MOUTHING OFF ABOUT BEST PRACTISE MOUTH CARE TO REDUCE RISK OF VENTILATOR ASSOCIATED PNEUMONIA

1. International Forum on Quality and Safety in Healthcare. Paris April 2008 MOUTHING OFF ABOUT BEST PRACTISE MOUTH CARE TO REDUCE RISK OF VENTILATOR ASSOCIATED PNEUMONIA  Safer Systems Saving Lives Project Lyell McEwin Hospital South Australia AUSTRALIA authors: Wendy Butvila Martin Reilly & Genevieve Sturman Merci Beaucoup Don. Bonjour messiermesdames. Paris est tres bon. Je m�appelle Wendy Butvila et je suis l�infirmiere projet clinicale lsur a Lyell McEwin Hospital. Excusez moi, je ne parle le francais pas! Good afternoon ladies and gentlemen. I am Wendy Butvila, Safer Systems Saving lives Project clinical nurse at LMH in South Australia. I thank you for coming to this presentaion and must commend the conveners and organisers for this prestigious international forum where already amazing things have been learned and shared. My presentation is about changing our culture and embracing team work as we strive for system improvement and change to better clinical outcomes for all patients and in particular, ventilated patients in our ICU. I come here to share with you our progress on our continuous journey for patient quality and safety through clinical practise innovations.Merci Beaucoup Don. Bonjour messiermesdames. Paris est tres bon. Je m�appelle Wendy Butvila et je suis l�infirmiere projet clinicale lsur a Lyell McEwin Hospital. Excusez moi, je ne parle le francais pas! Good afternoon ladies and gentlemen. I am Wendy Butvila, Safer Systems Saving lives Project clinical nurse at LMH in South Australia. I thank you for coming to this presentaion and must commend the conveners and organisers for this prestigious international forum where already amazing things have been learned and shared. My presentation is about changing our culture and embracing team work as we strive for system improvement and change to better clinical outcomes for all patients and in particular, ventilated patients in our ICU. I come here to share with you our progress on our continuous journey for patient quality and safety through clinical practise innovations.

2. International Forum on Quality and Safety in Healthcare. Paris April 2008 In one year ? VAP by > 18% ? ventilation hours ? length of stay ? mortality risk ? health care costs Simple, effective $18.97 / patient The BIG message $500,000 saved with even more savings potential in patient comfortThe Big Message minimum cost $18.91 / patient >$500,000 saved decreased VAP by > 18 % in one year Simple effective �simply illuminating' poster The BIG message $500,000 saved with even more savings potential in patient comfortThe Big Message minimum cost $18.91 / patient >$500,000 saved decreased VAP by > 18 % in one year Simple effective �simply illuminating' poster

3. International Forum on Quality and Safety in Healthcare. Paris April 2008 OUTLINE The Australian �Safer Systems Saving Lives� (SSSL) �do no harm� initiative demonstrated system re-design using the bundle tools from the �Preventing Ventilator Associated Complications� (PVAC) bundle for ventilated patients �First, do no harm� PVAC bundle ?expanded to include mouth care under skin integrity Clinical practise improvement / patient focus Developed solutions Safer systems saving Lives. � what is it? A national collaborative project initiated and funded by the ACQSHC which was adpted from the SAVING 100,000 lives campaign, an initiative of the Institute for Healthcare Improvement (IHI) * international initiative Engaged nationa; expert consultation tp develop bundles All states 37 sites both public and privatr Evidenced based, Sustainable and measurable healthcare innovations LMH STATS South Australia 230 beds undergoing a rapid expansion & development of its ICU and acute care services, under the SA Healthcare Plan Expected to have 30 ICU beds by 2012 WHAT DID WE DO? Identified a problem and established ownership of the problem Evidence search (paediatric and dependant patient models) Developed the teams Provide education DEVELOPED SOLUTIONS MOUTH CARE POLICY DEVELOPMENT IMPLEMENTATION OF MOUTH CARE DALIY AUDIT TO BUNDLE COMPLIANCESafer systems saving Lives. � what is it? A national collaborative project initiated and funded by the ACQSHC which was adpted from the SAVING 100,000 lives campaign, an initiative of the Institute for Healthcare Improvement (IHI) * international initiative Engaged nationa; expert consultation tp develop bundles All states 37 sites both public and privatr Evidenced based, Sustainable and measurable healthcare innovations LMH STATS South Australia 230 beds undergoing a rapid expansion & development of its ICU and acute care services, under the SA Healthcare Plan Expected to have 30 ICU beds by 2012 WHAT DID WE DO? Identified a problem and established ownership of the problem Evidence search (paediatric and dependant patient models) Developed the teams Provide education DEVELOPED SOLUTIONS MOUTH CARE POLICY DEVELOPMENT IMPLEMENTATION OF MOUTH CARE DALIY AUDIT TO BUNDLE COMPLIANCE

4. International Forum on Quality and Safety in Healthcare. Paris April 2008 Non standardised, non evidenced based care VAP rate = 25% Research ? increased risk of VAP from pooled sub-glottal secretions & colonisation of resident bacteria in the mouth / oro-pharnyx VAP patients averaged 3 days longer in hospital > doubled the Length of Stay (LOS) in ICU trebled ventilation hours Number one cause of death from infectious disease in ICU Niederman MS, et al. Am J Respir Crit Care Med2001;163:1730 -1754 THE PROBLEM Scope of the current clinical problem Sixth leading cause of death in ICU Number one cause of death from infectious disease Up to 5.6 million cases per year 1.1 million hospitalizations Average rate of mortality for hospitalized patients 12% Diagnosis There is no current �golden standard� for the diagnosis of pneumonia in the critically ill patient requiring mechanical ventilation � Clinical, radiological, microbiological criteria Research increased risk of Ventilator Acquired Pneumonia (VAP) development from pooled sub-glottal secretions and colonisation of resident bacteria in the mouth and oro-pharynx The problem in our ICU Non standardised care VAP added financial liability in every case. VAP 25% Poor understanding /education/ compliance to care Care not evidenced based Scope of the current clinical problem Sixth leading cause of death in ICU Number one cause of death from infectious disease Up to 5.6 million cases per year 1.1 million hospitalizations Average rate of mortality for hospitalized patients 12% Diagnosis There is no current �golden standard� for the diagnosis of pneumonia in the critically ill patient requiring mechanical ventilation � Clinical, radiological, microbiological criteria Research increased risk of Ventilator Acquired Pneumonia (VAP) development from pooled sub-glottal secretions and colonisation of resident bacteria in the mouth and oro-pharynx The problem in our ICU Non standardised care VAP added financial liability in every case. VAP 25% Poor understanding /education/ compliance to care Care not evidenced based

5. International Forum on Quality and Safety in Healthcare. Paris April 2008

6. International Forum on Quality and Safety in Healthcare. Paris April 2008 VAP COST COMPARISON Averaged Individual cases vary eg $181,000Averaged Individual cases vary eg $181,000

7. International Forum on Quality and Safety in Healthcare. Paris April 2008 LENGTH OF STAY non VAP vs VAP LOS (based on June 06 VAP cases) Average VAP Patient 285 Hours Average ICU Patient 152 Hours Average ventilation hours 121 Non VAP Average ICU Patient 230 TOTAL los Icu STAY 69 VENTILATION HOURS 35LOS (based on June 06 VAP cases) Average VAP Patient 285 Hours Average ICU Patient 152 Hours Average ventilation hours 121 Non VAP Average ICU Patient 230 TOTAL los Icu STAY 69 VENTILATION HOURS 35

8. International Forum on Quality and Safety in Healthcare. Paris April 2008 WHAT DID WE DO? Ownership of problem Development of �guidance teams� & established clinical partnerships Daily audit of compliance Evidence search Provided education Developed solutions First �do no harm� philosophy patient focused Implemented evidenced mouth care policy Early prevention strategy: commence antibiotics Early detection strategy - repeated Mondays and Thursdays whilst intubated. Added MSSU to counter check for new infection - daily CXR - separated analgesia and sedation ? Routine T/Asp OA & where possible prior to 1st IV A/B dose - repeated Mondays and Thursdays whilst intubated. Added MSSU to counter check for new infection - daily CXR - separated analgesia and sedation ? Routine T/Asp OA & where possible prior to 1st IV A/B dose

9. International Forum on Quality and Safety in Healthcare. Paris April 2008 DAILY GOALS EACH patient looked at individually & objectively Patient assessment Bedside nurse present on ward round Standardised nursing initiatives Designed as an educational �tool� Decisions re ventilation goals/ parameters /care Daily compliance to bundle audit

10. International Forum on Quality and Safety in Healthcare. Paris April 2008

11. International Forum on Quality and Safety in Healthcare. Paris April 2008 VAP COMPARISON CHART 2005-7

12. International Forum on Quality and Safety in Healthcare. Paris April 2008 WHAT CAN WE IMPROVE? Embedding of PVAC Standardised patient care Standardise EQUIPMENT ? further evidence & audit required ? Better antibiotics new equipment e.g. �microcuff� polyurethrane ETT Pre-elective intubation mouth disinfection Benchmarking & audit Continuous ongoing education of all staff & teams e.g. ?humidification vs. dry circuits e.g. ?continuous sub-glottic suction: e.g. ?humidification vs. dry circuits e.g. ?continuous sub-glottic suction:

13. International Forum on Quality and Safety in Healthcare. Paris April 2008 MESSAGE FOR OTHERS-resuscitating health care $$ Must haves Vision Guidance Strength to carry on IT support essential Clinical practise improvement Significant savings of health care $$ Improved clinical outcomes Created more �buy � in� & enlisted support of Executive The planned sequence of systematic and documented activity successfully reduced the ventilator associated pneumonia in ventilated clients in Intensive Care at Lyell McEwin Hospital�.

14. International Forum on Quality and Safety in Healthcare. Paris April 2008 WHERE ARE WE NOW? ? FUTURE DIRECTIONS Snapshot of last 3/12 2007 ? VAP ventilated patients � up 35% from previous yr > acuity > ventilation hours Sustainability ?holding �the gains� EXTENSION OF PROJECTEXTENSION OF PROJECT

15. International Forum on Quality and Safety in Healthcare. Paris April 2008 ACKNOWLEDGMENTS Australian Commission of Safety and Quality in Healthcare (ACSQHC) Department of Human Services (Vic) Department of Health (SA) Central Northern Area Health Service (CNAHS) Lyell McEwin Hospital SQRMU & ICU LMH weblink: www.lmh.sa.gov.au For a copy of mouth care protocol or references please Email: Wendy.Butvila@nwahs.sa.gov.au QUESTIONS? Dr Conrad Wareham Genevieve Sturman Martin Reilly Josette Wood Funding from ACQSHC)Dr Conrad Wareham Genevieve Sturman Martin Reilly Josette Wood Funding from ACQSHC)