Reducing Infections: Ventilator Central Line

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Reducing InfectionsVentilatorCentral Line
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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
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Overlake HospitalMedical Center
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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

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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

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Developing a Physician Champion
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Developing a Physician Champion

• Look for a physician who believes in the change
• Need to be in a position to affect change
• Physicians respond to data
• Present evidence
• Align incentives

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Communication with Staff and Physicians 

• Personal letters
• Newsletters
• Face to face
• E-mail
• Presented at meetings
• Posted data/ report cards

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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

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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.

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Ventilator Bundle

• Elevating the head of the patients 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 patients readiness to wean
  from the ventilator

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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

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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

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Central Line Management Changes
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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

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Multidisciplinary Rounding

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

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Daily Goals Sheet/ Rounding Sheet
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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

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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

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Barriers we experienced

• No active critical care manager during project
• Staff ready and organized at rounding time

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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

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Results!

• Baseline average VAP rate 16.33
• Project Average VAP rate 2.50 85 Reduction
• 4 out of 7 months with zero VAP

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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

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Results!

• Baseline ALOS for MV rate 2.25
• Project ALOS for MV rate 1.59 30 Reduction

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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)

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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 DCd
• Found a patient that went into renal failure was
  on too much Digoxin and was becoming toxic

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Keys to Success

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

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SwedishMedical Center
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Presentation Overview

• Background
• Committee composition
• Communication strategy
• Composition of bundles
• Data tracking
• Results
• Barriers
• Words of advice

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Background

• IHI 3rd Annual International Summit on
  Innovations in Critical Care Delivery March 2004

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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

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Our Collaborative Team Members
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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

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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)

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Critical Care Committee Department Composition

• Intensivists
• Nursing Managers, CNS, supervisors
• Respiratory care
• Epidemiology
• e-ICU
• Clinical Effectiveness

• Pharmacy
• Cardiology
• Nephrology
• Neurology
• Inpatient Hospitalist Team
• Surgery

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Multiple Focused Projects

• Ventilator Bundle
• Central line Bundle
• Multidisicplinary Rounds
• Rapid Response Team
• Sepsis Bundle

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Rapid PDSA
P
D
SA (P)
Weekly Meeting
Test of Change
Huddle
Test of Change One Patient, One Physician, One
Time
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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

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Vent Bundle Elements

• Head of bed elevation
• Deep vein thrombosis prophylaxis
• Peptic ulcer disease prophylaxis
• Sedation interruption
• Daily assessment of readiness to wean

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Sedation Interruption

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

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Rapid PDSA
P
D
SA (P)
Weekly Meeting
Test of Change
Huddle
Test of Change One Patient, One Physician, One
Time
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Sedation Interruption

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

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Units of Focus
3rd
Ballard Providence ICUs
2nd
Other First Hill ICUs
7E
1st
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Monitoring/Communication Education Process

• All elements reviewed during night shift or first
  thing in AM (e-ICU)
• Daily AM rounds by manager
• Multidisciplinary Rounds

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Data Feedback - Old Way(Usual Approach)
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Data Feedback Focus on Process Percent of
vented patients with all 5 bundle items
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Data Feedback New WayVent Bundle Compliance
and VAP Infection Rates
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Multiple PDSAs

• 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

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Central Line Bundle Elements

• Remove unnecessary lines
• Practice hand hygiene
• Select optimal insertion site
• Use maximal barrier precautions
• Apply Chlorhexidine for skin antisepsis
• Appropriate site care

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Central Line - PDSA High Impact Tests of Change

• Checklist and supply cart
• Safety pause (including script for staff)
• Physician letter
• Bundle piloted at Ballard and Providence
• Full roll-out March 05
• Trial Biopatch and Statlock

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• Central Line Insertion Checklist -Adults
• Operator________________________________________D
  ate_______________________
• RN Assisting____________________________________
  Room/Location______________
• Safety Pause
• ? Correct Patient ? Correct Procedure
• ? Correct Site ? Verbal agreement from all
  members of the team.
• In order to eliminate central line associated
  blood stream infections, we will be following the
  Central Line Insertion Procedure Checklist based
  on CDC Guidelines.
• Prior to the Procedure
• 1. Hand Hygiene done with Chlorhexidine
  Gluconate (CHG) 2 surgical hand scrub and water
  or waterless alcohol based gel before patient
  contact and before donning sterile gloves.
• YES
• 2. Cleanse Site with CHG 2 Chloraprep Sponge
  1.5mL.
• YES
• 3. Disinfect Site with a back and forth friction
  scrub, utilizing CHG 2 Chloraprep Wand 10.5mL
  for 30 seconds and allow to dry completely before
  catheter insertion.
• YES
• 4. Maximum Barriers Did the operator wear
• YES Cap/Bouffant
• YES Mask
• YES Sterile Gown

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To Physicians and Nurses placing central lines
in SMC intensive care units From Martin Siegel,
M.D., Curtis Veal, M.D., Derel Finch, M.D. and
Greg Sorensen, M.D. Re Improvements in our ICUs
to eliminate central line associated blood stream
infections You are aware that the hospital
strives to improve the quality of patient care
and has activities in place to eliminate needless
death and harm. As part of these ongoing efforts
we are implementing practices called bundles
based on national guidelines and evidence-based
medicine to create significant outcome
improvements. A bundle is a group of
individual interventions forming a collection of
practices or process steps. When these practices
are implemented together as a bundle they
result in better outcomes than when implemented
individually. Consistent with these aims we are
asking all physicians to assure their practice of
inserting central lines includes the following
bundle of activities known as the Central Line
Bundle. 1. A Safety Pause Correct patient,
Correct site, Correct procedure, and Correct
physician. 2. Hand Hygiene and Cleaning the
Patient Skin prior to antiseptic prep of the
insertion site a) Upon entering the
room perform routine hand washing or use alcohol
gel. b) Clean the insertion site
with BD EZ Scrub foam pad brush with 3 CHG
c) Re-sanitize your hands with 2
chlorhexidine gluconate (CHG) antiseptic scrub
(current brand is Exidine 2), alcohol gel or
alcohol scrub containing
chlorhexidine gluconate (Avagard) and put on
sterile gloves 3. Prep the Insertion Site with
antiseptic 2 chlorhexidine gluconate which will
be provided in the 10.5 mL ChloraPrep wand with
sponge applicator. 4. Maximum Barrier
Precautions observed by MD and other healthcare
personnel in the sterile fieldBouffant Cap,
Mask, Sterile Gown, Sterile Gloves,
Full size patient drape, Maintain the sterile
field, individuals on the far side of the bed
simply opening supplies on to the field will at a
minimum use cap, and mask with gloving
as appropriate. 5. Sterile Dressing Applied
Immediately by the MD wearing full barrier
precautions Our ICU nurses assisting you with
line insertions will be using a checklist and
script to help us achieve 100 compliance with
the central line bundle. Anyone involved in the
procedure who sees a break in technique has a
responsibility to the patients safety to quickly
assist in correcting the situation. We will be
testing the central line bundle implementation
with small tests of change. This means we will
be refining our bundle with one MD and one
patient during one procedure. We will then make
small improvements before we repeat this process
with the next MD and patient. The small tests
of change will result in improvements of the
central line bundle checklist, our script for
notifying healthcare professionals of breaks in
technique, and the availability of the correct
standardized supplies in the central line
insertion carts in all ICUs on all campuses. The
central line bundle is just one part of our
overall evidence based quality improvement
program to increase patient safety. The recent
implementations of the ventilator bundle,
multidisciplinary ICU patient rounds and the
deployment of our rapid response team are all
part of this process. We thank you for your
ongoing support for all of these
efforts.Endorsed by the Critical Care Committee
2/8/05
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Central Line Bundle Compliance and CLBSI
Infection Rates
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Communication

• Weekly collaborative meetings
• Weekly data feedback
• Monthly reporting to Critical Care Committee
• Rapid data sharing
• Sharing ideas with IHI
• There is never too much communication

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Barriers

• Lack of standardization
• Data Collection
• Prioritization of work and issues
• Transforming the culture

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Helpful Advice

• Board and senior leadership buy-in
• Physician champions
• Management support
• Empower the staff
• Have process for immediate feedback
• Celebrate team success

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Conclusion
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Why is Ventilator-Associated Pneumonia of
Concern?

• VAP occurs in 15 of patients receiving
  mechanical ventilation.
• Hospital mortality rate of patients with VAP is
  46 compared to 32 for ventilator patients
  without VAP.
• VAP is associated with prolonged stay and
  increase costs.

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What is a Ventilator Bundle?

• Head of bed up 30 degrees
• Daily sedation vacations
• Daily assessment of readiness to extubate
• Peptic ulcer disease prophylaxis
• Deep vein thrombosis prophylaxis.

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Why is Central Line-Associated Infection of
Concern?

• 48 of ICU patients have central venous catheters
  in ICUs.
• There are approximately 5.3 catheter-related
  blood-stream infections per 1,000 catheter-days
  in ICUs.
• Mortality for between 14,000 to 28,000 deaths
  per year.

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What is a Central Line Bundle?

• Hand Hygiene
• Maximal barrier precautions
• Chlorohexidine skin antisepsis, appropriate
  catheter site
• Appropriate administration system care
• No routine replacement

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Recommendations

• Go For It!
• Best change this year!

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Key Points

• Develop physician and administrative champions
• Communicate, communicate, communicate
• Measure and provide immediate feedback

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Measurement

• Number of times bundle not used
• Number of central line infections per 1,000
  catheter days
• Number of ventilator-associated pneumonia per
  1,000 catheter days

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Polling
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Questions?
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Thank you for participating!

• Please fill out the evaluation.