Smart use of Care bundles- HII4 and SSI and NICE quality standards

Manjula NatarajanConsultant Microbiologist and DIPC

Deputy MD

KGHFTMedium DGH 580-600 BedsBowel cancer screening, PPCI, downs screening for the

regionPrimary arthroplasty- Hips and knees800/year. 76 revisions (9.5%)- 2012 dataGeneral surgery including colorectal, urology, Upper GI,

breast surgery-including onco-plastic surgeryObstetrics & Gynaecology

• Importance of pre-op, peri-op and post op phase

NICE CG74 2008

• New evidence had no impact on previous guidance

• Antibiotic coated sutures in abdominal surgery

NICE SSI Evidence

update June 2013

• Importance of advice on wound care, antibiotics for treatment of wound infections

• Need to monitor SSI rates & provide feedback to stakeholders for continuous improvement through adjustment of clinical practice

NICE Quality Standard 49

October 2013

High Impact InterventionsHII4- DH 2011

Surveillance

Patient journey- HII4, theatre ventilation validation, ward behaviours, Wound care education and management

Specimen journey- Lab internal QA

Surveillance- ward based, lab based, SSI, MDT and reports

Also via reports from clinicians regarding incidence of infections

Aim• To use HII4 as evidence of theatre practice• Using this as a monitoring tool to see improvements in

practice• Correlate with SSI surveillance rates• Use HII4 and SSI rates and MDT discussions to change practice• Use presentation mode to surgeons to change practice• Use ICNet to gather data for SSI and HII4• Monitor and demonstrate continuous improvement in theatre

practice, compliance with NICE quality standards

HII4During SSI

module- Random & targeted

Post SSI module- random

HII4Ortho- MDT based

surveillance

Random audit to assure practice-

procedure related

KGH approach to using HII4

CASE STUDIES

Breast SSI surveillance 2010-14

PERIOD NUMBER OF OPERATIONS

NUMBER OF SSI’s

PERCENT NATIONAL AVERAGE

JULY- SEPT 2010 32 0 0% 5.2%

JAN- MARCH 2012 58 1X STAPH A 1.7% 4.6%

APRIL- JUNE 2012 52 0 0% 4.6%

OCT- DEC 2013 56 3X STAPH A 5.5% 4.5%

JAN- MARCH 2014 50 1X STAPH A 2% 4.5%

Patient no

1 2 3 4 5 6 7 8 9 10 TOTAL

MRSA Screen Yes YES

Yes Yes

Yes

Yes

Yes

Yes Yes

Yes

100%

Pre-op shower documented

no no no no no no no No no no 0%

BMI Documented

30 37 35 46 36 41 26 24 21 31 100%

Hair removal with clippers

n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a

Skin prep 2% Chlorhex with 70% Alc/PI

No No No YesPov/Iod

No No No No No No 10%

Prophylactic Antibiotics

Aug Teico Aug None Cef Aug Cef Aug Aug Cef 80%

Temp > 36 yes yes yes yes yes yes No 35.6

yes yes yes 90%

SATS >95%

yes yes yes yes No 94%

yes yes yes yes No94%

80%

Glucose < 8 n/a No 9.4

n/a n/a No 9.2

n/a n/a n/a n/a Yes8.0

33%

Wound dressing checked and documented

yes yes yes yes yes yes yes yes yes yes 100%

Dressing left in situ for a minimum of 48 hrs

yes yes yes yes yes yes yes yes yes yes 100%

TOTAL

80% 60% 70% 70% 60% 80% 70% 80% 80% 70%

Breast Surgery HII4, December 2013

Breast surgery SSI

• SSI surveillance showed evidence of MSSA infections

• No particular themes• HII4 revealed gaps in practice• Initially defensive team willing to engage

change practice after viewing evidence• Next SSI module showed results• Face to face meeting helps

SURGICAL SITE SURVEILLANCE January 2013 To December 2013

PERIOD TYPE OF SURGERY NO OF OPS

NO OF SSI’s PERCENT NATIONALAVERAGE

REPORTED TO

JAN 2013 TO MARCH 2013

LARGE BOWEL 60 3 X COLIFORMS1x PSUEDOMONAS1 X STAPH A

8.3% 12.5% ICCConsultantsSurgical CMT

APRIL 2013TO JUNE 2013

#NOF

HIP REPLACEMENTS

76

81

1x MRSA

1x MSSA

1.3%

1.2%

1.8%

1.2%

ICCConsultantsSurgical CMTSurgical MatronWard Managers

JULY 2013TO SEPT 2013

C SECTIONS 240 14 X STAPH A3 X GBS3 x MIXED GROWTH2 X COLIFORMS1 X MRSA1 X PROTEUS

10% 8.6%ICCConsultantsW&C CMTHONWard Managers

OCT 2013 TODEC 2013

BREAST

KNEE REPLACEMENTS

56

64

2 x STAPH A

1 X Staph A

3.6%

1.5%

1.2%

1.7%

ConsultantsSurgical CMT

We undertook HII4 to look prospectively for emergency and electives, and retrospectively at the MSSA cases.

No emerging themes with surgeons or operating teams

Skin prep was variable Pre-op shower not done for elective

and emergency

Hibiscrub for electives, wipes for emergencies introduced

Wound care advice and leaflets given to patients

Recommendations acted on.

Rates of infection reduced in Q2 2014 to 3.3%

• Theatre ventilation issues in June

• We undertook SSI for CS from July to august.

• 240 C Sections, 50% emergency/ elective split

• 10% infections, last national data was 8.6%

• 50% were MSSA, superficial, GP swabbed, no re-admissions.

• Large BMI in 60-70% of cases noted

C sections and surveillanceThe Problem Results

SURGICAL SITE SURVEILLANCEJanuary 2014 To December 2014

PERIOD TYPE OF SURGERY NO OF OPS

NO OF SSI’s PERCENT NATIONALAVERAGE

REPORTED TO

JAN 2014 TO MARCH 2014

BREAST

HYSTERECTOMY

50

61

1 x Staph A

0

2%

0%

4.2%

4.5%

ICCConsultantsW&C CMTHONWard Managers

APRIL 2014TO JUNE 2014

LARGE BOWEL

#NOF

64

77

3 x Coliforms1 x ESBL

0

6.25% Last years NA was 12.5%

Awaiting report and new NA

JULY 2014TO SEPT 2014

C SECTIONS 236 Strep B x 21 x coliform1 x anaerobe

3.3% 8.6% (National average in 2009)

OCT 2014 TODEC 2014

Trust-wide use of HII4

• During SSI module- evidence to challenge and change practice

• Large bowel SSI module- used to change practice despite SSI rates being low

• Radiology and angiography- use of razors• Core business in Surgery

Use of technology

• ICNet SSI module with NG• Use of ICNet to extract HII4 data from theatre

system (ORMIS in KGH)

The IC Net Dashboard

Future –HII4 on IC Net SSI module

Effective tool to reduce SSI

HII4, manual or

ICNet

NICE compliance

Evidence to change practice

Cost benefit analysis

• To analyse KGH data for LOS, and cost of SSI in Orthopaedics – using ICNet

• To achieve reduction in SSI and cost using HII4

Changing epidemiology of organisms

Acknowledgements

• Pam Howe- Lead Nurse, IPaC • Jennie Lovell- ICN• Katrina Rufea- Surveillance and Practice

Development Nurse• DR. Dina El-Zimaity- Consultant Microbiologist