Navigating through Frontline Competencies, Training and Audits Carol Vance MSN, RN, CIC Multi-site Director, Infection Prevention Advocate Children s Hospital Objectives Discuss the relationship between training, competency and audits. Provide concrete and practical solutions to training and competency challenges. Identify the key stake holders that are important for training and competency success. 1
Infection Preventionist Daily Work Infection Control Assessment and Response (ICAR) Program The Infection Control Assessment and Response Tools were developed by CDC Used by healthcare facilities to conduct internal quality improvement audits Assessment tools Acute care (including short stay acute and longterm acute care hospitals) Outpatient Long-term care Hemodialysis Healthcare Personnel Infection Prevention Competency Healthcare Personnel Infection Prevention Competency Based Training Competency Assessment 2
APIC Competency Domains Domain 2: Infection Prevention and Control Domain 4: Performance Improvement and Implementation Science Healthcare Personnel Infection Prevention Competency The proven ability to apply essential knowledge, skills, and abilities to prevent the transmission of pathogens during the provision of care 3
Domains with Gaps in Training and Competency Hand Hygiene Central Line Associated Blood Stream Infection Prevention (CLABSI) Catheter Associated Urinary Tract Infection (CAUTI) Low Level Disinfection Personal Protective Equipment Injection Safety Ventilator Associated Events (VAE) Healthcare Personnel Infection Prevention Competency-Based Training The provision of job-specific education, training, and assessment to ensure that healthcare personnel possess IP competency Competency-based Training Infection Control Risk Assessment Educational Needs Assessment Job-specific employee roles Department-specific needs https://www.freepik.com/free-vector/medical-teamdesign_1023371.htm#term=nurse&page=1&position=45 4
Competency-based Training Direct observation/return demonstration Methods to assess competency Documentation https://www.freepik.com/free-vector/statistical-data-abstract-on-paper-andtablet_1311213.htm#term=documentation&page=2&position=0 Assessing Educational Needs Methods that can be used to determine educational needs of the learner population include the following: Learner self-assessment Focus group discussion Test development Personal interviews Job analysis and performance reviews Observational studies https://www.freepik.com/free-vector/to-do-list-concept_1577756.htm#term=tests&page=1&position=32 Learning Retention APIC Text Ch 2 5
Training Strategies Case studies Simulation Quizzes Games Role-playing https://www.freepik.com/free-vector/man-and-woman-presenting-their-projectbusiness_1311616.htm#term=training page=1&position=16 Competency Assessment The verification of IP competency through the use of knowledge-based testing and direct observation Audit Direct observation or monitoring of healthcare personnel adherence to job-specific IP measures Feedback Communication of audit results to the end user Audit and Feedback Process Determination of number and frequency of audits Engage staff in auditing and performance improvement processes. Communication of audit results Informal random audits 6
Key stake holders Senior Leadership Nursing Environmental Services Education Department Facilities Medical Staff https://www.freepik.com/free-vector/illustrated-medicalteamwork_831095.htm#term=medical&page=8&position=31 Challenges Identified During ICAR Visits Hand Hygiene & Personal Protective Equipment (PPE) 7
Hand Hygiene Return demonstrations are not utilized to demonstrate competency Risk assessment to review hand hygiene compliance data to determine if instituting a return demonstration into position and/or departmentspecific annual competency/performance assessment checklists Personal Protective Equipment (PPE) PPE training does not include information on or a return demonstration of donning and doffing Training at hire and annually Return demonstration validated by the preceptor in the clinical space Evaluate the benefit and feasibility of adding to annual skills day training and/or competency assessment CDC resources PPE Utilization PPE selection and proper use are not monitored Hand hygiene compliance observers to collect PPE compliance data Utilize an app suggested for hand hygiene observations that can also be used to collect PPE compliance data The University of Iowa. iscrub Lite. Available at: https://itunes.apple.com/us/app/iscrublite/id329764570?mt=8 Accessed August 11, 2017 8
Prevention of CAUTI Training Staff do not receive annual training on indwelling urinary catheter insertion Minimum - include didactic information on insertion of indwelling urinary catheters on an annual basis The Joint Commission (TJC) National Patient Safety Goal (NPSG) 07.06.01 Annual insertion return demonstration for the units/locations with the highest CDC National Healthcare Safety Network (NHSN) cumulative attributable difference (CAD) produced by the targeted assessment for prevention (TAP) report Computer Based Training Annual training for insertion and maintenance of an indwelling urinary catheter is computer based and does not include a return demonstration Utilize CAUTI outcome and process measures to assess the need for return demonstration for insertion and maintenance on an annual basis Results may indicate that return demonstration would only be beneficial on certain units 9
Insertion and Maintenance Audits Indwelling urinary catheter insertion and maintenance audits are not conducted and; therefore, feedback on performance is not provided to the frontline staff TJC NPSG.07.06.01 states that CAUTI process and outcome measures should be collected Infection prevention and control risk assessment and/or the CDC NHSN CAD Implementing a two-person Feedback of the audit data and lessons learned Prevention of CLABSI Licensed Independent Practitioners (LIP) Licensed independent practitioners (LIP) do not participate in an initial or annual standardized training and competency assessment program for insertion of central lines Standardizing central line insertion practices for LIPs Central line insertion practices in the credentialing process Investigate the use of the simulation The insertion checklist could be added to the LIPs credentialing 10
Audits and Maintenance Neither central line insertion nor maintenance audits are conducted and; therefore, feedback on compliance with best practices cannot be provided Central line insertion checklist TJC has examples of insertion checklists in their CLABSI Toolkit Explore use of the Electronic Medical Record for documentation of the insertion checklist data and then leverage the electronic capture to produce reports on compliance Report compliance Provide both metrics to frontline staff Feed Back Insertion and maintenance audit data are collected, but not routinely fed back to the frontline clinicians Utilize computer documentation to create reports to provide the information to frontline staff Feedback will inform staff of the gaps in practice and progress of improvement efforts Maintenance The facility does not have an annual competency based training program for maintenance of central lines Consider the use of the NHSN CLABSI CAD to target units for annual maintenance competency including return demonstration, particularly if surveillance data suggests CLABSIs are related to maintenance 11
Prevention of Ventilator Associated Events (VAE) Training Formalized competency based training for prevention of VAEs is not provided at hire or annually Collaborate with nursing and respiratory therapy to develop a competency based training program for the prevention of VAEs Injection Safety 12
Training Staff do not receive training on safe injection practices at hire or on an annual basis Patient safety component of Standard Precautions CDC One and Only Campaign to initial and annual training Audits Safe injection practice audits are not completed Include injection safety tracers into environment of care and/or regulatory rounds Formal feedback to clinical staff and modify education and competency to address identified gaps Random documented audits of scrub the hub protocols Engage unit champions to complete the audits Provide feedback of the audits to frontline staff Audit and Feed Back No formalized audit or feedback process has been established for monitoring point of care testing or safe injection practices CDC-defined Training Programs and Audit Processes section Routinely share audit results with frontline staff. Utilize the contracted pharmacy to assist with safe injection practices audits 13
Prevention of Clostridium difficle Infection (CDI) Recommended practices for prevention of CDI are not audited Review the CDI CAD to focus improvement efforts Discuss the use of best practices audits with the CDI prevention team Focusing audits on units with the highest CAD Identify gaps and allow for focused improvement initiatives Communicate feed back of audit results Environmental Cleaning Surgery staff is responsible for cleaning and disinfection of OR suites. Surgery staff have not received training for environmental cleaning and disinfection The EVS manager should provide education and training to the surgery staff on how to use products and how to effectively clean and disinfect the OR space Document the training Antibiotic Stewardship All clinical staff have not received antimicrobial stewardship education Engage frontline staff Educate them on the importance of antibiotic stewardship and speaking up for judicious use of antibiotics Review the contract and roles/responsibilities of the pharmacist Research other possible resources to support stewardship 14
Strengths Identified During ICAR Visits Training and Competency Each department performs an annual onepage risk assessment that includes but is not limited to High risk High volume Low volume Pertinent data Staff input to identify top three of ten competencies per job code per year to target for education and training Hand Hygiene The IP meets with all new employees and provides hand hygiene education during orientation Hand hygiene competency is assessed by return demonstration Glo Germ and ultraviolet light training tool Annual training is provided by use of a computer-based learning module 15
Personal Protective Equipment (PPE) PPE use and compliance is being monitored by the secret shoppers who complete HH audits Infection preventionist has coined a saying, no flourishing The IP feels this has helped staff understand the concept of spreading germs or routes of transmission Prevention of CAUTI Training and education for urinary catheter insertion is done upon hire. Personnel are observed when they insert their first catheter Prevention of CLABSI The central line insertion checklist is required to be completed for all line insertions even if inserted by a CRNA or surgeon The IP receives all central line insertion checklists for review Any omissions or deviations are dealt with on an individual basis Injection Safety The facility s tracer team performs injection safety tracers in all clinical areas twice per year Tracer data are entered into a database for follow-up by appropriate managers Managers follow-up actions are tracked and trended 16
Environmental Cleaning New EVS staff receive one-to-one training and shadow with a designated mentor until competency is demonstrated The IP uses Glo Germ powder and ultraviolet light technology to monitor surface cleaning The hospital has a well-developed orientation and training program for staff working in the environmental services (EVS) department New hires are paired with a trainer for one to two weeks The EVS manager validates skills Ambulatory & Ambulatory Surgery Centers Training and Competency All sterile reprocessing technicians are certified through The International Association of Healthcare Central Service Material Management (IAHCSMM) Gastrointestinal (GI) endoscopy registered nurses (RNs) are cross-trained and rotate through pre/post, procedure and reprocessing areas. All training includes return demonstration Hand Hygiene All HCP must demonstrate hand washing competency during orientation Questions? 17
Resources Centers for Disease Control and Prevention. Infection Control Assessment Tool. https://www.cdc.gov/hai/prevent/infection-control-assessmenttools.html. Accessed April 18, 2017 Centers for Disease Control and Prevention. Infection Control Assessment Tool. https://www.cdc.gov/hai/prevent/infection-control-assessment-tools.html. Accessed April 18, 2017. Centers for Disease Control and Prevention. Sequence for Donning and Doffing Personal Protective Equipment. Available at: https://www.cdc.gov/hai/pdfs/ppe/ppeposter148.pdf Accessed July 26, 2017. The University of Iowa. iscrub Lite. Available at: https://itunes.apple.com/us/app/iscrub-lite/id329764570?mt=8 Accessed August 11, 2017. The Joint Commission. National Patient Safety Goals, Hospital Accreditation Program. Goal 7, NPSG.07.06.01 EP1. January 2017. Available at: https://www.jointcommission.org/hap_2017_npsgs/ Accessed July 26, 2017. Centers for Disease Control and Prevention. The Targeted Assessment for Prevention (TAP) Strategy. Available at: https://www.cdc.gov/hai/prevent/tap.html Accessed July 20, 2017. The Joint Commission. National Patient Safety Goals, Hospital Accreditation Program. Goal 7, NPSG.07.06.01 EP1. January 2017. Available at: https://www.jointcommission.org/hap_2017_npsgs/ Accessed July 26, 2017. Centers for Disease Control and Prevention. The Targeted Assessment for Prevention (TAP) Strategy. Available at: https://www.cdc.gov/hai/prevent/tap.html Accessed July 20, 2017. The Joint Commission. CLABSI Toolkit- Chapter 3. Available at: https://www.jointcommission.org/topics/clabsi_toolkit chapter_3.aspx Accessed July 27, 2017. Agency for Healthcare Research and Quality. Tools for Reducing Central Line-Associated Blood Stream Infections. Available at: https://www.ahrq.gov/professionals/education/curriculum-tools/clabsitools/index.html Accessed July 27, 2017. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings Available at: https://www.cdc.gov/infectioncontrol/guidelines/isolation/ Accessed July 28, 2017. Centers for Disease Control and Prevention. One & Only Campaign. Available at: http://www.oneandonlycampaign.org/ Accessed July 20, 2017 APIC professional and practice standards Tania N. Bubb, Corrianne Billings, Dorine Berriel-Cass, William Bridges, Lisa Caffery, Jennifer Cox, Moraima Rodriguez, Jessica Swanson, and others, American Journal of Infection Control, Vol. 44, Issue 7, p745 749 Published online: April 11, 2016 APIC Text To obtain your certificate, please click the Evaluation Link: http://webinars.apic.org/evaluation/index.php?id=18985 and enter the certificate code below: SASS3223 18