FHA Call to Action: Eliminating Infection-Related Ventilator-Associated Complications IVAC Bi-Monthly Webinar #2 May 3, 2018

Transcription

1 FHA Call to Action: Eliminating Infection-Related Ventilator-Associated Complications IVAC Bi-Monthly Webinar #2 May 3, 2018

2 Agenda FHA MTC Call to Action for IVAC Data Review HRET HIIN Hospital Peer Sharing Meryl Montgomery, RN, MSN Sonya Floyd, RN, BSN,CIC Valerie Fox, RRT Medical Center Navicent Health Available Resources Closing Remarks

3 SAVE LIVES: Cleaner hands are safer hands May 5, 2018 For resources and more information, visit the World Health Organization s World Hand Hygiene Day page

4 Call to Action FHA Quality Committee FHA Annual Meeting CEO Call to Action

5 How are We Doing? FHA Board Call to Action Baseline Rate = 2.15 Rate per 1, Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 FL Rate # Reporting Effective date: April 13, 2018 Feb 2018

6 Polling Do you round daily to ascertain both bundle compliance? Do you also assess for appropriative indications during rounds? Do you use endotracheal tubes with subglottic secretion drainage? Do you investigate each IVAC occurrence? Which condition is the most frequent contributor to your IVAC cases? Trauma Sepsis Abdominal Trauma Thoracic Trauma Other

7 H.A.C.ING VAE S FHA SONYA FLOYD, RN, BSN, CIC VALERIE FOX, RRT MERYL MONTGOMERY, RN, MSN

8 Medical Center Navicent Health Macon, GA 637 beds, 5 adult ICUs (86 beds) VAE, VAE VAP, VAP

9 Aim and Background Aim How much improvement? By when? For whom? By 9/30/17, decrease Ventilator Associated Events 30% (from 74 to 52) in the five adult ICUs. Background Why this project and why now? While VAP rate <10, the five adult ICUs underperformed compared to NDNQI and HRET HIIN benchmarks. Ventilator utilization rates on the rise with higher acuity; need to focus on preventing VAE. 9

10 But, our PVAP rate is low! Resting on our laurels of low VAP for several years complacency in 5 adult ICUs (86 beds) In 2013, CDC criteria changed to VAE= VAC+ IVAC+ PVAP PVAP no longer the only issue- keeping up with the change Impact of bench-marking: 70% 60% 50% 40% 30% 20% 10% HRET HIIN: our VAE rates nearly double average of hosp average NDNQI-4Q under-performance % ICUs that outperform NDNQI >500 bed mean 0% 10 1Q15 2Q15 3Q15 4Q15 1Q16 2Q16 % out-perform target

11 Methodology VAE task force with MD, executives, interdisciplinary Use of 6 sigma DMAIC and PDSA/ rapid cycle change Deep dive RCA trends Data- benchmark HRET HIIN, NDNQI Process and outcome measures Multi-modal education Front line and leader engagement Participation in HRET HIIN AI fellowship

12 Key Performance Measures Outcome Measures: How is the system performing? What are the results? VAE incidence overall and by unit VAC, IVAC, VAP incidence rates Benchmark comparisons: GHA HEN, HRET HIIN, NDNQI Process Measures: Are the parts or steps in the process or system performing as planned? CLRT, Turn q 2 hr, HOB 30, CHG, oral hygiene, hi-lo ETT, separate oral/ ETT suction- observation/ interview/ documentation audit Balance Measures: What happened to the system as we improve the outcome and process measures? Ventilator days LOS for ventilator patients Mortality rate for ventilator patients 12

13 Driver Diagram 13

14 Key Changes Since Fall 2016 Re-education Documentation parameters PEEP FiO2 Transport protocol PAD (Pain Agitation Delirium) protocol Focus on basics- hand hygiene, vent bundle, mobility Hardwired accountability Adequate material resources Closed ICUs (intensivists) Standardize all changes across ICUs, services 14

15 VAE Improvement Timeline

16 16 Data driven timeline

17 Communication of burning platform of VAE reduction Tied to goals in performance review Post/ review data, transparency Committees, staff meetings, huddles Involvement of front line staff in solutions/ engagement Education of all levels Paying attention to expected behavior Administrative, interdisciplinary involvementincorporated into rounds- PAD, bundles, mobility, de-escalation, alternatives Newsletters, BB, signs, Potty Training

18 RCA form

19 Vent Bundle monitoring tool

20 Transport monitoring tool

21 Outcomes

22 KPI: VAE Incidence Rates/month all adult ICUs 14 VAE Incidence 8/16-3/18 VAE/1000 pt days VAE/1000 pt days

23 #IVAC/PVAP over time 40 #IVAC PVAP 2015-FY #IVAC #PVAP YTD18

24 ICU mobility: with a smile on his face!

25 Cost savings Reduced VAE by 60% ( , ) Met GHA HRET HIIN two year 20% target reduction in year one (our baseline was 84) HRET HIIN cost calculator= $ 21,000 / VAC Total estimated savings due to VAE: $987,000

26 Benchmarking HRET HIIN benchmarks both IVAC and VAC (=CDC VAE definition which includes VAC, IVAC, VAP) VAC- FiO2 and/or PEEP for 2 days IVAC- FiO2 and/or PEEP for 2 days, infection S/S (T >38, wbc>12,000), antibiotics started in infection window/ continued for 4 days

27 Adult ICU vs HRET HIIN VAE-1

28 HRET HIIN VAE IVAC rate

29 Adult ICU vs NDNQI >500 bed units. N 174 units 120% VAE: % Adult ICU outperform NDNQI >500 bed mean rolling 8 quarters 100% % units outperform NDNQI + 80% 60% 40% 20% 0% 4Q15 1Q16 2Q16 3Q16 4Q16 1Q17 2Q17 3Q17 4Q17 % out-perform 60% 20% 80% 60% 100% 80% 100% 100% 100% target 51% 51% 51% 51% 51% 51% 51% 51% 51%

30 Sustaining the drop! #1 accountability Accountability Interdisciplinary team Interdisciplinary bedside rounds Nursing leadership rounds- PAD? Mobility? Intensivist model- 4 of 5 closed units by spring

31 Having what staff need Portable suction machines Portable vents- circuit breaks 100% % pts transport on vent vs "ambu" 95% 80% 60% 40% 39% Sufficient suction regulators Hi/Lo ETT Cuff manometers 20% 0% Jan-Jun

32 32 Back to the Basics- hand hygiene

33 Transport protocol audits RRT supv audit use of transport protocol 79% in VAE correlated with transport #/% of patients w VAEs with transports off unit within 4 days of event 35 80% #/% VAE pts w transports off unit % 60% 50% 40% 30% 20% 10% 0 pre implement post implement # VAE w transports 31 3 % VAEs 72% 15% 0% 33

34 How about bundle compliance? Average of 200 vent pts/ week are audited observation/ documentation review- all units Average 98%, minimum 92.% compliance 34

35 Celebrating milestones Respiratory staff and managers- Pay for performance- BPR goals Individual and group Good Catch, +feedback re posted data Admin and leadership rounds- observations and feedback Huddles, staff meetings, interdisciplinary rounds Pizza party for overall reduction in VAE and bundle compliance

36 Goal vs Outcome Goal Results Stat us VAE in five adult ICUs by 25% in 12 months by 44.6% (from 74 to 41) met transport-related VAE by 25% by 79% met Achieve ventilator bundle compliance >90% Out-perform benchmark NDNQI the majority of quarters from 4Q16-4Q17 Out-perform benchmark HRET HIIN majority of months since October 2016 Average 98%. Lowest at 92.6% compliance. Out-performed the past 6 quarters Out-performed all project organizations 13 of 16 mos. met met met 36

37 Reflections/ Lessons Learned Lessons Learned Overcoming key barriers build in EMR- refocus IT and engage Executive Sponsors cultural change to embrace need to reduce VAE- leadership change, benchmark comparison, reporting through HARM Committee structure prior unsuccessful attempt to implement mobility and PAD- nurse-driven mobility protocol, PAD in EMR Surprises Key clinical leaders reluctant to adopt changes Failure of timely documentation triggered VAEs Insufficient working suction regulators, bedside patient chairs, among others LOS and vent days did NOT drop as VAE rate decreased. We did see a 12% in vent 3d mortality Advice Lessons Learned Complete RCAs and establish trends, use national benchmarks to drive initiatives Evaluate documentation to assure not causative of VAE Develop transport protocol to eliminate procedure related breaks in circuit Keep an eye on all KPIs 37

38 2018 action items: Firm up PAD utilization via intensivists, Pharmacy, Nursing staff Implement mobility protocol Build EMR reports for PAD/ mobility Expand usage of hi-lo ETT. Regular status check with front line staff re barriers and needed resources. 38

39 2018 continued Real time hip phone for alerts for vent setting changes in PEEP and FiO2 Expand electronic hand hygiene monitoring system from CVICU to all ICUs Ongoing education and monitoring Intensivist model, including NP, expanded to 3 of 5 ICU s Dedicated ICU PT s to support mobility

40 Questions? Contact us! Sonya Floyd Valerie Fox Meryl Montgomery

41 FHA IVAC Resource Toolkit

42 Contact Us We are here to help! SAVE THE DATE! IVAC Bi-Monthly Webinar #3 July 12pm ET Registration: