Patient Safety - Infection Prevention
Donna Armellino, RN, DNP, CICVice President, Infection Prevention
North Shore – LIJ Health System
Deep incisional SSI
Organ/space SSI
Superficial incisional SSI
• Data is collected by staff that has certification by the Certification Board of Infection Control and Epidemiology, Inc.
Infection Surveillance
• Definition for healthcare-associated infections are from the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN)
• Information used to screen for cases includes laboratory data, admission diagnosis, readmission data, Emergency Department chief complaint, return to the operating room, etc...
Healthcare-Acquired Infection (HAIs) Central Line Associated
Bacteremias (CLABSI)– Intensive Care Units (ICU)– Non-ICU
Ventilator Associated Pneumonias (VAPs)
– ICU– Non-ICU
Surgical Site Infections (SSIs) Select or all high volume
procedures
Catheter Associated Urinary Tract Infections (CAUTI) ICU Non-ICU
Methicillin Resistant Staphylococcus aureus (MRSA) infections and colonization Facility-wide
Clostridium difficile Facility-wide
3
Required HAI Monitoring and Reporting• New York State Department of Health (NYSDOH) and Center
for Medicare & Medicaid Services (CMS) Through the National Healthcare Safety (NHSN):
– Surgical procedure monitored and SSIs reported based on ICD-9 codes for:
• Hip• Colon * CMS 01/01/12• Cardiac• Hysterectomies *CMS 01/01/12
– Other HAIs:• Central line-associated bacteremias (CLABSI) *CMS 01/01/11 - ICU• Catheter-associated urinary tract infection (CAUTI) *CMS 01/01/12 – ICU
only• Clostridium difficile
HAI Data Comparison
• NHSN:– SSI comparison to other reporting facilities within the
United States is with a Standard Infection Ration (SIR):• The SIR adjusts for patients of varying risk within each facility. • An SIR > 1.0 indicates that more SSIs were observed than
predicted and a SIR < 1.0 indicates that fewer SSIs were observed than predicted.
• New York State Department of Health– Report using upper and lower confidence levels and the average for
the NYSDOH – below, average, and higher than the NYS average.
HAI Sample NHSN Data
More information can be found at:http://www.cdc.gov/nhsn/PDFs/dataStat/NHSN-Report_2010-Data-Summary.pdf
HAI Sample NYSDOH Data
More information can be found at: http://www.health.ny.gov/statistics/facilities/hospital/hospital_acquired_infections
HAI Impact
• Potentially preventable HAIs cause patient harm:
– morbidity– mortality– increased length of stay– Increase health care cost
Health System Facilities CLABSI Free Months
• Intensive Care Unit (ICU)– Glen Cove - >41 months – Forest Hills - >6 months– Huntington ICU - > 24 months– Southside ICU – 9 months– Long Island Jewish 2 ICUs - >24 months– North Shore University Hospital PICU - >14 months & NSCU - >6
months
• Non-ICU– Glen Cove - >18 months– Syosset - >22 months– Franklin - >6 Months– Medical & Adolescent – >24 months
3.25 3.21
2.031.8
1.231.45
1.091.39
0
0.5
1
1.5
2
2.5
3
3.5
2004 2005 2006 2007 2008 2009 2010 2011
From September 2005 to December 2008, central line insertion bundle compliance increased from 25% to >80%.
CLABSI: 2004 - 2011
ICU CLABSI per 1,000 Central Line Days
Change: 2005 through 2008
11
• Central line insertion and dressing kit with chlorhexidine/alcohol• Standardized evidence-based central line protocol• Antiseptic-impregnated catheters for high risk patients • Insertion bundle checklist (skin preparation with chlorhexidine,
use of barriers when inserting, site selection, daily assessment)• Procedure “STOP” when there is a break in insertion technique• Antiseptic dressings/impregnated chlorhexidine disk• Needless connectors (neutral pressure)• Scrub the hub or alcohol cap• Daily chlorhexidine baths• Simulation to increase competency
Standards of Practice: CLABSI
Journey Toward Zero – Ongoing Learning
CLABSI
IV tubing not changed on a timely basis
Line in for too long
Dressing not change using aseptic
techniques
IV tubing not labeled properly to change
Line not manipulated appropriately
Injection hubnot disinfected
Not compliant with hand hygiene
Line inserted w/o sterile technique
Inadequate use of maximal barrier
precautions
Inadequate prep before insertion
Femoral line chosen instead of subclavian
Inexperienced residents and
clinicians
Clinicians not knowledgeable about
Central Line Bundle
Nurses do not properly know how to change
dressings
MD does not select a catheter with the least
number of lumens
Clinicians unaware of line maintenance
LINE MAINTENANCE TECHNIQUENOT ADEQUATE LACK OF EDUCATION
CLABSI
Assessment:
Identification of
patterns or
trends
CAUTI Process Change = Outcome Change
Syosset Hospital – infection
Baseline* (Feb. 2011 – July 2011) Post-intervention* (Aug. 2011 – Feb. 14, 2012)
Southside Hospital – device utilization
Plainview Hospital – device utilization
LIJ – infection decrease
• Place indwelling urinary catheters only when indicated:– Urinary tract obstruction– Gross hematuria– Neurogenic bladder with retention– Urologic surgery or studies– Hospice, Comfort or Palliative Care (if patient requests)
• When inserted adhere to:– Hand hygiene– Aseptic technique when inserting– Maintain indwelling urinary catheter based on center for Disease
Control and Prevention guidelines– Review the need for indwelling urinary catheters daily and remove
when no longer needed
Standard of Practice: Indwelling Urinary Catheter
• Use of an alcohol-containing antiseptic agent for preoperative skin preparation.
• Preoperative bathing or showering for 3 days prior to surgery with:– 2% CHG impregnated wipe, or– 4% Chlorhexidine Gluconate soap
• Nasal Staphylococcus aureus screening and use of intranasal Mupirocin for 5 days
• Surgical Care Improvement Project (SCIP) practices: • Appropriate use of prophylactic antibiotics
• dosing• selection• timing prior to incision• re-dosing based on the facility protocol
• Appropriate hair removal
Joint Project Bundle
Potential Avoidance: Case Review
• Patient: 67 year-old male • Past Medical History: chronic obstructive pulmonary disease,
elevated blood pressure, and osteoarthritis • Surgical History: open reduction and internal fixation (ORIF)
for a tibia fracture on 08/25/11 following a motor vehicle accident
• Post-operatively: Uncomplicated admission and was discharged home
• Readmission Chief Complaint: – On 09/13/11 he had drainage, pain, and increased swelling at the
surgical site – The patient was evaluated by the surgeon within the office, sent to the
Emergency Department and subsequently admitted
Potential Avoidance: Case Review• Hospitalization:
– Laboratory: • Surgical wound and blood cultures were positive for methicillin
resistant Staphylococcus aureus• Patient remained bacteremic for 8 days
– Procedures:• Transesophageal echocardiogram (TEE) negative for endocarditis• Return to the operating room for a wound debridement on 09/13/11
– Antibiotic treatment: Treatment with vancomycin for more than 42 days
– Additional management: Return to the operating room for removal of hardware
Continued
Problem: Hand Hygiene
Project Aim: Improved and sustained high hand hygiene compliance
3rd Party Remote Video Auditing
• Door motion detector triggers audit
• Video camera records activity
• Digital Video Recorders stores footage locally
• External auditors connect remotely
• Auditors rate activity based on pass/fail criteria
• Audits stored in external auditors database
• Feedback delivered via on-site light emitting diode boards, daily e-mails, and weekly e-mails
Timeline: 2008
1 4
3 06/10/08
Hand hygiene compliance calculated with the use of remote video auditing
07/04/10
Remote video auditing with feedback continues
03/08
Cameras and door alarms installed
10/06/08
Hand hygiene compliance calculated with the use of remote
video auditing and real-time feedback
03/08 04/08 05/08 06/08 07/08 8/08 9/08 10/08 11/08 12/08 01/09 02/09 03/09 04/09
2
02/08
Discussion with staff on the use of Cameras for
Hand Hygiene Compliance
Hand Hygiene Measurement
• Measurement: Hand hygiene with soap and water or an alcohol based hand sanitizer– Pass: hand hygiene observed in a patient room or neighboring
area within 10 seconds (before or after) of entry or exit to a patient room
– Fail: no hand hygiene observed as per protocol– Discarded events: entries/exits by non-clinical staff or visitor and
multiple entries/exits within 60 seconds of another
• Quality control audits: 5% of the recorded events to ensure consistency and accuracy
Inclusion/Exclusion Criteria
• Inclusion: Nurses, aides, house staff, and other clinicians wearing any type of scrub or uniform were classified into the category of other health care professional, and physicians not wearing scrubs were classified as attending physician
• Exclusion: Non-clinical workers and visitors
Figure Without and With Feedback
StartFeedback10/06/08
• Without feedback: hand hygiene rates of <10% (3,833/60,066) • With feedback the rates were >86% (223,187/261,091) (p<0.001)
Internal Self-Auditing Scores
Partnership for Patients
• Healthcare Association of New York State/Greater New York Hospital Association initiative to decrease:– CLABSI– CAUTI
• Goal:– To eliminate and sustain
reductions in CLABSI and CAUTIs by >40% by 11/2013.
IPRO 10th Scope of Work
• Aim:– Prevention, Reduction, Elimination
• CLABSI reduction of 50% by 03/13• CAUTI reduction of 25% by 03/13• Clostridium difficile • Surgical Site Infections (SSIs)
Health Care Personnel Vaccination
• Average vaccination rate -~45%. • 20111/2012 vaccinate rate -58%. • Highest vaccination rate was
when New York State Department of Health mandated the influenza vaccine in 2009/2010 - 79%.
• 2012/2013 plan: 100% program participation:– accept the vaccine or – declining with knowledge regarding
placing yourself and others at risk
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