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Human Factors Engineering and Positive Deviance

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  1. Human Factors Engineering and Positive Deviance to Stop Hospital Acquired Infections (HAI) Will Sawyer MD APIC SW Ohio May 13, 2008

  2. Audience participation during this presentation Identify 2-3 other HCWs in this room and note how many times they “touch” their mucus membranes during this presentation. (Positive Deviance behavior). Possible “colonizer” of MRSA.

  3. Objectives 1.Convert you to the practice of “Hand Awareness” (Hand hygiene and Respiratory Etiquette and cross contamination). 2. You understand the necessity for establishing a “culture of safety” in the healthcare environment. 3. You accept that the drastic situation of HAI requires drastic measures to make the change to protect both the patient and HCW from infectious disease (patient safety shield). 4. To understand that is transmission of HAI that is most important to reducing HAIs. 5. To understand that the Champion Handwasher Hospital Campaign will help your hospital accomplish the first 4 objectives.

  4. Who is “Dr.Will” traditional medical role Solo practice Family Medicine, 1986 to present, Cincinnati, Ohio Trihealth Hospital System Patient Safety Committee, 2004-present. Bethesda North Hospital Med. Executive Committee, 2000-07. Bridges to Excellence: Pay for Performance Program, founding member, 2003-2005(NCQA, CMMS, GE, Humana et al). Clean Hands Coalition, founding member and partner of CDC, 2003 to present. Henry the Hand Foundation, founder 1999. Henry the Hand Champion Handwasher, creator,1996. Influenza Sentinel Network for CDC,member, 2003 to present. Ohio Carrier Advisory Committee for Medicare Co-chair, 1994 to present. Ohio Medicaid Advisory Committee member 1995-2004. Patient’s Choice, founder and President/CEO, 1993-2003, 450 physician IPA AMA OMSS, delegate, 1999 to 2007.

  5. Who is “Dr.Will” Positive Deviance Strategist Solo practice Family Medicine, 1986 to present, Cincinnati, Ohio Bridges to Excellence: Pay for Performance Program, founding member, 2003-2005(NCQA, CMMS, GE, Humana et al). Clean Hands Coalition, founding member (partnership of CDC, USDA, ASM, SDA, industry and universities) 2003 to present. Influenza Sentinel Network for CDC, one of 100 sites,member, 2003 to present. Hand Awareness presentations: Non Pharmaceutical Approach to Prevent Human Illness and Transmission of Emerging Pathogens; NEHA 2006, NAHEC 2006 and USDA Food Safety Conference, 2006. Human Factors Engineering: Stopping Hospital Acquired Infections, TapRoot(Root Cause Analysis) Conference 2007 Champion Handwasher Hospital Campaign presentations: John Muir Health System 2006 Thompson Health System 2006

  6. A Hospital System can drastically reduce HAI by looking in the mirror. Of the 98,000 preventable deaths each year 90,000 are due to infectious disease, according to IOM.

  7. This Tool Kit will help meet the Elements of Performance for JCAHO IC.4.10 1. Interventions are designed to incorporate relevant guidelines for infection prevention and control activities. Interventions are implemented which include the following (EPs 2 and 3): 2. A hospital wide hand hygiene program that complies with current CDC hand hygiene guidelines (National Patient Safety Goal 7, requirement 7a.) 3. Methods to reduce the risks associated with procedures, medical equipment, and medical devices, including the following: Appropriate storage, cleaning, disinfection, sterilization, and/or disposal of supplies and equipment.

  8. The Tool Kit meets the National Patient Safety Goal 7 • Reduce the risk of health care-associated infections. Requirement 7A: Comply with current CDC hand hygiene guidelines. note: This requirement is scored at standard at IC.4.10,EP 2. Requirement 7B: Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.

  9. The Powerof Positive Deviance Solutions before our very eyes The Premise: In every community there are certain individuals whose uncommon practices/behaviors enable them to find better solutions to problems than their neighbors who have access to the same resources

  10. Let’s admit to the Public that HCWs need to make changes to prevent the spread of HAI. As HCWs, we are interested in a “culture of safety” in the hospital to achieve a “zero denominator” for HAI.

  11. Evidence-based medicine and infection prevention measures can go no where without our ability to influence decision-makers to support our efforts and to persuade healthcare teams to adopt safe behaviors. Denise Murphy RN, BSN, MPH, CIC, VP, Chief Patient Safety and Quality Officer Barnes-Jewish Hospital Washington University Medical Center

  12. Culture of Safety It is only through “genuine communication” and accountability for ones behavior in the hospital community, that we will foster a “culture of safety”, that will help prevent the spread of infectious disease, hence HAI. A key component to the Champion Handwasher Hospital Campaign success is based upon one’s personal awareness and personal accountability not age, educational accomplishments or level of authority in the hospital community.

  13. Human Factors Engineering • We need to apply the same evidence based medicine approach to empower HCWs that the Power of Infection Prevention is in their hands! They simply need more Hand Awareness practice.

  14. Hand Awareness • Knowing where your hands are and what they are doing AT ALL TIMES. • Scientifically stated it is the integration of Hand Hygiene, Respiratory Etiquette and cross-contamination awarenessin a best practice model.

  15. How New is Hand Awareness? • John Snow MD(1854): Broad Street pump handle and Cholera epidemic. • Ignaz Semmelweis MD (1847): Perinatal mortality reduced by using a dilute chlorine solution rinse between the morgue and L&D suite. • Although it took 20 years for acceptance of both their discoveries now described as Positive Deviance. • Will Sawyer MD(1999): The 4 Principles of Hand Awareness as primary infection prevention. • Let’s not wait 20 years to accept and miss the opportunity to prevent many HAIs.

  16. Preventing transmission is an important part of MRSA control • Entire healthcare-associated MRSA problem caused by spread of a few clones • Preventing widespread colonization minimizes circulating pool of resistance genes that can contribute to cycle of increasing multi-drug resistance (e.g. VRSA is likely a product of widespread colonization with VRE and MRSA) • Improving antibiograms helps ease pressure for broad spectrum antibiotic use and preserves effectiveness of preferred antimicrobial agents • Preventing colonization helps prevent infections • Including those that might happen post-discharge (newly colonized patients have up to 30% risk of infection in the ensuing year). *Prevention and Control of Healthcare-associated MRSA, John Jernigan MD, Division of Healthcare Quality Promotion, CDC and Prevention April 29, 2008.

  17. So what do we need to change today to prevent HAI? STOP TRANSMITTING by OUR HANDS!!! 1. Practice the 4 Principles of Hand Awareness. 2. Stop keyboard and RFID gun cross contamination during patient care. 3. Remove neck ties that are causing cross contamination. 4. Stop using cell phones in the midst of patient care that are contributing to cross contamination. 5. There will be more suggestions to better engineer the patient care process.

  18. PD Focus onPracticeRatherthan Knowledge “It’s easier to ACT your way into a new way of THINKING, than to THINK your way into a new way of ACTING”

  19. The 4 Principles of Hand Awareness 1. Wash your hands when they are dirty and before eating. 2. Do not cough into your hands. 3. Do not sneeze into your hands. 4. Above all, do not put your fingers into your eyes, nose or mouth. *Endorsed by the AMA and the AAFP (2001) *referred to as individual ideas for flu prevention by CDC, but not packaged as an integrated concept.

  20. The 4 Principles of Hand Awareness 1. Wash your hands when they are dirty and before eating. 2. Do not cough into your hands. 3. Do not sneeze into your hands. 4. Above all, do not put your fingers into your eyes, nose or mouth. *Endorsed by the AMA and the AAFP (2001) *referred to as individual ideas for flu prevention by CDC, but not packaged as an integrated concept.

  21. The 4 Principles of Hand Awareness 1. Wash your hands when they are dirty and before eating. 2. Do not cough into your hands. 3. Do not sneeze into your hands. 4. Above all, do not put your fingers into your eyes, nose or mouth. *Endorsed by the AMA and the AAFP (2001) *referred to as individual ideas for flu prevention by CDC, but not packaged as an integrated concept.

  22. The 4 Principles of Hand Awareness 1. Wash your hands when they are dirty and before eating. 2. Do not cough into your hands. 3. Do not sneeze into your hands. 4. Above all, do not put your fingers into your eyes, nose or mouth. *Endorsed by the AMA and the AAFP (2001) *referred to as individual ideas for flu prevention by CDC, but not packaged as an integrated concept.

  23. We ALL know or have heard of someone who went into the hospital contracted MRSA,VRE, C. difficile or other infectious diseases causing illness or death! Which health systems are consistantly 75% compliant with CDC Hand Hygiene guidelines? Correct, none!

  24. The emergence of MRSA has been due to transmission of relatively few clones, not de novo selection Hiramatsu, et al. Trends in Microbiology 2001;9:486

  25. HCWs are a Petri Dish for many diseases in the hospital. Remember as long as we do not introduce the infectious disease into our mucus membranes then the disease will less likely spread in and out of the hospital.

  26. Which Behaviorsare we talking about? • Nose picking and rubbing • Eye rubbing • Nail biting, finger licking, etc. Curtailing these habits, “Is a simple solution to a complex problem” of HAI.

  27. PD Enables us to Act TODAY Although most problems have complex, interlinked underlying causes . . . The presence of Positive Deviants demonstrates that it is possible to find successful solutions TODAY before all the underlying causes are addressed!

  28. Perhaps we should institute wearing a Patient Safety Shield, as a safety device? Creating a “physical barrier” to prevent inoculation and colonization of MRSA and other germs to reduce Hospital Acquired Infections (HAI).

  29. “It is our duty to our Patients, their families and healthcare workers… Let us move forward together! Each of us can make a difference; a small but significant effort from all of us.” Sir Liam Donaldson – Professor Didier Pittet MD Clean Hands reduce the burden of disease. Lancet;366:185-86, 2005

  30. There are several models talking about the Culture of Safety hospital wide: “Cleanyourhands”Campaign in the U.K. “Clean Care is Safer Care” by the WHO “Champion Handwasher Hospital Campaign” in the U.S.

  31. Hospitals are still functioning in “silos” in OUR communities. • Collaborating to teach a consistent message can help protect the public, our patients, from HAI. • Introducing “friendly competition” between hospitals in a region will help initiate the “culture of safety” in your region.

  32. Community-Associated Healthcare-Associated (community-onset) Healthcare-Associated (hospital-onset) Most Healthcare-Associated Invasive MRSA Infections Have Their Onset Outside of the Hospital 28% 14% 59% Source: ABCs Population-based surveillance System, Klevens et al. JAMA 2007

  33. In December, 2006 IHI(Institute for Healthcare Improvement) initiated the 5 million Lives Campaign which asks hospitals to develop simple techniques to prevent MRSA infections in the hospital. And asks their Boards to “Get on board!” The 4 Principles of Hand Awareness.

  34. SHEA (Society for Healthcare Epidemiology of America) just finished their Annual Congress where they devoted much of their program to discussing programs to prevent MRSA infections. The 4 Principles of Hand Awareness.

  35. Amazing “preventable” statistics in the US from the CDC and Prevention! • 90,000 patients die each year from Hospital Acquired Infections (HAI) • 2,000,000 HAI occur each year, at a cost of $6.7 billion • 5,000 people die from food borne illness annually, • 76,000,000 cases of food borne illness annually • More than 300,000 hospitalizations due to food borne illness • 33,000,000 hospital admissions annually

  36. More “preventable” statistics in the US from the CDC and Prevention! • 52,000,000 Upper Respiratory Infections occur each year, • 164,000,000 days lost from school due to illness, • 22,000,000 days lost from school due to the common cold • 36,000 people die from the Flu and flu-like illness annually • 800,000,000 patient visits annually

  37. What are the 10 most deadly weapons?

  38. Our Fingers and Thumbs!

  39. HCWs Nares organism found in several patients mediastinal site infections on the same floor, 1989. Reduction of Surgical site Infections in Cardiothoracic Surgery by Elimination of Nasal Carriage of Staphylococcus Aureus, Jan, AJ et al, Infection Control and Hospital Epidemiology, November 1996.

  40. Other Evidence that the “colonized” HCWs are the source for Staph aureus outbreaks • Boyce JM, Opal SM, Potter-Bynoe G, Medeiros AA. Spread of MRSA in a hospital after exposure to a HCW with chronic sinusitis. Clin Infect Dis 1993;17:496-504. • Boyce JM. Preventing Staphylococcal Infections by Eradicating Nasal Carriage of Staphylococcus aureus: Proceeding with Caution. Infect Control and Hosp Epidemiol 1996;17:775-779. • CoovadiaYM, Bhana RH. Johnson AP, Haffejee I, Marples RR. A laboratory confirmed outbreak of rifampin-methicillin resistant Staphylococcus aureus (RMSA) in a newborn nursery.. J Hosp Infect 1989;14:303-312. • Gaynes R, Maroska R, Mowry-Hanley et al. Mediastinitis following coronary artery bypass surgery: a 3 year review. J Infect Dis 1991;163:117-121. • Meier PA, Carter CD, Wallace SE, Pfaller MA, Herwalt LA. Eradication of MRSA from the burn unit at a tertiary medical center. Infect Control Hospital Epidemiol 1996;17:798-802.

  41. Perhaps we should institute wearing a Patient Safety Shield, as a safety device. Since there is insufficient compliance with the CDC hand hygiene guidelines, creating a physical barrier to prevent inoculation and colonization of MRSA and other germs in nares would reduce HAI. (Positive Deviance strategy) Prevention and Control of Healthcare-associated MRSA, John Jernigan, MD April 29,2008

  42. Hand Awareness • People who are “Hand Aware” are much less likely to contaminate themselves, another person, patient, device or surface. • Why would anyone knowingly give themselves E.Coli 0157:H7, MRSA,VRE, Shigella, Pertussis, Croup, Meningitis,TB, Flu, Strep, Impetigo, Pink Eye, hepatitis A and many others?

  43. Respiratory Etiquette • Principle 2 and 3. • Do not Cough or sneeze into your hand. Use a sleeve, kleenex, crook of your elbow, etc., anything except a bare hand. Very few people are running to the sink to wash their hands after coughing or sneezing. • Pertussis, viral illness, pneumococcus, meningococcus, SARS, Mumps, Measles, Rubella, and many similar diseases would be prevented by diligent practicing of the 4 Principles of Hand Awareness.

  44. Respiratory Etiquette

  45. Hand Hygiene • Principle 1 and 4. • Handwashing is publicly discussed. • Mucus membrane contact has NOT been “publicly discussed” as it should be, to prevent inoculation and colonization.

  46. Hand Hygiene

  47. The Hand is quicker than the eye! Unfortunately the single act of handwashing or sanitizing alone does not prevent cross-contamination!

  48. Bacterial counts on surfaces*: 2.7 million bacterial cells/ square inch on a drinking fountain. 33,800 bacteria/sq. inch on a cafeteria tray. 3,200 bacteria cells/sq. inch on a toilet seat. 260 bacterial cells/sq inch on key boards. 740 bacterial cells/sq inch on ear phones. *National Sanitation Foundation, www.nsf.org

  49. The Hand is quicker than the eye! People “unknowingly” touch a contaminated surface, then transmit the organism to another surface, themselves or a patient due to “unconscious” personal habits.

  50. How soon after starting to work in the hospital do HCW nares become “colonized” with MRSA? • 2 weeks? 6 weeks? Who is checking? • Does your pre-employment interview ask if you comply with the 4 Principles of Hand Awareness? • Or are you a nose picker, nail biter, finger licker, eye rubber, etc.? • 20-30% of HCWs are colonized with MRSA at any one time - Boyce,1996