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Improving Patient Safety, Clinical Quality and Unfunded Mandates: What ICPs Should Know. APIC 2005 Baltimore, MD. Denise Murphy, RN, BSN, MPH, CIC Chief Patient Safety and Quality Officer Barnes-Jewish Hospital at Washington University Medical Center St. Louis, MO. I LOVE CHANGE!.

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Improving patient safety clinical quality and unfunded mandates what icps should know
Improving Patient Safety, Clinical Quality and Unfunded Mandates: What ICPs Should Know

APIC 2005

Baltimore, MD

Denise Murphy, RN, BSN, MPH, CIC

Chief Patient Safety and Quality Officer

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


Who keeps moving the cheese and why

I LOVE Mandates:

CHANGE!

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


What should icps know about quality initiatives
What Should ICPs Know About Mandates: 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? Compliance

  • 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!


ORYX/ CMS Core Measures -Current Compliance

CMS/AHA & JCAHO Measures - Anticipated

Best-in-Class 2004

NPSG

Indicator

Safety Culture1

Employee perception of management commitment to patient safety

 x

Employee willingness to report errors

 x

Patient Identification2

Surgical/procedural site ID compliance

 x

Surgical/procedural time-out compliance

 x

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

 x

Medication Safety2

Compliance with "Do Not Use" abbreviation list

 x

Infection Control

Trained medical direction in Infection Control

x

Antibiotic management program enhancements

x

Surgical patients receiving prophylactic antibiotic within standard

x

Hand hygiene policy and education

x

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

x

Reduce VAP Infections in ICU (SIR < 1)

x

Patient Identification

Mislabeled/unlabeled lab specimens

x

Medication Safety

Tall man lettering utilized at medication storage locations

x

WHAT IS BEING MEASURED

and BY WHOM?


JCAHO Core Measures -Current Compliance

JCAHO Core Measures - Future

Best-in-Class 2005

CMS Annual Payment Update

Indicator

AMI

Admission Treatment

ASA within 24 hours of hospital arrival1

x

x

x

Beta-blockers within 24 hours of hospital arrival1

x

x

x

Cholesterol testing within 24 hours of hospital arrival

x

Discharge Treatment

ACE-I/ARB prescribed at discharge for LV systolic dysfunction1

x

x

x

ASA prescribed at discharge1

x

x

x

Beta-blockers prescribed at discharge1

x

x

x

Lipid-lowering agents prescribed at discharge

x

Reperfusion therapy within standard (Thrombolytic & PTCA)1

x

x

-Smoking cessation advice/counseling2

x

x

Inpatient mortality

x

Society of Thoracic Surgeons (STS) CABG

ASA/antiplatelet prescribed at discharge

x

x

Lipid-lowering agents prescribed at discharge

x

x

ACE-I prescribed at discharge

x

Beta-blockers prescribed at discharge

x

x

Exercise program and/or cardiac rehabilitation therapy prescribed at discharge

x

Smoking cessation advice/counseling

x

x


Indicator Compliance

JCAHOCore Measures -Current

JCAHOCore Measures - Future

Best-in-Class 2005

CMSAnnual Payment Update

CAP

Antibiotic administration within 4 hours of hospital arrival1

x

x

x

Admission Treatment

Oxygenation assessment1

x

x

Initial selection of antibiotic

x

x

Blood cultures before antibiotics2

x

x

Preventive Care

x

Smoking cessation advice/counseling (adult/pediatric)2

x

x

Pneumococcal vaccine screening and/or vaccination1

x

x

x

Influenza vaccination3

x

x

CHF

ACE-I prescribed at discharge1

x

x

x

Antithrombotics Rx at discharge for patients with AFib

x

Discharge instructions2

x

x

LV function assessment1

x

x

x

Smoking cessation advice/counseling (adult)2

x

x

PCI

ASA/antiplatelet prescribed at discharge

x


Indicator Compliance

Best-in-Class 2005

CMS Annual Payment Update

JCAHO Core Measures -Current

JCAHO Core Measures - Future

SIP (Surgical Infection Prevention)

Duration of prophylactic antibiotics3

x

x

x

Duration of prophylaxis3

x

x

x

Selection of antibiotic3

x

x

x

Other

HCAHPS (patient satisfaction survey)4

x

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

2 Publicly reported beginning Q1 2005 (Q2 2004 discharges)

3 Publicly reported Summer 2005 (Q3 2004 discharges)

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


Indicator Compliance

NPSG

Improve accuracy of patient identification

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

x

Prior 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

x

Improve the effectiveness of communication among caregivers

To 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

x

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

x

Measure, 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

x

Improve the safety of using medications

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

x

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

x

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

x

Eliminate wrong site, wrong patient and wrong procedure surgery

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

x

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

x


Indicator Compliance

NPSG

Improve the safety of using infusion pumps.

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

x

Improve the effectiveness of clinical alarm systems

Implement regular preventive maintenance and testing of alarm systems

x

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

x

Reduce the risk of healthcare-acquired infections

Comply with current CDC hand hygiene guidelines

x

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

x

Accurately & completely reconcile medications across the continuum of care

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

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

x

Reduce the risk of patient harm resulting from falls

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

x


INDICATOR Compliance

Magnet Status

*NDNQI

Pressureulcer prevalence

x

x

Pressure ulcer occurrence

x

x

Nursing care hours provided per patient day

x

x

Nursing staff satisfaction

x

x

Falls occurrence

x

x

Fall injury occurrence

x

x

Patient satisfaction in relation to:

x

x

- Nursing care

- Pain management

x

x

- Patient education

x

x

- Overall care

x

x

Skill mix of RN, LPN and unlicensed staff

x

x

*National Database of Nursing Quality Indicators


Indicator Compliance

ORYX/ CMS Core Measures -Current

CMS/AHA & JCAHO Measures - Anticipated

Best-in-Class 2004

Magnet/ NDNQI

NQF Nursing-Sensitive Voluntary Consensus Standards

X

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

Pressure ulcer prevalence

X

x

Falls prevalence

X

x

Falls with injury

X

x

Restraint prevalence (vest and limb only)

X

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

X

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

X

x

Ventilator-associated pneumonia for ICU and HRN patients

x

x

Smoking cessation counseling for AMI

x

x

Smoking cessation counseling for HF

x

x

Smoking cessation counseling for pneumonia

x

x

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

x

x

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

x

x

Practice Environment Scale - Nursing Work Index

x

Voluntary turnover

x


Indicator Compliance

ORYX/ CMS Core Measures -Current

CMS/AHA & JCAHO Measures - Anticipated

Best-in-Class 2004

Magnet/ NDNQI

JCAHO ORYX ICU Measures

Ventilator-Associated Pneumonia (VAP Prevention – Patient Positioning)

x

x

Stress Ulcer Disease (SUD) Prophylaxis

x

Deep Vein Thrombosis (DVT) Prophylaxis

x

x

Central Line-Associated Primary Blood Stream Infection

x

x

Risk-Adjusted ICU LOS by type of ICU

x

Risk-Adjusted Hospital Mortality for ICU Patients

x


PROPOSED 2006 NATIONAL PATIENT SAFETY GOALS Compliance

Goal #10: Reduce Influenza and Pneumonia

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

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

Assess Culture of Safety and take action on results of assessment

Encourage external reporting of adverse events

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

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

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

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

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)

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

Implement comprehensive patient involvement program

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

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


PROPOSED 2006 NATIONAL PATIENT SAFETY GOALS Compliance

Goal #16: Prevent Healthcare-Associated Decubitus Ulcers

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

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


What is interventional patient hygiene
What is Interventional Patient Hygiene? Compliance

  • 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? Compliance

  • 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!

  • Volunteeryour expertise to teams addressing other types of adverse outcomes of patient care

    • Data management, analysis and reporting

    • Intervention development

    • Education and literature interpretation

    • Evaluation of products and technologies

    • Science-based, cross-functional, multi-disciplinary approach to problem solving


Get involved…WHY? Compliance

ICPs are Safety, Quality and Performance Improvement

EXPERTS!


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

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


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

Robert Garcia, BS, MMT(ASCP), CIC

The Brookdale University Medical Center, Brooklyn, New York


High risk high morbidity high cost
High Risk, High Morbidity, High Cost Infection: Call for New Interventions in a Patient Safety World


Vap facts
VAP Facts Infection: Call for New Interventions in a Patient Safety World

  • 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

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

Step 11: Isolate the pathogen

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

Type of ICU BSI* VAP* UTI*

Coronary 43% 42% 40%

Medical 44% 56% 46%

Surgical 31% 38% 30%

Pediatric 32% 26% 59%

*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

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.


Icu rates of vap nnis study jan 2002 jun 2004
ICU Rates of VAP, NNIS Study, Adults Jan 2002-Jun 2004

Pooled means:

Medical – 4.9

Med-Surg – 5.4

Surgical – 9.3


Cost of vap
Cost of VAP Adults

  • 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 pneumonia
HICPAC guidelines on preventing pneumonia Adults

  • Issued 3/26/04

  • Evidence-based

  • Expert review

  • Recommendations categorized

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


Hicpac categories
HICPAC categories Adults

  • 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.



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


H circuit when it is visibly soiled or mechanically malfunctioning. eat

Moisture

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.


Photographs courtesy of D. Ryan routinely changing the

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


Stress ulcer prophylaxis
Stress Ulcer Prophylaxis routinely changing the

  • 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 decontamination
Selective Digestive Decontamination routinely changing the

  • 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.”


Weaning
Weaning routinely changing the

  • 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?


Prevention or modulation of oropharyngeal colonization
Prevention or Modulation of Oropharyngeal Colonization dental colonization with respiratory illness?

  • 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 colonization
1. Oral Cavity vs. Gastric Colonization dental colonization with respiratory illness?

  • 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

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

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


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 oropharynx
2. Decontamination of the Oropharynx Support

  • 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 Solutions

  • 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 Solutions

  • 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 Solutions

  • 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 infection
Additional 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 Respiratory Infection

Teeth

Tongue

Tissues

Secretions

Major Areas of Oropharyngeal Colonization


A case study
A Case Study Respiratory Infection

Reduction of Microbial Colonization in the Oropharynx and Dental Plaque

Reduces VAP

Update!

R Garcia, L Jendresky, L Colbert

Brookdale University Medical Center, Brooklyn NY

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



Prioritization action
Prioritization & Action Respiratory Infection

  • 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 force
VAP Reduction Task Force Respiratory Infection

  • 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


Assessment
Assessment Respiratory Infection

  • Interviews of front line workers

  • Observation of procedures

  • Review of products

  • Review of policies

  • Review of literature, guidelines


People Respiratory Infection

Procedures

Communication

Between Providers

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

Intubation/Extubation

Physicians

VAP surveillance rounds (observational periods between IC and nurses)

Suctioning (closed/oral)

Nurses

Oral Care

Relay surveillance data to healthcare providers

Respiratory Therapists

Cleaning & maintenance of ventilator and components

Feedback from healthcare providers

Pharmacists

Handwashing

Placement & maintenance of nasogastric tube

Nutritional Specialists

VAP

Definition of VAP

Intubation/Extubation

Mechanical ventilator (Heated humidifier or HME)

Self-extubation

Vent circuits, filters

Closed suctioning

Semi-recumbent positioning

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

Handwashing

Oral & Dental Care

Cleaning of ventilator/other devices

Use of H2 antagonists/sucralfate

Tracheostomy devices

Tracheostomy care

Nasogastric tubes

Ventilator circuits

Filters

Nebulizers

Cleaning of laryngoscopes

Nebulizers

Multidose vials

Suction canisters

Resuscitation bags

Laryngoscopes

Enteral feeding

Weaning

Resusitation bags

Placement and care of nasogastric tubes

Barrier equipment

Equipment &

Devices

Policies


Identification of needs
Identification of Needs Respiratory Infection

  • 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 education
Key Strategy #1: Education Respiratory Infection

  • Handout created, includesanswers 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 Respiratory Infection

  • 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



Maintaining a closed system
Maintaining a Closed System Respiratory Infection


Covered yankauer
Covered Yankauer Respiratory Infection

Policy: Use as needed


Yankauer
Yankauer Respiratory Infection

  • Proper storage

  • Keep yankauer covered when not in use

  • Assists in decreasing the risk of environmental contamination

  • Replace every day and PRN


Suction catheter
Suction Catheter Respiratory Infection

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 Respiratory InfectionSodium Bicarbonate

Policy: 2 X per day


Suction swab with moisturizer
Suction Swab with Moisturizer Respiratory Infection

Policy: Every 6 hrs.


Feeling fuzzy
Feeling fuzzy??? Respiratory Infection

Photographs courtesy of D. Ryan


Vap rates micu bumc 2001 2004
VAP Rates, MICU, BUMC, 2001-2004 Respiratory Infection

Pre-intervention Period

Post-intervention Period


Vap rates micu bumc
VAP Rates, MICU, BUMC Respiratory Infection


Cost avoidance
Cost Avoidance Respiratory Infection

  • 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 summarize
Let’s Summarize Respiratory Infection

  • 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 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.

Assistant Director of Infection Control

Brookdale University Medical Center

One Brookdale Plaza, Brooklyn, NY 11212

718-240-5924

[email protected]


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 Reduce the Risk of Skin Breakdown and Impact Patient Safety

Quality improvement methodologies to enhance core patient care processes

  • Define

  • Measure

  • Analyze

  • Improve

  • Control

Reducing VAP with 6 Sigma, Nursing Management, June 2004


Prevalence vs incidence rates
Prevalence vs. Incidence Rates Reduce the Risk of Skin Breakdown and Impact Patient Safety

  • 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? Reduce the Risk of Skin Breakdown and Impact Patient Safety

Example:

Average size hospital -

opportunity cost

$400,000

to

$700,000

Clinical data:

$500 -$50,000 average incremental costs per episode

National average prevalence rate of pressure ulcers in acute care:

9%

Pressure ulcers increase

LOS by 2 to 5 times

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 hospitals
Critical Issues Facing Hospitals Reduce the Risk of Skin Breakdown and Impact Patient Safety

  • 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


PREVENTION Reduce the Risk of Skin Breakdown and Impact Patient Safety


Early identification
Early Identification Reduce the Risk of Skin Breakdown and Impact Patient Safety

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 identification1
Early Identification Reduce the Risk of Skin Breakdown and Impact Patient Safety

  • 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


Communication
Communication Reduce the Risk of Skin Breakdown and Impact Patient Safety

  • 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 factors

Over 60 Reduce the Risk of Skin Breakdown and Impact Patient Safety

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

Our Patient’s Risk Factors

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


Empowering the nursing staff
Empowering the Nursing Staff Reduce the Risk of Skin Breakdown and Impact Patient Safety

  • 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:

  • The bathing process for bed ridden patient

  • Incontinence cleansing and protection


Why is the bath given
Why is the Bath Given? Outcomes?

Social

  • Control patient odor

  • Provide patient well-being

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


Why is the bath given1
Why is the Bath Given? Outcomes?

Comfort

  • Provide sensory stimulation

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


Why is the bath given2
Why is the Bath Given? Outcomes?

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? Outcomes?

  • Non-licensed personnel?

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


Who s providing the care
Who’s Providing the Care? Outcomes?

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

  • What can we do?


Bathing process solution
Bathing Process Solution Outcomes?

  • Partner with Wound Care Nurse

  • Empower non-licensed personnel

    • Define

      • Issue

      • Expected outcome

    • Provide

      • Training and education

      • Simple communication tools

      • Cleansing and moisturizing in one

    • Measure, Analyze, Improve, Control



Incontinence management
Incontinence Management Outcomes?

Utilize the tools to “help us do our jobs”

If it gets to this stage,

it’s too late!


Pilot survey of incontinence and perineal skin injury prevalence in acute care

35% Outcomes?with aFoley Catheter

3%UrinaryIncontinence

13%StoolIncontinence

976Total Number of Patients Surveyed

5%DualIncontinence

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

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


976 Outcomes?Total Number of Patients Surveyed

198Number of Incontinent Patients

27%Perineal Dermatitis

33%Pressure Ulcers

18%Fungal Infection

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

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


Incontinence management program
Incontinence Outcomes? 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 solution
Incontinence Process Solution Outcomes?

  • Partner with Wound Care Nurse

  • Empower non-licensed personnel

    • Define

      • Issue

      • Expected outcome

    • Provide

      • Training and education

      • Cleansing and protection in one

    • Measure, Analyze, Improve, Control



Quality improvement initiative reduce pu incidence rates
Quality Improvement Initiative -Reduce PU Incidence Rates Outcomes?

  • 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 change
Process Strategies for Change Outcomes?

  • 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 started
Getting Started Outcomes?

  • 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 Outcomes?

  • Drives compliance

  • Personalize your rates

  • Staff take ownership

  • Benchmark against yourself

  • Use the data to inspire staff or to keep the momentum


Your focus
Your Focus? Outcomes?

Emphasis on outcomes rather than tasks!



Debbie Trau, RN Outcomes?

6 Sigma Black Belt

OSF Saint Francis Medical Center

530 NE Glen Oak, Peoria, IL 61637

(309) 671-1540

[email protected]



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