preventing hospital acquired pneumonia (hap) in neuroscience patients ucsf center for nursing...
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Preventing Hospital Acquired Pneumonia (HAP) in Neuroscience Patients
UCSF Center for Nursing Research and InnovationOctober 22, 2014
Presenters:Kathryn Snow, RN, MS, CNS, CNRNJacqueline Narkizian, RN, MSN
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Acknowledgements• Cathy Parker, RN, Clinical Adult Services Director• Nora Tam, Operations Specialist & Senior Staff Assistant• Barbara VanAmburg, RN, Chief Nursing Officer• Michelle Brown, Neuroscience Nurse Manager• Mary Machanga, ICU Nurse Manager• Staff Champions, ICU and Neuroscience Unit• The Hospital and Emergency Department Reliability and
Operational Excellence for Safety Committee (HEROES)– Kaiser Permanente Redwood City
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Preventing HAP
• Purpose: To reduce Hospital Acquired Pneumonia by 15%.
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Hospital Acquired Infections
HAP
C Difficile
Surgical Site
Central Line Associated Blood Stream Infection
Catheter Associated Urinary Tract
Infection
365 deaths 21,900 days
2037 pts 110 deaths 18,600 days
997 pts 18 deaths 5,184 days
83 pts 4 deaths 395 days
163 pts 0 deaths 234 days
# Patients # Deaths # Attrib Pt Days# Patients with HAI/yr
# Attributable deaths
# Attributable Hosp Days
2,661 pts
Preventing HAP – Background Data
10/22/2014 Kathryn Snow, RN, MS
Preventing HAP – Background Data
Characteristics of 87% of Actual HAP Cases:
• Confused, obtunded or sedated• NG or feeding tubes• Low albumin• Post-operative patients
All commonplace for neuro patients
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Preventing HAP – 2013 Rate
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12.5 per 1K Patient Days
Risk Profile - Neuro Patients
• Airway obstruction• LOC• Poor head position• Poor cough / gag• Poor control of saliva• Poor muscle control / tone• Airway edema• Diagnoses: cervical surgery, craniotomy,
diaphragm paralysis, stroke
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100% = 70
Stroke = 27 of 39
100% = 30(12 at our hospital, 18 within 12
months)
Preventing HAP – Case Attribution
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Preventing HAP – Case Attribution
HAP 2013
Surgical Med-Surg
Unit 1
Telemetry Med-Surg Unit 2
ICU Neuro Total
Total Cases
12 5 9 5 19 20 70
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Observed Patterns• Oral care inconsistent• Mobility not a primary priority• Incentive Spirometer Use inconsistent• Nurses lacked confidence with naso-tracheal
suctioning• Aspects of tracheostomy care policy were
not being followed• Lack of awareness about HAP
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Observed Patterns• Head of Bed ≥ 30° hard-wired• Dysphagia screen • Kaiser Permanente devised ROUTE Bundle
for Medical-Surgical areas• Concurrent project in ICU:
Rethinking Critical Care
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ROUTE Bundle
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Rethinking Critical Care Initiatives
• Delirium Assessment using Confusion Assessment Method (CAM-ICU) tool
• Daily Spontaneous Awakening and Spontaneous Breathing trials (SAT / SBT) for mechanically ventilated patients
• Mobility Protocol
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Methods• 2012, 4th quarter, HAP Summit• 2013 Interventions:
• Chlorhexidine rinse every twelve hours added to MAR• ROUTE Bundle education initiated for medical-surgical units• Tile markers placed in floor to encourage ambulation• Standardized HAP Prevention order sets initiated• Nasogastric tube policy changed to reflect order sets• Ongoing tracking of ROUTE Bundle compliance by
management and HEROES committee• Multi-disciplinary Rounds
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Methods• 2014 Interventions:
• HAP Prevention orders added to Stroke order sets• Targeted education for the Neuroscience unit focusing on
HAP statistics, ROUTE Bundle interventions, naso-tracheal suctioning technique and tracheostomy care
• ICU Nurses received HAP education as part of annual Stroke training
• Collaboration between RN, Neuroscience physician, and Respiratory Therapy teams to optimize respiratory treatment strategies
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Preventing HAP Results
Jan-Aug2013
Jan-Aug2014
11
20
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YTD 45% Reduction
Preventing HAP - Results37 HAP cases in 2014 (Jan-Aug)Based on Primary Diagnosis:
• Neurosurgery/Neurology service 11 cases (30%)
• Internal Medicine service14 cases (38%)
• Surgical services12 cases (32%)
72% Overall Reduction from 2013
YTD 2014 HAP Cases by Service
Neuro
Internal Medicine
Surgical
Neuro, 11, 30%
Internal Medicine, 14,
38%
Surgical, 12, 32%
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Discussion and Clinical Implications• Rethinking Critical Care initiatives coincided
with HAP initiatives• Majority of ICU patients flow to Neuro unit• Standardized orders sets ensured compliance• Multiple layers of reinforcement:
nurse managers, educators, critical care and neuro physicians, HEROES committee, multi-disciplinary rounds
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Discussion and Clinical Implications• Staff nurses drove program success• Clinical Adult Services Director champions
mobility• Culture change has occurred
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