Multi Professional Conference NES

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Multi- Professional Conference NES SAPG Prudent
Prescribing of Antimicrobials1st Oct 09Using
local data a Quality Improvement Approach to
drive sustained reduction in CDIJackie LeyHAI
Nurse ConsultantNHS QIS


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Session Overview

• CDI - Why does it matter?
• CDI Overview
• Surveillance
• Using The model for Improvement to reduce CDI
• Key Messages

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CDI - Why does it matter ?

• Patient safety
• Legal responsibilities - Health and safety
• Increased morbidity and mortality
• Health Efficiency Access and Treatment
• (HEAT) Targets

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CDI - Why does it matter ?

• OUTBREAKS
• Stoke Mandeville Bucks 2006
• Maidstone Tunbridge Wells 2007
• Northern Ireland 2008
• Scotland - Vale of Leven 2008, Orkney, Dr Grays
  Caithness 2009

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Media Reports
"What happened at the Vale of Leven must be fully
investigated," "It's vital that all possible
lessons are learned to prevent it happening
again."
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• How are we tackling the problem

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CDI - Overview Scotland

• Evidence there has been a reduction in overall
  rate of CDI during year ending March 09
• Trends among NHS Boards vary
• 8 NHS boards likely to meet CDI HEAT target if
  current trend continues

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Risk Reduction Strategies include

• Behaviours
• Environment
• Focus on systems rather than people
• Focus actions where they will be most effective
• Identify what the main routes of infection are

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Scottish - CDI reduction programme

• New HEAT target 30 reduction of CDI by 2011
• Nationally agreed core prescribing indicators
  HEAT target
• National and local surveillance

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Surveillance

• National allows monitoring of trends in
  Scotland over time and comparisons of boards with
  Scottish average
• Local - allows NHS boards to monitor their own
  results over time -to identify outbreaks, unusual
  clusters and drive quality improvement

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Surveillance cycle

• Accessed HPS website Sept 09

Data Collection
Application to Prevention Control
Analysis

Dissemination
Interpretation
Planning
Evaluation
Implementation
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Why perform Surveillance?

• Obtain baseline data
• Improve patient outcomes
• Identify problems
• Monitor quality of infection control
• practice
• Education Healthcare Workers

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Why perform Surveillance?

• To define a threshold incidence (or frequency) of
  CDI cases that would trigger implementation of
  additional infection control measures
• to feedback surveillance data and its
  interpretations to all relevant staff which is
  essential to prevent and control CDI

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CDI Surveillance data

• How do we use it to drive improvement ?

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Scenario- Exercise

• Problem
• High rates of CDI, despite a focus on
• infection control practice, local surveillance
  and
• environmental cleaning figures continue to rise
• Setting
• University Teaching Hospital with 900
• acute beds
• Task
• Identify 3 or 4 Key actions and describe how you
• would measure their impact to drive a reduction
• in CDI

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• Using local data a Quality Improvement Approach
  to drive sustained reduction in CDI
• The Salford NHS Foundation Trust Approach

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Traditionally

• Write policies
• Education, education, education
• Audit
• Advice leading to harder work and more
• diligence
• HAS IT WORKED ?
• How do we measure and know which of our efforts
  are leading to an improvement?

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The definition ofinsanity iscontinuing to
dothe same thing overand over again
andexpecting adifferent result Albert
Einstein
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The need for change

• Healthcare Associated Infection
• (CDI) is a major patient safety issue
• We have scientific evidence for the
• interventions that are likely to lead to
• Reduced CDI
• We know what to do
• Studies have demonstrated that
• guidance does not translate into
• Practice
• We dont know how to do it

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Things you have to accept if

• we are human, and humans make errors
• "trying harder" makes no one
• superhuman
• expecting perfection in human
• action, or simply telling our doctors
• and nurses to "try harder has
• nothing at all to do with
• success
• Don Berwick MD, President CE, IHI

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Most Quality Improvement Methodologies make use
of

• The cycle of improvement
• Data collection
• Problem description
• Diagnosis
• Selection of potential changes
• Implementation evaluation of those changes
  likely to lead to sustainable improvements

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The Model for Improvement
Plan Do Study Act (PDSA) Cycle

• A simple yet powerful tool for accelerating
  improvement

Ref IHI SPSP Model for Improvement
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The Three Questions

• What are we trying to accomplish?
• (AIM)
• How will we know that a change is
• an improvement? (MEASURES)
• What change can we make that will
• result in improvement ?
• (CHANGES)

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Salford Royal Foundation Trust Approach

• Approach included
• Expert group included microbiology, infection
  control, pharmacy, elderly care medicine
  improvement expert
• Development of a time limited, measurable stretch
  goal
• Which included 5 wards to reduce CDI by 50
  within 1 Year
• Identified 4 key drivers for change antibiotic
  stewardship, environmental cleaning,
  identification of containment and habits and
  patterns

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A schematic of the key drivers of change in the
reduction of C. difficile which were to be
completed within one year
Ref Salford Royal NHS Foundation Trust
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Table 2 Detailed changes designed, implemented
and included in change package. N.B. All
changes introduced to all wards in February
2007. In a small number of clinical exceptions
antimicrobials were left in ward stocks and a
system of monitoring by pharmacy and microbiology
was implemented. Ref Salford Royal NHS
Foundation Trust
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The Breakthrough Series Collaborative Model for
Improvement taken from www.ihi.org Ref
Salford Royal NHS Foundation Trust
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The Collaborative Model

• Teams committed to working together over a 9
  month period
• Attend 2 day learning sessions.
• Which provided instruction in the theory and
  practice of improvement, local context CDI,
  measurement, principles of reliability

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• Prevention Team and improvement advisor
• In between learning sessions, teams participated
  in action sessions
• Mentoring visits, access to Infection

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Figure 3 Cases of CDI on five collaborative
wards from April 2006 to December 2008.
Baseline data are shown from April 2006 March
2007. Key events in the collaborative are
identified in the legend. The shift in the
mean identified in August 2007 represents a
71 reduction.
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Figure 4 Cases of CDI in the non-collaborative
areas from April 2006 December 2008.
Baseline data are shown from April 2006 June
2007. Key events in the collaborative are
identified in the legend. There are two shifts in
the mean in July 2007 and March 2008.
This represents an overall reduction of 44 and
85 respectively.
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Key Messages- Salford Approach

• A collaborative model is effective in reducing
  CDI
• The pilot sites achieved a marked and sustainable
  improvement of up to 85
• Changes can be spread to other areas
• Collaborative model created an environment that
  facilitated key changes into a change package

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Key Messages

• Teams had to describe how reduction accomplished
• Teams given time to reflect on changes
• Team ownership of data is crucial develop an
  awareness of their performance

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Key Messages- Salford Approach

• Combination of system wide ownership,
  antimicrobial stewardship and a focus on
  re-design of basic processes for infection
  control and environmental cleaning is important

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Key Messages

• CDI can be controlled
• It has implications for patients
• It has to be managed and monitored to keep it to
  a minimum
• Local surveillance and feedback as well as using
  improvement methodologies are vital
• If you cant measure it you cant improve it
• Team owner-ship of data is crucial
• Identifying the key drivers for change are crucial

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Whats the theory

• Safe, effective, patient-centred care
• Assurance at all level
• Every patient, every time Model for Improvement
  concept