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Primum non nocere (Latin : First Do No Harm)

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Crisis in Healthcare Associated infectionsCalfee DP. Annul Rev Med 2012; 63: 9.1 – 9.13

posted online on October 13,2011

In USA > 1.7 million HAI occur every year

= 5% of all persons admitted (CDC 2002 data)

Prolonged duration of hospitalization

Greater morbidity

Increased risk of death

98,000 death (top ten causes of death)

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Deaths in USA due to HAI areEquivalent to ONE Fully loaded Jumbo jet

crashing every day of the year

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Hospital Associated Infections

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Preventable Infections and costs of getting it wrong

Target ZEROHealthcare Associated Infections

Zero tolerance for preventable healthcare associated infections &

inappropriate practices

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Qs 1. Is the patient colonized or infected with indicator bacteria ?

At time of admission:

Culture Nose, Axilla & Groin for MRSA

Culture stool / rectal swab for Carbapenemase producing enterobacteria (CRE)

If yes (TAT 24 hours):

Institute contract precautions

OR: Consider ALL pts to be infected & institute contact precautions till cultures reported as Negative for MRSA &/or CRE

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Qs. 2 Is patient acquiring indicator bacteria from the environment ?

Environment: A. Frequent touch areas

B. Floors, walls, toilet etc

Need to be cleaned regularly, aim for food processing unit quality of environment

Microbiology monitoring of environment, air, HCW hands etc would be intensive to document compliance

If indictor bacteria (MRSA, CRE, MDR P aeruginosa, MDR Acinetobacter spp isolated)

Review cleaning practices & institute corrective measures

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Qs 3. Standard of care in Infection prevention100 % compliance with bundles

Bundles will be operational for Infection Prevention:

CVC (I & M) & PVC (I & M),

CAUTI (I & M),

VAP, SSI

MRSA,

Hand Hygiene,

Clostridium difficile

Immediate feedback on compliance to operator, weekly feedback to chairman

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Qs. 4. If infection occurs

Rapid diagnosis of infection (Multiplex PCR, PCT etc)

Antibiotic care bundle

Review of all results after 72 hours & de escalation (if required)

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Qs. 5. Did the patient acquire indicator bacteria during his stay at Medanta ?

One day before discharge, culture Nose for MRSA & stool / RS for CRE

If positive: Indicates breach of Infection Prevention practices

Root cause analysis & corrective action

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Bundles: do they work ?

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Berenholtz SM, Pronovost PJ, Lipset PA, et al. Eliminating catheter related bloodstream infection in the intensive care unit. Critical Care Medicine. 2004; 32:2014-2020

Al-Tewfiq JA & Abed MS:Decreasing VAP in adults ICU using Institute forHealthcare Improvement Bundle.Am J Infect Control 2010;38:552-6

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A cause and effect chart describes all the elements of a system under 4 main headings:

Environment,

Equipment,

People,

Methods

How are Bundle elements developed ?

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The Goal

Environment Equipment

People Methods

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Central Line Bundle Elements

1. Hand hygiene

2. Maximal barrier precautions

3. Chlorhexidine skin antisepsis

4. Optimal catheter site selection, with avoidance of using the femoral vein for central venous access in adult patients

5. Daily review of line necessity with prompt removal of unnecessary lines

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1.Hand Hygiene

Wash hands if they are obviously soiled

Wash hands or use an alcohol based waterless hand cleaner

5 moments for hand washing

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Monitoring & Feedback on compliance is essentialIn Quality parlance: If it is not documented, it is not done

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2. What Are Maximal Barrier Precautions?

For Provider & Assistants:

Hand hygiene

Non-sterile cap and mask

All hair should be under cap

Mask should cover nose and mouth tightly

Sterile gown and gloves

For the Patient:

Cover patient’s head and body with a large sterile drape (use more than one if needed for large patients)

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3. Chlorhexidine Skin Antisepsis

Prepare skin with antiseptic/detergent Chlorhexidine 2% in 70% isopropyl alcohol.

Apply chlorhexidine solution using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot.

Allow antiseptic solution time to dry completely before puncturing the site ( ~ 2 minutes).

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4. Optimal Site Selection

Femoral site: greatest risk of infection, especially in overweight patients

Subclavian site: lower risk of CLABSI than the internal jugular veinPreferred when infection is only consideration

Higher risk of mechanical complications

Physicians must weigh risk-benefit of site selection for individual patientBundle compliance met if documented

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5. Daily Assessment

Goal: reduce line days

Include daily review of line necessity in multidisciplinary rounds

Remove promptly when no longer needed

Define appropriate timeframe for review when applied to central lines intended for long term use

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Key Change: Central Line Checklist

Have the nurse document compliance with the insertion criteria at the time of insertion.

Create a culture of safety and prevention:

empower nurses to stop line placement if improper techniques are used

Instruct nurses in use of critical communication strategies to facilitate important exchanges.

e.g. “the sterile field has been contaminated,” rather than “You contaminated the catheter!”

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Checklist Elements

Before the procedure, did they:

Wash hands?

Sterilize procedure site?

Drape entire patient in a sterile fashion?

During the procedure, did they:

Use sterile gloves, mask and sterile gown?

Maintain a sterile field?

Verify: did all personnel assisting with procedure

follow the above precautions?

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Tips for Success

STOP the lineempower nurses to stop line placement if improper

techniques are used

Leadership support & culture

Evidence

Standard equipments packs

Clinical appropriateness

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Measure: CLABSI per 1000 Line Days

Central line-associated BSI rate per 1000

central line-days:

Numerator: Number of central line-associated BSI

x 1000.

Denominator: Number of central line-days (total number of days of exposure to central venous catheters by all patients in the selected population during the selected time period).

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Measure: Central Line Bundle Compliance

Central line bundle elements in place:

Numerator: Number of patients with central line bundle in place.

Denominator: Total number of pts on central lines per day of week of prevalence sample.

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Does it Work?

ICUs that have implemented multifaceted interventions

similar to the central-line bundle have nearly eliminated

CLABSIs.

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SEVEN steps in successful bundle implementation

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Step 1 - Commitment

The first step is for the team leader to get everyone to commit to doing the bundle to improve patient safety.

RememberPatient safety is for life – not just for this Dewali !

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Medanta Medicity Gurgaon

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Step 2 - Understand there will be consequences

The team must consider that they will find out things they did not want to know, e.g. your team is not perfect!

Consider how you will deal with this before you startCommit to feedback being for improvement and not judgement

Acknowledge that where you are, is not where you want to be, and this process will help you improve

Commit to not shooting the messenger, i.e. the one collecting the data!

Commit to a no blame culture

Remember you are doing this for optimal patient safety and to show the quality of your care – not to damage your care team

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Step 3 - Work out the process that fits in with your systems of working

How often do you want to measure compliance (at least once a week)?

Who will collect the data?When will they collect the data?Where will they put the completed sheets?Where will you display your results?What will you do with the results – how will you act on

them?Is everyone agreed on the process?

The data must be collected on the

same day and at the same time!

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Step 4 – Start small

Remember the PDSA methodology One patient, one nurse, one doctor one dayThe next time three patients, The next time five patientsThe next time all

Don’t expect to get it right first time, but it will help if you DO

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Step - 5 When you are all agreed that it works on five get ready to implement it ward wide

Pick a start date

Make sure everyone knows

Have the bundle data collection forms ready

BEGIN

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Potential Impact of central line bundleBerenholtz SM et al. Critical Care Medicine 2004; 32: 2014 - 220

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Step 6 Continuously assess progress

What are we trying to accomplish?

How will we know that change is improvement?

What changes can we make that will result in improvement?

Act Plan

Study Do

No skin and soft tissue infections due to CVC

There will be 100% compliance with the bundle

There will be no skin or soft tissue infections due to CVCs

Don’t use CVCs unless absolutely necessary.

Remove CVCs as soon as possible

Don’t use a CVC – just in case

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Step 7 – If it’s going well & you have improved processes & reduce the risk of CLABSI – try another bundle

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Bundles available & ready for deployment

Central venous catheter: Insertion & maintenance

Urinary tract catheter: insertion & maintenance

VAP

Surgical site

Hand washing

MRSA

Clostridium difficile

Sepsis

Antibiotic use

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TARGET ZEROHealthcare associated Infections

Zero Tolerance for Preventable Healthcare Associated Infections &Inappropriate practices