connie steed, msn, rn, cic director, infection prevention
TRANSCRIPT
Connie Steed, MSN, RN, CICDirector, 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.01.02.01Leaders allocate needed resources for IPC
program. Standard IC.01.03.01Identifies risk for acquiring and
transmitting infections. …input from at minimum IP personnel,
medical staff, nursing and leadership
Standard IC.01.03.01Identified risks for transmitting infections. Standard IC.01.04.01Based on identified risks, the hospital sets
goals to minimize the possibility of transmitting infections.
Standard IC.01.05.01Has and infection prevention and control
plan…Hospital components and functions
integrated into the IPC activities. …Methods for communicating
responsibilities and reporting data.
Standard IC.01.06.01Prepares to respond to influx of
potentially infectious patients Standard IC.02.01.01Implements IPC planStandard IC.02.02.01Reduces 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.02.04.01Offers vaccination against influenza to LIPs
and staff. IC Standard.03.01.01Evaluates the effectiveness of IPC plan …Are findings communicated at least
annually to the individuals or interdisciplinary group that manages the patient safety program?
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.
CultureOrganizational structureSize and complexity
Reporting/ communicating forum needs to be what works best for the organization.
GHS IPC CommitteeHospital epidemiologist, IPs, Pharmacy, MDs, Nursing,
Sterile Processing, OR, Employee Health, Lab, VP Quality; Public Health rep, RT , Ambulatory Care, Home
HealthMeet every other Month
Key focus: IPC program oversight, data analysis, decision making, recommendations to leadership
IPC Policy and Procedure SubcommitteeKey focus: Standards of Practice
Sterilization Subcommittee Key focus:
Instrument/ equipment
Antibiotic Stewardship
Subcommittee
Medical staff Process
Improvement Committee
Quality Management Committee
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)
Clear Purpose/ visionGood leader/ facilitatorOrganization: Agenda, timekeeper,
minutesMembership: Engaged; appropriate to
purpose of committee; diverse; preparedMethod of communicating and reporting
is consistent/ easy to understandAppropriate content to purposeCan 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
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Edward O’Rourke, M.D , Harvard University –Harvard Medical School
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
Sources of Resistance Causes/Reasons for Resistance
Rating(0-100%)
Lack of understanding
Political
Cultural
Identify by Group* To understand the nature of resistance.
*Use groups from the key constituents Map
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 committeeInterestRepresent group in hospitalExperts in their fieldDiplomatic What do you do if key
influencer is disruptive? Good communicatorsCare about the membership, change it up if
needed to improve involvement 21
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.
Role definition: Building the Team/ CommitteeA.R.M.I. analysis
IPC Plan KEYSTAKEHOLDERS IMPLEMENTATION EVALUATIONSTARTUP
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/ Vision2.Stakeholders3.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 SubEmployee Health
Sterilization Sub
IPC P & P Sub
Antibiotic SubEmployee Heath
SterilizationSub
IPC P & PSubMeeting Frequency and timing can influence
attendance
Time Agenda Topic Purpose Leader Desired Outcome
7:30-7:35 am
I. Call to Order/ Review of Minutes
Minutes Review
Dr. Kelly Approval of minutes
7:35-7:55
II. Surveillance/PI
CLABSIAnalysis S.
Boeker*
Recommendations
7:55-8:15
MDROs 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
Agenda
*Other Infection Preventionists conducting surveillance
Material ( needs to hold attention) Paper/ handoutPowerPointVerbal discussionRoom Set upClassroomMeeting set upPlanning is key
•Report generated November 21, 2011
BaselineOct-Dec
‘09Jan-Mar
‘10Apr-Jun
‘10Jul-Sep
‘10Oct-Dec
’10Jan-Mar
‘11Apr-Jun
’11Jul-Sep
‘11Oct ‘11
GHS Overall Weighted
Hand Hyg Rate 53.8% 72.6% 80.0% 86.2% 85.2% 87.2% 91.0% 90.2% 91.8% 91.5%
Correct HH 659 615 5773 6022 3879 4220 5948 5565 5090 1826
Observations 1222 847 7213 6990 4552 4837 6045 6169 5543 1996
GMMC (GMH, MIP, RCP)
Hand Hyg Rate 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
Greer Memorial Hospital
Hand Hyg Rate 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
Hillcrest Memorial Hospital
Hand Hyg Rate 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
North Greenville LTACH
Hand Hyg Rate 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
Patewood Memorial Hospital
Hand Hyg Rate 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
KEY < 60% 60-69% 70-79% 80-89% 90-100%
Note: Baseline Jun-Sep ‘09.
•Report generated November 21, 2011
08-09 SeasonPeak: 131
Focused SCIP Quality Measure
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
1
1
1
1
1
1
2
3
3
7
Cardiac Telemetry
Cardiology Med
CV & Monit Surg
NTICU
Palliative Care
CCU
Vasc. & Uro Surg
MSICU
CVICU
Ortho Trauma Surg(2D)
Failed Cases by Unit
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.
.
Year/ Quarter
Total2010
2011Qt 1 Qt 2 Qt3
HCA VRE Colonization/ Infection
212 70 69 37
Pt Days 199322 50165 50892 51323Rate 1.06 1.40 1.36 0.72
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
2008 2009 2010 2011 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3CLABSI - 54 39 39 31 41 30 36 16 15 18 12 17 13 9Line Days - 12140 11595
11585 11196
10604
10625 11190 9033 8505 9061 9482 9515 8748 9618
•Report generated Oct. 17, 2011
Infections 20 5 3 3Line Days 11439 3230 2978 2962Pt Days 28172 7360 7199 7077CL Ratio 0.41 0.44 0.41 0.42
NHSN Pooled Mean 0.57 0.56 0.56 0.56
2010 Jan-Sept 11
GrMH
Infections 0 0
Line Days 640 533
Rate 0 0
HMH
Infections 0 2
Line Days 613 497
Rate 0 4.02
PMH
Infections 0 0
Line Days 43 19
Rate 0 0
Jul ‘08-Jun ‘09
Jul ‘09-Jun ’10
Jan ‘10-Dec ’10
Jan ‘11-Sep ’11
% Improvement Pre-Intervention 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 ---
Expected CLABSI 12 10 9 7 ----
Excess CLABSI 138 87 52 32 69.6%
NHSN Mean 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
$4,440,000
•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)
Surgical SiteObserved Infections
Total Surgeries
Statistically Expected Infections
Standardized Infection Ratio
(SIR)
95% Lower Confidence
Limit
95% Upper Confidence
Limit
Statistical Significance
CABG (Chest and Donor)* 7 418 11.37 0.62 0.25 1.27 Not different than expected
Abdominal Hysterectomy* 9 610 10.69 0.84 0.39 1.60 Not different than expected
Hip Replacement* 12 616 8.77 1.37 0.71 2.39 Not different than expected
Knee Replacement* 12 786 6.42 1.87 0.97 3.26 Not different than expected
Colon Resection 28 474 26.69 1.05 0.70 1.52 Not different than expected
Bariatric Surgery 1 269 6.13 0.16 0.05 0.91 Lower than expected
Small Bowel 15 343 20.89 0.72 0.40 1.18 Not different than expected
Ventral Hernia 15 498 11.25 1.33 0.75 2.20 Not different than expected
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
Statistically Expected Infections Based on NHSN Data; Standardized Infection Ratio (SIR) = Observed Infections / Expected Infections95% Confidence Limits = The Confidence Interval provides the range in which the TRUE SIR will fall 95% of the time
•Report generated Sep 20, 2011* New risk adjustment methodology
The organization needs to have a means to integrate IPC program:
1. Data analysis2. Recommendations/ follow-up3. Policy development/ approval4. 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 [email protected]