structure and process indicators for hai-net icu surveillance alain lepape (france)
TRANSCRIPT
Structure and process indicators for HAI-Net ICU surveillance European Center for Disease Control (ECDC)
Chair : Carl Suetens CR-ECDC ICU group: Antonella Agodi (IT), Michael Hiesmayr (AT), Alain Lepape
(Fr/ESICM), Mercedes Palomar (ES), Anne Savey (FR)
Indicators were limited to five topics with many items
• 1)Hand hygiene : – alcohol hand rub consumption in the ICU
• 2) Staff resources : – nurse to patient ratio and nurse-aid to patient ratio
• 3) Antimicrobial policy – Re-evaluation of antimicrobial therapy within 3 days after beginning of
therapy and documented in patient charts • 4) Device: intubation :
– Position of the patient – Endotracheal cuff pressure (> 20 mm H2O) controlled and/or
corrected at least twice a day, and documented in patient charts – Oral decontamination
• 5) Device: CVC – CVC dressing observation: not loosened, not damp, not visibly soiled.
Adapted from : K Ellingson et al. Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene. ICHE
35, No. 8 (August 2014), pp. 937-960 Observation methods Strengths Weaknesses
Direct observation Gold standard Only method that can discern all opportunities for hand hygiene
within patient care encounter and assess hand hygiene technique
Allows for immediate corrective feedback
Labor intensive and costly Observers must be trained and validated Subject to Hawthorne effect Subject to selection and observer bias
Technology-assisted direct observation Use of technology (eg, tablet) to save data entry step or to assist observer in standardizing measurement (ie, removing subjectivity)
Assessment of all or most opportunities to be analyzed at remote location
Less time-consuming and costly
Requires investment and maintenance of infrastructure Video monitoring requires trained observers has limited
opportunity for immediate feedback, and has potential to impact patient privacy
Product volume or event count measurement
Not subject to Hawthorne effect and selection or observer bias Unobtrusive and encompasses all opportunities Counters can detect changes in frequency of use according to time
of day or patterns of use in a hospital unit
May assist in optimal location of dispensers Relies on accurate usage data, which may be
compromised by system gaps or intentional tampering
Cannot distinguish hand hygiene opportunities(no denominator) or who used the product
Cannot assess adequacy of technique
Advanced technologies for automated monitoring
Systems with wearable components can provide positive feedback or just-in-time reminders to perform hand hygiene and individual-level monitoring
Captures all episodes entering and leaving a patient zone (eliminating selection and observer bias) and associated adherence
Expensive to implement Difficult to detect opportunities within the patient
encounter or to assess technique Limited data outside of research settings
Self-report Can raise individuals’ awareness of their practice Unreliable as healthcare personnel overestimate their performance
Distribution of ICUs according to alcoholic hand rub consumption (AHC) (ml per patient day) 2010
75th percentile
25th percentile
10th percentile
90th percentile
Median
Hand rub consumption (ml per patient day)
ICUs
Median value: 84 ml / patient-day
Rationale
• The importance of hand hygiene as cornerstone of standard precautions for infection prevention and control has been demonstrated since more than one century.
• The consumption of alcohol-based hand rubs (AHR) in liters per 1 000 patient-days is regarded as a good proxy indicator of hand hygiene compliance
Boyce JM. Measuring healthcare worker hand hygiene activity: current practices and emerging technologies. Infect Control Hosp Epidemiol. 2011 Oct;32(10):1016-28.
ESICM infection section survey 1)Hand hygiene : alcohol hand rub consumption during the surveillance period Concerns about the standardization
2) Staff resources : number of nurse-hours during a period of 7 days Concern about mixing different type of
nurses
3) Antimicrobial policy Re-evaluation of antimicrobial therapy within 3 days after beginning of therapy and documented in patient charts
Many concerns about the signification of de-escalation in ICU.
4) Device: intubation : Endotracheal cuff pressure (> 20 mm Hg) controlled and/or corrected at least twice a day, and documented in patient charts
OK
Oral decontamination with an antiseptic product OK
5) Device: CVC CVC dressing observation: not loosened, not damp, not visibly soiled. OK if done at a given time according to
the nurse shift.
Rationale
• Understaffing is one of the main reasons for low quality of care (mortality…)
• It is one of the indicators with the strongest evidence of an association with cross-transmission.
• But, regarding the staffing, not the only one … 1. Daud-Gallotti RM, Costa SF, Guimarães T, Padilha KG, Inoue EN, Vasconcelos TN, et al. Nursing workload as a risk factor for healthcare associated infections in ICU: a prospective study. PloS One. 2012;7(12):e52342. 2. Hugonnet S, Uçkay I, Pittet D. Staffing level: a determinant of late-onset ventilator-associated pneumonia. Crit Care Lond Engl. 2007;11(4):R80. 3. Schwab F, Meyer E, Geffers C, Gastmeier P. Understaffing, overcrowding, inappropriate nurse:ventilated patient ratio and nosocomial infections: which parameter is the best reflection of deficits? J Hosp Infect. févr 2012;80(2):133-9.
Staffing ressources
• nurse to patient ratio and nurse-aid to patient ratio
• Decision to keep it simple. 1. Daud-Gallotti RM, Costa SF, Guimarães T, Padilha KG, Inoue EN, Vasconcelos TN, et al. Nursing workload as a risk factor for healthcare associated infections in ICU: a prospective study. PloS One. 2012;7(12):e52342. 2. Hugonnet S, Uçkay I, Pittet D. Staffing level: a determinant of late-onset ventilator-associated pneumonia. Crit Care Lond Engl. 2007;11(4):R80. 3. Schwab F, Meyer E, Geffers C, Gastmeier P. Understaffing, overcrowding, inappropriate nurse:ventilated patient ratio and nosocomial infections: which parameter is the best reflection of deficits? J Hosp Infect. févr 2012;80(2):133-9.
ESICM infection section survey 1)Hand hygiene : alcohol hand rub consumption during the surveillance period Concerns about the standardization
2) Staff resources : number of nurse-hours during a period of 7 days Concern about mixing different type of
nurses/nurse-aids
3) Antimicrobial policy Re-evaluation of antimicrobial therapy within 3 days after beginning of therapy and documented in patient charts
Many concerns about the signification of de-escalation in ICU.
4) Device: intubation : Endotracheal cuff pressure (> 20 mm Hg) controlled and/or corrected at least twice a day, and documented in patient charts
OK
Oral decontamination with an antiseptic product OK
5) Device: CVC CVC dressing observation: not loosened, not damp, not visibly soiled. OK if done at a given time according to
the nurse shift.
Antimicrobial utilization in ICU Items How & when What Indicator Comments / limits
AB reevaluation Chart review of 20 to 30 patients under AB treatment
Reevaluation of AB treatment* within 3 days after start (*= in order to evaluate clinical efficiency and/or cost and/or MO susceptibility and/or possibility of AM de-escalation and/or stop of AB association etc.) In general , recommended 24-72h - 48-72h
% of AB treatments with documented* reevaluation (* = traceability on patient chart or ICU sheet… that the reevaluation has been actually performed by the intensivist or physician …)
- Traceability of the reevaluation? - If the chart review is done by an ICN, help and validation by an intensivist is necessary. Rque: Based on clinical evaluation if there is no M-O identified. 1 observation par patient traite
Carbapenem consumption
- Unit questionnaire - asked once (Pharmacy data) - period: same surveillance period (min 3 months)
- Num: volume of carbapanem distributed to the ICU by the pharmacy converted in DDD - Denom: all patients-days
DDD / 1000 patient-days Distributions and trends follow-up. Linked to AMR prevention (Enterobacteriaceae ESBL and CPE) Real problem in Southern Europe, but not in Northern Europe (could be considered in ESAC network)
AB referent
- Unit questionnaire - asked once
Access to an AB referent Y/N Difficult to define what is an " AB referent": in or out unit resources, level (ID physician, dedicated intensivist), permanent or not …
Aminoglycosides monitoring
Unit questionnaire - asked once
Systematic monitoring of aminoglycosides (dosage of peak)
Y/N Questionnaire or traceability? (retrospective chart review ? last 5-10 prescriptions of aminoglycosides)) Limit : unit not using aminoglycosides
Early treatment : timely AB treatment
Unit questionnaire - asked once
Beginning of treatment < 1 hour if septic choc or < 4 hours if community acquired pneumonia
Y/N Questionnaire or traceability? (retrospective chart review?). Rare event
Short duration AB association
Unit questionnaire - asked once
No AB association > 3 days without justification
Y/N Questionnaire or traceability? (retrospective chart review?).
Short AB treatment
Unit questionnaire - asked once
No AB treatment > 7 days without justification
Y/N Questionnaire or traceability? (retrospective chart review?).
Delay of treatment
Unit questionnaire - asked once
Beginning of treatment < 1 hour if septic choc or < 4 hours if community acquired pneumonia
Y/N Questionnaire or traceability? (retrospective chart review?). Rare event
Sample before treatment
Chart review 20 to 30 patients under AB treatment
Systematic sampling of the concerned infected site and/or blood cultures before treatment
% of AB treatments microbiologically documented
Quality of diagnosis and AB orientation.
Rationale • About 60 % of ICU patients will receive antimicrobials during an ICU stay • Reducing the duration of antimicrobial use and using narrower spectrum
antimicrobials or switching to monotherapy when possible limit the emergence and dissemination of drug-resistant strains and minimize antibiotic-related toxicity.
• Post-prescription review by a physician, pharmacist or other staff member of an antimicrobial after 48 hours from the initial order : core Indicators for hospital antimicrobial stewardship programs by the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR).
• !!! A specific category of patients : septic shock, severe sepsis.
ESICM infection section survey 1)Hand hygiene : alcohol hand rub consumption during the surveillance period Concerns about the standardization
2) Staff resources : number of nurse-hours during a period of 7 days Concern about mixing different type of
nurses
3) Antimicrobial policy Re-evaluation of antimicrobial therapy within 3 days after beginning of therapy and documented in patient charts
Many concerns about the signification of de-escalation in ICU.
4) Device: intubation : Endotracheal cuff pressure (> 20 mm Hg) controlled and/or corrected at least twice a day, and documented in patient charts
OK
Oral decontamination with an antiseptic product OK
5) Device: CVC CVC dressing observation: not loosened, not damp, not visibly soiled. OK if done at a given time according to
the nurse shift.
Prevention of VAP
Pneumonia prevention to decrease mortality in intensive care unit: a systematic review and meta-analysis. Roquilly A, Marret E, Abraham E, Asehnoune K. Clin Infect Dis. 2015 Jan 1;60(1):64-75.
Prevention of VAP: many prevention measures « on the market ».
Items How & when What Indicator Comments / limits Cuff pressure control
Chart review of 30 intubated patients/days
Endotracheal cuff pressure (> 20 mm H2O)
% of conformity
Daily traceability ? 30 patients- days ?
Oral decontamination
Chart review of 30 intubated patients/days
Oral decontamination >= 3 / j
% of conformity
Daily traceability at least 2 times/day Antiseptic product (chlorhexidine or other antiseptic) 30 patients- days ?
Patient position
30 Observations of intubated patients (1 obs / patient /d)
Intubated patients in semi-recumbent position
% of conformity
Direct patient observation Avoidance of supine position
Sedation Chart review of 30 intubated patients
Daily prescription of sedation level
% of conformity
Traceability ? 30 patients or 30 patients- days ?
Need for device exposure
Chart review of 30 intubated patients
Daily review of the need of intubation/ventilation
% of conformity
Difficult. Traceability ? 30 patients or 30 patients- days ?
SDD ? Y/N Controversial SOD ? Y/N ? Sub-glottic asp. ? Y/N Equipment not available in all ICU
Endotracheal cuff pressure
Correct cuff pressure: between 20 and 30 cm H2O
Over-inflated cuff pressure: Ischemia tracheal mucosa, risk of tracheal stenosis
Under-inflated cuff: risk of micro-inhalation
Rationale • Cuff pressure
– Maintaining the endotracheal cuff pressure in the recommended range limits micro-inhalations while preserving the mucosal integrity.
– Recommended range for the pressure varies between studies and guidelines: 25-30 cm H2O, 20-30 cm H2O or 15-22 mm Hg.
• Oral decontamination – Regular oropharyngeal decontamination with chlorhexidine or povidone-
iodine reduces the number of microorganisms colonising oropharyngeal secretions, which are involved in the development of ventilator-associated pneumonia through aspiration in the lower respiratory tract in intubated patients.
• Patient position: – Patients should not be maintained in supine position (except in case of specific
indications) in order to reduce micro-aspiration. – The existing evidence mainly supports an elevated head of the bed to 30-45
degrees – Very debated
ESICM infection section survey 1)Hand hygiene : alcohol hand rub consumption during the surveillance period Concerns about the standardization
2) Staff resources : number of nurse-hours during a period of 7 days Concern about mixing different type of
nurses
3) Antimicrobial policy Re-evaluation of antimicrobial therapy within 3 days after beginning of therapy and documented in patient charts
Many concerns about the signification of de-escalation in ICU.
4) Device: intubation : Endotracheal cuff pressure (> 20 mm Hg) controlled and/or corrected at least twice a day, and documented in patient charts
OK
Oral decontamination with an antiseptic product OK for most of them. More often than twice a day .
5) Device: CVC CVC dressing observation: not loosened, not damp, not visibly soiled. OK if done at a given time according to
the nurse shift.
CVC related-infections
Items How & when What Indicator Comments / limits Dressing observation
Patient observation: 20 to 30 observations of CVC dressings (once a day)
Dressing: not loosened, not damp, not visibly soiled
% of conformity Once direct observation pp per day
Clinical surveillance of the insertion site
Chart review of 20 to 30 patients with CVC
Daily surveillance of insertion site (palpation through the dressing to discern tenderness and by inspection if a transparent dressing is in use)
% of conformity? traceability?
= Done and traced? or only traced? Rque: If the patient has local tenderness or other signs of possible CRBSI, an opaque dressing should be removed and the site inspected visually.
Need for CVC exposure Chart review of 20 to 30 patients with CVC
Daily review of the need of CVC % of conformity Difficult. Traceability? 20 to 30 patients or patients- days?
Hand hygiene compliance
Nurse observation - trained auditor - 20 to 30 observations in one week
- Num: N of hand hygiene performed - Denom: N of opportunities
% compliance - nothing about hand hygiene technique (quality of the procedure) -definition of opportunities (before, after, care series…)
Aseptic technique Nurse observation - trained auditor - 20 to 30 observations in one week
- Num: N of aseptic techniques performed = no touch or sterile gauze impregnated with antiseptic - Denom: N of opportunities
% compliance -definition of opportunities (before, after, care series…) - type of antiseptic? (alcoholic?) - could be for dressing refection
Access port disinfection Nurse observation - trained auditor - 20 to 30 observations in one week
- Num: N of access port disinfection performed with antiseptic before each manipulation - Denom: N of opportunities
% compliance type of product? antiseptics, better alcoholic (?)
Hand hygiene compliance
Nurse observation - trained auditor - 20 to 30 observations in one week
- Num: N of hand hygiene performed - Denom: N of opportunities
% compliance - nothing about hand hygiene technique (quality of the procedure) -heavy workload - complex methodology and definitions of opportunities (before, after, care series…)
Gloves compliance Nurse observation - trained auditor - 20 to 30 observations in one week
- Num: N of gloves wearing - Denom: N of opportunities
% compliance - nothing about "gloves abuse" -heavy workload - complex methodology and definitions of opportunities (before, after, care series…)
Observation of CVC insertion techniques: excluded (Rare event, not always scheduled. Many CVC are inserted in surgery or emergency units)
Rationale
• An indicator of CVC maintenance preferred over an indicator of CVC insertion because of feasibility, in particular the number of observation opportunities is much higher for CVC maintenance than for CVC insertion
• SHEA recommandations : “For non-tunneled CVCs in adults and adolescents, change transparent dressings and perform site care with a chlorhexidine-based antiseptic every 5-7 days or more frequently if the dressing is soiled, loose, or damp; change gauze dressings every 2 days or more frequently if the dressing is soiled, loose, or damp”
Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O'Grady NP, Pettis AM, Rupp ME, Sandora T, Maragakis LL, Yokoe DS. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Sep;35 Suppl 2:S89-107.
ESICM infection section survey 1)Hand hygiene : alcohol hand rub consumption during the surveillance period Concerns about the standardization
2) Staff resources : number of nurse-hours during a period of 7 days Concern about mixing different type of
nurses
3) Antimicrobial policy Re-evaluation of antimicrobial therapy within 3 days after beginning of therapy and documented in patient charts
Many concerns about the signification of de-escalation in ICU.
4) Device: intubation : Endotracheal cuff pressure (> 20 mm Hg) controlled and/or corrected at least twice a day, and documented in patient charts
OK
Oral decontamination with an antiseptic product OK
5) Device: CVC CVC dressing observation: not loosened, not damp, not visibly soiled. OK if done at a given time according to
the nurse shift.
Conclusion on the Structure and process indicators for HAI-Net ICU surveillance
• No consensus solution exist, all indicators can be discussed. • Should be taken into account: the feasibility, the ease of collection in all
EU countries, the generated workload and the robustness. • We must consider this work as a starting point and modify it the following
years depending on the results. • ICU is a very costly activity generating many infectious complications
USA: Between 2000 and 2005, annual critical care medicine costs increased from $56.6 to $81.7 billion, representing 13.4% of hospital costs, 4.1% of national health
expenditures, and 0.66% of gross domestic product