Science. Nursing Basics 101:Taking Ownership to Reduce Medical Errors. Session Content. Evidenced-Based Practice. Driving Forces for Change

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1 Nursing Basics 101:Taking Ownership to Reduce Medical Errors Kathleen M. Vollman MSN, RN, CCNS, FCCM Clinical Nurse Specialist / Educator / Consultant ADVANCING NURSING kvollman@comcast.net Northville Michigan Dr. Maryanne McGuckin McGuckin Methods International, Inc. Associate Faculty/Fellow-University of Pennsylvania/LDI Senior Scholar, Health Policy Department Thomas Jefferson University, Philadelphia, PA. Senior Fellow, Society Healthcare Epidemiology of America Session Content Interventional Patient Hygiene Definition Models Knowledge/Survey Hand Hygiene CA-BSI (catheter related blood-stream infections VAP/Oral care & mobility Reduction of pressure ulcers Case studies How to started ADVANCING NURSING 2007 Driving Forces for Change Scientific Driver Evidence-based practice movement Economic & Social Drivers IOM/Medical error Leap Frog group Institute for HealthCare Improvement/VHA 100,000 lives campaign 5,000,000 lives campaign Joint Commission Professional Driver: Back to the basics Evidenced-Based Practice The conscientious, explicit, and judicious integration of the best available evidence from systematic research, with individual clinical expertise and patient preference at the bedside in making decisions about clinical practice. Vollman KM. Crit Care Nurs Clin N Am, 2006; 18: Basic Care Science Technology/Medical vs. Fundamental Basic Care Practices Prior to 3 Years Ago How was quality nursing care measured? Reduced medication errors Reduced order misses Patient and family satisfaction Is this the full measurement of the quality of nursing care we deliver? 1

2 Behavioral Rationale for Current Environment of Nursing Practice Behavior that is recognized and reinforced continues Behavior that is ignored or not reinforced does not continue Science Needs to Drive the Practice Change..Otherwise It s Like Shooting in the Dark The target is out of focus, less accurate and more shots are necessary to make a hit Science narrows the focus, sets the sight and hits the target. CLINICAL RESEARCH ROUTINE PRACTICE How do we get information to leap from the pages of magazines and become part of our new daily routine? In God We Trust! Research Utilization Research Utilization BELL SHAPED CURVE Notes on Hospitals: 1859 Negatoids Tweeners Positrons It may seem a strange principal to enunciate as the very first requirement in a Hospital that it should do the sick no harm. -Florence Nightingale 2

3 Fortifying Host Defense Implement Interventional Patient Hygiene Interventional Patient Hygiene Hand Hygiene Hygiene the science and practice of the establishment and maintenance of health Interventional Patient Hygiene.nursing action plan directly focused on fortifying the patients host defense through proactive use of evidence based hygiene care strategies Comprehensive Oral Care Plan Incontinence Associated Dermatitis Prevention Program Bathing & Assessment Catheter Care Pressure Ulcer Prevention Interventional Patient Hygiene INTERVENTIONAL PATIENT HYGIENE (IPH) Skin Injury Dr. Maryanne McGuckin McGuckin Methods International, Inc. Associate Faculty/Fellow-University of Pennsylvania/LDI Senior Scholar, Health Policy Department Thomas Jefferson University, Philadelphia, PA. Senior Fellow, Society Healthcare Epidemiology of America VAP UTI SSI BSI Evidence Based Practice Intervention Oral Care Catheter Care Skin Care Hand Hygiene IPH Practices/Prevention Outcomes Responsibility HCW HCW HCW & Patient HCW & Patient Measurable Outcome VAP BSI SSI, UTI, Reduction of Resistant Organism Infections, PU and Skin Breakdown All of above Interventional Patient Hygiene Survey* Practitioners Surveyed: n=453 ICP 30.9% CCRN 22.8% CCRN Mgr/Specialist 15.5% RN 42.2% Demographics Employed >20 years 48.8% Community Hospital 67.7% University/Academic 28.3% Knowledge is Powerful *McGuckin, et al. AJIC In press 2007 *McGuckin, et al. APIC Annual Meeting, Tampa, FL

4 Identify Components of IPH Hand Hygiene 98.7% Oral Hygiene 94.8% Early Pre-op Skin Prep 69.9% (night before and morning of surgery) Bathing/Skin Assessment 93.5% Incontinence Care 92.4% Scientific Evidence/ IPH Pressure Ulcer 72% SSI 66% VAP 86% UTI 75% LOS 74% MRSA/VRE 77% CCRN/RN Questions CCRN/RN (con t) Policy for IPH in Your Institution Care Item Written Policy for: Documentation Forms for: YES: 48.4% NO: 34.7% Don t Know 16.8% Oral Care Bathing/Skin Assessment Incontinence Care 77% 68% 54% 81% 86% 60% IPH Discussed at Orientation or In-Service Yes: 42.2% No: 40.4% Don t Remember: 17.3% Ranking of Factors Relating to IPH Item Adequate/ Appropriate Supplies Adequate Time Very Important Somewhat Important 94% 4% 90% 7% Skipped Question: 17% Standardization of Protocol 86% 11% Documentation forms for monitoring 73% 25% 4

5 Driving Factors for IPH Patient Safety HAI s Mandatory Reporting Patient Expectations Patient Safety Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective, and potentially dangerous. Sir Cyril Chantler Courtesy: Phillip M. Kibort, MD,MBA,CMO Children s Hospital of Minnesota How Hazardous Is Health Care? DANGEROUS REGULATED ULTRA-SAFE 100,000 10,000 1, Health Care Mountain Climbing Driving Chartered Flights Chemical Manufacturing Scheduled Airlines European Railroads Bungee Nuclear 1 Jumping Power , ,000 1,000,000 10,000,000 Number of encounters for each fatality Courtesy: Phillip Kibort, MD, MBA HAI s Costs Real Numbers / Real People 2.5 million HAI s year Everyday, 247 people die in the USA as a result of a HAI Worldwide, at least 1 in 4 patients in ICU will acquire a HAI during their stay WHO Costs and LOS for HAI s in ICU Costs of HAI s CDC $6 billion PHCA $3.5 billion Other Group $30-50 billion Infect Control Hosp Epidemiol 2005;26: ,000,000 Estimated infections per year X $15,000 Average additional hospital costs when a patient contracts an Infection $30 Billion Spent per year treating HAI s 5

6 Mandatory Reporting HAI s - Impact Only 12 States do not have some program Patient View Points: Choosing a Hospital Ranking of Factors Top Two 94% rate clean very important 85% low infection rates 93% knowing infection rates for hospital/doctor would influence their selection McGuckin M, et al. Am J Med Qual 2006;21: What s Wrong With Our Healthcare System? U.S. patients receive proper medical care from doctors and nurses 55% of time N.E.J.M Vol 354, No 11, 2006 The Way to Fix Medicine is Obvious Not Another Study on Statistics But Study on Why We Don t Implement Sick.Jonathan Cohn It was about the year 1910 when it became possible to say of the US that a random patient with a random disease consulting a doctor chosen at random stood better than a 50/50 chance of benefiting from the encounter Herb Denenberg, March 2006 April 2007 Proven Care/90 Day Warranty 137 elective Bypass surgeries with the 90 day warranty Checklist with 5 categories Results Hand Hygiene is the Single Most Important Factor in Preventing the Spread of Infection Readmission to ICU from 2.9% to 0.9% In hospital mortality from 1.5% to 0% Pulmonary complications from 7.3% to 2.6% Discharge not to home from 19% to 9% Geisinger Medical Center, PA New York Time 05/15/2007 6

7 Normal Bacterial Skin Flora Total Bacterial Contamination on Hands of Medical Personnel 3.9 x 104 to 4.6 x 106 Hand Hygiene Studies Observed: 40 Physicians, 15 Nurses Measured: % Washed Care Giver Physicians Nurses RT Teaching Hospital 28% 43% 48% Private Hospital 14%. 28% 76% Alberts and Condie, N. Eng. J. Medicine, 1981 Handwashing Patterns Versus Sink Availability Bed/sink ration % Washed SICU 4:1 51 MICU 1:1 76 HANDWASHING BY HCW s Physicians 19% Nurses 63% Others 25% McGuckin M, et al. Am. J. Infect Control 7: , 1986 DURATION OF HANDWASHING IN INTENSIVE CARE UNITS 188 Hand Washes of HCW by Level of Care HIGH MEDIUM Physicians Nurses Technicians McGuckin M, et al. Am J. Infect Control 11:83-87, 1984 COMPLIANCE WITH HAND WASHING IN A TEACHING HOSPITAL 2834 observations 1043 HCW Average compliance : 48% Average soap usage : 34% Antisepsis : 14% Handwashing Compliance HCW s - 85% said they washed HCW s peers - 50% said they washed Observation - 25% washed Females - 33% more likely to wash than males but males wash more effectively Lowest compliance: ICU, higher risk procedures & work load University of Geneva Annals of Internal Medicine January 19, 1999 Vol 130 No. 2 Robert Weinstein, M.D th Decennial Conference on HAI s 7

8 Least Compliant? Physicians! Why: Survey by Boyce, et al (2002) 2/3 respondents perceived HH as a difficult task However: Pittet, et al (2004) showed that physicians who see themselves as role model had better adherence. Doctors Serve As Role Models For Hospital Hygiene CDC - Northwestern Memorial Hospital If doctors don t wash / staffers wash only 10% of time New / Old Hospitals - 23% versus 53% Best and Worst Doc s Pittet University of Geneva Survey of 167 Doc s Worst Anesthesiologist (23%) Surgeons (36%) E.R. (50%) Best Internal Medicine (87%) Overall Compliance (57%) U.S: 40-60% Handwashing Compliance Years of Data/Research Findings: 1) Healthcare workers wash hands less than 50% of time after direct patient contact. 2) Higher workload and activities of higher risk for transmission lower handwashing compliance Barriers and Solutions to Hand Hygiene Barriers 1 Solutions 2 Skin Irritation - Product Prefer Using Gloves - Education Failure to Remember - Patient (24/7) How Can We Succeed? Patient and HCW Empowerment Patients should be sure that any Physician, Nurse, Therapist, has washed his/her hands before touching them 1. Infect Control Hosp Epidemiol 2005; 26: Am J Infect Control 2004;32: Journal of Hospital Infection 2001;48: NPSG 13 Patient Empowerment 2007 McGuckin, M Medical World News February 15,

9 How Do We Know Patient s Want to Be Empowered? 4/5 (80%) respondents said they would ask their HCW to wash hands if educated by staff 52% respondents saw HCW put on gloves rather than practice HH McGuckin M, et al. Consumer Attitudes About Healthcare- Acquired Infections and Hand Hygiene. Amer Journal of Med Quality. 21:1-5, 2006 Does Empowerment Work? Acute Care McGuckin M, et al, Patient Education Model for Increasing Handwashing Compliance. Am J Infect Control, Vol 27(4); , 1999 Acute Care McGuckin M, et al, Evaluation of Patient Empowering Hand Hygiene Programme in UK The Journal of Hospital Infection 48: Rehab McGuckin M, et al, Evaluation of a Patient Education Model for Increasing Hand Hygiene Compliance in an In-Patient Rehabilitation Unit. Am J Infect Control, 32:235-8,2004 LTC McGuckin M, et al, Validation of a Comprehensive Infection Control Program in LTC. The Director, Vol 12;1:14-17, 2004 ICU McGuckin M, et al. The Effect of Random Voice Hand Hygiene Messages Delivered By Medical, Nursing and Infection Control Staff On Hand Hygiene Compliance in Intensive Care. Am J Infect Control, Vol 34;(10): ,2006 Empowerment of ICU HCW s 16 Bed Med/Surgical ICU 12 Week Baseline/intervention 12 Voice messages / 1-15 minutes link to computer at unit / speakers McGuckin M, et al, The Effect of Random Voice Hand Hygiene Messages Delivered By Medical, Nursing and Infection Control Staff On Hand Hygiene Compliance In Intensive Care. Amer J Infec Cont Vol 34;(10) , 2006 Methodology of Voice Prompts Recorded message by authority figures ICU Medical Director ICP DON Nurse Manager Delivery of RHHP 6AM - 10PM Random times (1-15 minutes) Sample Recorded Messages Slide 32 We want 100% HH compliance in our ICU Remember, handwashing before and after patient contact Gloves do not replace hand hygiene 9

10 Product Soap Sanitizer (Soap and Sanitizer Baseline Product usage (ml) 18,000 9,940 27,940 Results Hand Hygiene (HH/bedday) Intervention Product usage (ml) 21,000 15,496 36,496 Hand Hygiene (HH/bed-day) 25* UNIT TYPE ICU NON-ICU PEDIATRICS ER/OP CLINIC REHAB/LTC COMPLIANCE GOAL 144 HH events/patient bed day 72 HH events/patient bed day 72 HH events/patient bed day 6 HH events/patient visit 3 HH events/patient visit 20 HH events/patient bed day *p<.01 p<.001 Hand Hygiene Basic 101 HH Before and After Patient Contact HH Before and After Glove Usage Gloves do not replace HH HH at entrance of room or in room, not the previous patient s room Sanitizer/Foams very effective Soap/Water Visibly dirty C.difficile -? Soap/Water Policies And Guidelines Will Not Increase Hand Hygiene Compliance Unless Measurement And Feedback Are Part Of The Process What Can You Do as a Nurse, Manager to Assure Measurement and Feedback Example of Measurement/Benchmarking Program 1. Make sure ICP is part of your team as you develop IPH program 2. Insist on a measurement process and monthly reports on compliance for your unit 3. Observation should be combined with objective measurement such as product volume 10

11 Individual unit scores are posted to give staff feedback and to identify poor performers who need support GOT CLEAN Patients and CLEAN PAWS? TARGET ZERO!!!!!!! Don t slide into bad habits, remember to CLEAN HANDS and PATIENTS OFTEN Courtesy of Jeri Winters Wenatchee Valley Hospital Hospital Acquired Pneumonia (HAP) and Ventilator-Associated Pneumonia(VAP) VAP crude mortality approximately 10-40%. HAP crude mortality 15-18% Median rates range 2.4 to 14.7 per 1000 ventilator days HAP rates 5-15 per 1000 patient days Associated cost $30,000-$40,000 per VAP Increase LOS up to 16 days Annual cost $2 billion dollars. Sole M.L. Am J of Crit Care. 2003;12(3): Collard HR. Ann Intern Med. 2003;138: Rello J. Chest. 2002;12: ATS Guidelines for HealthCare Acquired Pneumonia 2006 Risk Factor Categories for Nosocomial Pneumonia Factors that increase bacterial burden or colonization Factors that increase risk of aspiration 11

12 Factors that Increase Bacterial Burden or Colonization Extreme age, severe underlying condition/ immunosuppression Administration of antibiotics Agents which raise the gastric ph Withholding gastric feeding Mechanical ventilation Lack of oral care Poor infection control practices Contaminated respiratory equipment/contamina ted condensate Saline administration Immobility Practices in Oral Care Culture cup, ½ H2O2, ½ sterile H2O little bit of mouthwash Lemon glycerine swabs Toothette with water &/or mouthwash No oral care That s s not the way we do it here!!! Lemon & Glycerin Swabs Harmful Hastens drying of mucosa by depleting the saliva reserve caused by over-stimulation of salivary glands by lemon juice Citric acid has no moisturizing capabilities Irritates oral mucosa & decalcifies teeth Glycerin is a trihydric alcohol that absorbs water causing drying Oral Care Practices: Large Multi-site Study 72% oral swab q 4hrs 75% suction oral secretions q 4 hrs 65% suction nose PRN 34% brush q 8-12hrs & 41% rarely or not at all Foss-Durant Am et al. Clin Nurs Res. 1997;6(1): Krishnasamy M. Eur J Cancer Care. 1995;4(4): Regnard C et al. Br Med J. 1997;315(7114): Van Drimmelen JR et al. Nurs Res 1969;18: Sole M.L. Am J of Crit Care. 2003;12(3): Oropharyngeal Colonization Methodology: 89 critically ill patients Examined microbial colonization of the oropharynx through out ICU stay Used pulse field gel electrophoresis to compare chromosomal DNA Results: Diagnosed 31 VAPs 28 of 31 VAP s the causative organism was identical via DNA analysis Garrouste-Orgeas et. al. Am J Respir Crit Care Med. 1997;156: Oropharyngeal Colonization Methodology: 49 elderly nursing home residents admitted to the hospital Examined baseline dental plaque scores & microorganism within dental plaque Used pulse field gel electrophoresis to compare chromosomal DNA Results: 14/49 adults developed pneumonia 10 of 14 pneumonias, the causative organism was identical via DNA analysis El-Solh AA. Chest. 2004;126:

13 Role of Salivary Flow Provides mechanical removal of plaque and microorganisms Innate & specific immune components (IgA, cortisol, lactoferrin) Patients receiving mechanical ventilation have dry mouth which in turn contributes to accumulation of plaque & reduced distribution of salivary immune factors Munro CL & Grap MJ. AJCC. 2004;13:25-34 Frequency of Oral Care and Suctioning Process of giving oral care rather than specific agent has a greater influence on the general condition of the mouth. 2 to 4 hour interval tends to show a greater improvement in oral health. If oral care is omitted for a period of 4 to 6 hours the previous benefits are lost. Ginsberg MK. Am J of Nurs. 1961;61:67-69 DeWalt EM. Nurs Research. 1975;24(2): Drimmelen and Rollins. Nurs Research. 1969;18: O Reilly M. Australian Critical Care. 2003;16(3):101:110 Oral Hygiene Implementation of a comprehensive oral care program ( Cat II) Systematic method of delivery Clean oral cavity frequently Keep oral mucosa moist Cleansing solution Brush twice daily CDC Guidelines for Prevention of Healthcare Associated Pneumonia. MMWR. 2004;53(no RR-3) Impact of a Comprehensive Oral Care Protocol on VAP: The Good Shepherd Study Methodology: Retrospective study 10 bed Med-Surg Protocol included: Covered Yankauer for nontraumatic oral suctioning, soft-suction toothbrush, Suction Oral Swab, use of a 1.5% H 2 O 2 peroxide mouth rinse for cleansing, subglottic suction catheter used 4x daily, dedicated oral suction line for infection control and ease of use. Education provided and presence of clinical champion. Schleder B. et al. J Advocate Health 2002;4(1):27-30 Impact of a Comprehensive Oral Care Protocol on VAP: The Good Shepherd Study Results: VAP rate prior to introduction of the oral care program was 5.6 per 1000 ventilator days. VAP rate after oral care program implementation was 2.2 per 1000 ventilator days. Cost savings approximately $30,000 per incident Schleder B. et al. J Advocate Health 2002;4(1):27-30 Reduction of Microbial Colonization in the Oropharynx & Dental Plaque Reduces VAP Methodology: MICU Mechanically ventilated patients between 01/2003 to 12/2003 provided a comprehensive oral care assessment & intervention Compared against 01/2002 to 12/2002 who received standard care Intervention: Oral care kit including covered yankauer, deep oral cleansing catheters (q6hrs), suction toothbrush (q12hrs) and oral suction swabs and mouth moisturizer (q4 hrs) No other interventions introduced during study period. Garcia R et al. Presentation APIC 2004 Abs 13

14 Reduction of Microbial Colonization in the Oropharynx & Dental Plaque Reduces VAP Results: No difference in demographics between groups Vent utilization for pre and post intervention groups in the 75 to 90% based on NISS 2002: VAP rate 8.3 per 1000 ventilator days 2003: VAP rate 4.4 per 1000 ventilator days 42.1% reduction in overall rate Garcia R et al. Presentation APIC 2004 Abs Oral Care Reduces Pneumonia In Nursing Homes Methodology 11 nursing homes in Japan over 2 year period 417 enrolled / 366 residents analyzed (death from other causes) 184 received oral care program/182 did not Tooth brushing after each meal (teeth or dentures) & 1x weekly review by dentist/or hygienist Results Febrile Pneumonia Death MMSE No Oral 29% 19% 16% Oral Care 15% 11% 7% Increase p value p<.01 p<.05 p<.01 p<.05 Yoneyama et al. JAGS. 2002;50: The Right Cleaning Solution 1.5% H 2 O 2 >3% may cause harm. <1% no benefit in plaque removal. Must be diluted properly, not with normal saline. 3x a day mouth rinse with 1.5% H revealed no mucosal damage, improved plaque scores and overall gingival health. Gomes BC et.al. Clin Prev Dentistry. 1984; 6: Boyd RL. et. al. J Clin Periodentol.1989; 16: West TL et. al. Journal of Peridontol ; 54(6):339 Tombes MA et. al. Nursing Research. 1993; 42(6): Beck S. Cancer Nursing. 1979; 2: CHG: Impact on VAP???? Methodology Multi-center, double-blind, placebo-controlled efficacy study 228 patients MV pts with > 5 day LOS Antiseptic decontamination of gingival and dental plaque with.2% CHG gel or placebo 3x a day for entire ICU stay. Results Baseline characteristics similar Placebo VAP rate: 13.2 per/1000 vent days CHG VAP rate: 13.3 per/1000 vent days CHG decrease colonization but did not reduce VAP Fourrier F. et al. Critical Care Medicine, 2005;33: The Effect of Oral Decontamination with Chlorhexidine on the Incidence of Nosocomial Pneumonia: A Meta Analysis Meta Analysis 1251 articles screened 4 randomized controlled trials used 1202 patients No significant difference in VAP rates (0.42;95% CI ) Pineda LA, et al. Critical Care, 2006;10:R35 CHX Research 2006 Methodology 385 mechanically ventilated patients (>48hrs) Randomized, double blind, placebo controlled 3 arms: placebo, Chlorhexidine (CHX), CHX & Colistin (COL), placebo administered q 6 hrs Measured: VAP, oral colonization & endotracheal tube colonization Results Baseline data similar Statistically significant reduction in risk for VAP in patients with CHX & CHX/COL CHX recommended for prevention Koeman M et al. Amer J of Respir & Crit Care Med, 2006;173:

15 0.12% CHG Gluconate Oral Rinse Package Insert: The clinical significance of CHG rinse antimicrobial activities is not clear Therapy should be initiated following dental prophylaxis Recommend use 15cc x2 daily 30 second rinse after toothbrushing Needs to be expectorated/suctioned after rinsing VAP Pressure Ulcers UNDERSTANDING THE IMPACT OF A STATIONARY SUPINE POSITION Minimal Physiologic Mobility Requirement Move Every 11 Minutes During Sleep Keane, F.X. Paraplegia, 1978; 16: Impact of Q 2 hours on Healthy Mechanically Ventilated Lungs Methodology 12 adult healthy baboons were randomized to CLRT or control for 11 days Mechanically ventilated, paralyzed and sedated and received normal supportive therapy Measured x-ray results, cultures, bronchioalveolar lavage, oxygenation indices, pulmonary function and lung volumes Impact of Q 2 hours on Healthy Mechanically Ventilated Lungs Results No significant difference in hemodynamics, gas exchange or pulmonary function Day 7 the control group showed patchy atelectasis Day 11 two animals showed persistent radiological abnormalities. Bronchoalveolar lavage day 7 and 11 revealed significant increase in neutrophils Lung pathology in control group showed areas of bronchiolitis with 5 of 7 of the control animals demonstrating surrounding bronchopneumonia Anzueto A et al Crit Care Med 1997;25(9): Anzueto A et al Crit Care Med 1997;25(9):

16 Body Position: Clinical Practice vs. Standard Do We Achieve Q2 Hours? Methodology 74 patients/566 total hours of observation 3 tertiary hospitals Change in body position recorded every 15 minutes Average observation time 7.7 hours Online MD survey Results 49.3% of observed time no body position change 2.7% had a q 2 hour body position change 80-90% believed q 2 hour position change should occur but only 57% believed it happened in their ICU Krishnagopalan S. Crit Care Med 2002;30: Changes in Positioning Practices Education on the science of positioning critically ill patients Education on importance of HOB elevation in preventing aspiration Baseline data on mobility practices Protocol based introduction of prone positioning, continuous lateral rotation therapy and early progressive mobilization out of bed once hemodynamically stable Buy off of protocol by multidisciplinary group What is Your Next Move!!!! Marik PE. Et al. Crit Care Med,2002;30(9): Combating deconditioning through progressive positioning when CLRT treatment is completed: HOB elevated 45 degrees HOB elevated 45 degrees and legs placed in a dependent position (partial chair position) HOB elevated to 90 degrees, legs in dependant position and feet on the floor (full chair position) HOB elevated to 90 degrees, legs in dependant position, feet on the floor and stand HOB elevated to 90 degrees, legs in dependant position, feet on the floor, stand and walk a few feet and sit in a chair 16

17 Hemodynamic Instability Hemodynamic Status No differences noted in hemodyanmic variables between supine & positions Lateral turn results in a 3-9% decrease in SVO2 which takes 5-10 minutes to return to baseline Appears the act of turning has the greatest impact on any instability seen Minimize factors which contribute to imbalances in oxygen supply & demand Winslow, E.H. Heart and Lung, 1990 Volume 19, Price P. CACCN, 2006, 17(1): Patients at Risk for Intolerance to Positioning Elderly Diabetes with neuropathy Prolonged bedrest Low Hb an cardiovascular reserve Prolonged gravitational equilibrium Vollman KM. Crit Care Nurs Clin of North Amer, 2004;16(3): VAP Pressure Ulcers Pressure Ulcer Prevalence & Incidence Rates in Acute Care Prevalence Rate 15% Incidence Rate 7% Pressure Ulcers Risk Factors 1. Immobility 87.0% 2. Fecal Incontinence 56.7% 3. Malnutrition 54.4% 4. Decreased Mental Status 50.7% 5. Peripheral Vascular Disease 28.1% 6. Urinary Incontinence 27.0% 7. Diabetes 23.7% National Pressure Ulcer Advisory Panel, 2001 Maklebust & Magnan. Adv in Wound Care. 1994;7(6):

18 Anatomic Locations of Pressure Ulcers 1. Sacrum 36.9% 2. Heel 30.3% 3. Ischium (sit bone) 8.0% 4. Elbow 6.9% 5. Malleolus (ankle bone) 6.1% 6. Trochanter (hip bone) 5.1% 7.. Knee 3.0% 8. Scapula (shoulder blade) 2.4% 9. Occiput (back of head) 1.3% 8.0% Elbow Occiput Trochanter Ischium Malleolus Scapula Sacrum Knee Heel Maklebust & Magnan. Adv in Wound Care. 1994;7(6):25-42 Minimize Pressure Turn & reposition every 2 hours Pillows and cushioning devices to maintain alignment & prevent pressure on boney prominences Use lifting device or draw shifts to move patients to prevent shear Use pressure-relieving surfaces (in all areas) Changes to sustain the gain Tools inside the patients room (turn clock) Unit or hospital wide musical cues Use products that makes it easier to prevent pressure Keeping Heels Intact: Evaluation of a Protocol for Preventing Facility-Acquired Heel Ulcers Keeping Heels Intact: Evaluation of a Protocol for Preventing Facility-Acquired Heel Ulcers 53 patients on intervention unit that used the preventpressure relieving product did not develop heel ulcers Product trial demonstrated higher scores in comfort, temperature, comparability with DVT prevention devices, no sharp or rough edges and total floatation of the heel achieved Walsh J et al. Poster at symposium on Advances in Wound Care, San Antonio, April 2006 Walsh J et al. Poster at symposium on Advances in Wound Care, San n Antonio, April 2006 IHI 5 Million Lives Campaign Fortifying Host Defense Against Injury & Invasion Preventing Pressure Ulcers Skin Inspection: Bathing Minimize Pressure Manage Moisture: Incontinence Care Prevent Pressure Ulcers Reduce surgical complications Reduce MRSA infection Prevent harm from high-alert medications Deliver reliable evidence-based care for congestive heart failure 18

19 Prevalence Trend Chart All Facilities Including Stage I Percent of Patients 16% 14% 12% 10% 8% 6% 4% 2% 0% Hill-Rom 9.2% 11.2% 11.1% 10.1% Prevalence 14.8% 7.1% 14.7% Facility-Acquired Prevalence 8.6% 15.5% 6.8% * Prior to 1999, pressure ulcer source was not reported. 15.5% 7.7% Facts about Pressure Ulcers 2.5 million patients treated for pressure ulcers per year Associated with extended LOS 60,000 patients are estimated to die each year from complications r/t a hospital-acquired pressure ulcer Cost of managing a single ulcer as high as $70, billion in preventable costs Reddy M et al. JAMA 2006;296: Extended stay So Why Should You Care? Patient Discomfort - Pain & Suffering Family 2-Steps to Preventing Pressure Ulcers Labor Intensive Huge Cost 11 Billion Other complications now possible! JCAHO Identify patients at risk Reliably implement prevention strategies for all patients who are idenitfied at risk Recoverable $? Lawsuits Identify Patients at High Risk Assessment of Risk Use of a standardized tool to assess risk on admission/once daily Use of multiple methods to visually cue staff as to which patients are at risk Stickers of chart or outside patients door Post days since last pressure ulcer data Change documentation tools to ensure admission & daily risk assessment Education of staff Ayello EA, et al. Advances in Skin & Wound Care. 2002;15(3):

20 The Bath: The First Line Of Defense Early Detection of Skin Injury nurse! Reducing Microorganism spread Who is Giving the Care? Who is doing the bath? Who is turning the patient? Who is changing the linen? Where should the focus of our education be? Efficiency & Effectiveness What Happens During a Bath in Addition to Cleaning? Assessments: Complete assessment of the skin Muscle tone & strength Range of motion Participation in ADL s physical & mental Pain assessment with activity Opportunity to communicate Opportunity to identify coping, feelings of powerlessness, depression, family support etc. Fatigue factor Goal: Improve the effectiveness of communication among caregivers. Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt... Nurse, I See Red Project Carol Balcavage, a WOC nurse from Lehigh Valley Hospital, wanted to decrease nosocomial pressure ulcers The goal empower non-licensed personnel to communicate issues to the RN responsible for the patient so skin issues could be addressed early, before they became costly! Method to educate non-licensed personnel on: 1. What is a pressure ulcer 2. What does a pressure ulcer look like 3. What are the risk factors 4. What can I do to prevent pressure ulcers? Conclusion: Overall rates of P.U. s declined housewide Early Identification/Communication & Rapid Intervention Implemented a bathing process with a skin check communication tool Role of the nonlicense personnel & role of the RN Education & auditing Bayerl K. et al. IHI 18 th Annual National Forum on Quality Improvement, Orlando FA, Dec

21 Early Identification/Communication & Rapid Intervention Strategies from the 5 million Lives Campaign Maintain healthy skin Prevent spread of resistant microorganism Manage moisture Minimize pressure Bayerl K. et al. IHI 18 th Annual National Forum on Quality Improvement, Orlando FA, Dec 2006 The Bath: The First Line Of Defense Early Detection of Skin Injury Efficiency & Effectiveness nurse! Reducing Microorganism spread Comparison of Basinless Bath to a Basin Bath Methodology: 60 patient in a progressive & surgical unit in an acute care institution compared basin bath vs. comfort bath Served as their own control with the right side of the body bathed with basinless bath/ left side with a basin bath Required a partial or complete bath conducted over 3 consecutive days Measured:skin condition using SCDF, nurse satisfaction & patient satisfaction Kron-Chalupa J et. al. Iowa City Veterans Medical Center Comparison of Basinless Bath to a Basin Bath Questions Overall preference Nurse satisfaction Time SCDF (skin condition) Basinless Bath 97% 100% 10 minutes Significantly improved Basin Bath 3% 0% 21 minutes Improved Kron-Chalupa J et.al. Iowa City Veterans Medical Center The Impact of Traditional Bathing with Soap & Water Natural or synthetic surfactants in soap remove the natural lipid layer during cleansing, compromising the natural infection barrier of the top layer of the skin..the epidermis Bar soaps may harbor pathogenic bacteria Skin ph requires 45 minutes to return to normal following a ordinary washing Drying of the skin Bettly FR. Br Med J. 1960; 5187: Kabara JJ. et. al. J Environ Pathol Toxicol Oncol ;5: Bryant RA, Rolstad BS. Ostomy & Wound Manage 2001; 47(6):

22 ph Balance of Soaps Traditional vs. Disposable Bath in Critically Ill Patients Methodology: 40 patients in Surgical, Medical and CT ICU received both baths on different days Compare basin bath vs. disposable Measure: time, quality of bath, microbial counts on skin (periumbilicus & groin, nurse satisfaction & costs Larson E. et al. AJCC. 2004; 13(3): Traditional vs. Disposable Bath in Critically Ill Patients Results: No difference in quality or microbial scores between the two bathing procedures Fewer products used*, lower costs, less time and higher nurse satisfaction with disposable bath* The Bath: The First Line Of Defense Early Detection of Skin Injury Efficiency & Effectiveness nurse! Reducing Microorganism spread p <.001 Larson E. et al. AJCC. 2004; 13(3): SOURCE CONTROL Reducing the Patients Risk of Infection Why Source Control? MRSA accounts for > 50% of hospital acquired S aureus infections 63% of S aureus acquired in the ICU Now being acquired in the community 126,000 hospitalized persons are infected annually (3.95 MRSA infections occur per 1000 hospital discharges) Over 5000 patients die as a result of these infections 2.5 billion excess health care cost attributable to MRSA 22

23 The Facts: Each Patient with MRSA Infection Results In. 9.1 days longer in the hospital Extra cost between $7,000-$32,000 more (average $20,000) A 4% higher inhospital mortality 5 Million Lives Campaign: Reducing MRSA Hand hygiene Decontamination of environment and equipment Active surveillance cultures Contact precautions for infected and colonized patients Practice the device bundles (VAP & BSI) Start in the ICU & have a clinical champion or opinion leader Grundmann H, et al. Lancet 2006;368: Practical Application of Recommendations Resources to ensure effective cleaning and decontamination Use of a check list Clean equipment that is transported from room to room Dedicated equipment in isolation rooms Reduce load Education of healthcare workers and support staff Boyce JM et al Infec Control Hosp Epidemiol. 1997;18: Huang SS, et al. Arch Intern Med 2006;166(18): Practical Application of Recommendations Active surveillance cultures (ASC s) are necessary on all admitted patients not as expensive as caring for the MRSA patient ASCs of the anterior nares capture 80% of colonized adults ASC s of the anterior nares & wounds capture 92% of colonized adults To truly capture the problem & begin to develop realistic solutions ASC s performed on admission, weekly and/or at discharge Provide real time notification of the staff so contact precautions can be implemented Karchmer TB, et al. J Hosp Infect, 2002;51(2): Getting Started: 5 Million Lives Campaign 2-Steps to Preventing Pressure Ulcers Identify patients at risk Reliably implement prevention strategies for all patients who are identified at risk Minimize pressure Manage moisture Nutrition & hydration Guidelines for Hand Hygiene in Health Care Settings CDC. Hand Hygiene Guidelines: MMWR 2002; 51(No. RR-16):[1 16):[1-45] 23

24 Bath Water: A Source of Nosocomial Microbiological Contamination Compared normal bath water with chlorhexidine bath water on 3 wards Without Chlorhexidine: All samples + for bacterial growth (14/23 > 10 5 cfu/ml) With Chlorhexidine: 5/32 grew bacteria with growth 240 to 1900 cfu/ml Gloved hands/bathing: objects touch grew significant numbers of bacteria Shannon RJ. et.al. Journal of Health Care, Compliance & Safety Control. 1999;3(4): Waterborne Infections Study Hospital tap water is the most overlooked source for nosocomial pathogens 29 evidenced-based studies present solid evidence of waterborne nosocomial infections Transmission occurs via drinking, bathing, items rinsed with tap water and contaminated environmental surfaces Anaissie E. et. al. Arch Int Med. 2002; 162: Waterborne Infections Study Conservative estimates suggest significant morbidity and mortality from waterborne pathogens Immunocompromised patients are at the greatest risk Recommendation I: Minimize patient exposure to hospital tap water via bottled water and pre-packaged, disposable bathing sponges Anaissie E. et. al. Arch Int Med. 2002; 162: Guidelines for Environmental Infection Control Practice hand hygiene to prevent the hand transfer of water borne pathogens and use barrier precautions (Cat 1A) Eliminate contaminated water or fluid environmental reservoirs wherever possible (Cat 1B) Clean and disinfect sinks & wash basins on a regular basis using an EPA-registered product (Cat 2) Evaluate for possible environmental sources ie colonization after use of tap water in patient care (Cat 1B) CDC. MMWR June 6 th, 2003, 52;No. RR-10 P. aeruginosa Outbreak: Tap Water the Culprit Single genotype 59 burn patients (hydrotherapy tank) 19 adult ICU patients (wash basins & water taps) 13/31 ICU patients (tap water) 5/14 surgical unit patients (tap water) Bathing with CHG Basinless Cloths Prospective sequential group single arm clinical trial 1787 patients bathed Period 1: soap & water Period 2: CHG cloth cleansing Period 3: non-medicated basinless cloth bath Trautmann M, et al. Infect Control.2005;33:S41Y9. Veron MO et al. Archives Internal Med 2006;166:

25 26 colonization's with VRE per 1000 patients days vs. 9 colonization's per 1000 patient days with CHG bath Veron MO et al. Archives Internal Med 2006;166: Veron MO et al. Archives Internal Med 2006;166: Strategies for Bathing to Reduce Source Control & Improve Skin Defense Basin Bath transmission of organisms time & effort # of supplies Harmful soaps Rough washcloths Cold/tepid water Scrubbing technique Strategies for Bathing to Reduce Source Control & Improve Skin Defense All ICU patients receive the CHG basinless bath All other patients receive the nonmedicated basinless bath unless admitted from a high risk location* All Patients in the ICU with a + swab for VRE, MRSA receive CHG basinless bath All other patients receive the nonmedicated basinless bath unless admitted from a high risk location* All ICU patients admitted from a high risk location* receive CHG basinless bath All other patients receive the nonmedicated basinless bath *High Risk Location: LTC, Chronic dialysis, past hospitalization within 30 days Getting Started: 5 Million Lives Campaign 2-Steps to Preventing Pressure Ulcers Identify patients at risk Reliably implement prevention strategies for all patients who are identified at risk Minimize pressure Manage moisture Nutrition & hydration Fortifying Host Defense Against Injury & Invasion Preventing Pressure Ulcers Skin Inspection: Bathing Minimize Pressure Manage Moisture: Incontinence Care 25

26 What is Incontinence Associated Dermatitis? Pilot Survey of Incontinence and Perineal Skin Injury Prevalence in Acute Care Inflammatory response to the injury of the water-protein-lipid matrix of the skin Caused from prolonged exposure to urinary and fecal incontinence Physical signs on the perineum & buttocks Erythema, swelling, oozing, erosion or denudation of superficial layers, vesiculation, crusting and scaling Gray M, et al. J Wound Ostomy Continence Nurs, 2007; 34(1): Junkin J, et al. Poster at Clinical Symposium on Advances in Skin and Wound Care. Oct 2005, Las Vegas NV. Pilot Survey of Incontinence and Perineal Skin Injury Prevalence in Acute Care 27% Perineal Dermatitis 976 Total Number of Patients Surveyed 198 Number of Incontinent Patients 33% Pressure Ulcers 18% Fungal Infection Junkin J, et al. Poster at Clinical Symposium on Advances in Skin and Wound Care. Oct 2005, Las Vegas NV. Pressure Ulcers Risk Factors Patients with fecal incontinence were 22 times more likely to have pressure ulcers than patients without fecal incontinence. When impaired mobility is combined with fecal incontinence those odds rise to 37.5 times more likely. Maklebust & Magnan. Adv in Wound Care. 1994;7(6):25-42 Pressure Ulcer Prevention Guidelines for Incontinence Care Challenges of Incontinence Care Clean your skin as soon as it becomes soiled. Use a protective cream or ointment on the skin to protect it from wetness. Use an incontinence pad and/or briefs to absorb wetness away from the skin. NPUAP (National Pressure Ulcer Advisory Panel) 1992 NIH (National Institutes of Health) Standards of Practice 2001 AHRQ (Agency for Health Care Research and Quality) formerly AHCPR 1992 WOCN (Wound, Ostomy, Continence Nurses Society) 2003 Individually packaged products are not always within reach during incontinence clean up Risk of unprotected skin is high Cleaning and protection usually done as separate activities Washcloths often become disposable when soiled Increased risk for contamination Not all products have a chemical barrier 26

27 Process Variation Your incontinence care products don t work either - if they aren t being used! 32 State Survey on Perineal Skin Care Protocols Methodology: 76 protocols form Acute and LTC facilities Analyzed to determine correlation with evidence-based practices per the literature HPIS (Healthcare Products Information Services) data used to evaluated amount sold to each facility HPIS data compared to urinary & fecal incontinence prevalence data Results: All 76 protocols lack 1 or more interventions considered important in perineal care 75% included use of skin protectants Analysis against HPIS data and incontinence data suggests under utilization of skin protectants (< 10 cents per day vs. $1.35) Nix D et al. Ostomy/Wound Management 2004;50(12):59-67 Evaluating the Efficacy of a Uniquely Delivered Skin Protectant and Its Effect on the Formation of Sacral/Buttock Pressure Ulcers Methodology: Retrospective/prospective quasi-experimental study 57 bed LTC Data collected 3 months before use & 3 months following conversion Demographics comparable between groups Age, LOS, mobility in bed, transfer between surfaces, incontinence of bowel/bladder, BMI, albumin and concurrent disease scale Pre-data revealed 12 residents with incontinence developed 15 sacral stage 1 & 2 ulcers. Monthly incidence rates over 9 months 4.7% Clever K. OWM. 2002;48(12): Clever et al. Pressure Ulcer Study Evaluating the Efficacy of a Uniquely Delivered Skin Protectant and Its Effect on the Formation of Sacral/Buttock Pressure Ulcers Average Monthly Incidence of Sacral/Buttock Pressure Ulcers Old standard of care compared to use of Comfort Shield as preventative* 4.7% Old Standard of Care 0.5% New Standard of Care 89% Reduction in Incidence July 2000 to May to July 2001 March 2001 Feb to April 2002 *No significant differences in impact variables between groups Clever K. OWM. 2002;48(12): Treatment of Incontinence Associated Dermatitis Barrier Non alcohol-chemical barrier Zinc or petroleum based Fecal containment devices Bag Tube Indications: Treatment of injury created by incontinence of urine or stool Bard FCD Fecal Containment Device Provides a method for managing fecal incontinence. Remains securely attached to ambulatory patients Kit contains collection bag, closure clip, drainage bag adapter, powder adhesive and adhesive remover. 27

28 New Jersey Hospital Association Collaborative: No Ulcers Save Our Skin: Six Sigma Project N utirition and fluid status O bservation of skin U p and walking or turn & position L ift, don t drag skin C lean skin & continence care E levate heels R isk assessment S upport surfaces for pressure redistribution Ayello EA presented 10/22/06 Courtney BA, et al. Nursing Management 2006;37(4):35-46 The Clinical & Financial Outcomes 15 million CVC days occur annually in US ICU s NNIS BSI s range from 2.9 to 11.3 per 1000 catheter days Mean BSI rate is 5.3/1000 catheter days 80,000 catheter-associated BSI s annually in the ICU s 250,000 catheter-associated BSI s annually in hospitals The Clinical & Financial Outcomes Mortality range from no change to a 35% increase $34,508 to $56,000 to treat 1 catheterassociated BSI in the ICU 25,000 to treat 1 catheter-associated BSI in the hospital Annual financial outcome for CVCassociated BSIs is between $296 million & $2.3 billion CDC. Prevention of Catheter Infection: MMWR 2002;51 (No. RR-10):[1-29] CDC. Prevention of Catheter Infection: MMWR 2002;51 (No. RR-10):[1-29] Risk Factors Associated with Increased Infection Rates Cutaneous colonization of insertion site Moisture under the dressing Prolonged catheter time Technique of care and placement Appropriate staffing levels (Cat 1B) Focus on care practices that reduce the risk factors; prep & clean the site with the most effective barrier & use full sterile barrier precautions for insertion CDC Guidelines for Insertion Site Preparation Sterile technique; cap, mask, gown, gloves, and a large sterile drape Recommend 2% Chlorhexidine be the cleanser of choice if available CDC. Prevention of Catheter Infection: MMWR 2002;51 (No. RR-10):[1-29] 28

29 Efficacy of Maximal Sterile Barrier Precautions Local Infection CVC-BSI Minimal* 7.2% 3.6% * sterile gloves, small sterile drape Maximum** 2.3% 0.6% **cap, mask, sterile gloves, sterile gown, head/body of patient covered with large sterile drape What are Maximal Barrier Precautions? For Provider: Hands hygiene Non-sterile cap and mask All hair should be under cap Mask should cover nose and mouth tightly Sterile gown and gloves For the Patient Cover patient s head and body with a large sterile drape Raad II, et al. Infect Control Hosp Epidemiol 1994;15:231-8 Chlorhexidine vs. Povidone Iodine for Catheter Site Care Chlorehexidine Gluconate 2% with Isopropyl Alcohol 70%: Why is a Better Barrier than Betadine? Rapid bactericidal activity (affective after 30 sec vs. 2 min) Persistent activity on the skin & cumulative Maintains its activity in the presence of other organic material Low allergic or toxic response None or mild systemic absorption Ann Intern Med 2002:136: Chalyakunapruk N. et al. Ann Intern Med. 2002;136: Cleansing Motion Betadine: prep done in circular motion from center to periphery Betadine not an antiseptic until dry Center to periphery necessary to prevent going back & forth over the site and contaminating the cleaned area Chloraprep: Prep motion back & forth and up & down in order to clean multiple layers of the skin An antiseptic when wet Cross over of previously cleaned area does not cause contamination If circular motion used, must do a forward & reverse clean & penetrate 1-3 layers of epidermis for sustained action CDC Recommendations for Site Care Use either sterile gauze or transparent dressing (High MVP rate) to cover the site (Cat 1A) If you place the 2x2 under the transparent it becomes a gauze dressing Change gauze q 2 days & transparent q 7 days (Cat 1A) Replace dressing if damp, loosened or soiled or inspection of the site is necessary Chlorhexidine/Alcohol skin prep recommended for every dressing change. Do not routinely apply antimicrobial ointments to the site (Cat 1A) CDC. Prevention of Catheter Infection: MMWR 2002;51 (No. RR-10):[1-29] 29

30 CDC Recommendation for Catheter Replacement Replace all catheters inserted under emergency conditions within 48 hours Do not routinely replaced non-tunnelled CVC catheters PA catheters should be changed no more frequently than every 7 days. Use a guidewire assisted catheter exchange if infection is not suspected. Do not use guidewire technique to replace catheters if there is a clinical suspicion for CR-BSI. Routine culture of the tip is not recommended. For arterial lines: changed no more frequently than q 5 days along with the transducer and tubing. CDC. Prevention of Catheter Infection: MMWR 2002;51 (No. RR-10):[1-29] What Site is Best? RCT of femoral and SC lines in the ICU 145 pts femoral/144 pts SC Outcomes Higher rate of infectious complications in femoral grp: 19.8% vs 4.5% (p<.001) Higher rate of thrombotic complications in femoral grp: 21.5% vs 1.9% (p<.001); complete thrombosis 6% vs 0% Similar rates of mechanical complications: 17.3% vs 18.8% (p=ns) JAMA 2001,286: CDC Recommendation for Use of Impregnated Catheters Consider use of impregnated catheter if after full adherence to the guidelines, there is still an unacceptability high rate of infection Type of catheter under debate Impregnated Cuff Flowers et al. JAMA, 1989;261:878 Maki et al. AM J Med, 1988;85:307 Babycos et al. JPEN, 1993;17:61 Bonanitz et al. Am Surg, 1991;57:618 Results: Significant reduction in infection rates (Unresolved) Impregnated Catheters Jansen et al. J of Hosp Infect. 1992;222:93 Kamul et al. JAMA, 1991;265: 2364 Ball et al. CCM 1996;23:A250 Darouiche RO. et al N Engl J Med 1999;340:1-8 Results: Decrease CVC infection rate with increased catheter duration Minocycline/rifampin better than Chlorhexidine/silver sulfadiazine in preventing CVC-associated BSI QUALITY IMPROVEMENT PROJECT USING THE EVIDENCE 30

31 Medical Critical Care Project Structures to Facilitate the Change Initial project 1996 CDC guidelines Baseline data: 6.8 per 1000 catheter days with 90% device utilization (50%) Pre-change practice: Gown, gloves, towels Every 4 day line change Gauze dressing/changed q 4 days As many punctures as it took to get the job done Standardization on how BSI s are measured New strategy for collecting denominator National guidelines with graded evidence Unit collaborative practice group Multiple drivers of change Department chair, Unit Medical Director, Unit Nursing leadership, Unit practice committee staff nurses Nosocomial Infections: Central Lines Implementation of CDC Guidelines 1996 No routine changes of central lines If infection suspected, perform guidewire exchange and culture the tip If tip positive, remove line and perform a new stick No routine dressing changes/use of transparent dressing to view the site Full barrier precautions Three strikes and the most experience practitioner places the line (HFH guideline) Obstacles to Implementation Variations in practice within the different areas of the hospital Resident & float nurse education Equipment type, location and restocking process Empowering nurses to stop procedure if correct sterile barrier not in place getting the buy in Planning for the Change Invasive line carts stocked with the right equipment Monthly education during resident orientation Support material at the bedside on how to do the right thing Product evaluation by staff to look at transparent dressings Role modeling by leadership on holding physicians accountable for doing the right thing Nosocomial Infections: Central Lines Device Utilization Benchmark > 50 MICU Central Line data (Pre change) > 90 HFH MCC Central Line data (Post change 2000) HFH MCC Central Line data (Post change 2002) HFH MCC Central Line data > 90 > 90 Bloodstream Infection * 1.33 Rank Comparison 50-75% 50-75% 10-25% 10-25% * Significant at p <

32 The Outcome 31 prevented BSI s per year $34, $56,000 per BSI infection Cost avoidance of $1, to $1,736, Benchmarking with NNIS data Presented data at quality day and at a national meeting Shared with other ICU s Monthly data reported to the staff 2002 New Guidelines New Practice CHG prep for both insertion and dressing care (Category 1A) Full sterile barrier (hat, gown, glove, mask and full drape sheet) Category 1A No guidewire exchange unless for mechanical reasons (Category 1B) Avoid unnecessary lines CDC. Prevention of Catheter Infection: MMWR 2002;51 (No. RR-10):[1-29] 2002 New Guidelines New Practice Lessons Learned Standardization across all ICU s in both practice & equipment is necessary to reduce process variation Line cart is not enough to ensure the correct procedure is done Old habits are hard to break so remove the opportunity New Practices Guidelines reviewed and adopted at institutional critical care Insertion equipment available in one kit Remove products to prevent use Bundle worksheet implemented for accountability Blood Stream Infection (BSI) Bundle Remove/Avoid unnecessary lines Hand hygiene Maximal barrier Chlorahexadine for skin prep Avoid femoral lines Scan in Work sheet To Prevent Mistakes Create culture of safety Improve Processes Reduce complexity Create independent checks for key processes Automate Training to senior medical staff and residents Education to nurses and respiratory therapists Nurses/RT assist with lines insertions Empower nurses/rt to stop line placement 32