Tracy Johns , RN, BSN, CPHQ Medical Center of Central Georgia · •637 bed, acute-care academic medical center •2nd largest hospital in Georgia •Magnet designation 2005 •Level

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


5



3. 2013 & forward


6



3. 2013 & forward


7



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


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


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


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Outdated competency assessment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


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


Structure of Care

Process of Care Outcomes


Structure of Care

Process of Care

15

↓ vent times

Prevent HAI = VAP

↓ Unplanned extubations

↓ ICU & hospital LOS


Hardwire Evidence Based

Best Practice

Organizational Vent policy

SAT/SBT guidelines

Physician credentials

Interaction: Emp - Pt Compliance

Frequency & Coordination

of care


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


18



Hardwiring the care process



(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

http://www.effectivehealthcare.ahrq.gov/reports/final.cfm


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


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)



• 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


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!


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!


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


29



3. 2013 & forward


Lagging patient outcome

Surveillance for Vent Associated Events

– CDC Prevention Epicenters http://www.cdc.gov/hai/epicenters

– Critical Care Societies Collaborative http://ccsonline.org


http://www.cdc.gov/hai/epicenters

http://ccsonline.org/

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


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


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)



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


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


37

1. Actions for Impact – Cause Care Best Practice

– Effect Outcomes Goals of Care


38



2. Engagement & Accountability – Engagement coordination of care

– Accountability by caregivers: “where the buck stops”


39



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)



• Ventilator care is a complex process

• Do not assume knowledge = application

• Measure care + outcomes regular output

• Involve interdisciplinary bedside (point of care) staff


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.


http://www.cdc.gov/nhsn/psc_da-vae.html



http://www.effectivehealthcare.ahrq.gov/reports/final.cfm


Documents

Tracy Johns , RN, BSN, CPHQ Medical Center of Central Georgia · •637 bed, acute-care academic medical center •2nd largest hospital in Georgia •Magnet designation 2005 •Level