Key Messages for Infection Prevention and Control Leaders

1. Key Messages for Infection Prevention and Control Leaders Denise Murphy, RN, BSN, MPH, CIC Vice President, Quality and Patient Safety Main Line Health System Philadelphia, PA USA April 2010 Nice, FR

2. Disclosures 2010 • CDC International Meeting on Healthcare Associated Infections (Decennial); CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) • AHSRM/APIC/Chartis Insurance: Patient Safety Tour faculty • APIC International Conference and Education Meeting faculty; APIC Consulting, Inc. Board • NPSF/APIC Patient Safety Awareness Webinar faculty • TMIT faculty for IHI International Conference and Educational Meeting • National Quality Forum (NQF) Patient Safety Advisory Committee

3. Objectives Discuss the scope of the problem created by healthcare associated infections (HAIs) globally Discuss impact of HAIs: clinical, financial and societal Emphasize the role of culture related to reduction/elimination of preventable harm Outline what top performers are doing to eliminate HAIs 3

4. HAIs: Scope of the Problem • At any time, over 1.4 million people worldwide suffer from healthcare associated infections (HAI) • Prevalence survey in 55 hospitals in 14 countries in Europe, Eastern Mediterranean, South-East Asia and Western Pacific showed average of 8.7% of hospital patients had HAIs • In England, 9% inpatients have HAI at any time, equivalent to at least 100,000 infections a year* FOR MORE INFO... Tikhomirov E. WHO Programme for the Control of Hospital Infections. Chemiotherapia, 1987, 3:148–151.*Management and Control of HAI in Acute NHS Trusts in England. Feb 2000

5. Impact of HAI in the U.S. • At least 1.7 million HAI in US hospitals (2002*) • 155,000 deaths; 99,000 attributable to the infection** FOR MORE INFO... *Klevens RM et al., 2007; ** National Vital Statistics Reports, Deaths: Injuries 2002

6. Beyond Death…. • One HAI leads to risk for multiple HAIs • Excess LOS increases risk for other patient safety events (e.g., medication errors, fall, pressure ulcers) • MDROs • Societal costs • Loss of trust • Increased legislation and litigation • Personal loss: productivity, sense of well being, impact on family and caregivers

7. Why Target Elimination of HAI? Too many people are dying or are harmed by HAI. Theresa Marie Murphy 1927-2001

8. U.S. DHHS* Steering Committee on Healthcare Associated Infection Reduction CHARGE: Develop a Coordinated Strategy National goals for reduction will target: • Catheter-associated urinary tract infections • Central line-associated blood stream infections • Surgical Site infections • Ventilator-associated pneumonia • MRSA • Clostridium difficile NOTE: Tier one - focus on hospitals; tier two - out of hospital care and additional types of HAI *Department of Health and Human Services

9. Recommendations: Prevention and Implementation • Many goals call for at least 50% reduction over 5 years • Use and improve metrics needed to assess progress • Prioritize existing prevention strategies (CDC HICPAC guidelines) – setNational performance standards

10. DHHS Challenge to Leaders • Identify specific actions to fix broken processes and systems AND to address staff behavior/compliance • Responsible parties to drive each tactic or step • Timelines and resources to complete actions • Briefings to senior leaders • Make performance transparent: scorecards • Watch for barriers in each step of implementation

11. Financial Impact of HAI FOR MORE INFO... Perencevich EN, et al. Infect Control Hosp Epi, October 2007 (Studies from 1999-2005)

12. Comparison of Economics – Patients with/without Central Line Associated Bloodstream Infection FOR MORE INFO... Shannon et al. Amer J Med Quality Nov/Dec 2006; pgs 7S-16S

13. Preventable Complications No Longer Covered by CMS* • Foreign object retained after surgery; • Air embolism; • Blood incompatibility; • Stages III and IV pressure ulcers; • In-hospital falls and trauma; • Catheter-associated urinary tract infection (UTI); • Vascular catheter–associated infection; • Surgical site infection—mediastinitis after CABG FOR MORE INFO... * Center for Mediicare and Medicaid Services; Source: McNair et al. Health Affairs 2009:28(5):1485-93.

14. Business Solution: Focus on Length of Stay • Know the financial impact of HAI and medical errors and the attributable excess length of stay • Realize how many additional patients can be admitted into beds not occupied by patients with an HAI • Calculate added revenue from reducing infections (not costs saved) FOR MORE INFO... *Ward EJ, Healthc Financ Manage. 2006 Dec;60(12):92-8

15. Clinical Solution: Focus on Implementation of and Compliance with Infection Prevention Bundles (see appendix) • CLABSI • CAUTI • VAP • SSI • MDRO

16. Cultural and Administrative Solutions: Setting the theoretical goal of elimination of HAIs – not even 1 HAI is acceptable; Setting expectations that infection prevention and control measures will be applied consistently by all health care workers, 100% of the time; Creating a safe environment for health care workers to pursue 100% adherence, where they are empowered to hold each other accountable for infection prevention; Ensuring resources and leadership support as the foundation to successfully implement prevention measures; FOR MORE INFO... Warye K, Murphy DM. Am J Infect Control 2008;36:683-4.

17. Cultural and Administrative Solutions: Transparency and continuous learning allow for mistakes to be openly discussed without fear of penalty; Prompt investigation of HAI’s of greatest concern to the patients, the organization and/or community; drilldown into root and contributing causes. View problems and solutions from a human factors perspective (People, Tools, Work, Environment) Providing real time data to front-line staff for the purpose of driving improvement. FOR MORE INFO... Warye K, Murphy DM. Am J Infect Control 2008;36:683-4.

18. Complementary Improvement Strategies Falls Pressure Ulcers Patient Satisfaction …and on, and on… Culture  © 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Used with Permission. Surgical Site Infections Central Line Infections Codes Outside the ICU Hand Hygiene

19. Process Design Behavioral Accountability VAP Prevention 1. Elevation of the head of the bed to between 30 and 45 degrees 2. Daily “sedation vacation” and assessment of readiness to extubate 3. Peptic ulcer disease (PUD) prophylaxis 4. Deep venous thrombosis (DVT) prophylaxis (unless contraindicated) “Clinical Bundle” “People Bundle”

20. Who has gotten to ZERO HAI? CT ICU Primary Bloodstream Infection Rates 8 2006 - 2008 Mercy Hospital ICU VAP Rate NNIS Benchmark 6 Ventilator Associated Pneumonia (VAP) Quarterly May04- 4 Suction BSI Rate (per 1000 line days) and oral care education. 8 2 Aug05 - 7 Hilo evac tubes in 6 0 use. Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 5 Feb08 - 2006 2007 2008 4 BAL/PBS for susp Rate Mean NHSN 3 VAP 2 1 Source: Barnes Jewish Hospital Epidemiology and Infection Prevention Department 0 Baseline 3Q03 4Q03 1Q04 2Q04 3Q04 4Q04 1Q05 2Q05 3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 1Q08 2Q08 3Q08 1Q-2Q03 n=1/203 n=0/261 n=2/302 n=0/343 n=0/203 n=0/150 n=1/241 n=1/281 n=0/201 n=0/187 n=0/316 n=0/331 n=0/313 n=0/347 n=0/331 n=0/324 n=1/287 n=0/333 n=0/259 n=1/325 n=1/352 n=3/499

21. Johns Hopkins Medical Institution CLABSI for All Adult ICU’s 2001 –2009 Trish M. Perl, MD, MSc, Johns Hopkins Hospital, Baltimore, MD And the Hospital Epidemiology Department Allegheny General Hospital CCU Central Line Associated Bacteremia 2002 Through April 2007 9 Process Standardization Process Extinction Education Programs Cultural Shift? 8 7 6 CLABSI/1,000 Line Days 5 4 3 2 Jerome E. Granato MD MBA, Medical Director Joy Peters, RN MSN MBA, Nursing Director Coronary Care Unit, Allegheny General Hospital, PA And Cheryl Herbert, Manager, IC 1 0 Jul 02 Mar 07

22. Main Line Health System – Phila, PA Mark Ingerman, MD and Connie Cutler, Medical Director and System Director, Main Line Health System’s Adult Critical Care Units Suburban Philadelphia, PA

23. Incidence of CRBSI in PICC LinesHouse-Wide; January 2005-March 2009 Incidence of CRBSI- all CVCHouse-Wide; January 2005- March 2009 Sophie Harnage RN,BSN Clinical Manager Infusion Services Sutter Roseville Medical Center Roseville, CA Sutter Roseville Medical Center, Roseville, California

24. Targeting Zero – Global Challenge

25. “An intervention conducted over two years at a 450 bed hospital in Pratumthani, Thailand involved 2,412 patients with urinary catheters. A nurse-driven intervention involving daily assessment of appropriateness of catheter use and reminders to physicians about importance of catheter removal resulted in • fewer urinary catheter days (11d vs. 3 days), • lower UTI rates (23.4/1,000 catheter days vs. 3.5/1,000) • lower hospitalization (16 d vs. 5 d) • lower costs ($3,739 vs. $1,378.).”   We realized a 73% reduction in catheter utilization and decreased UTI 85%.” “An educational intervention, using the WHAP VAP modules, was also conducted at Thammasart Univiversity Hospital - VAP was reduced 59%. Submitted by Anucha Apisarnthanarak, MD and the Thammasart University VAP intervention team

26. Targeting zero is culture change – takes time Strong Sr. Leader support: Champions/multidisciplinary teams IHI’s bundle approach/EBM Transparency/data feedback Analysis – real time Personalize HAI Communication! Celebrate success Plan to sustain the gains Critical event analysis Daily assessment of device use/reminders to remove Building in reliability Human Factors training Board involvement IPC Liaisons “Link Nurses” Weekly Executive Report Web-based education Empowered staff STOP THE LINE Teams who have gotten to zero HAI… What’s Standard? What’s Different?

27. Summary Leaders must: • Educate themselves and their teams about the total impact of HAI. • Must BELIEVE that zero HAI is an achievable imperative and sustainable for long periods of time. They must set and actively support that goal. • Understand HOW to achieve zero and what is required to sustain that performance. • Set cultural and behavioral expectations: 100% compliance with evidence based measures to prevent infection is expected from every one, for every patient, every day. • Provide the environment, equipment, human and financial resources to reduce HAI to zero. • Ensure that when even one HAI occurs, it should trigger immediate concern and a drilldown into potential causes (process breakdown, new equipment, slip in compliance, lack of knowledge, etc.) • Educate their communities about more than the risk for HAI, but also efforts targeted at prevention. Then market successful reductions.

28. “Never forget that a small group of people can change the world. It is the only thing that ever has…” - Margaret Mead

29. APPENDIX:Table of “What Top Performers in Patient Safety are Doing”Main Line Health System’s: - Clinical Bundles - Culture of Safety (People Bundle)

30. What Top Patient Safety Performers Are Doing

31. MLHS Central line-associated Bloodstream Infection (CLABSI) Prevention • Appropriate criteria-based utilization of central line • Line site choice (internal jugular<subclavian<PICC): avoid femoral site • Hand hygiene • Central line carts or kits (cabinet in Interventional Radiology) • Chlorhexidine gluconate to cleanse site before insertion • Full barrier precautions for insertion • Protect line integrity: do not use for blood draws! • Scrub the hub before all necessary usage • Daily assessment of need for central line • Drill down on use of PICC lines and using central line for blood draw • Timely feedback about outcomes (rates) and process (bundles) • Review of each case by BSI prevention PI team • Comprehensive Unit-based Safety Program (CUSP) collaborative • Standardization of component locations in carts or kits • Observation of central line insertions and use of checklist • Engagement of senior leadership Evidence-based Prevention Measures and Best Practice

32. MLHS Catheter-associated Urinary Tract Infection (UTI) Prevention • Hand Hygiene • Appropriate criteria-based Foley catheter insertion • Nurse-driven Foley catheter removal protocol • Evaluation of silver-coated catheters • Rounds with daily assessment of need for catheter • Point prevalence survey on documentation • Education for residents and nurses on insertion technique • Review of each case by UTI prevention PI team • CMS Surgical Care Improvement Project requirement to remove on first or second post-op day (or document why catheter is necessary) Evidence-based Prevention Measures and Best Practice

33. MLHS Ventilator-associated Pneumonia (VAP) Prevention • Hand Hygiene • Daily weaning assessments, “sedation vacation” in standing orders • Elevate head of bed (HOB) at least 30 degrees • High-low evacuation endotracheal tubes for subglottic suction • Oral care every 2 hours by nursing or respiratory therapy • Chlorhexidine gluconate oral rinse twice/day • Mandatory documentation fields for HOB and mouth care in • electronic documentation • Feedback to caregivers when opportunity for mouth care is missed • No routine vent circuit changes • Emphasis on minimal opening of vent circuits • Ambulate as early as possible or investigate mobility options • Review of each case by VAP prevention PI teams Evidence-based Prevention Measures and Best Practice

34. MLHS Surgical Site Infection (SSI) Prevention • NO RAZORS; if hair must be removed, use clippers • CHG wipe (skin antiseptic) for hip/knee surgery patients • Use of CHG/alcohol skin prep • Pre-operative prophylactic antibiotic choice and timing • Post-operative discontinuation of prophylactic antibiotic • Meeting with surgical specialty group when cluster identified • Normothermia (normal body temperature) • Infection prevention rounds in surgical suites • Review of each case by SSI prevention PI teams Evidence-based Prevention Measures and Best Practice

35. MLHS Culture of Safety ( “People Bundle”) • Leaders make safety a visible and vocal priority • We have zero tolerance for reckless behavior • Management sets clear expectations around safe(ty) behaviors • Staff understand their accountability • Managers hold staff accountable 100% of the time • Staff speak up about risk without fear • Peers observe, coach and hold one another accountable for safety • Staff are equipped with critical thinking skills and apply them when safety is at risk • Our patients and our workforce are surrounded by safe systems and processes enabling them to prevent harm • Staff proactively engage patients and families in their healthcare BEST PRACTICE and MLHS CULTURE OF SAFETY GOALS