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Ahrq Hai Collab Meeting 7.13 14.2009
 

Ahrq Hai Collab Meeting 7.13 14.2009

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Presentation from AHRQ Hospital Acquired Infections Collaborative Meeting July 2009

Presentation from AHRQ Hospital Acquired Infections Collaborative Meeting July 2009

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  • The actual design of the forms was a very important component of this phase because entry for each partner would require approximately 250-260 uses of the web-based solution. Good design can have a number of benefits to include: enforcing standards in entry, eliminating errors, eliminating user frustration and minimizing ergonomic injuries to the end-user.

Ahrq Hai Collab Meeting 7.13 14.2009 Ahrq Hai Collab Meeting 7.13 14.2009 Presentation Transcript

  • HAI: Barriers & Challenges to Infection Prevention at the Point of Care
    July 13 and 14th
    Brad Doebbeling, Chris Kiess & Shawn Hoke
    AHRQ HAI Coordinating Ctr.
    Regenstrief Institute, Indianapolis
    Indiana University School of Medicine
  • Welcome
    Introductions and Reintroductions
    Overview of Day One
    Presentations by partners
    CDC Speaker
    Materials/Binders
    Group Dinner
  • Day Two Overview
    Continue Presentations
    Update on data collection, entry, and analysis
    DHHS HAI Portfolio Update
    Manuscript Plans/Publication Committee
    Review Goals
    Next Steps
    Upcoming Calls
    Deadlines
  • Goals of Meeting
    Reconnect with the partners
    Discuss experiences with the project
    Identify lessons learned
    Implementation lessons
    Data Collection and Sharing lessons
    Infection Control and HAI content areas
    Fostering Collaboratives
    Energize and Have Fun
    Help AHRQ Identify future funding priorities
    Brainstorm possible manuscripts
  • Update: Where We Are In Data CollectionCurrent as of 7/08/09
  • Data Collection for Three Information Collection Forms
    Web-based solution proposed wherein Partners would enter information via web to be transmitted to RI database
    Issues of consideration: Form Design & Usability, Technical issues in transferring the data and setting permissions/parameters for consistency in entry
    HTML (Hypertext Markup Language), CSS (Cascading Style Sheets) and Javascript were used to design the forms
    PHP and PostGreSQL were used to transfer the entered data in a secure manner from the Partners to RI
  • Web Form Design for Data Entry
    Form design was a very important part of the process and has a number of benefits to include:
    Enforcing standards in entry
    Eliminating errors
    Eliminating user frustration
    Minimizing ergonomic injuries to the end-user.
  • Defaults added
    where appropriate
    Dropdown menus allowed
    for standardization of data
    Sections were used
    rather than separate
    entry pages
    Alignment of vertical &
    horizontal elements
    Alignment of elements eases entry when
    repetitive processes are required
  • Data Entry Lessons Learned
    Time for pilot of forms did not allow for rigorous testing
    No method of tracking form entry (i.e. no form identification)
    Length of data vs. field size
    Web-based solution is not always the most stable
  • Overview of Analysis Plan for Information Collection Forms
    Calculate descriptive statistics (frequencies, means, etc.) from three information collection forms* for sites and partners
    Descriptive statistics presented in tabular and graphical form in Site Reports (up to six) and Partner Reports* (goal: to be completed by July 13, 2009)
    Present graphs comparing partner responses from information collection forms (i.e., dimension means, averages on items of interest)* in final presentation to AHRQ (to be completed by January 2010)
  • Analysis Plan for Case Reports
    Case study approach will be used to analyze open-text items from the three Information Collection forms and Case Reports
    Each partner represents one “case”
    IU Assessment Team will review and code open-ended items and case reports
    Questions about case reports addressed via phone conversation(s) with case report authors and other relevant partnership personnel
  • Analysis Plan for Case Reports (cont.)
    Analysis of case reports will focus on the following sections and questions:
    IB: Activities, Methods of Engaging Personnel
    IIA: What was expected to happen, What actually happened
    IIB: Challenges and Barriers, Solutions, Share a story describing a solution used
    III: Key learnings, Most important lesson learned, what key steps would you recommend
    IV: Future research questions, ideas for related projects, topics that should NOT be emphasized
    IU to code and categorize concepts for each section within a case. Reach agreement via consensus process
    Identify themes across partners for HAI reduction efforts
    Output: Written summarization of key concepts for each case and high-level themes across cases (to be completed January 2010).
  • Assessment Team Manuscript Plans
    Descriptive paper based on 3 information collection forms 
    This manuscript will focus on:
    patient safety and hospital-associated infection reduction efforts
    hospital improvements
    surveillance & monitoring
    work environment and work practices
    attitudes about patient safety
    A description of each Partner’s characteristics will also be included (e.g., number of hospitals, urban vs. rural, bed size, profit status).
    *Brainstorm strategies to estimate a response rate
  • Assessment Team Manuscript Plans (cont.)
    Barriers/Facilitators to HAI reduction efforts - themes across case studies.
    Report findings from a qualitative thematic analysis of case studies
    Describe:
    hospitals participating in the study
    type of HAI reduction efforts undertaken
    challenges and solutions to HAI reduction efforts
    sustainability of each HAI reduction effort.
    Data will come from the:
    open-ended questions on the information collection forms
    case study reports
    follow-up conversations (with regard to case study reports). 
  • PossibleHAI Publication Journals
    Quality and Safety in Healthcare
    American Journal of Medical Quality
    American Journal of Public Health
    Joint Commission Journal on Quality and Patient Safety
    Journal of Patient Safety
    Nursing Care Quality
    Modern Health
    Hospitals and Healthcare Networks
    Infection Controls and Hospital Epidemiology
    American Journal of Infection Control
  • Review Goals
    Reconnect with the partners
    Discuss experiences with the project
    Identify lessons learned
    Implementation lessons
    Data Collection and Sharing lessons
    Infection Control and HAI content areas
    Fostering collaboratives
    Brainstorm possible manuscripts
    Help AHRQ Identify future Research priorities
  • Discussion
    Other Analytic Ideas
    Other Summary Manuscripts
    Publication Committee
    What we have done in the past
    Representation of each partner
    Volunteer to Chair Committee
    Review Drafts
    What would best help the Partners
    Further Research Ideas
  • Next Steps
    Next Steps
    Continue Analyses
    Publication
    Final Reports
    Teleconferences:
    August 18
    September 15 (AHRQ Conference)
    October 20
  • Key Barriers Encountered in HAI Reduction and Implementation Efforts
    -challenges in turnover of residents monthly-disruption with changes in champions in units-nurses wary of attempting wean at night, but added at night attending to help-nursing staffing a major challenge-importance of demonstrating cost effectiveness since limited additional funds available to get underway-Use and documentation of bundle variables inconsistent-competing priorities, level of required documentation in daily work-real time data collection-new information system being implemented-redesign of units (multiple floors for single unit, large ICU forming)-standardizing processes across units
  • Key Barriers Encountered in HAI Reduction and Implementation Efforts
  • Key Barriers Encountered in HAI Reduction and Implementation Efforts
    • OMB clearance waiting time,
    • timing of intervention implementation,
    • amount of time to complete training modules,
    • surveys were lengthy,
    • difficult to enforce mandatory training
  • Key Barriers Encountered in HAI Reduction and Implementation Efforts
    Need to convince professional (MD, RN) it is beneficial to them and their patients—given limited time
    Mix of hospitals.
    Challenges of a small rural community, non-profit hospital, Evolve guidelines based on developing evidence.
    Problems when leadership support is MIA.
    -resistance from front-line staff-naivete about resource requirements-may need to pay physicians and provide other resources-unrealistic data collection plans-lack of support for multidisciplinary rounds-time needed for practice change to take hold.
  • Key Barriers Encountered in HAI Reduction and Implementation Efforts
    -Lack of staff support, Lack of Management support, Lack of Time and Money
  • Key Facilitators Encountered in HAI Reduction and Implementation Efforts
    -importance of training (format, focus, breadth), -Involving key stakeholders (role of unit champions, front-line staff, integrating into the unit-Persistence of culture change efforts, working “smart”
  • Key Facilitators Encountered in HAI Reduction and Implementation Efforts
    Implementation of HIPPI champion program implemented during OMB waiting period,
    incentives provided to encourage participation and completion of surveys and training
    Promise of providing back data one of greatest motivators. Want to understand where they fit in.
  • Key Facilitators Encountered in HAI Reduction and Implementation Efforts
  • Key Facilitators Encountered in HAI Reduction and Implementation Efforts
    -the leader isn’t always in the front (bicycle racing team)-provide staff with strong evidence-base (small drapes, betadyne problems)-communicate expectations and require accountability (calling out student nurse for not stopping staff for not handwashing—very strong)-provide strong administrative support-do what works locally
  • Key Facilitators to HAI Reduction and Implementation Efforts
    -strong physician and nurse leadership and champions-celebrating the successes-IT develops an electronic checklist whenever central line inserted to track denominators (data warehouse) to allow data queries and feedback compliance on process measures to units and patient safety and quality-Top executives make rounds and are out there (explain?)-mandatory state reporting (NHSN) and changes in CMS reimbursement made described initiatives stand out among myriad of competing initiatives-Leadership support results in sufficient time for front-line staff to improve processes, change systems and achieve success-communication with support staff imperative-involvement of front-line staff
  • Lessons Learned/“Positive Deviants”
    Focused interventions on VAP, CLABSI prevention.
    Developed audit tool, assess sustained translation of prevention interventions in clinical practice.
    Developed brief educational action plans to supplement online training and identified opportunities for improvements (CLABSI action plan—nursing cl maintenance approach; sedation vacation action plan-multidisciplinary approach)
    Developed lanyards and tools to identify champions.
    CVC Checklist-adapted and implemented by ICU nurses, undergone several revisions.
    Goal to identify current practices with CVC placement.
    AHRQ survey implementation. Pizza party for the unit with highest percent return rate (DH) and coffee cards for individuals who completed a survey (PL)
    Cultural barriers still exist and may impede implementation of HAI initiatives
    Timing of HIA interventions critical to implementation success
    Utilize strengths of individuals to motivate and sustain changes in behaviors—nurses really want to train younger nurses and mentor
    Triangle as universal change symbol
    Cultural beliefs and barriers, years of experiences and interactions with IP, years of clinical experience, attitudes and perceptions about IP, knowledge and awareness of issues, IP initiative
    Need to use strength and experiences of champions key to implementing and sustaining changes over time
  • Lessons Learned/“Positive Deviants”
    --use multiple venues to raise awareness and reinforce practice (start with medical leadership, then staff, getting board involved, posting BSI rates in bathrooms)-provide performance data at least quarterly and post in unit-establish nurse protocols (e.g., urinary catheter—identify criteria, get authorization for d/c)-CUSP critical to success (starting at unit, “dangerous activity”, easy success begets success, started in ICUs (VAPs, CLABSI), handwashing to other units)-need to identify how to foster “professional will” to absolutely ensure best practice occurs at all times-collect limited data that is most relevant to showing impact of interventions-data collection needs to have face validity with clinicians and be timely-participants need to be able to pull down data
  • Lessons Learned/“Positive Deviants”
    -long-standing program for nurses in TRIP, reviewing evidence, coaching TRIP project, manuscript (Titler)
    -Physician (ICU) unit leadership adopt goals to be the best in hand hygiene for the hospital-Regularly (daily) measuring and feeding back hand hygiene at unit level really reinforces adherence-Nurses encouraged by manager and ICU directors to “call out” non-adherence and teasing/cajoling low adherence providers-Advanced Practice Institute provides training in implementing EBP, critique of CPGs, and hospital-specific action plans
  • Lessons Learned/“Positive Deviants”
    -IT develops an electronic checklist whenever central line inserted to track denominators (data warehouse) to allow data queries and feedback compliance on process measures to units and patient safety and quality-After eliminating CLA-BSIs in trial unit for a year, then every subsequent BSI is reviewed and discussed by an interdisciplinary team--respiratory therapy team rounds twice daily to review compliance with VAP protocol-Chief of Nursing sends out weekly email reporting number of days since last VAP, causes great attention to any break in best practices to reduce (nurses started to “own” VAP)-Emory U. Midtown—VAP Prevention Bundle Daily Goal Sheet completed during multidisciplinary rounds (RT and Pulm fellow discuss who to be weaned, sedation vacation)-EUM substantial reduction of VAP, one unit with no VAPS x 18 mos-Active involvement of executive leadership essential for making changes happen-multiple champions, staff engagement helps overcome turnover in project leadership-Integrating checklists into electronic systems is effective
  • Wrap Up
    Questions
    Comments
    Final Thoughts