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
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
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.
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
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
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
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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
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
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
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
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
Debbie Trau, RN6 Sigma Black Belt
OSF Saint Francis Medical Center
530 NE Glen Oak, Peoria, IL 61637
(309) 671-1540
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