Beyond CLABSI: Sustaining Gains from Three Quality Improvement Efforts … · 2014-10-27 · Beyond CLABSI: Sustaining Gains from Three Quality Improvement Efforts in the NICU Susan

Beyond CLABSI: Sustaining Gains from Three Quality Improvement Efforts in the NICU

Susan A. Furdon RN, MS, NNP-BC

November 2, 1014 1

+

BEYOND CLABSI: Sustaining Gains from Three Quality Improvement Initiatives in the NICU

Susan Arana Furdon MS, RN, NNP-BC

+Disclosure

Susan A. Furdon MS, RN, NNP-BC does not have any financial arrangement or affiliations with a commercial entity.

Ms. Furdon will not be discussing the unlabeled use of a commercial product in her presentation.

+Objectives:

Identify one model for improvinghealthcare quality in the NICUDescribe one unit’s process oftranslating evidence into bedsidepracticeDiscuss the use of ongoing audits& feedback to all members of thehealthcare team to sustain the GAINS

+Quality Initiatives to Improve Outcomes of VLBW

Is Zero Possible? CLABSI Reduction After Implementation of Insertion & Maintenance Bundles

Lynn J Spilman MS, RN, NNP-BC, Susan A. Furdon MS, RN, NNP-BC, Michael J Horgan MD, Rebecca O’Donnell, MT(ASCP), CIC

Operation “Toasty Tot”: A Quality Improvement Initiative to Minimize Hypothermia During Delivery Room Stabilization of the VLBW Neonates

Susan A Furdon MS, RN, NNP-BC, Joaquim M. Pinheiro MD, MPH, Susan Boynton BSN, RNC, Robin Dugan BSN, RNC, Christine Reu Donlon MS, RNC, NNP-BC, Mary Wedrychowicz MS, RN

“Love My Curves”: Prevention of Postnatal Growth Restriction by the Implementation of an Evidenced-Based Premature Infant Feeding Bundle

Pauline Graziano MS, RN, NNP-BC, Michael Horgan MD, Theresa Loomis RD, CNSD

+Plan Study Do Act

+Plan Study Do Act

What doWe THINK weneed to improve?

Baseline data



November 2, 1014 2

+ELEMENTS OF SUCCESS:

+Recognition & Belief:

Prior to the meeting, we didn’t believe 0 was possible

Thought sepsis evaluations & sepsis were just part of the work we did – blamed our patient population

Also thought that any unit that had small CLABSI rates must be different than us – less acute patients

WE HAVE A PROBLEM!! NYS RPC MEETING 2007

+

Transparency of Data & Process Definitions reviewed / operationalized

Best site (s) identified: processes at those sites described: Bundle elements defined

Networked with clinical coordinator / toured nursery & interviewed staff

(Especially grateful for the in-depth lecture by Grace Marin RN, BSN (Clinical Coordinator of Neonatal ICU @ Kravis Children’s Hospital)

+Plan Study Do Act

PRACTICECHANGE!

+PICC Insertion

Elements of bundle

Establish a central line kit or cart to consolidate all items necessary for the procedure (1B)

Perform hand hygiene with hospital approved alcohol-based product or antiseptic- containing soap (CHG): before and after palpating insertion

sites before and after inserting central line.

(1A)

AMC Change in Practice

PICC cart developed

Already implemented: Reinforced with

education/ audits Added hand hygiene

stations

+Insertion

Elements of bundle

Use maximal barrier precautions (including sterile gown, sterile gloves, surgical mask, hat & large sterile drape) (1A)

Disinfect skin with appropriate antiseptic (eg CHG 2%) before catheter insertion (1A)

Use either a sterile transparent semi-permeable dressing or sterile gauze to cover the insertion site (1A)


No change in policy

Did change ‘kit’ – larger drape

Did education and staff took on role of enforcer of the 3-foot rule

No change

No change – use Opsite3000 (Smith & Nephrew)



November 2, 1014 3

+PICC Maintenance

Elements of bundle

Perform hand hygiene with hospital approved alcohol-based product or antiseptic-containing soap before and after accessing a catheter or changing the dressing (1A)

Evaluate the catheter insertion site daily for signs of infection and to assess dressing integrity (1B)

At a minimum, if the dressing is damp, soiled or loose, change it aseptically (1B)

Disinfect the skin around the insertion site with an appropriate antiseptic (1A)


Reinforced element with education; increased visibility of hand sanitizer along outside perimeter of our pods

Reinforced element with education Nursing assessment in E-HR Audits

Discontinued use of Biopatchwhich required q7 day dressing change;

Changed unit standard: change dressing when damp, loosened or soiled

+Maintenance

Elements of bundle

Develop and use standardized intravenous tubing set-up and changes (1B)

Maintain aseptic technique when changing IV tubing and when entering the catheter including “scrub the hub” (1A)

Daily review of catheter necessity with prompt removal when no longeressential (1B)


Closed medication system adopted – Churchill Medical 6” trifurcated extension set

Tubing changes using sterile technique;

Reinforced ‘scrub the hub’ for 60 sec with education;

Implemented ‘chains’ as reminder of sterility during tubing change (3 foot rule)

Daily interdisciplinary review of necessity of catheter with attending on am rounds

+Space constraints: 3 foot rule around sterile procedure

RESPECTTHECHAIN!

Yoda’s Rules to Jedi Warriors:DEFEAT THE ENEMY!

1] Keep up to date!

All Jedi will be ‘in the know’ after the Fair

2] Organize PICC supplies

Dressing supplies are already in one bag

In process of setting up cart for insertion supplies

We have a vendor who will prepackage insertion supplies (will be ready ~ 10 weeks)

ANNUAL SKILLS FAIR: 2008

+Yoda’s rules

3] Maximum Barrier

Precautions: insertion of PICC

Mask, gowns, hat & sterile gloves

Sterile drape entirely covers baby

Mask, hat on anyone within 3 foot invisible shield

4] Use evidence for dressing changes:

Stop using Biopatch

Change dressing within 24h of insertion [remove blood]

Change dressing when loosened or soiled (bloody)

2 person procedure to maintain sterility

Yoda’s rules

5] Standardize tubing

6] Maintain sterility with tubing changes

2 person technique

sterile field & sterile gloves/ mask with tubing changes

Jedi #1 Jedi #2Jedi’s wardrobe

Mask/ non-sterile gloves Gown, sterile gloves, mask, hat

Assembling our weapons

Assistant for preparation of new set up

Prepare supplies on sterile drape

Actions Remove old tubing Connect new tubing to PICC using aseptic technique



November 2, 1014 4

+Standardized Tubing is a Closed Medication System … Our weapon

in fighting bacteria Tubing changed q 24h

Tubing changed using

sterile technique

No entry of tubing close to the patient or the patient’s environment

Limits the # of entries to the line per day

Continue to scrub the hub (scrub the q-site) as medication syringe is changed (60 seconds using clock)

Scrub the CLC valve at time of tubing change with alcohol for 60 seconds

Most important rule

8] ALL JEDI’S MUST WASH HANDS

Use waterless skin cleanser

Wear gloves for all patient contact

+Points of clarification

This new tubing is a trial – there will be an evaluation tool in order to give feedback

Tubing is just for PICCs for now

Tubing is NOT a triple lumen ie compatibility of solutions still important because the solutions come together within the tubing

+ CLABSI Prevention Bundle: Maintenance

Should practice extend to all lines?

Daily assessment of catheter need

Removal when 100‐120 mL/kg/day enteral nutrition achieved

Monitor dressing integrity & cleanliness

Use closed system for infusion, blood sampling & medication administration

Assemble & connect infusion tubing using aseptic technique.

Use consistent tubing configuration

+Setting UP

+



November 2, 1014 5

+

Insertion audits

Completed by RN, NP or fellow who inserts the PICC

Audit is part of the universal protocol & procedure note

Separate section for adherence to guidelines that is not part of the medical record

Useful to define expectations to new fellows/staff involved in the procedure

+ Insertion Audit

+Checklist: Do They Work?

+

Audits done by 2 CNS & 2 experienced PICC team nurses Staff know we are actively

looking at set up/ dressing integrity/ scrub the hub & line necessity

Currently, staff provide the ‘answer’ before the question is asked

Increased conversation about the PICC itself during rounds

Parents know the plan!

+Plan Study Do Act

DATA & ANALYSIS!

NICU Number of Central Line Related

Blood Stream Infections 2007- 2008

1 1 1

0 0 0 0 0 0 0 0

5

3

1

5

3

6

4 4

9

5

3

1

2

1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 122007 2008

0

2

4

6

8

10

12<= 750 751-1000 1001-1500 1501-2500 >2500

# o

f ce

ntra

l lin

e re

late

d bl

ood

stre

am in

fect

ions



November 2, 1014 6

+ NICU Number of Central Line Related

Blood Stream Infections

0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0

1

0 0 0 0 00 0 0 0 0 0 0 0 0 0 0

Jan Feb March April May June July Aug Sep Oct Nov Dec0

2

4

6

8

10

12<= 750 751-1000 1001-1500 1501-2500 >2500

# o

f ce

ntra

l lin

e re

late

d bl

ood

stre

am in

fect

ions

2009

+

Recipe ‘worked’ right away

Stick to a new diet –belief that this recipe ‘worked’: Reinforced the change in

behavior

Hardwired that change

In turn, results supported additional recognition to staff for their efforts

+Recipe for Success

Interdisciplinary Recognition –“we had a problem”

Sterile tubing change respecting space

Accessing line outside patient environment

Multidisciplinary effort to evaluate need for Central access DAILY

AMC

#1 ingredient:NURSES

+Plan Study Do Act

Ongoing ReviewNewChallenges

+CLABSI Prevention Bundle: Leadership Administrative involvement & support for zero HAIs

Engage staff with feedback Posting days since last CLABSI Posting rates of CLABSI

Perform investigation of each CLABSI

Surveillance activities for critical processes Hand hygiene Line management and entry Off unit procedures Stop the line support

Trained personnel to perform specialized maintenance activities

RECOGNITION OF NURSING& MEDICAL STAFF’S SUCCESS

+Investigating Failure



November 2, 1014 7

+How do we maintain the success of our current recipe as we go forward?

+AMC’s CLABSI rate since initiative started

11.2

1.190.21

1.17 0.930

0.77

2007 2008 2009 2010 2011 2012 2013

Rate per 1000 Central Line Days

Rate per 1000 Central Line Days

+AMC’s CLABSI initiative

Year CLABSI CL Days Rate per1000 CL Days

2007 38 3389 11.2

2008 4 3352 1.19

2009 1 4706 0.21

2010 5 4268 1.17

2011 3 3219 0.93

2012 ZERO! 4041 0

2013 3 3875 0.77

2014 ?

UGH!!

National NY State AMC NICU

+ELEMENTS OF SUCCESS:

BENCHMARKING

TRANSPARENCY IN DATA

BUNDLE ELEMENTS

UNIT CHAMPION(S)

COMMUNICATION: EVIDENCE TRANSLATION IN ACTION



November 2, 1014 8

+ Getting To Zero CLABSI! … A Believable Goal? We must focus on the

patient & challenge ourselves to no longer

accept the unacceptable…

CLABSI ARE PREVENTABLE!

+Maintaining Normothermia in the Delivery Room for Preterm Infants:OPERATION: TOASTY TOT

Pinheiro J, Furdon SA, Boynton S , Dugan R, Jensen S, Reu Donlon C, Abiodun O,Wedrychowicz M

Admission temperatures related to mortality

05

1015202530354045

<34

34-3

4.9

35-3

5.9

36-3

6.9

37-3

7.9

>38

% Adm Temp

% AdmTemp

46% of initial temperatures of VLBW < 36°C

28% increase in mortality for every 1°Cdecrease in temperature

Lapkook AR (2007)Pediatrics

AMC’s Admission Temperatures: VLBW

0

20

40

60

80

100

120

2005 2006 2007

>38

36-38

<36

AMC: a “better performer” when compared within Vermont Oxford Network (VON) – 2005 & 2006

AMC discontinued use of chemical warm packs for neonatal stabilization in 2007 after one infant experienced focal skin injury

Comparison showed an increase in hypothermia on admission AMC Period I 2006 to mid 2007

Chemical warm packs consistently used

AMC Period IIMid to end 2007

Chemical warm packs were discontinued

0%

10%

20%

30%

40%

50%

60%

70%

I II VON

% VLBW Hypothermia

% VLBWHypothermia



November 2, 1014 9

+Methods

Mobilized to make a change! Downward trend of AMC’s

admission temperatures of VLBW

Impact of hypothermia as described in the literature

Identify Unit ‘champions’: Developed an

interdisciplinary & interdepartmental (NICU & DR) workgroup to improve outcomes

Standardized stabilization processes in the DR to enhance infant temperature

Identified measurable objectives

Utilized Plan-Do-Check-Act methodology

+Objectives of Quality Initiative

To optimize/ standardize the delivery room thermoregulation procedures to maintain temperature 36.5-37.5°C in the VLBW (birthweight < 1500g) born at the regional center

To improve the prevalence of admission temperatures 36-38°C for inborn VLBW infants to > 90%

Saran wrap applied to head prior to intubation?Hat applied over Saran?Saran wrap wrapped around body?HR auscultated through Saran wrap? Door to room closed?

Sides to warmer raised? Sides in ‘up’ position for transfer

Prewarmed blankets available? ASK for them from the DR staff

Radiant warmer turned on when delivery anticipated? Turn on ‘early/ close door to warm the roomLean back – do not block infant’s access of heat

OPERATION: TOASTY TOTTARGET THE PINK ZONE

Target population: < 1500g Target temperature: 36.0 – 38.0 degrees

Four ways a newborn may lose heat to the environment

+Temperature Measurement

Admission temperature standardized: measured prior to transfer from the stabilization bed to the admission bed

Data collected & submitted to QI data coordinatorAccuracy of data: State Perinatal data sets

compared with Vermont Oxford data

Graphic display developed & updated monthly

+Increasing staff awareness of the problem“Call” for participants in workgroup

Graphic display developed & updated monthly – provided feedback to medical & nursing staff in the NICU

Develop a logo / name for our project to enhance recognitionOPERATION TOASTY TOT

Target the Pink ZoneGoal > 90% in-born VLBW neonates between 36-38° C

Very Low Birth Weight (VLBW) Neonates (less than 1500gms)

+

As of 05/19/08

OPERATION TOASTY TOTTarget the Pink Zone

As of 9/30/08



November 2, 1014 10

+OPERATION TOASTY TOT

Target the Pink Zone

71%

17% 18%27%

18%

33%

0

29%

90%

83% 82%73%

73%

66%

90%

22%

43%

70%

34%21%25%

78%

57%

30%

65%77%72%

10%

0%

20%

40%

60%

80%

100%

2005 2006 2007 Nov-07

Dec-07

Jan-08

Feb-08

Mar-08

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

< 36 deg 36-38 deg > 38 deg

2005 2006 2007 Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

139 150 119 10 7 18 7 10 12 11 11 11 6 10

Goal >/= 90% in-born VLBW between 36-38 C

+ Toasty Tot initiative continued: New Cycle PCDA …Continuing to optimize and standardize approach

to thermoregulation procedures in the delivery roomUse / implications of new radiant warmers in DR

with continuous heat source for transfer Purchase & use of blanket warmers in DR/ OROngoing education of medical staff (obstetric &

pediatric residents) – introduce @ Peds M&MOngoing education of nursing staff (OB & NICU) –

clinical fair next week with focus on use of Panda warmer

Statistical improvement after education: 2008

2008: Did not achieve goal > 90% VLBW admission temperatures between 36-38° C

Since education of staff in March 08 – 84% VLBW within target temperature range

Improvement noted: 84% within target temperature range (2008) vs 66% within range (2007)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

>36

36-36

<36

OPERATION TOASTY TOTTarget the Pink Zone

Goal >/= 90% in-born VLBW neonates between 36-38° C Very Low Birth Weight (VLBW) Neonates (less than 1500gms)

(P<.001)

+Toasty Tot initiative continues …Continuing to optimize and standardize approach to

thermoregulation procedures in the delivery room –new cycle PCDA Reviewed distribution of temperatures by birthweight Redefined standard for larger weight category (1000-1500g): all

infants < 1500g to have plastic wrap on head during stabilization & transfer to NICU

Report of admission temperatures < 36 ° C at monthly M&M Compliance tool (Evaluation of Thermoregulation in DR)

completed by NICU RN in attendance of the delivery of each infant admitted to NICU; now review done only when temperature < 36 ° C

+Thermoregulation Bundle Standard use of battery operated radiant warmer on

servo-control at 5 min & during transfer

Minimize convective heat loss through maintaining side rails in up position & closing door to resuscitation room

Minimize conductive heat loss through availability of warmed blankets

Wrap head of all infants < 34 wks GA with plastic wrap then cotton heat; Wrap torso of all infants < 29 weeks GA with second piece of plastic wrap

Admission temperature taken prior to transfer to admission bed

+2009: 92% admission temperatures of VLBW in the target zone!

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2005 2006 2007 2008* 2008** 2009 2010 1Q

>38

36-38

<36



November 2, 1014 11

+Lower proportions of hypothermic infants after staff education & Operation Toasty Tot bundle implementation

+Conclusion:

403 inborn VLBW babies over 36 months Lower proportions of hypothermic infants after staff

education and Operation Toasty Tot bundle implementation in month 15

Initial data showed more consistent improvement in lowest birthweight category (GA <29 weeks); bundle strategies then extended to those >29 weeks

Objective achieved: > 90% temperatures in VLBW admissions between 36-38°C

Hyperthermia (>38oC) incidence was ~2% both before and after bundle implementation

Continuing to standardize and institutionalize bundle elements to facilitate maintenance of gains

+

Pauline Graziano MS, RN, NNP-BC, Michael Horgan MD, Theresa Loomis RD, CNSD

“Love My Curves”: Prevention of Postnatal Growth Restriction by the Implementation of an Evidenced-Based Premature Infant Feeding Bundle

+Objectives:

1. Develop an evidenced-based enteral feeding “bundle” to address standardization of nutritional practices

2. Improve nutritional intake of VLBW infants

3. Establish goal: > 90% of admitted AGA VLBW infants will be discharged home above the 10th

percentile for weight and head circumference

+Background

Postnatal growth restriction remains a major morbidity for VLBW (< 1500g) infants affecting health & neurodevelopmental outcomes • Ehrenkranz RA (2010) Early Human Development

Despite early initiation of optimized parenteral nutrition, the majority of VLBW infants fall short of expected growth trajectories • Clark RH et al (2003) Journal of Perinatology

A retrospective review of Albany Medical Center NICU feeding practices/growth outcomes completed to identify baseline practices.

An interdisciplinary workgroup reviewed current literature on feeding practices and outcomes.

An evidenced-based enteral feeding bundle was developed and presented to the medical team for consensus.

Interactive education of the bundle elements was provided to all NICU staff. Education included a review of current evidence, planned changes in practice, resource materials and an auditing tool.

+ Feeding Bundle – Jan 2010Elements Objectives Details

Feed Substrate •Preferred: Breast Milk•If N/A: Premature 24 cal Formula

Feed Initiation •Goal: by DOL 2 (within 24 hrs of birth)•Volume/Frequency pre-defined by weight (10-20 ml/kg/day)

Feed Advancement

•No > 20 ml/kg/day per pre-defined advances unless PO feeding•Advance daily if meets tolerance definition•Goal: 140-160 ml/kg/day enteral intake

•Less than 1 KG: •MEN (10-20 ml/kg/day) x5 days. •Begin increase feed day 6• Advance daily as tolerated to goal.•Greater than 1 KG: •Advance daily as tolerated to goal.



November 2, 1014 12

+ Elements Objectives Details

Breast milk Fortification

•Fortify BM to 24 cal/oz using liquid HMF once enteralfeeding volume 50 ml/kg/day

Feed Tolerance •Definition of Tolerance: < 50% residual of daily enteral intake AND normal exam•Definition of Intolerance: > 50% residual of daily enteral intake while feeds advancing; > 30% residual once tolerating full feeds; OR abnormal exam

Management of Residuals:•< 25% of previous feed- re-feed residual and give full feed•> 25 % of previous feed- re-feed residual and give difference•> 25% residual and/or abnormal finding collaborate with provider

Definition of Abnormal Findings:•Abdominal distension, discoloration, visible loops, absent bowel sounds•Bloody stool•Bilious aspirates (defined by color chart)•Vital sign instability/Change from baseline status.

+Same recipe to achieve goals

NYS data sharing & evidence evaluation

Bundle Elements brought to medical & nursing leadership team for consensus

Bundle elements and background evidence brought to nursing staff

Data collection

Evaluation & new cycle of implementation

+Outcomes!

• Average DOL to First Feeding decreased from day 10 to day 2.

• Average day to Full Feedings decreased from day 28 to day 16.

• Average day to re-gain Birth Weight decreased from day 22 to day 10.

+Outcomes: Nutrition Initiative

0

5

10

15

20

25

30

First Feed Full Feeds BW Regained

2009

2010

2011

2012

P=0001

P=0.002

P=0.03

+All NYS RPCs

32.0 32.630.6

21.1 20.216.7

0.0

10.0

20.0

30.0

40.0

2009 2010 Jan-Sep 2011

Percentage of Newborns Discharged Below Fenton's 10th Percentile for Weight

Source: NYS NICU Module Data

All NYS RPCs

+Infants discharged > 10th

percentile for weight

0%10%20%30%40%50%60%70%80%90%

Pre-Bundle 2010 2011

AGA @ Birth AGA @ Discharge



November 2, 1014 13

+Conclusions:

• Establishing a standardized approach to feeding initiation and advancement (Feeding Bundle) significantly decreased number of days in initiating feedings, reaching full feeds, and regaining birth weight in our institution.

• Adherence with bundle (now > 90%) has led to improved growth outcome measurements for both weight and head circumference measurements

• Continuing to work towards goal of > 90% of AGA at birth infants maintaining > 10th percentile measurements at discharge.

• Additional monitoring has revealed AMC NICU’s central line utilization rates have fallen below national averages.

+Advanced Practice Nurse: Bridging the Evidence to Practice

Review science behind evidence as foundation of bundle elements

Clinical knowledge & expertise

Develop bundle elements into actionable care at the bedside

Provide education to nurses & physicians

Clinical presence: Provide support with ongoing audits/ feedback

Twin Bridges

+Quality Improvement …

Reliably adhering to defined practices on daily basis is immensely challenging

APN can focus on education & support of practice changes – both nursing & medical team

Organizational commitment to change is key to APN’s ability to fulfill this aspect of their role

+APN Colleagues: Providing leadership for Quality initiatives

CLABSI Reduction Lynn Spilman MS, RN, NNP-BC

Sue Furdon MS, RN, NNP-BC

Thermoregulation Initiative Christine Reu Donlon MS, RN, NNP-BC

Sue Furdon MS, RN, NNP-BC

Nutrition Initiative Pauline Graziano MS, RN, NNP-BC

RECOGNIZE THE TEAM @ ALBANY MED!

Ongoing, continuous auditing and feedback has successfully affected

a culture of practice change resulting in a new standard of care

and improved outcomes at our institution

Documents

Beyond CLABSI: Sustaining Gains from Three Quality Improvement Efforts … · 2014-10-27 · Beyond CLABSI: Sustaining Gains from Three Quality Improvement Efforts in the NICU Susan