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Running head: ISOLATION PRECAUTIONS 1

Isolation Precautions: Improving Staff Compliance with Safety and Education

Denise E. Cooney

Ferris State University

ISOLATION PRECAUTIONS 2

Author Note

Denise Cooney is currently a student in the Master of Science in Nursing Program at

Ferris State University, Big Rapids, Michigan. Cooney is employed as a Clinical Educator for

Staff Development at Henry Ford Allegiance Health in Jackson, Michigan.

Article word count is 2,601.

Abstract


The safety of patients and healthcare workers is the focus for maintaining compliance with

isolation precautions. To ensure compliance with the proper use of personal protective

equipment (PPE), staff members and visitors must be properly educated. Audits and surveys

were conducted on the use of PPE, using the correct isolation signs to identify patients with

multi-drug resistant organisms (MDROs), and whether patients were receiving education about

the MDROs. The audits were used to determine what areas needed education to increase the

safety of patients and staff members. Standards set by the Centers for Disease Control (CDC)

and the Joint Commission were used to develop the education. The stage theory and the concept

of transformational leadership were used to implement the change in practice. The results

showed that by increasing awareness of the isolation reports and providing education to staff

nurses, the documentation of patient education improved. Providing easy access to patient

education materials was planned for the project but the new materials were not yet available by

the completion of the project. With proper identification of patients requiring isolation, the

safety of patients and staff will be increased.

Keywords: multi-drug resistant organism (MDRO), compliance, personal protective

equipment, healthcare associated infection, education

Isolation Precautions: Improving Staff Compliance with Safety and Education


Transmission of multi-drug resistant organisms (MDROs) is an important issue identified

by the Joint Commission. Preventing the transmission of MDROs and healthcare acquired

infections is a challenge for all health care organizations. Staff members need to be

knowledgeable when asked questions during a survey by accreditation agencies, such as the

Centers for Medicare and Medicaid Services (CMS) and the Joint Commission. The surveyors

expect staff to know information about the organization’s quality and safety programs. Staff

members are often asked about infection control issues and what the organization does to resolve

or prevent problems to improve patient outcomes (Patrick & Hicks, 2013). It is due to these

expectations that an education project was implemented to increase the ability of staff to

demonstrate the proper use of isolation precautions, handwashing and wearing personal

protective equipment. Communication between staff members, patients, and visitors about

isolation precautions improves patient safety, increases the patient’s trust in their care, and also

has been shown to increase patient satisfaction (Levers & Farshait, 2014).

Background

The Centers for Disease Control and Prevention recommends a multidisciplinary method

to monitor and improve adherence to recommended isolation precautions (CDC, 2009).

Education needs to include all direct patient care staff members in order to promote a change in

behavior and a culture that supports and encourages adherence to the prevention practices (CDC,

2009). The Joint Commission requires organizations to provide education about MDROs during

staff orientation and on a regular basis, to include processes for isolation precautions and how to

report any issues or suggest improvements (Joint Commission, 2010a). A prospective audit by

Russell, Young, Leung, and Morris (2015) demonstrated that educating staff and providing them

with a reference card had a positive effect on compliance with transmission based precautions.


Other studies have shown the influence of staff members perceptions and attitudes on the use of

PPE and compliance with infection control guidelines (Gralton, Rawlinson, & McLaws, 2013;

Stein, Manarawo, & Ahmad, 2003). According to the literature, increasing staff knowledge and

awareness about MDROs will improve compliance and patient safety. Patients and their families

should also be educated about the need for isolation precautions. Visitors compliance with hand

hygiene and use of PPE helps decrease the incidence of exposing other individuals to MDROs.

The Joint Commission requires nurses to educate patients and their families about infection

prevention and control (Joint Commission, 2010b). This study will provide strategies to help

organizations comply with the requirements of the regulatory agencies.

Objective

The overall goal for this project was to decrease the incidence of healthcare associated

infections. The Agency for Healthcare Research and Quality (AHRQ) encourages patients,

families, and healthcare professionals to work together to improve the safety and quality of care

(AHRQ, 2013). The AHRQ has developed a guide for hospitals to engage patients and family

members in the plan of care. This guide is based on research that indicates if patients and

families are engaged in health care it can lead to improvements in safety and quality (AHRQ,

2013). Teaching patients, visitors, and healthcare workers the reasons for isolation precautions

can help to decrease the occurrence of healthcare associated infections.

To properly plan for this project, staff member compliance with the use of PPE was

audited. A root cause analysis (RCA) was completed to examine potential barriers interfering

with the proper use of PPE and identification of patients that require isolation. The purpose of

this project was to analyze the process of identifying a patient with a MDRO, measure and find a


way to improve staff knowledge and compliance with the use of personal protective equipment

(PPE), and improve the patient education process related to MDROs.

Methods

Project Site

This project was conducted at a 475-bed urban hospital. Auditing and interactions with

the staff were focused on the medical-surgical units of the hospital. The staff on the medical-

surgical units care for complex patients with wide ranging diagnoses. These diagnoses include,

cancer, stroke, renal disease, neurological problems, urological problems, post orthopedic

surgeries and various other post-surgical patients.

Root Cause Analysis

A RCA is the identification of possible actions or situations that lead to a particular

outcome (Johnson, 2012). The focus is on processes and system design and how to implement

improvements to prevent patient harm. A RCA was conducted with a staff nurse, the clinical

unit leader, staff responsible for patient bed placement, and the infection preventionist. The RCA

was conducted to identify barriers in wearing PPE and providing patient education.

During the RCA, the group addressed the following questions: 1) Are there current

policies and procedures that address the process for identification of patients with MDROs and if

so, are they available to staff? 2) Are the staff involved, qualified, and trained to perform the

necessary tasks? 3) Are the necessary tools and equipment easily accessible to the staff? 4) Do

automatic alerts or flags function correctly? 5) Does the patient’s record give clear information

about past MDRO isolation and is this information available upon admission to hospital? A

RCA diagram was used to depict the questions asked and possible causes that may lead to errors

in missing the MDRO identification. A category labeled People represents the questions about


proper staff training, staff compliance with PPE use, and communication through the use of

alerts in the computer system. The Process category looks into the different types of reports that

are used to identify patients with MDROs. Equipment tries to identify if signage and PPE are

available for use. The Materials category asks questions about education materials, prior audits

for proper signage and PPE use, and identifying if policies and procedures are in place to

recognize patients needing isolation. The final category is Environment. This portion of the

diagram looks for possible barriers to implementing precautions and using the PPE.

Data Collection

A patient needing isolation precautions has a sign placed on the door alerting staff to

wear proper PPE. Auditing of the isolation signs on the medical-surgical units was performed

three to four days per week over the span of four weeks. A list prepared by the infection

preventionists is sent daily to the inpatient units identifying those diagnosed with MDROs who

need to be in isolation precautions. With the use of the MDRO list, each patient room was

observed to determine if the correct isolation sign was in place. Another indication that a patient

needs to be in isolation is a color-coded border around the room on the electronic bed board.

The bed board information was compared to the MDRO list and the signs on the patient doors.

The presence or absence of the correct isolation sign was recorded.

Data from two other audits completed by the infection preventionists was examined to

develop a baseline for what areas needed interventions to improve compliance. One audit

focused on whether staff members wear the proper PPE when entering an isolation room. A

random sampling of observations on the in-patient units was collected each month. The other

audit was completed by reviewing nurses’ documentation of isolation education in patient charts.


An informational survey was distributed to the nursing staff. Questions on the survey

inquired about the use of personal protective equipment, educating patients and families about

isolation, documentation of isolation and education, and the availability of educational materials

to distribute to patients. The surveys were available for staff to complete in the unit break

rooms. To ensure participation, the clinical unit leaders were asked to mention the survey in the

huddles that take place at the beginning of each shift.

Theory

ANA Scope & Standards of Practice

Three Nursing Professional Development Standards of Practice were addressed during

the planning and implementation of this project. A standard which emphasizes identifying issues

and trends is utilized to improve processes for identifying patients with MRDOs. The standard

focuses on using data to identify needs and evidence of gaps in knowledge, skills, and practice

(ANA, 2010). Comparing data from various MDRO reports provides opportunities for

developing the most efficient and accurate report. This data helps to identify a necessary change

in practice, which can lead to improved quality reporting and safer patient care.

Another planning standard describes creating a proposal that will help to develop various

methods to reach the anticipated goals (ANA, 2010). Various activities were designed to help

meet the objectives set for each project goal. For example, chart audits were used to check for

compliance with documentation of isolation type and providing the patients with isolation

education. A survey of the staff helped to identify possible barriers in the use of PPE. A visual

check was completed to determine if the proper signage was in place outside of patients’ rooms

that were identified as having a MDRO. Planning also included collaborating with quality

specialists and the Infection Preventionists to develop a comprehensive project. Having staff


members that were directly affected by the project, as well as quality specialists, involved in the

planning process helped to keep communication open and helped to improve success in reaching

project goals.

The facilitation of a positive learning and practice environment meets another standard’s

goals (ANA, 2010). Part of providing quality patient care is ensuring that the patient is given

education about their disease process. Nurses should not have barriers in providing evidence-

based education to the patients. One activity during this project was to initiate a streamline

process for providing MDRO education for the patients. This involved creating information

cards with education about the precautions needed to prevent the spread of the different types of

MDROs to other patients, staff, or family members. Having this information readily available in

a card format, ensures nurses will not have to spend extra time retrieving the information and can

spend more time with the patients. This helps to create a more positive practice environment.

Leadership and Change Theory

The problem with proper and timely identification of patients with MDROs was

addressed with the Stage Theory. A four-stage model developed by Kaluzny and Hernandez

(1988), as cited in Butterfoss, Kegler, and Francisco, 2008, was adapted from the original stage

model by Kurt Lewin (1951). The Stage Theory focuses on change as a series of steps that must

each be achieved before proceeding to the next step (Butterfoss, Kegler, & Francisco, 2008). The

change is a gradual process. Step one is awareness or defining the problem. Information about

the MDROs needs to be provided to staff members. This information should include definitions

of the types of MDROs and how they are transmitted to other people. Step two is adoption or

initiating action. Actions include presenting ways in which the nursing staff can influence

prevention of transmission of the organisms. This includes proper signs on the door to patient


rooms, wearing PPE, handwashing, and cleaning rooms and equipment after patient use. Step

three is to implement the change. Implementation involves educating all staff members on the

isolation precautions. Step four is institutional change. Leaders and Infection Preventionists

need to continue to monitor and encourage compliance with the process.

The concept of Transformational Leadership, proposed by MacGregor Burns (1978),

involves leaders demonstrating the need for change through vision and inspiration in order to

influence their followers (Marshall, 2011a). In order for this project to be successful, the staff

members need to be convinced that the process for identifying patients with MDROs and

wearing the appropriate PPE is important and effective. Leaders will play a large role in

showing staff the importance of the change in practice. A transformational leader explains why a

change is needed and what each staff member needs to do to help make the change possible

(Luzinski, 2011). Not only do leaders need to show support for the new or changing process of

controlling infections, leaders also need to follow up with staff members that are not compliant

with the process. Keeping an open dialogue between staff and the leader will keep the change

process evolving. Transformational leaders “strive for continuous quality improvement by using

and generating evidence to inform best practice and organizational policies” (Marshall, 2011b, p.

ix). Staff members who have a leader who treats them with respect, includes them in decision

making, and shows interest in the staff members’ suggestions, will be more open to a change

(Rolfe, 2011). If staff know that their suggestions are heard and considered, they will feel

supported and part of the team.

Results

Prior to initiating the quality project, project leaders conducted three audits to determine

areas for improvement. Three months of data pertaining to documenting patient MDRO


education in the patient chart was reviewed. The results showed a low percentage of proper

documentation was currently being completed (see Appendix A). The target goal is for the

documentation to be completed at least 95% of the time. The average over three months

exhibited that only 38% of the patients identified with an MDRO received the proper education.

A barrier identified in the survey distributed to the staff nurses showed that there was a need for

more patient educational materials (see Appendix B). An audit on the use of proper isolation

signs outside of the patients’ rooms indicated that there was a need for more education and

interventions for this process (see Appendix C). Correct signage was in place approximately

38% of the time.

Education was given in multiple small group sessions with the nurses on the medical-

surgical units of the hospital. Nurses were shown where to properly document patient education

in the electronic medical record as well as the new education materials that were created for the

patients. These educational sessions took place over several weeks and included teaching the

nursing staff on both day and night shifts. The clinical unit leaders on each unit were reminded

to review the MDRO report that is faxed to the unit each day to ensure that the proper isolation

signs are in place on the patient door frames.

Audits were conducted after the educational sessions. Creating awareness and new

information seemed to have a positive effect on the performance of the staff nurses. Compliance

with PPE use and hand hygiene was maintained between 95% and 97%. Documentation of

patient MDRO education averaged 38% before and after education for all the units combined.

There was significant improvement on some of the individual units (see Appendix D). For

example, 6SE increased from an average of 6% correct documentation through August 2016 to

50% in October 2016. Proper use of isolation signage improved from 38% to 67% (see


Appendix C). Continued education and reinforcement on all units should help the organization

reach the target goal of 95% for correct signage and documentation.

Discussion

Due to the short amount of time that passed between educating the staff and completing

the follow-up audits, the results may not show a true trend in improvement. To assess an

accurate improvement in behaviors, monthly audits should be completed for at least three months

beyond the completion of the instruction. A larger percentage of the staff nurses should also

receive the documentation education. The nurses who received the information were

appreciative of the new education materials for the patients. The actual cards for the patients

were not available for the project implementation. The cards were approved by the necessary

committees but had not passed through the marketing department or the print shop. Having the

education cards available on the units will keep the need for patient education apparent to the

nurses. The slight improvement in the audit data indicates an increase in safe care provided to

the patients by the staff. The behaviors emphasized in this project need to be continued in order

for positive trends to be sustained.


References

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hospital quality and safety. Retrieved from:

http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/guide.html

American Nurses Association. (2010). Nursing professional development scope & standards of

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Butterfoss, F. D., Kegler, M. C., Francisco, V. T. (2008). Mobilizing organizations for health

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(Eds.) Health Behavior and Health Education Theory, Research, and Practice (4th ed.).

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site.ebrary.com.libcat.ferris.edu/lib/ferris/reader.action?docID=10250302&ppg=441

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uptake of personal protective equipment. American Journal of Infection Control, 41(1),

207. doi:10.1016/j.ajic.2012.01.019

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practices. In Joint Commission Resources, The Nurse’s Role in Infection Prevention and

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6701(03)00074-4


Appendix A

Blanks indicate no data available

Target is >= 95%


Appendix B

50 Surveys returned as of 9/30/2016

Education = Do you explain to patients and visitors what the isolation signs mean?

Document Iso= Do you know that if your patient is in isolation, this needs to be documented as

part of the assessment?

Document Educ. = If education is provided to patients and/or families, do you document it every

time?

Materials = Do more educational materials about MDROs need to be accessible for staff to hand

out?


Appendix C

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day80%

10%20%30%40%50%60%70%80%90%

Pre-Intervention Post Intervention

Correct Isolation Sign in Place


Appendix D

MDRO DocumentationPost-Intervention Data

3 S 4 T 5 N/A 5 S 6 NW 6 SE 7 NW 7 S0%

20%

40%

60%

80%

100%

120%

50% 50%

14%

40%

17%

50%57%

0%

100%

0% 0%

100%

33%

50%56%

0%

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