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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