Structure and process indicators for HAI-Net ICU surveillance European Center for Disease Control (ECDC)

Chair : Carl Suetens CR-ECDC ICU group: Antonella Agodi (IT), Michael Hiesmayr (AT), Alain Lepape

(Fr/ESICM), Mercedes Palomar (ES), Anne Savey (FR)

Indicators were limited to five topics with many items

• 1)Hand hygiene : – alcohol hand rub consumption in the ICU

• 2) Staff resources : – nurse to patient ratio and nurse-aid to patient ratio

• 3) Antimicrobial policy – Re-evaluation of antimicrobial therapy within 3 days after beginning of

therapy and documented in patient charts • 4) Device: intubation :

– Position of the patient – Endotracheal cuff pressure (> 20 mm H2O) controlled and/or

corrected at least twice a day, and documented in patient charts – Oral decontamination

• 5) Device: CVC – CVC dressing observation: not loosened, not damp, not visibly soiled.

Prevention by hand hygiene

Adapted from : K Ellingson et al. Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene. ICHE

35, No. 8 (August 2014), pp. 937-960 Observation methods Strengths Weaknesses

Direct observation Gold standard Only method that can discern all opportunities for hand hygiene

within patient care encounter and assess hand hygiene technique

Allows for immediate corrective feedback

Labor intensive and costly Observers must be trained and validated Subject to Hawthorne effect Subject to selection and observer bias

Technology-assisted direct observation Use of technology (eg, tablet) to save data entry step or to assist observer in standardizing measurement (ie, removing subjectivity)

Assessment of all or most opportunities to be analyzed at remote location

Less time-consuming and costly

Requires investment and maintenance of infrastructure Video monitoring requires trained observers has limited

opportunity for immediate feedback, and has potential to impact patient privacy

Product volume or event count measurement

Not subject to Hawthorne effect and selection or observer bias Unobtrusive and encompasses all opportunities Counters can detect changes in frequency of use according to time

of day or patterns of use in a hospital unit

May assist in optimal location of dispensers Relies on accurate usage data, which may be

compromised by system gaps or intentional tampering

Cannot distinguish hand hygiene opportunities(no denominator) or who used the product

Cannot assess adequacy of technique

Advanced technologies for automated monitoring

Systems with wearable components can provide positive feedback or just-in-time reminders to perform hand hygiene and individual-level monitoring

Captures all episodes entering and leaving a patient zone (eliminating selection and observer bias) and associated adherence

Expensive to implement Difficult to detect opportunities within the patient

encounter or to assess technique Limited data outside of research settings

Self-report Can raise individuals’ awareness of their practice Unreliable as healthcare personnel overestimate their performance

Distribution of ICUs according to alcoholic hand rub consumption (AHC) (ml per patient day) 2010

75th percentile

25th percentile

10th percentile

90th percentile

Median

Hand rub consumption (ml per patient day)

ICUs

Median value: 84 ml / patient-day

Rationale

• The importance of hand hygiene as cornerstone of standard precautions for infection prevention and control has been demonstrated since more than one century.

• The consumption of alcohol-based hand rubs (AHR) in liters per 1 000 patient-days is regarded as a good proxy indicator of hand hygiene compliance

Boyce JM. Measuring healthcare worker hand hygiene activity: current practices and emerging technologies. Infect Control Hosp Epidemiol. 2011 Oct;32(10):1016-28.

ESICM infection section survey 1)Hand hygiene : alcohol hand rub consumption during the surveillance period Concerns about the standardization

2) Staff resources : number of nurse-hours during a period of 7 days Concern about mixing different type of

nurses

3) Antimicrobial policy Re-evaluation of antimicrobial therapy within 3 days after beginning of therapy and documented in patient charts

Many concerns about the signification of de-escalation in ICU.

4) Device: intubation : Endotracheal cuff pressure (> 20 mm Hg) controlled and/or corrected at least twice a day, and documented in patient charts

OK

Oral decontamination with an antiseptic product OK

5) Device: CVC CVC dressing observation: not loosened, not damp, not visibly soiled. OK if done at a given time according to

the nurse shift.

2 – ICU staffing

DOCTORS

Rationale

• Understaffing is one of the main reasons for low quality of care (mortality…)

• It is one of the indicators with the strongest evidence of an association with cross-transmission.

• But, regarding the staffing, not the only one … 1. Daud-Gallotti RM, Costa SF, Guimarães T, Padilha KG, Inoue EN, Vasconcelos TN, et al. Nursing workload as a risk factor for healthcare associated infections in ICU: a prospective study. PloS One. 2012;7(12):e52342. 2. Hugonnet S, Uçkay I, Pittet D. Staffing level: a determinant of late-onset ventilator-associated pneumonia. Crit Care Lond Engl. 2007;11(4):R80. 3. Schwab F, Meyer E, Geffers C, Gastmeier P. Understaffing, overcrowding, inappropriate nurse:ventilated patient ratio and nosocomial infections: which parameter is the best reflection of deficits? J Hosp Infect. févr 2012;80(2):133-9.

Staffing ressources

• nurse to patient ratio and nurse-aid to patient ratio

• Decision to keep it simple. 1. Daud-Gallotti RM, Costa SF, Guimarães T, Padilha KG, Inoue EN, Vasconcelos TN, et al. Nursing workload as a risk factor for healthcare associated infections in ICU: a prospective study. PloS One. 2012;7(12):e52342. 2. Hugonnet S, Uçkay I, Pittet D. Staffing level: a determinant of late-onset ventilator-associated pneumonia. Crit Care Lond Engl. 2007;11(4):R80. 3. Schwab F, Meyer E, Geffers C, Gastmeier P. Understaffing, overcrowding, inappropriate nurse:ventilated patient ratio and nosocomial infections: which parameter is the best reflection of deficits? J Hosp Infect. févr 2012;80(2):133-9.

ESICM infection section survey 1)Hand hygiene : alcohol hand rub consumption during the surveillance period Concerns about the standardization

2) Staff resources : number of nurse-hours during a period of 7 days Concern about mixing different type of

nurses/nurse-aids

3) Antimicrobial policy Re-evaluation of antimicrobial therapy within 3 days after beginning of therapy and documented in patient charts

Many concerns about the signification of de-escalation in ICU.

4) Device: intubation : Endotracheal cuff pressure (> 20 mm Hg) controlled and/or corrected at least twice a day, and documented in patient charts

OK

Oral decontamination with an antiseptic product OK

5) Device: CVC CVC dressing observation: not loosened, not damp, not visibly soiled. OK if done at a given time according to

the nurse shift.

Antimicrobial utilization in ICU

Antimicrobial utilization in ICU Items How & when What Indicator Comments / limits

AB reevaluation Chart review of 20 to 30 patients under AB treatment

Reevaluation of AB treatment* within 3 days after start (*= in order to evaluate clinical efficiency and/or cost and/or MO susceptibility and/or possibility of AM de-escalation and/or stop of AB association etc.) In general , recommended 24-72h - 48-72h

% of AB treatments with documented* reevaluation (* = traceability on patient chart or ICU sheet… that the reevaluation has been actually performed by the intensivist or physician …)

- Traceability of the reevaluation? - If the chart review is done by an ICN, help and validation by an intensivist is necessary. Rque: Based on clinical evaluation if there is no M-O identified. 1 observation par patient traite

Carbapenem consumption

- Unit questionnaire - asked once (Pharmacy data) - period: same surveillance period (min 3 months)

- Num: volume of carbapanem distributed to the ICU by the pharmacy converted in DDD - Denom: all patients-days

DDD / 1000 patient-days Distributions and trends follow-up. Linked to AMR prevention (Enterobacteriaceae ESBL and CPE) Real problem in Southern Europe, but not in Northern Europe (could be considered in ESAC network)

AB referent

- Unit questionnaire - asked once

Access to an AB referent Y/N Difficult to define what is an " AB referent": in or out unit resources, level (ID physician, dedicated intensivist), permanent or not …

Aminoglycosides monitoring

Unit questionnaire - asked once

Systematic monitoring of aminoglycosides (dosage of peak)

Y/N Questionnaire or traceability? (retrospective chart review ? last 5-10 prescriptions of aminoglycosides)) Limit : unit not using aminoglycosides

Early treatment : timely AB treatment

Unit questionnaire - asked once

Beginning of treatment < 1 hour if septic choc or < 4 hours if community acquired pneumonia

Y/N Questionnaire or traceability? (retrospective chart review?). Rare event

Short duration AB association

Unit questionnaire - asked once

No AB association > 3 days without justification

Y/N Questionnaire or traceability? (retrospective chart review?).

Short AB treatment

Unit questionnaire - asked once

No AB treatment > 7 days without justification

Y/N Questionnaire or traceability? (retrospective chart review?).

Delay of treatment

Unit questionnaire - asked once

Beginning of treatment < 1 hour if septic choc or < 4 hours if community acquired pneumonia

Y/N Questionnaire or traceability? (retrospective chart review?). Rare event

Sample before treatment

Chart review 20 to 30 patients under AB treatment

Systematic sampling of the concerned infected site and/or blood cultures before treatment

% of AB treatments microbiologically documented

Quality of diagnosis and AB orientation.

Rationale • About 60 % of ICU patients will receive antimicrobials during an ICU stay • Reducing the duration of antimicrobial use and using narrower spectrum

antimicrobials or switching to monotherapy when possible limit the emergence and dissemination of drug-resistant strains and minimize antibiotic-related toxicity.

• Post-prescription review by a physician, pharmacist or other staff member of an antimicrobial after 48 hours from the initial order : core Indicators for hospital antimicrobial stewardship programs by the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR).

• !!! A specific category of patients : septic shock, severe sepsis.

ESICM infection section survey 1)Hand hygiene : alcohol hand rub consumption during the surveillance period Concerns about the standardization

2) Staff resources : number of nurse-hours during a period of 7 days Concern about mixing different type of

nurses

3) Antimicrobial policy Re-evaluation of antimicrobial therapy within 3 days after beginning of therapy and documented in patient charts

Many concerns about the signification of de-escalation in ICU.

4) Device: intubation : Endotracheal cuff pressure (> 20 mm Hg) controlled and/or corrected at least twice a day, and documented in patient charts

OK

Oral decontamination with an antiseptic product OK

5) Device: CVC CVC dressing observation: not loosened, not damp, not visibly soiled. OK if done at a given time according to

the nurse shift.

Prevention of VAP

Pneumonia prevention to decrease mortality in intensive care unit: a systematic review and meta-analysis. Roquilly A, Marret E, Abraham E, Asehnoune K. Clin Infect Dis. 2015 Jan 1;60(1):64-75.

Prevention of VAP: many prevention measures « on the market ».

Items How & when What Indicator Comments / limits Cuff pressure control

Chart review of 30 intubated patients/days

Endotracheal cuff pressure (> 20 mm H2O)

% of conformity

Daily traceability ? 30 patients- days ?

Oral decontamination

Chart review of 30 intubated patients/days

Oral decontamination >= 3 / j

% of conformity

Daily traceability at least 2 times/day Antiseptic product (chlorhexidine or other antiseptic) 30 patients- days ?

Patient position

30 Observations of intubated patients (1 obs / patient /d)

Intubated patients in semi-recumbent position

% of conformity

Direct patient observation Avoidance of supine position

Sedation Chart review of 30 intubated patients

Daily prescription of sedation level

% of conformity

Traceability ? 30 patients or 30 patients- days ?

Need for device exposure

Chart review of 30 intubated patients

Daily review of the need of intubation/ventilation

% of conformity

Difficult. Traceability ? 30 patients or 30 patients- days ?

SDD ? Y/N Controversial SOD ? Y/N ? Sub-glottic asp. ? Y/N Equipment not available in all ICU

Endotracheal cuff pressure

Correct cuff pressure: between 20 and 30 cm H2O

Over-inflated cuff pressure: Ischemia tracheal mucosa, risk of tracheal stenosis

Under-inflated cuff: risk of micro-inhalation

Subglottic secretion drainage in endotracheal tube

Rationale • Cuff pressure

– Maintaining the endotracheal cuff pressure in the recommended range limits micro-inhalations while preserving the mucosal integrity.

– Recommended range for the pressure varies between studies and guidelines: 25-30 cm H2O, 20-30 cm H2O or 15-22 mm Hg.

• Oral decontamination – Regular oropharyngeal decontamination with chlorhexidine or povidone-

iodine reduces the number of microorganisms colonising oropharyngeal secretions, which are involved in the development of ventilator-associated pneumonia through aspiration in the lower respiratory tract in intubated patients.

• Patient position: – Patients should not be maintained in supine position (except in case of specific

indications) in order to reduce micro-aspiration. – The existing evidence mainly supports an elevated head of the bed to 30-45

degrees – Very debated

ESICM infection section survey 1)Hand hygiene : alcohol hand rub consumption during the surveillance period Concerns about the standardization

2) Staff resources : number of nurse-hours during a period of 7 days Concern about mixing different type of

nurses

3) Antimicrobial policy Re-evaluation of antimicrobial therapy within 3 days after beginning of therapy and documented in patient charts

Many concerns about the signification of de-escalation in ICU.

4) Device: intubation : Endotracheal cuff pressure (> 20 mm Hg) controlled and/or corrected at least twice a day, and documented in patient charts

OK

Oral decontamination with an antiseptic product OK for most of them. More often than twice a day .

5) Device: CVC CVC dressing observation: not loosened, not damp, not visibly soiled. OK if done at a given time according to

the nurse shift.

CVC

CVC related-infections

Items How & when What Indicator Comments / limits Dressing observation

Patient observation: 20 to 30 observations of CVC dressings (once a day)

Dressing: not loosened, not damp, not visibly soiled

% of conformity Once direct observation pp per day

Clinical surveillance of the insertion site

Chart review of 20 to 30 patients with CVC

Daily surveillance of insertion site (palpation through the dressing to discern tenderness and by inspection if a transparent dressing is in use)

% of conformity? traceability?

= Done and traced? or only traced? Rque: If the patient has local tenderness or other signs of possible CRBSI, an opaque dressing should be removed and the site inspected visually.

Need for CVC exposure Chart review of 20 to 30 patients with CVC

Daily review of the need of CVC % of conformity Difficult. Traceability? 20 to 30 patients or patients- days?

Hand hygiene compliance

Nurse observation - trained auditor - 20 to 30 observations in one week

- Num: N of hand hygiene performed - Denom: N of opportunities

% compliance - nothing about hand hygiene technique (quality of the procedure) -definition of opportunities (before, after, care series…)

Aseptic technique Nurse observation - trained auditor - 20 to 30 observations in one week

- Num: N of aseptic techniques performed = no touch or sterile gauze impregnated with antiseptic - Denom: N of opportunities

% compliance -definition of opportunities (before, after, care series…) - type of antiseptic? (alcoholic?) - could be for dressing refection

Access port disinfection Nurse observation - trained auditor - 20 to 30 observations in one week

- Num: N of access port disinfection performed with antiseptic before each manipulation - Denom: N of opportunities

% compliance type of product? antiseptics, better alcoholic (?)

Hand hygiene compliance

Nurse observation - trained auditor - 20 to 30 observations in one week

- Num: N of hand hygiene performed - Denom: N of opportunities

% compliance - nothing about hand hygiene technique (quality of the procedure) -heavy workload - complex methodology and definitions of opportunities (before, after, care series…)

Gloves compliance Nurse observation - trained auditor - 20 to 30 observations in one week

- Num: N of gloves wearing - Denom: N of opportunities

% compliance - nothing about "gloves abuse" -heavy workload - complex methodology and definitions of opportunities (before, after, care series…)

Observation of CVC insertion techniques: excluded (Rare event, not always scheduled. Many CVC are inserted in surgery or emergency units)

Loose, damp or visibly soiled dressing

Rationale

• An indicator of CVC maintenance preferred over an indicator of CVC insertion because of feasibility, in particular the number of observation opportunities is much higher for CVC maintenance than for CVC insertion

• SHEA recommandations : “For non-tunneled CVCs in adults and adolescents, change transparent dressings and perform site care with a chlorhexidine-based antiseptic every 5-7 days or more frequently if the dressing is soiled, loose, or damp; change gauze dressings every 2 days or more frequently if the dressing is soiled, loose, or damp”

Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O'Grady NP, Pettis AM, Rupp ME, Sandora T, Maragakis LL, Yokoe DS. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Sep;35 Suppl 2:S89-107.

ESICM infection section survey 1)Hand hygiene : alcohol hand rub consumption during the surveillance period Concerns about the standardization

2) Staff resources : number of nurse-hours during a period of 7 days Concern about mixing different type of

nurses

3) Antimicrobial policy Re-evaluation of antimicrobial therapy within 3 days after beginning of therapy and documented in patient charts

Many concerns about the signification of de-escalation in ICU.

4) Device: intubation : Endotracheal cuff pressure (> 20 mm Hg) controlled and/or corrected at least twice a day, and documented in patient charts

OK

Oral decontamination with an antiseptic product OK

5) Device: CVC CVC dressing observation: not loosened, not damp, not visibly soiled. OK if done at a given time according to

the nurse shift.

Conclusion on the Structure and process indicators for HAI-Net ICU surveillance

• No consensus solution exist, all indicators can be discussed. • Should be taken into account: the feasibility, the ease of collection in all

EU countries, the generated workload and the robustness. • We must consider this work as a starting point and modify it the following

years depending on the results. • ICU is a very costly activity generating many infectious complications

USA: Between 2000 and 2005, annual critical care medicine costs increased from $56.6 to $81.7 billion, representing 13.4% of hospital costs, 4.1% of national health

expenditures, and 0.66% of gross domestic product