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Service Delivery Innovation Profile

Nurse–Physician Infection Prevention Teams Conduct Rounds and Provide Support to Frontline Clinicians, Leading to Fewer Health Care-Associated Infections


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Snapshot

Summary

At the University of Maryland Medical Center, three physician–nurse infection prevention teams round on hospital units at least weekly. Assigned to designated units to allow for development of collegial relations with clinical staff, teams perform surveillance, evaluate patient care needs, provide education, answer questions, and identify opportunities for system-wide quality improvement. The teams also report on infection control practices during monthly quality meetings and provide quarterly performance reports to units. This multiphysician system provides more epidemiology coverage than in most hospitals, which typically only have one physician functioning as a hospital epidemiologist. The program has reduced central line–associated bloodstream infections by 70 percent and allowed the hospital to achieve very low rates of surgical site infections and to meet most of its internal infection control goals.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post- quasi-experimental implementation comparisons of central line–associated bloodstream infections, post-implementation data on surgical infections, and achievement of internal infection control goals.
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Developing Organizations

University of Maryland Medical Center
Baltimore, MDend do

Date First Implemented

2008
Summer

Problem Addressed

Health care-associated infections are a growing, costly problem that poses severe health risks for patients, including prolonged length of stay (LOS) and the potential for death. Infection control practices (such as proper hand hygiene and use of protective gowns and gloves) can reduce the risk of infection, but adherence to these measures remains suboptimal in many facilities.
  • A common, growing problem: The prevalence of health care-associated infections from organisms such as methicillin-resistant Staphylococcus aureus (MRSA), highly resistant gram-negative bacteria, and vancomycin-resistant Enterococci (VRE) has increased in recent years. For example, between 1990 and 1997, the prevalence of VRE in hospitalized patients increased from less than 1 percent to approximately 15 percent.1 At present, an estimated 1.7 million health care-associated infections occur in the United States each year.2
  • Severe health risks, high costs, prolonged LOS: Numerous studies show that health care-associated infections lead to longer LOS, greater use of later-generation antibiotics, higher costs, and increased risk of death.1 Roughly 99,000 people die each year due to health care-associated infections.2
  • Unrealized potential of preventive strategies: Up to 70 percent of health care-associated infections can be prevented.3 Strategies such as proper hand hygiene and use of protective gowns and gloves can reduce the spread of infection. Yet adherence to these strategies remains suboptimal.4 A coordinated approach involving infection control experts, monitoring, and data analysis can help educate staff and improve adherence to these strategies,1 yet few organizations invest the time and resources necessary to execute such an approach.

What They Did

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Description of the Innovative Activity

Three physician–nurse infection prevention teams round on hospital units at least weekly. Assigned to designated units to allow for development of collegial relations with clinical staff, teams perform surveillance, evaluate patient care needs, provide education, answer questions, and identify opportunities for system-wide quality improvement. The teams also report on infection control practices during monthly quality meetings and provide quarterly performance reports to hospital units. (Note: This multiphysician system provides more epidemiology coverage than in most hospitals, which typically only have one physician functioning as a hospital epidemiologist.) Key elements include the following:
  • Weekly rounding: The three teams, each consisting of a physician epidemiologist who serves as team lead and a registered nurse with expertise in infection prevention, conduct weekly rounds on each hospital unit. Assigned to designated units to allow for development of good relations with unit-based clinicians, the teams discuss patient care and infection control with frontline physicians and nurses. Examples of rounding activities include the following:
    • Patient evaluation: The infection preventionist nurse uses computerized software to identify patients with positive cultures to facilitate surveillance and tracking. The infection preventionist nurse and physician discuss theses case just before rounding commences. The team rounds on all patients on the unit, evaluating infection control practices for those with an identified infection and discussing prevention strategies for those not infected. For example, the teams evaluate the treatment of each patient with a central line–associated bloodstream infection and discuss their progress with the frontline clinicians. Teams also visit other patients with a central line to assess the need for the line, evaluate its placement, and determine the earliest point at which it can be removed.
    • Observation to identify opportunities for improvement: The teams observe infection control practices on the units, identifying any gaps or issues related to adherence to proven control strategies, such as appropriate hand hygiene and gown/glove use in caring for isolated patients. Team members may offer real-time corrections, such as politely handing gloves and a gown to a clinician. They also make note of system-wide activities that could be developed to improve infection control, such as changes related to housekeeping, linen management, equipment cleaning, glove/gown availability, and general cleanliness.
    • Education of frontline clinicians: Team members answer questions from frontline clinicians and provide general information regarding infection control. Sometimes, small “huddles” occur on the units, with team members providing informal education on the topic at hand.
  • Monthly cross-team rounding: Each month, members of the three teams round together in selected hospital areas. This process improves the visibility of the team members and regularly reminds frontline staff of the institution's significant commitment to infection control.
  • Monthly education for residents and fellows: Each month, a team provides a 20-minute education session for new residents and fellows on infection control surveillance, glove/gown use, hand hygiene, and other infection control practices. Education sessions focus on current issues (such as influenza vaccination during flu season) and unit-specific issues (such as strategies to reduce the risk of a particular type of infection on the cardiac care unit).
  • Monthly unit quality meetings: The infection control team participates in monthly quality meetings held by each unit and department, weighing in as appropriate on agenda items relevant to infection prevention.
  • Performance reporting and feedback: The hospital collects a wide array of clinical and process measures related to infection control, and reports on infection incidence and other indicators at the monthly quality meetings. Collected indicators include (but are not limited to) the following: central line–associated bloodstream infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia rates. The teams also distribute quarterly data reports to each of their units, which include performance on hand hygiene (based on adherence upon exit from the patient room/environment), adherence to protocols for obtaining surveillance cultures for antibiotic-resistant bacteria on admission, and influenza vaccination rates among employees.
  • Quality improvement based on observations, performance data: Teams review performance data and their observations during rounding and track this information on an Excel spreadsheet to identify problems that can be addressed through quality improvement initiatives. Examples of system-wide changes prompted by the infection control teams include:
    • Automated active surveillance cultures: Unit-based electronic order sets now incorporate automatic test orders for patients who need to be evaluated for antibiotic-resistant bacteria. In addition, the nursing intake form includes two infection control–related questions that allow for identification of high-risk patients.
    • Better cleaning procedures: The teams spearheaded development of revised procedures for cleaning rooms (both while occupied and following discharge).
    • Better isolation signage: Isolation signage was revised to include pictures of personal protective equipment required to enter the room and to highlight special cleaning procedures.

Context of the Innovation

A 654-bed academic medical center offering a full range of secondary and tertiary care, the University of Maryland Medical Center employs approximately 6,000 people and handles roughly 38,000 inpatient admissions annually, with many patients being severely ill. The medical center’s infection prevention department faced an increase in demand for consultations regarding a wide array of issues, including management of bloodstream, urinary tract, and surgical site infections; ventilator-associated pneumonia; influenza; and antibiotic resistance. With limited manpower available to meet these demands, infection prevention leaders (including the Medical Director of Infection Prevention, the Director of Infection Prevention and Hospital Epidemiology, and an Associate Professor of Epidemiology and Preventive Medicine) considered options for better managing infection prevention services. They decided to replace a single hospital epidemiologist with a multiphysician (hospital epidemiologist and associate hospital epidemiologists) system to help address these problems. The multiperson system allowed the pairing of a physician and an infection prevention practitioner and allowed interventions such as team rounding, which enabled more clinicians to become engaged in infection prevention and control and facilitated frontline clinician access to experts in this area.

Did It Work?

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Results

The program reduced central line–associated bloodstream infections by 70 percent, surgical site infections associated with instrumented spinal surgery by 50 percent, and bloodstream infections associated with antibiotic-resistant bacteria by 25 percent.
  • Significant reduction in bloodstream infections: Central line–associated bloodstream infections in the hospital’s intensive care units have fallen by 70 percent since program implementation in 2008, representing an estimated total of 69 fewer infections. Bloodstream infections associated with antibiotic-resistant bacteria have declined by 25 percent.
  • Decline in surgical site infections: Surgical site infection rates remain low (1 to 2 percent) for both coronary artery bypass graft and instrumented spinal surgery patients (decline of 50 percent), which represents a sustained decline since 2008.
  • Achievement of most internal goals: Due in part to the rounding program, the hospital met 9 out of 10 internal infection control objectives in 2010, including those related to bloodstream and surgical site infection rates, influenza vaccinations among staff, incidence of gram-resistant bacteria, bacteremia rates, and others. The influenza vaccination rate among health care workers has increased from 52 to 80 percent since 2008.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post- quasi-experimental implementation comparisons of central line–associated bloodstream infections, post-implementation data on surgical infections, and achievement of internal infection control goals.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Obtaining medical leadership support: Program developers met with the chief medical officer to explain the need for more resources dedicated to infection prevention and describe the rounding model.
  • Creating separate department: Program developers sought and received approval from hospital leaders to create a separate Infection Prevention and Epidemiology Department (rather than the current approach of having infection control under the hospital’s quality department), with the department head reporting directly to the chief medical officer.
  • Obtaining budgetary approval: Program developers met with hospital leaders to obtain approval for physician time to be allocated to the program and for the hiring of an additional infection preventionist (a nurse).
  • Reorganizing nursing resources: The newly created department reorganized the responsibilities of existing nurse preventionists and hired an additional full-time nurse to ensure sufficient resources for rounding and other infection prevention activities.
  • Selecting physicians for teams: The chief medical officer selected physicians with specific training in hospital epidemiology and infection control to be part of the team.
  • Designating areas of responsibility: Program developers assigned teams to units based on team members’ familiarity with specific units and existing relationships with staff and physicians.

Resources Used and Skills Needed

  • Staffing: The hospital hired one new infection preventionist nurse for the program; this individual joined two other nurses who spend a portion of their time rounding. (The hospital has a total of five full-time infection prevention nurses who perform rounding and general prevention and infection control activities, but only three serve as part of a physician–nurse rounding team.) In addition, three physician epidemiologists serve part-time as team members. The three teams spend approximately 60 to 90 hours a week on rounding and related activities.
  • Costs: Data on program costs are unavailable; major costs include salary and benefits for the time that team members spend on the program.
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Funding Sources

University of Maryland Medical Center
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Adoption Considerations

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Getting Started with This Innovation

  • Win leadership support by emphasizing safety: Support from the chief executive officer and chief medical officer will be critical to ensuring that the hospital devotes adequate resources to the initiative. To win their support, emphasize the program's ability to promote a culture of patient safety.
  • Focus on team building: The infection preventionist nurses and physician epidemiologists must be able to work together effectively and efficiently. Weekly staff meetings including the entire team can promote communication and collaborative decision making.
  • Ensure appropriate skill set for physician team members: Fifteen years ago, any physician with infectious disease training could work in hospital epidemiology and infection prevention. At present, however, the best infection prevention programs use physicians with specific skills, experience, and knowledge related to hospital epidemiology and infection prevention and control.
  • Give teams proper authority: By creating a distinct infection prevention service line, program developers ensured that they have the senior management support and the authority to hold hospital staff and physicians accountable to incorporate infection prevention practices into their daily routines.
  • Teach team to communicate with frontline clinicians: Diplomacy remains critical during any communications with frontline staff, who can sometimes be defensive when hearing negative messages (e.g., data showing suboptimal hand hygiene on a unit). To ensure effective communication, teach team members to emphasize patient safety, reference empirical evidence whenever possible, elicit suggestions on ways to improve, and present solutions as “win-win” for everyone involved.

Sustaining This Innovation

  • Cultivate relationships with frontline staff over time: By being responsive to frontline clinicians’ questions and concerns, infection prevention teams can build strong relationships with staff over time, which will ultimately have a positive impact on infection prevention and patient outcomes.
  • Maintain lines of communication: Use formal mechanisms (such as departmental/unit-based meetings) and informal mechanisms (such as e-mail) to allow infection prevention staff to communicate with each other and with frontline clinicians on an ongoing basis.

More Information

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Contact the Innovator

Anthony Harris, MD, MPH
Department of Epidemiology and Public Health
Professor University of Maryland
School of Medicine
Acting Medical Director of Infection Control
University of Maryland Medical Center
(410) 706-0064
E-mail: aharris@epi.umaryland.edu

Michael Anne Preas, RN, BSN, CIC
University of Maryland Medical Center
E-mail: mpreas@umm.edu

Innovator Disclosures

Dr. Harris and Ms. Preas have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Neergaard L. Germ cops help hospitals prevent infection, death. The Washington Times. December 7, 2010. Available at: http://www.washingtontimes.com/news/2010/dec/7/germ-cops-help-hospitals-prevent-infection-death.

Footnotes

1 Siegel JD, Rhinehart E, Jackson M, et al; the Healthcare Infection Control Practices Advisory Committee. U.S. Centers for Disease Control and Prevention. Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006. December 29, 2009. Available at: http://www.cdc.gov/hicpac/mdro/mdro_3.html.
2 Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160-6. [PubMed] Available at: http://www.cdc.gov/HAI/pdfs/hai/infections_deaths.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.).
3 Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. Centers for Disease Control and Prevention. March 2009. Available via link provided at: http://www.cdc.gov/HAI/surveillance/index.html
4 US Department of Health and Human Services. HHS Action Plan to Prevent Healthcare-Associated Infections: Research. (No date provided.) Available at: http://www.hhs.gov/ash/initiatives/hai/actionplan/index.html.
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Original publication: October 12, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 18, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: October 26, 2013.
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.