Improving Patient Safety, Clinical
Quality and Unfunded Mandates:
What ICPs Should Know
Denise Murphy, RN, BSN, MPH, CIC
Chief Patient Safety and Quality Officer
Barnes-Jewish Hospital at Washington University Medical Center St.
Louis, MO
APIC 2005
Baltimore, MD
Who Keeps Moving the Cheese?
And WHY?
 Institute of Medicine Reports on
 Medical Errors (>100,000 lives lost annually)
 Quality Chasm (Safety,
 Government:
 Center for Medicare and Medicaid Services (CMS)
 Agency for Healthcare Research and Quality
 CDC






Healthcare research
Medical malpractice claims
JCAHO sentinel event tracking
Consumer’s Union and other advocacy groups
Insurers: Pay4Performance
Industry: Leapfrog Group
I LOVE
CHANGE!
What Should ICPs Know About
Quality Initiatives
 National Quality Forum, CMS, JCAHO and other
agencies require patient safety and quality (PSQ)
monitoring and reporting
 tied to reimbursement
 Consumers & payors demanding performance
data
 Non- and for-profit organizations driving quality
improvement (e.g., IHI, VHA)
 Infection prevention is included in improvement
initiatives (local and national scorecards)
What are Hospitals Responsible for
in Terms of Quality & Compliance
 Indicators related to
 Clinical Quality
 Infection Prevention
 Patient Safety
 Operational Excellence and Customer Satisfaction
 Reporting
 Federal and State agencies, accreditation agencies,
voluntary quality initiatives (AHA, IHI, etc.), insurers
 Governance boards
 Public reporting of hospital-acquired infections
 Reporting of other/all adverse events: stay tuned!
Why Should ICPs Care?
 We are experts in monitoring, reporting and driving
interventions related to adverse outcomes
 We are Quality Improvement and Patient Safety
Professionals – organizational consultants,
experts, and leaders in
 identifying risk
 mitigating and preventing adverse events
 If we bring our expertise to required, highly visible
PSQ activities, we demonstrate our value to
healthcare executives!
WHAT IS BEING
MEASURED
Indicator
and BY WHOM?
ORYX/
CMS
Core
Measures
-Current
CMS/AHA &
JCAHO
Measures Anticipated
Best-inClass
2004
Safety Culture1
Employee perception of management commitment to patient safety
x
Employee willingness to report errors
x
Patient Identification2
Surgical/procedural site ID compliance
x
Surgical/procedural time-out compliance
x
Patient rating of consistency of identification by care givers (survey)
x
Medication Safety2
Compliance with "Do Not Use" abbreviation list
x
Infection Control
Trained medical direction in Infection Control
x
Antibiotic management program enhancements
x
Surgical patients receiving prophylactic antibiotic within standard
x
Hand hygiene policy and education
x
Reduce Catheter-related Bloodstream Infections in ICU (SIR < 1)
x
Reduce VAP Infections in ICU (SIR < 1)
x
Patient Identification
Mislabeled/unlabeled lab specimens
x
Medication Safety
Tall man lettering utilized at medication storage locations
x
NPSG
Indicator
JCAHO
Core
Measures Current
JCAHO
Core
Measures Future
Best-inClass
2005
CMS
Annual
Payment
Update
AMI
Admission Treatment
ASA within 24 hours of hospital arrival1
x
x
x
Beta-blockers within 24 hours of hospital arrival1
x
x
x
Cholesterol testing within 24 hours of hospital arrival
x
Discharge Treatment
ACE-I/ARB prescribed at discharge for LV systolic
dysfunction1
x
x
x
ASA prescribed at discharge1
x
x
x
Beta-blockers prescribed at discharge1
x
x
x
Lipid-lowering agents prescribed at discharge
x
Reperfusion therapy within standard (Thrombolytic & PTCA)1
x
x
-Smoking cessation advice/counseling2
x
x
Inpatient mortality
x
Society of Thoracic Surgeons (STS) CABG
ASA/antiplatelet prescribed at discharge
x
x
Lipid-lowering agents prescribed at discharge
x
x
ACE-I prescribed at discharge
x
Beta-blockers prescribed at discharge
x
Exercise program and/or cardiac rehabilitation therapy
prescribed at discharge
x
Smoking cessation advice/counseling
x
x
x
Best-inClass
2005
CMS
Annual
Payment
Update
x
x
x
Oxygenation assessment1
x
x
Initial selection of antibiotic
x
x
Blood cultures before antibiotics2
x
x
Indicator
JCAHO
Core
Measures Current
JCAHO
Core
Measures Future
CAP
Antibiotic administration within 4 hours of hospital arrival1
Admission Treatment
x
Preventive Care
Smoking cessation advice/counseling (adult/pediatric)2
x
x
Pneumococcal vaccine screening and/or vaccination1
x
x
Influenza vaccination3
x
x
x
x
x
CHF
ACE-I prescribed at discharge1
Antithrombotics Rx at discharge for patients with AFib
x
Discharge instructions2
x
x
LV function assessment1
x
x
Smoking cessation advice/counseling (adult)2
x
x
PCI
ASA/antiplatelet prescribed at discharge
x
x
x
Indicator
JCAHO
Core
Measures
-Current
JCAHO
Core
Measures
- Future
Best-inClass
2005
CMS Annual
Payment
Update
SIP (Surgical Infection Prevention)
Duration of prophylactic antibiotics3
x
x
x
Duration of prophylaxis3
x
x
x
Selection of antibiotic3
x
x
x
Other
HCAHPS (patient satisfaction survey)4
1 Publicly
reported Q4 2003, Q1 2004 (Sept 2002 discharges)
2
Publicly reported beginning Q1 2005 (Q2 2004 discharges)
3
Publicly reported Summer 2005 (Q3 2004 discharges)
4 Publicly
reported Fall/Winter 2005 (Q1 2005 discharges)
x
Indicator
NPSG
Improve accuracy of patient identification
Use 2 patient identifiers when taking blood, administering medications or blood products, providing
any other treatments or procedures
x
Prior to the start of any surgical or invasive procedure, conduct a final verification process, or "time
out", to confirm correct pt., procedure, site using active communication techniques
x
Improve the effectiveness of communication among caregivers
To verify telephone or verbal orders, or critical test results, the person receiving the order must "read
back" the complete order or test result after transcription
x
Standardize abbreviations, acronyms and symbols used throughout the organization, including list
of abbreviations, acronyms and symbols not to use
x
Measure, assess, and take action to improve the timeliness of reporting, and the timeliness of
receipt by the responsible licensed caregiver of critical test results & values
x
Improve the safety of using medications
Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium
phosphate, sodium chloride >0.9%) from patient care units
x
Standardize and limit the number of drug concentrations available in the organization
x
Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs
x
Eliminate wrong site, wrong patient and wrong procedure surgery
Create and use a preoperative verification process, such as a checklist, to confirm that appropriate
documents, (e.g., medical records, imaging studies) are available
x
Implement a process to mark the surgical site and involve the patient in the marking process
x
Indicator
NPSG
Improve the safety of using infusion pumps.
Ensure free flow protection on all general use and PCA intravenous infusion pumps used in
the organization
x
Improve the effectiveness of clinical alarm systems
Implement regular preventive maintenance and testing of alarm systems
x
Assure that alarms are activated with appropriate settings and are sufficiently audible with
respect to distances and competing noise within unit
x
Reduce the risk of healthcare-acquired infections
Comply with current CDC hand hygiene guidelines
x
Manage as sentinel events all identified cases of unanticipated death or major permanent
loss of function associated with a healthcare-acquired infection
x
Accurately & completely reconcile medications across the continuum of care
Develop a process for obtaining & documenting a complete list of patient's current
medications upon admission and with any involvement of the patient
x
A complete list of the patient's medications is communicated to the next provider of services
when it refers or transfers a patient to another setting, service, practitioner or level of care
x
Reduce the risk of patient harm resulting from falls
Assess & periodically reassess each patient's risk for falling, including the potential risk
associated with the patient's medication regimen
x
Magnet
Status
*NDNQI
Pressure ulcer prevalence
x
x
Pressure ulcer occurrence
x
x
Nursing care hours provided per patient day
x
x
Nursing staff satisfaction
x
x
Falls occurrence
x
x
Fall injury occurrence
x
x
- Nursing care
x
x
- Pain management
x
x
- Patient education
x
x
- Overall care
x
x
Skill mix of RN, LPN and unlicensed staff
x
x
INDICATOR
Patient satisfaction in relation to:
*National Database of Nursing Quality Indicators
Indicator
ORYX/
CMS Core
Measures Current
CMS/AHA &
JCAHO
Measures Anticipated
BestinClass
2004
Magnet/
NDNQI
NQF Nursing-Sensitive Voluntary Consensus Standards
Death among surgical inpatients with treatable serious
complications (failure to rescue)
X
Pressure ulcer prevalence
X
x
Falls prevalence
X
x
Falls with injury
X
x
Restraint prevalence (vest and limb only)
X
Urinary catheter-associated UTI for intensive care unit (ICU)
patients
X
Central line catheter-associated blood stream infection rate
for ICU and high-risk nursery (HRN) patients
Ventilator-associated pneumonia for ICU and HRN patients
X
x
x
x
Smoking cessation counseling for AMI
x
x
Smoking cessation counseling for HF
x
x
Smoking cessation counseling for pneumonia
x
x
Skill mix (RN, LVN/LPN, UAP, and contract)
x
x
Nursing care hours per patient day (RN, LPN, and UAP)
x
Practice Environment Scale - Nursing Work Index
x
x
Indicator
ORYX/
CMS Core
Measures Current
CMS/AHA &
JCAHO
Measures Anticipated
BestinClass
2004
JCAHO ORYX ICU Measures
Ventilator-Associated Pneumonia (VAP Prevention – Patient
Positioning)
x
Stress Ulcer Disease (SUD) Prophylaxis
x
Deep Vein Thrombosis (DVT) Prophylaxis
x
x
Central Line-Associated Primary Blood Stream Infection
x
x
Risk-Adjusted ICU LOS by type of ICU
x
Risk-Adjusted Hospital Mortality for ICU Patients
x
x
Magnet/
NDNQI
PROPOSED 2006 NATIONAL PATIENT SAFETY GOALS
Goal #10: Reduce Influenza and Pneumonia
Develop and implement protocols for administration and documentation of influenza and pneumonia
vaccination.
Goal # 13: Achieve and Maintain an Organization-wide Safety Culture
Assess Culture of Safety and take action on results of assessment
Encourage external reporting of adverse events
Use external or expert information when designing new or modifying existing processes to improve
PS and reduce risk for sentinel events
Share lessons learned from root cause analysis conducted by the organization with all staff who
provide relevant services or may be impacted by proposed solutions
Increase awareness of and access to relevant patient safety literature and advisories for all
organizational leaders and staff
Goal #14: Involve Patients in their Own Care as a Patient Safety Strategy
Provide appropriate patient education to guide patient’s awareness and involvement in their own
care. (Assess health literacy level, language skills, ethnic and cultural factors)
Provide copy of medications to each patient and assist them in tracking/reconciling medications.
Implement comprehensive patient involvement program
Encourage patient participation in organization’s committees that relate to planning or providing
patient care services
Engage patients in the process of transitions across the continuum of care, including a dialogue
about their expectations and concerns about the next setting of care
Define and communicate the means to report concerns about safety and encourage pts. to do so
PROPOSED 2006 NATIONAL PATIENT SAFETY GOALS
Goal #16: Prevent Healthcare-Associated Decubitus Ulcers
Assess and periodically reassess each patient’s risk for developing a decubitus ulcer (pressure
sore) and take action to address any identified risks
Identify patients who enter the organization with a decubitus ulcer and provide appropriate medical,
physical and nutritional management to facilitate healing
What is Interventional Patient
Hygiene?
 Webster defines hygiene as the science and
practice of the establishment and maintenance
of health.
 Interventional Patient Hygiene is a nursing
action plan directly focused on fortifying the
patients host defense through use of evidencebased care.
 It works best with a protocol (action plan) and
PIP (measurement)
So What Can ICPs Do?
 KNOW the big picture of PSQ and where you and your
program fit in
 Position yourself as a leader in your organization’s PSQ
program…you are a Patient Safety Leader!
 Volunteer your expertise to teams addressing other
types of adverse outcomes of patient care
 Data management, analysis and reporting
 Intervention development
 Education and literature interpretation
 Evaluation of products and technologies
 Science-based, cross-functional, multi-disciplinary
approach to problem solving
Get involved…WHY?
ICPs are Safety, Quality and Performance Improvement
EXPERTS!
Now, it is my pleasure to introduce you
to our session experts…
Robert Garcia, BS, MMT(ASCP), CIC
Deborah Trau, RN, 6 Sigma Black Belt
to further address the role of infection
prevention in improving patient
safety and clinical quality
The Role of Oral and Dental
Colonization on Respiratory Infection:
Call for New Interventions in a Patient
Safety World
Robert Garcia, BS, MMT(ASCP), CIC
The Brookdale University Medical
Center, Brooklyn, New York
High Risk, High Morbidity, High Cost
VAP Facts
 Mechanical ventilation increases risk of
pneumonia 6-21 times (1% per day)
 Attributable mortality is 27% and
increases to 87% when etiologic agent is
P.aeruginosa or Acinetobacter sp.
 Length of stay with VAP is 34 days and
21 days without VAP
Garcia R., A review of the possible role of oral and dental colonization on the occurrence of
healthcare-associated pneumonia: Underappreciated risk and a call for interventions. Accepted
for publication. AJIC 2005
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Step 11: Isolate the pathogen
Hospital-Onset Infection Rates in NNIS
Intensive Care Units, 1990-1999
Type of ICU
BSI*
VAP*
UTI*
Coronary
Medical
Surgical
Pediatric
43%
44%
31%
32%
42%
56%
38%
26%
40%
46%
30%
59%
* BSI = central line-associated bloodstream infection rate
VAP = ventilator-associated pneumonia rate
UTI = catheter-associated urinary tract infection rate
Source: National Nosocomial Infections Surveillance (NNIS) System.
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Prevalence of Antimicrobial-Resistant (R)
Pathogens Causing Hospital-Onset Intensive Care
Unit Infections: 1999 versus 1994-98
Organism
Fluoroquinolone-R Pseudomonas spp.
3rd generation cephalosporin-R E. coli
Methicillin-R Staphylococcus aureus
Vancomycin-R enterococci
Imipenem-R Pseudomonas spp.
# Isolates
% Increase*
2657
1551
2546
4744
1839
49%
48%
40%
40%
20%
* Percent increase in proportion of pathogens resistant to indicated antimicrobial
Source: National Nosocomial Infections Surveillance (NNIS) System.
ICU Rates of VAP, NNIS Study,
Jan 2002-Jun 2004
Pooled means:
Medical – 4.9
Med-Surg – 5.4
Surgical – 9.3
Cost of VAP
 Retrospective matched cohort study
using data from large U.S. database
 9,080 patients; 842 with VAP (9.3%)
 Patients with VAP had significantly
longer duration of mechanical ventilation,
ICU stay, and hospital stay.
 VAP associated with increase of
>$40,000 in mean hospital charges
Rello J et al., Epidemiology and outcomes of VAP in a large US database.
Chest. 2002;122:2115-2121.
HICPAC guidelines on preventing pneumonia
 Issued 3/26/04
 Evidence-based
 Expert review
 Recommendations
categorized
www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm
HICPAC categories
 Category IA. Strongly recommended for implementation and
strongly supported by well-designed experimental, clinical, or
epidemiologic studies.
 Category IB. Strongly recommended for implementation and
supported by certain clinical or epidemiologic studies and by
strong theoretical rationale.
 Category IC. Required for implementation, as mandated by
federal or state regulation or standard.
 Category II. Suggested for implementation and supported by
suggestive clinical or epidemiologic studies or by strong
theoretical rationale.
 No recommendation; unresolved issue. Practices for which
insufficient evidence or no consensus exists about efficacy.
Guideline for the Prevention of Intravascular-Associated Infections, CDC, 3/26/04.
What strategies have been
advocated in preventing VAP?
Do not change routinely the ventilator circuit…Change the circuit when it is
visibly soiled or mechanically malfunctioning. Cat. IA
Heat
Moisture
Exchanger
No recommendation can be made for the preferential use of either
HMEs or heated humidifiers…Unresolved issue.
No recommendation can be made about the frequency of routinely changing the
in-line suction catheter of a closed suction system – Unresolved issue.
Photographs courtesy of D. Ryan
In the absence of medical contraindications, elevate at an angle of 30-45° the head of the
bed of a patient…receiving mechanically assisted ventilation…Cat. II
Stress Ulcer Prophylaxis
 Theory has it that modifying stomach acid effects
the bacterial colonization level
 HICPAC:
 No recommendation can be made for the preferential
use of sucralfate, H2-antagonists, and/or antacids for
stress-bleeding prophylaxis in patients receiving
mechanically assisted ventilation (unresolved issue).
 Livingston DH, Prevention of ventilator-associated
pneumonia. Am J Surg. 2000;179(suppl 2A):12S-17S.
 “After all of this time and study, it is likely that neither drug has
any advantage in significantly maintaining gastric flora and
reducing VAP.”
Selective Digestive Decontamination
 Preventive decolonization on the theory that
the gut is a major source of VAP
 HICPAC:
 No recommendation can be made for the routine
selective decontamination of the digestive tract (SDD) of
all critically-ill, mechanically ventilated, or ICU patients
(unresolved issue).
 30+ studies to date
 Eggimann P, Pittet D. Infection control in the ICU. Chest
2001;120:2059-2093:
 “…This selective pressure on the epidemiology of
resistance definitely precludes the systematic use of SDD
for critically ill patients.”
Weaning
 Duration, duration, duration!!!
 Cook D, Meade M, Guyatt G, Griffith L., Booker L, Criteria for
Weaning from Mechanical Ventilation. Evidence Report/Technology
Assessment No. 23 (Prepared by McMaster University under
Contract No. 290-97-0017). AHRQ Publication No. 01-E010.
Rockville MD: Agency for Health Care Research and Quality.
November 2002.
 Evidence-Based Guidelines for Weaning and Discontinuing
Ventilatory Support. A Collective Task Force Comprised of Members
of the American College of Chest Physicians, the American
Association for Respiratory Care and the American College of
Critical Care Medicine. Chest 2001;120:375S-395S.
Is there scientific evidence
that links oropharyngeal and
dental colonization with
respiratory illness?
Prevention or Modulation of
Oropharyngeal Colonization
 HICPAC:
 Oropharyngeal cleaning and decontamination with an
antiseptic agent: develop and implement a comprehensive
oral-hygiene program (that might include the use of an
antiseptic agent) for patients in acute-care settings or
residents in long-term-care facilities who are at high risk for
health-care-associated pneumonia. Cat. II
 Schleder B, Stott K, Lloyd RC, The effect of a comprehensive
oral care protocol on patients at risk for ventilator-associated
pneumonia. J Advocate Health 2002;4:27-30.
 Yoneyama T, et al., Oral care reduces pneumonia in older
patients in nursing homes. J Am Geriatr Soc. 2002;50:430-3.
1. Oral Cavity vs. Gastric Colonization
 Prospective study of 86 mechanically vented ICU patients
to assess relationship between oropharyngeal
colonization and subsequent occurrence of pneumonia
 Patients oral and gastric specimens were collected on
admission and twice weekly
 When pneumonia suspected, bronchoscopic specimens
were taken with protected specimen brush
 In 31 cases of pneumonia identified, DNA genomic analysis
demonstrated that oropharyngeal colonization was the
predominant factor in the development of pneumonia compared
with gastric colonization.
Garrouste-Orgeas M, et al., Oropharyngeal or gastric colonization and nosocomial
pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA
analysis. Am J Respir Crit Care Med. 1997;156:164.
Acquired bacterial colonization: Location of the
microorganisms in the 44 carrier patients
Colonizing
microorganisms
Patients
with OC
Patients
with GC
Patients
with BC
Colonized
patients
A. baumanii
7
0
1
8
K. Pneumoniae
12
0
3
15
Enterobacteriaceae
9
5
8
22
Psuedomonadaceae
8
2
1
11
S. aureus
17
0
3
20
2
1
1
4
22
5
17
Enterococcus sp.
Total
OC = oropharyngeal colonization; GC = gastric colonization; BC = both OC/GC colonization
Garrouste-Orgear M, et al., Am J Resp Crit Care Med 1997.
Oropharyngeal Rather Than Gastric
Colonization: Further Support
 Kerver AJ, et al., Colonization and infection in surgical
intensive care patients – a prospective study. Intensive
Care Med. 1987;13:347-51.
 Bonten MJM, et al., Risk factors for pneumonia, and
colonization of respiratory tract and stomach in
mechanically ventilated ICU patients. Am J Resp Crit
Care Med. 1996;154:1339-46.
 Ewig S, et al., Bacterial colonization patterns in
mechanically ventilated patients with traumatic head
injury. Am J Resp Crit Care Med. 1999;158:188-98.
2. Decontamination of the Oropharynx
 Prospective, randomized, double-blind study of
ICU patients to determine VAP while
manipulating oropharyngeal colonization and
without influencing gastric or intestinal
colonization
 87 given topical antibiotics (study group), 139
given placebo (control group)
 Results:
 VAP in study group: 10%
 VAP in control group: 27%
Bergmans D, et al. Prevention of ventilator-associated pneumonia by oral
decontamination. Am J Resp Crit Care Med. 2001;164:382-88.
Additional Studies and Reviews Using
Antibiotic Pastes or Solutions
 Rodriguez-Roldan JM, et al., Prevention of nosocomial
lung infection in ventilated patients: use of an
antimicrobial nonabsorbable paste. Crit Care Med.
1990;18:1239-42.
 Pugin J, et al., Oropharyngeal decontamination
decreases incidence of ventilator-associated pneumonia:
a randomized, placebo-controlled, double-blind clinical
trial. J Am Med Assoc. 1991;265:2704-10.
 Bonten MJ, et al., Role of colonization of the upper
intestinal tract in the pathogenesis of ventilatorassociated pneumonia. Clin Infect Dis. 1997;24:309-19.
3. Oral Decolonization: Use of
Chlorhexidine
 Prospective, randomized, double-blind, placebo-controlled
trial testing the effectiveness of oral decontamination on
nosocomial infection
 353 patients undergoing coronary bypass surgery
 Used chlorhexidine gluconate (0.12%) as oral rinse to
prevent nosocomial infections
 Randomized to receive CHG or placebo
 Results:
 Overall reduction in nosocomial infections of 65% when using
CHG
 Respiratory infections were reduced 69% in CHG group
DeRiso AJ II, et al., Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total
nosocomial respiratory infection and non-prophylactic systemic antibiotic use in patients
undergoing heart surgery. Chest 1996;109:1556-61.
4. Link Between Oral Pathogens &
Respiratory Infection
 A review article
 6 articles cited as support
for a relationship between
poor oral health and
respiratory infection
 Bacteria from colonized
dental plaque may be
aspirated into the lower
airway
Scannapieco, FA., Role of oral bacteria in respiratory infection. J Periodontol. 1999;70:794-802
5. Dental Plaque as a Bacterial Source of
VAP
 Study on dental plaque colonization and ICU
nosocomial infections.
 57 patients studied
 Results:
 Dental plaque occurred in 40% of patients
 Colonization of dental plaque was highly predictive
of nosocomial infection
 Salivary, dental, and tracheal aspirates cultures
were closely linked
Fourrier E, et al., Colonization of dental plaque: a source of nosocomial infections in
intensive care patients. Crit Care Med. 1998;26:301-8.
Additional Evidence Linking Colonized
Dental Plaque and Respiratory Infection
 Scannapieco FA, et al., Colonization of dental plaque by
respiratory pathogens in medical intensive care patients.
Crit Care Med. 1992;20:740-45.
 Fitch JA, et al., Oral care in the adult intensive care unit. Am
J Crit Care. 1999;8:314-18.
 Sumi Y, et al., Colonization of denture plaque by respiratory
pathogens in dependent elderly. Gerontolog. 2002;9:25-9.
 Russel SL, et al., Respiratory pathogen colonization of the
dental plaque of institutionalized elders. Spec Care Dentist.
1999;19:128-34.
Major Areas of
Oropharyngeal
Colonization
Lips &
Gums
Teeth
Tongue
Tissues
Secretions
A Case Study
Reduction of Microbial Colonization in
the Oropharynx and Dental Plaque
Reduces VAP
R Garcia, L Jendresky, L Colbert
Brookdale University Medical Center, Brooklyn NY
Abstract presented at the 2004 APIC Education Conference, Phoenix, AZ.
The Brookdale University Medical Center
Prioritization & Action
 Comparison of VAP rates with NNIS data
indicated MICU rate above 50th percentile
(6.0 cases per 1000 VD)
 Interventions taken prior to 2002 did not have
sufficient effect to reduce rate below the
benchmark
 ICP conducting VAP surveillance
 Interventional Epidemiology methodology
applied: interviews and observations
VAP Reduction Task Force
 Director of Nursing, Critical Care
 Nurse Manager, Critical Care
 Front Line Nurses
 Medical Director, Critical Care
 Emergency Room Physicians
 Respiratory Therapy
 Materials Management
 Infection Control
Assessment
 Interviews of front line workers
 Observation of procedures
 Review of products
 Review of policies
 Review of literature, guidelines
People
Communication
Between Providers
Procedures
Analysis of System
Components Influencing
the Occurrence of
Ventilator-Associated
Pneumonia
Intubation/Extubation
Physicians
VAP surveillance rounds
(observational periods between IC
and nurses)
Suctioning (closed/oral)
Nurses
Oral Care
Respiratory Therapists
Relay surveillance data
to healthcare providers
Cleaning & maintenance
of ventilator and
components
Pharmacists
Feedback from healthcare
providers
Handwashing
Nutritional Specialists
Placement &
maintenance of
nasogastric tube
VAP
Mechanical ventilator (Heated humidifier or HME)
Vent circuits, filters
Closed suction system, oral suction catheters, water, other
suction devices, suction canisters/tubing
Tracheostomy devices
Nasogastric tubes
Nebulizers
Multidose vials
Laryngoscopes
Resusitation bags
Definition of VAP
Intubation/Extubation
Self-extubation
Closed suctioning
Semi-recumbent positioning
Handwashing
Oral & Dental Care
Cleaning of
Use of H2
ventilator/other devices
antagonists/sucralfate
Tracheostomy care
Ventilator circuits
Filters
Cleaning of laryngoscopes Nebulizers
Suction canisters
Enteral feeding
Resuscitation bags
Weaning
Placement and care of nasogastric tubes
Barrier equipment
Equipment &
Devices
Policies
Identification of Needs
 A uniform education program for nurses






and respiratory therapists
Standards for oral assessment
Standards for oral care
Standards for dental care
Standardization of oral care solutions
Keeping a closed system CLOSED
Reduce environmental exposure
Key Strategy #1: Education
 Handout created, includes
answers to the following questions:
 Why is prevention of VAP important?
 What is hospital’s (unit’s) current rate?
 How do you compare with national benchmark?
 What are major interventions implemented to date?
 What role does bacterial colonization play in the
development of respiratory infection?
 What new products/techniques will be implemented to
address oral bacterial colonization?
Tip: Applicable HICPAC
Recommendation
 I. Staff Education and Involvement in Infection
Prevention
 Educate health-care workers about the epidemiology
of, and infection-control procedures for, preventing
health-care—associated bacterial pneumonia to
ensure worker competency according to the worker’s
level of responsibility in the health-care setting, and
involve the workers in the implementation of
interventions to prevent health-care—associated
pneumonia by using performance improvement tools
and techniques. Cat IA
Key Strategy #2: Reduce Oral
and Dental Colonization
Maintaining a Closed System
Covered Yankauer
Policy: Use as needed
Yankauer
 Proper storage
 Keep yankauer covered
when not in use
 Assists in decreasing the
risk of environmental
contamination
 Replace every day and
PRN
Suction Catheter
Policy: Every 4 hrs. or as needed
The device manufacturer does not market or approve of its use below the vocal cords
Suction Toothbrush with
Sodium Bicarbonate
Policy: 2 X per day
Suction Swab with Moisturizer
Policy: Every 6 hrs.
Feeling fuzzy???
Photographs courtesy of D. Ryan
0.0
Rate
Mean
Nov-04
Sep-04
Jul-04
May-04
Mar-04
Jan-04
Nov-03
Sep-03
Jul-03
May-03
Pre-intervention Period
Mar-03
Jan-03
Nov-02
Sep-02
Jul-02
May-02
Mar-02
Jan-02
Nov-01
Sep-01
Jul-01
May-01
Mar-01
Jan-01
VAP per 1000 ventilator days
VAP Rates, MICU, BUMC, 2001-2004
Post-intervention Period
25.0
20.0
15.0
10.0
5.0
VAP Rates, MICU, BUMC
VENT
DAYS
RATE
(VAP/
1000 VD)
% PTS
WITH
VAP
PERIOD
# PTS
# VAP
CASES
Jan 2001Dec 2002
859
44
5262
8.3
5.1
Jan 2003Dec 2004
755
20
5147
3.8
2.6
Cost Avoidance
 Attributable cost of a healthcare-acquired
pneumonia is estimated to be $40,000
(Rello, Chest, 2002).
 Based on the avoidance of approximately 10
VAP cases per year, BUMC estimates that the
annual avoided extra cost to the institution to be:
[10 x $40,000 (infection cost)]
– [$56,606 (product cost)] = $343,394.
Let’s Summarize
 VAP can be a serious and costly infection
 National quality initiatives are being
directed specifically at this type of infection
 There now exists strong scientific
evidence that controlling oropharyngeal
colonization reduces respiratory disease in
varied populations
The speaker gratefully acknowledges the supreme effort of all the
critical care nursing staff, the resident staff, and especially Mr. Trevor
Grazette, Director of Nursing, Ms. Althea Bailey, Nurse Manager, and
Ms. Henrietta Basanez, Nurse Educator.
Robert Garcia, BS, MMT(ASCP), CIC
Assistant Director of Infection Control
Brookdale University Medical Center
One Brookdale Plaza, Brooklyn, NY 11212
718-240-5924
rgarcia@brookdale.edu
Utilizing Assessment and
Interventional Strategies to Reduce
the Risk of Skin Breakdown and
Impact Patient Safety
Debbie Trau, RN, 6 Sigma Black Belt
OSF Saint Francis Medical Center
Peoria, IL
Applying 6 Sigma in Hospital
Setting
Quality improvement
methodologies to
enhance core
patient care
processes
 Define
 Measure
 Analyze
 Improve
 Control
Reliability Unreliability
“Sigma’s”
(approximate)
0.9
10-1
1
0.99
10-2
2
0.999
10-3
3
0.9999
10-4
4
0.99999
10-5
5
0.999999
10-6
6
Reducing VAP with 6 Sigma, Nursing Management, June 2004
Prevalence vs. Incidence
Rates
 How is one different than the other?
 Why does it matter?
 Why do we try to improve outcomes?
 Does JCAHO make us do this?
Why We Are Here?
Example:
National average
prevalence rate of
pressure ulcers in
acute care:
9%
Clinical data:
$500 -$50,000 average
incremental costs per
episode
Pressure ulcers
increase
LOS by 2 to 5 times
Average size
hospital opportunity cost
$400,000
to
$700,000
Lyder C, Basic Pressure Ulcer Care. Advance for Providers of Post-Acute Care. March/April 2005.
Beckrich K, Nursing Economic$, Sept/Oct 1999, Vol. 17, No. 5
Robinson C, et al., Ostomy/Wound Management 2003
Critical Issues Facing Hospitals
 PU’s are a growing cause of hospital morbidity
and mortality
 Hospitals spend up to $5-$8.5 billion per year in
incremental costs related to treating PU’s
 The trend towards Mandatory Reporting will
require further quantification of PU incidence
 Regulatory agencies are making hospitals
and their senior management accountable for
infection control
Beckrich K, Nursing Economic$, Sept/Oct 1999, Vol. 17, No. 5
Early Identification
Stage I




Stage II
Stage III
Stage IV
A Stage I wound costs about $1 per day
A Stage II wound jumps to $1,300 to $3,700
Stage III wounds can cost up to $50,000
The highest incidence is in acute care
Key is to catch them early . . .
Lyder C. Basic Pressure Ulcer Care. Advance for Providers of Post-Acute Care. March/April 2005.
Early Identification
 Awareness of risk factors
 Tools to trigger
 Trained eyes always looking and
communication with patient and family
members (everyone is responsible)
 Thorough assessment of the patient by all
members of the healthcare team
 Consistent scoring and communication
tools
Communication
 Transitioning from task to
outcome focused
 Tools and resources for staff
 Documentation or is it a lack
of documentation
 Outcomes to inspire staff or
keep the momentum
Our Patient’s Risk Factors
 Over 60
 Incontinence
 Atherosclerosis
 Malnutrition
 Diabetes or other
 Obesity
conditions that make
skin more susceptible
to infection
 Diminished sensation or
lack of feeling
 Heart problems
 Paralysis or
immobility
 Poor circulation
 Bedridden
 Spinal cord injury
http://www.healthatoz.com/healthatoz/Atoz/ency/bedsores.jsp
Empowering the Nursing Staff
 Quality issues for patient care
 Publicly reported scorecards
 Incorporate standardized assessment
More importantly:
 Make it simple and easy for them to
understand and implement
What Simple Interventional Patient
Hygiene Activities Affect
Outcomes?
Nurse-sensitive activities:
1. The bathing process for bed ridden patient
2. Incontinence cleansing and protection
Why is the Bath Given?
Social

Control patient odor

Provide patient well-being
Bryant R, Rolstad B, Ostomy Wound Management 2001: 47(6), 18-27.
Why is the Bath Given?
Comfort

Provide sensory stimulation
Bryant R, Rolstad B, Ostomy Wound Management 2001: 47(6), 18-27.
Why is the Bath Given?
Health/Clinical



Cleanse and moisturize the skin
Reduce gross bacterial count
Complete full skin assessment / monitoring
Bryant R, Rolstad B, Ostomy Wound Management 2001: 47(6), 18-27.
Who’s Providing the Bath?
 Non-licensed personnel?
 Are they trained and empowered
to know what to look for?
Who’s Providing the Care?
 How much more susceptible to
injury and infection is the patient
if this develops?
 What can we do?
Bathing Process Solution


Partner with Wound Care Nurse
Empower non-licensed personnel
 Define
1. Issue
2. Expected outcome
 Provide
1. Training and education
2. Simple communication tools
3. Cleansing and moisturizing in one
 Measure, Analyze, Improve, Control
Measure, Analyze, Improve, Control
Incontinence Management
Utilize the tools to “help us do our jobs”
If it gets to this stage,
it’s too late!
Pilot Survey of Incontinence and Perineal
Skin Injury Prevalence in Acute Care
35%
with a
Foley Catheter
3%
976
Total Number of
Patients Surveyed
Urinary
Incontinence
13%
Stool
Incontinence
5%
Dual
Incontinence
Sage Products Inc. Unpublished data 2005. Used with Permission.
Pilot Survey of Incontinence and Perineal
Skin Injury Prevalence in Acute Care
976
Total Number of
Patients Surveyed
198
Number of
Incontinent Patients
27%
33%
18%
Perineal Dermatitis
Pressure Ulcers
Fungal Infection
Sage Products Inc. Unpublished data 2005. Used with Permission.
Incontinence Management Program
 Providing a skin protectant prophylactically
 Supported by the 1992 AHRQ guidelines
 Look for products that make it easy for the
nursing staff.
 Products that save time
 Make cleaning and applying a skin barrier
one easy step
 Early intervention
prevention
Incontinence Process Solution

Partner with Wound Care Nurse
 Empower non-licensed personnel
 Define
1. Issue
2. Expected outcome
 Provide
1. Training and education
2. Cleansing and protection in one
 Measure, Analyze, Improve, Control
Measure, Analyze, Improve, Control
Quality Improvement Initiative Reduce PU Incidence Rates
 Early identification (the bath)
 Red skin is the warning sign
 Guaranteed communication between non-
licensed and RN responsible (protocol)
 Measurements / Interventions (PIP)
 Outcome rather than task focused
 BACK to the BASICS approach
Process Strategies for Change
 See what is out there: “Nurse I See Red”
 AHRQ guidelines
 Need a “believer”
 Highly motivated staff
with administrative support
 Partner with companies that make
it easy to do business with and can
provide solutions
Getting Started
 Education to non-licensed caregivers
 Triggers all caregivers in assessment and
recognition
 Create a “safety net” for our patients
 Standardized practice strategy
 Assessment tool during the cleansing and
each patient contact
 Use products that support your protocol
Measuring Results and Celebrate
your Success
 Drives compliance
 Personalize your rates
 Staff take ownership
 Benchmark against yourself
 Use the data to inspire staff or to
keep the momentum
Your Focus?
Emphasis on outcomes rather than tasks!
Study Guide on
Interventional Patient
Hygiene
One CE Credit
Debbie Trau, RN
6 Sigma Black Belt
OSF Saint Francis Medical Center
530 NE Glen Oak, Peoria, IL 61637
(309) 671-1540
Deborah.A.Trau@osfhealthcare.org
www.sageproducts.com