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Patient Safety - Infection Prevention

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.

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Patient Safety - Infection Prevention

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  1. Patient Safety - Infection Prevention Donna Armellino, RN, DNP, CICVice President, Infection PreventionNorth Shore – LIJ Health System

  2. Data is collected by staff that has certification by the Certification Board of Infection Control and Epidemiology, Inc. Superficial incisional SSI Organ/space SSI 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... Deep incisional SSI

  3. 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

  4. 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

  5. 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.

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

  7. HAI Sample NYSDOH Data More information can be found at: http://www.health.ny.gov/statistics/facilities/hospital/hospital_acquired_infections

  8. HAI Impact Potentially preventable HAIs cause patient harm: morbidity mortality increased length of stay Increase health care cost Are HAIs really preventable?

  9. 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

  10. CLABSI: 2004 - 2011 ICU CLABSI per 1,000 Central Line Days From September 2005 to December 2008, central line insertion bundle compliance increased from 25% to >80%. 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 11

  12. Journey Toward Zero – Ongoing Learning LINE MAINTENANCE TECHNIQUE NOT ADEQUATE LACK OF EDUCATION CLABSI Assessment:Identification of patterns or trends IV tubing not changed on a timely basis Not compliant with hand hygiene Inexperienced residents and clinicians Line in for too long Line inserted w/o sterile technique Clinicians not knowledgeable about Central Line Bundle Dressing not change using aseptic techniques Inadequate use of maximal barrier precautions Nurses do not properly know how to change dressings IV tubing not labeled properly to change MD does not select a catheter with the least number of lumens Inadequate prep before insertion Line not manipulated appropriately Femoral line chosen instead of subclavian Injection hub not disinfected Clinicians unaware of line maintenance CLABSI

  13. CAUTI Process Change = Outcome Change Baseline* (Feb. 2011 – July 2011) Post-intervention* (Aug. 2011 – Feb. 14, 2012) Southside Hospital – device utilization LIJ – infection decrease Syosset Hospital – infection Plainview Hospital – device utilization

  14. 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

  15. 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

  16. 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

  17. 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

  18. Problem: Hand Hygiene Project Aim:Improved and sustained high hand hygiene compliance

  19. 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

  20. Timeline: 2008 10/06/08 Hand hygiene compliance calculated with the use of remote video auditing and real-time feedback 4 1 02/08 Discussion with staff on the use of Cameras for Hand Hygiene Compliance 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 2

  21. 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

  22. 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

  23. Figure Without and With Feedback Internal Self-Auditing Scores Start Feedback 10/06/08 • Without feedback: hand hygiene rates of <10% (3,833/60,066) • With feedback the rates were >86% (223,187/261,091) (p<0.001)

  24. 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.

  25. 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)

  26. 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

  27. darmelli@nshs.edu

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