1. Nov. 9, 2006EPIC QI WorkshopSlide 1 EPIC/PHSI Quality Improvement Workshop: Interventions to prevent nosocomial infection and future directions Khalid Aziz November 10, 2006

2. Nov. 9, 2006EPIC QI WorkshopSlide 2 Janeway Children’s Health and Rehabilitation Centre, St. John’s NL

3. Nov. 9, 2006EPIC QI WorkshopSlide 3 Acknowledgements Nosocomial infection team centres: Children’s & Women’s Health Centre of BC Janeway Children’s Health and Rehabilitation Centre IWK Health Centre Hospital for Sick Children St. Joseph’s Hospital Royal Alexandra Hospital

4. Nov. 9, 2006EPIC QI WorkshopSlide 4 Objectives Nosocomial infection team interventions Methodologies Proposed methodologies for future interventions

5. Nov. 9, 2006EPIC QI WorkshopSlide 5 Interventions Teams were involved in developing interventions Interventions were truly interdisciplinary Interventions applied to diverse groups such as housekeeping, parents, respiratory therapy Interventions were made in each institution according to local priorities

6. Nov. 9, 2006EPIC QI WorkshopSlide 6 Reviews Varied in rigour Local interests Team interests Investigation of established reviews (eg CDC guidelines) Qualitative themes of focus groups Literature reviews Baseline EPIC results

7. Nov. 9, 2006EPIC QI WorkshopSlide 7 Baseline EPIC results PICCs reduce nosocomial infection in some centres Positive urine culture is as common as positive blood culture in centres who did both Culture negative sepsis and suspected sepsis are a considerable burden in NICU Units vary in their use of antibiotics for nosocomial infection, particularly vancomycin and cefotaxime

8. Nov. 9, 2006EPIC QI WorkshopSlide 8 Baseline data: UAC sepsis

9. Nov. 9, 2006EPIC QI WorkshopSlide 9 Baseline data: PICC sepsis

10. Nov. 9, 2006EPIC QI WorkshopSlide 10 Baseline data PICC sepsis by centre

11. Nov. 9, 2006EPIC QI WorkshopSlide 11 List of interventions 1 Hand hygiene Gloves and gowns Skin care Skin breaks Care of PICC lines

12. Nov. 9, 2006EPIC QI WorkshopSlide 12 List of interventions 2 Choice of first line antibiotics Duration of empiric antibiotic therapy Care of ventilator circuits Visiting policy Staff education

13. Nov. 9, 2006EPIC QI WorkshopSlide 13 Hand hygiene Add alcohol based waterless cleanser to hand cleansing areas/entrances to NICUs/improve availability of alcohol based cleansers/provide staff with 60ml bottles of hand hygiene to be kept on person Communicate handwashing protocol Increase vigilance in respect to the wearing of jewelry

14. Nov. 9, 2006EPIC QI WorkshopSlide 14 Gloves and gowns Discontinue use of routine gloves and gowns

15. Nov. 9, 2006EPIC QI WorkshopSlide 15 Skin care Cleanse umbilical sites with antiseptic (aquaphor ointment) prior to umbilical line placement Infants less than 32 weeks bathed only with warm water (no soap) during 1st week (mineral water prn) Use of 2% aqueous chlorhexidine rather than alcohol for skin antisepsis for infants with birth weight less than 1000g

16. Nov. 9, 2006EPIC QI WorkshopSlide 16 Skin breaks Skin break audit Compliance with “initiation of peripheral IV therapy policy” Reduce number of skin pokes Restrict number of pokes to 1-2 per person Restrict number of staff participating in the process Implement algorithms for blood sampling and IV starts: both algorithms define number of pokes per person and number of people participating

17. Nov. 9, 2006EPIC QI WorkshopSlide 17 Skin breaks (pokes audit)

18. Nov. 9, 2006EPIC QI WorkshopSlide 18 Skin breaks (IV starts audit)

19. Nov. 9, 2006EPIC QI WorkshopSlide 19 Care of PICC lines PICC line insertions restricted only to nurses who have been certifiedreduce PICC line dressings to prn Observe CDC guidelines for central lines

20. Nov. 9, 2006EPIC QI WorkshopSlide 20 Choice of first line antibiotics On admission: ampicillin and gentamicin Change first line abx to cloxacillin and gentamicin for suspected nosocomial sepsis until blood culture sensitivities received or unless the neonate has septic shock, suspected meningitis or necrotizing enterocolitis (then vancomycin and/or cefotaxime Caremap for choosing antibiotics

21. Nov. 9, 2006EPIC QI WorkshopSlide 21 Choice of first line antibiotics

22. Nov. 9, 2006EPIC QI WorkshopSlide 22 Duration of empiric antibiotic therapy Discontinue antibiotics if blood cultures are negative after 36 hours (assuming the baby is well)

23. Nov. 9, 2006EPIC QI WorkshopSlide 23 Duration of empiric antibiotic therapy

24. Nov. 9, 2006EPIC QI WorkshopSlide 24 Care of ventilator circuits Change ventilator circuits when visibly contaminated, malfunctioning, and between patients

25. Nov. 9, 2006EPIC QI WorkshopSlide 25 Visiting policy 2 visitors per neonate in NICU at any one time

26. Nov. 9, 2006EPIC QI WorkshopSlide 26 Staff education Encourage staff influenza immunization

27. Nov. 9, 2006EPIC QI WorkshopSlide 27 Future directions Revisions New interventions Standardization of reviews

28. Nov. 9, 2006EPIC QI WorkshopSlide 28 Revisions New information since 2001 Greater rigour Interprofessional approaches Site-specific issues Larger pool of reviewers New expertise in larger number of centres

29. Nov. 9, 2006EPIC QI WorkshopSlide 29 New interventions 5 years more of clinical studies (e.g. caffeine) New systematic reviews Data from EPIC-1 (e.g. benefits of PICC placement, incidence of UTI) Larger pool of participants for hypothesis generation “Ownership” of CNN database

30. Nov. 9, 2006EPIC QI WorkshopSlide 30 Standardization of reviews What might the advantages be to standardization of the review process? Ease of review Ease of cataloguing and presentation Ease of revision

31. Nov. 9, 2006EPIC QI WorkshopSlide 31 Standardization of reviews What might the disadvantages be of a standardized approach? Need to encompass qualitative and quantitative data Appears challenging to non-academic reviewers Time-consuming, particularly when a review or guideline already exists (do we need to re-review the original studies?)

32. Nov. 9, 2006EPIC QI WorkshopSlide 32 Suggested review methodologies Adaptation of an existing guideline(s) (eg CDC guideline on central line care) The ILCOR methodology (as used by the International Liaison Committee on Resuscitation for the 2005 recommendations) Informal methodologies

33. Nov. 9, 2006EPIC QI WorkshopSlide 33 The ILCOR Consensus Process Step 1 State the proposal ************ Step 2 Assess the quality of each study ************ Step 3 Determine the class of recommendation

34. Nov. 9, 2006EPIC QI WorkshopSlide 34 The ILCOR Consensus Process Step 1A.Refine the research question(s) Step 1B.Gather the evidence ************ Step 2A.Determine the level of evidence (levels 1-8) Step 2B.Critically assess each article for quality of design & methods Step 2C.Determine the direction of the results/statistics Step 2D.Cross-tabulate by level, quality and direction; combine & summarize ************ Step 3. Determine the Class of Recommendation

35. Nov. 9, 2006EPIC QI WorkshopSlide 35 The ILCOR Consensus Process Step 1: State the Proposal “To create a new guideline encouraging the use of continuous positive airway pressure (CPAP) or positive end expiratory pressure (PEEP) during neonatal resuscitation in the delivery room, particularly for very premature infants.”

36. Nov. 9, 2006EPIC QI WorkshopSlide 36 Step 1A.Refine the research question(s) During the resuscitation of very premature infants the use of CPAP will reduce the baby’s oxygen requirements and the need for ventilation. The use of either CPAP or PEEP during the resuscitation of very premature infants at birth will reduce the proportion requiring oxygen when they reach the equivalent of 36 weeks gestation. The ILCOR Consensus Process

37. Nov. 9, 2006EPIC QI WorkshopSlide 37 The ILCOR Consensus Process Step 1B.Gather the evidence Search with MESH headings all fields: CPAP AND resuscitation limited to the first 28 days, PEEP AND resuscitation limited to the first 28 days, neonatal resuscitation, delivery unit AND resuscitation. Cochrane database of systematic reviews.

38. Nov. 9, 2006EPIC QI WorkshopSlide 38 The ILCOR Consensus Process Step 2: Assess the quality of each study Step 2A.Determine the levels of evidence

39. Nov. 9, 2006EPIC QI WorkshopSlide 39 The ILCOR Consensus Process Step 2: Assess the quality of each study Step 2A.Determine the levels of evidence

40. Nov. 9, 2006EPIC QI WorkshopSlide 40 The ILCOR Consensus Process Step 2: Assess the quality of each study Step 2B. Critically assess each article for quality of design & methods

41. Nov. 9, 2006EPIC QI WorkshopSlide 41 The ILCOR Consensus Process Step 2: Assess the quality of each study Step 2C. Determine the direction of the results/statistics

42. Nov. 9, 2006EPIC QI WorkshopSlide 42 The ILCOR Consensus Process Step 2: Assess the quality of each study Step 2D. Cross-tabulate by level, quality and direction; combine and summarize

43. Nov. 9, 2006EPIC QI WorkshopSlide 43 The ILCOR Consensus Process Step 2: Assess the quality of each study Step 2D. Cross-tabulate by level, quality and direction; combine and summarize

44. Nov. 9, 2006EPIC QI WorkshopSlide 44 The ILCOR Consensus Process Step 3: Determine the class of recommendation

45. Nov. 9, 2006EPIC QI WorkshopSlide 45 Converting the scientific recommendations into clinical implications. Ultimately, no recommendation was made to use CPAP on its own as a means of resuscitating babies. The ILCOR Consensus Process Conclusion(s)

46. Nov. 9, 2006EPIC QI WorkshopSlide 46 Common sense. Inadequate or no evidence. Practised in centres with best outcomes. “Informal” methodologies

47. Nov. 9, 2006EPIC QI WorkshopSlide 47 Questions???