National Association of Directors of Nursing Administration in LTC (NADONA) 2011 Conference

July 16-20, 2011, Kissimmee, FL

How One Facility Cut Infection Rates by Changing Its Culture

Preventing dangerous, costly infections is a top priority for long-term care (LTC) facilities, and at the July annual meeting of the National Association of Directors of Nursing Administration in LTC, Deborah Heath, RN, BSN, director of nursing, discussed measures that Lenawee Medical Care Facility in Adrian, MI, has implemented to protect its residents against infection—measures that have brought about a major culture change at the facility.  It started with breaking down barriers between departments. Heath explained how the break room was once a microcosm of the atmosphere at the facility.  “Dietary had their table in the break room, housekeeping had their table, nursing had their table,” she said. “We had to get our blinders off.” Lenawee decided to eliminate department heads and soften the sharp lines delineating staffing roles. Next, they encouraged greater interaction between nursing and other staff and allowed everyone to operate with greater autonomy.

These initial steps opened up many opportunities for staff members at every level to contribute to bettering care at the facility, but they also complicated efforts to control infection. Heath said Lenawee’s leaders came to realize that infection control was something that had to be tackled facility-wide. Every department’s practices came under the microscope, and what they found was enlightening.

“Do you know how often you’re supposed to change a mop? Do you know you can’t use the same mop in the bathroom and the kitchen? ... What is the water temperature in the washing machine? … Did you know the temperature of the food when they serve has to be a different temperature than when they reheat? Did you know you can’t put a thumb on your plate?” asked Heath.

As Lenawee made the leap from infection control to infection prevention, Heath said it was decided to expand the infection preventionist position to full-time. “What a difference it made!”

In addition to helping the facility reduce its infection rate, the infection preventionist recommended changes to address antibiotic overuse, an ongoing problem at Lenawee that had culminated with a state citation for prescribing antibiotics to treat a urinary tract infection (UTI) in a patient with no documented symptoms of UTI. “We felt that our antibiotic use was out of control,” Heath admitted.

The preventionist developed an evidence-based algorithm for assessing patients with a possible UTI and instituted a process for reporting suspected infections to the medical director. Antibiotics were no longer issued solely based on a positive urine dip.

It was also discovered that even though nurses changed gloves between residents, they were not using proper hand hygiene practices. The risk of cross-contamination was high, with a monitoring program observing caregivers touching objects in an infected patient’s room with their hands ungloved. To improve hand hygiene practices, Heath said they implemented spot checks, posted hand hygiene reminders, and required staff members to carry pocket-sized bottles of alcohol gel.

Although instituting all these changes required significant time, effort, and adjustment, the hard work paid off. Lenawee’s annual total medical infection rate dropped from a high of 8.5% per 1000 resident days in 2002 to 3.0% per 1000 resident days in 2010, a trend Heath hopes will continue.

Relieving the Burden of Healthcare-Associated Infections on Your Budget

Preventing healthcare-associated infections (HAIs) could save $14 billion to $45 billion in hospital costs annually in the United States, according to Patricia Stone, PhD, FAAN, professor of nursing and director, Center for Health Policy, Columbia University School of Nursing, NY, who spoke at the annual meeting of the National Association of Directors of Nursing Administration in Long-Term Care (LTC). The lack of current data makes it hard to quantify the rates and costs of various HAIs in LTC facilities, but Stone said a recent article in Aging by Castle and associates claimed 15% of nursing homes were cited for poor infection control (F-Tag 441) in 2000-2007.

It is hard to quantify the burden of infections, but it is significant. Stone suggests calculating their financial impact on your facility. “Will you have physician visits? There’s a cost for that. Will there be laboratory tests? There are costs for that,” she said.

HAIs consume personnel time, as employees administer medication and attend to the sequelae of infection (eg, diarrhea, delirium, and falls), and that time has a price. Transferring residents to the hospital is costly, and Stone said infections account for 26% to 38% of transfers. Then there is the risk of lost revenue due to bad press, and she shared newspaper headlines from various towns recounting deadly nursing home infections. Additional revenue is lost to isolate patients or when holding a bed open in anticipation of a hospitalized patient’s return. Fines for poor infection control impose yet another financial burden.

Infections also exact a nonmonetary toll; they are the leading cause of morbidity and mortality in LTC residents. In 2002, it was estimated that 338,000 nursing home residents die of infection annually. High infection rates can affect employee morale and increase staff turnover.

Stone suggested hiring an infection preventionist to improve care and save money. In addition to salary, the cost of downtime for the preventionist to instruct staff on preventing infection should be considered. Before making a business case for hiring a preventionist, she recommended meeting with key administrators and decision makers.

“Get agreement on the problem,” Stone advised. “Talk to your reimbursement expert and ask, ‘What are the critical cost factors that we should include in this analysis?’ It helps to get people on board early.” Once the program is in effect, Stone said it is important to collect cost and outcomes data prospectively to assess its value.