clostridium difficile prevention using a approach
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Clostridium difficile Prevention Using a Human Factors and Systems Engineering ApproachProf. Nasia Safdar, University of Wisconsin-Madison
A Webber Training Teleclass
Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com
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Clostridium difficile prevention using a human factors and systems engineering
approach
Nasia Safdar, MD, PhD
William. S. Middleton Memorial Veterans Hospital and the University of Wisconsin-Madison
Hosted by Paul Webberpaul@webbertraining.com
www.webbertraining.com January 31, 2019
1. Identify how to apply a systems engineering approach to C. difficile prevention
2. Describe the complementary data collection approaches useful in characterizing C. difficile prevention efforts.
3. Examine the interprofessional aspects of C. difficile prevention
Objectives of the Session
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Clostridium difficile Prevention Using a Human Factors and Systems Engineering ApproachProf. Nasia Safdar, University of Wisconsin-Madison
A Webber Training Teleclass
Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com
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Complexity of C. difficile infection
Challengestocontainment§ Uncertainincubationperiod§ Multiplereservoirs§ Environmentalpersistence§ Highratesofrecurrence§ Needforsoapandwaterforhandhygiene§ Multidisciplinaryapproachtocontainment§ Needforbothinfectionpreventionprotocolsandantibioticstewardshipinterventions
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Fishbonediagramshowingthe complexityofCDI pre
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Clostridium difficile Prevention Using a Human Factors and Systems Engineering ApproachProf. Nasia Safdar, University of Wisconsin-Madison
A Webber Training Teleclass
Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com
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SystemsPerspective
An individual perspective may be narrow, underestimate the scope of the problem, may not be sufficient to recognize root causes and may make implementation of infection prevention for CDI challenging
A systems perspective takes the whole picture into consideration from all relevant perspectives and stakeholders
Breaks the problem down into its component parts
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• Misperceptions:– Fact#1: Humanfactorsisaboutdesigningsystemsthatareresilienttounanticipatedevents.
– Fiction: Humanfactorsisabouteliminatinghumanerror.– Fact#2: Humanfactorsaddressesproblemsbymodifyingthedesignofthesystemtobetteraidpeople.
– Fiction: Humanfactorsaddressesproblemsbyteachingpeopletomodifytheirbehaviour.
HumanFactors
The science of human factors: separating fact from fiction Alissa L Russ et al https://qualitysafety.bmj.com/content/22/10/802 6
Clostridium difficile Prevention Using a Human Factors and Systems Engineering ApproachProf. Nasia Safdar, University of Wisconsin-Madison
A Webber Training Teleclass
Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com
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– Fact#3: Humanfactorsworkrangesfromtheindividualtotheorganisational level.
– Fiction: Humanfactorsisfocusedonlyonindividuals.
– Fact#4: Humanfactorsisascientificdisciplinethatrequiresyearsoftraining;mosthumanfactorsprofessionalsholdrelevantgraduatedegrees.
– Fiction: Humanfactorsconsistsofalimitedsetofprinciplesthatcanbelearntduringbrieftraining.
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– Fact#5: Humanfactorsprofessionalsareboundtogetherbythecommongoalofimprovingdesignforhumanuse,butrepresentdifferentspecialtyareasandmethodologicalskillssets.
– Fiction: Humanfactorsscientistsandengineersallhavethesameexpertise.
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Clostridium difficile Prevention Using a Human Factors and Systems Engineering ApproachProf. Nasia Safdar, University of Wisconsin-Madison
A Webber Training Teleclass
Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com
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HFEmechanisms Objectivesofsystemdesign
1. AworksystemthatisnotdesignedaccordingtoHFEdesignprinciplescancreateopportunitiesforerrorsandhazards(seetable2forexamplesofdesignprinciples)
TheobjectiveofHFE-informedsystemdesignistoidentifyandremovesystemhazardsfromthedesignthroughmaintenancephases.
2. Performanceobstaclesthatexistintheworksystemcanhinderclinicians’abilitytoperformtheirworkanddeliversafecare
Ifsomeobstaclescannotberemoved,forinstance,becausetheyareintrinsictothejob,thenstrategiesshouldbedesignedtomitigatetheimpactofperformanceobstaclesbyenhancingothersystemelements(ie,balancetheoryofjobdesign)4142
3. Aworksystemthatdoesnotsupportresiliencecanproducecircumstanceswheresystemoperatorsmaynotbeabletodetect,adaptto,and/orrecoverfromerrors,hazards,disruptionsanddisturbances
Worksystemsshouldbedesignedtoenhanceresilienceandsupportadaptabilityandflexibilityinhumanwork,43 suchasallowingproblemorvariancecontrolatthesource44
4. Becausesystemcomponentsinteracttoinfluencecareprocessesandpatientsafety,HFEsystemdesigncannotfocusononeelementofworkinisolation.32 35
Wheneverthereisachangeintheworksystem,oneneedstoconsiderhowthechangewillaffecttheentireworksystem,andtheentiresystemneedstobeoptimised orbalanced41 42
HumanFactors/Ergonomics
HFE mechanisms between system design and patient safety•HFE, human factors and ergonomics.
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FocusofHFE ExamplesofHFEdesignprinciples
PhysicalHFE
Tominimiseperceptiontime,decisiontime,andmanipulationtime
Toreduceormitigateneedforexcessivephysicalexertion
Tooptimiseopportunitiesforphysicalmovement
CognitiveHFE
Toensureconsistencyofinterfacedesign
Tomatchbetweentechnologyandtheuser'smentalmodel
Tominimisecognitiveload
Toallowforerrordetectionandrecovery
Toprovidefeedbacktousers
OrganisationalHFE
Toprovideopportunitiestoworkerstolearnanddevelopnewskills
Toallowworkercontroloverworksystem
Tosupportworkeraccesstosocialsupport
Toinvolveusersinsystemdesign
HumanFactors/Ergonomics
Examples of HFE design principles•HFE, human factors and ergonomics. Human factors and ergonomics as a patient safety practice Pascale Carayon, Anping Xie, Sarah Kianfar
https://qualitysafety.bmj.com/content/23/3/196#block-system-main 10
Clostridium difficile Prevention Using a Human Factors and Systems Engineering ApproachProf. Nasia Safdar, University of Wisconsin-Madison
A Webber Training Teleclass
Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com
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Clostridium difficile Prevention Using a Human Factors and Systems Engineering ApproachProf. Nasia Safdar, University of Wisconsin-Madison
A Webber Training Teleclass
Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com
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Key interventions for CDI prevention- aCDIbundle
1) rapid, appropriate diagnostic testing for C. difficile
2) empiric isolation for patients with diarrhea and suspected CDI
3) contact isolation for patients with confirmed CDI
4) environmental decontamination of CDI patient rooms
5) full compliance with hand hygiene by all entering and leaving CDI patient rooms.
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SEIPSmodelforCDI
Five Components
• Tools• Technologies• Environment• People• Organization• Tasks
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Clostridium difficile Prevention Using a Human Factors and Systems Engineering ApproachProf. Nasia Safdar, University of Wisconsin-Madison
A Webber Training Teleclass
Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com
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SEIPSforevaluationofCdifficilebundle
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SEIPSapplicationtoCDI
• Createaprocessmaptounderstandcurrentpracticeandprocedures
• Reviewofpoliciesandprocedures,signage,diagnostictestingprocedure
• Supplementthisdatawithfocusgroups/interviewsofrelevantgroups
• SupplementwithdirectobservationsofPPEdonninganddoffing,roomlayout,PPEsupplies.
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Clostridium difficile Prevention Using a Human Factors and Systems Engineering ApproachProf. Nasia Safdar, University of Wisconsin-Madison
A Webber Training Teleclass
Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com
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Datacollection
• Threehomogenousfocusgroupsconvened– oneeachcomprisedofphysicians,nursesandenvironmentalservicesworkers(EVS)– overa4-weekperiod.
• Thephysicianfocusgroupincluded7medicineresidentsandoneattendingphysician
• Thenursingfocusgroupincluded10nursesfrommedicalunitswithvaryingexperience
• TheEVSgroupincludedsixparticipantswith2-30yearsofexperiencefromvaryingtypesofunits(ICU,medical,surgical).
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§ Facilitatedbyahumanfactorsengineerwithsignificantexperienceinhealthcaregroupfacilitation.
§ Participantsreceivednofinancialremunerationforattending.
§ Discussionwasaudiorecordedfortranscriptionbyaprofessionalserviceandsubsequentlycodedbytworesearchers
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Clostridium difficile Prevention Using a Human Factors and Systems Engineering ApproachProf. Nasia Safdar, University of Wisconsin-Madison
A Webber Training Teleclass
Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com
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TranscriptsofthethreefocusgroupswereuploadedtoDedoose® web-basedqualitativedataanalysissoftware.
Eachexcerptwascodedtothreedimensions–1) whichofthefiveCDIbundleinterventionsthe
excerptcorrespondedto2) whichofthefiveelementsoftheworksystemit
relatedto3) and3)whetheritwasaworksystembarrieror
facilitator.
Anexcerptcouldbecodedtomultiplebundleinterventions,multipleworksystemelementsandbebothabarrierandfacilitator.
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Person.
NursespresentedanissueassociatedwithrelyingonotherstoinformthemthatapatienttheycareforhasCDI.Thisbecomesaproblemwhentheexpectationisnotmet.Forexample,CDIpatientroomsmusthaveasignonthedoorinformingthepersonenteringtheroomtotakeadditionalprecautions.
Ifthepersonresponsibleforpostingthesignforgetsordoesnotpostthenotice,handhygieneandotherCDIinterventionsmaynotappropriatelyoccur.[Nursefocusgroup:“Orifsomebodyforgetstoputthesignupandit’syourpatient…youhavenoideatheywereinisolation.That’s(not)alwaysgreat.”
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Clostridium difficile Prevention Using a Human Factors and Systems Engineering ApproachProf. Nasia Safdar, University of Wisconsin-Madison
A Webber Training Teleclass
Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com
11
Tools/technology.
Allthreegroupsnotedsinkinterferenceposedbytheexcessiveamountofequipment(andalsopeople)inthepatientroom.
Posesinkaccessissues.[EVSfocusgroup:“(Thereare)hugechairsandthepatientsitsinfrontofthesink.Andthenwecan’tgettothesinktowashourhands.…Suppliesinfrontofthesink…(cause)interference.”]
EVSstaffcommentedontheirpositiveandconsistentuseofpagersasameansofinformingthemthat they will be cleaning a CDI patient room.
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Organization.Thechallengeofeducatingpatients’familiesregardingtheir
needtocomplywiththeCDIinterventionswassolelydiscussedbynurseswhonotedthatchangesinhandhygienepracticevariedbasedonfamilymemberperceptions.
Physiciansadmittedthelackofclarityofthehandhygienepolicyrelatedtowhen,where,andhowlonghandwashingshouldoccur.
Otherorganizationissuesthatwereidentifiedfrequentlyrelatedtorole-specificpoliciessolelyrelevanttoaparticulargroup.Forexample,EVSworkersdiscussedsignificantissuesrelatedtotrainingandstaffturnoverthathadanimpactoncompliancewithandunderstandingoftheimportanceofhandhygiene.Institutionalpressuretoturnoverroomfast 22
Clostridium difficile Prevention Using a Human Factors and Systems Engineering ApproachProf. Nasia Safdar, University of Wisconsin-Madison
A Webber Training Teleclass
Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com
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Environment
Eightofthe52totalcommentswererelatedtosinksandweremadebyallthreegroups.
Consistentissuesrelatedtothenumberandlocationofthesinks.
[Nursefocusgroup:“Wehavetousethesinksinthehallwaytowashourhandsbecauseyoucan’tgetoutofaC.diffroomwithoutrecontaminating yourhandsafteryou’vewashed.”]
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Tasks
Wet hands make gloving difficult
PPE when not anticipating touching patient or environment
Inconsistency in where used gowns are disposed
Inconsistency in where clean gowns are stored
Supply
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Clostridium difficile Prevention Using a Human Factors and Systems Engineering ApproachProf. Nasia Safdar, University of Wisconsin-Madison
A Webber Training Teleclass
Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com
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SEIPSApplicationtoPPEPerson
Type of healthcare workerPatient/visitorKnowledge/awarenessPerception of risk given anticipated activity
Tools/technologyPPE cumbersomeUse of phone/iPAD in isolation rooms difficult
TasksBundling of caresIncreases time Cleaning issues
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SEIPSApplicationtoPPEEnvironment
DisposalSuppliesSignage on doorStethoscope issues
OrganizationPoliciesPractice variationLeadership involvement
FacilitatorsLeadership engagementConsistency of messagesEase of availability and disposal 26
Clostridium difficile Prevention Using a Human Factors and Systems Engineering ApproachProf. Nasia Safdar, University of Wisconsin-Madison
A Webber Training Teleclass
Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com
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SEIPSandinterventions
• Createalistofbarriersandselectonesthataremodifiableandhavehighimpact
• Examples– Creationofnewsinks– Consistencyofmessaging- prosandcons– LeadershipsupportforEVS
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Acknowledgments
Funding:AHRQVAPCORINIHCDC UW-Madison
References:Barriers and facilitators to Clostridium difficile infection prevention: A nursing perspective.Ngam C, Schoofs Hundt A, Haun N, Carayon P, Stevens L, Safdar N.Am J Infect Control. 2017 Dec 1;45(12):1363-1368. doi: 10.1016/j.ajic.2017.07.009. Epub 2017 Sep 19.What do visitors know and how do they feel about contact precautions?Seibert G, Ewers T, Barker AK, Slavick A, Wright MO, Stevens L, Safdar N.Am J Infect Control. 2018 Jan;46(1):115-117. doi: 10.1016/j.ajic.2017.05.011. Epub 2017 Jul 18. 28
Clostridium difficile Prevention Using a Human Factors and Systems Engineering ApproachProf. Nasia Safdar, University of Wisconsin-Madison
A Webber Training Teleclass
Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com
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