Sustaining Quality in the Trauma Burn Intensive Care Unit through Evidence Based Practice

Sarah Taylor, BSN, RN and TBICU staff membersUniversity of Michigan, Ann Arbor, MI

Purpose

Synthesis

Change

Implementation Strategies

Evaluation

Significance

To achieve and sustain quality care in the TBICU utilizing evidenced based protocols related to hospital acquired infections, specifically, Ventilator Associated Pneumonia’s (VAP’s) and Blood Stream Infections (BSIs).

Almost a decade ago we noted an unacceptable rate of blood stream infections (BSI) and Ventilator Associated Pneumonia’s (VAP’s) in our 10 bed trauma burn unit (TBICU). Blood stream infections (BSI) and Ventilator associated pneumonia (VAP) are preventable hospital acquired infections. It was important that we looked at our nursing care practices aimed at preventing VAPs and BSIs.

Utilizing the latest evidence through MHA Keystone ICU, our practice was improved by implementing patient care bundles to reduce the incidence of the following:• Ventilator Associated Pneumonia (VAP) and Blood Stream Infection (BSI)Both bundles are outlined below:

BSI Bundle•Clean hands (waterless alcohol based sanitizer or hands washed with soap and water)•Select the best insertion site•Standardized the equipment used for line insertion and maintenance. This includes the use of a standardized line cart, which is taken to every bedside of every patient who will receive a CVC (central venous catheter) line.•Use of a standardized site prep – chlorhexidine• Standard barrier precautions (hat, mask, sterile gown and drape)•Empower staff to stop the catheter insertion if the standardized procedure is violated. •Standard line maintenance •Biopatch (chlorhexidine impregnated sponge) utilization in all burn patients•Remove catheter as soon as possible•Staff education and monthly updates on our BSI rates

For every VAP prevented approximately $25,000 saved for the institution and for every BSI prevented $6,000-$23,000 saved (Scott 2009).

Positive change occurs over time.We believe that several components are necessary to achieve and sustain quality care. These include: 1) Leadership that supports change2) Active engagement from front-line staff 3) Standardized work process 4) Constant vigilance by leadership to hold individuals to our

standards.

References

VAP Bundle•Clean hands (waterless alcohol based sanitizer or hands washed with soap and water)•Chlorhexidine oral rinse prior to intubation, then q 12 hours on a 0900-2100 schedule•Oral care with sage product or pink swabs q 2-3 hours•GI prophylaxis•DVT prophylaxis•Tight glucose control (Goal blood sugar <140)•HOB elevated 30-45 degrees on all patients at all times unless medically contraindicated•Early extubation-as soon as safely possible•Tube feedings turned off when placing patients flat for turning or for procedures, unless small bore feeding tube post pyloric•ETT tape changed every 48 hours•Minimal use of saline lavage•Ventilator tubing change only when soiled•Staff education and monthly updates on our VAP rates

The TBICU utilized many different venues to empower the staff to enhance their influence and create ownership over these hospital acquired complications. A lead person took on the task of promoting the practice change on the unit. The following were strategies used to promote an environment of change:

• Daily shift report• Monthly newsletter • Bedside goal sheet• Keystone ICU board in nursing break room• One on one education and reinforcement of PO care protocol• Head of bed observations• Staff education day with focus on Keystone initiatives

This information was presented to the Clinical Practice Council as a way to continue to improve our practice related to VAPs and BSIs. By creating “soldiers of change”, the TBICU staff were empowered to exert their influence thus sustaining the significant improvements in patient care data.

We are currently in the process of implementing an oral care kit to further reduce our VAP rates.

(this will go with the VAP graph)

Additional processes implemented included:• Standardized carts or equipment packs containing all equipment and supplies necessary for proper CVC line insertion were made

available on the unit.• A daily goals sheet which is utilized during RN shift report and during daily physician rounds to ensure that standards of care are

optimized.• Daily reminders board utilized at shift change to reinforce the bundles and protocols.• Consistent method for diagnosing VAP’s (BAL-Bronchial Alveolar lavage)

Brusselaers, N., Monstrey, S., Snoeij, T., Vandijck, D., Lizy, C., Hoste, E., Lauwaert, S., Colpaert, K., Vandekerckhove, L., Vogelaers, D., & Blot, S. (2010) Morbidity and mortality of bloodstream infections in patients with severe burn injury. American Journal of Critical Care, 19(6), e81-e87. doi:10.4037/ajcc20103

Mosier, M. J., Pham, T. N. (2009). American Burn Association practice guidelines for prevention, diagnosis, and treatment of ventilator-associated pneumonia (VAP) in burn patients. Journal of Burn Care & Research 30(6), 910-928. doi: 10.1097/BCR.0b013e3181bfb68f

Muller, A.C., Hujcs, M., Dubendorf, P., & Harrington, P. T. (2010). Sustaining excellence: clinical nurse specialist practice and magnet designation. Clinical Nurse Specialist 24(5), 252-259. doi: 10.1097/NUR.0b013e3181effe0f

Scott, R.D. (2009) The direct medical cost of healthcare associated infections in U.S. hospitals and the benefits of prevention. Retrieved from: www.cdc.gov/ncidod/dhqp/pdf/scott_costpaper.pd

Our VAP rate has trended down over time. Sustaining levels at or below the national benchmark takes teamwork and continued

education. The staff of the TBICU work to maintain the downward trend and an eventual goal of 0 VAPs.

The BSI rate in the TBICU also has steadily treaded down over time. This work takes effort from every member of the team. Hard work and diligent bundle adherence continue to improve our rate

over time. The TBICU is unique in that it cares for patients with inhalation injuries and large skin defects via burn injuries. The presence of inhalation injury and large skin defects is a unique risk factor in the development of VAPs and BSIs in the burn patient.

After achieving the goals of reducing VAPs and BSIs the TBICU was faced with how to sustain this positive practice change. Here are some of the actions we have implemented to sustain change:• Engage Clinical Practice Council• Standardized PO care Kits• Vigilance, vigilance, vigilance!