khalid aziz november 10, 2006
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EPIC/PHSI Quality Improvement Workshop: Interventions to prevent nosocomial infection and future directions. Khalid Aziz November 10, 2006. Janeway Children’s Health and Rehabilitation Centre, St. John’s NL. Acknowledgements. Nosocomial infection team centres: - PowerPoint PPT PresentationTRANSCRIPT
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Nov. 9, 2006 EPIC QI Workshop Slide 1
EPIC/PHSIQuality Improvement Workshop:
Interventions to prevent nosocomial infection and future directions
Khalid AzizNovember 10, 2006
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Nov. 9, 2006 EPIC QI Workshop Slide 2
Janeway Children’s Health and Rehabilitation Centre, St. John’s NL
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Nov. 9, 2006 EPIC QI Workshop Slide 3
Acknowledgements
Nosocomial infection team centres:
• Children’s & Women’s Health Centre of BC
• Janeway Children’s Health and Rehabilitation Centre
• IWK Health Centre
• Hospital for Sick Children
• St. Joseph’s Hospital
• Royal Alexandra Hospital
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Nov. 9, 2006 EPIC QI Workshop Slide 4
Objectives
• Nosocomial infection team interventions
• Methodologies
• Proposed methodologies for future interventions
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Nov. 9, 2006 EPIC QI Workshop Slide 5
Interventions
• Teams were involved in developing interventions
• Interventions were truly interdisciplinary
• Interventions applied to diverse groups such as housekeeping, parents, respiratory therapy
• Interventions were made in each institution according to local priorities
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Nov. 9, 2006 EPIC QI Workshop Slide 6
Reviews
• Varied in rigour• Local interests• Team interests• Investigation of established reviews (eg CDC
guidelines)• Qualitative themes of focus groups• Literature reviews• Baseline EPIC results
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Nov. 9, 2006 EPIC QI Workshop Slide 7
Baseline EPIC results
• PICCs reduce nosocomial infection in some centres
• Positive urine culture is as common as positive blood culture in centres who did both
• Culture negative sepsis and suspected sepsis are a considerable burden in NICU
• Units vary in their use of antibiotics for nosocomial infection, particularly vancomycin and cefotaxime
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Nov. 9, 2006 EPIC QI Workshop Slide 8
Baseline data: UAC sepsis
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Nov. 9, 2006 EPIC QI Workshop Slide 9
Baseline data: PICC sepsis
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Nov. 9, 2006 EPIC QI Workshop Slide 10
Baseline data
Days
Ris
k
0 20 40 60 80 100
0.0
0.2
0.4
0.6
0.8
1.0
A
Days
Ris
k
0 20 40 60 80 100
0.0
0.2
0.4
0.6
0.8
1.0
B
Days
Ris
k
0 20 40 60 80 100
0.0
0.2
0.4
0.6
0.8
1.0
C
Days
Ris
k
0 20 40 60 80 100
0.0
0.2
0.4
0.6
0.8
1.0
D
Days
Ris
k
0 20 40 60 80 100
0.0
0.2
0.4
0.6
0.8
1.0
E
Days
Ris
k
0 20 40 60 80 100
0.0
0.2
0.4
0.6
0.8
1.0
F
Days
Ris
k
0 20 40 60 80 100
0.0
0.2
0.4
0.6
0.8
1.0
G
Days
Ris
k
0 20 40 60 80 100
0.0
0.2
0.4
0.6
0.8
1.0
H
Days
Ris
k
0 20 40 60 80 100
0.0
0.2
0.4
0.6
0.8
1.0
I
Days
Ris
k
0 20 40 60 80 100
0.0
0.2
0.4
0.6
0.8
1.0
K
Days
Ris
k
0 20 40 60 80 100
0.0
0.2
0.4
0.6
0.8
1.0
L
Days
Ris
k
0 20 40 60 80 100
0.0
0.2
0.4
0.6
0.8
1.0
M
PICC sepsis by centre
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Nov. 9, 2006 EPIC QI Workshop Slide 11
List of interventions 1
• Hand hygiene
• Gloves and gowns
• Skin care
• Skin breaks
• Care of PICC lines
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Nov. 9, 2006 EPIC QI Workshop Slide 12
List of interventions 2
• Choice of first line antibiotics
• Duration of empiric antibiotic therapy
• Care of ventilator circuits
• Visiting policy
• Staff education
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Nov. 9, 2006 EPIC QI Workshop Slide 13
Hand hygiene
• Add alcohol based waterless cleanser to hand cleansing areas/entrances to NICUs/improve availability of alcohol based cleansers/provide staff with 60ml bottles of hand hygiene to be kept on person
• Communicate handwashing protocol
• Increase vigilance in respect to the wearing of jewelry
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Nov. 9, 2006 EPIC QI Workshop Slide 14
Gloves and gowns
• Discontinue use of routine gloves and gowns
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Nov. 9, 2006 EPIC QI Workshop Slide 15
Skin care
• Cleanse umbilical sites with antiseptic (aquaphor ointment) prior to umbilical line placement
• Infants less than 32 weeks bathed only with warm water (no soap) during 1st week (mineral water prn)
• Use of 2% aqueous chlorhexidine rather than alcohol for skin antisepsis for infants with birth weight less than 1000g
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Nov. 9, 2006 EPIC QI Workshop Slide 16
Skin breaks
• Skin break audit
• Compliance with “initiation of peripheral IV therapy policy”
• Reduce number of skin pokes
• Restrict number of pokes to 1-2 per person
• Restrict number of staff participating in the process
• Implement algorithms for blood sampling and IV starts: both algorithms define number of pokes per person and number of people participating
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Nov. 9, 2006 EPIC QI Workshop Slide 17
Skin breaks (pokes audit)
Average Pokes/Baby/Day for the First Two Weeks of Admission
0
0.2
0.4
0.6
0.8
1
1.2
Dec'04 Feb'05 April'05 June'05 Aug'05 Oct'05 Dec'05 Feb'06 April'06
Month
Av
era
ge
Po
ke
s/B
ab
y/D
ay
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Nov. 9, 2006 EPIC QI Workshop Slide 18
Skin breaks (IV starts audit)
Average IV Starts/Baby/Day for the First Two Weeks of Admission
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Dec'04 Feb'05 April'05 June'05 Aug'05 Oct'05 Dec'05 Feb'06 April'06
Month
Av
era
ge
IV S
tart
s/B
ab
y/D
ay
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Nov. 9, 2006 EPIC QI Workshop Slide 19
Care of PICC lines
• PICC line insertions restricted only to nurses who have been certifiedreduce
• PICC line dressings to prn
• Observe CDC guidelines for central lines
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Nov. 9, 2006 EPIC QI Workshop Slide 20
Choice of first line antibiotics
• On admission: ampicillin and gentamicin
• Change first line abx to cloxacillin and gentamicin for suspected nosocomial sepsis until blood culture sensitivities received or unless the neonate has septic shock, suspected meningitis or necrotizing enterocolitis (then vancomycin and/or cefotaxime
• Caremap for choosing antibiotics
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Nov. 9, 2006 EPIC QI Workshop Slide 21
Choice of first line antibiotics
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Nov. 9, 2006 EPIC QI Workshop Slide 22
Duration of empiric antibiotic therapy
• Discontinue antibiotics if blood cultures are negative after 36 hours (assuming the baby is well)
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Nov. 9, 2006 EPIC QI Workshop Slide 23
Duration of empiric antibiotic therapy
6
75
48
20
0 1 0 00
10
20
30
40
50
60
70
80
12 24 36 48 60 72 96 More
Hours
Fre
qu
en
cy
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Nov. 9, 2006 EPIC QI Workshop Slide 24
Care of ventilator circuits
• Change ventilator circuits when visibly contaminated, malfunctioning, and between patients
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Nov. 9, 2006 EPIC QI Workshop Slide 25
Visiting policy
• 2 visitors per neonate in NICU at any one time
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Nov. 9, 2006 EPIC QI Workshop Slide 26
Staff education
• Encourage staff influenza immunization
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Nov. 9, 2006 EPIC QI Workshop Slide 27
Future directions
• Revisions
• New interventions
• Standardization of reviews
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Nov. 9, 2006 EPIC QI Workshop Slide 28
Revisions
• New information since 2001
• Greater rigour
• Interprofessional approaches
• Site-specific issues
• Larger pool of reviewers
• New expertise in larger number of centres
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Nov. 9, 2006 EPIC QI Workshop Slide 29
New interventions
• 5 years more of clinical studies (e.g. caffeine)
• New systematic reviews
• Data from EPIC-1 (e.g. benefits of PICC placement, incidence of UTI)
• Larger pool of participants for hypothesis generation
• “Ownership” of CNN database
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Nov. 9, 2006 EPIC QI Workshop Slide 30
Standardization of reviews
What might the advantages be to standardization of the review process?
• Ease of review
• Ease of cataloguing and presentation
• Ease of revision
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Nov. 9, 2006 EPIC QI Workshop Slide 31
Standardization of reviews
What might the disadvantages be of a standardized approach?
• Need to encompass qualitative and quantitative data
• Appears challenging to non-academic reviewers
• Time-consuming, particularly when a review or guideline already exists (do we need to re-review the original studies?)
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Nov. 9, 2006 EPIC QI Workshop Slide 32
Suggested review methodologies
• Adaptation of an existing guideline(s) (eg CDC guideline on central line care)
• The ILCOR methodology (as used by the International Liaison Committee on Resuscitation for the 2005 recommendations)
• Informal methodologies
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Nov. 9, 2006 EPIC QI Workshop Slide 33
The ILCOR Consensus Process
Step 1 State the proposal
************
Step 2 Assess the quality of each study
************
Step 3 Determine the class of recommendation
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Nov. 9, 2006 EPIC QI Workshop Slide 34
The ILCOR Consensus Process
Step 1A. Refine the research question(s)Step 1B. Gather the evidence
************Step 2A. Determine the level of evidence (levels 1-8)Step 2B. Critically assess each article for quality of
design & methodsStep 2C. Determine the direction of the results/statisticsStep 2D. Cross-tabulate by level, quality and direction;
combine & summarize************
Step 3. Determine the Class of Recommendation
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Nov. 9, 2006 EPIC QI Workshop Slide 35
The ILCOR Consensus ProcessStep 1: State the Proposal
“To create a new guideline encouraging the use of continuous positive airway pressure (CPAP) or positive end expiratory pressure (PEEP) during neonatal resuscitation in the delivery room, particularly for very premature infants.”
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Nov. 9, 2006 EPIC QI Workshop Slide 36
Step 1A. Refine the research question(s)
• During the resuscitation of very premature infants the use of CPAP will reduce the baby’s oxygen requirements and the need for ventilation.
• The use of either CPAP or PEEP during the resuscitation of very premature infants at birth will reduce the proportion requiring oxygen when they reach the equivalent of 36 weeks gestation.
The ILCOR Consensus Process
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Nov. 9, 2006 EPIC QI Workshop Slide 37
The ILCOR Consensus Process
Step 1B.Gather the evidence
• Search with MESH headings all fields: CPAP AND resuscitation limited to the first 28 days, PEEP AND resuscitation limited to the first 28 days, neonatal resuscitation, delivery unit AND resuscitation.
• Cochrane database of systematic reviews.
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Nov. 9, 2006 EPIC QI Workshop Slide 38
The ILCOR Consensus ProcessStep 2: Assess the quality of each study
Step 2A. Determine the levels of evidence
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Nov. 9, 2006 EPIC QI Workshop Slide 39
The ILCOR Consensus ProcessStep 2: Assess the quality of each study
Step 2A. Determine the levels of evidence
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Nov. 9, 2006 EPIC QI Workshop Slide 40
The ILCOR Consensus ProcessStep 2: Assess the quality of each study
Step 2B. Critically assess each article for quality of design & methods
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Nov. 9, 2006 EPIC QI Workshop Slide 41
The ILCOR Consensus ProcessStep 2: Assess the quality of each study
Step 2C. Determine the direction of the results/statistics
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Nov. 9, 2006 EPIC QI Workshop Slide 42
The ILCOR Consensus ProcessStep 2: Assess the quality of each study
Step 2D. Cross-tabulate by level, quality and direction; combine and
summarize
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Nov. 9, 2006 EPIC QI Workshop Slide 43
The ILCOR Consensus ProcessStep 2: Assess the quality of each study
Step 2D. Cross-tabulate by level, quality and direction; combine and
summarize
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Nov. 9, 2006 EPIC QI Workshop Slide 44
The ILCOR Consensus ProcessStep 3: Determine the class of recommendation
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Nov. 9, 2006 EPIC QI Workshop Slide 45
Converting the scientific recommendations into clinical implications.
Ultimately, no recommendation was made to use CPAP on its own as a means of resuscitating babies.
The ILCOR Consensus ProcessConclusion(s)
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Nov. 9, 2006 EPIC QI Workshop Slide 46
Common sense.
Inadequate or no evidence.
Practised in centres with best outcomes.
“Informal” methodologies
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Nov. 9, 2006 EPIC QI Workshop Slide 47
Questions???