Infection preventionists gathered in October for Kaiser Permanente’s national infection prevention meeting. Photo courtesy of Kaiser Permanente.
By Kelly M. Pyrek
So much of the infection preventionist’s time has traditionally been spent in the pursuit of healthcare personnel education and training on infection control-related principles and practices, with varying degrees of success measured through compliance metrics. Be it hand hygiene compliance percentages, terminal cleaning effectiveness rates, or various infection prevention bundles, compliance can be suboptimal in many healthcare institutions — and healthcare workers freely admit it. For example, Yassi, et al. (2007) assessed the determinants of healthcare worker self-reported compliance with infection control procedures via a survey of personnel in 16 healthcare facilities. A strong correlation was found between both environmental and organizational factors and self-reported compliance; no relationship was found with individual factors. The researchers found that only 5 percent of survey respondents rated their training in infection control as excellent, and 30 percent felt they were not offered the necessary training. The investigators concluded that compliance with infection control procedures is tied to environmental factors and organizational characteristics, suggesting that efforts to improve availability of equipment and promote a safety culture are key. They added that training should be offered to high-risk personnel, demonstrating an organizational commitment to their safety.
We spoke with Sue Barnes, RN, CIC, the national leader of infection prevention and control in the Program Office for Kaiser Permanente in California, for her perspective on issues relating to boosting compliance with infection prevention and control imperatives, and what clinical issues are driving interventions.
Q In terms of healthcare personnel compliance, how do you characterize institutional success?
A I look at the outcomes and what the influencing factors are, such as the environment, the level of teamwork and overall morale, as well as the institutional culture. In general, if I am going to come into a hospital to determine how effective their infection prevention and control program is, I want to know primarily how they are doing in terms of implementing practices and monitoring processes, and then also how they are measuring their efforts including what their infection rates are.
There’s no perfect answer to the question of how to boost compliance. We just had our Kaiser-wide infection control meeting in which all of the IPs across our program meet once a year face to face, so we hear from each other as to what is working and what is not. In the programs where things are working best, there are management champions and physician partners, usually infectious disease doctors. There is also some decentralization of infection control, but those folks who are in the infection prevention department are the captains of the ship — they are respected as the ultimate authority and they are the ones who are directing what needs to happen, and what might need to change to improve practices.
We are not completely standardized, as there is variability from one facility to another. Although programs may not be structured all the same, you do see identical similar themes in terms of why programs are working successfully — personnel at the front lines — the people who are touching the patients — and the professionals at the managerial level are held accountable. Our champions hold people accountable for doing the right thing, and physician partners for the program are the hammer that makes things happen when they are not happening.
Q How important is feedback to healthcare personnel about their compliance rates and their overall performance?
A I think it is essential to do things like posting surgeons’ infection rates on the operating room staff bulletin board, or posting infection rates in the various units. There are automated systems that monitor compliance with hand hygiene in real time and provide feedback on compliance rates to staff in the moment and I think this new technology is very exciting. Sharing infection rates or the number of days between infections helps to generate healthy competition between nursing units, staff and physicians.
Q What do you do when an institution’s culture doesn’t facilitate transparency and collaboration to improve practice?
A It is a challenge within our organization and facilities everywhere. We have seven regions and one region in particular is not transparent, not interested in or willing to share infection data. So how do we change that? I’m not sure what the right answer is, but I think having patience and applying some pressure at both the peer level and the executive level, and hoping that influence will make a difference.
Q Do you believe in a reward system or a punitive system to try to improve healthcare workers’ compliance with infection prevention?
A In general I think the carrot approach works better, just knowing human nature. To me, a positive approach is always more successful. But we are affected by numerous regulatory and accreditation agencies that are punitive, and we can’t avoid that. So maybe it’s a little of both. But I still think the carrot works better when you are trying to change human behavior.
Q If compliance among healthcare personnel is lacking, is it a knowledge gap or an implementation gap?
A I think most people are doing the right thing most of the time. Our job as IPs is to focus on both, and intervene when they are not doing the right thing. That’s the exception, not the rule, and it’s getting more infrequent as we move forward and understand better the science of what causes infections and how can we prevent them. We are adding new technologies that are designed to make prevention even more effective easier, but something in addition to human factors that works against us is the complexity of healthcare. Clinical procedures and the instrumentation used are evolving, and it’s difficult for healthcare personnel to perform 100 steps in a protocol the right way every time. As an example, I am thinking about flexible endoscope reprocessing and what inadequate cleaning can lead to. Look at the complexity of this process — there are well over a hundred steps that someone has to perform correctly every time, and they are working with instruments that were not designed to be easily cleaned and disinfected. So there are many reasons why healthcare workers aren’t doing the right thing — sometimes it’s not that simple. I think we have to look at the products and instruments we use to provide healthcare. We have to apply pressure to industry to really think about how those are used and how they are cleaned, and the environment of healthcare and how that is cleaned — there is not enough thought going into that currently.
Q A recent study (Parrillo, 2015) indicated that IPs’ role is changing and they are spending less time on observational rounding; how does this impact healthcare personnel compliance with infection prevention?
A It’s really a crisis in our profession right now. The exploding focus on data is diverting the time the IP can spend teaching and engaging in face-to-face instruction and consulting. And it means there are fewer eyes on complex processes and practices, as IPs aren’t seeing what’s happening in the units that needs to be addressed in order to reduce the risk of infection. Unless the experts are out there on the front lines, we don’t have IPs where we need them to be. In some facilities, the expanding role of infection prevention is being better understood as a distinct, specialized discipline, so resources are being added to departments. But in other facilities, there is a growing perception that the infection preventionist is responsible only for data management. As an example, in one region, they have centralized infection surveillance for 22 hospitals, but then they I’ve observed centralization of surveillance which is the right direction to move I think in multi hospital systems. But sometimes IP staffing is being cut at the same time due to this perception because they perceived that to be that data management is the only function of infection prevention. So there is no face time, no eyes on anything, no expert out there. This trend is frightening to me. Complete that there is the perception that health systems can completely decentralization of infection prevention and put it back - putting it completely in the hands of nurses and doctors, or “cross-training” quality nurses to perform as IPs, would not in my opinion be safe for patients. Infection Prevention and Control is a complex . It’s way too complicated of a science — it’s like saying a car mechanic can take over for a veterinarian care of veterinary medicine. Infection prevention and control is a different, distinct clinical discipline, and in places in Kaiser Permanent where that’s recognized, the right things are happening. But I am hearing within the community that I am concerned for patients where executives are looking at infection preventionists as data managers only, and cutting resourcing, and/or where experienced IPs are just abandoning ship because it’s not the job for which they signed up. It’s a crisis in our profession right now and it’s been decades in the making.
Q How can IPs still reach healthcare workers who may be tuning them out?
A I think we need to try different training tools and strategies such as simulation and interactive gaming. There are so many competing priorities and frontline staff have to know much more than they used to, and it can be challenging to get the message across — so we need to explore different ways to share critical infection prevention and control information.
Q What are the perennial issues and practices that still need attention?
A Issues do evolve over time, but some of the things we never solve or get perfect at. Healthcare is also a moving target, in that healthcare delivery in general is moving from inpatient to outpatient. There are so many venues in ambulatory care and so many invasive procedures occurring there, so one of Kaiser Permanente’s focus a primary focus for IP departments right now is infection control in outpatient facilities — looking at the infection risk there, what we can do and how we can help. So much of healthcare these days is provided in the ambulatory arena, so we need to have more expert infection control professionals with formal oversight in those areas. From long-term care facilities and dialysis units, to infusion centers and ASCs, how can we make them safer? That is something we focus more and more on in our meetings at Kaiser Permanente and with colleagues at APIC meetings.
C. difficile is the biggest primary pathogen of concern in the last few years especially, and it is not going away. When it comes to bloodstream infections, we are now looking beyond the ICU; traditionally we just focused on the ICU for and on central line-associated bloodstream infections and now we are looking across the continuum and at CLABSIs, those BSIs that occur as a result of not just central lines, but peripheral lines and arterial lines as well. Healthcare-associated pneumonia and infections caused by continually emerging multi-drug resistant organisms have become more of a concern an issue than it ever was before. It’s about staying vigilant and responding to issues as they arise.
Yassi A, Lockhart K, Copes R, Kerr M, Corbiere M, Bryce E, Danyluk Q, Keen D, Yu S, Kidd C, Fitzgerald M, Thiessen R, Gamage B, Patrick D, Bigelow P, Saunders S. Determinants of healthcare workers’ compliance with infection control procedures. Healthc Q. 2007;10(1):44-52.
Parrillo SL. Oral Abstract #030: The Burden of National Healthcare Safety Network (NHSN) Reporting on the Infection Preventionist: A Community Hospital Perspective. Presented at the 42nd Annual Conference of the Association for Professionals in Infection Control and Epidemiology (APIC).