Transcript RAPID RESPONSE TEAM - University of California, San Francisco

Preventing Hospital Acquired
Pneumonia (HAP) in Neuroscience
Patients
UCSF Center for Nursing
Research and Innovation
October 22, 2014
Presenters:
Kathryn Snow, RN, MS, CNS, CNRN
Jacqueline Narkizian, RN, MSN
10/22/2014
Kathryn Snow, RN, MS
Acknowledgements
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Cathy Parker, RN, Clinical Adult Services Director
Nora Tam, Operations Specialist & Senior Staff Assistant
Barbara VanAmburg, RN, Chief Nursing Officer
Michelle Brown, Neuroscience Nurse Manager
Mary Machanga, ICU Nurse Manager
Staff Champions, ICU and Neuroscience Unit
The Hospital and Emergency Department Reliability and
Operational Excellence for Safety Committee (HEROES)–
Kaiser Permanente Redwood City
10/22/2014
Kathryn Snow, RN, MS
Preventing HAP
• Purpose: To reduce Hospital
Acquired Pneumonia by 15%.
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Kathryn Snow, RN, MS
Preventing HAP – Background Data
# Attributable
# Attributable
# Patients
deaths
Hosp Days
with
HAI/yr # Deaths
# Patients
# Attrib Pt Days
Hospital
Acquired
Infections
HAP
2,661 pts
365 deaths
21,900 days
C Difficile
2037 pts
110 deaths
18,600 days
Surgical
Site
997 pts
18 deaths
5,184 days
83 pts
4 deaths
395 days
163 pts
0 deaths
234 days
Central Line
Associated Blood
Stream Infection
Catheter Associated
Urinary Tract
Infection
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Kathryn Snow, RN, MS
Preventing HAP – Background Data
Characteristics of 87% of Actual HAP Cases:
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Confused, obtunded or sedated
NG or feeding tubes
Low albumin
Post-operative patients
All commonplace for neuro patients
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Preventing HAP – 2013 Rate
12.5 per 1K Patient Days
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Risk Profile - Neuro Patients
• Airway obstruction
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LOC
Poor head position
Poor cough / gag
Poor control of saliva
Poor muscle control / tone
Airway edema
Diagnoses: cervical surgery, craniotomy,
diaphragm paralysis, stroke
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Kathryn Snow, RN, MS
Preventing HAP – Case Attribution
100% = 30
100% = 70
(12 at our hospital, 18 within 12
months)
Stroke = 27 of 39
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Kathryn Snow, RN, MS
Preventing HAP – Case Attribution
HAP
2013
Surgical
Med-Surg
Unit 1
Telemetry
Med-Surg
Unit 2
ICU
Neuro
Total
Total
Cases
12
5
9
5
19
20
70
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Kathryn Snow, RN, MS
Observed Patterns
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Oral care inconsistent
Mobility not a primary priority
Incentive Spirometer Use inconsistent
Nurses lacked confidence with naso-tracheal
suctioning
• Aspects of tracheostomy care policy were
not being followed
• Lack of awareness about HAP
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Kathryn Snow, RN, MS
Observed Patterns
• Head of Bed ≥ 30° hard-wired
• Dysphagia screen
• Kaiser Permanente devised ROUTE Bundle
for Medical-Surgical areas
• Concurrent project in ICU:
Rethinking Critical Care
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Kathryn Snow, RN, MS
ROUTE Bundle
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Kathryn Snow, RN, MS
Rethinking Critical Care Initiatives
• Delirium Assessment using Confusion Assessment
Method (CAM-ICU) tool
• Daily Spontaneous Awakening and Spontaneous
Breathing trials (SAT / SBT) for mechanically ventilated
patients
• Mobility Protocol
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Methods
• 2012, 4th quarter, HAP Summit
• 2013 Interventions:
• Chlorhexidine rinse every twelve hours added to MAR
• ROUTE Bundle education initiated for medical-surgical units
• Tile markers placed in floor to encourage ambulation
• Standardized HAP Prevention order sets initiated
• Nasogastric tube policy changed to reflect order sets
• Ongoing tracking of ROUTE Bundle compliance by
management and HEROES committee
• Multi-disciplinary Rounds
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Kathryn Snow, RN, MS
Methods
• 2014 Interventions:
• HAP Prevention orders added to Stroke order sets
• Targeted education for the Neuroscience unit focusing on
HAP statistics, ROUTE Bundle interventions, naso-tracheal
suctioning technique and tracheostomy care
• ICU Nurses received HAP education as part of annual
Stroke training
• Collaboration between RN, Neuroscience physician, and
Respiratory Therapy teams to optimize respiratory
treatment strategies
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Kathryn Snow, RN, MS
Preventing HAP Results
YTD 45% Reduction
20
11
Jan-Aug
2013
10/22/2014
Jan-Aug
2014
Kathryn Snow, RN, MS
Preventing HAP - Results
37 HAP cases in 2014 (Jan-Aug)
Based on Primary Diagnosis:
YTD 2014 HAP Cases by Service
• Neurosurgery/Neurology service
11 cases (30%)
• Internal Medicine service
14 cases (38%)
• Surgical services
12 cases (32%)
Neuro
Surgical, 12,
32%
72% Overall Reduction from 2013
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Kathryn Snow, RN, MS
Neuro, 11,
30%
Internal
Medicine, 14,
38%
Internal
Medicine
Surgical
Discussion and Clinical Implications
• Rethinking Critical Care initiatives coincided
with HAP initiatives
• Majority of ICU patients flow to Neuro unit
• Standardized orders sets ensured compliance
• Multiple layers of reinforcement:
nurse managers, educators, critical care and
neuro physicians, HEROES committee,
multi-disciplinary rounds
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Kathryn Snow, RN, MS
Discussion and Clinical Implications
• Staff nurses drove program success
• Clinical Adult Services Director champions
mobility
• Culture change has occurred
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Kathryn Snow, RN, MS