1. Quality Improvement in Reducing Infection: An Example from Edinburgh
Claire L Smith
Consultant Neonatologist
Neonatal Unit,
The Simpson Centre for Reproductive Health,
Royal Infirmary of Edinburgh

2. Neonatal infection: the significance
Is infection reduction a realistic target?
The importance of data
The Edinburgh experience
Costs
Challenges
An ongoing journey

3. Late Onset Neonatal Infection

5. Is reducing late onset infection a realistic aim?

6. The optimal strategy for LOI reduction is uncertain
The Incidence of LOI varies widely
Neonatal unit culture and practices differ
The optimal strategy for LOI reduction is uncertain
Learn from what other people are doing

7. Good Data Matters

8. How can you be sure you are doing something well if you don’t measure it?
Is anyone doing better- who are they and what are they doing differently?
- Definitions
Benchmarking
Sharing experience

9. Our experience in Edinburgh

10. We thought we were doing OK.
We paid attention to infection control.
We measured our infection rates.
Hard to compare with literature: definitions
The infection rates were fairly static
Then we joined VON….. and benchmarked

11. Definitions Late onset infection: infection after day 3 of life
Pathogen or Fungal
Coagulase negative staphylococcus: 5 days of antibiotics, accompanying clinical/laboratory signs

12. Rate of late-onset BSI VLBWs in 2010
106 admissions
40 had at least one episode of sepsis
31 had 1 episode
7 had 2 episodes
2 had 3 episodes
CLABSI rate 23 per 1000 line days

13. Other = candida x 1 and pneumococcus x 1
Therefore 71% of all late onset infection in our NNU is CONS, again this appears to also be the case in other NNUs

14. Comparison with VON <30 weeks OR < 1500g
SCRH
Any late infection
18%
38%
Bacterial pathogen
10%
14%
Coag Neg Staph
26%
Fungal 2% 0%

15. Infection became our priority for improvement.

16. Neonatal QIP 2011-13 Convened MDT Review of QI literature Set targets
CoNS infection rates down to 5%
Zero transmission of MRSA
Zero MSSA bloodstream infections
Zero fungal infection
Actions
Implementation of practice change
Audit

17. Actions Improved hand hygiene
Expand concept of individual patient environment
Reduce environmental reservoirs
Stop movement of babies around unit
Bathing and skin care
Insertion and maintenance of peripheral and central lines
Promotion of early enteral feeds with human milk
Ventilator (nCPAP) associated pneumonia prevention
Urinary catheter care
Antifungal prophylaxis
Insist on closed system for taking cultures
Improved antibiotic stewardship
Improved staffing levels
Staff feedback

18. Hand hygiene and Patient Handling
Hand washing and alcohol gel
Gloves for every patient contact
in NICU (staff)
CoNS skin carriage among NICU staff:
likely cause for cross transfer of virulent strains
References:
V Hira et al. Journal of Clinical Microbiology 2010
PC Ng et al. Arch Dis Child Fetal Neonatal Ed 2004
Pessoa-Silva et al. Infect Control Hosp Epidemiol 2004
Bare below elbows
Hair tied back
No lanyards
Blues
No stethoscopes round neck

20. Environment: border control
Each baby has their own cot space: only enter if really necessary
Hand gel when entering and leaving cotspace
Dedicated pens/calculators/stethoscopes
No paperwork moved between spaces
Washable keyboards
References:
G French et al. Lancet 1998
Lu P-L et al. BMC Infectious Diseases 2009

21. Lines Line insertion bundle: aseptic checklist, 2 person technique
Line maintenance bundle – aseptic and non touch technique
Cannulae – sterile pack, sterile gloves
Skin preparation
Limit use of central lines
References:
D Fisher et al. Pediatrics : e1664

22. Feeding Promotion of early enteral feeds Lactation support
Use of donor EBM
Early enteral feeds > reduced use of lines and PN

23. Blood culture technique
Closed technique
Butterfly needle and syringe
Sterile pack and gloves
Skin prep

24. Antibiotic policies Automatic stop orders Use of CRP
Revised empirical treatment based on local sensitivities
Reduction of use of drugs requiring venepunture for monitoring

26. Staff
Regular staff feedback
Monthly run-chart displayed in NNU

27. Percentage of VLBW infants with LOI

28. Cost Many of measures low/no cost Staff Funding in this area important
Antibiotic bill has reduced significantly
Fewer blood tests for antibiotic levels
Reduced number of suspected infections

29. Cases of suspected infection

30. Going forward Continued data monitoring
Changing the way we present data
In depth case review of all cases of CLABSI
Random Safety Audits
Periodic staff awareness drive – staff feedback is important

31. Key Challenges Measurement is key Staff awareness and engagement vital
Time
Neonatal team dedicated and go the extra mile time and again – individual capacity
New ways of working to incorporate patient safety and quality improvement into everyday practice.
Share workload and avoid duplication

32. Conclusions
QI initiatives can have a large effect size on reducing late onset infection
Improved outcomes were accompanied by significant cost savings
Our experience with this QI initiative has been invaluable in taking forward other QI initiatives in our NNU
Continued measurement important

33. Any Questions?