1 / 53

Bundling up: measuring prevention on the road to zero

Bundling up: measuring prevention on the road to zero. Susan M. Kellie, MD, MPH Associate Professor of Medicine, University of New Mexico School of Medicine Hospital Epidemiologist, UNMHSC and NMVAHCS. Talk outline. What are bundles and how are they developed? Bundles -

may
Download Presentation

Bundling up: measuring prevention on the road to zero

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Bundling up: measuring prevention on the road to zero Susan M. Kellie, MD, MPH Associate Professor of Medicine, University of New Mexico School of Medicine Hospital Epidemiologist, UNMHSC and NMVAHCS

  2. Talk outline • What are bundles and how are they developed? • Bundles- • extending the bundle concept to new areas in prevention • Strengthening and extending our best bundles • Bundles go national -surveillance systems and accrediting agencies move in on bundles • Managing and reporting bundles: • Freeing ICPs to work on issues beyond the bundle

  3. The origins of the bundle • A “bundle”  is a collection of processes needed to effectively care for patients undergoing particular treatments with inherent risks.   • The idea is to bundle together several scientifically grounded elements essential to improving clinical outcomes. • A bundle should be relatively small and straightforward − a set of three to five practices or precautionary steps is ideal.

  4. Synergy and scoring the bundle • Thebundle is a cohesive unit.  The steps must all be completed to succeed; the “all or none” feature is the source of the bundle’s power.  • The difficulty of assuring the highest possible compliance with each element of the bundle dictates that bundles should be kept simple and straightforward for compliance and documentation • A bundled scoring system pushes us to raise the bar on health care performance.  • Institute for Healthcare Improvement

  5. Bundles in marketing • Offer several products for sale as one unit • Works best when • Economies of scale in production • Economies of scope in distribution • Marginal costs of bundling are low-adding an element is not expensive • Production set-up costs are high • Customer acquisition costs are high • Consumers appreciated the resulting simplification of the purchase decision and benefit from the joint performance of the bundled product • Bundling is most suitable for digital information goods with close to zero marginal cost

  6. Bundling to handle extreme medical complexity • Average ICU patient requires 178 tasks performed correctly per day by a super-specialized team • Is training enough? • One approach to the bundle began in October 30, 1935 at Wright Air Field in Dayton, Ohio

  7. Boeing Corporation Model 299-carried 5 times the bombs of Martin and Douglas planes, flew faster and twice as far, known as the “flying fortress”

  8. What happened?

  9. The creation of “the pilot’s checklist” • The Boeing 299 was deemed “too much plane for one man to fly”. The contract went to Douglas, but the US Army Air Corps bought a few as test planes • Test pilots created a checklist of all the steps required for takeoff, flight, landing and taxiing. • 1.8 million test miles were logged without incident • Ultimately, the Army bought 13,000 aircraft, which became a key part of the bombing campaign that led to Nazi defeat in WWII.

  10. The complex ICU patient: • “ICU life support has become too much medicine for one person to fly”. • Can a checklist cover the diversity of patients and conditions found in the ICU? • Dr. Pronovost’s central line insertion list: focus on process, nursing empowerment, and leadership to remove barriers • Checklists helped memory • Make explicit the minimum expected steps in complex processes • Overcome pushback of “more paperwork”, “we don’t need this”

  11. The dilemma of medical care delivery • Research into the delivery of care is funded at 1% the amount devoted to other ventures such as understanding disease biology or drug development and trials • Medical care delivery is regarded as the “art of medicine”. • Adequate delivery of care could save more lives than any existing therapy • AtulGawande. The Checklist. The New Yorker, December 10, 2007. www.newyorker.com

  12. Why are bundles necessary in infection control? Linear process Non-linear web of causation Multiple interventions required If the process were linear, a single highly effective intervention would be enough to prevent infection-e.g. effective vaccine

  13. Taking the bundle into new areas • Prevention concepts • UTIs • C. difficile • Management concepts • Sepsis • Antimicrobial stewardship

  14. CMS focuses on UTIs • Hospital-Acquired Conditions Selected for Fiscal Year2008 Final Rule (in Rank Order) • Serious preventable event—objectleft in place during surgerySerious preventable event—airembolismSerious preventable event—blood incompatibilityCatheter-associated urinary tract infectionsPressure ulcers(decubitus ulcers)Vascular catheter–associated infectionSurgical site infection—mediastinitis after coronaryartery bypass graft surgeryHospital-acquired injuries—fractures,dislocations, intracranial injury, crushing injury, burn, andother unspecified effects of external causes • From Centers forMedicare & Medicaid Services.

  15. DRG payments and UTIs • Patient with acute MI: reimbursement of $5,4366.66 • Patient with acute MI and UTI: $6,721.44 • Patient with acute MI and E. coli sepsis due to indwelling catheter $8,905.43 • Under the new IPPS rule, the hospital will not be paid the additional reimbursement for the catheter-associated urinary tract infection if it were not present on admission.

  16. Why are UTIs important? • Indwelling urinary catheters are used more frequently than almost any other device. • Indwelling catheters account for 80% of nosocomial UTIs, up to 1 million cases annually, and 40% of all nosocomial infections • 5% of patients will become colonized for each day of catheterization beyond 48 hours, and 10-25% of colonized patients will develop symptomatic UTIs. • Wald and Kramer. JAMA Dec 19, 2007

  17. Why are UTIs a problem for ICPs? • Low morbidity, low cost problem-not prioritized by staff or adminstration • CDC guideline last updated in 1981-now being updated • Definition and reporting of UTI in NHSN includes both symptomatic UTI and asymptomatic bacteriuria • CA-UTI includes episodes with catheters placed within 7 days • Incidence could be entirely culture-dependent • Collection of catheter-days • But: use of symptoms such as urgency, frequency and dysuria is problematic. • These symptoms occur with equal frequency among patients who have catheters with or without bacteriuria • Many catheterized patients are unable to report symptoms • Symptoms are not documented in the medical record.

  18. Unnecessary use of Abx for “UTI”is rampant and may become more so • Physician diagnosis or treatment are minor criteria- catheter-associated asymptomatic UTIS should not be treated • But most physicians treat asymptomatic bacteriuria unnecessarily. • IDSA has a guideline on the (NON)treatment of asymptomatic bacteriuria-www.idsa.org: only treat pregnant women and persons undergoing urologic procedures with mucosal bleeding anticipated • Proposal for national performance measure for not treating asymptomatic bacteriuria

  19. CMS : Present-on-admission coding • Consequences of unnecessary culturing and Rx. • IDSA and the US Preventive Services Task Force have published recommendations that there is no measurable benefit to screen for or provide antibiotic treatment of asymptomatic bacteriuria • in non-pregnant premenopausal women, patients with diabetes, older patients living in the community and in LTCFs and patients with spinal cord injuries or indwelling bladder catheters. • Only recommended for pregnant women and patients undergoing urologic procedures with anticipated mucosal bleeding

  20. Modifiable factors in CA-UTI • In one study, 85% of patients undergoing major surgery hadperioperative urinary catheters, with nearly 50% of patientshaving postoperative catheter duration exceeding 48 hours. • In-hospital infection rates were twice as highfor patients with catheter duration greater than 48 hours at14 days of follow-up, and catheter duration of greater than2 days was the strongest modifiable risk factor for UTI.

  21. Getting the catheters out • Nurse and physician education, • Surveillanceand feedback, • Computerized prompts, nursing-driven protocols, • Use of bladder scanners to avoid insertion • Reductions in catheter-associated UTIs by 46% to81% in a variety of inpatient settings. • BUT: <10% of US hospitals utilize reminders, less than 1/3 use bladder US or antimicrobial catheters-Saint CID Jan 15, 2008; 46: 243-50.

  22. Changing perceptions: extended use of urinary catheters is a patient safety problem • Database study of all Medicare patients admitted to a SNF after major surgery • Linked the National Inpatient Sample, and the Minimum data set from SNFs • 23% of all discharged patients (39,282) had a catheter on admission to SNF • 3.9-6.9% of this group had a coded indication for catheter • Adjusted OR for rehospitalization for UTI was 1.38-1.85 and for mortality was 1.25-1.48 among patients with a catheter in all major surgical categories • Wald et al. Infect Control Hosp Epidemiol Feb 2008; 29: 116-24

  23. A UTI bundle: AJIC June 2007 e63 • Daily assessment for removal of the urinary catheter • Maintaining the urine drainage bag below the bladder • Sustaining a closed system • Using a securing device to prevent movement of the catheter • Mandatory on line education and inservices, interdisciplinary care rounds • Collaborative discussion on every CA-UTI to identify gaps

  24. Available updated guidelines on CA-UTI: process-based • EPIC -2- guidelines of the National Health Service: J of Hosp Inf, 2007, 65 Suppl 1. • Extra- and intraluminal colonization leads to biofilm • Assess the need for colonization: • Use catheters only after considering alternative methods of management • Document the need for catheterization, catheter insertion and care • Regularly review the need for the catheter and remove it ASAP

  25. EPIC guidelines: process-based • Select the correct catheter type- • smaller gauge catheters with 10 ml balloon minimize trauma and retained urine (will need larger guages for urologic pts passing clots) • ?silver-alloy coated? • Catheter insertion-ensure competency in • Aseptic technique • Clean the meatus with sterile saline-there is no advantage to using antiseptic preparations • Use sterile single dose lubricant

  26. Urinary catheter maintenance • Use a closed system • Change the bag according to manufacturer’s recs. • Clean hands and wear gloves • Use aseptic technique to obtain urine samples • Position urinary bags below bladder, above the floor • Empty the bag frequently, using a clean container for each patient and avoid contact between the tap and the container • Do not use antiseptic solutions for meatal cleaning, routine daily personal hygiene is all that is necessary.

  27. Meta-analysis of coated catheters Figure 2. Outcomes (total and stratified) of randomized and quasi-randomized clinical trials of currently marketed antimicrobial urinary catheters. End point is proportion of participants (or catheters) developing catheter-associated bacteriuria. Three trials examined nitrofurazone catheters, 4 pre-1995 trials examined silver-alloy catheters, and 5 post-1995 trials examined silver-alloy catheters. The risk ratio is indicated by the horizontal position of the solid black squares. The 95% CIs around the risk ratios are indicated by the width of the solid lines.

  28. Clostridium difficile: the “bundle” • University of Pittsburgh faced an outbreak beginning in June 2000 with an increase in C. difficile from 2.7 to 7.2 per 1000 discharges • Severe cases quadrupled, resulting in 26 colectomies and 18 deaths from 2000-1 • Subsequent investigation showed the outbreak to have been caused by the B1/NAP1 strain, which is quinolone resistant and produces high levels of toxin • Muto et al. Clin Infect Dis 2007; Nov 15.

  29. The C. diff “bundle” • Electronic education module and printed materials for providers and patients, also presented at multiple meetings • Increased and early case finding using an email alert to providers for: • Patients in hospital for >7 d and WBC>10k or <2k • Patients readmitted within 14 days with WBC >10k • Patients with previous C.difficile-associated diarrhea • 18% of alerted providers tested the patient and 63% of those were positive

  30. C. difficile bundle • CD management team of ID clinicians was established in May 2001, all patients meeting criteria for potentially severe disease were surgically evaluated, IVIG therapy was considered if colectomy was imminent • Expanded IC measures • Environmental cleaning-used 1:10 bleach • Electronic flags and alerts • Soap and water hand hygiene • Isolation for duration of hospitalization and infection-control audits

  31. C. difficile bundle • Real-time electronic alert of positive results to point of care from lab with isolation requirement • Antimicrobial management program required prior authorization for clindamycin (reduced usage by 69%), ceftriaxone (not reduced), and levofloxacin (reduced by 54%) • Extension of C.difficile toxin testing to formed stool

  32. Lessons for MDRO control • Driven by local data • Tiered, successive, multidisciplinary approach • Was this really a bundle? • Highly complex, labor and IT-intensive and some interventions not readily measurable • Could try using measures of appropriate hand hygiene, cleaning, fluoroquinolone restriction, and rapid institution of contact precautions for all patients with diarrhea

  33. CLABS-extending a familiar bundle • Site   Subclavian Jugular Femoral • Hand Hygiene   • Inserter: Sterile Gown, Sterile Gloves, Mask, Hat and Assistant: Sterile Gown,Sterile Gloves, Mask , Hat   • Skin Disinfected  with chlorhexidine-containing solution • Patient is draped with Full Body Drape   • Type of Dressing  -gauze for first 24 hours, then BioPatch • Catheter Secured   • Dressing Dated  

  34. Pronovost. NEJM Dec 28, 2006 • To eliminate CR-BSIs, a quality improvement team implemented five interventions: • educating the staff; • creating a catheter insertion cart; • asking providers daily whether catheters could be removed; • implementing a checklist to ensure adherence to evidence-based guidelines for preventing CR-BSIs; • and empowering nurses to stop the catheter insertion procedure if a violation of the guidelines was observed.

  35. Background of cultural change • The 103 ICUs implemented the use of a dailygoals sheet to improve clinician-to-clinician communicationwithin the ICU • An intervention to reduce the incidence ofventilator-associated pneumonia was implemented • A comprehensive unit-basedsafety program to improve the safety culture was implemented

  36. Overall, at least a 50% reduction in CLABSIs was observed

  37. Editorial by Wenzel, NEJM Dec 28 2006

  38. What’s next in CLABSI prevention? • The line maintenance bundle • Aseptic technique for accessing lines-hand hygiene and gloves • Improving flushing technique • Daily review of line necessity • Checking for site infection at dressing change • Using chlorhexidine-alcohol product to clean hub • Adequate time and friction for cleaning the hub with at least 10 twists, let alcohol dry • Minimizing blood draws

  39. Next steps in CLABSI prevention • Changing needless connectors- • disinfect the hub when changing because blood and debris can collect in threads • Swab around the junction before accessing the device • Clean the threads before attaching a new hub • Addressing PICCs and other lines outside the ICU setting-wards, dialysis units

  40. Beth Israel Medical Center Bronx-Lebanon Hospital Center Brookdale Hospital Medical Center Cabrini Medical Center Good Samaritan Hospital Medical Center Interfaith Medical Center Kingsbrook Jewish Medical Center* Kingston Hospital* Lenox Hill Hospital Long Beach Medical Center Long Island College Hospital Lutheran Medical Center Montefiore Medical Center Mount Sinai Hospital Mount Sinai Hospital of Queens New York Downtown Hospital New York Hospital Queens* New York Methodist Hospital New York-Presbyterian Hospital New York University Medical Center North General Hospital Our Lady of Mercy Medical Center North Shore-Long Island Jewish Health System, including: Forest Hills Hospital Franklin Hospital Glen Cove Hospital Huntington Hospital Long Island Jewish Medical Center North Shore University Hospital Plainview Hospital Southside Hospital Staten Island University Hospital Syosset Hospital Peninsula Hospital Center Richmond University Medical Center* Sound Shore Medical Center of Westchester St. Catherine of Siena Medical St. Charles Hospital St. Joseph’s Medical Center, Yonkers* St. Luke’s - Roosevelt Hospital Center St. Luke's Cornwall Hospital St. Vincent’s Medical Center, Manhattan* Stamford Hospital The Parkway Hospital* Trinitas Hospital Winthrop University Hospital* Wyckoff Heights Medical Center GNYHA/UHF CLABs CollaborativeParticipating Hospitals *Hospitals that joined the CLABs Collaborative in the second round of participation (i.e., in August/September 2006).

  41. GNYHA/UHF CLABs Collaborative Design • Hospital leadership involvement and commitment • Interdisciplinary teams / Physician and Nurse champions • Evidence-based interventions: Implemented “Central Line Bundle” • 3 learning sessions: • Bi-weekly conference calls: Shared information / tools specific to reducing CLAB infections. • Collaborative web site for information-sharing: http://jeny.ipro.org/clabs • “Expert on Call” clinical consultant • Reinforcement of “zero tolerance” for CLAB infections • Standardized Materials: • Root Cause Analysis (RCA): • Tracking Success: Aggregate and hospital-specific results reported monthly and site visits made by Collaborative sponsors to identify areas in need of support

  42. Eradicating Catheter-associated Blood Stream Infections Initiative -   NACHRI, started in October 2006 • Phase I Results • 41 percent decrease in CA-BSI rates • (from 5.39 per 1,000 catheter days to a sustained rate of 3.19 per 1,000 catheter days in the 27 participating hospitals)-equals: • 177 infections prevented • $6 million saved • 20 deaths prevented

  43. Root cause or critical event analysis in infection prevention • The patient: describe the patient history • The course: describe the clinical course of the patient and the hospital-acquired infection in detail • Positive findings: summarize documentation or observed compliance with infection prevention measures • Opportunities for improvement: summarize infection prevention measures that could have prevented infection • Lessons learned: share lessons learned from the patient and how compliance or procedure changes may prevent infection in other patients.

  44. Beth Israel Medical CenterCLABs PreventionRoot Cause Analysis – August 2005 • 84 year old female with a history of hypertension, CHF, cardiac arrhythmia with pacer, insulin dependent diabetes • Admitted to ICU with CHF exacerbation, pleural effusion • Developed acute renal failure requiring dialysis • Nephrologist places Shiley catheter • Groin site chosen • Difficult procedure requiring multiple attempts • Maximal barrier precautions not fully utilized • Nursing staff attempt to assist • Call intensivist to place line • Blood cultures positive for C. albicans 48 hours later

  45. Bundles become the expectation • National Healthcare Safety Net • National Patient Safety Goals • Pitfalls • Still no standardized way of recording the bundle • Who collects the data?

  46. NHSN-CLIP- Central Line Insertion Practices • CLIP Adherence Monitoring Form is completed for every central line insertion that occurs during the month chosen for surveillance. • 20 required data elements • 10 optional elements

  47. Required elements • Demographics • Facility ID, Event number-autoentered, patient ID, gender, dob, event type CLIP-autoentered • Location, insertion date, person recording insertion practice data, occupational category of inserter, reason for insertion • Process: • Hand hygiene performed, maximal sterile barrier used, skin prep used and allowed to dry • Catheter: site, type, number of lumens, antiseptic ointment used

  48. Optional elements • Patient SSN and ethnicity/race • Central line inserter ID# • Name of central line inserter • Antimicrobial catheter used • Custom fields

More Related