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  1. 1. Reducing Infections: Ventilator Central Line
  2. 2. Presenters Stephanie Crow, RN Clinical Effectiveness Manager Overlake Hospital Medical Center Betsy Pesek, RN Critical Care Overlake Hospital Medical Center Caroline Truong, RN ICU Clinical Care Supervisor Swedish Medical Center Curtis F. Veal, Jr., MD Medical Director, Critical Care Services Swedish Medical Center
  3. 3. Overlake Hospital Medical Center
  4. 4. Project Goals <ul><li>Reduce Ventilator Associated Pneumonia (VAP) by 75% </li></ul><ul><li>Reduce Central Line Catheter-Associated Blood Stream Infections by 75% </li></ul><ul><li>Achieve 95% or higher compliance with Ventilator Bundle </li></ul><ul><li>Achieve 95% or higher compliance with Central Line Bundle </li></ul>
  5. 5. Project Goals <ul><li>Achieve 95% or higher compliance with use of daily goal sheets for patients </li></ul><ul><li>Reduce ALOS on Ventilator by 30% </li></ul><ul><li>Reduce ICU ALOS </li></ul><ul><li>Reduce ICU Costs </li></ul>
  6. 6. Developing a Physician Champion
  7. 7. Developing a Physician Champion <ul><li>Look for a physician who believes in the change </li></ul><ul><li>Need to be in a position to affect change </li></ul><ul><li>Physician’s respond to data </li></ul><ul><li>Present evidence </li></ul><ul><li>Align incentives </li></ul>
  8. 8. Communication with Staff and Physicians  <ul><li>Personal letters </li></ul><ul><li>Newsletters </li></ul><ul><li>Face to face </li></ul><ul><li>E-mail </li></ul><ul><li>Presented at meetings </li></ul><ul><li>Posted data/ report cards </li></ul>
  9. 9. “Every system is perfectly designed to achieve the results it gets” <ul><li>Ventilator and Central line bundles </li></ul><ul><li>Ventilator management changes </li></ul><ul><li>Central line management changes </li></ul><ul><li>Multidisciplinary rounding </li></ul><ul><li>Daily goals/ Rounding sheet </li></ul>
  10. 10. What are Bundles? <ul><li>A bundle is a group of precautionary steps with approximate time and space characteristics that, when executed collectively and reliably, have an enhanced affect on patient outcomes. </li></ul><ul><li>The bundle provides a &quot;forcing function&quot; for teamwork, and this teamwork has led to outstanding results. </li></ul>
  11. 11. Ventilator Bundle <ul><li>Elevating the head of the patient’s bed to 30 degrees or higher </li></ul><ul><li>Prophylactic treatment for deep venous thrombosis </li></ul><ul><li>Prophylactic treatment for peptic ulcer disease </li></ul><ul><li>Daily &quot;sedation vacation“ accompanied by an assessment of the patient’s readiness to wean from the ventilator </li></ul>
  12. 12. Central Line Bundle <ul><li>Hand-hygiene </li></ul><ul><li>Optimal insertion site (RIJ, LIJ) </li></ul><ul><li>Maximal sterile barrier use (covered to pt waist) </li></ul><ul><li>Prepare skin with antiseptic/ detergent chlorhexadine 2% in 70% isopropyl alcohol </li></ul><ul><li>Daily review of necessity </li></ul><ul><li>Early removal (5 day max) </li></ul><ul><li>Intact Dressing </li></ul>
  13. 13. Ventilator Management Changes <ul><li>Chlorhexadine on the unit </li></ul><ul><li>Sage oral care product www.sageproducts.com </li></ul><ul><li>Sedation reduction vs. Sedation vacation </li></ul><ul><li>Using DVT and PUD prophylaxis to prevent risk for vent patients </li></ul><ul><li>Using ventilator weaning protocol </li></ul><ul><li>Continuous aspiration of subglottic secretions www.atsjournals.org </li></ul>
  14. 14. Central Line Management Changes
  15. 15. Central Line Management Changes <ul><li>Created Cent line carts </li></ul><ul><li>Implemented Cent Line checklist </li></ul><ul><li>Created cath line insertion recommendations </li></ul><ul><li>CL catheter products for high risk patients available </li></ul><ul><li>New dressings for central lines </li></ul><ul><li>Central line dressing team </li></ul>
  16. 16. Multidisciplinary Rounding <ul><li>Introduces redundancy </li></ul><ul><li>Intensivist led/ CN facilitated </li></ul><ul><li>All patients in critical care </li></ul><ul><li>Pharmacy and RT involvement critical </li></ul>
  17. 17. Daily Goals Sheet/ Rounding Sheet
  18. 18. Daily Goals Sheet/ Rounding Sheet <ul><li>Creates accountability for practice expectations </li></ul><ul><li>Helps to ensure that key activities are done on each patient </li></ul><ul><li>Rounding form is a permanent part of the medical record and can be audited </li></ul><ul><li>Provides prompting for staff by using daily goals and safety risk checklists </li></ul><ul><li>Enhances communication among team members </li></ul>
  19. 19. Barriers we experienced <ul><li>Weekend coverage for rounds </li></ul><ul><li>Pharmacy involvement in rounds </li></ul><ul><li>Physician and nursing buy-in </li></ul><ul><li>Registry and new employees </li></ul><ul><li>Physician reluctance </li></ul><ul><li>Timeliness of trialing new products </li></ul>
  20. 20. Barriers we experienced <ul><li>No active critical care manager during project </li></ul><ul><li>Staff ready and organized at rounding time </li></ul>
  21. 21. Process for Data Collection <ul><li>Created a shared drive for each member to access data and graphs </li></ul><ul><li>Established owners for each indicator </li></ul><ul><li>Owners are responsible to enter data monthly (by the 10th of the month) onto the shared drive </li></ul><ul><li>Quality updates the graphs </li></ul>
  22. 22. Results! <ul><li>Baseline average VAP rate 16.33 </li></ul><ul><li>Project Average VAP rate 2.50 = 85% Reduction </li></ul><ul><li>4 out of 7 months with zero VAP </li></ul>
  23. 23. Results! <ul><li>Baseline average CA-BSI rate 2.84 </li></ul><ul><li>Project Average CA-BSI rate 1.24 = 56% Reduction </li></ul><ul><li>5 out of 7 months with zero CA-BSI </li></ul>
  24. 24. Results! <ul><li>Baseline ALOS for MV rate 2.25 </li></ul><ul><li>Project ALOS for MV rate 1.59 = 30% Reduction </li></ul>
  25. 25. Results! <ul><li>20 patients saved from needless harm (16.83 + 2.81) </li></ul><ul><li>Saved 6 lives (20 patients x 30% mortality rate) </li></ul><ul><li>$1,025,860.00 in cost avoided </li></ul><ul><li>Data is derived from baseline data Oct 2003-Sept 2004 </li></ul><ul><ul><li>34 VAP cas es (2.83 monthly avg, $52,000 a case & ALOS 22 days) </li></ul></ul><ul><ul><li>10 CA-BSI cases (.83 monthly avg, $54,000 a case & ALO S 17 days) </li></ul></ul>
  26. 26. Unmeasureable results! <ul><li>Culture of critical care: </li></ul><ul><ul><li>Improved critical thinking and planning for patient care </li></ul></ul><ul><ul><li>Staff are able to take view from 10,000 feet </li></ul></ul><ul><ul><li>Infections are not inevitable </li></ul></ul><ul><li>Great patient saves: </li></ul><ul><ul><li>Found that a renal failure patient was on full dose Lovinox </li></ul></ul><ul><ul><li>Found many patients that needed to have their antibiotics DC’d </li></ul></ul><ul><ul><li>Found a patient that went into renal failure was on too much Digoxin and was becoming toxic </li></ul></ul>
  27. 27. Keys to Success <ul><li>Senior leader support </li></ul><ul><li>Clinical Champion </li></ul><ul><li>Day to day leader </li></ul><ul><li>A multidisciplinary team </li></ul><ul><li>Staff buy in </li></ul><ul><li>Project sustainability </li></ul>
  28. 28. Swedish Medical Center
  29. 29. Presentation Overview <ul><li>Background </li></ul><ul><li>Committee composition </li></ul><ul><li>Communication strategy </li></ul><ul><li>Composition of bundles </li></ul><ul><li>Data tracking </li></ul><ul><li>Results </li></ul><ul><li>Barriers </li></ul><ul><li>Words of advice </li></ul>
  30. 30. Background <ul><li>IHI 3rd Annual International Summit on Innovations in Critical Care Delivery – March 2004 </li></ul>
  31. 31. Convention Highlights <ul><li>Nosocomial Infections: Zero Tolerance </li></ul><ul><li>Improving Critical Care: A Global Approach </li></ul><ul><li>“ Bundle” Up Your Critical Care Processes </li></ul><ul><li>Reducing Mortality and Morbidity </li></ul><ul><li>Establishing Culture of Safety in the ICU </li></ul><ul><li>Measuring ICU Quality </li></ul>
  32. 32. Our Collaborative Team Members
  33. 33. IHI Collaborative Team <ul><li>Chip Veal, MD; Medical Director </li></ul><ul><li>Derel Finch, MD; Intensivist </li></ul><ul><li>George Pappas, MD; Intensivist </li></ul><ul><li>June Altaras, Manager, First Hill ICU </li></ul><ul><li>Steve Hoppe, Project Manager, EICU </li></ul><ul><li>Joya Pickett, Clinical Nurse Specialist </li></ul><ul><li>Marie Arnone, Clinical Nurse Specialist </li></ul><ul><li>Patti Feley, Manager, Providence ICU </li></ul><ul><li>Will Shelton, Director Epidemiology </li></ul><ul><li>Jim Kumpula, Manager, Respiratory Therapy </li></ul><ul><li>Nancy Siegle, Manager, Ballard ICU </li></ul><ul><li>Jennifer Harville, Director, Clinical Effectiveness </li></ul><ul><li>Theresa Bervell, Admin Resident, Clinical Effectiveness </li></ul><ul><li>Tom Moore, Respiratory Care </li></ul><ul><li>Marjorie Svrjcek, Manager Respiratory Care </li></ul><ul><li>Debra Gruber, Manager, Respiratory Care </li></ul><ul><li>Caroline Truong, ICU Clinical Care Supervisor </li></ul><ul><li>Lilia Mullins, RN IV Team </li></ul><ul><li>Laura Make, RN Value Improvement Consultant </li></ul>
  34. 34. Team Charter Critical Care Collaborative <ul><li>Set Objectives </li></ul><ul><ul><li>Improve outcomes for ICU patients </li></ul></ul><ul><li>Defined Goals </li></ul><ul><ul><li>Create no harm culture </li></ul></ul><ul><ul><li>Establish shared understanding of bundle concept </li></ul></ul><ul><ul><li>Implement bundles </li></ul></ul><ul><ul><li>Implement Multidisciplinary Rounds </li></ul></ul><ul><li>Identified sponsoring committee (Critical Care Committee) </li></ul>
  35. 35. Critical Care Committee Department Composition <ul><li>Intensivists </li></ul><ul><li>Nursing Managers, CNS, supervisors </li></ul><ul><li>Respiratory care </li></ul><ul><li>Epidemiology </li></ul><ul><li>e-ICU® </li></ul><ul><li>Clinical Effectiveness </li></ul><ul><li>Pharmacy </li></ul><ul><li>Cardiology </li></ul><ul><li>Nephrology </li></ul><ul><li>Neurology </li></ul><ul><li>Inpatient Hospitalist Team </li></ul><ul><li>Surgery </li></ul>
  36. 36. Multiple Focused Projects <ul><li>Ventilator Bundle </li></ul><ul><li>Central line Bundle </li></ul><ul><li>Multidisicplinary Rounds </li></ul><ul><li>Rapid Response Team </li></ul><ul><li>Sepsis Bundle </li></ul>
  37. 37. Rapid PDSA Weekly Meeting Test of Change “ Huddle” P D SA (P) Test of Change: One Patient, One Physician, One Time
  38. 38. What are Bundles? <ul><li>Collection of practices or process steps </li></ul><ul><li>Individual elements based on solid science </li></ul><ul><li>Tasks must relate in time and space </li></ul><ul><li>Emphasis initially on process rather than outcome </li></ul><ul><li>Bundle measured as all or none </li></ul><ul><li>Eventual endpoint is outcome improvement </li></ul>
  39. 39. Vent Bundle Elements <ul><li>Head of bed elevation </li></ul><ul><li>Deep vein thrombosis prophylaxis </li></ul><ul><li>Peptic ulcer disease prophylaxis </li></ul><ul><li>Sedation interruption </li></ul><ul><li>Daily assessment of readiness to wean </li></ul>
  40. 40. Sedation Interruption <ul><li>Developed protocol and algorithm </li></ul><ul><li>Introduced Modified Ramsay Sedation Scale (MRSS) </li></ul><ul><li>1-1-1 </li></ul><ul><li>Implemented in pilot unit </li></ul><ul><li>ICU skills days </li></ul>
  41. 41. Rapid PDSA Weekly Meeting Test of Change “ Huddle” P D SA (P) Test of Change: One Patient, One Physician, One Time
  42. 42. Sedation Interruption <ul><li>Developed protocol and algorithm </li></ul><ul><li>Introduced Modified Ramsay Sedation Scale (MRSS) </li></ul><ul><li>1-1-1 </li></ul><ul><li>Implemented in pilot unit </li></ul><ul><li>ICU skills days </li></ul>
  43. 43. Units of Focus 7E Other First Hill ICUs Ballard & Providence ICUs 1 st 2 nd 3 rd
  44. 44. Monitoring/Communication Education Process <ul><li>All elements reviewed during night shift or first thing in AM (e-ICU®) </li></ul><ul><li>Daily AM rounds by manager </li></ul><ul><li>Multidisciplinary Rounds </li></ul>
  45. 45. VENTILATOR PNEUMONIA PREVENTION ORDERS* <ul><li>Reverse Trendelenberg 30 degrees unless contraindicated by hypotension </li></ul><ul><li>Sedation interruption daily (unless specifically contraindicated) </li></ul><ul><li>Famotidine 20 mg IV Q 12H (unless history of allergy) </li></ul><ul><li>IF DOCUMENTED BLEEDING or HIGH GI BLEEDING RISK ON ADMISSION: Protonix 40 mg IV daily </li></ul><ul><li>Heparin 5000 units SQ Q 12H (unless post-op heart, other anticoagulant ordered) </li></ul><ul><li>IF DOCUMENTED BLEEDING, HIGH BLEEDING RISK ON ADMISSION or HEPARIN ALLERGY: Sequential compression devices (SCDs) only </li></ul><ul><li>*Call attending physician if there are questions or concerns about any of these orders. </li></ul><ul><li>These orders are not intended to duplicate or conflict with those written by the Attending Physician. </li></ul>
  46. 47. Data Feedback - Old Way (Usual Approach) Mean
  47. 48. Data Feedback – Focus on Process Percent of vented patients with all 5 bundle items
  48. 49. Data Feedback – New Way Vent Bundle Compliance and VAP Infection Rates
  49. 50. Multiple PDSA’s <ul><li>One patient, one physician, one time </li></ul><ul><li>e-ICU® involvement and support </li></ul><ul><li>Group education followed by one to one education with manager </li></ul><ul><li>RNs and RTs coordinate sedation vacation </li></ul><ul><li>Multidisciplinary rounding </li></ul>
  50. 51. Central Line Bundle Elements <ul><li>Remove unnecessary lines </li></ul><ul><li>Practice hand hygiene </li></ul><ul><li>Select optimal insertion site </li></ul><ul><li>Use maximal barrier precautions </li></ul><ul><li>Apply Chlorhexidine for skin antisepsis </li></ul><ul><li>Appropriate site care </li></ul>
  51. 52. Central Line - PDSA High Impact Tests of Change <ul><li>Checklist and supply cart </li></ul><ul><li>Safety pause (including script for staff) </li></ul><ul><li>Physician letter </li></ul><ul><li>Bundle piloted at Ballard and Providence </li></ul><ul><li>Full roll-out March 05 </li></ul><ul><li>Trial Biopatch and Statlock </li></ul>
  52. 53. <ul><li>Central Line Insertion Checklist -Adults </li></ul><ul><li>Operator:________________________________________Date:_______________________ </li></ul><ul><li>RN Assisting:____________________________________ Room/Location:______________ </li></ul><ul><li>Safety Pause: </li></ul><ul><li> Correct Patient  Correct Procedure </li></ul><ul><li> Correct Site  Verbal agreement from all members of the team. </li></ul><ul><li>In order to eliminate central line associated blood stream infections, we will be following the Central Line Insertion Procedure Checklist based on CDC Guidelines. </li></ul><ul><li>Prior to the Procedure: </li></ul><ul><li>1. Hand Hygiene done with Chlorhexidine Gluconate (CHG) 2% surgical hand scrub and water or waterless alcohol based gel before patient contact and before donning sterile gloves. </li></ul><ul><li>YES </li></ul><ul><li>2. Cleanse Site with CHG 2% Chloraprep Sponge 1.5mL. </li></ul><ul><li>YES </li></ul><ul><li>3. Disinfect Site with a back and forth friction scrub, utilizing CHG 2% Chloraprep Wand 10.5mL for 30 seconds and allow to dry completely before catheter insertion. </li></ul><ul><li>YES </li></ul><ul><li>4. Maximum Barriers Did the operator wear: </li></ul><ul><li>YES Cap/Bouffant </li></ul><ul><li>YES Mask </li></ul><ul><li>YES Sterile Gown </li></ul><ul><li>YES Sterile Gloves </li></ul><ul><li>YES Patient draped with full body sterile sheet. (Drp Angi ADH) </li></ul><ul><li>During the procedure: </li></ul><ul><li>5. YES Operator(s) maintained the sterile field. </li></ul><ul><li>6. YES Personnel assisting wore a cap, mask and donned gloves appropriately. </li></ul><ul><li>After the procedure: </li></ul><ul><li>6. Sterile dressing applied immediately by the operator. </li></ul><ul><li>YES </li></ul><ul><li>QUALITY IMPROVEMENT </li></ul><ul><li>THIS FORM IS NOT PART OF THE PATIENT'S PERMANENT RECORD. </li></ul><ul><li>Please return the form to your Nurse Manager. If a step has was not followed, please note and the Nurse Manager will follow up with the physician. </li></ul>
  53. 54. To: Physicians and Nurses placing central lines in SMC intensive care units From: Martin Siegel, M.D., Curtis Veal, M.D., Derel Finch, M.D. and Greg Sorensen, M.D. Re: Improvements in our ICUs to eliminate central line associated blood stream infections You are aware that the hospital strives to improve the quality of patient care and has activities in place to eliminate needless death and harm. As part of these ongoing efforts we are implementing practices called “bundles” based on national guidelines and evidence-based medicine to create significant outcome improvements. A “bundle” is a group of individual interventions forming a collection of practices or process steps. When these practices are implemented together as a “bundle” they result in better outcomes than when implemented individually. Consistent with these aims we are asking all physicians to assure their practice of inserting central lines includes the following “bundle” of activities known as the “Central Line Bundle”. 1. A Safety Pause : Correct patient, Correct site, Correct procedure, and Correct physician. 2. Hand Hygiene and Cleaning the Patient Skin prior to antiseptic prep of the insertion site a) Upon entering the room perform routine hand washing or use alcohol gel. b) Clean the insertion site with BD EZ Scrub foam pad brush with 3% CHG c) Re-sanitize your hands with 2% chlorhexidine gluconate (CHG) antiseptic scrub (current brand is Exidine 2), alcohol gel or alcohol scrub containing chlorhexidine gluconate (Avagard) and put on sterile gloves 3. Prep the Insertion Site with antiseptic 2% chlorhexidine gluconate which will be provided in the 10.5 mL ChloraPrep wand with sponge applicator. 4. Maximum Barrier Precautions observed by MD and other healthcare personnel in the sterile field*Bouffant Cap, Mask, Sterile Gown, Sterile Gloves, Full size patient drape, Maintain the sterile field, individuals on the far side of the bed simply opening supplies on to the field will at a minimum use cap, and mask with gloving as appropriate. 5. Sterile Dressing Applied Immediately by the MD wearing full barrier precautions Our ICU nurses assisting you with line insertions will be using a checklist and script to help us achieve 100% compliance with the central line bundle . Anyone involved in the procedure who sees a break in technique has a responsibility to the patient’s safety to quickly assist in correcting the situation. We will be testing the central line bundle implementation with small tests of change. This means we will be refining our “bundle” with one MD and one patient during one procedure. We will then make small improvements before we repeat this process with the next MD and patient. The small tests of change will result in improvements of the central line bundle checklist, our script for notifying healthcare professionals of breaks in technique, and the availability of the correct standardized supplies in the central line insertion carts in all ICUs on all campuses. The central line bundle is just one part of our overall evidence based quality improvement program to increase patient safety. The recent implementations of the ventilator bundle, multidisciplinary ICU patient rounds and the deployment of our rapid response team are all part of this process. We thank you for your ongoing support for all of these efforts. Endorsed by the Critical Care Committee 2/8/05 Consistent with these aims we are asking all physicians to assure their practice of inserting central lines includes the following “bundle” of activities known as the “Central Line Bundle”…. Our ICU nurses assisting you with line insertions will be using a checklist and script to help us achieve 100% compliance with the central line bundle. Anyone involved in the procedure who sees a break in technique has a responsibility to the patient’s safety to quickly assist in correcting the situation.
  54. 55. Central Line Bundle Compliance and CLBSI Infection Rates
  55. 56. Communication <ul><li>Weekly collaborative meetings </li></ul><ul><li>Weekly data feedback </li></ul><ul><li>Monthly reporting to Critical Care Committee </li></ul><ul><li>Rapid data sharing </li></ul><ul><li>Sharing ideas with IHI </li></ul><ul><li>There is never too much communication </li></ul>
  56. 57. Barriers <ul><li>Lack of standardization </li></ul><ul><li>Data Collection </li></ul><ul><li>Prioritization of work and issues </li></ul><ul><li>Transforming the culture </li></ul>
  57. 58. Helpful Advice <ul><li>Board and senior leadership buy-in </li></ul><ul><li>Physician champions </li></ul><ul><li>Management support </li></ul><ul><li>Empower the staff </li></ul><ul><li>Have process for immediate feedback </li></ul><ul><li>Celebrate team success </li></ul>
  58. 59. Conclusion
  59. 60. Why is Ventilator-Associated Pneumonia of Concern? <ul><li>VAP occurs in 15% of patients receiving mechanical ventilation. </li></ul><ul><li>Hospital mortality rate of patients with VAP is 46% compared to 32% for ventilator patients without VAP. </li></ul><ul><li>VAP is associated with prolonged stay and increase costs. </li></ul>
  60. 61. What is a Ventilator Bundle? <ul><li>Head of bed up 30 degrees </li></ul><ul><li>Daily “sedation vacations” </li></ul><ul><li>Daily assessment of readiness to extubate </li></ul><ul><li>Peptic ulcer disease prophylaxis </li></ul><ul><li>Deep vein thrombosis prophylaxis. </li></ul>
  61. 62. Why is Central Line-Associated Infection of Concern? <ul><li>48% of ICU patients have central venous catheters in ICUs. </li></ul><ul><li>There are approximately 5.3 catheter-related blood-stream infections per 1,000 catheter-days in ICUs. </li></ul><ul><li>Mortality for between 14,000 to 28,000 deaths per year. </li></ul>
  62. 63. What is a Central Line Bundle? <ul><li>Hand Hygiene </li></ul><ul><li>Maximal barrier precautions </li></ul><ul><li>Chlorohexidine skin antisepsis, appropriate catheter site </li></ul><ul><li>Appropriate administration system care </li></ul><ul><li>No routine replacement </li></ul>
  63. 64. Recommendations <ul><li>Go For It! </li></ul><ul><li>Best change this year! </li></ul>
  64. 65. Key Points <ul><li>Develop physician and administrative champions </li></ul><ul><li>Communicate, communicate, communicate </li></ul><ul><li>Measure and provide immediate feedback </li></ul>
  65. 66. Measurement <ul><li>Number of times bundle not used </li></ul><ul><li>Number of central line infections per 1,000 catheter days </li></ul><ul><li>Number of ventilator-associated pneumonia per 1,000 catheter days </li></ul>
  66. 67. Polling
  67. 68. Questions?
  68. 69. Thank you for participating! Please fill out the evaluation.

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