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Automated Hand Hygiene Monitoring and Nosocomial Infection Marker Reduction
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Poster Abstracts / American Journal of Infection Control 41 (2013) S25-S145
Education and Competencies Presentation Number 5-303 Inter-rater Reliability of Catheter-associated Urinary Tract Infection among Infection Preventionists in a Multi-Hospital System Marc-Oliver Wright MT(ASCP),MS, CIC, Director, Infection Control, NorthShore University HealthSystem; Corrinna Brudner BSc, C.P.H. I (C), CIC, Infection Preventionist, NorthShore University HealthSystem; Adrienne Fisher MT(ASCP), CIC, Infection Preventionist, NorthShore University HealthSystem; Carolyn Hines RN, CIC, Infection Preventionist, NorthShore; Vanida Komutanon RN, MPH, CIC, Infection Preventionist, NorthShore; Anna Ogle RN, MPH, CIC, Infection Preventionist, NorthShore; Becky Smith MD, Hospital Epdiemiologist, Infectious Disease Physician, NorthShore University HealthSystem BACKGROUND/OBJECTIVES: Recent requirements from the Centers for Medicaid and Medicare Services have mandated catheterassociated urinary tract infection (CAUTI) surveillance and reporting among intensive care unit (ICU) patients. Manual surveillance by infection preventionists (IPs) can be subjective. METHODS: In a multi-hospital delivery system, within a single, unified infection prevention department with an available electronic medical record, 5 certified IPs were allocated a total of 51 charts for review. The charts were preferentially selected for patients with positive urine cultures on or after day 3 of hospitalization. Each IP had previously completed the online training for CAUTI surveillance provided by the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN). Each chart was reviewed by 2 IPs; in the event of discordance, the department director and hospital epidemiologist reviewed the case to make a final determination. Kappa scores with 95% confidence intervals (CI) are provided. RESULTS: Overall, the IPs were concordant 66.7% (34/51) of the time for a kappa of 0.24 (95% CI: -0.03, 0.51) and varied widely across the hospitals (50%, 60%, 65% and 90%). Proportions for positive and negative agreement were 0.48 and 0.75 respectively, suggesting that IPs were more likely to agree when the patient clearly did not represent a potential CAUTI. Common areas of disagreement included ascribing patients that met symptomatic CAUTI criteria to “secondary” causes (for which no criteria exist), interpreting Gram-stain results on spun (versus the definitional requirement for unspun) urine and disagreement regarding temporal requirements for symptom presentation. IPs underwent continuing education and training regarding the discordant cases and recurring themes following this exercise. CONCLUSIONS: Even among certified IPs within a single department with identical training and surveillance resources, discordance in manual surveillance of CAUTI is prevalent.
Presentation Number 5-304 Teaching Infection Prevention Using Concept Mapping Learning Strategies Peggy H. Anderson DNP, MS, RN, Associate Teaching Professor, Brigham Young University; Christie Johnson MSN, RN, Clinical Educator, Intermountain Healthcare Urban South Region; Karen Singson RN, MSN, CIC, Infection Preventionist, Intermountain Healthcare
ISSUE: Novice nurses are often overwhelmed as they apply new knowledge to nursing practice. They frequently fail to implement infection prevention strategies as prioritized nursing cares. Concept mapping has been shown to increase student and novice nurse ability to identify and prioritize nursing assessments/interventions. Instructors from a RN residency program evaluated the use of concept mapping to facilitate novice nurse learning and application of infection prevention strategies. PROJECT: Sixteen graduate nurses enrolled in a RN residency program participated in the concept mapping learning strategies study. Concept mapping was taught during an HAI prevention classroom session. After a review of concept mapping and infection prevention strategies, each resident developed a concept mapbased on a HAI case scenario. The concept map included the main diagnoses, medications, lab findings, critical nursing assessments and interventions, prioritization of interventions, and connections between related systems and pathological symptoms. Residents then recreated the concept map as a group by presenting the care needed for each pathophysiological system. Connections between related systems and nursing intervention priorities, including infection prevention strategies, were identified and discussed. Following the group discussion, residents developed an additional map based upon a similar patient care scenario. A third concept map was completed by the residents two weeks later. Completed concept maps were scored for evidence of critical thinking, identification of nursing assessment and interventions, and prioritization of nursing cares. At the study’s conclusion, residents evaluated the effectiveness of concept mapping as a learning tool. RESULTS: Statistical testing was used to determine interrater reliability and evaluate the completed concept map scores. Testing included paired t-tests, repeated measures analysis of variance (RM ANOVA) test and post hoc testing, Friedman test, and Generalizability Theory evaluation scores. Results indicated that the participants’ scores changed in a positive direction over time. There was a significant increase (p ¼ .001) in scores between Map 1 and Map 2 and a slight decrease between Map 2 and Map 3; the scores did not return to baseline however and the slight decline was not significant. The partial eta squared value indicated that 77.1% of variance in the concept map scores could be attributed to changes in scores across time. Residents commented that concept mapping helped them identify possible HAI risks and organize associated patient care needs, as summarized by one resident, “Unless you see the big picture you can overlook small things that can turn big.” LESSON LEARNED: Results of the project indicate that the concept mapping learning strategy intervention had a positive effect in improving novice graduate nurses’ critical thinking, prioritization of nursing assessments/interventions related to infection prevention, and retention of infection prevention nursing care knowledge.
Presentation Number 5-305 Automated Hand Hygiene Monitoring and Nosocomial Infection Marker Reduction Angela Cape RN, Infection Preventionist & Employee Health Coordinator, Medical Center Enterprise ISSUE: In 2011, Medical Center Enterprise used a form based on the iScrub application to monitor hand hygiene. Even with multiple personnel collecting data, we were unable to get large
APIC 40th Annual Conference j Ft Lauderdale, FL j June 8-10, 2013
Poster Abstracts / American Journal of Infection Control 41 (2013) S25-S145
denominator data. The results offered little insight beyond direct observation and it was impossible to generalize our findings to the entire staff and/or all hand cleansing opportunities. The findings also could have been affected by observer bias and by changes in caregiver behavior based on the knowledge that they were being observed. With this in mind, we began to seek other opportunities and technologies to help us with these challenges. PROJECT: We installed an automated hand hygiene monitoring system in the 29-bed 4 North medical-surgical unit. We monitored 29 soap dispensers and 31 alcohol-based hand rub (sanitizer) dispensers in patient rooms using communication units and radiofrequency identification (RFID) tags. We also monitored 6 hallway sanitizer dispensers and 1 sanitizer dispenser in a storage room. In June 2012, we distributed tags and educated five staff members from three departments on 4 North to validate system performance. In July 2012, we tagged and educated 34 more employees on 4 North. Hand-hygiene solution dispensing, hand-hygiene compliance and healthcare-associated infection (HAI) rates were measured from June 2012 through November 2012. In October 2012, newly hired employees were tagged and all tagged staff was reeducated. RESULTS: In June, hand-hygiene compliance among the initial five staff members was 67%. In July 2012, compliance dropped to 46% after giving tags to another 34 personnel. There was a 26.3% increase (20,188-25,502) in alcohol-based hand rub (sanitizer) dispenses and a 23.4% increase in total hand hygiene solution dispenses (21,861-26,977) when compared the first and second months of using the system. With continued education and feedback, hand-hygiene compliance rose to 58.6% in November (MTD November 20, 2012). Hand hygiene compliance for all employees increased 27% (46.1%-58.6%) when comparing the first and last months of compliance monitoring (July-MTD November 20, 2012). For June-August, we had a 50% reduction in nosocomial infection markers (NIMs) compared to the same time period from 2011. This reduction equals an estimated $93,470 direct cost savings, an estimated bottom line impact of $52,060 and 81.2 days of length of stay avoided. LESSON LEARNED: Constant feedback and holding staff members accountable, while recognizing those with excellent performance and frequent patient room visits, was vital to compliance with hand hygiene and improved patient outcomes.
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Presentation Number 5-306 Education Excellence in Scope Reprocessing to Improve Patient Safety Lisa K. Caffery MS, BSN, RN, BC, CIC, Infection Prevention Coordinator, Genesis Health System; Camilla Lancaster RN, CGRN, Charge Nurse, Genesis Medical Center; Marcia Buckles BSN, RN, BC, Level III Staff Nurse, Genesis Medical Center; Melissa Braddock BSN, RN, Manager, OR, Genesis Medical Center, DeWitt; Annette Holst MSN, RN, BC, Staff Development Specialist, Genesis Health System ISSUE: Imagine you are the patient that enters the hospital for a routine diagnostic endoscopic procedure and several days later you receive notification that you may have been exposed to an infectious disease due to improper scope reprocessing. While still a rare event, there have been outbreaks associated with improper reprocessing of scopes. Meticulous competency performance is imperative in endoscopic scope reprocessing in preventing transmission of pathogens from equipment. Accrediting agencies require organizations to follow nationally recognized guidelines for reprocessing to ensure safe patient outcomes. This organization identified issues in standardization and development of policy, procedures, training and quality improvement interventions were developed to prevent adverse outcomes related to high level disinfection. PROJECT: The PDCA Model for improvement was utilized in assessing current practices. Numerous opportunities for improvement were identified and solutions explored. Key elements for training were noted including inconsistency between departments. A collaborative team of Endo Nurses, Infection Prevention and Education was convened to address competency and training and improve learning outcomes. It was also identified that scope reprocessing was not limited to the endoscopy setting but also included perioperative and sterile processing departments across the health system. RESULTS: The team discovered that one department had created a training manual that included explicit procedures for staff to follow. Building on this best practice, the team implemented the training manual on all campuses. The team also developed a standardized competency, test and online learning module to ensure safe, effective outcomes of the program. Mandatory skills labs to validate correct return demonstration of competency were implemented in all involved departments. Peer validation and testing demonstrated significant improvement of staff performance. Post-testing analysis showed all 50 staff achieved a competency level of >95%. LESSON LEARNED: This project demonstrated the importance of teamwork and collaboration of multi-system departments and various disciplines including Pperioperative Sservices, Sterile Processing, Endoscopy, Infection Prevention Specialist and Education Specialists. The team was able to identify the issues and work together to allow for more effective competency development in prevention of potential contamination. Continued analysis of testing results and skills validation has targeted areas for further ongoing training.
Presentation Number 5-307 Improving Isolation Practice and Compliance with a Little Red Box Deborah Snell RN, Infection Prevention Nurse, Fletcher Allen Health CAre
APIC 40th Annual Conference j Ft Lauderdale, FL j June 8-10, 2013
Poster Abstracts / American Journal of Infection Control 41 (2013) S25-S145
Education and Competencies Presentation Number 5-303 Inter-rater Reliability of Catheter-associated Urinary Tract Infection among Infection Preventionists in a Multi-Hospital System Marc-Oliver Wright MT(ASCP),MS, CIC, Director, Infection Control, NorthShore University HealthSystem; Corrinna Brudner BSc, C.P.H. I (C), CIC, Infection Preventionist, NorthShore University HealthSystem; Adrienne Fisher MT(ASCP), CIC, Infection Preventionist, NorthShore University HealthSystem; Carolyn Hines RN, CIC, Infection Preventionist, NorthShore; Vanida Komutanon RN, MPH, CIC, Infection Preventionist, NorthShore; Anna Ogle RN, MPH, CIC, Infection Preventionist, NorthShore; Becky Smith MD, Hospital Epdiemiologist, Infectious Disease Physician, NorthShore University HealthSystem BACKGROUND/OBJECTIVES: Recent requirements from the Centers for Medicaid and Medicare Services have mandated catheterassociated urinary tract infection (CAUTI) surveillance and reporting among intensive care unit (ICU) patients. Manual surveillance by infection preventionists (IPs) can be subjective. METHODS: In a multi-hospital delivery system, within a single, unified infection prevention department with an available electronic medical record, 5 certified IPs were allocated a total of 51 charts for review. The charts were preferentially selected for patients with positive urine cultures on or after day 3 of hospitalization. Each IP had previously completed the online training for CAUTI surveillance provided by the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN). Each chart was reviewed by 2 IPs; in the event of discordance, the department director and hospital epidemiologist reviewed the case to make a final determination. Kappa scores with 95% confidence intervals (CI) are provided. RESULTS: Overall, the IPs were concordant 66.7% (34/51) of the time for a kappa of 0.24 (95% CI: -0.03, 0.51) and varied widely across the hospitals (50%, 60%, 65% and 90%). Proportions for positive and negative agreement were 0.48 and 0.75 respectively, suggesting that IPs were more likely to agree when the patient clearly did not represent a potential CAUTI. Common areas of disagreement included ascribing patients that met symptomatic CAUTI criteria to “secondary” causes (for which no criteria exist), interpreting Gram-stain results on spun (versus the definitional requirement for unspun) urine and disagreement regarding temporal requirements for symptom presentation. IPs underwent continuing education and training regarding the discordant cases and recurring themes following this exercise. CONCLUSIONS: Even among certified IPs within a single department with identical training and surveillance resources, discordance in manual surveillance of CAUTI is prevalent.
Presentation Number 5-304 Teaching Infection Prevention Using Concept Mapping Learning Strategies Peggy H. Anderson DNP, MS, RN, Associate Teaching Professor, Brigham Young University; Christie Johnson MSN, RN, Clinical Educator, Intermountain Healthcare Urban South Region; Karen Singson RN, MSN, CIC, Infection Preventionist, Intermountain Healthcare
ISSUE: Novice nurses are often overwhelmed as they apply new knowledge to nursing practice. They frequently fail to implement infection prevention strategies as prioritized nursing cares. Concept mapping has been shown to increase student and novice nurse ability to identify and prioritize nursing assessments/interventions. Instructors from a RN residency program evaluated the use of concept mapping to facilitate novice nurse learning and application of infection prevention strategies. PROJECT: Sixteen graduate nurses enrolled in a RN residency program participated in the concept mapping learning strategies study. Concept mapping was taught during an HAI prevention classroom session. After a review of concept mapping and infection prevention strategies, each resident developed a concept mapbased on a HAI case scenario. The concept map included the main diagnoses, medications, lab findings, critical nursing assessments and interventions, prioritization of interventions, and connections between related systems and pathological symptoms. Residents then recreated the concept map as a group by presenting the care needed for each pathophysiological system. Connections between related systems and nursing intervention priorities, including infection prevention strategies, were identified and discussed. Following the group discussion, residents developed an additional map based upon a similar patient care scenario. A third concept map was completed by the residents two weeks later. Completed concept maps were scored for evidence of critical thinking, identification of nursing assessment and interventions, and prioritization of nursing cares. At the study’s conclusion, residents evaluated the effectiveness of concept mapping as a learning tool. RESULTS: Statistical testing was used to determine interrater reliability and evaluate the completed concept map scores. Testing included paired t-tests, repeated measures analysis of variance (RM ANOVA) test and post hoc testing, Friedman test, and Generalizability Theory evaluation scores. Results indicated that the participants’ scores changed in a positive direction over time. There was a significant increase (p ¼ .001) in scores between Map 1 and Map 2 and a slight decrease between Map 2 and Map 3; the scores did not return to baseline however and the slight decline was not significant. The partial eta squared value indicated that 77.1% of variance in the concept map scores could be attributed to changes in scores across time. Residents commented that concept mapping helped them identify possible HAI risks and organize associated patient care needs, as summarized by one resident, “Unless you see the big picture you can overlook small things that can turn big.” LESSON LEARNED: Results of the project indicate that the concept mapping learning strategy intervention had a positive effect in improving novice graduate nurses’ critical thinking, prioritization of nursing assessments/interventions related to infection prevention, and retention of infection prevention nursing care knowledge.
Presentation Number 5-305 Automated Hand Hygiene Monitoring and Nosocomial Infection Marker Reduction Angela Cape RN, Infection Preventionist & Employee Health Coordinator, Medical Center Enterprise ISSUE: In 2011, Medical Center Enterprise used a form based on the iScrub application to monitor hand hygiene. Even with multiple personnel collecting data, we were unable to get large
APIC 40th Annual Conference j Ft Lauderdale, FL j June 8-10, 2013
Poster Abstracts / American Journal of Infection Control 41 (2013) S25-S145
denominator data. The results offered little insight beyond direct observation and it was impossible to generalize our findings to the entire staff and/or all hand cleansing opportunities. The findings also could have been affected by observer bias and by changes in caregiver behavior based on the knowledge that they were being observed. With this in mind, we began to seek other opportunities and technologies to help us with these challenges. PROJECT: We installed an automated hand hygiene monitoring system in the 29-bed 4 North medical-surgical unit. We monitored 29 soap dispensers and 31 alcohol-based hand rub (sanitizer) dispensers in patient rooms using communication units and radiofrequency identification (RFID) tags. We also monitored 6 hallway sanitizer dispensers and 1 sanitizer dispenser in a storage room. In June 2012, we distributed tags and educated five staff members from three departments on 4 North to validate system performance. In July 2012, we tagged and educated 34 more employees on 4 North. Hand-hygiene solution dispensing, hand-hygiene compliance and healthcare-associated infection (HAI) rates were measured from June 2012 through November 2012. In October 2012, newly hired employees were tagged and all tagged staff was reeducated. RESULTS: In June, hand-hygiene compliance among the initial five staff members was 67%. In July 2012, compliance dropped to 46% after giving tags to another 34 personnel. There was a 26.3% increase (20,188-25,502) in alcohol-based hand rub (sanitizer) dispenses and a 23.4% increase in total hand hygiene solution dispenses (21,861-26,977) when compared the first and second months of using the system. With continued education and feedback, hand-hygiene compliance rose to 58.6% in November (MTD November 20, 2012). Hand hygiene compliance for all employees increased 27% (46.1%-58.6%) when comparing the first and last months of compliance monitoring (July-MTD November 20, 2012). For June-August, we had a 50% reduction in nosocomial infection markers (NIMs) compared to the same time period from 2011. This reduction equals an estimated $93,470 direct cost savings, an estimated bottom line impact of $52,060 and 81.2 days of length of stay avoided. LESSON LEARNED: Constant feedback and holding staff members accountable, while recognizing those with excellent performance and frequent patient room visits, was vital to compliance with hand hygiene and improved patient outcomes.
S59
Presentation Number 5-306 Education Excellence in Scope Reprocessing to Improve Patient Safety Lisa K. Caffery MS, BSN, RN, BC, CIC, Infection Prevention Coordinator, Genesis Health System; Camilla Lancaster RN, CGRN, Charge Nurse, Genesis Medical Center; Marcia Buckles BSN, RN, BC, Level III Staff Nurse, Genesis Medical Center; Melissa Braddock BSN, RN, Manager, OR, Genesis Medical Center, DeWitt; Annette Holst MSN, RN, BC, Staff Development Specialist, Genesis Health System ISSUE: Imagine you are the patient that enters the hospital for a routine diagnostic endoscopic procedure and several days later you receive notification that you may have been exposed to an infectious disease due to improper scope reprocessing. While still a rare event, there have been outbreaks associated with improper reprocessing of scopes. Meticulous competency performance is imperative in endoscopic scope reprocessing in preventing transmission of pathogens from equipment. Accrediting agencies require organizations to follow nationally recognized guidelines for reprocessing to ensure safe patient outcomes. This organization identified issues in standardization and development of policy, procedures, training and quality improvement interventions were developed to prevent adverse outcomes related to high level disinfection. PROJECT: The PDCA Model for improvement was utilized in assessing current practices. Numerous opportunities for improvement were identified and solutions explored. Key elements for training were noted including inconsistency between departments. A collaborative team of Endo Nurses, Infection Prevention and Education was convened to address competency and training and improve learning outcomes. It was also identified that scope reprocessing was not limited to the endoscopy setting but also included perioperative and sterile processing departments across the health system. RESULTS: The team discovered that one department had created a training manual that included explicit procedures for staff to follow. Building on this best practice, the team implemented the training manual on all campuses. The team also developed a standardized competency, test and online learning module to ensure safe, effective outcomes of the program. Mandatory skills labs to validate correct return demonstration of competency were implemented in all involved departments. Peer validation and testing demonstrated significant improvement of staff performance. Post-testing analysis showed all 50 staff achieved a competency level of >95%. LESSON LEARNED: This project demonstrated the importance of teamwork and collaboration of multi-system departments and various disciplines including Pperioperative Sservices, Sterile Processing, Endoscopy, Infection Prevention Specialist and Education Specialists. The team was able to identify the issues and work together to allow for more effective competency development in prevention of potential contamination. Continued analysis of testing results and skills validation has targeted areas for further ongoing training.
Presentation Number 5-307 Improving Isolation Practice and Compliance with a Little Red Box Deborah Snell RN, Infection Prevention Nurse, Fletcher Allen Health CAre
APIC 40th Annual Conference j Ft Lauderdale, FL j June 8-10, 2013