Do No Harm: Evidence Based Prevention Strategies to Reduce Readmission

Transcription

1 Do No Harm: Evidence Based Prevention Strategies to Reduce Readmission Kathleen M. Vollman MSN, RN, CCNS, FCCM, FAAN Clinical Nurse Specialist / Educator / Consultant ADVANCING NURSING kvollman@comcast.net Northville Michigan ADVANCING NURSING LLC 2016

2 Disclosures for Kathleen Vollman Consultant-Michigan Hospital Association Keystone Center Consultant/Faculty for CUSP for MVP AHRQ funded national study Subject matter expert CAUTI, CLABSI, HAPU, Sepsis, Safety culture Consultant and speaker bureau for Sage Products LLC Consultant and speaker bureau for Hill-Rom Inc Consultant and speaker bureau for Eloquest Healthcare

3 Session Objectives Describe the forces within the health care environment that are driving the need to resuscitate the basics Outline a screening process for early recognition of septic resident and initial management Define key evidence based care practice that reduces pneumonia and CAUTI s Understanding the fundamentals of Antimicrobial Stewardship and resources available for implementation of a AMS program

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5 The Requirements for Long-Term Care (LTC) Facilities Must Meet in Order to Participate in the Medicare or Medicaid Programs Person-Centered Care Quality Development of a QI system-quality assurance and quality improvement Facility Assessment Competency-Based Approach Alignment with HHS priorities Comprehensive Review and Modernization Implementation of Legislation Education/Outreach/NPC/Downloads/Compliant-LTC-PP-for-MLN-National- Provider-Call.pdf

6 Align with Current HHS Initiatives Reducing unnecessary hospital readmissions In NQF# 2510: assesses the risk standardize rate of all cause, unplanned inpatient hospital readmissions for Medicare fee-for-service SNF patients within 30 days of discharge from a prior proximal hospitalization A prior proximal hospitalization is defined as an admission to an inpatient prospective payment system hospital, critical access hospital or psychiatric hospital Reducing the incidences of healthcare acquired infections Improving behavioral healthcare Safeguarding nursing home residents from the use of unnecessary psychotropic (antipsychotic) medications. Education/Outreach/NPC/Downloads/Compliant-LTC-PP-for- MLN-National-Provider-Call.pdf

7 Hospitalization by Age: US Levant S, Chari K, DeFrances CJ. Hospitalizations for patients aged 85 and over in the United States, NCHS data brief, no 182. Hyattsville, MD: National Center for Health Statistics

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9 Common Causes of Hospitalization Adults aged 85 and over: U.S. Levant S, Chari K, DeFrances CJ. Hospitalizations for patients aged 85 and over in the United States, NCHS data brief, no 182. Hyattsville, MD: National Center for Health Statistics

10 Mortality and Cost Sepsis is a leading cause of death and the most expensive disease in U.S. hospitals Mortality increased 26% in patients and 38% in those 85 years of age. 10

11 Discharge Disposition After Sepsis Septicemia or sepsis Other diagnoses Disposition Percent Routine Transfer to other short-term 6 3 care facility Transfer to long-term care institution Died during the 17 2 hospitalization Other or not stated 8 6 Total Difference is statistically significant at the 0.05 level. SOURCE: CDC/NCHS, National Hospital Discharge Survey,

12 Total All-Cause, 30 day Readmissions and Aggregate Cost by Payer

13 Chang DW; Tseng CH; Shapiro MF. Critical Care Medicine. 43(10): , 2015 Oct. 13 3

14 Michigan 2014 SNF Readmission Statistics Selected Diagnosis Codes for All Cause Readmissions Congestive Heart Failure (CHF) 28.57% Acute Myocardial Infarction (AMI) 24.77% Chronic Obstructive Lung Disease (COPD) 26.76% Dialysis/End Stage Renal Disease 38.27% Pneumonia 21.7% Sepsis 26.42% All-Cause Readmission Within 30 Days of Index Discharge from State of Michigan Acute Care Facilities by Selected Population Segments, State of Michigan Medicare Fee- For-Service (FFS) Beneficiaries [Q1, Q4, 2014 ] MPRO July 2015

15 Readmission Rates Among D/C Location 07/ /2015

16 South Dakota Readmissions

17 Screen for Sepsis and Create and Early Management Program

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19 Sepsis Impact on the Elderly Age itself independent risk factor for death More likely admitted to ICU Highest mortality in the old elderly (85+) Prolonged hospitalization Post Sepsis Impact Contributes to Cognitive decline Contributes to Physical long term disabilities (walking, ADLs, and IADLs) Crit Care Med Jan;34(1):15-21

20 Sepsis Recognition Challenges Febrile response not present in 47% of elderly Temperature >101 generally indicates severe infection Delirium occurs in 50% Common symptoms: altered mental status, delirium, of older adults with sepsis weakness, anorexia, malaise, falls, and urinary incontinence Dementia can make obtaining a history challenging Positioning for tests due to osteoarthritis presents challenges Girard et al Insights into severe sepsis in older patients: from epidemiology to evidence-based management. Clin Infect Dis 2005; 40:

21 Severe Sepsis: Defining a Disease Continuum Infection SIRS Sepsis Severe Sepsis Adult Criteria A clinical response arising from a nonspecific insult, including 2 of the following: Temperature: > 38 C or < 36 C Heart Rate: > 90 beats/min Respirations: > 20/min WBC count: > 12,000/mm 3, or < 4,000/mm 3, or > 10% immature neutrophils SIRS = Systemic Inflammatory Response Syndrome Bone et al. Chest. 1992;101: SIRS with a presumed or confirmed infectious process Sepsis with 1 sign of organ dysfunction, hypoperfusion or hypotension. Examples: Cardiovascular (refractory hypotension) Renal Respiratory Hepatic Hematologic CNS Unexplained metabolic acidosis Shock

22 Definitions Infection Sepsis: infection plus 2 or more SIRS Severe Sepsis: infection plus 2 or more SIRS plus new organ dysfunction Septic Shock: severe sepsis with a lactic acid greater than or equal to 4mmol/L OR continued hypotension (systolic BP<90 or 40mmHg decrease from their baseline) after initial fluid bolus (30ml/kg)

23 CORNERSTONES OF MULTIDISCIPLINARY MANAGEMENT OF SEVERE SEPSIS Prevention Screening and Early Identification Early Intervention: Source control, Blood cultures and broad spectrum antibiotics Initial Resuscitation Bundle Septic Shock Bundle at the hospital

24 SEP-1 SEP-1 TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION : 1. Measure lactate level 2. Obtain blood cultures prior to administration of antibiotics 3. Administer broad spectrum antibiotics 4. Administer 30ml/kg crystalloid for hypotension or lactate 4mmol/L time of presentation is defined as the time of earliest chart annotation consistent with all elements severe sepsis or septic shock ascertained through chart review.

25 SEP-1 SEP-1 TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION: 5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) 65mmHg 6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was 4 mmol/l, re-assess volume status and tissue perfusion and document findings according to table Re-measure lactate if initial lactate elevated.

26 Screening When do you screen? Upon admission, daily, with condition change or stop and watch alert First step: Does the patient have a known or suspected infection?

27 Screening Second Step: Does the patient have signs of systemic inflammatory response syndrome (SIRS)?

28 Screening Third Step: Does the patient have any new organ dysfunction in an organ system distant from site of infection?

29 Screening If screens positive for severe sepsis, then follow the SBAR at bottom of tool

30 ACT FAST! Early Detection of SEPSIS requires fast action STOP AND WATCH (INTERACT) S Seems different than usual T Talks or communicates less O Overall needs more help P Pain- new or worsening; Participated less in activities A Ate less N No bowel movement in 3 days; or diarrhea D Drank less W Weight change A Agitated or nervous more than usual T Tired, weak, confused, or drowsy C Change in skin color or condition H Help with walking, transferring, and toileting more than usual

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32 The Importance of Early Detection Efforts to just treat recognized sepsis alone is not enough. A critical aspect of mortality reduction has been pushing practitioners to identify sepsis early. It may well be that earlier recognition accounts for much of the signal in mortality reduction and partially explains sharply increasing incidence. Without recognition that the clock is ticking, there is simply no incentive to recognize a challenging diagnosis early. Levy MM, Dellinger RP, Townsend SR,et al. Crit Care Med Feb;38(2): Gaieski 13 DF, Edwards JM, Kallan MJ, et al. Crit Care Med Feb 25

33 Early Recognition and Management of Sepsis Overview of Training Program Example Monthly one hour face to face meetings Jan to June Monthly site specific coaching calls, starting in February to provide individualized support Provide training and educational materials Defined process and outcome measures to evaluate success of the program

34 Roles and Responsibilities Each facility must have a team identified to do this work Should include: medical director, DON, infection prevention nurse at a minimum Team work through action plan provided in specified timeframe Implement screening process Implement early management of sepsis process Educate staff on screening and management processes Collect defined process and outcome data

35 Sepsis Early Identification Action Plan Step Who? When? Status 1. Get team together to create early identification process 2. Develop screening tool/process 3.Get medical staff support for screening and early intervention 4. Develop and implement educational plan for sepsis and screening 5. Develop patient & family education process and tools 6. Develop an infection prevention education plan for PNA, UTI, and CLABSI, 7. Evaluate screening: define outcome and process metrics

36 Pneumonia Statistics Leading cause of death due to infectious disease in the USA, sixth leading cause of death overall >65, leading cause for NH. >900, 000 CAP cases in population over 65. Mortality rate in USA about 5%. Estimated HCAP per 1000 NH residents. 1st or 2 nd most common infection in NH (13-48%) Mortality rate 13-41% if NH resident. Medicare paid 17.4 billion in 2004 for readmissions (about 17%).

37 STATISTICS. Out of 12 million fee-for-service Medicare beneficiaries: 20% readmitted within 30 days 34% readmitted within 90 days 54% readmitted within one year 68.9% discharged with medical condition died within a year 53% discharged with surgical condition died within one year.

38 Preventing Infection Pneumonia

39 PNEUMONIA Infection of one or both lungs, lobar, segmental, or bronchial More than 30 different causes Can be serious, even fatal, especially for very young/very old. Pneumococcal vaccine, influenza vaccine, and ACE inhibitors may have protective effect.

40 Epidemiological & Risk Factor Categories for Institutional Pneumonia Residents >75 years old at 6x higher risk 33 out of 1000 nursing home residents require hospitalization for pneumonia per year vs out of 1000 elderly living in the community per year Leading cause of death in nursing home residents Annual cost of nursing home acquired pneumonia exceeds $8 billion dollars Factors that increase bacterial burden or colonization Factors that increase risk of aspiration Terpenning M. et al. JAGS 2002;50: Murder RR. Am J Med 1998;105:

41 The Older Adult At Risk Cognitively impaired Diminished swallow and cough reflex Functionally dependent Dry mouth Aspiration Multiple medications High rate tooth decay Behavioral problems during oral hygiene Lack of immunization Research Dissemination Core. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center; 2002 Nov. 48 p. Marik PE. et al. Chest; 2003; 124:

42 Significant Independent Predictors of Aspiration Pneumonia Dependant for feeding Dependant for oral care Number of decayed teeth Tube feeding Multiple medical diagnoses Number of medications Dry mouth Smoking Langmore SE. et al. Dysphagia 1998;13:69-81

43 Pathogenesis Prevention Germs in Mouth Dental plaque provides microhabitat Bacteria replicate 5X/24 hrs Aspirated into Lungs Most common route 50% of healthy adults micro-aspirate in sleep Weak Defenses Poor cough Immunosuppressed Multiple co-morbidities

44 Formation of Biofilm Over 13 Hours Loesche, W. 2012

45 Pathogenesis Prevention Germs in Mouth Dental plaque provides microhabitat Bacteria replicate 5X/24 hrs Aspirated into Lungs Most common route 50% of healthy adults micro-aspirate in sleep Weak Defenses Poor cough Immunosuppressed Multiple co-morbidities

46 Pathogenesis Prevention Germs in Mouth Comprehensive oral care Oral care protocol that includes all patients Aspirated into Lungs Swallow screens Tube feeding protocols Head of bed elevated Weak Defenses Lung expansion/mobilize Adequate nutrition Serum glucose target range Immunization

47 Risk Factor Categories for Health Care Acquired Pneumonia Factors that increase bacterial burden or colonization Factors that increase risk of aspiration

48 Why NV-HAP? HAP 1st most common HAI in U.S. Increased morbidity 50% are not discharged back home Increased mortality 18%-29% Extended LOS 4-9 days Increased Cost $28K to $109K 2x likely for readmission <30 day Understudied, under-addressed Focus has been on the other HAP VAP Surveillance not required.yet Kollef, M.H. et.al. (2005). Chest. 128, ATS, (2005). AmJ Respir Crit Care Med. 171, Lynch (2001) Chest. 119, 373S-384S. Pennsylvania Dept of Public Health (2010)

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50 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:

51 Practices in Oral Care Culture cup, ½ H2O2, ½ sterile H2O little bit of mouthwash Lemon glycerin swabs Toothette with water &/or mouthwash No oral care That s not the way we do it here!!!

52 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 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:

53 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 No Oral Oral Care p value Febrile 29% 15% p<.01 Pneumonia 19% 11% p<.05 Death 16% 7% p<.01 MMSE Increase p<.05 Yoneyama et al. JAGS. 2002;50:

54 Impact of Oral Care on HAP Kaneoka A, et al Infect. Control Hosp. Epidemiol, 2015;36(8):

55 Oral Care Reduces Pneumonia In Nursing Homes Residents Oral care improves swallowing and cough reflex sensitivities Watando A. et al. Chest, 2004; 126: )

56 BRUSH & SWAB 77% more clean proximal sites with brushing 44% more clean crevice sites with brushing Benefit of brushing is directly correlated with technique Foam swabs could not remove plaque from sheltered areas on or between teeth Pearson LS. et. al. J of Adv Nursing. 2002;39(5): Toothbrush; grade D, Swabs; unresolved, Use of flexible suction catheter post oral cleansing; Grade D (Berry AM et al. AJCC, 2007;16: )

57 Brushing Removes Plaque Methodology: 34 volunteers. Double-blind crossover study. Examine the amount and % of plaque removed with a single brushing with 3 solutions (Sodium Bicarb, Crest, Cologate). Results: Significantly higher % of plaque removed with one minute brush using Sodium Bicarb. Mankodi et al. J Clin Dent. 1998; 9(3):57-60

58 Proposed Oral Care Plan Independent Dependent on Oral Care Weekly assessment Encouragement to perform tooth brushing /denture cleaning minimum x2 daily Ability to expectorate Assist with brushing teeth/clearing out debris & /or cleaning dentures using with CPC after each meal/night & moisturize following cleaning Unable to expectorate Brush teeth (dentures) /clear debris using suction toothbrush am & pm with CPC followed by moisturizing Assist oral cleansing (dentures)/clear debris after lunch & dinner using a suction swab with CPC followed by moisturizing denture cleaning

59 Oral Care Protocol

60 Your Role in Preventing Pneumonia Proper hand hygiene Comprehensive Oral Care Prevention of Aspiration Swallow screens Proper positioning during eating/feeding and sleep Immunizations Mobility/ Lung expansion Adequate nutrition

61 PNA Prevention Action Plan Step Who? When? Status 1. Assess current infection prevention practices for PNA. 2. Identify gaps in application of PNA prevention practices and develop plan to implement strategies to close gaps 3. Develop an infection prevention education plan for PNA. 4. Audit PNA prevention practices 5. Submit facility acquired PNA rates to portal

62 Current State Assessment related to PNA Prevention Practices Prevention Practices Current Policy in Place Audit 5 patients to see if compliant with policy Proper hand hygiene Comprehensive Oral Care Prevention of Aspiration Swallow screens Proper positioning during eating/feeding and sleep Mobility/ Lung expansion (up at least 1/day) Adequate nutrition (consumed >50% of diet)

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64 The Why Urinary tract infection (UTI) are one of the most common hospitalacquired infections Along with other device associated infections (CLABSI and VAP) account for 25% of all hospital acquired infections 70-80% of UTIs are due to urinary catheters 12-16% of inpatients are catheterized Leads to increased morbidity and costs ($896) Medicare no longer reimburses U.S. hospitals for the additional costs of certain infections CLA-BSI & CAUTI are 65% of the clinical conditions for VBP CAUTI prevention is part of the 2012 National Patient Safety Goal Magill et al NEJM 2014; APIC Guide to Prevention of CAUTI, 2014; Lo et al SHEA/IDSA Practice Recommendations Inf Control and Hosp Epid 2014 Zimlichman E, et al. JAMA Intern, 2013;17:373:

65 Partnership for Patients CAUTI Venous thromboembolism Pressure ulcers Immobility Urinary Catheter Harm Increased Length of Stay Patient discomfort Falls Trauma Adverse drug events Isn t this a patient safety issue, not just CAUTI?

66 Pathogenesis of CAUTI Source: colonic or perineal flora on hands of personnel Microbes enter the bladder via extraluminal {around the external surface} (proportion = 2/3) or intraluminal {inside the catheter} (1/3) Daily risk of bacteriuria with catheterization is 3% to 10%; by day 30 = 100% APIC Guide to Preventing CAUT

67 Disrupting the Lifecycle of the Urinary Catheter 1. Preventing Unnecessary and Improper Placement 1 4. Preventing Catheter Replacement Maintaining Awareness & Proper Care of Catheters 3 3. Prompting Catheter Removal (Meddings. Clin Infect Dis 2011)

68 CDC, SHEA, IDSA and NHS: Indications for Placement Perioperative use for selected surgical procedures Urine output in critically ill patients Management of acute urinary retention and urinary obstruction Assistance in pressure ulcer healing for incontinent patients At a patient request to improve comfort(shea) or for comfort during end of life care (CDC) How-to Guide: Prevent Catheter-Associated Urinary Tract Infections. Cambridge, MA: Institute for Healthcare Improvement; (Available at Lo E, et al. Infect Contr & Hosp Epidemiol. 2014;35(5):

69 Core Recommendations Insert catheters only for appropriate indications (1B) Leave catheters in only as long as needed (1B) Ensure that only properly trained persons insert and maintain catheters (1B) Insert catheters using aseptic technique and sterile equipment (acute care settings) (1C) Consider use of alternatives (II) Maintain a close drainage system (1B) Secure the system (1B) Maintain unobstructed urine flow (1B) Key the collecting bag below the level of the bladder at all times (1B) Lo E, et al. Infect Contr & Hosp Epidemiol. 2014;35(5):

70 Simplified Insertion Checklist for Urinary Catheter 70

71 Core Recommendations Insert catheters only for appropriate indications (1B) Leave catheters in only as long as needed (1B) Ensure that only properly trained persons insert and maintain catheters (1B) Insert catheters using aseptic technique and sterile equipment ( acute care settings) (1C) Consider use of alternatives (II) Maintain a close drainage system (1B) Secure the system (1B) Maintain unobstructed urine flow (1B) Key the collecting bag below the level of the bladder at all times (1B)

72 Challenges with Current Appropriate Alternatives: External Male Catheters 1 out of every 200 men is born with what s medically known as micro-penis

73 Buried Penis

74 Condom Catheter

75 Common Problems Most common problems are: Skin irritation and maceration Difficult to keep the condom from falling off/retraction of the penis or decrease size Ischemia and penile obstruction/tightness Adherence: requires to secure on the shaft & adhesive mechanisms are challenging Reference: Newman, DK. Managing and Treating Urinary Incontinence. Health Professions Pr. 2002

76 Before & After QI Project 60 day comparison Use of a novel EMC device vs. indwelling catheter Inclusion criteria: No restraints No BPH No neurogenic bladder Cooperative Hospitalize 2 wks or greater Monitored wear time and evaluated the skin Average Wear Time = 24hrs Fitzwater M, IP Kindred Albuquerque, 2015

77 Core Recommendations Insert catheters only for appropriate indications (1B) Leave catheters in only as long as needed (1B) Ensure that only properly trained persons insert and maintain catheters (1B) Insert catheters using aseptic technique and sterile equipment ( acute care settings) (1C) Consider use of alternatives (II) Maintain a close drainage system (1B) Secure the system (1B) Maintain unobstructed urine flow (1B) Key the collecting bag below the level of the bladder at all times (1B)

78 Securement Devices

79 Core Recommendations Insert catheters only for appropriate indications (1B) Leave catheters in only as long as needed (1B) Ensure that only properly trained persons insert and maintain catheters (1B) Insert catheters using aseptic technique and sterile equipment ( acute care settings) (1C) Consider use of alternatives (II) Maintain a close drainage system (1B) Secure the system (1B) Maintain unobstructed urine flow (1B) Key the collecting bag below the level of the bladder at all times (1B)

80 Cleansing of Patients with Indwelling Catheter Indwelling catheter care should occur with the daily bath (basinless bathing)*, as a separate procedure using clean technique There is no evidence to support 2x a day indwelling catheter care If a large liquid stool occurs, bathe the patient with basin less bathing Use separate cloths to clean front to back in the perineal area and 6 inches of the catheter** Apply barrier cloth to area of skin requiring protection **Universal ICU Decolonization: An Enhanced Protocol. (Prepared by The REDUCE MRSA Trial Working Group, under contract HHSA i). AHRQ Publication No EF. Rockville, MD: Agency for Healthcare Research and Quality; September *Sage recommends following hospital policy

81 Additional Recommendations: SHEA Compendium Update 2014 Replace the catheter and the collecting system using aseptic technique when breaks in aseptic technique, disconnection, or leakage occur (quality of evidence: III). For examination of fresh urine, collect a small sample by aspirating urine from the needleless sampling port with a sterile syringe/cannula adaptor after cleansing the port with disinfectant (quality of evidence: III). Unresolved Antiseptic or sterile saline foe meatal cleaning before insertion Lo E, et al. Infect Contr & Hosp Epidemiol. 2014;35(5):

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83 Cost-Benefit Ratio CA-UTI vs. IAD & Pressure Ulcer

84 IAD Assessment Tool Junkin J, Selek JL. J WOCN 2007;34(3):

85 Preventing UTIs (no indwelling catheter) Ensure adequate fluid intake Urine should be light and clear Adequate toileting Bladder should be emptied every 2-3 hours Cleaning: front to back Manage incontinence with appropriate toileting and products

86 Strategies to not over treat asymptomatic bacteriuria.

87 Guidelines for Antibiotic Use The guidelines are based on evidence. Researchers developed guidelines for a few key infections, including a UTI. Other researchers independently used these guidelines, tested them, and found that they were effective in reducing the number of antibiotics used. 87

88 ABC for Diagnosing UTI

89 ABC for Diagnosing UTI

90 UTI SBAR UTI SBAR form: Is intended to guide communication regarding the potential need for antibiotic use between nursing staff and prescribing clinicians in long-term care facilities, such as nursing homes. Is based on the Situation, Background, Assessment, and Recommendation form of communication, or SBAR. Is based on clinical practice guidelines.

91 SBAR Tool Design S Situation: A concise statement of the problem (what is going on now). B Background: Pertinent and brief information related to the situation (what has happened). A Assessment: Analysis and consideration of options (what you found/think is going on). R Recommendation: Request/recommend action (what you want done).

92 Suspected UTI SBAR

93 Suspected UTI SBAR

94 Current State Assessment related to UTI/CAUTI Prevention Practices Prevention Practices Current Policy in Place Audit 5 patients to see if compliant with policy Proper hand hygiene Without indwelling catheter: Adequate fluid so urine is light and clear Appropriate toileting (empty bladder every 2-3 hours) With indwelling catheter: Aseptic technique followed during insertion Daily catheter care Catheter secured Closed system No dependent loops Catheter Bag not on floor

95 Prevention Bundles Work Chahoud J, et al. Heart & Lung, 2015;44: Navoa-Ng JA, et al. J of Infection and Public Health 2013;6:

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97 RESOURCES New Jersey Sepsis Learning-Action Collaborative Surviving Sepsis Campaign Centers for Disease Control and Prevention Sepsis Centers for Disease Control and Prevention - Nursing Homes and Assisted Living Resources Minnesota Hospital Association Seeing Sepsis Long Term Care Resources and-septic-shock American Hospital Association s Health Research and Educational Trust Sepsis Resources EVIDENCE-BASED LITERATURE RESOURCES Goodwin, A.J., Rice, D. A., Simpson, K. N. & Ford, D. W. Frequency, cost, and risk factors of readmissions among severe sepsis survivors. Critical Care Medicine. No. 43, Issue 4. (April 2015): Otego, A. et al. Hospital-based acute care use in survivors of septic shock. Critical Care Medicine. No. 43, Issue 4. (April 2015):