Maureen Fitzpatrick

Patient safety begins with proper planning: a quantitative method to improve hospital design

Background A quantitative methodology that enhances design of patient-safe healthcare facilities is presented. The prevailing paradigm of evaluating the design of healthcare facilities relies mainly on postconstruction criticism of design flaws; by then, design flaws may have already negatively affected patient safety. The methodology presented here utilises simulation-based testing in real-size replicas of proposed hospital designs. Other simulations to assess design solutions generated mainly qualitative data about user experience. To assess the methodology, we evaluated one patient safety variable in a proposed hospital patient room. Method Fifty-two physicians who volunteered to participate were randomly assigned to examine a standardised patient in two hospital room settings using a replica of the proposed architectural plan; the two settings differed only by the placement of the alcohol-based hand-rub dispenser. The primary outcome was the hand hygiene compliance rate. Results When the dispenser was in clear view of the physicians as they observed the patient, 53.8% sanitised their hands. When the dispenser was not in their field of view (as in the original architectural plan), 11.5% sanitised their hands (p=0.0011). Based on these results, the final architectural plans were adjusted accordingly. Conclusion The methodology is an effective and relatively inexpensive means to quantitatively evaluate proposed solutions, which can then be implemented to build patient-safe healthcare facilities. It enables actual users to proactively identify patient safety hazards before construction begins.

Double Gloves: A Randomized Trial to Evaluate a Simple Strategy to Reduce Contamination in the Operating Room

BACKGROUND:Oral flora, blood-borne pathogens, and bacterial contamination pose a direct risk of infection to patients and health care workers. We conducted a study in a simulated operating room using a newly validated technology to determine whether the use of 2 sets of gloves, with the outer set removed immediately after endotracheal intubation, may reduce this risk. METHODS:Forty-one anesthesiology residents (PGY 2–4) were enrolled in a study consisting of individual or group simulation sessions. On entry to the simulated operating room, the residents were asked to perform an anesthetic induction and tracheal intubation timed to approximately 6 minutes; they were unaware of the study design. Of the 22 simulation sessions, 11 were conducted with the intubating resident wearing single gloves, and 11 with the intubating resident using double gloves with the outer pair removed after verified intubation. Before the start of the scenario, we coated the lips and inside of the mouth of the mannequin with a fluorescent marking gel as a surrogate pathogen. After the simulation, an observer examined 40 different sites using a handheld ultraviolet light in the operating room to determine the transfer of surrogate pathogens to the patient and the patient’s environment. Residents who wore double gloves were instructed by a confederate nurse to remove the outer set immediately after completion of the intubation. Forty sites of potential intraoperative pathogen spread were identified and assigned a score. RESULTS:The difference in the rate of contamination between anesthesiology residents who wore single gloves versus those with double gloves was clinically and statistically significant. The number of sites that were contaminated in the operating room when the intubating resident wore single gloves was 20.3 ± 1.4 (mean ± SE); the number of contaminated sites when residents wore double gloves was 5.0 ± 0.7 (P < 0.001). CONCLUSIONS:The results of this study suggest that when an anesthesiologist wears 2 sets of gloves during laryngoscopy and intubation and then removes the outer set immediately after intubation, the contamination of the intraoperative environment is dramatically reduced.

Do hospital visitors wash their hands? Assessing the use of alcohol-based hand sanitizer in a hospital lobby

BACKGROUND Reports regarding hand hygiene compliance (HHC) among hospital visitors are limited. Although there is an implicit assumption that the availability of alcohol-based hand sanitizer (AHS) promotes visitor HHC, the degree of AHS use by visitors remains unclear. To assess AHS use, we observed visitor HHC and how it is affected by visual cues in a private university hospital. METHODS Using an observational controlled study, we tested 3 interventions: a desk sign mandating all visitors to use AHS, a free-standing AHS dispenser directly in front of a security desk, and a combination of a freestanding AHS dispenser and a sign. RESULTS HHC was 0.52% at baseline and did not improve significantly when the desk sign was provided as a cue 0.67% (P = .753). However, HHC did improve significantly with use of the freestanding AHS dispenser (9.33%) and the sign and dispenser combination (11.67%) (P < .001 for all comparisons of dispenser alone and sign and dispenser with baseline and sign alone). The degree of improvement with the sign and dispenser combination over the dispenser was not statistically significant. CONCLUSIONS Hospital visitors represent an important factor in infection prevention. A coordinated effort is needed to increase visitor HHC, including an evaluation of the AHS placement, education of visitors on the importance of HHC, and evaluation of corresponding changes in hand hygiene behavior.

A novel educational programme to improve knowledge regarding health care-associated infection and hand hygiene

Lack of hand hygiene by health-care workers is the most significant cause of health care-associated infection. This programme was designed to make health-care workers want to wash their hands, to change their knowledge regarding hand hygiene and health care-associated infection, and influence practice. Improvement between pre- and post-test scores was statistically significant. Compliance is a multifactorial problem that involves knowledge and behaviour. Educational awareness and frequent reminders are critical to maintain high rates of hand hygiene compliance.

The use of a novel technology to study dynamics of pathogen transmission in the operating room.

Pathogenic organisms have been found in the intraoperative environment, potentially posing a risk of infection that could cause morbidity and mortality. In an effort to understand how a patient’s bacteria can be spread throughout the operating room with the anesthesia provider as a vector, we conducted a study using recently developed experimental technology in a simulated operating room environment with a high-fidelity human patient simulator.

Sexual assault forensic examiners' training and assessment using simulation technology

INTRODUCTION More than 190,000 sexual assaults involving persons aged 12 years or older occur annually in the United States. For these victims, a forensic examination is the first step in the process to justice. Assessment and treatment of victims, as well as the meticulous collection and documentation of evidence, are vital for a strong case. Providing timely services 24/7 by qualified professionals can be taxing on schedules and budgets. Using in-house resources to cross-train ED personnel, we developed a program that introduced novice forensic examiners to common clinical scenarios encountered in the treatment of victims and provided a framework for the evaluation and management of each case. METHODS Seventeen ED personnel attended statewide sexual assault nurse examination training and participated in four simulation scenarios and debriefings. Pre-tests and post-tests were administered, and a checklist was used to assess competence in performing examinations independently. RESULTS The majority of participants achieved competence (≥85% on the checklist) with their first case and had statistically significant gains in knowledge between pre-test and post-test (pre-test mean score [±SE] of 69.1 ± 1.7 vs. post-test mean score of 84.4 ± 2.6, P < .001). Course evaluations were favorable, with a mean score of 91.3%. DISCUSSION Our results validated the use of simulation technology and in-house resources for cross-training in a sexual assault forensic examination program, together with a checklist to assess competence in performing examinations independently. Benefits of having a sexual assault forensic examination program in the emergency department are standardized and timely care for victims, as well as enhanced evidence collection and increased reporting and prosecution of crimes.

Factors impacting hand hygiene compliance among new interns: findings from a mandatory patient safety course.

BACKGROUND Residency is a critical transition during which individuals acquire lifelong behaviors important for professionalism and optimal patient care. One behavior is proper hand hygiene (HH), yet poor compliance with accepted HH practices remains a critical issue in many settings. This study explored the factors affecting hand hygiene compliance (HHC) in a diverse group of interns at the beginning of graduate training. METHODS During a required patient safety course, we observed HH behaviors using a standardized patient encounter. Interns were instructed to perform a focused exam in a simulated inpatient environment with HH products available and clearly visible. Participants were blinded to the HH component of the study. An auditory alert was triggered if participants failed to perform prepatient encounter HH. Compliance rates and the number of alerts were recorded. All encounters were videotaped. RESULTS The HHC among the 169 participants was 37.9% pre-encounter and was higher among female interns than males, although this difference was not statistically significant (41.6% versus 31.5%, P  =  .176). International medical graduates had significantly lower HHC compared with US graduates (23.2% versus 45.1%, P  =  .006). Most initially noncompliant participants performed HH after 1 alert (87.6%). DISCUSSION The initial low rate of HHC in our sample is comparable to other studies. Using direct video surveillance and auditory alarms, we improved our success rates for prepatient encounter HHC. Our study identified medical school origin as an important factor for HHC, and the significantly lower compliance for international medical graduates compared with US graduates has not been previously reported. These findings should be considered in designing interventions such as intern orientation and clinical education programs to improve HH behaviors.

An evaluation of hand hygiene in an intensive care unit: Are visitors a potential vector for pathogens?

Patients in an intensive care unit (ICU) are frequently immunocompromised and might be highly susceptible to infection. Visitors to an ICU who do not adequately clean their hands could carry pathogenic organisms, resulting in risk to a vulnerable patient population. This observational study identifies pathogens carried on the hands of visitors into an ICU and investigates the effect of hand hygiene. Two observers, one stationed outside and one inside the ICU, evaluated whether visitors performed hand hygiene at any of the wall-mounted alcohol-based hand sanitizer dispensers prior to reaching a patients room. Upon reaching a patients room, the dominant hand of all of the participants was cultured. Of the 55 participating visitors, 35 did not disinfect their hands. Among the cultures of those who failed to perform hand hygiene, eight cultures grew Gram-negative rods and one grew methicillin-resistant Staphylococcus aureus. Of the cultures of the 20 individuals who performed hand hygiene, 14 (70%) had no growth on the cultures, and the remaining six (30%) showed only the usual skin flora. The visitors who do not perform hand hygiene might carry pathogens that pose a risk to ICU patients.

A ubiquitous but ineffective intervention: Signs do not increase hand hygiene compliance

Proper hand hygiene is critical for preventing healthcare-associated infection, but provider compliance remains suboptimal. While signs are commonly used to remind physicians and nurses to perform hand hygiene, the content of these signs is rarely based on specific, validated health behavior theories. This observational study assessed the efficacy of a hand hygiene sign disseminated by the Centers for Disease Control and Prevention in an intensive care unit compared to an optimized evidence-based sign designed by a team of patient safety experts. The optimized sign was developed by four patient safety experts to include known evidence-based components and was subsequently validated by surveying ten physicians and ten nurses using a 10 point Likert scale. Eighty-two physicians and 98 nurses (102 females; 78 males) were observed for hand hygiene (HH) compliance, and the total HH compliance rate was 16%. HH compliance was not significantly different among the signs (Baseline 10% vs. CDC 18% vs. OIS 20%; p=0.280). The findings of this study suggest that even when the content and design of a hand hygiene reminder sign incorporates evidence-based constructs, healthcare providers comply only a fraction of the time.

Board 382 - Research Abstract Favorable Shifts in Teamwork Attitudes Following Completion of a Week Long InterProfessional Simulation-Based Patient Safety Course (Submission #359)

Introduction/Background We modified our university’s week-long patient safety course1 to include interprofessional collaboration between incoming third year medical students and post-baccalaureate nursing students. The course consisted of lectures, web-based didactic materials, small-group activities, simulation exercises and online discussions with an emphasis on experiential learning. Learning objectives focused on the concepts of leadership, teamwork, situational awareness, role clarity and utilization of external resources (i.e. calling for help). To measure the impact of the course, we assessed the student’s opinions using ATTITUDES, a validated survey2 developed to measure student perceptions of and attitudes toward interprofessional education (IPE), teamwork and simulation as a learning modality. We hypothesized that, similar to the Sigalet study,2 our course would have a positive impact on the students’ attitudes in these categories. Methods A total of 220 medical and nursing students participated in a week-long patient safety course. To assess a shift in student’s attitudes, we modified the ATTITUDES survey2 and administered it to the students before and after the course. One-way repeated measures analysis of variance (ANOVA) was used to compare student’s pre and post course scores and to explore any differences by gender and profession. Results Of 186 students who responded to the 28-question survey, only 161 completed the survey at both assessment points and consented to having their data included in the study. A significant time effect was found; on average pre- to post-test differences showed a significant difference f(1, 157)= 40.95, p<.001, Ã…â&OV0556;12=.21. The average pre-test score was 4.4 whereas the average post-test score was 4.8 on a 5-point Likert scale. There were no significant differences noted by gender f (1,157)=.07, p= .79 or intended profession f(1,157)=.65, p=.421, except for questions in the situational awareness category where nursing students scored higher than medical students on the pre-test (p<0.05) but this difference was not observed on the post-test. Conclusion Our week-long, simulation-based inter-professional patient safety course showed a positive impact on the students’ attitudes in the areas of IPE, teamwork, and simulation as a teaching modality. These findings are similar to those of Sigalet et al2 in their study of undergraduate medical, nursing and respiratory therapy students and further demonstrate the impact that similar courses can have on working in multi-professional teams.Most importantly, our Results support the efficacy of our simulation-based IPE curriculum and team-based learning activities for improving student’s perceptions of and attitudes toward simulation as a learning modality in teamwork training. References 1. Shekhter I, Rosen L, Sanko J, Everett-Thomas R, Fitzpatrick M, Birnbach DJ: A patient safety course for preclinical medical students. The Clinical Teacher 2012; 9:376-81. 2. Sigalet E, Donnon T, Grant V: Undergraduate students’ perceptions of and attitudes toward a simulation-based interprofessional curriculum: the KidSIM ATTITUDES questionnaire. Simulation in Healthcare 2012; 7:353-8. Disclosures None.