Infection Control & Hospital Epidemiology (2019), 40,95–99 doi:10.1017/ice.2018.308
Commentary
Infection prevention in long-term care: re-evaluating the system using a human factors engineering approach
Morgan Jane Katz MD, MHS1 and Ayse P Gurses PhD, MS, MPH2 1Johns Hopkins University, Baltimore, Maryland and 2Johns Hopkins Armstrong Institute Center for Health Care Human Factors, Baltimore Maryland
Abstract
The emergence and spread of extensively multidrug-resistant organisms is a public health crisis, and long-term care settings have been identified as a reservoir for the cultivation of these organisms. Long-term care settings are now taking on increasingly ill residents with complicated medical problems, indwelling devices, and significant healthcare exposure, all of which are considered risk factors selecting for resistant organisms. Despite this, guidelines addressing infection prevention procedures in long-term care remain vague, and implementation of these guidelines is challenging, largely due to staff turnover, limited resources, knowledge gaps, and lack of organizational support. Human factors engineering approaches have emerged as an important innovation to address patient safety issues and develop interventions in the healthcare work system (ie, tools and technologies, tasks, organization, physical environment) that support human performance, which, in turn, lead to improvements in processes (eg, compliance with infection prevention guidelines) and outcomes (eg, reduced infection rates). We propose the concept of using the methods and approaches from the scientific field of human factors engineering to address the unique challenges of implementing infection prevention in the long-term care setting.
(Received 31 July 2018; accepted 27 October 2018; electronically published 21 November 2018)
Rising healthcare costs and emphasis on pay for performance measures have led to a shift in health care, with a push to transfer patients to long-term care facilities (LTCFs) earlier to meet quality benchmarks and reduce mortality rates and length of stay. Exceedingly frail and debilitated patients are being transferred from acute care to the long-term care setting without any cor- responding changes or infrastructure development to support the increased workload imposed on LTCFs. With these changes, we have seen a rise in infection and colonization with multidrug- resistant organisms (MDROs) in residents in LTCFs1; this is likely due to a multiple-array and complex set of underlying factors given the complex, demanding, and typically underresourced nature of LTCFs. For example, high MDRO rates in these facilities are driven not only by inadequate infection control practices but also by poor antibiotic prescribing practices. Up to 75% of anti- biotic prescriptions ordered in the long-term care setting are considered unnecessary or inappropriate,2,3 and antibiotic stew- ardship programs are only just being developed in most LTCFs. Ambiguity regarding healthcare professionals’ roles, infection control procedures, and appropriate antibiotic prescribing prac- tices in long-term care is pervasive, and we do not yet understand how to address this from a patient safety perspective. In this article, we posit that human factors engineering (HFE) approaches and methods can be effective in improving infection control and antibiotic prescription practices in LTCFs. The International Ergonomics Association defines HFE as “the
Author for correspondence: Morgan Katz, Johns Hopkins Bayview, 5200 Eastern Avenue, MFL Building Rm 381, Baltimore MD 21224. E-mail:
mkatz26@jhmi.edu Cite this article: Katz MJ, Gurses AP. (2019). Infection prevention in long-term care:
re-evaluating the system using a human factors engineering approach. Infection Control & Hospital Epidemiology 2019, 40, 95–99. doi: 10.1017/ice.2018.308
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
scientific discipline concerned with the understanding of inter- actions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance.”4 Furthermore, HFE can be an important innova- tion in developing and implementing safety improvement stra- tegies in LTCFs.5 This discipline allows us to better understand how the characteristics of the individual work system elements (eg, cluttered supply closet) and their interactions with each other (eg, insufficient time to obtain materials) contribute to the safety and quality of processes (eg, patient care completed without proper sterile materials) and outcomes of the system as a whole. This process, in turn, can help us to develop effective solutions to reduce or mitigate the effects of safety risks, while considering the realities of the ‘work’ and simultaneously aiming to minimize the unintended consequences of proposed interventions.
Infection Prevention Challenges in Long-Term Care
Although acute-care hospitals have relatively well-established infection prevention protocols delineating appropriate hand hygiene, personal protective equipment (PPE), and isolation and cohorting procedures, these interventions are more of a challenge in LTCFs. In LTCFs, enhancing socialization and quality of life for residents is a priority, access to diagnostic tests is often lim- ited, there is little or no antibiotic stewardship, and the patient population is more complex and fragile due to advanced age and prolonged healthcare exposure.5 Minimal evidence has emerged to address MDRO transmission in nursing homes, and clear guidelines regarding infection prevention in this setting are
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131 |
Page 132 |
Page 133 |
Page 134 |
Page 135 |
Page 136
