FOCUS ON INFECTION PREVENTION A Conceptual Framework for Improving Isolation Awareness in Pennsylvania Acute Care Hospitals James Davis, MSN, RN, CCRN, CIC, HEM INTRODUCTION Senior Infection Prevention Analyst Antibiotics, powerful tools for treating bacterial infections, have been widely used Edward Finley BS since the 1940s. However, many of the organisms antibiotics were designed to kill have Data Analyst Pennsylvania Patient Safety Authority become resistant, making these drugs less effective.1 Bacterial resistance to antibiot- ics has become a leading concern for those responsible for protecting public health. ABSTRACT According to the Centers for Disease Control and Prevention, “each year in the United States, at least 2 million people become infected with bacteria that are resistant In Pennsylvania, two distinct statements to antibiotics and at least 23,000 people die as a direct result of these infections.”1 guide the management of health- With a dwindling antibiotic arsenal, healthcare workers must rely on personal protec- care worker exposure to pathogens. tive equipment (PPE), isolation precautions, and environmental controls to protect The Occupational Safety and Health themselves, other staff, patients, and the public from the spread of resistant pathogens. Administration’s bloodborne patho- PPE, isolation precautions, and environmental controls are considered so foundational gen standard provides information to for protection from infectious pathogens that federal and some state agencies have mitigate the risk of healthcare worker developed standards for their use. exposure, while Pennsylvania’s Medical Care Availability and Reduction of The Occupational Safety and Health Administration (OSHA) 29 C.F.R. 1910.1030 Error Act (MCARE) addresses the safety bloodborne pathogen standard states, “Engineering and work practice controls shall of patients and healthcare workers. be used to eliminate or minimize employee exposure. Where occupational exposure MCARE stresses patient screening for remains after institution of these controls, PPE shall also be used.”2 This phrase and multidrug-resistant organisms (MDROs) others within 29 C.F.R. 1910.1030 make it evident that the standard was written to and isolation precautions, including protect workers from contracting bloodborne pathogens from the patients for whom the use of personal protective equip- they care. Last amended in 2012, OSHA’s 29 C.F.R. 1910.1030 standard has been in ment to protect healthcare workers place for more than 20 years. and other patients they encounter Pennsylvania hospitals are required to screen patients for multidrug-resistant organisms from exposure to these organisms. (MDROs), mainly methicillin-resistant Staphylococcus aureus, because of the Medical Herein, the authors examine the Care Availability and Reduction of Error Act (MCARE) – Reduction and Prevention relationship between achievement, of Health Care-Associated Infection and Long-Term Care Nursing Facilities Act of avoidance of failure, and personal July 20, 2007, P.L. 331, No. 52. MCARE also requires hospitals to establish protocols, risk in terms of worker compliance including isolation procedures, based on nationally recognized standards.3 During this with isolation and related procedures. time, in compliance with MCARE, Pennsylvania hospitals have screened and isolated The authors explore situational and patients. In contrast to the OSHA standard, MCARE seeks to establish a culture in isolation precaution awareness, to which engineering controls, work practice controls, and PPE use focus on protecting describe healthcare-worker behavior the healthcare worker and the next patient encountered. in an environment where isolation precautions are indicated. Review of Failure and Personal Risk 2013 and 2014 National Healthcare If healthcare workers are overwhelmed with tasks, production pressure, or other time- Safety Network infection events dem- related workplace stressors, they may knowingly accept personal risk and fail to comply onstrated a decrease in the number of with isolation precautions so they can quickly perform patient care and other tasks. MDRO events during this time period. This may result in imminent (e.g., exposure) or latent failure (e.g., subsequent disease Event narratives, reported through the onset). In terms of MCARE, when healthcare workers accept personal risk by failing Pennsylvania Patient Safety Reporting to comply with proper PPE use, those workers fail not only themselves, but also their System, identified isolation precaution patient and the next patient they care for, by risking personal exposure and transloca- breaches during this period that suggest tion of MDROs and other bacteria or viruses between patients. gaps in knowledge, communication, and administrative engagement. Gaps METHODS identified in the qualitative data were used to develop a conceptual frame- In an attempt to increase knowledge about isolation precaution–related performance work for simulation and other activities failure and risk-taking behavior, Authority analysts queried the Pennsylvania Patient designed to improve facility-wide isola- Safety Reporting System (PA-PSRS) database for events associated with breaches in iso- tion precaution awareness.(Pa Patient lation procedures reported from January 1, 2013, through December 31, 2014. Analysts Saf Advis 2016 Mar;13[1]:24-28.) also queried the National Healthcare Safety Network (NHSN) for the prevalence of Page 24 Pennsylvania Patient Safety Advisory Vol. 13, No. 1—March 2016 ©2016 Pennsylvania Patient Safety Authority MDROs reported from January 1, 2013, Figure 1. Number of Isolation Precautions Breach–Related Events Reported to the through December 31, 2014. Analysts Pennsylvania Patient Safety Authority, January 2013 through December 2014 examined the NHSN data to determine NUMBER OF PA-PSRS REPORTS whether there was any relationship between reported breaches in isolation 60 precautions and the number of MDRO 50 y = 0.1583x + 29.855 49 infections. PA-PSRS event reports include 50 R2 = 0.0188 a narrative section, so the reporter can pro- 40 42 42 40 37 35 vide free-text information that augments 33 34 the event report. The narratives provide a 31 31 29 30 30 28 31 29 30 26 27 clearer description of the reported event. 24 24 Recurrent themes sometimes emerge when 21 20 21 20 these narratives are compared. 10 MS16088 RESULTS Figure 1 shows the number of reports 0 May May Nov Nov Mar Mar Aug Aug Dec Dec Oct Oct Sep Sep Feb Feb Apr Apr Jan Jan Jun Jun Jul Jul related to isolation precaution breaches by month and suggests an increase in 2013 2014 event reporting over time. When analysts MONTH/YEAR reviewed MDRO events in NHSN by pressure room was admitted to a Physician did not gown, glove, or month, a decrease in reported events over standard room. Miscommunication wear a mask to remove a dressing on time was noted (Figure 2). by staff was the contributing factor. an isolated patient. Themes were derived from qualitative anal- Bed reassignment was made within a Patient is on isolation precautions all ysis of the event narratives. PA-PSRS report few hours of admission. staff except CRNA [certified registered narratives regarding isolation precaution Physician at bedside performing proce- nurse anesthetist] followed standard breaches suggest gaps that include knowl- dure; housekeeping arrived on unit to isolation protocol. CRNA was asked edge, communication, and administrative change curtains. Previous patient was to put a gown on and refused. engagement. The following narratives from on contact isolation; curtains were Physician was observed entering the PA-PSRS event reports demonstrate sys- never changed prior to admitting [the isolation room without wearing proper tematic performance gaps and risk-taking next] patient. isolation garb. Physician did not wash behavior among healthcare workers:* The disposable isolation gowns and his hands when entering or exiting the Nurse was in the patient room with- PPE were in low supply. Washable room (touching patient’s colostomy). out gloves and isolation gown. Asked cloth gowns were provided for Anesthesia [provider was] unable to her if she knew that the patient was isolation protection. Due to miscom- find medication or blade needed to in isolation. She stated that yes, but munication, staff utilized the same intubate pt. Anesthesia personnel in she wasn’t touching the patient. gown for patients multiple times. room [wearing] isolation gown and Patient’s family member was seen Patient in isolation for contact. gloves [while] assisting at bedside coming out of an isolation room. Agency staff sitting with patient had came into the hallway without tak- The nurse in the room asked him to no PPE on. ing off gown and gloves or washing step out and put on isolation gown Patient is not in isolation; however, is hands; went into anesthesia bag and gloves. Patient’s family member roomed with a patient on respiratory to retrieve equipment. When told stated, “Why do I have to wear it droplet precautions. patient is in isolation, [provider] when the physician did not?” threw dirty gloves on floor and contin- A patient who required airborne iso- Patient admitted to rule out C-Diff ued to search bag until supplies [were] lation with placement in a negative colitis, patient not placed in proper found. After intubation [unit] staff isolation precautions until 3 days did not observe anesthesia personnel * The details of the PA-PSRS event narratives after admission. washing their hands. in this article have been modified to preserve confidentiality. Vol. 13, No. 1—March 2016 Pennsylvania Patient Safety Advisory Page 25 ©2016 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION Nurse brought the patient to the unit Projection level (3 SA) healthcare workers worker or patient, it is intuitively appeal- and stated patient is isolation. I then understand the immediate situation as ing to implement interventions aimed stated, “Why don’t you have gloves well as the fiscal implications and patient at improving SA, including improving on?” They responded “it [doesn't] and healthcare worker harm that can healthcare workers’ ability to project the matter.” result from spreading MDRO and other delayed consequences of their actions. As organisms in the environment. with SA, isolation-precautions awareness DISCUSSION If the concepts of SA are applied to requires healthcare workers to possess our results, the increased number of cognitive levels that make them truly aware The concept of situational awareness isolation-precautions breach reports in the within a situation or environment. That (SA) may provide a useful framework PA-PSRS database may signal increased is, each level builds upon the previous for interpreting the data from this staff SA related to the importance of isola- level of isolation-precautions awareness. A analysis. Situational awareness has been tion precautions, and perhaps increased healthcare worker cannot achieve isolation- described as involving three levels of intolerance of isolation-precautions precautions awareness without first having understanding:4,5,6 breaches, resulting in improved awareness perception, then comprehension, then pro- — Level 1 SA: Perception. This is the jection; each lower level is a prerequisite of isolation precautions. The decreased fundamental beginning of SA. With- to the next level. Figure 3 is a conceptual number of MDRO event reports in out basic perception and correct model based on our thematic analysis NHSN may signal more appropriate use interpretation of cues, the odds of of PA-PSRS narratives that shows how of PPE and isolation precautions, which forming incorrect perceptions and situational awareness levels translate into may also be related to SA. Limitations of conclusions increases. isolation-precautions awareness levels and this analysis include a lack of information — Level 2 SA: Comprehension. At about concurrent antibiotic stewardship may be used to mitigate gaps in informa- this level, a worker must integrate programs or other efforts to prevent infec- tion, communication, and administrative multiple pieces of information tions or improve the safety culture within engagement, to facilitate organizations’ and determine their relevance to reporting institutions. progress toward infection prevention. the outcome. Administrative engagement. Leaders — Level 3 SA: Projection. The high- Isolation-Precautions Awareness responsible for resource allocation can est level. At level 3, a worker may support environments so healthcare Because the complications that may result forecast future situation events and workers have the necessary resources to from isolation-precautions breaches are dynamics. Essentially, the worker conveniently and efficiently comply with not immediately evident to the healthcare has the highest level of ability to understand the situation and Figure 2. Number of Multidrug-Resistant Organism (MDRO) Infections Reported its implications. to the Pennsylvania Patient Safety Authority through National Healthcare Safety Healthcare workers functioning only at Network, January 2013 through December 2014 the perception level (1 SA) are typically NUMBER OF MDRO REPORTS aware of the OSHA bloodborne patho- gen standard and may comply with it, or 700 y = 2.5817x + 556.19 640 they may take personal risk by choosing R2 = 0.2539 600 585 560 549 542 540 537524 521534530 not to comply. This behavior may result 509 509 498491 509 518 504491523 515 494 492 from production pressure, perceived 500 459 expediency, lack of appreciation of 400 the seriousness of the hazard, or other causes. Healthcare workers functioning 300 at the comprehension level (2 SA) have the ability to process information and 200 comprehend compliance with isolation 100 MS16089 precautions and the potential outcomes. They may conceptually balance the haz- 0 May May Nov Nov Mar Mar Aug Aug Dec Dec Oct Oct Sep Sep Feb Feb Apr Apr Jan Jan Jun Jun ards of non-compliance—to the patient Jul Jul and themselves—with the desire to 2013 2014 accomplish patient care tasks expediently. MONTH/YEAR Page 26 Pennsylvania Patient Safety Advisory Vol. 13, No. 1—March 2016 ©2016 Pennsylvania Patient Safety Authority isolation precautions. Considerations prevent infection. Knowledge pertaining Communication. Communication pathways may include financial planning for day-to- to the appropriate use of isolation pre- could be developed to inform administra- day isolation precautions and screening cautions and related equipment should tion, healthcare workers, and educators activities, disaster preparedness planning, be current and aligned with nationally about clinical successes and failures. human resources management, and recognized standards. Information and Information from performance audits may noncompliant or disruptive behavior education about isolation precautions reinforce high levels of performance or interventions. would be available to all healthcare workers alert both leadership and front-line staff Knowledge. Providing information and (including ancillary personnel) who may about system or individual opportunities education may help healthcare workers be responsible for interacting with patients for improvement. and families understand the importance or environments where there is a threat of and process of isolation precautions to contamination to themselves or others. Figure 3. A Conceptual Framework for Improving Isolation Awareness Perception Comprehension Projection Administrative Engagement Prevention Knowledge Communication n Pro n Co tio sio jec mp jec en tio Pro reh reh n Per tio n en cep mp cep sio Co tio Per n n MS16090 Vol. 13, No. 1—March 2016 Pennsylvania Patient Safety Advisory Page 27 ©2016 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION CONCLUSION Healthcare workers who function in and related activities through in-situ Effective use of isolation precautions is environments where isolation precautions and laboratory-based simulation utiliz- important to protect healthcare work- are necessary may benefit from improved ing the conceptual framework presented ers, the next patient, other staff, and situational awareness, contributing to herein to assure that the facility and staff the public. Analysis of PA-PSRS narra- isolation-precautions awareness, to help are functioning at the highest levels of tive reports indicates that gaps exist in protect themselves, patients, and others isolation-precautions awareness, thereby terms of isolation-precautions awareness. within that environment. Facilities may preventing MDRO infection and the want to assess their isolation precautions spread of other pathogenic organisms. NOTES 1. Centers for Disease Control and Pre- 3. Medical Care Availability and Reduction 5. Wright MC, Taekman JM, Endsley MR. vention. Antibiotic / Antimicrobial of Error (MCARE) Act – Reduction and Objective measures of situational aware- Resistance. [online] [cited 16 Jan 2016]. Prevention of Health Care-associated ness in a simulated medical environment. http://www.cdc.gov/drugresistance/ Infection and Long-term Care Nursing Qual Saf Health Care 2004;13(suppl 1): 2. U.S. Department of Labor. Occupational Facilities Act of July 20, 2007, P.L. 331, i65-i71. Safety and Health Administration. Regu- No.52 (Act 52). [online] [cited 11 Jan 6. Kaber DB, Endsley MR. Team situa- lations (Standards – 29 C.F.R.) 1910.1020. 2015]. http://patientsafetyauthority.org/ tion awareness for process control safety Bloodborne pathogens. [online] [cited 11 PatientSafetyAuthority/Governance/ and performance. Process Safety Progress Jan 2015]. https://www.osha.gov/pls/ Pages/Act52.aspx 1998;17(1):43-48. oshaweb/owadisp.show_document?p_ 4. Endsley MR, Garland DJ, Editors. Situa- table=STANDARDS&p_id=10051 tion Awareness Analysis and Measurement. (Mahwah, NJ, London: Lawrence Erlbaum Associates, 2000, 3-7. Page 28 Pennsylvania Patient Safety Advisory Vol. 13, No. 1—March 2016 ©2016 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 13, No. 1—March 2016. 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