Education, Audits & Feedback for HAI Prevention

Transcription

1 Education, Audits & Feedback for HAI Prevention Using Competency-Based Training, Audits and Feedback to Drive Best- Practice for Infection Prevention

2 Acknowledgements Dan Bennett, CHESP, M-CHEST, T-CHEST David Calfee, MD, MS Ruth Carrico, PhD, APRN, FNP-C, CIC Marcia Cooke, DNP, RN-BC Shannon Davila, MSN, RN, CIC, CPHQ Erik Dubberke, MD Linda R. Green, MPS, RN, FAPIC Milisa Manojlovich, PhD, RN, CCRN Russ Olmstead, MPH, CIC Jeffrey Rohde, MD Laraine Washer, MD 2

3 Objectives Define competency-based training for infection prevention practices and explain their importance Describe the key components of an effective audit and feedback process Apply suggested tools and strategies to improve infection prevention practices 3

4 Improving Infection Prevention Practices Competency- Based Training Audit Feedback 4

5 Peripheral IV (PIV) Project Evaluated the effect of training, audits and feedback on processes related to PIV insertion & maintenance (Fakih, 2012) Evaluated 10 medical-surgical units and 72-bed emergency department at an 804-bed teaching hospital Steps for insertion, documentation, accurate site assessment, dressing integrity, accessing line to administer medication/flush, supplies 5

6 PIV Project - Training Education consisted of a 30-minute didactic module to nurses with pre- and post-tests on PIV knowledge Med-Surg: Site assessment; dressing; documentation; safe infusion practices ED: PIV insertion policy on hand hygiene; proper skin prep; technique and dressing Lots of photos, interactive questions Scenarios of actual patients poor outcomes What could we have done differently? 6

7 PIV Project Audits & Feedback 7

8 PIV Project Audits & Feedback 1. Wash/sanitize your hands 2. Scrub patient s skin with CHG for 30 seconds 3. Allow patient s skin to dry for 30 seconds 4. Do not re-palpate or contaminate site once cleaned 5. Apply sterile, transparent dressing with date and gauge documented (Fakih, 2012)

9 Nursing Feedback on Training, Audits & Feedback PIV Project Hearing about the patient outcomes was very eye-opening.... I won t look at an IV the same way again. The how-to s on IV care I knew about. It was the patient stories that really hit home. The nurse talking to staff and observing was great because she gave me useful feedback and pointed out things I wouldn t have thought of. I thought this would be a big waste of time IVs are basic nursing knowledge, right? That the hospital invests the time on this makes me realize they really care about safety. 9

10 Competency-Based Training (CBT) Application of knowledge & skills Performing a task correctly and skillfully Initial/Core Competency: upon hire or during orientation Ongoing Competency: annually, or when new practices are introduced Different roles, different competencies 10

11 Infection Prevention CBT Infection Prevention Competency Assessment for Healthcare Personnel: The verification of IP competency through the use of knowledgebased testing and direction observation. If direct observation is not included as part of a competency assessment, an alternative method to ensure that healthcare personnel possess essential knowledge, skills, and abilities should be used. CDC, Infection Control Assessment Tools; last updated February 15,

12 Do All HCP Know About Potential Harm? How are poor patient outcomes related to patient care (including invasive device use) shared with those directly working with patients? Relationship between care delivery (including device use) and infection risk Clear understanding how actions/non-actions impact patient outcomes 12

13 Essential Elements of CBT Are the right people included in the training? Is training done at hire or before providing care/performing specific procedures? Is training done at least annually and with new equipment or protocols? Are infection prevention domain elements addressed? Are HCP required to demonstrate competency? Is there a system to document competency for each HCP? Yes 13

14 Benefits of Auditing Gives a more realistic picture of how HCPs apply the knowledge, skills and attitudes in work environment Monitors adherence to infection prevention standards (gaps) Opens conversation with HCP - what do they perceive as barriers? Allows for actual examples/scenarios when providing feedback on performance 14

15 Infection Prevention Processes Adherence to Transmission- Based Precautions Hand Hygiene Environmental Cleaning/Disinfection Antibiotic Use Infection Prevention PPE Use Central Venous Catheter Use Urinary Catheter Use 15

16 Feedback Improves motivation and learning Supports performance improvement efforts Active involvement of HCPs - discussion & dialogue - will enhance feedback effects Unit staff may have creative ways to improve performance May find a unit champion during this process 16

17 More About Feedback Usually more effective to focus feedback on the task vs. the recipient of the feedback (less blaming ) Certain factors will affect feedback effectiveness Timing of feedback Characteristics of task being audited (one-step vs. multi-step task) Acceptance of feedback by healthcare personnel 17

18 What Do You Think? What s the biggest challenge at your facility - 1. Competency-Based Training Getting buy-in that it s important and/or having someone develop/implement the training 2. Audits & Feedback Having time/personnel to conduct effective audits and be able to effectively share feedback on performance with staff 18

19 Choose One Answer 1) Getting buy-in that competency-based training is important 2) Having someone develop and/or provide the training 3) Having time/personnel conduct audits with feedback 4) Ability to share feedback on performance with healthcare personnel 19

20 Hand Hygiene - Patient & Family Advisory Council Responses A Patient & Family Advisory was asked to review a new initiative at the hospital for increasing hand hygiene compliance. Some of their responses: Why isn t hand washing suggested to family members for adult patients like it s stressed in the NICU? I want nurses to know, Even if you washed your hands before coming in [outside of my view] it s really nice if you mention that you just did. I didn t see it happen but it s still important to me and I m not always comfortable asking. I would really like it if nurses initiated the hand hygiene conversation like, Hand hygiene is very important. If you don t see me wash my hands, please say something! It s really OK if you do. The last thing I want to do is to tick off my nurse!

21 Hand Hygiene ICAR Responses <50% of hospitals indicated that: Personnel are required to demonstrate competency with hand hygiene following training Hospital maintains current documentation of hand hygiene competency training for all personnel 21

22 22 (Image source: Hand Hygiene: Why, How & When?, WHO, Dubberke ER, et al., Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology)

23 CBT Hand Hygiene Hand hygiene education on hire to all staff and at least annually Be able to describe indications for hand hygiene moments Demonstrate correct technique for hand hygiene Use creative ways to explain the importance of correct hand hygiene Pathogen simulation Patient stories 23

24 Audits & Feedback - Hand Hygiene Direct Measurement Methods Covert observation/ Secret Shoppers Overt observation Technology-assisted How will you provide feedback? 24

25 Feedback Hand Hygiene Hand hygiene should be an expectation (leadership should model best behavior) Just in Time education when incorrect practices are observed Thank those who remind you Hold each other accountable remind any HCP, regardless of their position/role 25

26 Hand Hygiene Audit Tool (Adapted from St. John Hospital & Medical Center, Hand Hygiene Observation Collection Tool, 2017) 26

27 What Would You Do? A concerned ICU nurse reports to you, Mr. G had a group of surgical residents come in to examine his post-op wound. One wore gloves but didn t clean her hands after taking them off; she confidently said that gloves protect her and the patient and soap and water is a thing of the past. The other resident didn t wear gloves OR clean his hands. He just rolled his eyes when I confronted him about it. 27

28 Choose One Answer You re the infection preventionist. What would you do? 1) Find the residents and give a detailed explanation about glove use and hand hygiene 2) Call/message the residency director with details of the incident and your concerns 3) Tell the nurse to be more assertive with her explanation 4) Post more hand hygiene signs 28

29 Environmental Cleaning ICAR Responses <65% of hospitals report: The hospital has a defined frequency for auditing cleaning and disinfection procedures, including use of products in accordance with manufacturer s instruction (e.g., dilution, storage, shelf-life, contact time). <75% of hospitals report: The hospital maintains current documentation of competency with environmental cleaning procedures for all personnel who clean and disinfect patient care areas. 29

30 Role of Environmental Services in Infection Prevention Cleaning and disinfection is a critical component of any infection prevention program Improvement in cleaning and disinfection practices will prevent pathogen transmission Important to partner with our environmental services team that does the bulk of the cleaning and disinfection for the patient, visitor and healthcare worker environment 30

31 Competency-Based Training for Environmental Services New Hire Competency Assessments Training and Retraining Classroom training, with written quizzes Preceptor training Observation of PPE donning and doffing Observation of daily cleaning Observation of discharge cleaning Conduct trainings and administer written exams at monthly meeting Deliver trainings for team members that fail audits New recommended practices Review necessary cleaning procedures at daily huddles Review competencies tested during new hire training annually Observation of C. difficile isolation discharge (Guh A and Carling P, CDC, 2010) 31

32 Maintaining Competency through Annual Assessments Annual Competency Checks Successful attendance at monthly training and pass written exams Pass PPE donning and doffing observation by management Pass observation cleanings by management Daily cleaning Discharge cleaning C. difficile discharge Isolation cleaning CHEST: Certified Healthcare Environmental Services Technician Offered by Association for Healthcare Environment (AHE) Frontline staff certification Complete required training Pass certification exam 32

33 Infection Prevention and Environmental Partnership on two levels Services Partnership Environmental services and infection prevention Strategic planning, risk assessment, policy development Health care workers in every department Implementation and performance Success requires both partners to be recognized and supported Multidisciplinary collaboration brings different HCP groups together to work on shared problem 33

34 Visual assessment: not a reliable indicator of surface cleanliness Direct observation: measures individuals adherence to processes Fluorescent marker: determines if a particular area was wiped ATP bioluminescence: measures actively growing microorganisms through detection of adenosine triphosphate (ATP) (Guh A, CDC, 2010) 34 (Cooper et al., AJIC, 2007)

35 Audits and Feedback Environmental Cleaning (CDC, Prevention Toolkits, Evaluating Environmental Cleaning) 35

36 The Environment is More Than Horizontal Surfaces and Furniture Our efforts need to include the personnel (e.g., nurses, doctors, technicians) who are responsible for cleaning and disinfection of medical equipment. 36

37 Environmental Cleaning Responsibilities 37

38 Responsibility of Equipment Cleaning Multi-disciplinary agreement on cleaning and disinfection process of non-critical equipment Staff should be trained on who is responsible, when it should happen, and how it should be done 38

39 An Example of a Responsibility Framework Item Standard Method Responsible Crash cart When visibly soiled or dusty Disinfectant wipe Exam lights After use Disinfectant wipe User Feeding pumps Computer keyboard Glucose meter Isolettes Discharge When visibly soiled or dusty; regular intervals After each use Between patients; weekly Hospital-approved disinfectant Disinfectant wipe; IT-approved method Hospital-approved disinfectant Disinfectant wipe Environmental Services (EVS) EVS User; EVS contractor User Nursing Vital Sign Machine Between patients Disinfectant wipe Nurse assistant (Adapted from: Shore Health System, University of Maryland. 39

40 CBT Environmental Cleaning Check out: Environmental Cleaning Foundational Element modules Link process monitoring to outcome monitoring what is the goal of your organization? 40

41 Question & Answer Does your hospital/healthcare facility have a responsibility framework for cleaning and disinfection of shared equipment? 1) Yes, and it s a robust process 2) Yes, but confusion remains on who is responsible 3) No, but we are working to develop one 4) No, and it s not happening anytime soon 41

42 Personal Protective Equipment (PPE) ICAR Responses <50% hospitals indicated that: Personnel are required to demonstrate competency with selection and use of PPE following training (i.e., correct technique is observed by a trainer) Hospital maintains current documentation of PPE competency for all personnel who use PPE Hospital has a defined frequency for auditing PPE selection and use, including donning and doffing 42

43 Problems with PPE Removal Study published in JAMA Internal Medicine found most healthcare personnel have little or no training in using personal protective equipment (PPE) Highlighted the need to develop effective strategies to minimize risk of contamination during PPE removal Educational interventions that include practice, immediate visual feedback on skin and clothing can significantly reduce risk 43

44 Competency-Based Training for PPE Demonstrate selection of PPE How to use PPE Return demonstration of don & doff process including correct sequence Simulate contamination (with glo-germ, chocolate syrup, etc.) Hand hygiene 44

45 Evidence-based Highlight essential components Need a trained observer How will you document competency? CDC, Sequence for Donning and Removing Personal Protective Equipment. 45

46 HH & PPE Audit Tool (APIC, 2013) 46

47 American Nurses Association CAUTI Prevention Tool Evidence-based document For bedside nurses Reduce urinary catheter utilization Reinforce indications Promote alternatives Offer realistic expectations and what-ifs related to post-catheter urinary retention CBT - Provides a checklist for insertion (can be used for new or seasoned nurses alike) Patient & family engagement

48 (ANA, CAUTI Prevention Tool, Side 2)

49 Sharing Feedback with Staff WHAT Infections HH performed/opportuniti es (aggregate) Device Utilization WHERE Huddles Staff meetings Nursing leadership meetings Nurse practice council WHEN Daily Monthly Quarterly HOW Posted on board Posted on commonaccess hospital site Formal presentation 49

50 Summary Infection prevention will improve through competencybased training, effective audits and feedback on performance. Minimizing the risk of infection during hospitalization requires many components of HAI prevention strategies. Evidence-based practices for hand hygiene, environmental cleaning and personal protective equipment use are key foundational components in patient safety and quality of care. 50

51 References American Nurses Association (ANA), CAUTI Prevention Tool, Available at: Association for the Healthcare Environment (AHE), Practice Guidance for Healthcare Environmental Cleaning, 2nd Edition, Association for Professionals in Infection Control (APIC), Guide to Preventing Clostridium difficile Infections, Centers for Disease Control (CDC), Environmental Cleaning Evaluation. Retrieved from: cdc.gov/hai/toolkits/evaluating-environmental-cleaning CDC, Infection Control Assessment Tools; last updated February 15, Available at: Centers for Disease Control & Prevention (CDC). Preventing Clostridium difficile Infection, FAQs Factsheet. Available at: Centers for Disease Control & Prevention. Sequence for Donning and Removing Personal Protective Equipment. Cohen SH, Gerding DN, Johnson S, et al; Society for Healthcare Epidemiology of American; Infectious Diseases Society of America. Clinical Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of American (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Hospital Epidemiology, 2010; 31: Cooper, R.A., Griffith, C.J., Malik, R.E., Obee, P., Looker, N. Monitoring the effectiveness of cleaning in four British hospitals. Am J Infect Control. 2007;35: Dubberke ER, Preventing Clostridium difficile Infection: Clarifying Common Misperceptions. Medscape

52 References Dubberke ER, et al., Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology. Fakih, M, Jones, K, Rey, J, Berriel-Cass, D, Kalincheva, T, Szpunar, S and Saravolatz, L. Sustained improvements in peripheral venous catheter care in non-intensive care units: A quasi-experimental controlled study of education and feedback. Inf Contro l& Hospital Epidemiology, 2012;33(5): Guh, A., Carling, P. Options for evaluating environmental cleaning, Available from: Rutala, W.A., Weber, D.J. Disinfectants used for environmental disinfection and new room decontamination technology. Am J Infect Control Rutala, W.A., Gergen, M.F., Sickbert-Bennett, E.E., Williams, D.A., Weber, D.J. Effectiveness of improved hydrogen peroxide in decontaminating privacy curtains contaminated with multidrug-resistant pathogens. Am J Infect Control. 2014;42: Rutala WA, Weber DJ, Healthcare Infection Control Practices Advisory Committee. Guideline for disinfection and sterilization in healthcare facilities, Centers for Disease Control and Prevention Available at Siegel JD, et al., CDC, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Tomas M, PriyaleelaT, Sunkelsula K, Cadu, J, ManaT, Jencson A, O Donnell M, Zabarsky T, HeckerM, Ray A, Wilosn B, Donskey C Contamination of Health CARE Personnel During Removal of Personal Protective Equipment, JAMA Internal Medicine, 2015; 175(12) :

53 Thank You! Karen Jones, MPH, BSN, RN, CIC 53