Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

September 2016

More on Preventing HAI’s

Two recent studies done on specialized patient populations identified combinations of interventions that were able to reduce hospital-acquired infections (HAI’s) by over 50%. The first study utilized a bundle of evidence-based interventions in patients undergoing spine surgery (discectomy, decompression, spinal augmentation or spinal fusion) and found surgical site infections declined by 50% after implementation (Featherall 2016). Components of the “bundle” were:

screening for Staphylococcus aureus nasal colonization and decolonization with mupirocin
self-preparation bath with chlorhexidine gluconate
self-preparation with chlorhexidine gluconate wipes
storage optimization of operating room supplies
preoperative antibiotic administration algorithm
staff training on betadine scrub and paint
intrawound vancomycin in instrumented cases
postoperative early patient mobilization
wound checks at 2 and 6 weeks postoperatively

The number needed to treat (NNT) to prevent one infection was 47 patients. In addition to the 50 percent decline in SSIs there was an $866 cost reduction per case.

The second study (Halperin 2016) involved ventilator patients in patients in neurointensive care units and found an HAI reduction of 53% over an 18 month period. The two main interventions were (1) reducing the number of intrahospital transports and (2) reducing the number of urinary catheters. The primary way intrahospital transports was reduced was by the introduction of a mobile CT scanner so that patient needing frequent brain imaging could have the imaging done in the neuro ICU rather than being transported to the CT suite. Reduction in urinary catheters was accomplished by daily assessment of the continued need for such catheters, plus staff re-education on insertion and maintenance techniques plus introducing a new Foley kit that simplified and standardized the sterile insertion process Ventilator-associated events decreased 48 %, Foley use decreased 46 %, CAUTIs decreased from 11 per 1000 catheter days to 6.2.

Given our multiple columns on adverse events occurring in the Radiology suite (see full list below but in particular see our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite?”) we would be interested to see if the reduction in transports to Radiology also resulted in fewer overall adverse events of other types. That may well have been the case since they also found overall complication rate decreased 55 %, ICU length of stay decreased an average of 1.5 days, and risk-adjusted mortality decreased 11%.

Lastly, back to one of the most important interventions to reduce HAI’s: good hand hygiene. We often have difficulty convincing our healthcare workers (particularly our physicians) that better compliance with hand hygiene actually translates to fewer HAI’s. That is especially a problem where levels of compliance with hand hygiene are already relatively high. Well, a recent study in CDC’s Emerging Infectious Diseases journal should bolster your argument. Researchers from UNC Chapel Hill (Sickbert-Bennett 2016) found that taking a hand hygiene compliance rate of >80% to an even higher one at >95% resulted in a further significant reduction in HAI’s. The association between hand hygiene compliance and HAI showed a 10% improvement in hand hygiene was associated with a 6% reduction in overall HAI rate. The association between hand hygiene compliance and HA-CDI (healthcare associated C. diff infection) showed a 10% improvement in hand hygiene was associated with a 14% reduction in HA-CDI. No association was noted between hand hygiene compliance and MDRO infections. While the authors could not rule out a contribution from unknown confounders, there were no other specific infection prevention goals adopted during the study period.

Read the Sickbert-Bennett article for details on their successful interventions. But key features were that the focus for observation was simply on cleaning hands upon entering and leaving patient rooms and that all healthcare personnel (including physicians, advanced practice providers, nurses, nursing assistants, hospital unit coordinators, housekeeping, radiology, occupational/physical/recreational therapists, nutrition and food services staff, phlebotomists, and respiratory therapists) were asked to make observations and provide immediate feedback to each other.

Some of our prior columns on patient safety issues in the radiology suite:

October 16, 2007 “Radiology as a Site at High-Risk for Medication Errors”
February 19, 2008 “MRI Safety”
September 16, 2008 “More on Radiology as a High Risk Area”
October 7, 2008 “Lessons from Falls....from Rehab Medicine”

October 2008 “Preventing Infection in MRI”
March 17, 2009 “More on MRI Safety”
March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”

August 11, 2009 “The Radiology Suite…Again!”
January 2010 “Falls in the Radiology Suite”
August 2010 “Sedation Costs for Pediatric MRI”
January 25, 2011 “Procedural Sedation in Children”

February 1, 2011 “MRI Safety Audit”
October 25, 2011 “Renewed Focus on MRI Safety”
March 13, 2012 “Medical Emergency Team Calls to Radiology”
August 2012 “Newest MRI Hazard: Ingested Magnets”
October 22, 2013 “How Safe Is Your Radiology Suite?”
February 25, 2014 “Joint Commission Revised Diagnostic Imaging Requirements”
July 2014 “New MRI Risks: for Staff!”
July 1, 2014 “Interruptions and Radiologists”
November 2014 “More Radiologist Interruptions”
October 21, 2014 “The Fire Department and Your Hospital”
August 25, 2015 “Checklist for Intrahospital Transport”
March 22, 2016 “Radiology Communication Errors May Surprise You”
August 2016 “Guideline Update for Pediatric Sedation”

Our other columns on urinary catheter-associated UTI’s:

May 8, 2007 Tip of the Week “Doctor, when do I get this red rubber hose removed?”
January 8, 2008 Tip of the Week “Urinary Catheter-Associated Infections”
April 2008 What’s New in the Patient Safety World column “More on Nosocomial UTI’s”
June 24, 2008 Tip of the Week “Urinary Catheter-Related UTI’s: Bladder Bundles”
April 21, 2009 Tip of the Week “Still Futzing with Foleys?”
June 9, 2009 Tip of the Week “CDC Update to the Guideline for Prevention of CAUTI”
March 2010 “IDSA CAUTI Guidelines”
February 2011 What’s New in the Patient Safety World column “Catheters Not Needed in C-Sections?”
January 2012 “CAUTI’s Still Get No Respect”
May 2012 “Foley Catheter Hazards”
November 2012 “CAUTI Conundrum”
December 18, 2012 “Unintended Consequences of the CAUTI Measure?”
January 2013 “Silver-Coated Urinary Catheters Don’t Reduce CAUTI’s”
June 2013 “Barriers to CAUTI Prevention”
November 2013 “Further Reducing Urinary Catheter Use”
June 2014 “Updated HAI Prevention Guidelines from SHEA/IDSA”
June 30, 2015 “What Are Appropriate Indications for Urinary Catheters?”
December 2015 “CAUTI Prevention Tools”
July 2016 “Holy Moly, My Patient has a FOLEY!”

Some of our other columns on handwashing and hand hygiene:

January 5, 2010 “How’s Your Hand Hygiene?”

December 28, 2010 “HAI’s: Looking In All The Wrong Places”

May 24, 2011 “Hand Hygiene Resources”

October 2011 “Another Unintended Consequence of Hand Hygiene Device?”

March 2012 “Smile…You’re on Candid Camera”

August 2012 “Anesthesiology and Surgical Infections”

October 2013 “HAI’s: Costs, WHO Hand Hygiene, etc.”

November 18, 2014 “Handwashing Fades at End of Shift, ?Smartwatch to the Rescue”

January 20, 2015 “He Didn’t Wash His Hands After What!”

September 2015 “APIC’s New Guide to Hand Hygiene Programs”

November 2015 “Hand Hygiene: Paradoxical Solution?”

April 2016 “Nudge: An Example for Hand Hygiene”

August 2016 “Hand Hygiene: Who’s Watching? Does it Matter?”

References:

Featherall J, Miller JA, Bennett EE, et al. Implementation of an Infection Prevention Bundle to Reduce Surgical Site Infections and Cost Following Spine Surgery. JAMA Surgery 2016; Online First July 20, 2016

http://archsurg.jamanetwork.com/article.aspx?articleid=2534130

Halperin JJ, Moran S, Prasek D, et al. Reducing Hospital-Acquired Infections Among the Neurologically Critically Ill. Neurocritical Care 2016; 1-8 First online: 27 June 2016

http://link.springer.com/article/10.1007/s12028-016-0286-2

Sickbert-Bennett EE, DiBiase LM, Schade Willis TM, et al. Reduction of Healthcare-Associated Infections by Exceeding High Compliance with Hand Hygiene Practices. Emerging Infectious Diseases 2016; 22(9): September 2016

http://wwwnc.cdc.gov/eid/article/22/9/15-1440_article

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