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Khalid Aziz November 10, 2006

EPIC/PHSI Quality Improvement Workshop: Interventions to prevent nosocomial infection and future directions. Khalid Aziz November 10, 2006. Janeway Children’s Health and Rehabilitation Centre, St. John’s NL. Acknowledgements. Nosocomial infection team centres:

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Khalid Aziz November 10, 2006

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  1. EPIC/PHSIQuality Improvement Workshop: Interventions to prevent nosocomial infection and future directions Khalid Aziz November 10, 2006 EPIC QI Workshop

  2. Janeway Children’s Health and Rehabilitation Centre, St. John’s NL EPIC QI Workshop

  3. Acknowledgements Nosocomial infection team centres: • Children’s & Women’s Health Centre of BC • Janeway Children’s Health and Rehabilitation Centre • IWK Health Centre • Hospital for Sick Children • St. Joseph’s Hospital • Royal Alexandra Hospital EPIC QI Workshop

  4. Objectives • Nosocomial infection team interventions • Methodologies • Proposed methodologies for future interventions EPIC QI Workshop

  5. Interventions • Teams were involved in developing interventions • Interventions were truly interdisciplinary • Interventions applied to diverse groups such as housekeeping, parents, respiratory therapy • Interventions were made in each institution according to local priorities EPIC QI Workshop

  6. Reviews • Varied in rigour • Local interests • Team interests • Investigation of established reviews (eg CDC guidelines) • Qualitative themes of focus groups • Literature reviews • Baseline EPIC results EPIC QI Workshop

  7. Baseline EPIC results • PICCs reduce nosocomial infection in some centres • Positive urine culture is as common as positive blood culture in centres who did both • Culture negative sepsis and suspected sepsis are a considerable burden in NICU • Units vary in their use of antibiotics for nosocomial infection, particularly vancomycin and cefotaxime EPIC QI Workshop

  8. Baseline data: UAC sepsis EPIC QI Workshop

  9. Baseline data: PICC sepsis EPIC QI Workshop

  10. Baseline data PICC sepsis by centre EPIC QI Workshop

  11. List of interventions 1 • Hand hygiene • Gloves and gowns • Skin care • Skin breaks • Care of PICC lines EPIC QI Workshop

  12. List of interventions 2 • Choice of first line antibiotics • Duration of empiric antibiotic therapy • Care of ventilator circuits • Visiting policy • Staff education EPIC QI Workshop

  13. Hand hygiene • Add alcohol based waterless cleanser to hand cleansing areas/entrances to NICUs/improve availability of alcohol based cleansers/provide staff with 60ml bottles of hand hygiene to be kept on person • Communicate handwashing protocol • Increase vigilance in respect to the wearing of jewelry EPIC QI Workshop

  14. Gloves and gowns • Discontinue use of routine gloves and gowns EPIC QI Workshop

  15. Skin care • Cleanse umbilical sites with antiseptic (aquaphor ointment) prior to umbilical line placement • Infants less than 32 weeks bathed only with warm water (no soap) during 1st week (mineral water prn) • Use of 2% aqueous chlorhexidine rather than alcohol for skin antisepsis for infants with birth weight less than 1000g EPIC QI Workshop

  16. Skin breaks • Skin break audit • Compliance with “initiation of peripheral IV therapy policy” • Reduce number of skin pokes • Restrict number of pokes to 1-2 per person • Restrict number of staff participating in the process • Implement algorithms for blood sampling and IV starts: both algorithms define number of pokes per person and number of people participating EPIC QI Workshop

  17. Skin breaks (pokes audit) EPIC QI Workshop

  18. Skin breaks (IV starts audit) EPIC QI Workshop

  19. Care of PICC lines • PICC line insertions restricted only to nurses who have been certifiedreduce • PICC line dressings to prn • Observe CDC guidelines for central lines EPIC QI Workshop

  20. Choice of first line antibiotics • On admission: ampicillin and gentamicin • Change first line abx to cloxacillin and gentamicin for suspected nosocomial sepsis until blood culture sensitivities received or unless the neonate has septic shock, suspected meningitis or necrotizing enterocolitis (then vancomycin and/or cefotaxime • Caremap for choosing antibiotics EPIC QI Workshop

  21. Choice of first line antibiotics EPIC QI Workshop

  22. Duration of empiric antibiotic therapy • Discontinue antibiotics if blood cultures are negative after 36 hours (assuming the baby is well) EPIC QI Workshop

  23. Duration of empiric antibiotic therapy EPIC QI Workshop

  24. Care of ventilator circuits • Change ventilator circuits when visibly contaminated, malfunctioning, and between patients EPIC QI Workshop

  25. Visiting policy • 2 visitors per neonate in NICU at any one time EPIC QI Workshop

  26. Staff education • Encourage staff influenza immunization EPIC QI Workshop

  27. Future directions • Revisions • New interventions • Standardization of reviews EPIC QI Workshop

  28. Revisions • New information since 2001 • Greater rigour • Interprofessional approaches • Site-specific issues • Larger pool of reviewers • New expertise in larger number of centres EPIC QI Workshop

  29. New interventions • 5 years more of clinical studies (e.g. caffeine) • New systematic reviews • Data from EPIC-1 (e.g. benefits of PICC placement, incidence of UTI) • Larger pool of participants for hypothesis generation • “Ownership” of CNN database EPIC QI Workshop

  30. Standardization of reviews What might the advantages be to standardization of the review process? • Ease of review • Ease of cataloguing and presentation • Ease of revision EPIC QI Workshop

  31. Standardization of reviews What might the disadvantages be of a standardized approach? • Need to encompass qualitative and quantitative data • Appears challenging to non-academic reviewers • Time-consuming, particularly when a review or guideline already exists (do we need to re-review the original studies?) EPIC QI Workshop

  32. Suggested review methodologies • Adaptation of an existing guideline(s) (eg CDC guideline on central line care) • The ILCOR methodology (as used by the International Liaison Committee on Resuscitation for the 2005 recommendations) • Informal methodologies EPIC QI Workshop

  33. The ILCOR Consensus Process Step 1 State the proposal ************ Step 2 Assess the quality of each study ************ Step 3 Determine the class of recommendation EPIC QI Workshop

  34. The ILCOR Consensus Process Step 1A. Refine the research question(s) Step 1B. Gather the evidence ************ Step 2A. Determine the level of evidence (levels 1-8) Step 2B. Critically assess each article for quality of design & methods Step 2C. Determine the direction of the results/statistics Step 2D. Cross-tabulate by level, quality and direction; combine & summarize ************ Step 3. Determine the Class of Recommendation EPIC QI Workshop

  35. The ILCOR Consensus ProcessStep 1: State the Proposal “To create a new guideline encouraging the use of continuous positive airway pressure (CPAP) or positive end expiratory pressure (PEEP) during neonatal resuscitation in the delivery room, particularly for very premature infants.” EPIC QI Workshop

  36. The ILCOR Consensus Process Step 1A. Refine the research question(s) • During the resuscitation of very premature infants the use of CPAP will reduce the baby’s oxygen requirements and the need for ventilation. • The use of either CPAP or PEEP during the resuscitation of very premature infants at birth will reduce the proportion requiring oxygen when they reach the equivalent of 36 weeks gestation. EPIC QI Workshop

  37. The ILCOR Consensus Process Step 1B. Gather the evidence • Search with MESH headings all fields: CPAP AND resuscitation limited to the first 28 days, PEEP AND resuscitation limited to the first 28 days, neonatal resuscitation, delivery unit AND resuscitation. • Cochrane database of systematic reviews. EPIC QI Workshop

  38. The ILCOR Consensus ProcessStep 2: Assess the quality of each study Step 2A. Determine the levels of evidence EPIC QI Workshop

  39. The ILCOR Consensus ProcessStep 2: Assess the quality of each study Step 2A. Determine the levels of evidence EPIC QI Workshop

  40. The ILCOR Consensus ProcessStep 2: Assess the quality of each study Step 2B. Critically assess each article for quality of design & methods EPIC QI Workshop

  41. The ILCOR Consensus ProcessStep 2: Assess the quality of each study Step 2C. Determine the direction of the results/statistics EPIC QI Workshop

  42. The ILCOR Consensus ProcessStep 2: Assess the quality of each study Step 2D. Cross-tabulate by level, quality and direction; combine and summarize EPIC QI Workshop

  43. The ILCOR Consensus ProcessStep 2: Assess the quality of each study Step 2D. Cross-tabulate by level, quality and direction; combine and summarize EPIC QI Workshop

  44. The ILCOR Consensus ProcessStep 3: Determine the class of recommendation EPIC QI Workshop

  45. The ILCOR Consensus ProcessConclusion(s) Converting the scientific recommendations into clinical implications. Ultimately, no recommendation was made to use CPAP on its own as a means of resuscitating babies. EPIC QI Workshop

  46. “Informal” methodologies Common sense. Inadequate or no evidence. Practised in centres with best outcomes. EPIC QI Workshop

  47. Questions??? EPIC QI Workshop

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