learning session 1 cape town, february 2011. to reduce healthcare associated infection (hai) using a...
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To reduce Healthcare Associated Infection (HAI) using aSystems Improvement approach
Overall goal of BCA Campaign
Biggest challenges
Leadership invlovement
Understanding the bundles
Implementing bundles
Diagnosing the infection
measurement
Feeding back progress
Team work
Mentoring and support
Biggest challenges
x
x x
x x x x
x x x x
x x x x x x x xLeadership involvement
Understanding the bundles
Implementing bundles
Diagnosing the infection
measurement
Feeding back progress
Team work
Mentoring and support
Why spend our time and energy reducingHealthcare Associated Infections?
Building WillThe business case
Patients get “recommended care” ~ 50% of the time.
Adverse events occur in 10% of hospital patients.– 50% are preventable.– 7.5% of these patients die.
...the gap between evidence and practice
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NEJM 2003; 348:2635-2645
Qual Safety in Health Care 2008;17:216-223
Healthcare-Associated Infection
– Infection rates 5-10%– 1.4 million patients affected each day– USA 100,000 deaths, $6.5 billion / yr
JAMA 2009;301(12):1285-1287Lancet 2008;372(9651):1719-1720
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67.0
18.1
6.4 8.5
0.00.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
%
CompletelyAgree
Partially Agree Neutral PartiallyDisagree
CompletelyDisagree
Hospital-acquired infections are a serious problemn=94
Delegate Survey, FIDSSA Conference Aug 20-23 200985.1%
In the hospital(s) with which I am associated…
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Allegranzi B. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet Dec 2010.
Number of HAI studies 1995-2008
15
Healthcare-associated infections are 2-3 x more common in developing countries
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Allegranzi B. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet Dec 2010.
SA Hospitals?
– 9.7% HAI point prevalence– 28.6% in ICU
Prof A Duse. SA-HISC study (unpublished)
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Private + Public Hospitals in Gauteng
1 in 7 patients who enter SA Hospitals are at risk for developing an HAI
Brink A et al., SAMJ 2006; 96(7)
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IHI and others wondered if something could be done
• IHI (US) 100,000 lives campaign – 6 interventions including 3 of ours
• Canadian Safer Healthcare Now
• Scotland NHS Patient Safety Alliance
….and other successes around the world
Interventions were made into bundles
• What is a bundle and how does it work?A grouping of best practices that individually improve
care, but when applied together result in substantially greater improvement.
The science behind the bundle is so well established that it should be considered standard of care.
Bundle elements are dichotomous and compliance can be measured: yes/no answers.
Bundles shun the piecemeal application of proven therapies in favor of an “all elements” approach.
What was achieved when the bundles were implemented reliably
i.e.
all elements of the bundleto every patient
every time?
Results…Michigan (Keystone)
• 66% reduction in line-related infection
• Saved > 1,500 lives
• Saved $200 million in 18 months
New England Journal of Medicine. 2006; 355(26): 2725-2732
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Finding leverage and synergy to achieve sustainable, high quality health care…more quickly…at greater scale
Power of leverage and synergyLeverage: doing something smart that has a much bigger
impact.
Synergy: two or more people produce more together than the sum of what they could
have produced separately.
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4 infection prevention bundles• VAP (ventilator associated pneumonia)
• CLABSI (central line associated bloodstream infection)
• SSI (surgical site infections)
• CAUTI (catheter associated urinary tract infections)
Ideas for improvement
The size of the challengeat your facility
Ventilators
Central lines
Surgical Sites
Urinary Catheters
Unit 1
Unit 2
Unit 3
Unit 4
Exercise: i) mark the procedures relevant to each of your ICU or high care units with an ‘X’. ii) Prioritise the intervention most relevant to each unit by circling one of the X’s in each unit
The challenge at your facilityVentilators
Central lines
Surgical Sites
Urinary Catheters
ICU X X X X
Theatre X X X
High Care X X X X
Medical Ward
X X
Surgical Ward
X X
Emergency Unit
X XExercise: i) mark the procedures relevant to each of your ICU or high care units with an ‘X’.
ii) Prioritise the intervention most relevant to each unit by circling one of the X’s in each unit
Learning Network
Learning session 1
© Institute for Healthcare Improvement
Learning session 2
Activity
phase:
Activity
phase:
Learning session 3
18 -24 months
Support, support, support
preparation
Make it do-ablePrioritise ONE bundle/ or aspect of the problem• size of the problem• size of the impact• leadership preference
Start small then build up as you gain confidence• one ICU/high care• small improvement team• one aspect of the bundle• expand as confidence grows (data)
Start where you’ll get the best results• the most support
Start small to gain confidence
i) Choose one intervention bundle that will have the greatest effectii) Choose one unit where you have the greatest chance of
successiii) Who will you have on your team?
Ventilators
Central lines
Surgical Sites
Urinary Catheters
ICU X X X X
Theatre X X X
High Care X X X X
Medical Ward
X X
Surgical Ward
X X
Emergency Unit
X X
Exercise:
Choosing the improvement team
Late Majority
Early Majority
Early Adopters Tradition-
alists
Innovators
2% 13% 35% 35% 15%
Getting Started KitTeam Exercise:
i) look up the elements of your selected ‘Bundle’
ii) What reduction in the level of infection has been achieved using the bundle you selected?Adult Ventilator Associated Pneumonia pg 9 & 10Central Line Associated Bloodstream Infections pg 8 & 9 Surgical Site Infections Catheter Associated Urinary Tract Infection pg 5 & 6
Know where you’re headingWhat’s Possible with the bundles?
1. Adult Ventilator Associated PneumoniaAverage 45% reduction. With every bundle element every time – Zero cases for over long periods of time (pg 7)
2. Central Line Associated Blood Stream InfectionsNearly eliminate CLABSI (pg 7&8)
3. Surgical Site Infections(incidence in clean cases 2-3% USA) 40 – 60 % infections are preventable (pg 6)
4. Catheter Associated Urinary Tract InfectionReductions of 46% - 81% have been achieved (pg 6)
Define an Aim (for your bundle)
• must have a number• must have a time frame• must stretch you - not achievable in the current system - requires change • benchmark against what has been achieved elsewhere
Statement of where you want to go -you don’t need to know how to get there yet
Defining the AimTo reduce (VAP, CLA-BSI, SSI, CA-UTI)
By ……………. amount
By implementing the whole ………bundle to every patient every time
By August 2012 (in 18 months)
12/2008
Understanding Systems
1) choose two people in the room, don’t tell them who they are
2) one of them must be a person selected by the facilitator
3) keep the same distance between yourself and each of the two people you have chosen
Complete each of the steps in this process
Step 1: Pick a number
from 3 to 9
Step 2: Multiply your number by 9
Step 3:Add 12 to the
number from step 2
Step 7: Write down thename of a city
that begins with your letter
Step 4: Add your 2
digits together
Step 5:Divide # from step 4
by 3 to get a 1 digit number
Step 6:Convert your
Number to a letter:1=A 2=B 3=C 4=D 5=E 6=F 7=G 8=H 9 = I
Step 8: Go to the next Letter: A to B, B to C, C to D,
etc.
Step 9: Write down the nameof an animal (not bird,
fish, or insect) that begins with your letter
from Step 8
Step 10:Write down the color of
your animal
Do you have a 2-digit Number?
NO
YES
Output:
Color____________
Animal___________
City__________
‘Every improvement needs a change’
The changes:
1)Infection Control Bundles
1)A way of overcoming the implementation gap
Every element of the bundle To every patients Every time
I
The Implementation Gap
PLAN
IMPLEMENT
FAIL
PROBLEM
EVIDENCE BASED SOLUTION
“traditional” attempts to change
I
DO
STUDY
ACTIMPLEMENT
SUCCEED/ SUSTAIN
Overcoming the Implementation Gap
GREAT IDEAS
SYSTEM ANALYSIS to identify barriers to carePROBLEM
PLAN
Model for Improvement
What can we change that will
result in an improvement?
PLAN
DO
STUDY
ACT
How will we know that a
change is an improvement?
What are we trying to accomplish? AIM
MEASUREMENTCHANGE
Measurement
Did we use the whole bundlein every patient every time?
Process measure (Bundle compliance)
What is the real story?
Change Made
Change Made
Change Made
Change Made in June
Feb Aug
Feb AugFeb Aug
Feb Aug Feb Aug
I
Change Made
Median
Shift: 6 points in row on same side of the median Note: A point exactly on the centerline does not cancel or count towards a shift
Median
Median
Trend: 5 points in row headed in same directionNote: Ties between two consecutive points
don’t cancel or add to a trend
Rule 3
0
5
10
15
20
25
1 2 3 4 5 6 7 8 9 10
Mea
sure
or C
hara
cerist
ic
Median 11.4
Data line crosses onceToo few runs: total 2 runs
Run Chart: Rules for Identifying Statistically Significant Change
Rule 1 Rule 2
Rule 4Rule 3
I
Astronomical Point: a obviously, even blatantly different valueNote: Every set of data will have a highest and lowest data point. This does not mean the high or low are astronomical
Runs: too few or too many runs
Provost and Murray
Run Charts• One of the most powerful tools for improvement
• Describe a process over time
• Shows trends the process is experiencing
• Can be used to analyse whether the change was an improvement
• Data can be used to drive change
Outcome measurement
Are we getting to our target?
Was the change an improvement?
How do we measure HAIs?
Measuring Infection Rates
• Total number of infective cases per 1,000 device days:
Total No. of VAP cases
Ventilator daysX 1,000
Numerator
Denominator
Definition of VAP
“VAP is suspected when a patient on mechanical ventilation develops: a new or progressive pulmonary infiltrate with fever / leucocytosis and purulent tracheobronchial secretions”
“VAP is suspected when a patient on mechanical ventilation develops: a new or progressive pulmonary infiltrate with fever / leucocytosis and purulent tracheobronchial secretions”
“Pneumonia is considered as ventilator associated if the patient was intubated and ventilated at the time or within 48hrs before the onset of the infection”
“Pneumonia is considered as ventilator associated if the patient was intubated and ventilated at the time or within 48hrs before the onset of the infection”
Overcoming Denominator Issues
At the same time every day theUnit managercounts devicesin use in the ward
Measuring HAI
Percentages and rates
% (or rate) = Numerator/ denominator
eg
Rate of infection = readmissions for septic caesarian section wounds per week / number of Caesarian Sections performed per week
Rate of infection = Number of VAP / 1000 device days
Maternal deaths – Malawi
For the “NO Maternal Death” Campaign a colorful, laminated A4 paper that said “Days without a Maternal Death: ______”. were hung in every Labour Ward for all (providers, patients and guardians) to see and the number was filled in daily with a dry erase marker
Days between events (infection)
Days Betweenevents(egInfection)
Sequence of events (eg Infection)
1st 2nd3rd 4th 5th
510
15
20
25
July Aug Sep Oct
5/7 13/8 7/9 5/10
5/7 9/9 8/10
6/7 12/9 15/10
11/7 15/9 19/10
25/7 20/10
27/7 21/10
25/10
ICU: Sequence of VAP infections by date 2010
Use the tools to Display the data
July Aug Sep Oct
5/7 13/8 7/9 5/10
5/7 9/9 8/10
6/7 12/9 15/10
11/7 15/9 9/10
25/7 20/10
27/7 21/10
25/10
So far we have:
1.Mapped the size of the project in your facility2.Prioritise a unit and bundle to start with3.Written an aim
Now, write down:
1.Your aim2.The outcome measures
i) Rate = numerator/denominator (describe)ii) Days betweeniii) Welsh Safety calendariv) Other
3.How you will feedback the data every month toi) The frontline staffii) Management
Mark with a * areas that you want to strengthen
Improving your Outcome Measure
1) NumeratorStandardised diagnosis of infection
2) What is the measure for HAI?Rate = Infection/device dayDays between (CLABSI, VAP, UTI)Days or cases between SSI
3) Collecting and collating data: What (definition)/ Where/ How (tools)/ Who/ When
4) Presenting the data:Format - Safety Cross, GraphsFeedback/presentation - Management platform
PDSA –testing a change
MARUWhat is Maru trying to achieve?How many ideas does he try?Is he successful?What was the possible negative outcome?
From YouTube
Rapid Cycle Change
What can we change that will result in an improvement?
How will we know that a change is an improvement?
What are we trying to accomplish?
AIM: make our project and outcome measure ‘visible’ in the ward
PROBLEM : our staff are not engaged in the project
Use the Welsh Safety Cross