Running Head: INFECTION CONTROL AND INTERAGENCY TRANSFERS

Infection Control and Interagency Transfers

Monica Lawson

Western Washington University

NURS 402 Translational Research for Evidence-Based Practice

Christine Espina DNP, MN, RN

March 13th 2017

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Abstract

It has been noticed by Public Health Nurses in our community that there is a trend of infection

of both staff and patients in relation to inter-agency transfers. The purpose of this project was to

find effective infection control practices for inter-agency transfers of colonized or infectious

patients based on the best available evidence. Rigorous literature searches of peer reviewed

journals were conducted for this evidence based project. It was found that studies regarding

infection control practices and inter-agency transfers are little to none. Further studies need to be

conducted. However, there seems to be a trend with regards to inter-agency transfer and a

breakdown in communication. Several qualitative quasi experimental studies were found along

with a systematic review. The evidence suggests that there is a lack of standardization of practice

between facilities which is leading to vital patient information not being conveyed on transfer.

Another finding is that there is a nonadherence to infection control precautions related to lack of

communication. Collaboration by facilities to create a communication form and retrain staff on

infection prevention and disinfection practices is recommended. This would likely decrease

infection rates among staff and patients during transfers.

Keywords: communication, infection prevention, inter-agency transfer, infection control, transfer

form, and transport.

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It was identified by public health nurse Joni Hensley that there is a trend of infection

among staff and patients associated with interagency transfer. She noticed this during an

outbreak of norovirus back in 2008 that was so severe that all of Whatcom Countys emergency

medical services (EMS) staff were infected as were the patients. It was found that no infection

control precautions were taken by EMS and emergency department staff which resulted in a

shutdown of the local emergency department and depletion of EMS related to lack of staff (J.

Hensley, personal communication, February 14th, 2017).

For the purpose of this project we cast a wide net and included any study pertaining to

interagency or interfacility transfer. The population of interest is patients colonized with an

infection that are undergoing either a transfer within a facility or an inter-agency transfer. The

intervention of interest is a form with essential clinical information.

The comparison of interest is what is being done currently which varies depending on the

setting. A systematic review of literature done by the flex monitoring team stated that current

practice is that there is no standardized practice and that there are many different types of

communication both from the ambulance crews and the medical staff (Pearson & Coburn, 2013).

For example, current practice at St. Joseph hospital during a patient transfer is to use the

situation, assessment, background, and recommendation tool (SBAR). This is pulled up on the

computer during verbal report over the phone to the nursing home or accepting facility. However,

most staff do not use this form and it rarely has pertinent information for the transfer. The SBAR

form itself does not have a spot for contact precautions. When EMS or medical transport service

comes to take the patient there is no handoff given.

The outcome of interest is improved communication. This is relevant to infection control

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in the clinical setting because without proper communication staff are unable to use the proper

protective equipment or infection prevention practices.

Purpose

The purpose of this project was to evaluate research and make recommendations for

improvement to our current infection control clinical practice during inter-agency transfer based

on the best available evidence. Taking clinical judgement into consideration is also the aim of

this project as it important when looking at evidence based practice.

Methods

We combed the various databases including CINAHL, PubMed, Google scholar, Up-to-

Date, CDC, and Medline. There were countless searches for literature. The search terms used

were infection control, inter-agency transfer, infection prevention during transfer, transport

infection prevention, communication and infection prevention, communication tools and

infection prevention. Upon several more searches key terms were used such as EMS infection

control, hand hygiene and EMS, infection prevention practices and EMS.

This did not yield a lot of evidence in CINAHL and so google scholar was used where I

searched for studies related to infection control forms. This resulted in the discovery of a policy

brief which was also a literature review. I then typed each source from this policy brief into

CINAHL which required various inter-library loans. My first few searches only yielded about

three or four articles. Once my group came together we were able to find seven sources. Over

twenty-five articles were reviewed. We did not have exclusion criteria other than it had to be peer

reviewed, a reputable source, and pertaining to the population of interest. Further exclusion

criteria would have yielded no results as the information available is scant. The level of evidence

found was one systematic review which is level I, the highest level of evidence and some
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qualitative quasi-experimental studies which rank level III. The majority of these studies

measured outcomes qualitatively as many of them involved descriptive surveys and interviews.

The systematic review policy brief was the highest level of evidence found however, it is the

only one of its kind.

Findings/Synthesis of literature

A theme present in the literature is that adherence to infection control practices are poor

among emergency medical services staff. According a study in the American Journal of Infection

Control, firefighters hands are the main source of microbial transfer. Not only was hand washing

an issue but there was a lack of adherence to decontamination practices. The lack of a standard

policy in regards to decontamination and poor consistency of decontaminating surfaces was

leading to spread of bacteria and presence of bacteria on EMS surfaces and equipment (Valdez,

Sexton, & Reynolds, 2015).

This is especially disturbing because viruses such as influenza and norovirus can survive

twenty-four hours to twelve days on a nonporous surface and bacteria such as MRSA,

vancomycin-resistant enterococcus, and pseudomonas aeruginosa can survive seven hours to five

months on nonporous surfaces. Decontamination of surfaces is clearly needed to fight these

threats. Implementing a standardized protocol significantly reduced the presence of viruses and

bacteria on surfaces. It was recommended that training and advocating for surface disinfection

would be beneficial (Valdez, Sexton, & Reynolds, 2015). However, training on disinfection

practices is not enough there needs to clear communication between sending and receiving

facilities.

Non-adherence to infection prevention practices is just one of the puzzle pieces. A

common theme among the literature is that important health information is frequently not
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communicated during transfer of patients. It was noted that 10% of extended care facility (ECF)

transfers are done without any documentation. The 90% that do have documentation are

frequently missing vital information. A study done at the Methodist Hospital emergency

department in Indianapolis Indiana was conducted to test the theory that a one page standard

form would increase the rate of successful documentation. A one page document was

implemented and it was found that successful documentation increased by 19.3% which meant

that 95.6% of the transfers studied had successful documentation (Terrell et al, 2005). Clear

communication is something that all healthcare providers struggle with however improvement in

this area is paramount to infection prevention.

Furthermore, insufficient communication is resulting in poor patient care and contributes

to 65% of sentinel events. This deficit is not the sole problem of one facility but exists in

transfers between hospitals, primary care physician offices, and long term care facilities (Klinger

& Moscovice, 2012). Healthcare providers do not know when to wear personal protective

equipment if there is no communication to let them know that the patient has an infection.

One of the ways to improve this communication issue is to implement a standard

communication tool. A study featured in BMC Infectious Diseases found that implementation of

a standard checklist and color cue improved adherence to infection control precautions.

Adherence to infection control precautions went from 38% to 74% with the use of this system.

The results of this study highlight how effective communication is in aiding adherence to

infection control practices especially during the transfer of a patient. (Mei-Sing et al, 2013). A

color cue is an effective way to communicate important information, especially to individuals

that are visual learners. For example, at St. Joseph Hospital there is a color-coded sign on each

infectious patients room which corresponds to the type of infection precautions to adhere to.
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Healthcare providers would be less likely to adhere to these precautions were it not for the color-

coded sign outside the door reminding them.

While a standard form or check list may help resolve some of the communication

breakdown, effectively communicating involves cooperation from all parties involved. Flex

Monitoring Team wrote a policy brief that included a systematic review of the literature in

regards to patient safety and inter-agency transfers. It was made evident by the various studies

that implemented different types of communication such as forms or checklists that collaboration

on behalf of all the facilities involved was needed. This would ensure that the communication

tool being used would satisfy each facilities needs. It was recommended that collaboration and

standardized forms be implemented to improve communication. (Pearson & Coburn, 2013).

Although collaboration among facilities requires a great deal of work and cooperation the

benefits outweigh the risks in this case.

Without communication among staff and facilities there is no exchange of information

and one or more facilities or staff members is left blindsided to possible infection risks. It is

unacceptable that the local emergency department was shut down due to low staff levels related

to illness. If a natural disaster or mass casualty event had happened during that time the

community would have been in a vulnerable position and unable to receive aid from the local

emergency department or EMS. Having to divert patients to hospitals farther away results in

delayed care and may cost lives.

Each of these studies are valid however further studies linking infection rates to inter-

agency transfer and quantitative studies involving effective interventions for infection prevention

during transfer would be preferred. There seems to be a gap in the literature in regards to specific

interventions such as disinfection practices in comparison to other disinfection practices. While

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the study of EMS non-adherence did delve into this topic there were no other studies found to

compare two different types of disinfection practices in the setting of EMS transport or inter-

agency transfer. There is such a wide variety of interventions it is difficult to compare one to the

other. It is clear that the reason that only one systematic review was found regarding inter-agency

transfer is because there is scant literature to review on this topic.

Recommendations

Based on the literature available I recommend a simple color coded standardized form for

all transfers. Furthermore, this form should be collaborated on by each of the hospitals, nursing

homes, and EMS. By collaborating, each facility can agree upon the standard information needed

and familiarize their staff with this form. My third recommendation is to have each facility

including EMS hold an in-service on the new form not only training staff on how to use it but

also explaining why it is needed. This in-service should also include a review on infection

control precautions and disinfection practices. These like other education requirements should be

done on a yearly basis to keep the information fresh in the minds of staff. In addition, more

research is needed on the topic of infection control and inter-agency transfers which would

greatly benefit our community.

Implications for Practice

The outcome of collaboration, improving communications, and adherence to infection

prevention precautions could decrease transmission of infections to both patients and healthcare

workers. With any kind of change there is typically some resistance. A barrier to these new

practices maybe that facilities are resistant to collaborating and working together. Another

possibility is that staff may not follow the standard communication tool because they feel it is not
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needed. Staff may resist training because they believe they already know the information.

To combat these barriers it would be useful to give staff a rationale for the changes as

well as educating each of the facilities on the issues this community is facing in regards to

infection during inter-agency transfers. Providing staff with proper training and involving each of

the facilities staff in communication would not only benefit the patients but strengthen the

healthcare community in Whatcom County.

Conclusion

Infection associated with inter-agency transfer is a wide spread issue that effects

Whatcom County as well as other communities. Poor infection control practices leads to

insufficient staffing levels and results in delayed care. The literature identified some common

shortcomings such as inadequate communication, collaboration, and adherence to infection

control precautions. It is my hope that the various agencies transferring patients will come to an

agreement on a communication tool and as well as retraining staff on infection prevention and

disinfection practices. As healthcare providers, it is our responsibility to protect our community

and do no harm, lets start by taking the first step toward combating this problem and

communicate.
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References

Ong, M., Magrabi, F., Post, P., Morris, S.,Westbrook, J.,Wobcke, W., Calcroft, R., Coiera, E. (2013).

Communication Interventions to Improve Adherence to Infection Control Precautions: A

Randomised Crossover Trial. BMC Infectious Diseases. 13 (72). doi:10.1186/1471-2334-13-72.

Pearson, K. B., & Coburn, A. F., (January, 2013). Emergency Transfers of the Elderly from Nursing

Facilities to Critical Access Hospitals: Opportunities for Improving Patient Safety and Quality.

(Issue brief No.32). Retrieved from

http://www.flexmonitoring.org/wp-content/uploads/2013/07/PolicyBrief32-Transfer-Protocols-

with-Appendix.pdf.

Terrell, K. M., Brizendine, E. J., Bean, W. F., Giles, B. K., Davidson, J. R., Evers, S., Stier, P. A., &

Cordell, W. H. (2005). An Extended Care Facility-to-Emergency Department Transfer Form

Improves Communication. Academic Emergency Medicine 12 (2).

doi:10.1111/j.1553-2712.2005.tb00845.x.

Klingner, J., & Moscovice, I. (2012). Development and Testing of Emergency Department Patient

Transfer Communication Measures. The Journal of Rural Health 28(1).

doi:10.1111/j.1748-0361.2011.00374.x.

Valdez, M. K., Sexton, J. D., Lutz, E. A., Reynolds, K. A., (2005). Spread of infectious microbes

during emergency medical response. American Journal of Infection Control. 43 (11). doi:

http://dx.doi.org/10.1016/j.ajic.2015.02.025.