Nurse Driven Practice Change in HAI Reduction Brandi Holcomb BSN, RN Patient Care Coordinator Cardiothoracic Intensive Care Unit Our Journey Begins… Ventilator Associated Pneumonia Central Line Associated Blood Stream Infection Catheter Associated Urinary Tract Infection In March 2005, our facility had a sentinel event; the death of a patient due to a central line associated blood stream infection (CLABSI). Multidisciplinary efforts were implemented to investigate the root cause and structure interventions to reduce CLABSI. Our healthcare associated infections(HAI) rates were above the national benchmarks. Multi-disciplinary interventions brought our HAI rates down to, or below, the national benchmark, but we were unable to sustain zero. We discovered that our culture and lack of central leadership were our main barriers to success. Collaborative effort implementing Urinary Catheter Care Bundle 2012: Urinalysis upon insertion of urinary catheter Discontinuation of urinary catheters inserted from outlying facilities Reinsertion of facility approved catheter with urinalysis if patient has continued need for a catheter Daily evaluation of need during multidisciplinary rounds Insertion only when catheter need criteria met System-wide opportunities for improvement for central line catheters: Maintenance and screening for continued use. Establishment of a multidisciplinary physician team to review processes Implementation of action plan to reduce risk of recurrence of factors causing fatal infection. Collaborative effort of VAP Bundle production in 2008 Individualized oral care kits q 24 hours Oral care q 4 hours while intubated Subglottic suctioning Brushing teeth q 12 hours HOB elevated at least 30 degrees while intubated Frequent post operative assessments for readiness to extubate. Central Line insertion Bundle: Pre-procedure hand hygiene Pre-procedure Chlorhexadine Gluconate (CHG) skin scrub Surgical mask and cap for procedure Sterile gown for procedure Full body sterile drape Sterile gloves for procedure Stop the Line… Ventilator Weaning Protocol for CVICU System-wide education plan implemented to raise awareness regarding CAUTI Re-teach proper urinary catheter /perineal care Implemented: “don't break the seal” of catheterization systems no dependent loops empty prior to transport Daily evaluation of the need for the urinary catheter To help quantify CAUTI, the ICU staff chose to go beyond routine hospital policy and implemented change out of all catheters inserted outside of hospital and to send urinalysis on all patients who receive urinary catheter change out or new insertion. Initiated by CVICU RN and/or Respiratory Therapist Arterial Blood Gas (ABG) parameters PaO2 greater than 80 mmHg PaCO2 between 35-45 mm Hg pH between 7.35-7.45 SaO2 greater than 92% Titrate 2 breaths/min ≤ 30 min while monitoring hemodynamic stability On the “CUSP” In January of 2010, we enrolled in the “On the CUSP (Comprehensive Unit-Based Safety Program)”: Stop BSI (blood stream infection) initiative sponsored by Texas Hospital Association, to focus our multi-disciplinary efforts to reduce HAI. Our CUSP team’s goal was to change our healthcare culture of silence and build a culture of skilled communication and true collaboration, focusing on improving patient safety. CUSP teaches our critical care multidisciplinary teams that it is OK to speak frankly about breaks in technique, to “stop the line”, and to respectfully challenge current institutionalized ways of doing things. Stop the Line… System-wide Education Behavior and culture changes Implementation of “Scrub the Hub” Minimum 15 sec scrub of the IV port with alcohol prep Data collection Vent days, Invasive line days, etc. Standing documentation checklists Daily Charge Nurse rounds Daily multidisciplinary rounds Obtain successful weaning parameters Tidal Volume 5-7 ml/kg Vital Capacity 10-12 ml/kg Negative Inspiratory Force greater than negative 20 mmHg (> - 20 mmHg) If unsuccessful weaning mechanics achieved the following criteria must be met: Sustained head lift time five (5) seconds SpO2 > 90%, or equal to or greater than pre-op baseline Intact cough and gag reflex Bilateral equal hand grasp and release Absence of restlessness and/or confusion Regular respiratory pattern Respiratory rate appropriate for age Clear bilateral breath sounds Adequate respiratory effort that can be evidence by obtaining an Inspiratory Tidal Volume in CPAP mode that is equivalent to Incentive Spirometery. The patient must achieve 40% of predicted Inspiratory Volume based on IS nomogram or pre-op Incentive Spirometery level obtained Stop the Line… Approached as a Critical Care Team As part of the CUSP initiative, we used the National Healthcare Safety Network benchmarks as a starting point for our program. CVICU developed Ventilator Rapid Weaning Protocol Facilitated change through Unit Based Council & interdisciplinary rounding Instilled accountability for maintaining sterility during central line insertion Instilled accountability for indwelling urinary catheters Reducing our HAI rates can directly be attributed to: Staff dedication Delivery of stellar patient care A safe work environment Daily multidisciplinary rounding Ability for staff to “Stop the Line” without fear of retaliation Leadership support Nurse Driven Change… Outcomes… Implementation of nurse led PICC team Standardized IV tubing on Saturday/Wednesday to avoid “missing” a 96 hour change. Implementation of standardized central line cart for all insertions and use of full length barrier drape Daily shift change huddles focusing on one item for CLABSI bundles to reinforce commitment to achieving zero Scrub the hub awareness CUSP team willing to have frank discussions about processes in our culture which have, in the past and may, in the future, impede the staff’s ability to problem solve. Embraced concept of pre-shift huddles by critical care units to facilitate information sharing and provide forum to discuss need for staff to respectfully identify breaks in technique. Leadership provided financial resources to purchase equipment and supplies necessary to implement the technical aspects of the critical care bundles . With a coordinated leadership group focused on changing culture we have been able to achieve and maintain zero VAP for 56 consecutive months.