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Reducing Healthcare Associated Infections (HAI): Barriers and

Challenges

MHA Keystone Center for Patient Safety and Quality (MHA Keystone)

Chris George, RN MSMHA Keystone Center for Patient Safety and Quality

AHRQ HAI MeetingSeptember 27, 2010

Core Project Team

HRET MHA Keystone Deborah Bohr, PI Sam Watson, Co-PI

Kevin Van Dyke Christine George, RN

John Combes, MD Morgan Martin

Kimberly Sepulvado, RN

Study Objectives• Evidence-based Practice: How did clinicians and

hospital staff learn about evidence-based practice to prevent and mitigate HAI’s?

• Adaptive Work and the Comprehensive Unit-based Safety Program: How did teams get started with the adaptive work and what barriers were encountered?

• Critical Success Factors: What were the critical success factors in getting started?

• Future Research Needs: What types of AHRQ research are recommended?

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Study Methods• HAI Information Collection and Reporting

Summary: completed by the infection prevention lead at each hospital

• Patient Safety and Infection Prevention Catalogue: completed by the patient safety/quality improvement officers of each hospital

• Patient Safety and Infection Prevention Assessment: clinicians and other staff

• Semi-structured interviews with ICU coordinators at each facility

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Assessment Findings

Domain Mean Hospital Score (highest=5)AN=20CLABSI

BN=54CAUTI

CN=24VAP

DN=48Sepsis

General Work Environment 4.5 3.9 4.1 4.3

Attitudes 4.4 4.2 4.2 4.3

Practices 3.8 3.8 3.9 4.0

Mean % Yes Answers to Questions

Awareness of Patient Safety Training and Guidelines

75-95 86-94 96 92-98

Compliance with Patient Safety Practices

95 90 94 90

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Context: The Michigan Experience

History Results “Perfect is Possible” AHRQ and JHU collaboration

Comprehensive Unit-Based Safety Program (CUSP)

AHRQ-funded JHU-MHA Keystone success

CUSP elements:Educate staff on the Science of Safety Identify defects in careCommit executive leadership to patient safety at the

unit level

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Participating MHA Keystone Hospitals

Facility Type # Beds HAI Prevention

Effort

Timeline # IC FTEs

A Small/rural, non-tertiary, community, non-profit

73 BSI Early 2005 1.5

B Tertiary, community, non-profit

243 CAUTI 2003 1.5

C Tertiary, community, non-profit

411 VAP Late 2003 2

D Tertiary, teaching, community, non-profit

529 Sepsis Early 2004 4

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What Each Hospital Has in Common

Experience in the Keystone ICU Collaborative since 2004

Evidence-based practice specific to the HAI

Comprehensive Unit-Based Safety Program

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Barriers and Challenges

Resistance from front-line staff

Naïveté about resource requirements

Unrealistic data collection plans

Lack of staff support for multidisciplinary rounds

Time needed for practice change to take hold

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Key Lessons

Provide staff with strong evidence base

Communicate expectations and require accountability

Provide strong administrative support

Do what works locally

Use multiple venues to raise awareness and reinforce practice

Observe staff on rounds and provide regular real-time feedback

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Key Lessons (Cont…)

Provide performance data at least quarterly and post in unit

Establish Nurse Protocols

CUSP critical to success

Start small, then expand

Use arsenal of QI tools; change management, systems, small cycle change, in addition to CUSP tools

MD and RN champions essential

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Next Steps

Major need for implementation research

Best practices for implementing latest evidence-based practiceDedicated time for clinicians

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