Waging a War on Germs

The incidence of hospital-acquired infections may not be on the rise, but awareness of it certainly is. Trish Perl outlines the Johns Hopkins Hospital’s strategies to keep HAIs in check.

“There is a lot that we need to take forward that we've done very well over the years, but we do need to rethink some of it and make sure we are responding to a changing world”
-Trish Perl, Johns Hopkins Hospital

With the increased interest in healthcare associated infections, there is improved surveillance, but what is not clear to us is if we’re seeing increased infections or if we have enhanced case ascertainment. With some of the changes that we’re seeing within public reporting, we will soon be in a position to monitor this. It can be easy for people to say, “Our patients are sicker,” and it may be true, but it also may be an excuse.

Prevention
What is important in terms of prevention of infections and prevention of acquisition of resistant organisms, or epidemiologically significant organisms, includes hand hygiene and the use of isolation precautions: barrier precautions and cohorting. We look for the organizms and we measure them so that we can understand the problem.; we have a very active surveillance program.

We focus on cleaning the environment, and cleaning the whole interaction between patient and environment. We are interested in promoting immunization programs that prevent transmission primarily of respiratory diseases, but also other diseases where appropriate, so we put a lot of focus on getting our healthcare workers vaccinated against influenza, measles, mumps, rubella and chicken pox – all of these important vaccines.

How do we actually make those things happen? We do a lot of education. I’ve become very interested in marketing and I’ve realized it’s a very important part of what we do. We used to have tiny posters, but now they are much bigger. We use posters to present data and get our message out, and communicate at a visceral level. Building these elaborate communications marketing campaigns has been very, very effective.

The final thing that has been key is behavioral change. This has been driven by a number of groups, including the intensive involvement of leadership – getting them engaged so that you have programs in place to support your interventions. It’s great for us to have a hand hygiene campaign and we can have posters all over the place, but if we don’t have enough dispensers so people can make sure their hands are clean, it won’t happen. You need to have all of these pieces together to facilitate the behaviors you want to occur.

Bundling up
The concept of central line bundles focuses around five evidence-based procedures. Most of this was known as long as 20 years ago, but it has been packaged in a way that makes it easier to understand. We told healthcare workers, “We want you to do five things when you put in central lines. We want you to clean the skin with the right disinfection and we want you to use it the right way. We want you to wash your hands or clean your hands. We want you to use sterile drapes and keep the field sterile. We want you to take catheters out when you don’t need them anymore. And we want you to use sites that are less likely to get infected.”

These are five things that even a three-year-old would understand, and it was getting people to focus as opposed to handing them a cumbersome guideline. We learned a lot from this process. We learned that you had to have a cart with all the equipment because people wouldn’t do it if the equipment wasn’t available. Everyone would promise that the equipment was available but it never was. These are the kinds of things you need to work out when you’re trying to make things work efficiently.

Our hand hygiene initiative grew out of the interest in multi-drug-resistant organisms. It has been very helpful to have so much focus on that in the lay press, because this creates pressure from the outside. The woman who developed the campaign, Hanan Aboumatar, worked with a communications group in the School of Public Health and helped develop a campaign where there was a lot of buy-in from healthcare workers.

We worked on measurement. We have a standard measuring device and then we went out and started measuring, and feeding the data back, and then we went into the denial phase where everybody said, “We don’t like your measurement. We don’t believe what you’re finding,” and so we had to walk through that and start getting people to buy into it. Since then, we’ve developed it even further, and Hanan has developed a web-based program so you can get instant feedback on the hand hygiene rates in the department. It’s very elegant.

In order to have effective intervention, you need to have the knowledge, attitudes, and beliefs where you teach people about hand hygiene. You educate them about it and you work on changing their attitudes and beliefs. You need to facilitate it so that you have enough hand hygiene dispensers, as well as posters and reminders. People don’t usually fail to wash their hands because they’re sitting there thinking, “I’m not going to wash my hands and I’m going to purposely spread bacteria from one person to another.” It’s usually that they’re doing 800 things and they forget, so you have to have the reminders in place.

Then you have to have reinforcement, and that includes support from leadership. It includes having feedback of data. We now have a campaign in which we celebrate the groups that have done a really good job. We even sent out letters to a couple of groups that hadn’t improved their rates and said, “All right, you guys really need to ante up at this point. We’re looking at this and you aren’t going anywhere.” This caused a lot of angry emails and phone calls, but the result is that now they’re doing it.

Incentives
For a lot of the campaigns, more and more of what I’m seeing at this institution is the use of incentives. A couple of departments have said that the first unit that gets their rates up over 75 percent compliance for three months, gets a $2500 prize. Even at the executive level, we’re seeing a trend towards incentivizing pay for safety goals as well as financial goals.

These incentives are an important culture change that I’m seeing in at least our institution. We have always valued safety but now we’re putting our money where our mouths are, which is very important. You can feel it in the pulse of the organization and the healthcare workers. They can see that leadership is doing something about it.

Trying to look at novel ways to solve problems is very important. It has been a real paradigm shift in how we work – we’ve moved from a ‘woe is me’ department where we complain about not having enough resources to being much more proactive. That’s how you become a leader.

The other thing that’s been very important, especially in our organization, which is a research organization, is to do novel research. It’s a much more complex world than it was 20 years ago and to think that the techniques used 20 years ago will be adequate today is like being an ostrich and putting your head in the sand. There is a lot that we need to take forward that we’ve done very well over the years, but we do need to rethink some of it and make sure we are responding to a changing world.

Trish Perl is Director of Hospital Epidemiology and Infection Control, and Hospital Epidemiologist at The Johns Hopkins Hospital. She is also a Professor in the Departments of Medicine (Infectious Diseases) and Pathology at Johns Hopkins University School of Medicine in Baltimore, Maryland, and in the Department of Epidemiology at the Bloomberg School of Hygiene at Johns Hopkins University.

Perl has been a principal and co-principal investigator for studies on healthcare associated infections and antimicrobial resistance for the Centers for Disease Control and Prevention. Her scientific interests encompass avian influenza and pandemic influenza planning, surgical site infections, emerging infection prevention and interventions to prevent healthcare associated infections and epidemiologically significant organisms, bioterrorism preparedness, and patient and healthcare worker safety.