Getting to Near Zero with Infection Prevention

00;00;03;09 - 00;00;41;01 Tom Haederle Hospital Acquired infections or ages are a stubborn problem, not easily eradicated even when the will and the tools are there to do it. Still, itchy eyes can be defeated. And today's guest, an epidemiologist at a major New York City hospital, is here to share how his organization did just that. Welcome to Advancing Health, a podcast from the American Hospital Association. 00;00;41;03 - 00;01;10;07 Tom Haederle I'm Tom Haederle with AHA Communications. The AHA’s Health Care associated Infection and Antimicrobial Resistance is a funded partnership with the Centers for Disease Control and Prevention. Through the project, the AHA has been listening to the field share its challenges and successes with infection prevention and control. Mount Sinai Beth Israel Hospital in New York City has recently enjoyed a great success on this front, getting to zero with three different ages. 00;01;10;09 - 00;01;27;16 Tom Haederle Dr. Waleed Javaid, epidemiologist and director of Infection Prevention and Control shares tried and true strategies that can be adapted by other health care organizations. He's in conversation with Marie Cleary Fishman. AJ is vice president of Clinical Quality. 00;01;27;19 - 00;02;00;10 Marie Cleary-Fishman Dr. Javaid so nice to see you here today. We appreciate you joining us for this very important conversation about hospital acquired infections. I know that this is an area that you are very involved in, and I want to start talking a little bit about this pre-COVID, during COVID, and kind of post-COVID for the future of where where we're going and the experience that you've had with Mount Sinai at Beth Israel Hospital and the folks who work so hard to take care of our patients there. 00;02;00;12 - 00;02;12;01 Marie Cleary-Fishman So if you could tell me a little bit about what you would do at the hospital pre-COVID in order to work to prevent hospital acquired infections for your patients? 00;02;12;03 - 00;02;42;25 Waleed Javaid, MD Thank you so much for having me this fall, and I do appreciate that the importance of hospital acquired infections has been recognized by American Hospital Association. It's really, really also important for all of us, including myself, to kind of recognize that these are harms to the patients that we prevent. That is really the goal. That's the real that's really what we, myself and my team, my leadership actually thinks about these infections. 00;02;42;27 - 00;03;06;17 Waleed Javaid, MD Not only that they do harm to our patients, but also they delay the discharge. They cause additional medications to be given, complicate the already difficult situation for our patients. So before COVID, that was really how we looked at all that eyes. And then that was the theme we looked at that as during COVID as well. But there were additional things. 00;03;06;20 - 00;03;32;15 Waleed Javaid, MD Before COVID, we would look at these as an aggregate of harm. Five people were harmed because of central line infections. Ten people are harmed because of this infection and that infection. And once you kind of recognize it from core of your heart, it is harmful for the patients, not usual. It's not okay to have hospital acquired infections. Once you do that, you start looking at, oh, you know what? 00;03;32;18 - 00;03;55;05 Waleed Javaid, MD We could have removed this fully earlier or this central line was not actually needed. Those are the things that we would look at in all these patients that we look at. We didn't start with zero rates. We started with a much higher rate when we had an infection. We will look at each and every infection. We'll talk with all the providers. 00;03;55;07 - 00;04;21;07 Waleed Javaid, MD And I know most of the people, most of the hospitals try to do similar, but they talk we have these are which are not meant to be punitive, but we try to get everybody, the frontline staff, the nursing, the physicians, the residents, the house staff as well, and talk freely about exactly what they think, not necessarily what do agree with what we think or what they think was a problem. 00;04;21;10 - 00;04;47;02 Waleed Javaid, MD Sometimes things would become a little bit more difficult to navigate in terms of, well, you know what? This may be happening or that. But within that, sometimes of a difficult conversation, a lot of opportunity lie. So when when it is not clear, that means there's a problem. We need to know our patients very clearly. I can give you so many examples. 00;04;47;09 - 00;05;10;24 Waleed Javaid, MD Like I remember like each and every action we did was based on some sort of issue. For example, we were asking people after every seven days, why does the patient have a central line? In one patient, they had an infection within five days. And in our RCA, in our root cause analysis, we found that the line could have been removed on day five. 00;05;10;27 - 00;05;39;29 Waleed Javaid, MD So we started asking people on day three, putting a central line in an acute lead acute hospital. People are very sick. Their heart might be declining sharply, and it's very hard to determine why the why would they need the central line, why would they need it and for how long? But it says that within three days that would be a fact, that's the practice we actually continue to today for the last four and a half years old, things like that. 00;05;40;02 - 00;06;05;17 Waleed Javaid, MD We had similar issues with urinary catheters and urinary catheters are notorious to get infected. There were patients we found that there were opportunities and sometimes people were thinking the catheter is removed, but it didn't. So we would look at those opportunities and fix and tune those opportunities and make sure they don't happen again. 00;06;05;20 - 00;06;51;02 Marie Cleary-Fishman So let me pause you for a minute there, doctor. I want to just call out. You've said so many important things in in that short amount of time, but I just want to call out a few of those things so that we don't lose the the really important points you made. One is that you seem to have indicated that no matter whether it was before COVID or during COVID, your leadership, including the team, the physicians, nurses at the bedside and the senior leaders, the CEO, the nurse, CNO, that all of those folks were on the same page with understanding that these things were harm to the patient and that they caused additional problems for the 00;06;51;02 - 00;07;18;18 Marie Cleary-Fishman patient, whether it be readmissions or longer lengths of stay. And I just want to point out, I think that that is a really important concept to pull from this conversation that we're having today, because not only is it important for all those people to be involved, but for them to all have a common understanding of what this means to me is really important for how this moves forward. 00;07;18;18 - 00;07;44;01 Marie Cleary-Fishman And we'll talk about it in just a few minutes, the success you've had across time with this. I think the other thing that I would want to call out that you mentioned as well is that you involve and listen to those that are at the bedside. So it's not just a group of outside folks who sit and come up with all of the ideas and suggestions. 00;07;44;08 - 00;08;05;06 Marie Cleary-Fishman You go to the people at the bedside that are providing the care and doing the job and listen to what they're saying in order to work on. And I'm going to use this concept. I'm sure it will resonate with you. But to work on what are the structure issues, what are the process issues in order to get to the outcomes that you're looking for? 00;08;05;08 - 00;08;12;18 Marie Cleary-Fishman Is that a real summary of some of the things I heard in your in your comments? 00;08;12;21 - 00;08;52;29 Waleed Javaid, MD Absolutely. Like elaborate these a little bit at at different levels. For any organization to be successful, I think there needs to be an alignment from the frontline provider to the president or the CEO of the hospital about what the goals are with the institution, with the hospitals I work with. One of the best parts of this hospital, this organization, is the that we have a daily leadership call, which is very I know several hospitals do it, but it is unusual in many other healthcare settings. 00;08;53;02 - 00;09;16;09 Waleed Javaid, MD We do have a daily leadership call, and this is with all the leaders of all the departments throughout the hospital. So I have the hospitalist chief there. I have the infection control chief there, I have the hospital president there, but I have EDS there and also have our residency provider leadership there. I have a respirator be the chief. 00;09;16;11 - 00;09;47;29 Waleed Javaid, MD I have all the all the major nursing teams, all the major leaders, directors are in that leadership meeting. And that's exactly what I call it, the leadership meeting. But we actually bring a lot of issues to that leadership meeting depending on how how important those are. And from the get go, we were able to kind of establish a lot of a lot of conversation around the edges and have everybody think about these things similarly. 00;09;48;02 - 00;10;13;02 Waleed Javaid, MD So again, the leadership alignment and like having everybody on the same page: first thing. And second is engaging the first of front line providers is never easy. They are busy individuals, nurses, all of them are extremely busy. So we work around their schedule. It's not like I have a fixed RCA at 4 p.m. on Thursday that I'm going to have every time. 00;10;13;09 - 00;10;38;17 Waleed Javaid, MD No, no, no. We ask our nursing to schedule an RCA with the help of providers and whenever they can within a reasonable amount of time, we get them together and we have the support from our residency director as well. Whenever they tell us, okay, this has been our residents are available, we try to do that as much as possible, within reason that we have majority of these people available. 00;10;38;22 - 00;10;53;15 Waleed Javaid, MD And whenever that happens, whenever we have the right individuals in the call, it sounds really maybe too, too good to be true, but it really makes the makes the RCAs here a lot more meaningful and a lot more helpful. 00;10;53;17 - 00;11;08;09 Marie Cleary-Fishman And do you use the I know you've referred to using bundles previously. Do you use those bundles in those sessions or use the information from the bundles? And do you think that's been helpful? 00;11;08;11 - 00;11;41;04 Waleed Javaid, MD So absolutely. Bundles is part of our work, right? It's not all the work, but bundle this part or going back maybe 5 to 10 years. Almost all hospitals start to implement a lot of bundles. Some hospitals looked at the bundles and then looked at more opportunities. So they did bundles and added more things. Some hospitals implemented the bundles but may not be following up about looking at it the bundles, compliances being being done or not. 00;11;41;07 - 00;12;09;22 Waleed Javaid, MD And some hospitals like ours actually make sure bundles are the compliances there. So we make sure that we have checklists, that we do rounds on occasions and all on these RCAs is okay for central for for surgical side infections. Okay. Were the bundle elements meant for all these? Like make sure all these things are done appropriately are not so we look at our bundle compliance regardless of everything else. 00;12;09;29 - 00;12;35;19 Waleed Javaid, MD That is kind of like our baseline. In order to really go to the next step really is you have to have these bundles down. You have to make sure they are compliant. And I'm not saying that we find 100% times everything is done 100% times and no, but we look at these variations and we try to eliminate all these variations. 00;12;35;22 - 00;13;00;24 Marie Cleary-Fishman That's excellent. So so really the theme I'm hearing over and over again is this common understanding. And I think that's so important. But let me take you to COVID and the time where we are all dealing with that. What, if anything, changed or maybe worked differently during COVID for your team? I know that most of our hospitals dealt with staffing shortages. 00;13;00;24 - 00;13;20;15 Marie Cleary-Fishman They dealt with where families couldn't be at the bedside, which caused anxiety for folks. So what happened in your facility during COVID around these processes and that and, you know, were you able to continue these processes or how did you manage change that might have happened during that time? 00;13;20;18 - 00;13;46;09 Waleed Javaid, MD I think I want to start by saying I think COVID is probably the biggest tragedy in all of our collective life. Yeah. And I think we need to recognize that it really hurts me to think about the beginning, particularly when there was a lot of unknowns. But first few months ago, it was very difficult for us, for our staff and we are front line and infection prevention. 00;13;46;09 - 00;14;10;20 Waleed Javaid, MD So we were trying to prevent this from happening in our staff and our patients. So the focus there maybe move a little bit away. And we what we recognized was that we started having a central line infection control association. In fact, infection. We have this like, okay, what's happening? We had one. Then the second one, centerline infection. What's going on? 00;14;10;22 - 00;14;33;27 Waleed Javaid, MD I really want to highlight our are CMO. At that time she was like, What's happening? Hold me accountable. And I love that, right? So she would ask me and I'm like, okay, so, you know, all my staff is tied up. But then we saw you brainstorming what we can do, and we had shut down most of our outpatient practices because of the emergency mandate from the state. 00;14;33;29 - 00;15;03;12 Waleed Javaid, MD We had a lot of staff that now we were engaging into the hospital and asking and will give us a little bit more support by giving us a few nursing staff that otherwise would not be doing much to observe compliance to the bundles. And they kind of enhanced while my team was establishing the standards that we need to establish or needed to establish, they kind of helped us kind of bridge that gap a little. 00;15;03;14 - 00;15;24;23 Waleed Javaid, MD And we still owed a lot to them to help protect our patients. Those who are oncology nurses have been you are to look at the center lines, all that, and that's what we are. We were having issues, but that was that was then. But then like several years we knew where our weakness was. Our weakness was that we had critically ill people. 00;15;24;23 - 00;15;41;06 Waleed Javaid, MD We had higher than usual number of central lines and we had new nurses, traveling nurses. So we recognize all these things and established standards and practices and trainings with all these staff nurses as well. 00;15;41;09 - 00;16;02;23 Marie Cleary-Fishman And that's important. I know that a lot of folks had travel, travel staff or travel team members that they worked with. Did you have any practice that you did different with those traveling nurses, or staff, not just nurses, in order to get the bundles and the practices? That sounds like very much is the culture within your organization. 00;16;02;23 - 00;16;10;16 Marie Cleary-Fishman But now these folks are coming in from the outside and aren't part of that culture. So how did you manage that? 00;16;10;18 - 00;16;36;04 Waleed Javaid, MD So initially, as I said, like first few months of COVID are like, I don't even remember what we were doing. So many things going on. But then once we kind of recognize all these opportunities, we look at them as opportunities. Develop some education specific to the newcomers, to people who are coming to our institution, and then also like look at what we were educating people on. 00;16;36;06 - 00;16;53;04 Waleed Javaid, MD But then lastly, also recognize where our weakness was that that we need to not only rely on education, but also make sure that we monitor compliance at a much higher level. We know our weaknesses. We make sure that that is covered from on. 00;16;53;06 - 00;17;05;16 Marie Cleary-Fishman And I understand and you can correct me if I'm wrong on this, but your organization has achieved zero in CLAUTI or4 CLABSI and in some of these infection rates. Is that been possible for you? 00;17;05;18 - 00;17;22;26 Waleed Javaid, MD So we actually have a regular meeting that is called Destination Zero. It's an elusive destination is that there like those are those things I think about going to location on destination Z or that kind of that's. 00;17;22;26 - 00;17;24;22 Marie Cleary-Fishman A nice island, but hard to get there. 00;17;24;29 - 00;17;56;10 Waleed Javaid, MD Like it's it's like that. Like for me, it's Tahiti, right? So I'm thinking about that. So we have a meeting, a monthly with our nursing leadership called Destination Zero. We look at the opportunity of reducing infections down to zero, right? So that's where we continue to look at zero infections. We have had achieved zero infections for hundreds of days for all these all these different hospitals acquired infections. 00;17;56;12 - 00;18;19;27 Waleed Javaid, MD Keeping them there is hard. But if we get one infection, yes, all of us feel bad for a few secs or a few minutes, a few days, but we kind of learned from that. Now we have in another hospital I oversee we just had another other hospital acquired infection, so we looked at that. We already recognized several opportunities that, hey, you know what? 00;18;19;29 - 00;18;44;18 Waleed Javaid, MD We covered all the other bases, but this this wasn't covered for some reason. So we look at that and we look at the opportunities we can kind of provide, and that's our opportunity. So, yes, it's hard to have an infection, but then it also gives us opportunity. Also, we recognize that we are all inherently imperfect. We try to do our best, but being humans, we are not machines. 00;18;44;18 - 00;19;04;26 Waleed Javaid, MD We don't repeat everything exactly the same way every time, every day. We cannot do that. It's not how we are designed. We adapt. We find out, we see things and we try to do the best in the shortest amount of time. That's like how our body mind works. What we try to do is to put more of a system fix, not a human fix. 00;19;04;28 - 00;19;40;20 Waleed Javaid, MD So education is as important, but it still depends on the person learning and then performing and all that which we do. And it's important for them to recognize that everybody. Right we're also system fixes. So if anybody is, for example, trying to send urine culture in a certain circumstance and a patient doesn't have symptoms and all that, at those situations they are advised to call me or my team and we talk with them about the importance of cultures. 00;19;40;20 - 00;20;07;06 Waleed Javaid, MD But also why does our first question usually to them is why does a patient have a faulty right? So yes, we educate them to remove the faulty, but have a system there to also make sure the compliance is high. So that's kind of what I was trying to get to. And it there's a lot of new studies coming on on providing these checks and balances or what we call as testing stewardship. 00;20;07;13 - 00;20;31;02 Waleed Javaid, MD What it is really is fixing the system that makes us extremely difficult to make a mistake and makes it extremely easy to do the right thing. I think sometimes we see they are so easy to make a mistake and so difficult to do the right thing. And that's where I'm like, okay. And in our leadership calls, as I told you earlier, we have I.T folks as well and we bring it up to them. 00;20;31;02 - 00;20;38;17 Waleed Javaid, MD You know what? This makes no sense what's happening. So they help us kind of identify how to fix these issues as well. 00;20;38;19 - 00;21;04;26 Marie Cleary-Fishman That's really important, doctor, because I think you got to bring in is the non punitive aspect of this. Right? We're not blaming humans. We're looking at the systems and the processes that exist and in support of the humans doing the best work that they can. And I think that's a very, very important piece. We're getting close on time now, but I want to ask you one more question, and I want to give you the opportunity to be creative. 00;21;04;28 - 00;21;31;06 Marie Cleary-Fishman So I'm going to hand you a magic wand virtually. And if you had that magic wand, there you go. I love it. And you could wave that magic wand and change something about preventing HAIs or this work so that you could get closer to a consistent zero. What would that be? Do you have any idea of what you think would really make an impact? 00;21;31;08 - 00;22;07;19 Waleed Javaid, MD I want everybody, every provider, every doctor, nurse, front-line provider to recognize one thing: that people are not in the hospital by choice. They don't come to health care or seek health care by choice. Majority of times it's an accident and illness, a catastrophe or an unplanned event that takes them to the hospital. Our job really is to make their stay with us extremely safe. 00;22;07;21 - 00;22;30;29 Waleed Javaid, MD People recognize that and think about that as the major goal rather than just, Oh yeah, we need to just fix this situation. No, no. We need to identify why the person is here and they are humans. It's not an illness that gets admitted to the hospital. It's not pneumonia, getting it ready to fight. But it's Mrs. Jones with this problem. 00;22;30;29 - 00;22;52;23 Waleed Javaid, MD But this family issue coming to us, once we recognize the holistic approach, then we recognize how we can best serve them and how it impacts me or impacts our work is that it helps people also recognize that this is a hospital is not the best place for patients to be. We need to get them back to their familiar surroundings. 00;22;52;25 - 00;23;20;22 Waleed Javaid, MD We need to not put in a center line. If they don't need to have we need to remove any device as quickly as we put it in if we don't need it. We also need to recognize people don't have to be in hospital, for example, your time. They don't need to. We need to get them back so that people can recognize that the hospitals are not the choice destination for everyone. 00;23;20;24 - 00;23;29;10 Waleed Javaid, MD And a home is. I think once people recognize that's real and really where we start winning this this situation. 00;23;29;12 - 00;23;51;01 Marie Cleary-Fishman Well, with that answer, Doctor, I'm going to let you keep your magic wand and hopefully you will you will get to that. That's a that's an amazing answer. And one that you address patient centeredness as well. And as a nurse myself, I that just makes me yeah, it it brings me joy to hear that that's your focus and that's what you bring. 00;23;51;01 - 00;24;20;04 Marie Cleary-Fishman And I very much appreciate that. And congratulations to you and your team for all that you've done and for sharing hospital acquired infection prevention and that goal of getting to zero and reminding us all that these are patients, these are our family members, these are our friends, these are people we care about greatly. And while we're so busy and working so very hard, that's the humanity that it brings for all of us. 00;24;20;04 - 00;24;30;06 Marie Cleary-Fishman And I'm so appreciative of you bringing that through this conversation today. Any last words or anything you'd like to say for for our audience today? 00;24;30;08 - 00;25;00;02 Waleed Javaid, MD I think all your audience need to know from us is that zero is possible. We can get to zero. We have in our hospital gotten to zero. I think when we get into technicalities and statistics and all that, things get kind of diffused down. Retirement, humans. The one day that I prevented the infection and one of my patients is already in achievement and then sometimes we lose this and then sometimes we have an infection. 00;25;00;02 - 00;25;20;02 Waleed Javaid, MD It hurts us, but we learn. So don't let it be a big hurdle. Oh, my God. But yes, it is. Oh, my God. But we need to learn and figure out the best way in your institution, in your setting, figure out the best way you can get the best answers. Bringing down all these walls that we create. 00;25;20;05 - 00;25;37;08 Waleed Javaid, MD Let's bring all these things down and figure out exactly why the infection happened every time. And then you will figure out where your system is weak. Once you figured out where your system is, we will fix that. Hopefully, you'll also achieve the same thing and hopefully will protect everybody around us. 00;25;37;11 - 00;25;50;02 Marie Cleary-Fishman That's a wonderful answer. Thank you, Doctor. Thank you so very much for your wisdom and for your encouragement and suggestions and advice for others to achieve zero. So thank you very much. 00;25;50;05 - 00;26;23;21 Tom Haederle This publication is part of a program of the Health Research and Educational Trust, supported by the Centers for Disease Control and Prevention, CDC of the U.S. Department of Health and Human Services, HHS under CDC, HHS as part of a financial assistance award totaling $75,000 with 100% funded by CDC slash HHS. The contents are those of the authors and do not necessarily represent the official views of nor an endorsement by CDC, HHS, or the U.S. government.