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Eliminating Hospital Acquired Infections. Is it Possible? Is it Sustainable? Is it Worth It?. CCU / MICU Department of Medicine Allegheny General Hospital. FY 2003 Traditional Approach. FY 2004 PPC Approach. ICU Admissions (n). 1753 ASG: 2.1. 1798 ASG: 2.3. Patients with CLABs (n).

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Eliminating Hospital Acquired Infections

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Eliminating hospital acquired infections l.jpg

Eliminating Hospital Acquired Infections

Is it Possible?Is it Sustainable?Is it Worth It?

CCU / MICU

Department of Medicine

Allegheny General Hospital


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FY 2003

Traditional Approach

FY 2004

PPC Approach

ICU Admissions (n)

1753 ASG: 2.1

1798 ASG: 2.3

Patientswith CLABs (n)

37

6

Age (years)

62 (24-80)

62 (50-74)

Gender (male/female)

22/15

3/3

TotalCLABS

49

6

Lines

1063

1110

Linedays

4683

5052

10.5

1.2

Deaths in patients with CLABs

19 (51%)

1 (16%)

ComparativeResults

Overallrates

(infections /1000 line days)

Risk of CLAB

1 in 22

1 in 185


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FY 2004

PPC Approach

FY 2005

PPC Approach

ICU Admissions (n)

1798 ASG:2.3

1879 ASG:2.5

Patientswith CLABs (n)

6

11

Age (years)

62 (50-74)

65 (39-71)

Gender (male/female)

3/3

5/6

TotalCLABS

6

11

Lines

1110

1321

Linedays

5052

6505

1.2

1.5

Deaths in patients with CLABs

1 (16%)

1 (9%)

Are the Results Sustainable ?

Overallrates

(infections /1000 line days)

Risk of CLAB

1 in 185

1 in 120


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What Happened??

FY05

FY04

Education

Standardization


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Why Did We Slip?

  • 70% of the CLABs in FY05 were related to line placement issues

  • We had not developed training for line placement

  • Residents and fellows are masters of the “work around”

  • We are using more and more PICC without proper technique and training


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Central Line Training ModuleWorkers have to be given the training necessary to be successful

  • 1 hour didactic with test

  • “The Perfect Line Placement ” Video

  • Two Hours in the “Line training Simulator”

  • Inter disciplinary (residents/fellows/nurses)


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Eliminating VAP

  • July2004:

    We implemented real time problem solving around every VAP case

  • October, 2004:

    We implemented countermeasures developed by the people doing the work (AGH VAP Bundle)

  • July, 2005:

    We assessed improvement compared to data from the previous 2 years


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The Results with VAP

(46)

(45)

(8)

VAP Bundle


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Eliminating VAP:How Did We Do It?

  • Step 1: Elevate the head of the Bed 30

  • Step 2: Chlorhexidine mouthwash BID

  • Step 3: Change vent tubing daily

  • Step 4: Change suction catheter daily

  • Step 5: provide a hook for hanging resuscitation bag

Total Added Cost: $17/ intubated patient


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The Financial Losses due to VAP Are Sizable

(*Excluded from the data are 57 non-VAP cases in fiscal year 04/05 due to the lack of reimbursement data on these cases)


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Best Clinical Outcome Does Not Reward AGH

VAP vs. Non-VAP Separated into Clinical Outcomes

(*Excluded from the data are 57 non-VAP cases in fiscal year 04/05 due to the lack of reimbursement data on these cases)


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The Incentives Are Not Aligned with Outcomes

$6,938

$3,292

$8,426

$24,435


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Step 7 :Estimate the Cost of the Intervention

  • Variable costs of the actual components

    $ 0.4 / day(chlorohexidine mouthwash)

    +$ 1.0 / day(clear and blue ventilator tubes)

= $ 1.4 / day

*11.17 (average days on ventilator)

= $15.64 / patient

+ $ 0.58 / patient (Yankauer suction)

+ $ 0.75 / patient (resuscitation bag hook)

= $17 (per patient)

  • No other costs associated with implementation

    - no special training for nurses

    - little additional time for nurses to perform


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Savings Are Likely to Far Exceedthe Costs of Intervention


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CCU/MICU and HAIA Big Return on Investment

  • Total Savings

    CLAB= $1,235,765

    VAP= $1,003,162

  • Highmark PFP = $2,100,000

  • HAI elimination Initiatives = +$4,338,927

  • Investment = $34,927


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CCU/MICU and HAIThe Benefits are no Longer Theoretical

  • AGH has returned $1.5 million of the saving to further HAI elimination

  • $400,000 to hire 8 respiratory therapists

  • $350,000 for CLAB training module

  • The CCU/MICU experience needs to be confirmed (PHC4/JHF collaborative)


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Summary

  • Progress but by no means excellence

  • Each class of HAI represent a enormous clinical and economic opportunity

  • Training, commitment, and collaboration

    (not policies and guidelines) are needed.

  • Excuses are no longer acceptable


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