Clean Culture - Reducing Healthcare Associated Infections

Greater Southern Area Health Service

Abstract

Increased incidence of infections in 2006, together with poor infection prevention practices, were noted. Reducing the diversion of funds from patient care to a preventable problem was identified as a priority opportunity.

A project team was tasked with reducing Healthcare Associated Infections (HAIs) and the resulting associated cost of treating these.

The rates and expenditure on specific HAIs together with their prime causes were identified.
Strategies to reduce HAI incidence were implemented, and achieved the following within ten months:

• 51 fewer infections/colonisations
• $238,000 saved
• 63% fewer infections
• education increased understanding and focus on infection control practices
• Sample survey identified a 10.91% improvement in hand hygiene (HH) compliance
• implementation of cleaning audits
• audit of surgical antibiotic prophylaxis and restricted antibiotics planned.

Aim

To reduce HAI and Methicillin Resistant Staphylococcus Aureus (MRSA) colonisations in GSAHS patients by 30% and save $300,000 by June 30, 2008.

Nature of the Problem

7-10% of patients in Australia (NSW Health HAI Reduction Program, October 2007) develop a preventable HAI and these are a major cause of morbidity, mortality and unnecessary expenditure (NSW Health Policy Directive 2007_084).

The estimated annual cost to the health system nationally for HAI is $268 million.

During July to December 2006, GSAHS identified a peak in the incidence of infections in hip and knee replacements, lower uterine segment caesarean sections (LUSCS) procedures and MRSA infection/colonisations. The total cost of treating these consumed $531,000.

Focus reviews identified a number of human and system factors as the causes contributing to these HAIs.

Extent of the Problem

Monitoring of infections identified an increased incidence in specific infections across GSAHS in 2006 (26 surgical site infections, 86 MRSA colonisations/infections). This peak was 273% higher than the recorded average incidence of infections.

HAIs are recorded in the incident database which contains a number of HAIs in addition to those reported as part of the mandatory clinical indicator data collection.

Focus reviews at relevant facilities revealed various clinician practice, environmental and information gaps as prime causes of higher HAI rates.

A randomised patient survey identified the experience of patients acquiring a HAI to include increased hospital stay, depression, health decline and negative social effects on family and finances.

The actual expenditure in treatment of the specific HAIs in GSAHS was quantified and for some was more than twice the figure identified by NSW Health ($7,170). These actual costs have been used in modelling GSAHS savings.

Strategic Importance

The project contributes to the current Performance Agreement between the NSW Department of Health and GSAHS. In addition the project aimed to improve compliance with the following:

1. Infection Control Policy PD2007_036.
2. Infection Control Policy: Prevention and Management of Multi-Resistant Organisms (MRO) PD2007_084.
3. AS /NZS: 4360: 1999 Risk Management.
4. HB228: 2001 Guidelines for Managing Risk in Healthcare.
5. The ACHS Evaluation and Quality Improvement Program (EQuIP) Guide 4th edition.
6. NSW Health Patient Safety and Clinical Quality HAI Reduction Program.
7. NSW Health and GSAHS Patient Safety and Clinical Quality Program Performance Agreement 2007/08.

Planning and Implementation Solutions

A workshop was held to identify the prime causes which lead to the increased HAI rate within GSAHS. A cause and effect diagram was developed through a brainstorming session and from this information a Pareto graph was constructed to identify the 20% of causes, which created 80% of the problem.

• Staff - individual practice eg hand hygiene, antibiotic prescribing, knowledge.
• Environment - cleaning practices, occupancy rates.
• Management - policy, resourcing.
• Patient - co-morbidities, hygiene, obesity.
• Building/Equipment - aged, level of maintenance.
  

The team concentrated on strategies to resolve the most prominent causative factors. The following improvement strategies were agreed on and implemented to address the three leading causes:

1. Improve compliance with hand hygiene practices for staff involved in direct patient clinical care or treatment by 20% (71% - 85%) by June 2008.
2. Achieve 85% compliance with the level of intensity of cleaning clinical care areas corresponding to the functional area risks as detailed in the Infection Control Policy.
3. Achieve greater compliance with correct antibiotic prescribing in accordance with current Australian Therapeutic Antibiotic Guidelines.
4. Improve adherence to contact precautions for all Multi Resistant Organism (MRO) infections and colonisations.
5. Staff education regarding the significance of HAIs and MROs, costs involved, strategies required to reduce HAIs and MRO colonisations and the measures which will be used to assess progress in GSAHS.
6. Education of patients/clients and the wider community in the role that they can play in preventing HAIs and MRO colonisations.

Active implementation of the strategies occurred and the results were followed up, monitored and regularly reported to the Executive.

Infection Control Professionals (ICPs) delivered policy based education and provided infection reduction information to staff and patients.

There was a commitment by ICPs to provide prompt assessment, action and follow up on issues identified at facilities across the health service.

Clinical Pharmacists worked with doctors to identify antibiotic prescribing which did not follow better practice and provide information to achieve improved compliance with the Australian Therapeutic Antibiotic Guidelines.

Results for the first ten months of the project were reported to the Executive, the Area Quality Committee and are presented below.

Outcomes and Evaluation

The project is due for completion on June 30, 2008.

The following outcomes have been achieved during 10 months of the project:

• 51 (63%) fewer net infections.
• $238,000 saved.
• sample survey identified a 10.91% improvement in HH compliance.
• increased knowledge, understanding and focus of facility based ICPs on key infection control strategies and this is being spread to clinicians.
• development and implementation of environmental cleaning audits.
• annual audit of surgical antibiotic prophylaxis and review of restricted antibiotics is being undertaken with the results to be reviewed by the GSAHS Drug Committee.

It is acknowledged that a portion of the savings generated through reduced HAIs has been offset by increased usage of the recommended and more expensive antibiotics.

Increased detection of HAI’s may result from the closer focus on minimising HAIs and the surveillance of microbiology results.

Sustaining Change

Accurate reporting of HAI’s and compliance with infection reduction strategies will be achieved through the following:

• cohesive approach to infection control issues between management, ICPs and clinicians supported by the GSAHS Executive.
• close monitoring/auditing and relevant action in relation to infection reduction strategies.
• prompt assessment and management of infection outbreaks.
• infection control focus surveys.
• generalised and specific infection control education.
• continued collection and reporting of Clinical Indicators for HAIs.
• Continuation of the NSW Department of Health HAI Reduction Program.

Future Scope

• Transferability of the process and strategies is readily achievable within any health service.
• GSAHS is committed to supporting benchmarking partners throughout Australia.

Contact

This project was entered in the 2008 NSW Health Awards, Make Smart Choices about the Costs and Benefits of Health Services category.

More about the 2008 NSW Health Awards