Care Rounds Research Articles

Attitudes and Behavior towards Interprofessional Collaboration among Healthcare Professionals in a Large Academic Medical Center.

The increasing rates of comorbidities among patients and the complexity of care have warranted interprofessional collaboration (IPC) as an important component of the healthcare structure. An initial step towards assessing the effectiveness of collaboration requires the exploration of the attitudes and experience of healthcare professionals towards IPC. This online survey aimed to examine the attitudes of healthcare professionals working in a large public academic medical center toward IPC in patient care and the healthcare team, and their behavior and experience regarding IPC. The rankings, according to the perceived importance among the respondents, of the four Interprofessional Education Collaborative (IPEC) core competencies (values/ethics, roles/responsibilities, interprofessional communication, teams/teamwork) were assessed. There were strong but varying levels of consensus among healthcare professionals (N = 551) that IPC facilitates efficient patient care, improves patient problem-solving ability, and increases better clinical outcomes for patients. They acknowledged that IPC promotes mutual respect within the healthcare team and providers’ ability to make optimal patient care decisions. However, overall more than 35% of the respondents did not attend multidisciplinary education sessions (grand rounds, seminars, etc.), and about 23% did not participate in bedside patient care rounds. Interprofessional communication was ranked as the most important IPEC core competence. Although the attitude towards IPC among healthcare professionals is strongly positive, many healthcare professionals face challenges in participating in IPC. Institutional policies that facilitate interprofessional learning and interactions for this group of healthcare professionals should be formulated. Online distance learning and interactions, and simulation-enhanced interprofessional education, are options for addressing this barrier. Hospital administrators should facilitate conducive work environments that promote IPC, based on IPEC core competencies, and promote programs that address the challenges of IPC.

Preparing for a Joint Commission Survey: An Innovative Approach to Learning.

Graduate nurses report feeling unprepared for accreditation site visits, including the promotion of a safe, functional, supportive environment to preserve safety and quality through the provision of care, treatment, and services for patients. To address this gap, an academic health system's department of quality and a school of nursing collaborated on a three-phase capstone course for senior-level BSN students. The course included simulation training for all students; volunteers performed Environment of Care rounds and patient care record audits in the hospital setting. Nineteen students, who performed 74 rounds and 193 audits, reported feeling more knowledgeable during site visits.

Multidisciplinary Environment of Care Rounding to Mitigate Water Related Pathogens in the ICU

<h3>Background</h3> This project occurred at a 1010-bed tertiary academic hospital in the southeast. The Centers for Medicare and Medicaid Services issued a memorandum in June 2017 requiring healthcare facilities to reduce Legionella risk. This implies that healthcare facilities are responsible for identifying risks and preventing infections related to waterborne pathogens (WRP). WRP were screened from January 2018-March 2019 in the 17 bed Surgical Trauma Intensive Care Unit (STICU) with a baseline monthly average of 0.2. In April-June 2019 an increase was identified, including two colonizations and four infections. Multiple factors impacted this increase, including respiratory equipment storage, plumbing issues, sink storage, and Environmental Services (EVS) deficiencies. <h3>Methods</h3> A multidisciplinary team assembled to begin Environment of Care interventions in June 2019. Included were Infection Prevention (IP), Respiratory Therapy (RT), Facilities, Industrial Hygiene (IH), and EVS. RT initiated bedside anti-humidity measures by initiating the use of a new nebulizer mouthpiece for our vented patients and running continuous 1/2 liter of oxygen through stored equipment. Facilities committed to enhanced response times with IH mitigating challenging plumbing concerns. Nursing and IP initiated daily assessment of all STICU rooms. EVS initiated adenosine triphosphate testing of all terminally cleaned rooms. Biweekly multidisciplinary rounding began in August 2019. In September 2019, filters were installed on all STICU room faucets. <h3>Results</h3> Identification of WRP pathogens returned to baseline in July 2019-November 2019. Ongoing assessment notes continuation of this trend. <h3>Conclusions</h3> Multidisciplinary Environment of Care interventions and rounding reduces WRP in the ICU setting.

Can Structured Communication Affect the Patient-Family Experience?

Can Structured Communication Affect the Patient-Family Experience?

A Central Sterile Processing and Hospital Epidemiology and Infection Control Collaboration to Ensure Safe Patient Care.

Cleaning, disinfection, and sterilization (CDS) practices and protocols are the cornerstone of infection control and patient safety. Central sterile processing (CSP) leaders are responsible for updating policies and procedures for sterile processing and ensuring CSP staff members process instruments correctly. Monitoring staff member practices can be a demanding and difficult task, but it is critical for safe patient outcomes. The CSP and perioperative leaders at our facility found that regular consultation and collaboration with the Department of Hospital Epidemiology and Infection Control (HEIC) is an effective way to ensure that patient safety is at the forefront of CDS practices. These leaders established an oversight committee to address a variety of infection prevention concerns, including environment of care rounds, implementation of manufacturers' instructions for use, and CDS standardization. This article highlights how CSP and HEIC leaders and staff members partnered to implement and sustain CDS best practices and protocols.

Creating and Implementing a Resident Emotional Wellness Initiative in an Acute Care Setting: The Role of the Palliative Care Social Worker

Caring for dying patients is often a new experience for ICU residents. End-of-life and palliative training in medical schools is lacking. Many residents experience troublesome emotions during residency. Literature establishes that residents show lower well-being scores than similar populations. To make emotional wellness a priority for residents, monthly mandatory Palliative Care Rounds (PCR) were established in the ICU. The role of the Palliative Care Social Worker (PCSW) is central in planning and implementing PCR. Social workers have unique skills well-suited to this type of activity in an acute care setting. Residents present cases and the PCSW facilitates discussion to explore complex emotions helping residents process their feelings. Forty-five residents responded to a seven-item questionnaire, out of 70 potential resident respondents (64% response rate). Only 60% said they learned about end-of-life and its emotional aspects in medical school. Ninety-eight percent reported the PCR helped them be more aware of their feelings, and would recommend it to colleagues. Ninety-five percent said PCR are important for interns and residents to help them grow professionally and become better clinicians. Through the process of dissecting their emotions, PCR allows for personal and professional growth that improves residents’ ability to become empathic providers.

Enhanced Communication through Virtual Interdisciplinary Team Rounds for Pediatric Patients Receiving Hospice Care in Outlying Communities (FR408B)

•List three ways that virtual palliative care rounds may benefit community-based providers.•List three areas in which virtual palliative care rounds may be applied in metropolitan and rural regions. Providing hospice/palliative care (HPM) for children in the community is challenging due to limited numbers of experienced clinicians outside of medical centers. In rural areas, pediatric HPM is almost non-existent, although adult providers attempt to care for children referred to them. Telehealth has been used effectively for patient follow up. Our goal is to extend the reach of existing pediatric HPM clinicians to provide team oversight and consultation to adult organizations providing pediatric HPM care in outlying locations. Virtual Pediatric Consultative Rounds (VPCR) were developed with a large community-based adult HPM partner with nine regional offices. Each regional office typically cares for 1-5 children. A rounding sheet was developed to collate clinical information to enhance efficiency of VPCR sessions. VPCR sessions utilizing Skype for Business (HIPPAA compliant) were scheduled every other week for two hours beginning in July 2018. The hospital-based pediatric HPM team and the community-based coordinators were on-line as each nurse presented medical/psychosocial issues, medication reconciliation, code status, hospital/ED visits, follow-ups and goals. 5-10 minutes per patient was allotted including a short dialog/Q&A. Patient records were updated for both institutions and changes noted. An online survey was developed to assess the nurses' experiences with the VPCR process ranging from 1(strongly disagree) to 5 (strongly agree). Nine pediatric nurses participated in the VPCR initiative and seven completed the survey. Most nurses used a corporate cellphone for reporting; whereas, two used laptops with televideo when able. After an initial learning curve for logins, participants found the technological interface acceptable with good-to-excellent audio and video quality. –VPCR participation: (Likert 1-5) –Allowed better patient care: 3.86 –Facilitated better care coordination: 4.0 –Improved communication w/ family: 3.86 –Reduced ER visits/hospitalization: 2.57 –Enhanced dialog with referring MD: 4.29 –Improved understanding of MD's plan: 3.71 VPCR improves communication between referring hospitals and community providers, facilitates problem solving and a sense of professionalism.

The Mindful Manager: Validation of a Rounding Leadership Instrument for Residents.

In the context of inpatient general medicine, "rounding" refers to the process of seeing, assessing, and caring for patients as a team. The clinical leadership skills required of residents to lead rounds are essential to inpatient care and clinical education. Assessment of these skills has relevance to developing competent physicians; however, there is an absence of widely accepted tools to specifically measure this competency. To develop and collect validity evidence for a direct observation instrument of internal medicine residents' leadership skills during daily inpatient care rounds for future formative assessment. Prospective observational study. PGY2 and PGY3 internal medicine residents. The authors collected inferences of validity evidence according to Kane's validity model. They performed direct observations of PGY2 and PGY3 residents by individual faculty and trained raters and measured inter-rater reliability, using the kappa statistic. Mixed linear regression models were used to compare PGY2 and PGY3 residents. Surveys captured faculty perceptions about value of the instrument. A total of 223 observations were performed in 92 unique individuals. Twenty-four faculty used the observation instrument, of which 18 (75%) completed the post-survey, and 100% agreed that the instrument represented the resident's global leadership abilities. Inter-rater reliability was strong, with an overall kappa statistic equaling 0.82. The mean performance for PGY2 and PGY3 residents was 15.9 (SD 5.1) and 17.7 (SD 4.1), respectively. Adjusting for repeated measures, there was no statistically significant difference between groups. The authors reported evidence for all four stages of validity and use of the instrument in clinical practice. Their work provides a codification of best practices of rounding leadership, which directly impacts the education of trainees, care of hospitalized patients, and use for formative assessment. The instrument also has the potential to be used for summative assessment.

Using Qualitative Methods to Explore Communication Practices in the Context of Patient Care Rounds on General Care Units.

Poor communication between physicians and nurses is a significant contributor to adverse events for hospitalized patients. Overcoming communication difficulties requires examining communication practices to better understand some of the factors that affect the nurse-physician communication process. To develop a more detailed understanding of communication practices between nurses and physicians on general care units. We focused on patient care rounds as an important activity in the care delivery process for communication. Qualitative study design PARTICIPANTS: A total of 163 physicians, registered nurses, and nurse practitioners who worked on pre-specified general care units in each of four hospitals in the Midwest. On each unit, data collection consisted of 2weeks of observing and shadowing clinicians during rounds and at other times, as well as asking clinicians questions about rounds and communication during interviews and focus groups. A directed content analysis approach was used to code and analyze the data. Workflow differences contributed to organizational complexity, affecting rounds and subsequently communication practices, both across and within provider types. Nurse and patient participation during rounds appeared to reduce interruptions and hence cognitive load for physicians and nurses. Physicians adopted certain behaviors within the social context to improve communication, such as socializing and building relationships with the nurses, which contributed to nurse participation in rounds. When rapport was lacking, some nurses felt uncomfortable joining physicians during rounds unless they were explicitly invited. Improving communication requires bringing attention to three contextual dimensions of communication: organizational complexity, cognitive load, and the social context. Initiatives that seek to improve communication may be more successful if they acknowledge the complexity of communication and the context in which it occurs.

ACCESS TO CARE ROUNDS: A UNIQUE FORUM FOSTERING HEALTH SYSTEM AND SOCIAL SERVICE PARTNERSHIPS FOR OLDER VETERANS

Colorado Veteran Community Partnership (VCP) aims to connect Rocky Mountain Regional VA Medical Center front-line teams with diverse community partners to create integrated networks of support for older Veterans with complex needs and their family members and caregivers. To accomplish this goal, VCP launched Access to Care Rounds in January 2018 to build bridges between the healthcare system and community-based organizations. Each Access to Care Rounds features a cross-sector panel that discusses specific efforts to link a medically-complex, older Veteran to resources. This model was developed with stakeholder input and has highlighted topics related to chronic pain management, suicide prevention, homelessness, adult protective services, transportation, home-based primary care, hospice care, and firearm safety. Each Access to Care Rounds focuses on connecting VCP members, sharing expertise and resources, and highlights lessons learned related to care coordination, communication, and key processes that others can adopt/adapt to better serve older Veterans. On average, 30 individuals attend each session. Access to Care Rounds draw diverse audiences representing social services, mental health and other healthcare specialties. The latter include Social Workers (47%), Physicians (11%), Psychologists (8%), Registered Nurses (6%), and students/trainees (6%). Participants receive a description of the Veteran situation; the names, credentials, organizational affiliations and roles/expertise of each panelist; and, a resource list relevant to the constellation of issues addressed to enhance access to information and resources. Over 38% of respondents to session evaluations reported intentions to change their professional practice as a result of what they learned during an Access to Care Rounds.

1068. Implementation of an Antimicrobial Stewardship Program (ASP) Managed by an Infectious Disease Physician and Pharmacists in a Community Hospital

BackgroundThe implementation of antimicrobial stewardship program (ASP) is one of the basis for the control of multidrug-resistant bacteria (MDR), optimization of antibiotic use, minimization of adverse events, and reduction of unnecessary costs. We demonstrate the design, development, and participation in ASP program following CDC and Prevention Core Elements strategies.1,3,4 The objective is to evaluate the impact of clinical pharmacists working in conjunction with infectious disease (ID) physician on tracking and documenting antibacterial utilization in per patient-days, pharmacist clinical interventions, prescriber practices, and antibiotic purchases.MethodsWe conducted a multidisciplinary-team project of pharmacist-led prospective-audit-with-feedback ASP from 2015 to 2018. The ID physician and clinical pharmacist conducted patient care rounds twice weekly to make recommendations that include de-escalation, intensification of treatment, alternative therapy, dose optimization, order clarification, stop date/duration, additional monitoring, education, restriction enforcement, consult, IV to PO conversion, rejection of recommendation, and total monitored interventions requiring no changes.ResultsPharmacist tracked between 150 and 200 interventions monthly through the EMR system, reflecting both self-stewardship and during rounds with ID physician. Figures 2–8: Charts display the number of patient-days of therapy per 1,000 days at risk and yearly SVMH Antibacterial Utilization Rates compared nationally to other Teaching and Nonteaching hospitals.5 Below each graph exhibits yearly Drug Spend per patient-days of Therapy.6ConclusionOverall, the antibiotic utilization rates decreased over 4 years, particularly with aztreonam, meropenem, and levofloxacin.The formalization of an antimicrobial stewardship partnership between ID physician and pharmacy team led to increases in pharmacist-recommended interventions, streamlining of antimicrobial therapy, as well as decreases in antimicrobial purchasing costs. Proactively working in conjunction with hospitalists allows the pharmacists to play a critical role in sustaining a robust ASP service at our community hospital. The ASP at SVMH can serve as a model for other community hospitals with similar resources. Disclosures All authors: No reported disclosures.

311. Assessment of the effect of implementation of enhanced recovery after surgery program in spinal surgical procedures: a retrospective study

BACKGROUND CONTEXT Enhanced Recovery after Surgery (ERAS) protocols are multimodal and multidisciplinary perioperative care strategies, and have been demonstrated to be associated with facilitated functional recovery process, improved patient experience and outcomes, as well as reduced cost and length of hospital stay (LOS). Even with increasing evidences of success in many major surgical procedures, there is limited data related to ERAS programs on the spine surgery. In addition, implementation of new practices is difficult, and has been suggested that change in clinical practice occurs 15 yrs after clear evidence is available. PURPOSE In this retrospective analysis, we tested the hypothesis that implementation of ERAS protocol would contribute to decrease LOS after spinal fusion procedures. STUDY DESIGN/SETTING Quality Improvement Retrospective Study. PATIENT SAMPLE Refer to Methods. OUTCOME MEASURES Refer to Methods. METHODS The medical, surgical and anesthesia records of 1,399 patients aged ≥80 yr and ASA 1-3 undergoing spinal fusion procedures based on Medicare Severity Diagnosis Related Groups (MSDRG) (S460) during the years of 2015, 2016 and 2017 in our institution were reviewed. Study patients were assigned into one of three study groups based on experience of implementation of ERAS: Group 1 (Year-2015) was standard postoperative management with multimodal pain management, Group 2 (Year-2016) was standard postoperative management + initial implementation of Progression of Care Rounds (POCR) (Year I) program (multidisciplinary team members continuously provided patient care by addressing key points for each patient and taking necessary steps to improve the patient recovery process) and Group 3 (Year-2017) was standard postoperative management + POCR (Year II). The demographic characteristics, recovery profiles, opioid dosages, side effects and LOS were recorded. Data were analyzed using the Student's t-test, chi-square test or the Fisher exact test, with p-values RESULTS The 3 study groups were similar with respect to their demographic characteristics. However, the LOS was significantly reduced in patients who received more experience of POCR (Year II) management (Year-2017) when compared to either standard postoperative management (Year-2015) or initial POCR (Year I) management (Year-2016). Not surprisingly, the average direct cost per case was also decreased 8% when patient received more experience of POCR management. CONCLUSIONS In this retrospective review study, more experience of ERAS programs (PORC) improved patient recovery process, and decreased the LOS along with cost-savings in patients after spinal fusion procedures (MSDRG S460). Future studies are needed to design and implement more detail ERAS protocols, and evaluate their efficacy through prospective randomized, double-blinded and controlled clinical trials. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Investigation of a Serratia Marcescens bacteremia Cluster in a Cardiothoracic Intensive Care Unit (CICU) Utilizing Whole Genome Sequencing

BACKGROUND Serratia bacteremia is a significant cause of morbidity and mortality in the intensive care unit (ICU). In August 2018 we identified 5 cases in our CICU, prompting an investigation for patient risk factors, exposures, and environmental sources. METHODS To ascertain common exposures among the cases, patient demographic and mortality data, unit length of stay, room location, infection, and surgical histories were collected by chart review. Medication histories were obtained from pharmacy records and the potential for drug diversion was explored. Environment of care rounds were conducted in both the CICU and the Cardiac operating rooms. Environmental culturing was considered. Four case isolates along with 21 non-cluster Serratia blood isolates from the same facility were analyzed for relatedness by whole genome sequencing (WGS) analysis. RESULTS The case age range was 30-80 years with 80% male gender. Mortality rate among cases was 60%. The investigation did not reveal any common risk factors or exposures among cases either in the CICU or the operating room. Environmental cultures were not collected. No evidence of drug diversion or medication contamination was identified. WGS analysis did not show any close genotypic relationship among the patients’ isolates. CONCLUSIONS WGS was used to investigate Serratia bacteremia isolates which were clustered in time, clinical service and location. The WGS results, however, indicated that these cases did not arise from a common source nor from cross-infection. WGS provides an unprecedented level of specificity for outbreak investigations permitting infection prevention resources to be used appropriately and cost-efficiently.

PO-0878 Implementing a dedicated inpatient radiation team with multidisciplinary palliative care rounds

PO-0878 Implementing a dedicated inpatient radiation team with multidisciplinary palliative care rounds

Evaluation of Medication Errors at the Transition of Care From an ICU to Non-ICU Location.

To determine the point prevalence of medication errors at the time of transition of care from an ICU to non-ICU location and assess error types and risk factors for medication errors during transition of care. This was a multicenter, retrospective, 7-day point prevalence study. Fifty-eight ICUs within 34 institutions in the United States and two in the Netherlands. Nine-hundred eighty-five patients transferred from an ICU to non-ICU location. None. Of 985 patients transferred, 450 (45.7%) had a medication error occur during transition of care. Among patients with a medication error, an average of 1.88 errors per patient (SD, 1.30; range, 1-9) occurred. The most common types of errors were continuation of medication with ICU-only indication (28.4%), untreated condition (19.4%), and pharmacotherapy without indication (11.9%). Seventy-five percent of errors reached the patient but did not cause harm. The occurrence of errors varied by type and size of institution and ICU. Renal replacement therapy during ICU stay and number of medications ordered following transfer were identified as factors associated with occurrence of error (odds ratio, 2.93; 95% CI, 1.42-6.05; odds ratio 1.08, 95% CI, 1.02-1.14, respectively). Orders for anti-infective (odds ratio, 1.66; 95% CI, 1.19-2.32), hematologic agents (1.75; 95% CI, 1.17-2.62), and IV fluids, electrolytes, or diuretics (odds ratio, 1.73; 95% CI, 1.21-2.48) at transition of care were associated with an increased odds of error. Factors associated with decreased odds of error included daily patient care rounds in the ICU (odds ratio, 0.15; 95% CI, 0.07-0.34) and orders discontinued and rewritten at the time of transfer from the ICU (odds ratio, 0.36; 95% CI, 0.17-0.73). Nearly half of patients experienced medication errors at the time of transition of care from an ICU to non-ICU location. Most errors reached the patient but did not cause harm. This study identified risk factors upon which risk mitigation strategies should be focused.

Implementation of Interdisciplinary Wound Care Rounds in a Skilled Nursing Facility

There is scant literature regarding interdisciplinary teams providing wound care in long-term care. Our long-term care facility did not have a consistent process for evaluation and treatment of wounds by nursing and physician teams.

Pharmacists in Critical Care.

The beginnings of caring for critically ill patients date back to Florence Nightingale's work during the Crimean War in 1854, but the subspecialty of critical care medicine is relatively young. The first US multidisciplinary intensive care unit (ICU) was established in 1958, and the American Board of Medical Subspecialties first recognized the subspecialty of critical care medicine in 1986. Critical care pharmacy services began around the 1970s, growing in the intervening 40 years to become one of the largest practice areas for clinical pharmacists, with its own section in the SCCM, the largest international professional organization in the field. During the next decade, pharmacy services expanded to various ICU settings (both adult and pediatric), the operating room, and the emergency department. In these settings, pharmacists established clinical practices consisting of therapeutic drug monitoring, nutrition support, and participation in patient care rounds. Pharmacists also developed efficient and safe drug delivery systems with the evolution of critical care pharmacy satellites and other innovative programs. In the 1980s, critical care pharmacists designed specialized training programs and increased participation in critical care organizations. The number of critical care residencies and fellowships doubled between the early 1980s and the late 1990s. Standards for critical care residency were developed, and directories of residencies and fellowships were published. In 1989, the Clinical Pharmacy and Pharmacology Section was formed within the Society of Critical Care Medicine, the largest international, multidisciplinary, multispecialty critical care organization. This recognition acknowledged that pharmacists are necessary and valuable members of the physician-led multidisciplinary team. The Society of Critical Care Medicine Guidelines for Critical Care Services and Personnel deem that pharmacists are essential for the delivery of quality care to critically ill patients. These guidelines recommend that a pharmacist monitor drug regimen for dosing, adverse reactions, drug-drug interactions, and cost optimization for all hospitals providing critical care services. The guidelines also advocate that a specialized, decentralized pharmacist provide expertise in nutrition support, cardiorespiratory resuscitation, and clinical research in academic medical centers providing comprehensive critical care.

"Nightmares-Family Medicine" Course Is an Effective Acute Care Teaching Tool for Family Medicine Residents.

Simulation is an effective method for teaching acute care skills but has not been comprehensively evaluated with family medicine (FM) residents. We developed a comprehensive simulation-based approach for teaching acute care skills to FM residents and assessed it for effectiveness. We compared the effectiveness of our standard acute care simulation training [Acute Care Rounds (ACR)] to a more comprehensive simulation-based acute care program, Nightmares-Family Medicine (NM). We used a self-reported comfort scale as well as video-captured performance on an acute care Objective Structured Clinical Examination (OSCE). Seventy-seven of our FM residents in their postgraduate year 1 between July 2012 and June 2015 participated in the study. Wilcoxon matched pairs and one-tailed t tests analysis was used for analyzing the comfort scale, Whitney-Mann, and χ for the OSCE performance. Nightmares-Family Medicine's initial 2-day session significantly improved the resident's self-assessment scores on all 20 items of the questionnaire (P < 0.05). Time-matched ACR improved 11 of 20 items (P < 0.05) level. Follow-up NM sessions improved 5 to 8 of 20 items (P < 0.05). Follow-up ACR sessions improved 1 to 5 of 20 items (P < 0.05). The means taken at the end of postgraduate year 1 year were higher for 13 of 20 items in the NM group (P < 0.05) as compared with ACR group. The NM group scored significantly higher on both the mean scores of OSCE individual categories (P < 0.01) and the Global Assessment Score (P < 0.05). Significantly less NM residents failed the OSCE (n = 1/30, 3.3% vs n = 8/37, 21.6%, P < 0.05). "Nightmares-Family Medicine" course is very effective at teaching acute care skills to FM residents and more so than our previous curriculum.

Implementing guideline-checklists: Evaluating health care providers intentional behaviour using an extended model of the theory of planned behaviour.

Internationally, clinical guidelines as checklists are increasingly used in acute ward practice to standardize the delivery and raise the quality of care on acute hospital wards. However, when guideline-checklists are implemented repeatedly, health providers' intentions to carry out this type of behaviour are not well understood. Therefore, the objective of this study was to evaluate nurses' and health care assistants' (HCAs) intentions to implement a "care round checklist"; a guideline-intervention repeated hourly on hospital wards. Furthermore, an extended Theory of Planned Behaviour (TPB) model's usefulness in explaining this type of behaviour was also evaluated. A theory-informed questionnaire, guided by the TPB, habit, and clinical context variables, was developed to measure the guideline-checklist behaviour. Quantitative questionnaire data were analysed using descriptive and inferential tests to establish differences in nurses' and HCAs' intentions and the predictive value of the model. A sample of 270 nurses and HCAs returned questionnaires from 24 wards in a major hospital in England. The extended TPB model explained 20% of nurses and 24% of HCAs reported intentions to implement a care round checklist, a modest proportion of intent. Attitude and perceived control best predicted nurses' intentions, and attitude and practice habit HCAs' intentions. TPB belief variables helped explain why nurses and HCAs intentions were different. Statistically, the extended TPB model highlighted that nurses and HCAs intentions to implement this type of guideline are predicted by different variables. This implied professional "role" as an important variable in explaining differences in intentions, which should be evaluated and integrated into the future design of this type of checklist. Further variables could be added to explain and learn more about intentional thinking for this type of behaviour and should help to develop a theoretical understanding of intentions underpinning this type of behaviour and ultimately improve patient care.

537. Engaging the Bedside Nurse in Reducing Clostridium difficile Infection Through an Innovative Patient Care Rounding Program

BackgroundBedside nurses comprise the largest personnel group in a hospital and are intimately familiar with a patient’s day to day clinical status. They can be an effective group to engage and empower to assist with hospital-wide Clostridium difficile infection (CDI) reduction efforts. The objective of this study was to evaluate the impact of a nursing driven intervention bundle on CDI rates at a 365-bed community hospital.MethodsDaily nursing led CDI and invasive line assessment rounds were implemented in April 2017. Nurses were empowered through a pre-approved protocol to place symptomatic patients in isolation and order a test for C. difficile. Additionally, patient care rounds that included nursing leadership, the antibiotic stewardship program physician director, infection preventionist and bedside nurses were conducted three times weekly. During these rounds, all Foley catheters, central lines, and CDI cases were discussed and a root cause analysis was performed for healthcare-associated infections (HAIs). CDI standardized infection ratio (SIR) was the primary metric tracked to assess outcome and trends by quarter over a two year period were evaluated.ResultsCDI SIR rates for the two full quarter after program implementation (July to September 2017 and October to December 2017) declined by 27.8% and 51%, respectively when compared with matching quarters from 2016 (Figure 1). Overall calendar year 2016 rates were similar to 2017 rates, but this was due to a significant increase in CDI incidence in first quarter 2017.ConclusionA formalized program for CDI reduction that incorporated the bedside nurse, nursing leadership, infection prevention, and the ASP team was effective in reducing CDI rates as measured by SIRs for the two quarters after full program implementation when compared with 2016 baseline rates.Figure 1.SIRS comparison by quarter (2016–2017).Disclosures All authors: No reported disclosures.