Roadmap for infection_prevention


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Roadmap for infection_prevention

  1. 1. Primum non nocere (Latin : First Do No Harm) 1
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  4. 4. Crisis in Healthcare Associated infections Calfee DP. Annul Rev Med 2012; 63: 9.1 – 9.13 posted online on October 13,2011In USA > 1.7 million HAI occur every year= 5% of all persons admitted (CDC 2002 data) Prolonged duration of hospitalization Greater morbidity Increased risk of death98,000 death (top ten causes of death) 4
  5. 5. Deaths in USA due to HAI areEquivalent to ONE Fully loaded Jumbo jet crashing every day of the year 5
  6. 6. Hospital Associated Infections 6
  7. 7. Preventable Infections and costs of getting it wrong 7
  8. 8. Target ZERO Healthcare Associated Infections Zero tolerance for preventablehealthcare associated infections & inappropriate practices
  9. 9. Qs 1. Is the patient colonized or infected with indicator bacteria ?At time of admission: Culture Nose, Axilla & Groin for MRSA Culture stool / rectal swab for Carbapenemase producing enterobacteria (CRE)If yes (TAT 24 hours): Institute contract precautionsOR: Consider ALL pts to be infected & institute contact precautions till cultures reported as Negative for MRSA &/or CRE 9
  10. 10. Qs. 2 Is patient acquiring indicator bacteria from the environment ?Environment: A. Frequent touch areas B. Floors, walls, toilet etcNeed to be cleaned regularly, aim for food processing unit quality of environmentMicrobiology monitoring of environment, air, HCW hands etc would be intensive to document complianceIf indictor bacteria (MRSA, CRE, MDR P aeruginosa, MDR Acinetobacter spp isolated)Review cleaning practices & institute corrective measures 10
  11. 11. Qs 3. Standard of care in Infection prevention 100 % compliance with bundlesBundles will be operational for Infection Prevention: CVC (I & M) & PVC (I & M), CAUTI (I & M), VAP, SSI MRSA, Hand Hygiene, Clostridium difficileImmediate feedback on compliance to operator, weekly feedback to chairman 11
  12. 12. Qs. 4. If infection occursRapid diagnosis of infection (Multiplex PCR, PCT etc)Antibiotic care bundleReview of all results after 72 hours & de escalation (if required) 12
  13. 13. Qs. 5. Did the patient acquire indicator bacteria during his stay at Medanta ?One day before discharge, culture Nose for MRSA & stool / RS for CREIf positive: Indicates breach of Infection Prevention practicesRoot cause analysis & corrective action 13
  14. 14. Bundles: do they work ? 25 Rate per 1000 cath days 20 15 10 5 0 1998 - Qtr1 1998 - Qtr2 1998 - Qtr3 1998 - Qtr4 1999 - Qtr1 1999 - Qtr2 1999 - Qtr3 1999 - Qtr4 2000 - Qtr1 2000 - Qtr2 2000 - Qtr3 2000 - Qtr4 2001 - Qtr1 2001 - Qtr2 2001 - Qtr3 2001 - Qtr4 2002 - Qtr1 2002 - Qtr2 2002 - Qtr3 2002 - Qtr4 2003 - Qtr1Berenholtz SM, Pronovost PJ, Lipset PA, et al.Eliminating catheter related bloodstream infectionin the intensive care unit.Critical Care Medicine. 2004; 32:2014-2020 Al-Tewfiq JA & Abed MS: Decreasing VAP in adults ICU using Institute for Healthcare Improvement Bundle. Am J Infect Control 2010;38:552-6 14
  15. 15. How are Bundle elements developed ?A cause and effect chart describes all the elements of a system under 4 main headings: Environment, Equipment, People, Methods 15
  16. 16. Environment Equipment The GoalPeople Methods 16
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  18. 18. Central Line Bundle Elements1. Hand hygiene2. Maximal barrier precautions3. Chlorhexidine skin antisepsis4. Optimal catheter site selection, with avoidance of using the femoral vein for central venous access in adult patients5. Daily review of line necessity with prompt removal of unnecessary lines 18
  19. 19. 1.Hand HygieneWash hands if they are obviously soiledWash hands or use an alcohol based waterless hand cleaner 5 moments for hand washing 19
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  22. 22. Monitoring & Feedback on compliance is essential In Quality parlance: If it is not documented, it is not done 22
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  24. 24. 2. What Are Maximal Barrier Precautions?For Provider & Assistants: Hand hygiene Non-sterile cap and mask All hair should be under cap Mask should cover nose and mouth tightly Sterile gown and glovesFor the Patient: Cover patient’s head and body with a large sterile drape (use more than one if needed for large patients) 24
  25. 25. 3. Chlorhexidine Skin AntisepsisPrepare skin with antiseptic/detergent Chlorhexidine 2% in 70% isopropyl alcohol.Apply chlorhexidine solution using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot.Allow antiseptic solution time to dry completely before puncturing the site ( ~ 2 minutes). 25
  26. 26. 4. Optimal Site SelectionFemoral site: greatest risk of infection, especially in overweight patientsSubclavian site: lower risk of CLABSI than the internal jugular vein Preferred when infection is only consideration Higher risk of mechanical complicationsPhysicians must weigh risk-benefit of site selection for individual patient Bundle compliance met if documented 26
  27. 27. 5. Daily AssessmentGoal: reduce line daysInclude daily review of line necessity in multidisciplinary roundsRemove promptly when no longer neededDefine appropriate timeframe for review when applied to central lines intended for long term use 27
  28. 28. Key Change: Central Line ChecklistHave the nurse document compliance with the insertion criteria at the time of insertion.Create a culture of safety and prevention: empower nurses to stop line placement if improper techniques are usedInstruct nurses in use of critical communication strategies to facilitate important exchanges. e.g. “the sterile field has been contaminated,” rather than “You contaminated the catheter!” 28
  29. 29. Checklist ElementsBefore the procedure, did they: Wash hands? Sterilize procedure site? Drape entire patient in a sterile fashion?During the procedure, did they: Use sterile gloves, mask and sterile gown? Maintain a sterile field?Verify: did all personnel assisting with procedure follow the above precautions? 29
  30. 30. Tips for SuccessSTOP the line empower nurses to stop line placement if improper techniques are used Leadership support & culture EvidenceStandard equipments packsClinical appropriateness 30
  31. 31. Measure: CLABSI per 1000 Line DaysCentral line-associated BSI rate per 1000central line-days: Numerator: Number of central line-associated BSI x 1000. Denominator: Number of central line-days (total number of days of exposure to central venous catheters by all patients in the selected population during the selected time period). 31
  32. 32. Measure: Central Line Bundle ComplianceCentral line bundle elements in place: Numerator: Number of patients with central line bundle in place. Denominator: Total number of pts on central lines per day of week of prevalence sample. 32
  33. 33. Rate per 1000 cath days 10 15 20 25 0 5 CLABSIs.1998 - Qtr11998 - Qtr21998 - Qtr31998 - Qtr4 Does it Work?1999 - Qtr11999 - Qtr21999 - Qtr31999 - Qtr42000 - Qtr12000 - Qtr22000 - Qtr32000 - Qtr42001 - Qtr12001 - Qtr22001 - Qtr32001 - Qtr42002 - Qtr12002 - Qtr2 ICUs that have implemented multifaceted interventions2002 - Qtr3 similar to the central-line bundle have nearly eliminated2002 - Qtr42003 - Qtr133
  34. 34. SEVEN steps insuccessful bundle implementation 34
  35. 35. Step 1 - Commitment The first step is for the team leader to get everyone to commit to doing the bundle to improve patient safety. RememberPatient safety is for life – not just for this Dewali ! 35
  36. 36. Medanta Medicity Gurgaon 36
  37. 37. Step 2 - Understand there will be consequencesThe team must consider that they will find out things they did not want to know, e.g. your team is not perfect!Consider how you will deal with this before you start Commit to feedback being for improvement and not judgement Acknowledge that where you are, is not where you want to be, and this process will help you improve Commit to not shooting the messenger, i.e. the one collecting the data! Commit to a no blame cultureRemember you are doing this for optimal patient safety and to show the quality of your care – not to damage your care team 37
  38. 38. Step 3 - Work out the process that fits in with your systems of workingHow often do you want to measure compliance (at least once a week)?Who will collect the data?When will they collect the data?Where will they put the completed sheets?Where will you display your results?What will you do with the results – how will you act on them?Is everyone agreed on the process? 38
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  41. 41. Step 4 – Start smallRemember the PDSA methodology One patient, one nurse, one doctor one day The next time three patients, The next time five patients The next time allDon’t expect to get it right first time, but it will help if you DO 41
  42. 42. Step - 5 When you are all agreed that it works onfive get ready to implement it ward widePick a start dateMake sure everyone knowsHave the bundle data collection forms readyBEGIN 42
  43. 43. Potential Impact of central line bundleBerenholtz SM et al.Critical Care Medicine 2004; 32: 2014 - 220 43
  44. 44. Step 6 Continuously assess progress What are we trying to No skin and soft tissue infections due to CVC accomplish? There will be 100% compliance with the bundleHow will we know that change is improvement? There will be no skin or soft tissue infections due to CVCsWhat changes can we makethat will result in improvement? Don’t use CVCs unless absolutely necessary. Remove CVCs as soon as possible Don’t use a CVC – just in case Act Plan Study Do 44
  45. 45. Step 7 – If it’s going well & you have improved processes & reduce therisk of CLABSI – try another bundle 45
  46. 46. Bundles available & ready for deploymentCentral venous catheter: Insertion & maintenanceUrinary tract catheter: insertion & maintenanceVAPSurgical siteHand washingMRSAClostridium difficileSepsisAntibiotic use 46
  47. 47. TARGET ZERO Healthcare associated InfectionsZero Tolerance for Preventable Healthcare Associated Infections & Inappropriate practices 47