RP survey ID week 2013

ID Week 2013
Session 46; Presentation #209
Healthcare-Associated Infections: Knowledge, Training, and Practice of Resident Physicians
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
(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, 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:
Table 1: Prevention of CAUTI:
Discussion
Table 2: Prevention of CLABSI:
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 3: Prevention of SSI:
•  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 4: Prevention of VAP:
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.
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.