Nationally coordinated IPC initiatives – lessons learnt from the … · 2016-09-08 · Nationally coordinated IPC initiatives – lessons learnt from the Australian experience John

Nationally coordinated IPC initiatives –

lessons learnt from the Australian experience

John Ferguson August 2016

DRAFT

Overview

1. Australian Healthcare System – Structure, Process and Outcomes; reactive versus proactive approaches to system repair - adding the ‘Safety 2’ ethos

2. ACSQHC and other national programs & enablers

3. National Safety and Quality Healthcare Standards and Standard 3 – progress and challenges

Donabedian model

Donabedian’s Lasting Framework for Health Care Quality Ayanian et al, NEJM 2016: 375;205-6.

Structure- healthcare • Healthcare management structures in Australia

deficient in many key systems regarded as essential in high reliability industries: – Consistent staff competency assessment and re-

validation process – Accountability and governance – Standard operating procedures

• ISO 9001 quality management system specifies the essential cogs and wheels required

Preventing healthcare-associated infection: risks, healthcare systems and behaviour Internal Medicine 2009 574-581 Ferguson

Structure – ISO9001 elements

• Management requirements • Technical

+ Process

http://www.safetyandquality.gov.au/atlas/

Barriers impeding best practice

Kennedy-P et al. Med J Aust 2010; 193 (8): 97 National Institute of Clinical Studies. Identifying barriers to evidence uptake. Melbourne: NICS, 2006.

= Outcomes

Preventable healthcare-associated infection a common mode of injury

Outcomes - Australia: 2008 estimates

• 200,000 healthcare-associated infections per annum; 12,000 bloodstream infections

• 2,000,000 bed days lost : • Mortality: circa 5,000 per annum based on

international estimates

Australian Commission on Safety & Quality in Healthcare, 2008- Reducing harm to patients: the role of surveillance

Root cause analysis • Formal method used to analyse serious adverse events • Identify underlying problems that increase the

likelihood of errors, taking the focus away from mistakes by individuals.

• Causal statements are generated through event mapping and investigation of links between context, events, actions and patient outcomes.

• Ultimate goal – learn from error/mistakes - prevent future patient harm by proposing system changes

RCA Limitations • RCA effectiveness in lowering risk or improving

medical safety not systematically established • Quality of RCA dependent on accuracy of input data

as well as capability/experience /effectiveness of RCA team

• Open to political hijack • Accidents assumed to be caused by failures or

malfunctions.

Dixon-Woods et al. The Problem with RCA, BMJ Quality & Safety, 2016 Shaqdan K, et al Root-cause analysis and health failure mode and effect analysis: two leading techniques in health care quality assessment. J Am Coll Radiol. 2014 Jun; 11(6):572-9

• 2015 report: 6 preventable deaths 2012-April 2015, NSW

• 2 further deaths since then • 51 near-miss events

Preventing IV device morbidity: recurrent system issues

Structure Accountability & governance Staff competency Environmental controls Design of devices

Process Standardising insertion procedure & kit Aseptic technique- insertion and access Safe removal Documentation & detection of deteriorating patient Surveillance of patient outcomes Audits of process compliance

An alternative perspective on accident investigation

“Things basically happen in the same way, regardless of outcome. The purpose of an investigation is to understand how things usually go right as a basis for explaining how things occasionally go wrong.”

Hollnagel et al. From Safety 1 to Safety 2: A white paper, 2015

https://www.england.nhs.uk/signuptosafety/wp-content/uploads/sites/16/2015/10/safety-1-safety-2-whte-papr.pdf















How hazardous is healthcare? Dr. Lucien Leape National Patient Safety Network, 2004

Dangerous Regulated Ultrasafe (>1/1000) (< 1/100,000)

Total lives lost per

year

1

10

100

1000

10,000

100,000

1 10 100 1000 10,000 100,000 1M 10M

Bungee jumping

Mountain climbing

Healthcare (USA)

Driving

Chemical manufacturing

Chartered flights

Scheduled airlines European

railroads Nuclear power

Number of encounters for each fatality

‘High reliability organisations’ US Navy nuclear aircraft carriers, nuclear power plants, and air traffic control centres had these defining characteristics: • They were complex, internally dynamic, and,

intermittently, intensely interactive • They performed exacting tasks under considerable

time pressure • They had carried out these demanding activities

with low incident rates and an almost complete absence of catastrophic failures over several years

James Reason . Human error: models and management BMJ 2000;320:768–70

Paradoxes of high reliability • Traditional view: human unreliability attributed to

unwanted variability and strive to eliminate it as far as possible.

• High reliability organisations: recognise that human variability in the shape of compensations and adapta-tions to changing events represents one of the system's most important safeguards. Reliability is “a dynamic non-event.” Dynamic = safety preserved by timely human adjustments; Non-event = successful outcomes rarely call attention to themselves.


High reliability organisations

“Perhaps the most important distinguishing feature of high reliability organisations is their collective preoccupation with the possibility of failure. They expect to make errors and train their workforce to recognise and recover them. They continually rehearse familiar scenarios of failure and strive hard to imagine novel ones. Instead of isolating failures, they generalise them. Instead of making local repairs, they look for system reforms.”


Overview


2. The ACSQHC and other national programs & enablers


ACSQHC Structure

• Established 2006 to lead and coordinate national improvements in safety and quality in health care

• National Health Reform Act 2011 (NHR Act) which established the Commission as a corporate Commonwealth entity under the Public Governance, Performance and Accountability Act 2013 (PGPA Act).

• Joint funding etc

Governance - Committee membership

Clinical experts

Implementation

Authority

Leadership

Priorities

HAI Advisory

Infection Control Guidelines

Antimicrobial stewardship

Hand hygiene

AMS Network

Technical working group

ACSQHC Process: committees & modus operandi

• Expert groups – HAI Advisory Committee – AMS Advisory Committee

• Inter-Jurisdictional Committee – IJC will consider and provide advice to the Commission on the following: – The Commission’s programs, standards, guidelines and indicators and the

implementation of these; – The maintenance of effective working relationships with key stakeholders to facilitate

the work of the Commission; – Safety and quality issues regarding the Australian health care system; and – The process for collecting and reporting on national data on safety and quality issues.

• Liaison – Primary Care Committee

• The PCC is responsible for facilitating the engagement and uptake of Commission programs in the primary health care sector.

– Private Hospital Sector Committee • The PHSC is responsible for advising the Commission on key safety and quality initiatives from

the perspective of the private hospital sector.

ACSQHC Outcomes- in sequence

• Surveillance review and programs- SAB, CDI • National performance measures • NSQHS Standards • National IPC Guidelines- revision • Hand Hygiene Australia • Capacity building • AMS etc • CPE Guidelines

ACSQHC Tips for success

• Engagement of leaders – National – State and territory – Hospital – Professional organisations – Clinicians

• Provide “carrots” before the “stick” • National coordination • Recognise that “not one size fits all”

Other Australian national enablers • National communicable disease structures

– CDNA – PHLN – Laboratory : NPAAC, NATA, AGAR and NRL

• ACIPC – Credentialing – Journal – Research

• ASID & ASM • NHMRC research groups:

– N Graves group etc – AMS group etc

• ACHS and other accreditation assessors • Private Hospitals

Major Australian structural deficiencies

• Lack national Centre for Communicable Disease Control: • reliance on Expert panels for policy development • no centre for collation and epidemiological analysis of HAI

data • MRSA, VRE, CPE, C. difficile historically not regarded as

public health problems per se by some jurisdictions and the federal apparatus

• Aged care governance sits outside of ACSQHC’s province and the NSQHCS

McCall BJ et al. Aust Health Rev. 2013 Jun;37(3):300-3. The time has come for an Australian Centre for Disease Control.

Overview


2. The ACSQHC and other national programs & enablers


Standard 7 Blood and Blood

Products

Standard 10 Preventing Falls and

Harm from Falls

2011 NSQHS Standards: mandated 2013

Standard 1 Governance for Safety and

Quality in Health Service Organisations

Standard 2 Partnering with Consumers

Standard 4 Medication Safety

Standard 3 Healthcare Associated Infections

Standard 8 Preventing and

Managing Pressure Injuries

Standard 9 Recognising and

Responding to Clinical Deterioration in Acute

Health Care

Standard 5 Patient Identification and Procedure Matching

Standard 6 Clinical Handover

NSQHC Standards

What has worked well • Comprehensive • Risk based approach • AMS inclusion • Strong acceptance and

uptake

Work still to do • Accreditation process:

variability in assessment stringency

• Governance and management structures insufficiently specified

• Continuous quality systems focus required

Standard 3: progress and challenges

1. Surveillance: performance assessment 2. National Hand Hygiene Program 3. Enhancing Standard Precautions: safer healthcare

environments 4. CAUTI prevention 5. National surveillance: critique of current programs 6. Resourcing and implementation of antimicrobial

stewardship across all healthcare settings

QI vs Performance assessment

• Solberg schema • Surveillance review 2008- rec national level

SAB, CDI surv

• National perf agreement • AIHW and NHPA politics

Outcomes: Hand Hygiene program

What has worked well • Strong acceptance and

uptake • Comprehensive • Validity studies

Work still to do • Nursing compliance

drives figures • Medical compliance

lagging or not measured well enough

• Cost benefit questions

Quote Graves et al study

Hand Hygiene Performance: by Profession

HNE staff hand hygiene compliance and MRSA bloodstream infections and mortality

Outcomes- Hand Hygiene program

Medicos and HH

• Medical college statement 2016 • Poor or absent accountability systems for

medicos • Poor medical update re training and poor

understanding

Accountability- Vanderbilt framework Australian pilot 2016

Talbot et al. Sustained Improvement in Hand Hygiene Adherence: Utilizing Shared Accountability and Financial Incentives. Infect Control Hosp Epidemiol 2013;34(11):1129-1136.



environments 4. CAUTI prevention 5. National surveillance: critique of selected current

programs 6. Resourcing and implementation of antimicrobial


Healthcare environment- Prior room occupant studies

Systems and safe environments

Structure Accountability & governance Accommodation and design Advanced environmental auditing methods Microfibre cloths, Vapour disinfection , UV Surfaces and cloths that have disinfectant properties

Process Environmental cleaning & disinfection– procedure control, staff training and competency Disinfection of reused patient equipment Audits of process compliance

HAUTI and CAUTI

Impact: Priorities: Improving use of urinary catheters – compliance with insertion guidelines and aseptic technique, nurse-led removal, outcome measure – HAUTI / CAUTI

Standard 3: challenges and priorities

1. Surveillance: performance assessment 2. National Hand Hygiene Program: medical

compliance and wider engagement with IPC and AMS processes

3. Enhancing Standard Precautions: safer healthcare environments

4. CAUTI prevention 5. National surveillance: critique of current programs 6. Resourcing and implementation of antimicrobial


Staph. aureus BSI (SAB) Surveillance

http://www.safetyandquality.gov.au/our-work/healthcare-associated-infection/national-hai-surveillance-initiative/national-definition-and-caluculation-of-hai-staphylococcus-aureus-bacteraemia/






National SAB data

SAB surveillance What has worked well • Comprehensive coverage • Captures non-inpatient

events • High prominence –

publically reported, top level performance indicator; managers engaged++

Work still to do • Incident level reporting to

enable better analyses and data validation

• Private lab/hospital reports • Linkage of epidemiological

typing data • Public Health involvement –

MRSA issues in indigenous and RACF populations

• Many research level questions

Clostridium difficile infection (CDI) surveillance

• National CDI surveillance approach 2009

• Clostridium difficile workshop August 2010

• Clostridium difficile 027 Snapshot Study, October 2010

• Second national ribotyping survey November 2012

CDI surveillance definition

http://www.safetyandquality.gov.au/our-work/healthcare-associated-infection/national-hai-surveillance-initiative/national-definition-and-calculation-of-hospital-identified-clostridium-difficile-infection/



CDI surveillance

What has worked well • Surveillance definition –

few grey zones • Periodic snapshots with

subtyping • Has provided assurance

that epidemic CDI has not emerged in Australia

• High community rates

Work still to do • Test utilisation not

standardised • National reporting of HCA

CDI rates • Data completeness &

validation • Utility of CDI surveillance

for AMS/ IPC performance judgement?

ASID C. difficile guidelines update Internal Medicine 2016

Laboratory-based surveillance of Clostridium difficile circulating in Australia, September – November 2010. Cheng et al, Pathology 2016

C. difficile snapshot survey 2010

Increasing incidence of Clostridium difficile infection, Australia, 2011–2012. Slimings et al MJA 2014

MRO Surveillance

• AURA system- CARalert system • What defines a HCA event? • CPE

ACSQHC CARAlert reporting system 2016

http://www.safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/what-is-aura/national-alert-system-for-critical-antimicrobial-resistances-caralert/































Proposed CA, HACO, HO definition

Based on CDC (USA), Active Bacterial Core Surveillance definition

CPE

• Recent extended CPE outbreak- Melbourne- galvanising involvement of public health at state and national level

• Likely notifiability • Re-energised review and revision of national

CPE guidelines



environments 4. CAUTI prevention 5. National surveillance: critique of selected current

programs 6. Resourcing and implementation of antimicrobial


– Morgyn Warner (Chair) – Celia Cooper (Prev Chair) – Helen van Gessel – David Looke – Margaret Duguid – Marilyn Cruickshank – David Kong – David Maxwell – John Turnidge – John Ferguson – Tara Anderson – Karin Thursky – Kirsty Buising

AMS Advisory Committee

Antimicrobial Stewardship Network

• Departmental representatives • Private Hospital sector • Paediatric component • Members from Antibiotic Stewardship Advisory Committee • AMS clinical standard – small number of quality statements

that will provide standard at the clinician/patient level

The Clinical Care Standard for AMS Tackling AMS at the patient level

Nine (9) statements describing best practice for managing a person who has, or is suspected of having a bacterial infection, regardless of setting.

• For patients: describes the care they can expect to receive throughout the patient journey.

• For clinicians: gives clear guidance about what they need to do.

• For health services: systems are in place to support all clinicians in providing the care that is expected.

National Antimicrobial Prescribing Survey

Documents

Nationally coordinated IPC initiatives – lessons learnt from the … · 2016-09-08 · Nationally coordinated IPC initiatives – lessons learnt from the Australian experience John