Challenges faced by ambulance services. Nigel Barr

Transcription

1 Challenges faced by ambulance services Nigel Barr 1

2 Sequential mixed methods project Challenges for Infection Prevention and Control Practices in Paramedic-Led Healthcare: Self-reported Behaviours and Perceptions of Australian Paramedics Study 1 Document analysis Study 2 Semi-structured interviews Study 3 Online survey Study 4 Semi-structured focus groups Ethical clearance: USC HREC S/10/252 S/14/719 2

3 Situational Analysis Transition Attrition rates Education models Scope of practice Guidelines and standards 3

4 Situational analysis Difficulty Unscheduled healthcare Lack of harmonisation Cultural norms Paramedic apathy & varying standards Lack of reporting breaches Semi autonomous workforce Difficulty auditing Difficulty enforcing policy 4

5 Social analysis paramedic perceptions and knowledge The paramedic participants Felt confident with their IPC practices, and view IPC as being important Perceived that IPC was undervalued by peers and managers. Described perceived barriers to the application of IPC in the field Unlikely to report breaches Substantial knowledge gaps 5

6 Social analysis- Perceived Barriers to IPC Perceived Barrier Hand Hygiene & Gloving Env Hygiene Clinical Gov ANTT Insufficient time (operational pressure & scene time limits) x x x x Cultural norms and attitudes x x x Access to products x x x Appropriateness of products x x x Difficulty x x x Training x x x x Knowledge x Challenging environment x x 6

7 The percentage of responses aligning to NHMRC advice Process Met Mostly met Not met Small spills (n=330) Large spills (n=353) Small items (n=372) Large items (n-360)

8 Epidemiological assessment Problematic behaviours Hand hygiene Gloving Environmental hygiene Aseptic Non Touch Technique Clinical governance 8

9 Epidemiological assessment Problematic behaviours - hand hygiene Immediately before touching a patient After touching the patient s surroundings Immediately before inserting an intravenous cannula Shortly after inserting an intravenous cannula Prior to the recording notes, paper or electronic Immediately before driving After removing gloves or PPE At the completion of a case Percentage (%) Frequently performs hand hygiene Infrequently performs hand hygiene 9

10 Who frequently perform hand hygiene before IV insertion. Tests: Pearson Chi squared tests and Logistic regression (binary logistic model) to adjust the P value Demographic variables: Gender, clinical practice level, competency based training, pre /post-employment training, highest education, other health training, time post qualification, jurisdiction Variables of interest P value raw/adjusted Gender (n=417) / Competency based training for standard precautions (n=417) / Health training (n=387) / <0.001 Time post qualification (n=417) / Jurisdiction /

11 Epidemiological assessment Problematic behaviours - gloving Use All SoPIC participants for every clinical case Changing gloves 89.2% broken 85.6% soiled with blood 57.8% end of a case if not broken/soiled. Compliance worsened with increased acuity Workarounds - Double gloving My gloves stay on from the moment I arrive at the scene until I have completed all the case, including paperwork 11

12 Phase 2 Epidemiological assessment Problematic behaviours - environmental hygiene Inappropriate cleaning methods & biocide misuse Inconsistent schedules for the routine and deep cleaning of ambulances 12

13 Most frequently reported locations of blood contamination inside an ambulance by those who observed blood contamination more than 3x per year at the beginning of a shift. Stretcher frame Internal compartment Extrication equipment Patient restraint harness Patient care consumables Stretcher mattress Computerised equipment Non-computerised patient care equipment Vehicle generally Documents Percentage 13

14 Ecological and Educational diagnosis Identified factors that must be addressed for behavioural change Predisposing factors provide the rationale or motivation to behave in a particular way Predisposing Beliefs, attitudes, values and knowledge. Reinforcing factors contribute to behaviour repetition Reinforcing Positive and negative rewards Enabling Availability & accessibility of resources, policy and training Enabling factors assist to realise a motivation 14

15 Phase 3 Ecological and educational diagnosis studies 1 to 4. Factor direction Predisposing factors Enabling factors Reinforcing factors Positive Perceived importance of IPC (3) Glove use (3+4) Self-protection (2-4) ABHR use (3+4) Negative (challenges) Tough guy persona and self-protection (2-4) Glove misuse (3+4) Poor knowledge and awareness of IPC policies and practices (3) Declarative and functional knowledge deficit (3) Guidelines (1) Aide memoirs (2) Lack of harmonisation of IPC guidelines (1) Poor knowledge (3+4) Poor access to resources (3) Peers will raise concerns with peers after events (3) Difficulty auditing (2) Little audit or feedback by managers (2) Culture of not reporting (2+3) Culture of not stopping breaches (3) 15

16 Transformational change - recommendations National paramedic IPC guidelines Contextualise and harmonise national guidelines for paramedic-led healthcare Remove barriers to IPC Appropriate resources - disseminate policy and equip paramedics Improve skills training, knowledge & critical thinking Improve reporting of processes and breaches Promote transformational change Strong leadership IPC must be a priority Auditing and feedback Encourage champions to be the agents of change 16