CLINICAL & OT PROTOCOLS AND GOVERNANCE TO ENSURE

QUALITY IN EYE CARE SERVICES

DR. UDAY GAJIWALA

DIVYAJYOTI TRUST, MANDVI, GUJARAT

QUALITY ASSURANCE IN EYE CARE DELIVERY

CONCLAVE OF SIGHT FIRST HOSPITALS – MD 32212TH OCTOBER, 2014.

CATARACT SURGERY IN INDIA

1981 1983 1987 1993 1997 1999 2001 2008 2013

Performance 0.55 1.07 1.21 1.6 2.72 3.18 3.5 5.5 6.5

0.50

1.50

2.50

3.50

4.50

5.50

6.50

CAUSES OF BLINDNESS

2%4%5%2%

7%

80%

Cataract Ref. Erors Glaucoma Surg. Comp Others Corneal Opaciy

2%4%

5%2%

7%

80%

Cataract Ref. Erors Glaucoma Surg. Comp Others Corneal Opaciy

12%3%

19%

8%

54%

4%

PILOT SURVEY 1999

NATIONAL SURVEY1986-89

CURRENT ISSUES LARGE NUMBER OF EYE SURGEONS IN NON-

SURGICAL POSITION HIGH CONCENTRATION OF EYE SURGEONS IN

URBAN AREAS HIGHER PREVALENCE IN GEO-PHYSICALLY

DIFFICULT AREAS AND SOCIALLY UNDERPRIVILEGED GROUPS

INCREASE IN POPULATION OF AGED DUE TO RISE IN LIFE-EXPECTANCY

SUSTAINABILITY OF THE PROGRAMME DIFFICULT IN THE ABSENCE OF COST RECOVERY MECHANISMS

CHALLANGES – CLUSTER INFECTIONS

WHAT IS A CLUSTER INFECTION?INCIDENCE RATE?DO WE KNOW HOW TO PREVENT?ARE THERE GUIDELINES

AVAILABLE?QUALITY VS. QUANTITY QUALITY VS. COST

State and Year-wise Distribution

SN States No. of Mishaps(Blind/Seriously affected)

Place of Surgery

2006 2007 2008 2009

Assam 35 Guwahati

Manipur 5 Bishnupur

Rajasthan 31 Suratgarh, Beawar

UP 12 23 Barabanki, Lucknow

Orissa 9 Deogarh

TN 29 Tiruchirapalli

Total cases 44 5 72 23 144

NPCB DATA – CLUSTER INFECTION

Eye Mishaps: Month-wise

Year/Month J F M A M J J A S O N D TOTAL

2006 35 9 44

2007 5 5

2008 12 29 11 20 72

2009 23 23

TOTAL 41 5 29 35 9 11 20 144

Data: Source:

NPCB (1st April, 2009) – T 12019/1/2003-Ophth./BC (Pt)

Period: September 2006 – January 2009

Infection Percentage varies from 7.7% (35 of 450 in RIO Guwahati, Assam) to 100 % (23 of 23) in Lucknow.[1]

NPCB DATA – CLUSTER INFECTION

SN Place % blinded / seriously affected

Operating Team

1 Guwahati, Assam 7.7 Govt.

2 Barabanki, UP 13.6 NGO

3 Suratgarh, Sri Ganganagar

25.5 Mixed (?)

4 Beawar, Rajasthan 27.7 NGO

5 Bishnupur, Manipur 31 Govt.

6 Tiruchirapalli, TN 43.9 NGO

7 Deogarh, Orissa 64.2 Govt.

8 Lucknow, UP 100 Details awaited

NPCB DATA – CLUSTER INFECTION

Operating Team % Remarks

NGO 22.5 UP, TN, Rajasthan

Government 10.2 Assam, Manipur, Orissa

Mixed 25.58 Suratgarh

Being Investigated 10 Lucknow

NPCB DATA – CLUSTER INFECTION

AFTER EFFECTS OF CLUSTER INFECTION

DHARAMPUR, GUJARAT – THE EYE OT ORDERED A SHUT DOWN - STILL CLOSED.

JOSEPH EYE HOSPITAL, TRICHY – THEY HAVE FIVE HOSPITALS AND INFECTIONS OCCURRED IN SATELLITE HOSPITAL. GOVT. ORDERED A SHUT DOWN OF ALL FIVE HOSPITALS FOR ONE YEAR. LATER REVIEWED.

IN TAMILNADU, LAST WINTER, THE PERFORMANCE DROPPED BY 25%.

PALI SEVA MANDAL – THE OT REMAINED CLOSED FOR 8 MONTHS.

GOVT. OF RAJASTHAN ORDERED A BAN ON DIAGNOSTIC EYE CAMPS FOLLOWING REPORTS OF CLUSTER INFECTION AT SEVERAL PLACES. THE PERFORMANCE OF THE SURGERIES DROPPED TO 15000 FOR JAN. 2009 AGAINST 45000 IN JAN. 2008.

AFTER EFFECTS OF CLUSTER INFECTION

WORK LOAD DROPS SUBSTANTIALLYAFFORDING PATIENTS TURN AWAYFEAR EXPRESSED BY THE COMMUNITYLOSS OF FACEDEFAMATATIONMEDICOLEGAL ISSUES

OBSERVATIONS FROM EVALUATION ACTIVITY

IMPROPER LAY OUT OF THE THEATRE AVAILABILITY OF STAFF VS. VOLUME SCRUBBING – GOWNING – GLOVING

TECHNIQUE NEEDS MAJOR IMPROVEMENT

NO. OF INSTRUMENTS SETS AVAILABLECHEMICAL STERILISATION IN USE

OBSERVATIONS FROM EVALUATION ACTIVITY

80-100 SURGERIES DONE BY ONE SURGEON IN A DAY

OT BEING RUN FOR LONG HOURSSAME DAY SURGERY ON THE DAY OF

EXAMINATIONEXPIRED IOL BEING IMPLANTEDCOMMON TROLLEY IN USENO CHANGE OF GLOVES FOR ONE

SESSION

OBSERVATIONS FROM EVALUATION ACTIVITY

SAME SET OF INSTRUMENTS USED FOR SEVERAL SURGERIES

PLASTIC BOTTLE INJ. RL AND PRE FILLED VISCO ELASTIC IN USE

METHOD OF AUTOCLAVING NOT KNOWNNO MONITORING OF ACTIVITIESVERY WEAK PRE OPERATIVE PROTOCOL

OBSERVATIONS FROM EVALUATION ACTIVITY

NON EXISTENCE OF PROTOCOLNO / LITTLE IMPROVEMENT EVEN AFTER

EVALUATION AND FOLLOW UPCOUNTER ARGUMENTS COST CONSIDERATIONS KIND HEARTED PEOPLEVERY GOOD SURGICAL SKILLS

OBSERVATIONS FROM EVALUATION ACTIVITYROOT CAUSE OF THE PROBLEM

LACK OF UNIFORM GUIDELINE FOR THE COUNTRY

AVAILABLE GUIDELINE DOES NOT REACH THE END USER

PHILANTHROPIC MINDED PEOPLE UNAWARE OF THE PROTOCOLS AND GUIDELINES

MEDICAL EDUCATION LACKING IN TRAINING DOCTORS IN INFECTION CONTROL MEASURES

COST CONSTRAINTS ENFORCEMENT OF LAW POOR IN THE

COUNTRY LACK OF COMMMITTMENT FOR A CHANGE DISAGREEMENT ON THE METHODS / PROTOCOL

OBSERVATIONS FROM EVALUATION ACTIVITY

SITUATION LOOKS GRIM BUT IS IT ACTUALLY SO BAD?

WE HAVE COME FROM INTRA WITH FORCEPS TO PHACO WITH FOLDABLE IOL

THIS CHANGE WAS DUE TO DEMAND – IT WAS MARKET DRIVEN

WE NEED TO INJECT QUALITY CONSCIOUSNESS INTO THE SYSTEM

POSITIVE CHANGES ARE HAPPENING THOUGH AT A SLOWER PACE

Future GoalsCATARACTINCREASE CATARACT SURGICAL RATE

(CSR) TO 4,000 IMMEDIATELY AND TO 6,000+ IN THE NEAR FUTURE – TODAY WE ARE AT 5500

IMPROVE QUALITY OF CATARACT SURGERY FOR BETTER OUTCOMES BY 2005???

FUTURE GOALS

CLUSTER INFECTIONREDUCE THE CHANCES OF CLSTER

INFECTION

HOW?FOLLOWING PROPER GUIDELINEMAINTAINING NECESSARY

DISCIPLINE INSIDE THE OT

NEED OF THE HOUR

COME UP WITH A REVISED INFECTION CONTROL GUIDELINE UNDER THE NATIONAL PROGRAMME

SPREAD THE INFORMATION AMONG ALL THE PLAYERS IN THE COUNTRY

ENFORCE IMPLEMENTATION OF THE GUIDELINE THROUGH VARIOUS EFFORTS INCLUDING SUPERVISORY INPUTS

MAKE ALL THE PEOPLE INVOLVED IN MEDICAL CARE MORE QUALITY CONSCIOUS

ADD INFECTION CONTROL AS A SEPARATE SUBJECT IN THE MEDICAL CURRICULUM

WHAT IS ALL THIS?

ISO NABHCEISI

INTERNATIONAL GUIDELINES

INTERNATIONAL GUIDELINES

PUBLISHED FROMICEH, LONDON

HAND HYGIENECDC GUIDELINE

HOSPITAL INFECTION SOCIETY, INDIA

PUBLISHED YEARLYFrom

CMC, VELLORE

INFECTION CONTROL TEXT BOOK

INFECTION CONTROL JOURNAL

NPCB GUIDELINE

PROTOCOL – MANUAL AND VIDEO DEVELOPED BY

ARAVIND EYE CARE SYSTEMS

PROTOCOL – MANUAL AND VIDEO DEVELOPED BY

SEWA RURAL

OPERATIVE OPERATION THEATRE

Prevention Is Better Than Cure

A MANUAL FOREY E OPERATION THEATRE

SEWA RURAL, J HAGADIA(2008)

EY E OPERATION THEATRE

EYE OPERATION THEATRE PROTOCOL (ENGLISH FILM)

SIGHTSAVERS INTERNATIONAL

INITIATIVE

AIOS GUIDELINES TO PREVENT INTRAOCULAR INFECTION--WORKSHOP HELD IN NOV. 08 -- DRAFT IN FINAL STAGES. --25 EMINENT OPHTH. ATTENDED.

BUREAU OF INDIAN STANDARDS GUIDELINE FOR SETTING UP

HOSPTALS

AECS PAPER IN JOURNAL of CATARACT

AND REFRACTIVE

SURGERY

IMPLICATIONS OF FOLLOWING STRICT UIDELINE

COST OF SURGERYNO. OF SURGERIES NEED FOR TRAINING AND

RETRAINNG OF STAFFKEEPING UPDATED WITH THE

LATEST DEVELOPMENTS IN ASEPSIS AND ANTI SEPSIS

Country [reference] Year of Publication

Incidence (%) No. of Operations

USA [98] 1991 0.22 24105

USA [203] 1992 0.015 27181

France [40] 1992 0.32 ~34690

Germany [126] 1999 0.15 ~103090

Netherlands [135] 2000 0.10 ~25330

Canada [64] 2000 0.01 to 0.18 13886

Sweden [37] 2002 0.10 54666

Australia [110] 2003 0.16 to 0.36 83677

Japan [8] 2003 0.05 to 0.29 11595

USA [86] 2005 0.29 9079

Ireland [87] 2005 0.5 8763

UK [105] 2007 0.099 101920

Sweden [94] 2007 0.048 225471

Europe [5] 2007 0.05 to 0.35 16211

DATA FROM THE WESTERN WORLD

WHERE DO WE STAND TODAY?AT NATIONAL LEVEL

NPCB WORKING ON REVISED INFECTION CONTROL GUIDELINE

AIOS CONDUCTED A WORKSHOP ON CREATING PROTOCOL – FINAL VERSION MAY COME OUT SOON

VISION 2020 – RIGHT TO SIGHT INDIA PROGRAMME IS WORKING ON AN OUTBREAK POLICY

GOVT. OF RAJASTHAN HAS ISSUED REVISED GUIDELINES GOVT. OF GUJARAT CONDUCTED THREE WORKSHOPS

ZONE WISE & DISTRIBUTED IEC MATERIAL ACROSS THE STATE

AT AIOS ANNUAL CONFERENCE, SESSION ON INFECTION CONTROL MEASURES IS CONDUCTED REGULARLY

AT GOS, INFECTION CONTROL SESSION ORGANISED MORE AND MORE HOSPITALS ARE USING SOFTWARE FOR

OUTCOME MONITORING SOME HOSPITALS ARE ISO / CE CERTIFIED

WHERE DO WE STAND TODAY?AT LOCAL LEVEL

NEED FOR INTROSPECTION LOOK AT THE ENDOPHTHALMITIS RATE FOR OUR OWN

HOSPITAL INTERNALLY PREPARE A PROTOCOL FOR CATARACT SERVICES – SSI

MANUAL IS AVAILABLE TO GUIDE US LOOK AT THE STANDARD PROTOCOLS INCLUDING NPCB SHARE THE PROTOCOL WITH ALL THE STAFF AND MAKE

THEM AWARE KEEP UPDATED WITH THE LATEST DEVELOPMENTS IN THE

FIELD REGULAR CME FOR ALL THE STAFF BECOME QUALITY CONSCIOUS APPLY FOR NABH ACCREDITATION

OPD PROTOCOL

COMPLAINTSRELAVENT HISTORYTHOROUGH EXAMINATIONESTABLISHING THE DIAGNOSISCOMPLETE PRE OPERATIVE WORK UPPROPER PATIENT COUNSELINGPRE OPERATIVE DRUG REGIME

IPD PROTOCOLPRE OPERTIVE PREPARTION OF THE PATIENT

AT HOME AND IN THE WARDS BOTH ON THE PREVIOUS DAY AND ON THE DAY OF SUREGERY

TESTS TO BE CARRIED OUTMEDICAL FITNESS – INTERNIST CLEARANCEPREPARATION OF LOCAL PARTSDILATATION PROTOCOLPRE OPERATIVE CHECK LISTPROTOCOL FOR SENDING PATIENT TO OT

OT PROTOCOLFOR PERSONNELFOR SCRUBBING – GOWNING - GLOVINGFOR STERILISATION & USE OF PER STERILE

ITEMS & ENSURING STERILISATIONCLEANING & PACKING OF INSTRUMENTSDISINFECTION OF VARIOUS AREASOT PREPARATIONSURVEILLANCEDAILY – WEEKLY – MONTHLY – QUARTERLY

MONITORING

FOLLOW UP PROTOCOL

PROTOCOL FOR EXAMINATION AT EACH FOLLOW UP

PROTOCOL FOR FOLLOW UP – FIRST – SECOND – THIRD – FINAL FOLLOW UP

PROTOCOL FOR PRESCRIPTION OF GLASSES

OUTCOME ANALYSIS

MONITORING OF OUTCOMES

USE ICEH SOFTWARE OR THE MANUAL TALLY SHEET

HAPPY PATIENT >>>>>> HAPPY DOCTOR

MOST IMPORTANT FACTORS LEADING TO

INFECTION

INADVERTANT TOUCH STERILISATION FAILURE ENVIRONMENTAL FACTORS

• ARRANGED IN THE ORDER OF IMPORTANCE• WE HAVE NOT MENTIONED PATIENT FACTORS

HERE

SOURCE OF BACTERIA AND FUNGI

LIDS, CONJUNCTIVA, LACRIMAL SAC SURGICAL INSTRUMENTS, IRRIGATING

SOLUTIONS IOLs, VISCOELASTICS, MULTIPLE USE EYE

DROPS WOUND LEAKING, VITREOUS WEAK,

FILTERING BLEBS STAFF – SURGEONS, NURSES &

ANAESTHETISTS OPERATING THEATRE AIR - ENVIRONMENT RISK FACTORS – CLEAR CORNEAL VS. SCLERAL

TUNNEL, RUPTURED POST. CAPSULE ETC.

PREVENTING POST OPERATIVE INFECTION

LIMIT THE OPPORTUNITY FOR MICROBIAL CONTAMINATION• DECREASE MICROBES ON THE OCULAR

SURFACE• PREVENT INTRA OPERATIVE

INTRAOCULAR CONTAMINATION• PREVENT POST OPERATIVE INTRA

OCULAR CONTAMINATION• KILL MICROBES THAT ENTER THE EYE

AFTER SURGERY

PREVENT INTRA OPERATIVE INTRA OCULAR BACTERIAL

CONTAMINATION REDUCE – OPTIMISE TOTAL

OPERATING TIME DRAPING TECHNIQUE

• ISOLATE LIDS AND LASHES• USE OF PLASTIC DRAPE

AVOID POOLING OF SURFACE FLUIDS LIMIT ENTRANCES AVIOD COMPLICATIONS

• CAPSULE RUPTURE

IMPORTANT POINTS TO REMEMBER

FREQUENCY OF SCRUBBING FRESH SET OF STERILE INSTRUMENTS FOR

EACH SURGERY PREPARE TROLLEY AFRESH EACH TIME STERILISE IRRIGATING SOLUTION AND

VISCOELASTIC AT YOUR END APPLY CHLORHEXIDINE HAND RUB ON THE

SURFACE OF THE GLOVES USE 5% POVIDONE IODINE EYE DROP BEFORE

THE SURGERY MAINTAIN SILENCE INSIDE THE OT

WISH YOU A

FREE OF

THANK YOU