Low-hanging fruit for human factors design in infection prevention—still too high to reach?

Clack, Lauren; Kuster, Stefan P.; H, Giger; Giuliani, Francesca; Sax, Hugo

doi:10.1016/j.ajic.2014.03.002

Cited by 10 publications

(4 citation statements)

References 8 publications

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“…For cluster I the cardiac catheterization laboratory remained a suspected common source because of the semi-open design of the contrast medium injector that was found to pose an infectious risk, similar to the risk previously highlighted in other semi-open devices (e.g., syringes) [36]. The clinical outcome was favorable for all patients, as highlighted in other studies [8], irrespective of the use of different treatment regimens which followed the specific antibiogram.…”

Section: Discussionsupporting

confidence: 53%

Agrobacterium spp. nosocomial outbreak assessment using rapid MALDI-TOF MS based typing, confirmed by whole genome sequencing

Casanova

Priore

Egli

et al. 2019

Antimicrob Resist Infect Control

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BackgroundA number of episodes of nosocomial Agrobacterium spp. bacteremia (two cases per year) were observed at Bern University Hospital, Switzerland, from 2015 to 2017. This triggered an outbreak investigation.MethodsCases of Agrobacterium spp. bacteremias that occurred between August 2011 and February 2017 were investigated employing line lists, environmental sampling, rapid protein- (MALDI-TOF MS), and genome-based typing (pulsed field gel electrophoresis and whole genome sequencing) of the clinical isolates.ResultsWe describe a total of eight bacteremia episodes due to A. radiobacter (n = 2), Agrobacterium genomovar G3 (n = 5) and A. pusense (n = 1). Two tight clusters were observed by WGS typing, representing the two A. radiobacter isolates (cluster I, isolated in 2015) and four of the Agrobacterium genomovar G3 isolates (cluster II, isolated in 2016 and 2017), suggesting two different point sources. The epidemiological investigations revealed two computer tomography (CT) rooms as common patient locations, which correlated with the two outbreak clusters. MALDI-TOF MS permitted faster evaluation of strain relatedness than DNA-based methods. High resolution WGS-based typing confirmed the MALDI-TOF MS clustering.ConclusionsWe report clinical and epidemiological characteristics of two outbreak clusters with Agrobacterium. spp. bacteremia likely acquired during CT contrast medium injection and highlight the use of MALDI-TOF MS as a rapid tool to assess relatedness of rare gram-negative pathogens in an outbreak investigation.

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Section: Discussionsupporting

confidence: 53%

Agrobacterium spp. nosocomial outbreak assessment using rapid MALDI-TOF MS based typing, confirmed by whole genome sequencing

Casanova

Priore

Egli

et al. 2019

Antimicrob Resist Infect Control

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“…Over the past decade, human factors design has been increasingly recognized as a tool for optimizing healthcare, particularly in the field of patient safety and infection prevention. [11][12][13][14][15][16][17][18] The concept of mental models is an important design tool for human factors engineers.…”

Section: Mental Models At the Core Of Human Factors Design In Healthcarementioning

confidence: 99%

Mental models: a basic concept for human factors design in infection prevention

Sax

Clack

2015

Journal of Hospital Infection

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Much of the effort devoted to promoting better hand hygiene is based on the belief that poor hand hygiene reflects poor motivation. We argue, however, that automatic unconscious behaviour driven by 'mental models' is an important contributor to what actually happens. Mental models are concepts of reality-imaginary, often blurred, and sometimes unstable. Human beings use them to reduce mental load and free up capacity in the conscious mind to focus on deliberate activities. They are pragmatic solutions to the complexity of life. Knowledge of such mental processes helps healthcare designers and clinicians overcome barriers to behavioural change. This article reviews the concept of mental models and considers how it can be used to improve hand hygiene and patient safety.

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“…The improvement seen in audit cycle 1 was owing to the action taken by trainees who were already convinced and for the components that did not require much additional effort. In process improvement parlance, this is referred to as reaching for the “low-hanging fruit” [ 14 ]. Aiming for easy tasks at the beginning of any process improvement program achieves the twin objectives of boosting process improvement morale as well as winning over easy converts.…”

Section: Discussionmentioning

confidence: 99%

Use of a Clinical Audit System in Implementing Surviving Sepsis Campaign Guidelines in Patients With Peritonitis

Valiveru¹,

Cherian²,

Srinivasan³

et al. 2021

Cureus

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Background Sepsis is the predominant cause of morbidity and mortality in patients with peritonitis. "Surviving Sepsis Campaign" (SSC) is an international effort in reducing mortality based on evidence-based guidelines. This study aims to assess the impact of audit-based feedback in a Plan-Do-Study-Act (PDSA) format on improving the implementation of the SSC guidelines in patients with generalized peritonitis at our center. Methods This prospective observational study was conducted in four audit cycles in PDSA format. Multi-departmental inputs were taken to suggest modifications in practice. A questionnaire-based analysis of reasons for non-compliance was performed to find out the opinions and reasons for non-compliance. Morbidity, mortality, and the length of ICU and hospital stay among these patients were also analyzed. Results Baseline compliance with intravenous (IV) bolus administration, central venous pressure (CVP)-guided fluids, and inotropes support when indicated were 100%. Over the course of the three audit cycles, statistically significant improvement in compliance was noted for obtaining blood cultures before antibiotics, antibiotic administration within three hours of presentation, and serum lactate measurement. Overall bundle compliance improved from 9.2% to 64.7% by the end of audit cycle III. Conclusions This study demonstrates that audit-based feedback is a dependable means of improving compliance with SSC guidelines. It brings about improvement by educating users, modifying their behavior through feedback, and enhances process improvement by identifying and correcting systemic deficiencies in the organization.

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Low-hanging fruit for human factors design in infection prevention—still too high to reach?

Cited by 10 publications

References 8 publications

Agrobacterium spp. nosocomial outbreak assessment using rapid MALDI-TOF MS based typing, confirmed by whole genome sequencing

Agrobacterium spp. nosocomial outbreak assessment using rapid MALDI-TOF MS based typing, confirmed by whole genome sequencing

Mental models: a basic concept for human factors design in infection prevention

Use of a Clinical Audit System in Implementing Surviving Sepsis Campaign Guidelines in Patients With Peritonitis

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