Preventionofhealthcareassociatedinfectionandofantimicrobialresistance:anewmanagementapproach

José Artur PaivaMedicalDirector - CentroHospitalarSãoJoãoFaculty of Medicine– University of Porto

Infection and Sepsis I&DGroupSTOPInfeçãoHospitalarMonitoring Committee – FundaçãoCalousteGulbenkian

Porto- Portugal

Deathsattributabletoantimicrobialresistanceeveryyear,by2050

In 2014, in the EU,AMR is

responsible for 25 000 deaths and > EUR 1.5 billion of

healthcare costs and

productivity losses

annually

By2050,itcouldresultinareductionoftheEuropeanGDPby1%to4.5%

Antimicrobial consumption and antimicrobial resistance

EUandWHO“OneHealth”approach

Theagendatodecreaseantibioticuseincludes:n preventinginfectionsandtheirspreadn improvingmonitoringandsurveillancen avoidingunnecessaryuseofantibiotics:usingthemonlywhenneeded,forthe

lesstimepossibleandwiththeleastpossiblespectrumn developingresearchandinnovationtowardsneweffectiveantibioticsn developingnewwaystotackleinfectionwithoutharmingbacteria

Givenitsseverity,AMRisapoliticalhighprioritywithintheEUandalsofortheWHO,thatareusingthe"OneHealth"approach,whichrecognizesthatthehealthofpeople,animalsandtheenvironmentareinextricablylinkedandthatantibioticsareusedinhumanmedicine,veterinaryandagriculture.

CounciloftheEU.CouncilRecommendationof15November2001(2002/77/EC).OfficialJournaloftheEuropeanCommunities.2002(45):13-6.

HAIprevalence Antibioticconsumption

Portugal EU Portugal EU

Homem 12,4% 7,2% 48,3% 39,2%

Mulher 8,8% 5,4% 42,3% 33,2%

PopulaçãoGlobal 10,5% 6,1% 45,3% 35,8%

ECDC Point Prevalence Study PPCIRA/DGS, ECDC 2012

Portugal2011-2012:HighprevalenceofHAIandhighhospitalantibioticconsumption

2012: High ambulatory antibiotic consumption, and

very high quinolone consumption

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ESAC Net 2012, ECDC

Global consumption in DDD Quinolone consumption in DDD

Highhospitalconsumptionofcarbapenems,2010-2012

“In2012,consumptionofcarbapenemsvariedbyafactorof14,from0.01(Bulgaria)to0.14DDDper1000inhabitantsandperday(Portugal)“

“Theproportionofconsumptionofcarbapenemsoutofantibacterialsforsystemicuserangedfrom0.8%(Latvia)to9.8%(Portugal)withanEU/EEApopulation-weightedmeanof2.9%.”

2010

Carbapenems

ESAC Net 2012, ECDC

8

HighindexofantimicrobialresistanceFromPPS2011-2012,ECDC

ESKAPE

MortalityassociatedwithHCAIversusthatassociatedwithroadtrafficaccidents

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

2010 2011 2012 2013

Roadtrafficaccidents Infections

ANSR e PPCIRA/DGS

Estimated costs of 300 million euros

per year associated with HCAI

WeaknessesandthreatsofICfightinPortugal:early2013report

n Understaffing and underpowerment of the centralandperipheral ICstructures

n Low level of integration and synergy of the several processes;noholistic vision;toomany process leaders

n Low strategic sustainability;Absence of focus inthe mostrelevant issues;low involvement of the citizen

n Problems of datasharing among state institutions and of datafeedbacktothe providers;low reliability of indicators

n Difficulties inimplementing acollaborative model, increasingcapacity building and maximizing participation andtransparency

n Reimbursement system not reflecting the indicators and targetsand not boosting motivation

PaivaJAetal.PPCIRAlaunchingreport,feb.2013.DGH

NATIONALPROGRAMONPREVENTIONOFINFECTIONANDOFANTIMICROBIALRESISTANCE(PPCIRA)

NATIONALPROGRAMON

INFECTIONCONTROL

NATIONALPROGRAMONPREVENTIONOFANTIMICROBIALRESISTANCE

+

8Fev.2013

1999 2008

PPCIRA:ANationalPriorityProgram

ReduceHCAI Reduceantibioticconsumption

Reducetheemergenceofantibioticresistance

Evictionofantibioticuseintheabsenceofbacterial

infection

ReducetransmissionofMDRmicrorganisms

Reductionofantibioticdurationandspectrum

ReducetheincidenceofMDRmicrorganisms

EPIDEMIOLOGICALSURVEILLANCE

TacklingAMRbyreducingantibioticconsumption

TacklingAMRbyreducingantibioticconsumption,bylaunching:

(a) a Joint Alliance in the spirit of One Health to commit different stakeholders that agreed on a ten-point memorandum;

(b) an Antibiotic Awareness Campaign for the citizen;

(c) a national Antimicrobial Stewardship (AMS) programme.

(b)TheCitizen’sAntibioticAwarenessCampaign

n Itwasanationalcampaign,involvingprimarycarecenters,hospitals,schoolsandbigeventsarenasin2011-2012.

n Globalslogan“Moreantibiotics,lesshealth”.n Verysimplekeymessages,namely“donotself-medicatewith

antibiotics”,“unusedantibioticsshouldbereturnedtothepharmacy”and“donottreatcoldswithantibiotics”.

n 5millionflyersand10000posters;200billboardsandpublictransportsignswereplacardedinthe3mainportuguese cities;adailyTVspotwaspresentedfor30days.

n Attheendofthecampaign,atotalof226insertions/newswereissuedinthemedia,includingTV,radio,pressandinternet.

n Thecampaignwasrepeated,atasmallerscale,twoyearslater,inthewinter2013-14.

(c)TheAntimicrobialStewardshipProgrammen Anation-wideprogramme,locallycustomized,usingrestrictivebut

mainlypersuasive/enablementtechniques,ledbyalocalexpertteamn Focused onsurgicalantibioticprophylaxis,ononehand,andon

quinolones andcarbapenems therapies,ontheotherhand.n Targetswereclearlydefined:10%reductionforquinolonesand5%for

carbapenems,withconcomitantnon-riseofglobalantibioticuse.n Nationalguidelineswere issuedfortheuseofantibioticsinsurgical

prophylaxisandondurationofantibiotictherapy(focusingontonotmorethan7days,exceptforasmallgroupofinfectiousdiseases).

n AtwodayeducationalcoursewasperformedbytheHeadoftheNationalProgramme ineachofthesevenhealthregions,discussingandteachingreasonsforquinolones andcarbapenems useandstrategiesforlimitingitsusetocasesinwhichtheyarereallynecessary.

n Asagoal,allprescriptionsofthesetwoclassesofantibioticsshouldbechecked,discussedwiththebedsidemedicalteamandeventuallyvalidatedbytheAMSteaminthefirst96hoursafterprescription.

AMS:Howtouseit?

DeWaeleJetal,ICM2016

Think global,act localPatrick Geddes

Geddes believed in working with the environment, versus working against it

AMSteam

Clinical Pathology

Service A

Service E

Service D

Service C

Service B

Medical Direction- Definition of aims, goals and targets- Empowerment- Macro changes

Mainqualitygapsinantibioticstrategy

Presentation

History,physicalexamand

microbiologicalsamples

Antibiotic

Clinical evolutionand furtherculture andsusceptibilityresults andbiomarkers

48-72hours

Stop

Shorten

Narrow

RescueAntibioticchange

Incorrectempiricaltreatment:- 40% ofpatientswithBSI,- 50% ofthosewithHCABSI,- 70% ofthosewithfungemia

Wrong selection of patients that need antibiotic therapy

longtimetodirectedantibiotictherapy

ConsumptionofantibioticsinPortugalindefineddailydoses(DDD)per1000habitantsperdayYear Global

communityconsumptionofantibiotics#

Communityconsumptionofquinolones

Globalhospital

consumptionofantibiotics

Hospitalconsumption

ofcabapenems

Hospitalconsumption

ofquinolones

2011 23,72 2,91 1,73 0,139 0,222012 23,04 2,61 1,67 0,142 0,182013 19,04 2,18 1,64 0,146 0,182014 20,32 2,12 1,55 0,139 0,172015 21,30 2,05 1,57 0,133 0,152016 ? ? ? ? ?

#From2013on,thedatareferstosellingfiguresandnot,asuntilthen,tostockingfigures30%

By the end of 2015:n 78% ofPortuguesehospitalshadimplementedAMSteamandprocessn Theprocessextendedtoprimarycarecenters:11% ofthemhadAMSn Theeducationalcourseonadequateantibioticusewasreplicatedinsideeach

ofthehealthregions,bysteeringlocalgroups

10% 9% 4% 32%

ReduceHCAI Reduceantibioticconsumption

Reducetheemergenceofantibioticresistance

Evictionofantibioticuseintheabsenceofbacterial

infection

ReducetransmissionofMDRmicrorganisms

Reductionofantibioticdurationandspectrum

ReducetheincidenceofMDRmicrorganisms

EPIDEMIOLOGICALSURVEILLANCE

NATIONALANTIMICROBIALSTEWARDSHIPPROGRAMSTANDARD

PRECAUTIONSNATIONALCAMPAIGN

JOINTALLIANCE

ANTIBIOTICAWARENESSCAMPAIGN

Until 2014, no significative reduction in HCAI

PPCIRA/DGS (HELICS & INCS)

Staph aureus

hospital acq bacteremia(per 1 000

patient days)

MRSA hospital acquired

bacteremia(per 1 000

patient days)

ICU Catheter related

infection(per 1 000

cateter days)

Ventilator associated pneumonia(per 1 000 intubation

days)

Catheter related

sepsis in neonatal ICU

(per 1 000 cateter days)

2008 2,1 11,2 10,082009 2,2 10,6 11,342010 1,4 8,7 11,292011 1,5 8,6 13,402012 0,27 0,17 1,0 8,7 11,462013 0,27 0,16 1,3 7,4 9,132014 0,27 0,15 1,9 7,1

n The Gulbenkian Foundation invited the Institute for Healthcare Improvement (IHI) to become a program partner, due to its expertise in running large-scale collaborative improvement projects and its persistent focus on execution, measurement and results.

n In liaison with the National PPCIRA

n Aim: to reduce HAI by 50%, for a group of 12 selected Portugal NHS centers (19 hospitals) over a period of three years.

n Represented 25% to 30% of all inpatient episodes in Portuguese NHS hospitals

n The work commenced in late 2015, under the name of STOP Infeçao Hospitalar

Oursharednorth:toreduceHAIby50%

TheSTOPInfeçãoHospitalarProject

AGulbenkianFoundationProject

Fourworkstreamsandfourhospitalsites

TheStopinfeção hospitalar isfocusedonfourmaintypesofHAI:

n Catheter-AssociatedUrinaryTractInfection(CAUTI);

n Centralline-associated bloodstreaminfection(CLA BSI);

n SurgicalSiteInfection(SSI),namelyHipandKnee replacement,Colon-recto andGallbladder;

n Ventilator-associatedpneumonia(VAP).

Thepilot-sites/departmentsinclude:• General Wards (CAUTI and

CLA BSI), • Intensive care units (CLA BSI

and VAP), • Orthopedic (SSI related to hip

and knee replacement) • General Surgery

(SSI related to colon-rectum and gallbladder)

Multidisciplinaryfrontlineteamsarebeingsupportedtodesign,testandimplementimprovedwork

processesdesignedtodeliversaferandmorereliablecaretothepatients.

KeyelementsoftheSTOPprogramn anevidencebasedchangepackage

(e.g.bundlesforinsertionandmaintenanceofurinarycatheterandcentrallinecatheters,VAPpreventionandSSIprevention);

n arobustmeasurementanddatacollectionsystem(process,outcomeandbalancingmeasures);

n astrategyforbuildingcapacity(creationofasustainableinfra-structureforhealthcareimprovement,putinplacefirstatthe19participatinghospitalsandlaterspreadtootherhospitalsthroughoutthecountry);

n anevaluationplantomeasurethesuccessoftheQIinitiativeandtoidentifyareasforimprovementalongwithadisseminationplantopublishandsharepracticesandresultsachieved.

n Leadershipcommitment - apre-requisiteforparticipation

SchematicRepresentationoftheBreakthroughSeriesCollaborativeSTOPInfeçãoHospitalar!

Themodelforimprovementn A large number of teams from hospitals or

clinics seeking improvement in a focused area come together under a working environment where all members learn and all members teach.

n Teams are taught improvement methodology including The Model for Improvement.

n Interventions include participation at learning sessions, educational interventions and discussion of activities and progress at coaching conversations by telephone, webexcalls and face-to-face meetings.

• to build a learning community and system that is capable of future ongoing sustainable improvement

• to build improvement capability and improve organization cultures over time.

DynamicMeasurementisakeyactivity

n Measurement and monitoring of the targetof change is akey activityn Statistical process control maps variations over time,combining

statistical significance tests with chronological analysis of graphs ofsummary data

n Annotating timingof interventions and showing targetand controllimits

n Measuring process complianceand outcome improvement

n Constant feedbacktoprovidersat service level

n Themonthlycollectionandanalysisofdataallowsrealtimelearningandimprovement Accelerate

Real-WorldEvidence

DeriveEvidencefromEachCareExperience

ElectronicHealthRecordembeddedinitiatives

QualityBetter Worse

Action taken on all

occurrences

QualityImprovementthroughbreakthroughcollaborative

Alearningorganization,alearningcomunity

• ALLTEACH,ALLLEARN• Transparency• DistributedLeadership

Bestpracticesareharvestedandsharedthroughthecollaborativelearningsystem,boththroughthe

websiteandwebex callsandface-to-facemeetings

High-ImpactLeadershipBehaviorsWhatleadersdotomakeadifference

Swensen,Pugh,McMullan,Kabcenell.High-ImpactLeadership:ImproveCare,ImprovetheHealthofPopulations&ReduceCosts.InstituteforHealthcareImprovement;2013.Available:www.ihi.org.

MANAGEMENT

QUALITY IMPROVEMENT

CREATING A MOVEMENT

Results

Time

From holding to handing power

Holding power

Handing power

Sharing power

What’s the Matter?

What matters to you?

WehaveaproblemwithHCAIandantibioticuse

WearetryingtoreduceHCAIandempiricalantibiotictherapy

AMSandSTOPteamsareintheservicedoingit

Wearetreatingonlythosethatclearlyhavebacterialinfectionandonlyaftercollectingmicroexams:AMSandSTOPteamsarehelping

TheMentalShiftattheServicelevel

ResultsafterSTOPInfeçãoHospitalar,inseptember2017

Catheter Related Infection Prevention –compliance with insertion budle

Catheter Related Infection Prevention –compliance with maintenance budle

Reduction of 61%

Catheter related infection –All 19 hospitals

Compliance with the VAP prevention bundle

Reduction of 51%

VAP – All 19 hospitals

SSI in hip and knee replacement–compliance with SSI prevention bundle

Reduction of 78%

SSI in hip and knee replacement–All 19 hospitals

SSI in general surgery–compliance with the bundle

Reduction of 65%

SSI in general surgery– All 19 hospitals

CAUTI prevention-compliance with insertion bundle

CAUTI prevention-compliance with maintenance bundle

Reduction of 35%

CAUTI – All 19 hospitals

Scaleandspreadn TheQIinitiativeSTOPHAIwillsystematicallyworktospreadthe

knowledgeregardingsafetyinterventionsthathavealreadybeentestedandimplementedonprototypeunitsineachparticipatinghospital– “scalableunits”- andthathaveachievedbothreliabilityinprocessesandchangeinoutcomes.

n Overtime,theambitionofSTOPHAIisthatitsresultswillinfluencedepartment/hospital/healthpoliciesandotherhealthcareinstitutionsthroughoutPortugal,whowilllearnfromtheinitiativeandbe“contaminated”byitsunderling methodology,practicesand“philosophy”.

SousaP,PaivaJA.ReducingHospital-AcquiredInfectioninPortugueseHospitals:ACollaborativeApproachtowardQualityImprovement.InHealthSystemsImprovementAcrosstheGlobe:SuccessStoriesfrom60Countries.Editedby JeffreyBraithwaite, etal.2017.CRCPress2017

PPCIRAQuality IndexLaw March 2016

n Constantdynamicofqualityimprovement,followedbyqualitycontrol

n Qualityimprovementinitiativesn Changepackage(bundlesandestablishmentofcleartargets)n Iterative,incrementalPDSAcycles,usingeducationaland

behavioralinterventionsn Capacitybuildingn Datacollectionsystemn Dynamicandfeedbackedmeasurementn Highimpactleadershipcommitmentn Progressiveculturalchange

Infectionandantibioticresistanceprevention:Qualityimprovementcyclescanhelp

PPCIRA+STOPInfeçãoHospitalar

It´shappeninginPortugalwithsuccess