clinical & ot protocols and governance to ensure quality in eye care service
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Clinical & ot protocols and governance to ensure quality in eye care serviceTRANSCRIPT
CLINICAL & OT PROTOCOLS AND GOVERNANCE TO ENSURE
QUALITY IN EYE CARE SERVICES
DR. UDAY GAJIWALA
DIVYAJYOTI TRUST, MANDVI, GUJARAT
QUALITY ASSURANCE IN EYE CARE DELIVERY
CONCLAVE OF SIGHT FIRST HOSPITALS – MD 32212TH OCTOBER, 2014.
CATARACT SURGERY IN INDIA
1981 1983 1987 1993 1997 1999 2001 2008 2013
Performance 0.55 1.07 1.21 1.6 2.72 3.18 3.5 5.5 6.5
0.50
1.50
2.50
3.50
4.50
5.50
6.50
CAUSES OF BLINDNESS
2%4%5%2%
7%
80%
Cataract Ref. Erors Glaucoma Surg. Comp Others Corneal Opaciy
2%4%
5%2%
7%
80%
Cataract Ref. Erors Glaucoma Surg. Comp Others Corneal Opaciy
12%3%
19%
8%
54%
4%
PILOT SURVEY 1999
NATIONAL SURVEY1986-89
CURRENT ISSUES LARGE NUMBER OF EYE SURGEONS IN NON-
SURGICAL POSITION HIGH CONCENTRATION OF EYE SURGEONS IN
URBAN AREAS HIGHER PREVALENCE IN GEO-PHYSICALLY
DIFFICULT AREAS AND SOCIALLY UNDERPRIVILEGED GROUPS
INCREASE IN POPULATION OF AGED DUE TO RISE IN LIFE-EXPECTANCY
SUSTAINABILITY OF THE PROGRAMME DIFFICULT IN THE ABSENCE OF COST RECOVERY MECHANISMS
CHALLANGES – CLUSTER INFECTIONS
WHAT IS A CLUSTER INFECTION?INCIDENCE RATE?DO WE KNOW HOW TO PREVENT?ARE THERE GUIDELINES
AVAILABLE?QUALITY VS. QUANTITY QUALITY VS. COST
State and Year-wise Distribution
SN States No. of Mishaps(Blind/Seriously affected)
Place of Surgery
2006 2007 2008 2009
Assam 35 Guwahati
Manipur 5 Bishnupur
Rajasthan 31 Suratgarh, Beawar
UP 12 23 Barabanki, Lucknow
Orissa 9 Deogarh
TN 29 Tiruchirapalli
Total cases 44 5 72 23 144
NPCB DATA – CLUSTER INFECTION
Eye Mishaps: Month-wise
Year/Month J F M A M J J A S O N D TOTAL
2006 35 9 44
2007 5 5
2008 12 29 11 20 72
2009 23 23
TOTAL 41 5 29 35 9 11 20 144
Data: Source:
NPCB (1st April, 2009) – T 12019/1/2003-Ophth./BC (Pt)
Period: September 2006 – January 2009
Infection Percentage varies from 7.7% (35 of 450 in RIO Guwahati, Assam) to 100 % (23 of 23) in Lucknow.[1]
NPCB DATA – CLUSTER INFECTION
SN Place % blinded / seriously affected
Operating Team
1 Guwahati, Assam 7.7 Govt.
2 Barabanki, UP 13.6 NGO
3 Suratgarh, Sri Ganganagar
25.5 Mixed (?)
4 Beawar, Rajasthan 27.7 NGO
5 Bishnupur, Manipur 31 Govt.
6 Tiruchirapalli, TN 43.9 NGO
7 Deogarh, Orissa 64.2 Govt.
8 Lucknow, UP 100 Details awaited
NPCB DATA – CLUSTER INFECTION
Operating Team % Remarks
NGO 22.5 UP, TN, Rajasthan
Government 10.2 Assam, Manipur, Orissa
Mixed 25.58 Suratgarh
Being Investigated 10 Lucknow
NPCB DATA – CLUSTER INFECTION
AFTER EFFECTS OF CLUSTER INFECTION
DHARAMPUR, GUJARAT – THE EYE OT ORDERED A SHUT DOWN - STILL CLOSED.
JOSEPH EYE HOSPITAL, TRICHY – THEY HAVE FIVE HOSPITALS AND INFECTIONS OCCURRED IN SATELLITE HOSPITAL. GOVT. ORDERED A SHUT DOWN OF ALL FIVE HOSPITALS FOR ONE YEAR. LATER REVIEWED.
IN TAMILNADU, LAST WINTER, THE PERFORMANCE DROPPED BY 25%.
PALI SEVA MANDAL – THE OT REMAINED CLOSED FOR 8 MONTHS.
GOVT. OF RAJASTHAN ORDERED A BAN ON DIAGNOSTIC EYE CAMPS FOLLOWING REPORTS OF CLUSTER INFECTION AT SEVERAL PLACES. THE PERFORMANCE OF THE SURGERIES DROPPED TO 15000 FOR JAN. 2009 AGAINST 45000 IN JAN. 2008.
AFTER EFFECTS OF CLUSTER INFECTION
WORK LOAD DROPS SUBSTANTIALLYAFFORDING PATIENTS TURN AWAYFEAR EXPRESSED BY THE COMMUNITYLOSS OF FACEDEFAMATATIONMEDICOLEGAL ISSUES
OBSERVATIONS FROM EVALUATION ACTIVITY
IMPROPER LAY OUT OF THE THEATRE AVAILABILITY OF STAFF VS. VOLUME SCRUBBING – GOWNING – GLOVING
TECHNIQUE NEEDS MAJOR IMPROVEMENT
NO. OF INSTRUMENTS SETS AVAILABLECHEMICAL STERILISATION IN USE
OBSERVATIONS FROM EVALUATION ACTIVITY
80-100 SURGERIES DONE BY ONE SURGEON IN A DAY
OT BEING RUN FOR LONG HOURSSAME DAY SURGERY ON THE DAY OF
EXAMINATIONEXPIRED IOL BEING IMPLANTEDCOMMON TROLLEY IN USENO CHANGE OF GLOVES FOR ONE
SESSION
OBSERVATIONS FROM EVALUATION ACTIVITY
SAME SET OF INSTRUMENTS USED FOR SEVERAL SURGERIES
PLASTIC BOTTLE INJ. RL AND PRE FILLED VISCO ELASTIC IN USE
METHOD OF AUTOCLAVING NOT KNOWNNO MONITORING OF ACTIVITIESVERY WEAK PRE OPERATIVE PROTOCOL
OBSERVATIONS FROM EVALUATION ACTIVITY
NON EXISTENCE OF PROTOCOLNO / LITTLE IMPROVEMENT EVEN AFTER
EVALUATION AND FOLLOW UPCOUNTER ARGUMENTS COST CONSIDERATIONS KIND HEARTED PEOPLEVERY GOOD SURGICAL SKILLS
OBSERVATIONS FROM EVALUATION ACTIVITYROOT CAUSE OF THE PROBLEM
LACK OF UNIFORM GUIDELINE FOR THE COUNTRY
AVAILABLE GUIDELINE DOES NOT REACH THE END USER
PHILANTHROPIC MINDED PEOPLE UNAWARE OF THE PROTOCOLS AND GUIDELINES
MEDICAL EDUCATION LACKING IN TRAINING DOCTORS IN INFECTION CONTROL MEASURES
COST CONSTRAINTS ENFORCEMENT OF LAW POOR IN THE
COUNTRY LACK OF COMMMITTMENT FOR A CHANGE DISAGREEMENT ON THE METHODS / PROTOCOL
OBSERVATIONS FROM EVALUATION ACTIVITY
SITUATION LOOKS GRIM BUT IS IT ACTUALLY SO BAD?
WE HAVE COME FROM INTRA WITH FORCEPS TO PHACO WITH FOLDABLE IOL
THIS CHANGE WAS DUE TO DEMAND – IT WAS MARKET DRIVEN
WE NEED TO INJECT QUALITY CONSCIOUSNESS INTO THE SYSTEM
POSITIVE CHANGES ARE HAPPENING THOUGH AT A SLOWER PACE
Future GoalsCATARACTINCREASE CATARACT SURGICAL RATE
(CSR) TO 4,000 IMMEDIATELY AND TO 6,000+ IN THE NEAR FUTURE – TODAY WE ARE AT 5500
IMPROVE QUALITY OF CATARACT SURGERY FOR BETTER OUTCOMES BY 2005???
FUTURE GOALS
CLUSTER INFECTIONREDUCE THE CHANCES OF CLSTER
INFECTION
HOW?FOLLOWING PROPER GUIDELINEMAINTAINING NECESSARY
DISCIPLINE INSIDE THE OT
NEED OF THE HOUR
COME UP WITH A REVISED INFECTION CONTROL GUIDELINE UNDER THE NATIONAL PROGRAMME
SPREAD THE INFORMATION AMONG ALL THE PLAYERS IN THE COUNTRY
ENFORCE IMPLEMENTATION OF THE GUIDELINE THROUGH VARIOUS EFFORTS INCLUDING SUPERVISORY INPUTS
MAKE ALL THE PEOPLE INVOLVED IN MEDICAL CARE MORE QUALITY CONSCIOUS
ADD INFECTION CONTROL AS A SEPARATE SUBJECT IN THE MEDICAL CURRICULUM
WHAT IS ALL THIS?
ISO NABHCEISI
INTERNATIONAL GUIDELINES
INTERNATIONAL GUIDELINES
PUBLISHED FROMICEH, LONDON
HAND HYGIENECDC GUIDELINE
HOSPITAL INFECTION SOCIETY, INDIA
PUBLISHED YEARLYFrom
CMC, VELLORE
INFECTION CONTROL TEXT BOOK
INFECTION CONTROL JOURNAL
NPCB GUIDELINE
PROTOCOL – MANUAL AND VIDEO DEVELOPED BY
ARAVIND EYE CARE SYSTEMS
PROTOCOL – MANUAL AND VIDEO DEVELOPED BY
SEWA RURAL
OPERATIVE OPERATION THEATRE
Prevention Is Better Than Cure
A MANUAL FOREY E OPERATION THEATRE
SEWA RURAL, J HAGADIA(2008)
EY E OPERATION THEATRE
EYE OPERATION THEATRE PROTOCOL (ENGLISH FILM)
SIGHTSAVERS INTERNATIONAL
INITIATIVE
AIOS GUIDELINES TO PREVENT INTRAOCULAR INFECTION--WORKSHOP HELD IN NOV. 08 -- DRAFT IN FINAL STAGES. --25 EMINENT OPHTH. ATTENDED.
BUREAU OF INDIAN STANDARDS GUIDELINE FOR SETTING UP
HOSPTALS
AECS PAPER IN JOURNAL of CATARACT
AND REFRACTIVE
SURGERY
IMPLICATIONS OF FOLLOWING STRICT UIDELINE
COST OF SURGERYNO. OF SURGERIES NEED FOR TRAINING AND
RETRAINNG OF STAFFKEEPING UPDATED WITH THE
LATEST DEVELOPMENTS IN ASEPSIS AND ANTI SEPSIS
Country [reference] Year of Publication
Incidence (%) No. of Operations
USA [98] 1991 0.22 24105
USA [203] 1992 0.015 27181
France [40] 1992 0.32 ~34690
Germany [126] 1999 0.15 ~103090
Netherlands [135] 2000 0.10 ~25330
Canada [64] 2000 0.01 to 0.18 13886
Sweden [37] 2002 0.10 54666
Australia [110] 2003 0.16 to 0.36 83677
Japan [8] 2003 0.05 to 0.29 11595
USA [86] 2005 0.29 9079
Ireland [87] 2005 0.5 8763
UK [105] 2007 0.099 101920
Sweden [94] 2007 0.048 225471
Europe [5] 2007 0.05 to 0.35 16211
DATA FROM THE WESTERN WORLD
WHERE DO WE STAND TODAY?AT NATIONAL LEVEL
NPCB WORKING ON REVISED INFECTION CONTROL GUIDELINE
AIOS CONDUCTED A WORKSHOP ON CREATING PROTOCOL – FINAL VERSION MAY COME OUT SOON
VISION 2020 – RIGHT TO SIGHT INDIA PROGRAMME IS WORKING ON AN OUTBREAK POLICY
GOVT. OF RAJASTHAN HAS ISSUED REVISED GUIDELINES GOVT. OF GUJARAT CONDUCTED THREE WORKSHOPS
ZONE WISE & DISTRIBUTED IEC MATERIAL ACROSS THE STATE
AT AIOS ANNUAL CONFERENCE, SESSION ON INFECTION CONTROL MEASURES IS CONDUCTED REGULARLY
AT GOS, INFECTION CONTROL SESSION ORGANISED MORE AND MORE HOSPITALS ARE USING SOFTWARE FOR
OUTCOME MONITORING SOME HOSPITALS ARE ISO / CE CERTIFIED
WHERE DO WE STAND TODAY?AT LOCAL LEVEL
NEED FOR INTROSPECTION LOOK AT THE ENDOPHTHALMITIS RATE FOR OUR OWN
HOSPITAL INTERNALLY PREPARE A PROTOCOL FOR CATARACT SERVICES – SSI
MANUAL IS AVAILABLE TO GUIDE US LOOK AT THE STANDARD PROTOCOLS INCLUDING NPCB SHARE THE PROTOCOL WITH ALL THE STAFF AND MAKE
THEM AWARE KEEP UPDATED WITH THE LATEST DEVELOPMENTS IN THE
FIELD REGULAR CME FOR ALL THE STAFF BECOME QUALITY CONSCIOUS APPLY FOR NABH ACCREDITATION
OPD PROTOCOL
COMPLAINTSRELAVENT HISTORYTHOROUGH EXAMINATIONESTABLISHING THE DIAGNOSISCOMPLETE PRE OPERATIVE WORK UPPROPER PATIENT COUNSELINGPRE OPERATIVE DRUG REGIME
IPD PROTOCOLPRE OPERTIVE PREPARTION OF THE PATIENT
AT HOME AND IN THE WARDS BOTH ON THE PREVIOUS DAY AND ON THE DAY OF SUREGERY
TESTS TO BE CARRIED OUTMEDICAL FITNESS – INTERNIST CLEARANCEPREPARATION OF LOCAL PARTSDILATATION PROTOCOLPRE OPERATIVE CHECK LISTPROTOCOL FOR SENDING PATIENT TO OT
OT PROTOCOLFOR PERSONNELFOR SCRUBBING – GOWNING - GLOVINGFOR STERILISATION & USE OF PER STERILE
ITEMS & ENSURING STERILISATIONCLEANING & PACKING OF INSTRUMENTSDISINFECTION OF VARIOUS AREASOT PREPARATIONSURVEILLANCEDAILY – WEEKLY – MONTHLY – QUARTERLY
MONITORING
FOLLOW UP PROTOCOL
PROTOCOL FOR EXAMINATION AT EACH FOLLOW UP
PROTOCOL FOR FOLLOW UP – FIRST – SECOND – THIRD – FINAL FOLLOW UP
PROTOCOL FOR PRESCRIPTION OF GLASSES
OUTCOME ANALYSIS
MONITORING OF OUTCOMES
USE ICEH SOFTWARE OR THE MANUAL TALLY SHEET
HAPPY PATIENT >>>>>> HAPPY DOCTOR
MOST IMPORTANT FACTORS LEADING TO
INFECTION
INADVERTANT TOUCH STERILISATION FAILURE ENVIRONMENTAL FACTORS
• ARRANGED IN THE ORDER OF IMPORTANCE• WE HAVE NOT MENTIONED PATIENT FACTORS
HERE
SOURCE OF BACTERIA AND FUNGI
LIDS, CONJUNCTIVA, LACRIMAL SAC SURGICAL INSTRUMENTS, IRRIGATING
SOLUTIONS IOLs, VISCOELASTICS, MULTIPLE USE EYE
DROPS WOUND LEAKING, VITREOUS WEAK,
FILTERING BLEBS STAFF – SURGEONS, NURSES &
ANAESTHETISTS OPERATING THEATRE AIR - ENVIRONMENT RISK FACTORS – CLEAR CORNEAL VS. SCLERAL
TUNNEL, RUPTURED POST. CAPSULE ETC.
PREVENTING POST OPERATIVE INFECTION
LIMIT THE OPPORTUNITY FOR MICROBIAL CONTAMINATION• DECREASE MICROBES ON THE OCULAR
SURFACE• PREVENT INTRA OPERATIVE
INTRAOCULAR CONTAMINATION• PREVENT POST OPERATIVE INTRA
OCULAR CONTAMINATION• KILL MICROBES THAT ENTER THE EYE
AFTER SURGERY
PREVENT INTRA OPERATIVE INTRA OCULAR BACTERIAL
CONTAMINATION REDUCE – OPTIMISE TOTAL
OPERATING TIME DRAPING TECHNIQUE
• ISOLATE LIDS AND LASHES• USE OF PLASTIC DRAPE
AVOID POOLING OF SURFACE FLUIDS LIMIT ENTRANCES AVIOD COMPLICATIONS
• CAPSULE RUPTURE
IMPORTANT POINTS TO REMEMBER
FREQUENCY OF SCRUBBING FRESH SET OF STERILE INSTRUMENTS FOR
EACH SURGERY PREPARE TROLLEY AFRESH EACH TIME STERILISE IRRIGATING SOLUTION AND
VISCOELASTIC AT YOUR END APPLY CHLORHEXIDINE HAND RUB ON THE
SURFACE OF THE GLOVES USE 5% POVIDONE IODINE EYE DROP BEFORE
THE SURGERY MAINTAIN SILENCE INSIDE THE OT
WISH YOU A
FREE OF
THANK YOU