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of the guidelines included crossing subspecialty lines and buildingcohesiveness among the stakeholders. During this process it wasdiscovered that a regional pharmacy home care program had devel-opedguidelines forethanol lockprophylaxisusenot consistent for thepediatric patient population. Two pediatric home care patients hadrecurring thrombus in their lines. After sharing the guidelines bothpatients have gone six months without a thrombus.RESULTS: Raw data indicates adoption of the guidelines for linesalvaging and prophylaxis treatment. Currently, prophylactic treat-ment hasbeen initiated for 4 patientswith1month and3monthdataindicating 0 recurring CLABSIs. Line salvaging indicated 90% successrate. The team will continue to monitor results and to evaluate theusefulness of the guidelines with different patient populations.LESSON LEARNED: The concentration of ethanol delivered wasa concern for practitioners and needed to be addressed early andaccurately to overcome negative perceptions. Development of anethanol lock algorithmwould have assisted with the administrationprocedure. Early identification of the appropriate facility committeesand approval processes would have facilitated quicker adoption.

Presentation Number 9-439Impact and Results of Automated Hand HygieneCompliance Monitoring

Susan Blumstein MT, CIC, CPHQ, Manager, Infection Prevention,Shelby Baptist Medical Center

ISSUE: Hand hygiene (HH) improvement programs have beeninstituted at most acute care hospitals with limited long-termsuccess. Regulatory agencies as well as the World Health Organi-zation (WHO) recommend instituting programs which emphasizepatient safety to ultimately lead to sustainable quality improve-ment. However, hand hygiene compliance monitoring methods,such as periodic surveillance, self-reporting, and aggregate volumemeasurements, are often inaccurate and hard to implement. Highlevels of sustained hand hygiene compliance are elusive inhealthcare facilities around the world.PROJECT: A 35-bed intermediate care unit of a 242-bed acute carehospital studied the impact of an automated HH monitoring tech-nology on compliance rates and hand hygiene solution dispensingrates fromMay 2011 to Febraury 2013. Employees (w76) of the unitparticipated in the program by wearing radio-frequency identifi-cation (RFID) tags which were utilized to monitor HH compliance.Opportunities for HH were determined by sensing the RFID-taggedcaregiver’s entry and exit of the patient room. HH compliance wasconfirmed by the caregiver’s activation of a sensor within thedispenser when accessing solution for hand hygiene. No workflowchanges were needed to measure HH compliance, and automatedsurveillance occurred 24 hours a day, 7 days a week. All Soap andsanitizer dispensers on the unit were included in the dispensingand compliance measures.RESULTS: At the 22-month mark of the HH monitoring program,dispensing increased 173.9%, from 23,559 total dispenses (May 2011)to 64,539 total dispenses (February 2013). Compliance, measured byhand hygiene upon entry into and exit from patient rooms, hadincreased291.3%(from19.99% inMay2011to78.22% inFebruary2013).LESSON LEARNED: Adherence to HH standards increases whencompliance is monitored and then reviewed by leadership. The useof an automated HHmonitoring technologyhad a significant impacton the target unit’s hand hygiene solution dispensing and overallcompliance.

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Presentation Number 9-440Utilizing a Lean Six Sigma Approach to Reduce TotalJoint Arthroplasty Surgical Site Infections ina Community Hospital

Angela D. Dickson BSN, RN, CIC, Infection Preventionist,PeaceHealth, St John Medical Center

ISSUE: Total Joint Arthroplasty (TJA) Surgical Site Infections (SSI) hasbeen on the rise since mid 2010, three times higher than state andnational averages.SurgicalCare ImprovementProject (SCIP)measureswere consistentlyhigh.Chlorhexidine clothbathing, antibioticweightbased and redosing, screening and decolonization protocols wereimplemented. Despite these interventions, rates remained highindicating a new problem solving approach was warranted.

PROJECT: Lean Six Sigma (LSS) in healthcare seeks to improvequality and efficiency of processes by identifying and removingcauses of defects, decrease waste, and minimize variability throughdefined sequence of phases. These phases include: define, measure,analyze, improve, and control. In early 2011, a LSS team was char-teredwith endorsement from executive level stakeholders. The goalof the team was to reduce TJA SSI to at or below state and nationallevels. The teamutilized LSS strategies and tools to observe andmapcurrent state, identify data needs, analyze data; develop theory,identify root causes, develop solutions; define, implement, observefuture state; and create a control planwithprojectmetrics. Final rootcauses were gaps in horizontal infection prevention, technique, andpatient preoperative optimization. Final list of improvements forhorizontal infection prevention were hand hygiene, right disinfec-tant used properly, switch to microfiber cleaning cloths, cleaninghigh touch surfaces between cases, taking items dropped on floorout of service, skin prep, and proper use of personal protective

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equipment. Medical staff office dealt with technique issues. Patientpreoperative optimization included patient referrals and not doingelective TJA on patients with BMI >/¼ 40.

RESULTS: Project metrics were Standardized Infection Ratio (SIR) forexternal comparisons and SSI rate and % BMI >/¼ 40 for internalcomparison. First half of 2011 was baseline and first half of 2012 wascontrol phase. SIRwent from 3.3 to 1.8, a 46% reduction and no longerstatistically significant (chart 1). SSI rate went from 4.07 to 1.93, p-value 0.1456 and a 53% reduction (chart 2). Elective cases with a BMI>/¼ 40 went from 24% to 10%, p-value 0.001139 and a 71% reduction(chart 3). Utilizing case cost of $50,000, an estimated $300,000 savingswas calculated. Next steps are metrics reporting, routine IP rounding,case review with frontline staff, glucose control, and alternativestrategies. Second half of 2012 is showing sustainability of efforts.

LESSON LEARNED: A team approach cannot be underestimated.Executive stakeholder support is extremely important to projectsuccess. Next steps help with ongoing sustainability.

Presentation Number 9-441Impact of an Automated Hand Hygiene MonitoringTechnology on Hand Hygiene Compliance andInfection Rates

Lisa H. Moore RN, CPHRM, Director, Risk Management, InfectionPrevention, Patient Relations, Baptist Memorial Hospital -Memphis

ISSUE: Faced with the challenges of improving and sustaining handhygiene compliance through conventional means, increasingregulatory requirements and a desire to improve patient safety,Baptist Memorial Hospital Memphis made the decision to evaluatean automated hand hygiene monitoring system. Improvements inaggregate and individual hand hygiene rates were achieved only

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after the technology had earned clear executive support, visibleleadership involvement, goal setting and a caregiver awareness/engagement campaign including individual accountability andtransparency with posted weekly reports.PROJECT: Baptist Memorial Hospital Memphis (BMHM) workedwith a vendor to install wireless hand hygiene monitoring systemin the 12-bed Organ Transplant unit. Dispenses from 26 soapdispensers, 22 alcohol based hand rub (sanitizer) dispensers and 49employees including Nurses, Patient Care Assistants, Unit Clerks,etc. were monitored. Hand hygiene solution dispensing, handhygiene compliance and HAI rates were measured and reportedfrom March 2012 through October 2012.RESULTS: The Organ Transplant unit experienced increases in soapand alcohol based hand rub dispenses after the technology installa-tion. During the first fourmonths of service, therewas a 36% increasein soap dispensing, a 61.5% increase in sanitizer dispensing, anda41.3% increase in totalhandhygiene solutiondispensing.Despite theincrease inhandcleansing, for the same timeperiod therewas a16.2%decrease in hand hygiene compliance. In July 2012, Leadershipinvolvement was apparent, unit level goals were set, employeeeducation initiated, and the accountability campaign “kicked-off”.Following this reenergizing, there was a reported 62.9% increase insanitizer dispensing, and a 42.9% increase in total hand hygienesolution dispensing and a 65.9% improvement in hand hygienecompliance. During this same time frame, individual hand hygienecompliance rate increases for SolidOrganTransplant employeeswerestatistically significant (Student’s t-test, p<.0001, 95% CI 0.07708 -0.16094).Whencomparingfirst and lastmonthsof theproject (March2012-October 2012) hand hygiene solution dispensing increased by72.4%, and hand hygiene compliance rates increased by 35.3%.Ventilator-associated pneumonia, central line-associated blood-stream infection, and catheter-associated urinary tract infection rateswere decreased by 5.2%, 66.2% and 72.3% respectively. These reduc-tions equated to an associated cost savings of greater than $300,000.LESSON LEARNED: � Executive Leadership involvement andsupport� Communication of results and individual accountability� Clear, attainable goals and celebration of small successes� Compliance results in improved clinical and financial outcomes.

Presentation Number 9-442A Collaborative Innovative Approach to HandHygiene: Tackling Contaminated Hands ofHealthcare Providers and Patients

Janet Pate JD, MHA, BSN, RN, Director, Infection Prevention,University of Alabama Kirklin Clinic; J. Hudson Garrett Jr. PhD,MSN, MPH, FNP, VA-BC, Senior Director, Clinical Affairs, PDI

ISSUE: Hand Hygiene has beenwidely recognized as the single mostimportant intervention to breaking the chain of infection trans-mission. In the Ambulatory Care setting,many patients havemultipleappointmentswith various healthcare providers inmultiple clinics inthe same day, and the risk for transmission between the patient andsurfaces within each clinic is high. Community pathogens can beeasily introduced into the facility by the contaminated hands ofpatients entering the facility. The currently used alcohol-based gelsdriedout thehandsof thehealthcareproviders, aswell asdidnot fullyremove soil from the surfaces of contaminated hands.PROJECT: After a full facility assessment was conducted identifyingkey locations for hand hygiene stations, as well as a careful review

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