IMPORTANT READING E-mail updates raised accountability and got everyone's competitive juices flowing.

For many years, the battle we'd fought against a superbug that had taken up residence in our facility seemed destined to end in a draw. Our infection rates weren't getting worse, but they weren't getting better, either. We'd taken aim with patient-screening tests and isolation, we'd counterpunched with hand-hygiene interventions, we'd thrown hooks and haymakers like surface sampling and multidisciplinary meetings — but the resilient multi-drug resistant organism known as Acinetobacter baumannii wouldn't stay down.

Until, that is, we found a new secret weapon: e-mail. That's right. Mass-distribution missives were what finally gave us the upper hand. We haven't knocked the nuisance out yet, but we finally have it on the ropes.

Four key dynamics
Sending e-mail to a large distribution list made sense from a purely practical standpoint. Ours is such a large facility, it was hard to track down everybody I needed to update every week about the status of our interventions. But the mass communication also put several other key dynamics in motion. Those were what ultimately made the difference.

• Peer pressure. The distribution list included the C-suite, and every e-mail that went out included not just the number of new cases per unit and a comparison of units, but also the findings of environmental cleaning, of environmental cultures, of hand hygiene, of hand cultures, of all the interventions we were trying to employ at the time. Everyone was under the microscope and nobody wanted to be seen as the worst. People were keenly aware that top management was being kept informed and that the executives understood that it was a problem that could be corrected with the right measures. All of that added up to a healthy dose of peer pressure.
• Engagement. Before I started sending out the e-mails, there was a lot of discussion about the kinds of steps we needed to be taking. But people weren't fully engaged. For the interventions we were trying to implement to be fully effective, people needed to be engaged enough to do them consistently, as opposed to discussing them a lot and actually doing them only periodically.

• Accountability. By providing greater visibility, the e-mail made people and units more accountable. Until then, the problem could be seen as a facility-wide issue, and it was easier for individual units to escape scrutiny. But when we broke the information down into smaller segments, individuals could be called upon to explain why the problem seemed especially acute in their areas.
• Leadership. Units are sometimes driven enough to acknowledge problems and seek out solutions on their own, but in most situations that doesn't happen. It's important for leadership to be very clear about what they're expecting. Once leadership was in the loop and fully engaged, they made it clear to the providers that they considered infections in general, and this bacteria in particular, a problem — and that they expected behavioral changes and interventions that would appropriately address it.

Will they open the e-mails?
Of course, when I started sending the e-mails, there was no guarantee that people would read them. So getting right to the point was important. I started each with the number of infections that had developed since the previous update and the number of new cases in each unit. The fact that we were comparing findings in different units was a strong motivator for people to look at the e-mail. I also included maps of the units, illustrating where we'd found the bacteria. One of the problems with bacteria is that they can't be seen. The maps made the issue less abstract and more tangible.

Over time, we began to discern and discuss other issues. Shared objects, for example. It's very common for nurses to carry scissors around with them to open bandages. That needed to stop, because the bandages and the body surfaces the scissors touched were contaminating the scissors.

We addressed one thing at a time, depending on the findings from the previous week. The next week it might have been terminal cleaning, or something having to do with another type of equipment. Some weeks we just included reminders — that wearing gloves doesn't eliminate the need for hand hygiene, for example.

The improvement didn't happen overnight, but we finally begin to win the war: Over a 2-year period, the incidence of new cases declined from 5.13 per 10,000 patient days to 1.93, a 62% improvement. It all started with improved communication — in this case, figuring out how to more effectively communicate on a large scale. But I think our story illustrates that top-notch communication is something to keep in mind no matter how many people you're working with.

QUICK TURNOVER
Pain Management Packs

PRE-PACKAGED Pre-pack a blanket and gown with a filled bouffant hat.

To quickly turn over our pain management patients, our night shift assembles supply packs for the next day's patients.

• Take a bouffant hat and fill it with EKG pads, booties, a patient belonging bag and oxygen tubing.
• Place the filled bouffant hat inside a blanket that includes a patient gown.
• Place the pack on the clean beds, ready for the next patient.

Jenn Hiester, RN, BSN, CNOR, RNFA
Bluffton (Ohio) Hospital
[email protected]