The Bug Stops Here

At Roosevelt Warm Springs (RWS), a freestanding long-term care hospital and 35-bed inpatient rehabilitation hospital in central Georgia, compliance and adherence to food labeling and dating, environmental cleanliness issues, hand hygiene, poor use of personal protective equipment (PPE) and labeling of urinary supplies was noted to be less than 70 percent in 2003. As a result, discussion was held with the nurse manager group, and an action plan was developed using a PDCA (plan, do, check, act) model. Interventions were initially implemented to enhance compliance and potentially minimize the risk for acquisition and transmission of infectious disease, yet significant change was not seen over a period of four months.

In October 2003, RWS implemented the Centers for Disease Control and Prevention (CDC)s guidelines for the use of alcohol-based handrubs and overall hand hygiene. A unique program called Hand to Hand Combat was the impetus for behavior change and compliance. The other stated issues remained a concern. In December 2003, the infection control department introduced a new recommendation and concept to the nurse managers.

A volunteer group of health service technicians (HSTs) would be recruited from all shifts and floors. They would become an infection control team called the Bug Brigade. Their focus and training would be on basic infection control practices, multidrug-resistant organisms (MDROs), transmission-based precautions, and the use of a newly developed infection control tool. The Bug Brigade was created to foster an environment where the staff would take ownership and accept responsibility for areas they were assigned. The training took place on Feb. 4, 2004. Competency would be demonstrated in the afternoon session during the Bug Brigade intervention training rounds.

Multidisciplinary teams were formed for the purposes of training and included the housekeeping supervisor, nurse educator, infection control nurse and a representative from the local department of public health. Evidenced-based practices for environmental cleanliness, use of PPE, hand hygiene and basic infection control were derived from the CDC guidelines and from Joint Commission standards.

An education and training program was developed along with a measurement tool to be utilized monthly by the team of HSTs. Training included a review of the aforementioned basic infection control practices, lunch, and a brainstorming session on how processes could be improved. Teambuilding exercises were also a part of their training. The development of the hand hygiene monitoring tool and environmental rounds tools enabled their efforts to be consistent in all areas.

They were awarded certificates and gold bee-shaped pins to be worn on their uniforms, identifying them as a Bug Brigade member. It was clear to the infection control department that expectations were better accepted for all staff if monitoring came from those who did the job. The bee pin worn on the uniform was accepted as a medal of honor and worn proudly, and certificates were displayed on the units. They were given pencils and bee erasers to use when they made their monthly rounds. Members were also featured in the hospital newsletter, and their additional responsibility would be noted in their annual performance review.

Participants chose interventions that would be best to create good outcomes, and they now use terms such as culture of safety in day-to-day conversations. They are motivated to hold safety contests to see which department can be at 100 percent compliance in all areas monitored. Bulletin boards are maintained in both hospitals by the Bug Brigaders to further inform staff members about infection control efforts.

Success of the initiative was measured by a decrease in urinary tract infections and an increase in compliance for labeling of urinary supplies, use of PPE, observance of hand hygiene practices, and general environmental cleanliness.

A grid was instituted to report monthly the compliance rates. In 2007 rates continue to be between 89 percent and 100 percent.

The Bug Brigade Team has taken ownership of what it takes to provide quality patient care in a safe and healthy environment.


1. CDC guidelines for Hand Hygiene, Isolation and Management of Urinary Tract Infections.

2. Howto Guide: Improving Hand Hygiene: A guide for Improving Practices Among Healthcare Workers. Pages 1-32.

3. Joint Commission: The Source for Joint Commission Compliance Strategies Reduce the Spread of Infection with Proper Hand Hygiene. Volume 3, No. 5. May 2005.

4. 2007 Hospital Accreditation Standards: Surveillance, Prevention and Control of Infection. Pg 239-251.