1. 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 mm Hg
pH between
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 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.