Transcript A Multidisciplinary Approach to Eliminating VAP

A Multidisciplinary
Approach to Eliminating
VAP
Annette Forlenza RN, MSN, CCRN, CNML
Diane Sobel RRT, MHS
Lee Memorial Health System/ Cape Coral Hospital
9/19/2012
1
Overview
 VAP in 2005
 VAP Today
 Cape Coral Hospital’s Improvement Journey
 Our Results
 Lessons Learned
 Final Thoughts
2
In the beginning…2004
 Similar to most hospital ICUs our VAP rates were
consistent with the “national benchmark”.
 On average, we saw 9- 14 VAPs per year, so this
was an acceptable rate.
 In 2005 we joined a collaborative sponsored by the
Institute for Healthcare Improvement (IHI), focused
improving ICU care, part of the 100K Lives Saved
campaign.
 We were challenged to consider the possibility of 12
months without a VAP…
3
The Patient Case For Change
 Before we could move forward we had to
understand what was happening in ICUs and
why we needed to make some changes.
 After we stopped rolling our eyes and
mumbling about expected complications of
mechanical ventilation, our team got to work.
We LOVE a good challenge!
4
The Case For Change
 ICU care is complex, fragmented, and
expensive.
 4.4 million Americans receive ICU care
annually; that number will increase as “baby
boomers” age.
 Critically ill patients have the highest risk for
death and permanent disability.
 44,000 to 98,000 deaths annually are
attributed to HAIs.
5
The Case For Change
 HAIs affect 5-15% of all hospitalized patients, and 25-
50% of patients admitted to ICU.
 ICU patients have a three-fold risk of developing an
HAI.
 VAP, post op intra-abdominal infections, and
bacteremia related to intravascular devices account
for >80% of HAIs in ICU.
 VAP is the most common HAI among patients
receiving mechanical ventilation (up to 71%).
6
The Case For Change
 Mortality and morbidity significantly increase
when ICU care is complicated by VAP.

27-43% increase in mortality
 Length of stay is increased

4-19 days
 Overall cost estimated to be 1.2 billion
annually

Cost estimated at $40,000- $57,000 per
infection
(1,3,4,5,6,7,8,9,10)
7
Considerations…
 “Between the healthcare we have and the
care we could have lies not a gap but a
chasm”.
 Healthcare must reliably transfer best known
science into practice.
 Despite the best intentions processes fail
when care is not reliable.
 Healthcare’s intent to heal too often does just
the opposite, leading to unintended harm and
unnecessary death.
(1)
(2)
8
What’s Different Since 2004?
 HAIs still the most common complication in
hospitalized patients

VAP is second most common in the US.
 VAP is responsible for 25% of infections that occur in
ICUs.
 Estimated economic consequences of VAP vary
widely:


$11,000 to $57,000 per infection.
Increased ICU LOS 4-19 days.
9
What’s Different Since 2004…
 Healthcare reform: while we understand it’s here to
stay, reimbursement and formal structures are
transitioning.
 Unclear where we will be in 5 years.
 VAP is listed by CMS as “reasonably preventable”
and is expected to be non-reimbursable.
 Private insurers are likely to follow suit.
(12,13)
10
What’s Different Since 2004…
 Insurers expect efficient care using best
practices.
 Tightening controls:





Admission criteria
Eligibility
Services
Readmission rates
Education to prevent reoccurrences of chronic
illnesses and outpatient instructions
11
What’s Different Since 2004…
 Healthcare consumers are more savvy
 High expectations for quality care, patient satisfaction,
and transparent outcomes.
 Internet allows for viewing of websites with a
multitude of information/comparisons:
 Adherence to core measures, outcomes of
physician practice, public reporting of HAIs,
hospital readmission rates, and mortality.
 Consideration of ROI for reducing patient harm.
(13)
12
Cape Coral Hospital ICU: Our Journey
 We joined the IHI community in 2004 as part
of a collaborative to reduce complications
from ventilators and central lines.
 It was here we were introduced to the
concept of “bundling” care.
 A “bundle” is a group of evidence-based
interventions related to a disease that when
instituted together produce better outcomes
than when done individually.
13
Adopting The Ventilator Bundle
1. Head of bed elevation 30-45 degrees
2. Mouth care Q2H, and tooth-brushing Q12H
3. DVT and PUD prophylaxis
4. Daily sedation interruption (sedation
“vacation”)
5. Daily assessment of readiness to wean
14
“But we’ve always done it that way”
 It’s simplistic to believe that adopting the bundle was
responsible for our success.
 It’s simplistic to believe that 5 small practice changes
came easy.
 We were being challenged to evaluate practices that
were considered “sacred cows”…
 We resided in a national healthcare culture that
accepted mediocre results where change was
considered an “extreme sport”.
15
Implementing a Bundle?...
Consider the following
 Conduct small tests of change
 Be systematic and incremental with change
 Educate and communicate with staff
 Design processes to prevent harm
 Create independent redundancies to ensure




compliance with critical processes
Develop a culture of collaboration
Reduce complexity in all processes
Involve the front line; it’s the key to improvement
Share your ideas and work (15)
16
So…how do you eat an
elephant?
 Staff were introduced to the concept of care
“bundles”, however we did not get buy in overnight.
 We became well versed in small tests of change and
PDSA cycles.
 Staff were educated and there was a steady stream
of communication.


Chief Nurse and system Medical Director for ICUs
conducted 4 hour education to communicate new
expectations.
Mandatory for all ICU staff nurses and respiratory
therapists.
17
A Collaborative Culture



Multidisciplinary team established as a “home
team”.
Daily intensivist led multidisciplinary rounds.
Development of a Daily Goal sheet

Provided independent redundancy

Reduced complexity

Many revisions based on small tests of change
over a period of time
18
New Processes
 Apply best science and reliable processes
 Bundle use and compliance monitored and
reported to the home team at biweekly
meetings.
 Adopted CDC definition of VAP, although even
today concise definition alludes us.
 Aggressive hand hygiene campaign,
disinfecting hand gel placed in all patient
rooms and around units.
 Mouth care added to original IHI bundle
(11)
19
New Processes
 Establish protocols

Adopted Richmond Agitation and Sedation
(RASS) scale to monitor patient sedation. All
patients sedated to RASS of zero to -1 unless
other wise ordered


RT and RN independently score patients.
Nursing staff required to document sedation
score prior to adjusting medication.
20
Practice Changes
 Define and monitor process measures


ventilator bundle compliance
weaning protocol rate of utilization.
 Monitor balance measures


average length of stay on ventilator
ICU average length of stay.
 Define and monitor outcome measures:


VAP rate
ICU mortality.
21
Practice Changes
 RN/RT collaboration tool developed to
increase communication and expedite
extubation of appropriate patients.
 Daily wean screen and reevaluation of
patients later on in the day who failed the
initial screen.
 Adopted use of a closed enteral feeding
system to decrease the possibility of
contamination.
22
Practice Changes: Respiratory Care
 HME filter brand changed to reduce breaks in
the circuit and frequency of filter changes.
 All nebulizers replaced by MDI.
 Cuff pressures checked and documented
routinely.
 Insured equipment available for supra glottic
suction in radiology*.
 Individual rolls of tape for each patient
(instead of a common roll of tape that lived on
the practitioners stethoscope).
23
24
Practice Changes: Respiratory Care
 All resuscitation bags bacteria filtered, dated,
replaced after 7 days.
 Hard plastic oral cavity suction replaced by
one with a sleeve.
 Routine practice of saline lavage
discontinued.
 Ventilator control panel and tubing cleaned
daily with antiseptic wipes.
25
Practice Changes:
 HOB remains elevated at 30 degrees when
ventilator patients are transported.
 Physician order with rationale required for
HOB <30 degrees.
 Nursing and RT directors spread bundle and
new care expectations with other areas
where ventilator patients may reside.
 Costly oral care kits are replaced with less
expensive components.
26
Anticipating Risk: A Multidisciplinary
Approach to Care
 Daily Intensivist-led multidisciplinary rounds
(MDR)


Utilizes a patient centered approach to
determine explicit daily goals
Allows for “skillful and orchestrated
performance of the different competencies” (14)
Improves communication
 Decreases confusion regarding the plan of
care
 Clarifies goals and organizes work

27
A Multidisciplinary Approach to Care
 Identifies what needs to get done today to
facilitate the patient leaving the ICU
 Patient progress reviewed
 Plan of care developed
 Daily goal sheet completed
 Plan communicated to patients and
families
28
A Multidisciplinary Approach to Care




Provides a “safety net” to insure best practice
Allows for independent redundancy
Provides clear behavioral and practice
expectations
Can demonstrate effectiveness by decreasing
LOS, decreasing ventilator days, decreasing
cost of care (9)
29
A Multidisciplinary Approach to Care
 Our team
30
Developing a Culture of Safety
 Senior leadership adopts patient safety as number
one core value.
 Culture of Safety survey 2008, 2011, 2012
 Patient Safety and Medical Error Prevention training
 Practical tools and team behaviors to promote
patient safety
 All staff and volunteers attend
 Monthly Progress Report provides transparency
 Every meeting begins with a “safety story”.
31
Developing a Culture of Safety
 Safety Coach program


Empowers front line staff from each
department
Monthly meetings to provide support,
education, and reinforcement.
 Increased reporting errors and “good
catches”.
 Results: Over 1 Year without at serious safety
event (465 days as of 9/19).
32
Results
33
Results
34
Results
CCH ICU - Ventilator Bundle / VAP RATE
12.00
6.00
4.00
2.00
n
Fe -06
bM 06
ar
A p 06
r
M -06
ay
Ju -06
n0
Ju 6
Au l-06
g
Se -06
pOc 06
No t -06
v
De - 06
c
Ja - 06
n
Fe -07
bM 07
ar
A p 07
r
M -07
ay
Ju -07
n0
Ju 7
Au l-07
g07
0.00
Ja
VAP RATE
8.00
VENT BUNDLE
RELIABILITY
10.00
100%
100%
100%
100% 100%
100%
100%
100% 90%
96%96%95%96%97% 93% 100%
93%
93%92%89%
9.71
80%
87% 90%
70%
7.75
60%
6.71
6.33
50%
5.88
5.49
40%
4.63
30%
2.86
20%
10%
0
0
0 0
0
0 0 0 0 0 0 0 0%
VAP RATE
VENT BUNDLE
35
Results
CCH ICU - Ventilator Bundle / VAP RATE
100%100%100%100%
100%100%
100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%
30
100%
92%
90%
90%
25
80%
80%
VAP RATE
60%
50%
15
40%
10
30%
VENT BUNDLE RELIABILITY
70%
20
20%
5
4.61
10%
0
0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0%
8 08 08 09 09 09 09 09 09 09 09 09 09 09 09 10 10 10 10 10 10 10 10 10 10 10
-0
ct ov ec an eb
ar Apr ay un Jul ug ep Oct ov ec Jan eb
ar Apr ay un Jul ug ep Oct ov
O
J
F
M
J
F
M
J
D
D
S
S
N
N
N
M
A
M
A
36
Results
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
(# VAP cases / total monthly ICU vent days) * 1000
Jul-11
6.00
5.00
4.00
3.00
2.00
1.00
0.00
Jun-11
VAP RATE
CCH ICU Ventilator Associated
Pneumonia Rate
37
Lessons Learned
 Keep the patient and family as your #1 focus.
 Identify all stakeholders and all key players,
especially those you expect will be your
biggest opponents.
 Align agendas: recognize that your agenda
isn’t necessarily everyone else’s.
 Obtain and maintain interdisciplinary and
administrative buy-in.
 Set expectations, educate, reinforce
consistency: Hold everyone accountable.
38
Lessons Learned
 Provide clear and convincing evidence for
change.
 Don’t assume you’re “already doing that!”
 Be sure goals and outcomes are transparent.
 Measure and report outcomes celebrate
successes.
 Drill down defects.
 Eat the “elephant” one bite at a time.
39
Lessons Learned
 Never doubt that a committed group of caring
people can move mountains!
 Allow the front line to participate in identifying
goals and barriers.
 It’s the front line that will make the change
happen.
40
Final Thoughts
Healthcare is a highly complex system with broken
parts. For every broken part, there are
examples of excellence in organizations that
have overcome enormous obstacles to redesign
the way care is delivered.
(2)
"Quality is never an accident: It is always the result of
high intention, sincere effort, intelligent direction and
skillful execution. It represents the wise choice of many
alternatives."
-William A. Foster
41
Thanks for being here!
Questions?
42
References
1.
Institute of Medicine. (2001). Crossing the quality chasm: a new health system for the 21 st century.
Washington DC: National Academy Press
2.
Overview of the 100,000 Lives Campaign - Institute for Healthcare Improvement
www.ihi.org/.../Overview%20of%20the%20100K%20Campaign.pdf
1.
Randolph, A.G., & Pronovost, P. (2001). Reorganizing the delivery of intensive care could improve
efficiency and save lives. Journal of Evaluation in Clinical Practice, 8(1), 1-8.
3.
Thungjaroenkul, P., & Kunaviktikul, W. (2006). Possibilites for cost containment in intensive care.
Nursing and Health Sciences, 8, 237-240.
4.
American Association of Critical Care Nurses. (2008). Practice alert: ventilator-associated pneumonia.
Critical Care Nurse, 28(3), 83-85.
5
Augustyn, B. (2007). Ventilator-associated pneumonia: risk factors and prevention. Critical Care Nurse
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6
Hyllienmark, P., Gardlund, B., Persson, J.O., & Ekdahl, K. (2007). Nosocomial pneumonia in the ICU: a
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7
Powers, J. (2006). Managing VAP effectively to optimize outcomes and cost. Nursing Management,
available at www.nursingmanagmentt.com. Accessed on May 8, 2009.
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References
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9.
Pronovost, P., Berenholtz, S., & Dorman, T. (2003). Improving communication in the ICU: using daily
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Ames, N. (2011). Evidence to support tooth brushing in critically ill patients. American Journal of Critical
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Healthcare Financial Management Association Learning Solutions. (2011). Avoiding patient harm.
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