Infection Prevention and NHSN Webinar Series NHSN: - - PowerPoint PPT Presentation

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Infection Prevention and NHSN Webinar Series NHSN: - - PowerPoint PPT Presentation

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An Initiative of the Florida Hospital Association Hospital Improvement Innovation Network Infection Prevention and NHSN Webinar Series NHSN: Ventilator-Associated Events (VAE) Surveillance Identification and Analysis December 18, 2018 Agenda

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An Initiative of the Florida Hospital Association Hospital Improvement Innovation Network

Infection Prevention and NHSN Webinar Series NHSN: Ventilator-Associated Events (VAE) Surveillance Identification and Analysis

December 18, 2018

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  • Welcome & FHA Mission to Care HIIN Overview

– Cheryl Love, RN, BSN, BS-HCA, MBA, LHRM, CPHRM, Director of Quality and Patient Safety and Improvement Advisor, FHA

  • NHSN: Ventilator-associated Events (VAE) Surveillance

Identification and Analysis

– Linda R. Greene, RN, MPS, CIC, FAPIC, Manager of Infection Prevention, UR Highland Hospital, Rochester, NY

  • Q&A
  • Upcoming HIIN Events and Opportunities
  • Evaluation Survey & Continuing Nursing Education

Agenda

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  • Adverse Drug Events (ADE)
  • Catheter-associated Urinary Tract Infections (CAUTI)
  • Clostridium Difficile Infection (CDI)
  • Central line-associated Blood Stream Infections (CLABSI)
  • Hospital-onset MRSA Bacteremia
  • Injuries from Falls and Immobility
  • Pressure Ulcers (PrU)
  • Sepsis
  • Surgical Site Infections (SSI)
  • Venous Thromboembolisms (VTE)
  • Ventilator-Associated Events (VAE/IVAC/PVAP)
  • Readmissions (12% reduction)
  • Worker Safety

HIIN Core Topics – Aim is 20% reduction

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VAE Resources, Trainings and Tools

 Mission to Care Website  FHA IVAC Call to Action Website  HRET HIIN Website

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Designed to reduce multiple forms of harm with simple, easy-to-accomplish activities that cut across several topics to decrease harm. Focused on four components:

  • SOAP UP: Hardwire Hand Hygiene
  • GET UP: Mobilize Patients
  • WAKE UP: Prevent Over-sedation
  • SCRIPT UP: Optimize Inpatient

Medications

UP Campaign:

Spreading Cross Cutting Strategies

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FHA Mission to Care Update: Ventilator-associated Condition Rate

Source: HRET Comprehensive Data System, December 17, 2018

BL 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 4/18 5/18 6/18 7/18 8/18 9/18 FL Rate 6.5 5.3 6.4 6.3 5.0 5.5 5.6 6.6 5.5 6.0 5.8 6.1 5.0 6.0 3.3 5.7 4.3 6.2 4.0 5.9 6.2 6.3 5.1 5.3 4.7 HRET HIIN Rate 5.0 4.8 4.5 5.0 4.9 4.8 4.7 4.9 5.2 4.9 4.6 5.0 4.7 5.3 4.5 5.1 5.0 5.1 4.9 5.4 4.9 5.3 5.1 5.2 4.7 # FL Reporting 77 75 75 76 77 77 77 75 75 76 76 77 76 74 72 72 71 67 67 67 71 66 66 66 65 #HRET HIIN Reporting 921 917 908 898 895 888 887 882 874 873 875 867 871 876 863 865 857 846 845 838 849 835 812 800 771

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 Rate per 100

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FHA Mission to Care Update: Infection-related Ventilator-associated Condition Rate

Source: HRET Comprehensive Data System, December 17, 2018

BL 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 4/18 5/18 6/18 7/18 8/18 9/18 FL Rate 2.2 1.8 1.9 2.5 2.4 2.3 2.6 2.3 2.4 1.9 1.5 2.4 2.9 2.4 0.9 1.8 1.3 2.0 0.9 1.9 1.9 1.6 1.1 1.3 0.8 HRET HIIN Rate 1.6 1.5 1.4 1.6 1.7 1.4 1.6 1.5 1.8 1.5 1.4 1.7 1.5 1.7 1.7 1.6 1.2 1.6 1.4 1.8 1.3 1.5 1.5 1.6 1.0 # FL Reporting 77 75 75 76 77 77 77 75 75 76 76 77 76 75 73 73 72 68 68 68 72 67 66 66 65 #HRET HIIN Reporting 920 921 910 897 896 888 887 883 876 872 874 870 873 878 866 864 857 846 844 838 848 835 812 799 771

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 Rate per 100

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FHA Mission to Care Update: Florida | Ventilator-associated Events

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VAE Update and Review

Linda R. Greene, RN, MPS,CIC, FAPIC Manager, Infection Prevention UR Highland Hospital Rochester, NY linda_greene@urmc.rochester.edu

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Objectives

  • 1. Review VAE definitions and updates
  • 2. Discuss the rationale for the VAE definition
  • 3. Identify strategies to prevent VAE
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Polling Question 1

Please identify your background:

  • 1. Nursing
  • 2. Infection Prevention
  • 3. Quality
  • 4. Respiratory Care
  • 5. Other
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Let’s Review

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Possible and Probable VAP are combined (PVAP)

Provides simplification

Consistent with original plan for analysis (PoVAP and PrVAP combined as 1 event )

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Pathogen Exclusions

Community associated fungal pathogens that are not known or rarely cause healthcare-associated infections:

 Cryptococcus  Histoplasma  Coccidiodes  Paracoccidiodes  Blastomuces  Pneumocystis

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Denominator Options

Optional Field (Episodes of Mechanical Ventilation)

 Total number of episodes occurring during a month  Evidence based practices focus on getting the patient

  • ff the ventilator

 First step in exploring other denominators  Still require ventilator days and APRV days

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VAE 2019

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Test Your Knowledge

  • Mrs. Jones has a blood stream infection with ecoli om

12/1 She has had a PICC line in place since 11/27 She is has been intubated since 11/27 and placed on a ventilator She also has a VAE onset 11/29

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Polling Continued

Can the blood stream infection be considered secondary?

  • 1. No
  • 2. Yes
  • 3. If IVAC met
  • 4. If PVAP met
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Why Collect VAE Data ?

 Infection Prevention efforts may fail due to silo

mentality

 Need to view interventions under the larger context of

patient safety

 Connect the dots to harm

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Analysis

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Broadening the Surveillance

Intentional Associated Conditions:

  • ARDS
  • Pulmonary Edema
  • Thromboembolic disease
  • Sepsis

Respiratory deterioration in previously stable patients is a risk factor for increased morbidity and mortality

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The Chest X-RAY

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Why the Shift ?

Variations in Chest X-Ray Interpretation Poor Inter-rater reliability

inter-rater reliability

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Why the Shift?

Broaden the Focus

 Shifting the focus of surveillance from pneumonia alone

to complications in general emphasizes the importance

  • f preventing all complications of mechanical

ventilation, not just pneumonia.

 When definitions are objective, care givers can focus

  • n what went wrong rather than debate the definition.
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Challenge: We don’t know much about prevention practices

Strategy: Execute prevention practices that are evidence based. Standardize practices. The existing VAP prevention literature is the best available guide to improving outcomes for ventilated patients. VAP interventions that have been shown to improve objective

  • utcomes, such as duration of mechanical ventilation, intensive care
  • r hospital length of stay, mortality, and/or costs in randomized

controlled trials.

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Connect the Safety Dots

ARDS

Antibiotic Resistance

Atelectasis

C Diff infection

Ventilator Harm

IVAC VAC Pulmonary Edema

VAP

Morbidity Mortality

Delays, LOS Cost$

Immobility

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Get the patient off the ventilator sooner

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Studies

  • 20 ICUs Nov 2011- May 2013
  • Daily paired SATs and SBTs
  • SATs- stopped all sedatives and narcotics as indicated
  • SBTs- lower positive end-expiratory pressure support to 5-8 cm H2O for up

to 2 hours

  • Encourage extubation of patients who passed SBTs
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Findings

 Significant decreases in duration of mechanical

ventilation

 Decrease in hospital and ICU LOS  Decrease in VAE rate per episode of

mechanical ventilation

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37% in VACs 65% in IVACs

SATs & SBTs Increases

VAE Reductions

63% in SATs 16% in SBTs 81% in SBTs done with sedatives off

CDC Prevention Epicenters’ Wake Up and Breathe Collaborative

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Basic bundle

Sub Epiglottic Suctioning-Evidence supports HOB Monitoring- Low cost. Benefit unknown. Important with tube feeding Weaning, decreasing duration of ventilation-Suggestive evidence PUD Prophylaxis- not related to VAP DVT prophylaxis- not related to VAP

Enhanced Bundle

Mouth care- (chlorhexidine?) Education and Training Program- Ambulation- Evidence supports

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What about Oral Care?

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Challenge: This is not Infection Prevention

Strategy: Look at this in the broader context of patient safety Need a team approach - opportunity to expand Partner with Respiratory Therapy Many infectious complications are associated with prolonged ventilator use

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Reviewing Cases

Patient who develops a VAC

 Chronic vent  Ambulation protocols not implemented  Dehydrated  Sputum not documented  Nursing and respiratory not communicating

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Challenge: Not a CMS reportable event; I’ll wait until have to report

Strategies:

 Related to morbidity and mortality  Included in LTACH reporting  Most likely not “if “ but “ when”

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Determining VAE- Calculator

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Polling Question 3

Is this a VAC?

  • 1. Yes
  • 2. No
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The Calculator

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Evaluate the Data

eventType gender location patID patgname patsurname spcEvent VAE F ICU 1234 Mickey Mouse PVAP VAE F ICU 5678 Donald Duck PVAP VAE F ICU 2222 Charlie Brown VAC VAE F ICU 1333 Minnie Mouse VAC VAE M ICU 4444 Bugs Bunny VAC VAE M ICU 5555 Super Man VAC VAE F ICU 6666 Spider Woman VAC

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Data for Action

Vent unit

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How will I use my data to drive improvement?

 Review both Individual cases and system level issues  Do we have policies and procedures in place ?  Do we follow evidence based guidelines?  Are we consistent with our practices?

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Bundle

Process Measure Date Y/N Comments

Continuous Subglottic Suctioning Assess readiness to extubate ( Spontaneous breathing trials) Paired SBT’s and SATs Interrupt sedation daily ( Spontaneous awakening trials) If contraindications – note here Ambulate according to protocol* Note level Regular Mouth care (without chlorhexidine )* Elevate HOB 35-400 Conservative fluid management Blood Transfusions Given Rationale: Low Tidal Volume Identify:

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Opportunities

  • Hardwire ambulation protocols
  • Assure documentation of secretions
  • Work collaboratively with respiratory therapy

to identify subtle changes

  • Daily huddle
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Know your Data

Surveillance is a critical component of every quality improvement effort; you cannot prevent it if you cannot measure it.

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Ventilator-associated events A patient safety opportunity

Broaden Awareness

  • VAE surveillance provides hospitals with a fuller picture of

serious complications in mechanically ventilated patients Mobilize Prevention Efforts

  • A significant portion of VAEs are likely preventable

Inform Progress

  • VAE surveillance provides an efficient and objective

yardstick to track one’s progress relative to oneself and to peers

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The Bottom Line

 VAE associated with mortality and LOS (my

experience supports this)

 Continue to monitor processes of care and

  • utcomes

 Give feedback to providers and assess

potential for preventable events

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Infection Prevention and NHSN Virtual Series

*Access Event Archives (Recordings | Slides) on the Mission to Care HIIN Website

Date Topic Register Online

  • Oct. 23, 2018

NHSN: SSI Surveillance Identification and Analysis

Event archive*

  • Nov. 20, 2018

SSI-Colon: How to Assess Root Cause and Prevention Strategies

Event archive*

  • Dec. 18, 2018

NHSN: VAE Surveillance Identification and Analysis

Event archive will be available online*

  • Jan. 22, 2019

VAE: How to Assess Root Cause and Prevention Strategies

Register: https://cc.readytalk.com/r /x4sn9rfaubgq&eom

  • Feb. 19, 2019

NHSN: MRSA Bacteremia Surveillance Identification and Analysis

Register: https://cc.readytalk.com/r /lep4j00go9gg&eom

  • Mar. 26, 2019

MRSA Bacteremia : How to Assess Root Cause and Prevention Strategies

Register: https://cc.readytalk.com/r /duycwubuqgve&eom

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Virtual Events:

  • Dec. 18 (3-4 pm ET) – PASRR System Training for Hospitals [virtual event]
  • Dec. 19 – Measuring What Works to Achieve Health Equity
  • Dec. 20 – Falls Fishbowl #3
  • Jan. 4 – Readmissions MVP Webinar #4
  • Jan. 7 – TeamSTEPPS Master Trainer Intro Webinar
  • Jan. 9 – FHA Monthly Quality Hot Topics #3
  • Jan. 10 – 3M Potentially Preventable Readmissions Overview
  • Jan. 15 – 3M Population Focused Preventables (PFPs)
  • Jan. 17 – Readmissions Stakeholder Quarterly Virtual Meeting #5
  • Jan. 17 – Falls Fishbowl #3
  • Jan. 22 – VAE: How to Assess Root Cause & Prevention Strategies
  • Jan. 22 – CAUTI Fishbowl #2

Upcoming Virtual and In-Person Events

Check the weekly MTC HIIN Upcoming Events for details and registration

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In-Person Events:

  • Jan. 29-30 (Pensacola) – TeamSTEPPS Master Trainer Class

SAVE THE DATES IN 2019! Registration Coming Soon!

  • FHA MTC HIIN Nurse Leadership & UP Refresh Regional Meetings

–Jan. 28 (Pensacola) –Jan. 29 (South Florida) –Jan. 31 (Orlando) –Feb. 1 (Jacksonville)

Upcoming Virtual and In-Person Events

Check the weekly MTC HIIN Upcoming Events for details and registration

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  • Eligibility for Nursing CEU requires submission of an evaluation

survey for each participant requesting continuing education: https://www.surveymonkey.com/r/NHSN-VAE-121818

  • Share this link with all of your participants if viewing today’s

webinar as a group (Survey closes Dec. 28, 2018)

  • Be sure to include your contact information and Florida nursing

license number

  • FHA will report 1.0 credit hour to CE Broker and a certificate will

be sent via e-mail (Please allow at least 2 weeks after the survey closes)

Evaluation Survey & Continuing Nursing Education

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Cheryl D. Love, RN, BSN, BS-HCA, MBA, LHRM, CPHRM Florida Hospital Association cheryll@fha.org | 407-841-6230 Linda R. Greene, RN, MPS, CIC Manager of Infection Prevention UR Highland Hospital, Rochester, NY linda_greene@urmc.rochester.edu

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