Presentation from AHRQ Hospital Acquired Infections Collaborative Meeting July 2009

1. 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

2. Welcome Introductions and Reintroductions Overview of Day One Presentations by partners CDC Speaker Materials/Binders Group Dinner

3. 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

4. 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

5. Update: Where We Are In Data CollectionCurrent as of 7/08/09

6. 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

7. 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.

8. 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

9. 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

10. 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)

11. 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

12. 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).

13. 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

14. 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).

15. 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

16. 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

17. 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

18. Next Steps Next Steps Continue Analyses Publication Final Reports Teleconferences: August 18 September 15 (AHRQ Conference) October 20

19. 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

20. Key Barriers Encountered in HAI Reduction and Implementation Efforts

22. timing of intervention implementation,

23. amount of time to complete training modules,

24. surveys were lengthy,

26. Key Barriers Encountered in HAI Reduction and Implementation Efforts -Lack of staff support, Lack of Management support, Lack of Time and Money

27. 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”

28. 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.

29. Key Facilitators Encountered in HAI Reduction and Implementation Efforts

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. Wrap Up Questions Comments Final Thoughts