clostridium difficile prevention using a approach

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 [email protected]

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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 [email protected]

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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Complexity of C. difficile infection

Challengestocontainment§ Uncertainincubationperiod§ Multiplereservoirs§ Environmentalpersistence§ Highratesofrecurrence§ Needforsoapandwaterforhandhygiene§ Multidisciplinaryapproachtocontainment§ Needforbothinfectionpreventionprotocolsandantibioticstewardshipinterventions

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Fishbonediagramshowingthe complexityofCDI pre

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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




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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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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




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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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SEIPSforevaluationofCdifficilebundle

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SEIPSapplicationtoCDI

• Createaprocessmaptounderstandcurrentpracticeandprocedures

• Reviewofpoliciesandprocedures,signage,diagnostictestingprocedure

• Supplementthisdatawithfocusgroups/interviewsofrelevantgroups

• SupplementwithdirectobservationsofPPEdonninganddoffing,roomlayout,PPEsupplies.

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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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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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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




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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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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




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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




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clostridium difficile prevention using a approach

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