Reducing Infections: Ventilator Central Line

1. Reducing Infections:VentilatorCentral Line

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. Overlake HospitalMedical Center

4. Project Goals • Reduce Ventilator Associated Pneumonia (VAP) by 75% • Reduce Central Line Catheter-Associated Blood Stream Infections by 75% • Achieve 95% or higher compliance with Ventilator Bundle • Achieve 95% or higher compliance with Central Line Bundle

5. Project Goals • Achieve 95% or higher compliance with use of daily goal sheets for patients • Reduce ALOS on Ventilator by 30% • Reduce ICU ALOS • Reduce ICU Costs

6. Developing a Physician Champion

7. Developing a Physician Champion • Look for a physician who believes in the change • Need to be in a position to affect change • Physician’s respond to data • Present evidence • Align incentives

8. Communication with Staff and Physicians  • Personal letters • Newsletters • Face to face • E-mail • Presented at meetings • Posted data/ report cards

9. “Every system is perfectly designed to achieve the results it gets” • Ventilator and Central line bundles • Ventilator management changes • Central line management changes • Multidisciplinary rounding • Daily goals/ Rounding sheet

10. What are Bundles? • 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. • The bundle provides a "forcing function" for teamwork, and this teamwork has led to outstanding results.

11. Ventilator Bundle • Elevating the head of the patient’s bed to 30 degrees or higher • Prophylactic treatment for deep venous thrombosis • Prophylactic treatment for peptic ulcer disease • Daily "sedation vacation“ accompanied by an assessment of the patient’s readiness to wean from the ventilator

12. Central Line Bundle • Hand-hygiene • Optimal insertion site (RIJ, LIJ) • Maximal sterile barrier use (covered to pt waist) • Prepare skin with antiseptic/ detergent chlorhexadine 2% in 70% isopropyl alcohol • Daily review of necessity • Early removal (5 day max) • Intact Dressing

13. Ventilator Management Changes • Chlorhexadine on the unit • Sage oral care product www.sageproducts.com • Sedation reduction vs. Sedation vacation • Using DVT and PUD prophylaxis to prevent risk for vent patients • Using ventilator weaning protocol • Continuous aspiration of subglottic secretions www.atsjournals.org

14. Central Line Management Changes

15. Central Line Management Changes • Created Cent line carts • Implemented Cent Line checklist • Created cath line insertion recommendations • CL catheter products for high risk patients available • New dressings for central lines • Central line dressing team

16. Multidisciplinary Rounding • Introduces redundancy • Intensivist led/ CN facilitated • All patients in critical care • Pharmacy and RT involvement critical

17. Daily Goals Sheet/ Rounding Sheet

18. Daily Goals Sheet/ Rounding Sheet • Creates accountability for practice expectations • Helps to ensure that key activities are done on each patient • Rounding form is a permanent part of the medical record and can be audited • Provides prompting for staff by using daily goals and safety risk checklists • Enhances communication among team members

19. Barriers we experienced • Weekend coverage for rounds • Pharmacy involvement in rounds • Physician and nursing buy-in • Registry and new employees • Physician reluctance • Timeliness of trialing new products

20. Barriers we experienced • No active critical care manager during project • Staff ready and organized at rounding time

21. Process for Data Collection • Created a shared drive for each member to access data and graphs • Established owners for each indicator • Owners are responsible to enter data monthly (by the 10th of the month) onto the shared drive • Quality updates the graphs

22. Results! • Baseline average VAP rate 16.33 • Project Average VAP rate 2.50 = 85% Reduction • 4 out of 7 months with zero VAP

23. Results! • Baseline average CA-BSI rate 2.84 • Project Average CA-BSI rate 1.24 = 56% Reduction • 5 out of 7 months with zero CA-BSI

24. Results! • Baseline ALOS for MV rate 2.25 • Project ALOS for MV rate 1.59 = 30% Reduction

25. Results! • 20 patients saved from needless harm (16.83 + 2.81) • Saved 6 lives (20 patients x 30% mortality rate) • $1,025,860.00 in cost avoided • Data is derived from baseline data Oct 2003-Sept 2004 • 34 VAP cases (2.83 monthly avg, $52,000 a case & ALOS 22 days) • 10 CA-BSI cases (.83 monthly avg, $54,000 a case & ALOS 17 days)

26. Unmeasureable results! • Culture of critical care: • Improved critical thinking and planning for patient care • Staff are able to take view from 10,000 feet • Infections are not inevitable • Great patient saves: • Found that a renal failure patient was on full dose Lovinox • Found many patients that needed to have their antibiotics DC’d • Found a patient that went into renal failure was on too much Digoxin and was becoming toxic

27. Keys to Success • Senior leader support • Clinical Champion • Day to day leader • A multidisciplinary team • Staff buy in • Project sustainability

28. SwedishMedical Center

29. Presentation Overview • Background • Committee composition • Communication strategy • Composition of bundles • Data tracking • Results • Barriers • Words of advice

30. Background • IHI 3rd Annual International Summit on Innovations in Critical Care Delivery – March 2004

31. Convention Highlights • Nosocomial Infections: Zero Tolerance • Improving Critical Care: A Global Approach • “Bundle” Up Your Critical Care Processes • Reducing Mortality and Morbidity • Establishing Culture of Safety in the ICU • Measuring ICU Quality

32. Our Collaborative Team Members

33. IHI Collaborative Team • Chip Veal, MD; Medical Director • Derel Finch, MD; Intensivist • George Pappas, MD; Intensivist • June Altaras, Manager, First Hill ICU • Steve Hoppe, Project Manager, EICU • Joya Pickett, Clinical Nurse Specialist • Marie Arnone, Clinical Nurse Specialist • Patti Feley, Manager, Providence ICU • Will Shelton, Director Epidemiology • Jim Kumpula, Manager, Respiratory Therapy • Nancy Siegle, Manager, Ballard ICU • Jennifer Harville, Director, Clinical Effectiveness • Theresa Bervell, Admin Resident, Clinical Effectiveness • Tom Moore, Respiratory Care • Marjorie Svrjcek, Manager Respiratory Care • Debra Gruber, Manager, Respiratory Care • Caroline Truong, ICU Clinical Care Supervisor • Lilia Mullins, RN IV Team • Laura Make, RN Value Improvement Consultant

34. Team Charter Critical Care Collaborative • Set Objectives • Improve outcomes for ICU patients • Defined Goals • Create no harm culture • Establish shared understanding of bundle concept • Implement bundles • Implement Multidisciplinary Rounds • Identified sponsoring committee (Critical Care Committee)

35. Intensivists Nursing Managers, CNS, supervisors Respiratory care Epidemiology e-ICU® Clinical Effectiveness Pharmacy Cardiology Nephrology Neurology Inpatient Hospitalist Team Surgery Critical Care Committee Department Composition

36. Multiple Focused Projects • Ventilator Bundle • Central line Bundle • Multidisicplinary Rounds • Rapid Response Team • Sepsis Bundle

37. Rapid PDSA P D SA (P) Weekly Meeting Test of Change “Huddle” Test of Change: One Patient, One Physician, One Time

38. What are Bundles? • Collection of practices or process steps • Individual elements based on solid science • Tasks must relate in time and space • Emphasis initially on process rather than outcome • Bundle measured as all or none • Eventual endpoint is outcome improvement

39. Vent Bundle Elements • Head of bed elevation • Deep vein thrombosis prophylaxis • Peptic ulcer disease prophylaxis • Sedation interruption • Daily assessment of readiness to wean

40. Sedation Interruption • Developed protocol and algorithm • Introduced Modified Ramsay Sedation Scale (MRSS) • 1-1-1 • Implemented in pilot unit • ICU skills days

41. Rapid PDSA P D SA (P) Weekly Meeting Test of Change “Huddle” Test of Change: One Patient, One Physician, One Time

42. Sedation Interruption • Developed protocol and algorithm • Introduced Modified Ramsay Sedation Scale (MRSS) • 1-1-1 • Implemented in pilot unit • ICU skills days

43. Units of Focus 3rd Ballard & Providence ICUs 2nd Other First Hill ICUs 7E 1st

44. Monitoring/Communication Education Process • All elements reviewed during night shift or first thing in AM (e-ICU®) • Daily AM rounds by manager • Multidisciplinary Rounds

45. VENTILATOR PNEUMONIA PREVENTION ORDERS* • Reverse Trendelenberg 30 degrees unless contraindicated by hypotension • Sedation interruption daily (unless specifically contraindicated) • Famotidine 20 mg IV Q 12H (unless history of allergy) IF DOCUMENTED BLEEDING or HIGH GI BLEEDING RISK ON ADMISSION: Protonix 40 mg IV daily • Heparin 5000 units SQ Q 12H (unless post-op heart, other anticoagulant ordered) IF DOCUMENTED BLEEDING, HIGH BLEEDING RISK ON ADMISSION or HEPARIN ALLERGY: Sequential compression devices (SCDs) only *Call attending physician if there are questions or concerns about any of these orders. These orders are not intended to duplicate or conflict with those written by the Attending Physician.

47. Mean Data Feedback - Old Way(Usual Approach)

48. Data Feedback – Focus on ProcessPercent of vented patients with all 5 bundle items

49. Data Feedback – New WayVent Bundle Compliance and VAP Infection Rates

50. Multiple PDSA’s • One patient, one physician, one time • e-ICU® involvement and support • Group education followed by one to one education with manager • RNs and RTs coordinate sedation vacation • Multidisciplinary rounding