Transcript Closing the Quality Gap: What role surveillance

Closing the Quality Gap:
What role surveillance ?
Andrew Longmate
Kirsty Ellis
Stirling Royal Infirmary
SICS Annual Audit Meeting
November 2007
Surveillance
Supervise, closely observe, watch or guard over a
person, especially a criminal or prisoner
A dynamic process of gathering, managing,
analyzing and reporting data on events that
occur in a specific population
The act of systematically collecting, tabulating
analysing and disseminating data on the
occurrence of nosocomial infections.
Consuming the results for
improvement
Surveillance is not complete until the
results are disseminated to those who
use it to prevent and control
Partner stakeholders to implement
effective prevention strategies (CDC)
One Unit’s History
• Before 2004 we did not measure incidence
of HAI in our ITU.
• Anecdotally seemed high
• We performed a pilot for 4 months which
quantified rates for VAP 45%(40 /1000vd),
CrBSI 17%(16/1000pd) and MRSA
acquisition (10%).
• All seemed quite high.
What gets measured gets
controlled
• Local Surveillance Quality Improvement
programme for 2 years
• HELICS participation
• Dedicated nurse, Consultant Lead
• Multimodal Interventions for QI
• Basic infection control practices including
hand hygiene , engagement, feedback
education, behaviour change, local root
cause analysis, iterative problem solving.
Surveillance may be……….
Concurrent
• Flexible
• Informative
• Timely
• Capable of cluster
detection
• Capable of changing
behaviour
• Expensive
Active
• Accurate
• Complete
• Expensive
Retrospective
• Depends on
completeness, validity
and accuracy of existing
data
• Does not identify
problems as promptly as
concurrent does
• But isn’t expensive
Passive
• Misclassification
• Underreporting
• Lack of timeliness
• Less expensive
6 monthly ICU acquired Meticillin Related Staphylococcus Aureus
# colonisation
and infection
#
(per 1000 at risk patient days)
25
per 1000 at risk patient days
20
15
10
5
0
Sept 05 Feb 06
Mar Aug
Sept Feb 07
Mar Aug
800
2004
2005-6
2006-7
g chart
M R SA at risk pat ient
days bet ween acquisit ion
10%
7.2%
3.3%
700
outbreak 9-13
Cepeda 10-12%
91% with patient
sources in ward
HH compliance 21%
600
500
400
300
200
100
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
Hawthorne Effect
Change in behaviour or performance
(usually improvement)
New or increased attention (or change in
environment) “the feeling or awareness of
being studied or subject to an intervention”
Temporary and short lived - gradual return to
baseline
Independent of the manipulation or
intervention
Purposes of surveillance
1.
2.
•
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To reduce the risks and rate of HAI
To reduce morbidity and mortality
Establishing baseline rates
Identifying outbreaks
Convincing medical staff
Satisfying regulators
Defending malpractice claims
To reduce the costs to the patients, the
hospital and the healthcare system
To compare infection rates among hospitals
SENIC (Study on Efficacy of Nosocomial Infection Control)
Haley RW, Culver DH, White JW et al Am J Epidemiol 1985; 121(2):
182-205
The efficacy of infection surveillance and control programs in
preventing nosocomial infections in US hospitals.
• Retrospectively surveyed 169,526 admissions in 338 hospitals
between April 1975 and March 1976. Randomly sampled medical
records from 500 patients admitted in the 12 month study period.
• 30% reduction UTIs, Surgical Wound Infections, Pneumonia,
Bacteraemias
• if their infection surveillance and control programme included 4
components:
• appropriate emphasis on surveillance activities and vigorous control
efforts,
• at least one full time ICN per 250 beds,
• a trained hospital epidemiologist
• feedback of wound infection rates to surgeons.
Effectiveness of a nationwide nosocomial infection surveillance system
for reducing nosocomial infections. Gastmeier P, Geffers C, Brandt C et
al J Hosp Infect. 2006 Sept;64(1): 16-22
• Participation in KISS was associated with
a significant reduction in 3 Nosocomial
Infections.
• Relative risk for VAP 0.71 (CI 0.66-0.76)
• Relative risk for CRBSI 0.8 (CI 0.72-0.90)
Opinion
• WHO 1981 advisory group to consider surveillance control and
prevention of HAI.Recommended prevalence surveys. Stressed that
they did not directly point to the causes of the diseases that they
record.
• CDC/NNIS
• HELICs 1994: The creation of a database intended for the
comparative analysis and reduction in the rates of hospital acquired
infections in the 15 countries.
• ATS Guidelines 2005 for the HAP, VAP and HCAP.
Surveillance of ICU infections to identify and quantify endemic and
new MDR pathogens, and preparation of timely data for infection
control and to guide appropriate, antimicrobial therapy in patients
with suspected HAP or other nosocomial infections are
recommended (level II). (moderately well designed controlled trials
without randomisation).
The Scottish Executive
•
2002 SEHD (Scottish Executive Health Department) recommended that
surveillance of healthcare associated infection, be piloted in ICUs,
demonstrated that data collection from 5 sites was possible and concluded
that it should be expanded.
•
2006 (NHS HDL (2006) 38)- A revised Framework for National Surveillance
of HealthCare Associated Infection in Scotland - all infection control teams
should also target local HAI surveillance to locally identified priority areas.
Boards are encouraged to implement as many voluntary list surveillance
topics as possible, and a minimum of two in addition to compulsory
elements.
An integrated and validated system of surveillance is vital for informing local
and national interventions and strategic development, and in ensuring the
earliest possible ascertainment and characterisation of new and reemerging hazards.
•
2007 IHI National Patient Safety Alliance
HELICS DEFINITION of
CRI (central venous catheter-related infection)
CRI 1
Local CVC-related infection (no positive blood culture)
quantitative CVC culture  103 CFU/ml (3) or semi-quantitative CVC culture > 15 CFU (4)
and
pus/inflammation at the insertion site or tunnel
CRI 2
General CVC-related infection (no positive blood culture)
quantitative CVC culture  103 CFU/ml or semi-quantitative CVC culture > 15 CFU
and
clinical signs improve within 48 hours after catheter removal
CRI 3 CVC-related BSI
BSI occurring 48 hours before or after catheter removal
and positive culture with the same micro-organism of either:
semi-quantitative CVC culture > 15 CFU or quantitative CVC culture  103 CFU/ml or quantitive blood
culture ratio CVC blood sample/peripheral blood sample> 5(5)
differential delay of positivity of blood cultures (6): CVC blood sample culture positive 2 hours or less
before peripheral blood culture (blood samples drawn at the same time)
positive culture with the same micro-organism from pus from insertion site
$ excluding CRBSI
6 monthly ICU acquired CRI 1 and 2
$
(per 1000 Central Venous Catheter days)
18
16
14
per 1000 CVC days
12
10
8
6
4
2
0
Sept 05 Feb 06
Mar Aug
Sept Feb 07
Mar Aug
6 monthly ICU acquired CRI 3 (CRBSI)
(per 1000 Central Venous Catheter days)
?
6
5
per 1000 CVC days
4
3
2
1
0
Sept 05 Feb 06
Mar Aug
Sept Feb 07
Mar Aug
UCL
CRBSI U chart
09/05 - 08/07
0.02
LCL
Process Avg
UWL
LWL
0.018
0.016
0.014
Proportion
0.012
0.01
0.008
0.006
0.004
0.002
0
Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug
Quality Improvement in the NHS
• Bridging the gap between best evidence
and effective implementation in our
hospitals
• Identifying and overcoming barriers to
change
• Not just us but everyone – only as strong
as the weakest link
Change/Quality Improvement
Key Concepts for Sustainability for QI (Wall)
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Leadership Support
Interdisciplinary Teams
Standardise and Simplify work
Embed Measurement in Daily Work
Transparency and Avoidance of Blame
Real Time Process Measurement
Continuous Audit and Feedback
Systems approach
Structure, Process and Outcome
.
Wall RJ, Ely EW, Elasy TA, et al. 2005. Using Real Time Process Measurements to reduce Catheter Related Blodd Stream Infections
in the Intensive Care Unit. Quality and Safety in Healthcare, 14 ; 295-302.
Berenholtz SM, Pronovost PJ, Lipsett PA, et al.. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit
Care Med. 2004 Implementing 5 staggered interventions over a 4 year period
Effecting Change
• Passive interventions are unlikely to achieve
significant improvements in provider behaviour
and thus it is unlikely that significant
improvement in infection rates should occur as a
result of such interventions if the appropriate
process measures are not improved.
• IHI Recommend specific QI strategies for
implementing bundles such as audit and
feedback of infection rates and all or none
measurements, use of multidisciplinary rounds
and setting daily patient goals.
EBM
• Evidence for QI strategies to improve adherence to
preventative interventions for HAI is generally of sub
optimal quality, consisting primarily of single centre
simple B and A studies of limited internal and external
validity.
• Unable to reach any firm conclusions regarding
actionable QI strategies to prevent HAI.
• Most studies reporting adherence to process measures
reported a significant improvement. Striking lack of
negative reporting is highly likely to be a manifestation of
publication bias.
• Very few assessments of potential adverse effects of the
intervention
• No high quality studies assessed cost-benefit of
intervention
Prevention of Health Care Associated Infections.
A Critical Analysis of Quality Improvement Strategies.
Agency for Healthcare Research and Quality. Jan 2007
Lack of strong evidence supporting use of specific QI strategies should
not be taken to mean that ongoing QI efforts in HAI prevention have
been uniformly unsuccessful or that current strategies should not be
continued.
Higher quality studies of QI strategies for HAI prevention are urgently
needed.
Following strategies are worthy of future study and possibly wider
implementation:
 Use of printed or computer based reminders with stop orders to
reduce unnecessary catheterisation
 Printed or computer based reminders to improve surgical antibiotic
prophylaxis.
 Active educational Interventions, use of checklists to improve
improve adherence to preventative interventions for VAP.
Annual ICU acquired Ventilator associated Pneumonia
(per 1000 invasive mechanical ventilation days)
25
2004: 40/1000
per 1000 vent days
20
15
10
5
0
Sept 05 Aug 06
Sept 06 Aug 07
Hawe, Ellis, Cairns, Longmate
Protocol Compliance across three cycles
120%
Nov-06
May-07
Oct-07
100%
80%
60%
40%
20%
0%
semi-recumbent
HMEF above mouth
chlorhexidine
sub-glottic
w eaning plan
sedation holiday
50
1 ) Audit started.
01/12/2006
2) Education started.
27/02/07
45
3) Second audit
cycle 07/05/07
g chart
VAP
at risk ventialtion days between.
4) guideline refined
/relaunched01/08/07
4
3
guidelines in place
35
1
2
30
25
20
15
10
5
59
57
55
53
51
49
45
47
43
41
39
37
35
33
29
31
27
25
23
21
19
17
13
15
11
9
7
5
3
0
1
At risk patients ventilated between VAP
40
Conclusions
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Trends towards reduction in HAI
Confounders
Early
Consistent with what we know about
surveillance, educational interventions
Questions
Do we believe it ?
Is it Hawthorne ?
Does it matter if you are a patient ?
What intervention is causing the benefit ?
Do you need measurement (surveillance) ?
or just QI without measurement ?
Can you separate the measuring from the behaviour change
FV – dedicated nurse data collection education and change, active, concurrent
and clinically owned.
Relatively expensive
Is it an unnecessary luxury ?
Should we continue ?
How can we make it sustainable ?
National Patient Safety Alliance.
National Surveillance.
BSI-A:
1 positive blood culture for a recognised pathogen
or
Patient has at least one of the following signs or symptoms: fever (>38°C.),
chills, or hypotension and 2 positive blood cultures for a common skin
contaminant (from 2 separate blood samples drawn within 48 hours).
skin contaminants = coagulase-negative staphylococci, Micrococcus sp.,
Propionibacterium acnes, Bacillus sp., Corynebacterium sp.
BSI-B: Patient has at least one of the following signs or symptoms: fever
(>38°C.), chills, or hypotension
And either
1 positive blood culture with a skin contaminant in patient with an intravascular
line in place and in whom the physician instituted appropriate antimicrobial
therapy.
or
positive blood Antigen test (e.g. H.influenzae, S.pneumoniae, N. meningitidis or
Group B Streptococcus)