Interventional Patient Hygiene: Impacting Patient Outcomes by Implementing Evidence Based Nursing Care Interventions Kathleen M. Vollman MSN, RN, CCNS, FCCM, FAAN Clinical Nurse Specialist / Educator / Consultant ADVANCING NURSING kvollman@comcast.net Northville Michigan www.vollman.com ADVANCING NURSING LLC 2017 Some Slides Courtesy of Barb Quinn
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
Session Objectives Create the link of patient advocacy to the basic nursing care Define key fundamental evidence based nursing care practices that reduce non-vent HAP and reduce bacteria burden on the patient Discuss strategies to overcome barriers
Notes on Hospitals: 1859 It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. Florence Nightingale Advocacy = Safety
PROTECT THE PATIENT FROM BAD THINGS HAPPENING ON YOUR WATCH
Interventional Patient 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 Incontinence Associated Dermatitis Prevention Program
INTERVENTIONAL PATIENT HYGIENE(IPH) VAP/HAP Oral Care/ Mobility HAND Patient HYGIENE Catheter Care Skin Care/ Bathing/Mobility CA-UTI CA-BSI SSI Falls HASI Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154
Achieving the Use of the Evidence Factors Impacting the ability to Achieve Quality Nursing Outcomes at the Point of Care Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154 Value Attitude & Accountability
Building Resiliency Into Interventions Forcing functions and constraints Automation and computerization Strongest Standardization and protocols Checklists and independent check systems STRENGTH OF INTERVENTION Rules and policies Education and information 9 Weakest Vague warnings Be more careful!
Why HAI's? Protecting Patients From Harm Estimates: 183 Hospitals in 10 States HAI: 722,000/year HAI-related deaths: 75,000/year Hospitalized patients develop infection: 1 out of 25 (4%) Death due to sepsis/septic shock: 700/day Money spent: $45 billion/year Increase risk of 27days vs. 59 days readmission: Magill SS, et al. New England Journal of Med, 2014;370:1198-208
Health Care Associated Infection Data Measurement NHSN 2013 4567 hospitals in US Estimated # of Infections HAP/per 1000 patient days 157,500 (21.8%) VAP/per 1000 vent days CLA-BSI/per 1000 cath days 0.8 per 1000 vent days 0.2 (Ped CVICU) -4.4 (Burn ICU) (2012) data Range of pooled means 0.8 (CVICU)-2.9 (Burn ICU) 49,900 15,600 CA-UTI/per 1000 cath days 1.7 per 1000 catheter days 0.0 (Peds Surgical)-4.8 (Burn ICU) 35,600 Dudeck MA, et al Am J Infect Control,2015;43(3):206-222. Magill SS, et al. New England Journal of Med, 2014;370:1198-20 Rosenthal VD, et al. American Journal of Infection Control 44 (2016) 1495-5048
Missed Nursing Care Any aspect of required patient care that is omitted (either in part or whole) or significantly delayed. A predictor of patient outcomes Measures the process of nursing care
Hospital Variation in Missed Nursing Care Kalish, R. et al. (2012) Am Jour Med Quality, 26(4), 291-299.
Patient Perceptions of Missed Nursing Care Kalisch, B et al. (2012). TJC Jour Qual Patient Safety,38(4), 161-167.
Source Control: The Oral Cavity as a Risk Factor in NV-HAP and VAP
AACN Procedural Manual-6 th ed Procedure 4: Endotracheal Tube Care and Oral Care Authors: Kathleen M Vollman Mary Lou Sole Barbara Quinn
Methods: ICU-Acquired pneumonia: VAP vs. NV-HAP Prospective study of 135 consecutive episodes over 3 years of adults with ICU-acquired pneumonia Compared clinical and microbiological characteristics of VAP and NV- HAP Results for VAP & NV-HAP were not statistically different: Pathogens Comorbid conditions, Severity parameters, Mortality, and Hospital length of stay Among NV-HAP patients, 79 (52%) needed subsequent intubation Slide courtesy of Barb Quinn Esperatti et al (2010) Am J Respir Crit Care Med. Vol 182, p 1533-1539.
Build the Will: 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 Slide courtesy of Barb Quinn Kollef, M.H. et.al. (2005). Chest. 128, 3854-3862. ATS, (2005). AmJ Respir Crit Care Med. 171, 388-416. Lynch (2001) Chest. 119, 373S-384S. Pennsylvania Dept. of Public Health (2010).
Compelling Incidence Data Study Incidence Mortality +LOS Cost J. Davis (2012) Pennsylvania HCUP National database (P) 5,600 /3 yrs 18.9% Not queried $28,000 2/100 pts 14.5% 4 days $36,400 CDC (2014) 13% of all HAIs 19%-50% 4-9 days $40,000 Slide courtesy of Barb Quinn Davis, Pt Safety Authority 2012 9(3). Giuliano,K. et al. (2016) APIC Podium 2016 Magill, S.S. et.al. (2014) NEJM. 370(13), p 1198-1208
Hospital-Acquired Pneumonia: Non-Ventilated versus Ventilated Patients in Pennsylvania Purpose: Compare VAP and NV-HAP incidence, outcomes Methods: Pennsylvania Database queried All nosocomial pneumonia data sets (2009-2011) Retrieved on 4/24/13 from http://patientsafetyauthority.org/pages/default.aspx
Results: Mortality Incidence Total deaths Total cost Wide spread Retrieved on 4/24/13 from http://patientsafetyauthority.org/pages/default.aspx
Incidence, Prevalence of NV-HAP: A Local Study (2010) Purpose: Determine incidence and clinical factors of NV-HAP Method: Descriptive, quasi-experimental study using retrospective data Inclusion criteria: All adult discharges ICD-9 codes of pneumonia not POA AND met CDC definition of HAP Quinn, B., Baker, D., et. al. (2013). Journal of Nursing Scholarship.
NV HAP SMCS Research Findings: 2010 24,482 patients and 94,247 patient days Incidence: 115 adults 62% non-icu 50% surgical Average age 66 Common comorbidities: CAD, COPD, DM, GERD Common Risk Factors: Dependent for ADLs (80%) CNS depressant meds (79%) Cost: $4.6 million 23 deaths Mean Extended LOS 9 days 1035 extra days Quinn, B. et al. Journal of Nursing Scholarship, 2014. 46(1):11-19
Impact of NV-HAP in the ICU HAPPI-2 Preliminary Data 23 hospitals in U.S.; 2014 data; 1306 total cases 28% occurred in ICU 26% occurred on Med/Surg units and were transferred to ICU 54% of all NV-HAP cases spend some time in the ICU 33% transferred to ICU died 42% transferred to ICU survived but were discharged to a higher level of care; 25% home Impact of NV-HAP on one year mortality: Any length of time spent in an ICU increases mortality of elderly patients who survive to discharge Slide courtesy of Barb Quinn Quinn & Baker (2016) pend. Pub. Vivek et al. (2016) CC Med, 655-662.
Where is the Highest Risk for NV HAP? 2.5 Rate of Nonventilator Hospital- Acquired Pneumonia 2 1.5 1 0.5 Vent Med/Surg NV-ICU 0 Vent Med/Surg NV-ICU NV-HAP per 1000 patient days Slide courtesy of Barb Quinn
Reducing Risk of VAP & NV-HAP Through Evidence Based Fundamental Nursing Care Strategies
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 Quinn, B. et al. Journal of Nursing Scholarship, 2014. 46(1):11-19
Healthcare Acquired Pneumonia Risk Factor Categories Factors that increase bacterial burden or colonization Factors that increase risk of aspiration
Micro Aspiration During Sleep in Healthy Subjects Prospective duplicate full-night studies 10 normal male s 22-55 yrs of age Methods: Radioactive 99 mtc tracer inserted into the nasopharynx Lung scans conducted immediately following final awakening No difference in sleep efficacy btwn 2 study nights Results: 50% of subjects had tracer in the pulmonary parenchyma upon final awakening No difference in age, time spent in bed, efficacy of sleep, apnea-hyponea index, arousal plus awakening index or % sleep in the supine position between subjects that aspirated and those that did not. Gleeson K, et al. Chest. 1997;111:1266-72
Body Position: Supine versus Semi-recumbent (30-45 degrees) Methodology 19 mechanically ventilated patients 2 period crossover trial Study supine and semirecumbent positions over 2 days Labeled gastric contents (Tc 99m sulphur colloid) Measured q 30 min content of gastric secretions in endobronchial tree in each position Sampled ET secretions, gastric juice & pharyngeal contents for bacteria Torres A et. al Ann Intern Med 1992;116:540-543
Body Position: Supine versus Semirecumbent (30-45 degrees) Results Radioactive contents higher in endobronchial secretions in supine patients Time dependent: Supine: 298cpm/30min vs. 2592cpm/300min HOB: 103cpm/30min vs. 216cpm/300min Same microbes cultured in all 3 areas 32% with HOB vs. 68% supine. Torres A et. al. Ann Intern Med 1992;116:540-543
Risk Factors for Oral Bacteria in the Hospital Poor oral health in the U.S. (CDC, 2011) Increased bacteria counts Plaque, gingivitis, tooth decay Reduced salivary flow 24-48 hours for HAP pathogens in mouth If aspirated =100,000,000 bacteria/ml saliva into lungs Scannapieco FA, Stewart EM, Mylotte JM. Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Crit Care Med. 1992;20:740 745. Langmore, S. et.al. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia. 13, 69 81.
Oral Cavity & VAP 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 Garrouste-Orgeas 28 of et. 31 al. Am VAP s J Respir Crit the Care Med. 1997;156:1647-1655 causative organism id ti l i 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;126:1575-1582
Formation of Biofilm Over 13 Hours http://helios.bto.ed.ac.uk/bto/microbes/biofilm.htm Loesche, W. 2012
Oral Intensity: Reducing NV-HAP in Neuro Impaired Patients Method Quasi-experimental, comparative study Adults, acute Neuroscience unit Western Canada 51 retrospective patients standard oral care 34 prospective patients enhanced oral care Results Statistically significant decrease in NV-HAP (p<0.05) Robertson, T & Carter, D. (2013) Can J Neurosci Nurs, 35(2), 10 17.
Impact of Oral Care on HAP Kaneoka A, et al Infect. Control Hosp. Epidemiol, 2015;36(8):899-906
New VAP Prevention Bundle Extensive review of literature/guidelines Used a 2-step Delphi process 65 possible intervention-narrowed to 5 process and 14 structural Speck K. Am J of Infect Control 2016; in press
Comprehensive Oral Care Protocol: The Good Shepherd Study Methodology: Retrospective study 10 bed Med-Surg Protocol included: Covered Yankauer for non-traumatic oral suctioning, soft-suction toothbrush, Suction Oral Swab, use of a 1.5% H 2 O 2 peroxide mouth rinse for cleansing, deep oral 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
Literature Review: Oral Care Impact of VAP Comprehensive Oral Care: Reduction in VAP from 5.6 to 2.2 (Schleder B. et al. J Advocate Health 2002;4(1):27-30) Reduction in VAP from 4.10 (2005) to (2.15) in 2006 with addition of CPC & comprehensive oral care. Vent bundle & rotational therapy already being performed Reduction in VAP from 12.0 to 8.0 (p=.060) with 80% compliance, vent bundle already being preformed, 1538 patients randomized to control or study group, Additional outcomes; vent days (p=.05), ICU LOS (p=.05) time to VAP (p= <.001) & reduction in mortality (p=.05) (Garcia R et al AJCC, 2009;18:523-534)
Literature Review: Oral Care Impact of VAP Comprehensive Oral Care & CHG: Reduction in VAP to zero for 2 years, vent bundle, mobility, oral care & CHG with comprehensive education preformed (Murray TM et al. AACN Advanced Critical Care. 2007;18(2):190-199) Comprehensive oral care with CHG Dickinson S et al. SCCM Critical Connections, 02/2008 Heck K, et al. American Journal of Infection Control 40 (2012) 877-9
Does Compliance Make A Difference? Oral care compliance & use of the ventilator bundle resulted in a 89.7% reduction in VAP Hutchins K, et al. Amer J of Infect Control. 2009;37(7):590-597.
Phase 2: Could NV HAP be decreased simply brushing the patient s teeth?
SMCS HAP Prevention Plan Phase 1: Oral Care Formation of new quality team: Hospital-Acquired Pneumonia Prevention Initiative (HAPPI) New oral care protocol to include non-ventilated patients New oral care products and equipment for all patients Staff education and in-services on products Ongoing monitoring and measurement Monthly audits Quinn B, et al. J of Nursing Scholarship, 2014, 46(1):11-19
Protocol Plain & Simple Patient Type Tools Procedure Frequency Self Care / Assist Brush, paste, rinse, moisturizer Provide tools Brush 1-2 minutes Rinse 4 X / day Dependent / Aspiration Risk Suction toothbrush kit (4) Package instructions 4 X / day Dependent / Vent ICU Suction toothbrush kit (6) Package instructions 6 X / day Dentures Tools + Cleanser Adhesive Remove dentures & soak Brush gums, mouth Rinse 4X / day Quinn, B. et al. Journal of Nursing Scholarship, 2014. 46(1):11-19
Provide Meaningful Data 4.0 SGH Ortho - Association of Mean Oral Care to HAP Frequency Number HAP Cases Mean Oral Care 3 Ortho Unit had ZERO HAP cases in the last 4 months of 2013!! 3.0 2.5 Great WORK!! 2 HAP Cases 2.0 1.0 0.0 Mean Oral Care 1.5 1 0.5 0 Remember, the goal is to provide and document oral care after each meal and before bedtime. Used with permission from Barbara Quinn
Frequency of Oral Care: Increased in the ICU 4 3.5 3 2.5 2 1.5 1 0.5 Used with permission from Barbara Quinn 0 baseline Mar-13 Frequency of Oral Care for Non-vented patients in the ICU 300%
NV-HAP Incidence 50 % Decrease from Baseline 20 18 16 14 12 10 8 6 4 2 0 JAN 2010 FEB 2010 MAR 2010 APR 2010 MAY 2010 JUN 2010 JUL 2010 AUG 2010 SEP 2010 OCT 2010 NOV 2010 DEC 2010 MAY 2012 JUN 2012 JUL 2012 AUG 2012 SEP 2012 OCT 2012 NOV 2012 DEC 2012 JAN 2013 FEB 2013 MAR 2013 APR 2013 MAY 2013 JUN 2013 JUL 2013 AUG 2013 SEP 2013 Number of non-ventilator HAP cases OCT 2013 NOV 2013 DEC 2013 Baseline Control chart for NV-HAP January 2010 to December 2013 Oral Care Month/Year Quinn, B. et al. Journal of Nursing Scholarship, 2014. 46(1):11-19 UCL Average LCL
Open Heart Surgery Patients: NV HAP Reduced 75% Oral chlorhexidine periop started Used with permission from Barbara Quinn
Return on Investment 60 NV-HAP avoided Jan 1 Dec. 31 2013 $2,400,000 cost avoided - 117,600 cost increase for supplies $2,282,400 return on investment 8 lives saved Quinn, B. et al. Journal of Nursing Scholarship, 2014. 46(1):11-19
HAP Significant Trend Downward Jan 2010-June 2014 Used with permission from Barbara Quinn
Denture Care
Making it Happen: Comprehensive Oral Care with and Antiseptic Create visual cues to show evidence of compliance Overcoming barriers: formal education, strategies for addressing barriers (Dale CM, et al. AJCC,2016;25:249-256) Date and time the oral care kits Assign product change over to one shift Include oral care/more than CHG in order sets and on documentation Teach family and patient how to perform
It is not enough to do your best; you must know what to do, and THEN do your best. ~ W. Edwards Deming
Driving Change Gap analysis Build the Will Protocol Development Structure Make it Prescriptive Overcoming barriers Daily Integration Process Outcomes
Contact Kathleen Vollman at kvollman@comcast.net www.vollman.com