prevention of health care associated infection and of antimicrobial resistance: a new ... ·...
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Preventionofhealthcareassociatedinfectionandofantimicrobialresistance:anewmanagementapproach
José Artur PaivaMedicalDirector - CentroHospitalarSãoJoãoFaculty of Medicine– University of Porto
Infection and Sepsis I&DGroupSTOPInfeçãoHospitalarMonitoring Committee – FundaçãoCalousteGulbenkian
Porto- Portugal
Deathsattributabletoantimicrobialresistanceeveryyear,by2050
In 2014, in the EU,AMR is
responsible for 25 000 deaths and > EUR 1.5 billion of
healthcare costs and
productivity losses
annually
By2050,itcouldresultinareductionoftheEuropeanGDPby1%to4.5%
Antimicrobial consumption and antimicrobial resistance
EUandWHO“OneHealth”approach
Theagendatodecreaseantibioticuseincludes:n preventinginfectionsandtheirspreadn improvingmonitoringandsurveillancen avoidingunnecessaryuseofantibiotics:usingthemonlywhenneeded,forthe
lesstimepossibleandwiththeleastpossiblespectrumn developingresearchandinnovationtowardsneweffectiveantibioticsn developingnewwaystotackleinfectionwithoutharmingbacteria
Givenitsseverity,AMRisapoliticalhighprioritywithintheEUandalsofortheWHO,thatareusingthe"OneHealth"approach,whichrecognizesthatthehealthofpeople,animalsandtheenvironmentareinextricablylinkedandthatantibioticsareusedinhumanmedicine,veterinaryandagriculture.
CounciloftheEU.CouncilRecommendationof15November2001(2002/77/EC).OfficialJournaloftheEuropeanCommunities.2002(45):13-6.
HAIprevalence Antibioticconsumption
Portugal EU Portugal EU
Homem 12,4% 7,2% 48,3% 39,2%
Mulher 8,8% 5,4% 42,3% 33,2%
PopulaçãoGlobal 10,5% 6,1% 45,3% 35,8%
ECDC Point Prevalence Study PPCIRA/DGS, ECDC 2012
Portugal2011-2012:HighprevalenceofHAIandhighhospitalantibioticconsumption
2012: High ambulatory antibiotic consumption, and
very high quinolone consumption
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ESAC Net 2012, ECDC
Global consumption in DDD Quinolone consumption in DDD
Highhospitalconsumptionofcarbapenems,2010-2012
“In2012,consumptionofcarbapenemsvariedbyafactorof14,from0.01(Bulgaria)to0.14DDDper1000inhabitantsandperday(Portugal)“
“Theproportionofconsumptionofcarbapenemsoutofantibacterialsforsystemicuserangedfrom0.8%(Latvia)to9.8%(Portugal)withanEU/EEApopulation-weightedmeanof2.9%.”
2010
Carbapenems
ESAC Net 2012, ECDC
8
HighindexofantimicrobialresistanceFromPPS2011-2012,ECDC
ESKAPE
MortalityassociatedwithHCAIversusthatassociatedwithroadtrafficaccidents
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
2010 2011 2012 2013
Roadtrafficaccidents Infections
ANSR e PPCIRA/DGS
Estimated costs of 300 million euros
per year associated with HCAI
WeaknessesandthreatsofICfightinPortugal:early2013report
n Understaffing and underpowerment of the centralandperipheral ICstructures
n Low level of integration and synergy of the several processes;noholistic vision;toomany process leaders
n Low strategic sustainability;Absence of focus inthe mostrelevant issues;low involvement of the citizen
n Problems of datasharing among state institutions and of datafeedbacktothe providers;low reliability of indicators
n Difficulties inimplementing acollaborative model, increasingcapacity building and maximizing participation andtransparency
n Reimbursement system not reflecting the indicators and targetsand not boosting motivation
PaivaJAetal.PPCIRAlaunchingreport,feb.2013.DGH
NATIONALPROGRAMONPREVENTIONOFINFECTIONANDOFANTIMICROBIALRESISTANCE(PPCIRA)
NATIONALPROGRAMON
INFECTIONCONTROL
NATIONALPROGRAMONPREVENTIONOFANTIMICROBIALRESISTANCE
+
8Fev.2013
1999 2008
PPCIRA:ANationalPriorityProgram
ReduceHCAI Reduceantibioticconsumption
Reducetheemergenceofantibioticresistance
Evictionofantibioticuseintheabsenceofbacterial
infection
ReducetransmissionofMDRmicrorganisms
Reductionofantibioticdurationandspectrum
ReducetheincidenceofMDRmicrorganisms
EPIDEMIOLOGICALSURVEILLANCE
TacklingAMRbyreducingantibioticconsumption
TacklingAMRbyreducingantibioticconsumption,bylaunching:
(a) a Joint Alliance in the spirit of One Health to commit different stakeholders that agreed on a ten-point memorandum;
(b) an Antibiotic Awareness Campaign for the citizen;
(c) a national Antimicrobial Stewardship (AMS) programme.
(b)TheCitizen’sAntibioticAwarenessCampaign
n Itwasanationalcampaign,involvingprimarycarecenters,hospitals,schoolsandbigeventsarenasin2011-2012.
n Globalslogan“Moreantibiotics,lesshealth”.n Verysimplekeymessages,namely“donotself-medicatewith
antibiotics”,“unusedantibioticsshouldbereturnedtothepharmacy”and“donottreatcoldswithantibiotics”.
n 5millionflyersand10000posters;200billboardsandpublictransportsignswereplacardedinthe3mainportuguese cities;adailyTVspotwaspresentedfor30days.
n Attheendofthecampaign,atotalof226insertions/newswereissuedinthemedia,includingTV,radio,pressandinternet.
n Thecampaignwasrepeated,atasmallerscale,twoyearslater,inthewinter2013-14.
(c)TheAntimicrobialStewardshipProgrammen Anation-wideprogramme,locallycustomized,usingrestrictivebut
mainlypersuasive/enablementtechniques,ledbyalocalexpertteamn Focused onsurgicalantibioticprophylaxis,ononehand,andon
quinolones andcarbapenems therapies,ontheotherhand.n Targetswereclearlydefined:10%reductionforquinolonesand5%for
carbapenems,withconcomitantnon-riseofglobalantibioticuse.n Nationalguidelineswere issuedfortheuseofantibioticsinsurgical
prophylaxisandondurationofantibiotictherapy(focusingontonotmorethan7days,exceptforasmallgroupofinfectiousdiseases).
n AtwodayeducationalcoursewasperformedbytheHeadoftheNationalProgramme ineachofthesevenhealthregions,discussingandteachingreasonsforquinolones andcarbapenems useandstrategiesforlimitingitsusetocasesinwhichtheyarereallynecessary.
n Asagoal,allprescriptionsofthesetwoclassesofantibioticsshouldbechecked,discussedwiththebedsidemedicalteamandeventuallyvalidatedbytheAMSteaminthefirst96hoursafterprescription.
AMS:Howtouseit?
DeWaeleJetal,ICM2016
Think global,act localPatrick Geddes
Geddes believed in working with the environment, versus working against it
AMSteam
Clinical Pathology
Service A
Service E
Service D
Service C
Service B
Medical Direction- Definition of aims, goals and targets- Empowerment- Macro changes
Mainqualitygapsinantibioticstrategy
Presentation
History,physicalexamand
microbiologicalsamples
Antibiotic
Clinical evolutionand furtherculture andsusceptibilityresults andbiomarkers
48-72hours
Stop
Shorten
Narrow
RescueAntibioticchange
Incorrectempiricaltreatment:- 40% ofpatientswithBSI,- 50% ofthosewithHCABSI,- 70% ofthosewithfungemia
Wrong selection of patients that need antibiotic therapy
longtimetodirectedantibiotictherapy
ConsumptionofantibioticsinPortugalindefineddailydoses(DDD)per1000habitantsperdayYear Global
communityconsumptionofantibiotics#
Communityconsumptionofquinolones
Globalhospital
consumptionofantibiotics
Hospitalconsumption
ofcabapenems
Hospitalconsumption
ofquinolones
2011 23,72 2,91 1,73 0,139 0,222012 23,04 2,61 1,67 0,142 0,182013 19,04 2,18 1,64 0,146 0,182014 20,32 2,12 1,55 0,139 0,172015 21,30 2,05 1,57 0,133 0,152016 ? ? ? ? ?
#From2013on,thedatareferstosellingfiguresandnot,asuntilthen,tostockingfigures30%
By the end of 2015:n 78% ofPortuguesehospitalshadimplementedAMSteamandprocessn Theprocessextendedtoprimarycarecenters:11% ofthemhadAMSn Theeducationalcourseonadequateantibioticusewasreplicatedinsideeach
ofthehealthregions,bysteeringlocalgroups
10% 9% 4% 32%
ReduceHCAI Reduceantibioticconsumption
Reducetheemergenceofantibioticresistance
Evictionofantibioticuseintheabsenceofbacterial
infection
ReducetransmissionofMDRmicrorganisms
Reductionofantibioticdurationandspectrum
ReducetheincidenceofMDRmicrorganisms
EPIDEMIOLOGICALSURVEILLANCE
NATIONALANTIMICROBIALSTEWARDSHIPPROGRAMSTANDARD
PRECAUTIONSNATIONALCAMPAIGN
JOINTALLIANCE
ANTIBIOTICAWARENESSCAMPAIGN
Until 2014, no significative reduction in HCAI
PPCIRA/DGS (HELICS & INCS)
Staph aureus
hospital acq bacteremia(per 1 000
patient days)
MRSA hospital acquired
bacteremia(per 1 000
patient days)
ICU Catheter related
infection(per 1 000
cateter days)
Ventilator associated pneumonia(per 1 000 intubation
days)
Catheter related
sepsis in neonatal ICU
(per 1 000 cateter days)
2008 2,1 11,2 10,082009 2,2 10,6 11,342010 1,4 8,7 11,292011 1,5 8,6 13,402012 0,27 0,17 1,0 8,7 11,462013 0,27 0,16 1,3 7,4 9,132014 0,27 0,15 1,9 7,1
n The Gulbenkian Foundation invited the Institute for Healthcare Improvement (IHI) to become a program partner, due to its expertise in running large-scale collaborative improvement projects and its persistent focus on execution, measurement and results.
n In liaison with the National PPCIRA
n Aim: to reduce HAI by 50%, for a group of 12 selected Portugal NHS centers (19 hospitals) over a period of three years.
n Represented 25% to 30% of all inpatient episodes in Portuguese NHS hospitals
n The work commenced in late 2015, under the name of STOP Infeçao Hospitalar
Oursharednorth:toreduceHAIby50%
TheSTOPInfeçãoHospitalarProject
AGulbenkianFoundationProject
Fourworkstreamsandfourhospitalsites
TheStopinfeção hospitalar isfocusedonfourmaintypesofHAI:
n Catheter-AssociatedUrinaryTractInfection(CAUTI);
n Centralline-associated bloodstreaminfection(CLA BSI);
n SurgicalSiteInfection(SSI),namelyHipandKnee replacement,Colon-recto andGallbladder;
n Ventilator-associatedpneumonia(VAP).
Thepilot-sites/departmentsinclude:• General Wards (CAUTI and
CLA BSI), • Intensive care units (CLA BSI
and VAP), • Orthopedic (SSI related to hip
and knee replacement) • General Surgery
(SSI related to colon-rectum and gallbladder)
Multidisciplinaryfrontlineteamsarebeingsupportedtodesign,testandimplementimprovedwork
processesdesignedtodeliversaferandmorereliablecaretothepatients.
KeyelementsoftheSTOPprogramn anevidencebasedchangepackage
(e.g.bundlesforinsertionandmaintenanceofurinarycatheterandcentrallinecatheters,VAPpreventionandSSIprevention);
n arobustmeasurementanddatacollectionsystem(process,outcomeandbalancingmeasures);
n astrategyforbuildingcapacity(creationofasustainableinfra-structureforhealthcareimprovement,putinplacefirstatthe19participatinghospitalsandlaterspreadtootherhospitalsthroughoutthecountry);
n anevaluationplantomeasurethesuccessoftheQIinitiativeandtoidentifyareasforimprovementalongwithadisseminationplantopublishandsharepracticesandresultsachieved.
n Leadershipcommitment - apre-requisiteforparticipation
SchematicRepresentationoftheBreakthroughSeriesCollaborativeSTOPInfeçãoHospitalar!
Themodelforimprovementn A large number of teams from hospitals or
clinics seeking improvement in a focused area come together under a working environment where all members learn and all members teach.
n Teams are taught improvement methodology including The Model for Improvement.
n Interventions include participation at learning sessions, educational interventions and discussion of activities and progress at coaching conversations by telephone, webexcalls and face-to-face meetings.
• to build a learning community and system that is capable of future ongoing sustainable improvement
• to build improvement capability and improve organization cultures over time.
DynamicMeasurementisakeyactivity
n Measurement and monitoring of the targetof change is akey activityn Statistical process control maps variations over time,combining
statistical significance tests with chronological analysis of graphs ofsummary data
n Annotating timingof interventions and showing targetand controllimits
n Measuring process complianceand outcome improvement
n Constant feedbacktoprovidersat service level
n Themonthlycollectionandanalysisofdataallowsrealtimelearningandimprovement Accelerate
Real-WorldEvidence
DeriveEvidencefromEachCareExperience
ElectronicHealthRecordembeddedinitiatives
QualityBetter Worse
Action taken on all
occurrences
QualityImprovementthroughbreakthroughcollaborative
Alearningorganization,alearningcomunity
• ALLTEACH,ALLLEARN• Transparency• DistributedLeadership
Bestpracticesareharvestedandsharedthroughthecollaborativelearningsystem,boththroughthe
websiteandwebex callsandface-to-facemeetings
High-ImpactLeadershipBehaviorsWhatleadersdotomakeadifference
Swensen,Pugh,McMullan,Kabcenell.High-ImpactLeadership:ImproveCare,ImprovetheHealthofPopulations&ReduceCosts.InstituteforHealthcareImprovement;2013.Available:www.ihi.org.
MANAGEMENT
QUALITY IMPROVEMENT
CREATING A MOVEMENT
Results
Time
From holding to handing power
Holding power
Handing power
Sharing power
What’s the Matter?
What matters to you?
WehaveaproblemwithHCAIandantibioticuse
WearetryingtoreduceHCAIandempiricalantibiotictherapy
AMSandSTOPteamsareintheservicedoingit
Wearetreatingonlythosethatclearlyhavebacterialinfectionandonlyaftercollectingmicroexams:AMSandSTOPteamsarehelping
TheMentalShiftattheServicelevel
ResultsafterSTOPInfeçãoHospitalar,inseptember2017
Catheter Related Infection Prevention –compliance with insertion budle
Catheter Related Infection Prevention –compliance with maintenance budle
Reduction of 61%
Catheter related infection –All 19 hospitals
Compliance with the VAP prevention bundle
Reduction of 51%
VAP – All 19 hospitals
SSI in hip and knee replacement–compliance with SSI prevention bundle
Reduction of 78%
SSI in hip and knee replacement–All 19 hospitals
SSI in general surgery–compliance with the bundle
Reduction of 65%
SSI in general surgery– All 19 hospitals
CAUTI prevention-compliance with insertion bundle
CAUTI prevention-compliance with maintenance bundle
Reduction of 35%
CAUTI – All 19 hospitals
Scaleandspreadn TheQIinitiativeSTOPHAIwillsystematicallyworktospreadthe
knowledgeregardingsafetyinterventionsthathavealreadybeentestedandimplementedonprototypeunitsineachparticipatinghospital– “scalableunits”- andthathaveachievedbothreliabilityinprocessesandchangeinoutcomes.
n Overtime,theambitionofSTOPHAIisthatitsresultswillinfluencedepartment/hospital/healthpoliciesandotherhealthcareinstitutionsthroughoutPortugal,whowilllearnfromtheinitiativeandbe“contaminated”byitsunderling methodology,practicesand“philosophy”.
SousaP,PaivaJA.ReducingHospital-AcquiredInfectioninPortugueseHospitals:ACollaborativeApproachtowardQualityImprovement.InHealthSystemsImprovementAcrosstheGlobe:SuccessStoriesfrom60Countries.Editedby JeffreyBraithwaite, etal.2017.CRCPress2017
PPCIRAQuality IndexLaw March 2016
n Constantdynamicofqualityimprovement,followedbyqualitycontrol
n Qualityimprovementinitiativesn Changepackage(bundlesandestablishmentofcleartargets)n Iterative,incrementalPDSAcycles,usingeducationaland
behavioralinterventionsn Capacitybuildingn Datacollectionsystemn Dynamicandfeedbackedmeasurementn Highimpactleadershipcommitmentn Progressiveculturalchange
Infectionandantibioticresistanceprevention:Qualityimprovementcyclescanhelp
PPCIRA+STOPInfeçãoHospitalar
It´shappeninginPortugalwithsuccess