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1 For audio, join by telephone at , participant code # Your line is OPEN. Please do not use the hold feature on your phone but do mute your line by dialing *6. If you are having technical difficulties, You may ask questions through the chat box or anytime through the call today

2 August 16, 2018 Deb Campbell, RN-BC, MSN, CPHQ, CCRN Alumna K-HIIN Infection Prevention Improvement Advisor Ky Hospital Improvement Innovation Network

3 Discuss cross cutting interventions Hand hygiene Environmental hygiene Bundles Discuss testing options/best practices for C. difficile and MRSA bacteremia Explore possible associated process measures *Remember, the goal is not to discuss specific interventions in detail, but rather monitoring and feedback as prevention mechanisms!!

4 An intervention that has the potential to positively impact more than one harm area. REDUCE MRSA study supports a universal infection prevention approach To coin a phrase, we can kill 2 (or multiple) birds with one stone, but.

5 Bundles Environmental Cleaning Patient Hygiene HCW HH Antimicrobial Stewardship ** So, what is the money shot?? Is there one? How much time do you have?

6 Since 1847, we have known that HH (or lack thereof) makes a difference in the spread of infection. Average HH compliance rate nationally is quoted by HRET as 48%. How can we have made so little progress? No direct connection between actions and consequences Educate? Accountability? Human factors: busy, complex system- no forcing function No easy button!

7 The Joint Commission to increase focus on hand hygiene As of January 1, 2018, any observation by surveyors of individual failure to perform hand hygiene in the process of direct patient care will be cited as a deficiency resulting in a Requirement for Improvement (RFI) under the Infection Prevention and Control (IC) chapter (Standard IC ) for all accreditation programs. Read The Joint Commission article available on their website.

8 Remember: RI = the difference between a great policy and actual best practice at the bedside consistently every day every time for every patient. How do we get there? Surveillance is the best way to ensure appropriate compliance. Sound easy??

9 A sample is: A few of many Part of a whole A good sample is something else! Recent high functioning facility data 480 observations v. 632, 404 opportunities (HHO)* * Gel in and out only- missing MANY multiples more ( 5 moments ) 35% of HHO occur inside the patient room Higher risk Compliance rates are lower McCalla, et al AJIC

10 Common Errors: Too small Not representative Not accurate Representative samples allow us to make accurate statements about the population as a whole If you missed the first webinar, there are 6 slides on this topic.

11 Intervene immediately if a breach is observed Unscheduled observation by trained observers- secret shoppers No ability to intervene Not enough human resource (manpower) Staff dissatisfaction with spying De-identified data- no accountability

12 Should we care? We want them to do it, so.. Example: If I am observing 98% of the interactions, then the Hawthorne Effect would attain a 98% compliance rate!!!!!!!!!!!! The closer our sample size is to the population, the less we care, but remember the numbers we saw on the Sampling slide Kovacs, et al MDs overtly observed- 84% MDs covertly observed- 50% RNs 86% v. 45% New data %

13 To be useful, your measure needs to: Reflect specific behaviors Be consistently assessed Be unbiased (Is the fox watching the hen house?) Be representative of the whole population Length and frequency of training How can they ask questions/get clarification? Inter-rater reliability **QIO HH Observation Training Toolkit is available in the media library

14 The ICP/quality manager cannot do it all effectively! Nursing leaders/other leaders (Caution!) Positive deviants! (Optimum outliers) Champions evals, gift cards, lunch tickets Students Other departments Volunteers- PFAC? Families, patients Other disciplines (plus ward secretaries, etc) Surveys

15 Larger sample size Reduces bias Data allows improved accountability No coaching opportunities No technique assessment* No obstacle/barrier identification **EHCO- Electronic HH Compliance Organization: non-profit consortium Product brand neutral HH-The problem we only think we ve solved. APIC, IDSA, WHO, TJC, SHEA, DNV, CMS- all have cited their data

16 E-monitoring plus observations Is this our future? Best practice? No mandate Quantity v. quality conundrum

17 Share it- not just the numbers and not just on dashboards and at meetings!! Rewards for unit, department or discipline improvement Individual Accountability Include in evaluations- goals and measurable objectives! Use the same disciplinary process- just culture! Education-> Verbal warning->written warning-> Discover (and work to overcome) barriers!! Real (access) and excuses (time, skin issues) *TJC-document HH factors and solutions

18 100%?? Benchmark (unknown) v. incremental goals Use competition- make it fun! Compete against your past performance Compare units/departments/disciplines Celebrate success!

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20 TJC - Most cited issues in the last 5 years involve cleaning, disinfecting and sterilizing How can we best measure the effectiveness of our processes around this aspect of healthcare? Feel like world hunger? *One bite at a time!

21 Rooms Curtains (best practice v. practicality) Light switches, suction bucket rack, O2 dispensing valves/flowmeters, monitors, ventilator Inside of drawers, overbed tables, bedside commodes Mattresses, bed frames, stretchers ED and transport Portable electronic devices, computers EKG machines, exam lights Pill crushers/splitters BP cuffs/device, glucose monitors, IV poles, thermometers, SCDs, wheel chairs Remote control devices, call light, phones

22 Carts: med, anesthesia, crash, isolation, chemo, linen and trash, EVS, dietary, LAB TRAYS PT equipment- walkers, canes, gait belts Storage areas Ice machines/refrigerators Floors? Controversy! Are disposables disposed of? When? Urinals, bed pans, suction canisters and tubing *Who does what? The dot experiment

23 No touch UV H2O2 Ozone Chemical cleaners Kill claims, wet time Ready to use Dispensing equipment Microfiber? Enhanced coatings? Contact time? Compatibility? ** All of these may impact what process measure(s) you choose!

24 Bleach cleaning of all patient rooms at discharge* UV disinfection at discharge Replacement of curtains at discharge Routine bleach cleaning of other areasnurses station, hallway handrails, door knobs Increased monitoring of gowns and gloves with weekly compliance report at safety huddle ASP

25 Rates of infection by type/location/specialty Results of prior surveys Findings from rounding Ask your staff! EVS Nursing Ancillary departments Start small and build! Don t try to do it alone!

26 Observation-> regular purposeful ROUNDING Ripped upholstery (pillows, mattresses, chairs) Observations-> during task performance Covert? Not? Remember- people will proudly demo wrong technique, e.g., contact/wet times Inspections/Checklists Double check system Teresa Daniels ATP Phosphorescent markers Culturing (CDC recommends against routine cxing)

27 Walk rounds through entire facility looking at each and every piece of equipment Who cleans it? How is it cleaned? How frequently is it cleaned? How is it stored? How is it tracked/documented? Standard of Work (Lean verbiage)- in each department and used in orientation/training Took a photo of each room/color coded, e.g., outside EVS, inside RNs.

28 Numerator (clean) v. total items/surfaces on list Example- 6 things found unacceptable in a room with 48 things on the list to check. 42/48= 87.5% All or nothing Example 10 rooms cleaned by an EVS worker inspected, 8 completely cleaned. 8/10 = 80% Patient survey scores TATs- monitoring for too short a time* not

29 Share it- not just the numbers/not just on dashboards and at meetings!! What issues are you seeing? Use for training and re-training! Regular agenda item to keep topic top of mind to get resources needed Discover (and work to overcome) barriers!! Real (things in the way, knowledge deficit) v. excuses (TAT issues) Process for transport of pts in precautions not clear or absent

30 Overcoming this barrier-thinking of this work as a response to regulations/certification/survey scores v. patient safety Use for friendly competition/contests Rewards for shift and individual performance Individual Accountability for EVS AND others Include in evaluations- goals and measurable objectives!

31 Interventions that reduce inappropriate antibiotic usage have been shown to reduce MDRO and C. difficile incidence De-escalation, IV to PO, more targeted antibiotic therapy v. broad spectrum, timely discontinuation of antibiotics Decrease in unnecessary prescribing, e.g., asymptomatic bacteruria, many upper respiratory infections We can reverse resistance patterns! HRET C. difficile change package has a list of suggested process measures on p.5. # pts receiving Vancomycin as first line med/# pts treated

32 Enteric* Precautions Contact precautions PLUS HH with soap and water (PLUS ABHR?) Bleach for environmental cleaning Pt dedicated or disposable equipment Private room Gowns and gloves Unanswered question How long to maintain precautions 24, 48 or 72 hrs with no diarrhea, entire stay*, forever? Many decisions you have to make based on literature and your facility s needs Bottom line- these decisions will drive your process measures!

33 Observations for CORRECTLY performed soap and water HH HH observation data- 20/25 correct=80% Specific data more helpful- Of the 5, 4 washed for less than 15 seconds. More actionable! # pts provided HH product/#pts observed* Observations specific to use of sporicidal cleaning product(s) Checklist results 32/40 correctly cleaned=80% Specific data 1/40 failed to use sporicidal cleaner while 7/40 missed the IV poles. ** *AJIC Vol 45, Issue 9,

34 # correct use of PPE by staff/# observations # pts placed on precautions at time symptoms appear (don t wait for + test/# pts who should have been immediately isolated # C. diff discharge rooms receiving enhanced cleaning process/# C. diff discharge rooms # pts receiving PPIs (Proton Pump Inhibitors)/# patients appropriate to be receiving PPIs* Staffing Nursing EVS

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36 Order of testing aka Oh, NAAT, what have you done to us? Testing for toxin last to try to facilitate only reporting active disease, not colonization (not to mention treating) IDSA/SHEA 2017 C. diff guidelines recommend using GDH plus toxin OR NAAT plus toxin Best practice Using a testing algorithm and order sets Repeat tests and tests for cure are major issues Lab rejection of all but stool which conforms to the shape of the container When and how results are shared with IP, staff

37 # specimens sent that were rejected/# sent* # non liquid stools tested/# specimens sent # orders for C. diff testing that did not meet criteria/# orders for C. diff test # pts with tox- results treated/ # not treated when tox- Time from awareness of unexplained diarrhea to precautions in place * Journal of Clinical Microbiology, May 2017

38 Prevent device related infections CLABSI CAUTI VAP Prevent SSIs Prevent skin breakdown Burden reduction via CHG bathing/application+oral Wellness Optimization Hydration Nutrition Hygiene *See previous webinars for process measures related to all of the above!

39 To isolate or not to isolate Who and for how long? Pts with active infections v. colonized Decolonization- who? Pts with an infection, e.g., skin All pts in a specific population, egtkr Those who screen positive Who do you screen? All pts v. spec. populations (staff?) Decolonization-how? Antimicrobial prophy Nasal alcohol, Povidone Iodine or Mupiricin CHG baths/applications ( %, cloths/bottle, # days) Oral rinses *Morgan, et al, ICHE Oct 2015

40 # correct use of PPE by staff/# observations # pts admitted for TKR who had CHG application day before and day of surgery/# pts admitted for TKR # pts screened/# pts in population designated to be screened # pts who received a CHG application daily/# pts in the ICU # pts who received all elements of decolonization protocol/# designated to be decolonized

41 Contaminated specimens drawn for blood culture From CVLs which have biofilm present From venipunctures with poor technique and maybe even good technique AHA Webinar, Emergency Department, Lab, and Antimicrobial Stewardship: Connecting the Dots. Addressing a Clinical Decision Dilemma at the Source conducted by Christopher D. Doern Ph.D. Director of Clinical Microbiology VCU, Medical College of Virginia and Lindsey Nielsen PhD, University of Nebraska Medical Center. ConnectingtheDotsWebinar_On-DemandWebinarReplay.html

42 Blood culture contamination rate-> goal of 0, not just<2.5. # BC specimens drawn per venipuncture/# BC specimens collected # correct technique during BC specimen collection/# observed

43 Surgical/procedural areas Scopes Sterile supplies Reprocessing Pharmacy clean rooms Ancillary department specific equipment,e.g., MRI, lab benches Medication storage requirements Linen processing Construction areas Water safety- Legionella

44 Outcomes matter, but processes drive them!

45 PLEASE let us help if this is new for you or you would just like a second opinion or advice from someone outside your everyday work flow!! dcampbell@kyha.com Process measure webinar # 10 Sepsis process measures Thursday, September 20 at 11am ET (10am CT)