Frequently Identified Infection Prevention and Control Gaps in Critical

Access Hospitals

Presented by Margaret Drake, MT(ASCP), CIC

NEDHHS/Nebraska ICAP

Authors have no financial disclosures

ICAP Team

Margaret Drake, MT, ASCP, CIC1,5, Regina Nailon, PhD, RN1, Kate Tyner, RN, BSN, CIC1, Sue Beach, BA1, Teresa Fitzgerald, RN, BSN, CIC1, Elizabeth Lyden, MS2, Mark E. Rupp, MD5, Michelle Schwedhelm, MSN, RN1, Maureen Tierney, MD, MSc4 and Muhammad Salman

Ashraf, MBBS5

(1)Nebraska Infection Control Assessment and Promotion Program, Nebraska Medicine, Omaha, NE, (2)College of Public Health, University of Nebraska Medical Center, Omaha, NE, (3)Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center,

Omaha, NE, (4)Division of Epidemiology, Nebraska Department of Public Health, Lincoln, NE, (5)Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE

Session Objectives1.Describe various Infection prevention and control gaps

that exist in critical access hospitals (CAH).

2.List the Infection Control domains with the highest frequency of gaps in the CAH.

3. Identify key factors that are associated with infection prevention and control gaps in the CAH.

Background• As part of the Balanced Budget Act of 1997, the federal government developed the

designation of Critical Access Hospitals (CAHs) in an effort to improve access to health care services in rural communities by providing small rural hospitals with financial structures that would enable their continued viability.

• CAHs are eligible to participate in various quality programs; however, little is known about infection control (IC) gaps in CAHs.

• 2015, the Ebola supplement to the ELC grant established ICAR. In Nebraska this program is called ICAP supported by CDC funding through Nebraska DHHS.

• We studied the frequency of IC gaps and associated factors in 36 CAHs across Nebraska.

Survey Instrument

• On-site assessments were conducted in 36 CAHs. From 10/2015 to 2/2017

• CDC Infection Prevention and Control Assessment Tool for Acute Care Hospitals was used for assessments.

Study Methods

• Gap frequencies were identified using 80 core questions from the tool, representing best practice recommendations (BPR) in 11 IC domains.

• The factors studied for association with the gaps included

• median number of beds (MNB),

• presence of IC trained infection preventionist (IP),

• full time equivalent (FTE) of IP time/25 beds towards IC activities.

• Fisher’s exact, Kruskal-Wallis, and Mann Whitney tests were used for statistical analyses.

Results: Facility Demographics

Abbreviation: FTE = full-time equivalent

* NICN- Nebraska Infection Control Network, 2 day training course for professionals in infection prevention

Characteristics of CAH(N=36 CAH)

Median (Range)

Licensed beds 20 (10-25)

Infection Preventionist FTE 0.34 (0.05-1.0)

Infection Preventionist FTE per 25 beds

0.44 (0.10-1.6)

Infection PreventonistsReported Training (N=36)

Number (%)

CompletedAPIC/SHEA/NICN Course*

29 (80.5%)

Board Certified in Infection Control

2 (5.5%)

No Training in infection control

7 (19.4%)

16.7%

27.2%

56.7%

66.9%

75.0%

84.0%

30.6%

52.3%

49.4%

45.5%

30.1%

[I.] Infection Control Program and Infrastructure

[II. A.] Hand Hygiene

[II. B.] Personal Protective Equipment

[II. C.] Prevention of CAUTI

[II. D.] Prevention of CLABSI

[II. F.] Injection Safety

[II. G.] Prevention of SSI

[II. H.] Prevention of CDI

[II. I.] Environmental Cleaning

[II. J.] Device Reprocessing

[III.] Detect, Prevent, and Respond to HAI and MDROs

Prevalence of Infection Control Gaps in Critical Access Hospitals by Domains

Results

50%

42%

75%

92%

94%

89%

75%

61%

72%

67%

86%

[I.] Program does not perform annual facility infection riskassessment

[II. A.] No competency-based hand hygiene training program

[II. B.] No regular audits of adherence to proper PPE selection anduse

[II. C.] No urinary catheter insertion competency-based trainingprogram

[II. D.] No regular audits of adherence to practices for CVC insertion

[II. F.] No feedback from audits given to staff regarding safe injectionpractices

[II. G.] No regular audits of SSI prevention practices

[II. H.] No regular audits of CDI prevention practices

[II. I.] No environmental cleaning competency-based trainingprogram

[II. J.] No regular audits of semi-critical equipment reprocessing

[III.] No specific antibiotic stewardship strategies in place to reduceCDI

Most Common Infection Control Gaps Within each Domain

Description of Infection Control Practice Gaps (N=36 CAH) Number of (%) CAH with gaps

No competency based training for preparing parenteral meds outside pharmacy 29 (80.5%)

No competency based training program for PPE selection & use 26 (72.2%)

No regular audits of reprocessing procedures for critical devices 23 (63.8%)

No system in place for detection of potential infectious persons on entry 18 (50%)

No system for inter-facility transfer communication of possible infectious patients 17 (47.2%)

No policies delineating cleaning responsibilities 17 (47.2%)

No monitoring or use of CDI data to direct prevention activities 15 (41.6%)

Examples of Some Other Notable Gaps

Comparison of CAH based on Implemented BPR

Facilities divided into quartiles based

on implemented BPR (n=9 for each

quartile)

No. (%) of implemented BPR on average out of the 80 assessed during the visits

Median number of beds

Median IP FTE/25 beds

% of CAH with trained IP

Top Quartile 56 (70%) 21 0.6 100%

2nd Quartile 45 (56%) 24 0.4 77.7%

3rd Quartile 35 (44%) 20 0.4 77.7%

Bottom Quartile 27 (33%) 16 0.4 88.9%

P value 0.32 0.75 0.72

Hospital has a competency-based training program for reprocessing of semi-critical equipment

No Yes TotalCAH without trained IP 4

30.771

4.355

CAH with trained IP 969.23%

2295.65%

31

Total 13 23 36

p-value 0.0470

Possible Impact of Presence of trained IP

Patients with CVCs are assessed at least daily for continued need for the

catheter.# Facilities Median

IP FTE/25 beds

No 27 0.40

Yes 9 0.83

p-value 0.023

Possible Impact of Higher IP FTE

Hospital has a competency-based training program for reprocessing of semi-critical

equipment# Facilities Median Number of

Beds

No 13 16.00

Yes 23 23.00

p-value 0.0034

Association of Bed Size with Specific BPR

Conclusions

• Opportunities for improvement of infection control program exist in CAH

• Lack of competency-based training programs and failure to perform audits and feedback appears to be recurrent theme in several domains

• Mitigation strategies should include:

• Advocating for Higher IP FTE

• Advocating for IP Training

• NE-ICAP team has already developed training program for infection preventionistsbased on the gap data and made several resources available online for mitigation strategies

• Specific guidance from a recognized authority, e.g. APIC, on the infection preventionistFTE dedicated towards infection prevention and control activities may also help in improving infection control programs.

Thank youQuestions?

Margaret.drake@Nebraska.gov