International Quality Improvement Collaborative for Congenital Heart Surgery

1. International Quality Improvement Collaborative for Congenital Heart Surgery

2. Vision Facilitate a collaborative of healthcare teams from around the world creating a culture of patient safety & quality for children receiving congenital heart surgery in developing world countries

3. Mission Our mission is to reduce mortality and major complications for children undergoing congenital heart surgery.

4. Data Entry Map Ukraine Poland Belarus China (Changchun) Serbia China (Shanghai) Dominican Republic Pakistan India (Frontier) Vietnam Guatemala India (Amrita) India (Innova) Columbia India (Star) Uganda Brazil

5. Objective • Create tailored QI strategies to reduce mortality and major complications for developing world programs. • Employ a telemedicine platform to facilitate distance learning, dialogue, disseminate knowledge & skills.

6. Drivers of Mortality • Team-based Practice through Nurse Empowerment • Reduce Surgical Site Infections and Bacterial Sepsis • Safe Operative Practices

7. Change Strategies Key Drivers Aim Utilize a surgical safety checklist to prompt and document evidence-based process measures (i.e. antibiotics given within 60 minutes of surgical incision) Safe Perioperative Practice Focus on hand hygiene for ALL clinical personnel in contact with patient care. Reduction In 30 day mortality associated with congenital heart surgery Reduce Surgical Site Infections & Bacterial Sepsis Empowering nurses Evidence-based nursing practice Scripting nurses in ward and ICU on how to give reports Accurate 24hr total patient intakes and outputs Accurate daily recording of patient weight Effective Communication-SBAR Team-based Practice Key Driver Diagram

8. Learning Modules • Contain QI strategies for each of the 3 drivers that impact mortality. • Each module contains a series of 3 educational sessions (one session/webcast). • Sessions advance from beginning, intermediate, and advance-level of learning & acquisition of skills.

9. Learning Modules • Learning Module I: Team-based Practice and Nurse Empowerment • Learning Module II: Reducing Surgical Site Infection and Bacterial Sepsis • Learning Module III: Safe Perioperative Care

10. Timeline for Webcasts The color of each Learning Module corresponds to the date the topic will be presented during that month’s webcast. For example, Team-based practice will be the topic 2/17 and 5/19.

11. Preventing Health Care Associated Infections:Creating a Hand Hygiene Culture

12. Outline • Define Health Care Associated Infection • How Infections Occur • Hand Hygiene • Creating a Hand Hygiene Culture

13. What is a Health Care Associated Infection ? Definition • A condition resulting from an adverse reaction to an infectious agent, or to toxins produced by the agent. • An infection not present or incubating at the time of admission

14. In Mexico • Health care associated infections are the third leading cause of death • The cost of these infections equals 70% of the entire budget of the Ministry of Health World Health Organization Global Patient Safety Challenge 2006

15. In Brazil and Indonesia • More than half of neonatal patient admissions get a health care associated infection, with mortality rates between 12% to 52% World Health Organization Global Patient Safety Challenge 2006

16. In the United States • Health care associated sepsis and pneumonia led to $8.1 billion in increased health care costs in the years 1998 – 2006 • Highest mortality rates were associated with sepsis and pneumonia after surgery Eber et al. Archives of Internal Medicine 2010

17. Quality Improvement • Programs that target: • Education • Hand hygiene • Sterile device insertion • Management of invasive devices • Outcome of these efforts: • Health care associated infection = Medicalerror

18. What is Needed for an Infection to Occur? 3 elements: • An infectious agent • A susceptible person • Mode of transmission

19. The Susceptible Patient • Host factors • Medical interventions • Central venous lines • Mechanical ventilation • Total parenteral nutrition Grohskopf et al: Journal of Pediatrics, 2002

20. Modes of Transmission • Contact • Droplet • Airborne • Common vehicle • Vector

21. Modes of Transmission • Direct Contact: • Person to person Indirect Contact • Hands of health care workers • Hospital equipment • Hospital environment Contact

22. Xrepresents VRE culture positive sites Modes of Transmission

23. Modes of Transmission • Droplet • Respiratory droplets carrying infectious agents are propelled short distances by • Coughing • Sneezing • Endotracheal suctioning

24. Modes of Transmission Airborne Particles containing infectious agents that are small enough to be carried on air currents or dust particles

25. Modes of Transmission • Common vehicle: • Food • Water • Medications • Vector: • Disease is carried • by an animal or an • insect

26. Preventing Transmission of Infection The #1 intervention is careful hand hygiene by health care workers

27. #1 Intervention: Hand Hygiene 80% of transmission of infectious agents in hospitals is by the hands of health care workers.

28. #1 Intervention: Hand Hygiene Multiple studies have demonstrated hand hygiene compliance of health care workers to be between 36 – 48% World Health Organization Global Patient Safety Challenge 2006

29. #1 Intervention:Hand Hygiene Barriers to hand hygiene compliance • Guidelines for hand hygiene are not clear • Limited knowledge about infection prevention • Products not available or near patient • Products cause skin irritation/allergic reactions • Too busy • Forget

30. #1 Intervention: Hand Hygiene Hand hygiene means: Clean Your Hands using antiseptic soapandclean water or alcohol based hand sanitizer

31. #1 Intervention: Hand Hygiene ►Use alcohol hand sanitizer for fast, efficient hand cleansing ►Use soap and water when: • Hands are visibly soiled • Patient has Clostridium difficile or other infection caused by a spore forming bacteria (anthrax) • Before eating • After using the toilet

32. Hand hygiene video

34. #1 Intervention: Hand Hygiene • When moving from a contaminated body site to a clean body site during patient care • Before and after: • Diaper changes • Dressing changes • Ostomy care • Endotracheal tube suctioning • Oral hygiene • When moving back to the patient after touching equipment in the patient’s room

35. #1 Intervention: Hand Hygiene Other aspects of hand hygiene: • Dry hands before patient contact • Use hospital hand lotions • Avoid multiple use products: bar soap, cloth hand towels • Keep nails short: less than 0.5 cm long • No artificial nails

36. #1 Intervention: Hand Hygiene Use of gloves: • Does not replace need for hand hygiene • Change gloves between patients • Wear gloves for contact with blood, other body fluids, mucous membranes, non intact skin, and wound dressings • Do not reuse gloves

37. Creating a Hand Hygiene Culture:Stage 1 Form a hand hygiene team and include: • Doctors and nurses • Infection control experts • Hospital leadership • Other hospital staff • Parents and patients

38. Creating a Hand Hygiene CultureStage 1 • Name the hand hygiene program • Involve hospital staff • Identify role models

39. Creating a Hand Hygiene Culture:Stage 1 • Evaluate barriers to hand hygiene compliance • Address areas to be improved: • Supply of hand hygiene products • Hand hygiene products available at “point of care” • Preference of products • Educate hand hygiene teachers • Educate staff to observe hand hygiene practice

40. Creating a Hand Hygiene CultureStage 2 Education • Educate staff on why hand hygiene is important and when it is necessary • Provide training for new staff and annual education review for all staff • Educate patients and their families • Educate staff to speak up when hand hygiene is not performed

41. Video

42. Creating a Hand Hygiene Culture:Stage 2 Observe practice and share results • Collect baseline data • Monitor hand hygiene practice • Post practice results in visible areas • Post reminders throughout the hospital

43. Hand Hygiene Observation Tool

45. May 2009 Hand Hygiene Percent Compliance

47. Creating a Hand Hygiene Culture: Summary • Designate leaders and form a team • Establish a timeline • Educate, Educate, Educate • Observe hand hygiene practice and share results

48. Creating a Hand Hygiene Culture:Summary • Set goals and expectations • Start with small changes • Evaluate progress frequently • Make changes if something is not working • Highlight good practice • Celebrate your success!

49. Remember -- infection prevention is in your hands

50. Resources Hand Hygiene Websites: • World Health Organization “Clean Care is Safer Care” http://www.who.int/gpsc/en/ • Centers for Disease Control and Prevention http://www.cdc.gov/handhygiene/