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Reaching Zero Ventilator-Associated Pneumonia (VAP) Using a Standard Order Set
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American Journal of Infection Control June 2009
rates as using silver impregnated urinary catheters. The hospital saved an estimated $40,000.The hospital continues to track CA-UTI rates in the ICUs and hopes to reduce rates below the recently published NHSN rates of 4.1 infections/ 1000 catheter days in medical and surgical ICUs. Since the Centers for Medicare and Medicaid Services (CMS) no longer reimburses hospitals for HAI CA-UTIs, reducing infections will also result in additional cost savings. Most importantly, reducing infections will lead to better patient outcomes. Weaknesses in the study included: it was not a double-blind case control study; cultures were obtained only from patients with suspected UTIs and not all patients; and different individuals collected the data from each ICU. Presentation Number: 5-56
Reaching Zero Ventilator-Associated Pneumonia (VAP) Using a Standard Order Set Cory Heitzman, RN, BSN, Infection Preventionist / Risk Manager, Arizona Heart Hospital, Phoenix, AZ Issue: Ventilator Associated Pneumonia (VAP) was at an unacceptable level at our facility, with staff unaware of or not consistently using appropriate practices reduce the numbers of VAPs.
Project: A multidisciplinary group was created in May of 2007 to examine the problem of VAP and make recommendations. The group chose the new recommendations from the Institute of Healthcare Improvement (IHI) regarding VAP reduction as the backbone of the new policy. The recommendations from the Center of Disease Control (CDC) were also determined to be highly valuable and these were added to the new policy as well. The new policy led to creation of a new physician order set since most of the recommendations dealt with medications, equipment and the possible contraindications associated with any one of them. The first incarnation of this order set was presented to the hospitalists for their recommendations, then for nursing input, and then to the different boards that made their recommendations for change and final approval. Before the order set was implemented, the opportunity was taken to revise the existing Ramsey Scale flowsheet with nursing input. Implementation: The new order set was rolled out using in-services with groups of three or four nurses twice each shift everyday for the first month. Over time, most of the nursing staff was made aware of the new order set and flowsheet. Part of the in servicing includes a poster that says, ‘‘If you’re using this (with an arrow pointing to the flowsheet), Then you MUST be using this (with an arrow pointing to the order set).’’ Monitoring: All ventilated patients charts are reviewed daily for the order set, and if it is not in place, a mini-in-service ensues. Results: The three quarters leading up to the implementation of the new order set saw 5 VAPs for Q2-07, 2 for Q3-07 and 4 for Q4-07. Since the implementation of the order set the facility has experienced zero VAPs.
www.ajicjournal.org Vol. 37 No. 5
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Lessons Learned: Change is slow, was the hardest lesson to learn and accept. When this was rolled out, the response was ‘‘we do that already!’’ What everyone thought was being done was in fact not being done to the degree that it needed to be. However, once it became an actual physician’s order, the appropriate preventive elements got done more consistently and on a timelier basis. In addition, with the new Compendium recommending the use of the subglottic suctioning ET tube, this piece is now being added to the standing order set.
Presentation Number: 5-57
Reducing Central Line-Associated Bloodstream Infections - Getting Back to Basics Lisa M. Fawley, RN, CIC, Julie E. Mangino, MD, Medical Director; Darcy Vankirk, RN, PICC Team Patient Care Coordinator; Constance P. Carey, RN, BSRN, Critical Care RN; Madhuri M. Sopirala, M.D., Assistant Medical Director, The Ohio State University Medical Center, Columbus, OH Background: Patients with catheter-associated bloodstream infection have significantly higher ICU length of stay, hospital length of stay, mortality rate, and total hospital costs. A steady increase in CLA-BSI was observed in our 18 bed intensive care unit (ICU) with resulting 12 infections (with 8/12 positive blood cultures from patients with PICC) in calender year (CY)2 compared to only 3 CLA-BSI (no positive cultures from PICC) in the CY1. This increase led to an evaluation of health care worker (HCW) adherence to the guidelines for the prevention of CLA-BSI. Methods: Our Epidemiology Department performs active surveillance for CLA-BSI in the ICU per National Healthcare Safety Network definitions. There were 12 CLA-BSI identified in CY 2 of this evaluation period and peaked in the third quarter. In response to this increase, Epidemiology began central line/PICC insertion and maintenance audits. All central venous catheter (CVC) and PICC insertion trays were evaluated for components that comply with the central line bundle. An ICU nurse and a PICC nurse were trained to be liaisons to the Epidemiology team and designated as ‘‘Link Nurses’’. Their role was to provide daily reinforcement for compliance to the insertion and maintenance principles for all ICU members and to work with Epidemiology to optimize practices. Results: Findings were: Increased use of PICCs instead of CVCs in ICU for short term intravenous (IV) access; placement of two dual channel PICC at a time in a patient when more than 2 ports were required for IV access. Routine PICC maintenance audits had been discontinued due to staff shortage in January of year 1. All ICU central line audits by nursing were inadvertently limited to once a month in August of CY2 followed by a peak in CLA-BSI in the subsequent months. PICC trays lacked fenestrated drapes and PICC were being inserted in patients with ongoing bacteremia. CLA-BSI had increased to 12 (with 8/12 positive blood cultures from patients with PICC) in CY2. Interventions included: Epidemiology worked with the PICC team to ensure the use of an algorithm during selection of type of IV access; ultrasound guidance was used for peripheral IV line placement whenever possible. Dual-lumen PICC were replaced by triple-lumen PICC. PICC insertion tray was improved to include fenestrated
American Journal of Infection Control June 2009
rates as using silver impregnated urinary catheters. The hospital saved an estimated $40,000.The hospital continues to track CA-UTI rates in the ICUs and hopes to reduce rates below the recently published NHSN rates of 4.1 infections/ 1000 catheter days in medical and surgical ICUs. Since the Centers for Medicare and Medicaid Services (CMS) no longer reimburses hospitals for HAI CA-UTIs, reducing infections will also result in additional cost savings. Most importantly, reducing infections will lead to better patient outcomes. Weaknesses in the study included: it was not a double-blind case control study; cultures were obtained only from patients with suspected UTIs and not all patients; and different individuals collected the data from each ICU. Presentation Number: 5-56
Reaching Zero Ventilator-Associated Pneumonia (VAP) Using a Standard Order Set Cory Heitzman, RN, BSN, Infection Preventionist / Risk Manager, Arizona Heart Hospital, Phoenix, AZ Issue: Ventilator Associated Pneumonia (VAP) was at an unacceptable level at our facility, with staff unaware of or not consistently using appropriate practices reduce the numbers of VAPs.
Project: A multidisciplinary group was created in May of 2007 to examine the problem of VAP and make recommendations. The group chose the new recommendations from the Institute of Healthcare Improvement (IHI) regarding VAP reduction as the backbone of the new policy. The recommendations from the Center of Disease Control (CDC) were also determined to be highly valuable and these were added to the new policy as well. The new policy led to creation of a new physician order set since most of the recommendations dealt with medications, equipment and the possible contraindications associated with any one of them. The first incarnation of this order set was presented to the hospitalists for their recommendations, then for nursing input, and then to the different boards that made their recommendations for change and final approval. Before the order set was implemented, the opportunity was taken to revise the existing Ramsey Scale flowsheet with nursing input. Implementation: The new order set was rolled out using in-services with groups of three or four nurses twice each shift everyday for the first month. Over time, most of the nursing staff was made aware of the new order set and flowsheet. Part of the in servicing includes a poster that says, ‘‘If you’re using this (with an arrow pointing to the flowsheet), Then you MUST be using this (with an arrow pointing to the order set).’’ Monitoring: All ventilated patients charts are reviewed daily for the order set, and if it is not in place, a mini-in-service ensues. Results: The three quarters leading up to the implementation of the new order set saw 5 VAPs for Q2-07, 2 for Q3-07 and 4 for Q4-07. Since the implementation of the order set the facility has experienced zero VAPs.
www.ajicjournal.org Vol. 37 No. 5
E53
Lessons Learned: Change is slow, was the hardest lesson to learn and accept. When this was rolled out, the response was ‘‘we do that already!’’ What everyone thought was being done was in fact not being done to the degree that it needed to be. However, once it became an actual physician’s order, the appropriate preventive elements got done more consistently and on a timelier basis. In addition, with the new Compendium recommending the use of the subglottic suctioning ET tube, this piece is now being added to the standing order set.
Presentation Number: 5-57
Reducing Central Line-Associated Bloodstream Infections - Getting Back to Basics Lisa M. Fawley, RN, CIC, Julie E. Mangino, MD, Medical Director; Darcy Vankirk, RN, PICC Team Patient Care Coordinator; Constance P. Carey, RN, BSRN, Critical Care RN; Madhuri M. Sopirala, M.D., Assistant Medical Director, The Ohio State University Medical Center, Columbus, OH Background: Patients with catheter-associated bloodstream infection have significantly higher ICU length of stay, hospital length of stay, mortality rate, and total hospital costs. A steady increase in CLA-BSI was observed in our 18 bed intensive care unit (ICU) with resulting 12 infections (with 8/12 positive blood cultures from patients with PICC) in calender year (CY)2 compared to only 3 CLA-BSI (no positive cultures from PICC) in the CY1. This increase led to an evaluation of health care worker (HCW) adherence to the guidelines for the prevention of CLA-BSI. Methods: Our Epidemiology Department performs active surveillance for CLA-BSI in the ICU per National Healthcare Safety Network definitions. There were 12 CLA-BSI identified in CY 2 of this evaluation period and peaked in the third quarter. In response to this increase, Epidemiology began central line/PICC insertion and maintenance audits. All central venous catheter (CVC) and PICC insertion trays were evaluated for components that comply with the central line bundle. An ICU nurse and a PICC nurse were trained to be liaisons to the Epidemiology team and designated as ‘‘Link Nurses’’. Their role was to provide daily reinforcement for compliance to the insertion and maintenance principles for all ICU members and to work with Epidemiology to optimize practices. Results: Findings were: Increased use of PICCs instead of CVCs in ICU for short term intravenous (IV) access; placement of two dual channel PICC at a time in a patient when more than 2 ports were required for IV access. Routine PICC maintenance audits had been discontinued due to staff shortage in January of year 1. All ICU central line audits by nursing were inadvertently limited to once a month in August of CY2 followed by a peak in CLA-BSI in the subsequent months. PICC trays lacked fenestrated drapes and PICC were being inserted in patients with ongoing bacteremia. CLA-BSI had increased to 12 (with 8/12 positive blood cultures from patients with PICC) in CY2. Interventions included: Epidemiology worked with the PICC team to ensure the use of an algorithm during selection of type of IV access; ultrasound guidance was used for peripheral IV line placement whenever possible. Dual-lumen PICC were replaced by triple-lumen PICC. PICC insertion tray was improved to include fenestrated