Impact and learner perspectives of a spaced-education platform to assess hand hygiene auditor competency.

OBJECTIVE: To ensure whether spaced education, which increases long-term knowledge retention, could be integrated into auditor competency assessment. DESIGN: Quality improvement project. SETTING: Academic, freestanding children's hospital. PARTICIPANTS: Hand hygiene (HH) auditors. INTERVENTION: We enrolled trained HH auditors in an online spaced-education platform to assess mastery of knowledge, delivering 46 unique questions at spaced intervals followed by rationale; we retired questions after 3 correct answers. An e-mailed 10-item survey gauged participant satisfaction with the program. The Wilcoxon signed-rank test was used to compare change in median knowledge score from first to final attempt. RESULTS: A total of 12,120 questions were attempted by 126 auditors, and 49 (39%) completed the entire course. Median knowledge score increased significantly by 10.5 percentage points (IQR 4-15) between first and final attempts (P < 0.001). Thirty auditors (27%) responded to the survey. The majority agreed the number and complexity of questions were appropriate (57% and 67%, respectively). Eighty-seven percent reported the platform easy to navigate, and 77% agreed adequate time was provided for completion. Free-text suggestions included delivering fewer questions at a narrower spacing interval over a shorter time frame because of competing work demands. CONCLUSIONS: Auditor knowledge of HH indications and technique is critical to ensuring data validity. A spaced-education competency program improved HH auditor knowledge in the short term. Completion rate was low, and some participants expressed a desire for fewer questions over a shorter time frame. This study offers insight into ways to optimize spaced education as a potential tool for HH competency assessment.

Using a human factors framework to assess clinician perceptions of and barriers to high reliability in hand hygiene.

BACKGROUND: Hand hygiene (HH) is critical to prevent health care-associated infections (HAIs). Clinician perspectives on maintaining high reliability are poorly defined. METHODS: We surveyed physicians, nurse practitioners, and physician assistants to understand perceptions of and barriers to high reliability in HH. The Systems Engineering Initiative for Patient Safety 2.0 model was used to develop an electronic survey exploring 6 human factors engineering (HFE) domains. RESULTS: Among 61 respondents, 70% perceived HH as "essential" to patient safety. While 87% reported alcohol-based hand rub (ABHR) availability as very effective in improving HH reliability, 77% reported dispensers to be "sometimes" or "often" empty. Clinicians in surgery/anesthesia were more likely than those in medical specialties to note skin irritation from ABHR (OR 4.94; 95% CI 1.37-17.81) and less likely to believe feedback was effective in improving HH (OR 0.26; 95% CI 0.08-0.88). One quarter of respondents indicated the layout of patient care areas was not conducive to performing HH. Staffing shortages and the pace and demands of work precluded HH for 15% and 11% of respondents, respectively. CONCLUSIONS: Aspects of organizational culture, environment, tasks, and tools were identified as barriers to high reliability in HH. HFE principles can be applied to more effectively promote HH.

Preventing pediatric catheter-associated urinary tract infections utilizing urinary catheter Kamishibai cards (K-cards).

BACKGROUND: We instituted Kamishibai (K-card rounding) with the goals of improving indwelling urinary catheter maintenance bundle reliability and decreasing catheter-associated urinary tract infection (CAUTI) rates. METHOD: In a free-standing children's hospital, we undertook a hospital-wide quality improvement project from January 2019 to June 2021 after developing a K-card based on our urinary catheter maintenance bundle. Auditors used K-cards to ask standardized questions during weekly rounds. Bundle reliability and CAUTI rates were analyzed prospectively. RESULTS: During the study period, 826 K-card audits were performed for 657 unique patients. While overall maintenance bundle reliability remained stable at 84%, there was a statistically significant improvement in reliability to the bundle element "medical discussion of need for the urinary catheter" from 88% to 94% (P = .01). The hospital-wide CAUTI rate significantly decreased (incidence rate ratio, 0.38; 95% CI, 0.15-0.93; P = .04). DISCUSSION: Hospital-wide urinary catheter K-card rounding facilitated standardized data collection, discussion of reliability and real-time feedback to nurses. Maintenance bundle reliability remained stable after implementation, accompanied by a significant decrease in the CAUTI rate. CONCLUSIONS: Implementation of hospital-wide urinary catheter K-card rounding was associated with reduction in CAUTI rates. The project demonstrated likelihood of reproducibility with support of a multidisciplinary team.

Pediatric Clostridioides difficile Infection: Diagnosis and Diagnostic Stewardship.

Although the pathogenesis of Clostridioides difficile infection (CDI) is complex and incompletely understood, it is believed that the elaboration of C. difficile toxins is necessary for disease. There are a variety of tests available for the detection of both the C. difficile organism and its toxins; however, each has limitations and the best application of these tests to the diagnosis of CDI in children remains uncertain. Nucleic acid amplification tests are unable to reliably discriminate between CDI and C. difficile colonization, while commercially available enzyme immunoassays for toxin detection lack sensitivity. An understanding of preanalytic factors, relevant patient features, and test performance characteristics is essential to the accurate diagnosis of CDI in children. Specific diagnostic stewardship strategies can also increase the likelihood that positive tests reflect disease rather than colonization. Ultimately, CDI remains a clinical diagnosis and clinical judgment is essential when interpreting test results, regardless of the methods used.