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The rapid spread of coronavirus disease 2019 (COVID-19) required swift preparation to protect healthcare personnel (HCP) and patients, especially considering shortages of personal protective equipment (PPE). Due to the lack of a pre-existing biocontainment unit, we needed to develop a novel approach to placing patients in isolation cohorts while working with the pre-existing physical space.
To prevent disease transmission to non–COVID-19 patients and HCP caring for COVID-19 patients, to optimize PPE usage, and to provide a comfortable and safe working environment.
An interdisciplinary workgroup developed a combination of approaches to convert existing spaces into COVID-19 containment units with high-risk zones (HRZs). We developed standard workflow and visual management in conjunction with updated staff training and workflows. The infection prevention team created PPE standard practices for ease of use, conservation, and staff safety.
The interventions resulted in 1 possible case of patient-to-HCP transmission and zero cases of patient-to-patient transmission. PPE usage decreased with the HRZ model while maintaining a safe environment of care. Staff on the COVID-19 units were extremely satisfied with PPE availability (76.7%) and efforts to protect them from COVID-19 (72.7%). Moreover, 54.8% of HCP working in the COVID-19 unit agreed that PPE monitors played an essential role in staff safety.
The HRZ model of containment unit is an effective method to prevent the spread of COVID-19 with several benefits. It is easily implemented and scaled to accommodate census changes. Our experience suggests that other institutions do not need to modify existing physical structures to create similarly protective spaces.
Background: The use of personal protective equipment (PPE) is a critical intervention in preventing the spread of transmission-based infections in healthcare settings. However, contamination of the skin and clothing of healthcare personnel (HCP) frequently occurs during the doffing of PPE. In fact, nearly 40% of HCP make errors while doffing their PPE, causing them to contaminate themselves. PPE monitors are staff that help to promote their colleagues’ safety by guiding them through the PPE donning and doffing processes. With the advent of the COVID-19 pandemic in early 2020, the UNC Medical Center chose to incorporate PPE monitors as part of its comprehensive COVID-19 prevention strategy, using them in inpatient areas (including COVID-19 containment units and all other units with known or suspected SARS-CoV-2–positive patients), procedural areas, and outpatient clinics. Methods: Infection prevention and nursing developed a PPE monitoring team using redeployed staff from outpatient clinics and inpatient areas temporarily closed because of the pandemic. Employee training took place online and included fundamentals of disease transmission, hand hygiene basics, COVID-19 policies and signage, and videos on proper donning and doffing, including coaching tips. The monitors’ first shifts were supervised by experienced monitors to continue in-place training. Employees had competency sheets signed off by a supervisor. Results: The Medical Center’s nursing house supervisors took over management and deployment of the PPE monitoring team, and infection prevention staff continued to train new members. Eventually, as closed clinics and areas reopened and these PPE monitors returned to their regular positions, areas used their own staff to perform the role of PPE monitor. In the fall of 2020, a facility-wide survey was sent to all inpatient staff to assess their perceptions of the Medical Center’s efforts to protect them from acquiring COVID-19. It included a question asking how much staff agreed or disagreed that PPE monitors “play an important role in keeping our staff who care for COVID-19 patients safe.” Of the 626 staff who answered this question, 67.6% agreed or strongly agreed that PPE monitors played an important role in keeping staff safe. Thus far, there has been no direct transmission or clusters of COVID-19 involving HCP in COVID-19 containment units with PPE monitors. Conclusions: PPE monitors are an important part of a comprehensive COVID-19 prevention strategy. In early 2021, the UNC Medical Center posted and hired paid PPE monitor positions to continue this critical work in a sustainable way.
Background: Care bundles comprise evidence-based practices and interventions that are easily and consistently implemented while improving patient outcomes. As patient acuity and task overload continue to increase, infection prevention bundle and process measure compliance and data collection may become a lower priority for registered nurses (RNs). In early 2019, a certified nursing assistant (CNA) began full-time quality liaison work on a 53-bed inpatient adult oncology unit at UNC Medical Center to provide targeted compliance data collection and to correct deficits in real time when possible and within the appropriate scope of practice. Methods: The quality liaison CNA is highly motivated, with a relevant clinical background and effective communication skills. After conducting a gap analysis, the unit developed specific responsibilities for several areas of quality improvement, including infection prevention. In addition to rounding on all patients daily, the quality liaison (1) performs direct patient care tasks like Foley catheter care, (2) conducts patient education on topics such as chlorhexidine gluconate treatments, (3) performs all relevant process measure audits, and (4) easily relays missed or needed care to RNs with a door sign created as part of this initiative. High-risk findings, such as a loose central-line dressing, prompt immediate communication to the RN, with follow-up and escalation when necessary. Results: Patients and staff received the quality liaison well, and the increased attention to care bundle components and auditing ensured consistent, evidence-based care along with accurate and reliable data collection. Compared to the previous calendar year, the number of central-line audits on the unit increased by >1,400 by the end of 2019. Patient outcomes improved, and during 1 fiscal year, the unit achieved rate reductions between 40% and 55% for central-line–associated bloodstream infections, catheter-associated urinary tract infections, and healthcare-associated C. difficile infections. Staffing and logistical challenges imposed by the COVID-19 global pandemic have hampered this work because the quality liaison was redeployed to direct patient care intermittently. Correspondingly, from July to October 2020, the same infection rates increased between 30% and 353%. Conclusions: Having a designated quality liaison is an effective means to achieving quality improvements while remaining an integral member of the patient care team. As staffing has improved on this unit, the quality liaison has refocused efforts, and infection rates are beginning to improve. Given the success of the quality liaison role in improving quality outcomes on this unit, the hospital is exploring expansion of this model to additional units.
Background: Infection prevention efforts are complex, and sustaining reductions is even more challenging. At the UNC Medical Center, multidisciplinary hospital-wide work groups implement quality improvement initiatives to prevent healthcare-associated infections. The first and most successful initiative has been our catheter-associated urinary tract infection (CAUTI) prevention effort, which started in 2014. The program led to initial dramatic reductions, with continued reductions in CAUTI rates each year since then. Methods: A multidisciplinary workgroup formed in 2014 developed an evidence-based CAUTI prevention bundle and partnered with the nursing staff in 2015–2016 to implement practice changes as part of our hospital’s quality improvement “Spread of Innovations” model. These changes included (1) creation of a 2-person catheter-insertion checklist; (2) insertion skills validation for all nursing staff and nursing assistants; (3) standardization of a maintenance protocol and subsequent education and skills validation with nurses and nurse assistants; and (4) peer audits of urinary catheter maintenance. Additional initiatives implemented over the past 5 years include (1) routine resident education on CAUTI prevention; (2) annual nurse competencies to reinforce skills around CAUTI prevention; (3) introduction of products (eg, PureWick) as alternatives to indwelling catheters; (4) diagnostic stewardship efforts; (5) revisions to the electronic medical record; and (6) efforts to encourage removal of unnecessary catheters such as the “nurse-driven conversation” and Trial of Void. Results: Our CAUTI rates decreased 65% from 2.94 per 1,000 catheter days in the baseline period of 2014 to 1.02 in 2018. In our ICUs (excluding the neonatal ICU), the rate dropped 75% from 4.30 in 2014 to 1.08 per 1,000 catheter days in 2018. Conclusions: We attribute our continued reductions and successful sustainment of low CAUTI rates to several factors. First, the use of a multidisciplinary team was critical to obtaining buy-in from key stakeholders including nursing, nurse assistants, physicians, pharmacists, performance improvement specialists, and administration. Second, continuation of the maintenance peer audits outside the initial project year has provided an important framework for this project, giving regular opportunities for frontline staff to evaluate patients’ catheter condition and to give feedback to colleagues or “just in time education.” These activities potentially prevent infections in real time. Third, with the many competing priorities demanding clinicians’ attention, it has been important for the CAUTI workgroup to continue to evaluate the problem, to determine where opportunities for improvement remain, and to tailor initiatives to meet those needs. In this way, new work can focus on priorities identified by staff, and CAUTI prevention initiatives remain relevant.
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