These environmental cleaning and disinfection measures should have a horizontal effect, Donskey said, with potential benefits beyond controlling the spread of C. difficile. “Because a lot of these pathogens, including Acinetobacter, MRSA, VRE [vancomycin-resistant Enterococci], can also be on surfaces and can potentially be transmitted that way, the environmental disinfection issue that’s part of what we’re trying to do for C. difficile should have impact on some of these other pathogens.”

Donskey also pointed out that within VA facilities as well as outside of the VA, a variety of infection control bundles are being implemented for specific types of infections – for example, bundles for central line-associated bloodstream infections or ventilator-associated pneumonia – as another strategy. “Part of the reduction we’ve seen in MRSA infections [overall] seems to be related to the effectiveness of this bundle in reducing MRSA bloodstream infections,” he said.

“There’s also a great deal of interest – and  again, this is not specific to the VA – in chlorhexidine bathing of patients in intensive care units or patients who are very high risk,” said Donskey. “Chlorhexidine is a special soap which reduces the burden of organisms, including pathogens, on their skin and because of that you can potentially reduce the risk for infection. That has actually been shown to reduce bloodstream infections and transmission of some of these pathogens in ICUs.”

“The key is to change the culture so that if everybody believes that wearing gloves and washing their hands is essential, then it’s much easier to gain compliance than if this is just another mandate that someone is telling us to do.”

Donskey also highlighted the importance of culture change in the successful implementation of these measures. “The key is to change the culture so that if everybody believes that wearing gloves and washing their hands is essential, then it’s much easier to gain compliance than if this is just another mandate that someone is telling us to do,” he said. “The key is getting the people on the front lines to be aware of the importance of what we’re doing and the rationale for why things are being implemented. And then if they’re in agreement with what we’re trying to accomplish, then everything is much easier.”

He also stressed that these are not local initiatives. “These [initiatives] are supported by the VA Central Office,” he said. “They are looking for the best practices from the experts in the field and then asking every VA [healthcare facility] to implement these measures, and then in addition, have ways to monitor how effectively things have been implemented.”

He continued, “We have a system where coordinators who are assigned to the MRSA Initiative, for example, are inputting data that is reviewed on a national level and ensuring compliance with the measures that we’re asked to implement. For MRSA, for example, the VA nationally expected that patients are going to be screened for MRSA on admission and discharge. And when rates initially were not where we wanted them, the VA Central Office basically asked that these things be done. So pressure comes down from the Central VA to implement these things effectively. It’s essential, I think, that you have support from the top.”

Donskey also emphasized the importance of resources in implementing the initiatives. “The VA has provided a coordinator for MRSA and for MDRO at each facility who is involved in making sure things are being implemented appropriately and then putting data in so that nationally we can look at our data. So it’s support from the top, resources to do it, and then, for example, I participated in a variety of educational conferences as well. So the VA will sponsor conferences where the environmental services people from each program and the infection control people will be able to come together and learn about what the standard practices are and what the rationale is for the program that we’re putting in place. So everybody gets the resources they need and gets education.”

Looking ahead, in addition to the implementation of the measures in the initiatives, Donskey indicated that one strategy to improve results is an ongoing quest for the development of new technologies that can address some of the challenges, for example, in environmental disinfection – finding products that work better and make the job easier.

One such technological system recently introduced for environmental disinfection is a device that uses ultraviolet light. Donskey said this technology is now in use in about 20 VA hospitals, including at his location. “Our experience has been kind of mixed with those devices. I think that standard environmental disinfection practices can work just as well, if we can find ways to just improve our standard practices,” he said, adding, “I’m a little bit skeptical that this is the answer to all of our issues with environmental cleaning.”

With regard to new antibiotics to treat drug-resistant bacteria, Donskey said there are some limitations in their development. “I think one thing that would really help us would be smarter use of the drugs we already have,” he said. “The VA, as a lot of other places are as well, is really trying to do a lot to emphasize antimicrobial stewardship of the drugs we currently have to treat infections. So for example, we have national conference calls with education about stewardship and we’re trying to develop this as a national approach to reduce the inappropriate use of antibiotics.”

Even with significant progress in the battle against some HAIs, challenges remain, and efforts to control or even eliminate these infections are ongoing within the VA. With the dramatic increases they’ve seen in C. difficile infections, Donskey said they continue to look closely for other potentially important sources of transmission while placing tremendous effort into optimizing best practices to control the spread of these pathogens. Fortunately, the progress the VA has made to date sets the stage to successfully meet the challenges of the future.

This article was first published in The Year in Veterans Affairs and Military Medicine: 2013-2014 Edition.