Elements of an Effective Program Linda R Greene

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Elements of an Effective Program Linda R. Greene, RN, MPS, CIC, FAPIC Manager, Infection

Elements of an Effective Program Linda R. Greene, RN, MPS, CIC, FAPIC Manager, Infection Prevention UR Highland Hospital Rochester, NY linda_greene@urmc. rochester. edu Barbara Russell, MPH, BS, RN, CIC, FAPIC Consultant Barbarar. Russell 627@gmail. com

Objectives Discuss the basic elements of an effective infection prevention program Describe how to

Objectives Discuss the basic elements of an effective infection prevention program Describe how to conduct a risk assessment Identify key strategies related to improving hand hygiene Explain surveillance essentials

Let’s Start at the Beginning Why do a risk assessment ? Types of Risk

Let’s Start at the Beginning Why do a risk assessment ? Types of Risk assessment – annual Targeted – new procedures, equipment, guidelines

Why do a Risk Assessment ? In order to set priorities, we must first

Why do a Risk Assessment ? In order to set priorities, we must first assess the current status Mandated by regulatory and accrediting agencies Should be considered in all patient care settings

What is a Risk Assessment This is a process that examines recognized and potential

What is a Risk Assessment This is a process that examines recognized and potential risks for acquiring and transmitting infections in a healthcare system. It identifies evidence-based measures to reduce these risks. It prioritizes risk based upon the potential or actual impact on care.

Performing a IC Risk Assessment Leadership Identify Risk Targets For Analysis Determine Goals Strategies

Performing a IC Risk Assessment Leadership Identify Risk Targets For Analysis Determine Goals Strategies Evaluation Process Establish Priorities Qualitative or Quantitative Perform Assessment Establish Priorities Templates Establish Timelines • Local Community • Organizational • Societal Risk Assessment Cycle Involve Others • ICC • Leadership • Key Staff • Health Dept Develop Methods • Quantitative • Qualitative • SWOT • Gap Analysis

Consider This Some risks are common in all healthcare settings Others occur in special

Consider This Some risks are common in all healthcare settings Others occur in special settings The risk assessment takes into account: - Geographic location - Care and services offered - Population served

Check List What age patients do you see? What services are provided? Does site

Check List What age patients do you see? What services are provided? Does site see a varied population? What procedures and treatments do you perform? Endoscopy? Vaginal ultrasound? Minor suturing? Do you do any sterilization or high level disinfection?

Applying the Definition Example – Tuberculosis Population- Small rural hospital in Montana Community cases

Applying the Definition Example – Tuberculosis Population- Small rural hospital in Montana Community cases past 2 years – none Risk ? Example- Finland

Components of a Risk Assessment Populations served- identify the demographics of the population Consider

Components of a Risk Assessment Populations served- identify the demographics of the population Consider Age Immune Status Race and ethnicity Special non immunized populations ie. Amish

Services Provided Long Term Care- Ventilator, Rehab Inpatient vs. Outpatient Cancer Care Medical and

Services Provided Long Term Care- Ventilator, Rehab Inpatient vs. Outpatient Cancer Care Medical and Surgical Special Services

Procedures Performed Surgical Procedures High Risk, High Volume, Problem Prone Endoscopy, Interventional Radiology

Procedures Performed Surgical Procedures High Risk, High Volume, Problem Prone Endoscopy, Interventional Radiology

Geographic Location Texas vs. Montana NYC vs. Olean, NY

Geographic Location Texas vs. Montana NYC vs. Olean, NY

Surveillance Data C Difficle Rates MRSA Surgical Site Infections ESBL Central Line Bloodstream Infections

Surveillance Data C Difficle Rates MRSA Surgical Site Infections ESBL Central Line Bloodstream Infections Urinary Tract infections

New Procedures or Devices Consider the Learning curve Examples : Robotic surgery ,

New Procedures or Devices Consider the Learning curve Examples : Robotic surgery ,

Other Types Legionella Risk assessment Fans in patient rooms Construction

Other Types Legionella Risk assessment Fans in patient rooms Construction

Disease and Conditions In the Community TB Legionella Meningitis Community-Acquired MRSA Listeria Hepatitis A

Disease and Conditions In the Community TB Legionella Meningitis Community-Acquired MRSA Listeria Hepatitis A

Sample

Sample

Hand Hygiene

Hand Hygiene

Ignaz Semmelweis, 1815 -1865 • 1840’s: General Hospital of Vienna • Divided into two

Ignaz Semmelweis, 1815 -1865 • 1840’s: General Hospital of Vienna • Divided into two clinics, alternating admissions every 24 hours: – First Clinic: Doctors and medical students – Second Clinic: Midwives

Hand Hygiene: Not a New Concept Semmelweis’ Hand Hygiene Intervention ~ Hand antisepsis reduces

Hand Hygiene: Not a New Concept Semmelweis’ Hand Hygiene Intervention ~ Hand antisepsis reduces the frequency of patient infections ~ Adapted from: Hosp Epidemiol Infect Control, 2 nd Edition, 1999.

Literature

Literature

Findings

Findings

Face to Face interviews with 13 senior managers at a large university hospital Seven

Face to Face interviews with 13 senior managers at a large university hospital Seven distinct themes: Culture change starts with leaders Refresh and Renew the message Connect the 5 moments to the whole patient journey Actionable audit results Empower patients Reconceptualize non compliance Start the hammer

Participants All affiliated nurses of the nursing wards. Wards were randomly assigned to either

Participants All affiliated nurses of the nursing wards. Wards were randomly assigned to either the team and leaders-directed strategy (30 wards) or the state-of-the-art strategy (37 wards). Methods The control arm received a state-of-the-art strategy including education, reminders, feedback and targeting adequate products and facilities. The experimental group received all elements of the state-ofthe-art strategy supplemented with interventions based on social influence and leadership, comprising specific team and leaders-directed activities. Strategies were delivered during a period of six months

Results 10, 785 opportunities for appropriate hand hygiene in 2733 nurses. The compliance in

Results 10, 785 opportunities for appropriate hand hygiene in 2733 nurses. The compliance in the state-of-the-art group increased from 23% to 42% in the short term and to 46% in the long run. The hand hygiene compliance in the team and leaders-directed group improved from 20% to 53% in the short term and remained 53% in the long run. The difference between both strategies showed an Odds Ratio of 1. 64 (95% CI 1. 33– 2. 02) in favor of the team and leaders-directed strategy. Conclusions Our results support the added value of social influence and enhanced leadership in hand hygiene improvement strategies. The methodology of the latter also seems promising for improving team performance with other patient safety issues

Wash Your Hands With alcohol-based hand rub: When? ? ?

Wash Your Hands With alcohol-based hand rub: When? ? ?

Five Moments for Hand Hygiene World Health Organization: 1. Before touching a patient 2.

Five Moments for Hand Hygiene World Health Organization: 1. Before touching a patient 2. Before aseptic/clean procedure 3. After body fluid exposure risk 4. After touching a patient 5. After touching patient surroundings

Central line insertion and Maintena nce Preventio n of diarrheal outbreaks UC insertion and

Central line insertion and Maintena nce Preventio n of diarrheal outbreaks UC insertion and maintenanc e Prevention of MDRO Hand Hygien e Surgical scrub Preventi on of c difficile 40

FACTS ABOUT ALCOHOL BASED HAND SANITIZERS Everyone should know the truth about hand hygiene

FACTS ABOUT ALCOHOL BASED HAND SANITIZERS Everyone should know the truth about hand hygiene and alcoholbased hand sanitizer: Alcohol-based hand sanitizer kills most of the bad germs that make you sick and is the preferred way to clean your hands in healthcare settings. Alcohol-based hand sanitizer does not kill C. difficile or rotovirus are common community and healthcare-associated infection that causes severe diarrhea. Patients with these organisms should wash their hands with soap and water and make sure their healthcare providers always wear gloves when caring for them. Alcohol-based hand sanitizer is more effective and less drying than using soap and water, and does not create antibioticresistant superbugs.

WASH YOUR HANDS!! With Soap and Water: When? Hands are visibly soiled After any

WASH YOUR HANDS!! With Soap and Water: When? Hands are visibly soiled After any contact with C. diff or Rotovirus After using the restroom

 Compliance Measurement

Compliance Measurement

Measurement Direct observation Product use Electronic systems

Measurement Direct observation Product use Electronic systems

Engaging Patients

Engaging Patients

Discussion

Discussion

Surveillance

Surveillance

Prioritize Assess the Population and determine those at greatest risk Examples: Select surgical Site

Prioritize Assess the Population and determine those at greatest risk Examples: Select surgical Site Infections Pneumonia Patients ICU Patients

Determine the Type of Surveillance Process vs. Outcome Ø Outcome – Healthcare acquired Infections

Determine the Type of Surveillance Process vs. Outcome Ø Outcome – Healthcare acquired Infections Ø Process- Patient Care Practices aimed at preventing HAI’S

Utilize Standardized Definitions Process Identify the process to be measured Identify the methodology for

Utilize Standardized Definitions Process Identify the process to be measured Identify the methodology for collection Outcome Utilize standard definitions- generally accepted, published i. e. NHSN

Standardized Criteria Needed to : Ø Identify an event Ø Monitor trends over time

Standardized Criteria Needed to : Ø Identify an event Ø Monitor trends over time Ø Compare rates between groups

Select Appropriate Denominator Data Outcome – Device days Process- Compliance rates Immunization rates

Select Appropriate Denominator Data Outcome – Device days Process- Compliance rates Immunization rates

Advantages to Process Indicators Work well in long term care and outpatient setting [

Advantages to Process Indicators Work well in long term care and outpatient setting [ Infection rate vs. Immunization rate]

Process Indicators Methods to collect data Observation vs. Chart Review

Process Indicators Methods to collect data Observation vs. Chart Review

Give examples of process indicators

Give examples of process indicators

Difficulty with Process Indicators Reliability / Inter-rater reliability Difficulty with observing processes If measuring

Difficulty with Process Indicators Reliability / Inter-rater reliability Difficulty with observing processes If measuring by documentation – may not adequately reflect the care provided i. e. Surgical prophylaxis

Regulatory/ Accrediting Agencies Frequently use Process Indicators State Dept. of Health Joint Commission, DNV

Regulatory/ Accrediting Agencies Frequently use Process Indicators State Dept. of Health Joint Commission, DNV CMS

Observations

Observations

When all else Fails

When all else Fails

You have to be Kidding!

You have to be Kidding!

Data Reporting Spreading the Message to Key Stakeholders

Data Reporting Spreading the Message to Key Stakeholders

Communication

Communication

Data Dissemination

Data Dissemination

Unit-Based Reporting on Process and Outcome Metrics

Unit-Based Reporting on Process and Outcome Metrics

Data Display

Data Display

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Why is Education Important? Evolving and emerging best practices Attention to basics erode over

Why is Education Important? Evolving and emerging best practices Attention to basics erode over time IP no longer the “Cinderella” program “Teaching can occur without learning and learning can occur without teaching” anonymous

The IP as Content Expert A crucial part of our role: Develop, facilitate, evaluate

The IP as Content Expert A crucial part of our role: Develop, facilitate, evaluate teaching and learning Create an environment for participation and interaction Stimulate reflective and critical thinking to promote good practice

Opportunities abound National conferences State and local conferences Annual competencies Special topics of interest:

Opportunities abound National conferences State and local conferences Annual competencies Special topics of interest: H 1 N 1, NPSGs Grand rounds Orientation APIC webinars CDC, OSHA, WHO, etc

Orientation Diverse backgrounds and educational levels Info overload Focus on 1 -3 key objectives

Orientation Diverse backgrounds and educational levels Info overload Focus on 1 -3 key objectives Provide handouts & contact info Prepare questions to engage group Be creative (games, costumes, music)

Why do we educate HCPs? To improve job skills and competencies.

Why do we educate HCPs? To improve job skills and competencies.

What is Learning? “Learning is a persistent change in performance that results from experience

What is Learning? “Learning is a persistent change in performance that results from experience and interaction with the world” Driscoll 2000

Barriers to Effective Education Welcome to 2020! Rapid change (regulatory, technology) Info overload Staff

Barriers to Effective Education Welcome to 2020! Rapid change (regulatory, technology) Info overload Staff turnover Message not tailored to audience

Basic Theory of Learning Receive a stimulus: experiencing (concrete) vs. thinking (abstract) Then Process

Basic Theory of Learning Receive a stimulus: experiencing (concrete) vs. thinking (abstract) Then Process information gained: experimentation (active) or reflection (passive)

Pedagogy vs. Andragogy study of adult learning Pedagogy study of how children learn a

Pedagogy vs. Andragogy study of adult learning Pedagogy study of how children learn a continuum of learning HCPs must pursue a lifetime of learning Malcolm Knowles

Learning Styles Kolb 1980 s Activists- hands on/role playing/games Reflectors-watch AV/discussion Theorists- complex situations/problem

Learning Styles Kolb 1980 s Activists- hands on/role playing/games Reflectors-watch AV/discussion Theorists- complex situations/problem solving Pragmatists -practical situations with goals DON’T PIGEON HOLE!

Visual Learners Graphic illustrations Sit up front Take notes Repeat verbal directions

Visual Learners Graphic illustrations Sit up front Take notes Repeat verbal directions

Auditory Learners Lecture Group discussion Oral reports

Auditory Learners Lecture Group discussion Oral reports

Kinesthetic Learners Hands on experience Gestures to make a point Role playing Frequent breaks

Kinesthetic Learners Hands on experience Gestures to make a point Role playing Frequent breaks “just do it”

Who Are Adult Learners? Adult learners are self directed.

Who Are Adult Learners? Adult learners are self directed.

 Adult learners are unique.

Adult learners are unique.

Their readiness to learn is affected by their need to know or do something.

Their readiness to learn is affected by their need to know or do something.

Adult learners can get BORED EASILY!

Adult learners can get BORED EASILY!

Humor as a Tool Must be relevant to content Not sarcastic Relieves tension and

Humor as a Tool Must be relevant to content Not sarcastic Relieves tension and breaks the ice Increases motivation, interest, comprehension Can bridge cultural gap…. or not

Hand Hygiene

Hand Hygiene