SummaryTo drive down unacceptably high rates of vancomycin-resistant Enterococcus (VRE)–related infections, an interdisciplinary team implemented a multipronged active surveillance program on a 12-bed transplant intensive care unit. Utilizing a "search-and-control" approach to containing the spread of infectious disease, this program screened patients for VRE on admission, instituted an automated surveillance database, shifted screening days to better reflect unit census, and educated nurses on strategies for reducing the spread of infections. The program significantly reduced VRE transmission rates.
The program has been discontinued, according to information supplied in February 2014.Moderate: The evidence consisted of a before-and-after comparison of infection and screening rates.
Developing OrganizationsUniversity Health System, San Antonio, TX
Date First Implemented2005
Problem AddressedVRE transmission is a common, preventable problem that frequently leads to hospital-acquired infections and their associated complications. Immunocompromised transplant patients are especially vulnerable to infection.
- A common problem: VRE, first reported in U.S. hospitals in 1989, causes about one in three infections in hospital intensive care units (ICUs).1 Of the hospital-acquired infections, 20 to 30 percent are enterococcal infections that are resistant to vancomycin.2 VRE among liver transplant patients is easily spread through contact with blood, stool, or urine containing VRE, and through indirect contact with health care provider hands and contaminated environmental surfaces.3,4
- Significant consequences: VRE causes infections such as urinary tract infections, wound infections, bloodstream infections, infective endocarditis, and intra-abdominal abscesses. VRE is associated with increased mortality, length of stay, need for surgical procedures, and admissions to the ICU. The average treatment can run $20,000 or more per patient.5
- Highly preventable: Lack of prescreening and lax compliance with hand and environmental hygiene contribute to the spread of VRE. Inconsistent use of active surveillance protocols and error-inducing manual data collection often fail to convey critical data in a timely fashion to allow for corrective action by staff.4
Description of the Innovative ActivityActive surveillance was a multi-intervention strategy that was implemented in the hospital's 12-bed transplant ICU. The strategy bundled a number of processes together that were thought to work more effectively in combination than separately. There were two primary sets of activities: one designed to identify and isolate individuals who were colonized or had infections before they transmitted the bacteria to others, and a second set designed to minimize the risk of acquiring an infection in the first place:
Activities To Identify Patients With an Infection
- Prescreening of patients for VRE: The collection of a perirectal swab culture occurred at or within 48 hours of admission to the unit. The swab tested for Enterococcus, a gram-positive bacteria commonly found in the gastrointestinal tract. VRE is Enterococcus that is resistant to vancomycin, a drug of "last resort" if other antibiotics fail. Patients without signs or symptoms of infection may test positive for VRE, a status known as "colonization" that can last more than 6 months. Individuals colonized with VRE serve as a reservoir for transmission among immunocompromised patients in hospitals.
- Weekly screening compliance: To test for acquisition during the hospitalization, a weekly perirectal swab was obtained on each patient on Wednesdays, when the transplant ICU census was usually at a peak and a maximum number of patients were available for testing.
Automated surveillance to identify those with infections: An electronic database imported microbiology records, including patient census, laboratory results from the prescreen test, and results from weekly cultures. The system generated surveillance reports that allowed for timely, automatically generated information from which to identify patients who were colonized or had active infections.
Immediate isolation of infected patients: Patients identified with VRE were immediately isolated, and appropriate precautions and environmental cleaning were instituted to minimize the potential spread of VRE.
Activities To Minimize the Risk of Infection
Improved hand hygiene by providers: To encourage appropriate hand hygiene, hand sanitizers were conveniently located in rooms and hallways, providing easy access for providers both before and after attending to patients. Staff members were also educated on the importance of hand hygiene through periodic educational inservice programs. In addition, "auditors" observed the hand hygiene behavior of providers and provided feedback to individuals as needed.
Customized, one-on-one provider education: Ongoing one-on-one updates with nurses and staff conveyed new information and helped to reinforce existing knowledge about VRE transmission, active surveillance, and isolation precautions. The 10-minute training sessions and as-needed followup meetings addressed new questions and concerns about active surveillance and provided further opportunities for enhanced infection control.
Context of the InnovationUniversity Hospital is the primary teaching hospital for the University of Texas Health Science Center at San Antonio and serves as the public hospital district for Bexar County, TX. As a level-one trauma center that also specializes in organ transplantation, the hospital is San Antonio's only hospital recognized by U.S. News & World Report as one of America's Best Hospitals. Hospital leaders discovered that VRE rates in the 12-bed transplant unit were higher than in any other unit of the hospital. Staff at the hospital reviewed evidence suggesting that reductions of 39 to 65 percent in the annual incidence of VRE colonization and transmission could be achieved, with even higher rates of reduction (up to 95 percent) being possible when automated active surveillance techniques are used. Based on this information, a decision was made to adopt this type of automated surveillance system within the 12-bed transplant ICU.
ResultsThe multifaceted surveillance program produced significant reduction in VRE transmissions on the transplant ICU unit in the first month.6
Moderate: The evidence consisted of a before-and-after comparison of infection and screening rates.
Dramatic reduction in infections: The monthly prevalence of VRE for the transplant ICU unit (e.g., the number of patients infected and/or colonized with VRE, including both unit-acquired and imported cases) plummeted from 44 to 7 percent, while VRE transmission (acquisition) rates fell from 7 per 100 risk days to 1 per 100 risk days. (Risk days were defined as the number of days between admission to the unit and the culture date for the first positive or the last negative VRE screen.) The unit reported an absence of cases of VRE bacteremia after February 2006.
Better screening: At-admission screening compliance rose from 0 to 23 percent of patients, and the percentage of patients screened on a weekly basis increased from 42 to 85 percent over a 12-month period.
- Improved hygiene: Although no hard data were available, anecdotal evidence suggested that hand hygiene and environmental cleaning improved.
- Adoption by other units: Based on the success in the transplant ICU, the active surveillance program was used within other departments of the University Health System, including the Medicine Critical Care Unit. These departments and providers found it relatively easy to adopt the initiative.
Planning and Development ProcessKey steps in the planning and development process included the following:
- Data collection and analysis: Staff gathered and analyzed baseline data on infection transmission trends.
- Review and assessment of evidence-based best practices: As noted, staff reviewed the literature and discovered substantial evidence supporting use of an automated surveillance system. After completing this review, staff assessed the feasibility of implementing various best practices.
- Cultivation of champions: The director of nursing and nurse educators promoted the program to staff.
- Determination of optimal data collection day: Nurses provided input about the best day to collect cultures each week.
- Establishment of clinical management team: This team reviewed monthly data on prevalence rates, acquisition rates, admission compliance, and weekly compliance. The multidisciplinary team included physicians, nurses, along with quality, safety, and compliance officers.
- Design and implementation of automated surveillance database: Within the Infection Control Department, a customized database using Microsoft Access® was developed. Data on patient census and microbiology culture results from the laboratory were uploaded into the system.
- Development of educational and training materials: A scripted 5- to 10-minute inservice education program was developed for nurses, along with manuals that made liberal use of graphics to facilitate cognitive processing and usability. The hospital epidemiologist had previous experience with the use of "flip cards" to promote education. Nurses received one-on-one training that made use of these laminated cards, which contained research evidence on controlling VRE. Laminated reminder cards regarding admission and weekly screening were posted in relevant departments and the staff break room.
Resources Used and Skills Needed
- Staffing: The following individuals were involved in the program to varying degrees: an epidemiologist, infection control specialist, information technology (IT) personnel or others with knowledge of databases, the nursing director of the unit, and the medical director of the unit.
- Training materials: An assistant professor of medical and infectious diseases, a hospital epidemiologist, a senior analyst for quality and process improvement, the transplant unit nursing director, and the director of the transplant program were all involved to varying degrees in the development of training materials, which took 2 months to complete. A standard software program was used to create the laminated reminder cards.
Funding SourcesThis initiative was funded with internal resources.
Getting Started with This Innovation
- Use information technology: Develop an automated database for surveillance of nosocomial pathogens. Recruit information technology expertise to automate reporting process.
- Educate all disciplines: Design a multidisciplinary education program.
- Develop several initiatives: Consider a multipronged approach to reducing infections, which can be more effective than single initiatives.
- Motivate staff members: Enlist nurse and staff manager support, and equip and empower them to be leaders. Train, inspire, and motivate those who will transmit the knowledge and culture.
Sustaining This Innovation
- Reemphasize protocols: Reemphasize and reinforce the protocols on a regular basis. Reinforce continued use of surveillance protocols to sustain improvements.
- Minimize ongoing training requirements: Keep ongoing staff training to a minimum. Initial brief training sessions may be supplemented with team meetings as needed.
Comprehensive screening is key: Be aware that much of the success was due to more comprehensive screening than existed before the implementation.
Program requires patience: Recognize that this program is a multifaceted process that requires multiple team members from different disciplines. The process does not produce immediate results but rather requires a timeline of events to occur before seeing improvements.
- Spread the process: Consider using this approach as a process improvement model for other areas in infection control.
Contact the InnovatorBeth Ann Kavanagh, MT(ASCP), MS, MBA, CIC
Infection Control and Prevention
University Health System
4502 Medical Drive
San Antonio, Texas 78229
Innovator DisclosuresMs. Kavanagh did not indicate whether she had financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesCalfee D, Giannetta E, Durbin L, et al. Control of endemic vancomycin-resistant enterococcus among inpatients at a university hospital. Clin Infect Dis. 2003;37(3):326-32. [PubMed]
National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) System report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32(8):470-85. Accessed February 24, 2008. Available at: http://www.cdc.gov/nhsn/PDFs/dataStat/NNIS_2004.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .)
Siegel JD, Rhinehart E, Jackson M, et al, Healthcare Infection Control Practices Advisory Committee. 2007 guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. Education and training. Atlanta: Centers for Disease Control and Prevention (CDC); 2007 Jun. 2. Available at: http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
Centers for Disease Control and Prevention. Recommendations for preventing the spread of vancomycin resistance. Recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep. 1995;44(RR12):1-13. [PubMed]
Available at: http://www.md.ucl.ac.be/didac/hosp/vre.htm
National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) System report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004 32(8):470-85. [PubMed]
Available at: http://www.cdc.gov/nhsn/PDFs/dataStat/NNIS_2004.pdf
McNeil SA, Malani PN, Chenoweth CE, et al. Vancomycin-resistant enterococcal colonization and infection in liver transplant candidates and recipients: a prospective surveillance study. Clin Infect Dis. 2006;42(2):195-203. [PubMed]
Siegel JD, Rhinehart E, Jackson M, et al. Healthcare Infection Control Practices Advisory Committee. 2007 guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. Education and training. Atlanta: Centers for Disease Control and Prevention (CDC); 2007 June 2. Available at: http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
Perencevich E, Fisman D, Lipsitch M, et al. Projected benefits of active surveillance for vancomycin-resistant enterococci in intensive care units. Clin Infect Dis. 2004;38(8):1108-15. [PubMed]
6 Gonzalez K, Mancinas C, Gerhardt S, et al. Improved Evidence-Based VRE Surveillance for Immunocompromised Patients. Poster presentation. San Antonio, TX: University Health System, 2007.
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Original publication: April 18, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: February 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: February 18, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.