The Challenge: Advances in emergency medicine, surgery, and technology enable medical professionals to save more lives than ever before. But with all the progress, the basics of good care — such as preventing hospital-acquired infection — are more important than ever. Regions Hospital in St. Paul, Minnesota, has had an effective infection prevention program for years. Nevertheless, they knew there was room for improvement in two areas in particular: preventing ventilator-associated pneumonia and catheter-related bloodstream infections.
The Background: Regions Hospital is a 427-bed, full-service, private hospital located in St. Paul, Minnesota. As the only Level I trauma center in the Twin Cities’ east metro and western Wisconsin area, and one of only a few such centers in all of Minnesota, Regions receives more than 61,000 emergency room visits each year, and performs more than 11,000 surgeries annually. Part of the HealthPartners family of care organizations, Regions is also affiliated with the University of Minnesota Medical School and hosts several residency training programs.
The Situation: Patients in critical condition who can’t breathe effectively on their own — often because of disease, surgery, or trauma — are placed on a ventilator for respiratory assistance. However, as a complication of this therapy, infections can sometimes develop. ventilator-associated pneumonia (VAP) may contribute to the death of critical care patients: It is estimated that up to 46 percent of patients who develop VAP don’t survive. VAP also prolongs patients’ lengths-of-stay, and adds an estimated $40,000 to the cost of a typical hospital admission.
Central venous catheters — sometimes called central lines — are used with an estimated 48 percent of intensive care unit (ICU) patients in the US, accounting for 15 million central-venous-catheter days per year in ICUs. The devices are long, thin, flexible tubes inserted into a patient’s vein in order to deliver medications, fluids, nutrients, or blood products over a long period of time, usually several days to weeks. Infection can develop if the line is not placed or maintained using sterile conditions and the highest infection control standards. Difficult to diagnose and often difficult to treat, catheter-related bloodstream infections (CR-BSIs) may also contribute to the death of a critically ill patient. In the US, an estimated four to 20 percent of patients who develop CR-BSIs, or 14,000 to 28,000 patients annually, die from them.
As part of its 100,000 Lives Campaign, the Institute for Healthcare Improvement (IHI) advocates the use of six proven, life-saving interventions, including a series of steps to reduce or prevent ventilator-associated pneumonia and catheter-related bloodstream infections.
When done in concert, these interdependent steps, also called “bundles,” typically result in significantly better outcomes than when implemented individually. [See the information (at right) on the components of the Ventilator Bundle and Central Line Bundle.]
The goal of the 100,000 Lives Campaign is to dramatically increase the number of hospitals that use the Central Line and Ventilator Bundles.
The Solution: Since 1998, Regions Hospital has been doing elements of both the Ventilator and Central Line Bundles in its ICUs with positive results. VAP and BSI rates have dropped over the years. Pursuing Perfection, and now the 100,000 Lives Campaign, have intensified the hospital’s commitment to make further improvements and hardwire bundle interventions. "We use the bundle methodology to standardize patient care across all intensive care units,” says Avi Nahum, MD, Medical Director and VAP champion at Regions. “By continuously measuring our compliance with the bundle elements, as well as patient outcomes, we can identify opportunities to improve patient care even further."
According to Noe Mateo, MD, Medical Director for Infection Control, “Standardized best patient care practices involve a multidisciplinary approach.” Physicians, residents, nurses, pharmacists, infection control practitioners, and respiratory care practitioners together play key roles in implementation of and compliance with the bundles.
To facilitate consistent use of the bundles, Mateo and Kathy Bechtel, RN, Director of Nursing Critical Care, co-sponsored a team to fast-track interventions that would improve compliance with the 100,000 Lives Campaign’s Ventilator and Central Line Bundles. Team members included representatives from Emergency Medicine, Respiratory Care, Advanced Nurse Practitioners, Surgical ICU Nurses, Infection Control, Pulmonary Medicine, and Anesthesia. The group worked together to provide additional education and training; develop and post best-practice guidelines and checklists; standardize the use of maximal sterile barriers during insertion of lines; standardize insertion techniques; and audit hand hygiene, documentation, and bundle practice compliance.
The Ventilator Bundle: Specific interventions to prevent VAP were initiated in Regions’ Surgical Intensive Care Unit (SICU) as early as 1998. Now, those interventions and more are part of the care in the Medical ICU (MICU), Cardiac ICU (CICU), and the Burn Center. These initiatives included education and support for better hand hygiene and best respiratory care procedures, as well as the development of protocols for daily sedation vacations, daily assessment of readiness to wean, head of the bed elevation, and patient positioning. Staff in each unit receive monthly feedback on the rates of infection and bundle compliance for their unit, as well as comparative national benchmarks for their particular patient type on their unit. There is variation among units on the specifics of how the bundle interventions are carried out; however, all ICUs work together rolling out major practice changes. “We have a formal forum for sharing what works and what doesn’t among all of our ICUs,” says Kathy Bechtel.
Regions staff members say that, despite the simplicity of the bundle list, implementing each bundle element requires daily vigilance because it involves changing set habits and patterns.
Simple reminders on admission order sets and on daily rounding sheets help staff remember to check that the head of the bed is elevated, for example. Respiratory therapists assess patients on a daily basis for readiness to wean off the ventilator.
Effective teamwork is the key to making it all work. “The ICU nurses and respiratory staff have really learned to work as a team,” says Stephanie Tismer, RN, an Infection Control Nurse. “They trust and consult each other, and that makes a critical difference.” Respiratory therapist Bob Voges, RCP, RRT, agrees. “The weaning protocol really gets the respiratory therapist and RN involved, which is what really makes the difference.”
And, as in most areas of medicine, professional judgment and experience are important. Reducing patients’ sedation must be done carefully and requires a thorough, ongoing, and individualized assessment of how the patient is responding to sedation reduction. According to Pam Peine, RN, Nurse Manager in the MICU, the implementation of the sedation vacation protocol in the MICU has helped all staff understand that “sometimes we were using more sedation than the patient actually needed.” Sedation reduction requires education and support for family members of patients as well.
Like many hospitals that employ the Ventilator Bundle, Regions Hospital also adds steps to boost patient outcomes even further, such as suctioning and oral cleanings to prevent bacteria from collecting in the mouth. This effort, like many of the elements in the Ventilator Bundle, is primarily nurse-driven, because nurses provide the minute-to-minute care of ICU patients.
The Central Line Bundle: Implementing the Central Line Bundle at Regions involved standardizing line insertion practices across departments. Use of maximum barriers when inserting a central line — a sterile gown, gloves, mask and hat, and a large drape on the patient — has been shown to decrease the likelihood of a bloodstream infection developing.
Because Regions Hospital is a Level I trauma center, emergency interventions to save lives can mean inserting a central line under less-than-ideal conditions. Lines inserted in this fashion need to be removed within 24 hours. “What we learned through the action workout team,” says Jon Henkel, RN, Assistant Nurse Manager in the emergency department, “was that we needed a clearer way to communicate to the ICU which lines need to be removed within 24 hours of insertion.”
Now when a line is placed under less-than-sterile conditions, a red sticker is placed on the line to indicate that it needs to be removed. A green sticker is put on lines that are placed in the emergency department using maximum sterile barriers.
MICU Nurse Manager Pam Peine points to other practical innovations that have reduced the chances for infection. For instance, she says there’s now a central line cart that holds all the supplies needed for the procedure, a change that has been “incredibly helpful.” Having all the supplies available right from the beginning decreases the likelihood that sterile technique will be interrupted to get a needed item that was forgotten.
It’s hard to change habits, and Infection Control Nurse Stephanie Tismer says this was the case in switching from betadine to chlorhexidine as a skin antiseptic to prepare the site for insertion of the catheter. “Doctors and nurses have been taught for 50 years to apply betadine, which is orange, in concentric circles. Chlorhexidine is colorless, and it should be applied with a friction scrub in all directions to permeate the layers of skin at the insertion site. So we had to train ourselves about the importance of prepping based on landmarks like rib markings, rather than the color of the antiseptic.”
In addition to using new techniques, the Central Line Bundle prompted a culture change that required new communication skills, says Bechtel. “Ensuring best practice means developing a culture of empowerment, including scripting language that team members can use to respectfully remind others when protocols are not being followed or breaks in technique occur,” she says.
The Results: Use of the Ventilator Bundle and Central Line Bundle elements in the critical care units at Regions Hospital currently ranges from 67 percent to 100 percent. Data show that the use of bundles is associated with reductions in infections. Although the methods for measuring Regions’ VAP rates in 1997 were slightly different from today’s methods, still it’s clear that use of the Ventilator Bundle has contributed to a decrease in VAP rates.
For example, in 1997 VAP rates in the Surgical ICU were 29/1,000 ventilator days; in 2004, that rate had dropped to just under 18/1,000 ventilator days. Similar declines have been seen in the Medical ICU and Burn Center.
What Team Members Say: “There is no single key to implementing the bundle strategies. It takes hard work, surveillance, cheerleading, education, and continuous assessment and monitoring.”
— Hannah Grace, RN, Nurse Manager, SICU
“We work to remind our staff that this represents best care practices, and not only is that what we want to deliver as health care professionals, it is what we would all want our own loved ones to receive if they were hospitalized. That helps keep us focused.”
— Theresa Cain, RN, Infection Control Nurse and Quality Consultant
Copy from:http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories
/PursuingPerfectionReportfromHealthPartnersonReducingVAPCRBSI.htm
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