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Optimizing Infection Prevention Resources through Standardization of Workflow Integrated with Infection Prevention Software
Oral Abstacts / American Journal of Infection Control 41 (2013) S3-S24
BACKGROUND/OBJECTIVES: The role of infection preventionists (IPs) is expanding in response to demands for quality and transparency in healthcare. Practice analyses and survey research have demonstrated that IPs spend a majority of their time on surveillance and are increasingly responsible for prevention activities and management; however, deeper qualitative aspects of the IP role have rarely been explored. Our objective was to describe the current IP role, specifically the ways IPs effect improvements and the facilitators and barriers they face. METHODS: We conducted in-depth interviews with 19 IPs at hospitals across the US between October 2010 and February 2011. Hospitals were purposively sampled for maximum variation in size, geographic region, healthcare-associated infection (HAI) rates, and degree of implementation of HAI prevention strategies. Topics in the semi-structured interview guide included the structure and function of the infection control department, personnel and roles, education of clinicians, compliance monitoring, facilitators and barriers to infection prevention, and the impact of technological advances and mandatory reporting. Research team members received training in interview techniques from an expert qualitative researcher and engaged in regular peer debriefings. Two IP researchers conducted a qualitative analysis, systematically reviewing and coding the content of interview transcripts in order to derive contextual meaning. The transcripts were read line by line during an extended period of immersion; agreement on emerging themes was reached through consensus. Ideas shared by multiple IPs, as well as divergent opinions, were coded into categories within the themes and faithfully captured in exemplar quotations. RESULTS: The IPs’ interviews documented that the IP role has evolved in response to recent changes in the healthcare landscape, and revealed that this progression was associated with friction and uncertainty. Tensions inherent in the evolving role of the IP emerged from the content analysis as 4 broad themes: (1) expanding responsibilities outstrip resources, (2) shifting role boundaries create uncertainty, (3) evolving mechanisms of influence involve tradeoffs, and (4) the stress of constant change is compounded by chronic recurring challenges. IPs reported using personal interaction, local data, and education to influence clinical practices; however, these mechanisms of influence competed for the IPs’ time and were not always effective at ensuring compliance with institutional policies. CONCLUSIONS: Using rich, verbatim description, this study elucidates the evolution of IPs from siloed experts to facilitators of quality improvement. To support IPs in their developing role, advances in implementation science, data standardization, and training in leadership skills are needed.
Presentation Number 035 Optimizing Infection Prevention Resources through Standardization of Workflow Integrated with Infection Prevention Software Sara B. Bienvenu RN, MSN, Clinical Manager, Infection Prevention, HCA; Julia Moody MS, SM, ASCP, Director Infection Prevention and Control, HCA Inc. Clinical Services Group; Jason Hickok MBA, RN, Associate Vice President Critical Care and Infection Prevention, HCA Inc., Clinical Services Group; Edward Septimus MD, FIDSA, FACP, FSHEA, Medical Director, Infection Prevention and Epidemiology, HCA Inc., Clinical Services Group ISSUE: Variation of infection prevention (IP) workflow and surveillance of hospital-associated infections (HAI) across a large
S21
healthcare organization reveals opportunities to improve work effectiveness and optimize IP resources PROJECT: The concept of leveraging IP software to standardize IP workflow and HAI surveillance for a large healthcare organization was one measure in a proof of concept pilot implementation in six acute care hospitals. The hypothesis was to optimize IP resources by shifting from clerical to clinical interventions, submit electronic datasets to National Healthcare Safety Network (NHSN) for public reporting and reduce HAIs by providing facility and system-wide data analysis. IP work flow design was developed which standardized IP workflow, documentation input and report output for selected IP vendor software. The IP software provided clinical information (electronic medical record, laboratory, radiology, admit/discharge/transfer, surgical procedures and device information) in a single platform providing automated alerts, ease of surveillance, and immediate access to HAI data analysis. IP software training was aligned with standardized workflow and integrated into a structured implementation. A pre- and seven months posttime study was completed by pilot IPs to measure workflow changes. Pilot aggregate central line-associated blood stream infections (CLABSI) and catheter associated urinary tract infection (CAUTI) rates in intensive care units (ICUs) were compared pre- and seven months post- implementation. RESULTS: Compared to pre-pilot time study results, pilot IP workflow expanded from targeted to house-wide surveillance without adversely affecting IP resources; NHSN reporting requirements increased yet required no additional IP resources; and IP time was shifted primarily from clerical to clinical. Pilot aggregate CLABSI rates decreased by 30% year/year comparing first quarter 2011 to 2012 and 6% comparing second quarter 2011 to 2012. Pilot aggregate CAUTI rates decreased by 20% quarter/quarter comparing first quarter to second quarter 2012. The pilot provided a successful business case for executive approval to implement IP software across the organization. Pilot Time Study Results and Outcomes IP Workflow Categories
Pre- Post- Difference
Surveillance
21%
26%
+5
7%
5%
-2
13%
23%
+10
18%
11%
-7
Shift of IP resources to clinical
13% 10%
13% 7%
0 -3
18%
16%
-2
No change; culture dependent Decreased need for consults likely related to increased early clinical preventative interventions and surveillance Shifted resources to surveillance
Public Reporting Clinical Education preventative interventions Clerical Report preparation Rounding Consulting
Other Alerts Daily Reports
Outcomes Expanded from targeted to house-wide Decreased with increased reporting: CAUTI and SSI added Shift of IP resources from clerical
LESSON LEARNED: Our findings demonstrated successful pilot adoption of standardized IP workflow integrated with IP software which optimized IP resources. Overall, IP resources shifted to clinical interventions which contributed to lower pilot aggregate
APIC 40th Annual Conference j Ft Lauderdale, FL j June 8-10, 2013
S22
Oral Abstacts / American Journal of Infection Control 41 (2013) S3-S24
CLABSI and CAUTI rates. Comprehensive workflow design and standardization in a structured implementation, laid a sound foundation for ease of adoption. Integration of cultural change in concert with further standardization of IP workflow with IP software may further optimize IP resources resulting in additional improvement of patient HAI outcomes.
Presentation Number 036 Improving IV Connector Disinfection by Using Human Factors Engineering to Identify Effective, Nurse-Friendly Solutions
Contemporary Issues in Infection Prevention & Surveillance Presentation Number 037 Assessment of the Application of NHSN Surveillance Definitions to Clinical Case Studies: Opportunities for Improvement
Patricia Posa RN, BSN, MSA, FAAN, System Performance Improvement Leader, St. Joseph Mercy Health System; Gail Siedlaczek RN, BSN, Infection Prevention and Control Specialist, St. Joseph Mercy Hospital
Marc-Oliver Wright MT(ASCP), MS, CIC, Director, Infection Control, NorthShore University HealthSystem; Joan Hebden RN, MS, CIC, Clinical Consultant, Sentri7 Woelters Kluwer Health; Kathy Allen-Bridson RN, BSN, MScPH, CIC, Nurse Consultant, Centers for Disease Control and Prevention; Gloria Morrell RN, MS, MSN, CIC, Nurse Consultant, Centers for Disease Control and Prevention; Teresa Horan, Epidemiologist, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention
ISSUE: As a participant in the Keystone ICU Project, our hospital examines every central line-associated bloodstream infection (CLABSI) for insights about prevention, as part of our “journey” to eliminate CLABSI. We uncovered inconsistency in nurses’ execution of the “scrub-the-hub” method for disinfecting intravenous therapy (IV) needleless connector/valve hubs. Scrubbing is a widely used protocol but our analysis showed noncompliance, which increased CLABSI risk, due to the fast pace of nurses’ work. The IV connector design also made adequate scrubbing difficult. We sought a solution that, incorporating human factors engineering (HFE), would make disinfection easier and more efficient for nurses. PROJECT: We identified a disinfection cap as a potential solution. The cap delivered continuous passive disinfection when left in place between line accesses; reached surfaces that scrubbing could not; and could be applied to tubing openings to create a closed system. Initial research strongly associated the cap with lower CLABSI rates. We implemented it in our three intensive care units (ICUs) in January 2011. In January 2012, we made available to nurses a new version in which the cap is held in a flush syringe plunger. This improves compliance by incorporating HFE, to make the cap even more readily available when the IV line is flushed. RESULTS: Our ICU data since joining Keystone show a steady decline in CLABSI rate since 2004, attributable to multiple interventions including insertion and line care bundles, chlorhexidine gluconate (CHG) bathing of patients, and CHG insertion-site dressing. Since implementing the disinfection cap and then improving compliance with the cap-syringe combination, we have approached our goal of zero CLABSIs. As of January 15, 2032, we have had zero CLABSIs in the previous 13 months in our three ICUs (and only one CLABSI in the past 18 months). Because of this success, we implemented the cap and cap-syringe combination hospital-wide in May 2012. The devices are used on all central and peripheral IV lines. Housewide, we’ve seen a 86% CLABSI reduction in the eight months since implementation. LESSON LEARNED: *Shortcomings of the scrub-the-hub method are an often-overlooked source of CLABSI risk. *Use of a disinfection cap, packaged with a flush syringe, incorporates human factors’ engineering to improve both compliance with cap use and effective disinfection of valves. *Monthly compliance auditing and feedback to staff on performance was vital to achieving positive outcomes.
BACKGROUND/OBJECTIVES: Definitions for healthcare-associated infections (HAIs) developed by the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) are used by infection preventionists (IPs) for surveillance activities. Concerns have been raised about the inconsistent application of these definitions among IPs. METHODS: Nine case studies based on 2012 definitions were published in the American Journal of Infection Control. Participants submitted responses via the CDC’s online training website to receive continuing education credits (passing score 80%). All cases, answers, and explanations were reviewed and approved by NHSN. Pearson’s chi-square is used for significance testing. Those participants who self- identified as having a professional role in infection prevention are collectively referred to as IPs. RESULTS: During the evaluation (6/2012 e 9/2012), 297 total respondents participated in the 9 case studies; 27.9% (83/297) achieved the passing score on their first attempt and self-identified as working in healthcare (83.8%), completing education beyond a bachelor’s degree (42.4%) and having 5 or fewer years of experience (45.1%) in infection prevention. Of the 8,613 answers, 64.6% (5,567) were correct, and overall scores ranged 13.8% - 100% with a median and mode of 69.0%. Participants were most accurate answering questions related to attributing skin colonizing organisms in the blood to a clearly infected peripheral site in the presence of a central line and attributing the infection to the correct patient care location (Case #8) and least accurate (Case #2; p<0.001) recognizing that secondary sources of infection do not require matching antibiograms. The 144 IPs were more likely to pass the exam on their first attempt (37.5%, 54/144, p<0.001) and answered correctly more often than non-IPs (73.7% p<0.001). Participants with 10 or more years of experience in infection prevention answered questions correctly more often (69.7%) than those with less experience (64.8% p<0.001) and those having completed a master’s degree passed the entire case study series more often than participants having attained an associate’s or bachelor’s degree (36.7% vs. 23.8% p¼0.02). CONCLUSIONS: IPs attained a passing score of 80% only 37.5% of the time, suggesting a need for competency assessment and further training in applying the NHSN definitions. Performance varied widely by subject matter. The use of case studies can identify definition criteria that require further clarity and guide development of targeted educational efforts.
APIC 40th Annual Conference j Ft Lauderdale, FL j June 8-10, 2013
BACKGROUND/OBJECTIVES: The role of infection preventionists (IPs) is expanding in response to demands for quality and transparency in healthcare. Practice analyses and survey research have demonstrated that IPs spend a majority of their time on surveillance and are increasingly responsible for prevention activities and management; however, deeper qualitative aspects of the IP role have rarely been explored. Our objective was to describe the current IP role, specifically the ways IPs effect improvements and the facilitators and barriers they face. METHODS: We conducted in-depth interviews with 19 IPs at hospitals across the US between October 2010 and February 2011. Hospitals were purposively sampled for maximum variation in size, geographic region, healthcare-associated infection (HAI) rates, and degree of implementation of HAI prevention strategies. Topics in the semi-structured interview guide included the structure and function of the infection control department, personnel and roles, education of clinicians, compliance monitoring, facilitators and barriers to infection prevention, and the impact of technological advances and mandatory reporting. Research team members received training in interview techniques from an expert qualitative researcher and engaged in regular peer debriefings. Two IP researchers conducted a qualitative analysis, systematically reviewing and coding the content of interview transcripts in order to derive contextual meaning. The transcripts were read line by line during an extended period of immersion; agreement on emerging themes was reached through consensus. Ideas shared by multiple IPs, as well as divergent opinions, were coded into categories within the themes and faithfully captured in exemplar quotations. RESULTS: The IPs’ interviews documented that the IP role has evolved in response to recent changes in the healthcare landscape, and revealed that this progression was associated with friction and uncertainty. Tensions inherent in the evolving role of the IP emerged from the content analysis as 4 broad themes: (1) expanding responsibilities outstrip resources, (2) shifting role boundaries create uncertainty, (3) evolving mechanisms of influence involve tradeoffs, and (4) the stress of constant change is compounded by chronic recurring challenges. IPs reported using personal interaction, local data, and education to influence clinical practices; however, these mechanisms of influence competed for the IPs’ time and were not always effective at ensuring compliance with institutional policies. CONCLUSIONS: Using rich, verbatim description, this study elucidates the evolution of IPs from siloed experts to facilitators of quality improvement. To support IPs in their developing role, advances in implementation science, data standardization, and training in leadership skills are needed.
Presentation Number 035 Optimizing Infection Prevention Resources through Standardization of Workflow Integrated with Infection Prevention Software Sara B. Bienvenu RN, MSN, Clinical Manager, Infection Prevention, HCA; Julia Moody MS, SM, ASCP, Director Infection Prevention and Control, HCA Inc. Clinical Services Group; Jason Hickok MBA, RN, Associate Vice President Critical Care and Infection Prevention, HCA Inc., Clinical Services Group; Edward Septimus MD, FIDSA, FACP, FSHEA, Medical Director, Infection Prevention and Epidemiology, HCA Inc., Clinical Services Group ISSUE: Variation of infection prevention (IP) workflow and surveillance of hospital-associated infections (HAI) across a large
S21
healthcare organization reveals opportunities to improve work effectiveness and optimize IP resources PROJECT: The concept of leveraging IP software to standardize IP workflow and HAI surveillance for a large healthcare organization was one measure in a proof of concept pilot implementation in six acute care hospitals. The hypothesis was to optimize IP resources by shifting from clerical to clinical interventions, submit electronic datasets to National Healthcare Safety Network (NHSN) for public reporting and reduce HAIs by providing facility and system-wide data analysis. IP work flow design was developed which standardized IP workflow, documentation input and report output for selected IP vendor software. The IP software provided clinical information (electronic medical record, laboratory, radiology, admit/discharge/transfer, surgical procedures and device information) in a single platform providing automated alerts, ease of surveillance, and immediate access to HAI data analysis. IP software training was aligned with standardized workflow and integrated into a structured implementation. A pre- and seven months posttime study was completed by pilot IPs to measure workflow changes. Pilot aggregate central line-associated blood stream infections (CLABSI) and catheter associated urinary tract infection (CAUTI) rates in intensive care units (ICUs) were compared pre- and seven months post- implementation. RESULTS: Compared to pre-pilot time study results, pilot IP workflow expanded from targeted to house-wide surveillance without adversely affecting IP resources; NHSN reporting requirements increased yet required no additional IP resources; and IP time was shifted primarily from clerical to clinical. Pilot aggregate CLABSI rates decreased by 30% year/year comparing first quarter 2011 to 2012 and 6% comparing second quarter 2011 to 2012. Pilot aggregate CAUTI rates decreased by 20% quarter/quarter comparing first quarter to second quarter 2012. The pilot provided a successful business case for executive approval to implement IP software across the organization. Pilot Time Study Results and Outcomes IP Workflow Categories
Pre- Post- Difference
Surveillance
21%
26%
+5
7%
5%
-2
13%
23%
+10
18%
11%
-7
Shift of IP resources to clinical
13% 10%
13% 7%
0 -3
18%
16%
-2
No change; culture dependent Decreased need for consults likely related to increased early clinical preventative interventions and surveillance Shifted resources to surveillance
Public Reporting Clinical Education preventative interventions Clerical Report preparation Rounding Consulting
Other Alerts Daily Reports
Outcomes Expanded from targeted to house-wide Decreased with increased reporting: CAUTI and SSI added Shift of IP resources from clerical
LESSON LEARNED: Our findings demonstrated successful pilot adoption of standardized IP workflow integrated with IP software which optimized IP resources. Overall, IP resources shifted to clinical interventions which contributed to lower pilot aggregate
APIC 40th Annual Conference j Ft Lauderdale, FL j June 8-10, 2013
S22
Oral Abstacts / American Journal of Infection Control 41 (2013) S3-S24
CLABSI and CAUTI rates. Comprehensive workflow design and standardization in a structured implementation, laid a sound foundation for ease of adoption. Integration of cultural change in concert with further standardization of IP workflow with IP software may further optimize IP resources resulting in additional improvement of patient HAI outcomes.
Presentation Number 036 Improving IV Connector Disinfection by Using Human Factors Engineering to Identify Effective, Nurse-Friendly Solutions
Contemporary Issues in Infection Prevention & Surveillance Presentation Number 037 Assessment of the Application of NHSN Surveillance Definitions to Clinical Case Studies: Opportunities for Improvement
Patricia Posa RN, BSN, MSA, FAAN, System Performance Improvement Leader, St. Joseph Mercy Health System; Gail Siedlaczek RN, BSN, Infection Prevention and Control Specialist, St. Joseph Mercy Hospital
Marc-Oliver Wright MT(ASCP), MS, CIC, Director, Infection Control, NorthShore University HealthSystem; Joan Hebden RN, MS, CIC, Clinical Consultant, Sentri7 Woelters Kluwer Health; Kathy Allen-Bridson RN, BSN, MScPH, CIC, Nurse Consultant, Centers for Disease Control and Prevention; Gloria Morrell RN, MS, MSN, CIC, Nurse Consultant, Centers for Disease Control and Prevention; Teresa Horan, Epidemiologist, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention
ISSUE: As a participant in the Keystone ICU Project, our hospital examines every central line-associated bloodstream infection (CLABSI) for insights about prevention, as part of our “journey” to eliminate CLABSI. We uncovered inconsistency in nurses’ execution of the “scrub-the-hub” method for disinfecting intravenous therapy (IV) needleless connector/valve hubs. Scrubbing is a widely used protocol but our analysis showed noncompliance, which increased CLABSI risk, due to the fast pace of nurses’ work. The IV connector design also made adequate scrubbing difficult. We sought a solution that, incorporating human factors engineering (HFE), would make disinfection easier and more efficient for nurses. PROJECT: We identified a disinfection cap as a potential solution. The cap delivered continuous passive disinfection when left in place between line accesses; reached surfaces that scrubbing could not; and could be applied to tubing openings to create a closed system. Initial research strongly associated the cap with lower CLABSI rates. We implemented it in our three intensive care units (ICUs) in January 2011. In January 2012, we made available to nurses a new version in which the cap is held in a flush syringe plunger. This improves compliance by incorporating HFE, to make the cap even more readily available when the IV line is flushed. RESULTS: Our ICU data since joining Keystone show a steady decline in CLABSI rate since 2004, attributable to multiple interventions including insertion and line care bundles, chlorhexidine gluconate (CHG) bathing of patients, and CHG insertion-site dressing. Since implementing the disinfection cap and then improving compliance with the cap-syringe combination, we have approached our goal of zero CLABSIs. As of January 15, 2032, we have had zero CLABSIs in the previous 13 months in our three ICUs (and only one CLABSI in the past 18 months). Because of this success, we implemented the cap and cap-syringe combination hospital-wide in May 2012. The devices are used on all central and peripheral IV lines. Housewide, we’ve seen a 86% CLABSI reduction in the eight months since implementation. LESSON LEARNED: *Shortcomings of the scrub-the-hub method are an often-overlooked source of CLABSI risk. *Use of a disinfection cap, packaged with a flush syringe, incorporates human factors’ engineering to improve both compliance with cap use and effective disinfection of valves. *Monthly compliance auditing and feedback to staff on performance was vital to achieving positive outcomes.
BACKGROUND/OBJECTIVES: Definitions for healthcare-associated infections (HAIs) developed by the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) are used by infection preventionists (IPs) for surveillance activities. Concerns have been raised about the inconsistent application of these definitions among IPs. METHODS: Nine case studies based on 2012 definitions were published in the American Journal of Infection Control. Participants submitted responses via the CDC’s online training website to receive continuing education credits (passing score 80%). All cases, answers, and explanations were reviewed and approved by NHSN. Pearson’s chi-square is used for significance testing. Those participants who self- identified as having a professional role in infection prevention are collectively referred to as IPs. RESULTS: During the evaluation (6/2012 e 9/2012), 297 total respondents participated in the 9 case studies; 27.9% (83/297) achieved the passing score on their first attempt and self-identified as working in healthcare (83.8%), completing education beyond a bachelor’s degree (42.4%) and having 5 or fewer years of experience (45.1%) in infection prevention. Of the 8,613 answers, 64.6% (5,567) were correct, and overall scores ranged 13.8% - 100% with a median and mode of 69.0%. Participants were most accurate answering questions related to attributing skin colonizing organisms in the blood to a clearly infected peripheral site in the presence of a central line and attributing the infection to the correct patient care location (Case #8) and least accurate (Case #2; p<0.001) recognizing that secondary sources of infection do not require matching antibiograms. The 144 IPs were more likely to pass the exam on their first attempt (37.5%, 54/144, p<0.001) and answered correctly more often than non-IPs (73.7% p<0.001). Participants with 10 or more years of experience in infection prevention answered questions correctly more often (69.7%) than those with less experience (64.8% p<0.001) and those having completed a master’s degree passed the entire case study series more often than participants having attained an associate’s or bachelor’s degree (36.7% vs. 23.8% p¼0.02). CONCLUSIONS: IPs attained a passing score of 80% only 37.5% of the time, suggesting a need for competency assessment and further training in applying the NHSN definitions. Performance varied widely by subject matter. The use of case studies can identify definition criteria that require further clarity and guide development of targeted educational efforts.
APIC 40th Annual Conference j Ft Lauderdale, FL j June 8-10, 2013