Quality Improvement in Reducing Infection:

An Example from Edinburgh

Claire L Smith

Consultant NeonatologistNeonatal Unit,The Simpson Centre for Reproductive Health, Royal Infirmary of EdinburghClaire.l.smith@nhslothian.scot.nhs.uk

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

Late Onset Neonatal Infection

Is reducing late onset infection a realistic aim?

• The optimal strategy for LOI reduction is uncertain• Learn from what other people are doing

Good Data Matters

• 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

Our experience in Edinburgh

• 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

Definitions

• Late onset infection: infection after day 3 of life • Pathogen or Fungal• Coagulase negative staphylococcus: 5 days of

antibiotics, accompanying clinical/laboratory signs

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

Late onset organisms

618

101

312

20

20

40

60

80

100

120

Group

B st

rep

Gram

nega

tives

CONS

staph

aure

us

enter

ococc

usot

her

Organisms

Nu

mb

ers

Comparison with VON<30 weeks OR < 1500g

VON SCRH

Any late infection

18% 38%

Bacterial pathogen

10% 14%

Coag Neg Staph

10% 26%

Fungal 2% 0%

Infection became our priority for improvement.

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

• 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

Actions

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 2010PC Ng et al. Arch Dis Child Fetal Neonatal Ed 2004Pessoa-Silva et al. Infect Control Hosp Epidemiol 2004

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 1998Lu P-L et al. BMC Infectious Diseases 2009

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 2013 132: e1664

Feeding

• Promotion of early enteral feeds• Lactation support• Use of donor EBM

Early enteral feeds > reduced use of lines and PN

Blood culture technique

• Closed technique• Butterfly needle and syringe• Sterile pack and gloves• Skin prep

Antibiotic policies

• Automatic stop orders• Use of CRP• Revised empirical treatment based on local

sensitivities• Reduction of use of drugs requiring venepunture

for monitoring

Staff

• Regular staff feedback

• Monthly run-chart displayed in NNU

Percentage of VLBW infants with LOI

0

5

10

15

20

25

30

35

40

45

Jul1

1-D

ec11

Au

g11

-Jan

12

Sep

11-F

eb12

Oct

11-M

ar12

No

v11-

Ap

r12

Dec

11-M

ay12

Jan

12-J

un

12

Feb

12-J

ul1

2

Mar

12-A

ug

12

Ap

r12-

Sep

12

May

12-O

ct12

Jun

12-N

ov1

2

Jul1

2-D

ec12

Au

g12

-Jan

13

Sep

12-F

eb13

Oct

12-M

ar13

No

v12-

Ap

r13

Dec

12-M

ay13

Jan

13-J

un

13

Feb

13-J

ul1

3

Mar

13-A

ug

13

Ap

r13-

Sep

13

May

13-O

ct13

Jun

13-N

ov1

3

Jul1

3-D

ec13

6 month date range

Per

cen

tag

e o

f V

LB

W in

fan

ts w

ith

LO

I

6M Any

6M CONS

6M Pathogen

6M Fungal

CONS target

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

Cases of suspected infection

0

100

200

300

400

500

600

700

800

2010 2011 2012 2013 2014

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

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

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

Any Questions?

claire.l.smith@nhslothian.scot.nhs.uk