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Introduction of technology to reduce HAI’s and improve surveillance
Jeff Deane Clinical Nurse Consultant John Hunter Hospital 2016
Our area
• 900,000 people • 16,000 staff • 59 trained ICNET Users • 47 Infection Prevention
Nurses • 3 Administrators • 3 Super Administrators • 6 Reporting Users • 4 beginning training for SSI
Reporting
In the beginning
• Multiple worksheets – – Often incomplete – No standardised use of worksheet by staff – Worksheets kept and archived
• Multiple spreadsheets to document data – Inability of some staff to produce graphs of data
• Delays in compilation and analysis of outbreak data due to paper system requiring manual sorting
Prior to ICNet MRO worksheet (4 pages)
Sentinel Organism eICAT Event Sheet
PLEASE USE GUMMED LABEL IF AVAILABLE UNIT NUMBER
SURNAME: OTHER NAME: ADDRESS: DATE OF BIRTH: M.O.
Date of Specimen: Lab number: IIMS: Organism: MRSA
CMRSA sen
MRAB
eMRSA
VRE
C. difficile
CRE
M-ESBL
Cleared Date:________
Site: blood urine
respiratory rectal
faeces
wound/skin
screening
ICU Screening
device
Other
Acquisition: Healthcare-associated
HCA Ward
Transfer in _____________
Community
Other
New Isolate Previous isolate
Infection Colonised
Cohort
Date of Specimen: Lab number: IIMS: Organism: MRSA
CMRSA sen
MRAB
eMRSA
VRE
C. difficile
CRE
M-ESBL
Cleared Date:________
Site: blood urine
respiratory rectal
faeces
wound/skin
screening
ICU Screening
device
Other
Acquisition: Healthcare-associated
HCA Ward
Transfer in _____________
Community
Other
New Isolate Previous isolate
Infection Colonised
Cohort
PIMS Alert
Category 1 2 3 4 5 Set: ___/___/___ By: Removed: ___/___/___ By:
Category 1 2 3 4 5 Set: ___/___/___ By: Removed: ___/___/___ By:
Admission History
Date
Unit/Ward
Chair/ Bed
Disch Date:
Admission History
Date
Unit/Ward
Chair/ Bed
Disch Date:
Deceased Date: Cause of death:
S E N T I N E L
O R G A N I S M
S U R V E I L L A N C E
E I C A T
E V E N T
S H E E T
H NEA H S
PLEASE USE GUMMED LABEL IF AVAILABLE UNIT NUMBER
SURNAME: OTHER NAME: ADDRESS: DATE OF BIRTH: M.O.
PATHOLOGY REPORTS
Date Site Organism Date Site Organism
PATIENT COHORT
SURNAME: MRN: Date Site Result
OTHER NAME: ADDRESS: DATE OF BIRTH:
SURNAME: MRN: Date Site Result
OTHER NAME: ADDRESS: DATE OF BIRTH:
SURNAME: MRN: Date Site Result
OTHER NAME: ADDRESS: DATE OF BIRTH:
BSI worksheet
BLOODSTREAM EVENT NOTIFICATION Laboratory Lab. number
LMNC Pathology
Mayne-Laverty Pathology
New England Pathology
SydPath
HAPS
Attending MO (initial, surname) __________________________ MO Address/Fax number __________________
LABORATORY
First positive sample date ___/____/___
Enter organisms grown from positive sets (within 48 hrs)
Blood culture set 1 Set 2 Set 3
Organism 1
Organism 2
Organism 3 SIGNIFICANCE CRITERIA
Criterion 1 (recognised pathogens) Criterion 2 (potential contaminants in patients aged >1 year)
Criterion 3 (potential contaminants in patients aged <1 year) Contaminant (still report these please) Unknown (insufficient information)
ACQUISITION Healthcare-associated
Healthcare (inpatient> 48hr) Healthcare (non-inpatient) Maternally-acq (< 48hrs of birth)
Community-associated (Not healthcare-associated AND do not manifest more than 48 hrs after admission or within 48 hrs of discharge)
Nursing Home associated
Unknown(insufficient information) Relapse within 21 days Relapse within 3 months
FOCUS Specific Organ Site (specify below)
Line Associated (see over) (no documented other focus)
Unknown (insufficient information) Disseminated infection
Specific Organ Site (provide detail below) ICN Documentation
Cardiovascular (specify below) Ear, nose, throat GI tract including mucositis Hepatobiliary (specify type) Intra-abdominal (specify CAPD) Osteomyelitis (specify hardware) Wound infection (surgical)
Joint infection (specify prosthesis) CNS infection (specify device) Reproductive tract (specify type) Pneumonia (specify device) Skin / soft tissue (specify type) Urinary tract (specify IDC) Vascular infection (not line-assoc)
Auslab comments entered Validated by ID ICNET completed IIMs completed Yes / NA
IIMs No:___________________
Investigation Comments: Completed by: Date notified:
Patient Identification MRN
DOB:
Surname
Given Name
Address
Date admitted ___/__/___ Date discharged ___/___/___
Discharge outcome Home Transfer Died Ward at time of event:
Investigation
Other factors relevant to the onset & origin of the bacteraemia (Y or N in each of first 4 boxes)
Was there a deep abscess at the primary site of origin?
Was the patient neutropenic at the time of diagnosis (neutrophil count < 1000
Was there an invasive procedure < 48hrs previously related to the source (e.g. insertion CVC, biliary stent etc?
Was there a surgical site infection related to the source from a procedure in the previous 30 days e.g. hip wound?
If YES, name of procedure.
If YES, details of surgical site.
CLINICAL TREATMENT
Principal treatment (main agent used for the definitive IV treatment of SAB, i.e. after susceptibility results): Choose one only.
Not treated at all Daptomycin Moxifloxacin Benzylpenicillin/Amp/Amox Dicloxacillin Piperacillin-tazabactum Cephazolin/Cephalothin Flucloxacillin Teicoplanin Clindamycin/Lindomycin Linezolid Ticacillin-clavuanate Co-trimoxazole (Bactrim) Meropenem/Imipenem Tigercyline Vancomycin Gentamycin Other (specify)
OUTCOME @ 7 and 30 days
Outcome @ 7 days after collection of initial blood culture
Survived Outcome @ 30 days after collection of initial blood culture
Survived
Died Died
Unable to determine Unable to determine
CASE REVIEW OF RISK FACTORS & POTENTIAL PREVENTABLE FACTORS Co morbid conditions
Burns Diabetes Vascular disease
Chronic renal disease Immunocompromised (including non-steroid drugs, e.g chemo)
Relevant skin condition
Chronic respiratory disease Likely self-contamination (e.g.
confused pt, IVDU) Other relevant condition
(specify)
Chronic steroid use Previous S.aureus bacteraemia with same type
Complete this section if isolate was MSSA & MRSA
If MSSA & MRSA, has this type of S.aureus been isolated before?
What was the 1st date isolated, if known (year only if approximating) if applicable
If YES, had decolonisation been attempted?
Source of 1st isolate i.e. HCA, Community, NH
Site of original isolate? Has pt been isolated & Contact Precautions commenced?
Yes, single room No, on general ward Yes, cohorted
Complete this section if a device, including IV, was identified as the primary cause of the bacteraemia
What was the device?
Where was the device located?
Date of insertion (if unknown please state)
Was device removed? Include date Was the same type of S.aureus isolated from the device?
If the device was an IV line (PVL, CVL etc) what was the main indication (e.g. antibiotics, TPN, inotropes, chemo, dialysis, IV fluids etc)
If the device was not an IV, what was the main indication?
Was device left in longer than required? Was device left in longer than recommended?
SSI worksheet
Sentinel Surgical Procedure Surveillance Event Sheet Date admitted: ___/___/___ Date discharged: ___/___/__ Ward: Unit: Bed No:
Procedure Details Date: ___/____/_____ Surgical Specialty Theatre No
Start time:__________ End time: __________ Duration of procedure: hrs mins
Procedure code: _____________(ICD 10 code) Procedure
ASA score: (*Unknown) 0*
1
2
3
4
5
Wound Class 1
2
3
4
Consultant: Primary Surgeon:
Anaesthetic Type GA Spinal/Epidural Local Other
Implant Unplanned/emergency
Prophylactic antibiotic
Antibiotic 1:____________________________ Antibiotic 2:____________________________ Antibiotic 3:
Surgical Site Observation Date seen Codes Comments
1. ___/___/___ AFE HAE
2. ___/___/___ CLE SRE
3. ___/___/___ INT SWE
4. ___/___/___ NOO RED
5. ___/___/___ FEB TEN
6. ___/___/___ SOZ DEH
7. ___/___/___ MOI SLO
8. ___/___/___ SER PUS
9. ___/___/___ HSE RTT
10. ___/___/___ BRU HEA
Outcome Inhospital wound infection Post-discharge wound infection Date: ___/___/___
No infection superficial incisional deep incisional organ space infection -
specify:
Surgeon diagnosis Pain/tenderness Heat Localised swelling Purulent drainage Surgeon re-opens Redness
Fever >380C Culture negative, pt on antibiotics Spontaneous dehiscence Organism aseptically obtained Abscess or other evidence of infection Lab confirmation
Site of SSI primary Secondary Both Stab wound
Infective Organism Organism 1:____________________________ Organism 2:____________________________ Organism 3:
Post discharge survey response Date: ___/___/___
Record complete
Comments:
Data entry complete
Patient Identification
Medical Record Number
Surname:
Given Name: Address:
Phone: Post Code:
DOB: ____/____/_____ Sex:
Version 2.2 for HISS
Oct
MRN SURNAME
FORENAME
URGENCY_DESCRIPTION
PROCEDURE_CODE
SURGERY_START_DATE
SURGERY_COMPLETE_DATE
ASA_SCORE_DESCRIPTION
ANAESTHETIC_1_DESCRIPTION
SURGICAL_CONSULTANT_SURNAME
SURGEON_OPERATING_SURNAME
THEATRE
Planned 4932400 ######## ######## ASA 3 Not Specified
Harrington
Harrington RNCORA
Planned 4932400 ######## ######## ASA 4 General Gill Gill RNCORA
Planned 4932400 ######## ######## ASA 2 Epidural/Spinal Hellman Hellman RNCORB
Implementation – a brief history • 2012
– ICNet purchased – Large amount of background work (IPN 1 day per week)
• Configuring hospitals / wards • Auditing pathology & pt information system imports • Cleaning up of current pt alert system
• 2013 – Face to face & WebEx education of staff – Feb - Live across all facilities – May - Follow up training sessions – Sept – Development of facility specific reports – Update of computers to support Google Chrome
Implementation • 2014
– June – site visit to RMH – Laptops provided – Project officer employed – HNE specific user guide developed – Oct - Workshop conducted
• Pre & post knowledge quiz • Inservice on user issues • Scenarios for users
• 2015 – Further refining of ICNet to suit our needs – Facility visits by project officer
ICNet implementation ICNet program IPN requirements – flesh it out
Facility implementation the road to success
Barriers to our success • Lack of planning re what IPNs wanted built into system
• Lack of implementation strategy
• Underestimation of geographical area & variety of facilities
• Varied computer literacy amongst users
• Interpretation of guidelines between users
• Frequent changes being made to ICNet during implementation phase
• Poor communication to users regarding changes
• Inconsistent data entry by users
Barriers to our success • Limited understanding of ICNet & its benefits • Reluctance of users to use ICNet as their primary
source of information e.g. an audit identified only 64% logged in when rostered the previous week
• Staff continued outdated, labor intensive work practices
• Lack of accountability for users • Often staff complain that it takes more time and is
becoming too complex • Lack of follow up and continual review with IPNs
Are we there yet?
ICNet
Ignore it, continue reporting unreliable data & fall behind
Increased workload using ICNet
Standardised team approach producing valid data & streamlined reporting
Implementing change successfully - Did we? (Kotter model)
– Create urgency • What currently wasn’t working • What were the opportunities • Buy-in from users
– Form a coalition • Change team continued to build urgency & momentum around
need for change – Create a vision for change
• Everyone understood what we were trying to achieve • Formalised strategy
– Communicate the vision • Talked about it often to users • Addressed staff concerns / issues • Applied aspects of operation from training to performance reviews
Implementing change successfully – Remove obstacles
• Staff resistance • Rewarded/acknowledged for making change happen
– Create short term wins • Celebrated quick wins that staff could see • Created short-term targets
– Build on the change • Identified what's working & what needs improving • Set goals
– Anchor the change into the culture – Continued support for the change – Acknowledged staff for their contributions – Communicated progress – Included in training
Things to consider
ICNet
Facility technology
Facility staff Data requirements
Things to consider
• Facility technology – Is your patient management systems & pathology
systems compatible – Do you need laptops or computer upgrades – Have you got the latest software eg Chome or IE
• Data – Identify statutory and facility reporting requirements – Clearly identify wards / pt locations / theatres – Regularly run “missing data” reports
Things to consider
• Staff requirements – Computer experience – User group meetings prior to implementation & then
periodic – Development of local user guide – Nominate a local ICNet support person – Workshop including small group work & practicals – Staged implementation if multi site – Follow up visits by support person to individual staff – Consult with & communicate changes to users
How to make it work • Plan – formal implementation plan
– Who - needs to be involved – What - needs to be done – Where – one facility or multiple roll out – What is the facilities data reporting needs – What data you want / need to collect
• Staff – Appoint a project person from the start – User needs and capabilities determined – Education, education, education – Develop a troubleshooting question & answer file that staff
can access
How to make it work
• Communication – Consultation re proposed and actual changes – What's working, what's not – Regular follow up with users – Celebrate small wins
• How could we have done it better? – we could have utilised the principles of change
management
Current Information Flow
IPM AUSLAB
Micro data ADT
ICNet
Infection Prevention
Alerts
Medication
SABs AB Stewardship Scope sterility testing SSI re-admits
Surveillance Officer role
Current • System configuration • Development of reports and
alerts • Testing changes & updates • Auditing data • User support • User training • User guide maintenance
Possible Future • As per current • BSI, SSI & C Diff data
analysis & investigation (liaising with IPN)
• Collation of HNELHD reports for local and state reporting bodies
Surveillance
• Improved compliance across our 42 facilities. • Ability to accurately benchmark with like facilities. • Universal access to reporting for NSW Health,
National Indicators, ACHS and regional KPI’s. • Numerator and denominator data. • Systematic collection, analysis and interpretation of
data. • Prevention and control programs aimed at reducing
HAI’s benefit from ICNET surveillance, thus providing safe and quality services.
Data Highlights
• Summarise HAI rates at meetings instantly • Improved graphics and readability • Specifically targeted searches i.e MRO or
facility ward. • Everything in one spot i.e. line days, patient
records, colonisations, infections, KPI’s, SSI’s, CLABS, letters, contact tracing
• No more multiple excel/word documents
Reporting
Reports
XP’s
XPs & Bundles
Tasks
Bundles
Letters
Thanks