Electronic Bug Management
13 May 2013 Last updated:
30 September 2014
Electronic Bug Management
By The Children's Hospital at Westmead (CHW)
The Children's Hospital at Westmead (CHW) developed an:
- electronic multi-resistant organism (MRO) flagging and information system
- infection control note in the Electronic Medical Record (EMR)
- individualised electronic MRO care plan which includes input from families.
These are all available in the Patient Management System and the EMR for round the clock accessibility in order to ensure continuity of safe care.
In addition, 556 Multi Resistant Staphylococcus aureus (MRSA) positive patients had their MRO status reviewed for clearance, ensuring those children who were cleared no longer experienced burdensome isolation.
Extent of the problem
MROs are increasing in the community and hospitals worldwide (Gottlieb T, 2012). Informal reports as well as Incident Information Management System (IIMS) reports and parent/carer complaints highlighted that children with MRSA and other MROs were being admitted to multi-bedded rooms overnight or on weekends.
As well as generating unnecessary patient movement when the error was detected, this put other children at risk of colonisation or infection with the MRO. Parents are very aware of, and frequently distressed by, inconsistencies in isolation practices. It has been argued that isolation is the only medical intervention where potential harms, but no benefits, fall to the person on whom the intervention is applied (Kirkland K, 2009).
In addition, previously care plans for children with MROs have not been individualised, or negotiated with the family and other clinicians involved in the child’s care, or included in the EMR.
Infection Control (IC) audited the placement of children with MROs on a daily basis and then interviewed staff to establish the reason for each child's placement. We reviewed the 23 complaints received over six months from clinicians and families about incorrect placement and excessive movement of children during their inpatient journey.
Children had been moved, for IC indications, up to five times per admission. Also approximately 50% of after-hours admissions and Paediatric Intensive Care Unit patient transfers resulted in inappropriate patient placement and incorrect IC precautions that were unsafe.
Planning and implementing solutions
The IC management team set out to improve the existing process through:
1. Development of electronic MRO flagging and information system
A system for flagging the EMR for children with MROs was implemented. The flag is on the front screen of the EMR, and alerts any clinician accessing the record to the MRO status of the child. Retrospective data for EMR electronic flagging has been entered on all 1,756 children with known MROs.
An electronic form detailing the MRO was developed, reviewed and amended by the Infection Control Committee and Clinical Applications Support Unit. This electronic system went live January 2012 and new information has been entered prospectively by IC staff.
The new electronic flagging and information system has been audited against data held in the IC MRO isolate database and corrections made where required. This was essential to detect data entry errors and other inconsistences. We corrected any identified gaps in the Patient Management System where children identified with MROs when an outpatient could not be flagged. A new platform was developed to overcome this issue.
2. Individualised electronic MRO care plan
An MRO care plan for each patient is discussed with the parent/carer/patient by the IC staff and is now available in the EMR. The plan is also negotiated with key stakeholders in the child's care team, including medical team, nursing and allied health staff, and where appropriate, teachers providing ongoing education while the child is in hospital.
The care plan is then available to all clinicians involved in the child's care and is reviewed on every inpatient presentation to this hospital. This promotes consistency of isolation practices.
3. MRSA clearance
Additionally, 556 children with MRSA have had their MRO status reviewed against NSW Health criteria (PD 2007_084) for clearance.
This has resulted in the active follow up of 56 children with MRSA of whom 41 have been cleared and 15 are in the process of clearance. Children cleared of MRSA colonisation no longer require isolation precautions and this ensures appropriate use of limited isolation spaces and allows the child more socialisation opportunities.
The IC office manual has been updated to include the new processes of MRO flagging, development of the care plan and MRSA clearance for patients.
A standard letter to be sent to parents/carers and General Practitioners of patients diagnosed with MROs after discharge has been developed. A factsheet is also sent after the treating team has contacted the family.
Outcomes and evaluation
1. Family benefits
The IC consultation, care plan and fact sheets for parents/carers/patients improved family understanding and compliance with IC isolation procedures. Complaints have reduced from 23 in the six months prior to implementation to five in the six months post implementation.
2. Positive clinician feedback
Verbal and email feedback was received from medical staff which was mostly positive and always constructive. Nursing staff commented that patient placement decisions were much clearer.
3. Electronic system audit
IC audited both EMR and Patient Management systems against the MRO database to check that all current children were flagged, had an MRO note and a care plan available. This audit identified 175 children without flags.
4. Correction of identified gaps
The 175 children who were previously un-flagged, because their MRO status was identified as an outpatient, have now been flagged ensuring correct placement on admission.
5. Patient placement audit
Audits of appropriate IC placement and signage of patients has demonstrated a significant improvement from 50% to 84% post-introduction. No IIMS relating to incorrect placement have been received since the introduction of this system.
6. Positive patient feedback
Parents/carers/patients have given very positive feedback when MRSA clearance has occurred and isolation procedures discontinued.
7. Compliance with NSW Health PD 2007_084
This project has improved our compliance with the Policy Directive, in particular, facilitating decolonisation and clearance procedures.
The electronic flagging of children with an MRO, detailed in the IC office manual, is now part of the daily work processes. The Clinical Nurse Consultant audits this process every three months to ensure correct and accurate information is entered into all electronic systems.
An IC consultation is provided to any MRO positive inpatient to discuss their care plan and the appropriate fact sheet. One team member is designated to review the status and facilitate children for MRSA clearance.
The outcomes achieved contribute to ensuring that patients are correctly identified and placed thus minimising the transmission of hospital acquired infections, whilst ensuring that children that no longer need to be in isolation are cleared as quickly as possible.
CNC Infection Control
The Children's Hospital at Westmead
Phone: 02 9845 2578
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