Target zero: Hospital proves it’s possible

Target zero: Hospital proves it’s possible

ICUs drive vent pneumonia rate to 0’

The new mindset of zero infection rates generally is considered more of a goal than a practical reality, an unattainable threshold meant to shake the complacency and comfort of some longstanding benchmark range. On the contrary, some infection control professionals are taking it literally. For certain infections on certain units, target zero is being obtained.

"At the beginning, we expected a vent pneumonia every eight days based on our historical data," says Laurie Fish, RN, CIC, infection control practitioner at Community Hospital East in Indianapolis. "Now we have gone over 365 days. That’s how long we have extended that period [between infections]."

Deadly serious about preventing ventilator-associated pneumonia (VAP), Fish and colleagues have implemented a state-of-the-art program that is reaping goose eggs for infection rates. In 1998, Community Health Network developed a program to reduce the number of VAP cases; and in 1999, a task force was assembled to change bedside practice.

Currently, the network has adopted a program to reduce the number of cases of VAP in all seven of its intensive care units at all of affiliated hospitals. However, the ICUs at Community Hospital East are the first in the network to reach the zero infection rate level.

"Our coronary care unit just passed two years without any VAP," says Dan Kidwell, RRT, respiratory therapist at the hospital.

The program has been spearheaded by Fish, Kidwell, and critical care nurse Theresa Murray, RN, MSN, CCRN. The trio credits the success of the program to the commitment of a broad array of staff, including nurses, respiratory therapists, physicians, and infection control professionals.

A modest proposal — cut them in half

The effort began with the more modest goal of a 50% reduction in VAP in 1998. Fish admits she was somewhat skeptical at first about the impact of the effort but became a believer as the group effort took hold and the rates pushed down toward zero.

Administrative leadership support was a key feature, with senior officials participating to the point of playing patients in an instructional video. But the clinical interventions are where the rubber meets the road in this program, which features an aggressive vent-weaning program and views heavy sedation of patients with disdain.

"We don’t oversedate," Fish says. "We try to sedate just enough to keep them comfortable but conscious."

A ventilator order sheet sets critical clinical interventions to a default position, preventing VAP through such measures as deep venous thrombosis prophylaxis, peptic ulcer disease prophylaxis, aerosol treatments, and keeping the head of the patient’s bed 30° or higher.

The daily weaning protocol evaluation includes assessment of readiness for a spontaneous breathing trial, and a mobility protocol is enacted unless contraindicated.

"All of these evidence-based things are defaulted to occur unless the physician says they shouldn’t," Fish notes. "The weaning protocol is part of that. The secret is that it makes it somewhat mindless for the staff. The system works for the staff and supports them in being successful at the job. [It] makes it automatic. That’s where we have really gotten this last burst to get us down to such a low level."

By setting the critical VAP prevention protocols in the default position, the effort becomes a standard of care more than simply standing orders, Kidwell adds. "That feeds back to the sense of accomplishment and responsibility for the staff," he says. "We trust them enough to do the right thing, and they have the tools. They feel like they are making a difference every day with every patient. They are very passionate about it."

Visuals include a "clinical dashboard" that strives to keep all indicators in the green, meaning all systems are in place to prevent VAP. "Our concept has been embraced so well that this goes down to the level of if we aren’t at green, then somebody may not get a raise — including the president of the hospital," Kidwell says. "Because these things are serious enough, and we believe in them strongly enough, and we have the information to prevent [infections] — if we are not doing it, then somebody needs to answer why."

In addition, the system uses various checks and quality redundancies to ensure prevention efforts do not lapse. "We have different checks throughout the system to make sure that what we have identified as best practice is in place with every patient every day," Fish notes. "The pharmacy double-checks the nurse on meds; the respiratory therapist double-checks the nurse on head-of-bed [elevation]. There are all of these check steps in the system built in automatically to make sure that everything that should happen is happening."

Bottom line has zeros and dollar signs

By the same token, individual caregivers must be on the same page. For example, the respiratory therapist interested in weaning the patient from the vent must work with the nurse who is administering medications.

"We have contraindications just like we do in any practice, but we’re empowering the bedside staff to make that [weaning] decision," Kidwell says. "Everyday the expectation is that the respiratory therapist [ask], Is this patient weanable?’ [But] our expectation is that they will talk about what the plan is for today. The therapist is not going to turn down the ventilator support without talking to the nurse because the nurse might need to give some particular medication or a test. The nurse isn’t going to give that medication without talking to the therapist because then it sets the patient up to fail."

ICPs are well aware that the sooner ventilators and other medical devices can be safely removed from patients the better the odds are of preventing infection and pushing the patient toward full recovery. But the same is not necessarily true for ventilator breathing circuits, which once were changed so frequently (e.g., 24 hours) that the constant handling may have actually contributed to infection. The policy at the hospital now is that the breathing circuits are changed only as necessary or every 30 days.

"We have really gone a step forward to say that anything that is attached between the patient and the ventilator is considered a link, and no link will be interchanged," Kidwell says. "Basically, once you start with it, you stay with it. We are pushing the boundaries a little bit, and we have had tremendous success with this clinically. It doesn’t hurt to save money by not paying for those disposable [circuits] every day. We are saving several hundred thousand dollars a year."

When you include cost-savings for reduced VAPs and shortened patient lengths of stay that adds more zeros on the end of the dollar sign. Target zero has its benefits.