Transcript Slide 1

Connie Steed, MSN, RN, CIC
Director, Infection Prevention
1.Discuss whether an Infection Prevention and
Control (IPC) committee is required by guideline
and regulating agencies.
2. List characteristics of a successful IPC meeting.
3. Identify at least 2 strategies to facilitate
engagement and attendance by IPC committee
members.
4. Discuss what kind of data and information
should be presented at IPC committee
meetings.
Do you have to have one?
Interpretive Guidelines §482.42(a)(1)

The infection control officer or officers must develop, implement
and evaluate measures governing the identification, investigation,
reporting, prevention and control of infections and communicable
diseases within the hospital, including both healthcare–associated
infections and community-acquired infections. Infection control
policies should be specific to each department, service, and
location, including off-site locations, and be evaluated and revised
when indicated. The successful development,
implementation and evaluation of a hospital-wide
infection prevention and control program requires
frequent collaboration with persons
administratively and clinically responsible for
inpatient and outpatient departments and services,
as well as, non-patient-care support staff, such as
maintenance and housekeeping staff.
Standard IC.01.01.01
Identifies the individual(s) responsible for the
infection prevention and control ( IPC) program
 Standard IC.01.02.01
Leaders allocate needed resources for IPC
program.
 Standard IC.01.03.01
Identifies risk for acquiring and transmitting
infections.
…input from at minimum IP personnel, medical
staff, nursing and leadership

Standard IC.01.03.01
Identified risks for transmitting infections.
 Standard IC.01.04.01
Based on identified risks, the hospital sets goals to
minimize the possibility of transmitting
infections.
 Standard IC.01.05.01
Has and infection prevention and control plan
…Hospital components and functions integrated
into the IPC activities.
…Methods for communicating responsibilities and
reporting data.

Standard IC.01.06.01
Prepares to respond to influx of potentially
infectious patients
 Standard IC.02.01.01
Implements IPC plan
 Standard IC.02.02.01
Reduces the risk of infections associated with
medical equipment, devices and supplies.

IC Standard.02.03.01
Works to prevent the transmission of infectious
disease among patients, licensed independent
practitioners (LIPs), and staff.
 IC Standard.02.04.01
Offers vaccination against influenza to LIPs and
staff.
 IC Standard.03.01.01
Evaluates the effectiveness of IPC plan
…Are findings communicated at least annually to
the individuals or interdisciplinary group that
manages the patient safety program?

1. Annual IC
Risk
Assessment
2. Priorities/
Needs
of
Organization
3. IC Plan: Goals
and Strategies
5. Ongoing
Assessment
4.
Implementation

Integrating: To make into a whole by bringing
all parts together; unify.

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
Not necessarily!!! But… There needs to be a
means to, in a collaborative fashion, report,
analyze, and make decisions specific to the
IPC program.
Various committees are used:
e.g. Quality Management, Medical Care,
Safety committees
Need to be able to prove interdisciplinary
work/ communication and integration…
Minutes—document your activity.



Culture
Organizational structure
Size and complexity
Reporting/ communicating forum needs to be
what works best for the organization.
Quality
Management
Committee
Medical staff Process
Improvement
Committee
GHS IPC Committee
Hospital epidemiologist, IPs, Pharmacy, MDs, Nursing, Sterile
Processing, OR, Employee Health, Lab, VP Quality; Public Health rep,
RT , Ambulatory Care, Home Health
Meet every other Month
Key focus: IPC program oversight, data analysis, decision making,
recommendations to leadership
IPC Policy and Procedure
Subcommittee
Key focus: Standards of
Practice



Sterilization
Subcommittee
Key focus:
Instrument/
equipment


Antibiotic
Stewardship
Subcommittee
GMMC: Academic Medical Center: IP Team meets
every other week: Medical Director, IPs, others as
needed
 PMH: Short stay surgical hospital: Quality Committee
meets monthly, diverse membership
 HMH: Small Community Hospital: IPC Committee,
meets quarterly, membership similar to GHS IPC
Committee , Also reports to Quality Committee
 GrMH: Small Community Hospital: Medical Care
Committee, diverse leadership
 NG LTACH: Long Term Acute Care: (QCPC) Quality
Committee, meets monthly; diverse staff and leaders;
Also reports to Steering Group
All facility IP representatives report to: Safety
Committees and Medical Care Committees (ICRAs)
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
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
Clear Purpose/ vision
Good leader/ facilitator
Organization: Agenda, timekeeper, minutes
Membership: Engaged; appropriate to
purpose of committee; diverse; prepared
Method of communicating and reporting is
consistent/ easy to understand
Appropriate content to purpose
Can make decisions/ recommendations
Authority / power of committee needs to be clear
 Advisory
 Review ideas from infection control team
 Review/ Analyze surveillance data

Expert resource
 Help understand hospital systems and policies

Decision making
 Assesses Plan and conducts or reviews infection control risk
assessment
 Review and approve policies and surveillance plans
 Policies binding throughout hospital

Education
 Help disseminate information and influence others
Edward O’Rourke, M.D , Harvard University –Harvard Medical School
16
Who is your Chairman? MD? You?
Are they/ you effective? Engaged?; interested?;
attends?; effective communicator?
 Leader: opens the meeting and takes group
through agenda and encourages decision making
 Facilitator: Helps prepare for meeting to ensure it
goes smoothly
Keys to success: If leader and facilitator aren’t the
same person, communicate prior to meeting
regarding agenda; Make sure you have the right
person chairing committee.


Are all members of the committee aligned in terms of
the need of IP program and for change? ( ICRA>>
Plan development)
 Have we framed the need for committee/ IP program
such a way to reflect the concerns of the customers
and key stakeholders?
 Would each team member deliver essentially the
same message regarding the need for IP program and
committee if asked by someone outside the team?
Creating a shared need involves framing the need to
appeal to the interest of key stakeholders/
Committee members.

Multidisciplinary: Key Influencers, interested
 MDs
 Nursing
 Leadership
 Employee Health
 Infection Prevention
 Sterile processing
 Lab
 Pharmacy
 Public Health
 Others/ ex-officio: e.g. Environmental Services
To understand the nature of resistance.
Identify by Group*
Sources of
Resistance
Causes/Reasons for Resistance
Lack of
understanding
Political
Cultural
*Use groups from the key constituents Map
Rating
(0-100%)
How do you get them to attend? They have to
want to attend.
 Ask members for input to improve/ facilitate good
meetings- make this part of annual assessment
 Qualifications to be on the committee
Interest
Represent group in hospital
Experts in their field
Diplomatic What do you do if key influencer is
disruptive?
Good communicators
Care about the membership, change it up if needed to
improve involvement
21
Role definition: Building the Team/ Committee
A.R.M.I. analysis
KEY
STAKEHOLDERS
IPC Plan
STARTUP
IMPLEMENTATION
EVALUATION
A – Approval of issues such as project scope, resources, and ultimately team recommendations for
improvement
R - Resource to the team, whose expertise, skills, or influence may be needed on an ad hoc basis.
M - Member of team, with critical working knowledge of the problem and/or process .
I - Interested party, who will need to be kept informed on direction, findings, if later support is to be
forthcoming.
Understand that we are change agents and the
committee held decide/ direct the program.
 Understand the importance of preparation when
facilitating, leading a team or committee. Go
slow to go fast.
 Use tools when motivating a commitment to the
IPC program and/ or effecting major change:
1. Creating a shared need/ Vision
2. Stakeholders
3. Mobilizing Commitment

Example GHS in Cultural Transformation
 CEO-Mike:
Leading us to go from
being a victim to making a difference
through ourselves.
 VP Quality-Tom: Leading us to think
through things to assess the barriers to
change and make a plan to influence
them.
Where does the IP program fit? Is it seen
as positive or negative? A change
force…..
January
March
May
July
September
November
-VAP
-Hand
Hygiene
-Aspergillus/
Construction
-CAUTI
-ICRA
-SSIs
-BBFE
-Home
Health
-CABC
( nursing
home)
-CLABSI
-MDRO
-Syndromic
Surveillance
-TB
-VAP
-Hand
Hygiene
-Subacute
-CAUTI
-SSI’s
-MIP (Psy)
-BBFE
-Home
Health
-Dialysis
-CLABSI
-MDRO
-Syndromic
Surveillance
-EPPI
-Ambulatory
Care/MD
Practices
Antibiotic
Sub
Employee
Health
Sterilization
IPC P & P
Sub
Antibiotic
Sub
Employee
Heath
Sterilization IPC P & P
Sub
Sub
Sub
Meeting Frequency and timing can influence attendance
Agenda
Time
Agenda Topic
Purpose
Leader
Desired Outcome
7:307:35 am
I. Call to Order/
Review of Minutes
Minutes
Review
Dr. Kelly
Approval of minutes
7:35-7:55
II. Surveillance/PI
CLABSI
7:55-8:15
MDROs
Recommendations
Analysis
S. Boeker*
Analysis
M.
Littlejohn*
Recommendations
8:15-8: 25
III. Flu Vaccination
Program
Give Update
P. Billings
Follow-up/ Actions
8:25-8:40
IV. IPC Policy and
Procedure
Committee
Review of
dept policies
C. Steed
Approval of policy
changes
*Other Infection Preventionists conducting surveillance
Material ( needs to hold attention)
 Paper/ handout
 PowerPoint
 Verbal discussion
Room Set up
 Classroom
 Meeting set up
Planning is key
•Report generated November 21, 2011
Baseline
86.2%
85.2%
87.2%
91.0%
90.2%
91.8%
91.5%
659
615
5773
6022
3879
4220
5948
5565
5090
1826
1222
847
7213
6990
4552
4837
6045
6169
5543
1996
50.7%
66.4%
78.3%
86.2%
85.5%
86.6%
90.6%
90.1%
91.3%
91.6%
Correct HH
305
95
4245
4010
2824
2918
3808
3956
3573
1281
Observations
601
143
5419
4653
3304
3370
4201
4390
3915
1399
64.5%
97.0%
82.6%
84.7%
79.9%
95.7%
93.2%
92.8%
95.7%
92.9%
Correct HH
51
224
739
439
306
509
619
602
638
208
Observations
79
231
895
518
383
532
664
649
667
224
65.0%
89.7%
80.9%
87.8%
84.3%
86.8%
95.3%
95.0%
92.2%
97.8%
Correct HH
139
96
161
173
220
401
609
531
438
178
Observations
214
107
199
197
261
462
639
559
475
182
73.4%
86.4%
91.6%
94.6%
89.3%
93.4%
95.2%
89.4%
96.4%
93.7%
Correct HH
138
153
229
123
225
183
179
220
188
59
Observations
188
177
250
130
252
196
188
246
195
63
94.3%
100%
93.3%
91.8%
84.4%
93.5%
97.2%
94.8%
96.2%
97.7%
Correct HH
132
128
70
225
205
259
315
308
280
125
Observations
140
128
75
245
243
277
324
325
291
128
Hand Hyg Rate
Hand Hyg Rate
North
Greenville
LTACH
Hand Hyg Rate
Patewood
Memorial
Hospital
Oct ‘11
80.0%
Hand Hyg Rate
Hillcrest
Memorial
Hospital
Oct-Dec
Apr-Jun Jul-Sep
Jan-Mar ‘11
’10
’11
‘11
72.6%
Hand Hyg Rate
Greer
Memorial
Hospital
Jul-Sep
‘10
53.8%
Hand Hyg Rate
GHS
Correct HH
Overall
Weighted Observations
GMMC
(GMH, MIP,
RCP)
Oct-Dec Jan-Mar Apr-Jun
‘09
‘10
‘10
Note: Baseline Jun-Sep ‘09.
KEY
< 60%
60-69%
70-79%
80-89%
90-100%
•Report generated November 21, 2011
4/4/11
3/4/11
2/4/11
1/4/11
12/4/10
H1N1 Pandemic
Peak: 338
11/4/10
10/4/10
9/4/10
8/4/10
7/4/10
6/4/10
5/4/10
4/4/10
3/4/10
2/4/10
1/4/10
350
12/4/09
11/4/09
10/4/09
9/4/09
8/4/09
7/4/09
6/4/09
5/4/09
4/4/09
200
3/4/09
250
2/4/09
1/4/09
400
Weekly Flu-like Illness Chief Complaint for All GHS ER's
1/4/09 to 5/7/11
10-11 Season
Peak: 293
300
08-09 Season
Peak: 131
150
100
50
0
4/4/11
3/4/11
4/4/11
3/4/11
2/4/11
1/4/11
12/4/10
200
2/4/11
70
11/4/10
10/4/10
9/4/10
8/4/10
7/4/10
6/4/10
5/4/10
4/4/10
3/4/10
2/4/10
1/4/10
12/4/09
250
1/4/11
80
12/4/10
90
11/4/10
10/4/10
9/4/10
8/4/10
7/4/10
6/4/10
5/4/10
4/4/10
3/4/10
2/4/10
1/4/10
10
11/4/09
350
12/4/09
20
10/4/09
9/4/09
8/4/09
7/4/09
6/4/09
5/4/09
4/4/09
400
11/4/09
3/8/09
Peak: 28
10/4/09
9/4/09
8/4/09
7/4/09
100
6/4/09
30
5/4/09
40
4/4/09
50
3/4/09
50
3/4/09
100
2/4/09
1/4/09
150
2/4/09
1/4/09
450
Weekly Positive Flu A for ALL GHS:1/4/09 to 5/7/11
10/4/09
Peak: 404
300
2/13/11
Peak: 150
3/8/09
Peak: 25
0
Weekly Positive Flu B for ALL GHS: 1/4/09 to 5/7/11
2/13/11
Peak: 88
60
11/1/09
Peak: 7
0
Urinary Cath Removed
100%
95%
90%
85%
80%
Q110
Q210
Q310
Q410
Urinary Cath Removed
Q111
Q211
Q311
Focused SCIP Quality Measure
Failed Cases by Unit
7
Ortho Trauma Surg
(2D)
3
CVICU
3
MSICU
2
Vasc. & Uro Surg
1
CCU
Palliative Care
NTICU
CV & Monit Surg
Cardiology Med
1
1
1
1
1
Cardiac Telemetry
 Measure: Removal of post op
urinary catheter by the end of
POD #2
 GMH chart review conducted
on all ‘failed’ cases for the
quarter Oct 10 – Dec 10.
 Cases are randomly selected
from all eligible surgical cases
 Graph displays distribution of
‘failed cases’ by unit at GMH.
Example: 14 cases on the
Ortho/Trauma unit were
included in the random
sample. Seven out of these 14
cases did not meet criteria for
removing the post op urinary
catheter
 SCIP urinary catheter
workgroup in progress
GMMC
Healthcare Associated
Vancomycin Resistant Enterococcus
Jan 2009-September 2011
HCA Upper Warning= 2.00
HCA Upper Control= 1.73
HCA VRE Mean=1.22
HCA VRE Rate
2.50
Rate per 1000 Patient Days
2.00
1.40
1.50
1.00
1.36
1.06
0.72
0.50
0.00
Year/
Quarter
HCA VRE
Colonization/
Infection
Pt Days
Rate
Total
2010
2011
Qt 1
Qt 2
Qt3
212
70
69
37
199322
1.06
50165
1.40
50892
1.36
51323
0.72
March- April 2011- VRE cluster in 4003 and 4005. Education and enhanced rotational cleaning, 3M Cleantrace testing and culturing done
MSICU VRE Isolates from patients and surfaces sent to Johns Hopkins for PFGE.
Possible HCW transmission via the environment and hands.
HCA
Colonization
Rate
HCA Infection
Rate
Pt days
Colonization
rate/per 1000 pt
days
Infection rate/per
1000 pt days
MRSA
Jan – Sept 11
0
0
1763
0
0
2010
0
1
2617
0
0.38
VRE
No cases to report
C-diff
No cases to report
CLABSI Rate
CLABSI Rate per 1000 Line Days
5.0
NHSN Pooled Mean
Top 25th Percentile
4.45
4.5
3.87
4.0
3.37
3.5
3.22
3.36
3.0
2.77
2.5
2.82
1.77 1.76
2.0
1.5
July: ICU
Intervention
1.0
1.99
1.79
1.49
Oct: Non-ICU
Intervention
0.94
1.27
0.5
0.26
0.0
Q1
Q2
Q3
Q4
Q1
2008
Q2
Q3
Q1
Q2
-
54
12140
Q4
Q1
2009
2008
CLABSI
Line Days
1.66
Q2
Q3
Q4
39
39
11595 11585
Q1
Q2
Q1
2010
2009
Q3
Q4
Q3
31
41
30
11196 10604 10625
Q2
Q3
2011
2010
2011
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
36
11190
16
9033
15
8505
18
9061
12
9482
17
9515
13
8748
9
9618
•Report generated Oct. 17, 2011
Combined ICU CLABSI Rate per 1000 Line Days
Rate
NHSN Pooled Mean (1.6)
NHSN 75th Percentile (0.23)
2.50
2.00
1.75
1.55
1.50
1.01
1.01
1.00
0.50
0.00
2010
Infections
Line Days
Pt Days
CL Ratio
NHSN Pooled Mean
20
11439
28172
0.41
0.57
J-M 11
5
3230
7360
0.44
0.56
A-J 11
3
2978
7199
0.41
0.56
J-S 11
3
2962
7077
0.42
0.56
GrMH
HMH
PMH
2010
Jan-Sept 11
Infections
0
0
Line Days
640
533
Rate
0
0
Infections
0
2
Line Days
613
497
Rate
0
4.02
Infections
0
0
Line Days
43
19
Rate
0
0
Jul ‘08Jun ‘09
Jul ‘09Jun ’10
Jan ‘10Dec ’10
Jan ‘11Sep ’11
% Improvement PreIntervention to
Projected CY 2011
CLABSI #
150
97
61
39
65.3%
Line Days
44,980
39,353
36,081
27,881
17.4%
Rate
3.33
2.46
1.69
1.40
58.0%
NHSN Top Quartile
0.26
0.26
0.26
0.26
---
12
10
9
7
----
138
87
52
32
69.6%
1.66
1.66
1.66
1.66
----
Expected CLABSI
75
65
60
46
----
Excess
75
32
1
-7
112%
CLABSI Prevented
-----
53
89
111
Lives Saved (10-20%)
-----
5-10
9-18
11-22
Cost Savings
($40,000/Case)
-----
$2,120,000
$3,560,000
$4,440,00
0
Expected CLABSI
Excess CLABSI
NHSN Mean
•Report generated Oct. 17, 2011
•Report generated Sep 20, 2011
GHS System-Wide (GMH, PMH, GrMH, HMH)
Surgical Site Infections (July 1, 2010 – June 30, 2011)
Statistically Standardized 95% Lower
Expected Infection Ratio Confidence
Infections
(SIR)
Limit
95% Upper
Confidence
Limit
Statistical
Significance
Observed
Infections
Total
Surgeries
CABG (Chest and Donor)*
7
418
11.37
0.62
0.25
1.27
Abdominal Hysterectomy*
9
610
10.69
0.84
0.39
1.60
Hip Replacement*
12
616
8.77
1.37
0.71
2.39
Knee Replacement*
12
786
6.42
1.87
0.97
3.26
Colon Resection
28
474
26.69
1.05
0.70
1.52
Bariatric Surgery
1
269
6.13
0.16
0.05
0.91
Small Bowel
15
343
20.89
0.72
0.40
1.18
Ventral Hernia
15
498
11.25
1.33
0.75
2.20
C-Section
11
1789
32.91
0.33
0.17
0.60
Lower than expected
TOTAL All Sites
110
5803
135.1
0.81
0.67
0.98
Lower than expected
Surgical Site
Statistically Expected Infections Based on NHSN Data;
Not different than
expected
Not different than
expected
Not different than
expected
Not different than
expected
Not different than
expected
Lower than expected
Not different than
expected
Not different than
expected
Standardized Infection Ratio (SIR) = Observed Infections / Expected Infections
95% Confidence Limits = The Confidence Interval provides the range in which the TRUE SIR will fall 95% of the time
* New risk adjustment methodology
•Report generated Sep 20, 2011
The organization needs to have a means to integrate IPC
program:
1. Data analysis
2. Recommendations/ follow-up
3. Policy development/ approval
4. Means to bring people together to address ICRA and
program planning
5. Communication: multiple committees/ team
 IPC committee is worth the time if it serves a purpose in the
organization’s culture/ structure.
 Committees/ teams need to be organized/ planned;
members need to be engaged to make a difference



Thank you!!!!
[email protected]