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
HEROESGOES CSIControlling the
Spread of Infection
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
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
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
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
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)
HEROES GOES CSIC Difficile Reduction
Simulation Workshops
Chief of Chiefs for Infectious Disease Regional HEROES Team
Regional Infection Preventionists
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
No Shortcut to Becoming an Expert
CurrentFrame
Deliberate Practice
10,000 hour rule
ExpertPerformance
420 Representatives from all Medical Centers
Nurses 163Nursing Managers 25EVS 46Physicians 24Infection Prevention 23PCT/Transporter 19Laboratory 17Educators 16Radiology 12Non-Nursing Managers 11
Resp. Therapy 11Physical Therapy 9Dietary 9Quality/Risk 8Directors 7ED 3Pharmacy 1Social Worker 1Other 14
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
Glove EtiquetteTo 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.
CONTACT PLUS ISOLATIONGOWN 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
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 glovesWash hands
Remove gown and glovesWash handsDon new gloves
Assist patient with hand hygiene and to don a clean gown
Cover patient with a clean sheet
NCal HEROES 3.12
Rolling 12 Month HA-CDI Rate per 1000 Admits through April 2013
Reg HA-CDI Summit
(Apr 2010) Secret ShopperAudits
(Apr 2011)
Deliberate Practice
Workshops(Apr 2012)
TARGET54% decreasein 3 yrs