a model for the 2013-2014 UNC Hospitals’ Clean In, Clean Out campaign.

Clean In, Clean Out

In 2007, PICU leaders believed hand hygiene compliance rates on the unit were high. Infection control team visits confirmed that medical staff members were cleaning their hands at appropriate times, at rates of 90 to 100 percent.

It wasn’t until PICU staff began self-monitoring that unit leaders realized the compliance rate was misleading.

“We started doing our own secret, incognito observations, with staff observing other staff,” says Cherissa Hanson, MD, assistant professor of pediatrics and director of the pediatric rapid response team. “We found that our rates weren’t as good as we thought. In fact, without the visual cue of seeing the infection control team, often times we weren’t doing as well as documented.”

Determined to improve compliance, the PICU implemented a unit-wide hand hygiene campaign with the goal of decreasing ventilator-associated pneumonia (VAP) and central line-associated bloodstream infections (CLABSI), thereby contributing to lower patient mortality rates and reduced hospital costs. Doing so required PICU leaders to look carefully at the location of hand hygiene products in patient rooms and closely examine policies to determine exactly when care providers should wash their hands.

“We looked at a very detailed hand hygiene regimen, including all those care activities within the room,” says Dr. Hanson. “We found that by changing where the alcohol was placed, creating a culture of monitoring and compliance, and giving positive reinforcement to people who cleaned their hands and negative  reinforcement to those who did not, rates dramatically improved not only among members of our unit, but also among the subspecialty teams who entered the unit.”

PICU hand hygiene rates rose from percentages in the 60s to rates of more than 90 percent compliance. But the dramatic improvement, which involved the participation of some 200 nurses, physicians, and respiratory therapists on the unit, didn’t happen overnight. Correcting problems required buy-in from all medical staff – it required a complete change in culture.

Part of that cultural change came from monitoring the frequency of infections and building a sense of collective accountability.

“We posted how many days we went between infections,” says Roger Saunders, RN, nurse manager of the PICU. “We’d see that number go from 120 days back to 0, and everyone would ask, ‘How did it happen? What could we have done? Could we have prevented it?’ And these questions would then help us identify the risk moments and be aware of them before the next infection would occur.”

PICU leaders kicked off their campaign with several educational fairs stressing the importance of hand hygiene. Staff could come and go as their schedules permitted. As unit members learned more about the importance of hand hygiene to the health of their young patients, they felt increasingly comfortable addressing coworkers who used proper hand hygiene as well as those who didn’t.

“After those educational experiences and learning about the positive and negative reinforcement we recommended, a lot of the staff felt very empowered to look at a team of physicians, nursing students, or respiratory therapists and say, ‘Excuse me, I need you to wash your hands,’” says Doreen Marlowe, RN, CCRN, assistant nurse manager on the PICU. “And they really took ownership of that.”

Although sometimes difficult to provide negative feedback to a colleague, the backing of unit leadership and the passion staff developed for hand hygiene helped improve communication among coworkers and establish a new culture on the unit. But, as Dr. Hanson notes, positive reinforcement was equally, if not more, effective.

“In addition to emails we’d send dealing with improper hand hygiene, we sent out emails congratulating subspecialty teams that improved and thanking them for demonstrating leadership,” says Dr. Hanson.

Naturally, visits from large teams of medical students and residents presented challenges for the PICU as it sought to decrease infection rates. An entire team may enter a room without planning on touching or interacting with the patient. But plans often change when providers arrive.

“They might go into a room planning on simply communicating with the patient, but the patient’s mother may express concern about x, y, or z, and the provider will need to touch the patient,” says Dr. Hanson. “So we really stressed that situations change when providers enter a room, and all medical personnel in the room need to embrace the culture of washing hands even when they’re not planning to touch and interact with a patient.”

Nothing encouraged members of the PICU more than the decrease in infection rates, and in turn the lives they were saving and the costs they were helping to reduce. PICU providers felt a sense of personal responsibility for continuing the lengthy streaks they built between instances of infection.

Dr. Hanson observed the differences in her colleagues before and after the PICU began its hand hygiene campaign. “There was an even clearer responsibility we felt to the patient and each other,” she says. “When you see that the care you’re providing is making a difference, then you want to continue it. That’s why we come to work every day in this setting, to make a difference in a child’s life, and hand hygiene became one way for us to do that.”

The results of the PICU campaign have been tangible, with significant high compliance rates leading to improved outcomes for patients and lower costs for the hospital. Now in its fourth month, the “Clean In, Clean Out” campaign provides all UNC Hospitals’ employees the chance to make the same impact staff did for the PICU.

“One of the most rewarding parts of our campaign was the reminder that others across the hospital have the same pride in ownership of our patients’ health and wanting them to do well as we do,” says Dr. Hanson. “It was inspiring to see it in action.”

Hand hygiene is of paramount importance to the safety of our patients. We ask that you participate in the Clean In, Clean Out campaign by visiting the page and learning how to submit your observations.

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