Infection Control in Long Term Care: Design for Change in Practice Project

Cindy BennettChamberlain College of NursingNR 451: Capstone Course10/8/2011

• The identified problem was the lack of infection control prevention awareness in Long Term Care Facilities (LTCF). This was noted while visiting a local hospital that used multiple mediums to make visitors and staff aware of infection control.• The concern was that without increased

awareness, the residents residing in the LTCF’s were not benefitting from infection prevention, specifically during influenza (flu) season.

What is the problem?

How Can we Make a Difference?

• A superior plan for infection control in the LTCF will educate internal and external customers on the need for continued vigilance (CDC,2007).• Infection control is the single most important

aspect for disease prevention. By utilizing all available medium, the rates of influenza or flu-like illnesses may be decreased.

Formulating the Plan• A hand-washing statistical review in the Journal of Applied

Microbiology supported the theory that improved hand-washing had considerable impact on infection prevention(Barker, 2001). The infection rate for the group who participated in good hand-washing decreased by 50%. This is irrefutable proof that hand washing does decrease respiratory infections.

• Randomized controlled trials reviewed in The Journal of the American Geriatrics Society identified that elderly patients benefitted from good oral hygiene as it reduced respiratory tract infection (Sjogren, 2008).

Summary of Relevant Literature

• The MMWR Advisory Committee did a study in 2008 that compared illness outcomes for the elderly who received the flu vaccine to those who did not. The outcomes were supportive of receiving the flu vaccine annually for elderly patients. An impressive 58% efficacy rate against influenza was evidence that supports this project of change.• A review of random surveys in four LTCF’s indicated that

the reason people did not receive the flu vaccine was in most part due to 2 reasons: misconceptions concerning the vaccine and inability to receive it easily (Kimura, 2007).

Summary of Relevant Literature

• The outcomes of Kimura’s study was creation of a “Vaccine Day” to increase ease of receiving the vaccine, and educating customers on the vaccine itself.

• The goal was to eliminate the negative reasoning associated with flu vaccination. With just these 2 interventions, vaccine coverage increased by 53%.

Summary of Literature continued

• A valuable tool for completion of the project was the information obtained for Administrative controls.• Those administrative controls were to make sure

staff came to work only when healthy and to promote the process by ensuring all items were available. Having ample tissues, hand sanitizers, soap and towels is one of the most important parts of the project (CDC, 2011). The administrative controls releases the monies needed for purchase.

Utilizing Deming’s Circle of Performance Improvement• The stakeholders are all staff, families and customers who will

benefit from increased education on infection. The true stakeholders are the elderly that reside in the LTCF. They are at high risk for infection and by educating the public, we are increasing their protection.

• The project was implemented by utilizing Deming’s circle of quality improvement, specifically the P=plan, Do=make the change and implement, C= make sure the change is achieving desired results and A= act on follow up.

• Representatives of all departments of the LTCF made up 2 teams to follow the PDCA cycle. They created the hypothesis statement “If we establish a plan that included the addition of extra hand sanitization, signage for infection prevention, increased fomite cleaning, and increased education on hand washing, the amount of flu like infections would decrease accordingly.”

Deming’s Circle of Performance Improvement

Plan

Do

CheckAct

Assess outcomes

Plan for the Change in Design• P (Plan) was the plan for each department. Nursing hung posters

throughout the building of how to hand wash effectively. Specific areas were in the bathrooms and nurses stations. Housekeeping applied hand sanitizers to strategic areas in the building and devised a schedule to make sure they were kept full. They also planned to increase fomite disinfection. Central supply increased the order of soap, towels, tissues and ordered small bottle of hand sanitizer to keep at the nurses station for staff to keep in their pockets. Administration sent CDC education on flu prevention and vaccination to families and issued the education to all staff and residents. They made it available for all vendors and external customers. Part of the signage in the facility was encouraging families to not visit when sick. A vaccine day was chosen and 16 hours were dedicated to giving flu vaccines to internal and external customers.

Project Details - Do• D (Do) was each department head in serviced all their staff

and the recited expectation on their personal responsibility. The Administration sent the CDC influenza control education out via mail for families and via paychecks for employees. Posters were sent to local businesses to inform of vaccine day. A final check was done by the teams on making sure posters were up, hand sanitizers were attached and full, vaccine was ordered, and nurses (volunteers)had their schedules for vaccine day.

Project Details - Check• Check = obtaining feedback from staff as well as

internal/external customers. The staff had a great buy in and central supply informed the team there was an increase in paper towel and soap usage. This was directly related to increased usage, thus increased infection control prevention. A list was formed for those who wanted the flu vaccine on the established vaccine day. Other facilities in our company were asking for our results.

Project Details – Act and Follow up• A (ACT) = weekly follow up with the committees and staff on

continued implementation of the project. At the end of each month during the flu season, comparisons will be made against the results from last year. The results from the number of people who receive the flu vaccine on vaccine day October 14, 2011 will be compared with the number of people who received the vaccine October 2010. IT will give the Performance Improvement Team number graphs for true comparison.

• Follow up assessment= If at any time there is a drop in efficiency of the project, begin the cycle at the planning stage.

Summary of Project: Design for Change in Practice• In summary, the design for change in practice concerning

increased infection control was assessed, planned, and fully implemented in two facilities on September 30, 2011.• Vaccine day is scheduled for October 14, 2011, with a

second one projected for November 2011.

Summary of Project: Resolution of the Problem/Concern continued

• The plan will continue to be implemented throughout the flu season, which will go through the month of March. Evaluation of the plan will occur monthly in Performance Improvement Committee Meeting that includes the medical Director

• When evaluation of who already signed up for the flu vaccine was completed, we were up to 92% of staff. Our goal is 100%. We have not quite met the goal, but we still have a few days left prior to our vaccine day. The identified non-compliant 8% have not yet turned their consent sheets in, so it is not yet counted as a negative, just slow response.

Evidenced Based Practices Support

• The entire solution and change in design plan was supported by Evidenced-Based Practices. The interventions also make good sense, therefore it was readily accepted by staff. Massive education to the staff that included EBP was successful. Education to the residents on their rights concerning infection control proved to be positive as staff were reporting in the weekly review meeting that residents were asking staff to wash their hands before touching them.

Next Steps• Because each intervention is supported by Evidenced Based

Practice (EBP), it will be easier to promote other projects by citing EBP.

• Through massive education, the facility now associates EBP with common sense as well, thus making staff understand and support EBP.

• Staff have been exposed to web-sites and search engines where EBP is cited.

Next Steps• This project is already scheduled to be shared with the entire

region at our companies December Regional meeting. In attendance will be other LTCF’s and Corporate representatives. New projects are reviewed and those projects chosen are adopted as addition to the annual Corporate Performance Improvement Calendar. I feel confident this one will be chosen. This program has already been added to the facility annual Performance Improvement Plan.

The Process Used to Complete the Project• Rosswurm and Larrabee’s “Model for change to Evidence-

Based practice (Rosswurm & Larrabee,1999)guided me with a framework to systematically gather Evidence-based information to support this change in practice. The implemented project utilizes the best evidence in practice and changed infection control awareness in the Long Term Care Facility. In the end, the project promotes better health and wellness for our seniors.

Abstract• Infection control remains the single most important aspect for

disease prevention. Within the boundaries of the Long Term Care Facility (LTCF), infection control education remains inferior to that of the acute care facilities. While assessing the need for change in practice, we realized a design for change was needed specific to increasing education for a superior plan regarding infection control (CDC, 2007). External data obtained from local hospitals were far superior to the internal education supported in the LTC sector. In the LTCF, the elderly are highly susceptible to influenza (flu) and those around them should be conscious of ways to help their loved ones remain healthy (Girabaldi, 1999). Through education of internal and external customers, we can decrease the amount of flu or flu-like symptoms. Visual reminders as well as written education will be a constant reminder on the importance of continued vigilance on infection control prevention.

References

• Advisory Committee et al (2007). Prevention and control of influenza. MMWR, 56(RR06), 1-54. Retrieved on September 19, 2011, from Google Scholar.

http://www.cdc.gov/MMWR/Preview/mmwrhtml/rr5606a1.htm• Barker, J., Stevens, D, Bloomfield, S. (2001). Spread and prevention of some

common viral Infections in community facilities and domestic homes. Journal of Applied Microbiology, 91, 7-21. Retrieved September 20, 2011 from EBSCohost.

http://h1n1.fsu.edu/doc/Virus%20prevention%20-%20good%20summary.pdf• Centers for Disease Control and Prevention. (2007). CDC guidelines and

recommendations. Retrieved September 10, 2011, fromhttp://www.cdc.gov/flu/professionals/infectioncontrol/pdf/longtermcare.pdf

• Center for Disease Control and Prevention. (2010). Prevention Strategies for Seasonal Influenza in Health care Settings. Centers for disease control and prevention. Retrieved on September 20, 2011, from the Nursing reference Center.http://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm

References• Girabaldi, RA (1999). Residential care and the elderly: the burden of infection.

Retrieved September 10, 2011, fromhttp://www.ncbi.nlm.nih.gov/pubmed/10658754

• Jefferson, T, D. M.A. (2010, July). Physical intervention to interrupt or reduce the spread of Respiratory viruses: a Cochrane review. Retrieved September 10, 2011, from

http://www/ncbi.nlm.nih.gov/pubmed/20648717• Sjogren, P., Nilsso, E., Forsell, M., Johansson, O., Hoogstraate, J. (2008). A systemic

review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials. Journal of the American geriatrics society, 56(11) 2124-2130. Retrieved September 20, 2011, from Google Scholar.

• http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2008.01926.x/full