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Blockers and promoters
ANTIMICROBIAL STEWARDSHIP AND INFECTION CONTROL
MERCEDES PALOMAR
SMI H ARNAU DE VILANOVA (LLEIDA)
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Patient Safety: Reporting of Adverse Events Health Policy Reports
Leape L. L. NEJM 2002; 347:1633-1638,
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Theories of error developed in aviation and other high-risk industries
suggest that errors are likely to occur in all complex systems.
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Richard Branson (VIRGIN) in call for new safeguards
„If you go into hospital you have a one in 300 chance of being killed - not from the
illness you went in with, but because of mistakes and other unnecessary problems
such as hospital-acquired infections.
„If one in 300 of our passengers died unnecessarily we would rightly be grounded
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They implemented a VAP bundle by displaying copies of the
protocol at every ICU bedside.
Compliance, assessed only periodically, was dismal during this
passive implementation phase and no VAP reduction was seen.
An active implementation phase that included educational
workshops, compliance reporting, addressing barriers to
delivery, and discussion of bundle adherence on daily
multidisciplinary rounds was initiated.
Compliance improved from 0% to 54% and VAP rates decreased
dramatically from 19.17 to 7.5 VAP cases/1000 ventilator days.
Here, the education, feedback, and daily goal-setting were key
to clinical success.
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ID VAP: 19.17 to 7.5
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Key Points for the Implementation
• Identify priority recommendations within the guideline
• Produce guideline in conjunction with an implementation plan for priority recommendations
• Carefully consider how the guideline is presented and how recommendations are phrased
• Involve key stakeholders in production of implementation plan
• Pilot test both the guideline and implementation plan
• Refine guideline and implementation plan before widespread dissemination
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Quality Agency SMoH
HR Department
HR Cordinating
Team Cordinator, ICU physician
ICU nurse, preventivist
ICU-1 ICU-2 ICU-n
Information, engagement
Managers commitment
Leadership
Organize: Functions
Resources distribution
Training
Monitoring
Evaluation reports: results
Structure & Process evaluation
Physician, Nurse, Executive,
infectious diseases comitee
Training
Implementation
Self-evaluation
Improvement
Cofinancing & coordination
Monitoring & spreading
NATIONAL ORGANIZATION
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DEFINE THE BUNDLE
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35 measures Efficaccy Adverse
Ev
Applicability All
Subglotic drainage 70 35 31 136
No Ventilatory circuits changes 76 38 39 171
Oral care with chlorhexidine 74 44 45 163
Control and maintenance of cuff
pressure
61 35 40 136
Endotracheal tubes with silver 39 40 18 97
Kinetics beds 31 10 9 50
Avoid prone position (0º) 56 36 34 126
SDDS 88 36 26 150
SOD 86 38 26 150
ATB iv, (2 days) 72 30 37 139
SPANISH BUNDLE (SEMICYUC-SMoH)
TASK FORCE:
A total of 35 preventive measures selected
Grading of Recommendations Assessment, Development and Evaluation Working
Group methodology.
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Z Programs: Barriers
PROBLEMS
• Problems with definitions
• Problems with CUSP
• Managers involvement
• Lack/ delay of data
• MD reluctant
• Founding didn’t reach ICU
ACTIONS
• Wokshop, training
• Workshop, training
• SMoH, SEMICYUC
• Calls, some ICU excluded
• HR: incentives
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SURVEILLANCE VARIABILITY IN ICU
• SURVEILLANCE METHODS
-Incidence vs prevalence -Patient-based surveillance (individual RF) -Unit-based surveillance (collective RF)
• DEFINITIONS OF INFECTIONS -VAP (clínical vs different microbiológical tests) -Bacteremias (primary vs catheter, patients with catheter vs n of catheters, PIC)
• DURATION OF SURVEILLANCE -Seasonality -Outbreaks -Sample size (>100 pts)
• DEMOGRAPHIC AND FUNCTIONAL DIFFERENCES
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BACTERIEMIA PRIMARIA
BACTERIEMIA ORIGEN DESCONOCIDO
Blood Stream Infection
CRBSI
Central-LineABSI
PRIMARY BACTEREMIA
Positive Hemoculture
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Difference between CDC/NHSN and
HELICS origin of BSI
EU/HELICS-ECDCCDC-DE (KISS)
catheter-”related”BSI (microb. proof (CRI3) or clinical signs)
catheter-”associated” BSI (CVC use in 48h before infection)
Primary BSI
Secondary BSI
BSI of unknown origin
BSI of unknown origin
Other infection with secondary BSI
CR
I3
PUL
UTI
DIG
SSI
SST
OTH
EU/HELICS-ECDCCDC-DE (KISS)
catheter-”related”BSI (microb. proof (CRI3) or clinical signs)
catheter-”associated” BSI (CVC use in 48h before infection)
Primary BSI
Secondary BSI
BSI of unknown origin
BSI of unknown origin
Other infection with secondary BSI
CR
I3
PUL
UTI
DIG
SSI
SST
OTH
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PROMOTERS
SURVEILLANCE NETWORKS
(ENVIN-HELICS, ECDCD)
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LESSONS FROM BZ
Barriers to use Chlorhexidine :
-Not believe in its effectiveness: education
-Difficulties to get it: information
-Dislike colorless: new presentations
-Do not know the standard: education
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BZ: Barriers
PROBLEMS
• Problems with definitions
• Problems with CUSP
• Managers involvement
• Lack/ delay of data
• MD reluctant
• Lack of communication
• Founding didn’t reach ICU
ACTIONS
• Wokshop, training
• Workshop, training
• SMoH, SEMICYUC
• Calls, some ICU excluded
• HR: incentives
• Periodical feed-back
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CUPS BARRIERS
Daily goals
-Difficulties to find the usefull model (Type of ICU)
-Not believe in its effectiveness
-No time to meet nurses/physicians
Safety rounds :
-Difficulties to find the useful model
-Not executive's collaboration
Learning from errors sessions
-Fear of the punishment
-Feeling guilty
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8,57
9,088,78
15,6
14,45
14,74
50,244,9
41,84
39,5
41,541,2
87,486,6
90,3 94,593,8
97,5
88,3
97,998,69
87,9
96,4
99,74
0
20
40
60
80
100
% d
e c
um
pli
mie
nto
RONDAS SESIONES OBJ DIAR CHECK-L BANDEJA CLORHEX HIG BUCAL NEUMOT
2011 2012 2013
CUMPLIMENTACION PSI 2011-2013
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CHECK-LIST BARRIERS
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Check list
Daily goals
CHECK-LIST BARRIERS
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Check list
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Check list
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Check list
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ACCIDENTE BARAJAS.
Ambos pilotos estaban en ese momento con la after start checklist cuando
encontraron un hueco en frecuencia y pidieron rodaje. Tras la petición,
dieron por finalizada la checklist, siendo la última línea, (que se pasaron
por alto) la referente al status de los flaps
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Rebound in VAP rates during a prevention checklist washout period Ali A Cheema et al. BMJ Qual Saf 2011 20: 811-817
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Conocer los factores facilitadores y las barreras en la implementación
de un paquete de medidas para la prevención de la NAV.
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QUESTIONNAIRE
• Adherence to each of the VAP bundle components
• Nurses / physicians
• (adherence + vs.-)
- know the standard
- believe in its effectiveness
- unaware of the consequences
- have time to implement
- have the means to implement
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• Control and maintenance of cuff pressure. (N/P)
• Oral care with chlorhexidine(N/P)
• The use of strict hand hygiene using
alcohol.(N/P)
• The incorporation of sedation and weaning
protocols into patient care.(P/N)
VAP BUNDLE
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DIFFICULTIES FOR BUNDLE COMPLIANCE (QUESTIONNAIRE)
19
14,515,6
34,4
0
10
20
30
40
%
Cuff Clorh HH S/W protocol
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I experience difficulties with the bundle element
Cuff pressure control before situations of risk
Disagreement Lack of time Lack of pneumotac
NURSES
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I experience difficulties with the bundle element Hygiene of the oral cavity with Clorhexidine once per turn
Yes: 14,5%
I don`t know the indication lack of clorhexidine Not my duty
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YES : 15,6%
I experience difficulties with the bundle element
Hand hygiene with alcoholic solutions before handling airway
Lack of time Skin problems
NURSES
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BUNDLE REGISTER (NURSES)
TURN: T-T-S DAY
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 %
Cuff
control
Y Y Y Y Y Y Y Y Y Y 100
Hand
hygiene
Y Y Y Y N Y Y Y Y Y 90
Sedation/
weaning
Y Y N Y N Y N Y Y Y 80
Oral
clorhex
Y N Y Y N N Y Y Y Y 70
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P11 P2 P3 P4 P5 P6 P7 P8 P9 P10 %
Cuff control Y Y Y Y Y Y Y Y Y Y 100
Hand
hygiene
Y Y Y Y N Y Y Y Y Y 90
Sedation/
weaning
Y Y N Y N Y N Y Y Y 80
Oral clorhex Y N Y Y N N Y Y Y Y 70
85%
BUNDLE REGISTER (NURSES)
TURN: T-T-S DAY
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BUNDLE REGISTER (NURSES)
TURN: T-T-S DAY Patients
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10
Cuff
control
Y Y Y Y Y Y Y Y Y Y
Hand
hygiene
Y Y Y Y N Y Y Y Y Y
Sedation/
weaning
Y Y N Y N Y N Y Y Y
Oral
clorhex
Y N Y Y N N Y Y Y Y
% Full
bundle
100 75 75 100 25 75 75 100 100 100
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BUNDLE REGISTER (NURSES)
TURN: T-T-S DAY Patients
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10
Cuff
control
Y Y Y Y Y Y Y Y Y Y
Hand
hygiene
Y Y Y Y N Y Y Y Y Y
Sedation/
weaning
Y Y N Y N Y N Y Y Y
Oral
clorhex
Y N Y Y N N Y Y Y Y
% Full
bundle
100 75 75 100 25 75 75 100 100 100 50%
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Aviation Accidents per million departures
0 10 20 30 40 50 60 70 80
Flight Crew
Airplane
Maintenance
Weather
FAA
Other
Primary accident causes (%)
Courtesy: Chris Goeschel
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Today, pilots can fail their certification based on poor
interpersonal, or “non technical” aspects of their
performance.
Teamwork by Edict:
Focus on interpersonal improvements
Frontline staff must assume responsibility for quality
and safety
Safety interventions must be goal directed
Culture changes incrementally
Document (measure) improvements
Courtesy: Chris Goeschel
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Communication
breakdowns are
frequently the
root cause of…
undesirable
outcomes
Courtesy: Chris Goeschel
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Good teamwork means
I am asked for my input
PHYSICIANS AND NURSES COLLABORATION
Teamwork Disconnect
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Good teamwork means
I am asked for my input
PHYSICIANS AND NURSES COLLABORATION
Teamwork Disconnect
Good teamwork means
the nurse does what I say
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Familiarity with others is a critical
component of effective teamwork
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Familiarity with others is a critical
component of effective teamwork
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BZ: Barriers
PROBLEMS
• Problems with definitions
• Problems with CUSP
• Managers involvement
• Lack/ delay of data
• MD reluctant
• Founding didn’t reach ICU
ACTIONS
• Wokshop, training
• Workshop, training
• SMoH, SEMICYUC
• Calls, some ICU excluded
• HR: incentives
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Senior executive partnership/safety rounds
•Perform monthly safety rounds in which the executive interacts with
staff on the unit and discusses safety issues with them. All staff
should be invited to attend.
•SR bridge the gap between senior leaders and frontline staff.
-executive become more familiar with safety issues at the ground
level
-leader has access to organizational resources that can help
the team to accomplish its safety goals.
•Evidence indicates that rounding with an executive monthly has
increased culture of safety, which in turn reduces infections—and
that sustained rounding with an executive leads to further
improvements
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0,9
8,7
20,1
41,3
1116
0
10
20
30
40
50
60
70
80
90
100
Strongly disagree
Disagree
Indifferent
Agree
Strongly agree
NR
% encuestados
Management / direction only seems interested in patient safety
when an adverse event has occurred
Pilote (2008)
N workers: 438
52,3
Implementation(2009-2010)
N workers:6.629
60,1
2,64
14,8920,2
44,2
15,91
1,8
0
10
20
30
40
50
60
70
80
90
100
Strongly disagree
Disagree
Indifferent
Agree
Strongly agree
NR
% encuestados
60,1
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BZ: Barriers
PROBLEMS
• Problems with definitions
• Problems with CUSP
• Managers involvement
• Lack/ delay of data
• MD reluctant
• Founding didn‟t reach ICU
ACTIONS
• Wokshops, training
• Workshops, training
• SMoH, SEMICYUC
• Calls, some ICU excluded
• HR: incentives
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• The goal was reached at national level:
– Decrease in the rate of BRC,VAP
– Saving costs
– All HR and 70% of the ICU are involved
– Information about ICU, charateristics of BSI, VAP, pattern of resistance
Behaviour changes:
– Informed vs auntonomous decision making
– Decisions based in evidence
– Improvement of the nurses role
• Spread of PSC
– Network for safer care in ICU
– Learning from errors, Using risk management tools
– Learning from others (Benchmarking)
Zero Projects: Success factors
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Promoters
-Leadership (national/local levels)
-Institutional support (managers engagement)
-Consolidated surveillance network (ENVIN)
-In real time feed-back (webb based)
-Meetings (worshops, others)
-Results (BZ -> BZ,RZ higher ICUs participation)
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Medical engagement is a complex technical, socio-
political and motivational issue that is underpinned
by a series of inter-related factors associated with
- the organisational context,
- the design of improvement programmes
- how they are implemented and promoted.