Healthcare Associated Infections (HAIs) are the fourth leading cause of death in the USA. About 1.8 million patients suffer annually from care-related infections. HAIs cause 99,000 deaths every year in the US alone, at a cost of $3.1 billion dollars in excess healthcare costs in acute care hospitals. Besides HAIs kill more people than AIDS, breast cancer and auto accidents combined. It is estimated that 271 people died each day from healthcare-associated infections (HAIs) such as Methicillin-resistant Staphylococcus aureus (MRSA) infections. Which is equivalent to one airline crash per day.

1. Krish Sankaranarayanan MS, MBA, CPHQ
Senior Safety Officer, Tawam Hospital. UAE

2. Introduction-About me
•
•
•
•
•
Been in healthcare domain for over 24 years.
Triple Masters degree.
MS in Patient Safety Leadership from UOI- Chicago.
Certified Professional in Healthcare Quality (CPHQ)
Educational consultant- Canadian Healthcare
Association- Risk Management & CQI program
• Member Patient Safety Task Force- American Society
for Healthcare Risk Management
• 2009-Received $ 10,000 scholarship from IHI to attend
the Patient Safety Executive Development Program at
Boston.
• Noted regional and international speaker “Culture of
Safety” and “Disclosure of Medical Errors.”

3. Introduction-About me…Contd
• Membership
–
–
–
–
–
Member American College of Healthcare Executives
Member National Association of Healthcare Quality
Member American Society for Healthcare Risk Management
Member American Society of Professionals in Patient Safety
Vice President of the ACHE Middle East and North Africa Group
• Publication
–
–
–
Gurdeep S. Dhatt, Hassan Abu Damir, Steven Matarelli, Krishnan Sankaranarayanan, and
David M. James “Patient safety: patient identification wristband errors”. Clin Chem Lab Med.
2011 May;49(5):927-9. Epub 2011 Feb 3.
Krishnan Sankaranarayanan, Steven A. Matarelli, Hasrat Parkar, and Mamoon Abu Haltem
“From Blame to Fair and Just Culture: A Hospital in the Middle East Shifts Its Paradigm.”
PSQH. 2013 July/August; pg 30.
Krishnan Sankaranarayanan and Steven A. Matarelli, “Putting a SMILE on the Culture of
Safety frame work.” Arab Medical Hygiene 2013 October; pg 28

4. Pledge

5. Items for discussion
• Ice breaker
– Video: Capt. Chesley "Sully" Sullenberger
• Why is healthcare unsafe?
– Healthcare Associated Infections Definitions
– Facts and figures
• Tools & Techniques to prevent
Healthcare Associated Infections
2013-10-18
5

6. Ice- breaker
Capt. Chesley "Sully" Sullenberger- Video

7. 2013-10-18
7

8. Hippocratic Oath
5th century BC -Physicians and other healthcare professionals swearing to
practice medicine honestly

9. Florence Nightingale -The founder of modern nursing
1863-“the very first requirement in a Hospital is that it should do the sick no
harm

10. Dr. Ernest Codman
1905 started "end result idea.“ Hospital standardization.
Doctors should follow up with all patients to assess the results of their treatment
and that the outcomes actively be made public.

11. How is it that aviation became safer than
healthcare ???

13. High Reliability Organizations
Zero compromise to safety

14. So……Why is healthcare unsafe?

16. The patients saw an average of 17.8 health
professionals during their hospitalization1
1Whitt
N, Harvey R, McLeod G, Child S. How many health professionals does a patient see during an average hospital stay? NZMJ 4
May 2007; Vol 120 No 1253

17. Healthcare Associated Infections- HAIs

18. Healthcare Associated Infection- Definition
• The World Health Organization
– Health care-associated infection (HCAI), also
referred to as "nosocomial" or "hospital" infection,
is an infection occurring in a patient during the
process of care in a hospital or other health care
facility which was not present or incubating at the
time of admission.
• Centers for Disease Control and Prevention
– Healthcare-associated infections (HAIs) are
infections that patients acquire during the course
of receiving treatment for other conditions within a
healthcare setting

19. FACTS And FIGURESU.S. Hospital-Acquired Infections
• HAIs are the fourth leading cause of death
in the USA.2
• 1.8 million patients suffer annually from carerelated infections.
• HAIs cause 99,000 deaths every year
• HAIs cost $3.1 billion dollars in excess
healthcare costs in acute care hospitals
alone.
• HAIs kill more people than AIDS, breast
cancer and auto accidents combined
2www.cdc.gov/ncidod/dhqp/healthDis.html

20. FACTS And FIGURES• 271 people died each day from healthcareassociated infections (HAIs) such as Methicillinresistant Staphylococcus aureus (MRSA) infections.
• Equivalent to one airline crash per day

21. World Health Organization
• WHO estimates that HAIs results in3
– Prolonged hospital stays
– Long-term disability
– Increased resistance of microorganisms to
antimicrobials
– Massive additional costs for health
systems
– High costs for patients and their family,
and
– Unnecessary deaths.
3http://www.who.int/gpsc/country_work/burden_hcai/en/

22. Healthcare Associated Infection- HAI
• Central line Associated Blood Stream
Infection- CLABSI
• Surgical Site Infection-SSI
• Cather Associated Urinary Tract
Infection-CAUTI
• Ventilator Associated Pneumonia -VAP

23. Dangerous environment
Spread of infection- Video

25. Tools & Techniques
To Prevent Healthcare Associated
Infections

26. Accreditation programs -Seeking gold standards

27. Patient Safety Goals

30. Technology support
Hand sanitizer dispenser
Sharps disposal box

31. Antimicrobial Stewardship
• Antibiotic stewardship refers to a set of
coordinated strategies to improve the
use of antimicrobial medications with
the goal of enhancing patient health
outcomes, reducing resistance to
antibiotics, and decreasing
unnecessary costs.
• The Infectious Diseases Society of America
(IDSA)
• http://www.antimicrobialstewardship.com/

32. Are these tools and techniques sufficient to
prevent & eliminate HAIs?

33. Building a Culture of Safety
2013-10-18
33

34. Johns Hopkins Medicine
Comprehensive Unit-based Safety Program (CUSP)
6-step safety program
Step 1: Safety Attitude Questionnaire (SAQ)
Step 2:Staff education on the Science of Safety
Step 3: 2-item Staff Safety Survey
▪ Please describe how you think the next patient in your unit/clinical area
will be harmed?
▪ Please describe what you think can be done to prevent or minimize this
harm?
Step 4: Executive Walk Rounds
Step 5:
a) Learning from defects
b) Improving teamwork and communication
Step 6 : Resurvey staff about Safety Culture (annually)
2013-10-18
34

35. Twelve CUSP units
2013-10-18
35

36. Culture linkages to Clinical, Operational & other
Outcomes4
•Wrong Site Surgeries
•Decubitus Ulcers
•Delays
•Bloodstream
Infections
•Post-Op Sepsis
•Post-Op Infections
•Post-Op Bleeding
•PE/DVT
•RN Turnover
•Absenteeism
•VAP
4Colla
•Burnout
•Unit size
•Communication
breakdowns
•Familiarity
•Spirituality
JB et al. 2005. “Measuring patient safety climate: a review of surveys.” Qual Saf Health Care, 14:364–366
36

37. HAI- Central Line Associated Blood Stream Infection
(CLABSI)
• CLABSI
– Attributable mortality: 9-25%5
– Attributable cost: $25,000-$45,0006
– Of patients who get a bloodstream infection
from having a central line, up to 1 in 4 die.7
• CMS Medicare and Medicaid no longer pays
hospital for CLABSI
5Dumont,
C. & Nesselrodt, D. 2012. Preventing CLABSI: Central line-associated bloodstream infections. Nursing2012, 6.
N, Weinhold D, Tong E, et al. Effect of healthcare-acquired infection on length of hospital stay and cost. Infect
Control Hosp Epidemiol 2007;28:280–292.
7CDC Vital Signs. Making healthcare safer: reducing bloodstream infections. March 2011. Available at:
http://www.cdc.gov/VitalSigns/Issues.html
6Graves

38. CLABSI Prevention Techniques5
1. Wash Hands Prior to Procedure
2. Use Maximal Barrier
Precautions
3. Clean Skin with Chlorhexidine
4. Remove Unnecessary Lines
5. Avoid Femoral Lines
5Dumont,
C. & Nesselrodt, D. 2012. Preventing CLABSI: Central line-associated bloodstream infections. Nursing2012, 6.

39. Lessons from aviation- Use of checklists

41. Central line insertion checklist

42. Central line maintenance checklist

43. Electronic Checklist

44. Other techniques
• Chlorhexidine Bathing
• Chlorhexidine Impregnated Sponges and
Antisepctic Coated Catherters.8
• Alcohol-impregnated disinfection caps
8Timsit
JF, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of
catheterrelated infections in critically ill adults: a randomized controlled trial. JAMA 2009;301:1231–1241

45. ICU -VAP & CLABSI
Ventilator Associated Pneumonia -ICU
Infections/1000 device days
20
18
16
14
12
10
8
6
4
2
0
ICU Average Rate for VAP Bundle
Compliance
17.3
5.5
4.2
5.3
2.3
2006
2007
2
2008
2009
2011
2010
1.8
2012
97
96
95
94
93
92
91
90
89
88
96
91
2011
Ventilator Associated …
ICU Average Rate for CVL Bundle Compliance
Infections/ 1000 device days
Central Line Associated Blood Stream
Infections - ICU
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0.8
0.7
2012
93
94
92
90
0.5
88
86
86
84
82
2010
2011
2012
Rate/1000 device days
2011
2012

46. NICU -VAP & CLABSI
Ventilator Associated Pneumonia -NICU
1.2
7
6
1
0.8
0.6
0.3
0.2
0
0
Infections/1000 device days
Infections/1000 device days
1
0.4
Central Line Associated Blood Stream
Infections -NICU
6
5.9
5
3.6
4
3
2
1
0
2009
2010
year
2011
2009
2010
year
2011

47. Following High Risk Industry Model
Replicating the same for
CLBASI Free Days

48. NNU CLABSI Free Days
48

49. PICU CLABSI Free Days
49

50. ICU CLABSI Free Days
CUSP Team with the ICU Executive - COO
50

51. PICU & ICU- CLABSI Free Days

52. CLABSI- Conversation tool 9, 10
1.
2.
3.
4.
5.
What is the prevailing CLABSI rate in the unit?
What is the CLABSI rate goal for the unit?
Do providers routinely use head-to-toe drapes?
How many drapes were used to cover the patient from head -to-toe?
Does the unit have a guideline to remove femoral catheters as soon as
possible?
6. What is the level of compliance from providers?
7. Does the unit have guidelines to check on a daily basis whether lines can be
removed?
8. Does the unit have a central line insertion checklist? Do providers routinely
use the checklist?
9. Does the unit have a central line maintenance checklist? Do providers
routinely use the checklist?
10. When inserting a central line, do staff have access to line cart and
equipment’s that they need?
9Pronovost
PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation.
BMJ2008;337:963-5
10Tools for Reducing Central Line-Associated Blood Stream Infections. January 2012. Agency for Healthcare Research and
Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum- tools/clabsitools/index.html

53. CLABSI- Conversation tool……contd
• To increase staff awareness
• To ensure staff active involvement
• To ensure conscientious implementation

54. “I Watch The Line” Campaign- Video

56. Opportunities for improvement
“I Watch The Line”- Campaign
• To increase staff awareness
• To ensure staff active involvement
• To ensure conscientious implementation
ICU
NNU
PICU
56

57. CLABSI Badge Competition

58. Discussions- Simple strategies

59. Simple strategies to prevent Healthcare Associated
Infections
• Strict hand hygiene before and after contact with
each patient or their environment
• Adequate hand hygiene facilities for staff and
patients
• A clean hospital environment and good hygiene
practice
• Isolation of patients in single rooms, when
necessary, to reduce the risk of infection
• Careful prescription of antimicrobial drugs
• Training on infection prevention and control for all
staff

60. Five moments of hand hygiene

61. Complete the pledge

62. Thank You
Email- ksankara@tawamhospital.ae Cell # 050 9211649