Step off the elevator on the eighth floor of Pavilion K at the Jewish General Hospital, and you’re greeted with the news: posted on the wall of the lobby are the unsurpassed results by K8 staff in practicing proper hand hygiene. The size and appearance of the flyer may be modest, but its implications are enormous.
“The team on this unit is so meticulous, it’s little wonder that their hand hygiene compliance is exceptional,” says former Associate Nursing Director Anna Pevreal. “On K8, there is no room for error.”
Two acute care patient populations, one unit…
The post-surgical team had barely moved to Pav K when in the spring of 2016, any medical patient testing positive for CRO who was not in the ICU, was placed on their unit. Eight beds—one quarter of the 32-bed floor—would be reserved for patients with the highly antibiotic-resistant bacterial infection, forming a CRO grouping, or cohort.
“It was a big challenge for us, we were not as yet used to our new environment,” says Head Nurse Mona Abou Sader. Ms. Pevreal explains that the team has a high level of expertise within their own specialty of post surgery, responsible for patients who had undergone head and neck, thoracic or vascular surgery. This specialty alone, she adds, serves a particularly complex patient profile.
“Our training and experience was in caring for patients recovering from complex surgeries, whose post-operative care is challenging, with many potential complications,” says Ms. Abou Sader. “Patients often emerge from these big surgeries unable to talk. Others, particularly the vascular patients, have other conditions as well, such as diabetes, and may have heart or breathing problems.”
The CRO cohort, however, is largely composed of medically sick patients, who require a different kind of highly specialized care. “The K8 nurses were now responsible for specialties outside their expertise, from cardiology, neurology and oncology to geriatrics, family medicine, and many others,” notes Adila Zahir, a Clinical Nurse Specialist in Infection Prevention and Control (IPAC). “We had never worked in this kind of unit,” says Ms. About-Sader. “We set about the identifying needs of this new clientele, such as dedicated equipment for medical patients. So we brought in EKGs, Dopplers, bladder scans and lifts for the cohort. Also, my nurses started to build professional trusting relationships with the medical and multidisiplinary teams within different specialties than we were used to.”
Another difficulty faced by the K8 team was the susceptibility of the post-surgical patients to infection. “The staff had to learn new levels of infection-prevention precautions to be able to protect this extremely vulnerable patient population,” says Ms. Pevreal. “Every measure had to be followed with extreme diligence to safeguard against the transmission of CRO, be it swabbing for each admission and discharge, proper degowning and regowning, hand hygiene observance, and caution when taking anything from one room to another. They also had to educate the patients’ family members and visitors, who came in and out of patient rooms willy nilly.”
… zero transmissions
Beyond the risk of CRO spreading from the cohort to the post-surgical patients, there was also the danger within the cohort of cross-contamination, of infecting a CRO-positive patient with a different strain of the bacteria. The K8 team grasped the gravity of this threat, and so from the very earliest stages called on the Infection Prevention and Control team for training and guidance. “This unit is very intensive. The team took to heart and understood the seriousness of implementing safety measures to keep the cohort going,” attests IPAC Nursing Consultant Lara Maalouf.
“From the beginning, we realized that we needed to instantly enforce infection prevention measures with everyone, including visitors,” says Ms. Abou Sader. “At one time we even had a patient with dementia who wandered, and we would take turns following him, cleaning whatever he touched. It became clear that in addition to isolating the CRO group, we required a security agent stationed at the access to the cohort area, watching all who entered and exited.”
With the support of Infectious Diseases Specialist Dr. Yves Longtin and the IPAC team, as well as multidisciplinary input from Physiotherapy, Radiology and Pharmacy, the K8 nurses created a detailed protocol to minimize the risk of contamination. It addresses, among other pertinent infection prevention procedures:
• When to perform hand hygiene
• When to put on a gown
• What to do with personal belongings of visitors
• The safe use of lab coats, and equipment such as stethoscopes
• The disinfection of all equipment used within the cohort
“We also had to come up with some creative solutions, together with IPAC, to limit transmission,” says Ms. About Sader. These include disposable gowns for the nurses while working in the CRO area, as well as additional scrubs that are cleaned in house instead of brought home. To address the team’s concern about the possibility of the pathogen spreading through dust particles, the infection prevention team came up with the idea of sticky mats placed at the exit of the cohort. These mats trap any loose particles on the floor and from the bottom of any traffic coming through such as shoes, canes, stretchers or wheelchairs.
“You see how proactive this team is, they’ve collaborated with us closely and worked so hard,” says Ms. Maalouf. “They’re also curious and understand the importance of education. They request in-services of small teaching sessions specifically relating to the cohort from our infection-prevention specialists on an ongoing basis. In addition, the team conducts regular rounds and audits to ensure the safest possible quality care is provided. Everyone—the nurses, PABs, security, housekeeping—they all uphold the high standard in this hospital by being familiar with the details, with the breaches, and how to remedy these. The IPAC team appreciate their work enormously.”
And the result? “There has not been a single transmission between the cohort and post-surgical patients, not even any cross contamination between CRO patients,” reports Ms. Pevreal. “What’s more, the number of patients with CRO during period 11 of last year was 37, while this year it stands at 19. That’s a 50 per cent drop. It’s an astonishing achievement by this incredibly dedicated team, one of which the whole hospital can be proud, and from which the whole medical establishment can learn.”
‘Making miracles’… together
The success of the team isn’t only reflected in numbers, but in its people.
“After 13 years here, I can adapt to very heavy demands, IV medications, turning positions, incontinence,” says K8 Nurse Clinician Yvette Duhaney. “I’m also always here to encourage our younger nurses, to help manage the pressure. The key is to be highly organized and never hesitate to ask for help. Our team comes together, we don’t work in isolation, we share when times are tough. On K8 you can’t drown, because there’s always someone to save you when it becomes very heavy.”
Ms. Duhaney says it also helps to manage the demands of the unit by, when appropriate, “keeping it light with patients.” When the CRO patients were first introduced to K8, she concedes, “I was scared initially. But you adapt, you become more vigilant and alert, and learn what steps to take to protect yourself.”
A graph shows how meticulously infection prevention precautions such as hand hygiene and gowning are recorded, and how frequently these practices are performed within the K8 CRO cohort.
Ms. Duhaney’s colleague Maria Caryl Tabanay, a Nurse on the unit for a decade, agrees, “it was hard at first. Having to perform the hand hygiene and gowning precautions takes a lot of time, as we go back and forth, in and out of the patient rooms and the cohort area. But we got reminders from IPAC, and were careful to introduce younger nurses in baby steps with senior nurses, to keep it balanced. How were we able to control CRO? The team has good judgment and critical thinking and of course, support from Mona. We are a family.” Annella Patricia Adams, who has worked as a PAB “dedicated exclusively to the cohort for a year, echoes the sentiment. “I love it here, it’s home.”
“K8 is our second home,” says Ms. Abou Sader. She remarks that this “strong feeling of belonging” reflects her team’s cohesiveness. “They support and encourage each other. I can’t make miracles alone! When you consider that we had so little to work with, and if you count how many times a day we gown, remove our gown and gloves, do our hand hygiene…. But even though it’s been a big challenge, we took the challenge with brio. They gave everything they have, applying their nursing knowledge and professionalism. They wanted this project to be a success, so they made this project a success!”
Follow the leader
Ms. Zahir considers that success even more noteworthy, given that the unit continues to receive all CRO-positive patients apart from those sent to the ICU. “Thanks to their teamwork and culture of diligence, they know how to control CRO the best. They advise each other and speak for IPAC at all times, they’re even trained well enough that they can train others. They are the IPAC champions.”
“This exemplary collaboration and constant attention to detail are evident in the outstanding achievements of the K8 team in preventing the spread of infection,” declares Dr. Lawrence Rosenberg, President and CEO of CIUSSS West-Central Montreal. “These outcomes reflect our CIUSSS’s priority of safeguarding the well-being of our patients and other healthcare users at every step in their journey through our facilities.”
That infection prevention savvy is not only practiced and shared on the unit, agree the IPAC team. Thanks to the strong leadership of Ms. Abou Sader, it extends well beyond her floor. “Mona is rigorous, for her, there are no half measures. She on top of her team, she follows up with them and with us, as well as with the CIUSSS administration,” says Ms. Maalouf. “Mona inspires others, and has become a consultant to all other managers, and even other facilities. Her cohort example is applied to Catherine Booth, to the Richardson, and to Mount Sinai. Her work has not only helped the whole hospital to reduce CRO cases, but in fact the whole CIUSSS.”