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Reducing the Cost and Impact of Infectious Disease

Proud Recipients of 2006 Malcolm Baldrige
National Quality Award
Dan Peterson, MD, MPH Vice President, Medical
Director
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Reasons to address HAIs -- NOT

• Substantial Morbidity and Mortality
• 5-10 of hospitalized patients acquire an
  infection
• 90,000 lives annually
• Most common bad thing to happen to a patient in
  the hospital
• However
• Seen as something that just happens
• If you have infection control department, you are
  addressing it
• You might even make money on it

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Reasons HAIs are Top of Mind in the C-Suite

• New Expectations Zero tolerance

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Original Article An Intervention to Decrease
Catheter-Related Bloodstream Infections in the ICU
Peter Pronovost, M.D., Ph.D., Dale Needham, M.D.,
Ph.D., Sean Berenholtz, M.D., David Sinopoli,
M.P.H., M.B.A., Haitao Chu, M.D., Ph.D., Sara
Cosgrove, M.D., Bryan Sexton, Ph.D., Robert Hyzy,
M.D., Robert Welsh, M.D., Gary Roth, M.D., Joseph
Bander, M.D., John Kepros, M.D., and Christine
Goeschel, R.N., M.P.A.
N Engl J Med Volume 355(26)2725-2732 December
28, 2006
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Study Overview

• Catheter-related bloodstream infections are
  associated with significant morbidity
• In Michigan, a statewide initiative to reduce
  catheter-related bloodstream infections in
  intensive care units (ICUs) was implemented
• This simple intervention included washing hands,
  using full-barrier precautions with central-line
  placement, cleaning the skin with chlorhexidine,
  avoiding the femoral site if possible, and
  removing unnecessary catheters
• The median rate of infection per 1000
  catheter-days decreased from 2.7 at baseline to 0
  throughout all periods after implementation of
  the study intervention

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Rates of Catheter-Related Bloodstream Infection
from Baseline (before Implementation of the Study
Intervention) to 18 Months of Follow-up
Pronovost P et al. N Engl J Med 20063552725-2732
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Reasons HAIs are Top of Mind in the C-Suite

• Costs

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Economics of Central LineAssociatedBloodstream
Infections

• The average payment for a case complicated by
  CLAB was 64,894, and the average expense was
  91,733 with gross margin of 26,839 per case
  and a total loss from operations of 1,449,306 in
  the 54 cases. The costs of CLABs and the
  associated complications averaged 43 of the
  total cost of care. The elimination of these
  preventable infections constitutes not only an
  opportunity to improve patient outcomes but also
  a significant financial opportunity.
• Am J Med Qual 2006 21suppl7S-16S

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Economics
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Economics
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Reasons HAIs are Top of Mind in the C-Suite

• New Expectations Zero tolerance
• Costs Publicity Public Awareness
• Public Reporting
• Ability to do something IHI Bundles
• Liability
• Revenue

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Prevention of Ventilator-Associated Pneumonia

• Robert Garcia, BS, MMT(ASCP), CIC
• Infection Control Professional

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Pathogenesis
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Major Areas of Oropharyngeal Colonization
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Current Preventive Recommendations
IHI 100K Lives Campaign. Getting Started Kit VAP
How-to Guide CDC Guideline for Preventing
Healthcare-Associated Pneumonia, 2002. UI
unresolved issue NA not addressed
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10 Essential Interventions to Prevent VAP
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1. Establish Credibility

• Recruit Physician Nurse Champions
• Key areas
• ER
• ICUs
• Anesthesiology
• Med-Surg Units
• All must be committed to same goals
• Leaders must convince their own
• Appoint VAP Leader for each patient unit

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2. Educate Train the Frontline Healthcare
Worker

• A. Educate health-care workers regarding the
  indications for intravascular catheter use,
  proper procedures for the insertion and
  maintenance of intravascular catheters, and
  appropriate infection-control measuresCat IA.
• B. Assess knowledge of and adherence to
  guidelines periodically for all persons who
  insert and manage intravascular catheters. Cat.
  IA

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3. Demand Strict Hand Hygiene

• Observe proper hand washing procedures either by
  washing hands with conventional
  antiseptic-containing soap and water or with
  waterless alcohol-based gels or foams. Cat. IA
• JCAHO Patient safety Goal 7 requirement

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4. Know the Technology Keep it Clean
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Outbreaks Contaminated Environment

• Pimentel, et al. Control of an outbreak of
  multi-drug-resistant Acinetobacter baumannii in
  an intensive care unit and a surgical ward. J
  Hosp Infect 200559249-53
• Denton, et al. Role of environmental cleaning in
  controlling an outbreak of Acinetobacter
  baumannii on a neurosurgical intensive care unit.
  Inten Crit Care Nurs 20052194-8.

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5. Replace Vent Components only as Needed

• Circuits only when visibly soiled
• HME filter do not replace more frequently than
  every 48 hrs.
• Closed Suction Catheters only when visibly soiled

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6. Elevate the Head of the Bed

• Recent randomized controlled study that disputes
  study referenced by CDC to recommend use of
  semirecumbent positioning to prevent VAP
• Study is unique in three aspects
• Patient positioning was continuously monitored in
  first week
• The semirecumbent position was compared to the
  standard of care
• Data analyzed according to the intention-to-treat
  principle
• Results
• Patients in supine position (control) reached
  only 9.8 to 14.8 degrees (i.e., standard of care)
• Mean backrest position in study group was 30
  degrees
• No difference in VAP rates between the groups

van Nieuwenhoven CA, et al. Feasibility and
effects of the semirecumbent position to prevent
ventilator-associated pneumonia A randomized
study. Crit Care med 200634396-402.
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Cant make it to 30 degrees?

• Situations when HOB up 30 degrees may not be
  possible
• Low BP/unstable VS
• Agitated and at risk of falling out of bed
• Compromised circulation due to femoral lines
• Spinal clearance/Spinal cord injury patients
  MUST have a physicians order identifying the
  degree of elevation allowed
• Use combination of HOB up and reverse
  Trendelenburg to obtain a 30 degree angle

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7. Administer Stress Ulcer Prophylaxis
Flanders SA, Collard HP, Saint S. Nosocomial
pneumonia State of the Science. Am J Infect
Control 20063684-93

• 7 meta-analyses, 20 studies
• 4 showed significant VAP reductions
• 3 showed similar but non-significant VAP
  reductions

• Cook D, et al. A comparison of sucralfate and
  rantidine for the prevention of upper
  gastrointestinal bleeding in patients requiring
  mechanical ventilation. Canadian Critical Care
  Trials Group. N Eng J Med 1998338781-97.
• Large randomized trial showed no benefit in
  either sucralfate or H2 antagonists
• Kantorova I, et al. Stress ulcer prophylaxis in
  clinically ill patients a randomized controlled
  trial. Hepatogastroenterology, 2004200451757-61
  .
• randomized, placebo-controlled trial, 287 pts.
• studied omeprazole (PPI), famotidine (H2
  antagonist), sucralfate
• No significant differences in bleeding or
  pneumonia rates among the 4 groups

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8. Implement Comprehensive Oral Care Interventions

• Strategies to prevent VAP are likely to be
  successful only if based upon a sound
  understanding of pathogenesis and epidemiology.
  The major route for acquiring endemic VAP is
  oropharyngeal colonization by endogenous flora or
  by pathogens acquired exogenously from the
  intensive care unit environment, especially the
  hands or apparel of health-care workers,
  contaminated equipment, hospital water, or air.
  The stomach represents a potential site of
  secondary colonization and reservoir of
  nosocomial gram-negative bacilli.

Safdar N, Crnich CJ, Maki DG. The pathogenesis of
ventilator-associated pneumonia its relevance to
developing effective strategies for prevention.
Respir Care 200550725-39.
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Linking Oral and Dental Colonization with
Respiratory Infection

• A review of the published evidence linking
  oropharyngeal colonization and respiratory
  infection, including VAP (20 studies)
• Provides suggested oral and dental interventions,
  some beyond the scope of current guidelines

Garcia R. A review of the possible role of oral
and dental colonization on the occurrence of
health care-associated pneumonia
Underappreciated risk and a call for
interventions. Am J Infect Control 200533527-41.
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Oral Cavity vs. Gastric Colonization

• Prospective study of 86 mechanically vented ICU
  patients to assess relationship between
  oropharyngeal colonization and subsequent
  occurrence of pneumonia
• Patients oral and gastric specimens were
  collected on admission and twice weekly
• When pneumonia suspected, bronchoscopic specimens
  were taken with protected specimen brush
• In 31 cases of pneumonia identified, DNA genomic
  analysis demonstrated that oropharyngeal
  colonization was the predominant factor in the
  development of pneumonia compared with gastric
  colonization

Garrouste-Orgeas M, et al. Oropharyngeal or
gastric colonization and nosocomial pneumonia in
adult intensive care unit patients. A prospective
study based on genomic DNA analysis. Am J Respir
Crit Care Med 1997156164
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Acquired bacterial colonization Location of the
microorganisms in the 44 carrier patients
OC oropharyngeal colonization GC gastric
colonization BC both OC/GC colonization
Garrouste-Orgear M, et al. Am J Resp Crit Care
Med 1997.
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Decontamination of the Oropharynx

• Prospective, randomized, double-blind study of
  ICU patients to determine VAP while manipulating
  oropharyngeal colonization and without
  influencing gastric or intestinal colonization
• 87 given topical antibiotics (study group), 139
  given placebo (control group)
• Results
• VAP in study group 10
• VAP in control group 27

Bergmans D, et al. Prevention of
ventilator-associated pneumonia by oral
decontamination. Am J Resp Crit Care Med
2001164382-88.
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Dental Plaque as a Bacterial Source of VAP

• Study on dental plaque colonization and ICU
  nosocomial infs.
• 57 patients studied
• Results
• Dental plaque occurred in 40 of pts.
• Colonization of dental plaque was highly
  predictive of nosocomial infection
• Salivary, dental, and tracheal aspirates cultures
  were closely linked

Fourrier E, et al. Colonization of dental plaque
a source of nosocomial infections in intensive
care patients. Crit Care Med 199826301-8.
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Suggested Oral Dental Care Interventions
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Suggested Oral Dental Care Interventions
(contd)
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Outcome Data
VAP Prevention Initiative, Brookdale Medical
Center, publication pending 2007
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VAP Rates, MICU, 2001-2005
VAP Prevention Initiative, Brookdale Medical
Center, publication pending 2007
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9. Institute Active Weaning

• Duration, duration, duration!!!
• Cook D, Meade M, Guyatt G, Griffith L, Booker L.
  Criteria for Weaning from Mechanical Ventilation.
  Evidence Report/Technology Assessment No. 23
  (Prepared by McMaster University under Contract
  No. 290-97-0017). AHRQ Publication No. 01-E010.
  Rockville MD Agency for Health Care Research and
  Quality. November 2002.
• Evidence-Based Guidelines for Weaning and
  Discontinuing Ventilatory Support. A Collective
  Task Force comprised of members of the American
  College of Chest Physicians, the American
  Association for Respiratory Care and the American
  College of Critical care Medicine. Chest
  2001120375S-395S.

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Active Weaning Protocols

• Effect of a protocol-driven vent weaning on
  outcomes
• Results
• Vent use from 0.47 to 0.33 (VD/ICU days)
• VAP 17 in 2000 to 5 in 2002

Dries DJ, et al. Protocol-driven ventilator
weaning reduces use of mechanical ventilation,
rate of early reintubation, and VAP. J Trauma
200456943-51.
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Cost of Mechanical Ventilation

• Retrospective, cohort study designed to examine
  costs associated with mechanical ventilation
• Data from 253 hospitals, 51,009 pts.
• Mean cost with vent 31,574
• Mean cost without vent 12,931
• Incremental cost of mech. vent per day 1,552

Dasta JF, et al. Daily cost of an intensive care
unit day the contribution of mechanical
ventilation. Crit Care Med 2005331266-71.
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10. Monitor for Compliance

• Design form and log as point prevalence
• HOB where is it documented?
• SUP what drugs are used?
• Oral-Dental care How often do they do each
  component? Where d they document?
• Weaning where is the initial decision to start
  weaning documented?

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Lets Summarize Interventions

• Education Proper Hand Hygiene
• Perform proper cleaning and maintenance of
  respiratory care equipment
• If HMEs are used, replace vent circuits as needed
• Elevate HOB when not contraindicated
• Perform comprehensive oropharyngeal care
• Establish active weaning protocols

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Robert Garcia, BS, MMT(ASCP), CIC Assistant
Director of Infection Control Brookdale
University Hospital Medical Center One Brookdale
Plaza Brooklyn, NY 11212 718.240.5924 rgarcia_at_broo
kdale.edu President, Enhanced Epidemiology,
LLC P.O. Box 211 Valley Stream, NY
11580 516.810.3093 rgarciaicp_at_aol.com
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Reduction of VAP

• An Evidence-Based Approach to Ventilator
  Management

Devin Carr, MSN, RN, APRN, BC, CCRN February 28,
2007
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What is Evidence-Based Medicine?

• the conscientious, explicit, and judicious use
  of current best evidence in making decisions
  about the care of people.
• Dr. David Sackett

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Institute for Healthcare ImprovementThe 100,000
Lives Campaign

• Some is not a number,
• Soon is not a time.
• www.ihi.org

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Six Changes That Save Lives

• Deployment of Rapid Response Teamsat the first
  sign of patient decline
• Delivery of Reliable, Evidence-Based Care for
  Acute Myocardial Infarctionto prevent deaths
  from heart attack
• Prevention of Adverse Drug Events (ADEs)by
  implementing medication reconciliation
• Prevention of Central Line Infections by
  implementing a series of interdependent,
  scientifically grounded steps called the Central
  Line Bundle
• Prevention of Surgical Site Infections by
  reliably delivering the correct perioperative
  antibiotics at the proper time
• Prevention of Ventilator-Associated Pneumonia by
  implementing a series of interdependent,
  scientifically grounded steps called the
  Ventilator Bundle

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The 100,000 Lives Campaign

• Prevention of Ventilator-Associated Pneumoniaby
  implementing a series of interdependent,
  scientifically grounded steps called the
  Ventilator Bundle

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Prevent Ventilator-Associated Pneumonia

• Elevation of the head of the bed to between 30
  and 45 degrees
• Daily Sedation Vacation and daily assessment of
  readiness to extubate
• Peptic ulcer disease (PUD) prophylaxis
• Deep vein thrombosis (DVT) prophylaxis (unless
  contraindicated)

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Prevention Nursing Interventions

• Patient positioning
• HOB elevated 30-45
• Facilitates breathing
• Reduces risk of gastric reflux and subsequent
  aspiration

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Prevention

• Nursing Interventions
• Airway management
• STAMP Study (Sole, Byers, Ludy, Zhang, Banta,
  Brummel)
• Multi-site study of facilities using
  closed-system suctioning (CSS)
• 1665 nurses and respiratory therapists at 27
  sites throughout US
• Objectives to describe institutional policies
  and procedures related to CSS and airway
  management of intubated patients

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Prevention

• STAMP Study
• Policies very widely
• Policies not always research based
• 74 of sites recommend instillation of isotonic
  sodium chloride for thick secretions
• instillation of isotonic sodium chloride may
  actually be harmful
• Ridling, Martin Bratton (2001), American
  Journal of Critical Care, 12(3), 212.
• 82 of sites use single tubing and canister for
  both CSS and oral suctioning
• 48 of sites recommend minimal leak technique for
  maintaining ETT cuff pressures

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Prevention

• STAMP Study
• 50 of sites do not have specificpolicies for
  oral care of intubated patients
• 10 reported toothbrushes and toothpaste
  available
• 41 use mouthwash
• 30 use suction swabs
• 15 use chlorhexidine mouth rinse (by
  prescription)

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Prevention

• STAMP Study
• 52 reported VAP rates
• Many sites do not track VAP
• Top 5 organisms responsible for VAP
• Pseudomonas aeruginose
• Enterobacter species
• Methicillin-resistant Staphylococcus aureus
• Methicillin-sensitive Staphylococcus aureus
• Klebsiella pneumoniae

Sole, ML Byers, JF Ludy, JE Zhang, Y Banta,
C, and Brummer, K. (2003) A multisite survey of
suctioning techniques and airway management
practices (CE Article). American Journal of
Critical Care, 12(3), 220.
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Prevention Nursing Interventions

• Ventilator Equipment
• Closed circuit
• Method of humidification
• Frequency of equipment change

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Prevention Nursing Interventions

• Oral Care
• Evidenced-based practice
• Current research to determine best practices

• Best Practice Examples
• AACN Procedure Manual (2005)
• CDC Recommendations (2003)

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Comprehensive Oral Care Program

• The Good Shepherd
• Retrospective study
• VAP rate after practice change showed decrease of
  3.4 per 1000 ventilator days
• Cost savings approximately 30,000 per VAP

Schleder, B., Stott, K., Lloyd, R.C. (2002)
The effect of a comprehensive oral care protocol
on patients at risk for ventilator-associated
pneumonias. Journal of Advocate Health Care,
3(1), 1-8.
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The Vanderbilt Experience

• Protocol
• Assess Oral Cavity q shift
• Brush Teeth q shift with Suction Oral Brush and
  1.5 H2O2 solution
• Oral care q2h with Suction Oral Swabs and 1.5
  H2O2 solution
• Hypopharyngeal suctioning at least q6h and PRN
• Apply mouth moisturizer PRN

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The Vanderbilt Experience

• Education
• Bedside inservices by product manufacturer
• E-mail communication
• Posters
• Product brochures
• Communication at staff meetings

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The Vanderbilt Experience

• Trend Reduction 46 over 2 year period
• 35 in 2002 vs. 2001
• 18 in 2003 vs. 2002
• (additional 11 compared to 2001)

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Tracking Compliance
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The 100,000 Lives Campaign Scorecard

• An estimated 122,300 lives saved by participating
  hospitals
• Over 3,100 hospitals enrolled
• Over 78 of all discharges
• Over 78 of all acute-care beds
• Over 85 of participating hospitals sending IHI
  mortality data
• Participation in Campaign interventions
• Rapid Response Teams 60
• AMI Care Reliability 77
• Medication Reconciliation 73
• Surgical Site Infection Bundles 72
• Ventilator Bundles 67
• Central Venous Line Bundles 65
• All six 42

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The 5 Million Lives Campaign
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Our Definition of Medical Harm

• Unintended physical injury resulting from or
  contributed to by medical care (including the
  absence of indicated medical treatment), that
  requires additional monitoring, treatment or
  hospitalization, or that results in death.
• Such injury is considered harm whether or not it
  is considered preventable, whether or not it
  resulted from a medical error, and whether or not
  it occurred within a hospital.
• For more information, please reference detailed
  FAQs at www.ihi.org/campaign.

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The Platform

• New interventions targeted at harm
• Prevent Pressure Ulcers... by reliably using
  science-based guidelines for their prevention
• Reduce Methicillin-Resistant Staphylococcus
  aureus (MRSA) Infectionby reliably implementing
  scientifically proven infection control practices
• Prevent Harm from High-Alert Medications...
  starting with a focus on anticoagulants,
  sedatives, narcotics, and insulin
• Reduce Surgical Complications... by reliably
  implementing all of the changes in care
  recommended by the Surgical Care Improvement
  Project (SCIP)
• Deliver Reliable, Evidence-Based Care for
  Congestive Heart Failureto reduce readmissions
• Get Boards on Board.Defining and spreading the
  best-known leveraged processes for hospital
  Boards of Directors, so that they can become far
  more effective in accelerating organizational
  progress toward safe care

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Assessment of Risk
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Are We Numb to the Risk?
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Call to Action