Understanding the current state of infection prevention to prevent Clostridium difficile infection: a human factors and systems engineering approach.
BACKGROUND
Achieving and sustaining high levels of health care worker (HCW) compliance with contact isolation precautions is challenging. The aim of this study was to determine HCW work system barriers to and facilitators of adherence to contact isolation for patients with suspected or confirmed Clostridium difficile infection (CDI) using a human factors and systems engineering approach.


METHODS
This prospective cohort study took place between September 2013 and November 2013 at a large academic medical center (hospital A) and an affiliated Veterans Administration hospital (hospital B). A human factors engineering (HFE) model for patient safety, the Systems Engineering Initiative for Patient Safety model, was used to guide work system analysis and direct observation data collection. There were 288 observations conducted. HCWs and visitors were assessed for compliance with all components of contact isolation precautions (hand hygiene, gowning, and gloving) before and after patient contact. Time required to complete contact isolation precautions was measured, and adequacy of contact isolation supplies was assessed.


RESULTS
Full compliance with contact isolation precautions was low at both hospitals A (7%) and B (22%). Lack of appropriate hand hygiene prior to room entry (compliance for hospital A: 18%; compliance for hospital B: 29%) was the most common reason for lack of full compliance. More time was required for full compliance compared with compliance with no components of contact isolation precautions before patient room entry, inside patient room, and after patient room exit (59.9 vs 3.2 seconds, P < .001; 507.3 vs 149.7 seconds, P = .006; 15.2 vs 1.3 seconds, P < .001, respectively). Compliance was lower when contact isolation supplies were inadequate (4% vs 16%, P = .005).


CONCLUSIONS
Adherence to contact isolation precautions for CDI is a complex, time-consuming process. HFE analysis indicates that multiple work system components serve as barriers and facilitators to full compliance with contact isolation precautions and should be addressed further to prevent CDI.
Department of Medicine, William S. Middleton Memorial Veterans Hospital, Madison, WI.
Eric
E
Yanke
College of Agricultural and Life Sciences, University of Wisconsin-Madison, Madison, WI.
Caroline
C
Zellmer
Department of Infection Control, University of Wisconsin Hospital and Clinics, Madison, WI.
Sarah
S
Van Hoof
Villanova University College of Nursing, Villanova, PA; Philadelphia Veterans Affairs Medical Center, Philadelphia, PA.
Helene
H
Moriarty
Department of Industrial and Systems Engineering, Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI.
Pascale
P
Carayon
William S. Middleton Memorial Veterans Hospital, Madison, WI; Division of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School, Madison, WI; Infection Control Department, University of Wisconsin-Madison, Madison, WI. Electronic address: ns2@medicine.wisc.edu.
Nasia
N
Safdar
D000046:Academic Medical Centers; D016360:Clostridioides difficile / Q000302:isolation & purification*; D003015:Clostridium Infections / Q000382:microbiology / Q000517:prevention & control*; D015331:Cohort Studies; D003428:Cross Infection / Q000382:microbiology / Q000517:prevention & control*; D003967:Diarrhea / Q000382:microbiology / Q000517:prevention & control*; D019983:Guideline Adherence; D006787:Hospitals, Veterans; D006801:Humans; D017053:Infection Control / Q000379:methods*; D061214:Patient Safety; D011446:Prospective Studies
Clostridium difficile; Contact precautions; Human factors; Infection control; Systems engineering