Transcript Key Messages for Infection Prevention and Control Leaders

Denise Murphy, RN, BSN, MPH, CIC
Vice President, Quality and Patient Safety
Main Line Health System
Philadelphia, PA USA
April 2010
Nice, FR
Disclosures 2010
 CDC International Meeting on Healthcare Associated
Infections (Decennial); CDC Healthcare Infection Control
Practices Advisory Committee (HICPAC)
 AHSRM/APIC/Chartis Insurance: Patient Safety Tour faculty
 APIC International Conference and Education Meeting
faculty; APIC Consulting, Inc. Board
 NPSF/APIC Patient Safety Awareness Webinar faculty
 TMIT faculty for IHI International Conference and
Educational Meeting
 National Quality Forum (NQF) Patient Safety Advisory
Committee
2
Objectives
 Discuss the scope of the problem created by healthcare
associated infections (HAIs) globally
 Discuss impact of HAIs: clinical, financial and societal
 Emphasize the role of culture related to
reduction/elimination of preventable harm
 Outline what top performers are doing to eliminate
HAIs
3
HAIs: Scope of the Problem
 At any time, over 1.4 million people worldwide suffer from
healthcare associated infections (HAI)
 Prevalence survey in 55 hospitals in 14 countries in Europe,
Eastern Mediterranean, South-East Asia and Western Pacific
showed average of 8.7% of hospital patients had HAIs
 In England, 9% inpatients have HAI at any time, equivalent to
at least 100,000 infections a year*
FOR MORE INFO...
Tikhomirov E. WHO Programme for the Control of Hospital Infections. Chemiotherapia, 1987,
3:148–151.*Management and Control of HAI in Acute NHS Trusts in England. Feb 2000
Impact of HAI in the U.S.
 At least 1.7 million HAI in US hospitals (2002*)
 155,000 deaths; 99,000 attributable to the infection**
Heart Disease
Cancer
Chronic Lung
Disease
Accidents
HAI
FOR MORE INFO...
0
100000 200000 300000 400000 500000 600000 700000 800000
*Klevens RM et al., 2007; ** National Vital Statistics Reports, Deaths: Injuries 2002
Beyond Death….
 One HAI leads to risk for multiple HAIs
 Excess LOS increases risk for other patient safety
events (e.g., medication errors, fall, pressure ulcers)
 MDROs
 Societal costs
Loss of trust
Increased legislation and litigation
 Personal loss: productivity, sense of well being,
impact on family and caregivers
Why Target Elimination of HAI?
Too many people are dying
or are harmed by HAI.
Theresa Marie Murphy
1927-2001
U.S. DHHS* Steering Committee on
Healthcare Associated Infection Reduction
CHARGE: Develop a Coordinated Strategy
National goals for reduction will target:
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Catheter-associated urinary tract infections
Central line-associated blood stream infections
Surgical Site infections
Ventilator-associated pneumonia
MRSA
Clostridium difficile
NOTE: Tier one - focus on hospitals; tier two - out of hospital care and
additional types of HAI
*Department of Health and Human Services
8
Recommendations:
Prevention and Implementation
 Many goals call for at least 50% reduction over 5 years
 Use and improve metrics needed to assess progress
 Prioritize existing prevention strategies (CDC HICPAC
guidelines) – set National performance standards
9
DHHS Challenge to Leaders
 Identify specific actions to fix broken processes and
systems AND to address staff behavior/compliance
 Responsible parties to drive each tactic or step
 Timelines and resources to complete actions
 Briefings to senior leaders
 Make performance transparent: scorecards
 Watch for barriers in each step of implementation
Financial Impact of HAI
Attributable Costs
2005 US$
Infection Type
Excess Length of Stay
(Days)
Mean
Min
Max
Mean
Min
Max
Ventilator associated
pneumonia
22,875
9,986
54,503
9.6
7.4
11.5
CABG-associated SSI
17,944
3,592
26,668
25.7
20
35
Central line associated
bloodstream infection
18,432
3,592
34,410
12
4.5
19.6
1,257
804
1,710
-
-
-
Catheter associated urinary tract
infection
FOR MORE INFO...
Perencevich EN, et al. Infect Control Hosp Epi, October 2007 (Studies from 1999-2005)
Comparison of Economics – Patients with/without
Central Line Associated Bloodstream Infection
N = 20
Patient
Admit diagnosis
Respiratory failure
Respiratory failure
Age
71
75
Payer
Medicare + commercial
Medicare + commercial
Revenue $
20,792
20,417
Expense $
19,501
37,075
Gross margin $
+1,291
-16,658
Costs attributable to BSI
LOS (days)
13,696
10
FOR MORE INFO...
Shannon et al. Amer J Med Quality Nov/Dec 2006; pgs 7S-16S
15
Preventable Complications No
Longer Covered by CMS*
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Foreign object retained after surgery;
Air embolism;
Blood incompatibility;
Stages III and IV pressure ulcers;
In-hospital falls and trauma;
Catheter-associated urinary tract infection (UTI);
Vascular catheter–associated infection;
Surgical site infection—mediastinitis after CABG
FOR MORE INFO...
* Center for Mediicare and Medicaid Services; Source: McNair et al. Health Affairs 2009:28(5):1485-93.
Business Solution: Focus on Length of Stay
 Know the financial impact of HAI and medical
errors and the attributable excess length of stay
 Realize how many additional patients can be
admitted into beds not occupied by patients
with an HAI
 Calculate added revenue from reducing
infections (not costs saved)
FOR MORE INFO...
*Ward EJ, Healthc Financ Manage. 2006 Dec;60(12):92-8
Clinical Solution: Focus on Implementation of
and Compliance with Infection Prevention
Bundles (see appendix)
 CLABSI
 CAUTI
 VAP
 SSI
 MDRO
Cultural and Administrative Solutions:
 Setting the theoretical goal of elimination of HAIs –
not even 1 HAI is acceptable;
 Setting expectations that infection prevention and control
measures will be applied consistently by all health care
workers, 100% of the time;
 Creating a safe environment for health care workers to pursue
100% adherence, where they are empowered to hold each
other accountable for infection prevention;
 Ensuring resources and leadership support as the foundation
to successfully implement prevention measures;
FOR MORE INFO...
Warye K, Murphy DM. Am J Infect Control 2008;36:683-4.
Cultural and Administrative Solutions:
 Transparency and continuous learning allow for mistakes to be
openly discussed without fear of penalty;
 Prompt investigation of HAI’s of greatest concern to the
patients, the organization and/or community; drilldown into
root and contributing causes.
• View problems and solutions from a human factors
perspective (People, Tools, Work, Environment)
 Providing real time data to front-line staff for the purpose of
driving improvement.
FOR MORE INFO...
Warye K, Murphy DM. Am J Infect Control 2008;36:683-4.
Complementary Improvement Strategies
Codes Outside
the ICU
Surgical Site
Infections
Hand
Hygiene
Central Line
Infections
Culture
Falls
Pressure Ulcers
Patient Satisfaction
…and on, and on…


© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Used with Permission.
Process Design
Behavioral Accountability
VAP Prevention
1. Elevation of the head of
the bed to between 30
and 45 degrees
2. Daily “sedation vacation”
and assessment of
readiness to extubate
3. Peptic ulcer disease
(PUD) prophylaxis
4. Deep venous thrombosis
(DVT) prophylaxis
(unless contraindicated)
“Clinical Bundle”
“People Bundle”
Who has gotten to ZERO HAI?
Ventilator Associated Pneumonia (VAP)
VAP Rate
NNIS Benchmark
Quarterly
8
May04Suction
and oral
care
education.
Aug05 Hilo evac
tubes in
use.
7
6
5
Feb08 BAL/PBS
for susp
VAP
4
3
2
CT ICU Primary Bloodstream Infection Rates
BSI Rate (per 1000 line days)
Mercy Hospital ICU
8
2006 - 2008
6
4
2
0
JanFebMarAprMayJunJulAugSepOctNovDecJanFebMarAprMayJunJulAugSepOctNovDecJanFeb
2006
2007
Rate
1
Mean
2008
NHSN
0
Baseline
3Q034Q031Q042Q043Q044Q041Q052Q053Q054Q051Q062Q063Q064Q061Q072Q073Q074Q071Q082Q083Q08
1Q-2Q03
n=1/203
n=0/261
n=2/302
n=0/343
n=0/203
n=0/150
n=1/241
n=1/281
n=0/201
n=0/187
n=0/316
n=0/331
n=0/313
n=0/347
n=0/331
n=0/324
n=1/287
n=0/333
n=0/259
n=1/325
n=1/352
n=3/499
Source: Barnes Jewish Hospital
Epidemiology and Infection Prevention
Department
Johns Hopkins Medical Institution
CLABSI for All Adult ICU’s
2001 –2009
Trish M. Perl, MD, MSc,
Johns Hopkins Hospital, Baltimore, MD
And the Hospital Epidemiology Department
Allegheny General Hospital CCU
Central Line Associated Bacteremia
CLABSI/1,000 Line Days
9
8
7
6
5
4
3
2
Jerome E. Granato MD MBA, Medical Director
Joy Peters, RN MSN MBA, Nursing Director
Coronary Care Unit,
Allegheny General Hospital, PA
And Cheryl Herbert, Manager, IC
1
0
2002 Through April 2007
Process
Standardization
Process
Extinction
Education
Programs
Cultural
Shift?
Main Line Health System – Phila, PA
Mark Ingerman, MD and Connie Cutler,
Medical Director and System Director,
Main Line Health System’s Adult Critical Care Units
Suburban Philadelphia, PA
Sutter Roseville Medical Center, Roseville, California
Incidence of CRBSI in PICC Lines
House-Wide; January 2005-March 2009
4.5
4
4
3.5
3
3
2.5
2
2
CRBSI
2
1.5
Incidence of CRBSI- all CVC
House-Wide; January 2005- March 2009
1
0.5
0 0 0 0 0 0 0 0 0 0 0 0 0
1Q
05
2Q
05
3Q
05
4Q
05
1Q
06
2Q
06
3Q
06
4Q
06
1Q
07
2Q
07
3Q
07
4Q
07
1Q
08
2Q
08
3Q
08
4Q
08
1Q
09
4.5
4
4
3.5
3
3
2.5
2
2
CRBSI
2
1.5
Sophie Harnage RN,BSN
Clinical Manager Infusion Services
Sutter Roseville Medical Center
Roseville, CA
1
1
0.5
0
0 0 0 0 0
0 0 0 0 0 0 0
1Q
05
2Q
05
3Q
05
4Q
05
1Q
06
2Q
06
3Q
06
4Q
06
1Q
07
2Q
07
3Q
07
4Q
07
1Q
08
2Q
08
3Q
08
4Q
08
1Q
09
0
Targeting Zero – Global Challenge
“An intervention conducted over two years at a 450 bed hospital in
Pratumthani, Thailand involved 2,412 patients with urinary catheters.
A nurse-driven intervention involving daily assessment of appropriateness
of catheter use and reminders to physicians about importance of catheter
removal resulted in
 fewer urinary catheter days (11d vs. 3 days),
 lower UTI rates (23.4/1,000 catheter days vs. 3.5/1,000)
 lower hospitalization (16 d vs. 5 d)
 lower costs ($3,739 vs. $1,378.).”
We realized a 73% reduction in catheter utilization and decreased UTI 85%.”
“An educational intervention, using the WHAP VAP modules, was also
conducted at Thammasart Univiversity Hospital - VAP was reduced 59%.
Submitted by Anucha Apisarnthanarak, MD
and the Thammasart University VAP intervention team
Teams who have gotten to zero HAI…
What’s Standard?
 Targeting zero is culture change –

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takes time
Strong Sr. Leader support:
Champions/multidisciplinary teams
IHI’s bundle approach/EBM
Transparency/data feedback
Analysis – real time
Personalize HAI
Communication!
Celebrate success
Plan to sustain the gains
What’s Different?
 Critical event analysis
 Daily assessment of device

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use/reminders to remove
Building in reliability
Human Factors training
Board involvement
IPC Liaisons “Link Nurses”
Weekly Executive Report
Web-based education
Empowered staff
STOP THE LINE
Summary
Leaders must:
 Educate themselves and their teams about the total impact of HAI.
 Must BELIEVE that zero HAI is an achievable imperative and sustainable


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for long periods of time. They must set and actively support that goal.
Understand HOW to achieve zero and what is required to sustain that
performance.
Set cultural and behavioral expectations: 100% compliance with evidence
based measures to prevent infection is expected from every one, for every
patient, every day.
Provide the environment, equipment, human and financial resources
to reduce HAI to zero.
Ensure that when even one HAI occurs, it should trigger immediate
concern and a drilldown into potential causes (process breakdown,
new equipment, slip in compliance, lack of knowledge, etc.)
Educate their communities about more than the risk for HAI, but also
efforts targeted at prevention. Then market successful reductions.
“Never forget that a small group of
people can change the world. It is
the only thing that ever has…”
- Margaret Mead
APPENDIX:
Table of “What Top Performers in Patient
Safety are Doing”
Main Line Health System’s:
- Clinical Bundles
- Culture of Safety (People Bundle)
What Top Patient Safety
Performers Are Doing
Culture of zero preventable
harm/highest quality care
Reliability engineered into processes
(cues, forcing functions, human factors)
Just Culture of Safety, Service Excellence Standardized processes (e.g., order sets)
Transparency and rapid feedback system
Technology enabled QPS and service
Medical staff fully engaged
Real time analysis of events
Front line empowered
Certification for risky procedures
Clear expectations set for safe behaviors
Strong measurement/analysis
Reciprocal accountability
Organized spread of learning
Commitment to teamwork
Effective PI framework and tools
Formal, standard communication system Dedicated, skilled facilitators
Evidence-based measures (bundles)
PI oversight function
Systems approach to problem solving
Simulation
MLHS Central line-associated Bloodstream
Infection (CLABSI) Prevention
•
•
•
•
•
•
•
•
•
•
•
•
•
Appropriate criteria-based utilization of central line
Line site choice (internal jugular<subclavian<PICC): avoid femoral site
Hand hygiene
Central line carts or kits (cabinet in Interventional Radiology)
Chlorhexidine gluconate to cleanse site before insertion
Full barrier precautions for insertion
Protect line integrity: do not use for blood draws!
Scrub the hub before all necessary usage
Daily assessment of need for central line
Drill down on use of PICC lines and using central line for blood draw
Timely feedback about outcomes (rates) and process (bundles)
Review of each case by BSI prevention PI team
Comprehensive Unit-based Safety Program (CUSP) collaborative
Standardization of component locations in carts or kits
Observation of central line insertions and use of checklist
Engagement of senior leadership
Evidence-based Prevention Measures and Best Practice
MLHS Catheter-associated Urinary Tract
Infection (UTI) Prevention
• Hand Hygiene
• Appropriate criteria-based Foley catheter insertion
• Nurse-driven Foley catheter removal protocol
• Evaluation of silver-coated catheters
• Rounds with daily assessment of need for catheter
• Point prevalence survey on documentation
• Education for residents and nurses on insertion technique
• Review of each case by UTI prevention PI team
• CMS Surgical Care Improvement Project requirement to
remove on first or second post-op day (or document why
catheter is necessary)
Evidence-based Prevention Measures and Best Practice
MLHS Ventilator-associated Pneumonia
(VAP) Prevention
•
•
•
•
•
•
•
Hand Hygiene
Daily weaning assessments, “sedation vacation” in standing orders
Elevate head of bed (HOB) at least 30 degrees
High-low evacuation endotracheal tubes for subglottic suction
Oral care every 2 hours by nursing or respiratory therapy
Chlorhexidine gluconate oral rinse twice/day
Mandatory documentation fields for HOB and mouth care in
electronic documentation
• Feedback to caregivers when opportunity for mouth care is missed
• No routine vent circuit changes
• Emphasis on minimal opening of vent circuits
• Ambulate as early as possible or investigate mobility options
• Review of each case by VAP prevention PI teams
Evidence-based Prevention Measures and Best Practice
MLHS Surgical Site Infection
(SSI) Prevention
•
•
•
•
•
•
•
•
•
NO RAZORS; if hair must be removed, use clippers
CHG wipe (skin antiseptic) for hip/knee surgery patients
Use of CHG/alcohol skin prep
Pre-operative prophylactic antibiotic choice and timing
Post-operative discontinuation of prophylactic antibiotic
Meeting with surgical specialty group when cluster identified
Normothermia (normal body temperature)
Infection prevention rounds in surgical suites
Review of each case by SSI prevention PI teams
Evidence-based Prevention Measures and Best Practice
MLHS Culture of Safety ( “People Bundle”)
1.
2.
3.
4.
5.
6.
7.
8.
Leaders make safety a visible and vocal priority
We have zero tolerance for reckless behavior
Management sets clear expectations around safe(ty) behaviors
Staff understand their accountability
Managers hold staff accountable 100% of the time
Staff speak up about risk without fear
Peers observe, coach and hold one another accountable for safety
Staff are equipped with critical thinking skills and apply them when
safety is at risk
9. Our patients and our workforce are surrounded by safe systems and
processes enabling them to prevent harm
10.Staff proactively engage patients and families in their healthcare
BEST PRACTICE and
MLHS CULTURE OF SAFETY GOALS