Patient Safety - Infection Prevention
Donna Armellino, RN, DNP, CIC
Vice President, Infection Prevention
North Shore – LIJ Health System
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 Prevention’s National Healthcare
Safety Network (NHSN)
Superficial
incisional SSI
• 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
Organ/space SSI
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
3
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
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 > 1.0 indicates that more SSIs were observed than
predicted and a SIR < 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.
HAI Sample NHSN Data
More information can be found
at:http://www.cdc.gov/nhsn/PDFs/dataStat/NHSN-
Report_2010-Data-Summary.pdf
HAI Sample NYSDOH Data
More information can be found at:
http://www.health.ny.gov/statistics/facilities/hospital/hospita
l_acquired_infections
HAI Impact
• Potentially preventable HAIs
cause patient harm:
–
–
–
–
morbidity
mortality
increased length of stay
Increase health care cost
Health System Facilities CLABSI Free Months
• Intensive Care Unit (ICU)
–
–
–
–
–
–
Glen Cove - >41 months
Forest Hills - >6 months
Huntington ICU - > 24 months
Southside ICU – 9 months
Long Island Jewish 2 ICUs - >24 months
North Shore University Hospital PICU - >14 months & NSCU - >6
months
• Non-ICU
–
–
–
–
Glen Cove - >18 months
Syosset - >22 months
Franklin - >6 Months
Medical & Adolescent – >24 months
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 >80%.
3.5
Change: 2005
through 2008
3
2.5
3.25
3.21
2
2.03
1.5
1.8
1
1.23
1.39
1.45
1.09
0.5
0
2004
2005
2006
2007
2008
2009
2010
2011
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
11
Journey Toward Zero – Ongoing Learning
LINE MAINTENANCE
IV tubing not changed
on a timely basis
Line in for too long
Dressing not change
using aseptic
techniques
IV tubing not labeled
properly to change
Line not manipulated
appropriately
Injection hub
not disinfected
TECHNIQUE
NOT ADEQUATE
Not compliant
with hand hygiene
Line inserted w/o
sterile technique
Inadequate use of
maximal barrier
precautions
Inadequate prep
before insertion
Femoral line chosen
instead of subclavian
LACK OF EDUCATION
Inexperienced
residents and clinicians
CLABSI
Clinicians not
knowledgeable about
Central Line Bundle
Nurses do not properly
know how to change
dressings
MD does not select a
catheter with the least
number of lumens
Assessment:
Identification of
patterns or
trends
Clinicians unaware of
line maintenance
CLABSI
CAUTI Process Change = Outcome Change
Baseline* (Feb. 2011 – July 2011)
Post-intervention* (Aug. 2011 – Feb. 14, 2012)
Southside Hospital – device utilization
Syosset Hospital – infection
LIJ – infection decrease
Plainview Hospital – device utilization
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
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
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
Potential Avoidance: Case Review
• Hospitalization:
Continued
– 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
Problem: Hand Hygiene
Project Aim: Improved
and sustained high hand
hygiene compliance
3rd Party Remote Video Auditing
•
Door motion
detector triggers
audit
•
Auditors rate activity
based on pass/fail
criteria
•
Video camera
records activity
•
•
Digital Video
Recorders stores
footage locally
Audits stored in
external auditors
database
•
Feedback delivered
via on-site light
emitting diode
boards, daily e-mails,
and weekly e-mails
•
External auditors
connect remotely
Timeline: 2008
1
4
02/08
Hand hygiene compliance
calculated with the use of remote
video auditing and real-time
feedback
Discussion with staff on
the use of Cameras for
Hand Hygiene
Compliance
03/08
2
04/08 05/08 06/08 07/08
03/08
Cameras and door
alarms installed
10/06/08
3
8/08
9/08
10/08 11/08 12/08 01/09 02/09 03/09 04/09
06/10/08
Hand hygiene compliance calculated
with the use of remote video auditing
07/04/10
Remote video auditing
with feedback continues
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
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
Figure Without and With Feedback
Internal Self-Auditing Scores
Start
Feedback
10/06/08
•
•
Without feedback: hand hygiene rates of <10% (3,833/60,066)
With feedback the rates were >86% (223,187/261,091) (p<0.001)
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 >40% by 11/2013.
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)
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
darmelli@nshs.edu