Tracking bug's spread galvanizes hospital staff

The infection-control staff at Jackson Health System in Miami tried every strategy they could think of to stop the spread of the deadly bacterium Acinetobacter baumannii, but nothing worked.

For nearly two decades, the number of cases of carbapenem-resistant A baumannii, a hard-to-treat organism that causes many types of hospital-acquired infections, had remained consistent at the 1,570-bed public hospital. It held steady even during 2009 and 2010, after the hospital instituted an aggressive bundle of targeted interventions including more stringent disinfection practices, weekly surveillance cultures and isolation of patients who tested positive.

Infections from A baumannii occur primarily in already-fragile intensive-care patients. All-cause mortality rates among patients colonized with the bacterium can be as high as 40%. Concern about such organisms is increasing as federal agencies including the Centers for Disease Control and Prevention sound the alarm about the dangers of inappropriate antibiotic use and the resulting growth of antibiotic resistance.

In a 2013 report, the CDC categorized multidrug-resistant Acinetobacter—a term referring to a group of bacteria of which A baumannii is one type—as a serious threat requiring “prompt and sustained action to ensure the problem does not grow.”

But prevention efforts at Jackson seemed to hit a wall. In January 2011, a team of researchers led by Dr. Silvia Muñoz-Price, the hospital's medical director of infection control, decided to try a new approach. They began sending weekly e-mails to more than 200 hospital leaders. The messages included the number of new cases of A baumannii each week, how those cases were distributed among units, a ranking of unit performance and an action plan that evolved based on new findings. The e-mails also provided maps of the units showing transmission pathways and exactly where the bacterium was found—on a bedside table, for instance.

The goal was to help hospital staff think of A baumannii as a tangible thing. “Given that they can't see it, it's harder to change behavior,” Muñoz-Price said. “This was our way of trying to make it more objective for them.”

The e-mail messages packaged a complex topic in a way that was pertinent and actionable, said Laura Harris, Jackson's director of clinical care, who was on the recipient list. “People are very visual and the maps really brought it home.”

“The e-mails just kept coming, they were relentless,” said Elizabeth Davidson, nurse manager of the hospital's surgical ICU.

After receiving one of the e-mails, unit management teams examined each new case, discussing the details in a huddle. “We would cut and paste our unit roadmap and send it out to the staff, saying, 'Look, the bacteria went here and here and here,' ” Davidson said. “We couldn't make excuses, we had to look in the mirror and take responsibility.”

The data were impossible for the C-suite to ignore as well, said Dr. Michael Butler, Jackson's executive vice president and chief medical administration officer. “The key is putting the numbers in front of your face and associating them with benchmarks,” he said. “It makes you realize that it's inappropriate to go on with business as usual.”

That combination of heightened awareness, peer pressure among units, accountability and buy-in from senior leaders soon proved potent, Muñoz-Price said. The number of new cases of A baumannii began to plummet.

From January 2010 through June 2013, the transmission rate fell 63%, from 5.13 per 10,000 patient days to 1.93, according to an article about Jackson's program in the American Journal of Infection Control. By March 2012, the number of new cases had slowed to a trickle and Muñoz-Price was able to stop sending weekly e-mails.

“I'm not surprised by (Jackson's) results at all,” said Jennie Mayfield, a clinical epidemiologist at Barnes-Jewish Hospital in St. Louis and president of the Association for Professionals in Infection Control and Epidemiology. “A report with a rate doesn't do much. But a diagram of a unit showing that this patient has this organism and this other patient two rooms down acquired it—that makes it real to people.”

Mayfield said she hoped Jackson's success would spur other hospitals to develop initiatives to curb A baumannii and other types of infection-causing organisms. “It really does work,” she said.

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