Five years without VAP? Two years without BSI?
Projects help MI hospitals attain the enviable
On March 14, there was a big celebration at Mercy Memorial Hospital in Monroe, MI, attended by officials from the Michigan Hospital Association. What was the occasion? Five full years without a single case of ventilator-associated pneumonia (VAP) in the hospital. It put the facility in the top 1% of the country, says Ellie Wahl-Lenkovich, RN, MA, chief nursing officer and senior vice president of patient care services at the 238-bed community hospital. The success is the result of a series of projects promoted by the Michigan Hospital Association's Keystone Center Intensive Care Unit (ICU) collaborative.
Wahl-Lenkovich was a critical care nurse when the project began in 2003. She remembers being the one who was making sure that every item on the protocols was done, doing the very work that was celebrated in mid-March.
It is not just VAP that was part of the program. Michigan hospitals also worked together to tackle catheter-related bloodstream infections and the bane of every infection control professional in a hospital urinary tract infections (UTIs).
The original peer review study, which covered catheter-related bloodstream infections, was published in the New England Journal of Medicine in 2006.1 Peter Pronovost and his peers looked at data from 103 ICUs, mostly in Michigan. Initially, the rate of infection was 2.7 per 1,000 catheter days. Three months after the intervention, that was down to zero. The project included five steps, all recommended by the Centers for Disease Control and Prevention (CDC): hand-washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site whenever possible, and removing unnecessary catheters as soon as possible. Last year, researchers went back to the participating facilities to look at whether the impact was sustained2 and found that, over 18 months, the reduction was about two-thirds.
Since the original implementation, Mercy Memorial has had stretches as long as 18 months without a single central-line infection. The success has been so promising that Wahl-Lenkovich says they expanded it to wherever there was a central-line insertion. "What happens in the ICU should not be different care than the same thing happening on another unit," she says. It has been expanded, too, to epidurals given in obstetrics. "We use the same sterile technique."
The ventilator and UTI portions of the project were also based on CDC recommendations and likewise reduced infections, which lowered length of stay, and, as an added bonus, saved money. That becomes increasingly important as payers commonly refuse to reimburse for any hospital-acquired infection, says Wahl-Lenkovich.
A study in the January issue of the British Medical Journal3 looked at all three of the interventions and their impact on mortality and length of stay (LOS). Lead author Allison Lipitz-Snyderman, PhD, now a postdoctoral fellow at the Johns Hopkins Bloomberg School of Public Health, says that while it may be intuitive that reduced infection rates will also lead to lower mortality rates and shorter hospital stays, good science mandates proving it. And her retrospective look shows it has, at least in terms of mortality rates. However, she found that the post-study period did not show as lasting an impact for the group as a whole as those that some of the participating hospitals are still enjoying and found no statistically significant change in LOS.
Lipitz-Snyderman says educating staff and creating a culture of safety seems to have been an important first step for the ICUs in question. Encouraging staff to speak up and talk about potential safety problems and giving them the authority to stop a procedure like a central line placement if they did not see someone following the new protocols was key, she says. "You have to encourage everyone to focus on quality."
The other element of their success was to get physicians to accept and adapt to the changes. That alone can require culture change and convincing providers that particular interventions are important. Having some huffy physicians who object to being told to wash their hands will not lead to success, she says.
There is always push-back when change is implemented, says Gretchen Schrage, MBA, MT(ASCP)SH, CPHQ, manager of performance improvement and a patient safety officer at Northern Michigan Regional Hospital in Petoskey, a 214-bed regional referral center. But it is worth it to push back against those naysayers. "I'm proud to say we have not had a bloodstream infection in almost four years, ventilator-associated pneumonia in two years, and just one UTI since last November."
She says that getting the bloodstream infection rate down was easy. Convincing people that a zero rate was possible was harder. "Just being below the mean was considered good enough," Schrage says. "Now that we have been this successful, it is not anymore."
The bloodstream infection bundle has been rolled out hospitalwide and is used whenever there is any kind of procedure done on a patient. "A sign goes up closing the room until the procedure is completed," says Schrage. "People cannot poke their heads in anymore."
The hospital rolled out a checklist for the infection reduction protocol, and also created fishbone diagrams that focused on everything that could cause an infection (see tables). "If there is an infection, we use it to help us do a mini-root cause analysis on why it happened." There is a similar diagram for ventilator-associated pneumonia. Not that either diagram is getting much of a workout these days.
The latter condition has several parts. Among them:
- Raise the head of the bed to greater than 30 degrees.
- Implement an oral hygiene protocol with a chlorhexidrine rinse.
- Deep vein thrombosis prophylaxis.
- Stress ulcer prophylaxis.
- Tight glucose control.
- Daily sedation awakening trials.
- Subglottal suctioning.
UTIs have been a headache for a number of years, Schrage says. It was problem enough that the hospital actually created its own bundle and protocol before Keystone attacked it. The results have been gratifying, even if the zero infection rate remains elusive. In 2007, there were 5.6 urinary infections per 1,000 device days. By 2010, it was down to 0.8, which was a single infection in Schrage's recollection.
The protocol includes daily washing with soap and water and an admonishment to be gentle, as Schrage thinks one problem might have been people scrubbing too hard. There is a device to secure the catheter, a requirement to keep all bags below the bladder, and an elimination of the dependent loop. There was an issue with some new ICU beds in the beginning that had to be addressed, and the organization opted to use a single kind of bag with a urometer. That bag was more expensive than others, but if measurement was required, it meant one less catheter change and one less chance for an infection to catch hold. They use a large-mouth system to empty the bags and attempt to get the catheter out every single day.
A surgical unit is now using the same protocol. "I can spread the excitement not just from one initiative to another by sharing successes, but from one unit to another. I can act as a bridge," Schrage says.
There is no "there," she adds. They continue to look for ways to improve performance. For example, this year, they are expanding the ICU protocols to include working on reducing sedation delirium, she says. Another big push is to work on reducing sepsis. And these programs have people champing at the bit, she says. "When you have great success, things get done, excitement."
Wahl-Lenkovich concurs that a single great success can have an impact on how whole-heartedly hospital personnel embrace other quality improvement projects. "You see a goal improvement and helping so many patients that makes you want to do it again.
Both hospitals are excited to continue further with Keystone initiatives. If their peers are not, the Keystone Center has some data that might change minds. According to the CDC, there were 1.7 million hospital-acquired infections and 99,000 associated deaths in 2002. They cost as much as $34 billion in preventable expenses which will no longer be reimbursed by payers. Meanwhile, in Michigan between 2004 and 2009, the Keystone ICU project saved an estimated 1,830 lives, nearly 140,000 excess hospital days, and more than $271 million.
References
- Pronovost P, Needham D, Berenholtz S et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-273. (full text available free online at http://www.nejm.org/doi/full/10.1056/NEJMoa061115#t=articleTop).
- Pronovost P, Goeschel CA, Colantuoni E et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ. 2010 Feb 4;340:c309. doi: 10.1136/bmj.c309 (full text available free online at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2816728/).
- Lipitz-Snyderman A, Steinwachs D, Needham DM, et al. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: Retrospective comparative analysis. BMJ. 2011 Jan 28;342:d219. doi: 10.1136/bmj.d219 (full text available free online at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031651/).
For more information contact:
Ellie Wahl-Lenkovich, RN, MA, Chief Nursing Officer, Senior Vice President of PatientCcare Services, Mercy Memorial Hospital, Monroe, MI. Telephone: (734) 755-6328. Email: [email protected].
Allison Lipitz-Snyderman, PhD, Postdoctoral Fellow, Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD. Email: [email protected].
Gretchen Schrage, MBA, MT(ASCP)SH, CPHQ, Manager Performance Improvement, Patient Safety Officer, Northern Michigan Regional Hospital, Petoskey, MI. Telephone: (231) 487-7812. Email: [email protected].
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