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Ventilator-Associated Pneumonia in the Trauma Intensive Care Unit: Getting to Zero and Staying There
www.ajicjournal.org Vol. 39 No. 5
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aspects to the initiative. The group identified four key performance improvement initiatives that would decrease rates of HA-CDI. The first was enhanced environmental cleaning with bleach. Instead of bleach cleaning at time of discharge, rooms of patients with HA-CDI were cleaned daily with bleach. Second Infection Control implemented a policy in which Contact Isolation was initiated at the time stool was sent for testing. Early initiation of isolation precautions was a nursing driven process. Third Infection Control performed real-time surveillance for each CDI case and provide feedback to Environmental Services, Nursing and clinicians. These three interventions occurred over a two month period between July and August 2008. In July 2009 the fourth intervention was the automation of Contact Isolation order when a C. difficile antigen test is ordered. Results: As an institution we observed significant decreases (slope - 0.33, p,0.001) in HA-CDI rates, with a FY 2010 HA-CDI rate of 3.56. The current fiscal year data includes three consecutive months with zero HA-CDI and a five month fiscal year to date rate of 1.94 per 10,000 patient days. Lessons Learned: Interdisciplinary collaboration led to identification of barriers and issues that contributed to increased HA-CDI in our institution. The same team that identified the barriers set up process-oriented independent solutions. The persistence and participation of members outside the Infection Control Department have driven the sustainability of the initiative and fueled the success to reach zero. Presentation Number 13-174
Ventilator-Associated Pneumonia in the Trauma Intensive Care Unit: Getting to Zero and Staying There Molly Hale, MPH, CIC, Gail Carberry, RN, MSN, PHN, Infection Control Specialist; Jennifer Watters, MD, Physician; Scott Sherry, MS, PA-C, Physician Assistant; Kathleen Murray, RN, MPH, Interim Nurse Manager; Oregon Health & Science University, Portland, OR Background: Trauma patients have been shown to be at high risk of ventilator-associated pneumonia (VAP), with an incidence estimated to reach 40-50%. Organisms present in the airway may spread into the lower respiratory tract at the time of injury or during emergent intubation, placing the patient at risk for early-onset pneumonia. VAP rates reported through the National Healthcare Safety Network (NHSN) for Trauma Critical Care Units are 8.1 VAP per 1,000 ventilator days. As a Level 1 Trauma Center at a university medical center, the Trauma Intensive Care Unit (TICU) at our facility provides care to critically injured patients from a tri-State area.
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American Journal of Infection Control June 2011
Methods: Infection Prevention (IP) staff evaluated TICU patients for VAP using the National Healthcare Safety Network criteria. A VAP Performance Improvement project was initiated in the TICU in January 2009. Primary prevention efforts were led by a physician champion and an engaged nurse manager. The physician champion emphasized the importance of oral care with medical and nursing staff on rounds. Intubated patients had their teeth cleaned with toothbrushes and a rinse with a chlorhexidine gluconate (CHG) solution. The nurse manager conducted rounds using a patient safety checklist that included VAP prevention elements such as head-of-bed audits and documentation of sedation holds. IP staff also began reporting VAP rates to the TICU monthly. Prior to January 2009, the TICU was notified of their VAP cases quarterly. Results: The 2008 TICU VAP rate was 10.22 VAP per 1,000 ventilator days (n519). The 2009 TICU VAP rate was 0.60 VAP per 1,000 ventilator days (n51), representing a statistically significant decrease in VAP (p,0.001). This decrease was sustained in January-August 2010, when the TICU VAP rate was 2.17 VAP per 1,000 ventilator days (n52). Conclusions: The collective efforts of a Trauma physician, nurse manager, and engaged nursing and IP staff resulted in a significant and sustained decline of VAP in high risk patients. Prevention strategies included teeth brushing and CHG mouth rinse for intubated and other high risk patients, bedside audits of best practices, increased awareness by nursing staff of VAP prevention and more timely notification of VAP.
Presentation Number 13-175
Zero CAUTIs Over 33 Months as a Result of Low Urinary Catheter Utilization Rates John Flaherty, RN, Infection Preventionist; Jason Thornton, RN, Manager; Michael Agus, MD, Director, Medicine Critical Care Program; Gail Potter-Bynoe, Manager, Infection Prevention & Control Program; Children’s Hospital Boston, Boston, MA Issue: Device related infections have been identified as a significant source of morbidity and mortality of the hospitalized patient. Infections as a result of urinary catheterization are the most common type of these nosocomial infections. Limiting urinary catheterization to those that demonstrate a clinical need and minimizing the duration of catheter use are strategies that result in lower device utilization and consequently, lower CAUTI rates. Project: Upon opening a 12 bed pediatric Medical ICU in March of 2008, criteria were established for urinary catheter placement only in patients that demonstrated a clinical need. Nurses were also trained in the use of bladder scanning devices that enabled a quantification of the volume of urine within a patient’s bladder to minimize unnecessary catheterization. Additionally, a checklist was developed and utilized daily on patient rounds that prompted clinicians to inquire if a catheter in situ still met established criteria for its use, and to remove it if it didn’t. Results: Surveillance data collected over the 33 months since the unit opened shows a significantly lower urinary catheter utilization (0.076) than similar hospital units, which report a pooled mean for urinary catheter utilization of 0.21, according to data from the National Healthcare Safety Network (NHSN) (p,0.0001). The pooled mean for CAUTIs from the NHSN data for similar units is 4.0 per 1000 catheter days, while our unit has maintained a rate of 0 since it opened. Lessons Learned: Our data demonstrates that minimizing urinary catheter device utilization can result in a low or zero rate of CAUTIs. By adhering to criteria established for the use of urinary catheters based on clinical need, assessing bladder volumes to minimize unnecessary catheterizations, and employing the use of a checklist as a tool to remind clinicians to assess daily for the continued need for a urinary catheter, low urinary catheter utilization can result. We suggest employing these strategies to minimize urinary catheter utilization which consequently can result in low CAUTI rates.
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aspects to the initiative. The group identified four key performance improvement initiatives that would decrease rates of HA-CDI. The first was enhanced environmental cleaning with bleach. Instead of bleach cleaning at time of discharge, rooms of patients with HA-CDI were cleaned daily with bleach. Second Infection Control implemented a policy in which Contact Isolation was initiated at the time stool was sent for testing. Early initiation of isolation precautions was a nursing driven process. Third Infection Control performed real-time surveillance for each CDI case and provide feedback to Environmental Services, Nursing and clinicians. These three interventions occurred over a two month period between July and August 2008. In July 2009 the fourth intervention was the automation of Contact Isolation order when a C. difficile antigen test is ordered. Results: As an institution we observed significant decreases (slope - 0.33, p,0.001) in HA-CDI rates, with a FY 2010 HA-CDI rate of 3.56. The current fiscal year data includes three consecutive months with zero HA-CDI and a five month fiscal year to date rate of 1.94 per 10,000 patient days. Lessons Learned: Interdisciplinary collaboration led to identification of barriers and issues that contributed to increased HA-CDI in our institution. The same team that identified the barriers set up process-oriented independent solutions. The persistence and participation of members outside the Infection Control Department have driven the sustainability of the initiative and fueled the success to reach zero. Presentation Number 13-174
Ventilator-Associated Pneumonia in the Trauma Intensive Care Unit: Getting to Zero and Staying There Molly Hale, MPH, CIC, Gail Carberry, RN, MSN, PHN, Infection Control Specialist; Jennifer Watters, MD, Physician; Scott Sherry, MS, PA-C, Physician Assistant; Kathleen Murray, RN, MPH, Interim Nurse Manager; Oregon Health & Science University, Portland, OR Background: Trauma patients have been shown to be at high risk of ventilator-associated pneumonia (VAP), with an incidence estimated to reach 40-50%. Organisms present in the airway may spread into the lower respiratory tract at the time of injury or during emergent intubation, placing the patient at risk for early-onset pneumonia. VAP rates reported through the National Healthcare Safety Network (NHSN) for Trauma Critical Care Units are 8.1 VAP per 1,000 ventilator days. As a Level 1 Trauma Center at a university medical center, the Trauma Intensive Care Unit (TICU) at our facility provides care to critically injured patients from a tri-State area.
E60
American Journal of Infection Control June 2011
Methods: Infection Prevention (IP) staff evaluated TICU patients for VAP using the National Healthcare Safety Network criteria. A VAP Performance Improvement project was initiated in the TICU in January 2009. Primary prevention efforts were led by a physician champion and an engaged nurse manager. The physician champion emphasized the importance of oral care with medical and nursing staff on rounds. Intubated patients had their teeth cleaned with toothbrushes and a rinse with a chlorhexidine gluconate (CHG) solution. The nurse manager conducted rounds using a patient safety checklist that included VAP prevention elements such as head-of-bed audits and documentation of sedation holds. IP staff also began reporting VAP rates to the TICU monthly. Prior to January 2009, the TICU was notified of their VAP cases quarterly. Results: The 2008 TICU VAP rate was 10.22 VAP per 1,000 ventilator days (n519). The 2009 TICU VAP rate was 0.60 VAP per 1,000 ventilator days (n51), representing a statistically significant decrease in VAP (p,0.001). This decrease was sustained in January-August 2010, when the TICU VAP rate was 2.17 VAP per 1,000 ventilator days (n52). Conclusions: The collective efforts of a Trauma physician, nurse manager, and engaged nursing and IP staff resulted in a significant and sustained decline of VAP in high risk patients. Prevention strategies included teeth brushing and CHG mouth rinse for intubated and other high risk patients, bedside audits of best practices, increased awareness by nursing staff of VAP prevention and more timely notification of VAP.
Presentation Number 13-175
Zero CAUTIs Over 33 Months as a Result of Low Urinary Catheter Utilization Rates John Flaherty, RN, Infection Preventionist; Jason Thornton, RN, Manager; Michael Agus, MD, Director, Medicine Critical Care Program; Gail Potter-Bynoe, Manager, Infection Prevention & Control Program; Children’s Hospital Boston, Boston, MA Issue: Device related infections have been identified as a significant source of morbidity and mortality of the hospitalized patient. Infections as a result of urinary catheterization are the most common type of these nosocomial infections. Limiting urinary catheterization to those that demonstrate a clinical need and minimizing the duration of catheter use are strategies that result in lower device utilization and consequently, lower CAUTI rates. Project: Upon opening a 12 bed pediatric Medical ICU in March of 2008, criteria were established for urinary catheter placement only in patients that demonstrated a clinical need. Nurses were also trained in the use of bladder scanning devices that enabled a quantification of the volume of urine within a patient’s bladder to minimize unnecessary catheterization. Additionally, a checklist was developed and utilized daily on patient rounds that prompted clinicians to inquire if a catheter in situ still met established criteria for its use, and to remove it if it didn’t. Results: Surveillance data collected over the 33 months since the unit opened shows a significantly lower urinary catheter utilization (0.076) than similar hospital units, which report a pooled mean for urinary catheter utilization of 0.21, according to data from the National Healthcare Safety Network (NHSN) (p,0.0001). The pooled mean for CAUTIs from the NHSN data for similar units is 4.0 per 1000 catheter days, while our unit has maintained a rate of 0 since it opened. Lessons Learned: Our data demonstrates that minimizing urinary catheter device utilization can result in a low or zero rate of CAUTIs. By adhering to criteria established for the use of urinary catheters based on clinical need, assessing bladder volumes to minimize unnecessary catheterizations, and employing the use of a checklist as a tool to remind clinicians to assess daily for the continued need for a urinary catheter, low urinary catheter utilization can result. We suggest employing these strategies to minimize urinary catheter utilization which consequently can result in low CAUTI rates.