Disclosure Susan A. Furdon MS, RN, NNP-BC does not have any financial arrangement or affiliations with a commercial entity. Ms. Furdon will not be discussing the unlabeled use of a commercial product in her presentation. BEYOND CLABSI: Sustaining Gains from Three Quality Improvement Initiatives in the NICU Susan Arana Furdon MS, RN, NNP-BC Objectives: Quality Initiatives to Improve Outcomes of VLBW Is Zero Possible? CLABSI Reduction After Implementation of Insertion & Maintenance Bundles Identify one model for improving healthcare quality in the NICU Describe one unit s process of translating evidence into bedside practice Discuss the use of ongoing audits & feedback to all members of the healthcare team to sustain the GAINS Lynn J Spilman MS, RN, NNP-BC, Susan A. Furdon MS, RN, NNP-BC, Michael J Horgan MD, Rebecca O Donnell, MT(ASCP), CIC Operation Toasty Tot : A Quality Improvement Initiative to Minimize Hypothermia During Delivery Room Stabilization of the VLBW Neonates Susan A Furdon MS, RN, NNP-BC, Joaquim M. Pinheiro MD, MPH, Susan Boynton BSN, RNC, Robin Dugan BSN, RNC, Christine Reu Donlon MS, RNC, NNP-BC, Mary Wedrychowicz MS, RN Love My Curves : Prevention of Postnatal Growth Restriction by the Implementation of an Evidenced-Based Premature Infant Feeding Bundle Pauline Graziano MS, RN, NNP-BC, Michael Horgan MD, Theresa Loomis RD, CNSD Plan Study Do Act Plan Study Do Act What do We THINK we need to improve? Baseline data November 2, 114 1
ELEMENTS OF SUCCESS: Recognition & Belief: WE HAVE A PROBLEM!! NYS RPC MEETING 27 Prior to the meeting, we didn t believe was possible Thought sepsis evaluations & sepsis were just part of the work we did blamed our patient population Also thought that any unit that had small CLABSI rates must be different than us less acute patients Transparency of Data & Process Definitions reviewed / operationalized Plan Study Do Act Best site (s) identified: processes at those sites described: Bundle elements defined Networked with clinical coordinator / toured nursery & interviewed staff (Especially grateful for the indepth lecture by Grace Marin RN, BSN (Clinical Coordinator of Neonatal ICU @ Kravis Children s Hospital) PRACTICE CHANGE! PICC Insertion Insertion Elements of bundle Establish a central line kit or cart to consolidate all items necessary for the procedure (1B) Perform hand hygiene with hospital approved alcohol-based product or antiseptic- containing soap (CHG): before and after palpating insertion sites before and after inserting central line. (1A) AMC Change in Practice PICC cart developed Already implemented: Reinforced with education/ audits Added hand hygiene stations Elements of bundle Use maximal barrier precautions (including sterile gown, sterile gloves, surgical mask, hat & large sterile drape) (1A) Disinfect skin with appropriate antiseptic (eg CHG 2%) before catheter insertion (1A) Use either a sterile transparent semipermeable dressing or sterile gauze to cover the insertion site (1A) AMC Change in Practice No change in policy Did change kit larger drape Did education and staff took on role of enforcer of the 3- foot rule No change No change use Opsite 3 (Smith & Nephrew) November 2, 114 2
PICC Maintenance Maintenance Elements of bundle Perform hand hygiene with hospital approved alcohol-based product or antiseptic-containing soap before and after accessing a catheter or changing the dressing (1A) Evaluate the catheter insertion site daily for signs of infection and to assess dressing integrity (1B) At a minimum, if the dressing is damp, soiled or loose, change it aseptically (1B) Disinfect the skin around the insertion site with an appropriate antiseptic (1A) AMC Change in Practice Reinforced element with education; increased visibility of hand sanitizer along outside perimeter of our pods Reinforced element with education Nursing assessment in E-HR Audits Discontinued use of Biopatch which required q7 day dressing change; Changed unit standard: change dressing when damp, loosened or soiled Elements of bundle Develop and use standardized intravenous tubing set-up and changes (1B) Maintain aseptic technique when changing IV tubing and when entering the catheter including scrub the hub (1A) AMC Change in Practice Closed medication system adopted Churchill Medical 6 trifurcated extension set Tubing changes using sterile technique; Reinforced scrub the hub for 6 sec with education; Daily review of catheter necessity Implemented chains as reminder of sterility with prompt removal when no longer during tubing change (3 essential (1B) foot rule) Daily interdisciplinary review of necessity of catheter with attending on am rounds Space constraints: 3 foot rule around sterile procedure RESPECT THE CHAIN! Yoda s Rules to Jedi Warriors: DEFEAT THE ENEMY! 1] Keep up to date! ANNUAL SKILLS FAIR: 28 All Jedi will be in the know after the Fair 2] Organize PICC supplies Dressing supplies are already in one bag In process of setting up cart for insertion supplies We have a vendor who will prepackage insertion supplies (will be ready ~ 1 weeks) 3] Maximum Barrier Precautions: insertion of PICC Yoda s rules Mask, gowns, hat & sterile gloves Sterile drape entirely covers baby Mask, hat on anyone within 3 foot invisible shield 4] Use evidence for dressing changes: Stop using Biopatch Change dressing within 24h of insertion [remove blood] Change dressing when loosened or soiled (bloody) 2 person procedure to maintain sterility Yoda s rules 5] Standardize tubing 6] Maintain sterility with tubing changes 2 person technique sterile field & sterile gloves/ mask with tubing changes Jedi #1 Jedi #2 Jedi s wardrobe Mask/ non-sterile gloves Gown, sterile gloves, mask, hat Assembling our weapons Assistant for preparation of new set up Prepare supplies on sterile drape Actions Remove old tubing Connect new tubing to PICC using aseptic technique November 2, 114 3
Standardized Tubing is a Closed Medication System Our weapon in fighting bacteria Tubing changed q 24h Tubing changed using sterile technique No entry of tubing close to the patient or the patient s environment Limits the # of entries to the line per day Continue to scrub the hub (scrub the q-site) as medication syringe is changed (6 seconds using clock) Scrub the CLC valve at time of tubing change with alcohol for 6 seconds Most important rule 8] ALL JEDI S MUST WASH HANDS Use waterless skin cleanser Wear gloves for all patient contact Points of clarification CLABSI Prevention Bundle: Maintenance This new tubing is a trial there will be an evaluation tool in order to give feedback Tubing is just for PICCs for now Tubing is NOT a triple lumen ie compatibility of solutions still important because the solutions come together within the tubing Should practice extend to all lines? Daily assessment of catheter need Removal when 1 12 ml/kg/day enteral nutrition achieved Monitor dressing integrity & cleanliness Use closed system for infusion, blood sampling & medication administration Assemble & connect infusion tubing using aseptic technique. Use consistent tubing configuration Setting UP November 2, 114 4
# of central line related blood stream infections Beyond CLABSI: Sustaining Gains from Three Quality Improvement Insertion audits Insertion Audit Completed by RN, NP or fellow who inserts the PICC Audit is part of the universal protocol & procedure note Separate section for adherence to guidelines that is not part of the medical record Useful to define expectations to new fellows/staff involved in the procedure Checklist: Do They Work? Audits done by 2 CNS & 2 experienced PICC team nurses Staff know we are actively looking at set up/ dressing integrity/ scrub the hub & line necessity Currently, staff provide the answer before the question is asked Increased conversation about the PICC itself during rounds Parents know the plan! Plan Study Do Act 12 1 9 NICU Number of Central Line Related Blood Stream Infections 27-28 <= 75 751-1 11-15 151-25 >25 8 DATA & ANALYSIS! 6 4 2 6 5 5 5 4 4 3 3 3 2 1 1 1 1 1 1 2 3 4 5 6 7 8 9 1 11 12 1 2 3 4 5 6 7 8 9 1 11 12 27 28 November 2, 114 5
# of central line related blood stream infections Beyond CLABSI: Sustaining Gains from Three Quality Improvement 12 NICU Number of Central Line Related Blood Stream Infections <= 75 751-1 11-15 151-25 >25 Recipe worked right away 1 8 6 4 2 1 Jan Feb March April May June July Aug Sep Oct Nov Dec Stick to a new diet belief that this recipe worked : Reinforced the change in behavior Hardwired that change In turn, results supported additional recognition to staff for their efforts 29 Recipe for Success Plan Study Do Act AMC Ongoing Review New Challenges Interdisciplinary Recognition we had a problem Sterile tubing change respecting space Accessing line outside patient environment Multidisciplinary effort to evaluate need for Central access DAILY #1 ingredient: NURSES CLABSI Prevention Bundle: Investigating Failure Leadership Administrative involvement & support for zero HAIs Engage staff with feedback Posting days since last CLABSI Posting rates of CLABSI Perform investigation of each CLABSI Surveillance activities for critical processes Hand hygiene Line management and entry Off unit procedures Stop the line support RECOGNITION OF NURSING & MEDICAL STAFF S SUCCESS Trained personnel to perform specialized maintenance activities November 2, 114 6
How do we maintain the success of our current recipe as we go forward? AMC s CLABSI rate since initiative started Rate per 1 Central Line Days Rate per 1 Central Line Days 11.2 1.19 1.17.93.21.77 27 28 29 21 211 212 213 AMC s CLABSI initiative Year CLABSI CL Days Rate per 1 CL Days 27 38 3389 11.2 28 4 3352 1.19 29 1 476.21 21 5 4268 1.17 211 3 3219.93 212 ZERO! 441 213 3 3875.77 214? UGH!! ELEMENTS OF SUCCESS: BENCHMARKING TRANSPARENCY IN DATA BUNDLE ELEMENTS UNIT CHAMPION(S) COMMUNICATION: EVIDENCE TRANSLATION IN ACTION National NY State AMC NICU November 2, 114 7
Getting To Zero CLABSI! A Believable Goal? We must focus on the patient & challenge ourselves to no longer accept the unacceptable CLABSI ARE PREVENTABLE! Maintaining Normothermia in the Delivery Room for Preterm Infants: OPERATION: TOASTY TOT Pinheiro J, Furdon SA, Boynton S, Dugan R, Jensen S, Reu Donlon C, Abiodun O,Wedrychowicz M Admission temperatures related to mortality 45 4 35 3 25 2 15 1 5 % Adm Temp <34 34-34.9 35-35.9 36-36.9 37-37.9 >38 % Adm Temp 46% of initial temperatures of VLBW < 36 C 28% increase in mortality for every 1 C decrease in temperature Lapkook AR (27) Pediatrics AMC s Admission Temperatures: VLBW 12 1 8 6 4 2 >38 36-38 <36 AMC: a better performer when compared within Vermont Oxford Network (VON) 25 & 26 AMC discontinued use of chemical warm packs for neonatal stabilization in 27 after one infant experienced focal skin injury Comparison showed an increase in hypothermia on admission AMC Period I 26 to mid 27 Chemical warm packs consistently used AMC Period II Mid to end 27 Chemical warm packs were discontinued 7% 6% 5% 4% 3% 2% 1% % VLBW Hypothermia % VLBW Hypother mia 25 26 27 % I II VON November 2, 114 8
Methods Objectives of Quality Initiative Mobilized to make a change! Downward trend of AMC s admission temperatures of VLBW Impact of hypothermia as described in the literature Identify Unit champions : Developed an interdisciplinary & interdepartmental (NICU & DR) workgroup to improve outcomes Standardized stabilization processes in the DR to enhance infant temperature Identified measurable objectives Utilized Plan-Do- Check-Act methodology To optimize/ standardize the delivery room thermoregulation procedures to maintain temperature 36.5-37.5 C in the VLBW (birthweight < 15g) born at the regional center To improve the prevalence of admission temperatures 36-38 C for inborn VLBW infants to > 9% OPERATION: TOASTY TOT TARGET THE PINK ZONE Target population: < 15g Target temperature: 36. 38. degrees Door to room closed? Sides to warmer raised? Sides in up position for transfer Radiant warmer turned on when delivery anticipated? Turn on early/ close door to warm the room Lean back do not block infant s access of heat Saran wrap applied to head prior to intubation? Hat applied over Saran? Saran wrap wrapped around body? HR auscultated through Saran wrap? Prewarmed blankets available? ASK for them from the DR staff Four ways a newborn may lose heat to the environment Temperature Measurement Admission temperature standardized: measured prior to transfer from the stabilization bed to the admission bed Data collected & submitted to QI data coordinator Accuracy of data: State Perinatal data sets compared with Vermont Oxford data Graphic display developed & updated monthly Increasing staff awareness of the problem Call for participants in workgroup Graphic display developed & updated monthly provided feedback to medical & nursing staff in the NICU OPERATION TOASTY TOT Target the Pink Zone Develop a logo / name for our project to enhance recognition OPERATION TOASTY TOT Target the Pink Zone Goal > 9% in-born VLBW neonates between 36-38 C Very Low Birth Weight (VLBW) Neonates (less than 15gms) As of 9/3/8 As of 5/19/8 November 2, 114 9
OPERATION TOASTY TOT Target the Pink Zone Goal >/= 9% in-born VLBW between 36-38 C 1% < 36 deg 36-38 deg > 38 deg 1% 3% 29% 8% 57% 65% 83% 82% 73% 66% 6% 72% 77% 78% 73% 9% 9% 4% 7% 71% 2% 43% 34% 17% 18% 27% 33% 25% 21% 22% 18% % 25 26 27 Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- 7 7 8 8 8 8 8 8 8 8 8 8 8 8 Toasty Tot initiative continued: New Cycle PCDA Continuing to optimize and standardize approach to thermoregulation procedures in the delivery room Use / implications of new radiant warmers in DR with continuous heat source for transfer Purchase & use of blanket warmers in DR/ OR Ongoing education of medical staff (obstetric & pediatric residents) introduce @ Peds M&M Ongoing education of nursing staff (OB & NICU) clinical fair next week with focus on use of Panda warmer 25 26 27 Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 139 15 119 1 7 18 7 1 12 11 11 11 6 1 Statistical improvement after education: 28 1% 9% 8% 7% 6% 5% 4% 3% 2% 1% % OPERATION TOASTY TOT Target the Pink Zone Goal >/= 9% in-born VLBW neonates between 36-38 C Very Low Birth Weight (VLBW) Neonates (less than 15gms) >36 36-36 <36 28: Did not achieve goal > 9% VLBW admission temperatures between 36-38 C Since education of staff in March 8 84% VLBW within target temperature range Improvement noted: 84% within target temperature range (28) vs 66% within range (27) (P<.1) Toasty Tot initiative continues Continuing to optimize and standardize approach to thermoregulation procedures in the delivery room new cycle PCDA Reviewed distribution of temperatures by birthweight Redefined standard for larger weight category (1-15g): all infants < 15g to have plastic wrap on head during stabilization & transfer to NICU Report of admission temperatures < 36 C at monthly M&M Compliance tool (Evaluation of Thermoregulation in DR) completed by NICU RN in attendance of the delivery of each infant admitted to NICU; now review done only when temperature < 36 C Thermoregulation Bundle Standard use of battery operated radiant warmer on servo-control at 5 min & during transfer Minimize convective heat loss through maintaining side rails in up position & closing door to resuscitation room Minimize conductive heat loss through availability of warmed blankets Wrap head of all infants < 34 wks GA with plastic wrap then cotton heat; Wrap torso of all infants < 29 weeks GA with second piece of plastic wrap Admission temperature taken prior to transfer to admission bed 29: 92% admission temperatures of VLBW in the target zone! 1% 9% 8% 7% 6% 5% 4% 3% 2% 1% % 25 26 27 28* 28** 29 21 1Q >38 36-38 <36 November 2, 114 1
Lower proportions of hypothermic infants after staff education & Operation Toasty Tot bundle implementation Conclusion: 43 inborn VLBW babies over 36 months Lower proportions of hypothermic infants after staff education and Operation Toasty Tot bundle implementation in month 15 Initial data showed more consistent improvement in lowest birthweight category (GA <29 weeks); bundle strategies then extended to those >29 weeks Objective achieved: > 9% temperatures in VLBW admissions between 36-38 C Hyperthermia (>38 o C) incidence was ~2% both before and after bundle implementation Continuing to standardize and institutionalize bundle elements to facilitate maintenance of gains Love My Curves : Prevention of Postnatal Growth Restriction by the Implementation of an Evidenced-Based Premature Infant Feeding Bundle Pauline Graziano MS, RN, NNP-BC, Michael Horgan MD, Theresa Loomis RD, CNSD Objectives: 1. Develop an evidenced-based enteral feeding bundle to address standardization of nutritional practices 2. Improve nutritional intake of VLBW infants 3. Establish goal: > 9% of admitted AGA VLBW infants will be discharged home above the 1 th percentile for weight and head circumference Background Feeding Bundle Jan 21 Postnatal growth restriction remains a major morbidity for VLBW (< 15g) infants affecting health & neurodevelopmental outcomes Ehrenkranz RA (21) Early Human Development Despite early initiation of optimized parenteral nutrition, the majority of VLBW infants fall short of expected growth trajectories Clark RH et al (23) Journal of Perinatology A retrospective review of Albany Medical Center NICU feeding practices/growth outcomes completed to identify baseline practices. An interdisciplinary workgroup reviewed current literature on feeding practices and outcomes. An evidenced-based enteral feeding bundle was developed and presented to the medical team for consensus. Interactive education of the bundle elements was provided to all NICU staff. Education included a review of current evidence, planned changes in practice, resource materials and an auditing tool. Elements Objectives Details Feed Substrate Preferred: Breast Milk If N/A: Premature 24 cal Formula Feed Initiation Goal: by DOL 2 (within 24 hrs of birth) Volume/Frequency predefined by weight (1-2 ml/kg/day) Feed Advancement No > 2 ml/kg/day per predefined advances unless PO feeding Advance daily if meets tolerance definition Goal: 14-16 ml/kg/day enteral intake Less than 1 KG: MEN (1-2 ml/kg/day) x 5 days. Begin increase feed day 6 Advance daily as tolerated to goal. Greater than 1 KG: Advance daily as tolerated to goal. November 2, 114 11
Elements Objectives Details Breast milk Fortification Fortify BM to 24 cal/oz using liquid HMF once enteral feeding volume 5 ml/kg/day Feed Tolerance Definition of Tolerance: < 5% residual of daily enteral intake AND normal exam Definition of Intolerance: > 5% residual of daily enteral intake while feeds advancing; > 3% residual once tolerating full feeds; OR abnormal exam Management of Residuals: < 25% of previous feed- refeed residual and give full feed > 25 % of previous feed- refeed residual and give difference > 25% residual and/or abnormal finding collaborate with provider Definition of Abnormal Findings: Abdominal distension, discoloration, visible loops, absent bowel sounds Bloody stool Bilious aspirates (defined by color chart) Vital sign instability/change from baseline status. Same recipe to achieve goals NYS data sharing & evidence evaluation Bundle Elements brought to medical & nursing leadership team for consensus Bundle elements and background evidence brought to nursing staff Data collection Evaluation & new cycle of implementation Outcomes! Outcomes: Nutrition Initiative Average DOL to First Feeding decreased from day 1 to day 2. Average day to Full Feedings decreased from day 28 to day 16. Average day to re-gain Birth Weight decreased from day 22 to day 1. 3 25 2 15 1 P= 1 P=.3 P=.2 29 21 211 212 5 First Feed Full Feeds BW Regained All NYS RPCs Infants discharged > 1 th percentile for weight 4. 3. 2. 1.. Percentage of Newborns Discharged Below Fenton's 1th Percentile for Weight Source: NYS NICU Module Data 32. 32.6 21.1 2.2 3.6 16.7 29 21 Jan-Sep 211 All NYS RPCs 9% 8% 7% 6% 5% 4% 3% 2% 1% % AGA @ Birth AGA @ Discharge Pre-Bundle 21 211 November 2, 114 12
Conclusions: Establishing a standardized approach to feeding initiation and advancement (Feeding Bundle) significantly decreased number of days in initiating feedings, reaching full feeds, and regaining birth weight in our institution. Adherence with bundle (now > 9%) has led to improved growth outcome measurements for both weight and head circumference measurements Continuing to work towards goal of > 9% of AGA at birth infants maintaining > 1 th percentile measurements at discharge. Additional monitoring has revealed AMC NICU s central line utilization rates have fallen below national averages. Advanced Practice Nurse: Bridging the Evidence to Practice Twin Bridges Review science behind evidence as foundation of bundle elements Clinical knowledge & expertise Develop bundle elements into actionable care at the bedside Provide education to nurses & physicians Clinical presence: Provide support with ongoing audits/ feedback Quality Improvement Reliably adhering to defined practices on daily basis is immensely challenging APN can focus on education & support of practice changes both nursing & medical team Organizational commitment to change is key to APN s ability to fulfill this aspect of their role APN Colleagues: Providing leadership for Quality initiatives CLABSI Reduction Lynn Spilman MS, RN, NNP-BC Sue Furdon MS, RN, NNP-BC Thermoregulation Initiative Christine Reu Donlon MS, RN, NNP-BC Sue Furdon MS, RN, NNP-BC Nutrition Initiative Pauline Graziano MS, RN, NNP-BC RECOGNIZE THE TEAM @ ALBANY MED! Ongoing, continuous auditing and feedback has successfully affected a culture of practice change resulting in a new standard of care and improved outcomes at our institution November 2, 114 13