Observing Infection Prevention Adherence in Complex Wound Care

Background: This project is part of a long-term systems redesign initiative to eliminate preventable healthcare associated infections (HAIs) with a university hospital.  The immediate goal is to understand current IP practices on a Burn Trauma Intensive Care Unit (BTICU) where patients are at high risk for healthcare associated infections (HAIs).

Objective:

Develop quantitative, staff-driven infection prevention (IP) IP adherence measurement in the context of redesigning complex wound care processes on a Burn-Trauma service.

Methods:

Direct, open observation of the wound care process was completed by a clinically experienced observer.  Detailed, semi-structured field notes were used to capture the observation length, professional role, and sequence of hand hygiene (HH), personal protective equipment (PPE), and clean technique (CT) actions within the temporal context of patient care activities.  Graphic process maps and qualitative summaries of problems have been used to engage staff in problem solving activities.  A measurement work team has adapted the “5 moments” framework to quantify “IP adherence” to recommended HH, PPE, and CT actions observed in the first procedure.  A list of all recommended actions was linked to care activities, workers, indications, and adherence actions defined as positive (performed) negative (missed) or unknown (not observed).  The adherence rate was computed as follows: N of positive IP actions / (Total recommended actions - N unknown actions).

Results:

A total of 8 procedures, spanning 7.1 cumulative hours and involving 24 health care workers (7 nursing professionals, 4 nursing care technicians, 8 physicians, and 5 therapy professionals) were observed.  Care activities included patient transport to and from a shared procedure room, wound care procedures, and room turnover between procedures.  Problems identified include cramped physical space, missing supplies, non-standard room turnover process, missed hand hygiene and use of PPE.  The IP adherence rate for 35 recommended actions (7 were not observed) in procedure 1 (total 55 minutes) was 0.5 (14 positive actions out of 28 observed).  Hand hygiene adherence was 0.55 (11 positive actions out of 20 observed).  Glove changes without HH and touching shared patient surroundings after body fluid exposure (e.g., privacy curtains or supply cart contents) was a common pattern.

Conclusions: The semi-structured, qualitative data collection technique provides useful information for purposes of implementing redesign activities.  Reviewing the underlying concepts of the adherence rate with staff has raised awareness of the need to connect IP actions with indications.  Analysis of remaining sessions is planned to provide a larger baseline data set, however the observation technique is difficult to generalize.  We plan to continue testing methods to promote generalizable staff-driven adherence measurement.