The How to Guide'

The ‘How to Guide’ for

Improving

Critical Care

Main contacts for Improving Critical Care

Campaign Director leading on the content area: Alan Willson

Faculty member for this content area: Mark Smithies, Dave Hope

Content Specialist: Chris Hancock

IA/Senior IA: Mike Davidge

Other (as determined by Director)

Improving Critical Care

Intranet: http://nww.1000livescampaign.wales.nhs.uk

Website: www.1000livescampaign.wales.nhs.uk

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Content Area Drivers Interventions

Improve Critical Care

Reduce complications from:• Ventilators• Central lines• Severe Sepsis• HCAIs

Provide patient and family driven care

Create an environment of collaboration and culture of safety

Involve Leadership in safety

Reliable processes of care:• Ventilator management• Central line management• Identification and treatment of sepsis• Hand hygiene

Processes• Inclusion of patient/ public

representation on local critical care improvement team

• Integrate patient/family into improvement work

• Promote open communication among team and family

Processes

• Multi disciplinary rounds and daily goal setting

• Ensure staff have knowledge and expertise in improvement work

• Ensure communication and collaboration within a multi disciplinary team

• Appropriate infrastructure: intensivist led model

Integrate leadership into improvement efforts

Rapid response to acutely ill patients (Shared with medical/surgical improvement, surgical complications and leadership)

Reliable processes are contained in the NICE guidance (50) on identification and treatment of acute illness and include

• Establishment of and training for a whole hospital early warning system

• Development of and training in graded risk based response to acute illness

• Audit process and outcomes • Inclusion of Trust board management,

referring medical teams and ward staff in audit feedback process

http://www.1000livescampaign.wales.nhs.uk/

http://nww.1000livescampaign.wales.nhs.uk/

ContentsThe ‘How to Guide’ for ................................................................... 1 Improving ................................................................................... 1 Critical Care ................................................................................................ 1

Improving Critical Care Getting Started List ................................................................... 4 Improving Critical Care ................................................................................................... 5 Drivers, Interventions and Measures ............................................................................... 6

Goal: Reduce mortality and harm from mechanical ventilation .................................. 6 Goal: Reduce mortality and harm due to complications of using central venous catheters ...................................................................................................................... 9 Goal: Reduce mortality and harm due to severe sepsis ............................................ 12 Goal: Reduce mortality and harm due to transmission of infection in critical care . . 15 Goal: Reduce mortality and harm by the creation in critical care of an environment of collaboration and a culture of safety ...................................................................... 17

Making it Happen .......................................................................................................... 18 Goal: Reduce mortality and harm from mechanical ventilation ................................ 18

Defining the Problem ............................................................................................. 18 The Ventilator Bundle ............................................................................................ 19

Goal: Reduce mortality and harm due to complications of using central venous catheters .................................................................................................................... 21 The Central Line Bundle ............................................................................................ 22 Preventing Catheter-Related Bloodstream Infections – Components of Care ........... 23 Goal: Reduce mortality and harm due to severe sepsis ............................................ 25

Surviving Sepsis Campaign ................................................................................... 25 .................................................................................................................................... 27 Goal: Reduce mortality and harm due to transmission of infection in critical care . . 28

What changes can we make that will result in improvement? ............................... 29 Goal: Reduce mortality and harm by the creation in critical care of an environment of collaboration and a culture of safety ...................................................................... 31

Leadership and Organisational Culture ................................................................. 31 Getting Started ............................................................................................................... 32

Using the Model for Improvement ............................................................................ 32 Forming the Team ...................................................................................................... 33 Setting Aims ............................................................................................................... 34 First Test of Change ................................................................................................... 34 Barriers That May Be Encountered ........................................................................... 34 Measurement .............................................................................................................. 35 Track Measures over Time ........................................................................................ 36 Tips for Gathering Data ............................................................................................. 36 Critical Success Factors ............................................................................................. 37

Programme managers ............................................................................................. 37 Local Champions ................................................................................................... 37 Patient involvement ............................................................................................... 37 Ownership of change ............................................................................................. 37

Links .......................................................................................................................... 38



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Improving Critical Care Getting Started List

Prior to testing and implementation of improving critical care, organisations may wish to consider the following:

• Engage senior leadership support

• Appoint a multi-disciplinary implementation team to: -

o Steer and co-ordinate the interventions

o Review process and outcome data

• Appoint individual or team as ‘process owner’.

This ‘local content specialist’ will have well developed links with both critical and acute care and will co-ordinate implementation of the interventions.

• Appoint clinical champions

• Provide education and training

• Establish quantitative and qualitative feedback mechanisms

• Measure effectiveness



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Improving Critical Care

The aim of the Improving Critical Care work area within the 1000 Lives Campaign is to build upon the achievements of the Welsh Critical Care Improvement Programme (WCCIP) and spread service improvement work to operational areas that also treat critically ill patients beyond the intensive care unit

During the years 2006 - 2008 the WCCIP has enabled the introduction of care bundles and change methodologies in Welsh adult critical care units. In collaboration with the Welsh Critical Care Advisory Group, Critical Care Networks and other stakeholders, the 1000 Lives Campaign will aim to further reduce the incidence of adverse events in critical care.

As part of the 1000 Lives Campaign, participating NHS Trusts will improve care of the critically Ill by improving communication, handwashing and patient involvement in the ICU and implementing the ventilator, central line and sepsis bundles in the wider hospital environs.

This booklet is adapted from the Safer Patient Initiative ‘how to kits’ and intended as a toolkit for the Trust Critical Care Team to use to introduce the various interventions within this work area. The interventions and measures are outlined and change methodology tools are introduced.



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Drivers, Interventions and Measures

Goal: Reduce mortality and harm from mechanical ventilationIntervention level: All level 3 and 3T critical care units

Reliable Processes:

Welsh ventilator care bundle elements:

• Elevation of head of the bed to between 30 and 45 degrees

• Daily “sedation vacation” and daily assessment of readiness to wean

• Peptic Ulcer (PU) Prophylaxis

• Deep Venous Thrombosis (DVT) Prophylaxis

Implement non-physician driven weaning protocol

Formal swallow evaluations for long term ventilated patients

Endotracheal tube cuff inflation via minimal pressure technique

Use protocols and auto-stop points for antibiotics

Measures

Measure Operational Definition

Data Collection Guidance

Data Collection Source

VAP RateCode: CC01

1. Determine the numerator: The total number of ventilator acquired pneumonia cases in the month Use definition agreed between the WCCIP and the WHAI Programme.

2. Determine the denominator: the total ventilator days in the month

The VAP rate is calculated by dividing the total number of VAPs occurring in the month by the total number of ventilator days in the month and then multiplying the result by 1000 to create a VAP rate for 1000 ventilator days

Report monthly infection rate for the months of April 08 through March 09. This serves as your baseline. Continue to report monthly data over the life of the initiative into the Extranet. Provide numerators and denominators when entering the data. The annotation section should be used to reflect any interventions that were made to reduce the VAP rate.

There should be no sampling for this measure.

VAP surveillance in Wales is due to be piloted from January / February 2008, with a view to the surveillance scheme being added to the mandatory CVC infection surveillance on ICU from September 2008. Data on all ventilated patients will be collected plus information on any VAP infections identified according to HELICS definitions. The data will be presented as a VAP rate per 1000 ventilator days and will be reported back to units on a monthly basis similar to the Central line infection surveillance see below.



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Percent compliance with ventilator bundleCode: CCP2

1. Determine the numerator: the number of vented patients in the sample receiving all 4 components of the ventilator bundle.

2. Determine the denominator: the total number of patients reviewed

3. Calculate the percent compliance with the ventilator bundle by dividing the numerator by the denominator and multiplying the result by 100

Note: The ventilator bundle components include: HOB, PUD prophylaxis, DVT prophylaxis, daily sedation vacation.

Ventilator compliance is measured by selecting all patients in the unit(s) on a randomly selected day each week and determining ventilator bundle compliance. Use daily goal sheet or consultant order sheet as the primary data source or direct observation. Review each sheet for implementation of the vent bundle. This is a sample Yes/No outcome. If the patient did not have ALL 4 components then they are considered not in compliance with the ventilator bundle.

Sample should include all vented patients. Only patients with all 4 aspects of vent bundle in place are recorded as compliant.

Conduct sample one day each week, this is a weekly prevalence measure. Rotate days of the week and shifts. All vented patients on the day of the sample are examined for evidence of bundle compliance. Report the 4 prevalence data points (the 4 days selected) for the month as an aggregated numerator and denominator each month on the Extranet.

This figure is at present collected on the WCCIP database and reports are generated as required.

ALOS on mechanical ventilationCode: CCP1

1. Determine the numerator: the total number of ICU mechanical ventilator days during the month.

2. Determine the denominator: The

This measure should not be based on a sample. Instead it should include all the vent days and patients in the ICU(s) being studied.

A monthly report on this measure is generated from the Welsh Critical Care Minimum Dataset (CCMDS).



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total number of ICU patients on a mechanical ventilator during the month.

3. Calculate the ALOS on mechanical ventilator by dividing the numerator (total number of vent days) by the denominator (total vent patients)

ICU ALOS (balancing measure)Code: CCB1

1. Determine the numerator: ICU monthly patient days

2. Determine the denominator: total number of patients discharged from the ICU in the month.

3. Calculate the ICU ALOS. All patients discharged in a given month should have their length of stays summed up and divided by the number of patients. This is the average for the month.

Collect and report this measure monthly for patients admitted to ICU.

A monthly report on this measure is generated from the Welsh Critical Care Minimum Dataset (CCMDS).

Monthly rate of delayed transfers of care

A patient who is identified as fit for discharge when the time between requesting a Ward bed and discharge from the Critical Care unit exceeds 4 hours

Check against the definition in the CCMDS of “fit for discharge” and the time the discharge was initiated but it was considered that the “clock starts” around the time the ward level bed was requested.



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Goal: Reduce mortality and harm due to complications of using central venous catheters Intervention level: All level 1, 2, 3 and 3T units in which CVCs are used

Reliable Processes:

Elements of the Welsh Central Line Insertion Bundle

• Wash hands before and after procedure: soap and water or alcohol-based agents.

• Use barrier precautions: gown and gloves must be worn; as much as possible of the patient should be covered with sterile drapes.

• Sterilise skin with 2% chlorhexidine in alcohol and wait until the skin is dry.

• Avoid the femoral site unless it is the last resort.

Elements of the Welsh Central Line Maintenance Bundle

• Review necessity of central line every day - and remove promptly if it is not needed.

• TPN should be given via a separate line or a dedicated lumen.

• Access to line must be made using a clean technique.

• Entry site to be checked every day for signs of leakage or inflammation and line removed promptly if these signs are present.

Implement preparation and dressing protocols for management of lines

Use line trolleys and dressing change kits

Measures

Measure Operational

Definition

Data Collection

Guidance

Data Collection

Source

Central line catheter-Related bloodstream infection rateCode: CC02

1. Determine the numerator: The total number of central line catheter-related infections for the month

2. Determine the denominator: the total number of central line days for the month

Report the numerator and denominator monthly to the Extranet. Provide annotations as appropriate to reflect any interventions you made during the month.

In Wales CVC infections on ICU are collected within a mandatory surveillance scheme (Mandatory since September 2007). Data is submitted to the WHAIP team centrally and reported back on a



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The CLC BSI rate is calculated by dividing the total numerator by the denominator and multiplying the result by 1000 to get the CLC BSI rate per 1000 catheter days

monthly basis in the form of central line infections per 1000 catheter days.

Days between a CLC bloodstream infectionsCode: CC03

This measure is a cumulative count of the number of days that have gone by with no CLC bloodstream infections being reported. Every time a CLC infection occurs the count is started over again. In this case, we are plotting successes between failures. The longer the run of cumulative successes (days with no CLC BSIs occurring) the better outcome.

Whenever events occur that are relatively rare in nature or when a ward or pilot area has sufficiently small numbers of events, the preferred way to go about analysing the data is to plot: (1) successes between failures, or (2) time between failures. Both of these techniques have being used in the SPI work.

For events, 150 days or more between CL infections is the target. If an intervention is initiated, however, and the period between events is greater than two times the baseline period average this is also significant. In this case, it may be possible to show a true improvement before going 150 days without a CLC BSI.

Days between infections can be calculated locally, but may become part of the report sent out by the WHAIP team in due course.

Percentage compliance with CVC insertionbundle

1. Determine the numerator: the total number of patients who have all 4 elements of the bundle in place

2. Determine the denominator: the total number of inserted lines.

3. Calculate the percent compliance with the central line bundle by dividing the numerator by the denominator and then multiplying the

A report on this measure is currently generated by the WCCIP database.



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resulting proportion by 100

Percentage compliance with central line bundleCode: CCP3

1. Determine the numerator: the total number of patients who have all 4 elements of the bundle in place2. Determine the denominator: the total number of patients reviewed3.Calculate the percent compliance with the central line bundle by dividing the numerator by the denominator and then multiplying the resulting proportion by 100

Use daily goal sheet or consultant order sheet as the primary data source. Review each sheet for implementation of the CL bundle.

Rotate the days of the week and shifts within a day. On the randomly selected days, all patients with CLs should be examined for evidence of CL bundle compliance. There is no sampling with this measure; include all patients with CLs, you could select a random sample of 5 patients with CLs on the day you select for the study.

Only patients with all 4 aspects of CL bundle in place are recorded as being in compliance.

Report monthly to the Extranet but report each week’s prevalence. This means that there should be 4 data points for each month unless the volume is low (e.g. some weeks there are no CLs in place) in which case the results for all CLs for the month will need to be aggregated.




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Goal: Reduce mortality and harm due to severe sepsis Intervention level: All level 0,1,2,3 and 3T units

Reliable processes:

Elements of the Surviving Sepsis Campaign Management Bundle

• Low-dose steroids administered for septic shock in accordance with a standard ICU policy

• Drotrecogin alfa (activated) administered in accordance with a standard ICU policy.

• Glucose control maintained > 3.5 mmol/L but < 8.3 mmol/L

• For mechanically ventilated patients inspiratory plateau pressures maintained < 30 cm H2O.

Elements of the Surviving Sepsis Campaign Resuscitation Bundle

• Serum lactate measured

• Blood cultures obtained prior to antibiotic administration

• From the time of presentation, broad-spectrum antibiotics to be given within 3 hours for ED admissions and 1 hour for non-ED ICU admissions

• In the event of hypotension and/or lactate >4mmol/L (36mg/dL):

• Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent)

• Give vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg.

• In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate >4 mmol/L (36 mg/dl):

Achieve central venous pressure (CVP) of >8 mm Hg

Achieve central venous oxygen saturation (ScvO2) >70%

Elements of the Sepsis Six

• Give 100% oxygen via non-rebreathe bag

• Take blood cultures

• Give IV antibiotics

• Start IV fluid resuscitation with Hartmann’s or equivalent

• Check haemoglobin and lactate



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• Place and monitor urinary catheter unless fully mobile (monitor UO)

Measures

Measure Operational Definition Data Collection Guidance


Percentage compliance with sepsis management bundle

1. Determine the numerator: the number of patients fully compliant within 24 hours with the sepsis management bundle in one month.

2. Determine the denominator: all severely septic patients treated on ICU in that month.

3.Calculate the bundle compliance as a percentage by dividing the numerator by the denominator and multiplying by 100


Percentage compliance with sepsis resuscitation bundle

1. Determine the numerator: the number of patients fully compliant within 6 hours with the sepsis resuscitation bundle in one month.

2. Determine the denominator: all patients identified as having severe sepsis requiring a response in one month.

3.Calculate the care bundle compliance as a percentage by dividing the numerator by the denominator and multiplying the result by 100


Percentage compliance with ‘sepsis six’

1. Determine the numerator: the number of patients fully compliant within 1 hour with the ‘sepsis six’ in one month.




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2. Determine the denominator: all patients identified as having sepsis requiring a response in one month.

3.Calculate the care bundle compliance as a percentage by dividing the numerator by the denominator and multiplying the result by 100

Severe sepsis mortality

1. Determine the denominator: all patients triggered as having severe sepsis requiring a response in one month.

1Determine the numerator: the number of patients within above set where hospital discharge = dead.

3.Calculate the mortality as a percentage by dividing the numerator by the denominator and multiplying the result by 100



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Goal: Reduce mortality and harm due to transmission of infection in critical care

Intervention level: All level 2, 3 and 3T units

Reliable Processes:

Use aggressive Hand-washing program to prevent risk of transmitting infection:

• Apply epic2 guidance for hospital practice

• Staff knowledge and competency

• Use waterless soap

• Install dispensers in all key locations

• Do periodic observational monitoring

• Staff accountability

• Involvement in the NPSA Clean your hands campaign

• Provide adequate hand washing facilities e.g. sinks must be convenient for patient/patient and caregiver in consideration of architectural standards that govern where sinks should be.

• Use of soap and water hand decontamination when there is an outbreak of diarrhoea on the unit or when caring for a patient who has diarrhoea.

• Regular audit of practice and feedback of results

Measures




Percent compliance with hand hygieneCode: CCP4 & GWP2

1. Determine the numerator: the total number of patient encounters in the sample where appropriate hand hygiene was conducted.

2. Determine the denominator: the total number of patients in the sample

3. Calculate the percent compliance with hand hygiene by dividing the

The sample of patients for this measure will come from a weekly observation of patient care encounters. Each week the designated observer(s) should spend 20-30 minutes observing as many patient encounters as possible. The observer task can be rotated among staff in order to reduce the likelihood that individuals may increase compliance because they knew that a designated

There is no national data collection on hand hygiene compliance in Wales although various audit tools have been made available at a national level:For regular and frequent observation of hand hygiene technique the NPSA clean your hands campaign audit tool or the Lewisham tool are examples of appropriate tools. The Infection Prevention Society (IPS formerly the ICNA) audit



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numerator by the denominator and then multiplying the resulting proportion by 100

In this case “appropriate” hand hygiene is defined as the observer witnessing that the healthcare provider (e,g, consultant, nurse, and technician) properly cleaned their hand (soap and water or alcohol gel) before contacting the patient and after contact with the patient was made.

A single contact has two opportunities to fail. This is a simple Yes/No. were BOTH hand hygiene activities observed (before and after patient contact)? If only one cleansing (either before contacting the patient or after contacting the patient)was observed then hand hygiene was not appropriate and a “No” would be recorded by the observer for this particular patient encounter.

individual was conducting the observations.

The sample should produce a total of 15-20 opportunities (the denominator) for hand hygiene per (week) or about 60 to 80 per month. The sampling approach is to select a random day each week to conduct the observation of clinicians and other employees who actually touch a patient. This can be done ahead of time in order to set up observers on the designated days.

If after a few tests you find that you are not getting 15-20 observations per day, you will need to select two days per week. Typically, however, one day a week should give you the required sample size.

tool should also be used regularly, but its focus is on the availability of hand washing facilities rather than on observation of hand hygiene episodes and should be used in conjunction with the observational tools perhaps to understand why in some cases staff are not employing appropriate hand hygiene.



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Goal: Reduce mortality and harm by the creation in critical care of an environment of collaboration and a culture of safetyIntervention level: All level 2, 3 and 3T critical care units

Reliable Processes

• Multi disciplinary rounds and daily goal setting

• Ensure staff have knowledge and expertise in improvement work

• Ensure communication and collaboration within a multi disciplinary team

• Appropriate infrastructure: intensivist led model

• Inclusion of patient/ public representation on local critical care improvement team

• Integrate patient/family into improvement work

Measures




Percent achievement of multi-disciplinary rounds and daily goalsCode: CCP6

1. Determine the numerator: the total number of patients with MDRs who also had DGs documented

2. Determine the denominator: the total number of patients who had MDRs

Calculate the percent achievement of daily goals by dividing the numerator by the denominator and multiplying the result by 100

One day per week (the same day as the MDRs study), conduct an audit for DGs. Look for documented evidence of DGs. Rotate data collection days of the week and shifts in order to avoid “data collection” fatigue and the possibility of having staff change their behaviours because they know the day of the week that will be used to observe this measure.Remember that the denominator for this for this measure is the number of patients who had MRDs.Enter data into the Campaign Extranet with appropriate annotations to document issues related to data collection (e.g., how you randomly select the day of the week for the study).



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Making it Happen

Goal: Reduce mortality and harm from mechanical ventilationIntervention level: All level 3 and 3T critical care units

Defining the ProblemVentilator-associated pneumonia (VAP) is a nosocomial lung infection that occurs in patients receiving mechanical ventilation and for whom the infection was not the reason for ventilation, i.e., the infection commenced after ventilation. Pneumonia is considered as ventilator associated if the patient was intubated and ventilated at the time or within 48 hours before the onset of infection.

Preventing pneumonia of any kind is certainly a laudable goal. However, based upon US data, there are some reasons to be particularly concerned about the impact of pneumonia associated with ventilator use: -

• VAP is the leading cause of death among hospital-acquired infections, exceeding the rate of death due to central line infections, severe sepsis, and respiratory tract infections in the non-intubated patient. Perhaps the most concerning aspect of VAP is the high rate of associated mortality. Hospital mortality of ventilated patients who develop VAP is 46%, compared to 32% for ventilated patients who do not develop VAP.

Ibrahim EH, Tracy L, Hill C, et al. The occurrence of ventilator-associated pneumonia in a community hospital: risk factors and clinical outcomes. Chest. 2001;20(2):555-561.

• In addition, VAP prolongs time spent on the ventilator, length of ICU stay, and length of hospital stay after discharge from the ICU.

Rello J, Ollendorf DA, Oster G, et al. VAP Outcomes Scientific Advisory Group. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;22(6):2115-2121.

• Strikingly, VAP adds an estimated cost of $40,000 to a typical hospital admission.

Tablan OC, Anderson LJ, Besser R, et al. CDC; Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53(RR-3):1-36.



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The Ventilator BundleCare bundles, in general, are groupings of best practices with respect to a disease process that individually improve care, but when applied together may result in substantially greater improvement. Ventilator patients are at high risk for several serious complications: VAP, venous thromboembolism (VTE), and stress-induced gastrointestinal bleeding. The core elements of the bundle are evidence-based strategies that may prevent or reduce risk of these complications and the bundle is an effort to design a standard approach to delivering these core elements of care.

Compliance with the ventilator bundle can be measured by simple assessment of the completion of each item. The approach has been most successful when all elements are executed together, an “all-or-none” strategy.

The ventilator bundle that was agreed by participants on WCCIP has four key components:

1. Elevation of the Head of the Bed

Elevation of the head of the bed is an integral part of the ventilator bundle and has been correlated with reduction in the rate of ventilator-associated pneumonia. The recommended elevation is 30-45 degrees.

Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet. Nov 27 1999;354(9193):1851-1858.

van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, et al. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med. 2006 Feb;34(2):396-402.

2. Daily Sedative Interruption and Daily Assessment of Readiness to Extubate

Using daily sedative interruptions and assessing the patient’s readiness to extubate are an integral part of the ventilator bundle and have been correlated with reduction in the rate of ventilator-associated pneumonia.

Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471-1477.

Schweickert WD, Gehlbach BK, Pohlman AS, Hall JB, Kress JP. Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients. Crit Care Med. 2004 Jun;32(6):1272-1276.

Kress JP, Gehlbach B, Lacy M, Pliskin N, Pohlman AS, Hall JB. The long-term psychological effects of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med. 2003 Dec 15;168(12):1457-1461. Epub 2003 Oct 2.

Esteban, A. A comparison of four methods of weaning patients from mechanical ventilation. N Eng J Med. 1995;332:345-350.



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3. Peptic Ulcer Disease (PUD) Prophylaxis

Stress ulcerations are the most common cause of gastrointestinal bleeding in intensive care unit patients, and the presence of gastrointestinal bleeding due to these lesions is associated with a five-fold increase in mortality compared to ICU patients without bleeding. Applying peptic ulcer disease prophylaxis is therefore a necessary intervention in critically ill patients.

Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal bleeding in critically ill patients. N Engl J Med. 1994;330:377.

Navab F, Steingrub J. Stress ulcer: Is routine prophylaxis necessary? Am J Gastroenterol. 1995; 90:708.

Cook DJ, Laine LA, Guyatt GH, Raffin TA. Nosocomial pneumonia and the role of gastric pH - a meta-analysis. Chest. 1991;100:7.

Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388.

Steinberg KP. Stress-related mucosal disease in the critically ill patient: risk factors and strategies to prevent stress-related bleeding in the intensive care unit. Crit Care Med. 2002;30(6 Suppl):S362-364.

Conrad SA, Gabrielli A, Margolis B, et al. Randomized, double-blind comparison of immediate-release omeprazole oral suspension versus intravenous cimetidine for the prevention of upper gastrointestinal bleeding in critically ill patients. Crit Care Med. 2005;33(4):760-765.

Dial S, Delaney JA, Barkun AN, Suissa S. Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease.JAMA. 2005;294(23):2989-2995.

4. Deep Venous Thrombosis (DVT) Prophylaxis

Applying deep venous thrombosis prophylaxis is an appropriate intervention in all patients who are sedentary; however, the higher incidence of deep venous thrombosis in critical illness justifies greater vigilance.

Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 Suppl):338S-400S.



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Goal: Reduce mortality and harm due to complications of using central venous catheters Intervention level: All level 1, 2, 3 and 3T units in which CVCs are used

• Central venous catheters (CVCs) are being used increasingly in the inpatient and outpatient setting to provide long-term venous access. CVCs disrupt the integrity of the skin, making infection with bacteria and/or fungi possible. Infection may spread to the bloodstream and haemodynamic changes and organ dysfunction (severe sepsis) may ensue, possibly leading to death. Approximately 90% of the catheter-related bloodstream infections (CR-BSIs) occur with CVCs.

Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med. 2000;132(5):391-402.

• Forty-eight percent of US intensive care unit (ICU) patients have central venous catheters, accounting for about 15 million central-venous-catheter-days per year in ICUs. Approximately 5.3 central line infections (often termed catheter-related bloodstream infections) occur per 1,000 catheter days in US ICUs. The attributable mortality for such central line infections is approximately 18%. Thus, probably about 14,000 deaths occur annually due to central line infections. Some estimates put this figure as high as 28,000 deaths per year.

Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1994;271:1598-1601.

Saint S. Chapter 16. Prevention of intravascular catheter-related infection. Making health care safer: a critical analysis of patient safety practices. AHRQ evidence report, number 43, July 20, 2001.

Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32:2014-2020.

• In addition, nosocomial bloodstream infections prolong hospitalization by a mean of 7 days. Estimates of attributable cost per bloodstream infection are estimated to be between $3,700 and $29,000.

Soufir L, Timsit JF, Mahe C, Carlet J, Regnier B, Chevret S. Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: a matched, risk-adjusted, cohort study. Infect Control Hosp Epidemiol. 1999;20(6):396-401.



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The Central Line BundleCare bundles, in general, are groupings of best practices with respect to a disease process that individually improve care, but when applied together may result in substantially greater improvement. The science supporting each bundle component is sufficiently established to be considered the standard of care.

The central line bundles are two groups of evidence-based interventions for patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually.

Elements of the Welsh Central Line Insertion Bundle

• Wash hands before and after procedure: soap and water or alcohol-based agents.

• Use barrier precautions: gown and gloves must be worn; as much as possible of the patient should be covered with sterile drapes.

• Sterilise skin with 2% chlorhexidine in alcohol and wait until the skin is dry.

• Avoid the femoral site unless it is the last resort.

Elements of the Welsh Central Line Maintenance Bundle

• Review necessity of central line every day - and remove promptly if it is not needed.

• TPN should be given via a separate line or a dedicated lumen.

• Access to line must be made using a clean technique.

• Entry site to be checked every day for signs of leakage or inflammation and line removed promptly if these signs are present.

This is not intended to be a comprehensive list of all elements of care related to central lines; rather, the bundle approach to a small group of interventions promotes teamwork and collaboration. Other elements of care, such as daily site care and selection of dressing material, may be recommended in guidelines from the CDC and others. These are not excluded for any purpose other than to have bundles that are focused.

The WCCIP has introduced the CVC bundles into adult general ICUs. This programme aims to ensure that the bundles are used in all clinical areas where CVCs are inserted and cared for.

Compliance with the central line bundle can be measured by simple assessment of the completion of each item. The approach has been most successful when all elements are executed together, an “all or none” strategy.



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Preventing Catheter-Related Bloodstream Infections – Components of Care

Hand hygiene

One way to decrease the likelihood of central line infections is to use proper hand hygiene. Washing hands or using an alcohol-based waterless hand cleaner helps prevent contamination of central line sites and resultant bloodstream infections.

O'Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep. Aug 9 2002;51(RR-10):1-29.

Maximal barrier precautions

A key change to decrease the likelihood of central line infections is to apply maximal barrier precautions in preparation for line insertion.

Mermel LA, McCormick RD, Springman SR, Maki DG. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping. Am J Med. Sep 16 1991;91(3B):197S-205S.

Raad, II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol. Apr 1994;15(4 Pt 1):231-238.

Chlorhexidine skin antisepsis

Chlorhexidine skin antisepsis has been proven to provide better skin antisepsis than other antiseptic agents such as povidone-iodine solutions.

Maki DG, Ringer M, Alvarado CJ. Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet. 1991 Aug 10;338(8763):339-343.

Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med. 2002 Jun 4;136(11):792-801.



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http://www.cdc.gov/mmwr/PDF/rr/rr5110.pdf


Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters in adults

Percutaneously inserted catheters are the most commonly used central catheters. In a recent prospective observational study assessing catheters placed by a critical care medicine department in a university teaching hospital, the site of insertion did not alter the risk of infection. The authors concluded that the site of insertion was not a risk factor for infection when experienced physicians insert the catheters, strict sterile technique is used, and trained intensive care unit nursing staff performs catheter care.

Deshpande KS, Hatem C, Ulrich HL, et al. The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population. Crit Care Med. 2005;33:13.

Mermel LA, McCormick RD, Springman SR, Maki DG. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping. Am J Med. Sep 16 1991;91(3B):197S-205S.

McCarthy MC, Shives JK, Robison RJ, Broadie TA. Prospective evaluation of single and triple lumen catheters in total parenteral nutrition. J Parenter Enteral Nutr. 1987 May-Jun;11(3):259-262.

Richet H, Hubert B, Nitemberg G, et al. Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-catheter cultures in intensive care unit patients. J Clin Microbiol. 1990;28:2520.

Collignon P, Soni N, Pearson I, et al. Sepsis associated with central vein catheters in critically ill patients. Intensive Care Med. 1988;14:227.

Merrer J, Jonghe BD, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients. A randomized controlled trial. JAMA. 2001;286:700.

Daily review of central line necessity with prompt removal of unnecessary lines

Daily review of central line necessity will prevent unnecessary delays in removing lines that are no longer clearly needed for the care of the patient. Many times, central lines remain in place simply because they provide reliable access and because personnel have not considered removing them. However, it is clear that the risk of infection increases over time as the line remains in place and that the risk of infection decreases if the line is removed.

O'Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep. Aug 9 2002;51(RR-10):10.



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Goal: Reduce mortality and harm due to severe sepsis Intervention level: All level 0,1,2,3 and 3T units

The term sepsis covers a number of infectious diseases that result in a common picture of multiple organ failure. It is a condition with high prevalence – about 2.3% of hospital patients and about 27% of intensive care patients 1, 2. Mortality rates are very high – around 30 – 50%. In Wales this equates to the deaths of between 700-1100 people in ICU annually. Globally, sepsis kills about half a million people a year: as many as myocardial infarction.Until recently sepsis has had a low public profile. Reporting of cause of death on death certificates often omits the term sepsis so its prevalence has been under-reported. Effective treatments have been hard to come by. Times are changing though and there is a growing international consensus both on the scale of the challenge and the practical ways to bring down mortality rates 3.The good news is that the most effective treatments are simple interventions such as giving oxygen, large volumes of intravenous fluids and antibiotics 4. The main challenge is that these treatments must be given early in the disease process to be effective. The main focus then has to be on the early identification of patients with sepsis and in delivery of a package of treatments within a few hours of the onset of the disease. These simple targets are hard to achieve and require us to redesign how patients are monitored and treated throughout the hospital.

1. Angus DC et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome and associated costs of care. Critical Care Medicine 2001; 29; 1303-10

2. Padkin AM et al. Epidemiology of severe sepsis occurring in the first 24 hours in intensive care units in England, Wales and Northern Ireland. Critical Care Medicine 2003: 31; 2332–8

3. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock 2008. Crit Care Med. 2008; 36(1): 296-327

4. Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368-1377

Surviving Sepsis CampaignThe Surviving Sepsis Campaign is an International campaign to reduce mortality and morbidity from sepsis by 25% over a 5 year period through the introduction of Sepsis Care Bundles. These bundles consist of interventions that have solid evidence in improving mortality.

These consist of 2 elements; the first 6 hours from the diagnosis of Severe Sepsis or Septic Shock (time zero) known as the Resuscitation Bundle and the first 24 hours from diagnosis known as the Management Bundle.

Early experience with the bundles at The University Hospital of Wales (UHW) and Neville Hall Hospital (NHH) highlighted the following difficulties:



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• Inconsistency in the early diagnosis of severe sepsis and septic shock

• Frequent inadequate volume resuscitation

• Late or inadequate use of antibiotics

• Frequent failure to support the cardiac output when depressed

• Frequent failure to control hyperglycemia adequately

• Frequent failure to use low tidal volumes and pressures in acute lung injury

• Frequent failure to treat adrenal inadequacy in refractory shock

To overcome these difficulties the SSC care bundles have, in some areas, been operationalised into a care pathway with achievement of the so called ‘sepsis six’ within 1 hour of severe sepsis diagnosis. The evidence base behind the implementation of Sepsis Care Bundles/Pathway:

Early recognition of severe sepsis and septic shock, with early aggressive resuscitation aimed at meeting defined goals [Rivers E, et al. Early recognition of severe sepsis and septic shock, with early aggressive resuscitation aimed at meeting defined goals. New England Journal of Medicine. 2001;345(19):1368-1377.]

Early use of appropriate antibiotics [Iregui M, et al. Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia. Chest. 2002;122(1): 262-268.]

Tight control of blood glucose [van den Berghe G, et al. Intensive insulin therapy in critically ill patients. New England Journal of Medicine. 2001;345(19):1359-1367.]

Low volume and low pressure ventilation for acute lung injury patients [The NIH-ARDS Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. New England Journal of Medicine. 2000;342(18):1301-1308.]

Use of activated protein C for severe sepsis [Bernard GR, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. New England Journal of Medicine. 2001;344(10): 699-709.]

Use of low-dose steroids in refractory septic shock [Annane D, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. Journal of the American Medical Association. 2002;288(7):862-887.]

The Survive Sepsis Resuscitation Pathway can be obtained from:

http://www.survivesepsis.org/

Further information can be obtained from the following links:

www.ihi.org

www.aboutsepsis.com


http://www.survivingsepsis.org/

http://www.sepsisforum.org/



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http://www.sepsisforum.org/

http://www.survivingsepsis.org/


http://www.aboutsepsis.com/

http://www.ihi.org/


http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Literature/Effectoftreatmentwithlowdosesofhydrocortisoneandfludrocortisoneonmortalityinpatientswithsepticshock.htm

http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Literature/EfficacyandsafetyofrecombinanthumanactivatedproteinCforseveresepsis.htm

http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Literature/VentilationwithlowertidalvolumesforacutelunginjuryandARDS.htm

http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Literature/Intensiveinsulintherapyinthecriticallyillpatients.htm

http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Literature/Clinicalimportanceofdelaysintheinitiationofappropriateantibiotictreatmentforventilatorassociatedpneu.htm

http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Literature/Earlygoaldirectedtherapyinthetreatmentofseveresepsisandsepticshock.htm

http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Literature/Earlygoaldirectedtherapyinthetreatmentofseveresepsisandsepticshock.htm



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Goal: Reduce mortality and harm due to transmission of infection in critical careIntervention level: All level 2, 3 and 3T units

The campaign is focusing on hand hygiene as a key measure in breaking the chain of cross infection and compliance with hand hygiene is one of the key process measures that the campaign will be looking at, however this should not be taken to mean that the other standard precautions are less important.

As hand hygiene compliance is considered to be a major factor in breaking the chain of infection, it will be one of the major process measures collected by the campaign, therefore there is more detail here regarding hand hygiene than for the other standard precautions.

Transient contamination of HCWs’ hands occurs while caring for colonised or infected patients. HCWs can contaminate their hands even while performing “low-risk” patient care activities such as taking a pulse or blood pressure, lifting a patient up in bed, or handling items in the patient’s vicinity.

Although wearing gloves when having direct contact with patients can reduce the risk of hand contamination, hands often are contaminated during glove removal. Therefore, cleaning hands before and after having contact with patients or their immediate environment is of paramount importance in reducing transmission of HCAI in health care facilities. Unfortunately, compliance with hand hygiene remains abysmal in many hospitals—often well under 50%. It is doubtful whether such low rates of compliance are compatible with efforts to dramatically reduce the rate of HCAI in health care.

When hands are heavily contaminated or visibly soiled, handwashing with soap and water is critical. Also when managing patients with diarrhoea it is imperative that washing with soap and water is undertaken as alcohol gels have poor activity against C. difficile and norovirus. Sinks must be conveniently located near the point of care.

Sinks with automatic controls or elbow faucet handles are preferred. If the water controls are hand-operated, personnel should turn them off with a clean paper towel. Alcohol hand rubs are the preferred method for general hand hygiene when hands are not heavily contaminated or visibly soiled. Alcohol hand rubs rapidly kill bacteria, including MRSA (but not Clostridium difficile spores), take far less time than handwashing, and are relatively gentle on the hands. Alcohol rub dispensers should be conveniently located directly at the point of care, as well as at numerous locations in the staff’s traffic pattern, to maximize adherence (Pittet et al., 2000).

The impact of a vigorous hand hygiene campaign was assessed in a widely-cited study from a teaching hospital in Geneva, Switzerland. Overall compliance with hand hygiene during routine patient care was measured before and during implementation of the campaign (Dec 1994 - Dec 1997), which included posters on handwashing and installation of alcohol-based hand rub dispensers by the patient’s bedside. Handwashing compliance increased from 48% in 1994 to 66%



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in 1997; consumption of alcohol-based rub solution increased concurrently. Healthcare Associated infection rates decreased significantly during this period (active surveillance was also in use during this time). The “Clean Your Hands Campaign” running in the UK since 2005, and the acknowledged importance of hand hygiene in controlling the transmission of antibiotic-resistant pathogens, should catalyse even higher rates of performance.

Most NHS Trusts in Wales are already engaged with the “Clean your Hands Campaign and there is now a drive to involve the community also. For further information visit the website http://www.npsa.nhs.uk/cleanyourhands

A study of handwashing frequency in ICUs in the 1980s (before alcohol-based hand rubs were widely used in the US) established “proof of concept” that personnel are more likely to wash their hands when appropriate equipment and supplies are readily available; in this case, compliance was greater when more sinks were placed in patient care areas. Similarly, appropriate use of alcohol-based rubs is far more likely if dispensers are widely available near the point of care. Of course, dispensers must not be empty, should be operational, and should dispense the correct amount of rub.

Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Infection Control Program. Ann Intern Med. 1999;130(2):126-130.

Lankford MG, Zembower TR, Trick WE, Hacek DM, Noskin GA, Peterson LR. Influence of role models and hospital design on hand hygiene of healthcare workers. Emerg Infect Dis. 2003;9(2):217-223.

Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet. 2000;356(9238):1307-1312.

Bischoff WE, Reynolds TM, Sessler CN, Edmond MB, Wenzel RP. Handwashing compliance by health care workers. The impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med. 2000;160:1017-1021.

Kaplan LM, McGuckin M. Increasing handwashing compliance with more accessible sinks. Infection Control. 1986;7(8):408-410.

What changes can we make that will result in improvement?Education and training in effective hand hygiene has been undertaken in the UK over many years a new approach is needed to improve the compliance rates significantly. In 2006, IHI prepared a How-to Guide on Hand Hygiene in collaboration with the Centers for Disease Control and Prevention (CDC), the Association for Professionals in Infection Control and Epidemiology (APIC), and the Society of Healthcare Epidemiology of America (SHEA). The Guide was endorsed by APIC and SHEA, and valuable input was provided by the World Health Organization's World Alliance for Patient Safety through the Global Patient Safety Challenge. The following four components of the hand hygiene intervention package are critical:



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1. Clinical staff, including new staff and trainees, understand key elements of hand hygiene practice (demonstrate knowledge)

2. Clinical staff, including new staff and trainees, use appropriate technique when cleansing their hands (demonstrate competence)

3. Alcohol-based hand rub and gloves are available at the point of care (enable staff)

4. Hand hygiene is performed at the right time and in the right way and gloves are used appropriately as recommended by CDC’s Standard Precautions (verify competency, monitor compliance, and provide feedback)

5. Keep soap/alcohol-based hand hygiene dispensers prominently placed and make universal precautions equipment, such as gloves, only available near hand sanitation equipment.

6. Initiate a campaign using posters including photos of celebrated hospital doctors/employees recommending hand hygiene.

7. Create an environment where reminding each other about hand hygiene is encouraged.

Refer to the Hand Hygiene Guide for a full description of this intervention.

In the UK the Clean Your Hands campaign has encouraged improvements in hand hygiene through a high impact poster campaign, the use of champions and the promulgation of good access to alcohol gel preparations.

Teams should use the best approach for their needs as agreed through PDSA cycles on the units to bring the hand hygiene compliance above 95%. Various audit tools are available to assess hand hygiene compliance. The most commonly used in the UK are

1. Infection Practitioner’s Society (IPS formerly known as the ICNA) audit tool

2. The Lewisham tool

3. The Clean Your Hands Campaign audit tool, National Patient Safety Agency.

The first of these provides a tool which assesses the provision of facilities for hand hygiene for staff and patients as well as assessing training. This tool could be used for baseline and subsequent assessments of the availability of facilities and resources for hand hygiene. The second and third listed tools are probably more appropriate for regular assessment of hand hygiene compliance through observation.

All these tools are available through the WHAIP website (intranet reference address needed) as well as from the individual websites listed.



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http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Tools/HowtoGuideImprovingHandHygiene.htm

Goal: Reduce mortality and harm by the creation in critical care of an environment of collaboration and a culture of safetyIntervention level: All level 2, 3 and 3T critical care units

Leadership and Organisational CultureChanging practice requires a change in organizational culture and attitudes about what is acceptable. Organisations that have nearly eliminated certain types of infections, such as ventilator-associated pneumonia (VAP) and central line infections (BSLI), have moved towards a culture where these infections are viewed as completely preventable.

The organisational culture within an individual organisation, or even at the local level of a department or patient care unit, develops based on overt and subtle messages employees receive. Leadership actions strongly influence employee beliefs as to what leaders consider important, even more so than what is actually said. This includes not only what leaders do, but also what they do not do.

Teamwork is essential in health care today, and communication within the team is indicative of the organisational culture. Everyone must be considered as an equally important member of the team, regardless of their role, and not only encouraged to speak up, but required to do so. If non-clinical or non-professional (i.e., non-licensed or certified) staff are not treated as equal members of the team, they will be less likely to point out an unsafe condition or take action. For example, environmental services personnel are critical members of the team for infection prevention, not just the clinical personnel who provide direct patient care.

» What changes can we make that will result in improvement?

Understanding how organizational culture develops is important to changing it, and practical tools are available to effect change:

• Implement Leadership WalkroundsTM, a structured approach for senior leaders to talk directly with front-line staff about patient safety.

• Train staff in the use of SBAR, a structured format for communication which stands for Situation-Background-Assessment-Recommendation and establishes a clear layout of information in a manner that is non-threatening and allows for appropriate assertion.

• Conduct briefings on units to increase staff awareness by bringing them together for 5 to 10 minutes as part of the daily routine.

• Involve patients and families in processes, such as rounds.



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http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/Safety+Briefings+(IHI+Tool).htm

http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm

http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/Patient+Safety+Leadership+WalkRounds?+(IHI+Tool).htm

Getting Started

Hospitals will not successfully implement these interventions overnight. If you do, chances are that you are doing something sub-optimally. A successful program involves careful planning, testing to determine if the process is successful, making modifications as needed, re-testing, and careful implementation.

• Select the team and the venue.

• Assess where you stand presently. Is there a process in place? If so, work with staff to begin preparing for changes.

• Organize an educational program. Teaching the core principles to staff will open many people’s minds to the process of change.

• Introduce the interventions to the staff.

Using the Model for ImprovementIn order to move this work forward, the campaign team recommends using the Model for Improvement. Developed by Associates in Process Improvement, the Model for Improvement is a simple yet powerful tool for accelerating improvement that has been used successfully by hundreds of health care organizations to improve many different health care processes and outcomes.

The model has two parts:

• Three fundamental questions that guide improvement teams to 1) set clear aims, 2) establish measures that will tell if changes are leading to improvement, and 3) identify changes that are likely to lead to improvement.

• The Plan-Do-Study-Act (PDSA) cycle to conduct small-scale tests of change in real work settings — by planning a test, trying it, observing the results, and acting on what is learned. This is the scientific method, used for action-oriented learning.

Implementation: After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team can implement the change on a broader scale — for example, for an entire pilot population or on an entire unit.

Spread: After successful implementation of a change or package of changes for a pilot population or an entire unit, the team can spread the changes to other parts of the organization or to other organizations.

You can learn more about the Model for Improvement on www.IHI.org.



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http://www.ihi.org/

Forming the TeamNo single person can create system-level improvements alone. First, it is crucial to have the active support of leadership in this work. The leadership must make patient safety and quality of care strategic priorities in order for any infection reduction improvement team to be successful.

Once leadership has publicly given recognition and support (financial resource, person-time) to the programme each hospital will have its own methods for selecting a core team. The team should use the Model for Improvement to conduct small-scale, rapid tests of the ideas for improvement over various conditions in a pilot population. The team should also track performance on a set of measures designed to help them see if the changes they are making are leading to improvement, and regularly report these measures back to leadership.

The Campaign Team recommends a multidisciplinary team approach to patient care in critical care. Improvement teams should be heterogeneous in make-up, but homogeneous in mindset. The value of bringing diverse personnel together is that all members of the care team are given a stake in the outcome and work to achieve the same goal.

All the stakeholders in the process must be included, in order to gain the buy-in and cooperation of all parties. For example, teams without nurses are bound to fail. Teams led by nurses and therapists may be successful, but often lack leverage; physicians must also be part of the team.

Some suggestions to attract and retain excellent team members include using data to define and solve the problem; finding champions within the hospital who are of sufficiently high profile and visibility to lend the effort immediate credibility; and working with those who want to work on the project rather than trying to convince those that do not.

The team needs encouragement and commitment from an authority in the intensive care unit. Identifying a champion increases a team’s motivation to succeed. When measures are not improving fast enough, the champion re-addresses the problems with staff and helps to keep everybody on track toward the aims and goals.

Eventually, the changes that are introduced become established. At some point, however, changes in the field or other changes in the ICU will require revisiting the processes that have been developed. Identifying a “process owner,” a figure who is responsible for the functioning of the process now and in the future, helps to maintain the long-term integrity of the effort.



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Setting AimsImprovement requires setting aims. An organization will not improve without a clear and firm intention to do so. The aim should be time-specific and measurable; it should also define the specific population of patients that will be affected. Agreeing on the aim is crucial; so is allocating the people and resources necessary to accomplish the aim.

An example of an aim that would be appropriate for reducing CR-BSIs can be as simple as, “Decrease the rate of CR-BSIs by 50% within one year by achieving greater than 95% compliance with the central line bundle.”

Teams are more successful when they have unambiguous, focused aims. Setting numerical goals clarifies the aim, helps to create tension for change, directs measurement, and focuses initial changes. Once the aim has been set, the team needs to be careful not to back away from it deliberately or "drift" away from it unconsciously.

First Test of ChangeOnce a team has prepared the way for change by studying the current process and educated the affected parties, the next step is to begin testing the intervention.

• Begin using the intervention with one patient.

• Work with each nurse who cares for the patient to be sure they are able to follow the bundle and implement the checklist and daily goals sheet.

• Make sure that the approach can be carried over from shift to shift to eliminate gaps in teaching and utilization.

• Process feedback and incorporate suggestions for improvement.

• Once the intervention has been applied to one patient and subsequent shifts, increase utilization to the remainder of the ward/unit.

• Engage in additional PDSA cycles to refine the process and make it more reliable.

Barriers That May Be Encountered

• Fear of change

All change is difficult. The antidote to fear is knowledge about the deficiencies of the present process and optimism about the potential benefits of a new process.

• Communication breakdown



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Organizations have not been successful when they failed to communicate with staff about the importance of the interventions, as well as when they failed to provide ongoing teaching as new staff become involved in the process.

MeasurementMeasurement is the only way to know whether a change represents an improvement. The systems for collection of the process data on compliance with the care bundles as part of WCCIP were developed by the individual units and therefore contain some variation in approach.

However, there are several common features. In all but one unit the system was paper based and relied upon the bedside nurse ensuring that a form, similar to that below, was completed on a daily basis.

Bundle elements were ticked as completed, signed if not completed and reasons for exclusion from the bundle recorded.Figure 1 – bedside ventilator compliance form

Yes No Clinical Exclusion

DVT Prophylaxis √

GU Prophylaxis √

Head Elevation - 30° √ √ √

Sedation Hold √

Bundle compliance was ‘all or nothing’ in that patients were only considered compliant if all elements of the bundles had either been performed or a reason had been given for not doing so.

Daily compliance for the unit for all eligible patients upon that unit was recorded on a chart similar to that below

VENTILATED CARE BUNDLE AUDIT FORM - UNIT

NETWORK_________________________________________ TRUST_____________________________________________ HOSPITAL__________________________________________ LEAD CONTACT____________________________________ DATE____________________

%

TOT

10

9

8

7

6

5

4

3

2

1

Local ExclusionNoYesLocal ExclusionNoYesLocal ExclusionNoYesLocal ExclusionNoYes

Sedation HoldHead Elevation (30 degrees)

GU ProphylaxisDVT ProphylaxisBed No.



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Track Measures over TimeImprovement takes place over time. Determining if improvement has really occurred and if it is a lasting effect requires observing patterns over time. Run charts are graphs of data over time and are one of the single most important tools in performance improvement. Using run charts has a variety of benefits:

• They help improvement teams formulate aims by depicting how well (or poorly) a process is performing.

• They help in determining when changes are truly improvements by displaying a pattern of data that you can observe as you make changes.

• They give direction as you work on improvement and information about the value of particular changes.

Tips for Gathering DataUse a form that allows you to record your efforts and track your success. In addition to helping improvement teams create run charts each month, a contemporaneous record documenting line placement and site care can help with prompting early removal. The decision as to whether the form becomes a permanent part of the medical record, or is simply used as a data collection tool, must be made locally at each hospital.

These strategies are particularly effective if used in conjunction with a Daily Goals assessment sheet. This form can be completed during daily rounds on the patient. Many organizations implement the central line bundle in tandem with the ventilator bundle to improve systematic care to patients in ICUs.



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Critical Success FactorsReflection on the WCCIP identified the following factors as critical to success in the implementation of the ventilator and central line care bundles in Welsh critical care.

Programme managersThroughout the programme it was shown time and again that the most important factor in local success was the programme manager. These individuals showed extraordinary determination and resilience in motivating their teams and introducing innovation. They achieved this often in the absence of adequate funding and in some cases whilst having to overcome considerable resistance to change.

The programme manager training and study days proved to be popular with the programme managers themselves as both a source of support and as a means of acquiring practical skills. Protected time to fulfil this role was invaluable and it was noticeable that sites where this role was not backfilled struggled at times in maintaining the momentum.

Local ChampionsClinical and Managerial support for WCCIP locally was essential to the successful implementation and sustainability of the care bundle approach. The programme required substantial amounts of senior staff time in the planning, implementation and monitoring of the care bundles in the units, and without managerial and clinical support, this resource would not have been made available.

Patient involvementAt the outset of the programme, patient involvement was not common within critical care across Wales. Patient involvement on the National Steering Group was key to ensuring the right questions were asked at key points in the programme, and promoted local involvement of patients and carers on improvement teams. These teams have since stated that this is a key element of their success, as it provides a unique perspective influence which NHS staff often overlook and underestimate.

Ownership of changeThe collaborative approach NLIAH took to agreeing and implementing national bundles ensured buy-in from all sites, clinicians, nursing and therapies staff prior to implementation.

It is an often repeated axiom that for change to stick it must be owned by those affected by that change. There is ample evidence within the units’ progress reports that this is true. It may also be claimed that the audit process to evaluate the change itself is also most effective when developed and owned by those participating.



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LinksExtensive evidence supports the care recommendations in this Guide. Selected references as well as practical tools are available on www.1000livescampaign.wales.nhs.uk

The WCCIP Year one Report, which contains many practical examples of implementation of care bundles, can be downloaded at www.wccip.wales.nhs.uk or by contacting Chris Hancock at [email protected]



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mailto:[email protected]

http://www.wccip.wales.nhs.uk/




The How to Guide'

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