Preventing “Healthcare Associated Infections”- Is it knowledge deficit or Culture???

PRESENTED AT TAWAM HOSPITAL’S INFECTION CONTROL STUDY DAY

22ND OCTOBER 2013

Krish Sankaranarayanan MS, MBA, CPHQ

Senior Safety Officer, Tawam Hospital. UAE

Introduction-About me

• Been in healthcare domain for over 24 years.• Triple Masters degree.• MS in Patient Safety Leadership from UOI- Chicago.• Certified Professional in Healthcare Quality (CPHQ)• Educational consultant- Canadian Healthcare

Association- Risk Management & CQI program• Member Patient Safety Task Force- American Society for

Healthcare Risk Management • 2009-Received $ 10,000 scholarship from IHI to attend

the Patient Safety Executive Development Program at Boston.

• Noted regional and international speaker “Culture of Safety” and “Disclosure of Medical Errors.”

Introduction-About me…Contd

• Membership– Member American College of Healthcare Executives– Member National Association of Healthcare Quality – Member American Society for Healthcare Risk Management – Member American Society of Professionals in Patient Safety– Vice President of the ACHE Middle East and North Africa Group

• Publication– Gurdeep S. Dhatt, Hassan Abu Damir, Steven Matarelli, Krishnan Sankaranarayanan, and

David M. James “Patient safety: patient identification wristband errors”. Clin Chem Lab Med. 2011 May;49(5):927-9. Epub 2011 Feb 3.

– Krishnan Sankaranarayanan, Steven A. Matarelli, Hasrat Parkar, and Mamoon Abu Haltem “From Blame to Fair and Just Culture: A Hospital in the Middle East Shifts Its Paradigm.” PSQH. 2013 July/August; pg 30.

– Krishnan Sankaranarayanan and Steven A. Matarelli, “Putting a SMILE on the Culture of Safety frame work.” Arab Medical Hygiene 2013 October; pg 28

Pledge

I will……

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Items for discussion

• Ice breaker– Video: Capt. Chesley "Sully" Sullenberger

• Why is healthcare unsafe?– Healthcare Associated Infections Definitions– Facts and figures

• Tools & Techniques to prevent Healthcare Associated Infections

Capt. Chesley "Sully" Sullenberger- Video

Ice- breaker

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Hippocratic Oath

5th century BC -Physicians and other healthcare professionals swearing to practice medicine honestly

Florence Nightingale -The founder of modern nursing

1863-“the very first requirement in a Hospital is that it should do the sick no harm

Dr. Ernest Codman

1905 started "end result idea.“ Hospital standardization. Doctors should follow up with all patients to assess the results of their treatment and that the outcomes actively be made public.

How is it that aviation became safer than healthcare ???

High Reliability Organizations

Zero compromise to safety

So……Why is healthcare unsafe?

The patients saw an average of 17.8 health professionals during their hospitalization1

1Whitt N, Harvey R, McLeod G, Child S. How many health professionals does a patient see during an average hospital stay? NZMJ 4 May 2007; Vol 120 No 1253

Healthcare Associated Infections- HAIs

Healthcare Associated Infection- Definition

• The World Health Organization– Health care-associated infection (HCAI), also

referred to as "nosocomial" or "hospital" infection, is an infection occurring in a patient during the process of care in a hospital or other health care facility which was not present or incubating at the time of admission.

• Centers for Disease Control and Prevention– Healthcare-associated infections (HAIs) are

infections that patients acquire during the course of receiving treatment for other conditions within a healthcare setting

FACTS And FIGURES- U.S. Hospital-Acquired Infections

• HAIs are the fourth leading cause of death in the USA.2

• 1.8 million patients suffer annually from care-related infections.

• HAIs cause 99,000 deaths every year• HAIs cost $3.1 billion dollars in excess

healthcare costs in acute care hospitals alone.

• HAIs kill more people than AIDS, breast cancer and auto accidents combined

2www.cdc.gov/ncidod/dhqp/healthDis.html

FACTS And FIGURES-

• 271 people died each day from healthcare-associated infections (HAIs) such as Methicillin-resistant Staphylococcus aureus (MRSA) infections.

• Equivalent to one airline crash per day

World Health Organization

• WHO estimates that HAIs results in3 – Prolonged hospital stays– Long-term disability– Increased resistance of microorganisms to

antimicrobials– Massive additional costs for health

systems– High costs for patients and their family,

and – Unnecessary deaths.

3http://www.who.int/gpsc/country_work/burden_hcai/en/

Healthcare Associated Infection- HAI

• Central line Associated Blood Stream Infection- CLABSI

• Surgical Site Infection-SSI• Cather Associated Urinary Tract

Infection-CAUTI• Ventilator Associated Pneumonia -VAP

Dangerous environmentSpread of infection- Video

Tools & Techniques To Prevent Healthcare Associated Infections

Accreditation programs -Seeking gold standards

Patient Safety Goals

Technology support

Sharps disposal box

Hand sanitizer dispenser

Antimicrobial Stewardship

• Antibiotic stewardship refers to a set of coordinated strategies to improve the use of antimicrobial medications with the goal of enhancing patient health outcomes, reducing resistance to antibiotics, and decreasing unnecessary costs.

• The Infectious Diseases Society of America (IDSA)

• http://www.antimicrobialstewardship.com/

Are these tools and techniques sufficient to prevent & eliminate HAIs?

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Building a Culture of Safety

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Johns Hopkins MedicineComprehensive Unit-based Safety Program (CUSP)

6-step safety programStep 1: Safety Attitude Questionnaire (SAQ) Step 2:Staff education on the Science of SafetyStep 3: 2-item Staff Safety Survey

▪ Please describe how you think the next patient in your unit/clinical area will be harmed?

▪ Please describe what you think can be done to prevent or minimize this harm?

Step 4: Executive Walk RoundsStep 5:

a) Learning from defects b) Improving teamwork and communication

Step 6 : Resurvey staff about Safety Culture (annually)

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Twelve CUSP units

Culture linkages to Clinical, Operational & other Outcomes4

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• Wrong Site Surgeries• Decubitus Ulcers • Delays• Bloodstream

Infections• Post-Op Sepsis• Post-Op Infections• Post-Op Bleeding• PE/DVT• RN Turnover• Absenteeism• VAP

• Burnout• Unit size• Communication

breakdowns• Familiarity• Spirituality

4Colla JB et al. 2005. “Measuring patient safety climate: a review of surveys.” Qual Saf Health Care, 14:364–366

HAI- Central Line Associated Blood Stream Infection (CLABSI)

• CLABSI – Attributable mortality: 9-25%5

– Attributable cost: $25,000-$45,0006

– Of patients who get a bloodstream infection from having a central line, up to 1 in 4 die.7

• CMS Medicare and Medicaid no longer pays hospital for CLABSI

5Dumont, C. & Nesselrodt, D. 2012. Preventing CLABSI: Central line-associated bloodstream infections. Nursing2012, 6.6Graves N, Weinhold D, Tong E, et al. Effect of healthcare-acquired infection on length of hospital stay and cost. Infect Control Hosp Epidemiol 2007;28:280–292.7CDC Vital Signs. Making healthcare safer: reducing bloodstream infections. March 2011. Available at: http://www.cdc.gov/VitalSigns/Issues.html

CLABSI Prevention Techniques5

1. Wash Hands Prior to Procedure

2. Use Maximal Barrier Precautions

3. Clean Skin with Chlorhexidine

4. Remove Unnecessary Lines

5. Avoid Femoral Lines

5Dumont, C. & Nesselrodt, D. 2012. Preventing CLABSI: Central line-associated bloodstream infections. Nursing2012, 6.

Lessons from aviation- Use of checklists

Central line insertion checklist

Central line maintenance checklist

Electronic Checklist

Other techniques

• Chlorhexidine Bathing

• Chlorhexidine Impregnated Sponges and Antisepctic Coated Catherters.8

• Alcohol-impregnated disinfection caps

8Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheterrelated infections in critically ill adults: a randomized controlled trial. JAMA 2009;301:1231–1241

ICU -VAP & CLABSI

2006 2007 2008 2009 2010 2011 20120

5

10

15

2017.3

5.5

2.34.2

5.3

2 1.8

Ventilator Associated Pneumonia -ICU

Ventilator Associated Pneumoni...

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ctio

ns/1

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ays

2010 2011 20120

0.10.20.30.40.50.60.70.80.9

0.5

0.700000000000001

0.8

Central Line Associated Blood Stream Infections - ICU

Rate/1000 device days

Infe

ctio

ns/

1000

dev

ice

days

2011 201288899091929394959697

91

96

ICU Average Rate for VAP Bundle Compliance

2011 201282

84

86

88

90

92

94

86

93

ICU Average Rate for CVL Bundle Compliance

2009 2010 20110

0.2

0.4

0.6

0.8

1

1.2

0

1

0.3

Ventilator Associated Pneumonia -NICU

year

Infe

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000

devi

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ays

2009 2010 20110

1

2

3

4

5

6

76 5.9

3.6

Central Line Associated Blood Stream In-fections -NICU

yearIn

fect

ions

/100

0 de

vice

day

s

NICU -VAP & CLABSI

Following High Risk Industry Model

Replicating the same for CLBASI Free Days

48

NNU CLABSI Free Days

49

PICU CLABSI Free Days

50

ICU CLABSI Free Days

CUSP Team with the ICU Executive - COO

PICU & ICU- CLABSI Free Days

CLABSI- Conversation tool 9, 10

1. What is the prevailing CLABSI rate in the unit?

2. What is the CLABSI rate goal for the unit?

3. Do providers routinely use head-to-toe drapes?

4. How many drapes were used to cover the patient from head -to-toe?

5. Does the unit have a guideline to remove femoral catheters as soon as possible?

6. What is the level of compliance from providers?

7. Does the unit have guidelines to check on a daily basis whether lines can be removed?

8. Does the unit have a central line insertion checklist? Do providers routinely use the checklist?

9. Does the unit have a central line maintenance checklist? Do providers routinely use the checklist?

10.When inserting a central line, do staff have access to line cart and equipment’s that they need?

9Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ2008;337:963-510Tools for Reducing Central Line-Associated Blood Stream Infections. January 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum- tools/clabsitools/index.html

CLABSI- Conversation tool……contd

• To increase staff awareness • To ensure staff active involvement• To ensure conscientious implementation

“I Watch The Line” Campaign- Video

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Opportunities for improvement “I Watch The Line”- Campaign

• To increase staff awareness • To ensure staff active involvement• To ensure conscientious implementation

ICU NNU PICU

CLABSI Badge Competition

Discussions- Simple strategies

Simple strategies to prevent Healthcare Associated Infections

• Strict hand hygiene before and after contact with each patient or their environment

• Adequate hand hygiene facilities for staff and patients

• A clean hospital environment and good hygiene practice

• Isolation of patients in single rooms, when necessary, to reduce the risk of infection

• Careful prescription of antimicrobial drugs• Training on infection prevention and control for all

staff

Five moments of hand hygiene

Complete the pledge

I will……

Thank You

Email- ksankara@tawamhospital.ae Cell # 050 9211649