Data and Mitigation Teri Fitzgerald Margaret Drake Sue Beach Kate Tyner Maureen Tierney and M Salman Ashraf Outline Approach to Assessment and Data Gathering Organization and Analyses of Data ID: 931841
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Slide1
Nebraska ICAR Hemodialysis VisitsData and Mitigation
Teri Fitzgerald, Margaret Drake, Sue Beach, Kate Tyner, Maureen Tierney, and M. Salman Ashraf,
Slide2Outline
Approach to Assessment and Data Gathering
Organization and Analyses of Data
Themes on IC Gaps from CDC ICAR OP HD Assessment Tool
Themes on IC Gaps from Making Dialysis Safer Observation ToolsEarly mitigation strategies
Slide3OP HD Center Assessment
Recruitment required multiple contact attempts
Scheduled for approximately 4 hours at each site
1 hour for ICAR Assessment Interview
Observations scheduled to coincide with shift turnover
NHSN Engagement during introduction, closing, and/ or interview
Assessment Team Composition and Tasks
Slide4NHSN Data Trends
Large corporations have a central infection manager who reports into NHSN on a regional basis. Staff generally are not aware what constitutes a dialysis event.
It is difficult
to pull charting on access site from some facilities.
Centers review their data only when corporation sends them a report. Unaware how they can pull a report from NHSN.Independent facilities may
do reporting themselves, but still may not have a sense of their BSI
rates. Rather, they
k
now the number
of positive blood cultures.
Slide5Nebraska ICAP Assessment Interaction Model
Continued availability by email and phone for support
Phone call after 12 months
Site Specific letter with identified gaps and recommendations
Interview and Observations
Slide6Nebraska ICAP Data Cycle
Slide7Themes on IC Gaps:
CDC ICAR Outpatient Hemodialysis
Assessment Tool
Image:
Pixabay
Slide8Nebraska Site Characteristics
Slide9Top ICAR Assessment/ Interview Gaps
Percent
No
Signs
posted
that
encourage patients to take an active role in and express their concerns about facility infection control
practices
93%
Facility has work-exclusion policies that encourage reporting of illnesses and do not penalize
60%
Facility provides
space and encourage persons with symptoms of respiratory infection to sit as far away from others as possible:
non
clinical areas
67%
Facility provides
space and encourage persons with symptoms of respiratory infection to sit as far away from others as possible:
clinical areas
67%
Routine application of
antibiotic ointment or
povidone
-iodine ointment to catheter exit sites during dressing changes
87%
Slide10Patient Separation is not ideal
Slide11Where to start with data analyses?
Slide12Best Practice Recommendations
(n = no. of facilities with particular BPR in place
out of total of 15 Ambulatory Dialysis Centers)
Associated Factors
CATEGORY I. Infection Control Policies and Infrastructure
Not Part of Chain
(N = 4)
Part of Chain
(N = 11)
P value
Census
<
50
(N = 8)
Census
> 50
(N = 7)
P value
Facility has shared computer charting terminal. (n = 7)
0
7 of 11
(
64%)
0.08
3 of 8
(38%)
4 of 7 (57%)
The shared computer terminal is cleaned at the end of each day. (n = 5)
0
5 of 11
(45%)
3 of 8
(38%)
2 of 7
(29%
The shared computer terminal is cleaned after each patient. (n = 2)
0
2 of 11 (18%)
0
2 of 7
(29%
CATEGORY III. Healthcare Personnel Safety
Facility has work-exclusion policies that encourage reporting of illnesses and do not penalize with loss of wages, benefits, or job status. (n = 6)3 of 4 (75%)3 of 11 (27%) 6 of 8 (75%)0 of 7<0.01
Facility provides space and encourages persons with symptoms of respiratory infection to sit as far away from others as possible. (n = 5)3 of 4 (75%)2 of 11 (18%) 0.085 of 8 (63%)0 of 7 <0.05
CATEGORY V. Respiratory Hygiene/Cough Etiquette
Slide13Themes on IC Gaps from Making Dialysis Safer Observation Tools
Slide14Slide15Dialysis Station Cleaning Observations
Total observations
30
Incomplete data
12
Complete
data
18
Complete
data + total compliance
8Complete data – total compliance10
N=18
Slide16Station Disinfection:Analysis of failure points
Part A: Before Beginning Routine Disinfection of the Dialysis Station
A1| Disconnect and takedown used blood tubing and dialyzer from the dialysis machine
A2| Discard tubing and dialyzers in a leak-proof container
A3| Check that there is no visible soil or blood on surfaces
A4| Ensure that the priming bucket has been emptied
A5| Ensure that the patient has left the dialysis station
A6| Discard all single-use supplies. Move any reusable supplies to an area where they will be cleaned and disinfected before being stored or returned to a dialysis station.
A7| Remove gloves and perform hand hygiene
.
% NO
0
0
0
0
10%
0
0
N=10
Slide17Station Disinfection:Analysis of failure points
PART B: Routine Disinfection of the Dialysis Station – AFTER patient has left station
B1| Wear clean gloves.
B6| Remove gloves and perform hand hygiene.
B2| Apply disinfectant to
all surfaces
in the dialysis station using a wiping motion (with friction).
B3| Ensure surfaces are visibly wet with disinfectant. Allow surfaces to air-dry.
B4| Disinfect all surfaces of the emptied priming bucket. Allow the bucket to air-dry before reconnection or reuse.
B5| Keep used or potentially contaminated items away from the disinfected surfaces.
Are stethoscopes that are kept in stations disinfected between patients?
Are blood pressure cuffs, if not disposable, cleaned between patients?
%NO
0
10%
60%
20%
10%
0
20%
0
N=10
Slide18Observation Discussion
Image: Wikimedia
Slide19Hand Hygiene Compliance: Better than expected at 85% overall
Number of
observations
per site
before patient contact (N = 289)
Number of
observations
per site
after patient contact
(N = 378)
Average
19
Average
26
Median
20
Median
30
Range
1 - 30
Range
1 - 40
Hand hygiene
compliance
per site
before patient contact
Hand hygiene
compliance
per site
after patient contact
Average
85%
Average
91%
Median
90%
Median
93%
Range
46%
- 100%
Range
74% - 100%
Slide20Hand Hygiene Failures at Critical Moments
ART FISTULA/GRAFT CANNULATION (n=25)
Perform
hand hygiene
Put
on new, clean gloves.
12%
8%
HD Catheter Disconnection (n=15)
Perform
hand hygiene
Put
on new, clean gloves.
13%
13%
ART FISTULA/GRAFT DECANNULATION (n=37)
Pre: Perform hand hygiene (staff and/or patient)
Post: Perform hand hygiene (staff and/or patient)
5%
8%
Catheter Connection (n=13)
Perform
hand hygiene
Put
on new, clean gloves.
9%
9
%
Slide21Early Stage Mitigation
Slide22Nebraska ICAP Process
Continued availability by email and phone for support
Slide23What are the most common recommendations?
Specific
Recommendation
Number of
sites
where
this
was
recommended
Hand hygiene compliance
12
Antibiotic ointment
as CDC Core Intervention
11
Dialysis
station
cleaning
11
W
ork
exclusion
policies
11
Cleaning protocol
for m
edication preparation area9
Infection control signage for patient engagement
9
Policies
for
early detection of
potentially
i
nfectious patients
9
Slide24Nebraska ICAP Website:Practice Briefs for H
emodialysis
https://icap.nebraskamed.com/practice-tools/practice-briefs
/
Slide25Comprehensive training intervention
Training Course for infection prevention in HD Centers
Support from local education network: Nebraska Infection Control Network
Meeting with leadership from ESRD Network for support and collaboration
Slide26Broad Policy Issues
Ability to care for a hemodialysis patient that requires isolation
Droplet precautions
Minimum distance from other chairs
Time and staffing allotment to provide screening before patient enters treatment areaNo current requirement for injection safety training
Slide27Questions?
Visit us online! https
://
icap.nebraskamed.com
Discussion questions:Are other assessment teams seeing heparin vials in use in the dialysis care area/ away from the medication preparation area?
During dialysis station cleaning, are other teams seeing that disinfectant is not applied to all surfaces/ items missed?
How are other teams providing feedback?
Are others seeing these same broad infection control gaps (minimum distance between chairs, lack of injection safety training, inability to care for a patient that requires droplet precautions)?