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

1. 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

2. Goals & Methods

3. Identify challenges in implementing HAI reduction efforts. Identify and key lessons learned. Identify areas of interest for future research. Project Goals

4. 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)

5. Hospital Characteristics * Total > 33 due to hospitals fitting into multiple types.

6. 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

7. 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

8. 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

9. 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

10. 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

11. Results

12. 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

13. HAI: Barriers & Challenges to Infection Prevention at the Point of Care

15. Challenges of unanticipated change (turnover of residents, champions in units, nursing staffing, redesign of units, new information system)

16. Demonstrating cost effectiveness, limited additional funds

17. Competing priorities, level of required documentation in daily work

18. Use and documentation of bundle variables inconsistent- Real time data collection, burden of reporting

19. Availability of time, staff and effective approaches for training

20. Need to convince professionals EBPs are beneficial to them and their patients—given limited time

21. Mix of hospitals (large, small) and unique challenges (surveillance) of a small rural community, non-profit hospital

22. Evolve guidelines based on developing evidence.

23. Time, persistence and structured communication needed for practice/culture change to take hold.

25. Mechanism to provide staff with strong evidence-base

26. Communicate expectations and require accountability

27. Do what works locally—ability to adapt to local context

28. Promise of providing back data one of greatest motivators.

29. Strong physician and nurse leadership and champions

30. IT develops an electronic checklist (data warehouse) to allow data queries and feedback compliance on process measures

31. Top executives make rounds and solve problems

32. Mandatory state reporting (NHSN) and changes in CMS reimbursement

33. Leadership support results in sufficient time for front-line staff to improve processes, change systems and achieve success

34. Communication, involvement of front-line staff imperative

36. "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

37. 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."

38. "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

39. "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

40. "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

41. "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

42. "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

43. 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

44. 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

45. 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

46. 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

47. 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

49. Changing habit

50. Acquiring resources (people, $$)

51. Getting buy-in from staff, physicians and administration

52. Time – burden on staff to learn and implement

53. Lessons Learned were:

54. People = engage, get local buy-in, value of champions, peer support

55. Implementing Processes = simplify, present evidence, be persistent, involve ancillary departments

56. Education = difficult to reach all people in right way

57. Time = culture change takes time, be patient

58. Might not get it right the first time

60. 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

62. Utilize strengths of individuals to motivate and sustain changes in behaviors—nurses really want to train younger nurses and mentor

63. Posting results engages staff, patients, families

64. After eliminating BSIs for a year in intervention unit, then every subsequent BSI is reviewed and discussed by an interdisciplinary team

66. Compare performance in a meaningful way

67. Fostering sharing, teamwork, competition

69. Posting results engages staff, patients, families

70. Fostering unit-based competitition

72. Nurses encouraged by manager and ICU directors to “call out” non-adherence and teasing/cajoling low adherence providers

73. Multiple champions, staff engagement helps overcome turnover in project leadership

75. Program for clinicians in TRIP, reviewing evidence, coaching TRIP project, write a manuscript

76. Advanced Practice Institute provides training in implementing EBP, critique of CPGs, and hospital-specific action plans

77. Training needed in leadership and organizational transformation

79. Need to use strength and experiences of champions key to implementing and sustaining changes over time

80. IT develops an electronic checklist whenever central line inserted to track denominators (data warehouse) for data queries and feedback compliance to units

82. Regularly (daily) measuring and feeding back hand hygiene at unit level really reinforces adherence

83. IT develops an electronic checklist whenever central line inserted to track denominators (data warehouse) for data queries and feedback compliance to units

84. Integrating checklists into work rounds, electronic systems is effective

85. Collect limited data that is most relevant to showing impact of interventions