1An Online Training Module in Infection Control for Temporary Clinic VolunteersMary Beth White-Comstock, MSN, RN, CICManakin Sabot, VirginiaADN, John Tyler Community College, 1985BSN, University of Virginia, 2009MSN, University of Virginia 2011A Capstone Presented to the Graduate Faculty of theUniversity of Virginia in Candidacy for the Degree ofDoctor of Nursing PracticeSchool of NursingUniversity of VirginiaMay, 2014

ONLINE INFECTION CONTROL TRAINING2AbstractThe recent increase in healthcare-associated infection (HAI) outbreaks in outpatient settingsunderscores the need for increased emphasis on infection prevention and control in thesesettings. Data from outbreak reports reveal a lack of staff knowledge about infection controlrecommendations and adherence to proven infection control standards. Temporary outpatientclinic settings pose unique challenges in promoting safe infection control practices because theylack the infrastructure and resources to ensure compliance with current practice standards and thestaff frequently includes volunteers that lack formal training in infection control. This gapprovides the rationale for the educational intervention described in this paper. An onlineinfection control training module was developed and placed on the Training Finder Real-TimeAffiliate Integrated Network (TRAIN), a web-based educational platform maintained by theVirginia Department of Health. The narrated module included a review of evidence-basedinfection control strategies, a post-test and course evaluation. The feasibility of the onlinetraining module was evaluated using the five domains of the RE-AIM model: Reach,Effectiveness, Adoption, Implementation and Maintenance. An online infection control trainingprogram tailored for temporary clinic volunteers was successfully completed by studentparticipants. Evaluation data obtained from participants indicated the program was successful inaddressing the five dimensions of the RE-AIM framework. An online training module is afeasible means of educating temporary clinics volunteers about infection control. There is a needfor further research to determine the utility of an online training module in promoting safeinfection control practices.

ONLINE INFECTION CONTROL TRAINING3Table of ContentsPROPOSALSection I-Introduction .5Purpose .9Rationale .9Research Question .10Section II-Review of Literature .11Implications for Practice .18Section III-Study Methods .20Purpose .20Terms .20Research Design .21Intervention .21Sample 22Evaluation .23Data Analysis .24Protection of Human Subjects .25Capstone Procedures .25Strengths of Project 27Weaknesses of Project .28Capstone Products .28

ONLINE INFECTION CONTROL TRAINING4FINAL CAPSTONE PRODUCTSection IV-Results . .30Development of Training Module .30Implementation .31Evaluation .32Discussion .34Nursing Implications .37Section V-Manuscript .38References .61Appendices 66Table 1-Literature Review Summary for Comparative Teaching Studies .66Table 2-RE-AIM Infection Control Evaluation Metric 73Table 3-Capstone Proposal Grid . .78Figure 1-RE-AIM Framework .80Figure 2-Flow Chart for Literature Review . 81Appendix A-Infection Control Training for Temporary Clinic Volunteers-Course .82Appendix B-Infection Control Training for Temporary Clinic Volunteers-Post-Test .83Appendix C-Infection Control Training for Temporary Clinic Volunteers-Course Evaluation.85Appendix D-Infection Control Training for Temporary Clinics-Participant Instructions 86Appendix E-Infection Control for Temporary Clinic Volunteers-TRAIN Course Details . .93Appendix F-Manuscript Submission Guidelines .95Appendix G-Institutional Review Board Notification Letter. .104

ONLINE INFECTION CONTROL TRAINING5Section I: IntroductionHealthcare-associated infections (HAIs) are a known and well-documented consequenceof hospitalization. Each year approximately one in 20 patients admitted to U.S. hospitals developa HAI, resulting in over a million infections, 100,000 deaths, and billions spent in healthcaredollars (Klevens, 2007; Scott, 2009). While these statistics are alarming, they only represent afraction of the patients who are at risk of acquiring a HAI. The shift in healthcare delivery frominpatient hospital settings to outpatient (or ambulatory) clinics has resulted in the creation ofthousands of non-hospital settings across the nation including ambulatory surgical centers,dialysis centers, long term care facilities and permanent and temporary medical clinics (Frieden,2010; Schaefer et al., 2010). As a result of this shift, HAI outbreaks are occurring with increasingfrequency in these settings. Data obtained from outbreak investigations reveal a lack ofknowledge about and adherence to infection control practices. The purpose of this project is todetermine the feasibility of using an online training module to train temporary clinic volunteersabout infection control.Temporary ClinicsFurther complicating the healthcare landscape is the utilization of free, temporaryambulatory clinics that provide medical and dental services to those who have limited access tocare. Free clinics serve approximately 38% of the population and the demand for them hasincreased steadily since the recession (Notaro et al. 2012). Temporary clinics are designed toserve large numbers of patients in short periods of time. They are held all over the world inpublic community settings such as school gymnasiums, auditoriums, fairgrounds, parks, andcoliseums. They are generally unregulated and rely heavily on donated resources includingspace, equipment, supplies and healthcare services (Remote Area Medical [RAM], 2013).

ONLINE INFECTION CONTROL TRAINING6Healthcare services are typically provided by volunteers, many of whom travel long distances toattend the clinics. Temporary clinic volunteers have diverse backgrounds and skill sets andinclude persons that have not had formal infection control training. Finally, due to the episodicnature of these clinics, most do not have the infrastructure to develop and implement qualityimprovement programs or provide training to clinic volunteers.Infection Risks in Temporary ClinicsThe risk of HAI infection in these clinics is similar to the risks in other healthcaresettings, as many perform the same procedures conducted in hospitals and permanent outpatientclinics and surgical centers. However, historically free clinics have been overlooked and operateoutside of the safety net system (Darnell, 2010). The medical services offered in temporaryclinics vary from simple health screenings (e.g., blood pressure, blood glucose screenings) toinvasive surgical procedures (e.g., biopsies, tooth extractions, root canals). Healthcare-associatedinfections that result from the care received at these clinics are likely underreported because theyoccur after patients leave the clinic. Uninsured patients are less likely to seek medical forconditions or symptoms that are not life-threatening so many conditions such as HAIs goundiagnosed.Healthcare-Associated Prevention InitiativesWhile the magnitude of the HAI burden is unknown, there is little disagreement thatHAIs are a public health problem worthy of prevention. The majority of HAIs result frombreaches in proven infection prevention strategies (Frieden, 2010). In a landmark studyconducted by Centers for Disease Control and Prevention (CDC) in the 1970s, known as theSENIC Study, researchers found that at least 30% of HAIs in hospitals are preventable whenproven infection control strategies are followed (Haley, Quade, Freeman, & Bennett, 1980).

ONLINE INFECTION CONTROL TRAINING7However, current researchers have shown an even larger margin of error and estimate that atleast 50% of HAIs are preventable when evidence-based infection control standards areconsistently implemented (Umscheid, Mitchell, Doshi, Agarwal, & Brennan, 2011). Infectionprevention is not a novel concept. Programs focused on infection control have been a mainstay inhospitals since the Joint Commission mandated them in the mid-1970s (Smith, Watkins, &Hewlett, 2012). In-patient HAI prevention initiatives spearheaded by the healthcare facilities andstate and federal agencies and organizations have shown that prevention programs reduceinfection rates of all types (Yoke et al., 2008; Institute for Healthcare Improvement [IHI];Association for Professional in Infection Control and Epidemiology [APIC], 2010).The shift in healthcare delivery to outpatient settings and the recent increase in HAIoutbreaks reported to the CDC, highlight the need for even more focused infection preventionefforts in these settings (Schaefer, 2010). Data from outbreak reports reveal a lack of knowledgeabout infection control recommendations and adherence to basic practice standards for infectioncontrol. HAI outbreaks have occurred in ambulatory settings of all types including dialysiscenters, pain clinics, temporary clinics and health fairs, dermatology clinics, pediatric, primarycare, and surgery and oncology clinics; and most involve common medical procedures such asmedication preparation and administration, and blood glucose monitoring. A recent reportpublished by the CDC (2013) documented 35 outbreaks of viral hepatitis in outpatient settingsfrom 2008 to 2012. Almost half (17 out of 35) of the infections occurred in outpatient medicalclinics, including one in a temporary dental clinic held in a school gymnasium. The temporarydental clinic outbreak resulted in the transmission of hepatitis B infection to both clinicvolunteers and patients. The exact cause of this outbreak is still unknown; however, the

ONLINE INFECTION CONTROL TRAINING8investigation revealed a lack of written infection control polices and protocols and adherence tobasic infection control practice standards.In an effort to address infection prevention and control in outpatient settings, the CDChas launched a HAI website dedicated to the prevention of infections in ambulatory care settings(CDC, 2011). The website provides resources for outpatient facilities including; a list ofoutbreaks and notification events, infection prevention guidelines and checklist, model infectioncontrol plan for oncology settings and additional recourses for ambulatory care personnel andpatients. The American Recovery and Reinvestment Act (ARRA) of 2009 (Recovery Act) hasled to increased efforts in HAI prevention. Approximately 50 million dollars were allocated toHAI prevention, 10 million of which was designated to increase regulatory oversight ofambulatory surgery centers (ASC) (Centers for Medicaid and Medicare Services [CMS], 2009).This has led to the development of HAI survey tools and training programs for ASC inspectors.ARRA funding also allowed the U.S. Department of Health and Human Services (HHS) to movebeyond HAI prevention in hospitals and extend their focus to outpatient settings. The HHSpublished an amendment to their 2009 National Action Plan to Prevent Health Care-AssociatedInfections: Road Map to Elimination that outlines infection prevention strategies for ambulatorysurgical centers and renal dialysis centers (HHS, 2013). The Action Plan details the challengesfaced by ASCs and dialysis centers in preventing HAIs and highlights the need for thedevelopment and dissemination of evidence-based infection control strategies including tailoredguidelines and training materials.The federal initiatives referenced above are evidence that the HAI prevention pendulumis beginning to shift to outpatient settings; however, change takes time. In the meantime, it isimportant to seize opportunities whenever possible to contribute to this positive movement. The

ONLINE INFECTION CONTROL TRAINING9project described in this proposal is an example of an evidence-based strategy developed andimplemented by an advanced practice nurse to address a serious public health issue.PurposeThe purpose of this project is to study the feasibility of an online infection controltraining module in educating temporary clinic volunteers about infection prevention and controlstrategies. This project will include the development, implementation and evaluation of an online training module tailored to address infection control risks and strategies in free, temporaryclinics.RationaleThe conceptual public health foundation of primary prevention, which encompassesinterventions aimed at keeping illness or injuries from occurring, provides the rationale for thisproject (Ervin, 2002). Primary prevention is the cornerstone of public health practice and criticalin preventing disease and promoting health. This project also incorporates the AmericanAssociation of Colleges of Nursing’s Doctor of Nursing Practice Essentials (McCaffrey, 2012),utilizing scientific-underpinnings of nursing practice, clinical scholarship, systems leadership,technology and inter-professional collaboration to create a clinical intervention that is designedto prevent infections and promote health for individual and populations. Finally, the three publichealth core functions of assessment, policy development, and assurance, provide a basis for thisintervention (Stanhope and Lancaster, 2011). This project involves a thorough assessment of aproblem, population, policies and practices and offers an intervention designed to assure thecompetency of workers caring for patients receiving community-oriented health services.

ONLINE INFECTION CONTROL TRAINING10Research QuestionThe primary research question in this project is: What is the feasibility of an onlinetraining program as a means of educating temporary clinic volunteers about infection control?The feasibility of the training module will be explored using the RE-AIM framework, awell-recognized and successful public health planning and evaluation model, see Figure 1 (, 2013; National Council on Aging, 2007; Glasgow, McKay, Piette, Reynolds, 2001).The RE-AIM framework utilizes five domains (reach, adoption, efficacy, implementation, andevaluation) to measure the impact of public health programs.

ONLINE INFECTION CONTROL TRAINING11Section II: Review of LiteratureAn assessment of current practice guidelines and review of current educational literaturewas performed to answer the following questions: What infection control guidance exists fortemporary clinics? Are online training programs effective in teaching infection control principlesto healthcare workers?Outpatient Infection Control Guidance InventoryThe shift in healthcare to the outbreak settings and the recent outbreak activity in thesesettings highlight the need to increase awareness of and compliance with recommended infectioncontrol strategies and practices. The next section of this paper describes an infection controlinventory that was conducted to identify the types of infection control guidelines on the web foroutpatient settings and identify gaps in infection control guidance in these settings.Literature review methods. A search was conducted using PubMed, Google, and theCDC’s website using the search terms: infection control, outpatient clinics, temporary clinics,and free clinics. No specific timeframe parameters were used to conduct the search. An initialsearch conducted on PubMed using the terms infection control and outpatient clinics, revealed1100 articles. The articles pertained primarily to diseases detected and treated in outpatientsettings, not infection control guidance for these settings. The search was refined to include theterms infection control guidance and outpatient clinics. One hundred articles were identified andapproximately 25 of 100 documents addressed infection control guidelines in outpatient settings.The CDC’s website was searched as CDC is a well-known and primary source for infectionprevention and control guidance. Two-hundred and thirty-six documents were found thatreferenced infection control in outpatient settings; these included case studies, newsletters,notices, guidance documents and other publications. Approximately 60 documents provided

ONLINE INFECTION CONTROL TRAINING12infection control recommendations for outpatient settings. Finally, a search was conducted usingGoogle to identify other outpatient infection control guidance documents not identifiedpreviously, this search yielded seven additional documents that referenced infection control inoutpatient or ambulatory care settings. Ninety-two documents were found using PubMed, theCDC’s website and Google. These articles were compiled in a database and analyzed bycategory (ambulatory care, dialysis center, disaster shelter, dental setting, home health setting,homeless shelter, long-term care [LTC], prison, and temporary clinic) and audience (healthcareworker or healthcare facility and patient or general public). Thirty-seven guidance documentstargeting LTC, home health and prison settings, the general public and other unrelated patientpopulations were eliminated due to the lack of relevance to this study. The remaining documentswere further analyzed.Findings of literature review. Fifty-five infection control guidance documents werefound that addressed infection control guidelines written for healthcare providers in outpatientclinics. Infection control recommendations were reviewed and categorized by setting. Infectioncontrol guidance was identified for the following outpatient settings; Ambulatory care (n 11);Dental (n 6); Dialysis (n 9); Disaster (n 19); Homeless Shelters (n 10). The CDC publishedover half of the documents and the others were authored by other public health agencies andprofessional organizations. The CDC was referenced in most of the documents not published bythe CDC.The documents in this review varied greatly in scope of practice from a singlerecommendation to more comprehensive guidance. Most of the documents included commoninfection control strategies such as hand hygiene, standard precautions, and personal protectiveequipment; however, all of documents highlighted the importance of infection control training

ONLINE INFECTION CONTROL TRAINING13and education for healthcare workers. The most comprehensive infection control document foroutpatient settings identified was the CDC’s Guide to Infection Prevention for OutpatientSettings, Minimum Expectations for Safe Care (CDC, 2011). This 17-page document containedan extensive list of evidence-based infection prevention and control strategies for ambulatoryclinics, an infection control program checklist and links to an exhaustive repository of infectionprevention resources and tools. Two other infection control checklists were found, one formobile dental clinics and another for oncology clinics. No infection control guidance documentswere found for temporary medical clinics.Discussion of literature review findings. This review describes the body of infectioncontrol guidance currently available on the web for ambulatory clinics and identifies settingspecific gaps in guidance. It highlights the need for infection control guidelines for temporaryclinics and the lack of accessibility of information to clinic programs planners and volunteers.Conducting medical care in temporary clinic settings is challenging due to the lack oforganizational infrastructure, resources, and training opportunities for healthcare providers.Infection control guidance and training is needed to address the unique challenges of temporaryclinics and to educate those who deliver care in these settings.Review of Traditional and Online Teaching LiteratureA fundamental component of any infection program is education and training. In fact,healthcare facilities are mandated by the Occupational Safety and Health Association (OSHA) toprovide training to all employees who have the potential for occupational exposure to blood andbody fluids (OSHA, 1991). Infection control training upon hire and annually has long been acondition of Joint Commission hospital accreditation (Joint Commission, 2011). In the past,hospitals met this requirement by providing face-to-face educational programs for their

ONLINE INFECTION CONTROL TRAINING14employees. However, advances in technology offer alternative delivery methods that allow moreflexibility for educators in presenting course content and increased accessibility to material byparticipants. Online programs are used with increasing frequency to deliver mandatory infectioncontrol training programs and meet annual competency requirements. However, the shift to online education has created on-going controversy among educators regarding the effectiveness ofon-line education compared to face-to-face education. A second literature review was conductedto examine the efficacy of online and face-to-face training programs.Literature review methods. A systematic review of the literature from January 2002November 2012 was conducted to identify studies that compared online (distance) and face-toface (traditional) training methods. The search began in the CINAHL, Cochrane and ERICdatabases using the terms “distance learning” and “traditional learning” and “nursing.” Theinitial search revealed 626 articles; 591 from CINAHL, 25 articles from ERIC and 10 inCochrane. Another search was conducted in CINAHL and PubMed using the terms “distancelearning” and “infection control.” In addition, ninety-two studies were identified; 42 in CINAHLand 50 from PubMed. Finally, a hand search identified two additional meta-analyses that werefrequently referenced in related studies. A total of 720 studies were identified during the searchas shown in Figure 2. Inclusion criteria for the studies selected included: (1) studies thatcompared distance learning to traditional learning and (2) studies including healthcare and nonhealthcare related educational programs. Exclusion criteria included: (1) intervention studieswith only one group and (2) studies without an English abstract. In an effort to evaluate the mostcurrent literature, individual studies were limited to those published between 2006 and 2012.Randomized clinical trial and quasi-experimental studies were included in this review and casestudies, multiple case series and descriptive studies were excluded.

ONLINE INFECTION CONTROL TRAINING15Findings of literature review. Eleven studies met the criteria for this study (see Table1). Four meta-analyses were found that compared face-to face educational courses with onlineeducational courses. In each of these reviews internet learning was found to be more effectivethan traditional classroom instruction. Shachar and Neumann (2010) reviewed 125 experimentaland quasi-experimental studies published from1990 to 2009. The researchers compared learningoutcomes of graduate, undergraduate and non-credit courses and found that students who tookthe online courses outperformed those who received face-to-face instruction. Similar results werepublished following a meta-analysis conducted by Cook, et al. (2008). This review examined 201studies conducted from 1990 to 2007 involving students who were enrolled in healthcareprograms or were practicing healthcare providers. While there was wide variability in coursecontent, students who received online training performed better than those who receivedclassroom training. A study by Bernard et al. (2004) supports these findings in an analysis of 232studies that compared distance learning to traditional classroom courses. Achievement outcomesof Internet learners were greater than those who received classroom instruction. Finally, a studyconducted by the U.S. Department of Education (2010) examined 46 studies that compared faceto-face instruction with on-line learning and blended instruction (a combination of face-to-faceand online learning). Learning outcomes for online learners exceeded those who had face-to-faceinstruction. Students who received blended instruction also outperformed students who receivedface-to-face instruction. There were no significant differences in students’ outcomes when onlineinstruction was compared to blended instruction.Several individual studies support the effectiveness of online education. In a randomizedcase-control study of forty-eight 3rd and 4th year medical, nursing, and physiology students,Phadtare, Bahmani, Shah, and Pietroban (2009), compared the classroom writing scores of

ONLINE INFECTION CONTROL TRAINING16students who received on-line instruction with students who received classroom instruction.Students who received the intervention (online instruction) scored significantly better than thecontrol group (classroom instruction) on three outcomes: text quality, satisfaction andcommunication. These results were supported in an experimental cohort study of physiciansconducted by Fakih, Enayet, Miinick & Saravolatz (2006). Two groups of physicians-in- trainingwere evaluated after receiving infection control training. One group took a web-based course andthe other a lecture-based course. Post-course scores from the web-based students weresignificantly higher immediately following the course. Campbell, Gibson, Hall & Callery (2008)also found web-based instruction to be effective in teaching research methods to graduatestudents. In this study 117 graduate students were divided into a control and intervention group.The students that received online training scored higher than those who received face-to faceinstruction. However, the researchers stated that selection bias may have been a factor sincestudents were allowed to self-select their group.In addition to teaching methods there may be other variables that affect learningoutcomes. A study conducted by Aggerwahl, et al. (2011), compared the learning outcomes of 58medical professionals and researchers. The participants were placed in two groups; each groupwas exposed to online and onsite courses in biostatistics and research ethics. A pre-test, post-testand satisfaction survey was administered to each student. Both groups showed a significantincrease in knowledge at the completion of both onsite and online courses. There was nodifference in the online vs. onsite learning scores or students’ satisfaction scores. The researcherconcluded that both methods of instruction were effective in highly motivated students.Another variable that may influence the effectiveness of online versus traditionalclassroom is subject matter. Reime, Harris, Aksnes, and Mikkelson (2008) conducted an

ONLINE INFECTION CONTROL TRAINING17intervention study to examine the effectiveness of online versus classroom infection controltraining in 2nd year nursing students. In this study, 141 nursing students were divided into twogroups, an intervention and a control group. The intervention group was given an online trainingmodule in infection control and the control group received classroom training in infectioncontrol. Multiple choice evaluations were used to measure the knowledge gained by students inboth courses. The evaluations were divided into five subcategories: standard precautions,isolation, protocols and practices, epidemiology and preoperative preparation. Scores for bothgroups showed an improvement in knowledge in all categories. However, the students whoreceived classroom training in epidemiology and preoperative preparation scored higher thanstudents who received training online.Bloomfield, Roberts and White (2008) also studied nursing students and the effects of acomputer-based vs. classroom-led program designed to improve hand washing skills in arandomized control study. The researchers studied the hand washing skills of 231 studentsfollowing the implementation of a computer- and classroom-based course. The students wererandomly assigned to an intervention (online) group and control group (classroom). Both groupsshowed increased knowledge about hand washing after the courses; however, no significantdifferences were detected in the scores of the two groups. Similar results were found by Linn,Lee, Tinker and Chiu (2006) following a large multi-state study that compared the knowledgeintegration of sixth-to twelfth grade students who took a web-based science (3712 students)course to those who attended class lectures (4520 students). No significant differences in theoverall group scores were detected; however, the web-based group scored slightly higher in somesubcategories.

ONLINE INFECTION CONTROL TRAINING18Discussion of literature review findings. This review was conducted to determine theeffectiveness of online training programs in teaching infection control principles to healthcareworkers. While few studies were found that compared infection control training in the classroomto online infection control training, the research conducted in this review clearly supports theeffectiveness of online education in teaching new information.The findings from all four of the meta-analyses showed distance learning (internet, online and web-based) to be more effective than traditional instruction (classroom, face-to-face).Six hundred and four comparison studies were represented in the findin

A Capstone Presented to the Graduate Faculty of the . School of Nursing University of Virginia May, 2014 . ONLINE INFECTION CONTROL TRAINING 2 Abstract The recent increase in healthcare-associated infection (HAI) outbreaks in outpatient settings underscores the need for increased