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2016/LSIF/FOR/012

Key Principles for Developing Sustainable, Results-Oriented and Scalable Partnerships in Infection

Prevention and Control - Experiences from Chinese Taipei

Submitted by: Chinese Taipei

Policy Forum on Strengthening Surveillance and Laboratory Capacity to Fight Healthcare Associated Infections and Antimicrobial

ResistanceHa Noi, Viet Nam

14-15 December 2016

Key principles for developing Sustainable, Results-oriented and

Scalable Partnerships in IPC Experiences from Chinese Taipei

Organization of Infection Prevention and Control Programs

Legislation, organization structure, Link with public health or other services

Surveillance Nosocomial Infections Surveillance System

(TNIS System) Guidelines & Toolkits

Domestic Campaigns Hand Hygiene,

Care Bundles to Prevent CLABSI, VAP, and CAUTI…

Framework of Economy-wide Infection Control Program in Chinese Taipei

External Inspection Hospital Accreditation, Nosocomial Infection Control Inspections…

2

Quality Improvement for Prevention and Control of

HAIs

Human Resources Education, Training… Research

Economy-wide Campaign to Combat HAIs

2010-2011 Hand hygiene

campaign

2013-2014 Central line

bundle

2013-2015 Antimicrobial stewardship

program

2015-2017 CAUTI bundle

and VAP bundle

4

Economy-wide Campaign on Hand Hygiene Goals

− Promoting healthcare workers to use alcohol-based hand rub (ABHR) for routine hand hygiene of non-soiled hands during caring activities

− Assuring the availability of ABHR at the point of care − Integrating “My Five Moments for Hand Hygiene” into daily work for healthcare

workers to improve compliance − Establishing the safety culture in hospitals

making continuous progress

Partnerships (Prototype)

Central

Planning Center

CDC of Chinese Taipei Center of Excellence for Hand Hygiene Joint Commission of Chinese Taipei Professional societies …

Local

Hospital leadership multidisciplinary team multiple units

6

Economy-wide Campaign on Hand Hygiene

• Certification of hospitals adopting proper hand-hygiene protocols –A total of 325 hospitals applied to participate.

Implementation of the economy-wide HH campaign resulted in significant increases in the availability of ABHR at point of care and the overall HH compliance. HH compliance rates steadily increased to 87.1% within 12 months after the start of economy-wide campaign.

• Establish the Center of Excellence for Hand Hygiene

– NTUH and KVGH were selected in the finalists of the Asia Pacific Hand Hygiene Excellence Award 2011– category for developed countries. After visits by 2 auditors from the expert review panel to the centers using the WHO Self Assessment Framework, NTUH was elected as the winner.

Economy-wide Campaign to Combat HAIs

2010-2011 Hand hygiene

campaign

2013-2014 Central line

bundle

2013-2015 Antimicrobial stewardship

program

2015-2017 CAUTI bundle

and VAP bundle

Partnerships Central

Planning Center CDC of Chinese Taipei Regional leading hospitals Joint Commission of Chinese Taipei Professional societies …

Regional

Regional Network 7 regions Leading hospital Participating hospitals (57 in 2013 and 103 in 2014)

Local

Hospital leadership multidisciplinary team multiple units

Hospitals Participating the Pilot Study Pilot Study • study period: 2011-2012 • main target: Implementation of central line insertion bundle

in ICUs • sponsored by CDC of Chinese Taipei, executed by the

Infection Control Society of Chinese Taipei

Hospital Level (No. of hospitals)

Before Intervention (2009/01~2011/10)

After Intervention (2011/11~2012/10) Reduction of

Infection Density

[(A-B)/A, %] CLABSI central line days

Infection density (‰) (A) CLABSI central line

days Infection

density (‰) (B)

Medical Center (10) 1,051 165,746 6.34 338 57,235 5.91 6.8

Regional Hospital (3) 135 36,255 3.06 29 12,886 2.25 26.5

Local Hospital (1) 6 3,282 1.83 0 941 0 100

Total (14) 1,192 205,283 5.81 367 71,062 5.16 11.2

Implementation of Central Line Bundle

9

Central Line Bundle

Insertion Bundle Maintenance Bundle

• Hand hygiene

• Maximal barrier upon insertion

• Appropriate disinfectant for skin antisepsis

• Optimal catheter site selection

• Daily review of line necessity

• Hand hygiene

• Dressing change

• Scrub the hub

• Tubing and devices change

Engagement

• Providing evidences and the progress around the world, making hospitals understand the project ‘s goals are compatible with organization’s goals, i.e. preventing HAIs and patient safety

• Establishing the multidisciplinary team, led by president or vice president of the hospital, sectors relevant to the project must be involved in the team

Education

12

Intra hospital

Within region

Economy-wide

e-learning & demonstration videos international conferences experience sharing and group competition

lectures & hand-on training

discussion with clinical units

OSCE/internal certification

bimonthly meetings timely discussion on-site coaching group building

& training resources sharing

Execution

13

Design drape with transparent window or specific tools to ease patient’s fear

No. of hospital

period Single drape

Combination of main drape and small drape(s)*

Both

2014/Q1 46 58 6

2014/Q3 64 42 4

*in Q1 of 2014, there were 5 hospitals using more than 3 drapes to cover patient from head to toe; till Q4 of 2014, all hospitals participating the project using ≤ 3 drapes

maximal barrier upon insertion sterile cover from head to toe use of a cap, mask, sterile

gown, sterile gloves

Execution

14

No. of hospital

period

CVC cart CVC package

YES NO YES NO

2014/Q1 62 48 82 28

2014/Q4* 84 26 91 19

CVC cart

Ensuring all supplies needed are available for use

*every hospital participating the project prepared either CVC cart (19) or CVC package (26) or prepared both of them (65)

Evaluation and Feedback

15

Internal & external auditing

workbook & checklist

Rewarding Performance award

• Leadership • Results of external audit • Completeness of checklists

and reporting of HAIs and denominator data to TNIS system

• Implementation measures • …

Innovative award • Tools, mechanisms, emblems,

publicity, micromedia, essays…

Medical Center

Regional Hospital

Local Hospital

CLAB

SI/1

,000

cen

tral

line

day

s (‰

)

2013-2014 Central Line Campaign

Annual rates of central line-associated bloodstream infections (CLABSI) per 1,000 central line days in ICUs for 2008-2015

Data Source：TNIS System

Infection density of CLABSI began to reverse downward

Tseng SH, et al. J Microbiol Immunol Infect (2014), http://dx.doi.org/10.1016/j.jmii.2014.04.001

Economy-wide Action Plan to AMR Antimicrobial Stewardship Plan

18

Domestic action plan –antimicrobial management project

VAP Bundle and CAUTI Bundle

VAP Bundle • Daily assessment of readiness to extubate

• Daily “sedative interruption”

• Elevation of the head of the bed (HOB) to 30º

to 45º unless medically contraindicated

• Daily oral care with chlorhexidine, at least

twice per day

• Empty condensation in tubing

CAUTI Bundle Insertion • Appropriate Urinary

Catheter Use • Clean hands before and

after insertion • Insert catheters using

aseptic technique and sterile equipment

• Properly secure catheter to prevent movement and urethral traction

Daily Care • Review Urinary Catheter

Necessity Daily • Hand hygiene • Properly secure catheter

and keep collection bag below the level of the bladder at all times

• Maintain a closed, sterile drainage system

• Perform routine daily meatal hygiene

Summary • Aforementioned partnerships among government, hospitals and

professional organizations were started with the characteristics of policy-driven and incentive-driven.

• Motives for working in partnerships could be referred to be project-oriented, organization-oriented or personal motives, whereas financial support, human resource support, effective leadership and the strong connection of regional network are important facilitators.

• Barriers to successful partnerships are numerous, limited resources and the belief that an organization can execute the project on its own might be the major reasons to keep hospitals from joining the project.