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An effective quality improvement program for prevention of nosocomial ventilator pneumonia
122
Abstracts
RISK OF PNEUMONlA FOLLOWING CORONARY ARTERY BYPASS GRAFT SURGERY. GA. Ha&ness.* RN. University of Connecticut School of Nursing. Stem. CT. Cornnary ancry bypass grafting (CABG) is the most commonly performed major operation in the United States, and accounts for considerable expenditure of total health care resources. Pulmonary complications pmlong the length of stay, increase cost, and increase monality. The putpose of this study was to assess the risk of developing “osocomial pnewnonia in patients having a comnaty artery bypass graft, using a model developed through prior research. Early identification of high risk patients will enable preventative intervention studies to be conducted. One hundred and sixty-five CABG patients were assessed preoperatively. day one, day three. and day six post-operatively, and weekly thereafter during a six-month period. The conceptual model included risk factors that altered the functional status of the respiratory system, and those that altered the general health status of the patient. The criteria for pneumonia included radiographic changes consistent with pneumonia. a fever greater than 38°C. and leukocytosis. The results of the univariate analysis and logistic regression will be presented. The assessment time period most predictive of pneumonia will be identified. Also. risk factor predictive data will be used to develop both a nosocamial pneumonia risk scale, and a decision tree model, for assessment of pneumonia risk. These assessment tools, along with supporting data, will be presented.
AN EFFECTIVE QUALITY IMPROVEMENT PROGRAM FOR PREVENTION OF NOSOCOMIAL VENTILATOR PNEUMONIA. S. Kelleghan,* RN, BS, C. Salemi, MD, MPH, S. Padilla. RN, BS.ClC, L. Becker. RN, BSN, MPH. Kaiser Permanente Medical Center. Fontana, CA. regulatory agencies arc emphasizing quality Increasingly. improvement based on outcome events which w stratified by risk. In 1989, OUT Medical Center created a multidisciplinary task force to reduce nosocomial ventilator pneumonia by at least 5%. Our task force included Medical Staff, Nursing, Quality Assurance. Respiratory Therapy. and Infection Contml departments. Interventions implemented in 1989 included handwashing studies, review, coordination and enforcement of ventilator policies and procedures, inservice programs, intensified infection control surveillance, and feedback to health care workers. Task force meetings were held regularly. During the baseline years of 1987 and 1988, we had a 7% average nosocomial ventilator pneumonia rate at a” estimated total cost of $282,ooO. In 1989, the rate increased. as expected. to a 10% average due to the intensified surveillance program. During 1990, however, we saw a 57% reduction as compared to the baseline years, IO a” average of 3%, resulting in a cost savings of $105,ooO. This reduction was statistically significant by t test, p
INTRA-AORTIC BALLOON PUMP TRANSDUCER STUDY. 48 HOURS VS 12 HOURS TRANSDUCER CHANGE COMPARISON IN POST-OPERATIVE CARDIAC SURGICAL PATlEhrTS. N. Valla”de,* BS, MT, CIC, S. Capanno, BSN, M. Spencer, RN, BSN, CIC. C. Hopkins, MD. Massachwsctts General Hospital. Boston. MA. The Infection Contml Unit recommends changing lntx-aomc balloon pump (IABP) transducer systems every 48 hours. Since “o documented studies have been performed to determine the safety and efficacy of changing IABP transducers at a longer interval, a study was initiated with the Ctiiac Surgical intensive Care Unit. Levels of contamination were compared between two consecutive groups: 23 wcn: patients who had system changes every 48 hours. and the second group of 23 palients had system changes every 72 hours. Pior to IABP wnovd, the IABP insenion site was swabbed for culture. After Nemoval. the IABP tip was swabbed for culture, as well as the entire transducer system. including flush bag, tubing, and stopcocks. Results:
IABP Transducer set-up
48-Hour Transducer Change
72.Hour i-ransducer Change UT3 (0%) 0123 (0%) 103 (4.3%) o/23 (0%) 0122 N1Q)
1. Transducer Bag
l/23 (4.3%)
2. Distal Transducer Line 3. Transducer Stopcock 4. Proximal Transducer Line
o/23 (0%)
5. IABP Stopcock
l/17 68%)
2,93 (8.6%) l/23 (4.3%)
These findings suggest that a 72.hour transducer cha”8e might hc considezd for these systems since contamination rates within the system are not increased with the less frequent change of 72 hours
THE USE OF BACI’ERIAL CELL WALL FATI’Y ACID ANALYSIS WlTH STATISTICAL CLUSTER ANALYSIS FOR THE RAPID ASSESSMENT OF BACTERIAL RELATEDNESS IN EPIDEMIOLOGIC lNVESTlGATIONS. L. Ayers,* MD. T. W&auto”. MT, W. Buesching. PhD. The Ohio State University Hospitals, Columbus. OH. Epidemiologic investigations of infection clusters use a number of clinical and laboratoty tools to determine if the cluster is due to cross infection with the same organism or due to different strains of the organism occurring at the same time in several patients in the same location. Some of the laboratory tools such as biochemical and antibiotic profiles ate readily available but others such as semtyping, phage typing. and plasmid profiling are time consuming a”d therefore expensive and are available only 6t selected institutions or refetwcc laboratories. We have investigated gas chmmatogmphed bacterial cell wall fatty acids (CWFA) evaluated by cluster analysis as a method fo: determining or anlsm relatedness (Micmbial Identification System Software. MIS & , by Micmbial ID, Inc. and Hewlett-Packard gas chromatograph). Specimen processing requires controlled overnight cultivation followed by about one hour processing time. Cluster analysis with 2-D plots and demograms were used to determine the relations between 3 strains of Klebsiella pnemniae that occumed in a three-patient cluster in the Bone Marrow Tratuplant [Jnit. The thaw strains CWFA profile did not cluster consistently in the three components examined by 2-D plot and the Euclidian distance between two strains was 2.87 and between these strains and the third strain was 5.41. An Euclidian distance of <2 is required for identical strains. therefore these isolates are not the same strdin. Plasmid profiling was used to validate the condusronc from gas chromatograp& analysis. The isolates were grow” in BHI brolh overnight and the plasmid DNA was extracted using a modification of the alkaline lysis technique. The isolated plasmid DNA was dissolved in TE (pH 8.0) plus tracking dye and electmphotwd thmogh a 0.8% (wt/vol) agamse gel at 60 volts in TAE buffer. The gel was stained with ethidium bromide and photographed with UV ligtd. There was no similarity between the plasmid profiles of the three organisms. No plasmids were detected in one strain. the second organism contained a single 6 kb plasmid and the third isolate contained multiple small plasmids.
Abstracts
RISK OF PNEUMONlA FOLLOWING CORONARY ARTERY BYPASS GRAFT SURGERY. GA. Ha&ness.* RN. University of Connecticut School of Nursing. Stem. CT. Cornnary ancry bypass grafting (CABG) is the most commonly performed major operation in the United States, and accounts for considerable expenditure of total health care resources. Pulmonary complications pmlong the length of stay, increase cost, and increase monality. The putpose of this study was to assess the risk of developing “osocomial pnewnonia in patients having a comnaty artery bypass graft, using a model developed through prior research. Early identification of high risk patients will enable preventative intervention studies to be conducted. One hundred and sixty-five CABG patients were assessed preoperatively. day one, day three. and day six post-operatively, and weekly thereafter during a six-month period. The conceptual model included risk factors that altered the functional status of the respiratory system, and those that altered the general health status of the patient. The criteria for pneumonia included radiographic changes consistent with pneumonia. a fever greater than 38°C. and leukocytosis. The results of the univariate analysis and logistic regression will be presented. The assessment time period most predictive of pneumonia will be identified. Also. risk factor predictive data will be used to develop both a nosocamial pneumonia risk scale, and a decision tree model, for assessment of pneumonia risk. These assessment tools, along with supporting data, will be presented.
AN EFFECTIVE QUALITY IMPROVEMENT PROGRAM FOR PREVENTION OF NOSOCOMIAL VENTILATOR PNEUMONIA. S. Kelleghan,* RN, BS, C. Salemi, MD, MPH, S. Padilla. RN, BS.ClC, L. Becker. RN, BSN, MPH. Kaiser Permanente Medical Center. Fontana, CA. regulatory agencies arc emphasizing quality Increasingly. improvement based on outcome events which w stratified by risk. In 1989, OUT Medical Center created a multidisciplinary task force to reduce nosocomial ventilator pneumonia by at least 5%. Our task force included Medical Staff, Nursing, Quality Assurance. Respiratory Therapy. and Infection Contml departments. Interventions implemented in 1989 included handwashing studies, review, coordination and enforcement of ventilator policies and procedures, inservice programs, intensified infection control surveillance, and feedback to health care workers. Task force meetings were held regularly. During the baseline years of 1987 and 1988, we had a 7% average nosocomial ventilator pneumonia rate at a” estimated total cost of $282,ooO. In 1989, the rate increased. as expected. to a 10% average due to the intensified surveillance program. During 1990, however, we saw a 57% reduction as compared to the baseline years, IO a” average of 3%, resulting in a cost savings of $105,ooO. This reduction was statistically significant by t test, p
INTRA-AORTIC BALLOON PUMP TRANSDUCER STUDY. 48 HOURS VS 12 HOURS TRANSDUCER CHANGE COMPARISON IN POST-OPERATIVE CARDIAC SURGICAL PATlEhrTS. N. Valla”de,* BS, MT, CIC, S. Capanno, BSN, M. Spencer, RN, BSN, CIC. C. Hopkins, MD. Massachwsctts General Hospital. Boston. MA. The Infection Contml Unit recommends changing lntx-aomc balloon pump (IABP) transducer systems every 48 hours. Since “o documented studies have been performed to determine the safety and efficacy of changing IABP transducers at a longer interval, a study was initiated with the Ctiiac Surgical intensive Care Unit. Levels of contamination were compared between two consecutive groups: 23 wcn: patients who had system changes every 48 hours. and the second group of 23 palients had system changes every 72 hours. Pior to IABP wnovd, the IABP insenion site was swabbed for culture. After Nemoval. the IABP tip was swabbed for culture, as well as the entire transducer system. including flush bag, tubing, and stopcocks. Results:
IABP Transducer set-up
48-Hour Transducer Change
72.Hour i-ransducer Change UT3 (0%) 0123 (0%) 103 (4.3%) o/23 (0%) 0122 N1Q)
1. Transducer Bag
l/23 (4.3%)
2. Distal Transducer Line 3. Transducer Stopcock 4. Proximal Transducer Line
o/23 (0%)
5. IABP Stopcock
l/17 68%)
2,93 (8.6%) l/23 (4.3%)
These findings suggest that a 72.hour transducer cha”8e might hc considezd for these systems since contamination rates within the system are not increased with the less frequent change of 72 hours
THE USE OF BACI’ERIAL CELL WALL FATI’Y ACID ANALYSIS WlTH STATISTICAL CLUSTER ANALYSIS FOR THE RAPID ASSESSMENT OF BACTERIAL RELATEDNESS IN EPIDEMIOLOGIC lNVESTlGATIONS. L. Ayers,* MD. T. W&auto”. MT, W. Buesching. PhD. The Ohio State University Hospitals, Columbus. OH. Epidemiologic investigations of infection clusters use a number of clinical and laboratoty tools to determine if the cluster is due to cross infection with the same organism or due to different strains of the organism occurring at the same time in several patients in the same location. Some of the laboratory tools such as biochemical and antibiotic profiles ate readily available but others such as semtyping, phage typing. and plasmid profiling are time consuming a”d therefore expensive and are available only 6t selected institutions or refetwcc laboratories. We have investigated gas chmmatogmphed bacterial cell wall fatty acids (CWFA) evaluated by cluster analysis as a method fo: determining or anlsm relatedness (Micmbial Identification System Software. MIS & , by Micmbial ID, Inc. and Hewlett-Packard gas chromatograph). Specimen processing requires controlled overnight cultivation followed by about one hour processing time. Cluster analysis with 2-D plots and demograms were used to determine the relations between 3 strains of Klebsiella pnemniae that occumed in a three-patient cluster in the Bone Marrow Tratuplant [Jnit. The thaw strains CWFA profile did not cluster consistently in the three components examined by 2-D plot and the Euclidian distance between two strains was 2.87 and between these strains and the third strain was 5.41. An Euclidian distance of <2 is required for identical strains. therefore these isolates are not the same strdin. Plasmid profiling was used to validate the condusronc from gas chromatograp& analysis. The isolates were grow” in BHI brolh overnight and the plasmid DNA was extracted using a modification of the alkaline lysis technique. The isolated plasmid DNA was dissolved in TE (pH 8.0) plus tracking dye and electmphotwd thmogh a 0.8% (wt/vol) agamse gel at 60 volts in TAE buffer. The gel was stained with ethidium bromide and photographed with UV ligtd. There was no similarity between the plasmid profiles of the three organisms. No plasmids were detected in one strain. the second organism contained a single 6 kb plasmid and the third isolate contained multiple small plasmids.