Aiming high from cover an Outstanding Leadership Award from the U.S. Department of Health and Human Services (HHS) and the designation of “Mentor Hospital” from IHI. Eliminating these infections has required changes in complex clinical practices as well as a strong focus on unit culture and teamwork. “Bundled” interventions to eliminate VAP and CLABSI
Research shows that both VAP and CLABSI lead to higher mortality rates. When patients do survive, they endure pain and suffering, time in the intensive care unit (ICU), and expense. For example, Mercy data show that eliminating CLABSI resulted in a total of 96 fewer days in the ICU for our patients treated between 2007 and 2010. Preventing VAP has saved approximately $18,000 per patient. For all of these reasons, the federal Affordable Care Act has set challenging goals for eliminating hospital-acquired infections. Solid evidence now supports the use of bundles—inter-
ventions implemented as a group—to eliminate VAP and CLABSI. The VAP bundle has several key elements: • Head-of-bed elevation to reduce aspiration pneumonia; • Daily sedation vacations and readiness-to-wean assessments, which ensure patients are weaned off ventilators as soon as possible; • Peptic ulcer disease prophylaxis to suppress acid that may contribute to aspiration of gastric secretions; and • Deep vein thrombosis prophylaxis to prevent thrombotic complications that would extend a patient’s stay in the ICU. Two CLABSI prevention bundles, including best practices for insertion and maintenance of the central line, were implemented. The insertion bundle includes hand hygiene practices, maximal 2 percent chorhexedine gluconate solution for insertion and site care, and optimal catheter site selection. The line maintenance bundle includes re-siting of the central line if the patient arrives with a line in the femoral
artery or if insertion was initially completed without sterility; daily, documented review of line necessity; daily bathing of patients with a CHG-impregnated cloth; and standardized site care, line maintenance, and hub-scrubbing practices. Culture and teamwork interventions
At Mercy, the key to success has been not just the infection-reducing clinical practices but also the culture and teamwork practices that help engage all clinicians in doing the work. One of Mercy’s first steps was to develop partnerships with the multidisciplinary team to help them drive and support the work. This involved making a clear, compelling, evidence-based case that this initiative would improve the quality of care for patients. Several interventions were particularly helpful in spurring partnerships with physicians. • Consultative and direct roles on clinical action teams (CAT teams). These unit-based teams of direct-care staff drove much of the work to accom-
plish our goals. Intensivists and pulmonologists directly participated on CAT teams in a consultative role. Teams’ activities were reported to the Critical Care Quality Improvement Committee, which includes a trauma surgeon, hospitalist, emergency medicine physician, and intensivists who reviewed and provided input on the approaches that the teams recommended. The CAT teams reviewed the scientific literature, implemented evidencebased improvements, and then “hard-wired” the best practices they recommended into work flows. These teams acted as a feedback mechanism where group members could bring up what wasn’t working and strategies could be developed to address areas of weakness. • Leadership support. When physicians have received a clear, evidence-based case for why new interventions will improve care quality but their actions still are not in line with the new interventions, leadership help is needed to remove these barriers. At
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When changes in the local health care landscape promised a major influx of new UCare members coming through metroarea clinics and hospitals, we made sure those providers were prepared. In a span of just two weeks, Rebecca was among the UCare staff that personally visited 449 unique health care locations to offer a heads-up and explain the impacts. Because being responsive to our partners’ needs isn’t just talk—it’s what we mean by health care that starts with you.
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MINNESOTA PHYSICIAN FEBRUARY 2012
©2012, UCare.