1. STANDARDIZATION OF ISOLATION PRACTICES IN THE PERIOPERATIVE CARE SETTING Lorrie Ingram, BSN, RN, Infection Control Practitioner; Susie (Treasa) Leming-Lee, MSN, RN, CPHQ, Director of Perioperative Quality Management; Vicki Brinsko, BSN, RN, CIC, Infection Control Practitioner, Dept. Coordinator; Jena Skinner, BSN, RN, CIC, Infection Control Practitioner; Ann H. Benco, MSTD, BSN, RN, CNOR, Perioperative Nurse Educator; Erin Kuhn, RN, MSN, CNOR, Perioperative Nurse Educator; Audrey H. Kuntz, EdD, RN, Director of Perioperative Education/Operative Services; Stephanie Randa, MHA, RN, Director of Operative Services; Thomas R. Talbot, III, MD, MPH, Hospital Epidemiologist, Infectious Disease, Titus L. Daniels, MD, MPH, Assistant Professor of Medicine-Infectious Disease, Associate Hospital Epidemiologist; Addison K. May, MD, FACS, FCCM, Associate Professor of Surgery and Anesthesiology ABSTRACT RESULTS IMPLEMENTATION: DESIGN: FLOW OF WORK PROCESS INTRODUCTION CONCLUSION & LESSONS LEARNED The management of operating room (OR) traffic, environmental cleaning, patient transport, supplies and appropriate signage were other key elements of concentration identified for practice change. Improved compliance with isolation practices was observed soon after implementation. While not directly attributable to the perioperative isolation enhancements (simultaneous interventions were introduced in the critical care areas) no further HR-ACBA cluster outbreaks were identified (Fig. 3). Although most staff understood the institution’s isolation mandates for contact, droplet and airborne precautions, problems were identified with communication between departments on patient isolation status and proper practices for transporting patients between perioperative areas and critical care. The concept that the OR environment, with respect to routine practices of sterile and aseptic technique, would inherently prevent cross transmission of organisms from patients in isolation was deficient as it did not include appropriate practice patterns prior to and after surgery. This intervention project served to increase awareness and education of the perioperative staff regarding infection prevention and control practices with their isolated patient population. Behavioral changes reflecting improved compliance were influenced by staff collaboration, use of new electronic case boarding prompts and creative methods of communication and education. with similar clinical challenges. Lessons Learned Include: 1. 1. Ensure need for support of project by visible leadership. 2. 2.Provision of a standardized process algorithm to guide staff adherence and education was a vital component of this quality improvement process. These concepts are reproducible for other service areas. 3. 3.Early Solicitation of staff input in the development of this process, as were the specific tools, was vital to overall success. 4. 4.Education of all perioperative staff and faculty was critical to the ownership of the process, and for its continued success. A multidisciplinary team was formed with representatives from surgical critical care, perioperative education, operating room personnel and infection control to review the existing practices used for handling patients in isolation and to map out an enhanced process for improvement. System barriers to compliance were identified in all phases of the perioperative patient care process. System enhancements were identified and implemented to facilitate compliance. These included specific education and training modules developed for all levels of staff, including physicians. Perioperative isolation practice standards were formally incorporated into the departmental policy and procedure manual. METHODOLOGY/TRAINING Key Fundamental Infection Control Concepts Applied: 1. 1.Strict Hand Hygiene adherence 2. 2.Strict/Consistent use of PPE for specific precautions 3. 3.Appropriate Environmental cleaning/disinfection processes 4. 4.Special indications (i.e. for air handling/exchanges for TB) 5. 5.Continuous good communication during surgery “booking” process, between the referral/transferring dept.; the Periop Services regarding patients isolation status 6. 6.Highlights and education pertaining to very specific and highly transmittable organisms in the healthcare environment reviewed NEW ISOLATION PRECAUTION PROCESS IN ACTION Acknowledgements Daniel Beauchamp, MD, Chair of Surgical Sciences Mike Higgins, MD, MPH, Executive Medical Director of Perioperative Services Nancye Feistritzer, MSN, RN Associate Hospital Administrator, Director of Perioperative Services Surgical Site Infection Prevention Collaborative Committee 2008 APIC Abstract 2008 APIC Abstract Subject Category - Quality Management Systems/Process Improvement/Adverse Outcomes Standardization of Isolation Practices in the Perioperative Service Line Lorrie Ingram, BSN, RN, Infection Control Practitioner; Vicki Brinsko, BSN, RN, CIC, Infection Control Practitioner, Dept. Coordinator; Jena Skinner, BSN, RN, CIC, Infection Control Practitioner; Ann Benco, RN, Nurse Educator, Operative Services; Erin Kuhn, RN, MSN, CNOR, Perioperative Nurse Educator; Audrey H. Kuntz, EdD, RN, Director of Perioperative Quality Mgmt/Operative Services; Susie Leming-Lee, MSN, RN, CPHQ, Associate Director of Perioperative Quality Management/Operative Services, Thomas R. Talbot, III, MD, MPH, Hospital Epidemiologist, Infectious Disease, Assistant Professor of Medicine and Preventive Medicine, Titus L. Daniels, MD, MPH, Assistant Professor of Medicine-Infectious Disease, Associate Hospital Epidemiologist ISSUE: A cluster of Highly-resistant Acinetobacter baumannii (HR-ACBA) cases in the surgical critical care unit of a large tertiary care medical center provided the impetus for detailed scrutiny of isolation practices, particularly for patients requiring multiple trips to surgery. Noncompliance with aspects of isolation was observed for patients during transport between surgery and critical care. Further investigation revealed a systems approach to improvement would be needed, not only to prevent transmission during transport, but to enhance compliance for all areas of patient contact throughout the perioperative service line. PROJECT: A multidisciplinary team was formed with representatives from surgical critical care, perioperative education, operating room personnel and infection control, to review the existing practices used for handling patients in isolation and to map out an enhanced process (Figure 1) for improvement. System barriers to compliance were identified in all phases of the perioperative patient care process. System enhancements were identified and implemented to facilitate compliance. These included specific education and training modules developed for all levels of staff, including physicians. Perioperative isolation practice standards were formally incorporated into the departmental policy and procedure manual. RESULTS: A unified set of isolation practice standards throughout the perioperative service line was established, which mirrored the existing isolation guidelines practiced throughout the rest of the medical center. System changes included creating electronic case boarding prompts, (Figure 2) to actively inquire as to isolation status and type required, as well as electronic reminders to book airborne isolation cases at the end of the day. The management of operating room (OR) traffic, environmental cleaning, patient transport, supplies and appropriate signage were other key elements of concentration identified for practice change. Improved compliance with isolation practices was observed soon after implementation. While not directly attributable to the perioperative isolation enhancements (simultaneous interventions were introduced in the critical care areas) no further HR- ACBA cluster outbreaks were identified (Figure 3). LESSONS LEARNED: Although most staff understood the institution’s isolation mandates for contact, droplet and airborne precautions, problems were identified with communication between departments on patient isolation status and proper practices for transporting patients between perioperative areas and critical care. The concept that the OR environment, with respect to routine practices of sterile and aseptic technique, would inherently prevent cross transmission of organisms from patients in isolation was deficient as it did not include appropriate practice patterns prior to and after surgery. This intervention project served to increase awareness and education of the perioperative staff regarding infection prevention and control practices with their isolated patient population. Behavioral changes reflecting improved compliance were influenced by staff collaboration, use of new electronic case boarding prompts and creative methods of communication and education. In addition, providing a new, concentrated and standardized process algorithm to guide the units/OR staff in preparing for and organizing the isolation patient’s transport, equipment handling and environment, was a vital tool for quality improvement. These concepts are reproducible for other service areas with similar clinical challenges. METHODOLOGY/TRAINING A unified set of isolation practice standards throughout the perioperative service line was established, which mirrored the existing isolation guidelines practiced throughout the rest of the medical center. System changes included creating electronic case boarding prompts (Fig. 2) to actively inquire as to isolation status and type required, as well as electronic reminders to book airborne isolation cases at the end of the day. The management of operating room (OR) traffic, environmental cleaning, patient transport, supplies and appropriate signage were other key elements of concentration identified for practice change. Simultaneous interventions were introduced in the critical care areas. Key Fundamental Infection Control Concepts Applied: 1. 1.Strict Hand Hygiene adherence 2. 2.Strict/Consistent use of PPE for specific precautions 3. 3.Appropriate Environmental cleaning/disinfection processes 4. 4.Special indications (i.e. for air handling/exchanges for TB) 5. 5.Continuous good communication during surgery “booking” process, between the referral/transferring dept.; the Periop Services regarding patients isolation status 6. 6.Highlights and education pertaining to very specific and highly transmittable organisms in the healthcare environment reviewed INTRODUCTION www.mc.vanderbilt.edu/infectioncontrol Fig. 1 Fig. 2 Fig. 3