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FHA/HRET HEN Reducing Harm Across the Board 1 Reducing Harm with HospitalAcquired Infections (HAI): Connecting the Dots Linda R. Greene, RN, MPS, CIC Manager of Infection Prevention Highland Hospital Rochester, NY Affiliate of University of Rochester Medical Center [email protected] Objectives Discuss the impact of HospitalAssociated Infections on Patient Outcomes Identify current evidence based practices for preventing HAIs Describe barriers to implementation of evidence based practices Discuss methods to overcome barriers to create a more collaborative health care environment

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Page 1: Harm with Hospital Acquired Infections (HAI): Connecting the · Health Care‐Acquired Infections • Results in ~ 100,000 associated deaths • Estimated hospital costs $30.5 billion

FHA/HRET HEN Reducing Harm Across the Board

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Reducing Harm with Hospital‐Acquired    Infections (HAI): Connecting the Dots

Linda R. Greene, RN, MPS, CICManager of Infection PreventionHighland Hospital Rochester, NY

Affiliate of University of Rochester Medical [email protected]

Objectives

• Discuss the impact of Hospital‐Associated Infections on Patient Outcomes

• Identify current evidence based practices for preventing HAIs

• Describe barriers to implementation of evidence based practices

• Discuss methods to overcome barriers to create a more collaborative health care environment

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Affects ~ 2 million patients

Health Care‐Acquired Infections

• Results in ~ 100,000 associated deaths

• Estimated hospital costs $30.5 billion

• More than 50% of Healthcare‐Associated Infections are attributed to medical devices

Healthcare Facility Reporting to CMS via NHSN: 

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Financial Impact

Problems with HAIs

CAUTI

Quality and InfectionPrevention Team

CLABS

C DIF

VAE

Prevention Team

SSI Hand Hygiene

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What Went Wrong?

• Mr. X is a 59 year old man who was admitted to the hospital for a colon resection  (diagnosis – primary colon cancer).

• He was in reasonably good health and had no other majorHe was in reasonably good health and had no other major health problems.

• He was given instructions on SSI Prevention and surgery proceeded as planned. Appropriate antibiotic therapy was given and the prophylactic antibiotic was discontinued after 1 post‐operative dose.

• He has a foley catheter inserted intra operatively• He has a foley catheter inserted intra‐operatively.

• The catheter was removed post‐operatively. 

• The patient had a history of BPH and had difficulty voiding post‐op.

• On the night shift after removal of the catheter the nurse called the on call physician and obtained an order to place a

Mr. X

called the on call physician and obtained an order to place a urinary catheter.

• The urinary catheter remained in place for the next 3 days.

• On day 4 post‐operatively, Mr. X began to spike a temperature of 38.3.

• A urine culture was obtained.

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Mr. X

• Urine grew 100,000 Klebsiella pneumoniae.

Th h i i t t d th ti t i 250• The physician started the patient on cipro 250mg. Q12 hours.

• Mr. X improved and was discharged with a prescription for cipro and a follow‐up appointment with his surgeon.

The Rest of the Story 

• On 4 after discharge, presented to the ED with fever, abdominal pain, diarrhea and increased WBC.

• Stool for cdif positive by EIA.

• Became septic, to OR for colon resection and to ICU post‐op.

• Expired on post‐operative day 5 from complications.

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“Connecting the Dots”

Could this happen in your hospital?

Could this have been averted?

What are your thoughts?

What “dots” didn’t we connect?

Connect the Safety Dots

Urinary T

Falls?

Urinary Catheter Harm

Immobility

Decubs?

Trauma

DiscomfortSatisfaction

Antibiotic

Resistance

DVT?

C Diff infection

CAUTIDelays,

LOS

Cost$

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Other Infections

• New VAE Definition

• Link between being ventilator deterioration and mortality

• IVAC (Ventilator deterioration, antibiotics, and increased WBC)

Ventilator Associated Event

VAC• Ventilator Associated Condition

IVAC• Infectious Ventilator Associated Condition

VAP

• Possible VAP

• Probable VAP

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VAE Surveillance Definition Algorithm Summary

Patient on mechanical ventilation > 2 days

Baseline period of stability or improvement, followed b t i d i d f i ti

• Respiratory status component

by sustained period of worsening oxygenation

Ventilator‐Associated Condition (VAC)

General evidence of infection/inflammation

Infection‐Related Ventilator‐Associated Complication (IVAC)

• Infection / inflammation component

Temperature or WBCand

New antimicrobial agent 

(IVAC)

Positive results of microbiological testing

Possible or Probable VAP

• Additional evidence

Summarize the Evidence

:HAI Supported by Evidence

CAUTI   Nurse Driven Removal Protocols

Insertion  only for appropriate Indications

Aseptic insertion

Early removal

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Evidence

HAI Supported byEvidence

CLABSI Site PrepAvoid unecessary linesRemove when no longer indicated

C difficile  Antibiotic StewardshipGlove Use

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Evidence

HAI  Supported by Evidence

VAE Use non‐invasive positive VAE ppressure ventilation for selected populationsAssess readiness to extubate dailyElevate the head of the bed to 30‐45 degrees Avoid unplanned extubation

Regular oral care (i.e. toothbrushing or gauze if notoothbrushing or gauze if no teethAmbulation

Evidence

HAI  Evidence Supports

Surgical Site InfectionsUse chlorhexidine gluconate alcohol in preference ofUse chlorhexidine gluconate-alcohol in preference of aqueous iodophor skin preparation, unless contraindicated.

No recommendation can be made regarding the safety and effectiveness of chlorhexidine gluconate-alcohol as compared to iodophor-alcohol skin preparation.

Maintain therapeutic levels of the prophylactic antimicrobial agent in serum and tissues throughout the operation based on individual agent pharmacokinetics

Redose intraoperatively when the procedure durationRedose intraoperatively when the procedure duration exceeds the half-life of the antimicrobial agent, when there is excessive blood loss (i.e., >1500 ml) or in cases of extensive burns

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Bringing Evidence to the Bedside

Engage

EducateEvaluate

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Execute

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Stages of Engagement

Engagement: The Frontline

• The trick to engagement is: engaging!

How are we going to hurt the next patient?

What can we do to prevent that?

• Light that fire and follow through

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Light that fire… and follow through.

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Ways to Engage Front Line Staff

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Educate

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Execute

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My Hospital

Theory of the Beehive

Communication

Visibility

Sharing

Awareness

Positive Reinforcement

• Adopting frontline ideas

• Poster displays

• Unit Safety Champion of the Month

• Prizes for ideas

• Underperformance?

– Nonpunitive approach to error

M dd h– Must address at the source:

– Attack the problem not the worker

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Mutual support is the essence of teamwork.       P t t t f k l d dProtects team from work overload and situations that reduce effectiveness and increase risk of error.

“I’ve got your back”

Your protocol will be GPS for most situations.  Great help but you

Standardization

“The bridge has been out 

Great help… but you WANT deviation sometimes. e.g. …

6 months… some of these drivers follow their GPS directions to a fault”

Autoblog.com

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Huddle 

Quick problem solving meetings held  h diti hwhenever conditions change

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What happened? (brief description)

Why did it happen? (what factors contributed)

+What prevented it from being worse?

-What happened to cause the defect?

What can e do to red ce the risk of it happening ith a different person?What can we do to reduce the risk of it happening with a different person?

Action Plan Responsible Person

Targeted Date

Evaluation Plan –How will we know risk is reduced?

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With whom shall we share our learning? (Communication plan)

Who When How Follow up

Evaluation

• Feedback is essential

• Feedback in the moment when possible

• The role of audits

• Data drives performance

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Level of InterventionLevel of Intervention

High

• Forced Function

• Automation

Medium

• Protocols

• Check lists

• Rules

• Education

Low

• Education

• Be more careful

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Measurement

http://www.cdc.gov/NHSN

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Strategies: “Connect the Dots”

• Help Everyone d d h

Story Telling –

understand their role in patient care

• Safety through optimizing their

1 mo

Monthswithouta C DIF

6 moNames and Faces

optimizing their practices

Feedback

• Timely

• Respectful

• Specific

• Directed toward improvement

• Considerate

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SBAR

• Situation‐What is going on with the patient?

• Background‐What is the clinical background?

• Assessment‐What do I think the problem is?

• Recommendation‐What would I recommend? 

What is a Positive Deviant?

• Individual(s) who exhibits unique and uncommon problem solving behaviors for problems that existproblem solving behaviors for problems that exist throughout an organization:

– Solutions achieved with similar resources to others in the organization

– Can potentially guide problem solving within the i ti id tifi dorganization once identified

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Traditional Top‐Down Problem Solving

Decision

• A few people make decisions for the many

Consequences

• Engagement & Empowerment

• Resistance to change

Result• No change, wasted money, wasted time

Implementation Tools –Liberating Structures

• Used for data collection/idea generation

• Minimal structure so that ideas are liberated and creativity is encouraged 

• Increases engagement & diversity of input, forming new social connections

• Group develops skills to guide themselves

L d d / l i• Leads to unexpected outcomes/solutions

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TRIZ

• “Teoriya Resheniya Izobretatelskikh Zadatch” or The Theory of Inventive Problem Solving

• Usually one of the first techniques used

– Quick, idea‐generating, fun

• Designs adverse system by asking questions

– Ex. “How would you give every patient C. diff?”

– Answers guide discussion about how to eliminatethe adverse system 

1‐2‐4‐All

• Individual reflection       Share with 1       Pair shares with 2      Whole group discussion

R i th t ib ti f ll b• Recognizes the contributions of all group members in a non‐threatening way

– Good for diverse groups 

– Encourages sharing outside comfort zones

– Helps identify similarities/differencesHelps identify similarities/differences in problem solving among group members

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Social Network Mapping

• Simple, minimal time commitment

• Provides visual cues about who is part of current team and who is left out

• Should change andShould change and expand over time 

DADS Example

1. How do you know someone has an infection?

2. What do you do to prevent infection spread?

3. What prevents you from doing this every time?

4. Who does a better job?

5. Any ideas about what to do next?

6 A l t ?6. Any volunteers?

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Measurement

Measure Type Source

• Shows progress• Encourages friendly competition

yp

% Appropriate hand hygiene Process Direct observation; Alcohol Based Hand Rub (ABHR) Volume

% Appropriate environmental cleaning

Process Direct observation; Adenosine triphosphate bioluminescence; UV markers

% Appropriate cleaning of shared patient equipment

Process  Direct observation

Healthcare Facility‐Onset C. difficile Incidence

Outcome NHSN

HA MRSA incidence by unit Outcome Infection prevention data; NHSN

What Does This Look Like in Real Life?

• Problem: HA MRSA rates increasing in the Veterans Health Administration’s Hospitals in Pittsburgh

• Background: Tried behavioral change that improved organizational efficiency but:- Was resource/personnel intensive- Reliance on team leaders, little staff empowerment- Not sustainable

• Aim: Reduce HA MRSA in 2 VA facilities by increasing adherence to prevention protocols and rates of swabbing for MRSA colonization on admission

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What Did They Do?

• Appointed a nurse leader as MRSA coordinator

• Held DADs with multiple disciplines

• Formed a multidisciplinary MRSA team

• Engaged high burden unit & shared data

• Initiated weekly MRSA meetings with “decision makers” present 

• Performed mini root cause analyses• Performed mini‐root cause analyses

• Continuous data feedback

Did it Work?

• 50% decrease in MRSA SSI rates & ~10% decrease in overall MRSA rates over 15 months

• Spread to other units emergency room andSpread to other units, emergency room, and outpatient settings

• Changed culture:

“We held a lot of floor‐wide events, and I made sure everyone was invited—doctors, nurses, patients and even staff from the environmental (housekeeping) unit ”staff from the environmental (housekeeping) unit.

Weekly MRSA meeting led by housekeeping

Nurses email MRSA Coordinator with ideas

Singhal A and Greiner K. 2007. ‘When the Task is Accomplished, Can We Say We Did It Ourselves?’ A Quest to Eliminate MRSA at the Veterans Health Administration’s Hospitals in Pittsburgh

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Ch i ti F l @ h t [email protected]

[email protected]

[email protected]