Human Factors Contributing to Infection Prevention in Outpatient Hemodialysis Centers: A Mixed Methods Study

RATIONALE & OBJECTIVE

Infection prevention efforts in dialysis centers can avert patient morbidity and mortality but are challenging to implement. The objective of this study was to better understand how the design of the work system might contribute to infection prevention in outpatient dialysis centers.

STUDY DESIGN

Mixed methods, observational study.

SETTING & PARTICIPANTS

Six dialysis facilities across the United States visited by a multidisciplinary team over 8 months.

ANALYTICAL APPROACH

At each facility, structured macroergonomic observations were undertaken by a multidisciplinary team using the SEIPS 1.0 model. Ethnographic observations were collected about staff encounters with dialysis patients including the content of staff conversations. Selective and axial coding were used for qualitative analysis and quantitative data were reported using descriptive statistics.

RESULTS

Organizational and sociotechnical barriers and facilitators to infection prevention in the outpatient dialysis setting were identified. Features related to human performance, (eg, alarms, interruptions, and task stacking), work system design (eg, physical space, scheduling, leadership, and culture), and extrinsic factors (eg, patient-related characteristics) were identified.

LIMITATIONS

This was an exploratory evaluation with a small sample size.

CONCLUSIONS

This study used a systematic macroergonomic approach in multiple outpatient dialysis facilities to identify infection prevention barriers and facilitators related to human performance. Several features common across facilities were identified that may influence infection prevention in outpatient care and warrant further exploration.

The within-day relation between lonely episodes and subsequent clinical pain in individuals with fibromyalgia: Mediating role of pain cognitions

OBJECTIVE

This daily diary study of individuals with fibromyalgia (FM) examined whether morning increases in loneliness relate to worsened evening bodily pain through afternoon negative pain cognitions.

METHODS

220 participants with FM completed electronic diaries 4 times a day for 21days to assess loneliness, negative pain cognitions, bodily pain, and social enjoyment. Multilevel structural equation modeling was used to examine within-person relations of morning increases in loneliness, afternoon negative pain cognitions, and evening pain, controlling for morning pain.

RESULTS

On mornings when individuals experienced higher than their usual levels of loneliness, they experienced higher levels of afternoon maladaptive pain cognitions, which in turn predicted increases in evening pain above the level of morning pain. Afternoon maladaptive pain cognitions fully mediated the relations between morning loneliness and evening pain.

CONCLUSIONS

Lonely episodes are associated with subsequent increases in negative patterns of thinking about pain, which in turn predict subsequent increases in bodily pain within a day. Because pain cognitions mediate the loneliness-pain link, FM interventions may benefit from addressing individuals' vulnerability to maladaptive cognitions following lonely episodes.

Mindfulness and cognitive-behavioral interventions for chronic pain: differential effects on daily pain reactivity and stress reactivity

OBJECTIVE

This study compared the impact of cognitive-behavioral therapy for pain (CBT-P), mindful awareness and acceptance treatment (M), and arthritis education (E) on day-to-day pain- and stress-related changes in cognitions, symptoms, and affect among adults with rheumatoid arthritis (RA).

METHOD

One hundred forty-three RA patients were randomized to 1 of the 3 treatment conditions. CBT-P targeted pain-coping skills; M targeted awareness and acceptance of current experience to enhance coping with a range of aversive experiences; E provided information regarding RA pain and its management. At pre- and posttreatment, participants completed 30 consecutive evening diaries assessing that day's pain, fatigue, pain-related catastrophizing and perceived control, morning disability, and serene and anxious affects.

RESULTS

Multilevel models compared groups in the magnitude of within-person change in daily pain and stress reactivity from pre- to posttreatment. M yielded greater reductions than did CBT-P and E in daily pain-related catastrophizing, morning disability, and fatigue and greater reductions in daily stress-related anxious affect. CBT-P yielded less pronounced declines in daily pain-related perceived control than did M and E.

CONCLUSIONS

For individuals with RA, M produces the broadest improvements in daily pain and stress reactivity relative to CBT-P and E. These findings also highlight the utility of a diary-based approach to evaluating the treatment-related changes in responses to daily life.

Describing nurses' work: combining quantitative and qualitative analysis

OBJECTIVE

To better understand nursing activities and working conditions.

BACKGROUND

Nursing practice involves astute clinical decision making and the competent delivery of nursing care procedures. To complete nursing procedures, nurses must simultaneously organize and reorganize priorities and manage changing clinical information for multiple patients. Few researchers have examined the specific nature of nurses' activities and the effect of the environment on their work.

METHODS

Quantitative and qualitative methods were used to collect data on 7 nurses engaged in nursing activities. Examples of methods include link analysis, subject matter expert, task analysis, cognitive pathway, and "stacking." Data collection focused on how nurses managed priorities, changing clinical information, and interruptions.

RESULTS

The "cognitive pathway" graphically depicts the nature of nurses' work. Specifically, it reveals the shifting of the nurse's attention from patient to patient and the occurrence of interruptions. "Stacking" shows the number of tasks a nurse must balance at any one time. On average, nurses had 10 or more activities waiting to be performed and experienced 3.4 interruptions/hr.

CONCLUSION

These methods provide unique insight into the dynamic nature of patient care and nursing work.

APPLICATION

Extension of the methods demonstrated here may be useful in guiding efforts to change the work of nursing to better provide quality care and less stressful work environments.

Effects of a participatory ergonomics team among hospital orderlies

BACKGROUND

High rates of work-related injuries are seen among health care workers involved in lifting and transferring patients. We studied the effects of a participatory worker-management ergonomics team among hospital orderlies.

METHODS

This prospective intervention trial examined work injuries and other outcomes before and after the intervention, with other hospital employees used as a concurrent control. All orderlies in a 1,200-bed urban hospital were studied using passively collected data (mean employment during study period 100-110 orderlies); 67 orderlies (preintervention) and 88 orderlies (postintervention) also completed a questionnaire. The intervention was the formation of a participatory ergonomics team with three orderlies, one supervisor, and technical advisors. This team designed and implemented changes in training and work practices.

RESULTS

The 2-year postintervention period was marked by decreased risks of work injury (RR = 0.50, 95% CI 0.35-0.72), lost time injury (RR = 0.26, 95% CI 0.14-0.48), and injury with three or more days of time loss (RR = 0.19, 95% CI 0.07-0.53). Total lost days declined from 136.2 to 23.0 annually per 100 full-time worker equivalents (FTE). Annual workers' compensation costs declined from $237/FTE to $139/FTE. The proportion of workers with musculoskeletal symptoms declined and there were statistically significant improvements in job satisfaction, perceived psychosocial stressors, and social support among the orderlies.

CONCLUSION

Substantial improvements in health and safety were seen following implementation of a participatory ergonomics program.

Implementing participatory ergonomics teams among health care workers

Three participatory ergonomics teams have been established among healthcare workers in a metropolitan medical center. Three teams, consisting of orderlies, intensive care unit nurses, and laboratory workers, were selected to provide a diversity of work activities and educational backgrounds. The effectiveness of these teams was assessed by observations of team interactions, by team members' perceptions of their effectiveness, and by the teams' success in identifying problems and implementing solutions. After 1 year, one of the three groups has been highly effective by these measures. To varying degrees, the groups encountered competing time demands and obstacles in implementing solutions within current administrative structures. For some groups of health care workers, participatory ergonomics teams seem to be an effective strategy to improve health and safety. This approach may not be feasible in all areas of health care, especially in high-demand clinical areas where patient needs may take precedence over the safety of health care workers.

Relationships among grip strength, work capacity, and recovery

The relationship between strength, fatigue, and work capacity is a central issue for occupational rehabilitation. Musculoskeletal impairments often are expressed functionally as a loss of strength. For work tasks that require strength, such impairments may have a detrimental effect on work capacity that is sufficient to be disabling. How important is strength as a component of work capacity? How do work capacity and strength affect recovery time from repetitive forceful upper extremity work ? A sample of 40 healthy subjects comprised of 20 males and 20 females was studied in a model that used the isotonic strength of each subject to set exercise levels for subsequent forceful repetitive gripping tasks. Resistance levels of 75%, 50%, and 25% of maximum were used for one-per-second repetitions until the subject could not maintain that pace. Isometric grip strength was measured after 1 minute of rest and after 5, 10, and 20 minutes. Results indicate that males and females do not differ in terms of their rate of recovery and that the best predictor of recovery time is the immediate measurement of strength loss following cessation of work activity.

Pulmonary embolism in total joint arthroplasty

With a greater understanding of the prevention of thromboembolic complications, the incidence of fatal pulmonary embolism after total joint arthroplasty has declined. Although much of our knowledge is centered around deep vein thrombosis and its use as a marker for thromboembolic complications, little is known about the natural history of both symptomatic and asymptomatic pulmonary embolism. Although differing methods of prophylaxis have shown some success, the ideal agent has yet to be discovered. The use of serial lung scanning has shown great use in the diagnosis of pulmonary embolism. Additional studies using effective diagnostic tools are needed to evaluate the risk of recurrent embolism. Only then can the duration of treatment and prophylaxis be determined. Despite the many unanswered questions, the following conclusions can be drawn: (1) fatal pulmonary emboli are a preventable complication of total joint arthroplasty; (2) fatal emboli are often preceded by small and frequently asymptomatic emboli; (3) detection and appropriate therapeutic measures for asymptomatic emboli are possible with the use of serial lung scans and judicious use of pulmonary angiography; and (4) low-dose coumadin has proven to be the most effective agent in lowering the risk of asymptomatic, symptomatic, and fatal pulmonary emboli.

The intensity of auditory warning tones in the automobile environment: detection and preference evaluations

A variety of auditory warning tones was evaluated to determine generally appropriate intensity levels for presentation in the automobile environment. Twenty-four subjects listened to tones presented at several intensity levels under three background noise conditions recorded in actual vehicles: relatively quiet (35 mile/h (56 km/h), smooth road), relatively loud (55 mile/h (89 km/h), rough road), and radio (35 mile/h (56 km/h), smooth road, and radio broadcast). Data were gathered on the minimum intensity level (in decibels (dB) above the masked threshold (MT) required to achieve a consistent criterion detection rate, as well as the preferred tone intensity level (in dB above the MT) in each background noise condition. The preferred levels were louder than those required to achieve the detection criterion in both the relatively loud and quiet background noise conditions; thus, the preferred levels are the recommended levels under those conditions. This was not the case in the radio condition; therefore, it is recommended that future research efforts evaluate the effects of automatically muting the radio/stereo system when important auditory warning tones are being presented.