Proposed change: Education/policy

Implementation, outcomes and evaluation: Changes the way we look at preventing infections in the NICU.

Implications for nursing practice: The aim of this project was to recreate the policy and procedure on infection control for the Infant Special Care Center (NICU).  This project was started in July 2008 after the unit joined the California Children’s Quality Initiative in January 2008.  The initial goal for 2008 was to reduce infection rates in the NICU by at least 30%.  This project was completed as follows.  The California Children’s Quality Initiative guidelines were collected and incorporated into the current infection control policy for the unit.  Second, each policy concerning infection control was reviewed.  Third, the last 5 years of peer-reviewed literature on infection control pertaining to neonatal intensive care was reviewed and pertinent information was added to the policy and procedure.  Fourth, each multidisciplinary group in the NICU was met with (for example the PICCteam).  These teams compiled input and the information was added as appropriate to the policy.  Finally, the policy was reviewed and approved by the medical director and delivered to the CORE group for the unit.  Once the policy was finished, the staff members were educated through the creation of a six-panel poster session on the policy.  Each staff member was required to walk through the poster session and answer a set of competency questions that pertained to the poster session.  Also, a parent agreement was created that centered on infection control and it holds parents to the same standards as the nurses and doctors.  During this time, specific audit tools were used to assess staff compliance with the components of the policy.  Overall, the infection rate was reduced by fifty-eight percent and audit data showed compliance to be at ninety-six percent and greater.  These data were presented to the 2009 California Perinatal Quality Control Collaborative annual meeting in Sacramento and at the hospital wide infection control committee. The policy was approved by the hospital wide infection control committee and is under review for adoption on other hospital units.  At this time our efforts are focused on sustaining the gains.  We are accomplishing this by reviewing current evidence based practice yearly and changing practice accordingly, continuing to complete audits on practice, and providing continuing education to new and current staff.

Keywords: NICU, CLABSI, quality initiative