Do you know where your flagged MDRO pts are?
Hint: They may not be in isolation
With the increasing reliance on computer tools and electronic records, infection preventionists may reasonably assume patients flagged for isolation on admission end up under the appropriate precautions.
For example, a patient admitted with a history of methicillin-resistant Staphylococcus aureus (MRSA) or some other multidrug resistant organism (MDRO) has their electronic record red flagged, contact isolation is instituted upon admission to a private room, other patients are protected from cross transmission and all is right with the world. Let us pause for a moment to return somewhat jarringly to reality, courtesy of Emily Landon Mawdsley, MD, hospital epidemiologist at the University of Chicago Medical Center.
"When I was a resident in infectious diseases it struck me that many times when I was seeing a patient who had been admitted to a semiprivate, double-patient room with no isolation precautions, I looked at their medical record and it looked like they had MRSA or something like that during a previous admission," she tells Hospital Infection Control & Prevention.
This was odd because the patient admission had been electronically red flagged signaling placement under contact isolation. But the message did not compute at the "bed desk" level, where the flags were ignored or overridden by staff. "[Some of] the nurses were not aware of the meaning of the electronic isolation flag that was showing up on their census report," Mawdsley discovered. "So there was an educational problem and a systems issue that needed to be fixed."
Infection preventionists need look no further than hand hygiene to realize a seemingly simple directive can suffer such a major breakdown. Moreover, as Mawdsley began resolving the situation and talking to colleagues at other hospitals it became clear that such gaps are all too common.
"They say, 'We have an electronic system so all that is taken care of,'" she says, describing a typical exchange. "I say, 'Did you go check the patients?' and they say, 'No, why would we do that. We have a flag.' A flag may not be enough, so other hospitals may have problems. I think it's pretty common. People in infection control have been doing performance improvement for a long time, but sometimes we skip circling back and move on to our next priority."
Worth time to do, time to check
This lesson could apply to all manner of interventions, as IPs try to "sustain the gain" of their various and sundry efforts.
"We keep this long list of projects that we have started in the past. We periodically do surveillance to make sure they are still happening," she says. "Because if it was worth your time to do it originally, it is worth your time to make sure it is still happening. Otherwise, you will find yourself having to do a new initiative later on."
In this particular case, the infection control team at the medical center attacked the problem, breaking down the process and ensuring from the onset that they were reviewing daily microbiology laboratory reports, and electronically flagging medical records of MDRO patients. Upon investigation, infection control personnel learned that bed desk attendants often removed electronic isolation flags if the physician's orders did not request isolation. To address this issue, they held a brief meeting with admissions staff to educate them about the importance of isolation and explain that the system would be changed to prevent overrides. Some nurses did not know how to find the flag on the patient census, while others did not realize that they could order isolation themselves — without a physician order.
"Education as a tool only goes so far — it still relies on an individual who has multiple competing responsibilities and priorities to remember something," Mawdsley says. "And there's always new information coming out about what they need to remember. So systems based solutions often work better. In this case, however, we felt like we already had a good systems based solution with this flag — and it wasn't working. We wanted to figure out a way to make this happen."
To ensure compliance, hospital IPs began doing weekly surveillance rounds to see if contact precautions are indeed in place for each flagged patient. If not, they ask nurses to arrange such precautions and provide education to improve future adherence.
"So it was targeted education whenever there was an error," she says. "It took about 20 minutes per IP per week, which ended being about 2 hours total for our 600-bed hospital."
The program led to a significant, sustained increase in adherence to contact precautions, with the percentage of flagged patients appropriately in isolation rising from 58% to 90% 16 weeks after program launch. The project was recently recognized and recommended by the Agency for Healthcare Research and Quality.