harm with hospital acquired infections (hai): connecting the · health care‐acquired infections...
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Reducing Harm with Hospital‐Acquired Infections (HAI): Connecting the Dots
Linda R. Greene, RN, MPS, CICManager of Infection PreventionHighland Hospital Rochester, NY
Affiliate of University of Rochester Medical [email protected]
Objectives
• Discuss the impact of Hospital‐Associated Infections on Patient Outcomes
• Identify current evidence based practices for preventing HAIs
• Describe barriers to implementation of evidence based practices
• Discuss methods to overcome barriers to create a more collaborative health care environment
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Affects ~ 2 million patients
Health Care‐Acquired Infections
• Results in ~ 100,000 associated deaths
• Estimated hospital costs $30.5 billion
• More than 50% of Healthcare‐Associated Infections are attributed to medical devices
Healthcare Facility Reporting to CMS via NHSN:
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Financial Impact
Problems with HAIs
CAUTI
Quality and InfectionPrevention Team
CLABS
C DIF
VAE
Prevention Team
SSI Hand Hygiene
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What Went Wrong?
• Mr. X is a 59 year old man who was admitted to the hospital for a colon resection (diagnosis – primary colon cancer).
• He was in reasonably good health and had no other majorHe was in reasonably good health and had no other major health problems.
• He was given instructions on SSI Prevention and surgery proceeded as planned. Appropriate antibiotic therapy was given and the prophylactic antibiotic was discontinued after 1 post‐operative dose.
• He has a foley catheter inserted intra operatively• He has a foley catheter inserted intra‐operatively.
• The catheter was removed post‐operatively.
• The patient had a history of BPH and had difficulty voiding post‐op.
• On the night shift after removal of the catheter the nurse called the on call physician and obtained an order to place a
Mr. X
called the on call physician and obtained an order to place a urinary catheter.
• The urinary catheter remained in place for the next 3 days.
• On day 4 post‐operatively, Mr. X began to spike a temperature of 38.3.
• A urine culture was obtained.
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Mr. X
• Urine grew 100,000 Klebsiella pneumoniae.
Th h i i t t d th ti t i 250• The physician started the patient on cipro 250mg. Q12 hours.
• Mr. X improved and was discharged with a prescription for cipro and a follow‐up appointment with his surgeon.
The Rest of the Story
• On 4 after discharge, presented to the ED with fever, abdominal pain, diarrhea and increased WBC.
• Stool for cdif positive by EIA.
• Became septic, to OR for colon resection and to ICU post‐op.
• Expired on post‐operative day 5 from complications.
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“Connecting the Dots”
Could this happen in your hospital?
Could this have been averted?
What are your thoughts?
What “dots” didn’t we connect?
Connect the Safety Dots
Urinary T
Falls?
Urinary Catheter Harm
Immobility
Decubs?
Trauma
DiscomfortSatisfaction
Antibiotic
Resistance
DVT?
C Diff infection
CAUTIDelays,
LOS
Cost$
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Other Infections
• New VAE Definition
• Link between being ventilator deterioration and mortality
• IVAC (Ventilator deterioration, antibiotics, and increased WBC)
Ventilator Associated Event
VAC• Ventilator Associated Condition
IVAC• Infectious Ventilator Associated Condition
VAP
• Possible VAP
• Probable VAP
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VAE Surveillance Definition Algorithm Summary
Patient on mechanical ventilation > 2 days
Baseline period of stability or improvement, followed b t i d i d f i ti
• Respiratory status component
by sustained period of worsening oxygenation
Ventilator‐Associated Condition (VAC)
General evidence of infection/inflammation
Infection‐Related Ventilator‐Associated Complication (IVAC)
• Infection / inflammation component
Temperature or WBCand
New antimicrobial agent
(IVAC)
Positive results of microbiological testing
Possible or Probable VAP
• Additional evidence
Summarize the Evidence
:HAI Supported by Evidence
CAUTI Nurse Driven Removal Protocols
Insertion only for appropriate Indications
Aseptic insertion
Early removal
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Evidence
HAI Supported byEvidence
CLABSI Site PrepAvoid unecessary linesRemove when no longer indicated
C difficile Antibiotic StewardshipGlove Use
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Evidence
HAI Supported by Evidence
VAE Use non‐invasive positive VAE ppressure ventilation for selected populationsAssess readiness to extubate dailyElevate the head of the bed to 30‐45 degrees Avoid unplanned extubation
Regular oral care (i.e. toothbrushing or gauze if notoothbrushing or gauze if no teethAmbulation
Evidence
HAI Evidence Supports
Surgical Site InfectionsUse chlorhexidine gluconate alcohol in preference ofUse chlorhexidine gluconate-alcohol in preference of aqueous iodophor skin preparation, unless contraindicated.
No recommendation can be made regarding the safety and effectiveness of chlorhexidine gluconate-alcohol as compared to iodophor-alcohol skin preparation.
Maintain therapeutic levels of the prophylactic antimicrobial agent in serum and tissues throughout the operation based on individual agent pharmacokinetics
Redose intraoperatively when the procedure durationRedose intraoperatively when the procedure duration exceeds the half-life of the antimicrobial agent, when there is excessive blood loss (i.e., >1500 ml) or in cases of extensive burns
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Bringing Evidence to the Bedside
Engage
EducateEvaluate
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Execute
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Stages of Engagement
Engagement: The Frontline
• The trick to engagement is: engaging!
How are we going to hurt the next patient?
What can we do to prevent that?
• Light that fire and follow through
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Light that fire… and follow through.
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Ways to Engage Front Line Staff
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Educate
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Execute
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My Hospital
Theory of the Beehive
Communication
Visibility
Sharing
Awareness
Positive Reinforcement
• Adopting frontline ideas
• Poster displays
• Unit Safety Champion of the Month
• Prizes for ideas
• Underperformance?
– Nonpunitive approach to error
M dd h– Must address at the source:
– Attack the problem not the worker
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Mutual support is the essence of teamwork. P t t t f k l d dProtects team from work overload and situations that reduce effectiveness and increase risk of error.
“I’ve got your back”
Your protocol will be GPS for most situations. Great help but you
Standardization
“The bridge has been out
Great help… but you WANT deviation sometimes. e.g. …
6 months… some of these drivers follow their GPS directions to a fault”
Autoblog.com
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Huddle
Quick problem solving meetings held h diti hwhenever conditions change
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What happened? (brief description)
Why did it happen? (what factors contributed)
+What prevented it from being worse?
-What happened to cause the defect?
What can e do to red ce the risk of it happening ith a different person?What can we do to reduce the risk of it happening with a different person?
Action Plan Responsible Person
Targeted Date
Evaluation Plan –How will we know risk is reduced?
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With whom shall we share our learning? (Communication plan)
Who When How Follow up
Evaluation
• Feedback is essential
• Feedback in the moment when possible
• The role of audits
• Data drives performance
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Level of InterventionLevel of Intervention
High
• Forced Function
• Automation
Medium
• Protocols
• Check lists
• Rules
• Education
Low
• Education
• Be more careful
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Measurement
http://www.cdc.gov/NHSN
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Strategies: “Connect the Dots”
• Help Everyone d d h
Story Telling –
understand their role in patient care
• Safety through optimizing their
1 mo
Monthswithouta C DIF
6 moNames and Faces
optimizing their practices
Feedback
• Timely
• Respectful
• Specific
• Directed toward improvement
• Considerate
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SBAR
• Situation‐What is going on with the patient?
• Background‐What is the clinical background?
• Assessment‐What do I think the problem is?
• Recommendation‐What would I recommend?
What is a Positive Deviant?
• Individual(s) who exhibits unique and uncommon problem solving behaviors for problems that existproblem solving behaviors for problems that exist throughout an organization:
– Solutions achieved with similar resources to others in the organization
– Can potentially guide problem solving within the i ti id tifi dorganization once identified
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Traditional Top‐Down Problem Solving
Decision
• A few people make decisions for the many
Consequences
• Engagement & Empowerment
• Resistance to change
Result• No change, wasted money, wasted time
Implementation Tools –Liberating Structures
• Used for data collection/idea generation
• Minimal structure so that ideas are liberated and creativity is encouraged
• Increases engagement & diversity of input, forming new social connections
• Group develops skills to guide themselves
L d d / l i• Leads to unexpected outcomes/solutions
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TRIZ
• “Teoriya Resheniya Izobretatelskikh Zadatch” or The Theory of Inventive Problem Solving
• Usually one of the first techniques used
– Quick, idea‐generating, fun
• Designs adverse system by asking questions
– Ex. “How would you give every patient C. diff?”
– Answers guide discussion about how to eliminatethe adverse system
1‐2‐4‐All
• Individual reflection Share with 1 Pair shares with 2 Whole group discussion
R i th t ib ti f ll b• Recognizes the contributions of all group members in a non‐threatening way
– Good for diverse groups
– Encourages sharing outside comfort zones
– Helps identify similarities/differencesHelps identify similarities/differences in problem solving among group members
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Social Network Mapping
• Simple, minimal time commitment
• Provides visual cues about who is part of current team and who is left out
• Should change andShould change and expand over time
DADS Example
1. How do you know someone has an infection?
2. What do you do to prevent infection spread?
3. What prevents you from doing this every time?
4. Who does a better job?
5. Any ideas about what to do next?
6 A l t ?6. Any volunteers?
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Measurement
Measure Type Source
• Shows progress• Encourages friendly competition
yp
% Appropriate hand hygiene Process Direct observation; Alcohol Based Hand Rub (ABHR) Volume
% Appropriate environmental cleaning
Process Direct observation; Adenosine triphosphate bioluminescence; UV markers
% Appropriate cleaning of shared patient equipment
Process Direct observation
Healthcare Facility‐Onset C. difficile Incidence
Outcome NHSN
HA MRSA incidence by unit Outcome Infection prevention data; NHSN
What Does This Look Like in Real Life?
• Problem: HA MRSA rates increasing in the Veterans Health Administration’s Hospitals in Pittsburgh
• Background: Tried behavioral change that improved organizational efficiency but:- Was resource/personnel intensive- Reliance on team leaders, little staff empowerment- Not sustainable
• Aim: Reduce HA MRSA in 2 VA facilities by increasing adherence to prevention protocols and rates of swabbing for MRSA colonization on admission
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What Did They Do?
• Appointed a nurse leader as MRSA coordinator
• Held DADs with multiple disciplines
• Formed a multidisciplinary MRSA team
• Engaged high burden unit & shared data
• Initiated weekly MRSA meetings with “decision makers” present
• Performed mini root cause analyses• Performed mini‐root cause analyses
• Continuous data feedback
Did it Work?
• 50% decrease in MRSA SSI rates & ~10% decrease in overall MRSA rates over 15 months
• Spread to other units emergency room andSpread to other units, emergency room, and outpatient settings
• Changed culture:
“We held a lot of floor‐wide events, and I made sure everyone was invited—doctors, nurses, patients and even staff from the environmental (housekeeping) unit ”staff from the environmental (housekeeping) unit.
Weekly MRSA meeting led by housekeeping
Nurses email MRSA Coordinator with ideas
Singhal A and Greiner K. 2007. ‘When the Task is Accomplished, Can We Say We Did It Ourselves?’ A Quest to Eliminate MRSA at the Veterans Health Administration’s Hospitals in Pittsburgh
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