1 © 2010 tmit nqf-endorsed ® safe practices for better healthcare safe practice 23 daily care of...

1© 2010 TMIT

NQF-Endorsed®

Safe Practices for Better Healthcare

Safe Practice 23Daily Care of the Ventilated Patient

Chapter 7: Improving Patient Safety Through the

Prevention of Healthcare-Associated Infections

© 2006 HCC, Inc. CD000000-0000XX 2© 2010 TMIT

Slide Deck Overview

Slide Set Includes:

Section 1: NQF-Endorsed® Safe Practices for Better Healthcare Overview

Section 2: Harmonization Partners Section 3: The Problem Section 4: Practice Specifications Section 5: Example Implementation Approaches Section 6: Front-line Resources

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NQF-Endorsed®

Safe Practices for Better HealthcareOverview

4© 2010 TMIT

2010 NQF Safe Practices for Better Healthcare: A Consensus Report

34 Safe Practices

• Criteria for Inclusion

• Specificity

• Benefit

• Evidence of Effectiveness

• Generalization

• Readiness

5© 2010 TMIT

Culture SP 1

2010 NQF Report

CHAPTER 7: Healthcare-Associated Infections• Hand Hygiene• Influenza Prevention• Central Line-Associated Blood Stream Infection

Prevention • Surgical-Site Infection Prevention• Daily Care of the Ventilated Patient• MDRO Prevention• Catheter-Associated UTI Prevention

Information Management and Continuity of Care

Medication Management

Healthcare-Associated Infections

Condition- and Site-Specific Practices

Consent & Disclosure

Wrong-siteSx Prevention

Press. Ulcer Prevention

VTE Prevention

Anticoag. Therapy

VAP Prevention

Central Line-Assoc.BSI Prevention

Sx-Site Inf.Prevention

Contrast Media Use

Hand HygieneInfluenza

Prevention

Pharmacist Leadership Structures and Systems

Med. Recon.

Culture

CPOE

Read-Back & Abbrev.

Discharge Systems

PatientCare Info.

LabelingDiag. Studies

Culture Meas.,FB., and Interv.

Structuresand Systems

Risk and HazardsTeam Trainingand Skill Bldg.

Nursing Workforce

ICU CareDirect

Caregivers

Workforce CHAPTER 4: Workforce• Nursing Workforce• Direct Caregivers• ICU Care

CHAPTER 2: Creating and Sustaining a Culture of Safety (Separated into Practices]

Culture of Safety Leadership Structures and Systems Culture Measurement, Feedback, and Intervention Teamwork Training and Skill Building Risks and Hazards

CHAPTER 5: Information Management and Continuity of Care

Patient Care Information Order Read-Back and Abbreviations Labeling Diagnostic Studies Discharge Systems Safe Adoption of Computerized Prescriber Order Entry

CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Leadership Structures and Systems

CHAPTER 8: Condition- and Site-Specific Practices• Wrong-Site, Wrong-Procedure, Wrong-Person

Surgery Prevention • Pressure Ulcer Prevention• VTE Prevention• Anticoagulation Therapy• Contrast Media-Induced Renal Failure Prevention• Organ Donation• Glycemic Control• Falls Prevention• Pediatric Imaging

Informed Consent

Life-Sustaining Treatment

Disclosure

CHAPTER 3: Consent and Disclosure• Informed Consent• Life-Sustaining Treatment• Disclosure• Care of the Caregiver

Consent and Disclosure

Care of Caregiver

MDROPrevention

UTIPrevention

FallsPrevention

OrganDonation

GlycemicControl

PediatricImaging

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Harmonization Partners

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Harmonization – The Quality Choir

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The Patient – Our Conductor

© 2006 HCC, Inc. CD000000-0000XX 10© 2010 TMIT

The Objective

Daily Care of the Ventilated Patient

Prevent healthcare-associated complications in ventilated patients

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The Problem

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The Problem

13© 2010 TMIT

[http://online.wsj.com/article/SB121867229022038907.html]

14© 2010 TMIT

[http://online.wsj.com/article/SB10001424052970204488304574428950126681432.html]

© 2006 HCC, Inc. CD000000-0000XX 15© 2010 TMIT

The Problem

Frequency

Reported to range from 1 to 4 cases per 1,000 ventilator days

May exceed 10 cases per 1,000 ventilator days in special populations, such as pediatric and surgical patients

VAP occurs in 8% to 28% of mechanically ventilated patients

[Edwards, Am J Infect Control 2007 Jun;35(5):290-301; NNIS, Am J Infect Control 2004 Dec;32(8):470-85]

© 2006 HCC, Inc. CD000000-0000XX 16© 2010 TMIT

The Problem

Severity

Mortality rate of 14.4% Presence of nosocomial pneumonia prolonged

the length of mechanical ventilation by 10.3 days and mean ICU unit length of stay by 12.2 days

[Klevens, Public Health Rep 2007 Mar-Apr;122(2):160-6; Levinson, Adverse events in hospitals: state reporting systems, 2008; Koulenti, Crit Care Med 2009 Aug;37(8):2360-8]

© 2006 HCC, Inc. CD000000-0000XX 17© 2010 TMIT

The Problem

Preventability

Reduce the duration of mechanical ventilation by assessing patients daily

Maintain patients in semi-recumbent position, with a 30°- 45° of elevation of the head of the bed

To reduce bacterial colonization, provide oral care with an antiseptic agent

[ATS/IDSA, Am J Respir Crit Care Med 2005 Feb 15;171(4):388-416; Resar, Jt Comm J Qual Patient Saf 2005 May;31(5):243-8; Dellinger, Crit Care Med 2005;9(6):653-4; Tablan, MMWR Recomm Rep 2004 Mar 26;53(RR-3):1-36; Panchabhi, Chest 2009 May;135(5):1150-6; Segers, JAMA 2006 Nov22;296(20):2460-6; Sona, J Intensive Care Med 2009 Jan-Feb;24(1):54-62]

© 2006 HCC, Inc. CD000000-0000XX 18© 2010 TMIT

The Problem

Cost Impact

Hospitalization costs were $48.9K higher in patients with VAP, and length of hospitalization 25 days longer

Hospital costs due to VAP range from $19.6K to $28.5K in 2007 dollars

Pediatric patients admitted to PICU had a mean additional hospitalization cost of $30.9K

[Warren, Crit Care Med 2003; 31: 1312-7; Scott, The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention, 2009 ; Foglia, Clin Microbiol Rev 2007 Jul;20(3):409-25]

19© 2010 TMIT




Practice Specifications

© 2006 HCC, Inc. CD000000-0000XX 20© 2010 TMIT

Additional Specifications

© 2006 HCC, Inc. CD000000-0000XX 21© 2010 TMIT

Safe Practice Statement

Daily Care of the Ventilated Patient

Take actions to prevent complications associated with ventilated patients: specifically, ventilator-associated pneumonia, venous thromboembolism, peptic ulcer disease, dental complications, and pressure ulcers

[Institute for Healthcare Improvement, Ventilator Bundle: IHI Improvement Map, 2009]

© 2006 HCC, Inc. CD000000-0000XX 22© 2010 TMIT


Educate healthcare workers about the daily care of ventilated patients

Implement policies and practices for disinfection, sterilization, and maintenance of respiratory equipment

Conduct active surveillance for VAP in units that care for ventilated patients at high risk for VAP based on risk assessment

[Coffin, Infect Control Hosp Epidemiol. 2008 Oct;29 Suppl 1:S31-40; Tablan, MMWR Recomm Rep 2004 Mar 26;53(RR-3):1-36; Centers for Disease Control and Prevention, An Overview of Ventilator-Associated Pneumonia, 2005; Brito, Crit Care Med 2009 Jan;37(1):350-2; Hortal, Crit Care 2009;13(3):R80]

© 2006 HCC, Inc. CD000000-0000XX 23© 2010 TMIT


Provide ventilated patient data to key stakeholders

Educate patients and their families about prevention measures involved in the care of ventilated patients

Institute a ventilated patient checklist and a standardized protocol

For pediatric patients, institute a ventilated patient checklist and a standardized protocol

24© 2010 TMIT




Example Implementation Approaches

© 2006 HCC, Inc. CD000000-0000XX 26© 2010 TMIT


Incorporate range-of-motion as daily care for ventilated patients per the organization’s protocol

Utilize antibiotic de-escalation therapy with critically ill patients who acquire a VAP

Perform regular oral care with an antiseptic solution, considering a chlorhexidine agent

Remove oral secretions before changing the patient’s position

[ASHP, Am J Health-Syst Pharm 1998; 55:1724-6; Clavet, CMAJ 2008 Mar 11;178(6):691-7; Trudel, Clin Orthop Relat Res 2008 May;466(5):1239-44; Eachempati, J Trauma 2009 May;66(5):1343-8; Yoneyama, J Am Geriatr Soc 2002 Mar;50(3):430-3; Kollef, Crit Care Med 2004 Jun;32(6):1396-405; Mori, Intensive Care Med 2006 Feb;32(2):230-6; Segers, JAMA 2006 Nov22;296(20):2460-6; Chan, BMJ 2007 Apr 28;334(7599):889; Silvestri, Crit Care Med 2007 Oct;35(10):2468; Chao, J Clin Nurs 2009 Jan;18(1):22-8]

© 2006 HCC, Inc. CD000000-0000XX 27© 2010 TMIT


Consider the use of direct antibiogram using E-test strips

Provide easy access to noninvasive ventilation equipment

Devise strategies to prevent aspiration Devise strategies to reduce colonization of the

aerodigestive tract Devise strategies to minimize contamination of

equipment

[Bouza, Curr Opin Infect Dis 2009 Aug;22(4):345-51; Kollef, Crit Care Med 2004 Jun;32(6):1396-405]

© 2006 HCC, Inc. CD000000-0000XX 28© 2010 TMIT


Strategies of Progressive Organizations

Set a goal of zero VAPS and visually display their successes in patient care areas

© 2006 HCC, Inc. CD000000-0000XX 35© 2010 TMIT

TMIT National Webinar Series

Healthcare-Associated Infection and You: Cleaner, Safer Care (Safe Practices 19-25)

Kathy Warye – Topic: Perspective on the Development of the Implementation Examples of the NQF Safe Practices

Peter Angood, MD – Topic: HAI National Attention and Harmonization

David Classen, MD – Topic: HAI Compendium Harmonization with the Safe Practices

Julianne Morath, RN – Topic: Implementation Jennifer Dingman – Topic: Call to Action Go to: http://www.safetyleaders.org/pages/idPage.jsp?ID=4932

(May 14, 2009)

© 2006 HCC, Inc. CD000000-0000XX 36© 2010 TMIT

TMIT National Webinar Series

Safer Critical Care: Resources to PreventVAP & CVC-BSI (SPs 19-20)

Joan Reischel, RN, BSN, CCRN – Clinical Coordinator, Critical Care, The Medical Center of Aurora

Tom Talbot, MD – Assistant Professor of Medicine and Preventive Medicine, Chief Hospital Epidemiologist, Vanderbilt University School of Medicine

Richard J. Wall, MD, MPH – Pulmonary, Critical Care, & Sleep Medicine, Southlake Clinic, Valley Medical Center

Mary E. Foley, MS, RN – Associate Director, Center for Research and Nursing Innovation, University of California, San Francisco

Go to: http://www.safetyleaders.org/pages/idPage.jsp?ID=4878 (May 14, 2008)

1 © 2010 tmit nqf-endorsed ® safe practices for better healthcare safe practice 23 daily care of...

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