The Carle Foundation Hospital Neonatal Intensive Care Unit (NICU) reduced the overall incidence of nosocomial infection in very low birth weight (500 to 1500 grams) infants surviving more than three days by 51 percent from 2000 to 2001, and an additional 25 percent from 2001 to 2002 by implementing improvements in nutrition, respiratory care, hub/IV lines, caregiver factors (hand washing, gloves, nail care, developmental care), diagnosis, and staffing.

The Vermont-Oxford Collaborative conducted a study that identified an increased incidence of sepsis in the neonatal population. This increased incidence leads to increased infant mortality, length of stay, and cost of care. The following changes were initiated in the Carle Foundation Hospital NICU in 2001:

• Revised and implemented a hub/IV line care policy and educated all NICU staff regarding changes
• Updated Umbilical Artery Catheter Line Drawing policy
• Removed Umbilical Artery Catheters and Umbilical Venous Catheters as soon as possible
• Utilized PICC placement in the first few days for the tiniest infants to reduce the number of invasive procedures
• Utilized biopatch for all surgically placed central venous lines (CVLs)
• Developed a policy that nothing could be added to total parenteral nutrition (TPN) fluids after preparation
• Reviewed and updated hand washing policy to meet Centers for Disease Control (CDC) guidelines
• Installed Avagard hand sanitizer units on the monitor posts
• Installed timer at scrub sink to utilize for initial scrub prior to entering the NICU (two-minute scrub with sponge side of scrub brush using chlorhexidine soap scrub)
• Developed a policy requiring all staff to don gloves for all contacts with babies in warmers and isolettes
• Implemented developmental care and its emphasis on minimal handling
• Reviewed and updated skin care policy
• Implemented World Health Organization’s (WHO) recommendation of using triple dye on umbilical stumps
• Changed to the "original" preparation of Aquaphor and educated staff regarding proper application
• Utilized neo-bars for endotrachael tubes
• Established guidelines and educated staff on food preparation and storage
• Defined care of intermittent gavage extension tubing
• Educated staff and infants' mothers on the "positives" of breast milk/feeding and established breast milk as a standard of care
• Established Enteral Feeding guidelines
• Developed and educated staff on premature infant feeding guidelines
• Approved a dedicated food preparation room
• Established practice for utilizing cleaned laryngoscope blade each time an infant was intubated
• Standardized the practice of inline suctioning and heated wire circuits
• Worked with pharmacy to minimize multiple use of single use vials
• Developed audit tools to track process improvements
• Developed and administered competency testing for nursing staff after implementation of "best practice" standards

Additional process changes made in 2002:

• Reviewed antibiotic use and possible antibiotic recycling
• Resumed prophylactic intravenous immunoglobulin (IVIG) in infants weighing less than 1,250 grams
• Reeducated staff on proper hand washing technique and utilization of Avagard-D
• Developed and initiated artificial nail and jewelry policy
• Utilized "tents" for infants less than 30 weeks gestation that are in open warmers.

Additional process changes for 2003:

• Replaced scrub brushes and three-minute scrub with Avagard (surgical hand antiseptic)

Implementing evidence-based potentially better practices (PBPs) has brought about significant change in the incidence of nosocomial infection in the Carle Foundation Hospital NICU. While the goal of less than 10 percent occurrence has not yet been realized, we continue to evaluate evidence-based PBPs and implement those practices that are appropriate for our unit in an effort to reach this goal.

Lessons Learned:

• Participating with the Vermont-Oxford Collaborative, an international organization, provided the support, resources, and guidance needed to initiate and sustain practice changes to improve patient outcomes.
• Multidisciplinary/administrative buy-in is essential. Support from administration and all disciplines that care for the infants in the NICU is instrumental in making and sustaining change.
• Frequent communication in many different forms is a must and is challenging. Bulletin boards were placed throughout the unit, a newsletter was designed and mailed weekly through email and hard copy, and team leaders from each discipline were identified to carry out one-on-one communication.
• Maintaining the "rapid cycle" pace helps to sustain the excitement and get the work done. Weekly meetings were established to support the change with the expectation that staff would attend... and they did!
• Protocols and procedures are imperative and they need to be readily accessible to the staff for reference. Utilization of prompts and algorithms were extremely useful to the staff through all the changes that were made.
• Changing the long-standing culture of a unit is difficult.  Establishing a culture that embraces change is a process that takes time. Understanding the present culture and continuous reinforcement of why change is necessary is essential.   

Kathy Tredway, RN, Facilitator, Foundation Quality
Carle Foundation Hospital
611 West Park Street
Urbana, Illinois 61801-2595
Kathy.Tredway@carle.com

[Storyboard presentation at IHI's National Forum, December 2003]