Search

Background Caring for patients in contact precautions can be challenging. In this pilot study, we sought to understand, using qualitative and visual methods, how nurses provide care for patients in contact precaution rooms and to identify potential breakdowns in practice that could increase risk of disease transmission. Methods Qualitative data were collected while shadowing 4 nurses on 2 medical/surgical units at a university medical center between September and October 2016. Observers documented nurses' movements in handwritten fieldnotes. Fieldnote data were analyzed using a descriptive approach with visual depiction to map care delivery in precaution and non-precaution rooms. Results Nurses moved between non-precaution rooms, completing 1-4 tasks per room entry, over the course of several brief room entries and exits. In contrast, nurses rarely entered contact precaution rooms to complete only a few tasks, generally completing ≥10 tasks per room entry. Although hand hygiene on room entry/exit was consistently performed, a breakdown in practice occurred in precaution rooms as nurses tended to move between tasks and contact with the environment without performing hand hygiene. Conclusions Differences in how nurses structure their work in contact precaution rooms may contribute to risk of infectious disease transmission. Understanding and addressing the challenges specific to how nurses work is a critical part of infection prevention in today's hospital environment.

Background Antibiotic overuse at hospital discharge is common and harmful; however, methods to improve prescribing during care transitions have been understudied. We aimed to pilot a pharmacist-facilitated antibiotic timeout prior to discharge. Methods From May 2019 to October 2019, we conducted a single-center, controlled pilot study of a pharmacist-facilitated antibiotic timeout prior to discharge. The timeout addressed key elements of stewardship (e.g., duration) and was designed and implemented using iterative cycles with rapid feedback. We evaluated implementation outcomes related to feasibility, including usability, adherence, and acceptability, using mixed methods. Pre vs. post intervention antibiotic use at discharge in intervention vs. control groups was assessed using logistic regression models controlling for patient characteristics. Results Pharmacists conducted 288 antibiotic timeouts. Timeouts were feasible (mean 2.5 minutes per timeout) and acceptable (85% [40/48] of hospitalists believed timeouts improved prescribing). Pharmacists recommended an antibiotic change in 25% (73/288) of timeouts with 70% (51/73) of recommended changes accepted by hospitalists. Barriers to adherence included unanticipated and weekend discharges. Compared to control services, there were no differences in antibiotic use after discharge during the intervention. Conclusions A pharmacist-facilitated antibiotic timeout at discharge was feasible and holds promise as a method to improve antibiotic use at discharge.

Background Reducing health care-associated infections (HAIs), such as catheter-associated urinary tract infection (CAUTI), is a critical performance improvement target in nursing homes. The Agency for Healthcare Research and Quality Safety Program for Long-term Care: Health Care-Associated Infections/Catheter-Associated Urinary Tract Infection, a national performance improvement program, was designed to promote implementation of a CAUTI prevention program through state-based or regional collaboratives in more than 500 nursing homes across the United States. Methods Qualitative interviews were conducted with 8 purposefully selected organizational leads (who led implementation activities for a group of facilities) and 8 facility leads (who led implementation activities at a given facility) to understand implementation successes and challenges and experiences of participants involved in the program. Key themes were identified using a rapid analysis approach. Results Key themes related to general perceptions, changes due to program participation, and factors influencing program implementation were identified. In general, the program was viewed positively by organizational and facility leads with changes in catheter care practices, staff empowerment, and improvements in knowledge identified as benefits. Implementation challenges included the time required for program start-up as well as issues with staff and physician support, logistic barriers, and staffing turnover. Conclusions Despite some challenges, the observed program success and positive views of those participating suggest that collaboratives are an important strategy for providing nursing homes with enhanced expertise and support to prevent HAIs and ensure resident safety.

Background Hospital-acquired infection, including catheter-associated urinary tract infection (CAUTI), is common. Although CAUTI is usually preventable, hospital units may struggle to reduce CAUTI rates. The CAUTI guide to patient safety (GPS) was developed to assess a unit's CAUTI prevention activities. Our aim was to qualitatively validate the GPS. Methods We interviewed participants from 2 units in each of 4 hospitals. Each unit's nurse manager completed the GPS and then discussed their answers with a trained research assistant. Semistructured interviews were conducted with unit nurses and physicians. We compared the nurse managers' answers to the unit physicians' and nurses' responses and assessed agreement. Results A total of 49 participants from 4 medical intensive care units and 4 medical-surgical units were interviewed. Nurse managers found the GPS helpful and complete. There was higher agreement between nurse managers and unit nurses than with physicians. Some questions generated more disagreement than others. Our findings suggest that the GPS is comprehensive and may be best used to stimulate discussions between stakeholders to address key issues. Conclusions Using the GPS to assess several stakeholders' views could allow a given unit to move its CAUTI prevention efforts forward in a more informed manner.

Adherence to isolation precaution practices, including use of personal protective equipment (PPE), remains a challenge in most hospitals. We surveyed inpatient and emergency department clinicians about their experiences and opinions of various isolation policies, specifically those related to wearing PPE. Our findings show several differences between inpatient and emergency department clinicians involving perceptions related to safety, and the difficulty associated with using PPE for certain types of organisms.

Background Health care personnel (HCP) use of personal protective equipment (PPE) reduces infectious disease transmission. However, PPE compliance remains low. The objective of this study was to better understand how HCP perceptions factor into PPE decision making as well as how organizational processes and the environment impact behavior. Methods This qualitative study used observation and focus groups at 2 medical centers. Data were analyzed using thematic analysis. Results The decision to use PPE and to follow precaution practices was influenced by risk perception as well as organizational and environmental factors. Perceived risk, related to certain organisms and work tasks, was considered by HCP when deciding to use PPE. Organizational processes, such as policies that were not applied uniformly, and environmental factors, such as clean versus contaminated space, also played a role in HCP PPE use. Discussion Because HCP seemed focused on organisms and work tasks, education on specific organisms and helping HCP think through their workflow may be more effective in conveying the importance of PPE in reducing transmission. Additionally, isolation practices should be compared across disciplines to ensure they complement, rather than contradict, one another. Assessment of the environment may help protect HCP and patients from infectious organisms. Conclusion Preventing the spread of infectious organisms should not depend solely on PPE use, but should also be recognized as an organizational responsibility.

Catheter-associated urinary tract infection (CAUTI) surveillance is labor intensive, generally involving manual medical record review. We developed a prototype automated report through iterative design. Surveys and qualitative interviews were administered to key stakeholders to assess the report design. We found that different provider types expressed different needs regarding report content and format. Therefore, determining the primary audience for reporting data on CAUTI a priori is critical to developing useful reports, particularly as this process becomes standardized and automated.

Preventing catheter-associated urinary tract infection (CAUTI) remains a significant challenge for US hospitals. The "On the CUSP: Stop CAUTI" initiative represents the single largest national effort (involving >950 hospitals) to mitigate urinary catheter risk. The program brings together key organizations to assist state hospital associations and hospitals by providing education and coaching support, addressing both the technical aspects of preventing CAUTI and CAUTI-specific socio-adaptive challenges. At the local level, engaging health care workers, from physicians and nurses to other ancillary services, is critical. This includes (1) making the importance of addressing CAUTI stakeholder specific, (2) ensuring support from leaders of essential disciplines, (3) underscoring the importance of the collaborative nature of CAUTI prevention, and (4) identifying champions within the organization to lead and be accountable for the work. Sustainability is ensured by integrating the process into the health care worker's daily routine activities.

BACKGROUND In November 2019, Centers for Medicare & Medicaid Services (CMS) will require skilled nursing facilities (SNFs) to have an infection preventionist (IP) with “specialized training.” Meeting this requirement may prove difficult for many SNFs due to staff turnover, lack of resources and increasing patient acuity. The purpose of this study was to better understand SNF readiness for meeting the challenges ahead. METHODS In 2018, data were collected through a survey administered to 12 SNFs. These SNFs participated in the pilot phase of larger project designed to reduce healthcare-associated infections (HAIs) by enhancing relationships between SNFs and hospitals. The survey included facility-based questions of services provided and their current infection prevention program; IP experience and education; and communication between SNFs and hospitals. Following the survey, qualitative data were collected through semi-structured interviews at 4 SNFs and analyzed using a descriptive approach. RESULTS The 12 SNFs varied in size and services provided. Over half of the 12 IPs had “five years or less” experience in infection prevention. All of the IPs had other responsibilities such as staff education/development, occupational health, or assistant director of nursing. Ten months into the 12-month pilot year, 7 of the 12 IPs had left their IP position. The SNFs remained enrolled in the project, with the project team engaging the SNF IP in their new role and acquainting them to project-related resources. Our qualitative analysis revealed that these meetings met a critical need for new IPs. One of the interviewees noted that the “mentorship” offered by the project was vital to continue existing IP efforts at the SNF. CONCLUSIONS Limited IP experience and turnover will pose a significant challenge for SNFs in trying to meet CMS mandates. Strategies should encourage relationships with experienced IPs to assist SNFs in training and retaining IPs.

Background The catheter-associated urinary tract infection (CAUTI) measure recommended by the National Healthcare Safety Network (NHSN) accounts for the risk of infection in patients with an indwelling urinary catheter, but might not adequately reflect all efforts aimed to enhance patient safety by reducing urinary catheter use. Methods We used computer-based Monte Carlo simulation to compare the NHSN-recommended CAUTI rate (CAUTIs per 1,000 catheter-days) with the proposed “population CAUTI rate” (CAUTIs per 10,000 patient-days). We simulated 100 interventions with a wide range of effects on catheter utilization and CAUTI risk in patients with catheters, and then compared the 2 measures before and after intervention across the simulated interventions. Results Out of our 100 simulated interventions, 93 yielded reductions in CAUTI; however, in 25 (27%) of these 93 simulations, the NHSN CAUTI rate increased after the intervention. In addition, among the 68 simulations in which both the NHSN and the population CAUTI rates decreased, the percent decreases in the population CAUTI rate were consistently greater than those in the NHSN rate. Conclusion The population CAUTI rate—CAUTIs per 10,000 patient-days—should be calculated along with the NHSN rate, particularly in settings where interventions lead to substantial reductions in catheter placement. We suspect that this population CAUTI rate may eventually emerge as a primary outcome for hospital-based quality improvement interventions for reducing urinary catheter utilization, especially those focusing on avoiding urinary catheter placement.

Catheter-associated urinary tract infection, 1 of the hospital-acquired conditions targeted for reduction by the US government, is challenging to prevent. We therefore developed a self-assessment tool (a catheter-associated urinary tract infection prevention guide to patient safety) based on extensive qualitative evaluations. We describe the rationale, features, and utility of such a quality improvement tool.

Infection control professionals and hospital epidemiologists are accustomed to using quantitative research. Although quantitative studies are extremely important in the field of infection control and prevention, often they cannot help us explain why certain factors affect the use of infection control practices and identify the underlying mechanisms through which they do so. Qualitative research methods, which use open-ended techniques, such as interviews, to collect data and nonstatistical techniques to analyze it, provide detailed, diverse insights of individuals, useful quotes that bring a realism to applied research, and information about how different health care settings operate. Qualitative research can illuminate the processes underlying statistical correlations, inform the development of interventions, and show how interventions work to produce observed outcomes. This article describes the key features of qualitative research and the advantages that such features add to existing quantitative research approaches in the study of infection control. We address the goal of qualitative research, the nature of the research process, sampling, data collection and analysis, validity, generalizability of findings, and presentation of findings. Health services researchers are increasingly using qualitative methods to address practical problems by uncovering interacting influences in complex health care environments. Qualitative research methods, applied with expertise and rigor, can contribute important insights to infection prevention efforts.

A national survey of infection preventionists was conducted in Thailand to assess career satisfaction, perceived barriers to implementing infection control practices and current sources of continuing education. Despite positive career satisfaction, several barriers were identified, including a lack of physicians to champion infection control efforts and difficulty remaining current with new evidence-based recommendations.

Background Because evidence-based health care is taking on increasing importance, we surveyed a national sample of infection control coordinators on their reading habits to discern which and how often various media are utilized. Methods Infection control coordinators at 797 hospitals in the United States were mailed a survey asking which peer-reviewed journals and other publications they subscribe to, their perception of the quality of the infection control articles provided by each, and the extent to which they use various resources for their work. Results The survey response rate was 74%. Infection control coordinators spend a mean of 3.6 hours/week reading journals or periodicals. Resources identified as most useful included the Centers for Disease Control and Prevention (CDC) Web site (52%), the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) text (11%), and the APIC e-mail list (8%). Proportion of subscribers was highest for the American Journal of Infection Control (84%) and Infection Control Today (72%). The top 3 journals ranked on a scale of 1 to 10 for quality of infection control articles were Infection Control & Hospital Epidemiology (8.0), the American Journal of Infection Control (7.5), and the New England Journal of Medicine (7.4). The American Journal of Infection Control (85%) and Infection Control & Hospital Epidemiology (72%) were the most frequently used peer-reviewed sources of information, whereas Morbidity and Mortality Weekly Report (85%) and Hospital Infection Control (63%) ranked at the top for nonpeer-reviewed periodicals. Conclusion Infection control coordinators devote limited time to reading and critically appraising published evidence and rely heavily on sources that provide rapid access to information or evidence summaries, suggesting a growing need for easy-to-read, reliable sources of information about evidence-based infection prevention and control practices.

BACKGROUND/OBJECTIVES: Professional and practice standards specify that infection control professionals (ICPs) acquire and maintain current knowledge and skills, critically appraise published evidence and then apply this knowledge towards infection prevention and control and epidemiology. Since evidence-based health care is taking on increasing importance we surveyed a nationwide sample of ICPs on their reading habits to discern which and how often various media are utilized. METHODS: As part of a larger study, IC Coordinators (ICCs) at 797 hospitals in the U.S., including all VA Medical Centers and a randomized, stratified sample of non-VA hospitals were mailed an 11-page evidence-based practice survey. Recipients were asked which of several peer-reviewed journals and others such as “throwaway” periodicals they subscribe to, perception of quality for each, and rank order on the extent to which these provided useful practice information. Frequency of responses was analyzed using SAS [ver.9.1, Cary, NC]. RESULTS: The survey response rate was 74.3%. Respondents spend a mean of 3.6 hours/week reading journals or periodicals. Resources identified as most helpful included the CDC website (51.7%), APIC Text (10.8%) and APIClist (8.4%). Proportion of subscribers was highest for American Journal of Infection Control (AJIC; 83.6%), Infection Control Today (71.5%) and Managing Infection Control (54.2%). The top three journals ranked on a scale of 1-10 for quality were Infection Control & Hospital Epidemiology (ICHE; 8.0), AJIC (7.5), and New England Journal of Medicine (7.4). Of peer-reviewed journals, AJIC (85.1%) and ICHE (71.8%) were deemed most helpful sources of practice information. For non-peer-reviewed, Morbidity and Mortality Weekly Report (85.1%) and Hospital Infection Control (61.3%) were ranked at the top. Using an average of mean rank scores based on a four point rating, ICCs indicated that non-peer-reviewed periodicals are the most commonly utilized (63.0%), followed by other sources [e.g. CDC website, professional conferences, networking; (61.6%)], and lastly peer-reviewed scientific journals (40.9%). CONCLUSIONS: Non-peer-reviewed periodicals such as throwaways do not meet objective scoring criteria for evidence-based practice, nonetheless we found they are the source of information used most frequently by ICPs.

Background Endemic health care-associated safety problems, including health care-associated infection, account for substantial morbidity and mortality. We outline a regional No Preventable Harms campaign to reduce these safety problems and describe the initial results from the first initiative focusing on catheter-associated urinary tract infection (CAUTI) prevention. Methods We formed a think tank composed of multidisciplinary experts from within a 7-hospital Midwestern Veterans Affairs network to identify hospital-acquired conditions that had strong evidence on how to prevent the harm and outcome data that could be easily collected to evaluate improvement efforts. The first initiative of this campaign focused on CAUTI prevention. Quantitative data on CAUTI rates and qualitative data from site visit interviews were used to evaluate the initiative. Results Quantitative data showed a significant reduction in CAUTI rates per 1,000 catheter days for nonintensive care units across the region (2.4 preinitiative and 0.8 postinitiative; P = .001), but no improvement in the intensive care unit rate (1.4 preinitiative and 2.1 postinitiative; P = .16). Themes that emerged from our qualitative data highlight the need for considering local context and the importance of communication when developing and implementing regional initiatives. Conclusions A regional collaborative can be a valuable strategy for addressing important endemic patient safety problems.