The compliance coach: A bedside observer, auditor, and educator as part of an infection prevention department's team approach for improving central line care and reducing central line-associated bloodstream infection risk

When Auditing Is Not Enough: Analysis of a Central Line Bundle Audit Program

BACKGROUND

Bundled interventions and auditing have been recommended to reduce central line-associated bloodstream infection (CLABSI) events at acute care hospitals. We review the outcomes of a bundle audit program at an adult and pediatric academic medical center from April 1, 2021, to May 31, 2022.

OBJECTIVES

To analyze the impact on CLABSI rates following the introduction of a central line maintenance bundle audit process.

METHODS

All audit survey data, CLABSI event rates, and line days were collected. Statistical relationships were evaluated for CLABSI bundle performance with CLABSI rates and audit volume with CLABSI rates. Analyses were conducted at the hospital and unit level.

RESULT

No correlation is found between CLABSI rates and audit performance at the hospital level (adult units, P = .619, r-sq = 2.13%; peds/NICU, P = .825, r-sq = 0.43%) or at the unit level (n = 7; P = .8-.896, r-sq = 0.15%-18.2%). There was no correlation in CLABSI rates when reviewing performance by audit volume at the hospital level (adult, P = .65, r-sq = 1.7%; peds/NICU, P = .677, r-sq = 1.5%) or at the unit level (n = 7; P = .25-.8, r-sq = 1.2%-8.5%). By contrast, a single unit that did not participate in the audit program during the sample period reported a lower CLABSI rate than comparable participating units (P = .008).

CONCLUSION

During the sample period, there was no relationship found between this CLABSI bundle audit program and improvement in CLABSI performance.

A helping hand: The impact of a central line insertion support team

As part of a central line-associated bloodstream infections prevention initiative, our academic medical center formed a dedicated nursing team to assist with central line insertions and provide support with caring for difficult lines and dressings. During the program's first 3 years, the proportion of insertion-related central line-associated bloodstream infections occurring in areas within the team's scope declined overall by 47%.

CLABSI Rounding Team: A Collaborative Approach to Prevention

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) are an ongoing concern in health care, resulting in increased mortality, morbidity, length of stay, and additional costs to hospitals.

LOCAL PROBLEM

Despite intermittent improvements in CLABSI rates within our facility, long-term sustainment has been challenging.

METHODS

This was a quality improvement project including a collaborative rounding approach supported by specialty nursing roles.

INTERVENTIONS

In addition to implementing a variety of evidence-based interventions, the rounding team performed audits to assess performance and created focused education tools to address the identified opportunities within each individual unit.

RESULTS

High levels of engagement as evidenced by increased audit completion resulted in CLABSI reductions. However, 2 peaks in CLABSI rates were associated with higher volumes of coronavirus disease (COVID-19) hospitalizations and decreased audits.

CONCLUSIONS

Despite challenges correlated with COVID-19, a collaborative rounding team promotes and enhances awareness of prevention methods and a culture of safety.

Content and Actionability of Recommendations to Providers After Shadow Coaching

BACKGROUND AND OBJECTIVES

Health care organizations track patient experience data, identify areas of improvement, monitor provider performance, and assist providers in improving their interactions with patients. Some practices use one-on-one provider counseling ("shadow coaching") to identify and modify provider behaviors. A recent evaluation of a large shadow coaching program found statistically significant improvements in coached providers' patient experience scores immediately after being coached. This study aimed to examine the content of the recommendations given to those providers aimed at improving provider-patient interactions, characterize these recommendations, and examine their actionability.

METHODS

Providers at a large, urban federally qualified health center were selected for coaching based on Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) patient experience scores (92 of 320 providers), shadowed by a trained peer coach for a half to full day and received recommendations on how to improve interactions with their patients. We coded 1082 recommendations found in the 92 coaching reports.

RESULTS

Reports contained an average of 12 recommendations. About half encouraged consistency of existing behaviors and half encouraged new behaviors. Most recommendations related to behaviors of the provider rather than support staff and targeted actions within the examination room rather than other spaces (eg, waiting room). The most common recommendations mapped to behavioral aspects of provider communication. Most recommendations targeted verbal rather than nonverbal communication behaviors. Most recommendations were actionable (ie, specific, descriptive), with recommendations that encouraged new behaviors being more actionable than those that encouraged existing actions.

CONCLUSIONS

Patient experience surveys are effective at identifying where improvement is needed but are not always informative enough to instruct providers on how to modify and improve their interactions with patients. Analyzing the feedback given to coached providers as part of an effective shadow-coaching program provides details about implementation on shadow-coaching feedback. Recommendations to providers aimed at improving their interactions with patients need to not only suggest the exact behaviors defined within patient experience survey items but also include recommended behaviors indirectly associated with those measured behaviors. Attention needs to be paid to supplementing patient experience data with explicit, tangible, and descriptive (ie, actionable) recommendations associated with the targeted, measured behaviors. Research is needed to understand how recommendations are put into practice by providers and what motivates and supports them to sustain changed behaviors.

Provider and coach perspectives on implementing shadow coaching to improve provider-patient interactions

BACKGROUND

Healthcare organizations want to improve patient care experiences. Some use 'shadow coaching' to improve interactions between providers and patients. A Federally Qualified Health Center (FQHC) implemented a half-day observation of individual primary-care providers by a 'shadow coach' during real-time patient visits, including an in-person verbal debrief afterwards and a written report with specific recommendations. Shadow coaching identified areas for improvement. We aimed to characterize lessons and barriers to implementing shadow coaching as a mechanism to improve interactions with patients and change organizational culture.

METHODS

We examined provider and coach perceptions of shadow coaching through interviewing coached providers, stratified by provider type and Consumer Assessment of Healthcare Providers and Systems (CAHPS) performance, and the coaches who coached the most providers. We interviewed 19 coached providers and 2 coaches in a large, urban FQHC. Content analysis identified implementation barriers, facilitators and themes.

RESULTS

Coaches reported needing 'buy-in' throughout the organization and the need to be credible and empathize with the providers being coached. Most providers reported behaviour changes based on recommendations. Almost all providers recalled at least one coaching recommendation that was actionable. Providers and coaches highlighted patient-level and practise-level barriers that impeded their ability to implement recommended improvements. CAHPS data was reported as an effective performance management metric for measuring change, counselling providers, and evaluating provider-level efforts but was not always specific enough to yield tangible recommendations.

CONCLUSIONS

Regular messaging by leadership about the priority and purpose of shadow coaching was essential for both physician engagement and its mature implementation across the organization. Coaching could be embedded into a long-term strategy of professional development with periodic re-coaching. Re-coaching sessions could target issues raised by providers, such as dealing with difficult patients or specific populations. Research on the timing and content of re-coaching is needed.

Prevention of Central-Line Associated Bloodstream Infections: 2021 Update

Despite a large volume of research in prevention, central line-associated bloodstream infections and catheter-related bloodstream infections continue to cause significant morbidity, mortality, and increased health care costs. Strategies in prevention, including decision about catheter placement, insertion bundles, adherence to standard of care guidelines, and technologic innovations, shown to decrease rates of catheter-related bloodstream infections and central line-associated bloodstream infections are described in this update. The coronavirus disease 2019 pandemic has resulted in increased health care-acquired infections, including central line-associated bloodstream infections.

Shadow Coaching Improves Patient Experience With Care, But Gains Erode Later

BACKGROUND

Health care organizations strive to improve patient care experiences. Some use one-on-one provider counseling (shadow coaching) to identify and target modifiable provider behaviors.

OBJECTIVE

We examined whether shadow coaching improves patient experience across 44 primary care practices in a large urban Federally Qualified Health Center.

RESEARCH DESIGN

Seventy-four providers with "medium" (ie, slightly below average) overall provider ratings received coaching and were compared with 246 uncoached providers. We fit mixed-effects regression models with random effects for provider (level of treatment assignment) and fixed effects for time (linear spline with a knot and "jump" at coaching date), patient characteristics and site indicators. By design, coached providers performed worse at selection; models account for the very small (0.2 point) regression-to-the-mean effects. We assessed differential effects by coach.

SUBJECTS

A total of 46,452 patients (from 320 providers) who completed the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) Visit Survey 2.0.

MEASURES

CAHPS overall provider rating and provider communication composite (scaled 0-100).

RESULTS

Providers not chosen for coaching had a nonsignificant change in performance during the period when selected providers were coached. We observed a statistically significant 2-point (small-to-medium) jump among coached providers after coaching on the CAHPS overall provider rating and provider communication score. However, these gains disappeared after 2.5 years; effects differed by coach.

CONCLUSIONS

Shadow coaching improved providers' overall performance and communication immediately after being coached. Regularly planned shadow coaching "booster" sessions might maintain or even increase the improvement gained in patient experience scores, but research examining additional coaching and optimal implementation is needed.

Management practices for leaders to promote infection prevention: Lessons from a qualitative study

BACKGROUND

Prevention of healthcare-associated infections (HAIs) is critical to reduce preventable deaths and healthcare costs. Variable success with HAI prevention efforts has suggested that management practices are critical to support clinical infection prevention practices. This study examined hospital leaders' management practices around the prevention of catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs) to identify actions that leaders can take to promote HAI prevention efforts.

METHODS

We conducted interviews with 420 key informants, including managers and frontline staff, in 18 hospitals across the United States. Interviewees were asked about management practices supporting HAI prevention. We analyzed interview transcripts using rigorous qualitative methods to understand how management practices were operationalized in infection prevention efforts.

RESULTS

Across hospitals and interviewees, three management practices were characterized as important facilitators of HAI prevention: (1) engagement of executive leadership; (2) information sharing; and (3) manager coaching. We found that visible executive leadership, efficient communication, and frequent opportunities to provide and promote learning from feedback were perceived to promote and sustain HAI prevention efforts.

CONCLUSIONS

Our findings provide insight into management practices for leaders that support successful HAI prevention. In practice, these tactics may need to be adjusted to accommodate the current restrictions caused by the COVID-19 pandemic, in order to maintain HAI prevention efforts as a priority.

Evaluation of neutrophil–lymphocyte ratio in predicting bloodstream infection

Aim: The prognostic role of neutrophil-to-lymphocyte ratio (NLR) in bloodstream infection (BSI) deserves further investigation. Patients & methods: The NLR values were measured and compared in BSI patients and healthy controls. The receiver operating characteristic of NLR and cut-off values were measured in BSI patients and subgroups. Results: We have measured the NLR of study group with 2160 BSI patients and normal group with 2523 healthy controls, which was significantly high in study group (11.36 ± 21.38 vs 2.53 ± 0.86; p < 0.001) and the area under the curve was 0.834 (95% CI: 0.825–0.842; p < 0.001). The critical value of NLR for diagnosis of BSI was 3.09, with a sensitivity of 75.3%, and a specificity of 93.6%. Conclusion: NLR is an effective diagnostic indicator of including BSIs of Gram-negative bacteria, Gram-positive bacteria and fungus.