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Iu Ahrq Hai Assessment Ctr Presentation Feb 22 2010 Final
 

Iu Ahrq Hai Assessment Ctr Presentation Feb 22 2010 Final

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75. Healthcare Associated Infections: Assessment Center Findings , Invited Talk, NCQIP, Agency for Healthcare Research and Quality, Bethesda, MD, February 22, 2010.

75. Healthcare Associated Infections: Assessment Center Findings , Invited Talk, NCQIP, Agency for Healthcare Research and Quality, Bethesda, MD, February 22, 2010.

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    Iu Ahrq Hai Assessment Ctr Presentation Feb 22 2010 Final Iu Ahrq Hai Assessment Ctr Presentation Feb 22 2010 Final Presentation Transcript

    • Healthcare Associated Infections (HAI) Initiative Assessment Program
      Final Report to AHRQ
      February 22, 2010
      Brad Doebbeling, MD, MSc
      Regenstrief Institute
      Indiana University School of Medicine,
      Indianapolis
      Award Number: HHSA290200600013I, Task Order No. 4
    • Goals & Methods
    • Identify challenges in implementing HAI reduction efforts.
      Identify and key lessons learned.
      Identify areas of interest for future research.
      Project Goals
    • 5 ACTION HAI Awardee Partners
      Denver/Parkland (2 hospitals)
      Iowa (16 hospitals)
      Yale (5 hospitals)
      HRET (4 hospitals)
      AIR/Carilion (6 hospitals)
      Total = 33 hospitals
      Participants (Collaboratives)
    • Hospital Characteristics
      * Total > 33 due to hospitals fitting into multiple types.
    • Multi-method approach using both qualitative and quantitative data collection
      Qualitative portion
      Case report forms and open-ended items from 3 Information collection forms
      Thematic analysis and synthesis
      Quantitative portion
      3 data collection forms (5-point Likertitems)
      “Hypothesis raising” (Convenience samples)
      Methods
    • Hospital characteristics (type, size, tertiary, profit status)
      HAI reduction activities (up to 6)
      Team characteristics (titles, how engaged)
      Outcomes (rates, behavior change)
      Challenges and barriers
      Key learnings
      Future research ideas
      Data Collection: Case Report Form
    • Completed by healthcare workers with direct patient care (nurses, physicians, respiratory therapists, clinical pharmacists)
      Convenience samples at each collaborative
      n=1212 (target N=250 at each of 5 collabs)
      Questions about work-team environment, attitudes about reducing HAIs, and work practices
      Data Collection: Pt Safety & InfPrev Assessment
    • Completed by Patient Safety Officers and Infection Control practitioners
      n=26 (79% response rate)
      Questions about facility education, improvements, HAI monitoring, use of printed and electronic materials, opinion of usefulness of such activities, and work-team environment
      Data Collection: Pt Safety & InfPrev Catalogue
    • Completed by Infection Control practitioners
      n=29 (88% response rate)
      Questions about HAI rates collected, algorithms used, opinion on usefulness of such activities, identification of challenges and successes in infection prevention
      Data Collection: Info Collection & Reporting Summary
    • Results
    • Bundle Implementation – CLABSI, CAUTI, VAP, MRSA, SSI, Sepsis, SCIP
      Color-coded Armbands
      Education/Training
      Environmental Cleaning
      Flu Vaccination
      Increasing Compliance
      Nurse Champion Program
      Product Testing
      Statewide Collaboratives
      HAI Reduction Activities
    • HAI: Barriers & Challenges to Infection Prevention at the Point of Care
    • Key Barriers
      • Problems when leadership support is MIA, naivete’ about resource requirements
      • Challenges of unanticipated change (turnover of residents, champions in units, nursing staffing, redesign of units, new information system)
      • Demonstrating cost effectiveness, limited additional funds
      • Competing priorities, level of required documentation in daily work
      • Use and documentation of bundle variables inconsistent- Real time data collection, burden of reporting
      • Availability of time, staff and effective approaches for training
      • Need to convince professionals EBPs are beneficial to them and their patients—given limited time
      • Mix of hospitals (large, small) and unique challenges (surveillance) of a small rural community, non-profit hospital
      • Evolve guidelines based on developing evidence.
      • Time, persistence and structured communication needed for practice/culture change to take hold.
      • Involving key stakeholders (unit champions, front-line) integrating into the unit
    • Key Facilitators
      • Teamwork Crucial (the leader isn’t always in the front (bicycle racing team))
      • Mechanism to provide staff with strong evidence-base
      • Communicate expectations and require accountability
      • Do what works locally—ability to adapt to local context
      • Promise of providing back data one of greatest motivators.
      • Strong physician and nurse leadership and champions
      • IT develops an electronic checklist (data warehouse) to allow data queries and feedback compliance on process measures
      • Top executives make rounds and solve problems
      • Mandatory state reporting (NHSN) and changes in CMS reimbursement
      • Leadership support results in sufficient time for front-line staff to improve processes, change systems and achieve success
      • Communication, involvement of front-line staff imperative
      • Celebrating the successes
    • Structured Case Report Form: 7 Lessons Learned Themes
      Fostering Change
      Communication & Collaboratives
      Local, Focused Implementation
      Frontline Staff Engagement
      Learning Organizations
      Support, Resources & Accountability
      Feedback & Reinforcement
    • "Changing practice was the biggest challenge. In this hospital's experience, it took six months to see the results of practice change."
      "Cultural and political barriers still exist and can hinder initiatives if frontline staff are not directly involved in the process and part of the decision-making."
      "Manager doesn't want to address issues with non-adherent staff members."
      1. Fostering Change
    • 2. Communication & Collaboratives
      "Use multiple venues to raise awareness and reinforce evidence-based practice."
      "Posters were strategically placed throughout the unit, notices and reminders were placed in staff mailboxes and email reminders were sent."
      "Being part of a larger collaborative allows us to continue to learn and share experiences, challenges and successes."
      "Having a state-wide effort spurred hospitals to embrace HAI reduction initiatives. No one hospital wanted to perform more poorly than the other."
    • "Start small. Build on successes. Celebrate successes in a big way."
      "Focusing on a few high priority patient safety efforts was critical. This helped prevent diluting the program."
      "Staff can be told the steps but they need to figure out how to accomplish the outcomes [themselves]."
      "Doing what works locally has been a critical success factor."
      3. Local, Focused Implementation
    • "Key success factors include involving frontline staff in improvement processes."
      "Empowerment of staff in a team approach (physicians, bedside nurses, unit managers, etc.) is key to success of a project and ensuring ongoing adherence to improvement measures."
      "Another vital success factor was having an engaging and popular physician champion (hospital epidemiologist)."
      "Having Nurse and Physician champions in each ICU and the ED has been very important."
      4. Frontline Staff Engagement
    • "Providing the evidence to the staff and educating them on the bundle were key success factors."
      "Have different in-person and online trainings for clinical and non-clinical staff.“
      "Busy clinicians are most interested in learning the best practice clinical skills to decrease HAIs.“
      "Constant education, re-education and reinforcement are critical. One-shot educational sessions do not work.”
      5. Learning Organizations
    • "Initiatives with the most administrative support are the most successful since they are discussed the most and because frontline workers are given time to participate in task forces which allows 'grassroots' promotion of the initiative."
      "Executive support was critical and helped inform staff that they aren't doing more work, but rather are focusing their efforts on the right work."
      "Know that the initiative will take dedicated staff and lots of time."
      6. Support, Resources & Accountability
    • "Provide regular feedback, including performance data to staff."
      "Give staff feedback on the results of the training interventions.“
      "Celebrate success."
      "It has also become a part of the annual bonus program for staff."
      7. Feedback & Reinforcement
    • N = 1212, 5-point Likert scale
      Majority nurses (51%)
      Overall mean 3.7 suggesting favorable work environment, attitudes and practices
      Work environment
      Range 3.7 – 4.4
      Low (3.7): Have adequate resources and staff
      High (4.4, 4.3): Monitor HAIs to improve them, have team culture of pt. safety, have supportive team
      Pt Safety & InfPrev Assessment
    • Attitudes
      Range 4.0 – 4.5 (high)
      Clean hands before/after pt contact, keep abreast of pt sfty, well-functioning approach to pt sfty, and there are practical things I can do to prevent HAIs
      Work Practices
      Range 3.0 – 4.4
      Low (3.0): Restrain upper limbs during chest tube insertion
      High (4.4, 4.2): Elevate head of bed to decrease risk of VAP, am comfortable asking for a Time Out on central line insertion
      Knowledge
      Range 84 – 94%
      84%: I know other org.s concerned with infection prevention
      94%: I am aware of JC mandated training on Pt Sfty.
      Pt Safety & InfPrev Assessment
    • N = 26 (79% response rate), open-ended
      Pt Sfty practitioners (50%) and IP practitioners (42%)
      Training & Education
      Majority general infection control (transmission/spread, proper cleaning, HH and use of PPE)
      Many specific clinical infection control trainings (preventing SSI, CLABSI, CAUTI, VAP, SCIP, BSI, C-Diff, MRSA screening, pressure ulcer prevention)
      Majority felt education was useful (83%)
      Hospital Improvements
      Most often cited improvement was additional hand hygiene dispensers (rooms, hallways, entrances, cafeteria), CHG protocols, bundle implementation (CAUTI, VAP, CLABSI, SCIP) and team/committee creation
      Pt Safety & InfPrev Catalogue
    • Monitoring Tools
      Most often cited tools were infection-specific scorecards (CLABSI, VAP, CAUTI, MRSA, VRE, C-Diff UTI, Sepsis, hand hygiene compliance, PPE compliance) and meetings/reviews
      Most hospitals used national standards such as NDNQI, NHSN, JC (CORE measures), AHRQ HSOPSC, HQI, and SCIP
      Materials
      Most hospitals used posters/signs, hand hygiene campaigns and graphs detailing rates
      65% felt their facility addresses patient safety and infection prevention well.
      Pt Safety & InfPrev Catalogue
    • N = 29 (88% response rate), open-ended
      Majority Infection Control practitioners (69%)
      Rates Collected
      Majority collect HAI rates for SSI, CLABSI, VAP, and CAUTI
      Use national standards (NHSN or CDC definitions)
      Nearly all hospitals report rates through committees, task forces
      Only 12 of 29 hospitals report overall HAI rates
      Majority (97%) felt collecting rates was helpful in targeting infection reduction.
      Suggestions for IP training and interventions were:
      More HAI prevention and infection-specific training opportunities
      Implement initiatives such as hand hygiene and contact precautions campaigns, unit infection control champions, compliance monitoring
      Info Collection & Reporting Summary
    • Info Collection & Reporting Summary
      • Top Challenges identified were:
      • Changing habit
      • Acquiring resources (people, $$)
      • Getting buy-in from staff, physicians and administration
      • Time – burden on staff to learn and implement
      • Lessons Learned were:
      • People = engage, get local buy-in, value of champions, peer support
      • Implementing Processes = simplify, present evidence, be persistent, involve ancillary departments
      • Education = difficult to reach all people in right way
      • Time = culture change takes time, be patient
      • Might not get it right the first time
      • 59% felt their facility addresses patient safety and infection prevention well.
    • Discussion
    • Organizational change & sustainability strategies needed.
      Change initiatives in hospitals need both top-down support and bottom-up involvement.
      Engaging staff and physician support critical.
      Resource and data intensive.
      Start small, build on success.
      Collaboratives foster teamwork!
      Discussion
    • Lessons Learned – Fostering Change
      • Identify current practices, opportunities and action plans for improvement
      • Utilize strengths of individuals to motivate and sustain changes in behaviors—nurses really want to train younger nurses and mentor
      • Posting results engages staff, patients, families
      • After eliminating BSIs for a year in intervention unit, then every subsequent BSI is reviewed and discussed by an interdisciplinary team
      • Use multiple venues to raise awareness and reinforce practice (start with medical leadership, then staff, getting board involved, posting BSI rates in bathrooms)
    • Lessons Learned – Communication & Collaboratives
      • Standardize practices and action plans for improvement
      • Compare performance in a meaningful way
      • Fostering sharing, teamwork, competition
      • Selection of awards for innovation
    • Lessons Learned – Local, Focused Implementation
      • Start small with enthusiastic, committed team
      • Posting results engages staff, patients, families
      • Fostering unit-based competitition
      • After eliminating BSIs for a year in intervention unit, then every subsequent BSI is reviewed and discussed by an interdisciplinary team
    • Lessons Learned – Frontline Staff Engagement
      • Once physician (ICU) unit leadership adopts goals to be the best in hand hygiene for the hospital—strong driver of change
      • Nurses encouraged by manager and ICU directors to “call out” non-adherence and teasing/cajoling low adherence providers
      • Multiple champions, staff engagement helps overcome turnover in project leadership
      • Regularly (daily) measuring and feeding back hand hygiene at unit level really reinforces adherence
    • Lessons Learned – Learning Organization
      • Mechanism for capturing novel approaches that work
      • Program for clinicians in TRIP, reviewing evidence, coaching TRIP project, write a manuscript
      • Advanced Practice Institute provides training in implementing EBP, critique of CPGs, and hospital-specific action plans
      • Training needed in leadership and organizational transformation
      • Redesigning workflow and practices so routine EBP is the natural thing to do
    • Lessons Learned – Support, Resources & Accountability
      • Developing implementation plans, audit tools, assess sustained translation of prevention interventions in clinical practice.
      • Need to use strength and experiences of champions key to implementing and sustaining changes over time
      • IT develops an electronic checklist whenever central line inserted to track denominators (data warehouse) for data queries and feedback compliance to units
      • Sustainable, timely data collection strategies key
    • Lessons Learned – Feedback and Reinforcement
      • Nurses encouraged by manager and ICU directors to “call out” non-adherence and teasing/cajoling low adherence providers
      • Regularly (daily) measuring and feeding back hand hygiene at unit level really reinforces adherence
      • IT develops an electronic checklist whenever central line inserted to track denominators (data warehouse) for data queries and feedback compliance to units
      • Integrating checklists into work rounds, electronic systems is effective
      • Collect limited data that is most relevant to showing impact of interventions
      • Data collection needs to have face validity with clinicians and be timely
    • Identify effective strategies for implementing, spreading & sustaining HAI reduction programs
      Better understanding (scenario based training) of organizational factors predicting success
      Alternate approaches to redesign practice and workflow
      Novel strategies for electronic data capture, analysis and feedback
      Future Research