Contra Costa Regional Medical Center
Culture of Safety: Continuous Improvement Nearly Eliminates VAP, CLABSI
Contra Costa Regional Medical Center’s quality improvement strategy involves multidisciplinary teams that help the hospital develop and sustain a culture of safety. Procedures such as regular multidisciplinary rounds that include family participation help foster this culture and improve care, especially for intensive care unit (ICU) patients with complex conditions. Over the past few years, Contra Costa improvement teams have worked to further embed safety into its culture by using evidence-based bundles and other innovative improvements to reduce cases of ventilator-associated pneumonia (VAP) and central line–associated bloodstream infections (CLABSIs) to nearly zero across 2 years.
To address VAP, Contra Costa staff instituted a three-part intervention that includes adopting an oral hygiene kit and protocol, implementing the “wake up and breathe” protocol and strategically placing red duct tape on the walls of patient rooms to remind staff to elevate the head of the patient’s bed by 30 degrees, which has been shown to reduce the risk of VAP.
For the oral hygiene kit, the night shift nurse hangs 24 hours’ worth of oral hygiene supplies on the wall in patients’ rooms. The easily accessible supplies remind staff to frequently clean and disinfect patients’ mouths. Regular oral hygiene has been shown to decrease the colonization of bacteria in the mouth, which can impact VAP.
According to Kathy Ferris, RN, BSN, manager of Contra Costa’s infection prevention and control program, the red duct tape and oral hygiene kits serve as visible reminders for staff to comply with and be accountable for safety practices. “Both the duct tape and the bundled oral hygiene kit are not only extremely low cost, but also make it easy for staff to follow the protocols,” Ferris says.
Meanwhile, the wake up and breathe protocol directs nurses to automatically turn off all sedation medications at 6 am, unless there is a contraindication. At 8 am, respiratory therapists begin a protocol-driven spontaneous breathing trial (SBT), which helps determine whether patients can breathe on their own. When the ICU physician makes rounds, patients have been off sedation and are undergoing an SBT, which expedites the decision to remove the ventilator.
The team also has incorporated elements of the Institute for Healthcare Improvement’s (IHI’s) ventilator bundle – a series of interventions for ventilator care – into nursing flow sheets and physician orders. Elements include the following:
- oral care, including a rinse with chlorhexidine antiseptic to inhibit the formation of dental plaque and gingivitis, which lead to the colonization of bacteria
- sedation vacation – a regular interruption in sedation, which has been shown to decrease the time spent on a ventilator
- peptic ulcer disease prophylaxis – preventive treatment to reduce the risk of peptic ulcers, which cause gastrointestinal bleeding
- deep vein thrombosis prophylaxis – preventive treatment to reduce the risk of venous thromboembolism, the formation of blood clots in the body
According to Ferris, nurses, physicians and respiratory therapists have worked diligently to ensure that all staff comply with the hospital’s ventilator bundles. The diligence has paid off – Contra Costa had zero cases of VAP in 23 of the 24 months from January 2010 to December 2011. “The dedication and devotion of all doctors, residents, nurses and respiratory therapists has led to better outcomes for all of our mechanically ventilated patients,” Ferris says.
Contra Costa’s leadership team now is looking to expand the wake up and breathe protocol to include the ABCDE (airway breathing coordination, delirium assessment and exercise) protocol, which is a set of evidence-based practices that address delirium, immobility, sedation/analgesia and ventilator management in the ICU. This bundle has greatly reduced overall morbidity and mortality in ICUs across the country, and is expected to further improve Contra Costa’s VAP rates.
To eliminate CLABSI, Contra Costa’s improvement teams drew on IHI’s central line bundle, developing kits that incorporate elements such as reminder and monitoring forms and appropriate clothing. The kits are used specifically by physicians and nurses inserting central lines – those inserted in a vein leading directly to the heart for monitoring venous pressure, providing access when no peripheral veins are available and administering certain drugs – and peripherally inserted central catheter (PICC) lines – primarily used for administering antibiotics, nutrients and fluids.
The strategy – which also required cooperation from all team members – helped Contra Costa maintain zero cases of CLABSI in 22 of the 24 months from January 2010 to December 2011. “Early on we interviewed the physicians and PICC nurses to see what would help them remember all the bundle elements. Everyone agreed that having all the supplies in one package would really save time,” Ferris says. “A custom kit was created that contained a full drape, surgical gown, cap, mask, compliance checklist and other supplies. The key is to make it easy to follow the protocol.”
For more information about Contra Costa’s VAP or CLABSI initiatives, please contact:
Kathy Ferris, RN, BSN
Manager Infection Prevention and Control Program
Contra Costa Regional Medical Center and Health Centers