tracy johns , rn, bsn, cphq medical center of central georgia · •637 bed, acute-care academic...
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Tracy Johns , RN, BSN, CPHQ
Medical Center of Central Georgia NDNQI Quality Conference: February 2013
Zapping VAP at MCCG / February 2013 2
• 637 bed, acute-care academic medical center • 2nd largest hospital in Georgia • Magnet designation 2005 • Level 1 trauma services • 142 ICU beds: 5 adult, neonatal,
pediatric
• Certified: – Hip & Knee replacement programs – Stroke program – Ventricular assist device (VAD) – Chest pain center – Palliative care program
3
Macon
Atlanta
Savannah
Zapping VAP at MCCG / February 2013
4
1. Designing Actions for Impact
2. Engagement AND Accountability
3. 2013 & forward
Zapping VAP at MCCG / February 2013
5
1. Designing Actions for Impact
2. Engagement AND Accountability
3. 2013 & forward
Zapping VAP at MCCG / February 2013
6
1. Designing Actions for Impact
2. Engagement AND Accountability
3. 2013 & forward
Zapping VAP at MCCG / February 2013
7
1. Designing Actions for Impact
Zapping VAP at MCCG / February 2013
Problem 6 years ago / Baseline • Leading:
• < 90% compliance with vent bundle (HOB, turn, Hi Lo ETT, oral care)
• Lagging: • Experiencing > 100 VAP cases/year (2006 = 114) • Adult ICUs had higher than expected vent LOS (10-11 days)
8 Zapping VAP at MCCG / February 2013
9 Zapping VAP at MCCG / February 2013
View: • Care of vent patients inconsistent
• Lack of evidence based practice
• Silo care versus interdisciplinary
• Not following guidelines for IHI, AACN, SSCM, APIC, NACHRI, and CMS
10 Zapping VAP at MCCG / February 2013
Aspiration
Vent bundle use inconsistent
Pneumonia Present on admit
Management
Not doc POA
CAP Other facility transfer
Mini BAL missed
CPIS missed
Separate Sx
Oral Care
CLRT
Change canisters
HiLo ETT
Hand Hygiene PUD prev
HOB 30°
Retrospective review
Competing priorities
No accountability for results
Results not emphasized
Data not disseminated
Expectations unclear
During intubation
PUD prev
High risk not ID’d
HOB 30° During intubation
Secretion management
Family feeds ice chips
11 Zapping VAP at MCCG / February 2013
Supplies, equip, meds
Emergency Department
Pre-existing DX, co-morbidities
Intubate / Extubate
Lack of experience
Transport monitoring
Outdated competency assessment
Too few ICU beds
Need quick ref info i.e. reinforcement
Same level of care
Coordination RRT & RN for SAT/SBT
BiPAP vs. intubation
Disagreement patient & family re: intubation
Nob-compliance with SAT/SBT
Emergency vs. planned
Altered mental status (AMS)
CAP Hx of smoking
Cough or gag reflex
Bacterial colonization MRSA Diabetes, COPD,
ESRD, Heart Dz Hard to find supplies
PUD prev
CHG not in stock
Too few suction ports in ICU rooms
Par stock too low
Over sedation
12 Zapping VAP at MCCG / February 2013
Assessment: • Most of our infections preventable
• 2006 -2007 VAP reduction became a STRATEGIC focus on quality improvement
• Initial goal to ↓ VAP by 50%
Structure Process Outcomes
13 Zapping VAP at MCCG / February 2013
Structure of Care
Process of Care Outcomes
14 Zapping VAP at MCCG / February 2013
Structure of Care
Process of Care
15
↓ vent times
Prevent HAI = VAP
↓ Unplanned extubations
↓ ICU & hospital LOS
Zapping VAP at MCCG / February 2013
Hardwire Evidence Based
Best Practice
Organizational Vent policy
SAT/SBT guidelines
Physician credentials
Interaction: Emp - Pt Compliance
Frequency & Coordination
of care
16 Zapping VAP at MCCG / February 2013
Actions for Impact: Recap
Process Structure Evidence Based, Best Practice
Monitor Process effect on Outcome (Donabedian)
Value of Process = connect to outcome
Hardwire Process make right process easy
17 Zapping VAP at MCCG / February 2013
18
1. Designing Actions for Impact
2. Engagement AND Accountability
Hardwiring the care process
Zapping VAP at MCCG / February 2013
19 Zapping VAP at MCCG / February 2013
(Audit & feedback) ADDED to
(provider reminder systems)
(Audit & Feedback) ADDED to
(organizational change) AND (provider education)
AHRQ: Prevention of Healthcare-Associated Infections: Closing the Quality Gap www.effectivehealthcare.ahrq.gov/reports/final.cfm
20 Zapping VAP at MCCG / February 2013
Make delivery of evidence-based, best practice EASY AS POSSIBLE.
Create alerts (reminders, visual aids, peer pressure) to MAKE POOR CARE DELIVERY DIFFICULT.
Audit & feedback
Provider Reminder Systems
Structure of Care
Process of Care Compliance
Frequency of care
Coordination of care
Zapping VAP at MCCG / February 2013
Share responsibility for mouth care with resp; scheduled via
MAR & task scheduler
RT assesses vent bundle compliance 3X/week on
all pts; deficiencies immediately reported to
RN Manager
Changed par level & storage of mouth care
kits to assure availability & visual reminder
Met with anesthesia & CRNA groups: use Hi- Lo ETT for ICU surgery
pts
Stock Hi- Lo ETT’s in ER,
code carts & with EMS
Vent bundle
SAT/SBT guidelines
Physician credentials
Upgraded ICU beds to include
CLRT module
Each time SBT not performed per criteria
RT manager f/u giving verbal or written warning
72%
70%
76%
77%
78%
71%
94%
95% 91%
85%
100%
95%
98%
98%
100%
98%
99%
98%
95%
94% 97%
98%
90%
96%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
3
6
9
12
15
Jul 10
Aug 1
0
Sep
10
Oct
10
Nov 1
0
Dec
10
Jan 1
1
Feb
11
Mar
11
Apr
11
May
11
Jun 1
1
Jul 11
Aug 1
1
Sep
11
Oct
-11
Nov-1
1
Dec
-11
Jan
-12
Feb
-12
Mar
-12
Apr-
12
May
-12
Jun
-12
Spont Breathing
Trial
Data Source:
APACHE IV
milliennium
Ven
t d
ays
Sp
on
taneo
us B
reathin
g T
rial Co
mp
liance
Goal: SAT/SBT
Compliance > 90%
Avg Vent Days:
FY09 Avg: 5.4 days
FY10 Avg: 5.5 days
FY11 Avg: 5.3 days
MCCG Adult ICUs: Avg. Compliance with SAT/SBT
(excludes (OHS)
22 Zapping VAP at MCCG / February 2013
23 Zapping VAP at MCCG / February 2013
• Increased the rigor of goals
• 2006: process perfection
• 2013: process value → connected to outcome
• Interdisciplinary frontline → Board involvement
• Utilized the Plan–Do-Check-Act (PCDA) methodology
• Continue to implement new strategies
• Joined GHA Hospital Engagement Network HAI – continue to implement new strategies
6.1 5.6
4.4
5.7 5.5
6.4 5.7 5.9 5.9 6.0
5.4
6.2
3.8
4.3 4.7
5.9 5.9
5.2 4.5 4.5
5.8
5.0 4.7
4.7
0
3
6
9
12
15
Mar
10
Apr
10
May
10
Jun 1
0
Jul 10
Aug 1
0
Sep
10
Oct
10
Nov 1
0
Dec
10
Jan 1
1
Feb
11
Mar
11
Apr
11
May
11
Jun 1
1
Jul 11
Aug 1
1
Sep
11
Oct
-11
Nov-1
1
Dec
-11
Jan-1
2
Feb
-12
MCCG Adult ICUs: Avg Vent Times
(excludes OHS)
All Avg Times
Data Source:
APACHE IV
millennium
Ve
nt
da
ys
Goal: Avg Vent Days < 5.4 days
Avg Vent Days:
FY09 Avg: 5.4 days
FY10 Avg: 5.5 days
FY11 Avg: 5.3 days
24 Zapping VAP at MCCG / February 2013
Display together: shows the “WHY” of measuring
6.1 5.6
4.4
5.7 5.5
6.4 5.7 5.9 5.9 6.0
5.4
6.2
3.8
4.3 4.7
5.9 5.9
5.2 4.5 4.5
5.8 5.0 4.7
4.7
73%
80%
90%
74%
72%
70% 76%
77% 78%
71%
94%
95% 91%
85%
100%
95% 98%
98%
100%
98%
99%
98% 95% 94%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
3
6
9
12
15
Mar
10
Ap
r 10
May
10
Jun 1
0
Jul 10
Au
g 1
0
Sep
10
Oct
10
No
v 1
0
Dec
10
Jan 1
1
Feb
11
Mar
11
Apr
11
May
11
Jun 1
1
Jul 11
Au
g 1
1
Sep
11
Oct
-11
No
v-1
1
Dec
-11
Jan-1
2
Feb
-12
MCCG Adult ICUs: Avg Vent Time
compared with Compliance with SBT
All Avg Times
Spont Breathing Trial
Data Source:
APACHE IV
millennium
Ven
t d
ays
Spontan
eous B
reathin
g T
rial Co
mp
liance
Goal: Avg Vent Days < 5.4
Avg Vent Days:
FY09 Avg: 5.4 days
FY10 Avg: 5.5 days
FY11 Avg: 5.3 days
25
Talk, reports, policy review – all with no
improvement. Crit Care Committee:
unacceptable!
Zapping VAP at MCCG / February 2013
Time to kick b.. and take names
6.1 5.6
4.4
5.7 5.5
6.4 5.7 5.9 5.9 6.0
5.4
6.2
3.8
4.3 4.7
5.9 5.9
5.2
4.5 4.5
5.8 5.0
4.7
4.7
73%
80%
90%
74%
72%
70% 76%
77% 78%
71%
94%
95% 91%
85%
100%
95% 98%
98%
100%
98%
99%
98% 95% 94%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
3
6
9
12
15
Mar
10
Apr
10
May
10
Jun 1
0
Jul 10
Aug
10
Sep
10
Oct
10
Nov 1
0
Dec
10
Jan 1
1
Feb
11
Mar
11
Apr
11
May
11
Jun 1
1
Jul 11
Aug 1
1
Sep
11
Oct
-11
Nov-1
1
Dec
-11
Jan-1
2
Feb
-12
MCCG Adult ICUs: Avg Vent Time compared
to Compliance with Spontaneous Breathing Trial
Data Source:
APACHE IV
millennium
Ven
t d
ays
Spontan
eous B
reathin
g T
rial Com
plian
ce
Goal: Avg Vent Days < 5.4 days
Avg Vent Days:
FY09 Avg: 5.4 days
FY10 Avg: 5.5 days
FY11 Avg: 5.3 days
26
Care best practice?
Outcome safer / improved outcomes
Cause compliance
Effect # vent days
changes
Care BEST PRACTICE!
Zapping VAP at MCCG / February 2013
27
2006 2007 2008 2009 2010 2011
#VAP 114 44 19 9 4 2
0
20
40
60
80
100
120
Nu
mb
er
of
VA
P c
as
es
# of VAP in MCCG ICU’s Critical Care 2006 - 2011
P
ICU
SB
T/S
AT
Re
se
arc
h
P
ICU
Bu
nd
le
P
UD
, D
VT
S
AT
, S
BT
in
Ad
ult
Cri
tic
al C
are
N
utr
itio
n B
un
dle
In
itia
l V
en
t B
un
dle
M
on
ito
r P
roc
es
s/O
utc
om
es
D
iscip
lin
ary
Ac
tio
n-
SB
T n
on
-co
mp
lia
nc
e
2012 Nutrition Bundle Revisited
Communicate Hardwire “ease the path of EBP”
Link Care Process & Outcomes
Communication with Individuals / Link performance to job
Med Staff Privileges vent management: individual or group
Employee performance individual compliance, accountability, warnings, &
annual evaluation
KB & TN
28 Zapping VAP at MCCG / February 2013
29
1. Designing Actions for Impact
2. Engagement AND Accountability
3. 2013 & forward
Zapping VAP at MCCG / February 2013
Lagging patient outcome
Surveillance for Vent Associated Events
– CDC Prevention Epicenters http://www.cdc.gov/hai/epicenters
– Critical Care Societies Collaborative http://ccsonline.org
30 Zapping VAP at MCCG / February 2013
Lagging: patient outcomes Incidence
NHSN: National Healthcare Safety Network
31
Vent Associated Pneumonia (VAP) Population
Acute & long-term care hospitals
Inpatient rehab facilities
> 18 years old
Mechanical vent time > 3 calendar days
EXCLUSIONS: patients on rescue mechanical ventilation • high-freq ventilation (HFV), • extracorporeal membrane oxygenation (ECMO), & • mechanical ventilation in prone position
Zapping VAP at MCCG / February 2013
Lagging: patient outcomes
NHSN: National Healthcare Safety Network
32
Probable VAP Public Reporting Definition
On or after calendar day 3 of mechanical ventilation AND within 2 calendar days before or after onset of worsening oxygenation ONE of the following is met:
Purulent respiratory secretions AND one of the following • (+) culture of endotracheal aspirate (> 105 CFU/ml or equivalent) • (+) culture of bronchoalveolar lavage (> 104 CFU/ml or equivalent) • (+) culture of lung tissue (> 104 CFU/ml or equivalent) • (+) culture of protected specimen brush (> 103 CFU/ml or equivalent)
If no purulent secretions, then one of the following: • (+) pleural fluid culture • (+) lung histopathology • (+) diagnostic test for Legionella spp. • (+) diagnostic test for flu virus, RSV, adenovirus, parainfluenza virus
Zapping VAP at MCCG / February 2013
Leading: consider these areas
• Vent utilization code status, patient/family communication & education
• Mobility HAPU, Fall prevention, restraint use
• Infection prevention oral care
• Nutrition tube feedings: start time, amount delivered vs. ordered, evidence based management
• Delirium management med management, noise levels, sleep deprivation (bundled care)
33 Zapping VAP at MCCG / February 2013
34 Zapping VAP at MCCG / February 2013
0.0%
2.0%
4.0%
6.0%
8.0%
(7/136) Apr-10
(3/138) Jun-10
(4/153) Aug-10
(7/130) Oct-10
(5/144) Dec-10
(5/121) Feb-11
(5/157) Apr-11
(8/127) Jun-11
(4/149) Aug-11
(4/140) Oct-11
(1/146) Dec-11
(4/126) Feb-12
(2/148) Apr-12
(6/156) Jun-12
(2/153) Aug-12
(5/149) Oct-12
(2/147) Dec-12
Month (# Unplanned Ext's / Total # Vent Patients; includes OHS)
% Adult Vent Patients with Unplanned-Extubations Data Source:
APACHE IV
millennium
Action taken by Resp
& Nurse Managers
FY 2010 avg: 2.7% FY 2011 avg: 4.0% FY 2012 avg: 3.0%
Mion, L. (2007) Patient-initiated device removal in intensive care units: A national prevalence study. Critical Care Medicine, 35(12), 2714-2720.
35
http://www.ajicjournal.org/article/S0196-6553(11)00373-7/fulltext
Zapping VAP at MCCG / February 2013
2010 2011 2012
MCCG 0.44 0.43 0.36
Nat'l Avg 0.45 0.43 0.40
0.44 0.43
0.36
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
0.50
MCCG Adult ICU Vent Utilization Ratio Comparison FY2010 - FY2012
MCCG Nat'l Avg
Data Sources: APACHE IV, PowerChart, Medipac
Vent Utilization Ratio # Vent Days / # Patient Days
Awareness NHSN - vent utilization
Mobility - slow/stop de-conditioning
Delirium - age, withdrawal (tobacco, Rx, ETOH)
Nutrition - timeliness to start, calories Rx
NHSN - Vent Acquired Conditions (VACs)
possible & probable pneumonia
36 Zapping VAP at MCCG / February 2013
37
1. Actions for Impact – Cause Care Best Practice
– Effect Outcomes Goals of Care
Zapping VAP at MCCG / February 2013
38
1. Actions for Impact – Cause Care Best Practice
– Effect Outcomes Goals of Care
2. Engagement & Accountability – Engagement coordination of care
– Accountability by caregivers: “where the buck stops”
Zapping VAP at MCCG / February 2013
39
1. Actions for Impact – Cause Care Best Practice
– Effect Outcomes Goals of Care
2. Engagement & Accountability – Engagement coordination of care
– Accountability by caregivers: “where the buck stops”
3. 2013 & beyond – Vent utilization, delirium, mobility, nutrition
– Vent Associated Conditions (VACs)
Zapping VAP at MCCG / February 2013
40 Zapping VAP at MCCG / February 2013
• Ventilator care is a complex process
• Do not assume knowledge = application
• Measure care + outcomes regular output
• Involve interdisciplinary bedside (point of care) staff
41 Zapping VAP at MCCG / February 2013
I believe a vision for quality must start with ownership.
We cannot just do what we are asked, but we must take it further by looking for what we can do to improve.
Quality must be integrated into our every day caring.
Betty Brown, MBA, MSN, RN, CPHQ, FNAHQ - VP Quality & PI, TriHealth, Inc.
42
Balas, M. (2012) Critical care nurses' role in implementing the ''ABCDE Bundle'' into practice. Critical Care Nurse, 32(2), 35-47.
Centers for Disease Control and Prevention. (2011, 12). National healthcare safety network ventilator-associated event. Retrieved from http://www.cdc.gov/nhsn/psc_da-vae.html
Dudeck, M. et. al. (2011) National healthcare safety network (NHSN) report, data summary for 2009, device-associated module. American Journal of Infection Control, 39(5), 349-367, doi: 10.1016/j.ajic.2011.04.011
Hillier, B., Wilson, C., Chamberlain, D. , & King, L. (2013) Preventing Ventilator-Associated Pneumonia Through Oral Care, Product Selection, and Application Method. AACN Advanced Critical Care, 24(1), 38-58.
Mauger-Rothenberg B. Prevention of healthcare-associated infections. Closing the quality gap: revisiting the state of the science. Evidence report / technology assessment No. 208. (Prepared by the Blue Cross and Blue Shield Association Technology Evaluation Center Evidence-based Practice Center under Contract No. 290-2007-10058-I.) AHRQ Publication No. 12(13)-E012-EF. Rockville, MD: Agency for Healthcare Research and Quality. November 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
Mion, L. (2007) Patient-initiated device removal in intensive care units: A national prevalence study. Critical Care Medicine, 35(12), 2714-2720.
Timmerman, R. (2007) A mobility protocol for critically ill adults. Dimensions of Critical Care Nursing, 26(5), 175-179.
Wunch, H. (2010) The epidemiology of mechanical ventilation use in the United States. Critical Care Medicine, 38(10), 1947-1953.
Zapping VAP at MCCG / February 2013
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