Bacteraemia zero: how is it possible?

MERCEDES PALOMAR

SMI H ARNAU DE VILANOVA (LLEIDA)

Objectives of nosocomial infection surveillance in

critically ill patients

• Know the rates of device-related infections acquired in ICU.

• Identify the most frequent microorganisms responsible for each surveyed infection.

• Monitor and assess multiresistance markers.

• Study of intrinsic risk factors and frequency and exposure to extrinsic risk factors.

• Outbreak detection.

• Evaluation of ICU-acquired infection’s impact.

• Study of control measures.

BACTERIEMIA PRIMARIA-CV.

NEUMONIA RELACIONADA CON VM

1 4 ,6 1 4 ,71 4 ,91 8 ,5

1 8

1 5 ,5

1 7 ,5

1 7 ,2

2 3 ,6

1 7 ,8

2 0 ,11 8 ,4

1 6 ,8

1 7 ,1

1 6 ,1

0

5

1 0

1 5

2 0

2 5

199

4

199

5

199

6

199

7

199

8

199

9

200

0

200

1

200

2

200

3

200

4

200

5

200

6

200

7

200

8

D E N S ID A D D E IN F E C C IO N D E N -V M

N-VM /1000 días de VM

TASA MEDIA NACIONAL

14,6-23.6 o/o o

ICU-ACQUIRED INFECTIONS.

ENVIN-HELICS 1994-2008

INFECCION URINARIA RELACIONADA CON SU

6,9

5,5 5,56

4,9

5,96,7

5,11 5 4,76

6,67,4

6,15,8

6,8

0

1

2

3

4

5

6

7

8

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

TASA MEDIA NACIONAL

4,9-7.4 (O/OO)

INFECCION URINARIA-SU / 1000 DÍAS DE SONDA URETRAL

6,776,22

7,7

6,8

7,947,49

5,044,7 4,89

4,013,67

4,54,02

4,73 4,46

3,19 3,1 3,05

0

1

2

3

4

5

6

7

8

9

10

2000 2001 2002 2003 2004 2005 2006 2007 2008

Nº/

100

0 d

BP-CV (CVC) BP-CV (CVC+CA)

TASA MEDIA NACIONAL

5.09-7.9 (O/OO)

Consolidated surveillance

Rates: no reduction

VENTILATOR ASSOCIATED PNEUMONIA

CATHETER RELATED BACTEREMIA URINARY TRACT INFECTION-UC

PRIMARY BACTERIEMIA (CVC +UNKOWN ORIGEN)

6,776,22

7,7

6,8

7,947,49

5,044,7 4,89

0

1

2

3

4

5

6

7

8

9

10

2000 2001 2002 2003 2004 2005 2006 2007 2008

Nº/

100

0 d

PRIMARY BACTERIEMIA (CVC +UNKOWN ORIGEN)

6,776,22

7,7

6,8

7,947,49

5,044,7 4,89

0

1

2

3

4

5

6

7

8

9

10

2000 2001 2002 2003 2004 2005 2006 2007 2008

Nº/

100

0 d

77915 patients

NOSOCOMIAL INFECTIONS

SURVEILLANCE PROGRAMS

• Whatever the detection, registration and reporting method, NI surveillance programs are necessary to establish corrective measures.

• NI-Surveillance Programs are relevant only if they aim at improving care

Technical Workshop on Patient Safety and

Care of Acutely Ill Patients: Changing the Paradigm Friday 22 September 2006, Barcelona

Mean from 7,7 epis/1.000 CVC days

to 1,4 after 18 months (p<0,002).

FROM SURVEILLANCE TO

PREVENTION

FROM ENVIN TO BACTERIEMIA,

PNEUMONIA & RESISTANCE-ZERO

REDUCTION OF CATHETER-RELATED BACTEREMIA IN INTENSIVE CARE

UNITS BY A MULTIFACTORIAL INTERVENTION: PILOT STUDY (2007)

Bacteriemia zero (2009-2010)

GENERAL FRAMEWORK

WHO

SMoH SEMICYUC

HR

(ICU)

BALTIMORE

agreement

agreement

Bacteriemia zero

Quality Agency SMoH

HR Department

HR Cordinating

Team Cordinator, ICU physician

ICU nurse, preventivist

ICU-1 ICU-2 ICU-n

Information, engagement

Managers commitment

Leadership

Organize: Functions

Resources distribution

Training

Monitoring

Evaluation reports: results

Structure & Process evaluation

Physician, Nurse, Executive,

infectious diseases comitee

Training

Implementation

Self-evaluation

Improvement

Cofinancing & coordination

Monitoring & spreading

NATIONAL ORGANIZATION

OBJECTIVES

• Reduce ICU CLABSI (< 4 episodes per 1000 CL days)

• Create through the HR an ICU network to apply

effective Safe Practices

• Promote Safety Culture in the Spanish ICU

• Improve CLABSI information system

• The original Keystone ICU project was adapted to fit the organizational and cultural characteristics of the Spanish health care system.

• The model to engage, educate, execute, and evaluate was unchanged and a key element of the study implementation

Bacteriemia zero

Bacteriemia zero

STOP-BRC

a. Hand hygiene.

b. Chlorhexidine skin antisepsis.

c. Maximal barriers precautions

d. Prefered site selection: subclavian vein.

e. Removal of unnecessary lines

f. Hygienic caheter managment

Pathogenesis of vascular access-related infections

MEDIDAS DE PREVENCIÓN BRC: EVIDENCIA 1A

1. Higiene de manos adecuada

2. Desinfección de la piel con clorhexidina

3. Máximas barreras de precaución

5. Retirada de CVC no necesarios

4. Preferencia de localización subclavia

6. Mantenimiento higiénico del catéter

Bacteriemia zero

Bacteriemia zero

Comprehensive Safety Plan

1. Evaluate safety culture

2. Education on safety culture

3. Identify defects in clinical practice

4. Establish alliances with Executive Board

5. Learn from defects

STOP-BRC

a. Hand hygiene.

b. Chlorhexidine skin antisepsis.

c. Maximal barriers precautions

d. Prefered site selection: subclavian vein.

e. Removal of unnecessary lines

f. Hygienic caheter managment

“BUNDLES “ PREVENCION BRC + CUSP

PROGRAMA DE MICHIGAN

• Hand hygiene

• Maximal barriers precautions

• Clorhexidine skin antisepsis

• Avoid femoral

• Removal of unnecessary lines

+ +

CUSP

Pronovost Pet al. Improving communication in the ICU using daily goals. J Crit Care 2003

Pronovost P. Implementing and validating a comprehensive unit-based safety program. J Patient Saf 2005.

Pronovost P Senior executive adopt-a-work unit: a model for safety improvement. Jt Cm J Qual Saf 2004.

Pronovost P, Goeschel C. Improving ICU care: it takes a team. Healthc Exec 2005

BZ IMPLEMENTATION

• Engage: local BSI cases, basal rates (locals, nationals, european)

• Educate

• Execute

– Cart line

– Check list at insertion

– Daily goals

– Learning frrom errors

– Nurse empowerment

• Evaluate

– Surveillance and feed-back (rates, check-list, safety clima)

– Consider infections = errors

• 1.000.000 CVC days /year in Spanish ICU(80% of ICU stay)

• 5.000-8.000 CRB /year

• 1.250-2.000 deaths (25% crude mortality) pts with CRB

• 400-600 deaths (9% attributable mortality) BRC-related

• Cost: Increase of ICU-LOS: 12 days

ENGAGE

El número oficial de muertos: 191

Educate (technical)

EDUCATE (PS)

Learning From Defects

Check-list at insertion Daily-goals

IMPLEMENTATION

Protocolo

Manual de aplicación

Checklist inserción

Daily goals Inventario +registro

Safety clima Equipo líder

Aprender de errores

Problemas de seguridad

Definiciones Protocolo inserción

Resumen evidencia

Manual web

Manual Instrumentos

MEDIDAS DE PREVENCIÓN BRC: EVIDENCIA 1A

Bacteriemia zero

1. Higiene de manos adecuada

2. Desinfección de la piel con clorhexidina

3. Máximas barreras de precaución

5. Retirada de CVC no necesarios

4. Preferencia de localización subclavia

6. Mantenimiento higiénico del catéter

MEDIDAS DE PREVENCIÓN BRC: EVIDENCIA 1A

1. Higiene de manos adecuada

2. Desinfección de la piel con clorhexidina

3. Máximas barreras de precaución

5. Retirada de CVC no necesarios

4. Preferencia de localización subclavia

6. Mantenimiento higiénico del catéter

Bacteriemia zero

MEDIDAS DE PREVENCIÓN BRC: EVIDENCIA 1A

1. Higiene de manos adecuada

2. Desinfección de la piel con clorhexidina

3. Máximas barreras de precaución

5. Retirada de CVC no necesarios

4. Preferencia de localización subclavia

6. Mantenimiento higiénico del catéter

Bacteriemia zero

Programa de Seguridad Integral Programa de Seguridad Integral

(PSI)(PSI)

1Evaluación

de cultura

de seguridad

5Aprender

de los

errores

2Formación

en

seguridad

33Identificación

de fallos

4Alianza

con la

Dirección

0

Formación

equipo

seguridad

Bacteriemia zero

BacteriemiaBacteriemia zero

1. Higiene adecuada de manos

2. Desinfección de la piel con clorhexidina

3. Medidas de barrera total durante la inserción

4. Preferencia de localización subclavia

5. Retirada de CVC innecesarios

6. Manejo higiénico de los catéteres

1. Evaluar la cultura de seguridad

2. Formación en seguridad del paciente

3. Identificar errores en la práctica habitual

4. Establecer alianzas con la dirección

5. Aprender de los errores

STOPSTOP--BRCBRC

Equipo Equipo

seguridad seguridad

UCIUCIPlan de seguridad integralPlan de seguridad integral

Resumen STOP-BRC PSI

Curso STOP-BRC

Traducción

PSI In

str

um

en

tos

Mate

rial

form

ació

n

Pó

ste

rs

Do

cu

men

tos

ap

oyo

Test STOP-BRC

Curso PSI

Bacteriemia

zero

+

Guía

de navegación

web web web

Evaluation

PB RATES

SAFETY INDICATORS

EZCOLLAB

This community based service allows you to exchange

resources, research papers, guidelines and other publications, to

share your own knowledge, experiences, and lessons learned.

Participate in online communities and discuss technical and

programmatic issues related to your work

Patients with BSI and CRBSI (%)

2,76

2,12

2,552,28

2,41

1,852,051,95

1,321,59

1,3 1,3

0,93 0,97

0

1

2

3

4

Basel

ine

Imple

m 0

-3m

4-6

m7-

9m

10-1

2m

13-1

5m

16-1

8m

%

BSI CRBSI

12,3

8,417,93

6,397,42

3,283,77

0

2

4

6

8

10

12

14

16

%

Bas

elin

e

Imple

m 0

-3m

4-6

m7-

9m

10-1

2m

13-1

5m

16-1

8m

Patients with >1 CRBSI

CRBSI: Incidence rate (Median)

3,07

2,08

2,5

2,06 2,1

0,861,12

0

1

2

3

4

5

Bas

elin

e

Imple

m 0

-3m

4-6

m7-

9m

10-1

2m

13-1

5m

16-1

8m

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

BaselineImplementation (0-3 months)

4-6 months

7-9 months

10-12 months

13-15 months

16-18 months

 Inci

de

nce

est

ima

te (

pe

r 1

00

0 c

ath

ete

r-d

ays

) 

All: Univariate

All: Adjusted Multivariate

University Unit: No

University Unit: Yes

Hospital Size: >500 beds

Hospital Size: 200-500 beds

Hospital Size: <200 beds

Incidence-rate ratio estimated

1

1,231,18

1,36

1,16

1,47

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

Imp

l(0-

3m)

4-6m

7-9m

10-1

2m

13-1

5m

16-1

8m

n/1

000

d s

tay

P = 0.013

P=0,022

NS NS NS

BSI-Secondary to other Infection Sites

CHARACTERISTICS OF PATIENTS WITH PB

BPSC (1.594 patients) ENVIN 2009 (14.984 patients)

• APACHE II 19,7 14, 3

• Age (years) 60,9 62,2

• Males (%) 68,7 64,4

• UD (%)

-Coronary 6,1 22,1

-Médical 55,8 42,7 - -Sched. surg 26,2 28,1

-Trauma 11,9 6,9

• Emerg surgery(%) 31,6 15,1

• ERD (%) 20,7 5,1

• TPN (%) 45,0 12,2

• ICU LOS (days) 33,9 7,7

• Mortality (%) 32,0 11,1

BZ BARRIERS

Barriers to use Chlorhexidine :

-Not believe in its effectiveness

-Difficulties to get it.

-Dislike colorless

-Do not know the standard

Daily goals

-Difficulties to find the usefull model (Type of ICU)

-Not believe in its effectiveness

-No time to meet nurses/physicians

Safety rounds :

-Difficulties to find the useful model

-Not executive's collaboration

52,9

65,2

73

97 95100

0

20

40

60

80

100

% U

CI

SAFETY

ROUNDS

ERROR

ANALYSIS

DAILY GOALS CHECK-LIST

INSERCCION

CART CLORHEX

CUPS

Total

Nº UCI

170

(92%)

1

1

2

6

3

26

4

24

5

42

6

71

1

0,59%

2

3,53%

3

15,2 %

4

14,1 %

5

24,7 %

6

41,7%

CHANGES IN THE MANAGMENT

OF CRITICALLY ILL PATIENT

LERN FROM

ERRORS

IMPROVEMENT

GOALS

COMUNICATION

IMPROVEMENT

FROM SURVEILLANCE TO PREVENTION

LESSONS FROM BZ

BUNDLE

SAFETY PROGRAM

ICU LEADERS

INSTITUTIONAL

COMINMENT

“NZ RZ” PROJECTS

“BZ” PROJECT

STRUCTURE PARTNERS NZ

SPECIFIC BUNDLE

http://blogs.21rs.es/corazones/2012/01/19/conversion-y-seguimiento/

BZ: ICUs PARTICIPATING

53

8 4

10 5

153

159

16 5

158 157158

16 316 616 7

171172173 174172 171

13 2

113111

10 410 1

9 9

11612 012 1

18 918 919 1

172

16 616 9

173176

16 9

18 418 8

19 0

2 122 0 9

2 0 7

18 7

17918 0177

173

16 5

16 0

16 7

16 1

2 0 3

19 8

19 3

177

16 016 4

157157

151152 151152

18 919 1

18 8

16 9

152

14 7

0

30

60

90

120

150

180

210

240

Jan 2009-Juny 2010 Jul-D 2010 2011 2012 2013 2014

N ICU 192 130 208 223 203 192

192

130

208

223

203192

0

50

100

150

200

250

n

2009-2010 Jl-D 2010 2011 2012 2013 2014

BZ NZ RZ

BZ: ICUs PARTICIPATING

HEALTH REGIONS PB RATES 2012- 2013

2,72

2,37

2,78

2,26

1,9

1,42

2,05

1,55

1,87

1,47

2,45

2,4

3,96

3,59

1,87

1,56

3,33

2,61

2,36

2,27

2,34

1,28

1,79

2,66

1,53

3,16

2,36

1,56

5,95

3

2,67

1,8

0 1 2 3 4 5 6

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

2013

2012

4,89

2,78 2,82,61

2,252,56 2,52

2,7

1,561,42

1,29 1,18

1,62

1,18

0

1

2

3

4

5

6

2008 E2009-

J2010

Jl-D 2010 2011 2012 2013 2014

Año

DI x 1

000 d

CV

C

PB BC

BZ

BZ RATES SUSTAINABILITY (BACTEREMIA ORIGIN CATHETER + UNKOWN ORIGIN)

HOSPITAL SIZE AND PB RATES

3,053,092,98

2,57

2,782,81

2,42,35

2,01

1,781,9

2,14

2,78

2,51

1,541,62

1,511,61

0

1

2

3

4

DI n

º B

RC

x 1

00

0 d

CV

C

>500 beds 201-500 <200 beds

BZ Jl-D 2010 2011 2012 2013 2014

1,5

1,7 1,64

1,461,33

1,24

0

0,5

1

1,5

2

2,5

2008 BZ 2011 2012 2013 2014

BZ: 1330 BSOF , 784.580 days of stay

2011: 863 BSOF, 527.414 days of stay

2012: 825 BSOF, 620.413 days of stay

2013: 789 BSOF, 541.943 days of stay

2014: 651 BSOF, 524.455 days of stay

BSI-Secondary to other Infection Sites

0

10

20

30

40

50

Subc Fem Yug Basil Axilar Otr

2009 2010 2011 2012 2013 2014

EPINE

ESTUDIO EPINE PREVALENCIA DE INFECCIÓN EN PACIENTES CRÍTICOS

37,2

26,8

30,7

24,05

32,9

25,3

28,7

22,41

0

5

10

15

20

25

30

35

40

%

2008 2009 2010 2011

Infect

Pts

EPINE STUDY

BACTERIEMIA PREVALENCE IN ICU

0,25

0,2 0,19 0,18

0

0,2

0,4

%

2008 2009 2010 2011

Time from ICU admission to onset of bloodstream infection

by country/network, 2008-2012 (n=26 815 BSI episodes)

Consider HCAI as an avoidable error,

is the first step to eradicate.

Surveillance is needed to quantify the

HCAI as to monitor the prevention

interventions.

BZ and NZ have promoted a culture of

safety, including training, teamwork

and implementation of guidelines and

bundles, which has helped to reduce

the risk.

Education, analysis and

dissemination of conclusions and

agreements, require technical and

financial resources