Big Changes through Small Steps Atlantic Note Quality Improvement Workshops

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EPIC/PHSIQuality Improvement Workshop
Interventions to prevent nosocomial infection and
future directions
Khalid Aziz November 10, 2006
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Janeway Childrens Health and Rehabilitation
Centre, St. Johns NL
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Acknowledgements

• Nosocomial infection team centres
• Childrens Womens Health Centre of BC
• Janeway Childrens Health and Rehabilitation
  Centre
• IWK Health Centre
• Hospital for Sick Children
• St. Josephs Hospital
• Royal Alexandra Hospital

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Objectives

• Nosocomial infection team interventions
• Methodologies
• Proposed methodologies for future interventions

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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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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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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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Baseline data UAC sepsis
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Baseline data PICC sepsis
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Baseline data
PICC sepsis by centre
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List of interventions 1

• Hand hygiene
• Gloves and gowns
• Skin care
• Skin breaks
• Care of PICC lines

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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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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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Gloves and gowns

• Discontinue use of routine gloves and gowns

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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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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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Skin breaks (pokes audit)
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Skin breaks (IV starts audit)
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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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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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Choice of first line antibiotics
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Duration of empiric antibiotic therapy

• Discontinue antibiotics if blood cultures are
  negative after 36 hours (assuming the baby is
  well)

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Duration of empiric antibiotic therapy
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Care of ventilator circuits

• Change ventilator circuits when visibly
  contaminated, malfunctioning, and between
  patients

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Visiting policy

• 2 visitors per neonate in NICU at any one time

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Staff education

• Encourage staff influenza immunization

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Future directions

• Revisions
• New interventions
• Standardization of reviews

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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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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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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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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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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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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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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 methods
• Step 2C. Determine the direction of the
  results/statistics
• Step 2D. Cross-tabulate by level, quality and
  direction combine summarize
• Step 3. Determine the Class of Recommendation

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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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The ILCOR Consensus Process

• Step 1A. Refine the research question(s)
• During the resuscitation of very premature
  infants the use of CPAP will reduce the babys
  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.

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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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The ILCOR Consensus ProcessStep 2 Assess the
quality of each study
Step 2A. Determine the levels of evidence
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The ILCOR Consensus ProcessStep 2 Assess the
quality of each study
Step 2A. Determine the levels of evidence
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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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The ILCOR Consensus ProcessStep 2 Assess the
quality of each study
Step 2C. Determine the direction of the
results/statistics
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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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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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The ILCOR Consensus ProcessStep 3 Determine the
class of recommendation
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The ILCOR Consensus ProcessConclusion(s)

• Converting the scientific recommendations into
  clinical implications.
• Ultimately, no recommendation was made to use
  CPAP on its own as a means of resuscitating
  babies.

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Informal methodologies

• Common sense.
• Inadequate or no evidence.
• Practised in centres with best outcomes.

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Questions???