alphabet soup: figuring out hospital acquired infections · pdf file3/2/2015 1 alphabet soup:...
TRANSCRIPT
3/2/2015
1
ALPHABET SOUP: FIGURING OUT HOSPITAL ACQUIRED INFECTIONS
SHARON A. MCNAMARA RN, BSN, MS, CNOR
HAI
SSI
SCIP
CLABSI
CAUTI SUSP
CDC HICPAC
NHSN
OBJECTIVES:
1. Describe the effect of HAI’s in the United States.
2. Identify three (3) evidence based initiatives to reduce HAI’s.
3. Discuss the importance of Defect Analysis (DA) in Surgical Site Infection (SSI)
prevention.
NATIONAL ANNUAL IMPACT
• 101 million medical procedures
• 10.8 million GI endoscopies
• 440,000 bronchoscopies
• 46.5 million surgical procedures
• 1.7 million hospital acquired infections (HAI)
• 99,000 deaths
• 500,000 SSIs occur yearly
• 2.7% surgeries result in SSIs
• 4% of pediatric surgeries result in SSIs
• $7 billion in healthcare expenditures
3/2/2015
2
PREVENTION IS THE GAME CHANGER!
40 to 60%
of SSIs
are
preventable
Joint Commission. Patient safety new NPSG implementation guide provides effective
practice for reducing SSIs. Joint Commission Online. May 22, 2013. Accessed June 11,
2013. [email protected].
CULTURE OF SAFETY
Safety depends on:
• Reliability
• Systems designed to withstand human errors
• Management and oversight
Safe Systems are characterized by:
• Commitment to safety
• Formal protocols for communication and teamwork
• Standardization as best practice
• Reporting problems for improvement
CULTURE OF SAFETY
Teamwork
• Shared goals
• Shared mental model
• Situational awareness
• Flat hierarchy
Clarke JR. Designing safety into minimally invasive surgical revolution. Surg Endos 2009. 23:216-220
3/2/2015
3
AREAS TO CONSIDER IN THE PREVENTION & SURVEILLANCE OF SSI
•Preparation of the patient
•Preparation of the personnel
•Preparation of the environment
•Examine these in every unit patient receives care
SOURCES FOR PATHOGENS
• Endogenous
• Accounts for the majority of infections
• Consider distant sites as sources
• Exogenous
• Personnel
• Environment
• Air
• Surgical instruments and equipment
Bacterial Dose Virulence
Impaired
Host Resistance
PATHOGENESIS OF INFECTION
Condition of
Surgical Site
at End of
Procedure
3/2/2015
4
PATIENT FACTORS CONTRIBUTING TO SSI
• Age
• Nutritional status
• Smoking/tobacco use
• Obesity
• Diabetes & hyperglycemia
• Microbial infection
• Remote infection
WHO Guidelines for Safe Surgery (1st Ed)
• Altered immune response
• Pre-and-post-operative LOS
• Patient hygiene
• Patient hand hygiene
• Normothermia
•Oxygenation
SURGICAL FACTORS CONTRIBUTING TO SSI
• Preoperative skin preparation
• Hair removal
• Antimicrobial prophylaxis
• Environmental controls
• Hand antisepsis of the surgical team
WHO Guidelines for Safe Surgery (1st Ed)
• Surgical attire
• Creation of the sterile field
• Instrument preparation and sterilization
• Length of procedure
• Surgical technique
• Post-operative dressings
SCIP SURGICAL CARE IMPROVEMENT PROGRAM
• Appropriate antibiotic within 1 hour prior to surgical incision
• Appropriate selection of antibiotic
• Discontinue antibiotic within 24 hours after surgical end time
• Appropriate hair removal
• Appropriate VTE prophylaxis ordered
• Appropriate VTE within 24 hours prior to surgery to 24 hours post surgery
• Cardiac patients with controlled 6AM postop serum glucose
• Surgical patients on Beta Blocker therapy prior to admission who received a BB
during perioperative period
• Urinary catheter removal on postop day 1 or 2
• Surgical patient with post op temperature management
http://www.jointcommission.org/surgical_care_improvement_project/
3/2/2015
5
SURGICAL CARE BUNDLES
• A surgical care bundle is a set of interventions that, when implemented as a
group, help to improve surgical patient outcomes.
• Structured on evidence based research and practices
• Developed by a multidisciplinary team for the particular facility
CUSP FRAMEWORK COMPREHENSIVE UNIT-BASED SAFETY PROGRAM
• Train staff in the science of safety
• Engage staff to identify defects
• Senior executive partnership/safety rounds
• Continue to learn from defects
• Implement tools for improvement
http://www.hopkinsmedicine.org/innovation_quality_patient_care/areas_expertise/improve_patient_safety/c
usp/cusp_tools_improvement.html
CLABSI CENTRAL LINE ASSOCIATED BLOODSTREAM INFECTIONS
CLABSIs are associated with bad outcomes
• – 500-4,000 U.S. patients die annually due to CLABSIs
• – Average increased length of stay is 7 days
• – Estimated cost per CLABSI is $3,700-29,000
http://www.hopkinsmedicine.org/heic/infection_surveillance/clabsi.html
3/2/2015
6
CLABSI BUNDLE
• Caps, masks, sterile gown & gloves
• Patient draped with maximum barrier
• Perform hand hygiene pre & post catheterization
• Use Chlorhexidine (CHG) for skin prep ( 30 sec. rub, IJ or subclavian, 2 min. in groin & 1 min.
dry)
• Use full barrier precautions during insertion (shown to reduce infection 2-3 fold)
• Avoid using femoral site in adults
• Post procedure assess the need for catheter each day, remove ASAP. Special procedures for
hub, site, and tubing care.
• Training, competency, checklists important aspects to bundle compliance
http://www.hopkinsmedicine.org/heic/infection_surveillance/clabsi.html
http://www.hopkinsmedicine.org/heic/infection_surveillance/clabsi.html
CAUTI BUNDLE CATHETER ASSOCIATED URINARY TRACT INFECTIONS
• Perform hand hygiene before and after catheter insertion or manipulation
• Use urinary catheters only when necessary and for the shortest time possible
• Assess catheter use at least daily and remove as soon as possible
• Ensure only properly trained individuals who know aseptic technique are
responsible for insertion of catheters and their maintenance (this includes all
healthcare personnel and caregivers)
http://www.cdc.gov/hicpac/CAUTI_fastFacts.html
APPROPRIATE INDICATIONS FOR URINARY CATHETER PLACEMENT
• Critically ill patients
• Surgical patients undergoing urologic or prolonged surgery
• Patients who have received large-volume infusions or diuretics during surgery
• Patients whose urinary output needs to be closely monitored
• Patients who have bladder obstruction, prolonged immobilization, or patients
needing additional comfort in end-of-life care
3/2/2015
7
HICPAC HEALTHCARE INFECTION CONTROL PRACTICES ADVISORY COMMITTEE
Perioperative use for selected surgical procedures:
• Patients undergoing urologic surgery or other surgery on contiguous structures of the
genitourinary tract
• Anticipated prolonged duration of surgery (catheters inserted for this reason should
be removed in PACU)
• Patients anticipated to receive large-volume infusions or diuretics during surgery
• Need for intraoperative monitoring of urinary output
• To assist in healing of open sacral or perineal wounds in incontinent patients
• Patient requires prolonged immobilization (e.g., potentially unstable thoracic or
lumbar spine, multiple traumatic injuries such as pelvic fractures).
http://www.cdc.gov/hicpac/cauti/002_cauti_sumORecom.html
SUSP CUSP FOR SAFE SURGERY
• Normothermia
• Euglycemia - Glucose Control
• Skin Preparation
• Antibiotic selection, dose, time administered, redosing
• Case duration
• Includes SCIP work
COLORECTAL SURGERY BUNDLE
PRE-OP
• Hibiclens shower night before and
day of surgery
• Patient cleansing CHG cloths AM
admission
• Ensure understanding Preventing SSI
pamphlet
INTRA-OP
• SCIP compliance w ABX
• Ensure re-dose of cefazolin within 3-4
hours after incision
• Chloraprep
• Closure tray for closure of fascia & skin
• Glove change by surgeon & staff
before closure of fascia
Cima R. Dankbar E. Lovely J. et al. Colorectal surgery: Surgical Site Infection Reduction Program: a national surgical quality program - driven multidisciplinary single institution experience.
J Am. Coll. Surg. 2012. 215; 193-200.
3/2/2015
8
PROJECT JOINTS: HIP & KNEE ARTHROPLASTY BUNDLE
• Patients bathe or shower with CHG soap for at least 3 days pre-op
• Screen patients for Staph aureus carriage and decolonize SA carriers with 5
days of intranasal mupirocin and 3 days of chlorhexidine soap prior to
surgery
• Use of alcohol-containing antiseptic for preoperative skin prep
• Appropriate use of prophylactic antibiotics
• Appropriate hair removal
LEARNING FROM DEFECTS
AN IMPORTANT TOOL IN SURGICAL SITE
INFECTION PREVENTION
LEARNING FROM EACH DEFECT
• Establish process to analyze defects
• Initiate analysis ASAP
•Use standard investigation tool
• Investigate details prior to meeting
• Build on established processes
•Challenge practice and traditional ways of thinking
• Embrace environment of psychological safety
3/2/2015
9
ENGAGE A MULTIDISCIPLINARY TEAM
Most critical step … include the right folks:
• Surgical Services
• Infection Preventionists and IP MD
• Surgeon(s)
• Anesthesia
• Administration
• Facility and Maintenance Services
• Quality, Safety, Risk Representatives
• Central Supply Materials Management
• Patient/Family (as appropriate)
5 BASIC STEPS IN LEARNING FROM DEFECTS PROCESS
Step 1 What happened?
Step 2 Why did it happen?
Step 3 How will you reduce the likelihood of it happening again?
Step 4 How will you know the risk is reduced?
Step 5 How do you communicate the findings and to whom?
AHRQ CUSP Tool Kit. Identify Defects Through Sensemaking.
STEP 1: WHAT HAPPENED?
• Use a standard event investigation format
• Use easy-to-use tool, tailored for organization
• Engage multiple shareholders in research
• Establish chronological order of events and related data
• Identify contributing factors
•… and don’t forget the Gemba Walk
3/2/2015
10
CONTRIBUTING FACTORS - HUMAN FAILURES
• Practitioner competency
• Failure to clean items properly
• Incorrect set up of chemical cleaners on
automatic washer
• Incorrect temperature setting on sterilizer
• Improperly packed sterilizer
• Failure to check that the parameters for
sterilization were met
• Failure to check biologic controls
© 2014 All Rights Reserved. IMS is a registered trademark of
Integrated Medical Systems International, Inc.
CONTRIBUTING FACTORS - EQUIPMENT, MATERIALS & ORGANIZATIONAL FAILURES
•Outdated, inaccurate or absent policies or procedures
• Use of incorrect channel connectors for endoscopes
• Lack of proper cleaning utensils, equipment
• Lack of maintenance for equipment
• Inappropriate storage environment
•Manufacturer design
• IFU
DON’T FORGET CRITICAL INFO!
• Assess for latent failures at time of event
• Staffing
• Throughput issues
• Emotional/psychological aspects of team
• Environmental conditions
• Build key questions into Defect Analysis Tool (DAT)
Resource: http://www.onthecuspstophai.org/stop-bsi/manuals-and-toolkits/
3/2/2015
11
STEP 2: WHY DID IT HAPPEN?
1. Review events from DAT with team
2. Identify gaps and contributing factors
3. Ask “Why?”
• For each gap identified
• For each reason generated
• And at least three more times or until root cause is found
WHY? WHY? WHY? WHY? WHY?
1. Lumens not being flushed?
2. Proper cleaning, equipment not
available?
3. Inspection of the instruments not
occurring?
4. Magnifying glass at every station not
being used?
5. Interruptions so frequent?
© 2014 All Rights Reserved. IMS is a registered trademark of Integrated
Medical Systems International, Inc.
STEP 3: HOW CAN WE REDUCE THE CHANCES OF IT HAPPENING AGAIN?
1. Prioritize most important contributing factors
2. Develop interventions (countermeasures) to defend against the most
important contributing factors
3. Rate each countermeasure on:
• Ability to mitigate root cause
• Team’s belief countermeasure will be executed
4. Draft action plan for 2-5 of highest scoring countermeasures
3/2/2015
12
COUNTERMEASURES
•Consider safe design principles • Standardize – eliminate steps when possible
• Create independent checklists
• Learn when things go wrong (analyze defects)
• Safe designs apply to:
• Technical
• Team work
• Brainstorm strategies • Ability to mitigate error
• Strength of countermeasures to prevent error
• Ease of implementation
• Standardize
1. Instructions to Be More Careful, Vigilant
2. Education/Information
3. Rules and Policies
4. Checklists and Double-check Systems
5. Standardization and Protocols
6. Automation and Computerization
7. Forcing Functions and Constraints
RANK ORDER: STRENGTH OF ERROR REDUCTION STRATEGIES
Adapted from the Institute of Safe Medication Practices (first presented on 12/3/2006 by Michael R. Cohen, RPh, MS, SCD)
Contributing Factor Countermeasure Rating (1 low – 5 high )
Potential for
implementation
Outdated policies and
procedures
Apply practices & procedures
that are consistent with
evidence-based and/or
professional guidelines:
• ANSI/AAMI ST79:2010 & A1:2010
& A2:2011 Comprehensive Guide to
Steam Sterilization and Sterility
Assurance in Healthcare Facilities
• AORN Standards and Recommended
Practices (2013) . Recommended
Practices on Sterilization &
Disinfection. PP 451-540
• Healthcare Infection Control Practice
Advisory Committee (HICPAC) Center
for Disease Control (CDC). Guideline
for Disinfection and Sterilization in
Healthcare Facilities, 2008
• IAHCSMM Position Paper on the
Management of Loaner
Instrumentation 2011
3. Rules and Policies
3/2/2015
13
Contributing Factor Countermeasure Rating (1 low – 5 high )
Potential for
implementation
Manufacturers IFU not
available for staff
1. Provide electronic or
hardcopy of IFU that is
assessable to practitioners
2. Review the manufacturer’s
IFU before purchase or
finalizing loaner agreements
6. Automation and Computerization
Contributing Factor Countermeasure Rating (1 low – 5 high )
Potential for
implementation
Failure of staff to clean
instrument and properly
inspect for failures
• Lack of IFUs
• Lack of certified CSMM
staff
• Competency evaluation
program inconsistent
Ensure personnel responsible for
reprocessing are competent:
• Education and initial competency
• Manufacturer IFU
• Inspection of devices
• Availability of cleaning equipment
and tools (checklists)
• Empower personnel to report and
investigate
• Certified Central Supply Material
Management Technicians/Managers
• Ongoing competency evaluation
2. Education/Information
4. Checklists and Double-check Systems
5. Standardization and Protocols
STEP 4: HOW WILL WE KNOW THE RISK IS REDUCED?
•Assess data
• Talk with staff to get their perspectives
• Talk with patients and families
•Do Gemba Walk
• Feedback from patient safety rounds
3/2/2015
14
STEP 5: HOW DO WE COMMUNICATE OUR FINDINGS AND TO WHOM? • Internal communications
• Areas/people prone to this defect
• Regulatory compliance, accreditation, and risk management
• Who needs to know for closure on the defect analysis
• Potential defects related to root causes found in analysis
• Hospital/nursing communications – story telling
• Patient story telling
• External communications
• PSOs
• Others
• Input/permission from Risk Management and Administration
HOW ARE WE DOING?
• Agency for Healthcare Research and Quality (AHRQ) estimates 1.3 million
fewer patients were harmed in U.S. Hospitals from 2010-2013.
• Represents a cumulative 17% reduction and an estimated 50,000 deaths
prevented after launch of Partnership for Patients
• Suggests a rapid and accelerating improvement over the three years
• CLABSI demonstrated 49% reduction 2010-2013
• SSI demonstrated 19% reduction 2010-2013
• CAUTI demonstrated 28% reduction 2010-2013
http://www.modernhealthcare.com/article/20141202/NEWS/312029936/1-3-million-adverse-events-
prevented-in-u-s-hospitals-since-2010
WHERE DO WE GO FROM HERE?
• Frontline practitioners must drive the evidence based practice
• Frontline practitioners must be invested in the sustainment of quality
improvements
• Frontline workers must hold themselves and each other accountable
• Practitioners need to be invested in creating and maintaining a culture of
safety
• Practitioners must practice effective team behaviors to protect themselves and
their patients
• Preventing SSI is a team effort and the patient must be a member of the team
3/2/2015
15
REFERENCES:
• HEIC Website http://intranet.insidehopkinsmedicine.org/heic
• Adult VAD Policy
www.insidehopkinsmedicine.org/hpo/policies/39/139/policy_139.pdf
• Pediatric VAD Policies
www.insidehopkinsmedicine.org/hpo/policies/50/2282/policy_2282.pdf
www.insidehopkinsmedicine.org/hpo/policies/50/2283/policy_2283.pdf
• CDC Guidelines www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm
• SHEA Guidelines www.shea-online.org/about/compendium.cfm.
• Rice S. 1.3 million adverse events prevented in u.s. hospitals since 2010, feds
say. Accessed at:
http://www.modernhealthcare.com/article/20141202/NEWS/312029936/
1-3-million-adverse-events-prevented-in-us-hospitals-since-2010
REFERENCES: • Edmiston CE. Spencer M. Key issues in infection prevention: an overview. AORN Journal 2014; 100(6):
586-589.
• Nelson RL, Glenny AM, Song F. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database
Syst Rev. 2009(1):CD001181.
• Guideline for prevention of surgical site infection, 1999. US Department of Health and Human Services,
Centers for Disease Control and Prevention Website.
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/SSI.pdf. Accessed: December 12, 2014.
• Khodyakov D. Ridgely MS. Huang C. et al. Project joints: what factors affect bundle adoption in a
voluntary quality improvement campaign? BMJ Qual Saf. 2014; 0: 1-11.
• Edmiston CE. Spencer M. A perspective on surgical site infection prevention: 10 Key issues in infection
prevention: an overview. 2) Patient care interventions to help reduce the risk of surgical site infections. 3)
The role of the OR environment in preventing surgical site infections. 4) endoscope reprocessing in 2014:
why is the margin of safety so small? 5) Going forward: preventing surgical site infections in 2015.
AORN Journal 2014; 100(6): 586-619.