Learning Objectives

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 2

3. HEROESGOES CSIControlling the Spread of Infection

4. 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

5. C difficile Prevention Bundle Risk Reduction Isolation Glove and Gown Etiquette Hand Hygiene Touch – Moveable Equipment Cleaning R Isolate at first sign infection I Contact Plus; Dedicated Equipment; PPE supplies; Isolate until discharge G Gel before, soap after gloves; Educate pt and family H Gel in, soap out; Remind each other, Response: Thank you T Clean moveable equipment with disinfectant between pts and with bleach before exiting Contact PLUS

6. Medical Center Self Audits Was this true? Secret Shopper Audits Started

7. 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

8. 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

9. Standardized Work Flows

10. HEROES GOES CSIC Difficile Reduction Simulation Workshops • Chief of Chiefs for Infectious Disease Regional HEROES Team • Regional Infection Preventionists

11. 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

12. No Shortcut to Becoming an Expert 10,000 hour rule Current Frame Deliberate Practice Expert Performance

14. 420 Representatives from all Medical Centers

15. 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

16. Speaking Up with Greg and Robbie

17. Modesto HH Vital Behaviors

18. Holey Glow

19. Glove EtiquetteTo Wear or Not To Wear Gloves Gloves Needed Gloves Not 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 • 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 Remember to perform hand hygiene (gel/foam/wash) before applying gloves and immediately after removal. 10.11

20. We Got You Covered

21. Every hospital staff member must put on gown and gloves to enter a Contact Plus isolation room. There is no exception. TAKING OFF PUTTING ON IN THE ROOM CONTACT PLUS ISOLATIONGOWN AND GLOVES EDIQUETTEE PUTTING ON, TAKING OFF, and IN ROOM Pull gown off, breaking neck loop and ties. Assemble gown, gloves, and gel/foam in one place. Perform all clean tasks first, e.g. medication administration, IV therapy maintenance, obtaining vital signs, and physical assessment Peel gown off shoulders and down arms, rolling the gown inside out into a ball. Perform hand hygiene with gel or foam. (Repeat this step if drawer, cart, or mobile computer handles are touched before next step.) 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. When gown is down to the gloves, remove the gloves – inside out - with the sleeves. Put gown on, pulling over head. Tie gown at waist. Put thumbs in loops atthe wrist. Place balled up gown and gloves in trash can Wash, gel, or foam hands before putting on new gloves. Put on mask if needed (Standard Precautions or patient also in Droplet or Airborne Precautions) Wash hands with soap and water 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 Put on gloves and pull over gown at the wrist 10.11

22. The Power of One

23. Deliberate Practice with Facilities Operations

24. Out and About

25. Due to room configurations and patient needs,twopeople 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 TRANSPORTING PATIENTS BY GURNEY OR WHEELCHAIR Return to Contact Plus Isolation room Cover patient with a clean sheet Perform hand hygiene (gel in) and put on gown and gloves Perform hand hygiene (gel in) and put on gown and gloves If gloves are visibly soiled, change them. (Wash hands between removal and reapplication of gloves) Assist patient with hand hygiene and to don a clean gown Transfer patient to bed Remove gown and gloves Wash hands Don new gloves Clean surfaces to be touched in transport with bleach wipe. Allow surfaces to dry. Bring gurney or wheelchair into room Wipe high touch surfaces of gurney or wheelchair with bleach wipe. Remove gloves and wash hands. Wash hands. Transfer patient to gurney or wheelchair Remove gloves Wash hands Transport patient NCal HEROES 3.12

26. Total Hand Hygiene Compliance Deliberate Practice Workshops

27. Rolling 12 Month HA-CDI Rate per 1000 Admits through April 2013 Reg HA-CDI Summit (Apr 2010) Secret Shopper Audits (Apr 2011) Deliberate Practice Workshops (Apr 2012) 54% decrease in 3 yrs TARGET