VAP CRBSI Collaborative

Informational CallsHosted by Canadian ICU Collaborative

November 18 and 20, 2008

November 2008 2

Purpose

• By the end of this call, participants will have:– Better understanding of topics, methods and

expectations associated with the Collaborative approach

– Questions answered

Context

November 2008 4

Why these Topics?

• The Gap: Evidence vs. Practice– International– Canadian

• Canadian ICU Collaborative• Safer Healthcare Now!• Accreditation Canada• Provincial expectations

November 2008 5

BRUCE - INSERT DATA

Rat

e pe

r 10

00 V

entil

ator

Day

sVAP Rates - National Data - September, 2008

Source: Safer Healthcare Now ! Quarterly Reports - September 2008

Individuals

UCL = 18.1

Mean = 10.6

LCL = 3.1

UCL = 8.0

Mean = 5.7

LCL = 3 .3

Nov'05

Dec'05

Jan'0

6Feb

"06Mar'

06Apr'

06May

'06Ju

n'06

Jul'06

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7Feb

'07Mar'

07Apr'

07May

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n'07

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Dec'07

Jan'0

8Feb

'08Mar'

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November 2008 6

Rat

e pe

r 10

00 L

ine

Day

sCLI Rates - National Data - September, 2008

Source: Safer Healthcare Now ! Quarterly Reports - September 2008

Individuals

UCL = 7.3

Mean = 2.9

UCL = 4.0

Mean = 2.0

LCL = 0.0

Nov'05

Dec'05

Jan'0

6Feb

"06Mar'

06Apr'

06May

'06Ju

n'06

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7Feb

'07Mar'

07Apr'

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10

What is Possible: Examples of Better Performance

Collaborative Teams

BC Children’s Hospital & Canadian Pediatric Centres

Ms. Tracie NorthwayCRBSI Team

November 2008 9

Reduction of Catheter Related Blood Stream Infections

A Canadian National PICU Collaborative Experience

October 2004 to December 2007

T. Northway, RN, MSN, BC Children’s Hospital;E. Folz, RN, BScN, Alberta Children’s Hospital; M. Golberg, RN, BScN, NP, Stollery Children’s Hospital;J. Plouffe, RN, BScN, NP, Winnipeg Children’s Hospital

November 2008 10

What is the Canadian ICU Collaborative?

• Like-minded ICU care providers & quality improvement experts

• Focused on improving patient outcomes• ICU specific content*• Accountable to each other for results• Funded through Canadian Patient Safety

Institute and unencumbered grants through private business

* Partner with hospital programs for spread of some initiatives

November 2008 11

http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/

Improvement Methodology

November 2008 12

• a collection of processes needed to effectively care for patients undergoing particular treatments with risks.

• bundle together scientifically grounded elements to improve clinical outcomes (4-5). • to be kept together…

What is a “Bundle?”

November 2008 13

Background

November 2008 14

Incidence of CRBSI

• Comparatively high rate of CRBSI in PICU (NNIS 6.6/1000 CVC line days)

• CDC reports 5.3/1000 CVC line days adult ICU• Attributable cost approximately $34,500-$56,000

US• Increased LOS (3 weeks)• Estimated mortality rate 13% - 19% (child) & 12% -

25% (adult)

oElward, A et al. (2005). Pediatrics 115(4), 868-872.o(2007) http://www.edwards.com/Products/CentralVenous/VantexInservice.htm?wbc_purpose=Basic&WBCMODE=PresentationUnpublishedoSlonim, A et. Al (2001). Pediatric Critical Care Medicine 2, 170-174.oYogaraj, J. et al. (2002). Pediatrics 110(3), 481-485.

November 2008 15

Aim and Goals/Objectives

• Aim:To reduce the incidence of catheter related

blood stream infections (CRBSI) within Canadian PICUs

• Goals/Objectives:To reduce the incidence of CRBSIs by 20% to

50% within 12 months (October 2005)

November 2008 16

CRBSI Improvement Bundles

Insertion Bundle• Hand Hygiene• Maximum Barrier Precautions

(Inserter & Patient)• Chlorhexidine for Skin Prep• Site selection

Maintenance Bundle• Hand Hygiene• Standardized Hub Antisepsis • Standardized Accessing of Line

– Line set-up– Accessing hubs– Dressing & tubing changes

• Daily Reviewing of Line Necessity

November 2008 17

Changes Tested

A P

S D

AP

SD

A P

S D

D S

P A

A P

S D

AP

SD

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D S

P A

Specif

ic Te

stCyc

les

BaselineStream

EducationStream

Establish current reality

Adoption of insertion& maintenance bundles

Adoption of CDC definition

Handwashing campaign

Moving to a culture of safety

Celebrating successes!

Developing staff clinical champions

Increased understanding ofICU Collaborative & process

Awareness of current reality

Awareness of importanceOf CVC infections

Creating controversy through transparency!

November 2008 18

A P

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Changes TestedChanges Tested

InsertionStream

MaintenanceStream

Creation of insertion bundle•Hand hygiene•Full barrier precautions•Site selection•Cleansing solution change

Standardize equipment:Creation of vascular access tray

Standardize equipment:Creation of line insertion cart

Create line insertion checklist

Culture shift: RNs halting insertionif insertion bundle violated

LetLet’’s make it easy to do the right thing & difficult to do the wrongs make it easy to do the right thing & difficult to do the wrong thing!thing!

Daily Goal Sheet to review line necessity

Standardized data collection

CVC Maintenance Bundle:•Hand hygiene•Line set-up (closed system)•Dressing & tubing changes• Standardized cleansing solution

CVC maintenance OSCE station at annual RN

competency validation days

November 2008 19

Collaborative Results

Canadian PICU Collaborative CRBSI National Rates

7.0

3.0

10.0

4.0

3.0

1.0

4.0

3.0

4.0

1.0

5.0

7.0

3.0

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7.0

0.0

2.0

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6.0

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12.0

Sep-04

Oct-04

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5Feb

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n-05

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-07

Date

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thly

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denc

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ulat

ive

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ays

Monthly IncidenceRate/1000 Line Days

November 2008 20

Lessons Learned

• Culture shifting “Finding Religion”• Adapting to improvement process is difficult

– Orientate team on improvement process…Research vs Improvement Process

• Maintaining the momentum is challenging due to time limitations, fiscal constraints & fatigue

Benefit of collaborating nationally is immeasurable!http://www.visualsunlimited.com/images/watermarked/161/1616.jpg

November 2008 21

Evidence to support practice changes:

• Berenholtz SM, Pronovost PJ, Lipset PA, et al. (2004). Eliminating catheter-related bloodstream infection in the intensive care unit. Critical Care Medicine. 32. pp 2014-2020.

• Block, M. (2008). Update: Catheter-related bloodstream infection rates in relation to clinical practice and needleless device type. Fall. pp 156-162

• Centers for Disease Control and Prevention Guidelines for the prevention of Intravascular Catheter- Related Infections MMWR 2002; 51 No. RR-10

• Chaiyakunapruk Nathorn,; Veenstra David L.; Lipsky Benjamin A.; and Saint Sanjay. (2002). Chlorhexidine compared with povidone-iodine solution for vascular catheter–site care: A meta-analysis. Ann Intern Med. 136. pp. 792-801.

• Cook D, Randolph A, Kernerman P et al. (1997). Central venous catheter replacement strategies: a systematic review of the literature. Crit Care Med 25:1417-24.

November 2008 22

Evidence to support practice changes:

• Costello, J., Morrow, D., Graham, D., Potter-Bynoe, G., Sandora, T. & Laussen, P. (2008). Systemic intervention to reduce central line–associated bloodstream infection rates in a pediatric cardiac intensive care unit. Pediatrics, 121(5), 915-923

• Eggimann, Philippe, Harbarth, Stephan, Constantin, Marie-Noëlle, Touveneau, Sylvie, Chevrolet Jean-Claude, Pittet Didier, Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care THE LANCET, Vol 355, May 27, 2000

• Maki DG, Ringer M, Alvarado CJ. Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet. 1991;338(8763):339-343

• McCarthy MC, Shives JK, Robison RJ, Broadie TA. Prospective evaluation of single and triple lumen catheters in total parenteral nutrition. J Parenter Enteral Nutr. 1987 May-Jun;11(3):259-262.

November 2008 23

Evidence to support practice changes:

• Mermel LA, McCormick RD, Springman SR, Maki DG. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping. Am J Med. 1991;91(3B):197S-205S.

• Michie, S., et al. (2005). Making psychological theory useful for implementing evidence based practice: a consensus approach. Quality & Safety in Health Care, 14, 26-33.

• Raad, II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol. 1994;15(4 Pt 1):231-238.

• Snydman DR, Murray SA, Kornfeld SJ, Majka JA, Ellis CA. Total parental nutrition-related infections: prospective epidemiologic study using semi-quantitative methods. Am J Med 1982;73:695-9

Sir MB Davis Jewish General Hospital

Dr. Denny LaportaCRBSI and VAP Team

November 2008 25

COMPLIANCE TO ELEMENTS OF THE BUNDLE

0,0

10,0

20,0

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70,0

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90,0

100,0

2001

2004

à 200

5-12 3 4 5 7 8 9 10 11 12 13

2005

à200

6-1 2 3 4 5 6 7 8 9 10 11 12 1320

06à2

007-1 2 3 4 5 7 8 9 10 11 12

COM

PLIA

NCE

(%)

HOB Feeding Tubes SBT EVAC

SUMMER

EVAC 48H + ICU

EVAC ALL OR + ICU

FULL IMPLEMENTATION

SHNCOLLABORATIVE

November 2008 26

95% Goal

Line

INTERVENTION - VAP MEASURE:VAP Bundle Compliance

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

nov-0

5dé

c-05

janv-0

6fév

r-06

mars-06

avr-0

6mai-

06jui

n-06

juil-06

août-

06se

pt-06

oct-0

6no

v-06

déc-0

6jan

v-07

févr-0

7mars

-07av

r-07

mai-07

juin-0

7jui

l-07

août-

07se

pt-07

oct-0

7no

v-07

déc-0

7jan

v-08

févr-0

8mars

-08av

r-08

mai-08

juin-0

8jui

l-08

août-

08se

pt-08

oct-0

8no

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déc-0

8jan

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mai-09

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9ao

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sept-

09oc

t-09

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9dé

c-09

Month

Perc

ent C

ompl

ianc

e

Local Team Nationa l Go al

November 2008 27

Evolution of VAP- all categories

11,5

7,3

15,4

10,2

5,8

0

2

4

6

8

10

12

14

16

18

2003-04 2006-07 20007-08

VA

P pe

r 100

0 vn

etila

tion-

days

cardiac surgery med-surg

↓43%

November 2008 28

11,5

14,4

12,7

7,3

15,4

5,9

0

2

4

6

8

10

12

14

16

18

2003-2004 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009-7

VAP

/ 100

0 Ve

nt d

ays

VAP CARDIAC SURGERY

ORAL DECONTAMINATION

About the VAP CRBSI Collaborative

Bruce Harries

November 2008 30

Benefits of Participating

• Faster learning and quicker gains

November 2008 31

Benefits of Participating (continued)

• Face-to-face Learning Sessions• Evidence-based changes, ready to test and implement• Coaching from experienced Faculty on application of changes• Education and training on tools for improvement and

measurement• Advice on targeted strategies to overcome resistance and

address barriers• Monthly feedback on progress from the Collaborative Faculty• Monthly conference calls specific to challenges your team is

facing• A website for storing and sharing your documents with others• A comprehensive Improvement Guide with examples,

checklists, tools• No cost to join!

November 2008 32

Expectations for Participating Teams

• Commitment of a team sponsor• Full participation of a multidisciplinary team• Development of measures• Regular reporting of progress to the Faculty• Willingness and commitment to implement

rapid and widespread changes• Desire to innovate• Regular access to email and Internet

November 2008 3333

Timelines

Learning Session

One

Learning Session

One

Learning Session

Two

Learning Session

Two

Learning Session

Three

Learning Session

Three

Support

Planning & Pre-work

Action Period One Action Period Two

Distribute Findings

A

S

P

D

A

S

P

D

Action Period Three

A

S

P

D

Enrolment Deadline

November 28

Pre-Work Calls

December

January 15-16

April 27-28

Oct TBD

Dec

Questions

How to Enroll

Ardis Eliason

November 2008 36

Expression of Interestwww.saferhealthcarenow.ca

November 2008 37

Enrollment Package & Questionnaire

VAP-CRBSI Collaborative Enrolment Questionnaire

Please complete and e-mail this information to Ardis Eliason, Project Coordinator at aeliason@telus.net 1. Key Contact

Organization

Contact Name

Title

Address

Phone

Fax

E-mail

2. Commitment: We wish to formally enroll in the Canadian ICU Collaborative. We have included a

Letter of Commitment from our senior leader. We agree to all the Expectations outlined in the Enrolment Package.

3. Briefly describe your organization, hospital or clinic (including type, size, patient population and

structure).

November 2008 38

Planning Team

• Dr. Claudio Martin, Collaborative Chairdrcm@rogers.com

• Cynthia Majewski cynthia.majewski@qhn.ca

• Clara Ballantineclara.ballantine@qhn.ca

• Bruce Harriesbharries@telus.net

• Leanne Couveslcouves@telus.net

• Ardis Eliasonaeliason@telus.net

November 2008 39

Faculty

• Ms. Paule Bernier, P.Dt., MSc, Sir MB Davis Jewish General Hospital, Montreal

• Dr. Paul Boiteau, Department Head, Critical Care Medicine, Calgary Health Region; Professor of Medicine, University of Calgary

• Dr. David Creery, Head, Paediatric Intensive Care, Children's Hospital of Eastern Ontario, Ottawa

• Ms. Rosmin Esmail, BSc, MSc• Mr. Gordon Krahn, BSc, RRT, Quality and Research Coordinator, BC

Children’s Hospital• Dr Denny Laporta, Chief, Department of Adult Critical Care; Director,

Respiratory Therapy, Sir MB Davis Jewish General Hospital, Montreal• Ms. Debbie Lynch, RN, ICP, Eastern Health, St. John’s• Dr. John Muscedere, Assistant Professor of Medicine, Queens University;

Intensivist, Kingston General Hospital• Ms. Tracie Northway, RN, MSN, Quality & Safety Leader, Critical Care

Program, BC Children's Hospital, Vancouver• Ms. Kim Rafuse, RN, BN, DOHN, ICP Annapolis Valley Annapolis Valley

District Health Authority • Dr. Peter Skippen, Division Head & Medical Director, Pediatric ICU, BC

Children’s Hospital, Vancouver