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Presentation File

2/11/2013
• 637 bed, acute-care academic medical center
• 2nd largest hospital in Georgia
• Magnet designation 2005
• Level 1 trauma services
Atlanta
• 142 ICU beds: 5 adult, neonatal,
pediatric
• Certified:
– Hip & Knee replacement programs
– Stroke program
– Ventricular assist device (VAD)
– Chest pain center
– Palliative care program
Tracy Johns , RN, BSN, CPHQ
Medical Center of Central Georgia
NDNQI Quality Conference: February 2013
1.
2.
3.
1.
2.
3.
Zapping VAP at MCCG / February 2013
Designing Actions for Impact
Engagement AND Accountability
2013 & forward
1.
2.
3.
3
2013 & forward
Macon
Savannah
2
2013 & forward
4
1. Designing Actions for Impact
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6
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2/11/2013
View:
Problem 6 years ago / Baseline
•
•
•
•
• Leading:
• < 90% compliance with vent bundle (HOB, turn, Hi Lo ETT,
oral care)
• Lagging:
• Experiencing > 100 VAP cases/year (2006 = 114)
• Adult ICUs had higher than expected vent LOS (10-11 days)
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Pneumonia
Present on admit
Aspiration
PUD prev
Family feeds ice chips
High risk not ID’d
During intubation
During intubation
HOB  30°
Secretion management
Oral Care
Change canisters
HiLo ETT
CLRT
HOB  30°
Vent bundle use
inconsistent
Data not
disseminated
Hand Hygiene
Separate Sx
PUD prev
Results not
emphasized
Expectations
unclear
Hard to find
supplies
Too few suction ports
in ICU rooms
CAP
Diabetes, COPD,
ESRD, Heart Dz
Competing
priorities
Transport monitoring
No accountability
for results
Too few ICU beds
Outdated competency
assessment
Management
Emergency Department
9
Cough or
gag reflex
Hx of smoking
Over sedation
Lack of experience
Need quick ref info
i.e. reinforcement
Bacterial colonization
MRSA
Altered mental
status (AMS)
Same level of care
Retrospective
review
Pre-existing DX, co-morbidities
Par stock too low
CHG not in stock
Mini BAL missed
Other facility transfer
PUD prev
8
Supplies, equip, meds
CPIS missed
Not doc POA
Care of vent patients inconsistent
Lack of evidence based practice
Silo care versus interdisciplinary
Not following guidelines for IHI, AACN, SSCM,
APIC, NACHRI, and CMS
CAP
Nob-compliance
with SAT/SBT
Emergency vs.
planned
BiPAP vs.
intubation
Coordination 
RRT & RN for
SAT/SBT
Disagreement 
patient & family re:
intubation
Intubate / Extubate
10
Assessment:
• Most of our infections preventable
• 2006 -2007 VAP reduction became a
STRATEGIC focus on quality improvement
Structure
• Initial goal to ↓ VAP by 50%
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Process
Outcomes
12
2
2/11/2013
Organizational
Process
of Care
Vent policy
SAT/SBT guidelines
Physician credentials
Structure
of Care
Process
of Care
Structure
of Care
Outcomes
Interaction: Emp - Pt
Compliance
Frequency & Coordination
of care
↓ vent times
Prevent HAI = VAP
↓ Unplanned extubations
↓ ICU & hospital LOS
Hardwire
Evidence Based
Best Practice
13
Actions for Impact: Recap
1.
2.
Process Structure  Evidence Based, Best Practice
Value of Process = connect to outcome
14
Hardwiring the care process
Hardwire Process  make right process easy
15
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Audit & feedback
(Audit & feedback)
ADDED to
(provider reminder systems)
Make delivery of evidence-based,
best practice EASY AS POSSIBLE.
(Audit & Feedback)
ADDED to
(organizational change)
AND (provider education)
Create alerts (reminders, visual aids,
peer pressure) to MAKE POOR CARE
DELIVERY DIFFICULT.
Provider Reminder Systems
AHRQ: Prevention of Healthcare-Associated Infections: Closing the Quality Gap
www.effectivehealthcare.ahrq.gov/reports/final.cfm
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3
2/11/2013
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Goal: Avg Vent Days < 5.4 days
12
Process
of Care
Each time SBT
not performed
per criteria 
RT manager f/u
giving verbal or
written warning
Compliance
Frequency of care
Coordination of care
All Avg Times
9
6.1
6
RT assesses vent bundle
compliance 3X/week on
all pts; deficiencies
immediately reported to
RN Manager
4.5
3
4.7
4.5
20%
3.8
Goal: Avg Vent Days < 5.4
6
Jan-12
Feb-12
Oct-11
Jul 11
Sep 11
Jun 11
Aug 11
Apr 11
May 11
Jan 11
Feb 11
Oct 10
Dec 10
Sep 10
Nov 10
Jul 10
Jun 10
Aug 10
Mar 11
5.4
4.3
3
5.8
40%
5.0 4.7
4.7
30%
4.7
4.5
20%
Effect
3.8
Goal: Avg Vent Days < 5.4 days
10%
# vent days
changes
Dec 10
Nov 10
Oct 10
Sep 10
Aug 10
Jul 10
0
Jun 10
Jan-12
5.9 5.9
4.5
Feb-12
Oct-11
Dec-11
Nov-11
Jul 11
Sep 11
Jun 11
Aug 11
Apr 11
May 11
Jan 11
Feb 11
Mar 11
Oct 10
Dec 10
Nov 10
Jul 10
Sep 10
Jun 10
Aug 10
Apr 10
6.2
5.2
21
60%
50%
5.7 5.9 5.9 6.0
4.4
0%
May 10
6.4
5.7 5.5
5.6
10%
0
Mar 10
Apr 10
6.1
0%
Feb-12
30%
5.2
70%
safer / improved outcomes
9
Jan-12
4.7
80%
71%
Dec-11
4.3
40%
5.0 4.7
100%
94%
95%
Outcome
76%
72%
Nov-11
4.4
5.8
74%
Sep 11
5.9 5.9
73%
Oct-11
6.2
5.4
98%
99%
90%
Aug 11
50%
98%
100%
85%
78%
Jul 11
60%
70%
Jun 11
5.7 5.9 5.9 6.0
70%
Spont Breathing Trial
98%
98%
95%
May 11
9
All Avg Times
77%
12
Feb 11
71%
91%
Apr 11
80%
80%
Mar 10
Vent days
76%
72%
6.4
May 10
Mar 10
85%
78%
Avg Vent Days:
FY09 Avg: 5.4 days
FY10 Avg: 5.5 days
FY11 Avg: 5.3 days
94%
Apr 10
77%
70%
95%
90%
May 10
80%
95% 94% 100%
90%
100%
15
Mar 11
99%
100%
98%
98%
Cause
MCCG Adult ICUs: Avg Vent Time compared
to Compliance with Spontaneous Breathing
Trial
compliance
Data Source:
APACHE IV
millennium
Jan 11
100%
91%
95%
98%
94%
5.7 5.5
20
Spontaneous Breathing Trial Compliance
98%
Spontaneous Breathing Trial Compliance
90%
74%
4.7
0
Vent days
MCCG Adult ICUs: Avg Vent Time
5.6
5.0 4.7
4.5
3.8
Avg Vent Days:
FY09 Avg: 5.4 days
FY10 Avg: 5.5 days
FY11 Avg: 5.3 days
compared to Compliance with SBT
95%
6.1
5.8
4.7
15
6
4.3
5.2
Display together: shows the “WHY” of measuring
73%
5.9 5.9
5.4
3
Upgraded ICU
beds to include
CLRT module
12
6.2
5.7 5.9 5.9 6.0
4.4
4.5
Stock Hi- Lo
ETT’s in ER,
code carts &
with EMS
Data Source:
APACHE IV
millennium
6.4
5.7 5.5
5.6
Dec-11
Vent bundle
SAT/SBT guidelines
Physician credentials
Avg Vent Days:
FY09 Avg: 5.4 days
FY10 Avg: 5.5 days
FY11 Avg: 5.3 days
MCCG Adult ICUs: Avg Vent Times
(excludes OHS)
Nov-11
Met with
anesthesia &
CRNA groups:
use Hi- Lo ETT
for ICU surgery
pts
Structure
of Care
Data Source:
APACHE IV
millennium
Share responsibility for mouth
care with resp; scheduled via
MAR & task scheduler
Vent days
Changed par level &
storage of mouth care
kits to assure availability
& visual reminder
22
0
#VAP
2006
114
2007
44
2008
19
2009
9
2010
4
Disciplinary Action- SBT non-compliance
 PICU SBT/SAT Research
20
 Nutrition Bundle
40
 SAT, SBT in Adult Critical Care
60
Communicate
2012 Nutrition Bundle Revisited
Process Oriented
 PUD, DVT
80
 Monitor Process/Outcomes
Number of VAP cases
100
 PICU Bundle
 Initial Vent Bundle
# of VAP in MCCG ICU’s Critical Care 2006 - 2011
120
Hardwire “ease the path of EBP”
Link Care Process & Outcomes
Communication with Individuals / Link performance to job
Med Staff Privileges
 vent management: individual or group
Employee performance  individual compliance, accountability, warnings, &
annual evaluation
KB & TN
2011
2
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2/11/2013
1.
2.
3.
Lagging  patient outcome
2013 & forward
Surveillance for Vent Associated Events
– CDC Prevention Epicenters
http://www.cdc.gov/hai/epicenters
– Critical Care Societies Collaborative
http://ccsonline.org
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Leading: consider these areas
Lagging: patient outcomes
• Vent utilization code status, patient/family
Incidence
communication & education
Mechanical vent time > 3 calendar days
• Mobility HAPU, Fall prevention, restraint use
• Infection prevention oral care
• Nutrition tube feedings: start time, amount
EXCLUSIONS: patients on rescue mechanical ventilation
• high-freq ventilation (HFV),
• extracorporeal membrane oxygenation (ECMO), &
• mechanical ventilation in prone position
• Delirium management
Vent Associated Pneumonia (VAP) Population
Acute & long-term care hospitals
Inpatient rehab facilities
> 18 years old
delivered vs. ordered, evidence based management
med management, noise
levels, sleep deprivation (bundled care)
NHSN: National Healthcare Safety Network
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Data Source:
APACHE IV
millennium
% Adult Vent Patients with Unplanned-Extubations
FY 2010 avg: 2.7%
FY 2011 avg: 4.0%
FY 2012 avg: 3.0%
Vent Utilization Ratio
# Vent Days / # Patient Days
MCCG Adult ICU Vent Utilization Ratio
Comparison FY2010 - FY2012
Action taken by Resp
& Nurse Managers
8.0%
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MCCG
Data Sources: APACHE IV,
PowerChart, Medipac
Nat'l Avg
0.50
0.45
6.0%
0.40
0.44
0.43
0.35
0.30
4.0%
0.36
0.25
0.20
0.15
2.0%
0.10
0.05
0.0%
0.00
(7/136) (3/138) (4/153) (7/130) (5/144) (5/121) (5/157) (8/127) (4/149) (4/140) (1/146) (4/126) (2/148) (6/156) (2/153) (5/149) (2/147)
Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 Feb-12 Apr-12 Jun-12 Aug-12 Oct-12 Dec-12
2010
2011
2012
MCCG
0.44
0.43
0.36
Nat'l Avg
0.45
0.43
0.40
Month
(# Unplanned Ext's / Total # Vent Patients; includes OHS)
http://www.ajicjournal.org/article/S0196-6553(11)00373-7/fulltext
Mion, L. (2007) Patient-initiated device removal in intensive care units: A national prevalence study. Critical Care
Medicine, 35(12), 2714-2720.
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2/11/2013
1. Actions for Impact
– Cause Care Best Practice
– Effect Outcomes Goals of Care
Awareness NHSN - vent utilization
Mobility - slow/stop de-conditioning
Delirium - age, withdrawal (tobacco, Rx, ETOH)
Nutrition - timeliness to start, calories Rx
NHSN - Vent Acquired Conditions (VACs)
possible & probable pneumonia
1.
31
Actions for Impact
1.
32
Actions for Impact
2.
2. Engagement & Accountability
Engagement & Accountability
– Engagement  coordination of care
– Accountability by caregivers: “where the buck stops”
– Engagement  coordination of care
– Accountability by caregivers: “where the buck stops”
3. 2013 & beyond
– Vent utilization, delirium, mobility, nutrition
– Vent Associated Conditions (VACs)
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34
Balas, M. (2012) Critical care nurses' role in implementing the ''ABCDE Bundle'' into practice. Critical Care Nurse, 32(2),
35-47.
Centers for Disease Control and Prevention. (2011, 12). National healthcare safety network ventilator-associated event.
Retrieved from http://www.cdc.gov/nhsn/psc_da-vae.html
I believe a vision for quality must start with ownership.
We cannot just do what we are asked, but we must
take it further by looking for what we can do to improve.
Quality must be integrated into
our every day caring.
Hillier, B., Wilson, C., Chamberlain, D. , & King, L. (2013) Preventing Ventilator-Associated Pneumonia Through Oral
Care, Product Selection, and Application Method. AACN Advanced Critical Care, 24(1), 38-58.
Mauger-Rothenberg B. Prevention of healthcare-associated infections. Closing the quality gap: revisiting the state of
the science. Evidence report / technology assessment No. 208. (Prepared by the Blue Cross and Blue Shield
Association Technology Evaluation Center Evidence-based Practice Center under Contract No. 290-2007-10058-I.)
AHRQ Publication No. 12(13)-E012-EF. Rockville, MD: Agency for Healthcare Research and Quality. November 2012.
www.effectivehealthcare.ahrq.gov/reports/final.cfm.
Mion, L. (2007) Patient-initiated device removal in intensive care units: A national prevalence study. Critical Care
Medicine, 35(12), 2714-2720.
Timmerman, R. (2007) A mobility protocol for critically ill adults. Dimensions of Critical Care Nursing, 26(5), 175-179.
Betty Brown, MBA, MSN, RN, CPHQ, FNAHQ - VP Quality & PI, TriHealth, Inc.
Dudeck, M. et. al. (2011) National healthcare safety network (NHSN) report, data summary for 2009, device-associated
module. American Journal of Infection Control, 39(5), 349-367, doi: 10.1016/j.ajic.2011.04.011
Wunch, H. (2010) The epidemiology of mechanical ventilation use in the United States. Critical Care Medicine, 38(10),
1947-1953.
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