Kendall K. Hall

Incidence and types of non-ideal care events in an emergency department

Aim To identify and characterise hazardous conditions in an Emergency Department (ED) using active surveillance. Methods This study was conducted in an urban, academic, tertiary care medical centre ED with over 45 000 annual adult visits. Trained research assistants interviewed care givers at the discharge of a systematically sampled group of patient visits across all shifts and days of the week. Care givers were asked to describe any part of the patients care that they considered to be ‘not ideal.’ Reports were categorised by the segment of emergency care in which the event occurred and by a broad event category and specific event type. The occurrence of harm was also determined. Results Surveillance was conducted for 656 h with 487 visits sampled, representing 15% of total visits. A total of 1180 care giver interviews were completed (29 declines), generating 210 non-duplicative event reports for 153 visits. Thirty-two per cent of the visits had at least one non-ideal care event. Segments of care with the highest percentage of events were: Diagnostic Testing (29%), Disposition (21%), Evaluation (18%) and Treatment (14%). Process-related delays were the most frequently reported events within the categories of medication delivery (53%), laboratory testing (88%) and radiology testing (79%). Fourteen (7%) of the reported events were associated with patient harm. Conclusions A significant number of non-ideal care events occurred during ED visits and involved failures in medication delivery, radiology testing and laboratory testing processes, and resulted in delays and patient harm.

Evidence-Based Design of Healthcare Facilities: Opportunities for Research and Practice in Infection Prevention

Affiliations: 1. SimTigrate Design Lab, School of Architecture, Georgia Institute of Technology, Atlanta, Georgia; 2. Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; 3. Health Systems Institute, Georgia Institute of Technology, Atlanta, Georgia; 4. School of Industrial Design, Georgia Institute of Technology, Atlanta, Georgia; 5. Agency for Healthcare Research and Quality, Rockville, Maryland; 6. RTI International, Washington, DC. Received October 2, 2012; accepted November 21, 2012; electronically published April 9, 2013. 2013 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2013/3405-0011

The Role of Facility Design in Preventing the Transmission of Healthcare-Associated Infections: Background and Conceptual Framework

15.00. DOI: 10.1086/670220 Evidence-based design (EBD) of healthcare facilities is an emerging field that has the potential to significantly reduce the burden of healthcare-associated infections (HAIs). There is a growing body of evidence demonstrating that the built environment of healthcare settings—their layout, materials, equipment, and furnishings—plays a key role in facilitating or preventing transmission of pathogens. The infection prevention community can be an important partner in further developing this evidence base by advocating for and including healthcare facility design in its research agenda. At the same time, the EBD of the built environment has the promise of providing an additional set of tools for infection prevention. A relatively new discipline, EBD has deep roots in environmental psychology, architecture, medicine, and other sciences. It postulates that the design of the built environment fundamentally impacts patient, provider, and organizational outcomes (ie, decreased infection rates, length of stay, falls, use of analgesics, and operating costs) while improving patient and caregiver experience and satisfaction. Similar to evidence-based medicine, EBD uses the best available evidence to inform decision making and includes measurement of outcomes. EBD of healthcare facilities gained prominence in the early 2000s with the publication of the Institute of Medicine’s report Crossing the Quality Chasm, a growing research evidence base, and the initiation of the largest hospital construction program in US history. After a decade of closing hospitals, the US began spending more than

Using Antibiograms to Improve Antibiotic Prescribing in Skilled Nursing Facilities

40 billion annually on new healthcare facilities to accommodate shifting demographics, advancing technologies, and competitive pressures. EBD is a multistep process that includes (1) framing of goals and models, (2) incorporation of healthcare facility guidelines, (3) planning and design, and (4) operations (Figure 1). These are in turn affected by the economic and professional culture in which decisions are made: the evidence base, the greater visibility and pay for performance that comes from the “quality revolution,” best practices or examples, and shrinking reimbursement margins in a competitive environment. Infection prevention plays a key role at each step, as follows. Framing. Specific decisions about guidelines, planning and design, and operations are framed by stakeholders’ understanding of the goals of healthcare design and the models that drive it. Owners, clinicians, patients, regulators, and designers develop a view of “good” healthcare settings: what they should achieve and how to do so. Early models included envisioning hospitals as churches or, more recently, as pristine, white, modern laboratories. In the 2000s, a series of literature reviews highlighted that design and the built environment could improve patient safety, decrease pain, and increase satisfaction. These reviews and the growing focus on patientand family-centered care helped create demand for larger, light-filled, quieter healthcare facilities that provided comfort and positive distractions for patients and families, such as designated family areas in patient rooms, gardens, and water features. Families were provided increased access to patient rooms, including within intensive care units, where there had previously been strict visiting hours. Healthcare workers were provided spaces that better suited their tasks and afforded respite when on break. Several prominent articles emerged suggesting that the return on investment for these design features was achieved in as little as 1–3 years, based on designs that increased market share and decreased length of stay, due in part to decreased infections, reduced falls, and reduced analgesic use. Guidelines. Evidence and expectations are translated to design in part through the process of writing guidelines and standards. These guidelines, such as those promulgated by the Facilities Guidelines Institute (FGI), are often written by volunteer committees of professionals and offer guidance or are adopted as codes in the majority of the states. The Hospital Infection Control Practices Advisory Committee’s

The Role of Facility Design in Preventing Healthcare-Associated Infection: Interventions, Conclusions, and Research Needs

OBJECTIVE: To describe the conceptual framework and methodology used to conduct a comprehensive literature review of current evidence evaluating the role of the built environment in the transmission of healthcare-associated infections. BACKGROUND: A multidisciplinary approach to evaluating a vast and diverse dataset requires a conceptual framework to create a common understanding for interpretation. This common understanding is accomplished through the application of a “chain of transmission” model depicting temporal and physical paths of pathogens that cause healthcare-associated infections. The chain of transmission interventions model argues that infection can potentially be reduced by interrupting any of several links in the chain. TOPICAL HEADINGS: The key pathogens impacted by the built environment are identified. The chain of transmission and the conceptual framework are described. Opportunities for intervention through the built environment are presented, which in turn guide the subsequent methodology used to conduct the systematic literature review. CONCLUSIONS: The chain of transmission interventions model is a multidisciplinary conceptualization of the interaction between pathogens and the built environment, and this model facilitated a systematic literature review of a very large amount of data.

Expert Opinions on the Role of Facility Design in the Acquisition and Prevention of Healthcare-Associated Infections

BACKGROUND Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown. OBJECTIVE To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing. DESIGN AND SETTING Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs. METHODS Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities. RESULTS We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant ([Formula: see text]). CONCLUSIONS Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs.

The Role of the Hospital Environment in the Prevention of Healthcare-Associated Infections by Contact Transmission

OBJECTIVE: To summarize the findings and provide recommendations based on the multidisciplinary literature review and industry scan, focusing on the links between the built environment and healthcare-associated infections. To propose a research agenda in order to increase informed design decisions and advance the evidence base. BACKGROUND: The HAI-Design project explores the research linking a range of design interventions to healthcare-associated infection. The multidisciplinary team evaluated over 3,800 articles and conducted interviews with a range of stakeholders including CEOs, architects, designers, physicians and other healthcare experts, the results of which are featured in this special Supplement as topical papers. TOPICAL HEADINGS: The four topical papers describing the role of the built environment in the acquisition of healthcare-associated infections are summarized. The evidence evaluating the strategies for intervention through the built environment is analyzed, and a research agenda is proposed. CONCLUSIONS: While the evidence base supporting the efficacy of strategies and technologies continues to grow, there are currently few data that demonstrate a reduction in infection rates. The need for multidisciplinary collaboration and increased efforts to standardize the evaluation of environmental studies are essential to overcome the many challenges and improve the reliability of data

Variation in Infection Prevention Practices in Dialysis Facilities: Results from the National Opportunity to Improve Infection Control in ESRD (End-Stage Renal Disease) Project

OBJECTIVE: To assess expert knowledge, perceptions, and experience on the role of the built environment in the acquisition and transmission of healthcare-associated infections (HAIs), facility design decision-making considerations, and strategies for intervention through facility design and technologies. BACKGROUND: Healthcare-associated infections pose a serious and costly threat to public health in the United States. A growing evidence base suggests that the built environment can play a role in interrupting the chain of infection. METHODS: Semi-structured individual interviews and triads were conducted with 26 experts in hospital administration, architecture, interior design, infection control, and air and water quality. A grounded theory approach was used for interview coding and interpretation. RESULTS: Participants characterized the shift in thinking about the relationship between the built environment and HAI transmission as a “progression,” as accountability for infection prevention has expanded beyond clinicians. Organizational leaders aim to make informed design decisions, but this can be challenging due to the paucity of efficacy and return on investment data. Emerging interventions include copper impregnated materials, seamless flooring, and chilled beams. CONCLUSIONS: No single intervention is entirely effective in mitigating HAI risk; multiple interventions are needed. In addition to the built environment, human behavior must be considered, as noncompliance can render even the best designs ineffective. Increased multidisciplinary collaboration is needed to improve the application of evidence and experience in healthcare facility design. In the absence of conclusive evidence regarding interventions aimed at reducing HAI transmission, a combination of research data and practical experience should be used to inform design decisions.

Understanding the Role of Facility Design in the Acquisition and Prevention of Healthcare-Associated Infections:

OBJECTIVE: This article describes the role of the hospital environment in the spread of pathogens by direct and indirect contact. In addition, the prevention of transmission through interventions involving the built environment is discussed. BACKGROUND: The hospital environment can become contaminated with pathogenic microorganisms, some of which can persist for long periods of time. Although contamination is common, the contribution of the hospital environment to the development of healthcare-associated infections remains unclear. In part spurred by the development of newer technologies to enhance environmental cleaning or to prevent contamination, research into the role of the environment in causing healthcare-associated infections has accelerated. TOPICAL HEADINGS: A review of the recent literature finds an increasing body of evidence implicating contaminated surfaces in patient care areas in the transmission of pathogens and the development of infections. Single-patient rooms and optimally placed alcohol hand rub dispensers and other design features can mitigate infection risk. Enhanced environmental cleaning including touchless technologies and self-cleaning surfaces can reduce environmental contamination and may prevent infections. CONCLUSIONS: The hospital environment contributes to transmission of pathogens in hospitals and to the development of healthcare-associated infections. Newer technologies to prevent environmental contamination or to enhance cleaning are promising although additional studies with the endpoints of reduction of infections are needed before the role of these technologies is known.

Universal Glove and Gown Use and Acquisition of Antibiotic-Resistant Bacteria in the ICU: A Randomized Trial

OBJECTIVE To observe patient care across hemodialysis facilities enrolled in the National Opportunity to Improve Infection Control in ESRD (end-stage renal disease) (NOTICE) project in order to evaluate adherence to evidence-based practices aimed at prevention of infection. SETTING AND PARTICIPANTS Thirty-four hemodialysis facilities were randomly selected from among 772 facilities in 4 end-stage renal disease participating networks. Facility selection was stratified on dialysis organization affiliation, size, socioeconomic status, and urban/rural status. MEASUREMENTS Trained infection control evaluators used an infection control worksheet to observe 73 distinct infection control practices at the hemodialysis facilities, from October 1, 2011, through January 31, 2012. RESULTS There was considerable variation in infection control practices across enrolled facilities. Overall adherence to recommended practices was 68% (range, 45%-92%) across all facilities. Overall adherence to expected hand hygiene practice was 72% (range, 10%-100%). Compliance to hand hygiene before and after procedures was high; however, during procedures hand hygiene compliance averaged 58%. Use of chlorhexidine as the specific agent for exit site care was 19% overall but varied from 0% to 35% by facility type. The 8 checklists varied in the frequency of perfect performance from 0% for meeting every item on the checklist for disinfection practices to 22% on the arteriovenous access practices at initiation. CONCLUSIONS Our findings suggest that there are many areas for improvement in hand hygiene and other infection prevention practices in end-stage renal disease. These NOTICE project findings will help inform the development of a larger quality improvement initiative at dialysis facilities.