Il risk management nelle infezioni ospedaliere Nicola Petrosillo ...
Transcript of Il risk management nelle infezioni ospedaliere Nicola Petrosillo ...
Il risk management nelle infezioni ospedaliere
Nicola Petrosillo
Istituto Nazionale per le Malattie Infettive“Lazzaro Spallanzani” - Roma
Il risk management in sanità rappresenta l’insieme di varie azioni complesse messe in atto per migliorare la qualità delle prestazioni sanitarie e garantire la sicurezza del paziente, sicurezza basata sull’apprendere dall’errore.
Errore: componente ineliminabile della realtàumana; fonte di conoscenza e miglioramento per evitare il ripetersi delle circostanze che hanno portato l’individuo a sbagliare e mettere in atto iniziative che riducano l’incidenza di errori
Risk management in sanità
Min. Sal.-Dip. Qual. – Comm. Tecn Rischio Clin (DM 5/3/03)
Il risk management, perché sia efficace, deve interessare tutte le aree in cui si può manifestare durante il processo clinico assistenziale del paziente.
Gestione integrata del rischio.
Risk management in sanità
Min. Sal.-Dip. Qual. – Comm. Tecn Rischio Clin (DM 5/3/03)
D. Formisano. R. Emilia 2005
Pittet D et al. Int J Infect Dis 2006; 10: 419-24
Infectious diseases consultation: impact on outcomes for hospitalized patients
and results of a preliminary study.
Classen DC, Burke JP, Wenzel RP. Clin Infect Dis 1997; 24:468-70
•496 cases (seen by an ID consultant) were matchedwith 3,117 controls.
•Cases had longer lengths of hospital stays, longerintensive care unit lengths of stays, and higherantibiotic costs than did matched controls, and if the consultation occurred in the last one-third of hospitalization, cases had shorter lengths of hospital stay and lower antibiotic costs than did controls.
Sandora TJ, et al. Infect Control Hosp Epidemiol 2005;26:417-20
Error incidence density of 4.8 errors per 100 patient-days;
Lo E, et al. Clin Infect Dis 2004;38:1212-8
80% compliance rate
85% adherence tocrucial recomm
Higher when therapyinstead of diagnosis
if was legible andorganized
Ragioni per una non aderenzaalle lineeguida di controllo
delle infezioni
In primo luogo, si deve riconoscere chel’umanità, non è stata sempre in accordo con la razionalità.
Ragioni per una non aderenzaalle lineeguida di controllo
delle infezioni
...lo spirito è pronto, ma la carne èdebole…
Matteo 26.41
Ragioni per una non aderenzaalle lineeguida di controllo
delle infezioniMuch of the population has regularly failed tocomply with public health recommendationsagainst:•smoking•drinking and driving•driving without seatbelts•driving too rapidly through dense fog•experimenting with drug abuse
MMWR 1999;48:1-156
Tipo di infezione
N° studi Contesto Periodo Effetto intervento
(riduzione %) Tutte 10 Ospedale (5),
Chirurgia (2), Pat.Neonatale (1), Chir+ICU (1), Ostetricia (1)
1987-98 Mediana 29% (11-55%)
Ferita chirurgica
1 Cardiochirurgia 1991-94 34%
VAP 4 ICU 1987-98 Mediana 54,5% (38-70%)
CVC-BSI 8 Ospedale (1), ICU (5), NICU (2)
1992-2000 Mediana 54% (14-71%)
UTI 2 Ospedale, ICU 1992,1997 46%, 66%
Harbarth S, J Hosp Infect 2003
Una quota significativa di infezioni Una quota significativa di infezioni èè prevenibileprevenibile
Il controllo
Preventing ventilator-associatedpneumonia in adults: sowing seeds of
change.•Multiple risk factors for VAP involve complexhost factors and ubiquitous pathogens thatrequire several different types of preventionstrategies.
Prevention efforts should focus on •reducing bacterial colonization, •and limiting aspiration, •antibiotic exposure, •and use of invasive devices.
Craven DE. Chest 2006;130:251-60
La prevenzionedel rischio infettivo in ICU
nel singolo paziente
rivolta all’equipe
la prevenzione nel singolo paziente:
- il miglioramento di condizioni patologiche di base
- la sorveglianza delle colonizzazioni in pazienti selezionati
- la soppressione della flora endogena che potenzialmente potrebbe divenire responsabile di eventi infettivi a rilevanza clinica
e quella rivolta all’equipe che ruota intorno al paziente critico:
- misure di igiene e antisepsi, - le misure di barriera nelle condizioni
standard e negli isolamenti specifici, - le procedure per contenere la diffusione di agenti infettivi multiresistentio altamente diffusivi
- strategie di politica antibiotica.
Alp E, Voss A. Ann Clin Microbiol Antimicrob 2006;5:7
Perioperative Glucose Control• 1,000 cardiothoracic surgery patients• Diabetics and non-diabetics with hyperglycemia
Patients with a blood sugar > 300 mg/dL during or within 48 hours of surgery had more than 3X the likelihood of a wound infection!
Latham R, et al. Infect Control Hosp Epidemiol. 2001.
•A combination of topical and systemic prophylacticantibiotics reduces respiratory tract infections and overall mortality in adult patients receiving intensive care.
•A treatment based on the use of topical prophylaxisalone reduces respiratory infections but not mortality.
•The risk of occurrence of resistance as a negative consequence of antibiotic use was appropriatelyexplored only in the most recent trial by de Jonge whichdid not show any such effect.
Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care.
Liberati A, et al. Cochrane Database Syst Rev 2004;(1):CD000022.
Pan A et al. Infect Control Hosp Epidemiol 2005;26:127-133
Antibiotic usage in intensive care units: a pharmaco-epidemiological multicentre study
Malacarne P et al. JAC 2004; 54:221-4
153 had sepsis
164 pts (20.9%)
979 pts in 43 ICU
Combination 31%Mean duration 3d
3rd gen. cephal. 42%Mean duration 4.6d
Antibiotic Policies in Italian Hospitals: Still a Lot to Achieve
Moro ML, Petrosillo N, Gandin C. Microb Drug Resist 2003;9:219-22.
• Questionnaire survey (2000): response rate 80% (428/535)
• Hospital formulary 89%• Hospital pharmacy committee 73.1%
(50% met at least one in 1999)• Written justification for a list of AB 41.4%
(No. of antibiotics in the list 7 [1-49])• Hospitals with periodical pharmacy reports->54%• Data on DDD - 12%• Written protocols for surgical prophylaxis 37%
Ventilator Associated Pneumonia (VAP)
• Patients with VAP
– Mortality up to 46%– Additional days of mechanical ventilation
– 14.3 (VAP) vs 4.7 days (no VAP)
– Longer ICU stay – (11.7 vs 5.6)
– Longer hospital stay– (25 vs 14 days)
– Additional charges - $40,000
Ibrahim EH, Chest. 2001 Aug;120(2):555-561.Rello J. Chest 2002 Dec: 122: 2115-21
*Rate of Ventilator Associated Pneumonia (VAP) in the Intensive-Critical Care
• Coronary 4.4 0 - 9.8• Medical 4.9 0.5 - 8.9• Surgical 9.3 2.2-17.9• Neurosurgical 11.2 0 – 16.8• Trauma 15.2 4.3-25.3
Pooled Mean Range
•Expressed as incidence density of VAP/1000 ventilator days. •Source: NNIS Report, Jan 1992-June 2004. Am J Infect Control 2004;32:470-85.
Guidelines on Prevention of Ventilator Associated Pneumonia
• US Centers for Disease Control & Prevention (CDC) 2003
• US Agency for Healthcare Research & Quality 2001 • American Thoracic Society/Infectious Disease
Society of America, 2005 • Canadian Critical Care Society, 2004
Guidelines differ in the strength of the recommdations
• Available studies• Study designs/results• Types of publications accepted• Interpretation of the results• Expertise of committee members• Judgement
Collard HR et al. Ann Intern Med 2003;138:494-501.
Continuous aspiration of subglottal secretions (CASS)
• Meta-analysis of CASS1– 50% reduction in incidence of VAP – 3 days less in intensive care united– Delayed onset of VAP by 6 days
• Randomized controlled trial of both semi-recumbent position and continuous subglottic suctioning– No difference in colonization
1 Dezfulian Am J Med 2005; 118:11-182 Girou Intensive Care Med; 2004; 30:225-33
Continuous aspiration of subglottal secretions Comparison of Recommendations Based on Strength of the Evidence
1 US Centers for Disease Control and Prevention, 20032 Agency Healthcare Research & Quality 20013 American Thoracic Society/Infectious Disease Society of America, 20054 Canadian Critical Care Society, 2004
AHRQLevels 1-3
CDCLevels 1-3
ATS-IDSALevels 1-3
CanadaLevels 1-3
3- Lowest 1-Highest 1-Highest 2 Medium
Surveillance of Ventilator Associated Pneumonia (VAP) to
Evaluate Control Measures• Intervention:
– Daily assessment for weaning
– Targeted sedation
– 45 degree head of bed elevation
– Use of sulcralfate– Small enteral
feedings
0
2
4
6
8
10
12
14
Baselineperiod
InterventionPeriod
VAP casesper 1000ventilatordays
Baynes PS. Impact of NNIS surveillance on device-associated infection ratesin medical ICU. Fourth Decennial Int Conf on Nosocomial Inf. Mar 2000.
New Approach to Prevention of VAP
• Rather than focus on each individual evidence-based practice….Implement them as a “bundle” or group
• Improved outcome
Bundling of Evidence-Based Practices
• Evidence-based practices• Implemented in a series or group• Have better outcomes than when
implemented individually
The “Ventilator Bundle”
• Elevation of the head of bed (30-45º)• Consider daily interruption of sedation and
assessment of readiness to extubate• Consider stress ulcer prophylaxis (high
risk patients*)• Deep Vein Thrombosis (DVT) prophylaxis
(unless contraindicated)
*Respiratory failure, shock, coagulopathy
Elevate Head of Bed 30-45oCan Prevent VAP
• Randomized controlled trial• Patients supine - 23% VAP• Patients semi-recumbent – 5% VAP
Drakulovic MB Lancet 1999; 35 (9193): 1851
Feasibility and effectiveness of semi-recumbent vs prone
positioning
• Compare supine (<10 degrees) vs semi-recumbent (45 degrees)
• Results:– 45 degrees -only 15% of time during study– Difference in VAP rate - not significant
Groups similar in enteral feeding, stress ulcer prevention, duration of ventilation
Van Nieuwenjoven Critical Care Med 2006; 34(2): 559-61
Collard HR et al. Ann Intern Med 2003;138:494-501.
Daily reduction in sedation and assess readiness to discontinue ventilator
• Randomized controlled trial• “Sedation vacation” and daily assessment
to remove from ventilator• Reduction in duration of ventilation from
7.3 days to 4.9 days
Kress JP N Engl J Med 2000; 342 (20): 1471
Stress Ulcer Disease Prophylaxis
• H2antagonists – elevates pH and decreases gastric
colonization by pathogens• Sucralfate
– allows less gastric colonization with pathogens without changing pH
• H2 blockers preferable to sucralfatebecause of lower risk of GI bleeding
Cook D N Engl J Med 1998; 338: 791
Collard HR et al. Ann Intern Med 2003;138:494-501.
*Comparison of Recommendations for Prevention of VAP
CDC; AHRQ; ATSCDC; AHRQ; ATS--IDSA; CanadaIDSA; Canada
Semi Recumbent position
Stress ulcer prophylaxis
Daily sedation interruption
AHRQ2CDC1
ATS IDSA3 Canada4
2 - High3 3 --LowestLowest 11-- HighestHighest 3- Highest
4-LowUnresolved 1-Highest Not recommended
1 US Centers for Disease Control and Prevention, 20032 Agency Healthcare Research & Quality 2001Greatest; 3 American Thoracic Society/Infectious Disease Society of America, 20054 Canadian Critical Care Society, 2004
2-Medium
Level 1-3 Level 1-5 Level 1-3 Level 1-3
- -
St. Lukes Hospital Jacksonville FLVAP rate after implementing
Ventilator bundle
Burger and Resar (Ltr to Editor) Mayo Clin Proc June 2006 81 (6):849
Success Reported120 participating ICUs in 70 hospitals in
Michigan Keystone Project
• Implemented BSI and VAP bundle, and• Daily goals and multidisciplinary roundsRESULTS• 68 of 120 ICUs - ZERO VAP for > 6 mos• SAVED
– 1500 lives; 81,000 hospitals days – $166 million
FROM: Michigan Hospital Association (MHA) Keystone Project press release: Oct 15, 2005
Surgical Infection Prevention
Surgical Site Infections (SSI)
• 2 to 5% of operated patients will develop SSI – 40 million operations annually in the U.S.– 0.8 - 2 million SSI’s occur annually in the U.S.
• SSI increases LOS in hospital – average 7.5 days
• Excess cost per SSI:– *$2,734-26,019 (1985, US$)– US national costs: $130-845 million/year
*Jarvis, Infect Control HospEpidemiol. 1996;17.
1. Preparazione del paziente Identificare e trattare tutte le infezioni prima degli interventi elettivi, posticipare l’intervento fino alla risoluzione dell’infezione
• Evitare la tricotomia a meno che i peli nell’area di incisione non interferiscano con l’intervento
• Se necessaria, eseguirla prima dell’intervento e utilizzando rasoi elettrici • Controllare la glicemia nei pazienti diabetici; non iperglicemia nel perioperatorio • Incoraggiare la cessazione del fumo o non fumo nei 30 giorni precedenti • Non negare gli emoderivati ai pazienti chirurgici con lo scopo di prevenire ISC • Far eseguire al paziente una doccia o un bagno con antisettico la notte prima • Lavare e pulire accuratamente l’area della incisione per rimuovere le
macrocontaminazioni prima della antisepsi del campo operatorio • Utilizzare una appropriata preparazione antisettica per la cute 2. Preparazione dell’equipe chirurgica • Tenere le unghie corte ed evitare l’uso di unghie artificiali • Effettuare il lavaggio chirurgico con antisettico per 2-5 minuti. Lavare mani e
avambracci fino ai gomiti • Dopo essersi lavati, mantenere le braccia e le mani in alto e lontane dal corpo in modo
da far scolare l’acqua dalle dita verso i gomiti. Asciugare con un telo sterile e indossare guanti e camice sterili
3. Gestione del personale sanitario colonizzato o infetto • Istruire e incoraggiare il personale della sala operatoria che presenti eventuali
segni/sintomi di malattie trasmissibili a segnalarlo prontamente • Mettere a punto protocolli specifici per l’allontanamento o la riammissione dal lavoro in caso
di infezione trasmissibili del personale di sala operatoria • A scopo precauzionale, allontanare dal lavoro il personale con lesioni cutanee
essudative e ottenere colture appropriate della lesione Non escludere dal lavoro personale colonizzato con Staphylococcus aureus o Streptococco di gruppo A, in assenza di dimostrata relazione epidemiologica con i casi
Misure pre-operatorie di prevenzione delle infezioni della ferita chirurgica secondo la Linea Guida dei
CDC, 1999
Misure intraoperatorie, CDC 19991. Sistemi di ventilazione • Nella sala operatoria mantenere aria a pressione positiva rispetto ai locali adiacenti • Garantire almeno 15 ricambi l’ora di cui 3 di aria fresca • Filtrare tutta l’aria, ricircolante e fresca, con filtri appropriati • Far entrare l’aria dal soffitto e farla uscire dal pavimento • Non usare raggi ultravioletti in sala operatoria per prevenire ISC • Tenere le porte della sala operatoria chiuse 2. Pulizia e disinfezione dell’ambiente • In caso di contaminazione visibile del pavimento, di superfici o attrezzature con sangue o altri
liquidi biologici pulire prima del successivo intervento utilizzando un disinfettante approvato dalla apposita commissione locale
• Non effettuare interventi speciali di pulizia/chiusura della sala dopo int. contaminati/ sporchi • Non usare tappetini adesivi all’ingresso dell’area operatoria 3. Campionamento microbiologico ambientale • Non effettuare campionamento di routine. Ottenere campioni ambientali dell’aria e delle
superfici della sala operatoria solo nel contesto di specifiche indagini epidemiologiche 4. Sterilizzazione degli strumenti chirurgici • Sterilizzare tutti gli strumenti chirurgici secondo protocolli approvati • Ricorrere alla sterilizzazione “flash” solo per gli strumenti da riutilizzare immediatamente 5. Indumenti e teli chirurgici • All’ingresso della SO indossare mascherina, cuffia o copricapo • Non indossare soprascarpe allo scopo di prevenire le ISC • Indossare i guanti sterili, farlo dopo aver indossato un camice sterile • Usare camici e teli che mantengano efficacia di barriera anche quando bagnati • Cambiare l’abbigliamento chirurgico se visibilmente sporco o contaminato con sangue o altro 6. Asepsi e tecniche chirurgiche • Norme di asepsi se si posiziona catetere vascolare, anest. spinale o epidurale o farmaci e.v. • Manipolare i tessuti con cura, eseguire una buona emostasi, rimuovere i tessuti devitalizzati Portare la ferita a guarigione “per seconda intenzione” se il sito chirurgico è contaminato Laddove sia necessario un drenaggio, utilizzare un drenaggio chiuso. Posizionarlo attraverso incisione separata e distante dalla incisione chirurgica. Rimuovere il drenaggio appena possibile
7. Medicazione della ferita • Proteggere le ferite chirurgiche per 24-48 ore con medicazioni sterili • Lavarsi le mani prima e dopo aver effettuato la medicazione o aver toccato il sito chirurgico
Surgical Care Improvement Project
Performance measures - Process• Surgical infection prevention
• Antibiotics» Administration within one hour before incision» Use of antimicrobial recommended in guideline» Discontinuation within 24 hours of surgery end
• Glucose control in cardiac surgery patients• Proper hair removal• Normothermia in colorectal surgery patients
Single vs Multiple Dose Surgical Prophylaxis: Systematic Review
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Impact of Prolonged Antibiotic Prophylaxis
• 2,641 CABG patients– Grp 1 - < 48 hours of antibiotics– Grp 2 - > 48 hours of antibiotics
• SSI Rates– Grp 1 - 8.7% (131/1502)– Grp 2 - 8.8 % (100/1139)
• Antibiotic resistant pathogen - Grp 2– Odds Ratio 1.6 (95% CI: 1.1-2.6)
Harbarth S, et al. Circulation. 2000.
Hyperglycemia and Risk of SSI after Cardiac Operations
• No increased risk:Elevated HgbA1cPreoperative hyperglycemia
• Increased risk:Diagnosed diabetesUndiagnosed diabetesPost-op glucose > 200 mg% within 48h
Latham. Inf Contr Hosp Epidemiol. 2001;22:607Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604
Hyperglycemia and Risk of SSI after Cardiac Operations
• Hyperglycemia - doubled risk of SSI
• Hyperglycemic:48% of diabetics12% of nondiabetics30% of all patients
• 47% of hyperglycemic episodes were in nondiabetics
Latham. Inf Contr Hosp Epidemiol. 2001;22:607Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604
Perioperative Glucose Control• 1,000 cardiothoracic surgery patients• Diabetics and non-diabetics with hyperglycemia
Patients with a blood sugar > 300 mg/dL during or within 48 hours of surgery had more than 3X the likelihood of a wound infection!
Latham R, et al. Infect Control Hosp Epidemiol. 2001.
Furnary et al. Ann Thorac Surg 1999:67:352
Glucose Control and Deep Sternal Wound Infections
Shaving and SSI
Pre-operative shaving
• Shaving the surgical site with a razor induces small skin lacerations– potential sites for infection– disturbs hair follicles which are often colonized with S.
aureus– Risk greatest when done the night before– Patient education
• be sure patients know that they should not do you a favor and shave before they come to the hospital!
Hair removal
Prospective trial in pediatric neurosurgery ptsfound similar infection rate in children who hadthei hair shaved and those who did not.
Tang K, et al. Pediatr Neurosurg2001;35:13-17
Retrospective cohort study in neurosurgery: shaving of head hair prior to surgery did notreduce the rate of SSI vs pts who had their hairspared (shampoo 4% chlorexidine within 24 h)
Bekar A, et al. ActaNeurochir2001;143:533-6
Electrically clipped pts had 1/3 lower rate of mediastinitis than those manually shaved(OR: 3.25 95%CI 1.11-9.32)
Ko W, et al. AnnThorac Surg1992;52:301-5
Switching from razor shaving to clipper removalrate of deep sternotomy SSI 1.2 0.2rate of venectomy site SSI 1.6 0.4
Sellick JA, et al. Infect Control HospEpidemiol 2004
StudyAuthors/ref
Influence of Shaving on SSI
No HairGroup Removal Depilatory Shaved
Number 155 153 246
Infection rate 0.6% 0.6% 5.6%
Seropian. Am J Surg 1971; 121: 251
Shaving, Clipping and SSI
Cruse. Arch Surg 1973; 107: 206
% Infected
00,5
11,5
22,5
Shave Clip Neither
Hair Removal Techniques and SSI
% Infection
0
4
8
12
PMRazor
AMRazor
PMClipper
AMClipper
CleanClean-Contam
Alexander. Arch Surg 1983; 118: 347
Shaving vs ClippingCardiac Surgery
Number Infected (%)
Shaved 990 13 (1.3%)
Clipped 990 4 (0.4%)
p < 0.03
Ko. Ann Thorac surg 1992;53:301
Temperature Control
• 200 colorectal surgery patients– control - routine intraoperative thermal care
(mean temp 34.7°C)– treatment - active warming (mean temp on
arrival to recovery 36.6°C)
• Results– control - 19% SSI (18/96)– treatment - 6% SSI (6/104), P=0.009
Kurz A, et al. N Engl J Med. 1996.
Also: Melling AC, et al. Lancet. 2001. (preop warming)
Some see things as they areand ask why.[Others] see things as theyshould be and ask why not
John F. Kennedy
Hospital-acquired infections in Italy: a region wide prevalence study
- inappropriate use -
Zotti CM et al. J Hosp Infect 2004; 56:142-9
• Glycopeptides: enterobacteria, Ps. aeruginosa, MSSA
• 3rd and 4th gen. cephalosporins: enterococci
• 3rd generation cephalosporins: 35% in surgical prophylaxis
• Glycopeptides: 5% surgical prophylaxis (only 26.4% -prosthetic device – complied with GL)
• Clean surgery: 512 pts (30.9%) received prophylaxis
• Mean duration of surgical prophylaxis: 3.1 d (31% more than 4 d)
Paterson DL. Clin Infect Dis 2006; 42:S90-5
Antibiotic policy in the hospital setting
a. Implementation of educational programmes on use of antimicrobial agents (including pharmacokinetics and pharmacodynamics);
b. Establishment of guidelines and antibiotic audits for an evidence-based and standardized use of
antimicrobials;
c. Identification of those procedures that need and do not need antimicrobial prophylaxis either for surgical or non-surgical purpose (select the drugs for prophylaxis which are not needed for subsequent therapy);
Petrosillo & Struelens, ESCMID 2002
Antibiotic policy in the hospital setting
d. Implementation, with human and economic resources, of an antibiotic restriction programme, and identification of antibiotic molecules that need restriction;
e. Adoption of antibiotic cycling strategies, for empiric therapy, in “hot” hospital zones and based on local antibiotic resistance surveillance system programmes, better defining the molecular basis of antibiotic resistance;
f. Establishment of cost-effective surveillance systems using existing laboratory generated data.
Petrosillo & Struelens, ESCMID 2002
Use of a Front-End Approach as a Means to Decrease Antimicrobial
Resistance
antimicrobial cycling.
Paterson DL. Clin Infect Dis 2006; 42:S90-5
need for preapprovalbefore the administration
of restricted agents,
use of special antimicrobialrequest forms,
Pittet D et al. Int J Infect Dis 2006; 10: 419-24