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lacking.7–10 Interventions targeting MDROs in LTCFs with uni- versal screening and decolonization for MRSA or staff training have been largely unsuccessful.11–14 This has been attributed mainly to poor compliance by the nursing staff, as well as limited buy-in and support from management, both of which support a role for HFE-based analysis of contributing work-system factors and redesign of the work system.15 Intervention appropriateness and implementation issues may be major factors as well. LTCFs often do not have active surveillance programs, infection control and infectious diseases personnel resources are often limited, and communication during care transitions between facilities is poor. Therefore, MDRO colonization status in LTCFs is largely unknown.6
Applying Human Factors Engineering to Infection Prevention Practices
Using an HFE approach to improve infection prevention practices and antibiotic stewardship in LTCFs allows us to better under- stand the individual work system elements, their interactions, and their dynamic input on system processes and outcomes, and to develop more effective, sustainable solutions. Several recognized factors make compliance with infection prevention challenging from an HFE perspective.5 For example, in general, there is a cognitive disconnect and time lag between the impact of infection control tasks and safety of patient care.16 Tasks associated with infection prevention, unlike many other healthcare-related tasks, such as inserting an IV line or suctioning a tracheostomy, do not have a direct or immediate observable result. If a healthcare worker (HCW) does not perform hand hygiene and then provides patient care, which consequently leads to transmission of infec- tion, the infection is not observed until a later time, with no clear connection with the initial breach in technique. By the time the infection is recognized, days later, the personal identification with the outcome is either lost or impossible to make due to many other infection control breaches that may have occurred. The delayed nature of this feedback, even if it may be clearly linked to the source, makes it difficult to motivate the HCW in the face of other (presumably more pressing) tasks. Concordantly, it is challenging to connect infection prevention practices with a tangible positive result. The desired outcome in infection pre- vention is, in fact, the lack of an undesirable outcome (ie, transmission of infection), making positive feedback challenging. Time pressure and task complexity are also common pro-
blems, particularly with the recent shift to an increasingly ill patient population in LTCFs. Thus, HCWs are assuming more complicated tasks, including central-line maintenance and ven- tilator maintenance, which were rarely required in this setting previously. Furthermore, staff in LTCFs are notoriously over- worked, with a high resident-to-HCW ratio and multiple responsibilities.17 In the face of a growing list of tasks, infection prevention procedures are often overlooked due to time con- straints and the risk of interrupting the care process. For example, hand hygiene can be viewed by the HCW as a distraction or interruption from what they may perceive as their actual duty, such as administering a medication, and their focus on com- pleting that task may lead them to forgo infection prevention precautions. Due to the delay in or lack of feedback or a clear output, infection prevention may be considered an interruption to the real task; leading the HCW to abandon infection prevention
Morgan Jane Katz and Ayse P. Gurses
precautions. HFE can help us to better understand why HCWs behave or choose to do a task in a certain way given the system design, and thereby identify how to redesign the LTCF work system to better facilitate infection prevention and control.
Applying the SEIPS Model to Infection Control in Long-Term Care
The Systems Engineering Initiative for Patient Safety (SEIPS) is a human factors model that uses an engineering approach to patient safety to delineate ways to improve the system as a whole.18 Human factors engineers assess complex work systems, such as LTCF settings, applying their knowledge of human lim- itations and abilities to reduce safety risks to patients and care providers. This approach can be used systematically to identify specific barriers that may inhibit proper functioning of the work system and to design appropriate interventions based on the barriers identified. The SEIPS model proposes that the following 5 work system components continuously interact and influence one another: tools and technologies, tasks, organizational conditions, person(s), and the physical environment. Changes to any or multiple aspects of these components may either positively or negatively affect the resulting processes, and therefore patient, professional, or organizational outcomes.18 This approach can be applied to infection prevention processes in an LTCF to under- stand the key barriers and facilitators that may be affecting practice and resulting in transmission of resistant organisms (Fig. 1).18 Consider the process of effectively instituting the use of con-
tact precautions in an LTCF. Communication from the acute-care hospital transferring the resident to the LTCF may be inadequate, resulting in the resident being transferred without a designated MDRO colonization flag (external environment). The signage used to show that a resident should be on contact precautions may be confusing or unavailable (tools and technology). The facility itself may not endorse contact precautions due to the risk of resident stigma (organization). The nurse taking care of the patient may have limited training in appropriate infection pre- vention practices (person). The act of putting on the gowns and gloves prior to every room entry may be too arduous due to limited time and staffing (task). According to the SEIPS model, all these components and their interactions with each other must be considered to determine feasible and appropriate interventions while preventing introduction of unintended risks to the system. By analyzing each of these contributing components, human factors engineering approach takes in to account both macro-level factors (ie, the underlying culture of the facility) and micro-level factors (eg, design characteristics of contact precautions signage) in a work system, which may be contributing to the care processes and outcomes. This same conceptual approach can also be applied to the
pressing issue of improving antibiotic stewardship practices in an LTCF (Table 1). Consider the common LTCF practice of collec- tion of a urine culture (process). The nurse may prompt the order for a urine culture due to requests from the family for evaluation of a change in urine consistency or smell (people). While guidelines do not indicate the need for testing for foul-smelling urine or changes in consistency without associated symptoms, the HCW may feel inclined to obtain the urine culture due to family pressure or due to a lack of his or her own knowledge of the
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