2. 2 Learning Objectives – Communicate the value of standardized workflows to increase the reliability of hand hygiene and inpatient isolation practices to reduce hospital- acquired Clostridium difficile infections – Understand the application of deliberate practice simulation to implement and hardwire standardized work flows – Apply the basic skills of deliberate practice simulation in one’s work setting

3. HEROES GOES CSI Controlling the Spread of Infection

4. C Diff Reduction Timeline: Hand Hygiene and Isolation April 2010 C diff Reduction Summit; introduction to RIGHT bundle Dec 2010 - Vital Behaviors for Hand Hygiene video created by Senior Leaders Jan 2011 - Education provided to nursing unit leaders on Hand Hygiene Vital Behaviors and RIGHT bundle April 2011 – Quarterly Secret Shopper audits started 2011 – Development of standardized workflows April 2012 – Deliberate Practice Workshops

5. C difficile Prevention Bundle R Risk Reduction Isolation Glove and Gown Etiquette Hand Hygiene Touch – Moveable Equipment Cleaning I G H T Isolate at first sign infection Contact Plus; Dedicated Equipment; PPE supplies; Isolate until discharge Gel before, soap after gloves; Educate pt and family Clean moveable equipment with disinfectant between pts and with bleach before exiting Contact PLUS Gel in, soap out; Remind each other, Response: Thank you

6. Medical Center Self Audits Was this true? Secret Shopper Audits Started

7. Secret Shopper Audits Regional Team audit 21 Medical Centers quarterly Wide variation in practices within and across medical centers Few had hardwired appropriate practices – Gloves applied without prior hand hygiene – High glove use in and out of rooms – Hand hygiene coming out of the room more reliable than going into the room – PPE was not always use or used properly Work flows development began

8. Standardized Work Flows After 5,000+ observations Developed based on observed reliable practices Tested and approved by content experts and pilot sites Continue to learn with wide spread implementation Recognized as best practice across organization

9. Standardized Work Flows  Glove Etiquette  Donning and removal of PPE  Contact PLUS patient Transport  Meal Tray Distribution  Patient Ambulation  Medication Administration  Finger Stick Blood Glucose  Cleaning Occupied Room  Laboratory Blood Draw  Radiology (at bedside)

10. HEROES GOES CSI C Difficile Reduction Simulation Workshops Chief of Chiefs for Infectious Disease Regional HEROES Team Regional Infection Preventionists

11. Why Did We Do This Training Preventing Hospital Acquired Infections saves lives Need to – do things differently – change the culture – understand each others’ work flows Train leaders and staff differently

12. No Shortcut to Becoming an Expert Current Frame Deliberate Practice 10,000 hour rule Expert Performance

14. 420 Representatives from all Medical Centers Nurses 163 Nursing Managers 25 EVS 46 Physicians 24 Infection Prevention 23 PCT/Transporter 19 Laboratory 17 Educators 16 Radiology 12 Non-Nursing Managers 11 Resp. Therapy 11 Physical Therapy 9 Dietary 9 Quality/Risk 8 Directors 7 ED 3 Pharmacy 1 Social Worker 1 Other 14

15. Deliberate Practice Stations Speaking Up with Greg and Robbie – Vital behaviors for hand hygiene Holey Glow – Hand Hygiene and Glove Etiquette We Got You Covered – Proper application and removal of PPE What the Bleach? – Cleaning moveable equipment Out and About – Transport of C diff patient Not Just a Maid Service – EVS cleaning The Wow of the Wows – Medication administration and cleaning of moveable computer and scanner All Stuck Up – Lab draws

16. Speaking Up with Greg and Robbie

17. Modesto HH Vital Behaviors

18. Holey Glow

19. Glove Etiquette To Wear or Not To Wear Gloves Gloves Needed (along with gowns) Contact Isolation Contact Plus Isolation Standard Precautions Potential exposure to mucous membranes, blood, and/or body fluids Drawing blood Wound care Starting IVs Suctioning Handling urinary catheter Changing grossly soiled bed linens Oral hygiene Perineal/perianal care Picking/emptying trash Emptying soiled linen Using Saniwipes, other disinfectants, or bleach wipes Gloves Not Needed Very low or no potential exposure to mucous membranes, blood, and/or body fluids. This includes but is not limited to: Touch intact skin – such as hold or shake hands Measure vital signs Pass meal trays Administer medication, including injections (subcutaneous, intradermal or IM) unless the patient has a tendency to bleed IV maintenance (hanging new bag, starting piggyback medications, giving IV push medications) Patient transport – pushing gurney or wheelchair Carry specimens to the lab in zip closed bags Carry blood from the blood bank Ambulate or transfer continent patients Bathing (except for perineal and oral hygiene) Use computer keyboard or barcode scanner Patient is not in Contact or Contact Plus isolation 10.11 Remember to perform hand hygiene (gel/foam/wash) before applying gloves and immediately after removal.

20. We Got You Covered

21. CONTACT PLUS ISOLATION GOWN AND GLOVES EDIQUETTEE PUTTING ON, TAKING OFF, and IN ROOM PUTTING ON Perform hand hygiene with gel or foam. (Repeat this step if drawer, cart, or mobile computer handles are touched before next step.) Put gown on, pulling over head. Tie gown at waist. Put thumbs in loops at the wrist. Perform all clean tasks first, e.g. medication administration, IV therapy maintenance, obtaining vital signs, and physical assessment Change gloves after any dirty task such as any exposure to blood or body fluids. This can include but is not limited to: obtaining specimens, suctioning, wound care, post incontinence care, emptying urinary catheter bag, ostomy care. Wash, gel, or foam hands before putting on new gloves. TAKING OFF Pull gown off, breaking neck loop and ties. Peel gown off shoulders and down arms, rolling the gown inside out into a ball. Place balled up gown and gloves in trash can Wash hands with soap and water When gown is down to the gloves, remove the gloves – inside out - with the sleeves. Assemble gown, gloves, and gel/foam in one place. Put on gloves and pull over gown at the wrist 10.11 Every hospital staff member must put on gown and gloves to enter a Contact Plus isolation room. There is no exception. IN THE ROOM Put on mask if needed (Standard Precautions or patient also in Droplet or Airborne Precautions) If mask is used, remove from behind, using elastic straps Wash hands with soap and water after mask and/or goggle removal. Note: If a patient is on airborne and contact disinfect PAPR before and after procedure with a bleach wipes

22. The Power of One

23. Deliberate Practice with Facilities Operations

24. Out and About

25. TRANSPORTING PATIENTS BY GURNEY OR WHEELCHAIR Due to room configurations and patient needs, two people may be needed to prepare a patient for transport and to transport. Limit patient movement to medically necessary transports. Use gurney for transport. Reserve use of the bed for transport to unstable patients Notify receiving department of isolation precautions Diarrhea must be contained. PPE should be worn as needed according to Standard Precautions. Gloves worn during transport should be considered contaminated and care should be taken not to contaminate the hospital environment. In the event PPE is necessary be sure not all transport personnel is wearing PPE Perform hand hygiene (gel in) and put on gown and gloves Bring gurney or wheelchair into room Transfer patient to gurney or wheelchair If gloves are visibly soiled, change them. (Wash hands between removal and reapplication of gloves) Clean surfaces to be touched in transport with bleach wipe. Allow surfaces to dry. Remove gloves and wash hands. Wash hands. Transport patient Return to Contact Plus Isolation room Perform hand hygiene (gel in) and put on gown and gloves Transfer patient to bed Wipe high touch surfaces of gurney or wheelchair with bleach wipe. Remove gloves Wash hands Remove gown and gloves Wash hands Don new gloves Assist patient with hand hygiene and to don a clean gown Cover patient with a clean sheet NCal HEROES 3.12

26. Total Hand Hygiene Compliance Deliberate Practice Workshops

27. Rolling 12 Month HA-CDI Rate per 1000 Admits through April 2013 Reg HA-CDI Summit (Apr 2010) Secret Shopper Audits (Apr 2011) Deliberate Practice Workshops (Apr 2012) TARGET 54% decrease in 3 yrs