The emergence and proliferation of infectious diseases, combined with increasingly complex health care delivery systems, create challenges for hospitals endeavoring to ensure the safety of employees and patients alike. The recent concern over the threat of an Ebola outbreak in the US highlights the dilemmas inherent to managing infectious disease through patient isolation.
As infectious disease experts know, patient isolation is key to containing the spread of highly contagious diseases, but only if the tools and methods used to introduce and promote isolation are sound. Similarly, the characteristics of the infecting pathogen and its mode of transmission help determine the degree of isolation needed, as well as the level of precaution assumed by health care teams treating the patient. While many health care facilities are able to incorporate advanced equipment to assess patients and administer treatment, the absence of cohesive, institution-wide policies and procedures (P&Ps) to ensure the integrity of this equipment can make it quite easy for a well-meaning health care professional to unwittingly contribute to the spread of an infectious disease to vulnerable patients and other health care providers.
Foster a Culture of Safety
Valley Health, located in Virginia and West Virginia, is a nonprofit organization comprising six hospitals with a combined 594 licensed inpatient beds and 166 long-term care beds. With over 5,300 employees and a medical staff of over 500, the health system offers a wide variety of specialized surgical, medical, diagnostic, and rehabilitation services, all while promoting safety for patients and employees alike. The concept of fostering a culture of safety begins at the top of the organization, and the commitment to both patient and employee safety flows down to front-line staff, whose concerns are heard and addressed on a consistent basis. Integral to this culture are the P&Ps and actions that govern infectious disease isolation practices.
Managing proper patient isolation requires multiple steps, but begins with the exchange of essential information. As a matter of course, each patient care area is reviewed for the number of patients in isolation, the organism(s) being isolated, and whether the organism(s) was thought to be acquired in the hospital. As the majority of isolation scenarios differ from each other in some manner, an interdisciplinary leadership team reviews the data and helps determine whether each specific scenario elicits the need for additional education or revised P&Ps. The result of these reviews can include placing an entire unit on isolation precautions until appropriate education and workflow changes are implemented.
Thus, in order to avoid or mitigate the ramifications of improper or incomplete isolation measures, Valley Health employs a series of activities designed to insulate the practice.
Daily Safety Calls
One way to make sure the needs and observations of staff are addressed in a timely manner is through the establishment of daily safety calls. These calls are directed by a member of the leadership team and include brief reports given by a representative from each inpatient care area and auxiliary unit. The reports detail any safety concerns identified in the past 24 hours and outline appropriate follow-up to previously reported issues.
In order to gain an overall safety perspective, a team made up of management from each area performs daily safety rounds. These rounds can be directed to manage specific issues, or they may be non-directed, in which case the team visits areas looking for any safety issues and talking with front-line staff about challenges and potential solutions. During safety rounds, the team observes isolation P&Ps in action and is able to address identified discrepancies in real time. Additionally, safety rounds give leadership and management the opportunity to speak with staff members to ensure they have adequate supplies and the requisite knowledge to promote hospital-wide safety.
Informal Citation Form
Proper understanding and adherence to all current P&Ps is essential to the integrity of effective patient isolation. Furthermore, it allows for the identification of omissions or discrepancies leading to variations in execution that can result in disease transmission. To positively reinforce the necessity of strict adherence to isolation P&Ps, specifically hand hygiene, all staff members are encouraged to use an informal citation form that is non-punitive in nature to encourage accountability. The staff was uncomfortable confronting or giving direct feedback on hand washing to other health care professionals. Instead, a form, which says oopsy and that notes that a lapse in appropriate hand hygiene occurred, is given to leadership who follows up with any individual who is directly observed not following isolation procedures. Along with the form, education is provided on the importance of following the prescribed practice.
Proper Precautionary Measures
Early recognition of the signs and symptoms of infectious diseases is necessary to prevent transmission, so certain precautions are required, beginning with notification to all health care professionals of any patient rooms under isolation. Likewise, all necessary supplies for handling patients in isolation, including gloves, masks, and gowns, must be easily accessible. Ultimately, the most important aspect of maintaining isolation is the proper management of personnel and items that travel in and out of isolated patient care areas. Any mobile or handheld items used to treat patients in isolation—from workstations on wheels to stethoscopes—require additional disinfection procedures so that they do not transmit pathogens.
Comprehensive hand hygiene is considered among the most effective methods in preventing the spread of disease in the hospital, regardless of whether a patient is in isolation. Therefore, appropriate hand hygiene methodologies should be part of isolation P&Ps. Specifically, P&Ps should indicate which alcohol-based products or soap and water should be used against the infecting organism.
Beyond ensuring basic safety precautions, it is necessary to institute a review process for established P&Ps in order to identify risk points. At Valley Health, the catalyst to investigate patient isolation practices came about in a common manner—feedback from our most engaged front-line staff members. In this case, a group of pharmacy technicians responsible for the morning medication cart exchange approached pharmacy management with concerns regarding the procedures for storing and returning medications—specifically inhalers—from isolation units. The procedure at the time consisted of wiping down each inhaler after use and storing it in a medication drawer with all of the patient’s other medications. The technicians were concerned that it was not visually apparent whether an inhaler had been wiped, and that a patient’s saliva or other bodily fluid still might be present in or around the inhaler. Even with vigilant hand hygiene, such a scenario could expose staff and other patients to infectious disease.
As the pharmacy department examined this and other isolation procedures, it became apparent that the problem was quite complex and could not be resolved by pharmacy alone. Although the pharmacy department is a key player in the medication distribution process, effective change required representation from all affected departments. To enable changes to medication distribution processes specific to isolation patients, representation needed to include nurses, physicians, respiratory therapists, IV therapy clinicians, infection control, and the rapid response team. As hospital facilities differ in method of medication distribution, patient population, and isolation practices, an overall isolation strategy and operation must be tailored to the specific needs of the organization.
A System-Wide Strategy
To ensure successful buy-in, it is important to identify an appropriate interdisciplinary (and if necessary, inter-facility) forum to review and address isolation procedure safety concerns. Valley Health’s existing medication safety committee was deemed the most appropriate forum, given its overall goal of addressing patient safety concerns at a system level, and the high level of involvement from stakeholders, including pharmacy, nursing, respiratory, IV therapy, infection control, and physicians. This committee reviewed the health care system’s isolation P&Ps to identify points of risk and opportunities for improvement.
They found that the topic of isolation was addressed in several policies across several departments. For example, pharmacy policies addressed medication isolation procedures; respiratory therapy policies focused on issues surrounding respiratory medications for isolation patients; and general nursing policies discussed crash cart exchange and use of equipment in isolation rooms. As a result, the team is working currently to combine some policies and streamline others. Also, the committee decided it was important to perform a gap analysis and directly observe operations in order to identify areas for education and mitigate any workarounds that had developed.
Identifying Risk Points
Among the patient isolation and disease transmission risk points identified was the use of bedside bar code scanning technology. In order to gain a comprehensive view, the committee examined how this was accomplished in different practice areas and hospital sites throughout the system. The review revealed several different practices, depending on the workflow specific to the practice area and the setup of the patient care floor.
Most critical care areas had workstations and scanners in each room that were used only for the patients in those rooms. With this setup, the equipment did not leave the space and was cleaned upon patient discharge. In other patient care areas, nursing workstations with wireless scanners were shared among patient rooms, in which case the wireless scanners were cleaned upon exiting the room.
In addition to bar code scanning, the committee identified the following practices as potential disease transmission risk points that required immediate attention: the storage and use of patient-specific multidose medications in isolation rooms, as well as crash cart exchange and medication box exchange. Multidose medications, including inhalers, insulin pens, and ointments, pose transmission risks because they must be stored securely, but taken in and out of patient rooms. While some of the isolation rooms have secure patient medication drawers inside the room, most have locked bins located outside the room, requiring procedures to safely administer and store the medication over an extended period of time. Among these procedures was bringing only necessary medications into the room at each visit, wiping down the medication every time it enters and exits the patient care area, and storing each medication in its own plastic bag.
In Case of Emergency
It is not uncommon for an isolated patient’s condition to change suddenly requiring emergency intervention. Therefore, it is critical that isolation P&Ps address the use of emergency supplies and medications. Ideally, if an emergency cart is needed for an isolation patient, the cart remains outside of the room and needed equipment and medications are passed into the room. If the emergency cart must be brought into the patient’s room, P&Ps should outline the safe transportation of emergency equipment and medications to and from isolation rooms, including decontamination activities.
After examining our version of this procedure in operation, the team was able to identify areas for improvement, streamline procedures, and reduce waste. For example, medication boxes, such as rapid sequence intubation boxes or transport boxes that travel in and out of patient care areas, were identified as problematic. No policies existed that specifically addressed the use and cleaning of supplies and medication boxes that entered isolation rooms and came into contact with patients. This resulted in the need for a specific procedure to identify and properly decontaminate these boxes to avoid the transmission of infectious organisms. Understanding the type of isolation makes staff better able to understand which conditions require the disposal of medications and which do not have the risk of transmitting disease.
A Wise Investment
As with most system-wide changes, auditing and improving patient isolation P&Ps can take time and require continuous attention. But with a commitment to safety for patients and employees alike, daily operations can reflect evidence-based improvements. Before any changes can be implemented, all identified issues must be vetted through the appropriate departments for feedback and recommendations. Likewise, after changes are implemented, reviews should ensue to identify ongoing best practices.
Patient and employee safety is not a destination, but rather an ongoing journey of assessment and reassessment to ensure compliance and identify opportunities for improvement. The successful appraisal of P&Ps for patients in isolation cannot be performed in isolation; it requires the coordinated effort of the entire health care team.
Kimberly Miller, PharmD, MPH, is a medication safety program manager at Winchester Medical Center, part of Valley Health System, in Winchester, Virginia. She received her PharmD from the University of Pittsburgh School of Pharmacy, her MPH from the University of Pittsburgh School of Public Health, and a BS in biology from Shippensburg University.