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Background Hand hygiene (HH) compliance in health care is usually measured against versions of the World Health Organization's “Your 5 Moments” guidelines using direct observation. Such techniques result in small samples that are influenced by the presence of an observer. This study demonstrates that continuous electronic monitoring of individuals can overcome these limitations. Methods An electronic real-time prompting system collected HH data on a musculoskeletal rehabilitation unit for 12 weeks between October 2016 and October 2017. Aggregate and professional group scores and the distributions of individuals’ performance within groups were analyzed. Soiled utility room exits were monitored and compared with performance at patient rooms. Duration of patient room visits and the number of consecutive missed opportunities were calculated. Results Overall, 76,130 patient room and 1,448 soiled utility room HH opportunities were recorded from 98 health care professionals. Aggregate unit performance for patient and soiled utility rooms were both 67%, although individual compliance varied greatly. The number of hand wash events that occurred while inside patient rooms increased with longer visits, whereas HH performance at patient room exit decreased. Eighty-three percent of missed HH opportunities occurred as part of a series of missed events, not in isolation. Conclusions Continuous collection of HH data that includes temporal, spatial, and personnel details provides information on actual HH practices, whereas direct observation or dispenser counts show only aggregate trends.

Background The COVID-19 outbreak has highlighted the role of hospital-acquired infections in spreading epidemics. Adequately cleaning surfaces in patient rooms is an essential part of this fight to reduce the spread. Traditional audits, however, are insufficient. This study assesses surface cleaning practices using ultravoilet (UV) marker technology and the extent to which this technology can help improve cleaning audits and practices. Methods One hundred and forty-four audits (1,235 surfaces) were retrieved. UV-marker cleaning audits conducted at a major teaching hospital in 2018 after implementing a new cleaning protocol. In addition, semi-structured interviews were conducted with cleaning staff and supervisors. Results On average, 63% of surfaces were appropriately cleaned. Toilet handles (80%) and toilet seats underside (83%) scored highest while main room sink fixtures (54%), light switch (55%), and bedrails (56%) scored lowest. Training, staffing and time constraints may play a role in low cleaning rates. Discussion The high-touch patient surfaces in the bedroom remain neglected and a potential source of infections. UV marker audits provided an objective measure of cleaning practices that managers and staff were unaware of. Conclusions UV-markers audits can play a key role in revealing deficiencies in cleaning practices and help in raising awareness of these deficiencies and improving cleaning practices.

Background Environmental service workers may be exposed to pathogens during the cleaning of pathogen-containing bodily fluids. Methods Participants with experience cleaning hospital environments were asked to clean simulated, fluorescein-containing vomitus using normal practices in a simulated patient room. Fluorescein was visualized in the environment and on participants under black lights. Fluorescein was quantitatively measured on the floor, in the air, and on gloves and shoe covers. Results In all 21 trials involving 7 participants, fluorescein was found on the floor after cleaning and on participants' gloves. Lower levels of floor contamination were associated with the use of towels to remove bulk fluid (ρ = −0.56, P = .01). Glove contamination was not associated with the number or frequency of contacts with environmental surfaces, suggesting contamination occurs with specific events, such as picking up contaminated towels. Fluorescein contamination on shoe covers was measured in 19 trials. Fluorescein was not observed on participants' facial personal protective equipment, if worn, or faces. Contamination on other body parts, primarily the legs, was observed in 8 trials. Fluorescein was infrequently quantified in the air. Conclusions Using towels to remove bulk fluid prior to mopping is part of the recommended cleaning protocol and should be used to minimize residual contamination. Contamination on shoes and the floor may serve as reservoirs for pathogens.

Background Hand hygiene compliance (HHC) among healthcare workers (HCWs) remains suboptimal. Hand hygiene (HH) among HCWs is regarded one of the most effective measures to reduce healthcare-associated infections. We aimed to evaluate HH improvement in HCWs using an automated monitoring system to provide systematic feedback on staff HHC. Methods A prospective observational study was conducted in a Danish medical hospital ward (23 beds) between February-November 2020. Sensors were placed on alcohol-based sanitizers, HCW name tags, and patient beds. The sensors measured HH opportunities and sanitizations to be able to provide compliance feedback to staff groups and individuals. Baseline data were obtained before the reporting of feedback data. HCWs were grouped as caregivers (n=58) and doctors (n=18). Rooms were classified by type e.g., medication room and patient room. Overall data was regularly presented to the staff group and subgroups, caregivers, and doctors. Student's t-test was used for comparisons. A two-tailed value of p Results Baseline was performed twice (at weeks 4 and 5 because the COVID19 pandemic interrupted the study for a period). Both baselines showed similar initial compliance among HCW. Baseline HHC was lowest before patient contact (BPC) compared to after patient contact (APC) for both the doctors (16% vs. 26%) and the nurses (22% vs. 39%). Once data were shown and feedback provided, both the doctors (BPC: 16% vs. 24%, p=0.014; APC: 26% vs. 35% p=0.059) and caregivers (BPC: 22% vs. 37%, p Conclusions Feedback data from the automated hand hygiene monitoring system helped the HCWs to improve their HHC significantly.

Background The purpose of this study was to examine prevalence of environmental methicillin-resistant Staphylococcus aureus (MRSA) in a newly constructed children's outpatient clinic. Viable MRSA on floors and select surfaces in waiting areas and two medical units were compared for the last 3 months of construction through the first 6 months of occupation. Methods A total of 52 locations were swabbed weekly, including common areas (floors at check-in desks, waiting rooms, and on children's toys), and on patient room floors, counters, and return air ducts in pulmonary and general medicine units (3 rooms tested in each). Testing was performed during the last 3 months of construction (October-December 2018), and the first 6 months after opening (January - June 2019). HardyCHROM MRSA selective and differential agar media was used to identify viable MRSA. Results In common areas, during construction we observed 4/80 (5%) positive swabs for MRSA. After occupation, 72 /208 (35%) positive swabs for MRSA were found in the common areas. In pulmonary unit rooms during construction we observed 3/60 (5%) positive samples for MRSA, and 52/234 (22%) positive samples for MRSA after occupation (p Conclusions This study shows the rapid colonization of the clinical environment with MRSA within the first 6 months of opening of a children's outpatient clinic. The potential link between environmental bacteria and healthcare-associated infections is an important area of research in infectious disease, particularly for outpatient clinics, requiring monitoring studies such as this.

Background Acinetobacter is an important opportunistic pathogen causing healthcare-associated infections and outbreaks in burn patients. The healthcare environment can be persistently contaminated despite routine room cleaning/disinfection and recontaminated via healthcare personnel and patients. The aim of this study was to investigate the microbial burden on patient room environment in burn units and assess how much environmental sites become recontaminated with Acinetobacter over time after cleaning/disinfection. Methods This study was conducted in burn units of an academic hospital. A baseline of the amount of contamination were evaluated by sampling six environmental sites (i.e., chair, bed rail, overbed table, supply cart, stock cabinet, IV pump, and monitor) with Rodac plates in four rooms housing patients with Acinetobacter infection/colonization. After cleaning/disinfection, samples were taken from those sites at 1-hour intervals for ten hours. Two Rodac plates were collected at each site, and total colony forming units (CFU) and Acinetobacter counts were calculated. Results Mean aerobes and Acinetobacter CFU/RODAC in four rooms housing patients with Acinetobacter were determined. At baseline all environmental sites sampled except overbed table were contaminated with Acinetobacter. Immediately after cleaning/disinfection, Acinetobacter was only detected on the bed rail (1 CFU). First time to recontamination with Acinetobacter was as follows: chair, 3 hours; overbed table, 2 hours; stock cabinet, 3 hours; and IV pump, 2 hours. No recontamination were observed at the monitor. The level of Acinetobacter contamination on surfaces was occasionally high (e.g., when stock cabinet sampled at 5 hours, 75 of 96 CFU were Acinetobacter). The amount of recontamination with aerobes and Acinetobacter increased over time. Conclusions Our study demonstrated that recontamination with Acinetobacter occurred rapidly at environmental sites in burn units even after cleaning/disinfection and underscored the need for enhanced environmental cleaning, including continuous disinfection methods, to prevent transmission of healthcare-associated pathogens.

The objective of this study is to determine what percentage of patient room entries and exits (opportunities) are attributed to health care personnel (HCP) and non-HCP. A total of 14,876 opportunities were observed by clinicians in 29 units of 16 hospitals. HCP accounted for 83.6%; 95% confidence interval, 81.3%-87.6%. This finding provides hospitals an initial baseline for HCP room traffic when implementing community-based automated hand hygiene monitoring and compliance improvement efforts.

Background Poor hand hygiene by health care workers is a major cause of nosocomial infections. This research evaluated the ability of an electronic monitoring system with real-time prompting capability to change hand hygiene behaviors. Methods Handwashing activity was measured by counting dispenser activations on a single nursing unit before, during, and after installation of the system. The effect of changing the prompt duration on hand hygiene performance was determined by a cluster-randomized trial on 3 nursing units with 1 acting as control. Sustainability of performance and participation was observed on 4 nursing units over a year. All staff were eligible to participate. Results Between June 2015 and December 2016, a total of 459,376 hand hygiene opportunities and 330,740 handwashing events from 511 staff members were recorded. Dispenser activation counts were significantly influenced by use of the system (χ2[3] = 75.76; P Conclusions Use of electronic monitoring with real-time prompts of 20 seconds' duration nearly doubles handwashing activity and causes handwashing to occur sooner after entering a patient room. These improvements are sustainable over a year.

Background Clostridium difficile infection (CDI) is a critical patient safety issue. Consistent and regular performance of appropriate practices is effective in preventing CDI. Variation in adherence to these practices can impede their effective implementation and weaken CDI prevention. Methods Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework we convened a focus group of 10 nurses to identify barriers and facilitators to compliance with a CDI prevention bundle that includes (1) prompt diagnostic testing, (2) empirical isolation for patients with suspected CDI, (3) consistent and appropriate contact isolation, (4) hand hygiene, and (5) disinfection of the patient room and objects in the room. On completion of transcript coding, analyses were performed based on bundle intervention and the work system element of the SEIPS model. Results A total of 58 excerpts were coded. Work system barriers or facilitators were associated with nearly every bundle intervention. The work system elements raised in over half of the excerpts were task (n = 31) (eg, amount of additional effort required to don and doff gloves and gowns) and organization (n = 30) (eg, recognition by all staff of the severity of CDI). Contact isolation was the most frequently discussed bundle intervention (n = 24). Conclusions The SEIPS systems engineering framework is useful to evaluate infection prevention practices for CDI and identify opportunities for improvement. Addressing the work system barriers and facilitators identified in this study is essential to effective implementation of infection prevention interventions, specifically for CDI.

Background Multiple-drug-resistant organisms (MDROs) and Clostridium difficile (CD) are significant problems in health care. Evidence suggests that these organisms are transmitted to patients by the contaminated environment. Methods This is a retrospective study of the implementation of ultraviolet environmental disinfection (UVD) following discharge cleaning of contact precautions rooms and other high-risk areas at Westchester Medical Center, a 643-bed tertiary care academic medical center. Incidence rates of hospital-acquired MDROs plus CD before and during the UVD use were evaluated using rate ratios and piecewise regression. Results The average time per UVD was 51 minutes, and machines were in use 30% of available time. UVD was used 11,389 times; 3,833 (34%) of uses were for contact precautions discharges. UVD was completed for 76% of contact precautions discharges. There was a significant 20% decrease in hospital-acquired MDRO plus CD rates during the 22-month UVD period compared with the 30-month pre-UVD period (2.14 cases/1,000 patient-days vs 2.67 cases per 1,000 patient-days, respectively; rate ratio, 0.80; 95% confidence interval: 0.73-0.88, P Conclusion During the time period UVD was in use, there was a significant decrease in overall hospital-acquired MDRO plus CD in spite of missing 24% of opportunities to disinfect contact precautions rooms. This technology was feasible to use in our acute care setting and appeared to have a beneficial effect.

BACKGROUND Supported by the American Academy of Pediatrics, child Life Specialists (CLS) play a pivotal role in helping pediatric patients cope emotionally and psychologically with medical procedures or hospital stays. Literature shows that CLS involvement leads to decreased anxiety and fear, and improved cooperation and adjustment to medical challenges. These patients also report lower levels of procedural and post-procedural pain. Additionally, family member support and anxiety reduction leads to improved coping in the patient as well. METHODS Our hospital has a robust Child Life program, with multiple events each day. For patients in isolation precautions, access to these events and activities was limited to what the CLS was able to provide in the patient room. These patients were unable to experience the distraction and benefits of the fully stocked playroom, as well as other larger events. Working closely with the Child Life team, Infection Prevention developed guidelines?that allowed isolation patients to safely experience activities sponsored by Child Life without the risk of transmission to other patients. RESULTS IP and CLS have developed a number of protocols for unique situations. These include allowing patients in isolation to attend private playroom time, visits from therapy and zoo animals, including dogs, horses, and reindeer, use of virtual reality equipment to enhance physical therapy, and providing donated blankets, toys, and stuffed animals. CONCLUSIONS IP can successfully support CLS to offer developmentally appropriate and beneficial opportunities for our pediatric patients while adhering to hospital infection prevention policy through the use of protocols and creative problem solving.

Background Implementation of a hospital-wide program of terminal cleaning of patient rooms revolving around hydrogen peroxide vapor (HPV) technology and evaluation of its impact on endemic nosocomial Clostridium difficile -associated diarrhea (CDAD) have not been previously reported. Methods This was a retrospective quasiexperimental study involving a 900-bed community hospital. During the preintervention period (January 2007-November 2008), rooms vacated by patients with CDAD or on contact precautions for other targeted pathogens underwent 1 or more rounds of cleaning with bleach. During the intervention period (January-December 2009), targeted newly evacuated rooms underwent “enhanced cleaning” consisting of use of bleach followed by HPV decontamination utilizing a priority scale based on the pathogen and room location. Rooms vacated by patients with CDAD but for which HPV decontamination was not possible the same day underwent 4 rounds of cleaning with bleach instead. Results During the intervention period, 1,123 HPV decontamination rounds were performed involving 96.7% of hospital rooms. Of 334 rooms vacated by patients with CDAD (May-December 2009), 180 (54%) underwent HPV decontamination. The rate of nosocomial CDAD rate dropped significantly from 0.88 cases/1,000 patient-days to 0.55 cases/1,000 patient-days (rate ratio, 0.63; 95% confidence interval: 0.50-0.79, P Conclusion A hospital-wide program of enhanced terminal cleaning of targeted patient rooms revolving around HPV technology was practical and was associated with a significant reduction in CDAD rates.

Because increasing evidence suggests that the environment plays a role in transmission of health care-associated infections, more attention is focusing on environmental cleaning and improving its efficacy. Creating and sustaining a successful cleaning and disinfection program should include several key components using a bundle approach and requires ongoing commitment within the institution.

Objective To assess the ability of copper alloy surfaces to mitigate the bacterial burden associated with commonly touched surfaces in conjunction with daily and terminal cleaning in rural hospital settings. Design A prospective intention-to-treat trial design was used to evaluate the effectiveness of cooper alloy surfaces and respective controls to augment infection control practices under pragmatic conditions. Setting Half of the patient rooms in the medical-surgical suite in a 49-bed rural hospital were outfitted with copper alloy materials. The control rooms maintained traditional plastic, metal, and porcelain surfaces. Methods The primary outcome was a comparison of the bacterial burden harbored by 20 surfaces and components associated with control and intervention areas for 12 months. Locations were swabbed regardless of the occupancy status of the patient room. Significance was assessed using nonparametric methods employing the Mann-Whitney U test with significance assessed at P Results Components fabricated using copper alloys were found to have significantly lower concentrations of bacteria, at or below levels prescribed, upon completion of terminal cleaning. Vacant rooms were found to harbor significant concentrations of bacteria, whereas those fabricated from copper alloys were found to be at or below those concentrations prescribed subsequent to terminal cleaning. Conclusions Copper alloys can significantly decrease the burden harbored on high-touch surfaces, and thus warrant inclusion in an integrated infection control strategy for rural hospitals.

Environmental contamination plays an important role in the transmission of several key health care-associated pathogens. Effective and thorough cleaning/disinfecting of the patient environment is essential. Room decontamination units (such as ultraviolet-C and hydrogen peroxide systems) aid in reducing environmental contamination after terminal room cleaning and disinfection.

Evidence that contaminated surfaces contribute to the transmission of hospital pathogens comes from studies modeling transmission routes, microbiologic studies, observational epidemiologic studies, intervention studies, and outbreak reports. This review presents evidence that contaminated surfaces contribute to transmission and discusses the various strategies currently available to address environmental contamination in hospitals.

Methods: Using a descriptive survey design, a link to an electronic Survey Monkey questionnaire about nurses’ knowledge and compliance to catheter care policies was sent through hospital e-mail to 544 registered nurse (RN) and unlicensed assistive personnel (UAP) from 18 departments in three hospitals. A prevalence study was also conducted by infection control practitioners and their trained designees on 99 patients in June 2010 who had indwelling urinary catheters to assess documentation and compliance to urinary catheter protocols.

Background: The current U.S. standard for evaluating the in vivo activity of alcohol-based hand rubs (ABHR) is the Health Care Personnel Hand Wash (HCPHW) method, ASTM E 1174. The HCPHW method was developed for the evaluation of hand wash products and does not reflect the in-use conditions of ABHR. ASTM E 2755, a recently approved Standard Test Method specifically designed for evaluation of hand rubs, is more reflective of normal use conditions.

BACKGROUND/OBJECTIVES: Despite activities aimed at enhancing isolation practices and promoting increased use of hand hygiene products, the spread of health care associated pathogens continues to be a major problem. While clearly not an independent factor, environmental contamination with these resistent and resiliant pathogens in combination with suboptimal cleaning/disinfection activities has been shown to play a role in perpetuating the transmission of these pathogens in many settings. In this context we undertook a multi-institutional prospective evaluation of cleaning/disinfecting activities to determine if opportunities to enhance these activities could be identified. METHODS: An evaluation of the thoroughness of cleaning of the near patient environment using a non-biological targeting method was undertaken in twelve acute care hospitals ranging in size from 46 to 568 beds. The proportion of frequently touched objects cleaned as part of terminal room cleaning/disinfecting activities was calculated for between 30 and 52 rooms in each facility in a confidential manner. The results were analyzed to determine how specific interventions could be developed to enhance such cleaning activities. RESULTS: Substantial opportunites for improving terminal room cleaning were identified in all hospitals. While the overall thoroughness of cleaning of objects in the near patient environment was quite similar in this cohort of hospitals (mean % of objects cleaned = 45.3, SD = 3.4), wide differences in how well specific objects were cleaned both within and between institutions were noted. Analysis of these results disclosed a range of institutional specific opportunities for a) educational interventions, b) the re-assessment of environmental services personnel allocation and c) the identification of possible motivational issues as well as inter-institutional analyses of issues for which highly specific interventions could be implemented and their impact objectively measured. CONCLUSIONS: The programmatic use of a simple user-friendly targeting method to evaluate the thoroughness of terminal patient room cleaning identified many specific opportunities for improving cleaning/disinfecting activities in each of the twelve acute care hospitals studied.

BACKGROUND/OBJECTIVES: This medical center (MC) is a 400-bed community-based hospital in suburban St. Louis County. There was concern that the incidence of C. difficile was increasing. Therefore, an intervention study was initiated to improve C. difficile rates. METHODS: A case was defined as a patient with diarrhea and +C. difficile > 48 hours after admission. In January 2004, the definition was expanded to include a patient with a + C. difficile on admission and who was an MC inpatient within the past 60 days. Daily and discharge cleaning of the C. difficile patient room with a 1:10 bleach solution was initiated. Rooms were to be cleaned daily with a 1:10 solution of bleach and water, using a different wiping cloth for each room. Staff was instructed to wipe down bedside rails, which is not usually done until discharge. Education on C. difficile, transmission, and prevention was delivered. The bleach intervention was piloted in two areas from August 2003 through January 2004, and disseminated housewide in February 2004. Housekeeping was informed to implement the bleach protocol by the designation of the letter “B” on the contact isolation sign outside the patient room. An e-mail was also sent to the housekeeping supervisors notifying them of new C. difficile patients. RESULTS: From February 2002 to January 2004, the C. difficile rate was 2.2 per 1000 patient days. Post bleach and education intervention, the rates decreased to 1.5 per 1000 patient days. The rate decline was statistically significant. (p = 0.00007). CONCLUSIONS: The routine use of bleach cleaning in C. difficile rooms and education on preventing the transmission of C. difficile significantly decreased the C. difficile rate at MC.

BACKGROUND/OBJECTIVES: Hand hygiene is the most important intervention for preventing the spread of disease. However, rates of hand hygiene compliance continue to be low. Additionally, the gold standard for monitoring hand hygiene compliance, visual observation, is plagued by the Hawthorne effect and often overestimates hand hygiene compliance rates. Recently a number of electronic hand hygiene monitoring systems have been introduced, and are used more frequently as an adjunct to visual observation. The study objective was to determine the impact on compliance rates by introducing a hand hygiene program that includes an electronic compliance activity monitoring system in an acute care facility. METHODS: The study was conducted from June through October 2012 in Med / Surg and Infectious Disease units in a hospital in Fort Worth, TX. A compliance activity monitoring system was installed that monitors all patient room entries and exits (each one is considered an opportunity) and all hand hygiene events from automatic soapor sanitizerdispensers. Compliancewasmeasuredas#of events / # of opportunities, and included the entire community (based on room entry), not only HCWs. Baseline compliance measurements were taken without HCW knowledge from 6/8-6/18. Then the study period ran from 6/19-9/9, and included implementation of a comprehensive hand hygiene program that included HCW, patient and visitor education, development of a hand hygiene improvement goal, leadership support and feedback for the staff. Then a post-study assessment was done to determine whether the changes in compliance rates were sustainable from 9/10-10/28. Statistical comparisons were made using a probability value from a paired-difference t-test. RESULTS: There was a 92% increase in compliance rates from 16.5% to 31.7% from the baseline to study period. This difference was significant (P

ISSUE: Multiple studies have shown that high-touch surfaces, such as bed rails, over bed tables, and supply carts, play a role in the transmission of pathogens to susceptible patients. It was demonstrated that current cleaning practices result in high-touch surfaces being adequately disinfected less than half the time. While there are novalidated standardized practices for cleaning anddisinfection (CD) of patient rooms, there are recommended processes. We conducted an audit of patient room cleaning in acute care facilities to identify current gaps and developed a model for CD of a patient room.

ISSUE: In summer 2002, water and mold damage was identified in a patient room shower wall due to a plumbing leak. Exploration of other shower and sink back walls indicated mold damage to the entire area. Infection control surveillance identified no concerns prior to this finding. PROJECT: Facilities, Management, and Infection Control consulted with experts in Industrial Hygiene and Environmental Management to implement remediation strategies. Proposed was $2.9 million, 18-month containment, remediation, and renovation project of the involved areas. Infection Control Risk Assessment (ICRA) was completed. Units scheduled for renovation were closed, shifting patient admissions. Infection Control educated staff on maintaining a safe patient environment. Renovation was completed under strict supervision to ensure no mold contamination occurred of the HVAC system or other patient care areas. This included sealing the unit, use of HEPA filtration units, protective clothing for the workers, environmental rounds to ensure complete containment, and heightened surveillance of patients and staff. RESULTS: No cases of healthcare-associated fungal infections linked to the project have been identified. LESSONS LEARNED: Prevention of healthcare-associated infections is the responsibility of the entire healthcare team. A progressive, responsive management team provided the key financial and administrative support to help ensure a safe environment. A proactive approach to potential sources of healthcare-associated infections can be facilitated with the cooperation of Management, Infection Control, and Facilities.

BACKGROUND: Klebsiella pneumoniae (KPNE), previously an innocuous bug in our pediatric burn unit, changed its characteristics recently. A 13-year-old male was admitted from Mexico with a third-degree 60% TBSA flame burn. We isolated from his burn wound tracheal aspirate, banked autograft skin, and grew a KPNE sensitive only to Amikacin and Gentamycin. Over the next 3 months, this organism was isolated from 13 additional burn patients. METHODS: A search for a reservoir included water samples from OR and tub room hoses, various equipment cultures from both areas, and the burn unit. Peri-rectal swabs and tube feed stocks were monitored weekly. RESULTS: KPNE was recovered from two pieces of equipment in one of the ORs, a patient room (post discharge and cleaned), and one container of tube feed stock. The OR and patient room were temporarily closed for aggressive cleaning. Procedural changes were made for mixing and hang time of tube feedings. CONCLUSION: Ten of fourteen patients utilized the operating room where the KPNE was found, which implicated the OR suite as the potential source of transmission. The peri-rectal swabs showed no sign of the organism. Cleaning procedures have been reviewed, and cleaning rooms between cases is a joint effort of OR staff and Environmental Services with close attention to detail. Follow-up random cultures of clean ORs have not recovered the organism.

ISSUE: Robert Wood Johnson University Hospital (RWJUH) is a 520-bed academic hospital in central New Jersey. Like many hospitals, RWJUH experienced a steady rise in the rate of methicillin-resistant Staphylococcus aureus (MRSA) nosocomial infections (NI) over the past decade. Reduction in this rate became a priority performance improvement goal for Infection Control. The 2003 goal is at least 6 months with PROJECT: MRSA NI is calculated as rate per 1000 patient days and displayed using a “u” statistical process control chart to identify special cause. Reduction efforts initiated during July 2000 included mandatory handwashing education programs for staff and installation of an alcohol-based handwashing gel (AHWG) outside every patient room in all intensive care units. Based on physician requests, AHWG dispensers were installed throughout the institution in mid-2001. Concurrent with house-wide implementation of AHWG, a “feedback” system was developed to share monthly MRSA NI rates with all departmental and nursing supervisors via hospital e-mail. RESULTS: Statistical process control chart calculations comparing pre- and post-intervention rates showed a decrease in the mean from 1.6 (6/00) to 1.3 (8/00), with a further reduction to 1.1 infections per 1000 patient days in August 2001, indicating a positive special cause (p=0.003). MRSA NI rates have continued to decline.