ANTIMICROBIAL STEWARDSHIP AND INFECTION … 3/02...35 measures Efficaccy Adverse Ev Applicability...

Blockers and promoters

ANTIMICROBIAL STEWARDSHIP AND INFECTION CONTROL

MERCEDES PALOMAR

SMI H ARNAU DE VILANOVA (LLEIDA)

Patient Safety: Reporting of Adverse Events Health Policy Reports

Leape L. L. NEJM 2002; 347:1633-1638,

http://content.nejm.org/cgi/content/short/347/20/1633

Theories of error developed in aviation and other high-risk industries

suggest that errors are likely to occur in all complex systems.

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

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.

ID VAP: 19.17 to 7.5

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

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

DEFINE THE BUNDLE

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.

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

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

BACTERIEMIA PRIMARIA

BACTERIEMIA ORIGEN DESCONOCIDO

Blood Stream Infection

CRBSI

Central-LineABSI

PRIMARY BACTEREMIA

Positive Hemoculture

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


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



Other infection with secondary BSI

CR

I3

PUL

UTI

DIG

SSI

SST

OTH

PROMOTERS

SURVEILLANCE NETWORKS

(ENVIN-HELICS, ECDCD)

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

BZ: Barriers

PROBLEMS





• MD reluctant

• Lack of communication


ACTIONS



• SMoH, SEMICYUC


• HR: incentives

• Periodical feed-back

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

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

CHECK-LIST BARRIERS

Check list

Daily goals

CHECK-LIST BARRIERS

Check list

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

Rebound in VAP rates during a prevention checklist washout period Ali A Cheema et al. BMJ Qual Saf 2011 20: 811-817

Conocer los factores facilitadores y las barreras en la implementación

de un paquete de medidas para la prevención de la NAV.

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

• 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

DIFFICULTIES FOR BUNDLE COMPLIANCE (QUESTIONNAIRE)

19

14,515,6

34,4

0

10

20

30

40

%

Cuff Clorh HH S/W protocol

I experience difficulties with the bundle element

Cuff pressure control before situations of risk

Disagreement Lack of time Lack of pneumotac

NURSES

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

YES : 15,6%

I experience difficulties with the bundle element

Hand hygiene with alcoholic solutions before handling airway

Lack of time Skin problems

NURSES

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

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%


TURN: T-T-S DAY


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


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%

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

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


Communication

breakdowns are

frequently the

root cause of…

undesirable

outcomes


Good teamwork means

I am asked for my input

PHYSICIANS AND NURSES COLLABORATION

Teamwork Disconnect

Good teamwork means

I am asked for my input

PHYSICIANS AND NURSES COLLABORATION

Teamwork Disconnect

Good teamwork means

the nurse does what I say

Familiarity with others is a critical

component of effective teamwork

BZ: Barriers

PROBLEMS





• MD reluctant


ACTIONS



• SMoH, SEMICYUC


• HR: incentives

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

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

BZ: Barriers

PROBLEMS





• MD reluctant

• Founding didn‟t reach ICU

ACTIONS

• Wokshops, training

• Workshops, training

• SMoH, SEMICYUC


• HR: incentives

• 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

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)

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.

[email protected]

With adequate lidership, attention

and resources, improvements can be made

ANTIMICROBIAL STEWARDSHIP AND INFECTION … 3/02...35 measures Efficaccy Adverse Ev Applicability...

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