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MetroHealth Cuts Harm with ‘Wash-In, Wash-Out’

In 2010, Cleveland-based MetroHealth observed an uptick in its nosocomial infection rate, prompting the system to conduct an in-depth investigation of the care environment, the equipment used in care, and its hand hygiene compliance rates. The results showed that the system’s hand hygiene compliance rates stood at just 70 percent — which, while above the 2010 national average of 56-60 percent, still could be improved substantially.

MetroHealth researched best practices provided by renowned organizations, such as the World Health Organization (WHO), the Centers for Disease Control and Prevent, and The Joint Commission. The hospital then put into practice a hand hygiene program of its own, called “Wash-In, Wash-Out.” Throughout 2011 and 2012, MetroHealth maintained its hand hygiene compliance rate between 97 percent to 99 percent, an achievement that has helped the system slash rates for three types of hospital-acquired infections (HAIs).

MetroHealth built Wash-In, Wash-Out around four teams, each of which is responsible for a different driver of hand hygiene compliance. The four teams included:

  • an Education Team that facilitated video-based and didactic education sessions, planned and coordinated training sessions, and analyzed workflows;
  • a Hand Hygiene Product Assessment Team that ensured ideal placement and availability of soap-less hand hygiene product and developed plans to install lotion dispensers;
  • Just-in-Time Coaches, who monitored staff members to ensure compliance and provided feedback where appropriate; and
  • Infection Prevention Observers, who monitored hand hygiene on the patient care units, analyzed failures and identified individuals who are resistant to coaching.

As a result of the initiative and additional work with the erstwhile Essential Hospitals Engagement Network of America’s Essential Hospitals, yearly central line-associated bloodstream infections in the ICU fell from 40 in 2010 to 25 in 2012, ventilator-associated pneumonia (VAP) cases dropped from 51 in 2011 to 34 in 2012, and catheter-associated urinary tract infections (CAUTIs) fell from 119 in 2011 to 76 in 2012.

MetroHealth calculated that these reductions in infections saved the organization more than $1 million per year after an initial investment of $50,000. To sustain this success, MetroHealth launched a communication campaign that included buttons, table tents, and hallway signs; process and outcomes data that it shared biweekly with all staff and leaders; and strong executive sponsorship from the CEO, chief operating officer, chief medical officer, and chief nursing officer.

MetroHealth said its Wash-In, Wash-Out initiative showed that achieving sustainable results across the board does not have to be complicated or costly. Staff said the keys to their success were a simple message, mandatory education, frequent monitoring and feedback, and effective use of available resources. In addition, staff noted that the program improved the system’s overall safety culture, which had a positive impact on other quality improvement efforts.


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