PSQH.COM | OCTOBER 2021 1 SPONSORED MATERIAL The Association of periOperative Registered Nurses (AORN) recently updated its guide- lines for antisepsis and nasal decolonization. These updates lend weight to long-held practices and offer guidance toward safer pre-surgical and preoperative care. But what impact will they have on your organization? “Ultimately, what these guide- lines and changes represent is the incorporation of a very comprehen- sive bundle of care in the pre-proce- dural setting,” says Holly Monteja- no, MS, CIC, CPHQ, clinical science liaison with PDI Healthcare, and an epidemiologist and hospital in- fection prevention practitioner. “In- corporation of nasal decolonization makes it comprehensive.” The AORN guidelines discuss both skin and nasal decoloniza- tion and skin prep as well as anti- biotic prophylaxis and hair remov- al (among other topics), but the changes to decolonization guidelines are what jump out to Montejano. “There really hadn’t been a com- ponent within the guidelines address- ing nasal decolonization,” says Mon- tejano. “That’s a big addition to these skin antisepsis guidelines.” In terms of whether the changes will impact the workload for organi- zations and practitioners, a lot of fa- cilities in the preoperative arena had already started incorporating nasal decolonization, she notes. Profession- al guidelines are out in the field for certain subsets of patients to receive nasal decolonization. “Now we have AORN making a rec- ommendation for incorporating nasal decolonization into best practice guide- lines,” adding an influential weight to the practices, says Montejano. The concept was on profession- als’ radar even before the pandemic, she says. “At the facility I came from where I was an infection preventionist, we were doing nasal decolonization for at least 10 years—they were doing it prior to when I started there for certain high-risk surgery types,” says Montejano. “Now we’re seeing it be- come the norm.” Facilities had relied on research prior to official guidelines, which makes the update to AORN’s response impactful. The AORN adds their voice to the World Health Organization, the Institute for Healthcare Improvement, and the Society of Thoracic Surgeons, as well as the CDC and the Society for Healthcare Epidemiology of America. Montejano highlights a standout component of the AORN guidelines: the mention of povidone iodine, an anti- septic, on the list of recommendations. ““At the facility I came from where I was an infection preventionist, we were doing nasal decolonization for at least 10 years—they were doing it prior to when I started there for certain high-risk surgery types. Now we’re seeing it become the norm. ” — Holly Montejano, MS, CIC, CPHQ, clinical science liaison with PDI Healthcare AORN Updates Skin Antisepsis Guidelines: What This Means for Organizations By Matt Phillion
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PSQH.COM | OCTOBER 2021 1SPONSORED MATERIAL
The Association of periOperative Registered Nurses (AORN) recently updated its guide-
lines for antisepsis and nasal decolonization. These updates lend weight to long-held practices
and offer guidance toward safer pre-surgical and preoperative care. But what impact will they
have on your organization?
“Ultimately, what these guide-
lines and changes represent is the
incorporation of a very comprehen-
sive bundle of care in the pre-proce-
dural setting,” says Holly Monteja-
no, MS, CIC, CPHQ, clinical science
liaison with PDI Healthcare, and
an epidemiologist and hospital in-
fection prevention practitioner. “In-
corporation of nasal decolonization
makes it comprehensive.”
The AORN guidelines discuss
both skin and nasal decoloniza-
tion and skin prep as well as anti-
biotic prophylaxis and hair remov-
al (among other topics), but the
changes to decolonization guidelines
are what jump out to Montejano.
“There really hadn’t been a com-
ponent within the guidelines address-
ing nasal decolonization,” says Mon-
tejano. “That’s a big addition to these
skin antisepsis guidelines.”
In terms of whether the changes
will impact the workload for organi-
zations and practitioners, a lot of fa-
cilities in the preoperative arena had
already started incorporating nasal
decolonization, she notes. Profession-
al guidelines are out in the field for
certain subsets of patients to receive
nasal decolonization.
“Now we have AORN making a rec-
ommendation for incorporating nasal
decolonization into best practice guide-
lines,” adding an influential weight to
the practices, says Montejano.
The concept was on profession-
als’ radar even before the pandemic,
she says.
“At the facility I came from where
I was an infection preventionist, we
were doing nasal decolonization for
at least 10 years—they were doing
it prior to when I started there for
certain high-risk surgery types,” says
Montejano. “Now we’re seeing it be-
come the norm.”
Facilities had relied on research
prior to official guidelines, which
makes the update to AORN’s response
impactful. The AORN adds their voice
to the World Health Organization, the
Institute for Healthcare Improvement,
and the Society of Thoracic Surgeons,
as well as the CDC and the Society for
Healthcare Epidemiology of America.
Montejano highlights a standout
component of the AORN guidelines: the
mention of povidone iodine, an anti-
septic, on the list of recommendations.
““At the facility I came from where I was an infection preventionist, we
were doing nasal decolonization for at least 10 years—they were doing it prior to when I started there for
certain high-risk surgery types. Now we’re seeing it become the norm. ”
Healthcare professionals are continually under pressure to improve quality and safety, and performance improvement continues to present a major challenge for healthcare organizations. This is especially true for hand hygiene improvement efforts, and achieving and sustaining high compliance rates have been met with little success for many facilities.1
Tracking hand hygiene rates and providing feedback are essential elements of a
multimodal strategy to improve hand hygiene.2
Considering the inherent challenges with direct observation,1 some healthcare facilities are transitioning to automated hand hygiene monitoring technology to gather hand hygiene data. These systems quickly and efficiently provide substantially more quantitative data than direct observations without observer bias or a Hawthorne effect.3,4 However, data alone is insufficient in improving hand hygiene performance.
Good metrics and quality data drive strategy and direction and are fundamental driving forces in organizations. However, there is an aspect of data that is often overlooked. Quality metrics are outcomes data; they are lagging indicators and are a result of the processes that were in place prior to measurement. Hand hygiene events, opportunities, and compliance rates are outcomes data. They are lagging indicators downstream from the systems or processes that were in place prior to measurement. This is where facilities often veer off track, because hand hygiene is not improved by solely measuring and tracking the lagging indicators.
Valuable time and resources are invested in identifying root causes or reasons for noncompliance and developing targeted countermeasures for hand hygiene improvement. These countermeasures are leading indicators and can help predict outcomes. If the countermeasures have been correctly defined and implemented, then the outcome measures should improve. However, in order to determine whether the countermeasures are effective, they need to be measured and tracked relative to the outcomes. But for most facilities, little if any time is dedicated to tracking and measuring the leading indicators that are designed to influence the outcomes.
CREATING A CULTURE OF IMPROVEMENT FOR HAND HYGIENEBy: Lori Moore, MPH, BSN, RN, CPPS; Clinical Educator, Healthcare; GOJO Industries
When hand hygiene does not improve, the tendency is to focus improvement efforts on the behavior of healthcare workers, providing more training, more education and encouraging them to do better. However, focusing only on the hand hygiene behavior of healthcare workers is like treating the symptom without addressing the cause. The study of Human Factors Engineering has shown that telling people to do better next time is not a solution; this approach, often referred to as the “name, blame, and train mentality,” creates a poor environment and misdirects resources.5 Mark Graban states that it is unfair to ask employees to perform better than the system’s design will allow and further adds that it is the responsibility of leadership to provide a system in which people can be successful.6 Improving performance requires examining hand hygiene as a systems or process problem rather than strictly a people problem.
When it comes to patient safety and performance improvement, healthcare facilities are always on the road between what is and what can be. Atul Gawande states that “while the gap may be wide, better is possible” and further adds that in order to make a difference one should become a scientist and count things because “when you count something interesting, you will learn something interesting.”7 Quality and safety professionals spend a lot of time counting events and opportunities and calculating hand hygiene compliance rates, and there is much that can be learned from this outcomes data. But alone it is insufficient to improve hand hygiene. A culture of improvement must assume that the problem is caused by the system, and everyone, regardless of title or position, plays a role in the identification of problems and solutions to redesign the system. Action-based leading indicators upstream from the hand hygiene behavior must be developed, implemented, measured, and tracked (counted) relative to outcomes and adjusted as necessary.
• PURELL SMARTLINK™ Activity Monitoring System – Collects group-level data 24/7. Room sensors automatically count soap and sanitizer events and opportunities.
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As COVID-19 has stressed healthcare systems worldwide, a pre-existing healthcare worker shortage coupled with caregiver burnout has only become more visible. The healthcare workforce has had to triage not only their incoming patients, but also their daily responsibilities, prioritizing only the most essential elements of the job.
Well before COVID-19 appeared, Infection Prevention and Control teams battled tirelessly to control and prevent Antimicrobial Resistant Organisms (AROs) transmission in our communities and healthcare organizations. The work to reduce Healthcare Acquired Infections (HAIs) with fiscal restraints, limited resources and an overburdened workforce has always been challenging, but the pandemic has further stretched limited and overworked staff leading to a cascade of negative secondary impacts that could be mitigated with improved infection surveillance capabilities.
Current Challenges What we know
With the present pandemic, Infection Prevention and Control teams’ challenges have only intensified. According to the Cambridge University Press, significant increases in the national Standardized Infection Ratios for CLABSI, CAUTI, VAE and MRSA bacteremia were observed in 2020. This increase in HAIs during COVID-19 has highlighted the critical need to build resiliency into infection control programs, to ensure healthcare security and continuity of services while ensuring safer patient care and a safer environment for employees and contractors.
Staff shortages and staff burnout.
The potential for cross contaminations, breaches in protocol and breaches in care pathways increase substantially when staff members are overtaxed and rely on strained resources, requiring a focus on patients’ immediate care needs. Although this focus is necessary given the extreme pressure healthcare workers are under, infection surveillance processes can help to make reporting easier to mitigate and understand HAIs.
Environmental concerns.
If a health system does not have the resources to maintain a clean environment, the procedure and protocols can be followed perfectly and still result in negative health outcomes because of airborne, water or surface contaminants. Healthcare environments are complex and large numbers of patients, clients, staff and visitors can result in
contamination of environments, equipment and surfaces. Increased bed turnover and patient volumes result in bio burden and contaminant reservoirs, which lead to escalating contamination risks and associated costs. It is essential to have a monitoring process with timely and effective audit and feedback systems to ensure safer care.
Additionally, turnover has been high for staff who monitor and audit for infection compliance, resulting in a more junior workforce responsible for interpreting and managing frequently changing guidance from governing bodies.
Multi-drug resistant organisms.
Rising HAIs directly leads to increases in multi-drug resistant organisms. The increased use of empiric antibiotics to proactively treat secondary infection risks may contribute to evolutionary resistance increases, therefore making infections more difficult to treat in the future.
Delayed acute patient care.
Many people are aware of the increased infection risks in hospitals right now, causing them to delay seeking care, leading to sicker patients who are more susceptible to infection. These same patients have moved from an acute phase of illness to a chronic phase, adding to the complexity related to treatment and recovery.
However, delayed patient care is not limited solely to not seeking care when needed, but also includes “care gaps,” which commonly occur in outpatient settings. These care gaps can include missed diagnoses, medication errors in prescribing practice and decreased monitoring of patients, especially those with chronic conditions. These chronic conditions have the potential to become acute in presentation with delayed care.
Reporting A tool to meet surveillance mandates and improve patient safety
The temporary reprieve from governing bodies’ reporting requirements is unlikely to last long term and putting structures and technology in place to provide data feedback by surveillance will set your organization up to ensure the continuity of care and security of care delivery.
Additionally, the CDC plans to issue $2.1 billion in funding to U.S. health organizations to improve infection prevention and control and expand public health measures. Part of the funding is intended to strengthen states’ capacity to prevent, detect and contain infectious disease threats across healthcare settings and help provide data analysis about antibiotic use which will help to improve antibiotic prescribing.
Staff shortages and staff burnout.
Implementing systems allows for consistency in protocols and procedures and for a standardization of workflow, even with high turnover. With limited staff, it’s more important than ever to be able to save time through reduction of routine data aggregation and analysis to collaborate interdepartmentally more easily. Having consumable data reports and displays for shared distribution to care teams both at the macro (total care population) and micro (specific care services and patients) levels helps to keep everyone abreast of rising concerns and be proactive in addressing them.
Environmental concerns.
Quality assurance auditing of environmental services, cleaning and disinfection reports and collaborative monitoring of environmental reports like HVAC systems or climate humidity can help both cleaning teams and engineers to have real-time data available to them when they need it to highlight problem areas and address them before there is an event. This data can also help systems to focus limited resources in the most critical areas.
Multi-drug resistant organisms.
Managing MRDOs is a multifaceted problem that works best in a data-democratized facility, meaning a facility where all staff members have access to the data impacting their work. With the right data, IPAC teams and bed managers can ensure isolation and precautions are in place to limit spread, while also partnering with AMS teams and physicians to ensure good clinical guidelines exist for empiric therapy and perform timely prescription interventions.
Delayed acute patient care.
With such crushing urgency and demand on traditional healthcare systems, tracking, tracing, updating records and gaining insight from health systems and disparate data streams is not possible without specialized tools which notify providers of changes in data. This critical data is necessary to aid providers with the information they need to treat both the patients immediately in front of them and those whom are being cared for remotely. Patient status and dispositions may now be treated by hospitalists; however, the patient is likely to be outside the hospital environment for treatment and/or convalescing. In all cases, having access to clinical information in a centralized, consumable format is essential to a care provider so that they can bring context to the patient’s current presentation.
The global healthcare continuum is rapidly changing in complexity and urgency, requiring healthcare systems and their workforces to consistently adapt and innovate. Prioritizing a culture where departments collaborate together with access to relevant data and tools informs both immediate acute actions and longer-term strategic decisions which leads to safer patients, a safer workforce and ultimately, a safer organization.
Questions to ask your teams
Is your healthcare system prepared to handle the increase in HAIs following the COVID-19 pandemic to keep patients safer?
As you think toward the future, what gaps do you see? What technology will you need to address those gaps?
What resources will you need to ensure a safer workforce and improve staff retention?
How can you engage multiple departments for a more collaborative approach to achieve a safer organization?