2

Learning Objectives– Communicate the value of standardized

workflows to increase the reliability of hand hygiene and inpatient isolation practices to reduce hospital-acquired Clostridium difficile infections

– Understand the application of deliberate practice simulation to implement and hardwire standardized work flows

– Apply the basic skills of deliberate practice simulation in one’s work setting

HEROESGOES CSIControlling the

Spread of Infection

C Diff Reduction Timeline: Hand Hygiene and Isolation

• April 2010 C diff Reduction Summit; introduction to RIGHT bundle

• Dec 2010 - Vital Behaviors for Hand Hygiene video created by Senior Leaders

• Jan 2011 - Education provided to nursing unit leaders on Hand Hygiene Vital Behaviors and RIGHT bundle

• April 2011 – Quarterly Secret Shopper audits started • 2011 – Development of standardized workflows• April 2012 – Deliberate Practice Workshops

C difficile Prevention Bundle

R Risk Reduction

Isolation

Glove and Gown Etiquette

Hand Hygiene

Touch – Moveable Equipment Cleaning

I

G

H

T

Isolate at first sign infection

Contact Plus; Dedicated Equipment; PPE supplies; Isolate until discharge

Gel before, soap after gloves; Educate pt and family

Clean moveable equipment with disinfectant between pts and with bleach before exiting Contact PLUS

Gel in, soap out; Remind each other, Response: Thank you

Medical Center Self Audits

Was this true?

Secret Shopper Audits Started

Secret Shopper Audits• Regional Team audit 21 Medical Centers quarterly• Wide variation in practices within and across medical

centers• Few had hardwired appropriate practices

– Gloves applied without prior hand hygiene– High glove use in and out of rooms– Hand hygiene coming out of the room more reliable than

going into the room– PPE was not always use or used properly

• Work flows development began

Standardized Work Flows• After 5,000+ observations• Developed based on observed reliable

practices• Tested and approved by content experts and

pilot sites• Continue to learn with wide spread

implementation• Recognized as best practice across organization

Standardized Work Flows Glove Etiquette Donning and removal of PPE Contact PLUS patient Transport Meal Tray Distribution Patient Ambulation Medication Administration Finger Stick Blood Glucose Cleaning Occupied Room Laboratory Blood Draw Radiology (at bedside)

HEROES GOES CSIC Difficile Reduction

Simulation Workshops

Chief of Chiefs for Infectious Disease Regional HEROES Team

Regional Infection Preventionists

Why Did We Do This Training• Preventing Hospital Acquired Infections saves

lives• Need to

–do things differently–change the culture–understand each others’ work flows

• Train leaders and staff differently

No Shortcut to Becoming an Expert

CurrentFrame

Deliberate Practice

10,000 hour rule

ExpertPerformance

420 Representatives from all Medical Centers

Nurses 163Nursing Managers 25EVS 46Physicians 24Infection Prevention 23PCT/Transporter 19Laboratory 17Educators 16Radiology 12Non-Nursing Managers 11

Resp. Therapy 11Physical Therapy 9Dietary 9Quality/Risk 8Directors 7ED 3Pharmacy 1Social Worker 1Other 14

Deliberate Practice Stations• Speaking Up with Greg and Robbie – Vital behaviors for hand

hygiene• Holey Glow – Hand Hygiene and Glove Etiquette• We Got You Covered – Proper application and removal of PPE• What the Bleach? – Cleaning moveable equipment• Out and About – Transport of C diff patient• Not Just a Maid Service – EVS cleaning • The Wow of the Wows – Medication administration and

cleaning of moveable computer and scanner • All Stuck Up – Lab draws

Speaking Up with Greg and Robbie

Modesto HH Vital Behaviors

Holey Glow

Glove EtiquetteTo Wear or Not To Wear Gloves

Gloves Needed

(along with gowns)

Contact Isolation

Contact Plus Isolation

Standard Precautions

Potential exposure to mucous membranes, blood, and/or body fluids

• Drawing blood• Wound care• Starting IVs• Suctioning• Handling urinary

catheter• Changing grossly

soiled bed linens• Oral hygiene• Perineal/perianal care

Picking/emptying trash

Emptying soiled linen

Using Saniwipes, other disinfectants, or bleach wipes

Gloves Not Needed

Very low or no potential exposure to mucous membranes, blood, and/or body fluids. This includes but is not limited to:

• Touch intact skin – such as hold or shake hands

• Measure vital signs• Pass meal trays• Administer medication, including

injections (subcutaneous, intradermal or IM) unless the patient has a tendency to bleed

• IV maintenance (hanging new bag, starting piggyback medications, giving IV push medications)

• Patient transport – pushing gurney or wheelchair

• Carry specimens to the lab in zip closed bags

• Carry blood from the blood bank• Ambulate or transfer continent

patients• Bathing (except for perineal and

oral hygiene)• Use computer keyboard or barcode

scanner

Patient is not in Contact or Contact Plus isolation

10.11

Remember to perform hand hygiene (gel/foam/wash) before applying gloves and immediately after removal.

We Got You Covered

CONTACT PLUS ISOLATIONGOWN AND GLOVES EDIQUETTEE

PUTTING ON, TAKING OFF, and IN ROOM

PUTTING ON

Perform hand hygiene with gel or foam. (Repeat this step if drawer, cart, or mobile computer handles are touched before next step.)

Put gown on, pulling over head. Tie gown at waist.

Put thumbs in loops at the wrist.

Perform all clean tasks first, e.g. medication administration, IV therapy maintenance, obtaining vital signs, and physical assessment

Change gloves after any dirty task such as any exposure to blood or body fluids. This can include but is not limited to: obtaining specimens, suctioning, wound care, post incontinence care, emptying urinary catheter bag, ostomy care.

Wash, gel, or foam hands before putting on new gloves.

TAKING OFF

Pull gown off, breaking neck loop and ties.

Peel gown off shoulders and down arms, rolling the gown inside out into a ball.

Place balled up gown and gloves in trash can

Wash hands with soap and water

When gown is down to the gloves, remove the gloves – inside out - with the sleeves.

Assemble gown, gloves, and gel/foam in one place.

Put on gloves and pull over gown at the wrist

10.11

Every hospital staff member must put on gown and gloves to enter a Contact Plus isolation room. There is no exception.

IN THE ROOM

Put on mask if needed (Standard Precautions or patient also in Droplet or Airborne Precautions)

If mask is used, remove from behind, using elastic straps

Wash hands with soap and water after mask and/or goggle removal.

Note: If a patient is on airborne and contact disinfect PAPR before and after procedure with a bleach wipes

The Power of One

Deliberate Practice with Facilities Operations

Out and About

TRANSPORTING PATIENTS BY GURNEY OR WHEELCHAIR

• Due to room configurations and patient needs, two people may be needed to prepare a patient for transport and to transport.• Limit patient movement to medically necessary transports. Use gurney for transport. Reserve use of the bed for transport to

unstable patients• Notify receiving department of isolation precautions• Diarrhea must be contained.• PPE should be worn as needed according to Standard Precautions. Gloves worn during transport should be considered

contaminated and care should be taken not to contaminate the hospital environment. In the event PPE is necessary be sure not all transport personnel is wearing PPE

Perform hand hygiene (gel in) and put on gown and gloves

Bring gurney or wheelchair into room

Transfer patient to gurney or wheelchair

If gloves are visibly soiled, change them. (Wash hands between removal and reapplication of gloves)

Clean surfaces to be touched in transport with bleach wipe. Allow surfaces to dry.

Remove gloves and wash hands. Wash hands.

Transport patient

Return to Contact Plus Isolation room

Perform hand hygiene (gel in) and put on gown and gloves

Transfer patient to bed

Wipe high touch surfaces of gurney or wheelchair with bleach wipe.

Remove glovesWash hands

Remove gown and glovesWash handsDon new gloves

Assist patient with hand hygiene and to don a clean gown

Cover patient with a clean sheet

NCal HEROES 3.12

Total Hand Hygiene Compliance

Deliberate Practice Workshops

Rolling 12 Month HA-CDI Rate per 1000 Admits through April 2013

Reg HA-CDI Summit

(Apr 2010) Secret ShopperAudits

(Apr 2011)

Deliberate Practice

Workshops(Apr 2012)

TARGET54% decreasein 3 yrs