Leadership rounds to reduce health care-associated infections

Levofloxacin prophylaxis for pediatric leukemia patients: Longitudinal follow-up for impact on health care-associated infections

BACKGROUND

Bloodstream infections (BSIs) cause morbidity and mortality in pediatric patients with leukemia. Antibiotic prophylaxis during periods of chemotherapy-induced neutropenia may reduce the incidence of BSIs.

PROCEDURE

A levofloxacin prophylaxis guideline was implemented for pediatric patients with acute myeloid leukemia and relapsed acute lymphoblastic leukemia. We conducted a retrospective cohort study over 4 years (2 years pre and 2 years post implementation) of the practice guideline to assess the impact on central line-associated bloodstream infections (CLABSI) and BSI events. Secondary outcomes included incidence of Clostridioides difficile-associated diarrhea, bacteremia due to multidrug-resistant organisms (MDRO), and bacteremia due to levofloxacin nonsusceptible organisms. STATA was used for data analysis.

RESULTS

Sixty-three and 72 patients met inclusion criteria for the pre- and postimplementation cohorts, respectively. Demographics were similar between the groups. We observed 60 BSI events in the pre-group versus 49 events in the post-group (p = .1). Bacteremia due to Gram-negative rods (risk ratio [RR] 0.37 [0.21, 0.66], p < .001) and National Healthcare Safety Network (NHSN) CLABSIs (RR 0.62 [0.44, 0.89], p = .01) were significantly reduced in the postimplementation group. The incidences of C. difficile-associated diarrhea and MDRO bacteremia were similar between groups. However, we observed an increase in the incidence of BSI due to Gram-negative rods that were nonsusceptible to levofloxacin (RR 3.38 [0.72, 6.65], p < .001).

CONCLUSION

Following implementation of a levofloxacin prophylaxis guideline, we observed a significant decrease in BSIs due to Gram-negative rods and NHSN CLABSIs. Vigilant monitoring of outcomes post guideline implementation is critical to track emergence of resistant organisms.

Integrating antibiotic stewardship and infection prevention and control programs using a team science approach

Reduction of health care-associated infections is trending in the right direction after decades of work by those involved in infection prevention and control and antibiotic stewardship. With institutional priorities currently pivoting to meet the needs of COVID-19 patients, this may be an advantageous time to promote integration of facility-level antibiotic stewardship and infection prevention and control programs. We propose a team science framework as a tool to leverage the complementary expertise of stewardship and infection prevention and control professionals. This framework considers stages of team development and fluidity needed when working with shifting priorities and can be used by leaders and team members throughout all phases of team building—from developing and launching the team, through evaluating and modifying team activities to best suit local needs.

Management practices for leaders to promote infection prevention: Lessons from a qualitative study

BACKGROUND

Prevention of healthcare-associated infections (HAIs) is critical to reduce preventable deaths and healthcare costs. Variable success with HAI prevention efforts has suggested that management practices are critical to support clinical infection prevention practices. This study examined hospital leaders' management practices around the prevention of catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs) to identify actions that leaders can take to promote HAI prevention efforts.

METHODS

We conducted interviews with 420 key informants, including managers and frontline staff, in 18 hospitals across the United States. Interviewees were asked about management practices supporting HAI prevention. We analyzed interview transcripts using rigorous qualitative methods to understand how management practices were operationalized in infection prevention efforts.

RESULTS

Across hospitals and interviewees, three management practices were characterized as important facilitators of HAI prevention: (1) engagement of executive leadership; (2) information sharing; and (3) manager coaching. We found that visible executive leadership, efficient communication, and frequent opportunities to provide and promote learning from feedback were perceived to promote and sustain HAI prevention efforts.

CONCLUSIONS

Our findings provide insight into management practices for leaders that support successful HAI prevention. In practice, these tactics may need to be adjusted to accommodate the current restrictions caused by the COVID-19 pandemic, in order to maintain HAI prevention efforts as a priority.

Scope of a weekly infection control team rounding in an acute-care teaching hospital: a pilot study

Regular and well-organized inspection of infection control is an essential element of an infection control program. The aim of this study was to identify the functional scope of weekly infection control team rounding (ICTR) in an acute care hospital. We conducted weekly ICTR between January 18 and December 26, 2018 to improve the compliance to infection control and prevention measures at a 734-bed academic hospital in the Republic of Korea and analyzed the results retrospectively. We categorized the results into five groups: “well maintained,” “improvement needed,” “long-term support, such as space or manpower, needed,” “not applicable,” or “could not be observed”. A total of nine categories and 85 sub-elements of infection control and prevention practices were evaluated. The median number of infection control team (ICT) visits per department was 7 (interquartile range [IQR]: 6–7). The ICT assessed a median of 16 elements (IQR: 12–22), and a total of 7452 results were obtained. Of those, 75% were monitored properly, 22% were “not applicable”, and 4% were difficult to observe. The most common practices that were difficult to observe were strategies to prevent catheter-related surgical site infections, pneumonia, and occupationally acquired infections as well as injection safety practices. Although the ICTR was able to maintain regular visits to each department, further strategies beyond regular ICTR are needed to reduce category of “could not observed”. This pilot study may provide an important reference for institutional infection prevention practices as it is the first study to investigate the functional coverage of ICTR.

Exploring leadership within a systems approach to reduce health care-associated infections: A scoping review of one work system model

BACKGROUND

Despite efforts to prevent health care-associated infections (HAIs), these infections continue to challenge health care systems. The Centers for Disease Control and Prevention emphasizes implementation of evidence-based practices. Within the complex health care environment, sustained implementation calls for work systems that harness expertise of interprofessional teams, which, in turn, calls for suitable executive, mid-level, and local leadership. The purpose of this review is to highlight the need to study leadership when using a systems approach to reduce HAIs.

METHODS

This is a scoping review of HAI studies that used a systems engineering model called the Systems Engineering Initiative for Patient Safety model. We examined if and how leadership was addressed within 1 systems approach.

RESULTS

We found 15 studies using the Systems Engineering Initiative for Patient Safety model and, of these, leadership was directly mentioned in 3 studies. In the remaining studies, reference to leadership may be inferred by use of terms such as teamwork, managerial oversight, climate and culture, staffing support, and institutional/administrative support.

CONCLUSIONS

Research is needed to bring recognition of the role of leadership within a work systems approach to reducing HAIs. We need further examination of leadership attributes and communication behaviors that allow staff to diffuse and sustain best practices to prevent HAIs.

Kamishibai cards to sustain evidence-based practices to reduce healthcare-associated infections

BACKGROUND

Sustaining healthcare-associated infection (HAI) prevention practices is complex. We examined the use of Kamishibai Cards (K Cards) as a tool to encourage compliance interactions between leaders and staff.

METHODS

We explored one unit of a children's hospital to assess acceptability of K Cards. Interactions were recorded (n = 14), and interviews were conducted (n = 22). We used the Health Belief Model (HBM) for analyses. Central line utilization, bundle compliance and rates of HAIs were also examined.

RESULTS

Staff members consider K Card interactions reminders of bundle elements and acceptable for creating positive interactions. Although no causal inference can be made, during K Card implementation, CLABSI rates dropped from 1.83 in 2015 to 0.0 through June 2018. Central line utilization decreased by 3%.

DISCUSSION

Moving beyond theory to providing practical sustainability tools is an important implementation step. Although our findings are not generalizable, capturing what occurred on one unit provides opportunity to discover how key leadership factors (communication and leadership style) influence the uptake, acceptability and sustained adoption of evidence-based practices.

CONCLUSIONS

K Cards are a practical tool to sustain evidence-based practices and promote communication between leadership and staff - keeping compliance on the minds of frontline workers.

Reducing Infections "Together": A Review of Socioadaptive Approaches

Reducing healthcare-associated infections often requires the use of both technical and adaptive strategies. The experiences of Semmelweis and Nightingale teach us the importance of social adaptation of technical interventions. Because most infection prevention interventions require widespread participation by healthcare personnel, it is helpful for infectious diseases physicians to learn principles of diffusion of innovations theory and apply them to influence different groups. Comprehensive unit-based program has been successful in reducing device-associated infections. Positive deviance as a socioadaptive approach may be promising. These and other approaches such as social network analysis, relational coordination, link nurses, and stop the line policies need to be further evaluated in future studies. Future research on socioadaptive interventions needs to focus on developing tools and strategies for diagnosing local context and study how these interventions might influence culture of safety. Strategies to sustain momentum of improvement efforts in different healthcare settings need to be refined and further developed through additional research.

Interventions to decrease short-term peripheral venous catheter-related bloodstream infections: impact on incidence and mortality

BACKGROUND

Short-term peripheral venous catheters are a significant source of healthcare-acquired bloodstream infections and a preventable cause of death.

AIM

To assess the effectiveness of interventions applied to reduce the incidence and mortality associated with short-term peripheral venous catheter-related bloodstream infections (PVCR-BSIs).

METHODS

The intervention included continuous PVCR-BSI surveillance, implementation of preventive measures related to catheter insertion and maintenance in accordance with evidence-based recommendations and the hospital's own data, front-line staff educational campaigns, and assessment of adherence to hospital guidelines by ward rounds. A Poisson regression model was used to estimate the trend of rate per year.

FINDINGS

From January 2003 to December 2016, 227 episodes of PVCR-BSI were identified among hospitalized patients at a university hospital. The mean age of patients was 67 years (standard deviation 14 years), 69% were male and the median Charlson score was 3 (interquartile range 2-5). Staphylococcus aureus caused 115 (50.7%) episodes. Thirty-day mortality was 13.2%. After implementation of the intervention, the incidence of PVCR-BSIs decreased significantly from 30 episodes in 2003 (1.17 episodes/10,000 patient-days) to eight episodes in 2016 (0.36/10,000 patient-days). The number of episodes caused by S. aureus decreased from 18 episodes in 2003 (0.70/10,000 patient-days) to three episodes in 2016 (0.14/10,000 patient-day), and mortality decreased from seven cases in 2003 (0.27/10,000 patient-days) to zero cases in 2016 (0.00/10,000 patient-days).

CONCLUSIONS

Surveillance, implementation of a multi-modal strategy and periodical assessment of healthcare workers' adherence to hospital guidelines led to a sustained reduction in PVCR-BSIs. This reduction had a major impact on S. aureus BSI rates and associated mortality.

Building a safety culture in global health: lessons from Guatemala

Programmes to modify the safety culture have led to lasting improvements in patient safety and quality of care in high-income settings around the world, although their use in low-income and middle-income countries (LMICs) has been limited. This analysis explores (1) how to measure the safety culture using a health culture survey in an LMIC and (2) how to use survey data to develop targeted safety initiatives using a paediatric nephrology unit in Guatemala as a field test case. We used the Safety, Communication, Operational Reliability, and Engagement survey to assess staff views towards 13 health climate and engagement domains. Domains with low scores included personal burnout, local leadership, teamwork and work–life balance. We held a series of debriefings to implement interventions targeted towards areas of need as defined by the survey. Programmes included the use of morning briefings, expansion of staff break resources and use of teamwork tools. Implementation challenges included the need for education of leadership, limited resources and hierarchical work relationships. This report can serve as an operational guide for providers in LMICs for use of a health culture survey to promote a strong safety culture and to guide their quality improvement and safety programmes.