Superbugs and Bundles of Care

5,444 views

Published on

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

Published in: Health & Medicine
3 Comments
22 Likes
Statistics
Notes
No Downloads
Views
Total views
5,444
On SlideShare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
0
Comments
3
Likes
22
Embeds 0
No embeds

No notes for slide

Superbugs and Bundles of Care

  1. 1. “Superbugs”and“Poka Yoke”<br />Noel C. Santos, MD<br />Pathologist, Mission Hospital<br />May 31, 2011<br />
  2. 2. “Superbugs”<br />Microorganisms – bacteria<br />Develop resistance to antimicrobials or antibiotics<br />Multiple<br />MDR (Multidrug Resistance)<br />New Terms<br />Multi DR : sensitive to at least three antibiotic classes<br />Extended DR : sensitive to one or two antibiotic classes<br />Pan DR : not sensitive to all antibiotic classes<br />Sensitivity Tests Results<br />in vitro testing<br />
  3. 3. “Superbugs”<br />MRSA (Methicillin Resistant Staphylococcus aureus) – Oxacillin Sensitivity Testing<br />Real or true concern<br />Vancomycin Resistant Staphylococcus aureus<br />Not the only one!!!!<br />Watch Out for the “ESKAPE” (April 2011 by WHO)<br />Enterococcus sp.<br />Staphylococcus aureus<br />Klebsiella pneumoniae<br />Acinetobacter baumanii<br />Pseudomonas aeruginosa<br />Enterobacter sp.<br />
  4. 4. “Superbugs”<br />
  5. 5. “Superbugs”<br />Development of resistance<br />CAUSE/S: Irrational use of drugs<br />PREVENTION<br />Rational antibiotic use<br />Stop transmission<br />Early recognition and prompt treatment<br />Health education and universal precaution<br />TREATMENT<br />Hope and pray!!! Watch for clinical outcome<br />New antibiotics???? (Daptomycin and Linezolid)<br />out of more than 400 drugs in discovery and development<br />Only 5 are antibiotics<br />Among the 5, none is innovative or new<br />GO BACK TO PRE-ANTIBIOTIC ERA<br />
  6. 6. “Superbugs”<br />NOSOCOMIAL INFECTION vs Community Acquired Infection<br />Hospital Acquired<br />Healthcare Associated Infection<br />Healthcare Facility Acquired Infection<br />General Criteria:<br />Development of signs and symptoms (infection or sepsis) after 48 hours of admission<br />
  7. 7. Healthcare Associated Infection<br />“antibiotic” environment<br />Predisposing factors (invasive procedures)<br />Patient’s compromised status<br />Healthcare personnel, equipment, etc… “colonizers”<br />Very Important Hospital Committee<br />INFECTION CONTROL COMMITTEE<br />
  8. 8. Healthcare Associated Infection<br />Poor clinical outcome<br />Longer hospital stay<br />More resources and effort spent<br />Money<br />Manpower<br />Materials<br />Methods<br />Management<br />
  9. 9. Healthcare Associated Infection<br />“prototype” – development of checklist, standard operating procedures, etc………<br />“BUNDLES OF CARE”<br />Therapeutic and Nursing Care<br />Doctors and Nurses<br />Other stakeholders involved in the care and management of patients, ex. Pharmacists, Technologists, Maintenance Services, etc.<br />
  10. 10. “Poka Yoke”<br />System check or procedure that will prevent errors<br />“idiot proofing”, “fail safing” or “mistake proofing”<br />Enhance or improve quality and safety<br />“Bundle of Care” is a “Poka Yoke”<br />Considerations: QUALITY, SAFETY, EFFICIENCY and SPEED (fast)<br />
  11. 11. “Bundles of Care”http://www.hps.scot.nhs.uk/haiic/ic/bundles.aspx<br />A structured way of improving processes of care and patient outcomes.<br />Small straightforward set of practices - generally 3 to 5 elements, when performed collectively, reliably and continuously, have been proven to improve patient outcomes.<br />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.<br />
  12. 12. Who can use bundles of care?<br />Anyone in any clinical setting with the agreement of the clinical team leaders.<br />However infection control teams will be able to offer support with regard to implementation and advice on data collection, analysis of data and feedback.<br />
  13. 13. What are the types of bundles?<br />Central Vascular Catheter Maintenance Care Bundle and checklist<br />Catheter Associated Urinary Tract Infections Bundle and checklist<br />Peripheral Vascular Catheter Care Bundle<br />Surgical Site Infection Prevention Bundle<br />Clostridium difficile Infection Care Bundle<br />Maintenance bundle for use in the Community – Urinary Catheter Care Bundle<br />Ventilator Associated Pneumonia Bundle<br />
  14. 14. What is a bundle?<br />Needed to effectively care for patients undergoing particular treatments with inherent risks.<br />A grouping of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement.<br />The science behind the bundle is so well established that it should be considered standard of care.<br />
  15. 15. What is a bundle?<br />Bundle elements are dichotomous and compliance can be measures: YES or NO answers.<br />Bundles eschew the piecemeal application of proven therapies in favour of an “all or none” approach.<br />
  16. 16. Bundle of Care<br />Goal: To help health care providers more reliably deliver the best possible care for patients undergoing particular treatments with inherent risks.<br />
  17. 17. What makes a bundle so special?<br />The power of a bundle comes from the body of science behind it and the method of execution: with complete consistency.<br />A bundle ties the changes together into a package of interventions that people know must be followed for every patient, every single time.<br />
  18. 18. So a bundle is a list of the right things to do for a given patient?<br />It resembles a list, but a bundle is more than that<br />Specific elements that make bundles unique.<br />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.<br />It’s a cohesive unit of steps that must all be completed to succeed.<br />
  19. 19. So a bundle is a list of the right things to do for a given patient?<br />The changes are all based on randomized controlled trials, Level 1 evidence. They’ve been proven in scientific tests, accepted, and well established.<br />There should be no controversy involved, no debate or discussion of bundle elements.<br />A bundle focuses on how to deliver the best care – not what the care should be.<br />We want providers to get right to work on the how: on completing steps x, y, and z for every patient.<br />
  20. 20. So a bundle is a list of the right things to do for a given patient?<br />The changes in a bundle are clear-cut and straightforward; they involve all-or-nothing measurement.<br />Successfully completing each step is a simple and straightforward process.<br />It’s a “yes” or “no” answer: “YES, I did this step and that one; NO, I did not yet do this last one.”<br />Successfully implementing a bundle is clear-cut: “YES, I completed the ENTIRE bundle, or NO, I did not complete the ENTIRE bundle.”<br />There is no in between; no partial “credit” for doing some of the steps some of the time.<br />
  21. 21. So a bundle is a list of the right things to do for a given patient?<br />Bundle changes also occur in the same time and space continuum, at a specific time and in a specific place, no matter what.<br />This might be during morning rounds every day or every six hours at the patient’s bedside.<br />
  22. 22. Can you give an example?<br />Hand Hygiene bundle<br />Surgical Site Infection Prevention bundle<br />Peripheral Vascular Catheter Care bundle<br />Catheter Associated UTI Prevention bundle<br />
  23. 23. What’s the difference between a bundle and a checklist?<br />A checklist can be very helpful and an important vehicle for ensuring safe and reliable care.<br />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).<br />A checklist may also have many, many elements.<br />
  24. 24. What’s the difference between a bundle and a checklist?<br />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.<br />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.<br />When a bundle element is missed, the patient is at much greater risk for serious complications.<br />
  25. 25. What’s the difference between a bundle and a checklist?<br />There’s also a level of accountability tied to a bundle that you don’t always have with a checklist.<br />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.<br />Things don’t always get done.<br />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.<br />A bundle is a person or a team’s responsibility – period.<br />It’s their job at a certain point and time – during rounds every single day, possibly.<br />It’s very clear who has to do what and when, within a specific time frame.<br />The accountability and focus give a bundle a lot of its power.<br />
  26. 26. How to make a bundle of care?<br />Example: “The Ventilator Bundle” <br />Ventilator Assisted Pneumonia (VAP)<br />Nosocomial pneumonia is the leading cause of death from hospital-acquired infections.<br />Refers to pneumonia developing in a mechanically ventilated patient more than 48 hours after intubation.<br />
  27. 27. Facts About VAP<br />Incidence: 15% patients receiving mechanical ventilation<br />Risk Factors: tracheostomy, multiple central line insertions, re-intubation, and use of antacids<br />Mortality: 46% compared to 32% who do not develop VAP<br />
  28. 28. VAP Prolongs Care<br />Large retrospective matched cohort study of risk factors and consequences of VAP:<br />Prolonged mechanical ventilation<br />Prolonged ICU stay<br />Prolonged post-ICU hospital stay<br />Marked increased in cost of admission<br />
  29. 29. Studies in relation to VAP that affect clinical outcome<br />Head of the bed 30 to 45 degree angle<br />Sedative interruption and daily assessment of readiness to extubate<br />Peptic ulcer disease (PUD) prophylaxis<br />Deep venous thrombosis (DVT) prophylaxis<br />
  30. 30. Studies in relation to VAP that affect clinical outcome<br />Head of the bed 30 to 45 degree angle<br />Sedative interruption and daily assessment of readiness to extubate<br />Peptic ulcer disease (PUD) prophylaxis<br />Deep venous thrombosis (DVT) prophylaxis<br />
  31. 31. Randomized controlled trials: 88 intubated patients on mechanical ventilator<br />Increased incidence of VAP among patients in supine position<br />Advantage of semi-recumbent position<br />Apply in setting with patient on MV<br />
  32. 32. What changes can we make that will result in improvement ?<br />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.<br />Create an environment where respiratory therapists work collaboratively with nursing to maintain head-to-the-bed elevation.<br />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.<br />
  33. 33. What changes can we make that will result in improvement ?<br />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.<br />Include this intervention on order sets for initiation and weaning of MV, delivery of tube feedings, and provision of oral care.<br />Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.<br />
  34. 34. Studies in relation to VAP that affect clinical outcome<br />Head of the bed 30 to 45 degree angle<br />Sedative interruption and daily assessment of readiness to extubate<br />Peptic ulcer disease (PUD) prophylaxis<br />Deep venous thrombosis (DVT) prophylaxis<br />
  35. 35. Sedation Vacation<br />Why?<br />Has been demonstrated to reduce overall patient sedation<br />Promotes early weaning<br />Identified Issues and Concerns:<br />Increases potential for self-extubation<br />Increases potential for patient pain and anxiety<br />Increases episodes of desaturation<br />Anecdotal experience:<br />Promotes early extubation<br />No significant increase in patient self-extubation<br />
  36. 36. Studies: Sedation Vacation<br />128 adults on MV randomized to daily interruption of sedation until the patient was awake or interruption at the clinician’s discretion<br />Duration of ventilation:<br />4.9 days vs. 7.3 days<br />Shorter duration on MV<br />
  37. 37. What changes can we make that will result in improvement?<br />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.<br />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.<br />
  38. 38. What changes can we make that will result in improvement?<br />Assess compliance each day on multidisciplinary rounds.<br />Consider implementation of a sedation scale such as the Riker scale to avoid over-sedation.<br />Post compliance with the intervention in a prominent place in you ICU to encourage change and motivate staff.<br />
  39. 39. Studies in relation to VAP that affect clinical outcome<br />Head of the bed 30 to 45 degree angle<br />Sedative interruption and daily assessment of readiness to extubate<br />Peptic ulcer disease (PUD) prophylaxis<br />Deep venous thrombosis (DVT) prophylaxis<br />
  40. 40. PUD Prophylaxis<br />Why?<br />Stress ulcerations are the most common cause of GI bleeding in ICU patients.<br />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.<br />Identified Issues and Concerns:<br />Some studies have shown increased rates of VAP in patients with prophylactic treatments, ex. Sucralfate.<br />Anecdotal experience:<br />None significant<br />
  41. 41. Studies regarding PUD Prophylaxis<br />Surviving Sepsis Campaign Guidelines:<br />Stress ulcer prophylaxis should be given to all patients with severe sepsis.<br />H2 receptor inhibitors are more efficacious than sucralfate and are the preferred agents.<br />Proton pump inhibitors is as good as H2 blockers<br />They demonstrate equivalency in ability to increase gastric pH.<br />
  42. 42. What changes can we make that will result in improvement?<br />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.<br />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.<br />
  43. 43. What changes can we make that will result in improvement?<br />Empower pharmacy to review patients in the ICU to ensure that some form of PUD prophylaxis is provided for all appropriate ICU patients.<br />Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.<br />
  44. 44. Studies in relation to VAP that affect clinical outcome<br />Head of the bed 30 to 45 degree angle<br />Sedative interruption and daily assessment of readiness to extubate<br />Peptic ulcer disease (PUD) prophylaxis<br />Deep venous thrombosis (DVT) prophylaxis<br />
  45. 45. DVT Prophylaxis<br />Why?<br />Reduces potential for clot formation<br />Reduces potential for pulmonary emboli<br />Identified Issues and Concerns:<br />May increase the risk of bleeding<br />Anecdotal experience:<br />If using SCD’s (sequential compression devices), assure that they are on the patient.<br />
  46. 46. Studies on DVT Prophylaxis<br />Systematic review of risks of venous thromboembolism (VTE) and its prevention:<br />“We recommend, on admission to the ICU, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis.<br />
  47. 47. What changes can we make that will result in improvement?<br />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.<br />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.<br />
  48. 48. What changes can we make that will result in improvement?<br />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.<br />Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.<br />
  49. 49. VAP PreventionBundle of Care<br />Do bundles work?<br />They do based on follow-up studies<br />
  50. 50. Monitor and measure effectivity of bundle<br />Calculate the VAP Rate<br />Numerator: No. of VAP cases<br />Denominator: Total ventilator days<br />Multiply by 1,000 to convert to a rate<br />Calculate the compliance with Ventilator Bundle<br />Numerator: No. of vented patients receiving ALL components of bundle<br />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”.<br />Denominator: Total No. of patients on ventilators for the day of the prevalence sample<br />
  51. 51. Move on to New Areas<br />Develop a sedation protocol<br />Develop a weaning protocol<br />Create a pre-extubation worksheet to assess the risk of failed extubation<br />Spread the use of the ventilator bundle to other ICU’s in your hospital.<br />
  52. 52. ICU Infrastructure Changes<br />Encourage open visitation for ICU families<br />Request infection control practitioner to report VAO data monthly, not quarterly<br />Initiate intensivist-directed multidisciplinary team system.<br />
  53. 53. IMPACT: Reliability<br />SUMMARY<br />Possible mechanisms of success:<br />Does implementation of a standardized “bundle” of care result in better overall care?<br />Are the interventions synergistic?<br />Dramatic reduction in VAP:<br />More than could have been expected from the sum of the individual interventions.<br />
  54. 54. VAP PreventionBundle of Care<br />Do bundles work?<br />Answer: THEY DO WORK!!!<br />Example: VAP Prevention Bundle of Care<br />
  55. 55. No Ventilator Associated Pneumonia (VAP)<br />–<br />It CAN Be Done!!!<br />
  56. 56. SURGICAL SITE INFECTION (SSI)Application in our own setting – Mission Hospital<br />Background:<br />3.7% of patients experience serious adverse events related to medical management.<br />The top three causes were:<br />Medication-related (19%)<br />Wound infections (14%)<br />Technical complications (13%)<br />All of these events led to disability or prolonged stay; death occurred in 13.6% of these patients.<br />58% of these events were preventable mistakes – now called medical errors or patient safety failures<br />
  57. 57. Impact of SSI<br />*LOS – length of stay<br />
  58. 58. Opportunity to Prevent Surgical Infections<br />An estimated 40-60% of SSI’s are preventable.<br />Improper timing, selection, and duration of prophylactic antibiotics occurs in 25-50% of operations<br />SSI prevention is a key component of Surgical Care Improvement Project<br />
  59. 59. Reducing SSI: Four Components of Care<br />Appropriate use of prophylactic antibiotics.<br />Appropriate hair removal.<br />Controlled 6 AM postoperative serum glucose in cardiac surgery patients.<br />Immediate postoperative normothermia in colorectal surgery patients.<br />
  60. 60. Antibiotics<br />Selection<br />Consistent with national guidelines<br />Special cases: allergy, prolonged used<br />Timely administration<br />Within one hour prior to incision<br />Vancomycin or Fluoroquinolones: 2 hours<br />Make sure all antibiotic is infused prior to inflation of cuff.<br />Dosage:<br />At least a full therapeutic dose<br />Upper range for large patients and/or long operations<br />Repeat doses for long operations (>4 hours)<br />
  61. 61. Antibiotics<br />Timely discontinuation<br />Confirmed efficacy of ≥12 hours<br />Efficacy of a single dose<br />Shorter course has been as effective as the longer course<br />No need to continue coverage beyond 24 hours even with tubes or drains postoperatively<br />Lack of evidence preventing SSI’s if given after the end of operation<br />Increased use promotes antibiotic resistance<br /> <br />
  62. 62. SSI Prevention Bundle<br />ANTIBIOTICS USE: selection, dosage, timing and duration<br />
  63. 63. Hair Removal<br />Appropriate<br />No hair removal at all<br />Clipping<br />Depilatory use<br />Inappropriate<br />Razors<br />
  64. 64. Influence of Shaving on SSI<br />Ensure adequate supply of clippers and train staff in proper use.<br />Use reminders (signs, posters)<br />Educate patients not to self-shave preoperatively.<br />Remove all razors from the entire hospital.<br />Work with the purchasing department so that razors are no longer purchased by the hospital.<br />
  65. 65. SSI Prevention Bundle<br />ANTIBIOTICS USE: selection, dosage, timing and duration<br />HAIR SHAVING: what to use (if ever), how, when, who (?)<br />
  66. 66. CONTROLLED 6 A.M. Postoperative Serum Glucose<br />Hyperglycemia and Risk of SSI<br />No increased risk:<br />Elevated HgbA1c<br />Preoperative hyperglycemia<br />Increased risk:<br />Diagnosed diabetes<br />Undiagnosed diabetes<br />Post-operative glucose >200mg% within 48 hours<br />
  67. 67. SSI Prevention Bundle<br />ANTIBIOTICS USE: selection, dosage, timing and duration<br />HAIR SHAVING: what to use (if ever), how, when, who (?)<br />POSTOPERATIVE SERUM GLUCOSE DETERMINATION<br />
  68. 68. Normothermia<br />Hypothermia reduces tissue oxygen tension by vasoconstriction.<br />Hypothermia reduces leukocyte superoxide production.<br />Hypothermia increases bleeding and transfusion requirement.<br />Hypothermia increases duration of hospital stay even in uninfected patients.<br />
  69. 69. SSI Prevention Bundle<br />ANTIBIOTICS USE: selection, dosage, timing and duration<br />HAIR SHAVING: what to use (if ever), how, when, who (?)<br />POSTOPERATIVE SERUM GLUCOSE DETERMINATION<br />IMMEDIATE POSTOPERATIVE NORMOTHERMIA<br />
  70. 70. Any QUESTION? INQUIRY?<br />Can you make a bundle of care for our own, here at Mission Hospital?<br />Try making bundle of care for:<br />Hand Hygiene<br />Central Line Catheter<br />Peripheral Vascular Catheter<br />Urinary Tract Infection Prevention<br />Group yourself into 4<br />Make a 3 to 5 elements you think are important to be included in the bundle<br />15 to 20 minutes, the present!!!<br />
  71. 71. Examples of Bundles of Care<br />Foley Catheter Nursing Care Bundle<br />Central Vascular Catheter Maintenance Care Bundle<br />Peripheral Vascular Catheter Maintenance Care Bundle<br />Surgical Site Infection Prevention Care Bundle<br />Catheter Associated UTI Care Bundle<br />
  72. 72. My QUESTIONS………<br />Is the Bundle of Care:<br />Doable<br />Practical<br />Necessary<br />If ever we implement:<br />Commitment<br />Concern<br />Monitor<br />Assess<br />Improve<br />
  73. 73. If the answer is “YES”……<br />My Challenge:<br />Then what are you waiting for?<br />Make one now!!!<br />Publish and disseminate<br />Commitment and concern<br />DO IT!!!!!!<br />You have to monitor and improve<br />OVERALL IMPACT: SAFE, QUALITY, EFFICIENT AND FAST HEALTH CARE SERVICE (End Goal of “Poke Yoke”)<br />
  74. 74. Thank you very much for listening!!!!<br />GOOD MORNING……..<br />By Doc Noel<br />

×