Quality improvement Intervention based

on Patients Safety Incident (PSI)

Infection Prevention and Control

Program

Overview of the presentation 1. Introduction

2. Background

3. Policy and Legislative framework

4. Purpose

5. Steps followed

6. Outcomes

7. Recommendations

8. Quality Improvement to mitigate PSI based on Recommendations

9. References

INTRODUCTION

• The department of Health, Dr Matsotso, introduced a PSI policy to guide against provision of unsafe and inappropriate practices

• By introducing a standardized system of identification and notification of PSI event so that they are investigated and acted upon to prevent reoccurrence

• The PSI is replacing SOPs that facilities had to use address adverse health events, in the absence of any policy

• Improving patients safety is becoming very popular in managing HAIs as these are in the list of PSI

Purpose and Scope of the Policy

The aim of the PSI policy

• To provide direction to the public health sector of SA regarding the management of patients safety incidents

• This policy directive applies to all incidents that occur in public health establishments of SA

• It is applicable to all staff

• Articulates mandatory reporting requirements, time frames for reporting, results of the investigation, roles and responsivities

Policy and Legislative Framework

This presentation is in line with:

• National Policy for Patient Safety Incident Reporting and Learning in the Public Health Sector of South Africa, 2016

• National Health Act of 2003 as amended

• WHO: IPC guidelines

• CDC guidelines

• NDOH: National Core Stands Policy: 2013

• National IPC Policy

• PDOH: Provincial IPC policy

• Constitution of the Republic of SA, Act 108 of 1996

Purpose of the Presentation

• To unpack the policy and its implementation in a clinical setting

• To use the policy to improve patients safety as a QI intervention in real life

• To share QI implemented for learning and sharing

Definition of Quality Improvement according to

Norms and Standards

• QI is combined and continuous efforts by

health care providers and health facility to

make changes that would lead to:

1. Improved user outcomes and experience

2. Better performance

3. Better health provider development

4. Positive image of the HCE

Definition of Patient Safety Incident (PSI)

User safety incident” means an event or circumstance that:

1. Could have resulted, or did result in harm to a user, as a

2. Result of the health care services provided,

3. Not due to the underlying health condition

4. It can be a near miss, no harm or harmful incident (adverse event)

5. Can be coded as Severity Assessment Code

Steps to follow: Patient Safety Incident (PSI)

1. Identifying PSI 2. Immediate action taken 3. Prioritization 4. Notification 5. Investigation 6. Classification 7. Analysis 8. Implementation of recommendations 9. Learning

Incident identification

Incident can be identified in different ways:

1. Health care professionals

2. Complain

3. Clinical audits results

4. Research

5. Safety audit walks (MBWA)

6. Other

.

THE INCIDENT (what happened)

• Increased HAIs due to blood borne infections

• Five babies with confirmed Klebsiella pneumoniae at the neonatal nursery in a regional hospital in SA

• Klebsiella p was isolated from blood culture

• Between 7/01/2016 and 11/01/2017

• Line list was used to describe the infected babies

LINE LIST AND IMMEDIATE ACTIONS NAME OF PATIENT DATE OF

BIRTH WEIGHT DIAGNOSIS BLOOD

RESULTS CONDITION OF BABY

WARD IPC INTERVENTION

Hosp. no.: 00072 Sex: female.

03.01.2017 0.975kg. *Prematurity @ 33/40. *Neonatal Jaundice. *Nosocomial sepsis. * RVD exposed.

Blood culture results on 11.01.2017: Gram –ve bacilli.

Stable on room air and I.V antibiotics.

NPN 1 - Baby isolated in an incubator. - Good bed spacing maintained at 2-3m square aisle width. - Hand hygiene practices re-inforced to both staff and Mothers. -Equipment and surfaces cleaned and wiped down with biotane 70% alcohol.

Hosp. no.: 00080 Sex: male.

03.01.2017 1.16kg *Prematurity @ 33/40. *Neonatal Jaundice. * Resp. Distress Syndrome -resolved. *RVD exposed.

Blood culture results on 07.01.2017: Klebsiella pneumoniae esbl+.

Stable on room air and I.V antibiotics.

NPN 1 - Baby isolated in an incubator. - Good bed spacing maintained at 2-3m square aisle width. - Hand hygiene practices re-inforced to both staff and Mothers. -Equipment and surfaces cleaned and wiped down with biotane 70% alcohol.

Hosp. no.: 00118 Sex: female.

05.01.2017 1.18kg *Prematurity. * Recession. *NNJ. *Suspected congenital sepsis. * RVD unexposed.

Blood culture results on 10.01.2017: Klebsiella pneumoniae esbl+. Sensitive to: imipenem, amikacin & Tazocin.

Stable on room air and I.V antibiotics.

NPN 1 - Baby isolated in an incubator. - Good bed spacing maintained at 2-3m square aisle width. - Hand hygiene practices re-inforced to both staff and Mothers. -Equipment and surfaces cleaned and wiped down with biotane 70% alcohol.

Hosp. no.: 912890. Sex: female.

23.12.2016 1.5kg *Prematurity @ 32/40. * Mild RDS. * NN Jaundice –resolved. * RVD unexposed.

Blood culture results on 09.01.2017: Klebsiella pneumoniae esbl+ (s) imipenem & amikacin.

Stable on room air and I.V antibiotics.

NPN 1 - Baby isolated in an incubator. - Good bed spacing maintained at 2-3m square aisle width. - Hand hygiene practices re-inforced to both staff and Mothers. -Equipment and surfaces cleaned and wiped down with biotane 70% alcohol.

5Hosp. no.: 0800135

01.01.2017 955g *Severe Prematurity @ 28/40. * Nosocomial sepsis. * Hyaline membrane disease.

Blood culture results on 09.01.2017: Klebsiella pneumoniae esbl+ (s) imipenem & amikacin.

Remained critically ill until baby demised on 13.01.2017

NNICU Was kept on mechanical ventilator machine until the last day.

Prioritization • The aim is to ensure that a standardized, objective

measure of severity is allocated to each incident • The severity assessment code must be used to prioritize

all notifications • The purpose of SAC is to determine the level of harm,

investigations needed and actions required • The degree of harm suffered as prediction is preferred

as “likehood to occur” is unreliable

• SAC 1, SAC2 and SAC 3

Classification by Prioritization

• The Severity Assessment Code (SAC) is used to prioritize all notification relating to PSI

- Class 1 = incidents with serious harm / death

- Class 2 = incidents with serous harm no death

- Class 3 = incidents that caused mild or no harm

INCIDENT NOTIFICATION

According to WHO, it is important to develop an alert system to improve patient safety. Report the PSI according to the Provincial protocol: All HAIs are reported with MIM (what? what? and why? and what? For Person, Patient and Period ) and immediate actions within 24hrs of the incident, to all three levels at the same time in one email to: 1. The facility EXCO: CEO, Nurse Manager and Medical manager 2. The District Office: District Manager and IPC Office 3. The Provincial Office: HOD and IPC USING section A for notification by Manager, Section B for statement by significant other

Underlying conditions

• Prematurity: born between 28 weeks and 33wks

• Low birth weight: between 955g, 975, 1160,1180, 1500, 2.2kg and 2.5kg

• All were RVD exposed

• Mode of deliveries: Mixed between NVD and C/S

• One was critically ill with hyaline membrane Dx

• The NN ward in use was a temporal structure since the NN was under renovation since 2015

Immediate action taken

1. Isolated all babies in one cubicle, with strict access control

2. Good bed spacing maintained at 2-3m square aisle width

3. Staff allocated to nurse isolated babies 1:5 due to staff shortage

4. All babies were breathing on room air, except one baby who was critical ill, on ventilation and later demised

Immediate actions…

- Hand hygiene practices re-inforced to both staff and Mothers.

- Strict care bundle strengthened to control further bloodstream infections

- All put on IV antibiotics according to sensitivity profile

Investigations

An analysis of the antibiograms revealed various different strains Kp was found in ambubag, iv pumps and used feeding cups

NOTE: A hospital outbreak is defined as the isolation of two or more organisms that are genotypic ally identical, clinically significant and epidemiologically linked. In the absence of genotyping, the organisms must belong to the same genus, species and have an identical antibiogram.

Investigation

All PSI are classified as:

1. Agents (Annexure A)

2. Incident type (Annexure B)

3. Incident outcome (Annexure C)

Classification by incident type and sub

classification

1. Clinical administration: without consent 2. Clinical process / procedure 3. HCAI: bloodstream, SSI, VAP, CAUTI, CD 4. Medication / IV fluids: wrong 5. Blood and blood product: e.g. reactions 6. Medical device: e.g. failure, malfunction, unavailability 7. Behavior: e.g. suicide, assault, sexual assault 8. Patient accidents: e.g. falls 9. Infrastructure: e.g. damaged, faulty, inadequate 10. Organizational resources: e.g. resource availability, 11. Other

Classification by agent 5 factor system

1. Staff factors: cognitive, performance, patho physiology,

social, psychological

2. Patient factors: cognitive, performance, patho

physiological, social, psychological

3. Work environment factors: Building

4. Organizational / service factors: Policy, procedure,

protocol, etc.

5. External factors

Safety Walk (MBWA)

1. Patient care

2. Communication

3. Medication

4. Inter transfer

5. Equipment

6. Staffing norms

7. Safety and security

8. Hygiene: staff, patient, hand, environmental control, etc

Root Cause Analysis (safety walk)

• Patient Care: Clinical audit, Results of Specimen collected met TAT, Care

bundle, iv fluids in the iv pump not labelled with date and time, not clear when it would be changed

• Medication: Antimicrobials prescribed correctly, no doses omitted

Communication: multidisciplinary team approach with open

communication, no missed orders

• Equipment: ambubag lying untidy and uncovered in the resuscitation

trolley

• Inter transfer: N/A

• Safety & Security: Properly identified, security guard at the entrance

Environment

• Hygiene of the patient: Patient clean, linen clean, own linen not used

• Hygiene of the staff: Hair tied short, nails of one staff long and painted with nail polish

• Hand hygiene: Inappropriate facilities exist, staff did not always observe 5

moments by WHO, lodger mothers did not observe HH

• Hygiene of the environment: Surfaces not very clean, dust accumulated in the window seals

• Waste : Not properly segregated, bins uncovered

• Linen Management: Properly managed and segregated

• Abbluition facilities: Clean, adequate toilet paper and hand wash facilities

Investigation To exclude if it was human error, at risk behavior

or reckless behavior “use 3Q&A”

• Did the employee intend to cause harm? NO

• Did the employee come to work drunk or equally impaired? NO

• Would another employee similarly trained and skilled in the same situation act in a similar manner? YES

• ORGANIZATION

Outcome Patient outcome: Moderate impact

Organization: Increased resources for the facility to accommodate improved patient care

Outcome: Just Culture Model (individual

vs system)

Three Questions Model used?

1. Did employee intend to cause harm? NO

2. Did the employee come to work drunk or equally impaired? NO

3. Did the employee knowingly and unreasonably increase risk ? NO

4. Would another similarly trained and skilled employee in the same situation act in a similar manner? YES

Outcome: Just Culture Model (individual

vs system)

Case was concluded within 60 days by the interim structure of IPC PSI Team as ff:

• The case has been investigated concluded with an outcome and recommendations

• The case is being sued and will be managed by court of law x

• The case has been referred to Labour Relations for further management x

Implementation of Recommendations

PSI Committees at various levels in the health system are responsible for ongoing monitoring to ensure that recommendations are addressed in a timely manner and to evaluate the success of any action taken to achieve improvement

• Facility

• District

• Provincial

Contributory Factors and Recommendations Challenges Recommendations Personnel and

Time frames Results

1.Overcrowding A cubicle that admits 8 neonates had 12 neonates; bed spacing >1

Patients in labour were re rooted to other facilities Build another cubicle

Immediately by OM IPC Maintenance CEO

Done

IV pump in use and not labelled

Shortage of IVAC pumps due to high usage

To label all iv lines and medications according to BCA

Immediately by OM IPC Staff

IVAC pumps now in use

3. Poor infant feeding practices

No proper designated space for decanting of feeds – milk kitchen,

Use milk bank for decanting and storage of EBM and baby formula, whilst the milk kitchen is being identified and built

Immediately by OM IPC Milk bank facilitator

Done

Contributory Factors and Recommendations Challenges Recommendations Time frames Results

Ambubags not kept clean and sterile after use in accordance with manufactures instructions

Guidelines in use provided inadequate cleaning and decontamination

Ambubags to be dissembled and sent to CSSD for cleaning and decontamination after each single use Review SOP

Immediately by OM IPCP, QAC, M&E CSSD Manager CEO, District and PDOH Teams

Done SOP developed

Medicine fridge cluttered with single use medication

To discard all single use medication and adhere to SOP

The fridge was defrosted and cleaned thoroughly. All single use medication discarded

Immediately by OM IPCP M and E Manger

Need to review the SOP

2. Poor hand hygiene

No HWF in the cubicle due to poor design I per 8

To install appropriate hand washing facilities and reinstall accessible EOHR at the entrance

Immediately by OM IPC Maintenance

Done

Analysis by data

The following statistical data must be recorded and submitted:

1. Classification of agents involved

2. Classification of incident type

3. Classification of incident outcome

4. Indicators for PSI

Analysis by indicators There are three indicators monitored

1. Patient Safety Incident case Closure rate = Total number of PSI cases closed in the reporting month x100 /

Total nr. of PSI cases reported in the reporting month x 100

2. PSI case closure within 60 working days Total number of PSI cases closed within 60days in the reporting month x 100 / Total number of PSI cases closed in the reporting month

3. Severity Assessment Code 1 (SAC1) incidents Total number of SAC1 incidents reported within 24hrs in the reporting month x 100 / Total number of SAC 1 incidents in the reporting month

Before After, work in progress

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References

• National Policy for Patient Safety Incident Reporting and Learning in the Public Health Sector of South Africa, 2016

• National Health Act of 2003 as amended

• WHO: IPC guidelines

• CDC guidelines

• NDOH: National Core Stands Policy: 2013

• National IPC Policy

• Constitution of the Republic of SA, Act 108 of 1996