Khalid Aziz November 10, 2006

Nov. 9, 2006 EPIC QI Workshop Slide 1

EPIC/PHSIQuality Improvement Workshop:

Interventions to prevent nosocomial infection and future directions

Khalid AzizNovember 10, 2006


Janeway Children’s Health and Rehabilitation Centre, St. John’s NL


Acknowledgements

Nosocomial infection team centres:

• Children’s & Women’s Health Centre of BC

• Janeway Children’s Health and Rehabilitation Centre

• IWK Health Centre

• Hospital for Sick Children

• St. Joseph’s Hospital

• Royal Alexandra Hospital


Objectives

• Nosocomial infection team interventions

• Methodologies

• Proposed methodologies for future interventions


Interventions

• Teams were involved in developing interventions

• Interventions were truly interdisciplinary

• Interventions applied to diverse groups such as housekeeping, parents, respiratory therapy

• Interventions were made in each institution according to local priorities


Reviews

• Varied in rigour• Local interests• Team interests• Investigation of established reviews (eg CDC

guidelines)• Qualitative themes of focus groups• Literature reviews• Baseline EPIC results


Baseline EPIC results

• PICCs reduce nosocomial infection in some centres

• Positive urine culture is as common as positive blood culture in centres who did both

• Culture negative sepsis and suspected sepsis are a considerable burden in NICU

• Units vary in their use of antibiotics for nosocomial infection, particularly vancomycin and cefotaxime


Baseline data: UAC sepsis


Baseline data: PICC sepsis


Baseline data

Days

Ris

k

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

A

Days

Ris

k

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

B

Days

Ris

k

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

C

Days

Ris

k

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

D

Days

Ris

k

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

E

Days

Ris

k

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

F

Days

Ris

k

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

G

Days

Ris

k

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

H

Days

Ris

k

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

I

Days

Ris

k

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

K

Days

Ris

k

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

L

Days

Ris

k

0 20 40 60 80 100

0.0

0.2

0.4

0.6

0.8

1.0

M

PICC sepsis by centre


List of interventions 1

• Hand hygiene

• Gloves and gowns

• Skin care

• Skin breaks

• Care of PICC lines


List of interventions 2

• Choice of first line antibiotics

• Duration of empiric antibiotic therapy

• Care of ventilator circuits

• Visiting policy

• Staff education


Hand hygiene

• Add alcohol based waterless cleanser to hand cleansing areas/entrances to NICUs/improve availability of alcohol based cleansers/provide staff with 60ml bottles of hand hygiene to be kept on person

• Communicate handwashing protocol

• Increase vigilance in respect to the wearing of jewelry


Gloves and gowns

• Discontinue use of routine gloves and gowns


Skin care

• Cleanse umbilical sites with antiseptic (aquaphor ointment) prior to umbilical line placement

• Infants less than 32 weeks bathed only with warm water (no soap) during 1st week (mineral water prn)

• Use of 2% aqueous chlorhexidine rather than alcohol for skin antisepsis for infants with birth weight less than 1000g


Skin breaks

• Skin break audit

• Compliance with “initiation of peripheral IV therapy policy”

• Reduce number of skin pokes

• Restrict number of pokes to 1-2 per person

• Restrict number of staff participating in the process

• Implement algorithms for blood sampling and IV starts: both algorithms define number of pokes per person and number of people participating


Skin breaks (pokes audit)

Average Pokes/Baby/Day for the First Two Weeks of Admission

0

0.2

0.4

0.6

0.8

1

1.2

Dec'04 Feb'05 April'05 June'05 Aug'05 Oct'05 Dec'05 Feb'06 April'06

Month

Av

era

ge

Po

ke

s/B

ab

y/D

ay


Skin breaks (IV starts audit)

Average IV Starts/Baby/Day for the First Two Weeks of Admission

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Dec'04 Feb'05 April'05 June'05 Aug'05 Oct'05 Dec'05 Feb'06 April'06

Month

Av

era

ge

IV S

tart

s/B

ab

y/D

ay


Care of PICC lines

• PICC line insertions restricted only to nurses who have been certifiedreduce

• PICC line dressings to prn

• Observe CDC guidelines for central lines


Choice of first line antibiotics

• On admission: ampicillin and gentamicin

• Change first line abx to cloxacillin and gentamicin for suspected nosocomial sepsis until blood culture sensitivities received or unless the neonate has septic shock, suspected meningitis or necrotizing enterocolitis (then vancomycin and/or cefotaxime

• Caremap for choosing antibiotics


Choice of first line antibiotics


Duration of empiric antibiotic therapy

• Discontinue antibiotics if blood cultures are negative after 36 hours (assuming the baby is well)


Duration of empiric antibiotic therapy

6

75

48

20

0 1 0 00

10

20

30

40

50

60

70

80

12 24 36 48 60 72 96 More

Hours

Fre

qu

en

cy


Care of ventilator circuits

• Change ventilator circuits when visibly contaminated, malfunctioning, and between patients


Visiting policy

• 2 visitors per neonate in NICU at any one time


Staff education

• Encourage staff influenza immunization


Future directions

• Revisions

• New interventions

• Standardization of reviews


Revisions

• New information since 2001

• Greater rigour

• Interprofessional approaches

• Site-specific issues

• Larger pool of reviewers

• New expertise in larger number of centres


New interventions

• 5 years more of clinical studies (e.g. caffeine)

• New systematic reviews

• Data from EPIC-1 (e.g. benefits of PICC placement, incidence of UTI)

• Larger pool of participants for hypothesis generation

• “Ownership” of CNN database


Standardization of reviews

What might the advantages be to standardization of the review process?

• Ease of review

• Ease of cataloguing and presentation

• Ease of revision


Standardization of reviews

What might the disadvantages be of a standardized approach?

• Need to encompass qualitative and quantitative data

• Appears challenging to non-academic reviewers

• Time-consuming, particularly when a review or guideline already exists (do we need to re-review the original studies?)


Suggested review methodologies

• Adaptation of an existing guideline(s) (eg CDC guideline on central line care)

• The ILCOR methodology (as used by the International Liaison Committee on Resuscitation for the 2005 recommendations)

• Informal methodologies


The ILCOR Consensus Process

Step 1 State the proposal

************

Step 2 Assess the quality of each study

************

Step 3 Determine the class of recommendation



Step 1A. Refine the research question(s)Step 1B. Gather the evidence

************Step 2A. Determine the level of evidence (levels 1-8)Step 2B. Critically assess each article for quality of

design & methodsStep 2C. Determine the direction of the results/statisticsStep 2D. Cross-tabulate by level, quality and direction;

combine & summarize************

Step 3. Determine the Class of Recommendation


The ILCOR Consensus ProcessStep 1: State the Proposal

“To create a new guideline encouraging the use of continuous positive airway pressure (CPAP) or positive end expiratory pressure (PEEP) during neonatal resuscitation in the delivery room, particularly for very premature infants.”


Step 1A. Refine the research question(s)

• During the resuscitation of very premature infants the use of CPAP will reduce the baby’s oxygen requirements and the need for ventilation.

• The use of either CPAP or PEEP during the resuscitation of very premature infants at birth will reduce the proportion requiring oxygen when they reach the equivalent of 36 weeks gestation.




Step 1B.Gather the evidence

• Search with MESH headings all fields: CPAP AND resuscitation limited to the first 28 days, PEEP AND resuscitation limited to the first 28 days, neonatal resuscitation, delivery unit AND resuscitation.

• Cochrane database of systematic reviews.


The ILCOR Consensus ProcessStep 2: Assess the quality of each study

Step 2A. Determine the levels of evidence



Step 2A. Determine the levels of evidence



Step 2B. Critically assess each article for quality of design & methods



Step 2C. Determine the direction of the results/statistics



Step 2D. Cross-tabulate by level, quality and direction; combine and

summarize


The ILCOR Consensus ProcessStep 3: Determine the class of recommendation


Converting the scientific recommendations into clinical implications.

Ultimately, no recommendation was made to use CPAP on its own as a means of resuscitating babies.

The ILCOR Consensus ProcessConclusion(s)


Common sense.

Inadequate or no evidence.

Practised in centres with best outcomes.

“Informal” methodologies


Questions???

Khalid Aziz November 10, 2006

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Transcript of Khalid Aziz November 10, 2006