Denise Murphy, RN, BSN, MPH, CICChief Patient Safety and Quality Officer

Barnes-Jewish Hospital at Washington University Medical Center St. Louis, MO

APIC 2005

Baltimore, MD

APIC 2005

Baltimore, MD

Improving Patient Safety, Clinical Quality and Unfunded Mandates:

What ICPs Should Know

Improving Patient Safety, Clinical Quality and Unfunded Mandates:

What ICPs Should Know

Who Keeps Moving the Cheese? And WHY?

Who Keeps Moving the Cheese? And WHY?

Institute of Medicine Reports on Medical Errors (>100,000 lives lost annually) Quality Chasm (Safety,

Government: Center for Medicare and Medicaid Services (CMS) Agency for Healthcare Research and Quality CDC

Healthcare research Medical malpractice claims JCAHO sentinel event tracking Consumer’s Union and other advocacy groups Insurers: Pay4Performance Industry: Leapfrog Group

I LOVECHANGE!

What Should ICPs Know About Quality Initiatives

What Should ICPs Know About Quality Initiatives

National Quality Forum, CMS, JCAHO and other agencies require patient safety and quality (PSQ) monitoring and reporting tied to reimbursement

Consumers & payors demanding performance data

Non- and for-profit organizations driving quality improvement (e.g., IHI, VHA)

Infection prevention is included in improvement initiatives (local and national scorecards)

What are Hospitals Responsible for in Terms of Quality & Compliance

What are Hospitals Responsible for in Terms of Quality & Compliance

Indicators related to Clinical Quality Infection Prevention Patient Safety Operational Excellence and Customer Satisfaction

Reporting Federal and State agencies, accreditation agencies,

voluntary quality initiatives (AHA, IHI, etc.), insurers Governance boards Public reporting of hospital-acquired infections Reporting of other/all adverse events: stay tuned!

Why Should ICPs Care?Why Should ICPs Care?

We are experts in monitoring, reporting and driving interventions related to adverse outcomes

We are Quality Improvement and Patient Safety Professionals – organizational consultants, experts, and leaders in identifying risk mitigating and preventing adverse events

If we bring our expertise to required, highly visible PSQ activities, we demonstrate our value to healthcare executives!

   x  Tall man lettering utilized at medication storage locations

Medication SafetyMedication Safety

 x  Mislabeled/unlabeled lab specimens

Patient IdentificationPatient Identification

 x  Reduce VAP Infections in ICU (SIR < 1)Reduce VAP Infections in ICU (SIR < 1)

 x  Reduce Catheter-related Bloodstream Infections in ICU (SIR < 1)

 x  Hand hygiene policy and education

 x  Surgical patients receiving prophylactic antibiotic within standard

 x  Antibiotic management program enhancements

 x  Trained medical direction in Infection Control

Infection ControlInfection Control

  x  Compliance with "Do Not Use" abbreviation list

Medication SafetyMedication Safety22

  x  Patient rating of consistency of identification by care givers (survey)

  x  Surgical/procedural time-out compliance

  x  Surgical/procedural site ID compliance

Patient IdentificationPatient Identification22

  x  Employee willingness to report errors

  x  Employee perception of management commitment to patient safety

Safety CultureSafety Culture11

NPSGNPSG

Best-in-Best-in-Class Class 20042004

CMS/AHA CMS/AHA & JCAHO & JCAHO Measures - Measures - AnticipatedAnticipated

ORYX/ ORYX/ CMS CMS Core Core

Measures Measures -Current-Current

IndicatorIndicatorWHAT IS BEING MEASURED

and BY WHOM?WHAT IS BEING MEASURED

and BY WHOM?

   xx Smoking cessation advice/counseling

  x Exercise program and/or cardiac rehabilitation therapy prescribed at discharge

 xx Beta-blockers prescribed at discharge

  x ACE-I prescribed at discharge

 xx Lipid-lowering agents prescribed at discharge

 xx ASA/antiplatelet prescribed at discharge

    Society of Thoracic Surgeons (STS) CABGSociety of Thoracic Surgeons (STS) CABG

   xInpatient mortality

 x x-Smoking cessation advice/counseling2

 x xReperfusion therapy within standard (Thrombolytic & PTCA)1

 x  Lipid-lowering agents prescribed at discharge

xx xBeta-blockers prescribed at discharge1

xx xASA prescribed at discharge1

xx xACE-I/ARB prescribed at discharge for LV systolic dysfunction1

    Discharge Treatment

 x  Cholesterol testing within 24 hours of hospital arrival

xx xBeta-blockers within 24 hours of hospital arrival1xx xASA within 24 hours of hospital arrival1    Admission Treatment

    AMIAMI

CMS CMS Annual Annual

Payment Payment UpdateUpdate

Best-in-Best-in-Class Class 20052005

JCAHO JCAHO Core Core

Measures - Measures - FutureFuture

JCAHO JCAHO Core Core

Measures -Measures -CurrentCurrent

IndicatorIndicator

 

CMSCMS

Annual Annual Payment Payment UpdateUpdate

Best-in-Best-in-Class Class 20052005

JCAHOJCAHO

Core Core Measures - Measures -

FutureFuture

JCAHOJCAHO

Core Core Measures -Measures -

CurrentCurrentIndicatorIndicator

  xx    ASA/antiplatelet prescribed at dischargeASA/antiplatelet prescribed at discharge

        PCIPCI

  xx  xxSmoking cessation advice/counseling (adult)Smoking cessation advice/counseling (adult)22

xxxx  xxLV function assessmentLV function assessment11

  xx  xxDischarge instructionsDischarge instructions22

  xx    Antithrombotics Rx at discharge for patients with AFibAntithrombotics Rx at discharge for patients with AFib

xxxx  xxACE-I prescribed at dischargeACE-I prescribed at discharge11

        CHFCHF

  xx  xxInfluenza vaccinationInfluenza vaccination33

xxxx  xxPneumococcal vaccine screening and/or vaccinationPneumococcal vaccine screening and/or vaccination11

  xx  xxSmoking cessation advice/counseling (adult/pediatric)Smoking cessation advice/counseling (adult/pediatric)22

xx      Preventive CarePreventive Care

  xx  xxBlood cultures before antibioticsBlood cultures before antibiotics22

  xx  xxInitial selection of antibioticInitial selection of antibiotic

  xx  xxOxygenation assessmentOxygenation assessment11

        Admission TreatmentAdmission Treatment

xxxx  xxAntibiotic administration within 4 hours of hospital arrivalAntibiotic administration within 4 hours of hospital arrival11

        CAPCAP

  

CMS Annual CMS Annual

Payment Payment UpdateUpdate

Best-in-Best-in-Class Class 20052005

JCAHO JCAHO Core Core

Measures Measures - Future- Future

JCAHO JCAHO Core Core

Measures Measures -Current-CurrentIndicatorIndicator

4 Publicly reported Fall/Winter 2005 (Q1 2005 discharges)         

3 Publicly reported Summer 2005 (Q3 2004 discharges)         

2 Publicly reported beginning Q1 2005 (Q2 2004 discharges)        

1 Publicly reported Q4 2003, Q1 2004 (Sept 2002 discharges)

    xx  HCAHPS (patient satisfaction survey)4

  OtherOther

xxxx  xxSelection of antibiotic3

xxxx  xxDuration of prophylaxis3

xxxx  xxDuration of prophylactic antibiotics3

        SIP (Surgical Infection Prevention)SIP (Surgical Infection Prevention)

  xImplement a process to mark the surgical site and involve the patient in the marking process

xCreate and use a preoperative verification process, such as a checklist, to confirm that appropriate documents, (e.g., medical records, imaging studies) are available

Eliminate wrong site, wrong patient and wrong procedure surgery

xIdentify and, at a minimum, annually review a list of look-alike/sound-alike drugs

xStandardize and limit the number of drug concentrations available in the organization

xRemove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units

Improve the safety of using medications

xMeasure, assess, and take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver of critical test results & values

xStandardize abbreviations, acronyms and symbols used throughout the organization, including list of abbreviations, acronyms and symbols not to use

xTo verify telephone or verbal orders, or critical test results, the person receiving the order must "read back" the complete order or test result after transcription

Improve the effectiveness of communication among caregivers

xPrior to the start of any surgical or invasive procedure, conduct a final verification process, or "time out", to confirm correct pt., procedure, site using active communication techniques

xUse 2 patient identifiers when taking blood, administering medications or blood products, providing any other treatments or procedures

Improve accuracy of patient identification

NPSGNPSGIndicatorIndicator

 

NPSGNPSGIndicatorIndicator

xAssess & periodically reassess each patient's risk for falling, including the potential risk associated with the patient's medication regimen

Reduce the risk of patient harm resulting from falls

x

A complete list of the patient's medications is communicated to the next provider of services when it refers or transfers a patient to another setting, service, practitioner or level of care

xDevelop a process for obtaining & documenting a complete list of patient's current medications upon admission and with any involvement of the patient

Accurately & completely reconcile medications across the continuum of care

xManage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a healthcare-acquired infection

xComply with current CDC hand hygiene guidelines

Reduce the risk of healthcare-acquired infections

xAssure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within unit

xImplement regular preventive maintenance and testing of alarm systems

Improve the effectiveness of clinical alarm systems

xEnsure free flow protection on all general use and PCA intravenous infusion pumps used in the organization

Improve the safety of using infusion pumps.

xxSkill mix of RN, LPN and unlicensed staff

xx- Overall care

xx- Patient education

xx- Pain management

  - Nursing care

Patient satisfaction in relation to:

xxFall injury occurrence

xxFalls occurrence

xxNursing staff satisfaction

xxNursing care hours provided per patient day

xxPressure ulcer occurrence

xxPressure ulcer prevalence

*NDNQIMagnet StatusINDICATOR

xx

*National Database of Nursing Quality Indicators

    xx  Voluntary turnoverVoluntary turnover

    xx  Practice Environment Scale - Nursing Work IndexPractice Environment Scale - Nursing Work Index

xx  xx  Nursing care hours per patient day (RN, LPN, and UAP)Nursing care hours per patient day (RN, LPN, and UAP)

xx    xxSkill mix (RN, LVN/LPN, UAP, and contract)Skill mix (RN, LVN/LPN, UAP, and contract)

  xx  xxSmoking cessation counseling for pneumoniaSmoking cessation counseling for pneumonia

  xx  xxSmoking cessation counseling for HFSmoking cessation counseling for HF

  xx  xxSmoking cessation counseling for AMISmoking cessation counseling for AMI

  xxxx  Ventilator-associated pneumonia for ICU and HRN patientsVentilator-associated pneumonia for ICU and HRN patients

  xxXX  

Central line catheter-associated blood stream infection rate Central line catheter-associated blood stream infection rate for ICU and high-risk nursery (HRN) patientsfor ICU and high-risk nursery (HRN) patients

    XX  Urinary catheter-associated UTI for intensive care unit (ICU) Urinary catheter-associated UTI for intensive care unit (ICU) patientspatients

    XX  Restraint prevalence (vest and limb only)Restraint prevalence (vest and limb only)

xx  XX  Falls with injuryFalls with injury

xx  XX  Falls prevalenceFalls prevalence

xx  XX  Pressure ulcer prevalencePressure ulcer prevalence

    XX  Death among surgical inpatients with treatable serious Death among surgical inpatients with treatable serious complications (failure to rescue)complications (failure to rescue)

 NQF Nursing-Sensitive Voluntary Consensus StandardsNQF Nursing-Sensitive Voluntary Consensus Standards

Magnet/ Magnet/ NDNQINDNQI

Best-Best-in-in-

Class Class 20042004

CMS/AHA & CMS/AHA & JCAHO JCAHO

Measures - Measures - AnticipatedAnticipated

ORYX/ ORYX/ CMS Core CMS Core Measures -Measures -

CurrentCurrent

IndicatorIndicator

  x Risk-Adjusted Hospital Mortality for ICU Patients

  x Risk-Adjusted ICU LOS by type of ICU

 xx Central Line-Associated Primary Blood Stream Infection

 xx Deep Vein Thrombosis (DVT) Prophylaxis

  x Stress Ulcer Disease (SUD) Prophylaxis

 xx Ventilator-Associated Pneumonia (VAP Prevention – Patient Positioning)

 JCAHO ORYX ICU Measures

Magnet/ NDNQI

Best-in-

Class 2004

CMS/AHA & JCAHO

Measures - Anticipated

ORYX/ CMS Core Measures -

Current

Indicator

Assess Culture of Safety and take action on results of assessment

 

Engage patients in the process of transitions across the continuum of care, including a dialogue about their expectations and concerns about the next setting of care

Encourage patient participation in organization’s committees that relate to planning or providing patient care services

Implement comprehensive patient involvement program

Provide copy of medications to each patient and assist them in tracking/reconciling medications.

Provide appropriate patient education to guide patient’s awareness and involvement in their own care. (Assess health literacy level, language skills, ethnic and cultural factors)

Goal #14: Involve Patients in their Own Care as a Patient Safety Strategy

Increase awareness of and access to relevant patient safety literature and advisories for all organizational leaders and staff

Share lessons learned from root cause analysis conducted by the organization with all staff who provide relevant services or may be impacted by proposed solutions

Use external or expert information when designing new or modifying existing processes to improve PS and reduce risk for sentinel events

Goal # 13: Achieve and Maintain an Organization-wide Safety Culture

Develop and implement protocols for administration and documentation of influenza and pneumonia vaccination.

Goal #10: Reduce Influenza and Pneumonia

PROPOSED 2006 NATIONAL PATIENT SAFETY GOALSPROPOSED 2006 NATIONAL PATIENT SAFETY GOALS

Encourage external reporting of adverse events

Define and communicate the means to report concerns about safety and encourage pts. to do so

Identify patients who enter the organization with a decubitus ulcer and provide appropriate medical, physical and nutritional management to facilitate healing

 

Assess and periodically reassess each patient’s risk for developing a decubitus ulcer (pressure sore) and take action to address any identified risks

Goal #16: Prevent Healthcare-Associated Decubitus Ulcers

PROPOSED 2006 NATIONAL PATIENT SAFETY GOALSPROPOSED 2006 NATIONAL PATIENT SAFETY GOALS

What is Interventional Patient Hygiene?

What is Interventional Patient Hygiene?

Webster defines hygiene as the science and practice of the establishment and maintenance of health.

Interventional Patient Hygiene is a nursing action plan directly focused on fortifying the patients host defense through use of evidence-based care.

It works best with a protocol (action plan) and PIP (measurement)

So What Can ICPs Do?So What Can ICPs Do? KNOW the big picture of PSQ and where you and your

program fit in Position yourself as a leader in your organization’s PSQ

program…you are a Patient Safety Leader! Volunteer your expertise to teams addressing other

types of adverse outcomes of patient care Data management, analysis and reporting Intervention development Education and literature interpretation Evaluation of products and technologies Science-based, cross-functional, multi-disciplinary

approach to problem solving

Get involved…WHY?

ICPs are Safety, Quality and Performance ImprovementEXPERTS!

Robert Garcia, BS, MMT(ASCP), CIC

Deborah Trau, RN, 6 Sigma Black Belt

to further address the role of infection prevention in improving patient

safety and clinical quality

Robert Garcia, BS, MMT(ASCP), CIC

Deborah Trau, RN, 6 Sigma Black Belt

to further address the role of infection prevention in improving patient

safety and clinical quality

Now, it is my pleasure to introduce you to our session experts…Now, it is my pleasure to introduce you to our session experts…

The Role of Oral and Dental Colonization on Respiratory Infection: Call for New Interventions in a Patient

Safety World

The Role of Oral and Dental Colonization on Respiratory Infection: Call for New Interventions in a Patient

Safety World

The Brookdale University Medical Center, Brooklyn, New York

Robert Garcia, BS, MMT(ASCP), CIC

High Risk, High Morbidity, High CostHigh Risk, High Morbidity, High Cost

VAP FactsVAP Facts

Mechanical ventilation increases risk of pneumonia 6-21 times (1% per day)

Attributable mortality is 27% and increases to 87% when etiologic agent is P.aeruginosa or Acinetobacter sp.

Length of stay with VAP is 34 days and 21 days without VAP

Garcia R., A review of the possible role of oral and dental colonization on the occurrence of healthcare-associated pneumonia: Underappreciated risk and a call for interventions. Accepted for publication. AJIC 2005

Hospital-Onset Infection Rates in NNIS Intensive Care Units, 1990-1999

Hospital-Onset Infection Rates in NNIS Intensive Care Units, 1990-1999

Coronary 43% 42% 40%

Medical 44% 56% 46%

Surgical 31% 38% 30%

Pediatric 32% 26% 59%

Type of ICU BSI* VAP* UTI*

* BSI = central line-associated bloodstream infection rate VAP = ventilator-associated pneumonia rate UTI = catheter-associated urinary tract infection rate

Source: National Nosocomial Infections Surveillance (NNIS) System.

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

Step 11: Isolate the pathogen

Prevalence of Antimicrobial-Resistant (R) Pathogens Causing Hospital-Onset Intensive Care

Unit Infections: 1999 versus 1994-98

Prevalence of Antimicrobial-Resistant (R) Pathogens Causing Hospital-Onset Intensive Care

Unit Infections: 1999 versus 1994-98

Organism # Isolates % Increase*

Fluoroquinolone-R Pseudomonas spp. 2657 49%

3rd generation cephalosporin-R E. coli 1551 48%

Methicillin-R Staphylococcus aureus 2546 40%

Vancomycin-R enterococci 4744 40%

Imipenem-R Pseudomonas spp. 1839 20%

* Percent increase in proportion of pathogens resistant to indicated antimicrobial

Source: National Nosocomial Infections Surveillance (NNIS) System.

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

ICU Rates of VAP, NNIS Study, Jan 2002-Jun 2004

ICU Rates of VAP, NNIS Study, Jan 2002-Jun 2004

Pooled means:Medical – 4.9

Med-Surg – 5.4Surgical – 9.3

Cost of VAPCost of VAP Retrospective matched cohort study

using data from large U.S. database 9,080 patients; 842 with VAP (9.3%) Patients with VAP had significantly

longer duration of mechanical ventilation, ICU stay, and hospital stay.

VAP associated with increase of >$40,000 in mean hospital charges

Rello J et al., Epidemiology and outcomes of VAP in a large US database. Chest. 2002;122:2115-2121.

HICPAC guidelines on preventing pneumoniaHICPAC guidelines on preventing pneumonia

Issued 3/26/04

Evidence-based

Expert review

Recommendations categorized

www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm

HICPAC categoriesHICPAC categories Category IA. Strongly recommended for implementation and

strongly supported by well-designed experimental, clinical, or epidemiologic studies.

Category IB. Strongly recommended for implementation and supported by certain clinical or epidemiologic studies and by strong theoretical rationale.

Category IC. Required for implementation, as mandated by federal or state regulation or standard.

Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or by strong theoretical rationale.

No recommendation; unresolved issue. Practices for which insufficient evidence or no consensus exists about efficacy.

Guideline for the Prevention of Intravascular-Associated Infections, CDC, 3/26/04.

What strategies have been advocated in preventing VAP?

What strategies have been advocated in preventing VAP?

Do not change routinely the ventilator circuit…Change the circuit when it is visibly soiled or mechanically malfunctioning. Cat. IA

HeatMoisture Exchanger

No recommendation can be made for the preferential use of either HMEs or heated humidifiers…Unresolved issue.

No recommendation can be made about the frequency of routinely changing the in-line suction catheter of a closed suction system – Unresolved issue.

In the absence of medical contraindications, elevate at an angle of 30-45° the head of the bed of a patient…receiving mechanically assisted ventilation…Cat. II

Photographs courtesy of D. Ryan

Stress Ulcer ProphylaxisStress Ulcer Prophylaxis Theory has it that modifying stomach acid effects

the bacterial colonization level HICPAC:

No recommendation can be made for the preferential use of sucralfate, H2-antagonists, and/or antacids for stress-bleeding prophylaxis in patients receiving mechanically assisted ventilation (unresolved issue).

Livingston DH, Prevention of ventilator-associated pneumonia. Am J Surg. 2000;179(suppl 2A):12S-17S. “After all of this time and study, it is likely that neither drug

has any advantage in significantly maintaining gastric flora and reducing VAP.”

Selective Digestive DecontaminationSelective Digestive Decontamination Preventive decolonization on the theory that

the gut is a major source of VAP

HICPAC: No recommendation can be made for the routine

selective decontamination of the digestive tract (SDD) of all critically-ill, mechanically ventilated, or ICU patients (unresolved issue).

30+ studies to date Eggimann P, Pittet D. Infection control in the ICU. Chest

2001;120:2059-2093: “…This selective pressure on the epidemiology of

resistance definitely precludes the systematic use of SDD for critically ill patients.”

WeaningWeaning Duration, duration, duration!!!

Cook D, Meade M, Guyatt G, Griffith L., Booker L, Criteria for Weaning from Mechanical Ventilation. Evidence Report/Technology Assessment No. 23 (Prepared by McMaster University under Contract No. 290-97-0017). AHRQ Publication No. 01-E010. Rockville MD: Agency for Health Care Research and Quality. November 2002.

Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support. A Collective Task Force Comprised of Members of the American College of Chest Physicians, the American Association for Respiratory Care and the American College of Critical Care Medicine. Chest 2001;120:375S-395S.

Is there scientific evidence that links oropharyngeal and

dental colonization with respiratory illness?

Is there scientific evidence that links oropharyngeal and

dental colonization with respiratory illness?

Prevention or Modulation of Oropharyngeal ColonizationPrevention or Modulation of Oropharyngeal Colonization

HICPAC: Oropharyngeal cleaning and decontamination with an

antiseptic agent: develop and implement a comprehensive oral-hygiene program (that might include the use of an antiseptic agent) for patients in acute-care settings or residents in long-term-care facilities who are at high risk for health-care-associated pneumonia. Cat. II

Schleder B, Stott K, Lloyd RC, The effect of a comprehensive oral care protocol on patients at risk for ventilator-associated pneumonia. J Advocate Health 2002;4:27-30.

Yoneyama T, et al., Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc. 2002;50:430-3.

1. Oral Cavity vs. Gastric Colonization1. Oral Cavity vs. Gastric Colonization Prospective study of 86 mechanically vented ICU patients

to assess relationship between oropharyngeal colonization and subsequent occurrence of pneumonia

Patients oral and gastric specimens were collected on admission and twice weekly

When pneumonia suspected, bronchoscopic specimens were taken with protected specimen brush In 31 cases of pneumonia identified, DNA genomic analysis

demonstrated that oropharyngeal colonization was the predominant factor in the development of pneumonia compared with gastric colonization.

Garrouste-Orgeas M, et al., Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA analysis. Am J Respir Crit Care Med. 1997;156:164.

Acquired bacterial colonization: Location of the microorganisms in the 44 carrier patients

Acquired bacterial colonization: Location of the microorganisms in the 44 carrier patients

Colonizing microorganisms

Patients with OC

Patients with GC

Patients with BC

Colonized patients

A. baumanii 7 0 1 8

K. Pneumoniae 12 0 3 15

Enterobacteriaceae 9 5 8 22

Psuedomonadaceae 8 2 1 11

S. aureus 17 0 3 20

Enterococcus sp.2 1 1 4

Total 22 5 17

Garrouste-Orgear M, et al., Am J Resp Crit Care Med 1997.

OC = oropharyngeal colonization; GC = gastric colonization; BC = both OC/GC colonization

Oropharyngeal Rather Than Gastric Colonization: Further Support

Oropharyngeal Rather Than Gastric Colonization: Further Support

Kerver AJ, et al., Colonization and infection in surgical intensive care patients – a prospective study. Intensive Care Med. 1987;13:347-51.

Bonten MJM, et al., Risk factors for pneumonia, and colonization of respiratory tract and stomach in mechanically ventilated ICU patients. Am J Resp Crit Care Med. 1996;154:1339-46.

Ewig S, et al., Bacterial colonization patterns in mechanically ventilated patients with traumatic head injury. Am J Resp Crit Care Med. 1999;158:188-98.

2. Decontamination of the Oropharynx2. Decontamination of the Oropharynx

Prospective, randomized, double-blind study of ICU patients to determine VAP while manipulating oropharyngeal colonization and without influencing gastric or intestinal colonization

87 given topical antibiotics (study group), 139 given placebo (control group)

Results: VAP in study group: 10% VAP in control group: 27%

Bergmans D, et al. Prevention of ventilator-associated pneumonia by oral decontamination. Am J Resp Crit Care Med. 2001;164:382-88.

Additional Studies and Reviews Using Antibiotic Pastes or Solutions

Additional Studies and Reviews Using Antibiotic Pastes or Solutions

Rodriguez-Roldan JM, et al., Prevention of nosocomial lung infection in ventilated patients: use of an antimicrobial nonabsorbable paste. Crit Care Med. 1990;18:1239-42.

Pugin J, et al., Oropharyngeal decontamination decreases incidence of ventilator-associated pneumonia: a randomized, placebo-controlled, double-blind clinical trial. J Am Med Assoc. 1991;265:2704-10.

Bonten MJ, et al., Role of colonization of the upper intestinal tract in the pathogenesis of ventilator-associated pneumonia. Clin Infect Dis. 1997;24:309-19.

3. Oral Decolonization: Use of Chlorhexidine

3. Oral Decolonization: Use of Chlorhexidine

Prospective, randomized, double-blind, placebo-controlled trial testing the effectiveness of oral decontamination on nosocomial infection

353 patients undergoing coronary bypass surgery

Used chlorhexidine gluconate (0.12%) as oral rinse to prevent nosocomial infections

Randomized to receive CHG or placebo

Results: Overall reduction in nosocomial infections of 65% when using

CHG Respiratory infections were reduced 69% in CHG group

DeRiso AJ II, et al., Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and non-prophylactic systemic antibiotic use in patients undergoing heart surgery. Chest 1996;109:1556-61.

4. Link Between Oral Pathogens & Respiratory Infection

4. Link Between Oral Pathogens & Respiratory Infection

A review article

6 articles cited as support for a relationship between poor oral health and respiratory infection

Bacteria from colonized dental plaque may be aspirated into the lower airway

Scannapieco, FA., Role of oral bacteria in respiratory infection. J Periodontol. 1999;70:794-802

5. Dental Plaque as a Bacterial Source of VAP

5. Dental Plaque as a Bacterial Source of VAP

Study on dental plaque colonization and ICU nosocomial infections.

57 patients studied Results:

Dental plaque occurred in 40% of patients Colonization of dental plaque was highly predictive

of nosocomial infection Salivary, dental, and tracheal aspirates cultures

were closely linked

Fourrier E, et al., Colonization of dental plaque: a source of nosocomial infections in intensive care patients. Crit Care Med. 1998;26:301-8.

Additional Evidence Linking Colonized Dental Plaque and Respiratory InfectionAdditional Evidence Linking Colonized Dental Plaque and Respiratory Infection

Scannapieco FA, et al., Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Crit Care Med. 1992;20:740-45.

Fitch JA, et al., Oral care in the adult intensive care unit. Am J Crit Care. 1999;8:314-18.

Sumi Y, et al., Colonization of denture plaque by respiratory pathogens in dependent elderly. Gerontolog. 2002;9:25-9.

Russel SL, et al., Respiratory pathogen colonization of the dental plaque of institutionalized elders. Spec Care Dentist. 1999;19:128-34.

Lips & Gums TeethTeeth

Major Areas of Oropharyngeal

Colonization

Tongue

TissuesTissues

SecretionsSecretions

A Case StudyA Case Study

Reduction of Microbial Colonization in Reduction of Microbial Colonization in the Oropharynx and Dental Plaque the Oropharynx and Dental Plaque

Reduces VAPReduces VAP

R Garcia, L Jendresky, L Colbert

Brookdale University Medical Center, Brooklyn NY

Abstract presented at the 2004 APIC Education Conference, Phoenix, AZ.

The Brookdale University Medical CenterThe Brookdale University Medical Center

Prioritization & ActionPrioritization & Action Comparison of VAP rates with NNIS data

indicated MICU rate above 50th percentile (6.0 cases per 1000 VD)

Interventions taken prior to 2002 did not have sufficient effect to reduce rate below the benchmark

ICP conducting VAP surveillance

Interventional Epidemiology methodology applied: interviews and observations

VAP Reduction Task ForceVAP Reduction Task Force

Director of Nursing, Critical Care Nurse Manager, Critical Care Front Line Nurses Medical Director, Critical Care Emergency Room Physicians Respiratory Therapy Materials Management Infection Control

AssessmentAssessment

Interviews of front line workers

Observation of procedures

Review of products

Review of policies

Review of literature, guidelines

Communication Between ProvidersPeople Procedures

VAP

PoliciesEquipment & Devices

VAP surveillance rounds (observational periods between IC and nurses)

Physicians

Nurses

Intubation/Extubation

Cleaning & maintenance of ventilator and components

Definition of VAP

Oral & Dental Care

Cleaning of ventilator/other devices

Closed suction system, oral suction catheters, water, other suction devices, suction canisters/tubing

Mechanical ventilator (Heated humidifier or HME)

Tracheostomy devices

Closed suctioning

Use of H2 antagonists/sucralfate

Handwashing

Filters

Pharmacists

Intubation/Extubation

Analysis of System Components Influencing the Occurrence of Ventilator-Associated Pneumonia

Nutritional Specialists

Nasogastric tubes

Placement & maintenance of nasogastric tube

Respiratory Therapists

Handwashing

Suctioning (closed/oral)

Oral Care

Vent circuits, filters

Nebulizers

Multidose vials

Laryngoscopes

Resusitation bags

Barrier equipment

Ventilator circuitsTracheostomy care

Cleaning of laryngoscopes Nebulizers

Suction canisters Resuscitation bags

Placement and care of nasogastric tubes

Enteral feeding Weaning

Self-extubation

Semi-recumbent positioning

Relay surveillance data to healthcare providers

Feedback from healthcare providers

Identification of NeedsIdentification of Needs

A uniform education program for nurses and respiratory therapists

Standards for oral assessment Standards for oral care Standards for dental care Standardization of oral care solutions Keeping a closed system CLOSED Reduce environmental exposure

Key Strategy #1: EducationKey Strategy #1: Education Handout created, includes

answers to the following questions: Why is prevention of VAP important?

What is hospital’s (unit’s) current rate?

How do you compare with national benchmark?

What are major interventions implemented to date?

What role does bacterial colonization play in the development of respiratory infection?

What new products/techniques will be implemented to address oral bacterial colonization?

Tip: Applicable HICPAC Recommendation

Tip: Applicable HICPAC Recommendation

I. Staff Education and Involvement in Infection Prevention

Educate health-care workers about the epidemiology of, and infection-control procedures for, preventing health-care—associated bacterial pneumonia to ensure worker competency according to the worker’s level of responsibility in the health-care setting, and involve the workers in the implementation of interventions to prevent health-care—associated pneumonia by using performance improvement tools and techniques. Cat IA

Key Strategy #2: Reduce Oral and Dental Colonization

Key Strategy #2: Reduce Oral and Dental Colonization

Maintaining a Closed SystemMaintaining a Closed System

Covered YankauerCovered Yankauer

Policy: Use as needed

YankauerYankauer

Proper storage

Keep yankauer covered when not in use

Assists in decreasing the risk of environmental contamination

Replace every day and PRN

Suction CatheterSuction Catheter

Policy: Every 4 hrs. or as needed

The device manufacturer does not market or approve of its use below the vocal cords

Suction Toothbrush with Sodium Bicarbonate

Suction Toothbrush with Sodium Bicarbonate

Policy: 2 X per day

Suction Swab with MoisturizerSuction Swab with Moisturizer

Policy: Every 6 hrs.

Feeling fuzzy???Feeling fuzzy???

Photographs courtesy of D. Ryan

VAP Rates, MICU, BUMC, 2001-2004VAP Rates, MICU, BUMC, 2001-2004

0.0

5.0

10.0

15.0

20.0

25.0

Jan

-01

Mar

-01

May

-01

Jul-

01

Sep

-01

No

v-01

Jan

-02

Mar

-02

May

-02

Jul-

02

Sep

-02

No

v-02

Jan

-03

Mar

-03

May

-03

Jul-

03

Sep

-03

No

v-03

Jan

-04

Mar

-04

May

-04

Jul-

04

Sep

-04

No

v-04

VA

P p

er

10

00

ve

nti

lato

r d

ay

s

Rate Mean

Pre-intervention Period Post-intervention Period

VAP Rates, MICU, BUMCVAP Rates, MICU, BUMC

PERIOD # PTS# VAP CASES

VENTDAYS

RATE (VAP/

1000 VD)

% PTS WITH VAP

Jan 2001-Dec 2002

859 44 5262 8.3 5.1

Jan 2003-Dec 2004

755 20 5147 3.8 2.6

Cost AvoidanceCost Avoidance Attributable cost of a healthcare-acquired

pneumonia is estimated to be $40,000 (Rello, Chest, 2002).

Based on the avoidance of approximately 10 VAP cases per year, BUMC estimates that the annual avoided extra cost to the institution to be:

[10 x $40,000 (infection cost)] – [$56,606 (product cost)] = $343,394.

Let’s SummarizeLet’s Summarize VAP can be a serious and costly infection

National quality initiatives are being directed specifically at this type of infection

There now exists strong scientific evidence that controlling oropharyngeal colonization reduces respiratory disease in varied populations

The speaker gratefully acknowledges the supreme effort of all the critical care nursing staff, the resident staff, and especially Mr. Trevor Grazette, Director of Nursing, Ms. Althea Bailey, Nurse Manager, and Ms. Henrietta Basanez, Nurse Educator.

Robert Garcia, BS, MMT(ASCP), CIC

Assistant Director of Infection Control

Brookdale University Medical Center

One Brookdale Plaza, Brooklyn, NY 11212

718-240-5924

rgarcia@brookdale.edu

Utilizing Assessment and Interventional Strategies to Reduce

the Risk of Skin Breakdown and Impact Patient Safety

Utilizing Assessment and Interventional Strategies to Reduce

the Risk of Skin Breakdown and Impact Patient Safety

Debbie Trau, RN, 6 Sigma Black Belt

OSF Saint Francis Medical Center

Peoria, IL

Applying 6 Sigma in Hospital Setting

Applying 6 Sigma in Hospital Setting

Quality improvement methodologies to enhance core patient care processes

Define Measure Analyze Improve Control

Reliability Unreliability“Sigma’s”

(approximate)

0.9 10-1 1

0.99 10-2 2

0.999 10-3 3

0.9999 10-4 4

0.99999 10-5 5

0.999999 10-6 6

Reducing VAP with 6 Sigma, Nursing Management, June 2004

Prevalence vs. Incidence Rates

Prevalence vs. Incidence Rates

How is one different than the other?

Why does it matter?

Why do we try to improve outcomes?

Does JCAHO make us do this?

Why We Are Here? Why We Are Here?

National average prevalence rate of pressure ulcers in

acute care:

9%

National average prevalence rate of pressure ulcers in

acute care:

9%

Clinical data: $500 -$50,000 average incremental costs per

episode

Clinical data: $500 -$50,000 average incremental costs per

episode

Pressure ulcers increase

LOS by 2 to 5 times

Pressure ulcers increase

LOS by 2 to 5 times

Example:

Average size hospital -

opportunity cost

$400,000to

$700,000

Example:

Average size hospital -

opportunity cost

$400,000to

$700,000

Lyder C, Basic Pressure Ulcer Care. Advance for Providers of Post-Acute Care. March/April 2005.

Beckrich K, Nursing Economic$, Sept/Oct 1999, Vol. 17, No. 5

Robinson C, et al., Ostomy/Wound Management 2003

Critical Issues Facing HospitalsCritical Issues Facing Hospitals

PU’s are a growing cause of hospital morbidity and mortality

Hospitals spend up to $5-$8.5 billion per year in incremental costs related to treating PU’s

The trend towards Mandatory Reporting will require further quantification of PU incidence

Regulatory agencies are making hospitals and their senior management accountable for infection control

Beckrich K, Nursing Economic$, Sept/Oct 1999, Vol. 17, No. 5

Early IdentificationEarly Identification

Stage I Stage II Stage III Stage IV

A Stage I wound costs about $1 per day  A Stage II wound jumps to $1,300 to $3,700 Stage III wounds can cost up to $50,000 The highest incidence is in acute care

Key is to catch them early . . .

Lyder C. Basic Pressure Ulcer Care. Advance for Providers of Post-Acute Care. March/April 2005.

Early IdentificationEarly Identification

Awareness of risk factors Tools to trigger Trained eyes always looking and

communication with patient and family members (everyone is responsible)

Thorough assessment of the patient by all members of the healthcare team

Consistent scoring and communication tools

CommunicationCommunication

Transitioning from task to outcome focused

Tools and resources for staff Documentation or is it a lack

of documentation Outcomes to inspire staff or

keep the momentum

Our Patient’s Risk FactorsOur Patient’s Risk Factors Over 60 Atherosclerosis Diabetes or other

conditions that make skin more susceptible to infection

Diminished sensation or lack of feeling

Heart problems

Incontinence Malnutrition Obesity Paralysis or

immobility Poor circulation Bedridden Spinal cord injury

http://www.healthatoz.com/healthatoz/Atoz/ency/bedsores.jsp

Empowering the Nursing StaffEmpowering the Nursing Staff

Quality issues for patient care Publicly reported scorecards Incorporate standardized assessment

More importantly: Make it simple and easy for them to

understand and implement

What Simple Interventional Patient Hygiene Activities Affect

Outcomes?

What Simple Interventional Patient Hygiene Activities Affect

Outcomes?

Nurse-sensitive activities:1. The bathing process for bed ridden patient

2. Incontinence cleansing and protection

Why is the Bath Given?Why is the Bath Given?

Social Control patient odor

Provide patient well-being

Bryant R, Rolstad B, Ostomy Wound Management 2001: 47(6), 18-27.

Why is the Bath Given?Why is the Bath Given?

Comfort Provide sensory stimulation

Bryant R, Rolstad B, Ostomy Wound Management 2001: 47(6), 18-27.

Why is the Bath Given?Why is the Bath Given?

Health/Clinical Cleanse and moisturize the skin Reduce gross bacterial count Complete full skin assessment / monitoring

Bryant R, Rolstad B, Ostomy Wound Management 2001: 47(6), 18-27.

Who’s Providing the Bath?Who’s Providing the Bath?

Non-licensed personnel?

Are they trained and empowered to know what to look for?

Who’s Providing the Care?Who’s Providing the Care?

How much more susceptible to injury and infection is the patientif this develops?

What can we do?

Bathing Process SolutionBathing Process Solution

Partner with Wound Care Nurse Empower non-licensed personnel

Define1. Issue

2. Expected outcome

Provide1. Training and education

2. Simple communication tools

3. Cleansing and moisturizing in one

Measure, Analyze, Improve, Control

Measure, Analyze, Improve, ControlMeasure, Analyze, Improve, Control

Incontinence ManagementIncontinence Management

Utilize the tools to “help us do our jobs”

If it gets to this stage,

it’s too late!

Sage Products Inc. Unpublished data 2005. Used with Permission.

Pilot Survey of Incontinence and Perineal Skin Injury Prevalence in Acute Care

Pilot Survey of Incontinence and Perineal Skin Injury Prevalence in Acute Care

35%with a

Foley Catheter

3%Urinary

Incontinence

13%Stool

Incontinence

5%Dual

Incontinence

976Total Number of

Patients Surveyed

Sage Products Inc. Unpublished data 2005. Used with Permission.

Pilot Survey of Incontinence and Perineal Skin Injury Prevalence in Acute Care

Pilot Survey of Incontinence and Perineal Skin Injury Prevalence in Acute Care

976Total Number of

Patients Surveyed

198Number of

Incontinent Patients

33%Pressure Ulcers

18%Fungal Infection

27%Perineal Dermatitis

Incontinence Management ProgramIncontinence Management Program

Providing a skin protectant prophylactically Supported by the 1992 AHRQ guidelines Look for products that make it easy for the

nursing staff. Products that save time Make cleaning and applying a skin barrier

one easy step Early intervention prevention

Incontinence Process SolutionIncontinence Process Solution Partner with Wound Care Nurse Empower non-licensed personnel

Define1. Issue

2. Expected outcome

Provide1. Training and education

2. Cleansing and protection in one

Measure, Analyze, Improve, Control

Measure, Analyze, Improve, ControlMeasure, Analyze, Improve, Control

Quality Improvement Initiative -Reduce PU Incidence Rates

Quality Improvement Initiative -Reduce PU Incidence Rates

Early identification (the bath) Red skin is the warning sign Guaranteed communication between non-

licensed and RN responsible (protocol) Measurements / Interventions (PIP) Outcome rather than task focused BACK to the BASICS approach

Process Strategies for ChangeProcess Strategies for Change

See what is out there: “Nurse I See Red” AHRQ guidelines Need a “believer” Highly motivated staff

with administrative support Partner with companies that make

it easy to do business with and can provide solutions

Getting StartedGetting Started

Education to non-licensed caregivers Triggers all caregivers in assessment and

recognition Create a “safety net” for our patients Standardized practice strategy

Assessment tool during the cleansing and each patient contact

Use products that support your protocol

Measuring Results and Celebrate your Success

Measuring Results and Celebrate your Success

Drives compliance Personalize your rates Staff take ownership Benchmark against yourself Use the data to inspire staff or to

keep the momentum

Your Focus?Your Focus?

Emphasis on outcomes rather than tasks!

Study Guide on Interventional Patient

Hygiene

One CE Credit

Study Guide on Interventional Patient

Hygiene

One CE Credit

Debbie Trau, RN6 Sigma Black Belt

OSF Saint Francis Medical Center

530 NE Glen Oak, Peoria, IL 61637

(309) 671-1540

Deborah.A.Trau@osfhealthcare.org

Debbie Trau, RN6 Sigma Black Belt

OSF Saint Francis Medical Center

530 NE Glen Oak, Peoria, IL 61637

(309) 671-1540

Deborah.A.Trau@osfhealthcare.org

www.sageproducts.com