Quality improvement project

QUALITY IMPROVEMENT (QI) PROJECT

By Kiara Ramirez, Nancy Sladutto, Simona Krstevska,

Stefania and Sara Dahan

Improving the increase of nosocomial infections in the critical care unit

Define Goals and Objectives (Kiara)

Nosocomial infections are infections that have been acquired in a hospital setting, the pathogens that are often associated are bacteria, viruses and fungal parasites. These infections account for roughly 7-10 percent in developed and developing countries. The most common way of these types of infection is by the usage of catheters which cause CAUTI (catheter-associated urinary tract infection), central-line associated in bloodstream infections, surgical site infections, and ventilator associated pneumonia. According to the WHO around 25 percent of patients will have suffered at least one type of a nosocomial infection. “The most vulnerable patients are in Intensive Care Units (ICUs), burn units, undergoing organ transplant and neonates. According to Extended Prevalence of Infection in Intensive Care (EPIC II) study, the proportion of infected patients within the ICU are often as high as 51%.(J.L. Vincent) ”. The definitive goal is to reduce the percentage of nosocomial infections that occur in the clinical setting.

The primary objectives in reducing the increase of nosocomial infection rate in critical care units begin with implementing an effective and efficient infection control program, an antibiotic control policy, renewing information on antimicrobial and its resistance, and constant surveillance of implementation of policies. All persons in the clinical setting are responsible for taking action on the policies, not only to provide safety for the patients but for everyone in the setting as well. Secondary objectives is to focus on the environmental impact of nosocomial infections as well, and what is needed to make sure that environmental safety for the patient is regularly cleaned and checked constantly, what policies can be issued to prevent an increase of these infections.

Clinical Goals (Kiara)

As stated in the objectives, the clinical goal is to decrease the amount of nosocomial infections in the critical care units, this is primarily held by instilling an infection control program and revising it to improve its effectiveness.

Infection Control Program:

Establishing an infection control program begins with training and educating the staff how to properly follow regulations and provide safe infection control measures to protect the patients from nosocomial infections and protect the staff as well from transmitting any bacteria, viruses, or fungal infection amongst themselves. The infection control program should include the basics as per the CDC (Centers for Disease Control and Prevention) hand washing being the top tier of the program, should be performed “Immediately before touching a patient, Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, Before moving from work on a soiled body site to a clean body site on the same patient, After touching a patient or the patient’s immediate environment, After contact with blood, body fluids, or contaminated surfaces, and Immediately after glove removal. (Hand Hygiene Guidance.)” All facilities should follow the CDC recommendations, facilities should also ensure that all the required to follow proper hand hygiene is available to all personnel.

Second tier of the infection control program is ensuring proper patient placement, especially in critical care units patients are a lot more susceptible to nosocomial infections ensuring there are proper patient placement prevents from anymore infections to occur, by categorizing patient appropriately if they need contact, droplet, or airborne precautions and following the proper protocol within those precautions. It's recommended to “limit transport and movement outside of the room to medically-necessary purposes. When transport or movement is necessary, cover or contain the infected or colonized areas of the patient’s body for droplets and airborne precaution make sure the patient has a mask on as part of Respiratory Hygiene/Cough Etiquette make sure . Remove and dispose of contaminated PPE and perform hand hygiene prior to transporting patients on Contact Precautions.(Transmission-Based Precautions.)” Facilities are to provide PPE (Personal Protective Equipment) which includes gloves, gowns, goggles, masks, and face shields.

Environmental safety is another key to infection control, making sure that staff follows proper protocol in cleaning and disinfecting patient rooms, patient care equipment, devices, and instruments. Handling of textiles and laundry is also fundamental to know since they can be soiled with blood, stool, urine or other bodily fluids, important to establish a protocol on how to handle to ensure patient and staff safety. Also educating staff of proper injection practices and educating them about OSHA standards and what to do if needle-stick injuries and proper placements of syringes and medications.

Antibiotic control program:

Establishing an Antibiotic control program ensures that doctors do not over prescribe antibiotics to patients as it can cause more harm than good. A lot of nosocomial infections “such as MRSA or a multidrug-resistant Gram-negative bacteria are the cause of high incidence rates of nosocomial infections worldwide (WHO) ” Most of the time they start becoming resistant to antibiotics it is because patients begin to self medicate themselves with the antibiotics, or doctors are prescribing an incorrect dosage to the patient where the dosage may be to high for the patients body, and prolonged usage of the antibiotics, because of these reasons it threatens the effective control against bacteria that causes UTI, pneumonia and bloodstream infections (Khan, Hassan Ahmed).

Implementing an antibiotic control policy is to contain an infection before it gets worse, the antibiotic will come hand-in-hand with the the infection control program but re-educating doctors and staff on the usage of antibiotics such as correct medication and dosage so resistance is decreased and effectiveness is increased instead of vice versa. Most hospitals have implemented this program to collect information on how effective it is and hope to see future data that shows a decrease in nosocomial infection and or a decrease of resistance of antibiotics.

As stated previously surveillance is key to all implemented programs and policies in overcoming the increase of nosocomial infections in critical care units. With infection control programs constantly being reviewed and updated it is a key component into decreasing the rate of infections, and the constant surveillance on antibiotic usage is important for future data to overcome the resistance of antibiotics. These programs are not only beneficial to patient care safety, but are also beneficial to hospitals and their critical care units by being efficient and effective. In the sense of pushing forward with these programs it will decrease the costs.

Data Collection and Analysis (Stef)

Frequency (Simona)

Identify Opportunities for Improvement (Stef)

Process to Apply Interventions for Improvement / Implementing a QI plan (Nancy)

As stated in the objectives, the reason for implementing a QI plan for decreasing the amount of nosocomial infections in the critical care units, is to keep patients and healthcare workers safe. In order to be successful in implementing a quality improvement plan a process of identifying organizational problems and solving them has to be done first. Knowing that nosocomial infections are transmitted through one of three pathways is very important. Knowing which pathway is the most common form of transmission is going to play a huge factor in implementing a new plan to keep people safe. The three main pathways are through: air, surface, and water, and all will have their own plan of action in order to reduce the spread of transmission.

Implementing a plan to control and prevent airborne infections:

The importance of good air quality in controlling and preventing airborne infections in healthcare facilities is one of the most important plans to implement. Providing clean filtered air and effectively controlling indoor air pollution through ventilation are two key aspects of maintaining good air quality. The control of air pollutants such as, microorganisms, chemicals, dust, and smoke, at the source is the most effective way to maintain clean air. Filtration is the physical removal of particulates from air. It is the first step to achieving acceptable air quality indoors. These filters will be placed in all areas of the hospital.

Implementing a plan to keep surfaces clean:

Although infection caused by airborne transmission poses a major safety problem, most infections are now acquired in the hospital via the contact pathway. Microbiologically contaminated surfaces can be reservoirs of pathogens. However, these surfaces are generally not associated with the direct transmission of infection to patients or staff. Most of these infections come from healthcare workers not washing their hands as often as they should and transmitting germs from one patient to another. Educational programs have not been the most successful in increasing handwashing compliance among healthcare workers. Even intensive education or training programs produce only minimal increases in handwashing. Some more effective ways to implement handwashing:

· Establish ongoing monitoring and feedback on infection rates, such as tracking endemic and emerging drug resistant pathogens

· Create a multidisciplinary design and response team led by a senior administrator to emphasize that the organization is committed to hand-hygiene compliance.

· Ensure hand-hygiene resources are accessible throughout the organization, including patient care corridors and at the entrance and exit of patient rooms.

· Provide reminders throughout the healthcare setting.

· Develop an ongoing monitoring program that includes feedback. Some organizations, the report said, post monthly compliance data on hospital units or their hospitals' Web sites and discuss the findings with staff during meetings.

Implementing a plan to control waterborne infections:

Waterborne infections spread through direct contact, ingestion of contaminated water, indirect contact, and, inhalation of aerosols dispersed from water sources. Inhalation of aerosols from water sources that are contaminated, may cause a respiratory illness called Legionnaires’ disease—a multisystem illness with pneumonia, especially among immunosuppressed patients (e.g., transplant patients, cancer patients), immunocompromised patients (e.g., surgical patients, patients with underlying chronic lung disease, dialysis patients), elderly persons, and patients who smoke. An important aspect of preventing contamination through the water supply involves designing the water supply system to minimize stagnation and back flow as well as provide temperature control to prevent growth of bacteria. Regular maintenance and inspection of water in holding tanks is also highly recommended. Legionella enter healthcare facilities most often through aerosols generated by cooling towers, showers, faucets, respiratory therapy equipment, and room-air humidifiers. To prevent growth of Legionella and other bacteria in the water system, healthcare facilities are required to maintain cold water at a temperature below 68ºF and hot water at a minimum temperature of 124ºF. F. In addition, other methods, such as chlorine treatment or copper-silver ionization and UV light, may be used to treat water that is distributed in healthcare facilities. Some other ways to keep water clean and reduce the spread of infection:

· Keep the water temperature cool to cold and avoid the use of submerged lighting.

· Perform routine fountain cleaning and maintenance in accordance with manufacturer’s instructions.

· Avoid placing water fountains in areas that house high-risk patients.

· Install a glass barrier or maintain an appropriate distance between the water feature and the general public to minimize potential contact with droplets or aerosols.

Implementing antibiotic control plan

Antibiotics have transformed the practice of medicine, making once lethal infections readily treatable and making other medical advances, like cancer chemotherapy and organ transplants, possible. Prompt initiation of antibiotics to treat infections reduces morbidity and saves lives. However, about 30% of all antibiotics prescribed in U.S. acute care hospitals are unnecessary. Patients who are unnecessarily exposed to antibiotics are placed at risk for these adverse events with no benefit. The misuse of antibiotics has also contributed to antibiotic resistance, a serious threat to public health. The misuse of antibiotics can adversely impact the health of patients who are not even exposed to them through the spread of resistant organisms. Some ways to implement an antibiotic control plan:

· Tracking: Monitor antibiotic prescribing, impact of interventions, and other important outcomes like C. difficile infection and resistance patterns.

· It is important for hospitals to electronically submit antibiotic use data to the National Healthcare Safety Network (NHSN) Antimicrobial Use (AU) Option for monitoring and benchmarking inpatient antibiotic use.

· Reporting: Regularly report information on antibiotic use and resistance to prescribers, pharmacists, nurses, and hospital leadership.

· Education: Educate prescribers, pharmacists, and nurses about adverse reactions from antibiotics, antibiotic resistance and optimal prescribing.

Annual Evaluation and Work Plan Development (Sara)

Works Cited

Khan, Hassan Ahmed, et al. “Nosocomial Infections: Epidemiology, Prevention, Control and Surveillance.” Asian Pacific Journal of Tropical Biomedicine, No Longer Published by Elsevier, 7 Jan. 2017, www.sciencedirect.com/science/article/pii/S2221169116309509.

J.L. Vincent, J. Marshall, E. Silva, A. Anzueto, C.D. Martin, R. Moreno, et al.

International study of the prevalence and outcomes of infection in intensive care units

WHO. "Global action plan on antimicrobial resistance." (2015): 1-19.

“Standard Precautions for All Patient Care.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 26 Jan. 2016, www.cdc.gov/infectioncontrol/basics/standard-precautions.html.

“Hand Hygiene Guidance.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 30 Jan. 2020, www.cdc.gov/handhygiene/providers/guideline.html.

“Transmission-Based Precautions.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 7 Jan. 2016, www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html.

Collins, A. (n.d.). Preventing Health Care–Associated Infections. Retrieved January 03, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK2683/

Core Elements of Antibiotic Stewardship. (2019, August 15). Retrieved January 03, 2021, from https://www.cdc.gov/antibiotic-use/core-elements/index.html

Mehta, Y., Gupta, A., Todi, S., Myatra, S., Samaddar, D., Patil, V., . . . Ramasubban, S. (2014, March). Guidelines for prevention of hospital acquired infections. Retrieved January 03, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963198/

Mulero, A. (2015, July 21). An 8-step strategy to improve hand-hygiene compliance. Retrieved January 03, 2021, from https://www.fiercehealthcare.com/healthcare/8-step-strategy-to-improve-hand-hygiene-compliance