Improving outcomes in acute spinal cord injury (tetraplegia/paraplegia) PAMC ICU Outcomes Data 2017

Problem identification Bedside nursing asked for more education on best practice in caring for acute spinal cord injuries Physicians, nurses, case managers, and therapies asked: “Are we providing the best care possible?” and “How can we do better?” 2016—ICU saw a reduction in VAP rate, but the majority of VAPs declared were Acute Spinal cord injury patients Team agreed that this population were at high risk for CAUTI, CLABSI, increased LOS, hospital readmission, and other performance, indicators

Problem identification: 16 patients, 24 safety events (13 months)

Analysis/Information learned ICU: Acute SCI vs. general ICU VAP: 28.2 vs. 1.3 (per 1000 vent days) HAPU 34% vs. 7.5% (patients with HAPI/total patients) ICU LOS: 11.9 vs. 3.4 Acute SCI house-wide vs. general ICU population CAUTI: 11.32 vs. 2.69 (per 1000 line days) Acute SCI during entire hospital stay vs. house-wide C-diff 50.13 versus 6.67 (per 10,000 patient days) Also noted: Three 30-day readmissions (1 ED, 2 inpatient) seems disproportionately high

Acute Spinal Cord Injury Guidelines Protocols: Respiratory/VAP prevention Bowel regimen Catheter removal/CAUTI prevention Pressure Injury prevention Mobility guide Communication emphasis— Positioning/bracing/activity orders ICU/Rehab ICU/OR Caregivers/family/patient

Prioritization for Implementation How will we implement all of the guidelines effectively? Education focus starting with VAP and HAPU prevention Acute Spinal Cord Injury Protocol Implemented December 2016

Post-Implementation Findings (Dec 2016-Aug 2017) Zero VAPs and zero 30 day readmissions

Post-implementation Outcomes Similar patient population Significant reduction in ICU LOS Significant reduction in VAP rate Significant Reduction in HAPI rate (Only pressure injury was one patient with very small suspected DTI on toe. This patient was post- ICU in a department where protocol was not yet fully implemented)   2016 Baseline N=16 Post- Implementation N=13 ICU LOS 11.88 8.85 average vent days 15.8 14.7 VAP rate (per 1000 vent days) 28.2 catheter utilization .66 .59 central line utilization .31 .63 CAUTI rate (per 1000 line days) 11 16 CLABSI rate (per 1000 line days) HAPI rate (per patient) 34% 7.5% Cdiff rate (per 10000 patient days) 50.13 47.4

Continuing Quality Improvement Continue focus on VAP and HAPI to sustain improvements New measures to reduce CDIFF and CAUTI underway Disseminate EBP for care of acute spinal cord injuries via Epic focused order set November 2017