APIC Greater NY Chapter 13 - PowerPoint Presentation

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APIC Greater NY Chapter 13

Journal Club Session

April 20, 2016 by Brenda Denneny RN BSN MBA

Infection Prevention and Control

Department

Montefiore-Wakefield Campus

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CDC interventions show sustained success for outpatient hemodialysis infection preventionA new study by the U.S. Centers for Disease Control and Prevention (CDC) shows that decreases in certain bloodstream infection (BSI) rates can be maintained through the use and implementation of CDC dialysis BSI prevention tools. The new study reported a 44 percent drop in access-related bloodstream infections (ARBSI) and estimated more than 60 percent of expected ARBSIs may have been prevented over the four year period among dialysis patients treated at facilities using the CDC’s Core Interventions for Dialysis BSI Prevention as part of a collaborative project.

(APIC eNews <communications@apic.org sent Feb 17, 2016)

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CDC Approach to BSI Prevention in Dialysis Facilities(i.e., the Core Interventions for Dialysis BSI Prevention)Surveillance and feedback using NHSNHand hygiene observationsCatheter/vascular access care observationsStaff education and competencyPatient education/engagementCatheter reductionChlorhexidine for skin antisepsisCatheter hub disinfectionAntimicrobial ointmentPovidone-iodine (preferable with alcohol) or 70% alcohol are alternatives for patients with chlorhexidine intolerance

If closed needleless connector device is used, disinfect connector device per manufacturer’s instructionsSee information on selecting an antimicrobial ointment for hemodialysis catheter exit sites (selecting an antimicrobial ointment). Use of chlorhexidine-impregnated sponge dressing might be an alternative

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Higher Non-tunneled Tunneled Other LowerInfection Central Central Access InfectionRisk Lines Lines Devices Risk• Non-tunneled central line: a central venous catheter that is fixed in place at the point of insertion and travels directly from the skin entry site to a vein and terminates close to the heart or one of the great vessels, typically intended for short term use

.• Tunneled central line: a central venous catheter that travels a distance under the skin from the point of insertion before entering a vein, and terminates at or close to the heart or one of the great vessels (e.g., Hickman® or Broviac® catheters).GraftFistula- ButtonholeOther access devices: includes catheter-graft hybrid vascular access devices, ports, and any other vascular access devices that do not meet the above definitions. Do not use this field to report vascular accesses that are grafts, central venous catheters, or fistulas. Do not use this field to report peritoneal dialysis accesses. (Catheter-graft hybrid)

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Infection Control & Hospital Epidemiology- February 2016http://dx.doi.org/10.1017/ice.2016.22Downloaded Concise Communication from Cambridge Journals on March 28, 2016Sustained Infection Reduction in Outpatient Hemodialysis Centers Participating in a Collaborative Bloodstream Infection Prevention Effort

Sarah H. Yi, PhD;i AlexanderJ. Kallen,MD, MPH;iSallyHess, MPH, CIC;2Virginia R. Bren, MPH, RN, CIC;3Mary E. Lincoln,MHA,BSN;4Gemma Downham, MPH,CIC;5Karen Kelley,MHA,BSN,RN, CNN;6Stephanie L.Booth, CCHT-A;6Heather Weirich, BSN,RN, CNN;7AliciaShugart, MA;i

Christi Lines,MPH;iAnna Melville,MA,RD;l John A. Jernigan, MD, MS;iDavid G. Kleinbaum, PhD;i,8Priti R. Patel, MD, MPHi

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An analysis of 17 outpatient dialysis facilities in this Collaborative following implementation of a bundle of BSI preventionsReductions in overall BSI and Access-related BSI (ARBSI) incidence rate improvements were observed immediately and sustained for up to four years.Most of the decrease was identified soon after the implementation with reductions sustained through a 15-month periodArticle Goal: to re-evaluate the effect of the interventions using additional dataInvestigate the sustainability of the initial observed reductions during an extended period up to four years.

Overall, BSI incidence remained unchanged from baseline in the current analysis

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Hemodialysis Collaborative – ICHE Feb 2016MethodsEvaluation Period: overall spanned Jan 2009-Dec 2013 Baseline period = first year of data start of Jan 2009Intervention time frame began January 2010-Mar 2011 = “early intervention” period of 15 monthsFor this report: data collection through Dec 2013

“later intervention” period of 48 months. Collaborative:Last in-person meeting occurred Nov 2011Monthly educational conference calls reduced to quarterly starting March 2012Catheter hub disinfection upon connection or disconnection of CVCs was an intervention added in May 2011.

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Hemodialysis Collaborative – ICHE Feb 2016Methods (continued)Outcomes:BSI and ARBSI incidence rates were defined per NHSN Dialysis Event Protocol. “BSI is a positive blood culture from a hemodialysis patient as an outpatient or within 1 day after hospital admission”“ARBSI is a BSI suspected positive blood culture source is the vascular access or otherwise

uncertain”Outcome was stratified into 2 vascular access groupings:AV fistulas and graftsTunneled and non-tunneled CVCsIncidence rates reported per 100 patient monthsData restricted to facilities that reported using the monthly reporting plan showing intent to follow the protocol

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Hemodialysis Collaborative – ICHE Feb 2016Methods (continued)Analytic and Statistical Data:Effect of interventions - using the same segmented regression model consistent with the original model, the effect of interventions was re-evaluated with the additional baseline and intervention data

to estimate the baseline rate trendto estimate the level change after the intervention startto estimate the difference between the two trendsand the intervention rate trend was then quantified for the first and third trends above. (*see Table 1 of the last 2 slides for reference)Sustainability of effect - the early and later intervention periods were compared to assess the sustainability of the initial rate reduction. Two time-dependent variables were added to the original model:estimating the rate level change for the later intervention periodestimating the # of months since the start of that period estimating the difference in monthly rate trends between time periods. (*see Table 2, the last reference

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Hemodialysis Collaborative – ICHE Feb 2016Additional Data:Since the prior report, 60 months of baseline and 3 months of intervention data had been reported to NHSN without reporting plans. The data had been verified as collected per protocol under a reporting plan. The participating facilities then entered the reporting plans, and previously excluded data were incorporated into the present analysis.

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Hemodialysis Collaborative – ICHE Feb 2016Methods (continued-final)Model Specifications:Segmented regression models with the number of BSIs or ARBSIs as the outcome effect offset by patient monthsThe analysis involved longitudinal data for multiple facilities,clustering was considered:Within-facility correlation of errors over time

Variation between facilities in baseline ratesDue to the small number of clusters (in 17 facilities) and to safeguard against choosing the wrong correlation, Standard Errors were calculated using Morel, Bokossa, and Neerchal (MBN ) sandwich estimator. Data analysis used 9.3 SAS version

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Hemodialysis Collaborative – ICHE Feb 2016ResultsFacility Characteristics:Facilities reported a median of 12 baseline months (range, 0-12) and 48 intervention months (range, 43-48)1 facility had a 5-month baseline gap in reporting due to temporary closureBaseline data was available for 15 facilities Complete data was available for 12 facilities

Main Results:Unadjusted pooled mean BSI and ARBSI rates (both overall and stratified) decreased from the baseline to the intervention period

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Hemodialysis Collaborative – ICHE Feb 2016Results (continued)Other Analyses:Effect of Intervention-ARBSI rates dropped by 44% (p=0.005) overall and 49% (p= 0.002) in the CVC stratum immediately following the start of the intervention period.No changes in the modeled BSI rates were detectedSustainability of effect- No immediate changes were seen in BSI nor ARBSI rates, overall or in either stratumIn addition, the later intervention period rate trend did not statistically differ from the early intervention period rate trend overall, or in either stratum.

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Hemodialysis Collaborative – ICHE Feb 2016DiscussionBased on the overall baseline rate (1.03 ARBSIs per 100 patient months, and a denominator of 46,351 patient months in the intervention period), an estimated 286 of 477 expected (60%) were prevented during the 48-month intervention periodThis finding supports the effectiveness of the interventions and the sustainability of the reductions even after technical assistance from the CDC ended.The Collaborative included CHG for Catheter exit care and adherence to catheter “scrub-the-hub”)This lends support that reductions in CVC-related BSIs among patients undergoing hemodialysis are both achievable and sustainable.

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Hemodialysis Collaborative – ICHE Feb 2016Discussion (continued)While overall BSIs decreased significantly in the previous analysis, the reduction was not significant in the current analysis due to several changes:reduction in precision using the MBN instead of the classic sandwich standard error estimatoradditional data included for certain facilitiesadditional intervention period months for all facilitiesImprovements associated with the intervention implementation were not observed in the fistula-graft stratum as the collaborative interventions focused on the CVCs

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Hemodialysis Collaborative – ICHE Feb 2015Discussion (continued)Limitations of the analysis5 of the 17 lacked some or all data from the baseline periodsInformation was lacking on the level of adherence to specific interventions within the individual facilitiesAn interrupted time series study design without a control group is limited in the capacity to infer a causal relationship between the implementation of a bundle of BSI prevention interventions and changes in BSIs and ARBSIsThe “consistency in the findings of this and the initial study suggest the reported findings are accurate.” A study by

Penfold and Zhang from the Academy of Pediatrics 2013 and was end-noted on the Use of Interrupted Time Series Analysis in evaluating health care quality improvement (yes, In the early intervention period )

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Hemodialysis Collaborative – ICHE Feb 2016Discussion (Conclusion)“BSIs in hemodialysis patients are preventable through implementation of and adherence to recommended prevention practices focused on catheter care. Moreover for dialysis providers and patient safety advocates, these improvements can be maintained for multiple years after adoption.” I strongly agree mostly due to heightened diligence in performing the interventions used in this study which is now included in NHSN Preventive Process Measures Dialysis protocol.By complying with the required number of observations to each checklist provided in the protocol, heightened awareness of the provider being observed, with a reportable tool, also enhances patient teaching. Everyone wins!

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Continued Quality improvement efforts in BSI prevention in DialysisLocally:IPROs Quality Improvement Activity (QIA) to “improve HAIs in Dialysis by implementing surveillance audits at the facility level for cannulation, catheter connection/disconnection, and hand washing.The goal was to have the minimum number of audits of each type on a monthly basis using the observation tools provided. The data was entered into NHSN each month April through October of last year with reporting through November. The key activities for this project were

to perform the audits on a monthly basis for the facility. The final webinar in October showed minor improvement in BSI rates Yet our Dialysis Leadership decided to continue reporting, adding tools/checklists, and standardizing practice facility-wide.

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ESRD Network of New York – QIA HAI ProjectAuditors will be required to complete the following three audits (see tools links):1) A minimum of 30 HAND WASHING opportunity observations2) A minimum of 10 CATHETER CONNECTION AND/OR DISCONNECTION observations3) A minimum of 10 CANNULATION OBSERVATIONSUsing the following Tools and Checklists

:CDC Recommended Interventions to Prevent Bloodstream Infections in Dialysis Settings: http://www.cdc.gov/dialysis/prevention-tools/core-interventions.html CDC recommended checklists: http://www.cdc.gov/dialysis/prevention-tools/index.html

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ResultsThe observation sheets were reviewed for accuracy with the associates. The IP Dialysis leadership voluntarily added another Process MeasureHemodialysis Exit Site Care was added to the reporting plan in NHSNData was reported monthly to by S. Goldberg, QIC IPRO and stored in Cypress Web

The remaining PPMs are now required in the 2016 NHSN Dialysis PPM ProtocoI:Dialysis Station Routine Disinfection Observations (10)Injection Safety Medication Preparation Observations (10)Injection Safety Medication Administration Observations (20)

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Ongoing..Collaboratives like the two described today add to the ownership and accountability of dialysis providers to reduce the “second most common cause of death in end-stage renal disease patients accounting for 14% of deaths – infections.”Benefits of a Collaborative approach reinforces the recognition and dissemination of good ideas and standardizes practice based on evidence among the dialysis communityQuality improvement studies in Dialysis have stirred NHSN exponentially in the last 2-3 years in the development of education materials for dialysis providers and patients. CEs are offered in the training modules which have been developed. The NHSN dialysis website has become very rich in training with supportive tools/checklists for providers and reporting plans. The first SIRs have been allocated for 2015 and are in still a WIP for reporting.

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…my OutcomesThe reporting was accurate and well received by the associatesDialysis policy on catheter care was revised by dialysis leadershipThe denominators of TCL of total patients decreased in April of 2016 to 8% from 12% in April of 2015 (year-to-date) in our outpatient setting Learning Network have collaborated with IP in incorporating these checklists/tools in their competency training with DLCLABSI task force facility-wide recognizes dialysis catheters in overall CLABSI

rates. Dialysis catheter products are expanding (i.e., lumen size, 2L Palindromes) and so are opportunities for non-dialysis staff to access these lines! IR has joined the task force.Dialysis discussions continue to be part of the formal IPC monthly committee minutes and Surveillance PlanMore quality improvement studies in dialysis need to be generated with the increasing number of patients with ESRD.

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TY APIC Greater NY Chapter 13Thanks to the mentoring by the infamous Steven Bock!Thanks to the prompting and persistence of our fearless chapter President-Elect, Dr. “Bisi” Adeyeye!Allowing me to bring to you a topic that’s rapidly growing and sharing its piloting of Preventive Process Measures in 2015In addition, Dr. Yi (lead author) conducted a webinar following and offered her email for further questions sarahyi@cdc.govThanks again for awarding me the Professional Development Award for 2014

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