Tracy Johns, RN, BSN, CPHQ Medical Center of Central Georgia NDNQI Quality Conference: February 2013
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637 bed, acute-care academic medical center 2 nd largest hospital in Georgia Magnet designation 2005 Level 1 trauma services Atlanta 142 ICU beds: 5 adult, neonatal, pediatric Certified: Hip & Knee replacement programs Stroke program Ventricular assist device (VAD) Chest pain center Palliative care program Macon Savannah 3
1. Designing Actions for Impact 2. Engagement AND Accountability 3. 2013 & forward 4
1. Designing Actions for Impact 2. Engagement AND Accountability 3. 2013 & forward 5
1. Designing Actions for Impact 2. Engagement AND Accountability 3. 2013 & forward 6
1. Designing Actions for Impact 7
Problem 6 years ago / Baseline Leading: < 90% compliance with vent bundle (HOB, turn, Hi Lo ETT, oral care) Lagging: Experiencing > 100 VAP cases/year (2006 = 114) Adult ICUs had higher than expected vent LOS (10-11 days) 8
View: Care of vent patients inconsistent Lack of evidence based practice Silo care versus interdisciplinary Not following guidelines for IHI, AACN, SSCM, APIC, NACHRI, and CMS 9
Aspiration PUD prev Family feeds ice chips High risk not ID d During intubation During intubation HOB 30 Secretion management Pneumonia Present on admit Not doc POA CPIS missed Other facility transfer Mini BAL missed CAP Vent bundle use inconsistent Oral Care Change canisters HiLo ETT PUD prev CLRT HOB 30 Hand Hygiene Separate Sx Expectations unclear Results not emphasized Management Data not disseminated Competing priorities Retrospective review No accountability for results 10
Supplies, equip, meds PUD prev CHG not in stock Transport monitoring Need quick ref info i.e. reinforcement Emergency Department Par stock too low Too few suction ports in ICU rooms Same level of care Hard to find supplies Lack of experience Outdated competency assessment Pre-existing DX, co-morbidities Over sedation Too few ICU beds Diabetes, COPD, ESRD, Heart Dz Altered mental status (AMS) BiPAP vs. intubation Nob-compliance with SAT/SBT Emergency vs. planned Hx of smoking Intubate / Extubate Bacterial colonization MRSA Cough or gag reflex CAP Coordination RRT & RN for SAT/SBT Disagreement patient & family re: intubation 11
Assessment: Most of our infections preventable 2006-2007 VAP reduction became a STRATEGIC focus on quality improvement Initial goal to VAP by 50% 12
Structure Process Outcomes 13
Structure of Care Process of Care Outcomes 14
Organizational Vent policy SAT/SBT guidelines Physician credentials Structure of Care Process of Care Interaction: Emp - Pt Compliance Frequency & Coordination of care vent times Prevent HAI = VAP Unplanned extubations ICU & hospital LOS Hardwire Evidence Based Best Practice 15
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Actions for Impact: Recap Process Structure Evidence Based, Best Practice Monitor Process effect on Outcome (Donabedian) Value of Process = connect to outcome Hardwire Process make right process easy 17
1. Designing Actions for Impact 2. Engagement AND Accountability Hardwiring the care process 18
(Audit & feedback) ADDED to (provider reminder systems) (Audit & Feedback) ADDED to (organizational change) AND (provider education) AHRQ: Prevention of Healthcare-Associated Infections: Closing the Quality Gap www.effectivehealthcare.ahrq.gov/reports/final.cfm 19
Audit & feedback Make delivery of evidence-based, best practice EASY AS POSSIBLE. Create alerts (reminders, visual aids, peer pressure) to MAKE POOR CARE DELIVERY DIFFICULT. Provider Reminder Systems 20
Changed par level & storage of mouth care kits to assure availability & visual reminder Vent bundle SAT/SBT guidelines Physician credentials Structure of Care Stock Hi- Lo ETT s in ER, code carts & with EMS Met with anesthesia & CRNA groups: use Hi- Lo ETT for ICU surgery pts Upgraded ICU beds to include CLRT module Share responsibility for mouth care with resp; scheduled via MAR & task scheduler Process of Care Compliance Frequency of care Coordination of care RT assesses vent bundle compliance 3X/week on all pts; deficiencies immediately reported to RN Manager Each time SBT not performed per criteria RT manager f/u giving verbal or written warning
Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Vent days Data Source: APACHE IV milliennium 15 12 72% 9 6 3 76% 70% 77% 78% Spont Breathing Trial Goal: SAT/SBT Compliance > 90% 71% MCCG Adult ICUs: Avg. Compliance with SAT/SBT (excludes (OHS) 94% 95% 91% 85% 100% 95% 98% 98% 100% 98% 99% 98% 95% 94% 97% Avg Vent Days: FY09 Avg: 5.4 days FY10 Avg: 5.5 days FY11 Avg: 5.3 days 98% 90% 96% 100% 90% 80% 70% 60% 50% 40% 30% 20% Spontaneous Breathing Trial Compliance 10% 0 0% 22
Increased the rigor of goals 2006: process perfection 2013: process value connected to outcome Interdisciplinary frontline Board involvement Utilized the Plan Do-Check-Act (PCDA) methodology Continue to implement new strategies Joined GHA Hospital Engagement Network HAI continue to implement new strategies 23
Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 15 Data Source: APACHE IV millennium Goal: Avg Vent Days < 5.4 days MCCG Adult ICUs: Avg Vent Times (excludes OHS) Avg Vent Days: FY09 Avg: 5.4 days FY10 Avg: 5.5 days FY11 Avg: 5.3 days 12 All Avg Times Vent days 9 6 3 6.1 5.6 4.4 5.7 5.5 6.4 5.7 5.9 5.9 6.0 5.4 6.2 3.8 4.3 4.7 5.9 5.9 5.2 4.5 4.5 5.8 5.0 4.7 4.7 0 24
Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Display together: shows the WHY of measuring Vent days 15 12 Data Source: APACHE IV millennium 9 6 3 0 73% 6.1 80% 5.6 90% 74% 4.4 72% 5.7 5.5 70% 6.4 77% 78% 76% Talk, reports, policy review all with no improvement. Crit Care Committee: unacceptable! Goal: Avg Vent Days < 5.4 MCCG Adult ICUs: Avg Vent Time compared with Compliance with SBT 71% 5.7 5.9 5.9 6.0 94% 5.4 95% 6.2 98% 98% 98% 100% 95% 100% 91% 95% 98% 100% 99% 94% 90% 3.8 85% 4.3 4.7 All Avg Times Time to kick b.. and take names Spont Breathing Trial 5.9 5.9 5.2 5.8 4.5 4.5 5.0 Avg Vent Days: FY09 Avg: 5.4 days FY10 Avg: 5.5 days FY11 Avg: 5.3 days 4.7 4.7 80% 70% 60% 50% 40% 30% 20% 10% 0% Spontaneous Breathing Trial Compliance 25
Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Vent days 15 12 Data Source: APACHE IV millennium 9 6 3 0 6.1 80% 73% 5.6 90% 74% Care best practice? 4.4 72% 5.7 5.5 70% 6.4 77% 78% 76% 71% 5.7 5.9 5.9 6.0 Goal: Avg Vent Days < 5.4 days MCCG Adult ICUs: Avg Vent Time compared to Compliance with Spontaneous Breathing compliance Trial Care 100% BEST PRACTICE! 98% 94% 5.4 95% 6.2 91% 3.8 Effect # vent days changes 85% 4.3 95% 98% 4.7 Cause 5.9 5.9 5.2 100% 98% 5.8 4.5 4.5 99% 98% Outcome safer / improved outcomes 5.0 Avg Vent Days: FY09 Avg: 5.4 days FY10 Avg: 5.5 days FY11 Avg: 5.3 days 95% 100% 94% 4.7 4.7 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Spontaneous Breathing Trial Compliance 26
Number of VAP cases PICU Bundle PUD, DVT SAT, SBT in Adult Critical Care Nutrition Bundle PICU SBT/SAT Research Initial Vent Bundle Monitor Process/Outcomes Disciplinary Action- SBT non-compliance # of VAP in MCCG ICU s Critical Care 2006-2011 120 2012 Nutrition Bundle Revisited 100 80 60 40 20 0 2006 2007 2008 2009 2010 2011 #VAP 114 44 19 9 4 2 27
Communicate Hardwire ease the path of EBP Link Care Process & Outcomes Communication with Individuals / Link performance to job Med Staff Privileges Employee performance vent management: individual or group individual compliance, accountability, warnings, & annual evaluation KB & TN 28
1. Designing Actions for Impact 2. Engagement AND Accountability 3. 2013 & forward 29
Lagging patient outcome Surveillance for Vent Associated Events CDC Prevention Epicenters http://www.cdc.gov/hai/epicenters Critical Care Societies Collaborative http://ccsonline.org 30
Lagging: patient outcomes Incidence Vent Associated Pneumonia (VAP) Population Acute & long-term care hospitals Inpatient rehab facilities > 18 years old Mechanical vent time > 3 calendar days EXCLUSIONS: patients on rescue mechanical ventilation high-freq ventilation (HFV), extracorporeal membrane oxygenation (ECMO), & mechanical ventilation in prone position NHSN: National Healthcare Safety Network 31
Lagging: patient outcomes Probable VAP Public Reporting Definition On or after calendar day 3 of mechanical ventilation AND within 2 calendar days before or after onset of worsening oxygenation ONE of the following is met: Purulent respiratory secretions AND one of the following (+) culture of endotracheal aspirate (> 10 5 CFU/ml or equivalent) (+) culture of bronchoalveolar lavage (> 10 4 CFU/ml or equivalent) (+) culture of lung tissue (> 10 4 CFU/ml or equivalent) (+) culture of protected specimen brush (> 10 3 CFU/ml or equivalent) If no purulent secretions, then one of the following: (+) pleural fluid culture (+) lung histopathology (+) diagnostic test for Legionella spp. (+) diagnostic test for flu virus, RSV, adenovirus, parainfluenza virus NHSN: National Healthcare Safety Network 32
Leading: consider these areas Vent utilization code status, patient/family communication & education Mobility HAPU, Fall prevention, restraint use Infection prevention oral care Nutrition tube feedings: start time, amount delivered vs. ordered, evidence based management Delirium management med management, noise levels, sleep deprivation (bundled care) 33
Data Source: APACHE IV millennium 8.0% % Adult Vent Patients with Unplanned-Extubations Action taken by Resp & Nurse Managers FY 2010 avg: 2.7% FY 2011 avg: 4.0% FY 2012 avg: 3.0% 6.0% 4.0% 2.0% 0.0% (7/136) Apr-10 (3/138) Jun-10 (4/153) Aug-10 (7/130) Oct-10 (5/144) Dec-10 (5/121) Feb-11 (5/157) Apr-11 (8/127) Jun-11 (4/149) Aug-11 (4/140) Oct-11 (1/146) Dec-11 (4/126) Feb-12 (2/148) Apr-12 (6/156) Jun-12 (2/153) Aug-12 (5/149) Oct-12 (2/147) Dec-12 Month (# Unplanned Ext's / Total # Vent Patients; includes OHS) Mion, L. (2007) Patient-initiated device removal in intensive care units: A national prevalence study. Critical Care Medicine, 35(12), 2714-2720. 34
Vent Utilization Ratio # Vent Days / # Patient Days 0.50 0.45 0.40 0.35 0.30 0.25 0.20 0.15 0.10 0.05 MCCG Adult ICU Vent Utilization Ratio Comparison FY2010 - FY2012 MCCG 0.44 0.43 Nat'l Avg Data Sources: APACHE IV, PowerChart, Medipac 0.36 0.00 2010 2011 2012 MCCG 0.44 0.43 0.36 Nat'l Avg 0.45 0.43 0.40 http://www.ajicjournal.org/article/s0196-6553(11)00373-7/fulltext 35
Awareness NHSN - vent utilization Mobility - slow/stop de-conditioning Delirium - age, withdrawal (tobacco, Rx, ETOH) Nutrition - timeliness to start, calories Rx NHSN - Vent Acquired Conditions (VACs) possible & probable pneumonia 36
1. Actions for Impact Cause Care Best Practice Effect Outcomes Goals of Care 37
1. Actions for Impact Cause Care Best Practice Effect Outcomes Goals of Care 2. Engagement & Accountability Engagement coordination of care Accountability by caregivers: where the buck stops 38
1. Actions for Impact Cause Care Best Practice Effect Outcomes Goals of Care 2. Engagement & Accountability Engagement coordination of care Accountability by caregivers: where the buck stops 3. 2013 & beyond Vent utilization, delirium, mobility, nutrition Vent Associated Conditions (VACs) 39
Ventilator care is a complex process Do not assume knowledge = application Measure care + outcomes regular output Involve interdisciplinary bedside (point of care) staff 40
I believe a vision for quality must start with ownership. We cannot just do what we are asked, but we must take it further by looking for what we can do to improve. Quality must be integrated into our every day caring. Betty Brown, MBA, MSN, RN, CPHQ, FNAHQ - VP Quality & PI, TriHealth, Inc. 41
Balas, M. (2012) Critical care nurses' role in implementing the ''ABCDE Bundle'' into practice. Critical Care Nurse, 32(2), 35-47. Centers for Disease Control and Prevention. (2011, 12). National healthcare safety network ventilator-associated event. Retrieved from http://www.cdc.gov/nhsn/psc_da-vae.html Dudeck, M. et. al. (2011) National healthcare safety network (NHSN) report, data summary for 2009, device-associated module. American Journal of Infection Control, 39(5), 349-367, doi: 10.1016/j.ajic.2011.04.011 Hillier, B., Wilson, C., Chamberlain, D., & King, L. (2013) Preventing Ventilator-Associated Pneumonia Through Oral Care, Product Selection, and Application Method. AACN Advanced Critical Care, 24(1), 38-58. Mauger-Rothenberg B. Prevention of healthcare-associated infections. Closing the quality gap: revisiting the state of the science. Evidence report / technology assessment No. 208. (Prepared by the Blue Cross and Blue Shield Association Technology Evaluation Center Evidence-based Practice Center under Contract No. 290-2007-10058-I.) AHRQ Publication No. 12(13)-E012-EF. Rockville, MD: Agency for Healthcare Research and Quality. November 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm. Mion, L. (2007) Patient-initiated device removal in intensive care units: A national prevalence study. Critical Care Medicine, 35(12), 2714-2720. Timmerman, R. (2007) A mobility protocol for critically ill adults. Dimensions of Critical Care Nursing, 26(5), 175-179. Wunch, H. (2010) The epidemiology of mechanical ventilation use in the United States. Critical Care Medicine, 38(10), 1947-1953. 42
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