Healthcare-associated infections remain a preventable cause of patient harm in healthcare. Full documentation of adherence to evidence-based best practices for each patient can support monitoring and promotion of infection prevention measures. Hascic, et al. (2022) reviewed the extent, nature, and determinants of the documentation of infection prevention (IP) standards in patients with HAI.

The researchers reviewed electronic patient records (EMRs) of patients included in four annual point-prevalence studies 2013–2016 who developed a device- or procedure-related HAI (surgical site infection (SSI), catheter-associated urinary tract infection (CAUTI), ventilator-associated infection (VAP), catheter-related bloodstream infection (CRBSI)). The researchers examined the documentation quality of mandatory preventive measures published as institutional IP standards. Additionally, they undertook semi-structured interviews with healthcare providers and a two-step inductive (grounded theory) and deductive (Theory of Planned Behavior) content analysis.

Of 2,972 surveyed patients, 249 (8.4%) patients developed 272 healthcare-associated infections. Of these, 116 patients met the inclusion criteria, classified as patients with SSI, CAUTI, VAP, CRBSI in 78 (67%), 21 (18%), 10 (9%), 7 (6%), cases, respectively. The researchers found documentation of IP measures in EMRs in 432/1308 (33%) cases. Documentation of execution existed in the study patients’ EMRs for SSI, CAUTI, VAP, CRBSI, and overall, in 261/931 (28%), 27/104 (26%), 46/122 (38%), 26/151 (17%), and 360/1308 (28%) cases, respectively, and documentation of non-execution in 67/931 (7%), 2/104 (2%), 0/122 (0%), 3/151 (2%), and 72/1308 (6%) cases, respectively. Healthcare provider attitudes, subjective norms, and perceived behavioral control indicated reluctance to document IP standards.

The researchers conclude that mandatory institutional documentation protocols or technically automated documentation may be necessary to address such shortcomings in patient safety documentation.

Reference: Hascic A, et al. Documentation of adherence to infection prevention best practice in patient records: a mixed-methods investigation. Antimicrobial Resistance & Infection Control. Vol. 11, article number 107 (2022).