Don’t Shoot the Messenger: Being an MD Champion for

HAI Prevention

Philip Robinson, MD Medical Director, Infection Prevention Hoag Memorial Hospital Presbyterian

Hoag Orthopedic Institute

No Disclosures June 10, 2015

Ignas Simmelwise

Objectives • Tailor your message

– Example: Business case

• Be a solder in the trenches

– “Tribe on Tribe” – speaking the same “language”

• Provide solid actionable data and make it personal – data alone does not change behavior

– VAP

– Hand hygiene

– Antibiotic Exposure -- Procalcitonin

Hand Hygiene Adherence in Hospitals

1. Gould D, J Hosp Infect 1994;28:15-30. 2. Larson E, J Hosp Infect 1995;30:88-106. 3. Slaughter S, Ann Intern Med 1996;3:360-365. 4. Watanakunakorn C, Infect Control Hosp Epidemiol 1998;19:858-860. 5. Pittet D, Lancet 2000:356;1307-1312.

Year of Study Adherence Rate Hospital Area

1994 (1) 29% General and ICU

1995 (2) 41% General

1996 (3) 41% ICU

1998 (4) 30% General

2000 (5) 48% General

HHNB Percent Hand Hygiene Compliance Over

Time Exiting and Entering a Patient's Room

0

10

20

30

40

50

60

70

80

90

100

9-Dec 10-May 10-Jul 10-Nov 11-Mar

Perc

en

tag

e

Nursing

MD

RCP

Other

New Hand

Hygiene

Campaign

begins

I just threw you under the bus. by Stephen Lindsay, MD

Phil:

I was at the PEC and the abysmal performance of the physicians hand hygiene became the subject of much discussion. Some wanted heads, others were content with a blood offering from the jugular of dirty handed physicians. In order to appease the enraged MOB before they charged out of the Board room looking for victims, I proposed that our loved infection prevention physician (you) develop a proposal and bring it to MEC for discussion. This calmed the MOB but only for a time. They want sanctions with teeth! Please help me.

Chief of Staff

Dear Chief:

• My team’s familiar with the underbelly of the bus.

• Sorry that I was not present to shield you from this reaction to quarter old data.

• I hope you, PEC and the Board, will take comfort in the success of our most recent interventions and our latest hand hygiene audit results.

• Nonetheless, we agree that a few members of the medical staff may require some special attention to propel us and keep us above our 90% goal.

Phil

Getting to 100%

• Individual accountability

• Constant Reinforcement, Reminders

• Peer monitoring

• Rewards

Figure from Kirkland KB, et al. BMJ Qual Saf 2012;21:1019-26.

HHNB Healthcare Acquired VRE

and Hand Hygiene Compliance

56

41 43

71

0123456789

10

3W S

IC

4 W

CCU/C

VIC

U

5 W

est

6 W

est

7 W

est

8 W

est

9 W

est

SNIC

U

Unit

# H

ealt

hcare

Acq

uir

ed

VR

E

0102030405060708090100

% H

H C

om

pli

an

ce

Healthcare

Acquired VRE

Hand Hygiene

Compliance

Clinical Outcomes Related to Hand Hygiene at Hoag

Noncompliant Medical Staff

• IP will record and report names of those that are observed noncompliant

• List will be maintained by Medical Staff and Infection Prevention

• List to be presented to MEC at least quarterly

• Hand hygiene “school”

HHNB Percent Hand Hygiene Compliance Over

Time Entering and Exiting a Patient's Room

0

10

20

30

40

50

60

70

80

90

100

Mar

-12

Jun-

12

Sep

-12

Dec

-12

Mar

-13

Perc

en

tag

e

Nursing

MD

RCP

Other

;

HHNB Percent Hand Hygiene Compliance Over

Time Entering and Exiting a Patient's Room

0

10

20

30

40

50

60

70

80

90

100

Mar

-12

Jun-

12

Sep

-12

Dec

-12

Mar

ch 1

013

Perc

en

tag

e CCU/CVICU

ICU

6th Floor

8th Floor

ED

NICUQ1FY2010

Infections Prevented and Value Gained FY2010 Baseline Infections FYQ3-08 to FYQ2-09

Infections

FY1Q-10

Infections

FY2Q-10

Infections

FY3Q-10

Infections

FY4Q-10

Ventilator Pneumonia 13 3.3 5 6 3 3 Central Line

Infection 22 5.5 5 4 5 7 Urinary Catheter

Infection 92 23.0 5 8 15 12 MRSA

(Resistant Staph) 61 15.3 15 14 15 10

VRE (Resistant Enterococcus)

13 3.3 5 8 4 7 CDIFF

(Clostridium difficile) 89 22.3 20 13 13 5

Cost per Quarter $965,180 $924,245 $803,786 $737,052 $573,231

Savings and Value per Quarter

NA $40,935 $161,394 $228,128 $391,949

Patients Saved from Infections

NA 18 20 18 29

Bundle Score Updated 10/22/2010

2.43 (%Reduction) 290 infections/ 119,391 pt. days x

1,000

Baseline

1.81 (26%) 55 infections/30,345 pt.

days x 1,000

1.75 (28%) 53 infections/30,233 pt.

days x 1,000

1.85 (24%) 55 Infections/29,753 pt.

days x 1,000

1.44 (41%) 44 Infections/30,587 pt.

days x 1,000

Totals for FY2010 YTD Bundle Score = 1.71 (30% reduction)

YTD Patients Saved from infection = 83

YTD Savings and Value Added = $822,406

Year Ave. Qtr.

Healthcare Acquired Infections -- Harm Avoidance

Hoag Hospital Newport Beach/ Hoag Hospital Irvine

97.00

97.50

98.00

98.50

99.00

99.50

100.00Q

tr 1

FY

10

Qtr

2

Qtr

3

Qtr

4

Qtr

1

FY

11

Qtr

2

Qtr

3

Qtr

4

Qtr

1

FY

12

Quarter

Infe

cti

on

s P

rev

en

tio

n H

arm

In

dex

10

0 =

Zero

In

fecti

on

s

Rate of No Infections per 1000

Patient Days

VAP 0 Landon, 6 days old, CLABSI

Alfred, 83, CAUTI

Yasuo, 70, CAUTI

Hung, 50, CAUTI

Edith, 64 CAUTI

Catalina, 89, CAUTI

Rosa, 59, CAUTI

Rozita, 30, CAUTI

Larry, 40, MRSA

Anthony, 79, CAUTI

Violeta, 47, CAUTI

Alfred, 72, CAUTI

Dorene, 73, MRSA Donald, 69, MRSA

Richard, 44, MRSA

Philip, 81, C diff

Susan, 59, C diff

Yasuo, 70, C diff

Theodore, 92, MRSA Barbara, 84, C diff

Ruth, 88, VRE

Jonathan, 43, C diff

Mona, 86, C diff

Edward, 87, CAUTI

Elizabeth, 80, C diff

Michele, 44, MRSA

Elizabeth, 58, C diff

Tooran, 99, C diff Vinay, 63, CLABSI Phillip, 69, C diff

Karen, 67, CLABSI

Mary, 67, C diff

Aileen, 54, C diff

James, 76, MRSA Wilton, 84, C diff

Albert, 79, C diff

Antibiotic Overuse

• “It has been recognized for several

decades that up to 50% of antimicrobial

use is inappropriate” • Given when they are not needed

• Continued when they are no longer necessary

• Given at the wrong dose

• Broad spectrum agents are used to treat very

susceptible bacteria

• The wrong antibiotic is given to treat an infection

http://www.journals.uchicago.edu/doi/pdf/10.1086/510393

IDSA/SHEA Guidelines for Antimicrobial Stewardship Programs

Antibiotics prescribed for colds

NOTES: Includes antibiotics ordered or provided solely for cold symptoms during emergency department, outpatient, and physician visits. SOURCE: CDC/NCHS, Health, United States, 2013, Figure 26. Data from the National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey: Emergency Department and Outpatient Components.

JAMA. 2009 Sep 9;302(10):1059-66.

Effect of procalcitonin-based guidelines vs

standard guidelines on antibiotic use in lower

respiratory tract infections: the ProHOSP

randomized controlled trial.

Schuetz P, Christ-Crain M, Thomann R, Falconnier

C, Wolbers M, Widmer I, Neidert S, Fricker T, Blum

C, Schild U, Regez K, Schoenenberger R, Henzen

C,Bregenzer T, Hoess C, Krause M, Bucher

HC, Zimmerli W, Mueller B; ProHOSP Study Group.

What is Procalcitonin?

• Precursor to thyroid hormone calcitonin.

• PCT levels rise rapidly in presence of bacterial infection.

• Falls quickly in response to appropriate antibiotic therapy

• Most importantly, PCT remains low in viral illness, making it a unique acute phase reactant that can potentially distinguish bacterial from viral infections

Thyroid

Brahms PCT. http://www.procalcitonin.com 2009

Study protocol for intervention

group (PCT group)

Primary outcome

OR 0.76 (95%

CI 0.57-1.01),

favoring PCT

group

Secondary outcomes

Hoag’s PCT Background

• Intensivists were using procalcitonin assay (PCT)

• Send-out test with 1-3 day turn-around time.

• Challenge: Administration resistant bringing test in-house (cost, bench space, human resources, etc)

• Chart review (n = 20) showed a theoretical reduction in antibiotic treatment duration if PCT result was real-time.

• Leadership approved in-house PCT assay with a 2 hour turn-around time.

– $45 cost per test

– Proof of cost effectiveness requested 1. Nobre V, Harbarth S. Graf J, et al. Use of procalcitonin to shorten antibiotic treatment duration in septic patients.

American Journal of Respiratory and Critical Care Medicine. 2008: 177:498 – 505.

Methods--Patients

• Inclusion: – Pneumonia (ICD-9). – Infectious Disease (ID) Consult and/or

Intensive Care Unit (ICU) Stay.

• No PCT Group – July 1, 2008 to December 31,

2008.

• PCT Group – July 1, 2010 to December 31,

2010.

Diagnosis of Pneumonia

PCT (ng/mL) Interpretation Antibiotic

Suggestion Start

Antibiotics?

< 0.1 Indicates absence

of bacterial infection.

Antibiotics strongly discouraged.

NO!

0.1 – 0.25 Bacterial infection

unlikely. Antibiotics

discouraged. No.

≥ 0.25 - < 0.5 Bacterial infection

possible. Antibiotics

encouraged. Yes.

≥ 0.5 Suggestive of the

presence of bacterial infection.

Antibiotics strongly recommended.

YES!

Brahms PCT. http://www.procalcitonin.com 2009 PCT pneumonia chart http://www.procalcitonin.com/default.aspx?tree=_3_2&key=product_ab_treatment Brahms PCT. http://procalcitonin.com/

Study Profile

84 patients evaluated for inclusion

241 patients evaluated for inclusion

No PCT Group PCT Group

175 patients not eligible Did not have Critical Care

Stay or ID Consult

34 patients not eligible Did not have Critical Care

Stay or ID Consult

116 patients included in the study

Average Antibiotic Days

N = 116 No PCT

(n = 66)

PCT

(n = 50)

p-value

Antibiotic days 11.2 ± 7.1 7.6 ± 7.6 0.004

Data are mean ± SD.

Comparison of Average Antibiotic Days Between Groups

11.2

7.6

0

2

4

6

8

10

12

14

No PCT Group PCT Group

PCT Group

Ave

rage

Ant

ibio

tic

Day

s

No PCT Group

PCT Group

Average Antibiotic Cost

N = 116 No PCT

(n = 66)

PCT

(n = 50)

p-value

Average Antibiotic Cost ($)

926 ± 881 622 ± 528 0.023

Comparison of Average Antibiotic Days Between Groups

926

622

0

100

200

300

400

500

600

700

800

900

1000

No PCT Group PCT Group

PCT Group

Ave

rage

An

tib

ioti

c D

ays

No PCT Group

PCT Group

Data are mean ± SD

91

74

52

41

27 24

9

54

42

3224

1610

4

100100

0

10

20

30

40

50

60

70

80

90

100

AB

Started

>4 >6 >8 >10 >12 >14 >21

Antibiotic Days

Pat

ien

ts o

n A

nti

bio

tics

(%

)

NP group

P group

Median antibiotic DOT was 6 days in the P group and 9 days in the

NP group (95% confidence interval [CI] 1.20 to 6.02, p = 0.004)

IMPACT OF THE USE OF PROCALCITONIN ASSAY IN HOSPITALIZED ADULT

PATIENTS WITH PNEUMONIA AT A COMMUNITY ACUTE CARE HOSPITAL

Impact of the Use of Procalcitonin Assay in Hospitalized Adult Patients with Pneumonia at a Community Acute Care Hospital; Janet L.

Kook, Stephanie R. Chao, Jennifer Le and Philip A. Robinson; Infection Control and Hospital Epidemiology, Vol. 33, No. 4, Special Topic

Issue: Antimicrobial Stewardship, April 2012, pp. 424-426

Overall Ventilator Bundle Compliance

0

10

20

30

40

50

60

70

80

90

100

Perc

en

t C

om

pli

an

ce

HOB Oral

Hygiene

Sedation

Vacation

Peptic

Ulcer

DVT

Proph.

RED = Baseline April/May BLUE = Oral Hygiene Audit June

GREEN = Bundle Re-audit September Updated

10/29/10

ICU, CCU and CVICU; April 20 to Sept 30, 2010

Hourly Oral Hygiene Compliance

0

10

20

30

40

50

60

70

80

Perc

en

t C

om

pli

an

ce

0 to 4 4 to 8 8 to12 12 to 16 16 to 20 20 to 24

Hour (0 or 24 is midnight, 12 is noon)

136 audits in ICU, CCU and CVICU; April 20 to May 3, 2010

VAP Prevention

Oral Hygiene Compliance

2010

45

6262

66

82

0

25

50

75

100

CCU/CVICU-HHNB ICU-HHNB CCU-HHI

Hospital Unit

Perc

en

t C

om

plian

ce

June

September

Overall Ventilator Bundle Compliance

0

10

20

30

40

50

60

70

80

90

100

Perc

en

t C

om

plian

ce

HOB Oral

Hygiene

Sedation

Vacation

Peptic Ulcer DVT Proph.

Updated

10/15/13

2010-2013

Red = April/May 10

Blue = June 10

Green = Sept. 10

Yellow = Jan. 11

Orange = April 11

Purple = May 12

Pink= Nov 12

Lavender = June

2013