Sudden jump in VAP spurs QI to cut rate to near zero
New mouth care processes at heart of solution
Sometimes, as a quality manager, you can be proceeding with the confident assurance that you "are doing everything right" when it comes to a cohort of patients, when suddenly your data give you an uncomfortable wake-up call.
That’s precisely what happened at Coral Springs (FL) medical center several years ago.
"I noticed in 2002 that we had had a severe increase in VAP [ventilator-assisted pneumonia] compared to 2001; it went up by 70%," recalls Ava Dobin, RN, BSN, CIC, the facility’s epidemiology coordinator. Dobin, who has been at the facility for 19 years, "follows every single patient infection."
"We were most astounded by the increase in infection," adds Robin McElligott, CHCQM, LHRM, the quality manager at Coral Springs.
The good news is that a quality department-based team swung into action, and in the past three years, there have only been three cases of VAP — and those were in long-term patients who ultimately survived.
How did Coral Springs make such a dramatic turnaround? With one major process change: the introduction of a device that allowed them to brush ventilated patients’ teeth three times a day.
Identifying the source
The answer to the problem may seem simple at first blush, but many steps had to be taken to first identify the source of the problem and then subsequently determine the best solution.
"We formed a team through our quality department," Dobin explains. "It included physicians, infection control, respiratory therapists, the critical care manager, a quality specialist, and even our customer relations coordinator. Our goal was to find out why the infection rates were going up."
"Once the problem was identified, they brought the PI team proposal to the quality council," McElligott adds. "At that time, it was approved for the team to actually form. Then I joined the team, and we went through process improvement."
That included just-in-time training to get the team reoriented to any tools it might be needing, including cause/effect diagrams, control charts, and so forth.
"We also checked out all the best practices," Dobin notes. "We usually comply with CDC [the Centers for Disease Control and Prevention] guidelines, but it seemed like we were doing what we were supposed to do."
So she determined to sit in patients’ rooms and watch everything the caregivers did. "We wanted to see if it was hand washing, or not using antibiotics quite enough," she says. "What I found, in working with the manager of critical care, is that there was a missing piece."
And just what was that missing piece? "Not everybody was doing mouth care, and when they were doing it, they were all doing it differently," Dobin points out. "Some people were swabbing the patients’ lips a bit with glycerin to keep them from cracking, but that was about it."
Finding the solution
As part of the PI effort, "We pulled all the research we could find on mouth care when patients are on ventilator," she continues. "We found mouth care could play a role; when the bacteria in a patient’s mouth gets swallowed, it can lodge in the lungs and cause pneumonia."
Further research identified two vendors who had products for cleaning the mouth. "We even tried to make our own, but the home-grown product did not work very well," Dobin points out.
So the staff tried the two products, and the nurses ultimately preferred the device from Sage Products Inc. of Crystal Lake, IL. "It includes three different packages for the morning, afternoon, and evening nurse," Dobin explains. Each package includes a Yankauer connection to the ventilator, so the patient can remain on the ventilator without breaking open the system and contaminating it. "This way, we are able to brush the patients’ teeth three times a day without ever taking them off the ventilator," Dobin explains.
"The most interesting lesson we learned," says McElligott, "Is that the people closest to the work are the ones you should ask how to improve a process. The staff who initially were brought in reviewed a lot of the literature themselves, and one nurse tried developing the prototype herself." This was facilitated, she says, by that fact that the critical care manager "empowers her staff to be very proactive in problem solving."
Since the inception of the program, she continues, the facility has not had a single mortality.
The new regimen has now been instituted in all of the hospitals in the North Broward Hospital District. "Districtwide, we project savings of $4 million a year in patient infections," McElligott notes. "And, patient stays will be much shorter; VAP usually causes an additional 16 to 17 days of hospitalization."
Need More Information?
For more information, contact:
- Ava Dobin, RN, BSN, CIC, Epidemiology Coordinator, Coral Springs Medical Center, 3000 Coral Hills Drive. Coral Springs, FL 33065. Phone: (954) 344-3194. E-mail: [email protected].
- Robin McElligott, CHCQM, LHRM, Quality Manager, Coral Springs Medical Center, 3000 Coral Hills Drive. Coral Springs, FL 33065. Phone: (954) 344-3086. E-mail: [email protected].
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