it is more than just tasks: achieving sustainable reductions in … · 2015-08-12 · 8/12/2015 1...
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It is More than Just Tasks: Achieving Sustainable Reductions
in Non-Vented HAP’s by Connecting Basic Care to Nursing’s Advocacy Role
Kathleen M. Vollman MSN, RN, CCNS, FCCM, FAANClinical Nurse Specialist / Educator / Consultant
ADVANCING [email protected]
Northville Michiganwww.Vollman.com
© ADVANCING NURSING LLC 2015
Disclosures
Sage Products Speaker Bureau & Consultant
Hill-Rom
Eloquest Healthcare
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Session Objectives
• Create the link of patient advocacy to the basic nursing care
• Define key fundamental evidence based nursing care practice that reduces non-vented HAP Discuss strategies to overcome barriers
Notes on Hospitals: 1859
“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”
Florence Nightingale
Advocacy = Safety
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PROTECT THE PATIENT FROM BAD THINGS HAPPENING ON YOUR WATCH
Interventional Patient Hygiene
• Hygiene…the science and practice of the establishment and maintenance of health
• Interventional Patient Hygiene….nursing action plan directly focused on fortifying the patients host defense through proactive use of evidence based hygiene care strategies
Incontinence Associated Dermatitis Prevention
Program
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INTERVENTIONAL PATIENT HYGIENE(IPH)
Oral Care/ Mobility
VAP/HAP
Catheter Care
CA-UTI CA-BSI
Skin Care/ Bathing/Mobility
HASISSI
HAND
HYGIENE
Patient
Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154
Attitude &
Accountability
Factors Impacting theability to Achieve QualityNursing Outcomesat the Point of Care
Achieving the Use of the Evidence
Value Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154
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Missed Nursing Care
• “Any aspect of required patient care that is omitted (either in part or whole) or significantly delayed.”
• A predictor of patient outcomes
• Measures the process of nursing care
Hospital Variation in Missed Nursing Care
Kalish, R. et al. (2012) Am Jour Med Quality, 26(4), 291-299.
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Patient Perceptions of Missed Nursing Care
Kalisch, B et al. (2012). TJC Jour Qual Patient Safety,38(4), 161-167.
Why HAI's?Protecting Patients From Harm
Estimates: 183 Hospitals in 10 States
HAI: 722,000/year
HAI-related deaths: 75,000/year
Hospitalized patients develop infection: 1 out of 25 (4%)
Death due to sepsis/septic shock: 700/day
Money spent: $45 billion/year
Increase risk of readmission:
27days vs. 59 days
Magill SS, et al. New England Journal of Med, 2014;370:1198-208
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Health Care Associated Infection Data
Measurement NHSN 20123742 hospitals in US
Estimated # of Infections
HAP/per 1000 patient days
157,500 (21.8%)
VAP/per 1000 vent days
Range of pooled means0.2 (Ped CVICU) -4.4 (Burn ICU)
49,900
CLA-BSI/per 1000 cath days
Range of pooled means 0.8 (CVICU)-3.4 (Burn ICU)Step-down-Ward0.3 (Adult Rehab)-2.4 (Burn)
15,600
CA-UTI/per 1000 cath days
Range of pooled means0.7 (Peds Surgical)-5.0 (Neuro ICU)0.0 (Well Baby) – 4.1 (Peds rehab)
35,600
Dudek MA, et al Am J Infect Control,2013;41:1148-1166Magill SS, et al. New England Journal of Med, 2014;370:1198-208
Preventing NV-HAP Through Evidence Based Fundamental
Nursing Care Strategies & Do No Harm
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• Hospital-acquired pneumonia (HAP)– 48 hours
– Meets algorithm of criteria (CDC, 2003)
• Types of HAP– VAP
– NV-HAP
– Post op pneumonia
Definition: Hospital-Acquired Pneumonia
ATS (2005)CDC (2003)
Why NV-HAP?: DO NO HARM
• HAP 1st most common HAI in U.S.– Increased morbidity 50% are not discharged back
home
– Increased mortality 18%-29%
– Extended LOS 4-9 days
– Increased Cost $28K to $109K
– 2x likely for readmission <30 day
• Understudied, under-addressed
• Focus has been on the other HAP VAP
• Surveillance not required….yet
Kollef, M.H. et.al. (2005). Chest. 128, 3854-3862.ATS, (2005). AmJ Respir Crit Care Med. 171, 388-416.Lynch (2001) Chest. 119, 373S-384S.Pennsylvania Dept. of Public Health (2010).
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Oral Intensity: Reducing NV-HAP in Neuro Impaired Patients
• Method– Quasi-experimental, comparative study
– Adults, acute Neuroscience unit Western Canada
– 51 retrospective patients – standard oral care
– 34 prospective patients – enhanced oral care
• Results– Statistically significant decrease in NV-HAP (p<0.05)
Robertson, T & Carter, D. (2013) Can J Neurosci Nurs, 35(2), 10‐17.
Hospital-Acquired Pneumonia:Non-Ventilated versus Ventilated Patients in Pennsylvania”
• Purpose:– Compare VAP and NV-HAP incidence, outcomes
• Methods:– Pennsylvania Database queried
– All nosocomial pneumonia data sets (2009-2011)
Retrieved on 4/24/13 from http://patientsafetyauthority.org/Pages/Default.aspx
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Results:
•Mortality•Incidence•Total deaths•Total cost•Wide‐spread
Retrieved on 4/24/13 from http://patientsafetyauthority.org/Pages/Default.aspx
• Purpose:– Determine incidence and clinical factors of NV-HAP
• Method:– Descriptive, quasi-experimental study using retrospective
data
– Inclusion criteria:
• All adult discharges
• ICD-9 codes of pneumonia not POA
• AND met CDC definition of HAP
Incidence, Prevalence of NV-HAP: A Local Study (2010)
Quinn, B., Baker, D., et. al. (2013). Journal of Nursing Scholarship.
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Hap ICD-9 Codes480.8
481482
482.1482.2
482.39482.41482.42482.82482.83482.89
483.8484.1484.6484.7
485486
• 24,482 patients and 94,247 patient days
• 115 cases of NV-HAP
• Total estimated annual effect of NV-HAP:
– $4.6 million
– 23 deaths
– 1035 days
Results
Quinn, B., Baker, D., et. al. (2013). Basic nursing care to prevent nonventilator hospital‐acquired pneumonia. Journal of Nursing Scholarship.
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NV-HAP SMCS Research Findings: 2010
Incidence:
• 115 adults
• 62% non-ICU
• 50% surgical
• Average age 66
• Common comorbidities:
CAD, COPD, DM, GERD
• Common Risk Factors:
Dependent for ADLs (80%)
CNS depressant meds (79%)
Quinn, B. et al. Journal of Nursing Scholarship, 2014. 46(1):11-19
Pathogenesis Prevention
Germs in Mouth
• Dental plaque provides microhabitat• Bacteria replicate 5X/24 hrs
Aspirated into Lungs
• Most common route• 50% of healthy adults micro-aspirate
in sleep
Weak Defenses
• Poor cough• Immunosuppressed• Multiple co-morbidities
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Healthcare Acquired Pneumonia
• Risk Factor Categories– Factors that increase
bacterial burden or colonization
– Factors that increase risk of aspiration
Body Position: Supine versus Semi-recumbent(30-45 degrees)
Methodology• 19 mechanically ventilated patients• 2 period crossover trial• Study supine and semirecumbent
positions over 2 days• Labeled gastric contents
(Tc 99m sulphur colloid)• Measured q 30 min content of
gastric secretions in endobronchial tree in each position
• Sampled ET secretions, gastric juice & pharyngeal contents for bacteria
Torres A et. al Ann Intern Med 1992;116:540-543
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Body Position: Supine versus Semi-recumbent (30-45 degrees)
• Radioactive contents higher in endobronchialsecretions in supine patients
• Time dependent:
– Supine: 298cpm/30min vs. 2592cpm/300min
– HOB: 103cpm/30min vs. 216cpm/300min
• Same microbes cultured in all 3 areas 32% with HOB vs. 68% supine.
Torres A et. al. Ann Intern Med 1992;116:540- 543
Results
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Risk Factors for Oral Bacteria in the Hospital
• Poor oral health in the U.S. (CDC, 2011)
• Increased bacteria counts• Plaque, gingivitis, tooth decay
• Reduced salivary flow
• 24-48 hours for HAP pathogens in mouth
• If aspirated =100,000,000 bacteria/ml saliva into lungs
Langmore, S. et.al. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia. 13, 69‐81.
Scannapieco FA, Stewart EM, Mylotte JM. Colonization ofdental plaque by respiratory pathogens in medical intensivecare patients. Crit Care Med. 1992;20:740‐745.
Maintenance Of Oral Health
• Systemic health through prevention of aspiration pneumonia & blood borne infections
• Adequate nutritional intake• Quality of life• Well-being
Research Dissemination Core. Oral hygiene care for functionally dependent and cognitively impaired older adults. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center; 2002 Nov. 48 p.
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The Older Adult At Risk
• Cognitively impaired
• Diminished swallow and cough reflex
• Functionally dependant
• Dry mouth
• Multiple medications
• High rate tooth decay
• Behavioral problems during oral hygiene
Research Dissemination Core. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center; 2002 Nov. 48 p.
Marik PE. et al. Chest; 2003; 124:328–336
Oral Cavity Response to Disease and Insult
Mobilizes defense to maintain integrity & function
If initial defense fails, the oral cavity shifts to resisting the invasions impact
If resistance fails (seen in older adults at risk) the oral cavity succumbs
PainInfection
Bleeding &Inflammation
DifficultyEating & Communicating
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Significant Independent Predictors of Aspiration Pneumonia
Dependant for feedingDependant for oral careNumber of decayed teethTube feedingMultiple medical diagnosesNumber of medicationsDry mouthSmoking
Langmore SE. et al. Dysphagia 1998;13:69-81
Oral Cavity & VAP
• 89 critically ill patients• Examined microbial
colonization of the oropharynx through out ICU stay
• Used pulse field gel electrophoresis to compare chromosomal DNA
• Results:• Diagnosed 31 VAPs• 28 of 31 VAP’s the
causative organism was identical via DNA analysis
• 49 elderly nursing home residents admitted to the hospital
• Examined baseline dental plaque scores & microorganism within dental plaque
• Used pulse field gel electrophoresis to compare chromosomal DNA
• Results• 14/49 adults developed
pneumonia• 10 of 14 pneumonias, the
causative organism was identical via DNA analysis
El-Solh AA. Chest. 2004;126:1575-1582
Garrouste-Orgeas et. al. Am J Respir Crit Care Med. 1997;156:1647-1655
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Formation of Biofilm Over 13 Hours
http://helios.bto.ed.ac.uk/bto/microbes/biofilm.htmLoesche, W. 2012
Role of Salivary Flow
• Provides mechanical removal of plaque and microorganisms
• Innate & specific immune components (IgA, cortisol, lactoferrin)
• Patients receiving mechanical ventilation have dry mouth which in turn contributes to accumulation of plaque & reduced distribution of salivary immune factors
Munro CL & Grap MJ. AJCC. 2004;13:25-34
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Current Evidence for Oral Care Procedure• Method:
– Review of 7 RCTs and 1 meta-analysis
• Results:– Toothbrushing removes dental plaque; swabs do not.*
– Chlorhexidine reduces oropharyngeal colonization*
– Chlorhexidine interventions reduce rate of VAP*
– Optimal frequency of basic oral care – unknown*
*Halm, A. Amer J Crit Care. 2009. 18, 275‐278.**Schleder B. et al. J Advocate Health 2002;4(1):27‐30 **Garcia R et al AJCC, 2009;18:523‐534
Comprehensive oral care reduces rate of VAP**
Prevention of VAP with Oral Antisepsis: A Systematic Review & Meta-analysis
• 17 studies evaluated from 1996-2014
• 4249 patients• All randomize trials• 15 trails assessed the
effectiveness of CHG (51% were CABG pts)
• 2 trials evaluated Povidone-iodine (140pts)
• No difference in morality, LOS or VFD
• Variation of additional interventions;*– toothbrushing,– oropharyngel
aspiration– mechanical cleaning
of the mouth– Frequency of
antiseptic
*Labaeu SO, et.al. Lancet. 2011;11:845-854Longti Li, et al. Int J Clin Exp Med, 2015;8(2):1645-1657P=0.012
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ICU Oral Care Studies
• Before & after design
• Comprehensive oral care
• Comprehensive defined: Q 2-4hr cleansing, suctioning and moisturizing, brushing twice a day with or without CHG & deep oral cleansing q6hrs
• Results:– Reduction in VAP rates from 63% to 100%
– Protocol variation is significant
Cuccio L, et al, Dimensions in Critical Care Nursing. 2012;31(2):301-308.Hutchins K, et al Amer J of Infect Control. 2009;37(7):590-597.Heck K. , Amer J of Infection Control. 2012;40:877-879.Hillier B, et al Advances in Critical Care. 2013;24(1):38-58.
Does Compliance Make A Difference?
Oral care compliance & use of the ventilator bundle resulted in a 89.7% reduction in VAP
Hutchins K, et al Amer J of Infect Control. 2009;37(7):590-597
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Phase 2: Could NV‐HAP be decreased simply brushing the patient’s teeth?
SMCS HAP Prevention Plan
Phase 2: Oral Care
• Formation of new quality team: Hospital-Acquired Pneumonia Prevention Initiative (HAPPI)
• New oral care protocol to include non-ventilated patients
• New oral care products and equipment for all patients
• Staff education and in-services on products
• Ongoing monitoring and measurement– Monthly audits
Quinn B, et al. J of Nursing Scholarship, 2014, 46(1):11-19
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Gap Analysis
Best Practice Our Gaps Action To Take
Comprehensive oral care for all (CDC, SHEA)
ICU vent patients only Develop inclusive oral care protocol
Oral CHG (0.12%)periop adult CV surgery and vent pts. (CDC, ATS, IHI).
Not using CHG on these patients.
Added to preprinted orders, and to protocol
Therapeutic oral care tools (ADA)
Poor quality oral care tools. Absence of denture care supplies.
New tools and supplies.
Protocol – Plain & Simple
Patient Type Tools Procedure Frequency
Self Care / Assist
Brush, paste, rinse, moisturizer
Provide toolsBrush 1-2 minutesRinse
4 X / day
Dependent / Aspiration Risk
Suctiontoothbrush kit (4)
Package instructions 4 X / day
Dependent / Vent
ICU Suction toothbrush kit (6)
Package instructions 6 X / day
Dentures Tools +CleanserAdhesive
Remove dentures & soakBrush gums, mouthRinse
4X / day
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Provide Meaningful Data
0
0.5
1
1.5
2
2.5
3
0.0
1.0
2.0
3.0
4.0
Mea
n O
ral C
are
HA
P C
ases
SGH Ortho - Association of Mean Oral Care to HAP Frequency
Number HAP CasesMean Oral Care
Ortho Unit had ZERO HAP cases in the last 4 months of 2013!!
Great WORK!!
Remember, the goal is to provide and document oral care after each meal and before bedtime.
Provide Meaningful Data
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Frequency of Oral Care: Increased in the ICU
0
0.5
1
1.5
2
2.5
3
3.5
4
baseline Mar-13
Frequency of Oral Care for Non-vented patients in the ICU 300%
Open Heart Surgery Patients: NV-HAP Reduced 75%
Oral chlorhexidine periop started
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0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
X-bar chart mean oral care May, 2012 through December, 2013 (excludes months with < 10 cases)
Mean OralCare
Oral Care Frequency Per 24 Hours –All Units
Baseline
NV-HAP Incidence 50 % Decrease from Baseline
0
2
4
6
8
10
12
14
16
18
20
JAN
201
0
FE
B 2
010
MA
R 2
010
AP
R 2
010
MA
Y 2
010
JUN
201
0
JUL
201
0
AU
G 2
010
SE
P 2
010
OC
T 2
010
NO
V 2
010
DE
C 2
010
MA
Y 2
012
JUN
201
2
JUL
201
2
AU
G 2
012
SE
P 2
012
OC
T 2
012
NO
V 2
012
DE
C 2
012
JAN
201
3
FE
B 2
013
MA
R 2
013
AP
R 2
013
MA
Y 2
013
JUN
201
3
JUL
201
3
AU
G 2
013
SE
P 2
013
OC
T 2
013
NO
V 2
013
DE
C 2
013
Nu
mb
er o
f n
on
-ven
tila
tor
HA
P c
ases
Month/Year
Control chart for NV-HAP January 2010 to December 2013
UCL
LCL
Average
Oral CareBaseline
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Return on Investment
60 NV-HAP avoided Jan 1 – Dec. 31 2013
$2,400,000 cost avoided
- 117,600 cost increase for supplies
$2,282,400 return on investment
•12 lives saved
It is not enough to do your best; you must know what to do, and THEN do your best.
~ W. Edwards Deming
It is not enough to do your best; you must know what to do, and THEN do your best.
~ W. Edwards Deming
Used with Permission Advancing Nursing LLC Copyright 2013 AACN and Advancing Nursing LLC
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