University of Rochester Medical Center Strong Health 700 bed tertiary care medical center. Strong Health is a Trauma Center, Transplant Center (bone marrow, kidney, liver & heart). 4 adult ICU’s: MICU (17 beds), SICU (14 beds), Burn/Trauma (17 beds), and Cardiovascular ICU (14 beds) Barry Evans, RN, CNS , Adult Critical Care Quality Improvement Project Manager IHI Patient Safety Initiative URMC/Strong Health partnered with the collaborative members of the Institute for Healthcare Improvement to promote a culture of patient safety and improve outcomes for patients by improving the quality of our health care delivery. 1st Patient Safety Initiative 2003 Implement a Ventilator Bundle Reduce Ventilator-associated Pneumonia VENTILATOR BUNDLE Elevate HOB 30 degrees unless contraindicated Sedation Vacation • Turn off sedation until patient is able to follow commands or is fully awake. DVT Prophylaxis PUD Prophylaxis Daily assessment for readiness to wean Structured Oral Care and Mobility were added as adjunct therapies to enhance effectiveness of bundle IHI.org 2003, Ricart, Lorente, Diaz et al. 2003 VAP CRITERIA > 48 hours on ventilator • At least 3 out of 5: Radiographic evidence of new or progressive infiltrates Fever Leuckocytosis Change in sputum (color and/or amount) Worsening O2 requirements *Final determination of VAP diagnosis is made by the attending physician IHI.org 2003, CDC 2004 Medical Intensive Care Unit Pilot Unit 17 bed ICU ICU Intensivist Provider Care Model Population includes patients commonly diagnosed with: Sepsis, ARDS, Respiratory Failure, Pneumonia, TB, CVA, GI Bleed, Pancreatitis and Drug Overdose Closed Unit Admit 1,100 patients/year 70% of patients require mechanical ventilation Ventilator Bundle Implementation Plan Team Formation Education Implementation Communication Reporting Data Developing Champions Implementation Process Team Members Multidisciplinary in Scope Director of Adult Critical Care Associate Director of Critical Care Nursing Adult Critical Care Project Manager MICU Nurse Manager RN Care Coordinator Respiratory Therapist Pharmacy Critical Care Nursing Staff Implementation Process cont’d Staff Education Presentation of evidence-based findings/information about VAP to establish a solid foundation for support of the initiative Extensive initial education campaign to introduce ventilator bundle initiative Monthly educational presentations for the first 3 months for reinforcement Regularly scheduled in-services/poster presentations Ongoing 1:1 staff education and reinforcement Ventilator Bundle education is included in unit orientation for staff and residents Implementation Process cont’d Establish forums for open Communication Staff meetings Two times each week Individual discussions Daily Walk Rounds Critical Care Quality Council Initiative updates reported monthly Leadership Safety Rounds Monthly Implementation Process, cont’d Daily Goal Sheet Vital to implementation of the ventilator bundle Checklist with prompts for patient care priorities that were addressed each day during daily morning rounds by physicians, residents, nurses and the care coordinator Extensive modifications were required before final approval from the healthcare team Now part of the resident daily progress note and nursing plan of care Implementation Process cont’d Team Meetings Weekly Review data results Problem solving Planning Plan Do Study Act Cycles (Model for Improvement) Accountability Barriers Resistance to practice change Physicians Lack of buy-in Daily Goal Sheets time consuming Individual practice preferences Skepticism about results of research and evidence provided to support the initiative Staff Need to learn new protocols Concern about compromised patient safety with sedation vacation Practice boundary issues between Respiratory Therapy and Nursing when RT- Driven Weaning Protocol was implemented Barriers, cont’d Perceived increased workload Staff - more paperwork More time and effort required Another QI project that will go away Why are we doing this? Is this just another improvement project that will fall by the wayside? Our Ventilator Bundle Challenges HOB Noncompliance Inaccurate perception of 30 degrees Posted bedside signs and measurement cues HOB position documentation required on Flow Sheet Sedation Vacation Nursing Resistance (perceived risk to patient safety) Medical Director appealed to staff to develop a nursedriven sedation Daily Assessment for Ability to Wean Mechanical Ventilator Liberation Protocol presented issues of practice boundaries between Nursing and Respiratory Therapy Extensive in-services, 1:1education and reinforcement required before successful implementation achieved Practice Changes During Ventilator Bundle Implementation Protocols/Guidelines Revision of Mechanical Ventilator Orders/Guidelines Nurse-driven Sedation/Delirium/Sleep Wake Protocol Respiratory Therapist-driven Weaning Protocol Structured Oral Care Protocol for ventilator patients Mobility Guidelines (Carried out a pilot study and implemented a Lift Team) Glucose Management Protocol Daily Goal Sheet incorporated into daily resident note Adult Critical Care Goal Sheet/Nursing Care Plan D ec Fe -0 b- 2 A 03 p Ju r-0 A n-0 3 ug 3 O -03 c D t-0 e 3 Fe c-0 b 3 A -04 p Ju r-0 A n-0 4 ug 4 O -04 c D t-0 e 4 Fe c-0 b 4 A -0 p 5 Ju r-0 5 A n-0 ug 5 O -05 c D t-0 ec 5 Fe -0 b- 5 A 0 p 6 Ju r-0 6 A n-0 ug 6 O -06 c D t-0 e 6 Fe c-0 b 6 A -0 pr 7 -0 7 Rate Results MICU VAP RATE (# VAP/Vent Days x 1,000) 8 6 0 6 5.33 2 000 Structured Oral Care Protocol Implemented 4 2.52 2.9 00 2.9 0 00 0 00 0 00 0 00 0 00 0 00 0 00 Dates MICU 3.2 00 0 00 0 00 0 00 0 00 0 00 00 0 ov Fe 02 b M -03 ay A -03 ug N -03 ov Fe -03 b M -04 ay A -04 ug N -04 ov Fe 04 b M -05 ay A -05 ug N -05 ov Fe 05 b M -06 ay A -06 ug N -06 ov Fe 06 b M -07 ay -0 7 N Rate Results MICU Ventilator Bundle Compliance All Components Completed 120 100 80 60 40 20 0 Dates MICU Se pN 04 ov -0 Ja 4 nM 05 ar M 05 ay -0 Ju 5 lSe 05 pN 05 ov -0 Ja 5 nM 06 ar M 06 ay -0 Ju 6 lSe 06 pN 06 ov Ja 06 nM 07 ar M 07 ay -0 7 Days Per Month Results MICU Sedation Days 600 500 400 300 200 100 0 Dates MICU Linear (MICU) Benefits of our Initiative: Reduction in LOS $$$$ and Lives Saved Average cost of ICU day ~ $2,000/day Decrease LOS from 7.5 days to 6 days (1.5 days/patient) 1100 patients/year 1,650 days saved per year $3,300,000 saved per year (Plus beds available for elective cases) Mortality rate associated with VAP high
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