Connie Steed, MSN, RN, CICDirector, Infection Prevention

1.Discuss whether an Infection Prevention and Control (IPC) committee is required by guideline and regulating agencies.

2. List characteristics of a successful IPC meeting.

3. Identify at least 2 strategies to facilitate engagement and attendance by IPC committee members.

4. Discuss what kind of data and information should be presented at IPC committee meetings.

Do you have to have one?

Interpretive Guidelines §482.42(a)(1) The infection control officer or officers must develop,

implement and evaluate measures governing the identification, investigation, reporting, prevention and control of infections and communicable diseases within the hospital, including both healthcare–associated infections and community-acquired infections. Infection control policies should be specific to each department, service, and location, including off-site locations, and be evaluated and revised when indicated. The successful development, implementation and evaluation of a hospital-wide infection prevention and control program requires frequent collaboration with persons administratively and clinically responsible for inpatient and outpatient departments and services, as well as, non-patient-care support staff, such as maintenance and housekeeping staff.

Standard IC.01.01.01 Identifies the individual(s) responsible for

the infection prevention and control ( IPC) program

Standard IC.01.02.01Leaders allocate needed resources for IPC

program. Standard IC.01.03.01Identifies risk for acquiring and

transmitting infections. …input from at minimum IP personnel,

medical staff, nursing and leadership

Standard IC.01.03.01Identified risks for transmitting infections. Standard IC.01.04.01Based on identified risks, the hospital sets

goals to minimize the possibility of transmitting infections.

Standard IC.01.05.01Has and infection prevention and control

plan…Hospital components and functions

integrated into the IPC activities. …Methods for communicating

responsibilities and reporting data.

Standard IC.01.06.01Prepares to respond to influx of

potentially infectious patients Standard IC.02.01.01Implements IPC planStandard IC.02.02.01Reduces the risk of infections

associated with medical equipment, devices and supplies.

IC Standard.02.03.01 Works to prevent the transmission of

infectious disease among patients, licensed independent practitioners (LIPs), and staff.

IC Standard.02.04.01Offers vaccination against influenza to LIPs

and staff. IC Standard.03.01.01Evaluates the effectiveness of IPC plan …Are findings communicated at least

annually to the individuals or interdisciplinary group that manages the patient safety program?

Not necessarily!!! But… There needs to be a means to, in a collaborative fashion, report, analyze, and make decisions specific to the IPC program.

Various committees are used: e.g. Quality Management, Medical

Care, Safety committees Need to be able to prove interdisciplinary

work/ communication and integration… Minutes—document your activity.

CultureOrganizational structureSize and complexity

Reporting/ communicating forum needs to be what works best for the organization.

GHS IPC CommitteeHospital epidemiologist, IPs, Pharmacy, MDs, Nursing,

Sterile Processing, OR, Employee Health, Lab, VP Quality; Public Health rep, RT , Ambulatory Care, Home

HealthMeet every other Month

Key focus: IPC program oversight, data analysis, decision making, recommendations to leadership

IPC Policy and Procedure SubcommitteeKey focus: Standards of Practice

Sterilization Subcommittee Key focus:

Instrument/ equipment

Antibiotic Stewardship

Subcommittee

Medical staff Process

Improvement Committee

Quality Management Committee

GMMC: Academic Medical Center: IP Team meets every other week: Medical Director, IPs, others as needed

PMH: Short stay surgical hospital: Quality Committee meets monthly, diverse membership

HMH: Small Community Hospital: IPC Committee, meets quarterly, membership similar to GHS IPC Committee , Also reports to Quality Committee

GrMH: Small Community Hospital: Medical Care Committee, diverse leadership

NG LTACH: Long Term Acute Care: (QCPC) Quality Committee, meets monthly; diverse staff and leaders; Also reports to Steering Group

All facility IP representatives report to: Safety Committees and Medical Care Committees (ICRAs)

Clear Purpose/ visionGood leader/ facilitatorOrganization: Agenda, timekeeper,

minutesMembership: Engaged; appropriate to

purpose of committee; diverse; preparedMethod of communicating and reporting

is consistent/ easy to understandAppropriate content to purposeCan make decisions/ recommendations

Authority / power of committee needs to be clear

Advisory Review ideas from infection control team Review/ Analyze surveillance data

Expert resource Help understand hospital systems and policies

Decision making Assesses Plan and conducts or reviews infection

control risk assessment Review and approve policies and surveillance

plans Policies binding throughout hospital

Education Help disseminate information and influence others

16

Edward O’Rourke, M.D , Harvard University –Harvard Medical School

Who is your Chairman? MD? You? Are they/ you effective? Engaged?;

interested?; attends?; effective communicator?

Leader: opens the meeting and takes group through agenda and encourages decision making

Facilitator: Helps prepare for meeting to ensure it goes smoothly

Keys to success: If leader and facilitator aren’t the same person, communicate prior to meeting regarding agenda; Make sure you have the right person chairing committee.

Are all members of the committee aligned in terms of the need of IP program and for change? ( ICRA>> Plan development)

Have we framed the need for committee/ IP program such a way to reflect the concerns of the customers and key stakeholders?

Would each team member deliver essentially the same message regarding the need for IP program and committee if asked by someone outside the team?

Creating a shared need involves framing the need to appeal to the interest of key stakeholders/ Committee members.

Multidisciplinary: Key Influencers, interested MDs Nursing Leadership Employee Health Infection Prevention Sterile processing Lab Pharmacy Public Health Others/ ex-officio: e.g. Environmental

Services

Sources of Resistance Causes/Reasons for Resistance

Rating(0-100%)

Lack of understanding

Political

Cultural

Identify by Group* To understand the nature of resistance.

*Use groups from the key constituents Map

How do you get them to attend? They have to want to attend.

Ask members for input to improve/ facilitate good meetings- make this part of annual assessment

Qualifications to be on the committeeInterestRepresent group in hospitalExperts in their fieldDiplomatic What do you do if key

influencer is disruptive? Good communicatorsCare about the membership, change it up if

needed to improve involvement 21

A – Approval of issues such as project scope, resources, and ultimately team recommendations for improvement

R - Resource to the team, whose expertise, skills, or influence may be needed on an ad hoc basis.

M - Member of team, with critical working knowledge of the problem and/or process .

I - Interested party, who will need to be kept informed on direction, findings, if later support is to be forthcoming.

Role definition: Building the Team/ CommitteeA.R.M.I. analysis

IPC Plan KEYSTAKEHOLDERS IMPLEMENTATION EVALUATIONSTARTUP

Understand that we are change agents and the committee held decide/ direct the program.

Understand the importance of preparation when facilitating, leading a team or committee. Go slow to go fast.

Use tools when motivating a commitment to the IPC program and/ or effecting major change:

1.Creating a shared need/ Vision2.Stakeholders3.Mobilizing Commitment

Example GHS in Cultural Transformation

CEO-Mike: Leading us to go from being a victim to making a difference through ourselves.

VP Quality-Tom: Leading us to think through things to assess the barriers to change and make a plan to influence them.

Where does the IP program fit? Is it seen as positive or negative? A change force…..

January March May July September

November

-VAP-Hand Hygiene-Aspergillus/ Construction-CAUTI-ICRA

-SSIs-BBFE-Home Health-CABC ( nursing home)

-CLABSI-MDRO-Syndromic Surveillance-TB

-VAP-Hand Hygiene-Subacute-CAUTI

-SSI’s-MIP (Psy)-BBFE-Home Health-Dialysis

-CLABSI-MDRO-Syndromic Surveillance-EPPI-Ambulatory Care/MD Practices

Antibiotic SubEmployee Health

Sterilization Sub

IPC P & P Sub

Antibiotic SubEmployee Heath

SterilizationSub

IPC P & PSubMeeting Frequency and timing can influence

attendance

Time Agenda Topic Purpose Leader Desired Outcome

7:30-7:35 am

I. Call to Order/ Review of Minutes

Minutes Review

Dr. Kelly Approval of minutes

7:35-7:55

II. Surveillance/PI

CLABSIAnalysis S.

Boeker*

Recommendations

7:55-8:15

MDROs Analysis M. Littlejohn*

Recommendations

8:15-8: 25

III. Flu Vaccination Program

Give Update

P. Billings Follow-up/ Actions

8:25-8:40

IV. IPC Policy and Procedure Committee

Review of dept policies

C. Steed Approval of policy changes

Agenda

*Other Infection Preventionists conducting surveillance

Material ( needs to hold attention) Paper/ handoutPowerPointVerbal discussionRoom Set upClassroomMeeting set upPlanning is key

•Report generated November 21, 2011

    BaselineOct-Dec

‘09Jan-Mar

‘10Apr-Jun

‘10Jul-Sep

‘10Oct-Dec

’10Jan-Mar

‘11Apr-Jun

’11Jul-Sep

‘11Oct ‘11

GHS Overall Weighted

Hand Hyg Rate 53.8% 72.6% 80.0% 86.2% 85.2% 87.2% 91.0% 90.2% 91.8% 91.5%

Correct HH 659 615 5773 6022 3879 4220 5948 5565 5090 1826

Observations 1222 847 7213 6990 4552 4837 6045 6169 5543 1996

GMMC (GMH, MIP, RCP)

Hand Hyg Rate 50.7% 66.4% 78.3% 86.2% 85.5% 86.6% 90.6% 90.1% 91.3% 91.6%

Correct HH 305 95 4245 4010 2824 2918 3808 3956 3573 1281

Observations 601 143 5419 4653 3304 3370 4201 4390 3915 1399

Greer Memorial Hospital

Hand Hyg Rate 64.5% 97.0% 82.6% 84.7% 79.9% 95.7% 93.2% 92.8% 95.7% 92.9%

Correct HH 51 224 739 439 306 509 619 602 638 208

Observations 79 231 895 518 383 532 664 649 667 224

Hillcrest Memorial Hospital

Hand Hyg Rate 65.0% 89.7% 80.9% 87.8% 84.3% 86.8% 95.3% 95.0% 92.2% 97.8%

Correct HH 139 96 161 173 220 401 609 531 438 178

Observations 214 107 199 197 261 462 639 559 475 182

North Greenville LTACH

Hand Hyg Rate 73.4% 86.4% 91.6% 94.6% 89.3% 93.4% 95.2% 89.4% 96.4% 93.7%

Correct HH 138 153 229 123 225 183 179 220 188 59

Observations 188 177 250 130 252 196 188 246 195 63

Patewood Memorial Hospital

Hand Hyg Rate 94.3% 100% 93.3% 91.8% 84.4% 93.5% 97.2% 94.8% 96.2% 97.7%

Correct HH 132 128 70 225 205 259 315 308 280 125

Observations 140 128 75 245 243 277 324 325 291 128

KEY < 60% 60-69% 70-79% 80-89% 90-100%

Note: Baseline Jun-Sep ‘09.

•Report generated November 21, 2011

08-09 SeasonPeak: 131

Focused SCIP Quality Measure

Measure: Removal of post op urinary catheter by the end of POD #2

GMH chart review conducted on all ‘failed’ cases for the quarter Oct 10 – Dec 10.

Cases are randomly selected from all eligible surgical cases

Graph displays distribution of ‘failed cases’ by unit at GMH. Example: 14 cases on the Ortho/Trauma unit were included in the random sample. Seven out of these 14 cases did not meet criteria for removing the post op urinary catheter

SCIP urinary catheter workgroup in progress

1

1

1

1

1

1

2

3

3

7

Cardiac Telemetry

Cardiology Med

CV & Monit Surg

NTICU

Palliative Care

CCU

Vasc. & Uro Surg

MSICU

CVICU

Ortho Trauma Surg(2D)

Failed Cases by Unit

March- April 2011- VRE cluster in 4003 and 4005. Education and enhanced rotational cleaning, 3M Cleantrace testing and culturing done

MSICU VRE Isolates from patients and surfaces sent to Johns Hopkins for PFGE.

Possible HCW transmission via the environment and hands.

.

Year/ Quarter

Total2010

2011Qt 1 Qt 2 Qt3

HCA VRE Colonization/ Infection

212 70 69 37

Pt Days 199322 50165 50892 51323Rate 1.06 1.40 1.36 0.72

HCA Colonization Rate

HCA Infection Rate

Pt days Colonization rate/per 1000 pt days

Infection rate/per 1000 pt days

MRSA

Jan – Sept 11 0 0 1763 0 0

2010 0 1 2617 0 0.38

VRE No cases to report

C-diff No cases to report

2008 2009 2010 2011  Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3CLABSI - 54 39 39 31 41 30 36 16 15 18 12 17 13 9Line Days - 12140 11595

11585 11196

10604

10625 11190 9033 8505 9061 9482 9515 8748 9618

•Report generated Oct. 17, 2011

Infections 20 5 3 3Line Days 11439 3230 2978 2962Pt Days 28172 7360 7199 7077CL Ratio 0.41 0.44 0.41 0.42

NHSN Pooled Mean 0.57 0.56 0.56 0.56

2010 Jan-Sept 11

GrMH

Infections 0 0

Line Days 640 533

Rate 0 0

HMH

Infections 0 2

Line Days 613 497

Rate 0 4.02

PMH

Infections 0 0

Line Days 43 19

Rate 0 0

Jul ‘08-Jun ‘09

Jul ‘09-Jun ’10

Jan ‘10-Dec ’10

Jan ‘11-Sep ’11

% Improvement Pre-Intervention to Projected CY 2011

CLABSI # 150 97 61 39 65.3%

Line Days 44,980 39,353 36,081 27,881 17.4%

Rate 3.33 2.46 1.69 1.40 58.0%

NHSN Top Quartile 0.26 0.26 0.26 0.26 ---

Expected CLABSI 12 10 9 7 ----

Excess CLABSI 138 87 52 32 69.6%

NHSN Mean 1.66 1.66 1.66 1.66 ----

Expected CLABSI 75 65 60 46 ----

Excess 75 32 1 -7 112%

CLABSI Prevented

----- 53 89 111

Lives Saved (10-20%)

----- 5-10 9-18 11-22

Cost Savings ($40,000/Case)

----- $2,120,000

$3,560,000

$4,440,000

•Report generated Oct. 17, 2011

•Report generated Sep 20, 2011

GHS System-Wide (GMH, PMH, GrMH, HMH)Surgical Site Infections (July 1, 2010 – June 30, 2011)

Surgical SiteObserved Infections

Total Surgeries

Statistically Expected Infections

Standardized Infection Ratio

(SIR)

95% Lower Confidence

Limit

95% Upper Confidence

Limit

Statistical Significance

CABG (Chest and Donor)* 7 418 11.37 0.62 0.25 1.27 Not different than expected

Abdominal Hysterectomy* 9 610 10.69 0.84 0.39 1.60 Not different than expected

Hip Replacement* 12 616 8.77 1.37 0.71 2.39 Not different than expected

Knee Replacement* 12 786 6.42 1.87 0.97 3.26 Not different than expected

Colon Resection 28 474 26.69 1.05 0.70 1.52 Not different than expected

Bariatric Surgery 1 269 6.13 0.16 0.05 0.91 Lower than expected

Small Bowel 15 343 20.89 0.72 0.40 1.18 Not different than expected

Ventral Hernia 15 498 11.25 1.33 0.75 2.20 Not different than expected

C-Section 11 1789 32.91 0.33 0.17 0.60 Lower than expected

TOTAL All Sites 110 5803 135.1 0.81 0.67 0.98 Lower than expected

Statistically Expected Infections Based on NHSN Data; Standardized Infection Ratio (SIR) = Observed Infections / Expected Infections95% Confidence Limits = The Confidence Interval provides the range in which the TRUE SIR will fall 95% of the time

•Report generated Sep 20, 2011* New risk adjustment methodology

The organization needs to have a means to integrate IPC program:

1. Data analysis2. Recommendations/ follow-up3. Policy development/ approval4. Means to bring people together to address ICRA

and program planning 5. Communication: multiple committees/ team IPC committee is worth the time if it serves a

purpose in the organization’s culture/ structure. Committees/ teams need to be organized/

planned; members need to be engaged to make a difference

Thank you!!!!csteed@ghs.org