SICSAG VAP Prevention Bundle – does it work ?

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SICSAG VAP Prevention Bundle does it work ?
Malcolm Daniel, Andrew Longmate, Kevin Rooney
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Aims

• To review data from Scottish Centres
• To look at interpretation of run charts
• To look at ways of improving care

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• SICSAG VAP Prevention Bundle Jan 2008
• http//www.sicsag.scot.nhs.uk/SubGroup/HAI.htmlpu
  b
• Beard D, Booth M, Cook B, Cole S, Crofts S,
  Curran S, Kellagher A, Longmate A, Swann D
• Sedation to be reviewed and, if appropriate,
  stopped each day
• All patients will be assessed for weaning and
  extubation each day
• Avoid supine position, aiming to have the
  patient at least 30 head up
• Use Chlorhexidine as part of daily mouth care
• Use subglottic secretion drainage in patients
  likely to be ventilated for more than 48 hours

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What is the variation in one system over time?
Walter A. Shewhart - early 1920s, Bell
Laboratories
Dynamic View
Static View
Static View
LCL

• Every process displays variation
• Controlled variation
• stable, consistent pattern of variation
• chance, constant causes
• Special cause variation
• assignable pattern changes over time

Static View
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NHS Dumfries and Galloway Royal Infirmary VAP
Rate
Shift downward and sustained
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NHS Tayside Ninewells ICU VAP Rate
Shift downward and sustained
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Remember

• These are outcomes
• Are processes important ?
• Remember processes drive outcomes
• Structure Process Outcome
• (Avedis Donabedian 1966)

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Repeated Use of the Cycle
Changes That Result in Improvement
DATA
Implementation of Change
Wide-Scale Tests of Change
Follow-up Tests
Hunches Theories Ideas
Very Small Scale Test
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Improvement vs. ResearchContrast of
Complementary Methods

• Improvement
• Aim
• Improve practice of health care
• Methods
• Test observable
• Stable bias
• Just enough data
• Adaptation of the changes
• Many sequential tests
• Assess by statistical significance

• Clinical Research
• Aim
• Create New clinical knowledge
• Methods
• Test blinded
• Eliminate bias
• Just in case data
• Fixed hypotheses
• One fixed test
• Assess by statistical significance

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National Results
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Conclusions

• SICSAG developed a VAP Prevention Bundle
• Key step is working on improvement in process
  reliability
• Improvement in process reliability is driving a
  reduction in VAP rate

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Sustainability Key Concepts

• Leadership Support
• Systems approach
• Interdisciplinary Teams
• Standardise and Simplify work
• Embed Measurement in Daily Work
• Real Time Process Measurement
• Real Time Outcome Measurement
• Transparency and Avoidance of Blame

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Blue to Yellow published

• Reduction of Ventilator Associated Pneumonia
  Active versus Passive Guideline Implementation.
• C Hawe, KS Ellis, CJS Cairns, A Longmate.
  Intensive Care Medicine 2009 35 1180-1186

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Unit 1
Unit 2
Unit 3
R Lloyd, Institute for Healthcare Improvement
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Limitations and Strengths

• Non-controlled
• Non blinded
• Confounding variables
• Other changes
• VAP definition
• Hawthorne

• Continuous measurement
• Validated definitions
• Clear link between process and outcome
• Consistent with other studies

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Some u chart rules
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Drawing new limits
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Architecture of Quality Improvement Programmes
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Secondary DriverVAP prevention screening for
weaning
Cycle 1Econsolidation
Cycle 1D recording on WW at midnight
Cycle 1C daily prompt sheet charge
nurse-(police)
Cycle 1B 1-3-5 nurses. Recorded on 24hr chart
Cycle 1A Stickie developed (using existing
agreed work) trialled with one nurse several
times
Testing Trigger Screening for Weaning