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1/11/2010 5:00 PM

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Inside this issue

Superbugs – a super challenge?

 Dr. Michael Gardam
Dr. Michael Gardam
During the next 10 minutes you spend reading this newsletter roughly five patients will have acquired a likely preventable healthcare associated infection (HAI). Could it happen in your facility? 

For the last 30 to 40 years, Canadian hospitals have struggled to make a dent in reducing healthcare associated infections. These infections prolong a patient’s length of stay and often lead to serious complications – and tragically, thousands die every year from these largely preventable infections.  

When it comes to infection control there are a lot of strategies available to you that target different aspects of our healthcare system. To bring about improvement, we have to use many of them; no one size fits all.  Public reporting and Accreditation Canada’s required organizational practices (RoPs) are infection control strategies targeted toward senior management that look at compliance with hand hygiene, adherence to protocols and track and report healthcare associated infections. Behavioural techniques, such as Positive Deviance, look at the expertise and draw ideas for change from front-line providers, so that they take ownership over and implement their own ideas and solutions. Social marketing strategies can affect the entire spectrum, to help motivate healthcare workers to change their actions and later, their attitudes toward infections. And, implementing small tests of change by using the Plan-Do-Study-Act (PDSA) cycles to guide improvement work is another strategy for enhancing performance in many settings.

First and foremost, infection control must move away from a policing role to one of supporting healthcare workers; infection control are the experts when it comes to what needs to be done. But, while we can educate the importance of hand hygiene, we can’t wash your hands for you!
In the past, there has been a tendency for infection control staff to own and feel responsible for all infection control issues, rather than focusing on strategies that foster ownership of these issues by front-line providers. Infection Control people need to be involved when the problem is first identified, but it is those on front-line that will bring about the cultural change as part of their scope of practice. 

In this newsletter, we have compiled change ideas that demonstrate what you can do to reduce HAI. We know that we all need to work differently and look at the problem differently. You will read a lot about Positive Deviance and Hand Hygiene practices as strategies to reduce HAI. Positive Deviance as a “behavioural approach” is very helpful when you are faced with a problem that is serious, seems overwhelmingly difficult to solve, and extra resources are not readily available.  The Positive Deviance approach takes advantage of EXISTING successful practices – and teaches us HOW to use them as the stimulus for getting those practices and other just waiting to emerge into widespread and lasting practice.  That’s what we need to fight those superbugs!

The Safer Healthcare Now! Getting Started Kit for the ARO/MRSA intervention is currently being rewritten and will be posted soon to the Safer Healthcare Now! website. I encourage you to review this new how-to-guide for updated information on controlling antibiotic resistant organisms.

My thanks to all who contributed to this issue on healthcare associated infections.  Good things are happening on this front and by sharing our experiences we can all learn from each other -and make a difference in addressing this universal challenge. 

Michael Gardam, MSc, MD, CM, MSc, FRCPC
Antibiotic Resistant Organisms Intervention Lead, Safer Healthcare Now!
Director, Infectious Diseases Prevention and Control, Ontario Agency for Health Protection and Promotion
Medical Director, Infection Prevention and Control, University Health Network

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Change Ideas that have made a difference! Have you tried . . .?

Catching Butterflies?

“Butterflies” are those lovely little ideas that someone will float into a conversation – these ideas are often either so small, or so obvious, that in regular practice we frequently fail to capture them because we don’t notice them.  Use a ‘parking lot’ to capture these ideas and turn them into action.

A cleaning checklist?

Work with housekeeping staff to develop a cleaning checklist of items that require daily cleaning and “terminal” discharge cleaning. Post the list on every cleaning cart and supply closet.

Chocolate Pudding?

In training sessions, use chocolate pudding or tempera paint as a visible marker for germs to help reinforce the proper use and removal of personal protective equipment.

Coughing etiquette?

To teach coughing etiquette to those around you, a helpful video, “Why don’t we do it in our sleeves” can be found at: http://www.coughsafe.com

Creating a shield?

When holding a MRSA patient, place a clean sheet between yourself and the patient to prevent direct microbial transfer.

Cupcakes?

This playful experiment to improve hand hygiene compliance teaches strategy and principles to change behaviour using a group of 80 unsuspecting kids and cupcakes: www.crucialskills.com/2009/09/all-washed-up/

Discovery and action dialogues?

These brief sessions let staff share their ideas and act on them. Facilitators at “discovery and action” dialogues act as catalysts with questions, rather than experts with answers. 

Ditching your tie?

MRSA can live on cotton for nine days.  Stop wearing a tie, white coat and long sleeves – all vectors for the spread of MRSA infections.

Plastic bags?

Some Transporters are using plastic bags to cover charts when patients are moved – another vector for MRSA transmission.

Rescheduling rounds?

When physicians see MRSA patients last during rounds, it greatly reduces the risk of transmitting MRSA.

Sharing data?

Use charts, graphs, posters, emails and conversations to share information on your HAI data.  Celebrate successes and do some soul-searching if you need to improve.

Taking 20 seconds before you speak?

After asking a question, wait at least 20 seconds for someone else to speak. One way to encourage others to respond is to look down at your shoes.  This disrupts your eye contact with members of the group and signals that this is time for reflection, thinking and sharing their thoughts.

UV lights?

Fluorescent chemicals, such as UV lights, are an effective tool in evaluating environmental cleaning and reducing the transmission of antibiotic resistance organisms.

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Making the invisible visible

Using Positive Deviance and chocolate pudding to sustain cultural change

Participants of the Safer Healthcare Now! MRSA Western Collaborative learned by example during a presentation by Carlos Arce, Director of Organizational and Leadership Development – Billings Clinic (Billings, Montana). This post-Collaborative conversation captures how the Billings Clinic is using Positive Deviance to reduce MRSA infections.

The Billings Clinic has reduced its healthcare associated MRSA infections by 84 per cent in the last two and a half years.  How have you achieved these remarkable results?

We have been using what I call a “social change” methodology, known as Positive Deviance. Positive Deviance has allowed us to discover some of the basic elements of what it takes to create proactive and sustainable human change. Along this journey we have come to understand that some of our linear processes, the more cause and effect methodologies used in our quality improvement efforts, had limited impact on changing someone’s personal behaviour.  Positive Deviance helped us overcome that.

We understand that even though people know what they should be doing, they opt to act a different way.  Most people know that washing your hands is a great way to reduce healthcare associated infections. However, the challenge is how do you actually influence the behaviour of the individual so that they make the change and sustain the change. Rather than focusing on the traditional approach of telling folks what does and does not work, or rewarding or punishing employees to practice

How does Positive Deviance help to sustain cultural change?

safety, our approach focuses on creating conversations and interactions that allow folks to discover and try new actions that prevent MRSA transmission.

Positive Deviance is ultimately tapping into the minds and hearts of individuals in a subtly different way so that you get something to stick. The difference is the quality of the interaction, the way you invite people to try something new, the way you provide an opportunity for them to discover it on their own.  Change is more likely to happen when someone discovers a new behaviour for themselves.

We learned that we needed to be less directive because our people were so used to taking direction when it came to the standard practices related to preventing healthcare associated infections.  This method could only get us limited levels of compliance. However, it lacked the rigor and ownership necessary to truly reduce transmissions.  We asked ourselves, how can we change the interaction?  Can we have conversations about healthcare associated infections that are more enquiring?  Where people share what they do to prevent these types of things from happening?  Where we discuss what actually gets in the way of you executing those behaviours all of the time?  Where we might ask, “Do you know people that you work with who demonstrate consistent behaviours despite those obstacles you described?”  These are very subtly different questions.  It is not rocket science.  It is a matter of changing how you listen, changing how we enquire and giving some space for folks to discover and understand the possibilities by including them as opposed to doing things to them.

We hear that the Billings Clinic is doing some interesting things with chocolate pudding!  Please tell us more.

We love the concept of making the invisible visible. Chocolate pudding is used as a visible marker for germs.  It is playful, yet very powerful.  We have smeared chocolate pudding on the “patient’s wound” during learning sessions so that participants can see the invisible germs.  When we introduced improvisational theatre (improve) as a leaning methodology in our organization, it was used during practice sessions devoted to donning and doffing personal protective equipment (PPE). Chocolate pudding is smeared on gowns and gloves to simulate contamination. When participants remove the gowns and gloves, they can feel and see how they have been contaminated.  At employee health fairs, we have used tempera paint or chocolate pudding as an effective way to self-discover the need to clean hands after glove removal.

How are you using Positive Deviance help your staff to functioning differently? 

Positive Deviance is a methodology of inclusion, innovation and discovery.  In my role in organizational development, I need to help build competencies in our organization and teach people to be collaborative and to include others, to be innovators and to invite discovery. That is beneficial to the organization in whatever we are doing.  People feel that their voice matters and change is a by-product.  That has been a huge benefit in reducing MRSA transmission, as well as other healthcare associated infections. 

There is a positive impact to the overall culture of safety, where individuals feel that they can speak up, that they can take the opportunity to look at things differently, and combine ideas and see what comes out of that.  That has definitely helped improve the culture of our organization.

An additional side benefit of using the Positive Deviance methodology has been discovering that there may be other opportunities to apply this, such as the management of hypertension in patients.  We are looking at more effective ways of managing blood pressure and we have started using techniques and methods learned through Positive Deviance.

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The Canadian Positive Deviance Project

The Canadian Positive Deviance Project

Working towards the reduction of Healthcare Associated Infections

Safer Healthcare Now! MRSA Intervention Lead, Dr. Michael Gardam, together with the Ontario Agency for Health Protection and Promotion (OAHPP), is spearheading an innovative culture change initiative that aims to reduce healthcare associated infections throughout Canada. The Canadian Positive Deviance (PD) Project is an 18-month study funded by the Canadian Patient Safety Institute that is piloting the use of PD as a culture and behaviour change method in six hospital sites across the country. Many readers may say to themselves at this point: “Not another culture change initiative!”  However, it should be noted that PD has been found to be most successful when it is applied to problems that seem to have no solution – the type of problem where other methods have been tried unsuccessfully time and time again. For example, PD has been successfully used to reduce rates of MRSA infection in several hospitals in the United States, as well as to reduce childhood malnutrition in Vietnam.

Unlike many other change strategies, PD takes a bottom-up approach by focusing on individuals on the front lines; those who know the realities and intricacies of the problem, and who might also have ideas and solutions for how to tackle it.  Part of the PD process aims to identify ‘positive deviants’ within a particular setting, who are individuals, that with the same limitations and resource restrictions as others around them, seem to have better outcomes. Through identification of these ‘positive deviants’, they can then be engaged to share their successful practices with others who might find them useful. Another key component of PD is that those involved in the initiative must be interested in being a part of it. It is critical to the PD process that no one is told that they have to participate in PD, and that those who participate choose to do so, and are excited about it.

Over the summer of 2009, the PD project leads spread the word about the Canadian PD initiative in healthcare, and after three webinars with numerous attendees from across the country, six hospital sites applied to be PD pilot sites in the study. The six pilot sites participating in the initiate are Vancouver General Hospital, BC, Winnipeg Health Sciences Centre, MB, Kelowna General Hospital, BC, Trillium Health Centre, ON, Joseph Brant Memorial Hospital, ON, and Toronto East General Hospital, ON.

The Canadian PD Project officially started September 30, 2009, at a two-day all-members kickoff in Toronto. Representatives from each of the six sites attended, and spent time learning about the PD process and developing skills in several PD tools such as Discovery and Action Dialogues (DADs) and improvisational theatre. The kickoff was a huge success, and everyone left the meeting feeling ready to go, with their own plans charted out for how to get started on PD when they returned to their home facility.

Currently, the sites are working hard at implementing PD in their facilities with the help of PD coaches, and through sharing their experiences with each other, project leads are learning more about the process. Several of the sites have already begun to talk about PD with their staff, and others are working on plans for how best to introduce PD in their setting. As the project continues, each site will be collecting data looking at both process measures and outcome measures. Check the website www.positivedeviance.ca for more information on PD, the project and the progress at the six pilot sites over the next 18 months of the project. Updates will be posted soon!

 Canadian Positive Deviance Project kick-off, September 2009  Canadian Positive Deviance Project kick-off, September 2009

   Canadian Positive Deviance Project kick-off, September 2009

A creative approach from the Winnipeg Health Sciences Centre

“I have all the routine practices in place that everyone is supposed to follow all the time, but people tell me that it’s too difficult to do in a busy day. They also don’t always believe that routine practices stop the spread of these infections.  ... Then, I saw this project using Positive Deviance as a tool to improve compliance, and I JUST KNEW that this was the right time for me to try this out.”
An except from the Winnipeg Health Sciences Centre application for the PD Pilot Project

The Health Sciences Centre in Winnipeg knew that Positive Deviance Pilot Project was something they really wanted to be part of, so they took an innovative approach to personify their facility in their request to participate. Their unique application took the form of a journal, written from the perspective of the facility telling all, “... to let you have a peek at some of my deep thoughts – some of it shamelessly emphasizes my attributes, but I’ll also let you have a look at my warts and wrinkles.”

The application included a self-rated Report Card and suggested reading list for infection prevention and control (IPC).  Take a look at their “tell-all” approach, supported by sources of information.

Report Card

NAME:  Health Sciences Centre Winnipeg
CLASS: Infection Prevention and Control (IPC)
GRADE:  B–
REMARKS: Not bad, but room for improvement!

We have noticed that you regularly deal with infections/colonization caused by methicillin resistant Staphylococcus aureus (MRSA), vancomycin resistant enterococcus (VRE), and Clostridium difficile. Rapid detection and aggressive intervention by your Infection Control Unit staff bring these under control. However, remember these bacteria can lead to serious problems and outbreaks.

Your work is very good, but your attitude is inconsistent.  We would like to see you apply yourself harder to this subject and do your best at all times.

Significant patient movement into and out of the facility as well as throughout the facility – between rooms in the same ward and between wards – presents challenges for you and needs to be worked on.

You have demonstrated continual vigilance for infection-related issues and concerns pertinent to antimicrobial resistant microorganisms, and implications to your healthcare facility and patients.

You have also demonstrated a commitment to your scientific/academic community with your extracurricular, published reports that share your experiences with:

  • MRSA on your Burn Unit1
  • Clostridium difficile disease with a unique strain of C. Difficile2,3
  • Spondylodiscitis in the dialysis units4
  • Your experience with MRSA5
  • Bed resource utilization and MRSA6
  • MRSA in your diabetic foot and complicated wound clinic7

We have included these reports in our IPC class suggested reading list.

I urge you to continue your participation in the Canadian Nosocomial Infection Surveillance Programme – this will help you be an active part of the cutting-edge of infection prevention and control.

Keep up the good work.  You have leadership potential – it’s time to take this to the next level!

IPC CLASS – Suggested Reading:

  1. Embil JM, McLeod JA, Al-Barrack AM, Thompson GM, Aoki FY, Witicki EJ, Stranc MF, Kabani AM, Nicoll DR, Nicolle LE. An Outbreak of Methicillin-resistant Staphylococcus aureus on a Burn Unit: Potential Role of Contaminated Hydrotherapy Equipment. Burns 2001; 27: 681-688.
  2. Al-Barrak A, Embil JM, Dyck B, Olekson K, Nicoll D, Alfa M, Kabani A. An Outbreak of Toxin-A Negative Clostridium difficile Associated Disease/Diarrhea in a Canadian Tertiary Care Centre. Can Dis Wkly Rep 1999; 25: 65-72
  3. Alfa MJ, Kabani A, Lyerly D, Moncrief S, Neville LM, Al-Barrak A, Harding GK, Dyck B, Olekson K, Embil JM. Characterization of a Toxin A-negative, Toxin B-Positive Strain of Clostridium difficile Responsible for a Nosocomial Outbreak of Clostridium difficile-Associated Diarrhea. J Clin Micorbiol 2000; 38: 2706-2714.
  4. Helewa RM, Embil JM, Boughen CG, Cheang M, Gopytan M, Zacharias JM, Trepman E. Risk Factors for Infectious Spondylodiscitis in Patients Receiving Hemodialysis. Infect Control Hosp Epidemiol 2008; 29: 567-71.
  5. Embil JM, Almuneff M, Nicoll D, Makki S, Cunningham G, Wylie J, Nicolle L. Memish AZ. Methicillin –resistant Staphylococcus aureus Profiles Oceans Apart – A Canadian and Saudi Arabian Experience.  J Chemother 2001; 13 (Supl1): 28-33.
  6. Cooper CL, Dyck B, Nicoll D, Olekson K, McLeod J, Nicole LE, Embil JM.  Bed Utilization in Inpatient Care of Patients with Methicillin-resistant Staphylococcus aureus (MRSA) in a Canadian Tertiary Care Centre. Infect Control Hosp Epidemiol 2002; 23: 483-484.
  7. Lagace-Wiens P, Ormiston D, Nicolle LE, Hilderman T, Embil J.  The Diabetic Foot Clinic: Not a Significant Source of Acquisition of Methicillin Resistant Staphylococcus aureus (MRSA) In Press AM J Infect Control Feb 23 2009 [Epub ahead of print]

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Canmore team goes the extra mile to combat spread of infection

 :  The Safer Healthcare Now! team at Canmore Hospital
The Safer Healthcare Now! team at Canmore Hospital show off some of their weapons in the battle against infections. From left, Marcy Kaminski, licensed practical nurse; Gwyneth Meyers, rural Infection Prevention and Control (IPC) practitioner; Nina Livesley, registered nurse and lead of the IPC; Lisa Lynch, IT Specialist; and Dave Bateman, Manager of Acute Care Services
Back in 2007, the Safer Healthcare Now! team at the Canmore Hospital in Canmore, Alberta noticed increasing incidents of MRSA – Methicillin Resistant Staphylococcus aureus – which causes skin and soft tissue infections and is resistant to some antibiotics, including penicillin. The team spent more than a year researching and gathering data, and discovered much of the MRSA was of the community-acquired variety.  This presented a challenge as the teaching and awareness needed to be cultivated for community members rather than hospital staff. The team began raising awareness in the hospital about MRSA, and registered nurse Nina Livesley, who leads Infection Prevention and Control at the Canmore Hospital, travelled to the Stoney Health Centre in Morley, 50 km east of Canmore to deliver the same information to healthcare providers at the Stoney First Nation.
 
This First Nations Health Centre is operated by the federal government, not Alberta Health Services, but that did not deter Livesley.  “We are a hospital, there are walls and this group extended past the walls,” says Livesley. “We saw that we needed to go further to address MRSA and we did.”

Dave Bateman, Manger of Acute Care Services at the Canmore Hospital says health professionals and community leaders in Morley were receptive to the message on how to prevent the spread of MRSA.  Educational sessions took place in the clinic, schools and the community itself, which is an example of true public health awareness.

The focus has since shifted from MRSA to pandemic mode.  Livesley says that the tools and information from Safer Healthcare Now! have been invaluable and were incorporated into their planning for H1N1 at Canmore Hospital.  She credits the Plan-Act-Study-Do (PDSA) cycle as a basis for how to get information out to educate staff on the H1N1 virus, and early qualification for the use and fit testing of N95 respirators.

With both MRSA and H1N1, Livesley first looked at the impacts and targeted the populations that would most likely be affected. To get information out, she developed a storyboard that she uses to educate hospital staff, housekeeping and Lodges in the community, knowing that H1N1 would have a huge implication on hospital admissions. “You don’t need elaborate tools to get the message across, and a storyboard is a very effective in providing visual impact to your presentation,” says Livesley.  And knowing that Aboriginal peoples are compromised due to overcrowding, poor nutrition, less disposable income and often a lack of water and sewer services, meetings are planned with the Chiefs to raise awareness and address their concerns.

While MRSA may not be as concerning at present, the Canmore Hospital staff is still focused on infection control.  The format used for their Safer Healthcare Now! project has translated itself into how they are approaching many issues such as IPC, H1N1 and even ongoing yearly certifications for staff.  In addition, Dave Bateman recently made a presentation about H1N1 to Human Resources leaders of the Fairmont Hotels.

“Our focus initially was to reduce incidents of MRSA, but Safer Healthcare Now! has formed the foundation to do so much more,” says Livesley.

This article was compiled with files from Chris Simnett, Alberta Health Services.  Photo courtesy of Alberta Health Services.

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Sustained reduction in healthcare associated MRSA at Toronto’s University Health Network

This story profiles the work of Dr. Michael Gardam, Intervention Lead for the Safer Healthcare Now! ARO/MRSA intervention, in reducing MRSA transmission at the University Health Network in Toronto, Ontario.

University Health NetworkThe University Health Network (UHN), comprised of three academic teaching hospitals, has seen a sustained reduction in healthcare associated MRSA colonization and infection over the past three years.  Despite admitting more patients colonized with MRSA than ever before, this reduction has occurred at all three sites, with the Toronto General, Toronto Western, and Princess Margaret hospitals respectively reporting 68 per cent, 25 per cent and 58 per cent lower rates compared with three years ago. Compared to several years ago when one admitted MRSA patient would result in on average two additional patients who acquired MRSA in hospital, currently four MRSA patients are now being admitted for every one case acquired in hospital.

The UHN decided to focus on MRSA transmission several years ago because of the impact it was having on patient morbidity and mortality as well as the impact on patient flow and discharges.  With the strong support of senior leadership including the Board of Directors, the UHN infection prevention and control team developed a new, improved control strategy to tackle the MRSA problem. Their success with controlling MRSA corresponds with the adoption of a universal admission surveillance program: essentially all patients who stay in the hospital overnight are now cultured for MRSA carriage.

It is hard to attribute all the success to this one intervention, as multiple strategies have been applied to decrease infection rates, including a roughly 50 per cent improvement in hand hygiene compliance; systematic use of patient MRSA decolonization/suppression using chlorhexidine and antibacterial ointment; point prevalence and discharge surveillance in high risk areas; improved housekeeping support; and the use of the hospital incident report system to alert management when patients develop MRSA infections or when infection control procedures are not followed. 

Over the past year the UHN has also been an active participant in an Indianapolis-based collaborative project using Positive Deviance to help decrease rates of MRSA and other superbugs even further.  Positive Deviance is a technique that enables front line staff to come up with and implement their ideas to control superbugs.  This technique has been studied in four US hospitals and has been shown to be very effective in decreasing MRSA infections. This project, along with the success in controlling MRSA has resulted in a big increase in frontline staff enthusiasm and interest in infection control.  Success is infectious: they are witnessing frontline staff taking increasing ownership for infection control issues. 

For more information on using Positive Deviance, please see www.positivedeviance.ca and www.plexusinstitute.org

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A new way of thinking at Vancouver General

The Safer Healthcare Now! team at British Columbia’s Vancouver General Hospital (VGH) is using Positive Deviance to gain compliance with hand hygiene.  Positive Deviance subscribes to the view, “it is easier to act your way into a new way of thinking than to think your way into a new way of acting.” Positive Deviance and Discovery and action Dialogue (DAD) bridges the gap between what people know and what they do.

 Melissa Crump
 Melisssa Crump
Melissa Crump, Registered Nurse and Patient Care Coordinator at the VGH says that their unit started with a discovery and action dialogue, an approach that emphasizes hands-on learning and focuses on actionable behaviours.  It started with a conversation on what are hospital-acquired infections and how to decrease them. Hand hygiene was one of the actions at the forefront, so they came up with strategies to help increase compliance. Things like more micro-san dispensers and positioning them in more visible places, but they also talked about their own surveillance – making sure that each other are compliant. 

“I think that a lot of the staff have successes or strategies that work for them, however, they just did not have the opportunity to share them,” says Melissa.  “It is clear, when they say, ‘have you tried this?, have you tried that?, or what will happen if we try this?’, that they are coming up with their own solutions.”

The challenge now is to keep the momentum going to sustain hand hygiene compliance.  Melissa reports that they meet every two weeks to discuss what has happened, review data and to share ideas.

“I found using Positive Deviance to be tremendously rewarding and a great learning experience,” says Melissa. “It makes a difference when you give people a voice in what is happening around them in their environment. Every time you deal with a discovery and action dialogue, you learn something new.  Spending time listening to your staff and giving them the tools and power to go forward with their ideas is a very rewarding process.”

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Canada's Hand Hygiene Campaign

Optimal hand hygiene practices are considered to be the most effective and efficient way to prevent or reduce morbidity and mortality associated with the incidences of healthcare associated infections across the world. It is believed that between 8,000 and 12,000 patients die each year in Canada as a result of healthcare associated infections.1  That translates to somewhere between 22 and 33 patient deaths per day, every day!  At any given time across the world, 1.4 million people are suffering from infections they acquired in hospitals.2  The contaminated hands of healthcare workers are believed to be the most common source of transmission and yet we know that compliance rates among healthcare workers in Canada and across the world are generally reported to be below 50 per cent.

Hand HygieneIn addition to a number of Safer Healthcare Now! interventions, the Canadian Patient Safety Institute has also developed a Hand Hygiene campaign that aligns with the work of the World Health Organization.  Teams from across Canada have enrolled in this campaign in an effort to increase compliance to hand hygiene practices that will improve patient safety by reducing the incidences of healthcare associated infections in their respective organizations. 

It's time to consolidate the various hand hygiene and infection control initiatives and campaigns across the country into a single, accessible, open, and interactive series of activities for healthcare professionals.  To accomplish this endeavor, the Canadian Patient Safety Institute has hired a consultant to provide recommendations and a comprehensive work plan to amalgamate these activities into a single process. 

Annamarie Fuchs is a Registered Nurse and a Management Consultant based out of Central Alberta with a background in Infection Control, Project Management and Regional Leadership.  She has more than 20 years in healthcare having led a number of large projects in the last several years for her former health region and most currently for Alberta Health Services.  Though already launched, the project will continue until March 2010.

Annamarie would love to hear about your experiences and perspectives around your participation in Canada's Hand Hygiene Campaign or other local hand hygiene improvement initiatives.  If you have stories of success in achieving compliance, sustaining your improvements, or other related ideas you'd like to share, send them to aafuchs1@shaw.ca or contact the Canadian Patient Safety Institute at 1-866-421-6933.

  1. Zoutman, D., Ford, B.D. Bryce, E., Gourdeau, M., Hebert, G., Henderson, E., & Paton, S. Canadian Hospital Epidemiology Committee, Canadian Nosocomial infection Surveillance Program, and Health Canada.
  2. WHO Information Sheet: 1 "Clean Care is Safe Care Challenge"

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Keep it fresh!

Using an innovative communication strategy

Healthcare acquired infections (HAI) impact hundreds of thousands of patients, caregivers and their families every year. Since the World Health Organization’s launch of Clean Care is Safer Care in 2005, more than 120 countries have pledged their support to reduce HAI. In Canada, both provincially and federally, hand hygiene has been recognized as a critical component to reduce HAI. For decades Infection Control Professionals have championed hand hygiene as the single most important method to control the spread of infection. Yet that means changing ingrained behaviour. Never an easy task when ultimate success rests with each individual to take on the responsibility to change, and to perform proper hand hygiene each and every time it is required.

To keep the importance of hand hygiene at the forefront for staff and the community, as well as to ensure sustained staff compliance to hand hygiene practices, Peterborough Regional Health Centre (PRHC) launched an innovative campaign. By partnering with an artist and a communications company, PRHC produced a comic book entitled, The Bug Stops Here! The comic book, detailing the importance of hand hygiene and raising the awareness of HAI was a way to tell a complicated story in a simple way.

The comic book was launched September 23, 2009 at PRHC. It attracted local and provincial media attention. Aside from detailing the role everyone has in reducing HAI, the comic also directly acknowledges that the hospital understands its responsibility and every day enormous efforts are being made to prevent these life threatening events.

Contributed by Margaret Jay, Infection Prevention & Control Lead at the PRHC. The Peterborough Regional Health Centre is one of over 1100 participants in Safer Healthcare Now!

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Giving a hand to Hand Hygiene

Increasing hand hygiene compliance rates in healthcare workers has been a challenge for years.  The healthcare agencies in the Waterloo Wellington area of Ontario, participants in Safer Healthcare Now!, were looking for new ways to tackle this issue, as well as using economies of scale in developing their Infection Control Week activities in each agency.

The hospitals and public health units partnered with the Waterloo Wellington Infection Control Network (WWICN) to develop a campaign to increase awareness of hand hygiene for everyone who entered any of the area hospitals during Infection Control Week 2008 -- patients, visitors, volunteers and staff. The planning group wanted the activity to be fun, to use strategies beyond traditional in-services and posters, and to be replicated and expanded to other settings within the next year.

This campaign was developed using basic community-based social marketing principles.  These principles are the use of one clear message, prompts to remind of the desired behaviour, signed commitments that are publicly displayed and personal interaction.

 At the start of the day – representatives from the hospital, public health, the Infection Control Network and other hospitals.
At the start of the day – representatives from the hospital, public health, the Infection Control Network and other hospitals.
A “tree” was erected in the lobby or other high traffic area of each of the area’s ten hospital sites for one day during Infection Control Week. The day started with the senior management team of each hospital signing a commitment and placing their “leaves/hands” on the tree to demonstrate to staff the importance of the activity.  A team of Infection Prevention and Control Professionals from the host hospital, public health, other hospitals and the WWICN was on hand to interact with passersby as they came to the hospital to work, seek treatment or visit loved ones.  As people entered the hospital, one of the team noted whether they used the alcohol-based hand rub to clean their hands.  Other members of the team would interact with each individual to discuss the importance of hand hygiene and invite them to sign a “leaf/hand” and post it on the tree where other passersby would see it. Each participant was offered a bottle of alcohol-based hand rub and a bookmark reminding them of their commitment to keeping hands clean.  Each hospital retained their “tree” to use again in hospital events such as orientation and skills fairs.

Lessons Learned

 A full tree only halfway through the day!
A full tree only halfway through the day!
There were a number of good lessons learned that have been incorporated into the program.  It is recommended that the location for this activity be chosen for the amount of traffic and the reason why people are there to ensure they have time to chat (e.g. in front of coffee shop, rather than in front of emergency department).  It is important to have a good key message and stick to it – a short “elevator pitch” as people don’t have time to listen to a long speech.  Language barriers and sensitive populations should be considered (if there were mental health clients – no alcohol-hand rub would be offered and careful use of the word “commitment”).  People are upset if you remove their hands if the tree gets too full, so have a contingency plan if the response is greater than expected.  Some physicians were “too busy” to stop, but others participated and then encouraged other MDs to do the same – it is a good idea to have a physician participate on the team

Using social marketing techniques resulted in a unique experience to promote hand hygiene in hospitals that was positively received by staff and passersby.  Many of the hospitals involved now have trees on their units so staff can have constant reminders of their commitments to hand hygiene.

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Québec Campaign receives Patient Safety Award

The Québec Campaign, “Ensemble, améliorons la prestation sécuritaire des soins de santé!” (“Together, Let’s Improve Healthcare Safety”), received ‘la mention d'honneur’ (honourable mention) in the Québec Health Ministry patient safety competition. This award, along with a $5,000 cheque, was presented at a ceremony held in Québec City in October 2009.

The Québec Campaign was established in 2005 by the CHUM to improve healthcare delivery and patient safety during the receipt of care. Some 46 acute and long-term healthcare organizations are enrolled in this campaign and are working towards the implementation of one or more of 10 strategies that are based on evidence and proven practice guidelines, that when applied, diminish the risk to patients and reduce the consequences associated with adverse events. More than 86 clinical interdisciplinary teams in Québec are involved in the campaign to improve patient care.  In August 2009, the Campaign offices were moved from the CHUM to the Jewish General Hospital (JGH).

For more information, view the Award video clip (in French only) that features: the Québec Node and includes interviews with Anne Lemay and My Lan Pham Dang; the JGH’s CEO Dr. Hartley Stern and Director of Nursing Lynne McVey; Chief of the JGH’s Critical Care Unit Dr. Denny Laporta, and the JGH’s  ICU.

The $5,000 award will be used to offset costs of an educational event for the participating Québec Campaign organizations.

Congratulations from all of your colleagues at Safer Healthcare Now!

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VTE Hospital Award

VTE Prevention Hospital Award established

Safer Healthcare Now! has established an award to recognize hospitals that have made a significant commitment to preventing venous thromboembolism (VTE) and have dedicated the necessary resources to achieve this goal. The VTE Prevention Hospital Award program will showcase the details of three hospitals’ improvement strategies and implementation plans to help other hospitals enhance their efforts to prevent VTE and its potentially fatal complications.

Any hospital in Canada that provides major general surgery and/or hip fracture surgery and is enrolled in Safer Healthcare Now! is eligible to apply for the VTE Prevention Hospital Award.
Three centres of excellence will be recognized in November 2010 during Canadian Patient Safety Week. All three hospitals will be recognized nationally in the Safer Healthcare Now! newsletter, as well as the website and VTE Community of Practice. Award recipients will receive an unrestricted educational grant of $5,800 to help support additional patient safety initiatives in their institutions.

The VTE Prevention Hospital Award is made possible through an educational grant from Pfizer Canada Inc.   For more information, visit the Safer Healthcare Now! website.

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Save the Date!

Canada's Forum on Patient Safety & Quality Improvement

Canada’s Forum on Patient Safety and Quality Improvement will take place April 12 to 14, 2010 at the Westin Harbour Castle in Toronto, Ontario.  The theme of the 2nd Annual forum is “Improving Safety across the Continuum”.  The 2010 Forum will bring together some of the best speakers from around the world including Jim Easton, a leader in change and system transformation from the UK; and Rahaf Harfoush, who used social media in the campaign that changed history for Barack Obama. Click here for more information

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Safer Healthcare Now! Pre-Conference

Safer Healthcare Now! Moving Forward with New Energy, a one-day pre-Forum Conference, will be held on Monday, April 12, 2010, from 9:00 am to 4:00 pm at the Harbour Castle in Toronto.  Further details will be posted on the Safer Healthcare Now! website.

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Safe Surgery Checklist

Launch of Safe Surgery Saves Lives Collective – Checklist Action Series

The goal of this new Safe Surgery Saves Lives Collective is to bring people together who are working to improve surgical safety in Canadian healthcare. The collective will consist of a number of projects on various surgical safety topics (Checklist, VTE and SSI). The Checklist Action Series is the first program to be launched as part of the new Collective. It is a three-month virtual initiative offered at no cost for Canadian surgical programs, teams and individuals to assist with effective implementation of a surgical checklist. The Checklist Action Series will be offered in a number of “waves” if there is enough interest. Click here for more information

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