don't shoot the messenger: being an md champion for hai
TRANSCRIPT
Don’t Shoot the Messenger: Being an MD Champion for
HAI Prevention
Philip Robinson, MD Medical Director, Infection Prevention Hoag Memorial Hospital Presbyterian
Hoag Orthopedic Institute
No Disclosures June 10, 2015
Ignas Simmelwise
Objectives • Tailor your message
– Example: Business case
• Be a solder in the trenches
– “Tribe on Tribe” – speaking the same “language”
• Provide solid actionable data and make it personal – data alone does not change behavior
– VAP
– Hand hygiene
– Antibiotic Exposure -- Procalcitonin
Hand Hygiene Adherence in Hospitals
1. Gould D, J Hosp Infect 1994;28:15-30. 2. Larson E, J Hosp Infect 1995;30:88-106. 3. Slaughter S, Ann Intern Med 1996;3:360-365. 4. Watanakunakorn C, Infect Control Hosp Epidemiol 1998;19:858-860. 5. Pittet D, Lancet 2000:356;1307-1312.
Year of Study Adherence Rate Hospital Area
1994 (1) 29% General and ICU
1995 (2) 41% General
1996 (3) 41% ICU
1998 (4) 30% General
2000 (5) 48% General
HHNB Percent Hand Hygiene Compliance Over
Time Exiting and Entering a Patient's Room
0
10
20
30
40
50
60
70
80
90
100
9-Dec 10-May 10-Jul 10-Nov 11-Mar
Perc
en
tag
e
Nursing
MD
RCP
Other
New Hand
Hygiene
Campaign
begins
I just threw you under the bus. by Stephen Lindsay, MD
Phil:
I was at the PEC and the abysmal performance of the physicians hand hygiene became the subject of much discussion. Some wanted heads, others were content with a blood offering from the jugular of dirty handed physicians. In order to appease the enraged MOB before they charged out of the Board room looking for victims, I proposed that our loved infection prevention physician (you) develop a proposal and bring it to MEC for discussion. This calmed the MOB but only for a time. They want sanctions with teeth! Please help me.
Chief of Staff
Dear Chief:
• My team’s familiar with the underbelly of the bus.
• Sorry that I was not present to shield you from this reaction to quarter old data.
• I hope you, PEC and the Board, will take comfort in the success of our most recent interventions and our latest hand hygiene audit results.
• Nonetheless, we agree that a few members of the medical staff may require some special attention to propel us and keep us above our 90% goal.
Phil
Getting to 100%
• Individual accountability
• Constant Reinforcement, Reminders
• Peer monitoring
• Rewards
Figure from Kirkland KB, et al. BMJ Qual Saf 2012;21:1019-26.
HHNB Healthcare Acquired VRE
and Hand Hygiene Compliance
56
41 43
71
0123456789
10
3W S
IC
4 W
CCU/C
VIC
U
5 W
est
6 W
est
7 W
est
8 W
est
9 W
est
SNIC
U
Unit
# H
ealt
hcare
Acq
uir
ed
VR
E
0102030405060708090100
% H
H C
om
pli
an
ce
Healthcare
Acquired VRE
Hand Hygiene
Compliance
Clinical Outcomes Related to Hand Hygiene at Hoag
Noncompliant Medical Staff
• IP will record and report names of those that are observed noncompliant
• List will be maintained by Medical Staff and Infection Prevention
• List to be presented to MEC at least quarterly
• Hand hygiene “school”
HHNB Percent Hand Hygiene Compliance Over
Time Entering and Exiting a Patient's Room
0
10
20
30
40
50
60
70
80
90
100
Mar
-12
Jun-
12
Sep
-12
Dec
-12
Mar
-13
Perc
en
tag
e
Nursing
MD
RCP
Other
;
HHNB Percent Hand Hygiene Compliance Over
Time Entering and Exiting a Patient's Room
0
10
20
30
40
50
60
70
80
90
100
Mar
-12
Jun-
12
Sep
-12
Dec
-12
Mar
ch 1
013
Perc
en
tag
e CCU/CVICU
ICU
6th Floor
8th Floor
ED
NICUQ1FY2010
Infections Prevented and Value Gained FY2010 Baseline Infections FYQ3-08 to FYQ2-09
Infections
FY1Q-10
Infections
FY2Q-10
Infections
FY3Q-10
Infections
FY4Q-10
Ventilator Pneumonia 13 3.3 5 6 3 3 Central Line
Infection 22 5.5 5 4 5 7 Urinary Catheter
Infection 92 23.0 5 8 15 12 MRSA
(Resistant Staph) 61 15.3 15 14 15 10
VRE (Resistant Enterococcus)
13 3.3 5 8 4 7 CDIFF
(Clostridium difficile) 89 22.3 20 13 13 5
Cost per Quarter $965,180 $924,245 $803,786 $737,052 $573,231
Savings and Value per Quarter
NA $40,935 $161,394 $228,128 $391,949
Patients Saved from Infections
NA 18 20 18 29
Bundle Score Updated 10/22/2010
2.43 (%Reduction) 290 infections/ 119,391 pt. days x
1,000
Baseline
1.81 (26%) 55 infections/30,345 pt.
days x 1,000
1.75 (28%) 53 infections/30,233 pt.
days x 1,000
1.85 (24%) 55 Infections/29,753 pt.
days x 1,000
1.44 (41%) 44 Infections/30,587 pt.
days x 1,000
Totals for FY2010 YTD Bundle Score = 1.71 (30% reduction)
YTD Patients Saved from infection = 83
YTD Savings and Value Added = $822,406
Year Ave. Qtr.
Healthcare Acquired Infections -- Harm Avoidance
Hoag Hospital Newport Beach/ Hoag Hospital Irvine
97.00
97.50
98.00
98.50
99.00
99.50
100.00Q
tr 1
FY
10
Qtr
2
Qtr
3
Qtr
4
Qtr
1
FY
11
Qtr
2
Qtr
3
Qtr
4
Qtr
1
FY
12
Quarter
Infe
cti
on
s P
rev
en
tio
n H
arm
In
dex
10
0 =
Zero
In
fecti
on
s
Rate of No Infections per 1000
Patient Days
VAP 0 Landon, 6 days old, CLABSI
Alfred, 83, CAUTI
Yasuo, 70, CAUTI
Hung, 50, CAUTI
Edith, 64 CAUTI
Catalina, 89, CAUTI
Rosa, 59, CAUTI
Rozita, 30, CAUTI
Larry, 40, MRSA
Anthony, 79, CAUTI
Violeta, 47, CAUTI
Alfred, 72, CAUTI
Dorene, 73, MRSA Donald, 69, MRSA
Richard, 44, MRSA
Philip, 81, C diff
Susan, 59, C diff
Yasuo, 70, C diff
Theodore, 92, MRSA Barbara, 84, C diff
Ruth, 88, VRE
Jonathan, 43, C diff
Mona, 86, C diff
Edward, 87, CAUTI
Elizabeth, 80, C diff
Michele, 44, MRSA
Elizabeth, 58, C diff
Tooran, 99, C diff Vinay, 63, CLABSI Phillip, 69, C diff
Karen, 67, CLABSI
Mary, 67, C diff
Aileen, 54, C diff
James, 76, MRSA Wilton, 84, C diff
Albert, 79, C diff
Antibiotic Overuse
• “It has been recognized for several
decades that up to 50% of antimicrobial
use is inappropriate” • Given when they are not needed
• Continued when they are no longer necessary
• Given at the wrong dose
• Broad spectrum agents are used to treat very
susceptible bacteria
• The wrong antibiotic is given to treat an infection
http://www.journals.uchicago.edu/doi/pdf/10.1086/510393
IDSA/SHEA Guidelines for Antimicrobial Stewardship Programs
Antibiotics prescribed for colds
NOTES: Includes antibiotics ordered or provided solely for cold symptoms during emergency department, outpatient, and physician visits. SOURCE: CDC/NCHS, Health, United States, 2013, Figure 26. Data from the National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey: Emergency Department and Outpatient Components.
JAMA. 2009 Sep 9;302(10):1059-66.
Effect of procalcitonin-based guidelines vs
standard guidelines on antibiotic use in lower
respiratory tract infections: the ProHOSP
randomized controlled trial.
Schuetz P, Christ-Crain M, Thomann R, Falconnier
C, Wolbers M, Widmer I, Neidert S, Fricker T, Blum
C, Schild U, Regez K, Schoenenberger R, Henzen
C,Bregenzer T, Hoess C, Krause M, Bucher
HC, Zimmerli W, Mueller B; ProHOSP Study Group.
What is Procalcitonin?
• Precursor to thyroid hormone calcitonin.
• PCT levels rise rapidly in presence of bacterial infection.
• Falls quickly in response to appropriate antibiotic therapy
• Most importantly, PCT remains low in viral illness, making it a unique acute phase reactant that can potentially distinguish bacterial from viral infections
Thyroid
Brahms PCT. http://www.procalcitonin.com 2009
Study protocol for intervention
group (PCT group)
Primary outcome
OR 0.76 (95%
CI 0.57-1.01),
favoring PCT
group
Secondary outcomes
Hoag’s PCT Background
• Intensivists were using procalcitonin assay (PCT)
• Send-out test with 1-3 day turn-around time.
• Challenge: Administration resistant bringing test in-house (cost, bench space, human resources, etc)
• Chart review (n = 20) showed a theoretical reduction in antibiotic treatment duration if PCT result was real-time.
• Leadership approved in-house PCT assay with a 2 hour turn-around time.
– $45 cost per test
– Proof of cost effectiveness requested 1. Nobre V, Harbarth S. Graf J, et al. Use of procalcitonin to shorten antibiotic treatment duration in septic patients.
American Journal of Respiratory and Critical Care Medicine. 2008: 177:498 – 505.
Methods--Patients
• Inclusion: – Pneumonia (ICD-9). – Infectious Disease (ID) Consult and/or
Intensive Care Unit (ICU) Stay.
• No PCT Group – July 1, 2008 to December 31,
2008.
• PCT Group – July 1, 2010 to December 31,
2010.
Diagnosis of Pneumonia
PCT (ng/mL) Interpretation Antibiotic
Suggestion Start
Antibiotics?
< 0.1 Indicates absence
of bacterial infection.
Antibiotics strongly discouraged.
NO!
0.1 – 0.25 Bacterial infection
unlikely. Antibiotics
discouraged. No.
≥ 0.25 - < 0.5 Bacterial infection
possible. Antibiotics
encouraged. Yes.
≥ 0.5 Suggestive of the
presence of bacterial infection.
Antibiotics strongly recommended.
YES!
Brahms PCT. http://www.procalcitonin.com 2009 PCT pneumonia chart http://www.procalcitonin.com/default.aspx?tree=_3_2&key=product_ab_treatment Brahms PCT. http://procalcitonin.com/
Study Profile
84 patients evaluated for inclusion
241 patients evaluated for inclusion
No PCT Group PCT Group
175 patients not eligible Did not have Critical Care
Stay or ID Consult
34 patients not eligible Did not have Critical Care
Stay or ID Consult
116 patients included in the study
Average Antibiotic Days
N = 116 No PCT
(n = 66)
PCT
(n = 50)
p-value
Antibiotic days 11.2 ± 7.1 7.6 ± 7.6 0.004
Data are mean ± SD.
Comparison of Average Antibiotic Days Between Groups
11.2
7.6
0
2
4
6
8
10
12
14
No PCT Group PCT Group
PCT Group
Ave
rage
Ant
ibio
tic
Day
s
No PCT Group
PCT Group
Average Antibiotic Cost
N = 116 No PCT
(n = 66)
PCT
(n = 50)
p-value
Average Antibiotic Cost ($)
926 ± 881 622 ± 528 0.023
Comparison of Average Antibiotic Days Between Groups
926
622
0
100
200
300
400
500
600
700
800
900
1000
No PCT Group PCT Group
PCT Group
Ave
rage
An
tib
ioti
c D
ays
No PCT Group
PCT Group
Data are mean ± SD
91
74
52
41
27 24
9
54
42
3224
1610
4
100100
0
10
20
30
40
50
60
70
80
90
100
AB
Started
>4 >6 >8 >10 >12 >14 >21
Antibiotic Days
Pat
ien
ts o
n A
nti
bio
tics
(%
)
NP group
P group
Median antibiotic DOT was 6 days in the P group and 9 days in the
NP group (95% confidence interval [CI] 1.20 to 6.02, p = 0.004)
IMPACT OF THE USE OF PROCALCITONIN ASSAY IN HOSPITALIZED ADULT
PATIENTS WITH PNEUMONIA AT A COMMUNITY ACUTE CARE HOSPITAL
Impact of the Use of Procalcitonin Assay in Hospitalized Adult Patients with Pneumonia at a Community Acute Care Hospital; Janet L.
Kook, Stephanie R. Chao, Jennifer Le and Philip A. Robinson; Infection Control and Hospital Epidemiology, Vol. 33, No. 4, Special Topic
Issue: Antimicrobial Stewardship, April 2012, pp. 424-426
Overall Ventilator Bundle Compliance
0
10
20
30
40
50
60
70
80
90
100
Perc
en
t C
om
pli
an
ce
HOB Oral
Hygiene
Sedation
Vacation
Peptic
Ulcer
DVT
Proph.
RED = Baseline April/May BLUE = Oral Hygiene Audit June
GREEN = Bundle Re-audit September Updated
10/29/10
ICU, CCU and CVICU; April 20 to Sept 30, 2010
Hourly Oral Hygiene Compliance
0
10
20
30
40
50
60
70
80
Perc
en
t C
om
pli
an
ce
0 to 4 4 to 8 8 to12 12 to 16 16 to 20 20 to 24
Hour (0 or 24 is midnight, 12 is noon)
136 audits in ICU, CCU and CVICU; April 20 to May 3, 2010
VAP Prevention
Oral Hygiene Compliance
2010
45
6262
66
82
0
25
50
75
100
CCU/CVICU-HHNB ICU-HHNB CCU-HHI
Hospital Unit
Perc
en
t C
om
plian
ce
June
September
Overall Ventilator Bundle Compliance
0
10
20
30
40
50
60
70
80
90
100
Perc
en
t C
om
plian
ce
HOB Oral
Hygiene
Sedation
Vacation
Peptic Ulcer DVT Proph.
Updated
10/15/13
2010-2013
Red = April/May 10
Blue = June 10
Green = Sept. 10
Yellow = Jan. 11
Orange = April 11
Purple = May 12
Pink= Nov 12
Lavender = June
2013