FOCUS ON INFECTION PREVENTION Impact of Implementation of Evidence-Based Best Practices on Nursing Home Infections Sharon Bradley, RN, CIC INTRODUCTION Senior Infection Prevention Analyst The problem of healthcare-associated infections (HAIs) in nursing homes has been Phenelle Segal, RN, CIC Infection Prevention Analyst increasingly recognized over the last two decades.1 More robust literature and develop- ment of evidence-based recommendations devoted to nursing home infection control Edward Finley, BS Data Analyst have resulted in the widespread initiation of infection control programs in this setting.1 Pennsylvania Patient Safety Authority Yet limited studies are available to evaluate the effectiveness or level of adoption of specific basic infection control measures to minimize HAIs in nursing homes. ABSTRACT Long-term care facilities must have individualized infection control programs, as man- Reports of inconsistencies in the imple- dated by the Centers for Medicare and Medicaid Services’ State Operations Manual2 mentation of evidence-based infection and Pennsylvania Act 52 of 2007.3 In a seven-year study of infection control deficiency control best practices and the number of citations, Castle et al. found that an average of 15% of all nursing homes in the United deficiency citations for infection control States received a deficiency citation for infection control each year between 2000 and problems in nursing homes indicate the 2007.4 In a 2005 study, the results of a 43-item survey of 37 Michigan nursing homes need to identify barriers to the integra- found significant variability in implementation of infection control methods and tion of infection control practices in this guidelines.5 Strides have been made in infection control research in the nursing home setting. The Pennsylvania Patient Safety setting; however, the number of deficiency citations for infection control problems Authority conducted on-site assessment and the inconsistencies in the implementation of infection control practices suggest visits to 10 Pennsylvania nursing homes the need for increased emphasis and research focusing on identifying barriers to imple- with high healthcare-associated infection menting infection control best practices in nursing homes. (HAI) rates and 10 with low HAI rates. The A major focus of the Pennsylvania Patient Safety Authority is to drive targeted research, assessment’s purpose was to study the education, and guidance efforts in infection control and prevention based on the impact of various levels of implementation Authority’s analysis of the HAI data reported by Pennsylvania nursing homes through of infection prevention best practices on the Authority’s reporting system as required by Pennsylvania Act 52. Authority ana- HAI rates and to assess patterns of care lysts conducted an outreach project in order to study the impact of various levels of that could be targeted for improvement. implementation of infection prevention practices on HAI rates in Pennsylvania nurs- Authority analysts assessed the imple- ing homes and to assess patterns of care that could be targeted for improvement. This mentation of 50 evidence-based infection Authority study specifically sought to determine in which infection prevention domains prevention best practices. Analysis of the nursing homes performed well or poorly, in which implementation categories there were aggregate assessment data from the visits differences in the performance of facilities with low or high HAI rates, respectively, and demonstrated a relationship between high what elements of best practice were most lacking in areas of poor performance. infection rates and low implementation of best practices. Compared with nursing homes with low infection rates, those with METHODS high rates were deficient in one or more Participants and Data Sources of six levels of implementation for 45 of the 50 best practices. The assessments Study participants were selected from Pennsylvania nursing homes with overall HAI identified multidisciplinary implementation rates at either the high or low end of the performance spectrum. Nursing homes were barriers in nursing homes with high HAI sorted into performance quartiles based on HAI reports submitted to the Authority rates at the leadership, physician, clinical, from March 2010 through May 2010. Selection criteria involved analysis of character- and support staff levels and recognized istics of the nursing homes falling into the highest HAI-rate quartiles and those falling patterns of care that nursing homes could into the lowest HAI-rate quartiles of all nursing homes reporting statewide, the distri- target for improvement. (Pa Patient Saf bution of HAIs across all reportable infection types, and the occurrence of HAIs in Advis 2012 Sep;9[3]:89-98.) multiple care areas. Twenty nursing homes were selected that consistently reported utilization data (resi- Scan this code dent-days and Foley catheter-days): 10 with rates in the highest HAI quartile (referred to with your mobile as “H-HAI” nursing homes for the purposes of this article) and 10 with infection rates device’s QR in the lowest quartile (“L-HAI” nursing homes). Facilities selected for the study ranged reader to access from 19- to 453-bed facilities (the median was 142 beds) and included a cross-section of the Authority's corporate and single-owned facilities providing transitional care, nursing care, rehabili- toolkit on this topic. tation, and subacute care. A secondary data review was performed for the three months Vol. 9, No. 3—September 2012 Pennsylvania Patient Safety Advisory Page 89 ©2012 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION immediately prior to each assessment visit Study Design are reportable to the Authority. The tool to determine continued appropriateness The Authority’s Long-Term Care Best- incorporated a scoring system that identi- for inclusion in the respective high- or Practice Assessment Tool was designed to fied the level of implementation for each low-HAI-rate categories. The study was assess the structure and function of nurs- of the 50 best practices. Six secondary conducted employing the Authority’s ing homes’ infection control programs by implementation categories were used to Long-Term Care Best-Practice Assessment measuring the level of implementation of measure how each of the best practices Tool, which is based on best-practice current best practices in seven domains: were integrated into a facility’s infection strategies selected from current guidelines hand hygiene, environmental, urinary control program structure and clini- that have been shown in the research tract infection (UTI), respiratory tract cal practice functions. The tool can be literature to deliver better quality and infection (RTI), gastrointestinal (GI) and accessed at http://patientsafetyauthority. promote positive outcomes. Data from multidrug-resistant organism (MDRO) org/EducationalTools/PatientSafetyTools/ 8 of the 10 L-HAI facilities was available infection, skin and soft-tissue infection Pages/home.aspx. for analysis. Figure 1 shows that of the 10 (SSTI), and outbreaks. The tool’s implementation categories nursing homes selected with high HAI associated with infection control program Specific best practices listed in each of rates, 9 had significantly higher rates structure assessed the following: the seven domains were based on clearly than the state pooled mean rate (0.742 defined interventions found in the litera- — Integration of best practices into the HAIs per 1,000 resident-days). Further, ture and current guidelines for infection facility infection control plan, which all eight nursing homes selected with low categories by which self-assessment could is consistent with goals that are HAI rates had rates that were significantly be easily completed and on HAIs that updated annually lower than the state pooled mean rate. Figure 1. Healthcare-Associated Infection (HAI) Rates For Individual Nursing Homes, March 2010 to May 2010 11.0 10.0 HAIs PER 1,000 RESIDENT-DAYS 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 MS12474 1.0 0.0 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 Quartile Quartile mean mean H-HAI NURSING HOMES L-HAI NURSING HOMES Facility rate Lower confidence limit Upper confidence limit ∆ from state pooled mean Note: H-HAI = nursing homes with high rates of HAIs; L-HAI = nursing homes with low rates of HAIs. The state pooled mean rate of 0.742 HAIs per 1,000 resident-days reflects data reported to the Pennsylvania Patient Safety Authority from March 2010 to May 2010. Page 90 Pennsylvania Patient Safety Advisory Vol. 9, No. 3—September 2012 ©2012 Pennsylvania Patient Safety Authority — Policies and procedures that reflect practices were often not a priority. The which is consistent with goals that the facility infection control plan results of the study were measured by com- are updated annually (L-HAI: 78%, — Documentation of education pro- paring the differences in the percentage of H-HAI: 57%) vided on infection control goals and H-HAI and L-HAI nursing homes showing 2. Policies and procedures that reflect policies full implementation of each of the 50 best the facility infection control plan The tool’s implementation categories practices in three levels of analysis: domain (L-HAI: 90%, H-HAI: 86%) associated with infection control program assessment, implementation category 3. Education provided on infection clinical practice assessed the following: assessment, and best-practice performance. control goals and policies (L-HAI: — Standard documentation methods 89%, H-HAI: 88%). Domain Assessment 4. Standard documentation methods in in use Overall, the scores for both H-HAI and use (L-HAI: 81%, H-HAI: 70%) — Monitoring, documentation, and L-HAI nursing homes were lowest in full evaluation of process and outcome 5. Monitoring, documentation, and implementation of hand hygiene best measures evaluation of process and outcome practices. The highest overall scores for — Assigned accountability and follow- measures (L-HAI: 75%, H-HAI: 71%) the L-HAI homes were in implementation up by managers and leaders of SSTI prevention practices; the high- H-HAI and L-HAI nursing homes both est scores for the H-HAI homes were in scored 91% in overall implementation of Assessment Interviews implementation of GI and MDRO infec- assigned accountability and follow-up by Administrative and infection prevention tion prevention practices. Compared with managers and leaders. staff from each of the 20 facilities agreed H-HAI nursing homes, L-HAI nursing The H-HAI nursing homes scored to an on-site consultation to participate homes scored better in full implementa- higher in individual categories for in the best-practice assessment. The on- tion of best practices in five of the seven implementation of a plan, goals, educa- site consultations were conducted from assessment domains (see Figure 2). H-HAI tion, documentation, monitoring and October 2010 through November 2011, nursing homes scored lower than L-HAI assigned accountability for outbreak beginning with the H-HAI facilities. The nursing homes in full implementation control. H-HAI homes also scored higher authors looked for (and failed to find) of best practices for UTI (L-HAI: 83%, in integration of hand hygiene best prac- evidence that would have suggested differ- H-HAI: 70%), followed by SSTI (L-HAI: tices into the facility infection control ences in rates simply reflected in vigilance 95%, H-HAI: 84%), hand hygiene plan, education for environmental con- around surveillance and reporting. Assess- (L-HAI: 75%, H-HAI: 65%), environmen- trol, monitoring for RTI, and assigned ment methods during the on-site visit tal control (L-HAI: 84%, H-HAI: 76%), accountability and monitoring for GI and included a determination of adequate sur- and RTI (L-HAI: 85%, H-HAI: 79%). MDRO infection. veillance and reporting practices, a review H-HAI nursing homes scored better than There was no difference between the of the availability of administrative sup- L-HAI facilities in implementation of H-HAI and the L-HAI nursing homes in port and resources, and a detailed analysis outbreak control practices (L-HAI: 77%, the individual categories of integration of of the facility’s self-assessment. Assessment H-HAI: 84%), as well as in the GI and GI and MDRO infection prevention best tools used included the best-practice survey, MDRO infection domain (L-HAI: 86%, practices into the facility infection control record reviews, observational rounds, and H-HAI: 88%). plan or in implementation of policies and staff interviews. Each facility received a writ- procedures that reflect the facility infec- ten follow-up report summarizing barriers to Implementation Category tion control plan for SSTI and outbreak adherence to best practice for each facility, Assessment control. (For an interactive graphic of the as well as positive findings and opportuni- Assessment of the six implementation cat- scores, see http://patientsafetyauthority. ties for improvement. egories found notable differences between org/ADVISORIES/AdvisoryLibrary/ H-HAI and L-HAI nursing homes in Pages/Home.aspx.) RESULTS implementation of best practices (see While both H-HAI and L-HAI nursing Tables 1 and 2). Overall, L-HAI nursing Best-Practice Performance homes routinely implemented infection homes scored higher in full implementa- This level of analysis identified which surveillance activities and documented tion of best practices in five of the six specific elements of best practices were outcome measures, standardized process implementation categories: most lacking and indicated practices that measurement and evaluation of imple- 1. Integration of best practices into could be targeted for improvement. Study mentation of specific infection control the facility infection control plan, findings are described here by individual Vol. 9, No. 3—September 2012 Pennsylvania Patient Safety Advisory Page 91 ©2012 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION Figure 2. Difference in Percentages of Full Implementation of Nursing Home Best Practices DOMAINS 75% Hand hygiene 65% 84% Environmental control 76% 83% Urinary tract infection 70% 85% Respiratory tract infection 79% 86% Gastrointestinal infection 88% 95% Skin and soft-tissue infection 84% 77% Outbreak control 84% 0 20 40 60 80 100 % OF NURSING HOMES FULLY IMPLEMENTING BEST PRACTICES MS12442 L‐HAI H‐HAI Note: L-HAI = Nursing homes with low rates of healthcare-associated Infections; H-HAI = nursing homes with high rates of healthcare-associated infections domain. Figures associated with each H-HAI nursing homes also lacked — Policies, education, monitoring, and domain demonstrate the percentage of full implementation of the following assigned accountability for assuring H-HAI nursing homes that scored higher categories: that a closed, sterile system is in place or lower than the L-HAI nursing homes in — Education, monitoring, and assigned — Documentation and monitoring full implementation of each best practice accountability for the institution of a for aseptic Foley insertion and across all six implementation categories. toileting and hydration program maintenance UTIs. Compared with L-HAI nursing — Development of policies, procedures, Strategic approaches to sustain low UTI homes, H-HAI nursing homes scored and documentation for a daily rates in the L-HAI nursing homes included lower across all six implementation review of Foley catheter necessity oversight by the director of nursing of categories in full implementation of — Documentation of use of a Foley admission assessments of residents with written criteria for Foley catheter use and securement device and proper posi- Foley catheters, assigned accountability for in implementation of standing orders to tioning of Foley drainage bags catheter removal decisions, monitoring remove catheters if criteria are not met. of catheter maintenance, and a written — Policies, education, documentation, H-HAI nursing homes also scored lower training program for nursing assistants. and assigned accountability for daily in integration of all nine UTI prevention Additional strategies included use of a and postincontinence perineal care practices into the facility infection control bladder scanner to measure bladder vol- plan and goals. (See Figure 3.) ume and use of silver-coated catheters. Page 92 Pennsylvania Patient Safety Advisory Vol. 9, No. 3—September 2012 ©2012 Pennsylvania Patient Safety Authority Table 1. Average % of Full Implementation of Combined Best Practices for Nursing Homes with Low Rates of Healthcare-Associated Infec- tions, by Domain and Implementation Category STRUCTURE CATEGORIES CLINICAL PRACTICE CATEGORIES DOMAIN Plan Policy Education Documentation Monitoring Accountability Hand hygiene 73% 84% 84% 61% 66% 84% Environmental control 88% 98% 85% 65% 70% 100% Urinary tract infection 75% 86% 89% 82% 76% 90% Respiratory tract 79% 91% 91% 84% 71% 95% infection Gastrointestinal and 78% 91% 91% 91% 78% 91% multidrug-resistant organism infection Skin and soft-tissue 84% 95% 98% 97% 97% 98% infection Outbreak control 71% 84% 80% 80% 64% 80% Note: Shaded cells reflect a higher level of implementation when compared with nursing homes with high rates of healthcare-associated infections (H-HAI). Bolded percentages indicate no difference when compared with H-HAI nursing homes. Table 2. Average % of Full Implementation of Combined Best Practices for Nursing Homes with High Rates of Healthcare-Associated Infec- tions, by Domain and Implementation Category STRUCTURE CATEGORIES CLINICAL PRACTICE CATEGORIES DOMAIN Plan Policy Education Documentation Monitoring Accountability Hand hygiene 76% 77% 83% 37% 31% 83% Environmental control 74% 96% 98% 28% 62% 98% Urinary tract infection 32% 79% 80% 72% 70% 84% Respiratory tract infection 52% 85% 89% 74% 79% 94% Gastrointestinal and 78% 90% 90% 88% 85% 95% multidrug-resistant organism infection Skin and soft-tissue infection 30% 95% 96% 95% 90% 96% Outbreak control 86% 84% 87% 86% 74% 87% Note: Shaded cells reflect a higher level of implementation when compared with nursing homes with low rates of healthcare-associated infections (L-HAI). Bolded percentages indicate no difference when compared with L-HAI nursing homes. A two-tailed statistical test for comparing best practices into the facility infection tocols. (See Figure 4.) (Figures 4 through the proportions of the two groups’ com- control plan and goals, as well as a lack 9 are available exclusively with this article pliance rates was run on the percentage of of nutrition and hydration protocols in online at http://patientsafetyauthority. responses of full implementation for the all six implementation categories. H-HAI org/ADVISORIES/AdvisoryLibrary/ H-HAI group against the L-HAI group. nursing homes also scored lower in imple- 2012/Sep;9(3)/Pages/home.aspx.) The resultant z-score was -4.86, indicating mentation of policies, documentation, Strategies to sustain low SSTI rates in the that the difference between the H-HAI and monitoring of daily skin inspection L-HAI nursing homes included highly group and L-HAI group was significant at procedures, as well as in education, structured skin rounds—including a spe- the p value < 0.001. documentation, monitoring, and account- cific day and time for rounds completed SSTIs. The most notable difference ability for reassessing pressure ulcer risk. by a wound specialist and a nurse—a between the H-HAI and the L-HAI nurs- H-HAI nursing homes also lacked full dedicated skin care nurse or consultant, ing homes in the SSTI prevention domain implementation of policies for promot- monthly physician specialist rounds, was found in the H-HAI nursing homes’ ing wound healing and in education and and oversight by nursing administration. lack of incorporation of all eight SSTI monitoring for pressure-minimizing pro- Other factors contributing to low SSTI Vol. 9, No. 3—September 2012 Pennsylvania Patient Safety Advisory Page 93 ©2012 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION Figure 3. Comparison of Implementation of Urinary Tract Infection Prevention Best Practices for Nursing Homes with High Rates of Healthcare-Associated Infections (HAIs) and Nursing Homes with Low HAI rates % LOWER IMPLEMENTATION % HIGHER IMPLEMENTATION URINARY TRACT INFECTION THAN HOMES WITH THAN HOMES WITH PREVENTION BEST PRACTICES LOW HAI RATES LOW HAI RATES -70% -60% -50% -40% -30% -20% -10% 0% 10% 20% 30% -35% 5% The facility has instituted a -8% 15% toileting and hydration program. -15% -10% -23% The facility has adopted written -15% -28% -5% criteria for use of Foley catheter (FC). -15% -18% Necessity of continuation of FC is assessed -58% -10% 0% and documented as per facility policy, -10% 13% and unecessary catheters are removed. 0% -30% Standing orders are in place -43% -33% -33% to remove FC if criteria are not met. -20% -33% -48% Aseptic technique is followed for 0% 0% -10% FC insertion and maintenance. -18% 0% -45% 3% 3% A FC securement device is required. -18% 5% 13% -45% A process is in place to -8% -8% assure maintenance of the FC 18% -25% closed system (e.g., specimen ports). -8% -45% FC drainage bags are appropriately 13% 3% positioned to prevent backflow -25% 15% of urine into the bladder. 13% -58% -10% Perineal care is performed daily -10% -20% and after each fecal episode. 3% -10% Policy or Standard Monitoring Assigned MS12445 Plan goals procedure Education documentation process accountability rates were implementation of a novel feed- responses of full implementation for the individualized program to monitor hand back communication loop with written H-HAI group against the L-HAI group. hygiene compliance. H-HAI nursing homes receipts for delivery of messages, a rotat- The resultant z-score was -5.23, indicating also scored lower in documentation and pro- ing mattress replacement program, a low that the difference between the H-HAI cess monitoring for all of the hand hygiene incidence of bedbound residents, and a group and L-HAI group was significant at best practices, including the following: high nurse-to-resident ratio. the p value < 0.001. — Clinician’s demonstration of under- A two-tailed statistical test for comparing Hand hygiene. Across all six implementa- standing hand hygiene rationale, the proportions of the two groups’ com- tion categories, H-HAI nursing homes indications, and methods pliance rates was run on the percentage of were most lacking in implementation of an Page 94 Pennsylvania Patient Safety Advisory Vol. 9, No. 3—September 2012 ©2012 Pennsylvania Patient Safety Authority — Availability of alcohol-based H-HAI nursing homes’ lack of standard — Development of policies and an edu- handrubs and gloves at the point documentation for best practices for cation program for a standing order of care glove use and for handling, cleaning, and immunization process — Glove changes in between residents disinfecting reusable equipment, surfaces, — Provision of an education and and in between clean and dirty activi- and linens, as well as lower scores on infection control plan and policies ties on the same resident incorporation of all of these environmen- for use of single-dose aerosolized — Handwashing with soap and water tal control best practices (except for glove medications when hands are visibly soiled and use) into the facility’s infection control — Documentation and education with before and after resident care plan and goals. Additionally, H-HAI regard to separation of ill employees nursing homes showed opportunities for from residents — Residents’ and families members’ improvement in policy development for knowledge about hand hygiene — Development of policies and a linen handling and environmental surface H-HAI nursing homes also lacked full written plan to monitor, assign disinfection, as well as in monitoring of implementation of staff education on the accountability for, and document glove use, equipment disinfection, and glove changing process and developing cleaning and disinfection of respira- linen disposal. H-HAI nursing homes also facility infection control goals and poli- tory equipment failed to assign accountability to assure cies to help residents and family members proper cleaning of environmental sur- — Establishment of a plan and policies become knowledgeable about hand faces. (See Figure 6 online.) to assure education, documentation, hygiene. H-HAI nursing homes also failed and assigned accountability for use L-HAI nursing homes described several to assign accountability for clinical staff of sterile catheters and techniques strategies for sustained environmental understanding about hand hygiene. (See for suctioning. infection control, including use of a pre- Figure 5 online.) However, H-HAI nursing homes did determined daily cleaning schedule and Analysis of interviews with infection cleaning checklists, cleaning frequency score higher than L-HAI facilities in all prevention representatives from the increases based on clinical input, a implementation categories with respect L-HAI nursing homes found that suc- structured clean/dirty workflow process to employee influenza immunization cessful implementation of hand hygiene in laundry areas, and staff access to suf- programs and separation of residents with best practices was associated with the use ficient resources. communicable diseases from other resi- of hand hygiene competency checklists, dents. (See Figure 7 online.) A two-tailed statistical test for comparing involvement of administrative staff with Nursing homes with low RTI rates associ- the proportions of the two groups’ com- hands-on monitoring and interventions ated successful prevention with routine pliance rates was run on the percentage of in hand hygiene practices across all disci- dental care, an intense mobilization responses of full implementation for the plines on a daily basis, and the availability program, communication alerts for clus- H-HAI group against the L-HAI group. of hand sanitizers at each point of care ters of infections, and triggers for new The resultant z-score was -2.34, indicating and in critical access areas. Also helpful tracheostomy consults. Some nursing that the difference between the H-HAI were hand hygiene reminder paycheck homes found success with the services of group and L-HAI group was significant at inserts, annual hand-hygiene-specific a respiratory therapist who also performed the p value < 0.01. in-services, and the use of individual, regular educational and competency personal-size hand sanitizers. RTI (lower respiratory tract infection [LRTI] activities for the nursing staff. Additional and influenza-like illness [ILI]). The most A two-tailed statistical test for comparing interventions that may have impacted notable difference between the H-HAI the proportions of the two groups’ com- rates of influenza and pneumococcal nursing homes’ and L-HAI nursing pliance rates was run on the percentage of pneumonia and invasive disease included homes’ performances in the LRTI and ILI responses of full implementation for the preprinted vaccination orders, increased domains was the H-HAI nursing homes’ H-HAI group against the L-HAI group. staff vaccination, and vaccination con- lack of institution of a standardized oral The resultant z-score was -3.19, indicating sents obtained at the time of admission by care and aspiration prevention program that the difference between the H-HAI the facility admissions director. across all six implementation categories. group and L-HAI group was significant at H-HAI nursing homes also lacked imple- A two-tailed statistical test for comparing the p value < 0.001. mentation of the following practices: the proportions of two groups’ compli- Environmental control. The most notable ance rates was run on the percentage of — Integration of a respiratory etiquette difference between L-HAI and H-HAI responses of full implementation for the program into the facility infection nursing homes’ performance was the H-HAI group against the L-HAI group. control plan, goals, and policies Vol. 9, No. 3—September 2012 Pennsylvania Patient Safety Advisory Page 95 ©2012 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION The resultant z-score was -2.69, indicating GI and MDRO infection. Compared with BARRIERS that the difference between the H-HAI L-HAI nursing homes, those with high Assessment visits to H-HAI facilities group and L-HAI group was significant at HAI rates scored lower in documentation identified multiple barriers to staff and the p value < 0.01. of ensuring compliance with precautions, administrative performance of best prac- Outbreak control. Multiple opportuni- as well as in documentation, monitoring, tices for prevention of HAIs. Specific ties for improvement for H-HAI nursing and incorporation of communication of barriers reported included unavailability homes were found in this level of analysis GI and MDRO prevention practices into of alcohol-based handrub stations at the of individual best-practice assessment (see the facility infection control plan. The point of care, monitoring of antimicro- Figure 8 online), including in the follow- overall lowest scores in this domain for bial use performed only at the pharmacy ing practices: both L-HAI and H-HAI nursing homes level, a lack of knowledge of aspiration were in implementation of antimicrobial prevention strategies, use of the outdated — Incorporating methods to investigate monitoring best practices. In individual practice of routine changing and irriga- cases that rise above the facility’s nor- categories, H-HAI homes scored lower in tion of Foley catheters, and refusal of mal baseline into the facility infection integration of antimicrobial monitoring physicians or residents to remove Foley control plan, policies, and procedures into the facility plan, goals, policies, and catheters that do not meet evidence-based — Assigning accountability and devel- educational programs. Overall, H-HAI insertion criteria. oping documentation methods for homes scored slightly better than L-HAI identifying increased numbers of homes in all implementation categories Facility-wide barriers affecting all assess- outbreak cases for posting transmission-based precaution ment domains included high acuity, low signage. (See Figure 9 online.) staffing, and limited consultant services. — Developing a policy and documenta- Infection prevention designees described tion, monitoring, and accountability L-HAI nursing homes described several lack of training, responsibility for multiple methods for monitoring of infection strategies to sustain low GI and MDRO roles and multiple campuses, and lack control measures and isolation infection rates, including a novel feedback of administrative support for infection — Instituting policies, education, docu- loop among nursing assistants, nurses, control programs. Notable throughout mentation, and accountability for and administration, which requires the H-HAI survey results was an absence specific outbreak case definition and documentation of communication of of structured and/or documented timely institution of infection control infectious cases; preemptive isolation monitoring programs and communication H-HAI nursing homes did score higher and intervention with suspect conta- strategies to involve and educate staff on than L-HAI homes in all six categories of gious cases; and a removal-from-isolation infection issues and an absence of owner- full implementation for conducting case protocol. Approaches that may have con- ship of improvement projects, as well as finding and in having procedures to iden- tributed to low GI and MDRO rates were a lack of infection control education for tify transmission of disease. special Clostridium difficile cleaning proto- family members and residents. Limited cols, an active antimicrobial stewardship space to separate clean and dirty items The visited facilities described successful program with oversight by the director and unavailability of resources were also outbreak control strategies, including of nursing, and the use of private rooms cited by H-HAI nursing homes as barriers using a case-tracking form and the 24-hour for each resident. Additional resources to best-practice performance. While every report for identification of increasing can be accessed in the Authority’s online facility had a process improvement or infection trend action plans, placing norovirus prevention toolkit at http:// safety committee in place, H-HAI nursing residents in private rooms, and a using patientsafetyauthority.org/ADVISORIES/ homes described reactive versus proactive cohort/quarantine system to respond to a AdvisoryLibrary/2010/dec7(4)/Pages/ infection prevention programs, a lack of potential outbreak. 141.aspx. root-cause analysis for infection issues, and A two-tailed statistical test for comparing A two-tailed statistical test for comparing the frequent institution of infection con- the proportions of the two groups’ com- the proportions of the two groups’ com- trol strategies without a planned approach. pliance rates was run on the percentage of pliance rates was run on the percentage of responses of full implementation for the responses of full implementation for the LIMITATIONS H-HAI group against the L-HAI group. H-HAI group against the L-HAI group. The study results are limited by several The resultant z-score was 2.52, indicating The resultant z-score was 0.32, indicating factors. Analysis of the nursing homes’ that the difference between the H-HAI that the difference between the H-HAI HAI rates was based on compliance with group and L-HAI group was significant at group and L-HAI group was not signifi- HAI reporting to the Authority. The the p value < 0.01. cant at the p value < 0.636. Page 96 Pennsylvania Patient Safety Advisory Vol. 9, No. 3—September 2012 ©2012 Pennsylvania Patient Safety Authority sample size of 20 nursing homes was lim- ing home residents and provides both a previously mentioned. In addition, this ited and, in order to achieve diversity in pre- and postintervention assessment. It study suggests that moving best practices size and patient population, participants can be used to demonstrate the evidence from evidence to the bedside by fully were specifically selected (i.e., not selected needed to justify or prioritize implementa- implementing those practices at a higher randomly). The analysts conducted all 10 tion of appropriate prevention strategies level in each of the six implementation L-HAI nursing home assessment visits; and resources and to gain a fresh perspec- categories may be associated with lower however, data from two facilities was not tive on the effectiveness of improvement infection rates. available for analysis. Therefore, data strategies needed to enhance the infec- Nursing homes with consistently low analysis on the assessment results was tion control program. The tool has been infection rates described facility-wide strat- based on 10 H-HAI nursing homes and updated to include best-practice elements egies for success that require high visibility 8 L-HAI nursing homes. Practices from from the new CDC norovirus guidelines.6 of managers on resident care units in the new norovirus guidelines published by order to enhance communication, resolve the Centers for Disease Control and Pre- CONCLUSION problems, investigate changes in condi- vention (CDC) after development of the tions, ensure accountability, reward staff The results of this study suggest an asso- Long-Term Care Best-Practice Assessment performance, and foster an “it’s okay to ciation between high infection rates and Tool were not available for the GI and speak up” culture. Frequent competency limited implementation of best practices outbreak control domain assessments. evaluations at all staff levels ingrain best in Pennsylvania nursing homes. Examina- tion of the differences between L-HAI practices in a structured framework for DISCUSSION and H-HAI nursing homes’ applications application at the bedside. Corporate and Monitoring compliance with best of specific best practices within multiple administrative support was evident for practices aimed at preventing HAIs levels of implementation revealed that trained infection prevention designees is fundamental to improvement. The nursing homes reporting high HAI rates who implemented nationally recognized, Authority’s Long-Term Care Best-Practice also had limited adoption of best practices standardized surveillance methods to Assessment Tool and consultation pro- in one or more levels of implementation actively search for HAI cases. Multiple gram were designed to assist nursing for 45 of the 50 best practices in the sur- communication methods and feedback homes to increase success with integrating vey. Opportunities for improvement for loops—such as a multidisciplinary daily tri- infection control best-practice concepts H-HAI nursing homes were identified in age at each nursing station, standardized into clinical practice by exploring nursing all seven infection control domains and structured reports, and frequent, interac- homes’ areas of greatest challenge. The across all six categories of best-practice tive educational programs—keep staff practices listed under each of the seven implementation. The interviews and informed. A highly structured process- assessment categories mirror current observations conducted by the authors monitoring system supports a strong evidence-based guidelines and could be uncovered multidisciplinary implementa- infection control program and a proactive considered a “bundle” for success in that tion barriers in the H-HAI nursing homes performance improvement process. category. The implementation categories at the leadership, physician, clinical, and identify the particular area in which support staff levels. MOVING FORWARD resources may need to be directed. This study reveals the variability in imple- The Authority survey results identi- The tool was designed to apply a multi- mentation and maintenance of infection fied suboptimal patterns of care, thus disciplinary approach to information control practices in nursing homes and providing a targeted focus for follow-up gathering for the assessment and facili- demonstrates the need to better identify education programs that can be widely tates several different methods of review and overcome barriers to implementing applied in the long-term care setting for to simplify the process for monitoring infection control best practices in this set- collaboration with nursing homes to compliance with best practices. The tool ting. This survey identified problems that overcome obstacles to full implementa- is compact, customizable, and contains are likely present in almost all nursing tion of the current best practices for HAI elements that can be measured by clinical homes to some extent and demonstrated prevention and for development of a con- observation at the bedside, by interviews, multiple methods to focus on problems sistent framework to integrate successful and by record review. Once populated that nursing homes could reasonably infection control strategies into clinical with data, the tool displays a snapshot of address to improve infection control. practice. To support the Authority’s goal the existence and extent of process defects The L-HAI nursing homes’ strategies to minimize HAIs in Pennsylvania nurs- and barriers to HAI prevention in nurs- for success in each of the domains are ing homes, the next step of following Vol. 9, No. 3—September 2012 Pennsylvania Patient Safety Advisory Page 97 ©2012 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION up with nursing homes involved in this infection control educational strategies ACKNOWLEDGMENTS project is currently underway to compare and toolkits can be found at http://www. James Davis, BSN, RN, CCRN, CIC, and Lea Anne Gardner, PhD, RN, of the Pennsylvania pre- and postintervention HAI rates and patientsafetyauthority.org. Patient Safety Authority contributed to data methods of overcoming barriers. Multiple acquisition and validity. NOTES 1. Smith PW, Bennett G, Bradley S, et al. 3. Medical Care Availability and Reduction 5. Mody L, Langa KM, Saint S, et al. Pre- SHEA/APIC guideline: infection pre- of Error (MCARE) Act—reduction and venting infections in nursing homes: a vention and control in the long-term prevention of health care-associated survey of infection control practices in care facility. Am J Infect Control 2008 infection and long-term nursing facilities. southeast Michigan. Am J Infect Control Jul;36(7):504-35. Act of Jul. 20, 2007, Pub. L. No. 331. Also 2005 Oct;33(8):489-92. 2. Centers for Medicare and Medicaid Ser- available at http://patientsafetyauthority. 6. MacCannell T, Umscheid CA, Agarwal vices. Appendix PP—guidance to surveyors org/PatientSafetyAuthority/Governance/ RK, et al. Centers for Disease Control for long term care facilities. In: State Documents/act_52_of_2007_final_(2).pdf. and Prevention. Guideline for the operations manual [online]. 2009 Jun 12 4. Castle NG, Wagner LM, Ferguson-Rome prevention and control of norovirus [cited 2012 Feb 6]. http://www.cms.gov/ JC, et al. Nursing home deficiency cita- gastroenteritis outbreaks in healthcare set- manuals/Downloads/som107ap_pp_ tions for infection control. Am J Infect tings [online]. [cited 2012 Feb 6]. http:// guidelines_ltcf.pdf. Control 2011 May;39(4):263-9. www.cdc.gov/hicpac/pdf/norovirus/ Norovirus-Guideline-2011.pdf. Page 98 Pennsylvania Patient Safety Advisory Vol. 9, No. 3—September 2012 ©2012 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 9, No. 3—September 2012. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2012 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. 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For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. 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