The number of admissions in Thailand is ~6.2 million. With a prevalence rate of 6.4%, the estimated number of nosocomial cases was 396,800 cases with 26,586 deaths attributable to these infections in Year 2001.
Developed CLA-BSI วันที่ 10/3/2553 เชื้อ Escherichia coli = Dead ระยะเวลาในการคาสายสวน 21/62 วัน
ผลลัพธ์ของการรักษา: แรกรับ:ชายไทย รู้สึกตัวดี ไม่มีอาการ ปวดมึนศีรษะ ไม่มีรอยจ้ำเลือดที่ใด ก่อนกลับ: E1VtM1 pupil 2 mm แขนขา ไม่ขยับ หายใจ forced เสมหะปน bleed จางๆ จำนวนมาก urine ออกน้อย BP 75/45 แพทย์คุยกับญาติ no CPR เวลา 16.50 น. = DEAD
Were these CL-BSI deaths preventable ?
Causes of Death of Thai Physicians (1992-2001) No.=262 1= Cancers (35.1%) 1.1 Hepatoma (7.6%) 2= Heart Diseases (28.2%) 3=Accidents (12.6%) 4=Sepsis (3.4%) 5=Suicides (3.4%) Source: Sithisarankul P et al. Intern Med J Thai 2004;20:188-191
1000 post-mortem reports between 1975-1976 were analysed retrospectiveiy. In 6.3% of the patients, nosocomial infection was a contributory factor leading to death.
Nosocomial infection led to death in none of the 10 autopsied patients from the EENT Department and in none of 52 autopsied patients from the Department of Gynecology.
Year 2006, Admission Diagnoses,PSU Hospital RankDiseases Number of patients 1Senile cataract1,123 2Malignant neoplasm of bronchus and lung734 3Malignant neoplasm of breast576 4Malignant neoplasm of ovary483 5Intracranial injury445 6 Malignant neoplasm of liver and intrahepatic bile ducts442 7Malignant neoplasm of rectum415 8Malignant neoplasm of cervix uteri415 9 Maternal care for known or suspected abnormality of pelvic organs385 10Lymphoid leukaemia 331
Year 2006, Causes of Deaths, In-Patients, PSU Hospital RankCauses of Deaths No. of Patients 1Malignant neoplasm of bronchus and lung56 2Acute myocardial infarction51 3Other septicaemia38 4Intracerebral haemorrhage25 5Malignant neoplasm of liver and intrahepatic bile ducts22 6Diffuse non-Hodgkin's lymphoma20 7Aortic aneurysm and dissection18 8Chronic renal failure18 9Chronic ischaemic heart disease17 10Malignant neoplasm of cervix uteri16 11[HIV] disease resulting in15 infectious and parasitic diseases
“ติดเชื้อในกระแสเลือด มรณภาพ ”
“ There are substantially more nosocomial infections each year than hospital admissions for either cancer or accidents and at least four times more than admissions for acute myocardial infarction.”
The Inanimate Environment Can Facilitate Transmission ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL. X represents VRE culture positive sites
Is there any other national impact of nosocomial infections besides their impacts on mortality and economy???
HIV & OPD; T.B. OUTBREAK ST Vincent Hospital, Sydney, Australia O.P.D : Air conditioned treatment room September 1993 - One T.B. index case 91 HIVs followed for 7.4 mo. ( 1-14 mo.) 3 developed T.B. with identical RFLP All within 15 wks. of follow - up. Ref: Couldwell D.L. et al : AIDS 1996, 10-521
TB Prevalence/100,000 populations: Terms >1,000 = TB epidemic >100 = High risk for TB =<10 = Low risk for TB <1 = Entering the elimination phase 0.1 = TB eliminated
MDR –TB. OUTBREAKS- ? WHERE ? “ Enviroments where inmunocompromised persons are likely to be found, including health care facilities, homeless shelters and prisons. Virtually all MDR - TB. outbreaks have occurred in settings such as these.” Ref : Beck - sague C et al : JAMA 1992: 268 : 1280-1286
A hospital ward in Malaysia
An OPD. in a Thai provincial hospital
Is there any other example of the role of hospital as an amplification place for diseases???
Second Wave of Epidemic: in the Hospitals
Nosocomial transmission was the primary acceleration of SARS infections accounting for 72% of cases in Toronto and 55% of probable cases in Taiwan. Ref.: Booth CM et al. JAMA 2003;289:2801-9 CDC. MMWR 2003;52:461-6
EID 2004;10:782-788 Thirty- one cases of SARS occurred after exposure in the emergency room of the National Taiwan University Hospital.
“ Within 18 hrs of presentation, the patient was admitted to the ICU and 3 hrs later was placed in an isolation room.This 21-hr period of unprotected contact led to128 cases of SARS resulted from transmission of the virus within this hospital. (42% HCWs, 28% patients or visitors, and 30% household contacts). ”
An Overview of the 100,000 Lives Campaign Joe McCannon Vice President and 100,000 Lives Campaign Manager Institute for Healthcare Improvement November 15, 2006
Some Is Not a Number… Soon Is Not a Time The Number: 100,000 Lives The Time: June 14, 2006 – 9 a.m. ET
Campaign Objectives Save 100,000 Lives Enroll more than 2,000 hospitals in the initiative Build a reusable national infrastructure for change Complete implementation of the 6 Campaign interventions in participating hospitals by January 2007. Focus on spread and sustainability.
Six Changes That Save Lives Deployment of Rapid Response Teams…at the first sign of patient decline Delivery of Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack Prevention of Adverse Drug Events (ADEs)…by implementing medication reconciliation Prevention of Central Line Infections…by implementing a series of interdependent, scientifically grounded steps called the “Central Line Bundle” Prevention of Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time and taking several other associated actions Prevention of Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps called the “Ventilator Bundle”
The 100k Lives Campaign Scorecard Over 3,100 Hospitals Enrolled –Over 78% of all discharges –Over 78% of all acute care beds Participation in Campaign Interventions: –Rapid Response Teams: 60% –AMI Care Reliability: 77% –Medication Reconciliation: 73% –Surgical Site Infection Bundles: 72% –Ventilator Bundles: 67% –Central Venous Line Bundles: 65% –All six: 39% Over 85% of Participating Hospitals Are Sending IHI Mortality Data
Did Needless Deaths Fall?
Additional Campaign Status Related campaigns forming nationally and globally (Canada, Australia, Sweden, Denmark) Changes in standard of care in participating facilities (over 25 hospitals going a year without a VAP)
Sources of Optimism: Hospitals with No VAP for One Year 1.Baptist Memorial Hospital Golden Triangle – Columbus, MS 2.Bay Regional Medical Center – Bay City, MI 3.BryanLGH Medical Center – Lincoln, NE [no VAP as of 3/2/06] 4.Caruya Baptist Memorial DeSoto – Southhaven, MS 5.Medical Center – Ithaca, NY 6.Columbus Regional Hospital – Columbus, IN 7.Community Hospital Anderson – Indianapolis, IN [one unit has not had a VAP in two years] 8.Community Hospital East – Indianapolis, IN [one ICU went 25 months with no VAP] 9.Dominican Hospital – Santa Cruz, CA [no VAP since 10/12/04] 10.Geneva General Hospital – Geneva, NY 11.McLeod Regional Medical Center – Florence, SC [ICU has gone 21 months as of April without a VAP] 12.Memorial Hermann Texas Medical Center – Houston, TX 13.Oconee Memorial Hospital – Seneca, SC 14.OSF Saint Francis Medical Center – Peoria, IL 15.Overlake Hospital Medical Center – Bellevue, WA 16.Palmetto Health Baptist – Columbia, SC 17.Passavant Area Hospital – Jacksonville, IL 18.Providence Milwaukie Hospital – Milwaukie, OR [no VAP since February 2004] 19.Ridgeview Medical Center – Waconia, MN [no VAP in 2.5 years] 20.Sentara Leigh Hospital – Norfolk, VA 21.Sentara Norfolk General Hospital – Norfolk, VA [one unit has not had a VAP in over two years] 22.Sentara Williamsburg Community Hospital – Williamsburg, VA 23.St. Luke’s Hospital East – Ft. Thomas, Kentucky 24.St. Luke’s Hospital West – Florence, Kentucky 25.University of Rochester Medical Center/Strong Memorial Hospital – Rochester, NY 26.Upper Chesapeake Medical Center – Bel Air, MD
1.Capitol Region Medical Center – Jefferson City, MO 2.Cooley Dickinson Hospital – Northampton, MA 3.Community Hospital East – Indianapolis, IN 4.Community Hospital Anderson – Anderson, IN 5.East Alabama Medical Center – Opelika, AL 6.Immanuel St. Josephs, Mayo Health System – Mankato, MN 7.Indiana Heart Hospital – Indianapolis, IN 8.Overlake – Bellevue, WA 9.Passavant Area Hospital – Jacksonville, IL 10.South Shore Hospital – South Weymouth, MA 11.Southwestern Vermont – Bennington, VT Sources of Optimism: Hospitals with No VAP for One Year
Sources of Optimism Pronovost Report from 70 Hospitals Working on Central Line Infections: Source: Peter Pronovost, Keystone ICU Project
Central Line Bundle Elements 1.1.Hand hygiene 2.2.Maximal barrier precautions 3.3.Chlorhexidine skin antisepsis 4.4.Optimal catheter site selection, with avoidance of using the femoral vein for central venous access in adult patients 5.5.Daily review of line necessity with prompt removal of unnecessary lines
Maximal sterile barrier includes the use of a cap, mask, sterile gown, sterile gloves, and a large sterile sheet, for the insertion of CVCs or guidewire exchange. Maximal sterile barrier precautions substantially reduces the incidence of CRBSI compared with standard precautions (e.g., sterile gloves and small drapes) Category IA Suggestion. CDC.Guidelines for the Prevention of Intravascular Catheter-Related Infections MMWR 2002;51(RR10):1-28
BMJ 2010;340:c309 doi:10.1136/bmj.c309
Pronovost Report from 70 Hospitals Working on Central Line Infections: –1,578 lives saved –81,020 hospital days saved –Over $165,000,000 in costs averted Source: Peter Pronovost, Keystone ICU Project
180 procedures/month Utilization ratio = 0.14 Average duration = 7.9 catheter-days Application of Collaborative Quality Improvement Programs to Reduce Incidence of Catheter-Related Bloodstream Infection Central intravenous catheter : PSU
5. โรงพยาบาล ม.อ.สามารถลด การติดเชื้อจากการใส่สายสวน central line ให้เป็น 0 ได้ 1. ได้ 2. ยังไม่ได้
Nosocomial Infection Rate 1985-1986, Thailand Hospital beds Rate (%) >700 15.2 400 – 700 4.1 <400 2.8 Ref.: Pinyowiwat W et al. National Surveillance on Nosocomial Infection : A Pilot Study Journal of the Medical Association of Thailand 2531 71 Suppl 1-4
Journal of Health Systems Research 2012;6:352-360