/dr_gareth_kantor

Best Care…Always!

Campaign Global Forum on Bacterial Infec3on New Delhi ; October 4, 2011 Dr Gary Kantor

A loose coalition of stakeholders can initiate / sustain system strengthening for patient safety.

The process began with antibiotic stewardship, and was driven by a private funder, hospitals and professionals.

We are exploring new ways of building will, generating and sharing ideas and filling the execution gap ‌.changing the system.

Global Epidemic of Harm in Hospitals Adverse events in 9 – 18% of admissions ~ 50% preventable 2.5 – 7.5% are fatal

NEJM Nov 25, 2010 Qual Safety in Health Care 2008;17:216-223 3

Preventable Harm: 1 in 3 Hospital Patients

n=795 3 hospitals

#1. procedures #2. medications #3. infection

Voluntary reports are 1% of events Health Affairs, 30, no.4 (2011):581-589 4

Hospital-Acquired Infection • World – 1.4 million patients affected / day

• Developed countries

JAMA 2009;301(12):1285-1287 Lancet 2008;372(9651):1719-1720

– Hospital incidence up to 10% – USA: 100,000 deaths

• Developing countries – 3 x higher – S Africa 9.7% prevalence; 28.6% ICU A Duse. SA-HISC study (unpublished) Allegranzi B; Lancet 2010:61458 5

Median rate of infection: ZERO!!

CLABSI rates ↓ by 66% Better than 90% of US ICUs 1,500 lives and $$$ saved Sustained > 3 years

96 ICUs

Pronovost P. NEJM Dec 2006 6

EVIDENCE CLABSI Bundle

maximal barrier precautions chlorhexidine skin antisepsis optimal catheter site selection daily review of line necessity

ü ü ü ü

Checklists + Daily goals sheet + Unit-based safety program Pronovost P. NEJM Dec 2006 7

CAUTI

CLABSI + Antibiotic Stewardship

SSI

VAP

Public Sector Improvement Scientists Professionals Private Hospitals Sponsors

Expert Panel

BUILDING WILL

9

from

evidence-based medicine to

Evidence-based IMPLEMENTATION Subject Matter Knowledge

“what”

Effective changes that lead to an improvement

“where”

“how”

Improvement Science 10

202 Hospitals enrolled at least 1 intervention

11

“The Method for Improvement” = the Scien3fic Method

Not protocols Not “recipes” 12

AIMS

Decrease CLABSI to 0 or 300 patient days between by June 2010

10 DRIVERS Reliable identification of a CLABSI Reliable implementation of the insertion bundle

20 DRIVERS Reliable Definition – CLABSI Reliable data collection process – infections & device days Insertion bundle (HII) Line insertion documented in notes

Reliable implementation of the maintenance bundle

Reliable data collection Maintenance bundle (HII) Reliable data collection

Improve safety culture through multidisciplinary team working and communication

Clinical leadership rounding to view lines Bundles known by staff HAI surveillance data and bundle compliance shared with staff

95% compliance with insertion bundle and each element of bundle 95% compliance with maintenance bundle and each element of bundle

AIMS

Optimal antibiotic use in 80% of patients 30% reduction in antibiotic overuse Stable / decreased antibiotic resistance

10 DRIVERS

CHANGE CONCEPTS ↑ availability of first dose

Prompt initiation, for defined reasons Periodic review for cessation, route, reason for treatment Prescriber access to knowledge and data

Prevention of hospital-acquired infection

Separate AB prescribing from other Rx Day 3 and Day 7 review Info on how to Rx Info on what it costs

*Prevent SSI, CLABSI, VAP and CAUTI

*Interventions already associated with the BCA campaign

INTERVENTIONS

Antibiotic ward stock Antibiotic form AB Bundles Clinical pharmacist review Path lab hotline Resistance reports Cost reports SSI bundle CAUTI bundle CLABSI bundle VAP bundle

OUTCOME MEASURE

10 PROCESS MEASURE

20 PROCESS MEASURE

% with compliance to all bundles (“optimal use”)

% receiving timely % compliance with each Inception antibiotics for prevention or bundle element: 1. <2 hrs from order → admin treatment – first antibiotic (treatment) prescribed during hospital 2. Prophylaxis within 1 hr of incision course % overall compliance with Day 3 Bundle for the first antibiotic prescribed during hospital course

% compliance with each Maintenance bundle element:

% overall compliance with Day 7 Bundle for the first antibiotic prescribed during hospital course

% compliance with each Maintenance bundle element:

1.

2.

3.

4.

Treatment not prophylaxis State antibiotic indication or stop Culture(s) ordered or done Reassess drug choice

1. Stopped or re-ordered 2. Conversion from IV to oral or N/A

IDEAS 18 -24 months Repeated improvement cycles:

Expert and Planning Group formed

Learning session 1

Repeated improvement cycles:

Learning session 2

Learning session 3

Mentoring and support

16

8.00

CLABSI -­‐ Infec9on Rates Per 1000 Central Line Days 7.17 Life Healthcare Group -­‐ Oct 2008 to Sept 2010

7.00

6.00 5.66

5.57

5.22

5.00

4.00

4.95

4.21

Repor3ng system and training on BCA in all acute hospitals

3.85

3.00

3.48

3.36

3.22

3.12

2.93 2.58

2.90 2.98 2.46

2.01 2.10 2.01

2.00

Cross func3onal workshops in ICU's to implement bundle compliance ac3ons and increase involvement of Unit Managers 2.33 2.08

2.17

2.05

1.57 1.00

CLABSI-­‐Rate

1.67

Mean 0.85

Upper control limit

0.57

Lower control limit

0.00

n=41 hospitals 17

HAI : CLABSI RATE Central Line Associated Blood Stream Infections - CLABSI Central Line Associated Blood Stream Infec9ons -­‐ Bundle Compliance and Infec9on Rate Mar 09 -­‐ Aug 10 100%

6.00

87% 5.22 5.00

83%

4.95

83%

83%

85%

83%

85%

88% 84%

84%

87%

87%

87%

87%

90%

80%

78% 70%

4.00

90%

70%

3.22 3.00

3.12

2.93 2.58 2.01

2.00

2.10

60%

3.48

3.36

50%

2.90 2.98 2.46

2.33 2.08

2.01

40%

Infec3on Rate CLABSI

2.17 30% 1.57 20%

1.00

n=41 hospitals

Aug-­‐10

Jul-­‐10

Jun-­‐10

May-­‐10

Apr-­‐10

Mar-­‐10

Feb-­‐10

Jan-­‐10

Dec-­‐09

Nov-­‐09

Oct-­‐09

Sep-­‐09

Aug-­‐09

Jul-­‐09

Jun-­‐09

May-­‐09

Apr-­‐09

-­‐

Mar-­‐09

10% 0%

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BCA : COMPLIANCE : SSI Bundle Compliance to SSI Period: JUNE-10

100%

96% 89%

90%

89%

80% 70% 60%

57%

50% 40% 30% 20% 10% 0% If hair is removed, it is only done with Antibiotics are given within an hour of Glucose is maintained above 4 and The patients temperature is clippers or dipilatory cream incision below 8 after the initial post operative maintained at >36.5 and <37.2 after assessment in ICU the initial post operative assessment in ICU

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10 11 12 13 14 15 16 17 18 19 20 21 22

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10

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11

0

6

5

1

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11

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9

8

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14

2

1

12

9

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11 17

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4

3-­‐Jul

9-­‐Jul

15-­‐Jul

29-­‐Jul

31-­‐Jul

1-­‐Aug

13-­‐Aug

22-­‐Aug

26-­‐Aug

24-­‐Sep

28-­‐Sep

2-­‐Oct

7

1-­‐Jul

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24-­‐Jun

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18-­‐Jun

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10-­‐Jun

3

1-­‐Jun

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26-­‐May

1

22-­‐May

9 10 11 12 13 14 15 16 17 18 19 20 21 22 Infection

11-­‐May

8

•

8-­‐May

7

•

•

7-­‐May

6

Infection 3 days after admission

•

2-­‐May

5

•

26-­‐Apr

4

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26-­‐Apr

3

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15-­‐Apr

1

2

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4-­‐Apr

Date of infections

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1 Data Element Days between infections

•

•

Possible contaminant

•

August -­‐

7-­‐Sep

31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 •

Started with CLABSI Bundle

Neurosurgery I CU -­‐ Steve Biko Academic Hospital -­‐ Pretoria Month: April -­‐ July 2010

14-­‐Apr

Days between infections

Central Line Associated Bloodstream Infections

8

8

9 10 11 12

9

10 11 12

Days Between Infection 20

No incident

New incident

More than 1 incident Poor data

Visual Measurement 21

At the same time every day the Unit manager counts devices in use in the ward

Solving the Denominator Problem

www.bestcare.org.za

Not just infections Not just bundles

garyk@discovery.co.za

Everyone in healthcare has 2 jobs 1. Doing the work 2. Improving the work!

24

All improvement requires change (though not all change is an improvement)

Changing: How and why we measure Methods (of improvement) Our sense of responsibility Leadership Organisations and culture The Health industry

25

How and why we measure OLD

NEW

International data

Our data

Counts

Rates

Bar graphs

Run charts (over time)

Data for head office / ministry

Measurement for frontline staff

Individual measures

Measures across systems

Modified from: D van den Bergh, Netcare Hospital Group 26

BMJ Qual Saf 2011;20:46e51

“Run Chart”

Rules for iden3fying non-­‐ random signals

27 27

How we improve OLD

NEW

Audit and inspection (QA)

PDSA cycles

Checklists for checking

Checklists as aids

Writing more protocols

Focused interventions

â&#x20AC;&#x153;Spray and prayâ&#x20AC;?

Improving critical elements one a time

Modified from: D van den Bergh, Netcare Hospital Group 28

Taking Responsibility OLD

NEW

“it doesn’t happen here”

Knowing the facts

“we already do that”

Acknowledging we may not

Can’t do

“if they can so can we”

Accept the inevitable

Persistence

Victim of limitations

Building skills

Modified from: D van den Bergh, Netcare Hospital Group 29

Clinicians Skeptical and critical “this might work” “worth trying” “how can we support you” “I would like to initiate” 30

Leadership OLD

NEW

It’s up to the doctors

Active involvement of senior leadership

It’s up to the nurses

“Exco”

It’s up to the Infection Prevention Practitioners It’s up to the Infection Control Committee

Modified from: D van den Bergh, Netcare Hospital Group 31

The Culture OLD

NEW

Blaming and punishing

Learning and curious

Who (people)

Why (system)

Helping

Capacitating (mentors)

Modified from: D van den Bergh, Netcare Hospital Group 32

Health Sector OLD

NEW

Competition

Collaboration

Secrets

Sharing

Private vs public

Interconnected systems Public learns from Private Private learns from Public Public-private partnership

Modified from: D van den Bergh, Netcare Hospital Group 33

Antibiotic Stewardship OLD

NEW

Passive observers

Actively seeking solutions

No interventions

Identifying opportunities

No measures

First level utilisation data

Defensiveness

Working together to deal with it

Pilots

Multiple sites testing change

Modified from: D van den Bergh, Netcare Hospital Group 34

www.bestcare.org.za

The Changing View of Quality We are perfect!

NO ACTION

Get rid of the bad apples REACTION Quality Assurance “Standards”

M&M

Incident reporting

36

The Changing View of Quality “Quality” We are perfect!

INACTION

Get rid of the bad apples REACTION “Quality Assurance”

M&M

Safe Effective Timely Equitable Patient-centred Efficient

System thinking

PRO-ACTION Quality Improvement

“Standards”

Improvement Science

Incident reporting

Dashboard of Quality Measures

37

Improvement Science and Knowledge Systems Combine to Produce Improvement Generalisable scien9fic evidence “control context”

Patients get “recommended care” ~ 50% of the time standardisation, forcing Qual Saf Health Care + functions, education, etc

2007;16:2–3

Plans for change

+

Par9cular context “local processes, habits, traditions”

+

Execu9on “drivers of change” High performance (measured) “include time” 38