Transcript Central Line Bundle

Reducing Infections:
Ventilator
Central Line
Presenters
Stephanie Crow, RN
Betsy Pesek, RN
Caroline Truong, RN
Curtis F. Veal, Jr., MD
Clinical Effectiveness Manager
Overlake Hospital Medical Center
ICU Clinical Care Supervisor
Swedish Medical Center
Critical Care
Overlake Hospital
Medical Center
Medical Director,
Critical Care Services
Swedish Medical Center
Overlake Hospital
Medical Center
Project Goals
• Reduce Ventilator Associated
Pneumonia (VAP) by 75%
• Reduce Central Line CatheterAssociated Blood Stream
Infections by 75%
• Achieve 95% or higher
compliance with Ventilator
Bundle
• Achieve 95% or higher
compliance with Central Line
Bundle
Project Goals
• Achieve 95% or higher
compliance with use of daily
goal sheets for patients
• Reduce ALOS on Ventilator by
30%
• Reduce ICU ALOS
• Reduce ICU Costs
Developing a Physician
Champion
Developing a Physician
Champion
• Look for a physician who
believes in the change
• Need to be in a position to
affect change
• Physician’s respond to data
• Present evidence
• Align incentives
Communication with
Staff and Physicians
• Personal letters
• Newsletters
• Face to face
• E-mail
• Presented at meetings
• Posted data/ report cards
“Every system is perfectly
designed to achieve the
results it gets”
• Ventilator and Central line
bundles
• Ventilator management changes
• Central line management
changes
• Multidisciplinary rounding
• Daily goals/ Rounding sheet
What are Bundles?
• A bundle is a group of
precautionary steps with
approximate time and space
characteristics that, when
executed collectively and
reliably, have an enhanced
affect on patient outcomes.
• The bundle provides a "forcing
function" for teamwork, and this
teamwork has led to
outstanding results.
Ventilator Bundle
• Elevating the head of the patient’s
bed to 30 degrees or higher
• Prophylactic treatment for deep
venous thrombosis
• Prophylactic treatment for peptic
ulcer disease
• Daily "sedation vacation“
accompanied by an assessment of
the patient’s readiness to wean from
the ventilator
Central Line Bundle
• Hand-hygiene
• Optimal insertion site (RIJ, LIJ)
• Maximal sterile barrier use (covered
to pt waist)
• Prepare skin with antiseptic/
detergent chlorhexadine 2% in 70%
isopropyl alcohol
• Daily review of necessity
• Early removal (5 day max)
• Intact Dressing
Ventilator Management
Changes
• Chlorhexadine on the unit
• Sage oral care product
www.sageproducts.com
• Sedation reduction vs. Sedation
vacation
• Using DVT and PUD prophylaxis to
prevent risk for vent patients
• Using ventilator weaning protocol
• Continuous aspiration of subglottic
secretions www.atsjournals.org
Central Line Management
Changes
Central Line Management
Changes
• Created Cent line carts
• Implemented Cent Line checklist
• Created cath line insertion
recommendations
• CL catheter products for high risk
patients available
• New dressings for central lines
• Central line dressing team
Multidisciplinary Rounding
• Introduces redundancy
• Intensivist led/ CN facilitated
• All patients in critical care
• Pharmacy and RT involvement
critical
Daily Goals Sheet/
Rounding Sheet
Daily Goals Sheet/
Rounding Sheet
• Creates accountability for practice
expectations
• Helps to ensure that key activities
are done on each patient
• Rounding form is a permanent part
of the medical record and can be
audited
• Provides prompting for staff by using
daily goals and safety risk checklists
• Enhances communication among
team members
Barriers we experienced
• Weekend coverage for rounds
• Pharmacy involvement in rounds
• Physician and nursing buy-in
• Registry and new employees
• Physician reluctance
• Timeliness of trialing new
products
Barriers we experienced
• No active critical care manager
during project
• Staff ready and organized at
rounding time
Process for Data Collection
• Created a shared drive for each
member to access data and
graphs
• Established owners for each
indicator
• Owners are responsible to enter
data monthly (by the 10th of
the month) onto the shared
drive
• Quality updates the graphs
Results!
• Baseline average VAP rate 16.33
• Project Average VAP rate 2.50 = 85% Reduction
• 4 out of 7 months with zero VAP
100%
Compliance
80%
35.00
30.00
25.00
20.00
Started PI
60%
40%
20%
0%
Vent Bundle Compliance
Critical Care VAP Rate
VAP Cases
F-04 M-04 A-04 M-04 J-04
0%
0%
0%
0%
0%
J-04
A-04
0%
0%
12.66 33.56 18.63 25.32 17.54 5.05
2
5
3
4
4
1
S-04 O-04 N-04 D-04 J-05
16%
40%
5.99 16.30 5.85
1
3
1
F-05 M-05 A-05
50% 100% 100% 100% 100% 100%
6.25
0.00
0.00
0.00
0.00
5.41
1
0
0
0
0
2
15.00
10.00
5.00
0.00
VAP Rate
Critical Care VAP Process/ Outcome
Results!
• Baseline average CA-BSI rate 2.84
• Project Average CA-BSI rate 1.24 = 56% Reduction
• 5 out of 7 months with zero CA-BSI
CA-BSI Process/ Outcome
100%
14.00
Compliance
10.00
60%
8.00
Started PI
6.00
40%
4.00
20%
0%
2.00
F-04
M-04
A-04
M-04
J-04
J-04
A-04
S-04
O-04
N-04
D-04
J-05
F-05
M-05
A-05
CL Bundle Compliance
0%
0%
0%
0%
0%
0%
0%
0%
82%
67%
74%
70%
94%
91%
91%
CR-BSI Rate
0.00
0.00
0.00
4.00
11.83
3.13
3.47
3.46
0.00
0.00
0.00
5.68
3.02
0.00
0.00
0
0
0
1
4
1
1
1
0
0
0
2
1
0
0
CR-BSI Cases
0.00
CA-BSI Rate
12.00
80%
Results!
• Baseline ALOS for MV rate 2.25
• Project ALOS for MV rate 1.59 = 30% Reduction
ALOS for MV (CC m onthly pt m echanical ventilator days/
total m echanically ventilated pts)
3.00
2.50
2.00
1.50
1.00
0.50
0.00
Critical Care ALOSMV
J-04
F-04 M-04 A-04 M-04 J-04
J-04
A-04 S-04 O-04 N-04 D-04
1.65
2.32
2.11
2.51
2.24
2.54
2.51
2.74
1.59
1.51
1.59
2.07
J-05
1.5
F-05 M-05 A-05
1.72
1.91
1.24
Results!
Cummulative Expense Avoidance due to reduction in VAP and CA-BSI
•
•
•
20 patients
saved from
needless harm
(16.83 + 2.81)
Saved 6 lives
(20 patients x
30% mortality
rate)
$1,000,000.00
$874,120.00
$800,000.00
$600,000.00
VAP
$400,000.00
CA-BSI
$151,740.00
$200,000.00
$O-04
N-04
$1,025,860.00
in cost
avoided
D-04
J-05
F-05
15.00
10.00
5.00
•34 VAP cases (2.83 monthly avg, $52,000 a case
& ALOS 22 days)
•10 CA-BSI cases (.83 monthly avg, $54,000 a
case & ALOS 17 days)
A-05
Patients Saved from Harm (VAP & CA-BSI)
20.00
Data is derived from baseline data Oct 2003-Sept 2004
M-05
1.830.83
3.66
1.66
6.49
2.49
O-04
N-04
D-04
9.32
1.32
12.15
1.15
14.98
1.98
16.81
2.81
0.00
J-05
F-05
M-05
A-05
Cumulative Patients Unharmed (VAP) Cumulative Patients Unharmed (CA-BSI)
Unmeasureable results!
• Culture of critical care:
− Improved critical thinking and planning
for patient care
− Staff are able to take view from 10,000
feet
− Infections are not inevitable
• Great patient saves:
− Found that a renal failure patient was on
full dose Lovinox
− Found many patients that needed to
have their antibiotics DC’d
− Found a patient that went into renal
failure was on too much Digoxin and
was becoming toxic
Keys to Success
• Senior leader support
• Clinical Champion
• Day to day leader
• A multidisciplinary team
• Staff buy in
• Project sustainability
Swedish
Medical Center
Presentation Overview
• Background
• Committee composition
• Communication strategy
• Composition of bundles
• Data tracking
• Results
• Barriers
• Words of advice
Background
• IHI 3rd Annual International
Summit on Innovations in
Critical Care Delivery – March
2004
Convention Highlights
• Nosocomial Infections: Zero
Tolerance
• Improving Critical Care: A Global
Approach
• “Bundle” Up Your Critical Care
Processes
• Reducing Mortality and Morbidity
• Establishing Culture of Safety in the
ICU
• Measuring ICU Quality
Our Collaborative Team Members
IHI Collaborative Team
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Chip Veal, MD; Medical Director
Derel Finch, MD; Intensivist
George Pappas, MD; Intensivist
June Altaras, Manager, First Hill ICU
Steve Hoppe, Project Manager, EICU
Joya Pickett, Clinical Nurse Specialist
Marie Arnone, Clinical Nurse Specialist
Patti Feley, Manager, Providence ICU
Will Shelton, Director Epidemiology
Jim Kumpula, Manager, Respiratory Therapy
Nancy Siegle, Manager, Ballard ICU
Jennifer Harville, Director, Clinical Effectiveness
Theresa Bervell, Admin Resident, Clinical Effectiveness
Tom Moore, Respiratory Care
Marjorie Svrjcek, Manager Respiratory Care
Debra Gruber, Manager, Respiratory Care
Caroline Truong, ICU Clinical Care Supervisor
Lilia Mullins, RN IV Team
Laura Make, RN Value Improvement Consultant
Team Charter
Critical Care Collaborative
• Set Objectives
− Improve outcomes for ICU patients
• Defined Goals
− Create no harm culture
− Establish shared understanding of
bundle concept
− Implement bundles
− Implement Multidisciplinary Rounds
• Identified sponsoring committee
(Critical Care Committee)
Critical Care Committee
Department Composition
• Intensivists
• Nursing
Managers,
CNS,
supervisors
• Respiratory
care
• Epidemiology
• e-ICU®
• Clinical
Effectiveness
• Pharmacy
• Cardiology
• Nephrology
• Neurology
• Inpatient
Hospitalist
Team
• Surgery
Multiple Focused Projects
• Ventilator Bundle
• Central line Bundle
• Multidisicplinary Rounds
• Rapid Response Team
• Sepsis Bundle
Rapid PDSA
P
D
SA (P)
Weekly
Meeting
Test of
Change
“Huddle”
Test of Change:
One Patient,
One Physician,
One Time
What are Bundles?
• Collection of practices or process
steps
• Individual elements based on solid
science
• Tasks must relate in time and space
• Emphasis initially on process rather
than outcome
• Bundle measured as all or none
• Eventual endpoint is outcome
improvement
Vent Bundle Elements
• Head of bed elevation
• Deep vein thrombosis
prophylaxis
• Peptic ulcer disease
prophylaxis
• Sedation interruption
• Daily assessment of
readiness to wean
Sedation Interruption
• Developed protocol and
algorithm
• Introduced Modified Ramsay
Sedation Scale (MRSS)
• 1-1-1
• Implemented in pilot unit
• ICU skills days
Rapid PDSA
P
D
SA (P)
Weekly
Meeting
Test of
Change
“Huddle”
Test of Change:
One Patient,
One Physician,
One Time
Sedation Interruption
• Developed protocol and
algorithm
• Introduced Modified Ramsay
Sedation Scale (MRSS)
• 1-1-1
• Implemented in pilot unit
• ICU skills days
Units of Focus
Ballard &
Providence ICUs
Other First
Hill ICUs
7E
Monitoring/Communication
Education Process
• All elements reviewed during
night shift or first thing in AM
(e-ICU®)
• Daily AM rounds by manager
• Multidisciplinary Rounds
VENTILATOR PNEUMONIA
PREVENTION ORDERS*
1.
Reverse Trendelenberg 30 degrees unless contraindicated by
hypotension
2.
Sedation interruption daily (unless specifically contraindicated)
3.
Famotidine 20 mg IV Q 12H (unless history of allergy)
IF DOCUMENTED BLEEDING or HIGH GI BLEEDING RISK ON
ADMISSION: Protonix 40 mg IV daily
4.
Heparin 5000 units SQ Q 12H (unless post-op heart, other
anticoagulant ordered)
IF DOCUMENTED BLEEDING, HIGH BLEEDING RISK ON ADMISSION or
HEPARIN ALLERGY: Sequential compression devices (SCDs) only
*Call attending physician if there are questions or concerns about any of these
orders.
These orders are not intended to duplicate or conflict with those written by the
Attending Physician.
Data Feedback - Old Way
(Usual Approach)
100
90
80
70
60
50
40
30
20
10
0
Mean
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Data Feedback – Focus on Process
Percent of vented patients with all 5 bundle items
Percent of Vented Patients With All 5 Bundles
Ventilator Bundle Compliance
October to November 2004
Goal:95%
100%
90%
94%
89%
90%
% of Patients Compliant
80%
67%
66%
70%
58%
Desired
Direction
of
Improvement
60%
47%
50%
40%
30%
20%
10%
0
0%
Q1/Q2/Q3
2004
Week 1
(Oct 12)
Week 2
(Oct 19)
Week 3
(Oct 26)
Week 4
(Nov 2)
Q4-2004
Week 5
(Nov 9)
Week 6
(Nov 16)
Week 7
(Nov 23)
Data Feedback – New Way
Vent Bundle Compliance and VAP Infection Rates
100%
% Vent Bundle Compliance
Vent Bundle Goal=95%
VAP Infections/1000 Device Days
6.4
90%
100%
100% 100%100%100%100%
100%100%
100%100% 100%100% 100%
100%
100%
100%
97%
97%
96%
95%
95%
94%
93%92%
93%
7
90%89%
92%
87%
5.8 5.8 5.8
80%
% of Patients Compliant
Central Line
Bundle
Implemented
Implemented
Multidisciplinary
Rounds
66%
70%
Manager verifies
HOB at 30
degrees
67%
58%
Rapid Response
Team
Implemented
Spread vent
bundle to 6E/8E
ICU
60%
6
5
4
47%
e-ICU support;
RN's/RT's cooordinate
sedation vacation
50%
40%
30%
3
2
Daily audits; Sedation
interruption protocol
algorythm/orders in pt
room
20%
10%
0 0 One
0 patient,
0 0one0MD, 0one 0
time 0
0 0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
2
W
k
1
9
Q
Q
04
Q
(1 3 04
0/
12
/0
4)
W
k
2
W
k
3
W
k
4
W
k
5
W
k
6
W
k
7
W
k
8
W
k
9
W
k
10
W
k
11
W
k
W
1
k
(0
1/ 12
01
/0
5)
W
k
2
W
k
W
4
k
(0
3
1/
24
/0
5)
W
k
5
W
k
W
7
k
(0
6
2/
14
/0
5)
W
k
8
W
k
9
W
k
10
W
k
11
W
k
12
W
k
13
W
k
14
W
k
15
W
k
16
W
k
17
W
k
18
W
k
19
W
k
2
W 0
K
21
0
04
0%
0
2004
2005
CONFIDENTIAL PRIVILEGED DOCUMENT Per Washington State (RCW 4. 24.20 and RCW 70.41.20, 42 USC) and Federal Statutes. Release/Redisclosure is Prohibited.
Data Source: Daily Vent Bundle Weekly Audit; Epidemiology surveillance: National Nosocomial Infections Surveillance System (NNIS).
Multiple PDSA’s
• One patient, one physician, one
time
• e-ICU® involvement and
support
• Group education followed by
one to one education with
manager
• RNs and RTs coordinate
sedation vacation
• Multidisciplinary rounding
Central Line Bundle
Elements
• Remove unnecessary lines
• Practice hand hygiene
• Select optimal insertion site
• Use maximal barrier precautions
• Apply Chlorhexidine for skin
antisepsis
• Appropriate site care
Central Line - PDSA
High Impact Tests of
Change
• Checklist and supply cart
• Safety pause (including script
for staff)
• Physician letter
• Bundle piloted at Ballard and
Providence
• Full roll-out March 05
• Trial Biopatch and Statlock
Central Line Insertion Checklist -Adults
Operator:________________________________________Date:_______________________
RN Assisting:____________________________________ Room/Location:______________
Safety Pause:
 Correct Patient
 Correct Procedure
 Correct Site
 Verbal agreement from all members of the team.
In order to eliminate central line associated blood stream infections, we will be following the
Central Line Insertion Procedure Checklist based on CDC Guidelines.
Prior to the Procedure:
1. Hand Hygiene done with Chlorhexidine Gluconate (CHG) 2% surgical hand scrub and water or waterless
alcohol based gel before patient contact and before donning sterile gloves.
YES
2. Cleanse Site with CHG 2% Chloraprep Sponge 1.5mL.
YES
3. Disinfect Site with a back and forth friction scrub, utilizing CHG 2% Chloraprep Wand 10.5mL for 30
seconds and allow to dry completely before catheter insertion.
YES
4. Maximum Barriers Did the operator wear:
YES Cap/Bouffant
YES Mask
YES Sterile Gown
YES Sterile Gloves
YES Patient draped with full body sterile sheet. (Drp Angi ADH)
During the procedure:
5. YES Operator(s) maintained the sterile field.
6. YES Personnel assisting wore a cap, mask and donned gloves appropriately.
After the procedure:
6. Sterile dressing applied immediately by the operator.
YES
QUALITY IMPROVEMENT
THIS FORM IS NOT PART OF THE PATIENT'S PERMANENT RECORD.
Please return the form to your Nurse Manager. If a step has was not followed, please note and
the Nurse Manager will follow up with the physician.
To:
Physicians and Nurses placing central lines in SMC intensive care units
From: Martin Siegel, M.D., Curtis Veal, M.D., Derel Finch, M.D. and Greg Sorensen, M.D.
Re:
Improvements in our ICUs to eliminate central line associated blood stream infections
You are aware that the hospital strives to improve the quality of patient care and has activities in place to eliminate
needless death and harm. As part of these ongoing efforts we are implementing practices called “bundles”
based on national guidelines and evidence-based medicine to create significant outcome improvements. A
“bundle” is a group of individual interventions forming a collection of practices or process steps. When
these practices are implemented together as a “bundle” they result in better outcomes than when
implemented individually. Consistent with these aims we are asking all physicians to assure their practice
of inserting central lines includes the following “bundle” of activities known as the “Central Line
Bundle”.
1.
2.
Consistent with these aims we are asking all
physicians to assure their practice of inserting
central lines includes the following “bundle” of
A Safety Pause: Correct patient, Correct site, Correct procedure, and Correct physician.
Hand Hygiene
and Cleaning
the Patient
to antiseptic prep
of the insertion site
activities
known
as Skin
theprior
“Central
Line
a) Upon entering the room perform routine hand washing or use alcohol gel.
b) CleanBundle”….
the insertion site with BD EZ Scrub foam pad brush with 3% CHG
c) Re-sanitize your hands with 2% chlorhexidine gluconate (CHG) antiseptic scrub (current brand is Exidine
2), alcohol gel or alcohol scrub
containing chlorhexidine gluconate (Avagard) and put on sterile gloves
3. Prep the Insertion Site with antiseptic 2% chlorhexidine gluconate which will be provided in the 10.5 mL
ChloraPrep wand with sponge applicator.
4. Maximum Barrier Precautions observed by MD and other healthcare personnel in the sterile field*Bouffant
Cap, Mask, Sterile Gown, Sterile
Gloves, Full size patient drape, Maintain the sterile field, individuals on the far side of the bed simply opening
supplies on to the field will at a
minimum use cap, and mask with gloving as appropriate.
5. Sterile Dressing Applied Immediately by the MD wearing full barrier precautions
Our ICU nurses assisting you with line
insertions will be using a checklist and script
to help us achieve 100% compliance with the
central line bundle. Anyone involved in the
procedure who sees a break in technique
has a responsibility to the patient’s safety to
Our ICU nurses assisting you with line insertions will be using a checklist and script to help us
achieve
100% compliance
within
thecorrecting
central line bundle.
Anyone
involved in the procedure who
quickly
assist
the
situation.
sees a break in technique has a responsibility to the patient’s safety to quickly assist in correcting the
situation.
We will be testing the central line bundle implementation with small tests of change. This means we will be
refining our “bundle” with one MD and one patient during one procedure. We will then make small
improvements before we repeat this process with the next MD and patient. The small tests of change will
result in improvements of the central line bundle checklist, our script for notifying healthcare professionals
of breaks in technique, and the availability of the correct standardized supplies in the central line insertion
carts in all ICUs on all campuses.
The central line bundle is just one part of our overall evidence based quality improvement program to increase
patient safety. The recent implementations of the ventilator bundle, multidisciplinary ICU patient rounds
and the deployment of our rapid response team are all part of this process. We thank you for your
ongoing support for all of these efforts.
Central Line Bundle Compliance
and CLBSI Infection Rates
Communication
• Weekly collaborative meetings
• Weekly data feedback
• Monthly reporting to Critical
Care Committee
• Rapid data sharing
• Sharing ideas with IHI
• There is never too much
communication
Barriers
• Lack of standardization
• Data Collection
• Prioritization of work and issues
• Transforming the culture
Helpful Advice
• Board and senior leadership
buy-in
• Physician champions
• Management support
• Empower the staff
• Have process for immediate
feedback
• Celebrate team success
Conclusion
Why is VentilatorAssociated Pneumonia
of Concern?
• VAP occurs in 15% of patients
receiving mechanical ventilation.
• Hospital mortality rate of
patients with VAP is 46%
compared to 32% for ventilator
patients without VAP.
• VAP is associated with
prolonged stay and increase
costs.
What is a Ventilator
Bundle?
• Head of bed up 30 degrees
• Daily “sedation vacations”
• Daily assessment of readiness to
extubate
• Peptic ulcer disease prophylaxis
• Deep vein thrombosis
prophylaxis.
Why is Central LineAssociated Infection of
Concern?
• 48% of ICU patients have
central venous catheters in
ICUs.
• There are approximately 5.3
catheter-related blood-stream
infections per 1,000 catheterdays in ICUs.
• Mortality for between 14,000 to
28,000 deaths per year.
What is a Central Line
Bundle?
• Hand Hygiene
• Maximal barrier precautions
• Chlorohexidine skin antisepsis,
appropriate catheter site
• Appropriate administration
system care
• No routine replacement
Recommendations
• Go For It!
• Best change this year!
Key Points
• Develop physician and
administrative champions
• Communicate, communicate,
communicate
• Measure and provide immediate
feedback
Measurement
• Number of times bundle not
used
• Number of central line infections
per 1,000 catheter days
• Number of ventilator-associated
pneumonia per 1,000 catheter
days
Polling
Questions?
Thank you
for participating!
Please fill out the
evaluation.