Sustaining Quality in the Trauma Burn Intensive Care Unit through
Evidence Based Practice
Sarah Taylor, BSN, RN and TBICU staff members
University of Michigan, Ann Arbor, MI
Change
Purpose
To achieve and sustain quality care in the TBICU utilizing
evidenced based protocols related to hospital acquired
infections, specifically, Ventilator Associated Pneumonia’s
(VAP’s) and Blood Stream Infections (BSIs).
Synthesis
Almost a decade ago we noted an unacceptable rate of blood
stream infections (BSI) and Ventilator Associated Pneumonia’s
(VAP’s) in our 10 bed trauma burn unit (TBICU). Blood stream
infections (BSI) and Ventilator associated pneumonia (VAP)
are preventable hospital acquired infections. It was important
that we looked at our nursing care practices aimed at
preventing VAPs and BSIs.
The TBICU is unique in that it cares for patients with
inhalation injuries and large skin defects via burn injuries.
The presence of inhalation injury and large skin defects is a
unique risk factor in the development of VAPs and BSIs in the
burn patient.
Evaluation
Utilizing the latest evidence through MHA Keystone ICU, our practice was improved by implementing patient care
bundles to reduce the incidence of the following:
• Ventilator Associated Pneumonia (VAP) and Blood Stream Infection (BSI)
Both bundles are outlined below:
VAP Bundle
•Clean hands (waterless alcohol based sanitizer or hands washed
with soap and water)
•Chlorhexidine oral rinse prior to intubation, then q 12 hours on a
0900-2100 schedule
•Oral care with sage product or pink swabs q 2-3 hours
•GI prophylaxis
•DVT prophylaxis
•Tight glucose control (Goal blood sugar <140)
•HOB elevated 30-45 degrees on all patients at all times unless
medically contraindicated
•Early extubation-as soon as safely possible
•Tube feedings turned off when placing patients flat for turning or
for procedures, unless small bore feeding tube post pyloric
•ETT tape changed every 48 hours
•Minimal use of saline lavage
•Ventilator tubing change only when soiled
•Staff education and monthly updates on our VAP rates
BSI Bundle
•Clean hands (waterless alcohol based sanitizer or hands washed with
soap and water)
•Select the best insertion site
•Standardized the equipment used for line insertion and maintenance.
This includes the use of a standardized line cart, which is taken to every
bedside of every patient who will receive a CVC (central venous
catheter) line.
•Use of a standardized site prep – chlorhexidine
• Standard barrier precautions (hat, mask, sterile gown and drape)
•Empower staff to stop the catheter insertion if the standardized
procedure is violated.
•Standard line maintenance
•Biopatch (chlorhexidine impregnated sponge) utilization in all burn
patients
•Remove catheter as soon as possible
•Staff education and monthly updates on our BSI rates
Additional processes implemented included:
• Standardized carts or equipment packs containing all equipment and supplies necessary for proper CVC line insertion were
made available on the unit.
• A daily goals sheet which is utilized during RN shift report and during daily physician rounds to ensure that standards of care are
optimized.
• Daily reminders board utilized at shift change to reinforce the bundles and protocols.
• Consistent method for diagnosing VAP’s (BAL-Bronchial Alveolar lavage)
Implementation Strategies
References
Brusselaers, N., Monstrey, S., Snoeij, T., Vandijck, D., Lizy, C., Hoste, E., Lauwaert, S., Colpaert, K.,
Vandekerckhove, L., Vogelaers, D., & Blot, S. (2010) Morbidity and mortality of bloodstream
infections in patients with severe burn injury. American Journal of Critical Care, 19(6), e81-e87.
doi:10.4037/ajcc20103
Mosier, M. J., Pham, T. N. (2009). American Burn Association practice guidelines for prevention,
diagnosis, and treatment of ventilator-associated pneumonia (VAP) in burn patients. Journal of
Burn Care & Research 30(6), 910-928. doi: 10.1097/BCR.0b013e
3181bfb68f
Muller, A.C., Hujcs, M., Dubendorf, P., & Harrington, P. T. (2010). Sustaining excellence: clinical
nurse specialist practice and magnet designation. Clinical Nurse Specialist 24(5), 252-259. doi:
10.1097/NUR.0b013e3181effe0f
Scott, R.D. (2009) The direct medical cost of healthcare associated infections in U.S. hospitals and
the benefits of prevention. Retrieved from: www.cdc.gov/ncidod/dhqp/pdf/scott_
costpaper.pd
We are currently in the process of implementing an
oral care kit to further reduce our VAP rates.
(this will go with the VAP graph)
The TBICU utilized many different venues to empower the staff to enhance their influence and create ownership over these hospital
acquired complications. A lead person took on the task of promoting the practice change on the unit. The following were strategies
used to promote an environment of change:
• Daily shift report
• Monthly newsletter
• Bedside goal sheet
• Keystone ICU board in nursing break room
• One on one education and reinforcement of PO care protocol
• Head of bed observations
• Staff education day with focus on Keystone initiatives
This information was presented to the Clinical Practice Council as a way to continue to improve our practice related to VAPs and BSIs.
By creating “soldiers of change”, the TBICU staff were empowered to exert their influence thus sustaining the significant
improvements in patient care data.
Our VAP rate has trended down over time. Sustaining levels at or
below the national benchmark takes teamwork and continued
education. The staff of the TBICU work to maintain the
downward trend and an eventual goal of 0 VAPs.
The BSI rate in the TBICU also has steadily treaded down over
time. This work takes effort from every member of the team.
Hard work and diligent bundle adherence continue to improve
our rate over time.
After achieving the goals of reducing VAPs and BSIs the TBICU
was faced with how to sustain this positive practice change. Here
are some of the actions we have implemented to sustain change:
• Engage Clinical Practice Council
• Standardized PO care Kits
• Vigilance, vigilance, vigilance!
Significance
For every VAP prevented approximately $25,000 saved for the
institution and for every BSI prevented $6,000-$23,000 saved
(Scott 2009).
Positive change occurs over time.
We believe that several components are necessary to achieve and
sustain quality care. These include:
1) Leadership that supports change
2) Active engagement from front-line staff
3) Standardized work process
4) Constant vigilance by leadership to hold individuals to our
standards.