alphabet soup: figuring out hospital acquired infections · pdf file3/2/2015 1 alphabet soup:...

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ALPHABET SOUP: FIGURING OUT HOSPITAL ACQUIRED INFECTIONS

SHARON A. MCNAMARA RN, BSN, MS, CNOR

HAI

SSI

SCIP

CLABSI

CAUTI SUSP

CDC HICPAC

NHSN

OBJECTIVES:

1. Describe the effect of HAI’s in the United States.

2. Identify three (3) evidence based initiatives to reduce HAI’s.

3. Discuss the importance of Defect Analysis (DA) in Surgical Site Infection (SSI)

prevention.

NATIONAL ANNUAL IMPACT

• 101 million medical procedures

• 10.8 million GI endoscopies

• 440,000 bronchoscopies

• 46.5 million surgical procedures

• 1.7 million hospital acquired infections (HAI)

• 99,000 deaths

• 500,000 SSIs occur yearly

• 2.7% surgeries result in SSIs

• 4% of pediatric surgeries result in SSIs

• $7 billion in healthcare expenditures

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PREVENTION IS THE GAME CHANGER!

40 to 60%

of SSIs

are

preventable

Joint Commission. Patient safety new NPSG implementation guide provides effective

practice for reducing SSIs. Joint Commission Online. May 22, 2013. Accessed June 11,

2013. [email protected].

CULTURE OF SAFETY

Safety depends on:

• Reliability

• Systems designed to withstand human errors

• Management and oversight

Safe Systems are characterized by:

• Commitment to safety

• Formal protocols for communication and teamwork

• Standardization as best practice

• Reporting problems for improvement

CULTURE OF SAFETY

Teamwork

• Shared goals

• Shared mental model

• Situational awareness

• Flat hierarchy

Clarke JR. Designing safety into minimally invasive surgical revolution. Surg Endos 2009. 23:216-220

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AREAS TO CONSIDER IN THE PREVENTION & SURVEILLANCE OF SSI

•Preparation of the patient

•Preparation of the personnel

•Preparation of the environment

•Examine these in every unit patient receives care

SOURCES FOR PATHOGENS

• Endogenous

• Accounts for the majority of infections

• Consider distant sites as sources

• Exogenous

• Personnel

• Environment

• Air

• Surgical instruments and equipment

Bacterial Dose Virulence

Impaired

Host Resistance

PATHOGENESIS OF INFECTION

Condition of

Surgical Site

at End of

Procedure

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PATIENT FACTORS CONTRIBUTING TO SSI

• Age

• Nutritional status

• Smoking/tobacco use

• Obesity

• Diabetes & hyperglycemia

• Microbial infection

• Remote infection

WHO Guidelines for Safe Surgery (1st Ed)

• Altered immune response

• Pre-and-post-operative LOS

• Patient hygiene

• Patient hand hygiene

• Normothermia

•Oxygenation

SURGICAL FACTORS CONTRIBUTING TO SSI

• Preoperative skin preparation

• Hair removal

• Antimicrobial prophylaxis

• Environmental controls

• Hand antisepsis of the surgical team

WHO Guidelines for Safe Surgery (1st Ed)

• Surgical attire

• Creation of the sterile field

• Instrument preparation and sterilization

• Length of procedure

• Surgical technique

• Post-operative dressings

SCIP SURGICAL CARE IMPROVEMENT PROGRAM

• Appropriate antibiotic within 1 hour prior to surgical incision

• Appropriate selection of antibiotic

• Discontinue antibiotic within 24 hours after surgical end time

• Appropriate hair removal

• Appropriate VTE prophylaxis ordered

• Appropriate VTE within 24 hours prior to surgery to 24 hours post surgery

• Cardiac patients with controlled 6AM postop serum glucose

• Surgical patients on Beta Blocker therapy prior to admission who received a BB

during perioperative period

• Urinary catheter removal on postop day 1 or 2

• Surgical patient with post op temperature management

http://www.jointcommission.org/surgical_care_improvement_project/

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SURGICAL CARE BUNDLES

• A surgical care bundle is a set of interventions that, when implemented as a

group, help to improve surgical patient outcomes.

• Structured on evidence based research and practices

• Developed by a multidisciplinary team for the particular facility

CUSP FRAMEWORK COMPREHENSIVE UNIT-BASED SAFETY PROGRAM

• Train staff in the science of safety

• Engage staff to identify defects

• Senior executive partnership/safety rounds

• Continue to learn from defects

• Implement tools for improvement

http://www.hopkinsmedicine.org/innovation_quality_patient_care/areas_expertise/improve_patient_safety/c

usp/cusp_tools_improvement.html

CLABSI CENTRAL LINE ASSOCIATED BLOODSTREAM INFECTIONS

CLABSIs are associated with bad outcomes

• – 500-4,000 U.S. patients die annually due to CLABSIs

• – Average increased length of stay is 7 days

• – Estimated cost per CLABSI is $3,700-29,000

http://www.hopkinsmedicine.org/heic/infection_surveillance/clabsi.html

http://www.hopkinsmedicine.org/innovation_quality_patient_care/areas_expertise/improve_patient_safety/cusp/





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CLABSI BUNDLE

• Caps, masks, sterile gown & gloves

• Patient draped with maximum barrier

• Perform hand hygiene pre & post catheterization

• Use Chlorhexidine (CHG) for skin prep ( 30 sec. rub, IJ or subclavian, 2 min. in groin & 1 min.

dry)

• Use full barrier precautions during insertion (shown to reduce infection 2-3 fold)

• Avoid using femoral site in adults

• Post procedure assess the need for catheter each day, remove ASAP. Special procedures for

hub, site, and tubing care.

• Training, competency, checklists important aspects to bundle compliance



CAUTI BUNDLE CATHETER ASSOCIATED URINARY TRACT INFECTIONS

• Perform hand hygiene before and after catheter insertion or manipulation

• Use urinary catheters only when necessary and for the shortest time possible

• Assess catheter use at least daily and remove as soon as possible

• Ensure only properly trained individuals who know aseptic technique are

responsible for insertion of catheters and their maintenance (this includes all

healthcare personnel and caregivers)

http://www.cdc.gov/hicpac/CAUTI_fastFacts.html

APPROPRIATE INDICATIONS FOR URINARY CATHETER PLACEMENT

• Critically ill patients  

• Surgical patients undergoing urologic or prolonged surgery  

• Patients who have received large-volume infusions or diuretics during surgery  

• Patients whose urinary output needs to be closely monitored  

• Patients who have bladder obstruction, prolonged immobilization, or patients

needing additional comfort in end-of-life care

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HICPAC HEALTHCARE INFECTION CONTROL PRACTICES ADVISORY COMMITTEE

Perioperative use for selected surgical procedures:

• Patients undergoing urologic surgery or other surgery on contiguous structures of the

genitourinary tract

• Anticipated prolonged duration of surgery (catheters inserted for this reason should

be removed in PACU)

• Patients anticipated to receive large-volume infusions or diuretics during surgery

• Need for intraoperative monitoring of urinary output

• To assist in healing of open sacral or perineal wounds in incontinent patients

• Patient requires prolonged immobilization (e.g., potentially unstable thoracic or

lumbar spine, multiple traumatic injuries such as pelvic fractures).

http://www.cdc.gov/hicpac/cauti/002_cauti_sumORecom.html

SUSP CUSP FOR SAFE SURGERY

• Normothermia

• Euglycemia - Glucose Control

• Skin Preparation

• Antibiotic selection, dose, time administered, redosing

• Case duration

• Includes SCIP work

COLORECTAL SURGERY BUNDLE

PRE-OP

• Hibiclens shower night before and

day of surgery

• Patient cleansing CHG cloths AM

admission

• Ensure understanding Preventing SSI

pamphlet

INTRA-OP

• SCIP compliance w ABX

• Ensure re-dose of cefazolin within 3-4

hours after incision

• Chloraprep

• Closure tray for closure of fascia & skin

• Glove change by surgeon & staff

before closure of fascia

Cima R. Dankbar E. Lovely J. et al. Colorectal surgery: Surgical Site Infection Reduction Program: a national surgical quality program - driven multidisciplinary single institution experience.

J Am. Coll. Surg. 2012. 215; 193-200.

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PROJECT JOINTS: HIP & KNEE ARTHROPLASTY BUNDLE

• Patients bathe or shower with CHG soap for at least 3 days pre-op

• Screen patients for Staph aureus carriage and decolonize SA carriers with 5

days of intranasal mupirocin and 3 days of chlorhexidine soap prior to

surgery

• Use of alcohol-containing antiseptic for preoperative skin prep

• Appropriate use of prophylactic antibiotics

• Appropriate hair removal

LEARNING FROM DEFECTS

AN IMPORTANT TOOL IN SURGICAL SITE

INFECTION PREVENTION

LEARNING FROM EACH DEFECT

• Establish process to analyze defects

• Initiate analysis ASAP

•Use standard investigation tool

• Investigate details prior to meeting

• Build on established processes

•Challenge practice and traditional ways of thinking

• Embrace environment of psychological safety

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ENGAGE A MULTIDISCIPLINARY TEAM

Most critical step … include the right folks:

• Surgical Services

• Infection Preventionists and IP MD

• Surgeon(s)

• Anesthesia

• Administration

• Facility and Maintenance Services

• Quality, Safety, Risk Representatives

• Central Supply Materials Management

• Patient/Family (as appropriate)

5 BASIC STEPS IN LEARNING FROM DEFECTS PROCESS

Step 1 What happened?

Step 2 Why did it happen?

Step 3 How will you reduce the likelihood of it happening again?

Step 4 How will you know the risk is reduced?

Step 5 How do you communicate the findings and to whom?

AHRQ CUSP Tool Kit. Identify Defects Through Sensemaking.

STEP 1: WHAT HAPPENED?

• Use a standard event investigation format

• Use easy-to-use tool, tailored for organization

• Engage multiple shareholders in research

• Establish chronological order of events and related data

• Identify contributing factors

•… and don’t forget the Gemba Walk

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CONTRIBUTING FACTORS - HUMAN FAILURES

• Practitioner competency

• Failure to clean items properly

• Incorrect set up of chemical cleaners on

automatic washer

• Incorrect temperature setting on sterilizer

• Improperly packed sterilizer

• Failure to check that the parameters for

sterilization were met

• Failure to check biologic controls

© 2014 All Rights Reserved. IMS is a registered trademark of

Integrated Medical Systems International, Inc.

CONTRIBUTING FACTORS - EQUIPMENT, MATERIALS & ORGANIZATIONAL FAILURES

•Outdated, inaccurate or absent policies or procedures

• Use of incorrect channel connectors for endoscopes

• Lack of proper cleaning utensils, equipment

• Lack of maintenance for equipment

• Inappropriate storage environment

•Manufacturer design

• IFU

DON’T FORGET CRITICAL INFO!

• Assess for latent failures at time of event

• Staffing

• Throughput issues

• Emotional/psychological aspects of team

• Environmental conditions

• Build key questions into Defect Analysis Tool (DAT)

Resource: http://www.onthecuspstophai.org/stop-bsi/manuals-and-toolkits/

http://www.onthecuspstophai.org/stop-bsi/manuals-and-toolkits/







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STEP 2: WHY DID IT HAPPEN?

1. Review events from DAT with team

2. Identify gaps and contributing factors

3. Ask “Why?”

• For each gap identified

• For each reason generated

• And at least three more times or until root cause is found

WHY? WHY? WHY? WHY? WHY?

1. Lumens not being flushed?

2. Proper cleaning, equipment not

available?

3. Inspection of the instruments not

occurring?

4. Magnifying glass at every station not

being used?

5. Interruptions so frequent?

© 2014 All Rights Reserved. IMS is a registered trademark of Integrated

Medical Systems International, Inc.

STEP 3: HOW CAN WE REDUCE THE CHANCES OF IT HAPPENING AGAIN?

1. Prioritize most important contributing factors

2. Develop interventions (countermeasures) to defend against the most

important contributing factors

3. Rate each countermeasure on:

• Ability to mitigate root cause

• Team’s belief countermeasure will be executed

4. Draft action plan for 2-5 of highest scoring countermeasures

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COUNTERMEASURES

•Consider safe design principles • Standardize – eliminate steps when possible

• Create independent checklists

• Learn when things go wrong (analyze defects)

• Safe designs apply to:

• Technical

• Team work

• Brainstorm strategies • Ability to mitigate error

• Strength of countermeasures to prevent error

• Ease of implementation

• Standardize

1. Instructions to Be More Careful, Vigilant

2. Education/Information

3. Rules and Policies

4. Checklists and Double-check Systems

5. Standardization and Protocols

6. Automation and Computerization

7. Forcing Functions and Constraints

RANK ORDER: STRENGTH OF ERROR REDUCTION STRATEGIES

Adapted from the Institute of Safe Medication Practices (first presented on 12/3/2006 by Michael R. Cohen, RPh, MS, SCD)

Contributing Factor Countermeasure Rating (1 low – 5 high )

Potential for

implementation

Outdated policies and

procedures

Apply practices & procedures

that are consistent with

evidence-based and/or

professional guidelines:

• ANSI/AAMI ST79:2010 & A1:2010

& A2:2011 Comprehensive Guide to

Steam Sterilization and Sterility

Assurance in Healthcare Facilities

• AORN Standards and Recommended

Practices (2013) . Recommended

Practices on Sterilization &

Disinfection. PP 451-540

• Healthcare Infection Control Practice

Advisory Committee (HICPAC) Center

for Disease Control (CDC). Guideline

for Disinfection and Sterilization in

Healthcare Facilities, 2008

• IAHCSMM Position Paper on the

Management of Loaner

Instrumentation 2011

3. Rules and Policies

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Potential for

implementation

Manufacturers IFU not

available for staff

1. Provide electronic or

hardcopy of IFU that is

assessable to practitioners

2. Review the manufacturer’s

IFU before purchase or

finalizing loaner agreements

6. Automation and Computerization


Potential for

implementation

Failure of staff to clean

instrument and properly

inspect for failures

• Lack of IFUs

• Lack of certified CSMM

staff

• Competency evaluation

program inconsistent

Ensure personnel responsible for

reprocessing are competent:

• Education and initial competency

• Manufacturer IFU

• Inspection of devices

• Availability of cleaning equipment

and tools (checklists)

• Empower personnel to report and

investigate

• Certified Central Supply Material

Management Technicians/Managers

• Ongoing competency evaluation

2. Education/Information

4. Checklists and Double-check Systems

5. Standardization and Protocols

STEP 4: HOW WILL WE KNOW THE RISK IS REDUCED?

•Assess data

• Talk with staff to get their perspectives

• Talk with patients and families

•Do Gemba Walk

• Feedback from patient safety rounds

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STEP 5: HOW DO WE COMMUNICATE OUR FINDINGS AND TO WHOM? • Internal communications

• Areas/people prone to this defect

• Regulatory compliance, accreditation, and risk management

• Who needs to know for closure on the defect analysis

• Potential defects related to root causes found in analysis

• Hospital/nursing communications – story telling

• Patient story telling

• External communications

• PSOs

• Others

• Input/permission from Risk Management and Administration

HOW ARE WE DOING?

• Agency for Healthcare Research and Quality (AHRQ) estimates 1.3 million

fewer patients were harmed in U.S. Hospitals from 2010-2013.

• Represents a cumulative 17% reduction and an estimated 50,000 deaths

prevented after launch of Partnership for Patients

• Suggests a rapid and accelerating improvement over the three years

• CLABSI demonstrated 49% reduction 2010-2013

• SSI demonstrated 19% reduction 2010-2013

• CAUTI demonstrated 28% reduction 2010-2013

http://www.modernhealthcare.com/article/20141202/NEWS/312029936/1-3-million-adverse-events-

prevented-in-u-s-hospitals-since-2010

WHERE DO WE GO FROM HERE?

• Frontline practitioners must drive the evidence based practice

• Frontline practitioners must be invested in the sustainment of quality

improvements

• Frontline workers must hold themselves and each other accountable

• Practitioners need to be invested in creating and maintaining a culture of

safety

• Practitioners must practice effective team behaviors to protect themselves and

their patients

• Preventing SSI is a team effort and the patient must be a member of the team

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REFERENCES:

• HEIC Website http://intranet.insidehopkinsmedicine.org/heic

• Adult VAD Policy

www.insidehopkinsmedicine.org/hpo/policies/39/139/policy_139.pdf

• Pediatric VAD Policies



• CDC Guidelines www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm

• SHEA Guidelines www.shea-online.org/about/compendium.cfm.

• Rice S. 1.3 million adverse events prevented in u.s. hospitals since 2010, feds

say. Accessed at:

http://www.modernhealthcare.com/article/20141202/NEWS/312029936/

1-3-million-adverse-events-prevented-in-us-hospitals-since-2010

REFERENCES: • Edmiston CE. Spencer M. Key issues in infection prevention: an overview. AORN Journal 2014; 100(6):

586-589.

• Nelson RL, Glenny AM, Song F. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database

Syst Rev. 2009(1):CD001181.

• Guideline for prevention of surgical site infection, 1999. US Department of Health and Human Services,

Centers for Disease Control and Prevention Website.

http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/SSI.pdf. Accessed: December 12, 2014.

• Khodyakov D. Ridgely MS. Huang C. et al. Project joints: what factors affect bundle adoption in a

voluntary quality improvement campaign? BMJ Qual Saf. 2014; 0: 1-11.

• Edmiston CE. Spencer M. A perspective on surgical site infection prevention: 10 Key issues in infection

prevention: an overview. 2) Patient care interventions to help reduce the risk of surgical site infections. 3)

The role of the OR environment in preventing surgical site infections. 4) endoscope reprocessing in 2014:

why is the margin of safety so small? 5) Going forward: preventing surgical site infections in 2015.

AORN Journal 2014; 100(6): 586-619.

http://www.shea-online.org/about/compendium.cfm



http://www.modernhealthcare.com/article/20141202/NEWS/312029936/1-3-million-adverse-events-prevented-in-us-hospitals-since-2010






















alphabet soup: figuring out hospital acquired infections · pdf file3/2/2015 1 alphabet soup:...

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