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December 2009

Best Care Always! – a collaborative quality initiative for best

practice and patient safety

I looked up synonyms for ‘collaboration’ and found the words ‘teamwork’, ‘partnership’, ‘group effort’; ‘alliance’ and ‘cooperation’ . It has indeed taken all of these to bring us to the point we have reached with the Best Care Always! campaign. As of the 15th of November, 137 hospitals have formally signed up to implement one or more of the Best Care Always! infection prevention bundles and at the same time they have agreed to develop the capacity to measure the impact of the interventions on patient outcomes. The initial focus areas of the campaign were chosen against the background that healthcare-associated infec-tions (HAIs) - such as those caused by the use of ventilators, central lines, catheters or surgery - are among the most common and serious adverse events in hospitals across the world, with nearly 1 in 10 hospital admis-sions related to these infections. Together with increasing antibiotic resistance, HAIs are a signifi cant contributor to patient morbidity and mortality. There is nothing new in recognizing the important role that quality improvement interventions can play in delivering positive patient outcomes. Health organisations and health practitioners in South Africa already individually share a vision of providing best care to every patient. Most also all agree that

the interventions themselves and the ele-ments of the bundles are not particularly new. So why a campaign called Best Care Always! when there is nothing really new?There is in fact a lot that’s new about this campaign: • What is new is that different stakeholders within the private sector and between the private sector and public sector, have come together to explore ways in which we can work together to bring about improvements in day-to-day clinical practice for the good of all patients .• What is new is the decision to accelerate the pace, scale and spread of a set of best practices to improve patient care in specifi c targeted areas that are known to be impor-tant! • What is new is that we have agreed to share our learnings and help each other achieve the objective of best care to every patient every time. • What is new is to strive to implement all el-ements of each bundle to every patient every time, because those that say “we already do that” , when measured many do not do it all every time.• What is new is that clinical leadership or-ganizations in South Africa such as the Criti-cal Care Society, Infection Control Society, Anaesthesiologists Society and Federation of Infectious Diseases Societies have agreed to partner us to support implementation and the elevation of skills and knowledge of health professionals in the identifi ed areas. • What is new is that within individual units this work brings clinical teams together and creates the capacity, will and motivation for further improvement work . The success of the campaign will depend on our ability to sustain the goodwill that has been developed in these early stages . We are encouraged by the individual success stories that are already fl owing from hospitals so soon after our launch in August 2009. We are pleased to have three provincial Qual-ity Assurance leaders who have joined our task team as well as the endorsement from the National Department of Health for the

campaign. In true South African Ubuntu spirit, hospitals that had started this work earlier (based on the Insitute of Healthcare Improve-ment (IHI) 100K lives campaign) are reaching out to help those beginning now. Members of our advisory panel are working with the organizing task team to bring South African expertise and experience to the interventions which will further enhance acceptance of the evidence-based interventions. To succeed we will also need a good dose of innovation, courage and persever-ance. Innovation to fi nd new ways to tackle challenges, courage to cross barriers and perseverance to make it through the journey. Health practitioners and leaders will need to fi nd ways to integrate the work into existing care plans and routines. They will need to deal with the challenge of measurement as a way to bring facts to decision making. They will be required to transform skepticism to “can do” and they may also fi nd themselves explaining why the improvement work has increased previous infection rates – a result often experienced where trained staff im-prove surveillance. The Best Care Always! campaign rep-resents a step forward in creating leverage and synergy for quality improvement efforts through a process of collaboration. There are many other areas where a collaborative approach across healthcare organisations can accelerate progress. We hope this work provides a platform for both further quality improvement initiatives and additional paral-lel projects that support sustainable quality healthcare for all South Africans. A huge thank you to everyone that has made this work possible: the organizing task team, our sponsors, the advisory team members, the professional societies, the leadership in health care organizations at all levels and most of all the health profession-als rendering best care at the bedside. It is indeed a privilege to be on this journey with you all!Dena van den Bergh (Chairperson)[email protected]

Dena van den Bergh

[email protected] Phone: (011) 478-0156 Fax: (011) 478-0410

Antibiotic Stewardship – Q&A

NETCARE MILPARK HOSPITAL - ANTIBIOTIC STEWARDSHIP

Best Care…Always! at Netcare St Anne’s Hospital, Pietermaritzburg

What is it? Antibiotic stewardship is the responsible use of a critical and threatened health resource, namely the antimicrobial agents we depend on to prevent and treat infectious disease. Stewardship implies not only appropriate clinical decision-making for individual patients, but a population perspec-tive that maximizes overall benefits, minimiz-es adverse events and costs, and, important-ly, delays the onset of widespread microbial resistance to commonly used antibiotics.

Why is it needed? Antibiotic stewardship is urgently needed because of rising rates of antimicrobial resistance, a limited manu-facturing pipeline of new agents, and the morbidity burden and large costs associ-ated with disease that is improperly treated. The misuse of antibiotics is an international problem. Infections with multi-drug resistant organisms kill about 25,000 people a year in Europe and around 19,000 in the United States. South African figures are not known but we have the distinction of being a world leader in prevalence of gram-negative organ-isms with resistance (ESBL) to beta-lactam

antibiotics.What is our approach? Firstly, the Best Care…Always! campaign aims to raise awareness of antibiotic prescribing issues – highlighting both misuse, and appropriate use. Secondly it aims to test and implement a small set of defined interventions that measurably and positively impact the situ-ation. Among those interventions are: ICU prescribing rounds, the development of tools that both document and assist prescribing decisions, including guidelines, and the de-velopment of a team approach that supports the prescriber.

What about TB and HIV/AIDS? Although clearly the biggest infectious disease threats to our population, these epidemics are not currently the focus of the campaign or the antibiotic stewardship intervention. Clearly however, principles of good antimicrobial pre-scribing apply as much to TB and HIV/AIDS as to any other infectious disease.

Is there an antibiotic stewardship bundle? There is no antibiotic stewardship bundle, but

one output of the campaign may be some-thing resembling a bundle.Where is this happening? The stewardship intervention is to be piloted in the ICUs of a small number of hospitals, public and private, around the country.

Is this research or improvement? This component of the campaign differs from the infection prevention interventions in that what works is not fully established. In that sense, this is both a research and an improvement initiative. Once we have learned what works, it will be offered to other hospitals.

Is this about blocking access to antibiot-ics? No. The evidence suggests that limiting choice to only a few antibiotics may be coun-terproductive and that diversity is important. On the other hand, experts such as Prof Guy Richards and Dr Adrian Brink assert, “to delay the imminent end of the antibiotic era it may well be time now to challenge the right of doctors to prescribe whichever antibiotic they wish, including the dosage and dura-tion”. [SAMJ August 2008; 98(8):585]

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At Netcare Milpark Hospital a report on antimicrobial drug usage for inpatients is generated at day end. This report shows all antimicrobials issued to each patient since admission. It also shows the ward where the patient is located and provides information regarding duration of antimicrobial therapy. Where the same anti-microbial is issued 7 or more days after the first date of issue this is flagged.The antimicrobial report is delivered to each ward / ICU daily. It is available for the doctors on their rounds, to be used together by the infection control sister and doc-tor to review overall antimicrobial therapy to date, and, in conjunction with pathology results, to de-escalate or stop antimicrobial therapy when appropriate.This report has received very positive feedback as a tool to assist and guide the Doctors. It is updated daily and can be generated on demand for a particular ward / ICU; for a particular patient or for a particular antimi-crobial. The monitoring and appropriate adjustments in prescribing of antimicrobials based on pathology is essential to reduce the inappropriate use of a limited resourceThe cost implications of monitoring and potential savings by timeous intervention in therapy are huge. Importantly, a focus has also been made on prevention of infection rather than treatment with our “Bare below elbows” campaign and the “Hand washing” campaign.For more information on the Milpark daily antimicrobial report, contact:

Anthea [email protected]

The first time I spoke to the staff and doctors about the Best Care…Always! campaign, they appeared confused and disinterested in the initiative. How-ever, I persisted with talks at our PAB meetings, ICU forums, HOD meetings and also communicated the initiative via my newsletter. Our doctors and staff soon came to realise the benefits and the need to implement and evaluate our treatment outcomes. I am really excited about Best Care...Always! as I was nominated at FIDSSA in August to represent KwaZulu-Natal. I am in the process of initiat-ing the KwaZulu-Natal IPC Society with the help of Lesley Devenish, Joy Cleghorn and Andrew Whitelaw. We hope to launch Best Care…Always! on a large scale at the end of March 2010 and will target hospitals across KwaZulu Natal - public and private. I also serve on the Local AIDS Council and Lethal Communicable Disease (LCD) committee in Pietermaritzburg, both of which are also great platforms to get the word out. Initially, I decided to introduce smaller projects within the hospital. Hand hygiene is by far the most important principle of Infection Prevention and con-cept behind Best Care…Always!. So, I ran with hand hygiene drives of which we accomplished four during 2009, including a poster competition on the “5 Moments of Hand Hygiene”. Our ICU forum is headed by an anesthesiologist, Dr Mark Bainbridge, who, together with our team, has compiled an antibiotic surveillance document for ICU. Indeed, it is difficult to initiate antibiotic stewardship in an open ICU but it’s a start. We also have a user-friendly flow sheet for all microbiology reports and have implemented a document that tracks the days of ventilators, CVP lines, catheters, etc. I am currently working on a Best Care…Always! checklist that is short, concise and again, user-friendly for the staff. I will be happy to share copies of our newsletters and the documents we are trialing.

Shamane [email protected]

[email protected] Phone: (011) 478-0156 Fax: (011) 478-0410

Infection bundle compliance successes and learnings

Life Healthcare implemented the Surgical Site infections (SSI), Ventilator Associ-ated Pneumonia (VAP) and Central Line Associated Bloodstream Infection (CLABSI) bundles in 2007 and the CAUTI bundle in 2009. Regional workshops, involving hospi-tal Infection Prevention Coordinators and Unit Managers were held in April 2009 in order to progress this work and introduce compliance audits in intensive care units. As a result of the ongoing compliance audits in all our hospitals, bundle compliance can now accurately be tracked against infection rates. This provides valuable information for our infection prevention programmes and ensures the best possible outcomes for our patients. The data collected on CLABSI in Life Healthcare over that last three quarters clearly indicates the correlation between in-creased bundle compliance and decreasing infection rates. This trend supported trends reported internationally. The compliance in the fi rst quarter was 75% with an infection rate of 5.78. As a result of the focus on bundle compliance in our hospitals we have seen an increase in compliance to 84% with a substantial decrease in CLABSI to below three. Based on the average infection rate of 2.67 achieved in quarter two and three, we have achieved a 54% decrease in CLABSI. The trends are shown in the graph below.

Achieving and maintaining these results requires substantial effort and teamwork. Below is a good example of learnings from the implementation of Central Line Associated Blood-stream Infection Bundle compliance audits from the Life Empangeni Gar-den Clinic in KwaZulu Natal.

Implementation actions:

• Initially educated and trained all staff on CLABSI bundle elements and principles of the audit.• Implemented daily rounds to moni-tor total bundle compliance using a “snap shot” approach, included physi-cal inspection of dressings and line placement. Made use of all teachable moments to ensure staff was well versed in bundle elements.• Implemented checklist placed into all central line packs to document compli-ance to elements such as handwashing, maximal barrier precautions, chlorhexidine and alcohol skin prep.• Revised documents to incorporate all as-pects of Best Care Always bundle elements. • Provided Unit Managers with their own daily audit tool.• Reinforced the aspects of the central line bundle during rounds in the units with direct follow up to UM to ensure effective commu-nication to multi-disciplinary team.

• Implemented more accurate documenta-tion to indicate the number of central line days with focus on earliest possible re-moval. Implemented daily tool for immediate monitoring of line days.

Lessons Learned

• Communication with the doctors specifi -cally should be extremely good and data well prepared in order to achieve improved compliance to bundle elements.• Obtain buy-in from nursing as early on as possible. It is critical to success. It is clear that Nursing staff are willing to implement bundle elements provided that they too are well informed regarding reasons for change and the logic behind steps being taken. • Be prepared to constantly teach bundle elements.• Make the changes as easy as possible for the nursing staff.

Challenges

• Some doctors remain resistant to change despite communication particularly relat-ing to maximal barrier precautions. Be prepared to change strategy in order to get buy in.• Implementing bundle elements is chal-lenging when a large number of agency staff is used as education and buy in is delayed when different agency staff is used often.

Belinda Naudé[email protected]

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The team: Belinda Naudé, Lizel Marillier, Busi Mdletshe, Talitha Aspeling

[email protected] Phone: (011) 478-0156 Fax: (011) 478-0410

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As SA moves into a new health-care era in which quality care and patient safety are becoming paramount to improve healthcare outcomes, a concerted effort by leaders and stakeholders in the healthcare industry to achieve these objectives should be wel-comed and celebrated. Medical Chronicle is therefore a proud supporter of the Best Care…Always programme, realising the immense impact it will have in reducing patient morbidity and mortality. In the next few months, Medical Chronicle will aim to inform and update doctors, nurses and everyone commit-ted to quality patient care on the implementation of the plan and its successes in improving patient safety and reducing adverse incidents.

Clinix Lesedi Hospital

Medi-Clinic Initiating Care Bundles

A sound hand washing technique is a cornerstone in the prevention of spread-ing an infection within a hospital and in the community. In acknowledging this fact Lesedi Private Hospital decided to join the worldwide campaign Save-A-Life – Clean your Hands on 5th May 2009. A through assessment was conducted by the Infection Control Team under the auspices of Sr Yolanda Saayman. As a result of this assessment a number of systems were implemented, e.g. the touch-less dispensers, in service practical and theoretic training and fun daysThe hospitals participation kicked off by a day of song and dance as well as hand washing technique demonstrations by Kimberley Clark. All disciplines and doctors were involved. All the hospitals in the Clinix Health Group participated in the National Infec-tion Control Week during the month of September 2009. At Lesedi the focus on handwashing intensified. The technique as well as the importance of hand washing was demonstrated through song dance and demonstration. The efficacy of the day

was measured by participants completing questionnaires. All disciplines in the hospi-tal won lots of prizes. Monthly in services sessions are conducted in accordance with the Clinix Group Policy and practical evaluations are performed. Successful participants receive prizes. These sessions became so popular in that even doctors and specialists freely participated.Kimberley Clark assisted the hospital in assessing the efficacy of all training programmes by conducting ultra-violet light testing. Thirty-eight staff members were randomly chosen for the audits. Thirty-one of the staff audited achieved a 100% compliance. The usage of the touchless systems and D-Germ handsprays in all areas have es-calated dramatically since the inception of the above mentioned programme – clearly indicative of an increased awareness : Save-A-Life – Clean your Hands Y Saayman / Helena BaardCell : 082 908 7558 / Fax : 086 570 7683

The many advances in surgical techniques, new medical innova-tions and treatment choices that abound means patients are spoilt for choice; however not so when acquiring a healthcare associ-ated infection. The compendium of antibiotics previously at one’s disposal to treat these complications of hospitalisation has dimin-ished. The micro-organisms are more pathogenic, resistant to many groups of antibiotics and pose an increasing challenge to health-care facilities. So, what if by applying simple elements, based on evidence, in a meaningful way, we could improve the outcomes of hospitalised pa-tients? Medi-Clinic is proud to be a part of the Best Care… Always campaign and had started with the implementation with the bundle approach in the critical care units prior to the birth of the campaign. In support of the company’s commitment to quality care, a training initiative to support the campaign has been developed to adapt to

the bundle approach of providing care. As with all initiatives this is a campaign that is treading new ground in bringing all role players of healthcare together. Behind the scenes there is much preparation: the development of Training Material, informing all role players and stakeholders via commu-niqués on progress, standardising terminology and measurement instruments, to name but a few aspects. To co-ordinate this initiative within Medi-Clinic a Task Team is at the helm steering all aspects, in turn reporting to the National Industry Task Team on a monthly basis. As with all initiatives challenges abound, but the commitment to this initiative is steadfast…because it is the right thing to do!

Andrea Haakestad Mobile: 079 109 6588

For further information:www.bestcare.org.za

Contact details:[email protected]

Phone: (011) 478-0156 Fax: (011) 478-0410

[email protected] Phone: (011) 478-0156 Fax: (011) 478-0410