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How Yellow Tape Can Improve Healthcare Facility Resources and Healthcare Worker Efficiency for Contact and Contact-Enteric Precaution Patients
by
Tanya Staton
B.S., Clemson University, 2005
Applied Research Project Paper
Submitted in Partial Fulfillment
of the Requirements for the Degree of
Master in Public Health
Concordia University, Nebraska
April 2015
Abstract
Contact and contact-enteric precautions are healthcare isolation protocols that reduce the chance that germs will spread to hospital staff and patients. Patient care can decrease when patients are placed on isolation precautions because hospital staff generally finds the required personal protective equipment (PPE) a burden, so they do not observe or communicate with their patient as often as a non-isolated patient. Creating safe zones for patients on contact and contact-enteric precautions improves the utilization of the healthcare facility resources and healthcare worker efficiency through improved communication and observation with patients, decreased PPE cost and does not increase infection rates. A 2-month study was conducted at AnMed Health Medical Center in South Carolina to determine if safe zones would indeed be beneficial in improving patient care. An experimental unit did not have to wear PPE if they never crossed the yellow tape trialed for the safe zones, and a control unit continued precaution protocols as before implementation. During the trial, surveys where given to staff members in the experimental unit to determine satisfaction scores since implementation. Both units were also evaluated to see if there was a decrease or increase in infection rates since implementation. Costs were examined to see how much money could be saved with safe zone use. The results revealed that PPE costs inthe experimental unit were reduced since extra PPE did not have to be purchased. Staff was in favor of safe zones and 80% wanted the practice to continue on their unit. Finally, there was no change in infection rates from the experimental unit compared with the control unit. Safe zones are helpful in improving patient care, while also keeping infection rates and costs down. These results suggest that safe zones should be considered for widespread use in a healthcare setting.
Table of Contents
List of Figures
Chapter 1: Introduction to the Applied Research Project
Background of Applied Research Project
Thesis Statement
Purpose of the Study
Research Questions and Hypotheses
Theoretical Base
Definition of Terms
Assumptions
Limitations
Delimitations
Significance of the Study
Summary of Chapter 1
Chapter 2: Literature Review
Introduction
Body of Review
Increased Observation and Communication between Patient and Staff…………
Improving Healthcare Worker Resources………………………………………..
Improves HCW Efficiency and Satisfaction……………………………………..
Limitations noted………………………………………………………………...
Summary
Chapter 3: Research Method Introduction
Setting………………………………………………………………………………..
Participants
Intervention
Materials and Instrumentation
Procedure
Data Analysis
Ethical Considerations
Chapter 4: Results
Introduction
Data Results
Comparing PPE Costs:…………………………………………………………...
HCW Surveys:…………………………………………………………………...
Hospital Acquired Infection Rates:………………………………………………
Summary
Chapter 5: Discussion, Conclusions, and Recommendations
Introduction
Interpretation of Findings
Limitations
Summary
Recommendations for Action
Recommendations for Further Study
Appendices
Appendix A
Appendix B
References
List of Figures
Figure 1. AnMed Health’s Safe Zone...... 3
Figure 2. Trinity Regional’s Red Box...... …….14
Figure 3. December PPE Data……………………………………………………………29
Figure 4.Communication Change………………………………………………………..31
Figure 5. Observe Patient More…………………………………………………………..31
Figure 6. Hand Hygiene…………………………………………………………………..32
Figure 7. Time Savings…………………………………………………………………...33
Figure 8. PPE Comfort……………………………………………………………………33
Figure 9. Safe Zone Compliance…………………………………………………………..34
Figure 10. Safe Zone Continuation………………………………………………………..35
Figure 11. Number of Admissions………………………………………………………...36
Figure 12. Number of HAIs……………………………………………………………….37
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Chapter 1: Introduction to the Applied Research Project
Antimicrobial resistance or resistance to bacteriais evolving not only in acute-care settings, like hospitals, but also within the community.Resistance to bacteria can lead to community and healthcare associated infections (HAIs) that are difficult to treat. These superbugs are emerging everywhere. One in three people are colonized withStaphylococcusaureusin their nasal cavity, and Methicillin-Resistant Staphylococcus aureus (MRSA) is present in about two out of 100 patients (CDC, 2013). MRSA can lead to bloodstream infections, surgical site infections and pneumonia (CDC, 2013).Clostridium difficile (C. diff) is another leading bacterium that causes HAIs, and roughly 14,000 people die annually from the diarrhea associated with the bacteria (CDC, 2011). These organisms are becoming more widespread and are resulting in longer hospital stays and additional healthcare costs to the patient.
AnMed Health Medical Center, a Magnet status hospital in Anderson, South Carolina, is no exception when it comes to diagnosing and treating MRSA or C. diff patients. From January 2014 through September 2014, the healthcare facility reported 36 cases of MRSA and 43cases of C. diff thatwere hospital acquired (Midas, 2014). If a multi-drug resistant organism (MDRO) or a positive C. diff is suspected or confirmedthe patient is placed on isolation precautions to help prevent further spreading of the infection to staff and other patients. Contact precautions are ordered for MDRO patients and contact-enteric precautions are ordered forC. diff patients.
There are specific guidelines to whichhealthcare facilities must adhere to when a patient meets protocol to be put on contact and contact-enteric precautions. According to the Center for Disease Control and Prevention (2007), all clinical and non-clinical staff must wear gloves and an isolation gown when entering a contact and contact-enteric precaution room to prevent the spread of the infectious agent to other staff and patients in the healthcare facility. Contact-enteric precautions are slightly different because bleach wipes are recommended to wipe down equipment and staff must use soap and water upon exiting a patient’s room to ensure C. diff spores have been killed.The established precautions are in place to help decrease the spread of infection rates to protect other patients and health providers. Unfortunately, patient care decreases when patients are on contact precautions due to the barrier of having to don (put on) a gown and gloves before even entering the patient’s room (Kirkland & Weinstein, 1999). Healthcare workers (HCWs) are less likely to round (examine a patient) on contact and contact-enteric precaution patients because of donning (putting on) and doffing (taking off) personal protective equipment (PPE).
A prospective cohort study done at two university-affiliated medical centers concluded that patient care has a tendency to decrease for patients who are on precaution protocols. In the study, attending physicians only examined their contact precaution patients 35 percent of the time compared to 73 percent of the time for those not on any contact precaution (Saint et al., 2003). Another study that was done at Duke University revealed that HCWs were two times less likely to enter a patient’s room that was on contact precautions (Kirkland & Weinstein, 1999). The investigators believed that not only do patients suffer in treatment because they are visited less frequently, but they might also suffer psychologically from being put in an isolated condition (Kirkland & Weinstein, 1999).
Background of Applied Research Project
AnMed Health Medical Center wanted to set a professional goal to keep infection rates low while also improving the patient and staff experience for contact and contact-enteric precaution patients. They decided to develop “safe zones” based on the “Red Box Strategy” that was implemented by Trinity Regional Health Center. Trinity Regional Health Center placed red duct tape on the floor to create a red box inside of a contact precaution room (Franck et al., 2011). HCWs could then communicate with the patient without having to don PPE.AnMed Health is applying the same concept, but instead of using a “red box” the facility is expanding on the idea. AnMed Health is placing a piece of yellow frog tape (painters tape) three feet from the base of the patient’s bed in contact and contact-enteric precaution rooms. By placing the tape three feet from the base of the bed the HCW will be able to have visual contact with the patient and a bigger zone to work in. Figure 1 shows a contact precaution room where the safe zone is being utilized.
Just like the Red Box Strategy that Trinity implemented, staff does not have to don PPE when they are inside of the safe zone. HCWs are not physically coming in contact with the patients,so there should not be an opportunity to spread MDROs or C. diff organisms. Hospital acquired infection rates should not increase because of the new initiative.
There has not been ample research if the Red Box Strategy or safe zones are indeed helpful in contact and contact-enteric precaution rooms. Because of the need for more research,AnMed Health approved a quasi-experimental research study that would evaluate safe zone utilization. A two-month trial was conducted at AnMed Health to measure the effectiveness of safe zones and to determine if they were indeed helpful and would not interfere in patient care. An experimental unit implemented safe zones (4 Center) and a control unit (7 South) was established to see if patient observation and communication, costs and infection rates were different between the units. The principal investigator followed infection rates for both the control and experimental unit, developed surveys for staff members and looked at monthly PPE costs for the two units being studied.
Thesis Statement
Creating safe zones for patients on contact and contact-enteric precautions improves the utilization of the healthcare facility resources and healthcare worker efficiency through improved communication and observation with patients, decreased PPE costs and does not lead to an increase in hospital acquired infection rates.
Purpose of the Study
The purpose of the Safe Zone Research Project was to see if safe zones would save time and money while also not increasing nosocomial infectionsat AnMed Health. The study also exploredthe benefits of HCW satisfaction and compliance with utilizing the safe zones. There has been very little research in the past on safe zones and if they actually increase or decrease HAI rates. In 2009, Medicare quit covering the costs for any preventable health condition; Medicare will not pay for any infection that is acquired during a hospital stay (Medical News Today, 2007). This has given AnMed Health and other healthcare facilities an even bigger push to focus on keeping their patients safe from nosocomial infections. While AnMed Health realizes it is important to protect these patients that are on contact and contact-enteric precautions, the organization also realizes that it is imperative for the patient’s psychological state and treatment that HCWs round on these patients as often if not more than if they were not on contact or contact-enteric precautions.
TheAnMed Health Safe Zone Research Projectwas developed to determine if safe zones could increase communication between staff and patient, while keeping infection rates at bay. The principal investigator chose to include only contact and contact-enteric precaution patients in this research trial and did not study droplet or airborne precaution patients. The principal investigator believed that patients who are placed on droplet or airborne precautions for respiratory illnesses have no established safe zone; those precaution patients were not included as participants during the research trial. In the future, the principal investigator hopes to establish ways to increase patient care for these precaution patients as well, but for now the focus is only on contact and contact-enteric precaution patients.
Research Questions and Hypotheses
The purpose of the Safe Zone Research Project was to determine if safe zones could improve patient care for contact and contact-enteric precaution patients, while still keeping infection rates down.Although annual savings on PPE was to be determined, the main goal of the research project was to evaluate and prove that safe zones increased HCW and patient observation and interaction. In addition, the research project sought to gauge the staff’s level of acceptance of these zones, while also evaluating if there was an increase or decrease in infection rates.In order to secure that purpose the following research questions were explored.How does quality of care differ between control and experimental groups when safe zones are employed? WillPPE costs vary between the control and experimental unit?What is the relationship between HCWs attitude toward safe zones? Does the HCW find the safe zones beneficial when they are observing or communicating with their patients?Is there an increase in HAIs with safe zone implementation?The principal investigator sought the answer to these research questions by designing a quasi-experimental study based on the Diffusion of Innovations Theory, while using mixed methods to evaluate the data.
Theoretical Base
The Safe Zone Research Project is based on the Diffusion of Innovations Theory. The basis behind this theory is that people are more likely to adopt a new innovation if they observe others experience a positive outcome (DiClemente, Salazar & Crosby, 2013). This theory shows how new innovations, like safe zones for contact and contact-enteric rooms, diffuse and can be used to promote helpful innovations (DiClemente et al., 2013). The Diffusion Theory has four main elements: innovation, communication channels, time and social system (DiClemente et al., 2013). The Safe Zone Research Project is using ordinary yellow tapeto develop a new way of caring for precaution patients, thus making it an innovative strategy.Safe zones are a relatively new concept, and there are currently very few healthcare facilities utilizing this practice. Before the safe zones were implemented in Four Center the principal investigator communicated thoroughly about the zones and their use. Awareness knowledge informed the HCWs that the new innovation existed. The third element of the Diffusion Theory is time (DiClemente et al., 2013). AnMed Health’s staff adopted the new innovation quickly, because the safe zone was not complicated, and the staff had more to gain than lose. Finally, the social structure at AnMedHealth help diffused the idea. Physicians and nursing staff, not on the experimental unit, were excited about the safe zones, and would ask the infection preventionists when it would be coming to their unit.
The methodology for the research project on safe zones will be mixed methods. Mixed methods involve combining both qualitative and quantitative research approaches to allow for a clearer interpretation than just one single method alone (Bui, 2014). The principal investigator applied qualitative practices because the project did not start out with a hypothesis, but instead sought to find support that safe zones were actually helpful in a healthcare setting (Bui, 2014).The principal investigator collectednon-numerical data from staff surveys from Four Center (the experimental unit) and from Seven South (the control unit). The results were then compared to see if satisfaction and safe zone perception varied between the units. Quantitative and qualitative methods were applied to the safe zone research project. The principal investigator oversaw the application of the yellow tape (independent variable) to contact and contact-enteric rooms for the experimental unit, then examined to see if infection rates (dependent variable) increased or decreased. The percentage of infection rates for both the experimental unit and control unit were recorded.
Definition of Terms
Clostridium difficile (C. diff):A spore-forming, Gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea (AAD) (CDC, 2010).
Contact Precautions: Apply to patients who have MRSA or an MDRO. HCW must wear PPE when entering the patient’s room, and adhere to hand hygiene practices (CDC, 2011).
Contact-Enteric Precautions: Apply to patients who have C. diff. HCW must wear PPE when entering the patient’s room, adhere to hand hygiene practices and room must be cleaned with bleach to kill C. diff spores (CDC, 2011).
Don: To put on personal protective equipment.
Doff: To take off personal protective equipment.
Healthcare Associated Infection (HAI):Is any infection by any pathogen that is acquired as a consequence of a healthcare intervention or which is acquired by a HCW (The Free Dictionary, 2014)
Healthcare Worker (HCW): Any nursing, medical or supportive staff that help take care of patients in a healthcare setting.
Institutional Review Board (IRB):A board committee that is designed to approve proposed non-exempt research before involvement of human subjects can begin (HHS, n.d).