1. Primum non nocere (Latin : First Do No Harm)
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2. 2

3. 3

4. Crisis in Healthcare Associated infections
Calfee DP. Annul Rev Med 2012; 63: 9.1 – 9.13
posted online on October 13,2011
In USA > 1.7 million HAI occur every year
= 5% of all persons admitted (CDC 2002 data)
Prolonged duration of hospitalization
Greater morbidity
Increased risk of death
98,000 death (top ten causes of death)
4

5. Deaths in USA due to HAI are
Equivalent to ONE Fully loaded Jumbo jet
crashing every day of the year
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6. Hospital Associated Infections
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7. Preventable Infections and costs of getting it wrong
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8. Target ZERO
Healthcare Associated Infections
Zero tolerance for preventable
healthcare associated infections &
inappropriate practices

9. Qs 1. Is the patient colonized or infected with
indicator bacteria ?
At time of admission:
Culture Nose, Axilla & Groin for MRSA
Culture stool / rectal swab for Carbapenemase
producing enterobacteria (CRE)
If yes (TAT 24 hours):
Institute contract precautions
OR: Consider ALL pts to be infected & institute
contact precautions till cultures reported as
Negative for MRSA &/or CRE 9

10. Qs. 2 Is patient acquiring indicator bacteria from
the environment ?
Environment: A. Frequent touch areas
B. Floors, walls, toilet etc
Need to be cleaned regularly, aim for food processing
unit quality of environment
Microbiology monitoring of environment, air, HCW hands
etc would be intensive to document compliance
If indictor bacteria (MRSA, CRE, MDR P aeruginosa,
MDR Acinetobacter spp isolated)
Review cleaning practices & institute corrective measures
10

11. Qs 3. Standard of care in Infection prevention
100 % compliance with bundles
Bundles will be operational for Infection Prevention:
CVC (I & M) & PVC (I & M),
CAUTI (I & M),
VAP, SSI
MRSA,
Hand Hygiene,
Clostridium difficile
Immediate feedback on compliance to operator,
weekly feedback to chairman
11

12. Qs. 4. If infection occurs
Rapid diagnosis of infection (Multiplex PCR, PCT
etc)
Antibiotic care bundle
Review of all results after 72 hours & de
escalation (if required)
12

13. Qs. 5. Did the patient acquire indicator bacteria
during his stay at Medanta ?
One day before discharge, culture Nose for
MRSA & stool / RS for CRE
If positive: Indicates breach of Infection
Prevention practices
Root cause analysis & corrective action
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14. Bundles: do they work ?
25
Rate per 1000 cath days
20
15
10
5
0
1998 - Qtr1
1998 - Qtr2
1998 - Qtr3
1998 - Qtr4
1999 - Qtr1
1999 - Qtr2
1999 - Qtr3
1999 - Qtr4
2000 - Qtr1
2000 - Qtr2
2000 - Qtr3
2000 - Qtr4
2001 - Qtr1
2001 - Qtr2
2001 - Qtr3
2001 - Qtr4
2002 - Qtr1
2002 - Qtr2
2002 - Qtr3
2002 - Qtr4
2003 - Qtr1
Berenholtz SM, Pronovost PJ, Lipset PA, et al.
Eliminating catheter related bloodstream infection
in the intensive care unit.
Critical Care Medicine. 2004; 32:2014-2020
Al-Tewfiq JA & Abed MS:
Decreasing VAP in adults ICU using Institute for
Healthcare Improvement Bundle.
Am J Infect Control 2010;38:552-6
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15. How are Bundle elements developed ?
A cause and effect chart describes all the elements of
a system under 4 main headings:
Environment,
Equipment,
People,
Methods
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16. Environment Equipment
The Goal
People Methods
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17. 17

18. Central Line Bundle Elements
1. Hand hygiene
2. Maximal barrier precautions
3. Chlorhexidine skin antisepsis
4. Optimal catheter site selection, with
avoidance of using the femoral vein for
central venous access in adult patients
5. Daily review of line necessity with prompt
removal of unnecessary lines 18

19. 1.Hand Hygiene
Wash hands if they are obviously soiled
Wash hands or use an alcohol based waterless hand
cleaner
5 moments for hand washing
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21. 21

22. Monitoring & Feedback on compliance is essential
In Quality parlance: If it is not documented, it is not done
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23. 23

24. 2. What Are Maximal Barrier Precautions?
For Provider & Assistants:
Hand hygiene
Non-sterile cap and mask
All hair should be under cap
Mask should cover nose and mouth tightly
Sterile gown and gloves
For the Patient:
Cover patient’s head and body with a large sterile drape (use more than
one if needed for large patients)
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25. 3. Chlorhexidine Skin Antisepsis
Prepare skin with antiseptic/detergent
Chlorhexidine 2% in 70% isopropyl alcohol.
Apply chlorhexidine solution using a back and forth
friction scrub for at least 30 seconds. Do not wipe
or blot.
Allow antiseptic solution time to dry completely before
puncturing the site ( ~ 2 minutes).
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26. 4. Optimal Site Selection
Femoral site: greatest risk of infection, especially
in overweight patients
Subclavian site: lower risk of CLABSI than the
internal jugular vein
Preferred when infection is only consideration
Higher risk of mechanical complications
Physicians must weigh risk-benefit of site
selection for individual patient
Bundle compliance met if documented 26

27. 5. Daily Assessment
Goal: reduce line days
Include daily review of line necessity in
multidisciplinary rounds
Remove promptly when no longer needed
Define appropriate timeframe for review when
applied to central lines intended for long term use
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28. Key Change: Central Line Checklist
Have the nurse document compliance with the insertion criteria
at the time of insertion.
Create a culture of safety and prevention:
empower nurses to stop line placement if improper techniques are used
Instruct nurses in use of critical communication strategies to
facilitate important exchanges.
e.g. “the sterile field has been contaminated,” rather than “You contaminated
the catheter!” 28

29. Checklist Elements
Before the procedure, did they:
Wash hands?
Sterilize procedure site?
Drape entire patient in a sterile fashion?
During the procedure, did they:
Use sterile gloves, mask and sterile gown?
Maintain a sterile field?
Verify: did all personnel assisting with procedure
follow the above precautions?
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30. Tips for Success
STOP the line
empower nurses to stop line placement if improper
techniques are used
Leadership support & culture
Evidence
Standard equipments packs
Clinical appropriateness
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31. Measure: CLABSI per 1000 Line Days
Central line-associated BSI rate per 1000
central line-days:
Numerator: Number of central line-associated BSI
x 1000.
Denominator: Number of central line-days (total number of days of
exposure to central venous catheters by all
patients in the selected population during the
selected time period).
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32. Measure: Central Line Bundle Compliance
Central line bundle elements in place:
Numerator: Number of patients with central line
bundle in place.
Denominator: Total number of pts on central lines per
day of week of prevalence sample.
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33. Rate per 1000 cath days
10
15
20
25
0
5
CLABSIs.
1998 - Qtr1
1998 - Qtr2
1998 - Qtr3
1998 - Qtr4
Does it Work?
1999 - Qtr1
1999 - Qtr2
1999 - Qtr3
1999 - Qtr4
2000 - Qtr1
2000 - Qtr2
2000 - Qtr3
2000 - Qtr4
2001 - Qtr1
2001 - Qtr2
2001 - Qtr3
2001 - Qtr4
2002 - Qtr1
2002 - Qtr2
ICUs that have implemented multifaceted interventions
2002 - Qtr3
similar to the central-line bundle have nearly eliminated
2002 - Qtr4
2003 - Qtr1
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34. SEVEN steps in
successful bundle implementation
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35. Step 1 - Commitment
The first step is for the team leader to get everyone to
commit to doing the bundle to improve patient safety.
Remember
Patient safety is for life –
not just for this Dewali !
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36. Medanta Medicity Gurgaon
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37. Step 2 - Understand there will be consequences
The team must consider that they will find out things they did
not want to know, e.g. your team is not perfect!
Consider how you will deal with this before you start
Commit to feedback being for improvement and not judgement
Acknowledge that where you are, is not where you want to be, and this process
will help you improve
Commit to not shooting the messenger, i.e. the one collecting the data!
Commit to a no blame culture
Remember you are doing this for optimal patient safety and to
show the quality of your care – not to damage your care team
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38. Step 3 - Work out the process that fits in with your
systems of working
How often do you want to measure compliance (at least
once a week)?
Who will collect the data?
When will they collect the data?
Where will they put the completed sheets?
Where will you display your results?
What will you do with the results – how will you act on
them?
Is everyone agreed on the process?
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40. 40

41. Step 4 – Start small
Remember the PDSA methodology
One patient, one nurse, one doctor one day
The next time three patients,
The next time five patients
The next time all
Don’t expect to get it right first time, but it will
help if you DO
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42. Step - 5 When you are all agreed that it works on
five get ready to implement it ward wide
Pick a start date
Make sure everyone knows
Have the bundle data collection forms
ready
BEGIN
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43. Potential Impact of central line bundle
Berenholtz SM et al.
Critical Care Medicine 2004; 32: 2014 - 220
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44. Step 6 Continuously assess progress
What are we trying to No skin and soft tissue infections due to CVC
accomplish?
There will be 100% compliance with the bundle
How will we know that change is
improvement? There will be no skin or soft tissue infections due to
CVCs
What changes can we make
that will result in improvement? Don’t use CVCs unless absolutely necessary.
Remove CVCs as soon as possible
Don’t use a CVC – just in case
Act Plan
Study Do
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45. Step 7 – If it’s going well & you have improved processes & reduce the
risk of CLABSI – try another bundle
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46. Bundles available & ready for deployment
Central venous catheter: Insertion & maintenance
Urinary tract catheter: insertion & maintenance
VAP
Surgical site
Hand washing
MRSA
Clostridium difficile
Sepsis
Antibiotic use
46

47. TARGET ZERO
Healthcare associated Infections
Zero Tolerance for Preventable Healthcare Associated Infections &
Inappropriate practices 47