•Clinician perspectives on sustaining hand hygiene reliability are poorly defined.•Human factors engineering is effective but underutilized in infection prevention.•Using this framework, we surveyed ...pediatric clinicians about hand hygiene.•Organization, environment, tasks, and tools identified as barriers to hand hygiene.
Hand hygiene (HH) is critical to prevent health care-associated infections (HAIs). Clinician perspectives on maintaining high reliability are poorly defined.
We surveyed physicians, nurse practitioners, and physician assistants to understand perceptions of and barriers to high reliability in HH. The Systems Engineering Initiative for Patient Safety 2.0 model was used to develop an electronic survey exploring 6 human factors engineering (HFE) domains.
Among 61 respondents, 70% perceived HH as “essential” to patient safety. While 87% reported alcohol-based hand rub (ABHR) availability as very effective in improving HH reliability, 77% reported dispensers to be “sometimes” or “often” empty. Clinicians in surgery/anesthesia were more likely than those in medical specialties to note skin irritation from ABHR (OR 4.94; 95% CI 1.37-17.81) and less likely to believe feedback was effective in improving HH (OR 0.26; 95% CI 0.08-0.88). One quarter of respondents indicated the layout of patient care areas was not conducive to performing HH. Staffing shortages and the pace and demands of work precluded HH for 15% and 11% of respondents, respectively.
Aspects of organizational culture, environment, tasks, and tools were identified as barriers to high reliability in HH. HFE principles can be applied to more effectively promote HH.
•Quality improvement project was initiated at a large, academic freestanding children's hospital for inpatients with an indwelling urinary catheter.•An audit tool based on Kamishibai, a Japanese form ...of storytelling, was developed based on CDC CAUTI prevention recommendations.•Hospital-wide urinary catheter K-card rounding facilitated standardized data collection, discussion of reliability, and real-time feedback to nurses.
We instituted Kamishibai (K-card rounding) with the goals of improving indwelling urinary catheter maintenance bundle reliability and decreasing catheter-associated urinary tract infection (CAUTI) rates.
In a free-standing children's hospital, we undertook a hospital-wide quality improvement project from January 2019 to June 2021 after developing a K-card based on our urinary catheter maintenance bundle. Auditors used K-cards to ask standardized questions during weekly rounds. Bundle reliability and CAUTI rates were analyzed prospectively.
During the study period, 826 K-card audits were performed for 657 unique patients. While overall maintenance bundle reliability remained stable at 84%, there was a statistically significant improvement in reliability to the bundle element “medical discussion of need for the urinary catheter” from 88% to 94% (P = .01). The hospital-wide CAUTI rate significantly decreased (incidence rate ratio, 0.38; 95% CI, 0.15-0.93; P = .04).
Hospital-wide urinary catheter K-card rounding facilitated standardized data collection, discussion of reliability and real-time feedback to nurses. Maintenance bundle reliability remained stable after implementation, accompanied by a significant decrease in the CAUTI rate.
Implementation of hospital-wide urinary catheter K-card rounding was associated with reduction in CAUTI rates. The project demonstrated likelihood of reproducibility with support of a multidisciplinary team.
Abstract
Although the pathogenesis of Clostridioides difficile infection (CDI) is complex and incompletely understood, it is believed that the elaboration of C. difficile toxins is necessary for ...disease. There are a variety of tests available for the detection of both the C. difficile organism and its toxins; however, each has limitations and the best application of these tests to the diagnosis of CDI in children remains uncertain. Nucleic acid amplification tests are unable to reliably discriminate between CDI and C. difficile colonization, while commercially available enzyme immunoassays for toxin detection lack sensitivity. An understanding of preanalytic factors, relevant patient features, and test performance characteristics is essential to the accurate diagnosis of CDI in children. Specific diagnostic stewardship strategies can also increase the likelihood that positive tests reflect disease rather than colonization. Ultimately, CDI remains a clinical diagnosis and clinical judgment is essential when interpreting test results, regardless of the methods used.
Tests for the diagnosis of Clostridioides difficile infection (CDI) are designed to detect either the C. difficile organism itself or its toxins. Although the optimal approach to the diagnosis of CDI in children remains uncertain, potential diagnostic strategies are presented.
Abstract
Background
Hand hygiene reliability is a top priority in healthcare. Infection Prevention and Control (IPC) programs often rely on clinical personnel to audit hand hygiene performance. ...Interrater reliability among auditors is critical to ensuring data validity. We evaluated whether spaced education, which increases long-term knowledge retention, could be integrated into auditor competency assessment.
Methods
113 trained hand hygiene auditors were enrolled in a 13-month online spaced-education platform to assess their mastery of knowledge needed for the role. We delivered 46 unique questions (3 per week, with 2 weeks between repeat delivery of a question) followed by rationale; we retired questions after 3 correct answers. A 10-item survey consisting of 9 Likert-scale questions and one free-text comment was emailed to gauge participant satisfaction with the competency program. Frequencies and percentages were used to summarize Likert responses, and themes were elicited from comments.
Results
From November 2021 to December 2022, a total of 12,120 questions were attempted, and 32 of 113 auditors (28%) completed the competency. Auditors answered 70% of questions correctly on the first attempt and 83% on the final attempt. 30 of 113 auditors (27%) responded to the survey. The majority agreed the number and complexity of questions were appropriate (57% and 67%, respectively). 87% reported the platform easy to navigate, 63% reported the spaced-education model worked, and 77% agreed adequate time was provided for completion. 30% of respondents reported the individual competition as enjoyable. Time and effort required for completion was the most common theme identified among auditor comments; several respondents recommended fewer questions at a narrower spacing interval over a shorter time frame due to competing work demands; 5 individuals expressed a preference for an annual computer-based module.
Conclusion
A spaced education competency program improved hand hygiene auditor knowledge in the short term. Completion rate was low and participants expressed a desire for fewer questions over a shorter time frame. This study offers insight into ways to optimize spaced education as a potential tool for hand hygiene competency assessment.
Disclosures
Ana M. Vaughan-Malloy, MD, MPH, Asana: Stocks/Bonds|Aurora: Stocks/Bonds|Ayr Wellness: Stocks/Bonds|Bionano Genomics: Stocks/Bonds|Butterfly Network: Stocks/Bonds|Canopy Growth: Stocks/Bonds|Cresco Labs: Stocks/Bonds|CRISPR Therapeutics: Stocks/Bonds|Cronos Group: Stocks/Bonds|Curaleaf Holdings: Stocks/Bonds|Editas Medicine: Stocks/Bonds|Green Thumb Industries: Stocks/Bonds|High Tide: Stocks/Bonds|Iovance Biotherapeutics: Stocks/Bonds|Jushi Holdings: Stocks/Bonds|Moderna: Stocks/Bonds|Organigram Holdings: Stocks/Bonds|Pacific Biosciences of California: Stocks/Bonds|Personalis: Stocks/Bonds|Pfizer: Stocks/Bonds|SNDL Inc: Stocks/Bonds|Terrascend: Stocks/Bonds|Tilray Brands: Stocks/Bonds|Trulieve: Stocks/Bonds
Abstract
Background
Gram-negative bacteremia historically has been treated with 10-14 days of parenteral antibiotics. However, data supporting this practice are lacking, and recent evidence shows ...equivalent outcomes for short-course (SC) therapy (7 days) and early (by day 5) conversion to highly bioavailable enteral (PO) antibiotics for Enterobacterales bacteremia.
Methods
Under a QI framework, we used PDSA cycles to reduce treatment duration and increase use of PO levofloxacin or trimethoprim-sulfamethoxazole for uncomplicated Enterobacterales bacteremia among Infectious Diseases (ID) clinicians at a children’s hospital in Boston, MA. We conducted an education session on evidence to support these practices for ID faculty and fellows in October 2020. In December 2020, we implemented standardized recommendations for a 7-day duration and early PO transition for eligible patients (≥ 3-months-old, ≤ 2 days monomicrobial bacteremia, with source control and return to baseline clinical status) that could be inserted automatically into electronic consult notes. In February 2021, we reinforced this practice to ID providers. We collected data before and after these interventions on ID recommendations and on patients’ actual antibiotic management.
Results
From 11/01/20 to 05/31/21, mean recommended treatment decreased from 10.6 to 9.5 days; however, mean duration received was similar (11.2 vs 11.7 days) (Figure 1). The percentage of patients for whom ID recommended PO conversion and in whom transition to PO agents by day 5 occurred increased from 27% to 37.5%.
Figure 1. Change in average duration of antibiotics recommended and received, in days
Conclusion
Education and creation of automated standardized recommendations led to decreased recommended treatment durations and increased PO conversions for Enterobacterales bacteremia, but only modestly. This quality improvement initiative demonstrates the potential benefits of education and electronic documentation tools to facilitate evidence-based practice changes, but also highlights the difficulty in changing practice even amongst ID clinicians. Further PDSA cycles will be targeted at increasing more consistent awareness among a large ID division in addition to other stakeholders.
Disclosures
Gabriella S. Lamb, MD, MPH, Nothing to disclose
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