Bundles Emphasized as Part of a Multidisciplinary Team to Address CLABSIs, VAP and Sepsis

Multidisciplinary teamwork is especially critical as hospitals are increasingly following evidence-based practices and care improvement campaigns.

By Karin Lillis

I cant do this by myself. Thats the lament Diane Jacobsen, MPH, CPHQ, hears most often from stressed infection preventionists.
Thats absolutely correct, says Jacobsen, a director at the Institute for Healthcare Improvement (IHI). Infection prevention is not a solo discipline, and thats still a struggle for a number of infection prevention professionals. [Infection control] needs to be a team sport visible at the bedside, on the critical care units and on the floor.

That multidisciplinary teamwork is especially critical as hospitals are increasingly following evidence-based practices and care improvement campaigns. For example, the IHI, as part of its 100,000 and 5 Million Lives campaigns, introduced a set of steps, or bundles, for ventilator-associated pneumonia and central-line associated bloodstream infections. The Surviving Sepsis campaign has introduced similar protocol for preventing and treating cases of sepsis and septic shock.
Clearly the role of the infection prevention can and should be and in many hospitals is part of the multidisciplinary rounding team, Jacobsen says.

Central Line-Associated Bloodstream Infections (CLABSIs)
Stony Brook University Medical Center, in Stonybrook, N.Y., is among the top performers nationwide in its efforts to eradicate central line-associated bloodstream infections (CLABSIs), Jacobsen says.
The medical center received an Outstanding Leadership Award for its work to eliminate CLABSIs. Sponsored by the U.S. Department of Health and Human Services and the Critical Care Societies Collaborative, the designation honors healthcare organizations that show notable and sustained efforts to prevent healthcare-associated infections (HAIs) in the critical care setting, according to the hospital.

CLABSI rates at Stony Brook University Medical Center dropped by 59 percent from 2008 to 2010leading to a decrease of 1,144 patient days and an estimated cost savings of $7.6 million, according to a release from the medical center.

Ultimately, the hospital said it stopped monitoring CLABSI bundle compliance because the rate reached 100 percent, according to a 2010 report on the IHI Mentor Hospitals Registry.

The central line bundle includes handwashing protocol, optimal insertion site (subclavian), wearing full barrier protection, preparing skin with a solution of 2 percent chlorhexidine in 70 percent isopropyl alcohol, daily review of line necessity, early removal and an antibiotic-impregnated catheter, the hospital said on the IHI site. Last year, the hospital also adopted standardized nursing practices for caring for patients with central lines.

Another New York hospital also stands out. Beth Israel Medical Center, a 1,111-bed urban teaching hospital in New York City, implemented a five-step central line bundle for patients in its seven ICUs, emergency room, respiratory stepdown unit and general medical surgical wards,  according to information the hospital provided on the IHI mentor registry.

As of 2010, the hospital has reported 98 percent compliance with the bundle, and the average number of days without a CLABSI is 241 days. The medical center also said it had sustained decrease over time from 4.5 per 1,000 days in 2005 to less than 0.5 in 2010. Housewide, that translates to a 75 percent reduction of cases of CLABSI, 35 percent decrease in central line days and $3.2 million in costs avoided, according to the facility.

Beth Israel Medical Center reports several keys to success, including implementing the bundle using the Plan-Do-Study-Act method, according to the IHI registry. Each unit also takes responsibility for the CLABSI-prevention initiative and the department of infection control oversees the process, according to the medical center. Hospital staff launch a root-cause analysis in real time for every case of a catheter-associated bloodstream infection, and patients are assessed daily to determine whether the line is still necessary. The hospital also allowed staff to train as infection prevention coaches.


Ventilator-Associated Pneumonia (VAP)
Originally, the ventilator bundle was designed to improve care of patients who were on ventilators, Jacobsen says. Over time, though, healthcare practitioners saw that cases of infection (pneumonia) dropped.


In hospitals a number of years ago, ventilator-associated pneumonia and blood stream infections were a given it was accepted that patients would get infections, Jacobsen adds.

Today, achieving zero cases of VAP has become reality for many hospitals across the U.S.

For instance, Plainview Hospital is a 240-bed urban teaching hospital in Plainview, N.Y. The facility became an IHI Mentor Hospital in August 2006. The hospital said it has standardized its approach to managing ventilator-associated pneumonia, including a multidisciplinary Nosocomial Infection Steering Committee.  (Plainview Hospital says that involving healthcare providers at all levels is crucial to standardizing practices.)


That committee ensures that there is zero tolerance for hospital-acquired infections, and oversees the hospital's VAP Task Force, according to Plainview Hospital's report The hospital credits its success to several measures, including using evidence-based practice to implement standardized VAP protocol and offering educational forums.
Education, communication and weekly prevalence studies of the infection prevention practices [were] key in the success of this initiative, the hospital states.

Partners in the project included infection control, quality management, nursing, respiratory therapy, medical staff, administration, materials management, pharmacy and safety professionals, according to the hospital's report.

Plainview Hospital clinicians might write articles in an employee publication and results are posted on the healthcare system's website. Staff alsodiscuss results at daily briefing meetings and monthly collaborative care councils, as well as infection control and critical care meetings, according to the registry report.

From 2009 through March 2010, the hospital has not reported any cases of VAP.

Sepsis

The National Institutes of Health estimates sepsis affects 750,000 people in the United States every year, and between 28 percent and 50 percent of those cases prove fatal. Other estimates place the death rate for sepsis at 20 percent for patients who have severe sepsis and 60 percent for those who experience septic shock.

Statistics indicate the rate of sepsis has been increasing, possibly attributed to an aging population and more chronic or serious illnesses.
Jacobsen points to two Utah hospitals that have drastically reduced the number of sepsis-related deaths among patients. Intermountain Medical Center in Murray and LDS Hospital in Salt Lake City  have reported rates of 10.3 percent of patients, according to a release from the healthcare organizations. At other hospitals, the rate of death among patients with sepsis and septic shock can be as high as 80 percent, according to the healthcare organizations.

Jacobsen expects minor adjustments to the sepsis bundles at the national level within the next six months. They are being reviewed and we anticipate some updates coming within the next six months or so just some tweaks, nothing dramatic, Jacobsen says, noting the updates are being reviewed and have not been published or released yet.


Intermountain Medical Center and LDS Hospital introduced a sepsis bundle that includes 11 elements that provide consistency in the early recognition and treatment of sepsis, including specialized blood testing, administration of antibiotics, fluids and other medications, tight glucose control and protecting the lungs with a standardized ventilator strategy, the release said.

Todd Allen, MD, who led the hospitals' research team, said researchers based their findings on a certain set of patients with severe sepsis or septic shock at one of the two hospitals' emergency departments. Cases examined in the study were for patients over 18 and who were not pregnant, according to the healthcare facilities.

Two Utah hospitals have drastically reduced the number of sepsis-related deaths among patients, according to a release from Intermounta¬¬in Medical Center (Murray) and LDS Hospital (Salt Lake City.) The facilities have reported rates of 10.3 percent of patients. At other hospitals, the rate of death among patients with sepsis and septic shock can be as high as 80 percent, according to the healthcare organizations.

Intermountain Medical Center and LDS Hospital introduced a sepsis bundle that includes 11 elements that provide consistency in the early recognition and treatment of sepsis, including specialized blood testing, administration of antibiotics, fluids and other medications, tight glucose control and protecting the lungs with a standardized ventilator strategy, the release said.

Allen said researchers based their findings on a certain set of patients with severe sepsis or septic shock at one of the two hospitals' emergency departments. Cases examined in the study were for patients over 18 and who were not pregnant, according to the healthcare facilities.

Whats key among all of these examples hospitals are willing to share their triumphs and challenges. Hospitals are being open and sharing what is going well and what is not working, Jacobsen says. Sharing what we can do to improve has resulted in huge changes.

Karin Lillis is a freelance writer.

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