FHA Call to Action: Eliminating Infection-Related - PowerPoint PPT Presentation

FHA Call to Action: Eliminating Infection-Related Ventilator-Associated Complications IVAC Bi-Monthly Webinar #2 May 3, 2018

Agenda • FHA MTC Call to Action for IVAC • Data Review • HRET HIIN Hospital Peer Sharing – Meryl Montgomery, RN, MSN Sonya Floyd, RN, BSN,CIC Valerie Fox, RRT Medical Center Navicent Health • Available Resources • Closing Remarks

SAVE LIVES: Cleaner hands are safer hands May 5, 2018 For resources and more information, visit the World Health Organization’s World Hand Hygiene Day page http://www.who.int/infection-prevention

Call to Action • FHA Quality Committee • FHA Annual Meeting • CEO Call to Action

How are We Doing? 3.00 FHA Board Call to Action 2.50 Baseline Rate = 2.15 2.00 Rate per 1,000 1.50 1.00 0.50 0.00 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 FL Rate 1.75 1.72 2.33 2.42 2.49 2.56 1.95 2.59 1.92 1.50 2.37 2.52 2.43 1.02 1.91 1.25 1.49 # Reporting 89 89 90 93 93 93 90 91 92 92 92 92 91 89 86 74 66 Effective date: April 13, 2018

Polling – Do you round daily to ascertain both bundle compliance? – Do you also assess for appropriative indications during rounds? – Do you use endotracheal tubes with subglottic secretion drainage? – Do you investigate each IVAC occurrence? – Which condition is the most frequent contributor to your IVAC cases? • Trauma • Sepsis • Abdominal Trauma • Thoracic Trauma • Other

H.A.C.ING VAE’S FHA 5.3.18 SONYA FLOYD, RN, BSN, CIC VALERIE FOX, RRT MERYL MONTGOMERY, RN, MSN

Medical Center Navicent Health Macon, GA • 637 beds, 5 adult ICUs (86 beds) • 2015- 94 VAE, 2016- 74 VAE • 2015- 10 VAP, 2016- 8 VAP

Aim and Background Aim Ai Background Why this project and w hy How m uch im provem ent? now ? By w hen? For w hom ? While VAP rate <10, the By 9/ 30/ 17, decrease five adult ICUs under- Ventilator Associated performed compared to NDNQI and HRET HIIN Events 30% (from 74 benchmarks. to 52) in the five adult Ventilator utilization rates ICUs. on the rise with higher acuity; need to focus on preventing VAE. 9

“But, our PVAP rate is low!” • Resting on our laurels of low VAP for several years → complacency in 5 adult ICUs (86 beds) • In 2013, CDC criteria changed to VAE = VAC+ IVAC+ PVAP – PVAP no longer the only issue- keeping up with the change • Impact of bench-marking: – HRET HIIN: our VAE rates nearly double average of hosp average – NDNQI-4Q under-performance % ICUs that outperform NDNQI >500 bed mean 70% 60% 50% 40% 30% 20% 10% 0% 1Q15 2Q15 3Q15 4Q15 1Q16 2Q16 % out-perform target 10

Methodology • VAE task force with MD, executives, interdisciplinary • Use of 6 sigma DMAIC and PDSA/ rapid cycle change • Deep dive RCA trends • Data- benchmark HRET HIIN, NDNQI • Process and outcome measures • Multi-modal education • Front line and leader engagement • Participation in HRET HIIN AI fellowship

Key Performance Measures • Outcome Measures: How is the system perform ing? What are the results? – VAE incidence overall and by unit – VAC, IVAC, VAP incidence rates – Benchmark comparisons: GHA HEN, HRET HIIN, NDNQI • Process Measures: Are the parts or steps in the process or system perform ing as planned? CLRT, Turn q 2 hr , HOB ≥30◦ , CHG, oral hygiene, hi-lo ETT, separate oral/ ETT – suction- observation/ interview/ documentation audit • Balance Measures: What happened to the system as w e im prove the outcom e and process m easures? – Ventilator days – LOS for ventilator patients – Mortality rate for ventilator patients 12

Driver Diagram 13

Key Changes Since Fall 2016 • Re-education • Documentation parameters PEEP FiO2 • Transport protocol • PAD (Pain Agitation Delirium) protocol • Focus on basics- hand hygiene, vent bundle, mobility • Hardwired accountability • Adequate material resources • Closed ICUs (intensivists) • Standardize all changes across ICUs, services 14

VAE Improvement Timeline

Data driven timeline 16

Communication of “burning platform” of VAE reduction • Tied to goals in performance review • Post/ review data, transparency • Committees, staff meetings, huddles • Involvement of front line staff in solutions/ engagement • Education of all levels • Paying attention to expected behavior • Administrative, interdisciplinary involvement- incorporated into rounds- PAD, bundles, mobility, de-escalation, alternatives • Newsletters, BB, signs, “Potty Training”

RCA form

Vent Bundle monitoring tool

Transport monitoring tool

Outcomes

KPI: VAE Incidence Rates/ month all adult ICUs VAE Incidence 8/16-3/18 14 12 VAE/1000 pt days 10 8 6 4 2 0 -2 8.16 9.16 10.16 11.16 12.16 1.17 2.17 3.17 4.17 5.17 6.17 7.17 8.17 9.17 10.17 11.17 12.17 1.18 2.18 3.18 VAE/ 1000 pt days 12.4 8.2 10.2 2.5 6.4 4.5 5.6 2.8 2.1 2 2.6 0 1 5.4 3.9 0.9 1.8 3.3 0 0

#IVAC/ PVAP over time #IVAC PVAP 2015-FY18 40 35 30 25 20 15 10 5 0 #IVAC #PVAP 2015 2016 2017 YTD18

ICU mobility: with a smile on his face!

Cost savings • Reduced VAE by 60% (2016-78, 2017-31) • Met GHA HRET HIIN two year 20% target reduction in year one (our baseline was 84) • HRET HIIN cost calculator= $ 21,000 / ”VAC” • Total estimated savings due to ↓VAE : $987,000

Benchmarking • HRET HIIN benchmarks both IVAC and “VAC” (=CDC VAE definition which includes VAC, IVAC, VAP) – VAC- ↑ FiO2 and/or PEEP for ≥ 2 days – IVAC- ↑ FiO2 and/or PEEP for ≥ 2 days, infection S/S (T >38, wbc>12,000), antibiotics started in infection window/ continued for 4 days

Adult ICU vs HRET HIIN VAE-1

HRET HIIN VAE IVAC rate

Adult ICU vs NDNQI >500 bed units. N 174 units VAE: % Adult ICU outperform NDNQI >50 0 bed m ean rolling 8 quarters 120% 100% % units outperform NDNQI + 80% 60% 40% 20% 0% 4Q15 1Q16 2Q16 3Q16 4Q16 1Q17 2Q17 3Q17 4Q17 % out-perform 60% 20% 80% 60% 100% 80% 100% 100% 100% target 51% 51% 51% 51% 51% 51% 51% 51% 51%

Sustaining the drop! #1 accountability • Accountability – Interdisciplinary team – Interdisciplinary bedside rounds – Nursing leadership rounds- PAD? Mobility? – Intensivist model- 4 of 5 closed units by spring 2018 30

Having what staff need • Portable suction machines • Portable vents- ↓ circuit breaks % pts transport on vent vs "ambu" 95% 100% 80% 60% 39% 40% 20% 0% Jan-Jun 2016 2017 • Sufficient suction regulators • Hi/ Lo ETT • Cuff manometers 31

Back to the Basics- hand hygiene 32

Transport protocol audits • RRT supv audit use of transport protocol • 79% ↓ in VAE correlated with transport #/ % of patients w VAEs with transports off unit within 4 days of event 35 80% 70% 30 #/ % VAE pts w transports off unit 60% 25 50% 20 40% 15 30% 10 20% 5 10% 0 0% pre implement post implement # VAE w transports 31 3 % VAEs 72% 15% 33

How about bundle compliance? • Average of 200 vent pts/ week are audited – observation/ documentation review- all units • Average 98%, minimum 92.% compliance 34

Celebrating milestones • Respiratory staff and managers- Pay for performance- BPR goals • Individual and group “Good Catch,” +feedback re posted data • Admin and leadership rounds- observations and feedback • Huddles, staff meetings, interdisciplinary rounds • Pizza party for overall reduction in VAE and bundle compliance

Goal vs Outcome Goal Results Stat us ↓VAE in five adult ICUs by 25% in • ↓ by 44.6% (from 74 to 41) met 12 months ↓transport -related VAE by 25% ↓ by 79% met Achieve ventilator bundle Average 98%. Lowest at 92.6% met compliance >90% compliance. Out-perform benchmark NDNQI Out-performed the past 6 met the majority of quarters from 4Q16- quarters 4Q17 Out-perform benchmark HRET Out-performed all project met HIIN majority of months since organizations 13 of 16 mos . October 2016 36

Reflections/ Lessons Learned Overcom ing key barriers • Lessons Learned • build in EMR- refocus IT and engage Executive Sponsors • cultural change to embrace need to reduce VAE- leadership change, benchmark comparison, reporting through HARM Committee structure • prior unsuccessful attempt to implement mobility and PAD- nurse-driven mobility protocol, PAD in EMR Surprises • Key clinical leaders reluctant to adopt changes • Failure of timely documentation triggered VAEs • Insufficient working suction regulators, bedside patient chairs, among others LOS and vent days did NOT drop as VAE rate decreased. We did see a 12% ↓ in vent≥3d mortality • • Lessons Learned Advice • Complete RCAs and establish trends, use national benchmarks to drive initiatives • Evaluate documentation to assure not causative of VAE • Develop transport protocol to eliminate procedure related breaks in circuit • Keep an eye on all KPIs 37