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

1. “Superbugs”and“Poka Yoke” Noel C. Santos, MD Pathologist, Mission Hospital May 31, 2011

2. “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

3. “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.

4. “Superbugs”

5. “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

6. “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

7. 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

8. Healthcare Associated Infection Poor clinical outcome Longer hospital stay More resources and effort spent Money Manpower Materials Methods Management

9. 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.

10. “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)

11. “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.

12. 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.

13. 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

14. 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.

15. 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.

16. Bundle of Care Goal: To help health care providers more reliably deliver the best possible care for patients undergoing particular treatments with inherent risks.

17. 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.

18. 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.

19. 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.

20. 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.

21. 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.

22. Can you give an example? Hand Hygiene bundle Surgical Site Infection Prevention bundle Peripheral Vascular Catheter Care bundle Catheter Associated UTI Prevention bundle

23. 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.

24. 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.

25. 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.

26. 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.

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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.

33. 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.

34. 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

35. 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

36. 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

37. 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.

38. 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.

39. 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

40. 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

41. 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.

42. 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.

43. 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.

44. 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

45. 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.

46. 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.

47. 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.

48. 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.

49. VAP PreventionBundle of Care Do bundles work? They do based on follow-up studies

50. 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

51. 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.

52. 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.

53. 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.

54. VAP PreventionBundle of Care Do bundles work? Answer: THEY DO WORK!!! Example: VAP Prevention Bundle of Care

55. No Ventilator Associated Pneumonia (VAP) – It CAN Be Done!!!

56. 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

57. Impact of SSI *LOS – length of stay

58. 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

59. 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.

60. 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)

61. 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

62. SSI Prevention Bundle ANTIBIOTICS USE: selection, dosage, timing and duration

63. Hair Removal Appropriate No hair removal at all Clipping Depilatory use Inappropriate Razors

64. 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.

65. SSI Prevention Bundle ANTIBIOTICS USE: selection, dosage, timing and duration HAIR SHAVING: what to use (if ever), how, when, who (?)

66. 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

67. SSI Prevention Bundle ANTIBIOTICS USE: selection, dosage, timing and duration HAIR SHAVING: what to use (if ever), how, when, who (?) POSTOPERATIVE SERUM GLUCOSE DETERMINATION

68. 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.

69. 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

70. 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!!!

71. 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

72. My QUESTIONS……… Is the Bundle of Care: Doable Practical Necessary If ever we implement: Commitment Concern Monitor Assess Improve

73. 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”)

74. Thank you very much for listening!!!! GOOD MORNING…….. By Doc Noel