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Best Care…Always! Campaign Global Forum  on  Bacterial  Infec3on   New  Delhi  ;  October  4,  2011   Dr  Gary  Kantor    


A loose coalition of stakeholders can initiate / sustain system strengthening for patient safety. The process began with antibiotic stewardship, and was driven by a private funder, hospitals and professionals. We are exploring new ways of building will, generating and sharing ideas and filling the execution gap ‌.changing the system.


Global Epidemic of Harm in Hospitals Adverse events in 9 – 18% of admissions ~ 50% preventable 2.5 – 7.5% are fatal

NEJM Nov 25, 2010 Qual Safety in Health Care 2008;17:216-223 3


Preventable Harm: 1 in 3 Hospital Patients

n=795 3 hospitals

#1. procedures #2. medications #3. infection

Voluntary reports are 1% of events Health Affairs, 30, no.4 (2011):581-589 4


Hospital-Acquired Infection •  World –  1.4 million patients affected / day

•  Developed countries

JAMA 2009;301(12):1285-1287 Lancet 2008;372(9651):1719-1720

–  Hospital incidence up to 10% –  USA: 100,000 deaths

•  Developing countries –  3 x higher –  S Africa 9.7% prevalence; 28.6% ICU A Duse. SA-HISC study (unpublished) Allegranzi B; Lancet 2010:61458 5


Median rate of infection: ZERO!!

CLABSI rates ↓ by 66% Better than 90% of US ICUs 1,500 lives and $$$ saved Sustained > 3 years

96 ICUs

Pronovost P. NEJM Dec 2006 6


EVIDENCE CLABSI Bundle

maximal barrier precautions chlorhexidine skin antisepsis optimal catheter site selection daily review of line necessity

ü ü ü ü

Checklists + Daily goals sheet + Unit-based safety program Pronovost P. NEJM Dec 2006 7


CAUTI

CLABSI + Antibiotic Stewardship

SSI

VAP


Public Sector Improvement Scientists Professionals Private Hospitals Sponsors

Expert Panel

BUILDING WILL

9


from

evidence-based medicine to

Evidence-based IMPLEMENTATION Subject Matter Knowledge

“what”

Effective changes that lead to an improvement

“where”

“how”

Improvement Science 10


202 Hospitals enrolled at least 1 intervention

11


“The Method  for  Improvement”   =  the  Scien3fic  Method  

Not protocols Not “recipes” 12


AIMS

Decrease CLABSI to 0 or 300 patient days between by June 2010

10 DRIVERS Reliable identification of a CLABSI Reliable implementation of the insertion bundle

20 DRIVERS Reliable Definition – CLABSI Reliable data collection process – infections & device days Insertion bundle (HII) Line insertion documented in notes

Reliable implementation of the maintenance bundle

Reliable data collection Maintenance bundle (HII) Reliable data collection

Improve safety culture through multidisciplinary team working and communication

Clinical leadership rounding to view lines Bundles known by staff HAI surveillance data and bundle compliance shared with staff

95% compliance with insertion bundle and each element of bundle 95% compliance with maintenance bundle and each element of bundle


AIMS

Optimal antibiotic use in 80% of patients 30% reduction in antibiotic overuse Stable / decreased antibiotic resistance

10 DRIVERS

CHANGE CONCEPTS ↑ availability of first dose

Prompt initiation, for defined reasons Periodic review for cessation, route, reason for treatment Prescriber access to knowledge and data

Prevention of hospital-acquired infection

Separate AB prescribing from other Rx Day 3 and Day 7 review Info on how to Rx Info on what it costs

*Prevent SSI, CLABSI, VAP and CAUTI

*Interventions already associated with the BCA campaign

INTERVENTIONS

Antibiotic ward stock Antibiotic form AB Bundles Clinical pharmacist review Path lab hotline Resistance reports Cost reports SSI bundle CAUTI bundle CLABSI bundle VAP bundle


OUTCOME MEASURE

10 PROCESS MEASURE

20 PROCESS MEASURE

% with compliance to all bundles (“optimal use”)

% receiving timely % compliance with each Inception antibiotics for prevention or bundle element: 1.  <2 hrs from order → admin treatment – first antibiotic (treatment) prescribed during hospital 2.  Prophylaxis within 1 hr of incision course % overall compliance with Day 3 Bundle for the first antibiotic prescribed during hospital course

% compliance with each Maintenance bundle element:

% overall compliance with Day 7 Bundle for the first antibiotic prescribed during hospital course

% compliance with each Maintenance bundle element:

1.  2.  3.  4. 

Treatment not prophylaxis State antibiotic indication or stop Culture(s) ordered or done Reassess drug choice

1.  Stopped or re-ordered 2.  Conversion from IV to oral or N/A


IDEAS 18 -24 months Repeated improvement cycles:

Expert and Planning Group formed

Learning session 1

Repeated improvement cycles:

Learning session 2

Learning session 3

Mentoring and support

16


8.00

CLABSI -­‐  Infec9on  Rates  Per  1000  Central  Line  Days   7.17   Life  Healthcare  Group  -­‐  Oct  2008  to  Sept  2010  

7.00

6.00 5.66  

5.57

5.22

5.00

4.00

4.95

4.21

Repor3ng system  and    training   on  BCA  in  all  acute  hospitals      

3.85

3.00

3.48

3.36

3.22

3.12

2.93 2.58  

2.90 2.98   2.46  

2.01 2.10   2.01  

2.00

Cross func3onal  workshops  in   ICU's    to  implement    bundle   compliance  ac3ons  and   increase  involvement  of  Unit   Managers   2.33   2.08  

2.17    

2.05    

1.57     1.00  

CLABSI-­‐Rate  

1.67

Mean 0.85  

Upper control  limit  

0.57

Lower control  limit  

0.00

n=41 hospitals 17


HAI : CLABSI RATE Central Line Associated Blood Stream Infections - CLABSI Central Line  Associated  Blood  Stream  Infec9ons  -­‐  Bundle  Compliance  and   Infec9on  Rate   Mar  09  -­‐  Aug  10   100%  

6.00    

87%   5.22      5.00    

83%

4.95    

83%

83%

85%

83%

85%

88% 84%  

84%

87%

87%

87%

87%

90%

80%

78% 70%  

4.00    

90%

70%

3.22      3.00    

3.12    

2.93      2.58      2.01    

2.00    

2.10    

60%

3.48    

3.36    

50%

2.90      2.98      2.46    

2.33      2.08    

2.01    

40%

Infec3on Rate     CLABSI  

2.17     30%    1.57     20%  

1.00    

n=41 hospitals

Aug-­‐10

Jul-­‐10

Jun-­‐10

May-­‐10

Apr-­‐10

Mar-­‐10

Feb-­‐10

Jan-­‐10

Dec-­‐09

Nov-­‐09

Oct-­‐09

Sep-­‐09

Aug-­‐09

Jul-­‐09

Jun-­‐09

May-­‐09

Apr-­‐09

-­‐        

Mar-­‐09

10% 0%  

18


BCA : COMPLIANCE : SSI Bundle Compliance to SSI Period: JUNE-10

100%

96% 89%

90%

89%

80% 70% 60%

57%

50% 40% 30% 20% 10% 0% If hair is removed, it is only done with Antibiotics are given within an hour of Glucose is maintained above 4 and The patients temperature is clippers or dipilatory cream incision below 8 after the initial post operative maintained at >36.5 and <37.2 after assessment in ICU the initial post operative assessment in ICU

19


• •

2

3

4

5

6

7

8

9

10 11 12 13 14 15 16 17 18 19 20 21 22

1

2

3

4

5

6

7

10

1

11

0

6

5

1

3

11

4

6

9

8

6

7

2

6

6

14

2

1

12

9

4

11 17

4

4

3-­‐Jul

9-­‐Jul

15-­‐Jul

29-­‐Jul

31-­‐Jul

1-­‐Aug

13-­‐Aug

22-­‐Aug

26-­‐Aug

24-­‐Sep

28-­‐Sep

2-­‐Oct

7

1-­‐Jul

6

24-­‐Jun

5

18-­‐Jun

4

10-­‐Jun

3

1-­‐Jun

2

26-­‐May

1

22-­‐May

9 10 11 12 13 14 15 16 17 18 19 20 21 22 Infection

11-­‐May

8

8-­‐May

7

7-­‐May

6

Infection 3  days  after  admission

2-­‐May

5

26-­‐Apr

4

26-­‐Apr

3

15-­‐Apr

1

2

• •

• •

4-­‐Apr

Date of   infections

1 Data Element Days   between   infections

Possible contaminant

August -­‐

7-­‐Sep

31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 •

Started with  CLABSI  Bundle

Neurosurgery I CU  -­‐  Steve  Biko  Academic  Hospital  -­‐  Pretoria Month:  April  -­‐  July  2010

14-­‐Apr

Days between  infections

Central Line  Associated  Bloodstream  Infections

8

8

9 10 11 12

9

10 11 12

Days Between Infection 20


No incident

New incident

More than 1 incident Poor data

Visual Measurement 21


At the same time every day the Unit manager counts devices in use in the ward

Solving the Denominator Problem


www.bestcare.org.za

Not just infections Not just bundles

garyk@discovery.co.za


Everyone in healthcare has 2 jobs 1. Doing the work 2. Improving the work!

24


All improvement requires change (though not all change is an improvement)

Changing: How and why we measure Methods (of improvement) Our sense of responsibility Leadership Organisations and culture The Health industry

25


How and why we measure OLD

NEW

International data

Our data

Counts

Rates

Bar graphs

Run charts (over time)

Data for head office / ministry

Measurement for frontline staff

Individual measures

Measures across systems

Modified from: D van den Bergh, Netcare Hospital Group 26


BMJ Qual  Saf  2011;20:46e51  

“Run Chart”  

Rules for   iden3fying  non-­‐ random  signals  

27 27


How we improve OLD

NEW

Audit and inspection (QA)

PDSA cycles

Checklists for checking

Checklists as aids

Writing more protocols

Focused interventions

â&#x20AC;&#x153;Spray and prayâ&#x20AC;?

Improving critical elements one a time

Modified from: D van den Bergh, Netcare Hospital Group 28


Taking Responsibility OLD

NEW

“it doesn’t happen here”

Knowing the facts

“we already do that”

Acknowledging we may not

Can’t do

“if they can so can we”

Accept the inevitable

Persistence

Victim of limitations

Building skills

Modified from: D van den Bergh, Netcare Hospital Group 29


Clinicians Skeptical and critical “this might work” “worth trying” “how can we support you” “I would like to initiate” 30


Leadership OLD

NEW

It’s up to the doctors

Active involvement of senior leadership

It’s up to the nurses

“Exco”

It’s up to the Infection Prevention Practitioners It’s up to the Infection Control Committee

Modified from: D van den Bergh, Netcare Hospital Group 31


The Culture OLD

NEW

Blaming and punishing

Learning and curious

Who (people)

Why (system)

Helping

Capacitating (mentors)

Modified from: D van den Bergh, Netcare Hospital Group 32


Health Sector OLD

NEW

Competition

Collaboration

Secrets

Sharing

Private vs public

Interconnected systems Public learns from Private Private learns from Public Public-private partnership

Modified from: D van den Bergh, Netcare Hospital Group 33


Antibiotic Stewardship OLD

NEW

Passive observers

Actively seeking solutions

No interventions

Identifying opportunities

No measures

First level utilisation data

Defensiveness

Working together to deal with it

Pilots

Multiple sites testing change

Modified from: D van den Bergh, Netcare Hospital Group 34


www.bestcare.org.za


The Changing View of Quality We are perfect!

NO ACTION

Get rid of the bad apples REACTION Quality Assurance “Standards”

M&M

Incident reporting

36


The Changing View of Quality “Quality” We are perfect!

INACTION

Get rid of the bad apples REACTION “Quality Assurance”

M&M

Safe Effective Timely Equitable Patient-centred Efficient

System thinking

PRO-ACTION Quality Improvement

“Standards”

Improvement Science

Incident reporting

Dashboard of Quality Measures

37


Improvement Science and Knowledge Systems Combine to Produce Improvement Generalisable scien9fic   evidence   “control context”

Patients get “recommended care” ~ 50% of the time standardisation, forcing Qual Saf Health Care + functions, education, etc

2007;16:2–3

Plans for  change  

+

Par9cular context   “local processes, habits, traditions”

+

Execu9on “drivers of change” High   performance   (measured)   “include time” 38

/dr_gareth_kantor  

http://www.cddep.org/sites/cddep.org/files/dr_gareth_kantor.pdf

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