1. Grady Health SystemInfection Prevention & Control August 13, 2014 Mary Cole, RN, MSN, CIC

2. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

3. CLABSI Prevention Activities • Feb. 2011 Insertion bundle, CHG dressing, standardized carts, unit audits • March 2011 Unit based CVC Champions • May 2011 Cross audits to other areas • July 2011 Enhanced MD education, credentialed after CBL, proctored insertions • Sept. 2011 alcohol port protectors SICU Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

4. CLABSI Prevention Activities, cont. • Oct 2011 Alcohol port protectors MICU • Nov. 2011 Alcohol port protectors Med/Surg • Feb. 2012 CUSP MICU/SICU • June 2012 Alcohol port protectors ED/Radiology, blood culture collection limited to phlebotomy (ED and in-patient)

5. CLABSI Prevention Activities, cont. • March 2013 needle free adaptors and alcohol port protectors for vascath (dialysis) • April 2013 CUSP for Burns, Neuro, and Intermediate Care • July 2013 PICC Team (nurses) at bedside • Oct 2013 Neutral valve for IV ports to prevent backflow

6. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

7. CAUTI Prevention Activities • Upgraded foley tray & added securement device • CAUTI Champions, monthly meetings and conduct RCAs • Purchased additional bladder scanners to decrease re-insertion of foleys • Regular agenda item for CUSP teams Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

8. CAUTI Prevention Activities, cont. • On-going work with ED and OR to decrease foley usage • Nurse driven foley removal protocol • Increased various sizes of condom caths • MD and nurse daily justification in EMR • Infection Prevention & Nursing conduct weekly audit of bundle compliance with report to Executive Leadership

9. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

10. SSI Prevention Activities • SUSP team with Executive Leadership • SSI surveillance all COLO,HYST, CARDS, CABG, FUSN, HIPS, KNEES • IP presence in OR, monitoring a minimum of 4 procedures per week for HYST/Colon. Findings are reviewed in SUSP • RCA completion for all SSIs by OR, MDs, reviewed in SUSP. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

11. SSI Prevention Activities, cont. • Mandatory training of all staff and MDs on surgical site prep • CHG bath night before and morning of surgery in addition to nasal and oral prep for all surgeries below the neck, track compliance • Work with IT to add this to pre-op orders • Currently working to isolate separate instruments for skin closure for COLO and HYST

12. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

13. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

14. CRE Prevention Activities • MDRO designation in header of EMR • Orange bracelet on MDRO patients • IP receives E mail alert MDRO lab identification • MDRO admissions are followed daily by IP • EVS reports quarterly to ICC on ATP monitoring and UV disinfecting activities • Participated in recent CRE collaborative with GA DPH and CDC. Prepared by a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

15. Essentials to success • Active involvement from Executive leaders, MDs, and front-line staff • Partnership with IT • Partnership with EVS • Be persistent!

16. Questions? Thank you