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Superbugs and Bundles of Care
 

Superbugs and Bundles of Care

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Powerpoint presentation about antibiotic resistant microorganisms coupled with some examples of nursing bundles of care.

Powerpoint presentation about antibiotic resistant microorganisms coupled with some examples of nursing bundles of care.

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    Superbugs and Bundles of Care Superbugs and Bundles of Care Presentation Transcript

    • “Superbugs”and“Poka Yoke”
      Noel C. Santos, MD
      Pathologist, Mission Hospital
      May 31, 2011
    • “Superbugs”
      Microorganisms – bacteria
      Develop resistance to antimicrobials or antibiotics
      Multiple
      MDR (Multidrug Resistance)
      New Terms
      Multi DR : sensitive to at least three antibiotic classes
      Extended DR : sensitive to one or two antibiotic classes
      Pan DR : not sensitive to all antibiotic classes
      Sensitivity Tests Results
      in vitro testing
    • “Superbugs”
      MRSA (Methicillin Resistant Staphylococcus aureus) – Oxacillin Sensitivity Testing
      Real or true concern
      Vancomycin Resistant Staphylococcus aureus
      Not the only one!!!!
      Watch Out for the “ESKAPE” (April 2011 by WHO)
      Enterococcus sp.
      Staphylococcus aureus
      Klebsiella pneumoniae
      Acinetobacter baumanii
      Pseudomonas aeruginosa
      Enterobacter sp.
    • “Superbugs”
    • “Superbugs”
      Development of resistance
      CAUSE/S: Irrational use of drugs
      PREVENTION
      Rational antibiotic use
      Stop transmission
      Early recognition and prompt treatment
      Health education and universal precaution
      TREATMENT
      Hope and pray!!! Watch for clinical outcome
      New antibiotics???? (Daptomycin and Linezolid)
      out of more than 400 drugs in discovery and development
      Only 5 are antibiotics
      Among the 5, none is innovative or new
      GO BACK TO PRE-ANTIBIOTIC ERA
    • “Superbugs”
      NOSOCOMIAL INFECTION vs Community Acquired Infection
      Hospital Acquired
      Healthcare Associated Infection
      Healthcare Facility Acquired Infection
      General Criteria:
      Development of signs and symptoms (infection or sepsis) after 48 hours of admission
    • Healthcare Associated Infection
      “antibiotic” environment
      Predisposing factors (invasive procedures)
      Patient’s compromised status
      Healthcare personnel, equipment, etc… “colonizers”
      Very Important Hospital Committee
      INFECTION CONTROL COMMITTEE
    • Healthcare Associated Infection
      Poor clinical outcome
      Longer hospital stay
      More resources and effort spent
      Money
      Manpower
      Materials
      Methods
      Management
    • Healthcare Associated Infection
      “prototype” – development of checklist, standard operating procedures, etc………
      “BUNDLES OF CARE”
      Therapeutic and Nursing Care
      Doctors and Nurses
      Other stakeholders involved in the care and management of patients, ex. Pharmacists, Technologists, Maintenance Services, etc.
    • “Poka Yoke”
      System check or procedure that will prevent errors
      “idiot proofing”, “fail safing” or “mistake proofing”
      Enhance or improve quality and safety
      “Bundle of Care” is a “Poka Yoke”
      Considerations: QUALITY, SAFETY, EFFICIENCY and SPEED (fast)
    • “Bundles of Care”http://www.hps.scot.nhs.uk/haiic/ic/bundles.aspx
      A structured way of improving processes of care and patient outcomes.
      Small straightforward set of practices - generally 3 to 5 elements, when performed collectively, reliably and continuously, have been proven to improve patient outcomes.
      Data from these frequent measures fed back to those involved in the procedure has also been shown to result in improvements in process and reduction in negative actions.
    • Who can use bundles of care?
      Anyone in any clinical setting with the agreement of the clinical team leaders.
      However infection control teams will be able to offer support with regard to implementation and advice on data collection, analysis of data and feedback.
    • What are the types of bundles?
      Central Vascular Catheter Maintenance Care Bundle and checklist
      Catheter Associated Urinary Tract Infections Bundle and checklist
      Peripheral Vascular Catheter Care Bundle
      Surgical Site Infection Prevention Bundle
      Clostridium difficile Infection Care Bundle
      Maintenance bundle for use in the Community – Urinary Catheter Care Bundle
      Ventilator Associated Pneumonia Bundle
    • What is a bundle?
      Needed to effectively care for patients undergoing particular treatments with inherent risks.
      A grouping of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement.
      The science behind the bundle is so well established that it should be considered standard of care.
    • What is a bundle?
      Bundle elements are dichotomous and compliance can be measures: YES or NO answers.
      Bundles eschew the piecemeal application of proven therapies in favour of an “all or none” approach.
    • Bundle of Care
      Goal: To help health care providers more reliably deliver the best possible care for patients undergoing particular treatments with inherent risks.
    • What makes a bundle so special?
      The power of a bundle comes from the body of science behind it and the method of execution: with complete consistency.
      A bundle ties the changes together into a package of interventions that people know must be followed for every patient, every single time.
    • So a bundle is a list of the right things to do for a given patient?
      It resembles a list, but a bundle is more than that
      Specific elements that make bundles unique.
      The changes are all necessary and all sufficient, so if you’ve got four changes in the bundle and you remove any one of them, you wouldn’t get the same results – meaning: the patient won’t have as high a chance of getting better.
      It’s a cohesive unit of steps that must all be completed to succeed.
    • So a bundle is a list of the right things to do for a given patient?
      The changes are all based on randomized controlled trials, Level 1 evidence. They’ve been proven in scientific tests, accepted, and well established.
      There should be no controversy involved, no debate or discussion of bundle elements.
      A bundle focuses on how to deliver the best care – not what the care should be.
      We want providers to get right to work on the how: on completing steps x, y, and z for every patient.
    • So a bundle is a list of the right things to do for a given patient?
      The changes in a bundle are clear-cut and straightforward; they involve all-or-nothing measurement.
      Successfully completing each step is a simple and straightforward process.
      It’s a “yes” or “no” answer: “YES, I did this step and that one; NO, I did not yet do this last one.”
      Successfully implementing a bundle is clear-cut: “YES, I completed the ENTIRE bundle, or NO, I did not complete the ENTIRE bundle.”
      There is no in between; no partial “credit” for doing some of the steps some of the time.
    • So a bundle is a list of the right things to do for a given patient?
      Bundle changes also occur in the same time and space continuum, at a specific time and in a specific place, no matter what.
      This might be during morning rounds every day or every six hours at the patient’s bedside.
    • Can you give an example?
      Hand Hygiene bundle
      Surgical Site Infection Prevention bundle
      Peripheral Vascular Catheter Care bundle
      Catheter Associated UTI Prevention bundle
    • What’s the difference between a bundle and a checklist?
      A checklist can be very helpful and an important vehicle for ensuring safe and reliable care.
      The elements in a checklist are often a mixture of nice-to-do tasks or processes (useful and important but not evidence-based changes) and have-to-do processes (proven by randomized control trials).
      A checklist may also have many, many elements.
    • What’s the difference between a bundle and a checklist?
      A bundle is a small but critical set of processes all determined by Level 1 evidence. And it needs to meet all the criteria previously described.
      Because some elements of a checklist are nice to do but not required, when they are not completed, there may be no effect on the patient.
      When a bundle element is missed, the patient is at much greater risk for serious complications.
    • What’s the difference between a bundle and a checklist?
      There’s also a level of accountability tied to a bundle that you don’t always have with a checklist.
      An identified person or team owns it. A checklist might be owned by everybody on a floor or a team, but in reality, when it’s owned by everyone – nobody owns it.
      Things don’t always get done.
      So maybe the pharmacist does one thing in a checklist, a nurse another, the doctor something else, but in reality it’s no one’s job at the end of the day.
      A bundle is a person or a team’s responsibility – period.
      It’s their job at a certain point and time – during rounds every single day, possibly.
      It’s very clear who has to do what and when, within a specific time frame.
      The accountability and focus give a bundle a lot of its power.
    • How to make a bundle of care?
      Example: “The Ventilator Bundle”
      Ventilator Assisted Pneumonia (VAP)
      Nosocomial pneumonia is the leading cause of death from hospital-acquired infections.
      Refers to pneumonia developing in a mechanically ventilated patient more than 48 hours after intubation.
    • Facts About VAP
      Incidence: 15% patients receiving mechanical ventilation
      Risk Factors: tracheostomy, multiple central line insertions, re-intubation, and use of antacids
      Mortality: 46% compared to 32% who do not develop VAP
    • VAP Prolongs Care
      Large retrospective matched cohort study of risk factors and consequences of VAP:
      Prolonged mechanical ventilation
      Prolonged ICU stay
      Prolonged post-ICU hospital stay
      Marked increased in cost of admission
    • Studies in relation to VAP that affect clinical outcome
      Head of the bed 30 to 45 degree angle
      Sedative interruption and daily assessment of readiness to extubate
      Peptic ulcer disease (PUD) prophylaxis
      Deep venous thrombosis (DVT) prophylaxis
    • Studies in relation to VAP that affect clinical outcome
      Head of the bed 30 to 45 degree angle
      Sedative interruption and daily assessment of readiness to extubate
      Peptic ulcer disease (PUD) prophylaxis
      Deep venous thrombosis (DVT) prophylaxis
    • Randomized controlled trials: 88 intubated patients on mechanical ventilator
      Increased incidence of VAP among patients in supine position
      Advantage of semi-recumbent position
      Apply in setting with patient on MV
    • What changes can we make that will result in improvement ?
      Implement mechanism to ensure head-of-the-bed elevation, such as including this intervention on nursing flow sheets and as a topic at multidisciplinary rounds.
      Create an environment where respiratory therapists work collaboratively with nursing to maintain head-to-the-bed elevation.
      Involve families in the process by educating them about the importance of head-to-the-bed elevation and encourage them to notify clinical personnel when the bed does not appear to be in the proper position.
    • What changes can we make that will result in improvement ?
      Use visual cues so it is easy to identify when the bed is in the proper position, such as a line on the wall that can only be seen if the bed is below a 30-degree angle.
      Include this intervention on order sets for initiation and weaning of MV, delivery of tube feedings, and provision of oral care.
      Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.
    • Studies in relation to VAP that affect clinical outcome
      Head of the bed 30 to 45 degree angle
      Sedative interruption and daily assessment of readiness to extubate
      Peptic ulcer disease (PUD) prophylaxis
      Deep venous thrombosis (DVT) prophylaxis
    • Sedation Vacation
      Why?
      Has been demonstrated to reduce overall patient sedation
      Promotes early weaning
      Identified Issues and Concerns:
      Increases potential for self-extubation
      Increases potential for patient pain and anxiety
      Increases episodes of desaturation
      Anecdotal experience:
      Promotes early extubation
      No significant increase in patient self-extubation
    • Studies: Sedation Vacation
      128 adults on MV randomized to daily interruption of sedation until the patient was awake or interruption at the clinician’s discretion
      Duration of ventilation:
      4.9 days vs. 7.3 days
      Shorter duration on MV
    • What changes can we make that will result in improvement?
      Implement a protocol to lighten sedation daily at an appropriate time to assess for nuerological readiness to extubate. Include precautions to prevent self-extubation such as increased monitoring and vigilance during the trial.
      Include a sedative interruption strategy in your overall plan to wean the patient from the MV; if you have a weaning protocol, add sedative interruption to that strategy.
    • What changes can we make that will result in improvement?
      Assess compliance each day on multidisciplinary rounds.
      Consider implementation of a sedation scale such as the Riker scale to avoid over-sedation.
      Post compliance with the intervention in a prominent place in you ICU to encourage change and motivate staff.
    • Studies in relation to VAP that affect clinical outcome
      Head of the bed 30 to 45 degree angle
      Sedative interruption and daily assessment of readiness to extubate
      Peptic ulcer disease (PUD) prophylaxis
      Deep venous thrombosis (DVT) prophylaxis
    • PUD Prophylaxis
      Why?
      Stress ulcerations are the most common cause of GI bleeding in ICU patients.
      GI bleeding due to these lesions is associated with a five-fold increase in mortality compared to ICU patients without bleeding. Applying PUD prophylaxis is therefore a necessary intervention in critically ill patients.
      Identified Issues and Concerns:
      Some studies have shown increased rates of VAP in patients with prophylactic treatments, ex. Sucralfate.
      Anecdotal experience:
      None significant
    • Studies regarding PUD Prophylaxis
      Surviving Sepsis Campaign Guidelines:
      Stress ulcer prophylaxis should be given to all patients with severe sepsis.
      H2 receptor inhibitors are more efficacious than sucralfate and are the preferred agents.
      Proton pump inhibitors is as good as H2 blockers
      They demonstrate equivalency in ability to increase gastric pH.
    • What changes can we make that will result in improvement?
      Include PUD prophylaxis as part of your ICU order admission set and ventilator order set. Make application of prophylaxis the default value on the form.
      Include PUD prophylaxis as an item for discussion on daily multidisciplinary rounds. Count this item as “met” if the discussion occurs and is documented, even if there is a decision not to provide this intervention.
    • What changes can we make that will result in improvement?
      Empower pharmacy to review patients in the ICU to ensure that some form of PUD prophylaxis is provided for all appropriate ICU patients.
      Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.
    • Studies in relation to VAP that affect clinical outcome
      Head of the bed 30 to 45 degree angle
      Sedative interruption and daily assessment of readiness to extubate
      Peptic ulcer disease (PUD) prophylaxis
      Deep venous thrombosis (DVT) prophylaxis
    • DVT Prophylaxis
      Why?
      Reduces potential for clot formation
      Reduces potential for pulmonary emboli
      Identified Issues and Concerns:
      May increase the risk of bleeding
      Anecdotal experience:
      If using SCD’s (sequential compression devices), assure that they are on the patient.
    • Studies on DVT Prophylaxis
      Systematic review of risks of venous thromboembolism (VTE) and its prevention:
      “We recommend, on admission to the ICU, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis.
    • What changes can we make that will result in improvement?
      Include DVT prophylaxis as part of your ICU order admission set and ventilator order set. Make application of prophylaxis the default value on the form.
      Include DVT prophylaxis as an item for discussion on daily multidisciplinary round. Count this item as “met” if the discussion occurs and is documented, even if there is a decision not to provide this intervention.
    • What changes can we make that will result in improvement?
      Empower pharmacy to review orders for patients in the ICU to ensure that some form of DVT prophylaxis is in place at all times on ICU patients.
      Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.
    • VAP PreventionBundle of Care
      Do bundles work?
      They do based on follow-up studies
    • Monitor and measure effectivity of bundle
      Calculate the VAP Rate
      Numerator: No. of VAP cases
      Denominator: Total ventilator days
      Multiply by 1,000 to convert to a rate
      Calculate the compliance with Ventilator Bundle
      Numerator: No. of vented patients receiving ALL components of bundle
      Note: This is an “all or nothing” measure: a patient who had 1, 2 or 3 (not all) of the elements would count as a “no”.
      Denominator: Total No. of patients on ventilators for the day of the prevalence sample
    • Move on to New Areas
      Develop a sedation protocol
      Develop a weaning protocol
      Create a pre-extubation worksheet to assess the risk of failed extubation
      Spread the use of the ventilator bundle to other ICU’s in your hospital.
    • ICU Infrastructure Changes
      Encourage open visitation for ICU families
      Request infection control practitioner to report VAO data monthly, not quarterly
      Initiate intensivist-directed multidisciplinary team system.
    • IMPACT: Reliability
      SUMMARY
      Possible mechanisms of success:
      Does implementation of a standardized “bundle” of care result in better overall care?
      Are the interventions synergistic?
      Dramatic reduction in VAP:
      More than could have been expected from the sum of the individual interventions.
    • VAP PreventionBundle of Care
      Do bundles work?
      Answer: THEY DO WORK!!!
      Example: VAP Prevention Bundle of Care
    • No Ventilator Associated Pneumonia (VAP)

      It CAN Be Done!!!
    • SURGICAL SITE INFECTION (SSI)Application in our own setting – Mission Hospital
      Background:
      3.7% of patients experience serious adverse events related to medical management.
      The top three causes were:
      Medication-related (19%)
      Wound infections (14%)
      Technical complications (13%)
      All of these events led to disability or prolonged stay; death occurred in 13.6% of these patients.
      58% of these events were preventable mistakes – now called medical errors or patient safety failures
    • Impact of SSI
      *LOS – length of stay
    • Opportunity to Prevent Surgical Infections
      An estimated 40-60% of SSI’s are preventable.
      Improper timing, selection, and duration of prophylactic antibiotics occurs in 25-50% of operations
      SSI prevention is a key component of Surgical Care Improvement Project
    • Reducing SSI: Four Components of Care
      Appropriate use of prophylactic antibiotics.
      Appropriate hair removal.
      Controlled 6 AM postoperative serum glucose in cardiac surgery patients.
      Immediate postoperative normothermia in colorectal surgery patients.
    • Antibiotics
      Selection
      Consistent with national guidelines
      Special cases: allergy, prolonged used
      Timely administration
      Within one hour prior to incision
      Vancomycin or Fluoroquinolones: 2 hours
      Make sure all antibiotic is infused prior to inflation of cuff.
      Dosage:
      At least a full therapeutic dose
      Upper range for large patients and/or long operations
      Repeat doses for long operations (>4 hours)
    • Antibiotics
      Timely discontinuation
      Confirmed efficacy of ≥12 hours
      Efficacy of a single dose
      Shorter course has been as effective as the longer course
      No need to continue coverage beyond 24 hours even with tubes or drains postoperatively
      Lack of evidence preventing SSI’s if given after the end of operation
      Increased use promotes antibiotic resistance
       
    • SSI Prevention Bundle
      ANTIBIOTICS USE: selection, dosage, timing and duration
    • Hair Removal
      Appropriate
      No hair removal at all
      Clipping
      Depilatory use
      Inappropriate
      Razors
    • Influence of Shaving on SSI
      Ensure adequate supply of clippers and train staff in proper use.
      Use reminders (signs, posters)
      Educate patients not to self-shave preoperatively.
      Remove all razors from the entire hospital.
      Work with the purchasing department so that razors are no longer purchased by the hospital.
    • SSI Prevention Bundle
      ANTIBIOTICS USE: selection, dosage, timing and duration
      HAIR SHAVING: what to use (if ever), how, when, who (?)
    • CONTROLLED 6 A.M. Postoperative Serum Glucose
      Hyperglycemia and Risk of SSI
      No increased risk:
      Elevated HgbA1c
      Preoperative hyperglycemia
      Increased risk:
      Diagnosed diabetes
      Undiagnosed diabetes
      Post-operative glucose >200mg% within 48 hours
    • SSI Prevention Bundle
      ANTIBIOTICS USE: selection, dosage, timing and duration
      HAIR SHAVING: what to use (if ever), how, when, who (?)
      POSTOPERATIVE SERUM GLUCOSE DETERMINATION
    • Normothermia
      Hypothermia reduces tissue oxygen tension by vasoconstriction.
      Hypothermia reduces leukocyte superoxide production.
      Hypothermia increases bleeding and transfusion requirement.
      Hypothermia increases duration of hospital stay even in uninfected patients.
    • SSI Prevention Bundle
      ANTIBIOTICS USE: selection, dosage, timing and duration
      HAIR SHAVING: what to use (if ever), how, when, who (?)
      POSTOPERATIVE SERUM GLUCOSE DETERMINATION
      IMMEDIATE POSTOPERATIVE NORMOTHERMIA
    • Any QUESTION? INQUIRY?
      Can you make a bundle of care for our own, here at Mission Hospital?
      Try making bundle of care for:
      Hand Hygiene
      Central Line Catheter
      Peripheral Vascular Catheter
      Urinary Tract Infection Prevention
      Group yourself into 4
      Make a 3 to 5 elements you think are important to be included in the bundle
      15 to 20 minutes, the present!!!
    • Examples of Bundles of Care
      Foley Catheter Nursing Care Bundle
      Central Vascular Catheter Maintenance Care Bundle
      Peripheral Vascular Catheter Maintenance Care Bundle
      Surgical Site Infection Prevention Care Bundle
      Catheter Associated UTI Care Bundle
    • My QUESTIONS………
      Is the Bundle of Care:
      Doable
      Practical
      Necessary
      If ever we implement:
      Commitment
      Concern
      Monitor
      Assess
      Improve
    • If the answer is “YES”……
      My Challenge:
      Then what are you waiting for?
      Make one now!!!
      Publish and disseminate
      Commitment and concern
      DO IT!!!!!!
      You have to monitor and improve
      OVERALL IMPACT: SAFE, QUALITY, EFFICIENT AND FAST HEALTH CARE SERVICE (End Goal of “Poke Yoke”)
    • Thank you very much for listening!!!!
      GOOD MORNING……..
      By Doc Noel