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Hospital-wide Initiative Takes Aim at Hospital Acquired Infections

Engaging staff from all levels of an organization to focus on one key initiative can seem like a monumental task, regardless of the size and scope of the organization. This was the challenge as El Camino Hospital embarked on its journey last year to reduce Hospital Acquired Infections (HAI), a leading cause of unexpected death for hospital patients across the nation.

The El Camino HAI Reduction teams achieved, and in some cases, surpassed its hospital infection reduction goals and the processes put into place in 2018 continue to be refined as time goes on for even further improvement.

In honor of Hospital Week, there is no better time to recognize the El Camino HAI Reduction teams. Under the direction of Dr. Mark Adams, chief medical officer, and Catherine Carson, RN, chief quality officer, four multi-disciplinary teams, which spanned nursing, doctors, quality, education, environmental services, IT and other ancillary service groups, addressed the issue head on. All while making sure to keep patient care at the forefront whenever a process was modified or a new protocol was implemented.

The four teams took a lean performance approach to improve hand hygiene and reduce HAIs in three key areas: catheter-associated urinary tract infections (CAUTIs); central line-associated blood stream infections (CLABSIs); and Clostridium difficile (C. diff) infections. This hospital-wide initiative involved the use of process maps, constant feedback on results and data analysis to implement a plan of action for each challenge the team encountered. It was a focused plan, communicated well and with strict implementation that produced positive results, including: a 29% reduction in the use of Foley catheters, expansion of the use of UV disinfection, adoption of best practices, development of core competencies, and improvement of critical hygienic protocols for the prevention of HAIs.

“The success of this initiative was due to a team approach that involved everyone in the hospital across all disciplines. A key driver was the incentive put in place to reward everyone for meeting the goals. We made changes incrementally and built upon them, taking one process at a time, identifying best practices and testing them before implementing them on a broader basis,” said Catherine Carson.

The team agrees that the success of the work was the involvement of the front-line clinical staff in identifying issues and barriers, as well as the fact that the entire hospital took ownership of each HAI and worked to identify its cause and determine a process to address it and prevent a similar situation from occurring in the future.

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