Compliance with Isolation Precautions Presented by Denise Cooney, BSN, RN

Introduction Project Goal: Decrease incidence of Healthcare associated infections Activities: Current Staff Compliance Root Cause Analysis MDRO Documentation Compliance Department Jan-16 Feb-16 Mar-16 Apr-16 CY 16 TD Target 3S- CCU 87% 100% 89% 67% 95% 3E- CDU 85% 56% 60% 25% 4NSW 79% 0% 71% 4T- CUB 50% 5N/A 33% 5E nd 5S 44% 83% 6NW 90% 59% 75% 13% 62% 6SE 63% 10% 39% 7NW 66% 70% 58% 7S 88% 7E The overall goal for this project is to decrease the incidence of healthcare associated infections. The activities of the project will focus on analyzing a process of identifying a patient with a multidrug resistant organism, measuring the staff knowledge and compliance with the use of personal protective equipment and improving the process, if necessary. The third activity will focus on improving patient education process related to multi-drug resistant organisms. Henry Ford Allegiance Health IP Dashboard (2016)

Needs Assessment Recommendations: Literature support The Joint Commission Centers for Disease Control and Prevention Literature support A needs assessment identified that surveyors from the Centers for Medicare and Medicaid Services and The Joint Commission ask staff members questions about infection control issues that the organization may have, such as, transmission of multidrug resistant organisms, what is done to prevent them, or what is done to resolve a problem, if one occurs. In a conversation with an Infection Preventionist, she mentioned that there is a need for improvement with the compliance with MRDOs that starts with identifying the patient as soon as they enter the hospital. Research articles have also demonstrated the impact that educating staff has on the compliance in using the precautions and ultimately with patient safety. Joint Commission also requires that nurses educate patients and families. . (Gralton, Rawlinson & McLaws, 2013; Patrick & Hicks, 2013; Russell, Young, Leung & Morris, 2015; Stein, Manarawo & Ahmad, 2003)

Site and Preceptor Medical-Surgical units at Henry Ford Allegiance Health Stevie Huffman, MSN, RN, CIC Support staff Ashley Heller Quality Specialists This project will take place on med surg units, where a variety of patient diagnoses are treated. Stevie Huffman, MSN, RN, CIC has agreed to be my preceptor and support person for this project. Stevie, along with her partner in infection prevention, Ashley Heller, will provide the current data related to patients with MDROs, staff compliance with wearing the proper PPE, and hand hygiene. A team of quality specialists will help with data collection and analysis, along with assisting in the development of the auditing tools. .

Root Cause Analysis (RCA) Policies and Procedures Staff training Tools and equipment available Alerts A root cause analysis was completed in order to focus on processes and system design and how to implement different improvements to create a safe patient environment. The following questions were addressed in the root cause analysis: 1) Are there current policies and procedures that address the process of identifying patients with MDROs and if so, are they available for staff? The answer to that was yes. There is a policy online that highlights standard transmission based precautions and isolation signage. 2) Are the staff trained to perform the necessary tasks? Answer: Nurses and physicians receive infection prevention education and training upon hire and annually. 3) Are the necessary tools and equipment easily accessible to the staff? Answer: Proper isolation signs are located in a file cabinet at each nurses’ station. Proper PPE is located in each patient room on the nurse server, which is located just inside the door to the room. Additional PPE is stored in the clean supply room on the unit. 4) Do automatic alerts/flags function correctly? Answer: No, there are a couple different reports that are used by bed control to determine if isolation precautions are required for a patient and these reports contained inconsistent information. 5) Does the patient’s record give clear information about past MDRO isolation and is this information available upon admission to hospital? Clear answer was not available.

This root cause analysis diagram depicts the questions that were asked and possible causes that lead to the error of missing MDRO identification. The category labeled “People”, represents the questions about proper staff training, staff compliance with PPE use, and communication through the use of alerts in the computer system. The process category looks at different reports that are used to identify patients with MDROs. The equipment category tries to identify if signage and PPE are available for use. The materials category asks questions about education materials, prior audits for proper signage and PPE use, and identifying if policies and procedures are in place to identify patients needing isolation. The final category is environment. This portion of the diagram looks for possible barriers for implementing precautions and implementing PPE. There were two main areas for improvement identified during this root cause analysis. The initial identification of a patient with a multi-drug resistant organism and education of the patient regarding the MDRO. The identification of different reports with the MDRO information left too much room for error on the bed placement staff. It was identified that if the education materials were readily available, the nurses may be more apt to give them to the patients.

QSEN Competencies UALITY AFETY DUCATION URSES Quality Improvement Safety Informatics AFETY DUCATION The website for Quality and Safety Education for Nurses indicates that evidence based practice incorporates the use of current evidence and clinical expertise to provide the best health care. This project will integrate three of the QSEN competencies, Quality Improvement, Safety, and Informatics. A quality improvement outcome for this project is to identify gaps in the reporting system for a patient with a multi-drug resistant organism. The information from the different reporting systems will be compared to identify opportunities to improve accuracy and efficiency. Findings from the root cause analysis will be used to implement these improvements. Safety is identified by QSEN as improving individual actions and system processes, in order to reduce the risk of harm to patients and staff members. Initiating the correct isolation precautions alerts staff to use PPE in order to protect themselves as well as other patients. Reinforcing the staff knowledge will help improve this identification process and staff compliance with the use of PPE. Informatics will be used to identify gaps or variances in the different reporting systems that are used for MDRO identification. A survey monkey will be sent to staff members to identify any barrier to the use of PPE. Computer technology will also be used to enter data that is collected regarding staff compliance with PPE use. URSES (QSEN, 2014)

ANA Scope & Standards of Practice Standard 2: Identification of Issues and Trends Standard 4: Planning Standard 5B: Learning and Practice Environment Three ANA Nursing Professional Development Standards of Practice will be addressed during the planning and implementation of this project. Standard 2, the Identification of Issues and Trends, will be addressed by improving the process of identifying a patient with a MDRO. This will be accomplished by comparing the data from various reports to possibly create one quality report for the bed control nurses to use. Standard 4, Planning, related to various activities that have been designed to help meet objectives for each of the project goals. Standard 5B, the facilitation of a positive learning and practice environment, will be addressed by eliminating any barriers that the nurses may have in providing patient education. This will help to create a more positive practice environment. (American Nurses Association, 2010)

Project Plan Identify gaps or variances in reporting system Improve process for placing proper signage Improve compliance with use of proper personal protective equipment (PPE) Improve compliance with documentation of identified isolation type Assess availability and/or barriers to providing patient education Evaluate and revise content of current materials, as needed The following are project objectives that we will strive to meet in order to achieve our project goals. One of the goals is to improve the process of identifying the patient with a MDRO. The objective is to identify gaps or variances in the reporting system. This can be accomplished by comparing reports from the lab, infection prevention, and quality specialists to determine the accuracy of these reports. An Excel spreadsheet will be created to list the comparisons and identify opportunities for improvement. The second goal is to improve compliance with initiating isolation precautions. This will be accomplished by working with infection prevention to audit for the correct signage outside of the patient rooms. The staff will also be surveyed to identify any barriers in PPE compliance. Medical records will be audited for the correct documentation of MDRO patients. The third goal is to improve the patient education process related to MDRO. This will be accomplished by: 1) auditing the nursing process to identify barriers to providing patient and family education; 2) researching evidence based practice for MDRO education to determine the quality of the current education materials; 3) creating education cards with common MDRO information, such as what a particular MDRO is, what should be done to prevent the spread of the MDRO in the hospital and at home, and other information derived from the research of the evidenced based practice education; 4) educating the nurses on this new material.

Leadership and Change Stage Theory Transformational Leadership Awareness Implementation Institutional change (compliance) Adoption The implementation and success of this project will depend upon the assistance from leadership. A Stage Theory, by Lewin, focuses on change as a gradual process. Step one is Awareness or defining the problem, which is providing the staff with information about the types of MDROs and how they are spread. Step two is adoption or ways of preventing the transmission: are proper signs on the patient doors; are staff wearing the proper PPE; are they performing proper hand washing and cleaning the room and equipment? Step three is implementing the change. Educating the staff on the isolation precautions. Step four is institutional change or compliance. The leaders and infection preventionists will need to continue to monitor and encourage compliance with the new process. According to Luzinski, a transformational leader explains why and change is needed and what a staff member needs to help make that change possible. Marshall states that transformational leadership will provide the motivation for the staff to try this project, creating a new way for providing safe patient care. Transformational Leadership (Lewin, 1951; Luzinski, 2011; Marshall, 2011)

Infection Prevention Dashboard Measuring Success Audits Nurse Surveys Infection Prevention Dashboard The success of this project will be measured by auditing staff for the correct use of PPE, the placement of the correct signage outside of a patient room, and the accuracy of the documentation in the patient record. Nurse surveys on the use and effectiveness of patient education cards will also show the staff buy-in with the new process. Infection prevention dashboard will be monitored to see if multi-drug resistant process measures meet or surpass the desired target. With the assistance of the infection preventionists and members of the quality team, the plan is to streamline the process of identifying patients with MDROs and provide these patients with quality education.

References American Nurses Association. (2010). Nursing professional development scope & standards of practice. American Nurses Association. Silver Spring, MD: Nurses Books.org Centers for Disease Control and Prevention. (2009). Management of multidrug-resistant organisms in healthcare settings, 2006. Retrieved from http://www.cdc.gov/hicpac/mdro/mdro_table3.html Gralton, J., Rawlinson, W. D., McLaws, M. (2013). Health care workers' perceptions predicts uptake of personal protective equipment. American Journal of Infection Control, 41(1), 207. doi:10.1016/j.ajic.2012.01.019 Joint Commission. (2010a). Educating nursing staff on safe infection prevention and control practices. In Joint Commission Resources, The Nurse’s Role in Infection Prevention and Control (pp. 23-74). Oakbrook Terrace, IL: Joint Commission Resources Joint Commission. (2010b). The nurse’s role in educating patients and their families on safe infection prevention and control processes. In Joint Commission Resources, The Nurse’s Role in Infection Prevention and Control (pp. 97-153). Oakbrook Terrace, IL: Joint Commission Resources Lewin, K. (1951). Field Theory in Social Science. New York, N.Y.: Harper & Row.

References Luzinski, C. (2011). Transformational leadership. The Journal of Nursing Administration, 41(12), 501- 502. doi:10.1097/NNA.0b013e3182378a71 Marshall, E. S. (2011). Expert clinician to transformational leader in a complex healthcare organization. In E. Marshall (Ed.) Transformational Leadership in Nursing (pp. 1-26). New York, NY: Springer Publishing Company, LLC Patrick, M. R. & Hicks, R. W. (2013). Implementing AORN recommended practices for prevention of transmissible infections. AORN Journal, 98(6), 609-628. doi:10.1016/j.aorn.2013.08.018 Quality and Safety Education for Nurses (QSEN). (2014). Competencies: Graduate KSAS. Retrieved from http://qsen.org/competencies/graduate-ksas/ Russell, C. D., Young, I., Leung, V., & Morris, K. (2015). Healthcare workers' decision-making about transmission-based infection control precautions is improved by a guidance summary card. Journal of Hospital Infection, 90(3), 235-239. doi:10.1016/j.jhin.2014.12.025 Stein, A. D., Manarawo, T. P., & Ahmad, M. F. R. (2003). A survey of doctors’ and nurses’ knowledge, attitudes and compliance with infection control guidelines in Birmingham teaching hospitals. Journal of Hospital Infections, 54(1), 68-73. doi:10.1016/S0195-6701(03)00074-4