Introduction of technology to reduce HAI’s and improve surveillance

Jeff Deane Clinical Nurse Consultant John Hunter Hospital 2016

Our area

• 900,000 people • 16,000 staff • 59 trained ICNET Users • 47 Infection Prevention

Nurses • 3 Administrators • 3 Super Administrators • 6 Reporting Users • 4 beginning training for SSI

Reporting

In the beginning

• Multiple worksheets – – Often incomplete – No standardised use of worksheet by staff – Worksheets kept and archived

• Multiple spreadsheets to document data – Inability of some staff to produce graphs of data

• Delays in compilation and analysis of outbreak data due to paper system requiring manual sorting

Prior to ICNet MRO worksheet (4 pages)

Sentinel Organism eICAT Event Sheet

PLEASE USE GUMMED LABEL IF AVAILABLE UNIT NUMBER

SURNAME: OTHER NAME: ADDRESS: DATE OF BIRTH: M.O.

Date of Specimen: Lab number: IIMS: Organism: MRSA

CMRSA sen

MRAB

eMRSA

VRE

C. difficile

CRE

M-ESBL

Cleared Date:________

Site: blood urine

respiratory rectal

faeces

wound/skin

screening

ICU Screening

device

Other

Acquisition: Healthcare-associated

HCA Ward

Transfer in _____________

Community

Other

New Isolate Previous isolate

Infection Colonised

Cohort

Date of Specimen: Lab number: IIMS: Organism: MRSA

CMRSA sen

MRAB

eMRSA

VRE

C. difficile

CRE

M-ESBL

Cleared Date:________

Site: blood urine

respiratory rectal

faeces

wound/skin

screening

ICU Screening

device

Other

Acquisition: Healthcare-associated

HCA Ward

Transfer in _____________

Community

Other

New Isolate Previous isolate

Infection Colonised

Cohort

PIMS Alert

Category 1 2 3 4 5 Set: ___/___/___ By: Removed: ___/___/___ By:

Category 1 2 3 4 5 Set: ___/___/___ By: Removed: ___/___/___ By:

Admission History

Date

Unit/Ward

Chair/ Bed

Disch Date:

Admission History

Date

Unit/Ward

Chair/ Bed

Disch Date:

Deceased Date: Cause of death:

S E N T I N E L

O R G A N I S M

S U R V E I L L A N C E

E I C A T

E V E N T

S H E E T

H NEA H S

PLEASE USE GUMMED LABEL IF AVAILABLE UNIT NUMBER

SURNAME: OTHER NAME: ADDRESS: DATE OF BIRTH: M.O.

PATHOLOGY REPORTS

Date Site Organism Date Site Organism

PATIENT COHORT

SURNAME: MRN: Date Site Result

OTHER NAME: ADDRESS: DATE OF BIRTH:

SURNAME: MRN: Date Site Result

OTHER NAME: ADDRESS: DATE OF BIRTH:

SURNAME: MRN: Date Site Result

OTHER NAME: ADDRESS: DATE OF BIRTH:

BSI worksheet

BLOODSTREAM EVENT NOTIFICATION Laboratory Lab. number

LMNC Pathology

Mayne-Laverty Pathology

New England Pathology

SydPath

HAPS

Attending MO (initial, surname) __________________________ MO Address/Fax number __________________

LABORATORY

First positive sample date ___/____/___

Enter organisms grown from positive sets (within 48 hrs)

Blood culture set 1 Set 2 Set 3

Organism 1

Organism 2

Organism 3 SIGNIFICANCE CRITERIA

Criterion 1 (recognised pathogens) Criterion 2 (potential contaminants in patients aged >1 year)

Criterion 3 (potential contaminants in patients aged <1 year) Contaminant (still report these please) Unknown (insufficient information)

ACQUISITION Healthcare-associated

Healthcare (inpatient> 48hr) Healthcare (non-inpatient) Maternally-acq (< 48hrs of birth)

Community-associated (Not healthcare-associated AND do not manifest more than 48 hrs after admission or within 48 hrs of discharge)

Nursing Home associated

Unknown(insufficient information) Relapse within 21 days Relapse within 3 months

FOCUS Specific Organ Site (specify below)

Line Associated (see over) (no documented other focus)

Unknown (insufficient information) Disseminated infection

Specific Organ Site (provide detail below) ICN Documentation

Cardiovascular (specify below) Ear, nose, throat GI tract including mucositis Hepatobiliary (specify type) Intra-abdominal (specify CAPD) Osteomyelitis (specify hardware) Wound infection (surgical)

Joint infection (specify prosthesis) CNS infection (specify device) Reproductive tract (specify type) Pneumonia (specify device) Skin / soft tissue (specify type) Urinary tract (specify IDC) Vascular infection (not line-assoc)

Auslab comments entered Validated by ID ICNET completed IIMs completed Yes / NA

IIMs No:___________________

Investigation Comments: Completed by: Date notified:

Patient Identification MRN

DOB:

Surname

Given Name

Address

Date admitted ___/__/___ Date discharged ___/___/___

Discharge outcome Home Transfer Died Ward at time of event:

Investigation

Other factors relevant to the onset & origin of the bacteraemia (Y or N in each of first 4 boxes)

Was there a deep abscess at the primary site of origin?

Was the patient neutropenic at the time of diagnosis (neutrophil count < 1000

Was there an invasive procedure < 48hrs previously related to the source (e.g. insertion CVC, biliary stent etc?

Was there a surgical site infection related to the source from a procedure in the previous 30 days e.g. hip wound?

If YES, name of procedure.

If YES, details of surgical site.

CLINICAL TREATMENT

Principal treatment (main agent used for the definitive IV treatment of SAB, i.e. after susceptibility results): Choose one only.

Not treated at all Daptomycin Moxifloxacin Benzylpenicillin/Amp/Amox Dicloxacillin Piperacillin-tazabactum Cephazolin/Cephalothin Flucloxacillin Teicoplanin Clindamycin/Lindomycin Linezolid Ticacillin-clavuanate Co-trimoxazole (Bactrim) Meropenem/Imipenem Tigercyline Vancomycin Gentamycin Other (specify)

OUTCOME @ 7 and 30 days

Outcome @ 7 days after collection of initial blood culture

Survived Outcome @ 30 days after collection of initial blood culture

Survived

Died Died

Unable to determine Unable to determine

CASE REVIEW OF RISK FACTORS & POTENTIAL PREVENTABLE FACTORS Co morbid conditions

Burns Diabetes Vascular disease

Chronic renal disease Immunocompromised (including non-steroid drugs, e.g chemo)

Relevant skin condition

Chronic respiratory disease Likely self-contamination (e.g.

confused pt, IVDU) Other relevant condition

(specify)

Chronic steroid use Previous S.aureus bacteraemia with same type

Complete this section if isolate was MSSA & MRSA

If MSSA & MRSA, has this type of S.aureus been isolated before?

What was the 1st date isolated, if known (year only if approximating) if applicable

If YES, had decolonisation been attempted?

Source of 1st isolate i.e. HCA, Community, NH

Site of original isolate? Has pt been isolated & Contact Precautions commenced?

Yes, single room No, on general ward Yes, cohorted

Complete this section if a device, including IV, was identified as the primary cause of the bacteraemia

What was the device?

Where was the device located?

Date of insertion (if unknown please state)

Was device removed? Include date Was the same type of S.aureus isolated from the device?

If the device was an IV line (PVL, CVL etc) what was the main indication (e.g. antibiotics, TPN, inotropes, chemo, dialysis, IV fluids etc)

If the device was not an IV, what was the main indication?

Was device left in longer than required? Was device left in longer than recommended?

SSI worksheet

Sentinel Surgical Procedure Surveillance Event Sheet Date admitted: ___/___/___ Date discharged: ___/___/__ Ward: Unit: Bed No:

Procedure Details Date: ___/____/_____ Surgical Specialty Theatre No

Start time:__________ End time: __________ Duration of procedure: hrs mins

Procedure code: _____________(ICD 10 code) Procedure

ASA score: (*Unknown) 0*

1

2

3

4

5

Wound Class 1

2

3

4

Consultant: Primary Surgeon:

Anaesthetic Type GA Spinal/Epidural Local Other

Implant Unplanned/emergency

Prophylactic antibiotic

Antibiotic 1:____________________________ Antibiotic 2:____________________________ Antibiotic 3:

Surgical Site Observation Date seen Codes Comments

1. ___/___/___ AFE HAE

2. ___/___/___ CLE SRE

3. ___/___/___ INT SWE

4. ___/___/___ NOO RED

5. ___/___/___ FEB TEN

6. ___/___/___ SOZ DEH

7. ___/___/___ MOI SLO

8. ___/___/___ SER PUS

9. ___/___/___ HSE RTT

10. ___/___/___ BRU HEA

Outcome Inhospital wound infection Post-discharge wound infection Date: ___/___/___

No infection superficial incisional deep incisional organ space infection -

specify:

Surgeon diagnosis Pain/tenderness Heat Localised swelling Purulent drainage Surgeon re-opens Redness

Fever >380C Culture negative, pt on antibiotics Spontaneous dehiscence Organism aseptically obtained Abscess or other evidence of infection Lab confirmation

Site of SSI primary Secondary Both Stab wound

Infective Organism Organism 1:____________________________ Organism 2:____________________________ Organism 3:

Post discharge survey response Date: ___/___/___

Record complete

Comments:

Data entry complete

Patient Identification

Medical Record Number

Surname:

Given Name: Address:

Phone: Post Code:

DOB: ____/____/_____ Sex:

Version 2.2 for HISS

Oct

MRN SURNAME

FORENAME

URGENCY_DESCRIPTION

PROCEDURE_CODE

SURGERY_START_DATE

SURGERY_COMPLETE_DATE

ASA_SCORE_DESCRIPTION

ANAESTHETIC_1_DESCRIPTION

SURGICAL_CONSULTANT_SURNAME

SURGEON_OPERATING_SURNAME

THEATRE

Planned 4932400 ######## ######## ASA 3 Not Specified

Harrington

Harrington RNCORA

Planned 4932400 ######## ######## ASA 4 General Gill Gill RNCORA

Planned 4932400 ######## ######## ASA 2 Epidural/Spinal Hellman Hellman RNCORB

Implementation – a brief history • 2012

– ICNet purchased – Large amount of background work (IPN 1 day per week)

• Configuring hospitals / wards • Auditing pathology & pt information system imports • Cleaning up of current pt alert system

• 2013 – Face to face & WebEx education of staff – Feb - Live across all facilities – May - Follow up training sessions – Sept – Development of facility specific reports – Update of computers to support Google Chrome

Implementation • 2014

– June – site visit to RMH – Laptops provided – Project officer employed – HNE specific user guide developed – Oct - Workshop conducted

• Pre & post knowledge quiz • Inservice on user issues • Scenarios for users

• 2015 – Further refining of ICNet to suit our needs – Facility visits by project officer

ICNet implementation ICNet program IPN requirements – flesh it out

Facility implementation the road to success

Barriers to our success • Lack of planning re what IPNs wanted built into system

• Lack of implementation strategy

• Underestimation of geographical area & variety of facilities

• Varied computer literacy amongst users

• Interpretation of guidelines between users

• Frequent changes being made to ICNet during implementation phase

• Poor communication to users regarding changes

• Inconsistent data entry by users

Barriers to our success • Limited understanding of ICNet & its benefits • Reluctance of users to use ICNet as their primary

source of information e.g. an audit identified only 64% logged in when rostered the previous week

• Staff continued outdated, labor intensive work practices

• Lack of accountability for users • Often staff complain that it takes more time and is

becoming too complex • Lack of follow up and continual review with IPNs

Are we there yet?

ICNet

Ignore it, continue reporting unreliable data & fall behind

Increased workload using ICNet

Standardised team approach producing valid data & streamlined reporting

Implementing change successfully - Did we? (Kotter model)

– Create urgency • What currently wasn’t working • What were the opportunities • Buy-in from users

– Form a coalition • Change team continued to build urgency & momentum around

need for change – Create a vision for change

• Everyone understood what we were trying to achieve • Formalised strategy

– Communicate the vision • Talked about it often to users • Addressed staff concerns / issues • Applied aspects of operation from training to performance reviews

Implementing change successfully – Remove obstacles

• Staff resistance • Rewarded/acknowledged for making change happen

– Create short term wins • Celebrated quick wins that staff could see • Created short-term targets

– Build on the change • Identified what's working & what needs improving • Set goals

– Anchor the change into the culture – Continued support for the change – Acknowledged staff for their contributions – Communicated progress – Included in training

Things to consider

ICNet

Facility technology

Facility staff Data requirements

Things to consider

• Facility technology – Is your patient management systems & pathology

systems compatible – Do you need laptops or computer upgrades – Have you got the latest software eg Chome or IE

• Data – Identify statutory and facility reporting requirements – Clearly identify wards / pt locations / theatres – Regularly run “missing data” reports

Things to consider

• Staff requirements – Computer experience – User group meetings prior to implementation & then

periodic – Development of local user guide – Nominate a local ICNet support person – Workshop including small group work & practicals – Staged implementation if multi site – Follow up visits by support person to individual staff – Consult with & communicate changes to users

How to make it work • Plan – formal implementation plan

– Who - needs to be involved – What - needs to be done – Where – one facility or multiple roll out – What is the facilities data reporting needs – What data you want / need to collect

• Staff – Appoint a project person from the start – User needs and capabilities determined – Education, education, education – Develop a troubleshooting question & answer file that staff

can access

How to make it work

• Communication – Consultation re proposed and actual changes – What's working, what's not – Regular follow up with users – Celebrate small wins

• How could we have done it better? – we could have utilised the principles of change

management

Current Information Flow

IPM AUSLAB

Micro data ADT

ICNet

Infection Prevention

Alerts

Medication

SABs AB Stewardship Scope sterility testing SSI re-admits

Surveillance Officer role

Current • System configuration • Development of reports and

alerts • Testing changes & updates • Auditing data • User support • User training • User guide maintenance

Possible Future • As per current • BSI, SSI & C Diff data

analysis & investigation (liaising with IPN)

• Collation of HNELHD reports for local and state reporting bodies

Surveillance

• Improved compliance across our 42 facilities. • Ability to accurately benchmark with like facilities. • Universal access to reporting for NSW Health,

National Indicators, ACHS and regional KPI’s. • Numerator and denominator data. • Systematic collection, analysis and interpretation of

data. • Prevention and control programs aimed at reducing

HAI’s benefit from ICNET surveillance, thus providing safe and quality services.

Data Highlights

• Summarise HAI rates at meetings instantly • Improved graphics and readability • Specifically targeted searches i.e MRO or

facility ward. • Everything in one spot i.e. line days, patient

records, colonisations, infections, KPI’s, SSI’s, CLABS, letters, contact tracing

• No more multiple excel/word documents

Reporting

Reports

XP’s

XPs & Bundles

Tasks

Bundles

Letters

Thanks