Hostname: page-component-78c5997874-94fs2 Total loading time: 0 Render date: 2024-11-19T02:11:52.420Z Has data issue: false hasContentIssue false
  • English
  • Français

Translating Evidence into Practice Using a Systems Engineering Framework for Infection Prevention

Published online by Cambridge University Press:  10 May 2016

Eric Yanke ,
Pascale Carayon  and
Nasia Safdar
Eric Yanke
Affiliation:
Department of Medicine, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
Pascale Carayon
Affiliation:
Department of Industrial and Systems Engineering, Center for Quality and Productivity Improvement, University of Wisconsin–Madison, Madison, Wisconsin
Nasia Safdar*
Affiliation:
William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin; and Division of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School, Madison, Wisconsin
*
UWMF Centennial Building,1685 Highland Avenue, Madison, WI 53705 ([email protected]).
Get access Rights & Permissions [Opens in a new window]

Extract

The current infection prevention era is defined by the rise of healthcare-associated infections (HAIs) and multidrug-resistant organisms (MDROs). Efforts to combat these and other emerging pathogens have resulted in rapid and ongoing evolution of the contemporary infection prevention environment. Currently, HAIs impose a significant burden on the US healthcare system. Recent analysis of National Healthcare Safety Network data from the early 2000s suggests that at least 1.7 million HAIs occur yearly in US hospitals, associated with at least 99,000 deaths. These numbers have likely increased over the past decade and suggest that HAIs are among the leading causes of death in the United States.

Type
Commentary
Information
Infection Control & Hospital Epidemiology , Volume 35 , Issue 9 , 01 September 2014 , pp. 1176 - 1182
Copyright
© 2014 by The Society for Healthcare Epidemiology of America. All rights reserved.

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Klevens, RM, Edwards, JR, Richards, CL Jr, et al. Estimating health care–associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 2007;122:160–166.Google Scholar
2. Murphy, SL, Xu, J, Kochanek, KD. Deaths: final data for 2010. Natl Vital Stat Rep 2013;61:1–117.Google ScholarPubMed
3. Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Atlanta: Centers for Disease Control and Prevention, 2009.Google Scholar
4. Harris, AD, Pineles, L, Belton, B, et al. Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial. JAMA 2013;310:1571–1580.Google Scholar
5. Huang, SS, Septimus, E, Kleinman, K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med 2013;368:2255–2265.Google Scholar
6. Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press, 2012.Google Scholar
7. Donchin, Y, Gopher, D, Olin, M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med 1995;23:294–300.Google Scholar
8. Donchin, Y, Seagull, FJ. The hostile environment of the intensive care unit. Curr Opin Crit Care 2002;8:316–320.Google Scholar
9. Semel, ME, Bader, AM, Marston, A, Lipsitz, SR, Marshall, RE, Gawande, AA. Measuring the range of services clinicians are responsible for in ambulatory practice. J Eval Clin Pract 2012;18:404–408.Google Scholar
10. Gurses, AP, Seidl, KL, Vaidya, V, et al. Systems ambiguity and guideline compliance: a qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections. Qual Saf Health Care 2008;17:351–359.Google Scholar
11. Kenney, C. The Best Practice: How the New Quality Movement Is Transforming Medicine. New York: Public Affairs, 2008.Google Scholar
12. Oriol, MD. Crew resource management: applications in healthcare organizations. J Nurs Adm 2006;36:402–406.Google Scholar
13. Kaplan, G, Bo-Linn, G, Carayon, P, et al. 2013. Bringing a systems approach to health. Discussion paper at the Institute of Medicine (IOM)/National Academy of Engineering (NAE) Systems Approaches to Improving Health Innovation Collaborative and IOM Roundtable on Value and Science-Driven Health Care; July 10, 2013; Washington, DC.Google Scholar
14. What is ergonomics? International Ergonomics Association website. http://www.iea.cc/01_what/What%20is%20Ergonomics.html. Published 2010. Accessed November 1, 2013.Google Scholar
15. Carayon, P, Xie, A, Kianfar, S. Human factors and ergonomics as a patient safety practice. BMJ Qual Saf 2014;23:196–205.Google Scholar
16. Pronovost, P, Needham, D, Berenholtz, S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725–2732.Google Scholar
17. Patterson, JE, Malani, PN, Maragakis, LL. Infection control in the intensive care unit: progress and challenges in systems and accountability. Crit Care Med 2010;38:S265–S268.Google Scholar
18. Reason, J. Human error: models and management. BMJ 2000;320:768–770.CrossRefGoogle ScholarPubMed
19. Vincent, C, Taylor-Adams, S, Stanhope, N. Framework for analysing risk and safety in clinical medicine. BMJ 1998;316:1154–1157.CrossRefGoogle ScholarPubMed
20. Karsh, BT, Holden, RJ, Alper, SJ, Or, CK. A human factors engineering paradigm for patient safety: designing to support the performance of the healthcare professional. Qual Saf Health Care 2006;15:159–165.Google Scholar
21. Woods, DD, Hollnagel, E. Prologue: resilience engineering concepts. In: Hollnagel, E, Woods, DD, Leveson, N, eds. Resilience Engineering: Concepts and Precepts. Aldershot: Ashgate, 2006:1–6.Google Scholar
22. Weick, KE, Sutcliffe, KM. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco: Jossey-Bass, 2001.Google Scholar
23. Hollnagel, E, Woods, DD, Leveson, N, eds. Resilience Engineering: Concepts and Precepts. Aldershot: Ashgate, 2006.Google Scholar
24. Donabedian, A. The quality of medical care. Science 1978;200:856–864.CrossRefGoogle ScholarPubMed
25. Carayon, P, Schoofs Hundt, A, Karsh, BT, et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care 2006;15(15 suppl 1):i50–i58.Google Scholar
26. Singh, H, Thomas, EJ, Mani, S, et al. Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential? Arch Intern Med 2009;169:1578–1586.Google Scholar
27. Chui, MA, Mott, DA, Maxwell, L. A qualitative assessment of a community pharmacy cognitive pharmaceutical services program, using a work system approach. Res Social Adm Pharm 2012;8:206–216.Google Scholar
28. Carayon, P, Wetterneck, TB, Rivera-Rodriguez, AJ, et al. Human factors systems approach to healthcare quality and patient safety. Appl Ergon 2014;45:14–25.CrossRefGoogle ScholarPubMed
29. Safdar, NM, Medow, JM, Chinthapalli, K, et al. Optimizing management of ventilator-associated pneumonia using the 2005 IDSA/ATS management guideline paper. In: Program and abstracts of the Fifth Decennial International Conference on Healthcare-Associated Infections; March 18–22, 2010; Atlanta. Abstract 977.Google Scholar
30. McGlone, SM, Bailey, RR, Zimmer, SM, et al. The economic burden of Clostridium difficile. Clin Microbiol Infect 2012;18:282–289.Google Scholar
31. Loo, VG, Poirier, L, Miller, MA, et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile–associated diarrhea with high morbidity and mortality. N Engl J Med 2005;353:2442–2449.Google Scholar
32. McFarland, LV, Mulligan, ME, Kwok, RY, Stamm, WE. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 1989;320:204–210.Google Scholar
33. Honda, H, Dubberke, ER. The changing epidemiology of Clostridium difficile infection. Curr Opin Gastroenterol 2014;30:54–62.Google Scholar
34. Zilberberg, MD, Tillotson, GS, McDonald, C. Clostridium difficile infections among hospitalized children, United States, 1997–2006. Emerg Infect Dis 2010;16:604–609.Google Scholar
35. Garey, KW, Jiang, ZD, Yadav, Y, Mullins, B, Wong, K, Dupont, HL. Peripartum Clostridium difficile infection: case series and review of the literature. Am J Obstet Gynecol 2008;199:332–337.Google Scholar
36. Centers for Disease Control and Prevention. Surveillance for community-associated Clostridium difficile—Connecticut, 2006. MMWR Morb Mortal Wkly Rep 2008;57:340–343.Google Scholar
37. Card, A. A new tool for hazard analysis and force-field analysis: the Lovebug diagram. Clin Risk 2013;19:87–89.CrossRefGoogle Scholar
38. Carman, KL, Dardess, P, Maurer, M, et al. Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Aff (Millwood) 2013;32:223–231.Google Scholar
39. Storr, J, Wigglesworth, N, Kilpatrick, C. Integrating Human Factors with Infection Prevention and Control. London: The Health Foundation, 2013.Google Scholar
40. Alvarado, CJ. Human factors and ergonomics in infection prevention. In: Carayon, P, ed. Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. 2nd ed. Boca Raton, FL: Taylor & Francis Group, 2012:793–802.Google Scholar
41. Carrico, R. Preventing transmission of Clostridium difficile in healthcare settings. IP Tools website. http://www.infectionpreventiontools.com/tools-and-resources/doc_details/149-fishbone-cdiffrevised-april-2011. Published April 2011. Accessed November 1, 2013.Google Scholar