Looking through a New Lens to Reduce Infection Rates

In January, the CDC published its new report on the progress of health care-associated infections (HAI). This new HAI Progress Report includes 2014 data, published in 2016. The report describes significant reductions reported at the national level in 2014 for nearly all infection types when compared to the baseline data. CLABSI and abdominal hysterectomy SSI show the greatest reduction. There was some progress shown in reducing both hospital-onset MRSA bacteremia and hospital-onset C difficile infections.¹

As seen in previous CDC reports, most infections have decreased compared to the national baseline. Despite progress, more action is needed at every level of health care to eliminate infections that commonly threaten hospital patients, and to reach the new HHS proposed targets for December 2020.²

So how do we continue to make progress on eliminating these preventable infections?

Each year there are numerous novel products that promote antimicrobial properties and the hope of infection prevention. As we know, many of these products have been helpful, but none can claim to be the silver bullet.

Examine the tactics

After examination, most tactics are intended to influence behavior. Gurses et al suggest that many patient safety improvement efforts involve interventions that were developed with a narrow point of view, without sufficiently considering how and whether an intervention would fit with other elements of the care system or lead to unintended consequences. The bottom line is changing behavior is hard and sustaining good behavior is even harder.³

But there’s been a renewed interest in the utilization of human factors engineering. HFE is the discipline that takes into account human strengths and limitations in working toward greater safety, effectiveness, and ease of use in a system. But now we’re seeing it as an approach to patient safety and specifically infection prevention.

How to apply HFE

In the early days of focused CLABSI prevention, the insertion process was identified as a major source of contamination and bloodstream infections. The premise was that if the physician or clinician adhered to the evidence based bundle by following a checklist the risk of contamination and CLABSI would greatly decrease. CVC insertion practices that follow the practice bundle have products gathered into all-inclusive kits. They also have well-defined checklist that are responsible for the vast majority of success that has been seen in CLABSI reduction.⁴ Now it is the care and maintenance of the central line that has the dubious distinction of being the major cause of CLABSI.

In recent years, the application of HFE principles to the maintenance of central venous catheters has been explored. The idea was to design an all-inclusive central line dressing change kit that included instructional prompts of each step. This HFE intervention was aimed at the modification of process behavior to increase adherence to best practices and the reduction of CLABSI.

A few years ago, a prospective, interventional, non-randomized, observational study was conducted utilizing a central line maintenance kit that incorporated HFE to test its comparison against no kit. The results of the study suggested that a HFE-based kit improved adherence to best practices during central line maintenance. In addition, the number of CLABSIs was significantly reduced during the post implementation period.⁵

This is just one example of how HFE can help standardize products and practice. Since this study was published, commercially available HFE dressing change kits were developed. Before you consider adopting this kind of kit, here are some things that you should consider:

1. Have you identified the gaps in your process?
2. Will a standard HFE designed kit help you fill YOUR gaps?
3. Do you need a customized system(s) that is tailored to your specific needs?
4. Can you provide education, training and competency that include direct observation with just in time feedback to sustain success?

Refocusing on the prevention and control of infection through a human factors lens offers us a new way of looking at an old problem. Improving patient safety can only be achieved if it is based on a culture of understanding the interactions within healthcare between humans ranging from their practices to their procedures, their work environment, the organization itself, teamwork, technology, and the value.

Sources:

1. Healthcare Associated Infection (HAI) Progress Report. Centers for Disease Control and Prevention. Accessed January 22, 2018.

2. National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination. Healthy People.gov. https://www.healthypeople.gov/2020/tools-resources/evidence-based-resource/national-action-plan-prevent-health-care-associated. Accessed January 22, 2018.

3. Gurses AP, Ant Ozok A, Pronovost PJ. Time to accelerate integration of human factors and ergonomics in patient safety. BMJ Qual Saf 2012;21:347-51.

4. Ward DJ. Attitudes towards infection prevention and control: an interview study with nursing students and nurse mentors. BMJ Qual Saf 2012;21:301-306.

5. Drews FA , Bakdash JZ, Gleed JR. Improving central line maintenance to reduce central line-associated bloodstream infections. Am J Infect Control. 2017 Jul 3. pii: S0196-6553(17)30764-2. doi: 10.1016/j.ajic.2017.05.017