Healthcare-Associated Infections: Knowledge, Training, and Practice of Resident Physicians

(1) Infection Prevention and Control, (2) Medical Education, (3) Internal Medicine, (4) Emergency Medicine, (5) Surgery, (6) Pediatrics, (7) Family Medicine, (8) Obstetrics and Gynecology, (9) Podiatry, (10) Transitional Year Programs, St John Hospital and Medical Center, Detroit, Michigan

Mohamad G Fakih, MD, MPH1*, Steven Minnick, MD, MBA2, Karen Hagglund, MS2, Raymond Hilu, MD3, Patricia Nouhan, MD4, Elango Edhayan, MD5, Douglas Ziegler, MD6, Mark Paschall, MD7, Michael Prysak, MD8, Stuart Wertheimer, DPM9, Adonis Lorenzana , MD10

Discussion

RPs play a significant role in the prevention of HAI. Ensuring adequate knowledge, evaluating competencies, and assessing RP practice are key to efforts geared towards preventing CAUTI, CLABSI, SSI, and VAP. Opportunities for improvement in CAUTI prevention include education on the appropriate indications for urinary catheter use, examining the need of training RPs with limited exposures to urinary catheter placement procedures (e.g., considering simulation), and encouraging daily evaluation of further device need. RPs varied in their reporting of training for CVC placement, and many of the nonsurgical specialties had limited numbers of CVCs placed per year. Furthermore, the use of ultrasound varied depending on the specialty. Simulation and the using ultrasound guidance during CVC placement may reduce complication risks and prevent RPs from resorting to less than optimal lines (e.g. femoral). Additional opportunities reside in improving the use of the checklist and the daily evaluation of catheter necessity. For SSI prevention, ensuring competencies related to antiseptic surgical site preparation will improve the practice in surgery and likely lead to lower SSI risk. Further education may be sought for the type of antimicrobial prophylaxis used, the duration, and redosing incases with prolonged duration. Additional measures include education on risks related to surgical technique and OR traffic. For VAP prevention, we suggest providing more formal training of risks for VAP, and promoting the importance of prompt extubation when possible. Finally, we identified areas for improvement for VAP diagnosis for the different programs surveyed.

Table 2: Prevention of CLABSI:

Conclusions For hospitals that train RPs, it is important to link the education to competencies and practice. Evaluating RP knowledge and practice are important steps to start improvement efforts. With gaps identified, we plan to address them for each residency program through education and reassess any changes over time. Future efforts may focus on integrating certain areas in the Milestone process that all programs are expected to implement.

Mohamad G. Fakih, MD, MPH

19251 Mack Ave, Suite 190

Grosse Pointe Woods, MI 48236

mohamad.fakih@stjohn.org

Abstract: Background: Healthcare-associated infections (HAIs) lead to significant morbidity and mortality. Improving the knowledge and practice of resident physicians (RPs) helps reduce risk to patients. Methods: We administered a web-based survey to 194 RPs of 8 different specialty programs to evaluate knowledge and practice to prevent 4 HAIs. The 50 questions addressed preventing infection related to urinary catheters (UCs), central lines, ventilators, and surgical site. Each of the programs had additional questions specific to their specialty. Results: 183 (94.3%) RPs completed the survey. The mean ± SD reported hand hygiene by RPs was 85.3% ±16.2%. Knowledge and practice varied depending on specialty and HAI type. RPs reported knowledge of the appropriate indications for urinary catheter (UC) use in 64/127 (50.4%), with 55/127 (43.3%) having formal training on placement and maintenance of UCs. Only 34/98 (34.7%) RPs would assess daily for UC necessity >70% of the time and 47/115 (40.9%) would evaluate patients for UC need at the time of transfer out of intensive care >70% of the time. Although 83/98 (84.7%) reported knowing the proper insertion technique of a central line, only 78/98 (79.6%) would use chlorhexidine-alcohol for antisepsis. 40/98 (40.8%) RPs would stop and call for help after 2 attempts for placing a central line, 37/98 (37.8%) after 3 attempts, and 10/98 (10.2%) after 4 or more attempts. For RPs who performed surgical procedures, only 47/76 (61.8%) reported formal training on antisepsis of operative site, and only 17/76 (22.4%) reported documenting competence under supervision before performing the procedure independently. Interestingly, 42/76 (55.3%) were responsible for the antisepsis preparation of operative site in >70% of the time. 41/104 (39.4%) RPs reported being formally trained on preventing pneumonia in the mechanically ventilated, but only 51/104 (49%) would evaluate patients for head of bed elevation >70% of the time. Conclusions: Evaluating RP knowledge and practice is an important step to identify target areas for improvement efforts. With gaps identified, we plan to address them for each residency program through education and reassess any changes over time.

Results: •  183/194 (94.3%) of RPs completed the survey (response rates per program range

50-100%). When asked about their compliance with hand hygiene, RPs had a mean of 85.3% (surgery 79.2%, internal medicine 82.3%, pediatrics 92.7%, family medicine 85.2%, podiatry 80.7%, emergency medicine 87%, OB/GYN 92.1%, and transitional 82.5%). Podiatry RPs only answered questions related to SSI.

•  The results of the survey showed that RPs of some specialties (e.g., surgery) felt that they had formal training on the procedures; in addition, they reported doing more procedures that RPs from the different specialties. Each table represents the answers of the RPs to the specific questions. The denominator varied depending on the responses and we also provide the percentages of responses excluding those who answered N/A.

Table 1: Prevention of CAUTI:

ID Week 2013 Session 46; Presentation #209

Background: Healthcare associated infections are associated with significant morbidity and mortality. Patients are exposed to multiple risks during hospitalization including invasive devices and surgical procedures. The Centers for Medicare and Medicaid Services have established efforts to address healthcare associated infections through “Partnership for patients”. Twenty-six Hospital Engagement Networks (HEN) have been created to address hospital-acquired conditions including 4 infections: central line associated blood stream infections (CLABSI), catheter associated urinary tract infection (CAUTI), ventilator associated pneumonia (VAP), and surgical site infection (SSI). Resident physicians are involved in many of the procedures and affect outcomes. A first step to work on reducing risk to patients is evaluating the knowledge and practice of healthcare workers involved in the care. We evaluated the resident physician knowledge, training, and practice related to CLABSI, CAUTI, VAP, and SSI.

Methods:

§  We created different surveys for the training specialties that address CLABSI, CAUTI, VAP and SSI. The surveys included different scenarios with yes and no answers, in addition to multiple choice and Likert scale answers. Residents were sent a total of 3 emails (one per week) to encourage the completion of the survey. Prior to administering the survey, we piloted the survey on recently graduated physicians for clarity and any feedback. The 8 programs included internal medicine, surgery, pediatrics, family medicine, emergency medicine, Obstetrics/Gynecology, podiatry and transitional year. The surveys had also questions related to the different specialties.

Table 4: Prevention of VAP:

Table 3: Prevention of SSI: