Patient Safety - Infection Prevention

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

• Data is collected by staff that has certification
  by the Certification Board of Infection Control
  and Epidemiology, Inc.

• Definition for healthcare-associated infections
  are from the Centers for Disease Control and
  Preventions 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
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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

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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

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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 gt 1.0 indicates that more SSIs were
  observed than predicted and a SIR lt 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.

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HAI Sample NHSN Data
More information can be found athttp//www.cdc.go
v/nhsn/PDFs/dataStat/NHSN-Report_2010-Data-Summary
.pdf
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HAI Sample NYSDOH Data
More information can be found at
http//www.health.ny.gov/statistics/facilities/hos
pital/hospital_acquired_infections
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HAI Impact

• Potentially preventable HAIs cause patient harm
• morbidity
• mortality
• increased length of stay
• Increase health care cost

Are HAIs really preventable?
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Health System Facilities CLABSI Free Months

• Intensive Care Unit (ICU)
• Glen Cove - gt41 months
• Forest Hills - gt6 months
• Huntington ICU - gt 24 months
• Southside ICU 9 months
• Long Island Jewish 2 ICUs - gt24 months
• North Shore University Hospital PICU - gt14 months
  NSCU - gt6 months
• Non-ICU
• Glen Cove - gt18 months
• Syosset - gt22 months
• Franklin - gt6 Months
• Medical Adolescent gt24 months

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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 gt80.
Change 2005 through 2008
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Standards of Practice CLABSI

• 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

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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
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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
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Standard of Practice Indwelling Urinary Catheter

• 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

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Joint Project Bundle

• 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

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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

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Potential Avoidance Case Review
Continued

• 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

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

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

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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

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Figure Without and With Feedback
Internal Self-Auditing Scores
Start Feedback 10/06/08

• Without feedback hand hygiene rates of lt10
  (3,833/60,066)
• With feedback the rates were gt86
  (223,187/261,091) (plt0.001)

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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 gt40 by 11/2013.

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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)

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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

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darmelli_at_nshs.edu