patient safety - infection prevention

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Patient Safety - Infection Prevention Donna Armellino, RN, DNP, CIC Vice President, Infection Prevention North Shore – LIJ Health System

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Patient Safety - Infection Prevention. Donna Armellino, RN, DNP, CIC Vice President, Infection Prevention North Shore – LIJ Health System. Data is collected by staff that has certification by the Certification Board of Infection Control and Epidemiology, Inc. Superficial incisional SSI. - PowerPoint PPT Presentation

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Page 1: Patient Safety - Infection Prevention

Patient Safety - Infection Prevention

Donna Armellino, RN, DNP, CICVice President, Infection Prevention

North Shore – LIJ Health System

Page 2: Patient Safety - Infection Prevention

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...

Page 3: Patient Safety - Infection Prevention

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

Page 4: Patient Safety - Infection Prevention

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

Page 5: Patient Safety - Infection Prevention

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.

Page 6: Patient Safety - Infection Prevention

HAI Sample NHSN Data

More information can be found at:http://www.cdc.gov/nhsn/PDFs/dataStat/NHSN-Report_2010-Data-Summary.pdf

Page 7: Patient Safety - Infection Prevention

HAI Sample NYSDOH Data

More information can be found at: http://www.health.ny.gov/statistics/facilities/hospital/hospital_acquired_infections

Page 8: Patient Safety - Infection Prevention

HAI Impact

• Potentially preventable HAIs cause patient harm:

– morbidity– mortality– increased length of stay– Increase health care cost

Page 9: Patient Safety - Infection Prevention

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

Page 10: Patient Safety - Infection Prevention

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

Page 11: Patient Safety - Infection Prevention

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

Page 12: Patient Safety - Infection Prevention

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

Page 13: Patient Safety - Infection Prevention

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

Page 14: Patient Safety - Infection Prevention

• 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

Page 15: Patient Safety - Infection Prevention

• 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

Page 16: Patient Safety - Infection Prevention

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

Page 17: Patient Safety - Infection Prevention

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

Page 18: Patient Safety - Infection Prevention

Problem: Hand Hygiene

Project Aim: Improved and sustained high hand hygiene compliance

Page 19: Patient Safety - Infection Prevention

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

Page 20: Patient Safety - Infection Prevention

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

Page 21: Patient Safety - Infection Prevention

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

Page 22: Patient Safety - Infection Prevention

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

Page 23: Patient Safety - Infection Prevention

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

Page 24: Patient Safety - Infection Prevention

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.

Page 25: Patient Safety - Infection Prevention

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)

Page 26: Patient Safety - Infection Prevention

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