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«Welcome We appreciate the opportunity to present and learn from our colleagues, both at this session and throughout the VAPP Project. In the spirit ...»


We appreciate the opportunity to

present and learn from our colleagues,

both at this session and throughout the

VAPP Project.

In the spirit of sharing and continuous

improvement, we will tell you about our

experience to date at Jones Memorial


Infection Control

A unique,dynamic career to be a part of at this time

in history.

In our 6 year career as ICP’s, my partner and I have

learned about SARS, Smallpox, Monkeypox,

Bioterrorism, Pandemic Influenza, etc. These are the more publicized infection control concerns. We all know the more intimate challenges faced each day in the organizations we work in.

Infection Control is an integral part of, not only surveillance, but the healthcare delivery and systems directed toward quality improvement within the hospital.

Jones Memorial Hospital in Wellsville, New York http://www.jmhny.org/ We are a small hospital that faces both similar and different issues from other size hospitals across the state.

We have:

• 70 bed rural hospital, average daily census of ~25 • 6 bed ICU

• transitioned over the last 5 years from predominantly primary medical doctors (PMD) providing inpatient care to having a 24/7 hospitalist program with only one PMD still providing inpatient care to his clients.

Stumbling block:

The longterm relationship held with the primary MD’s afforded trust and ease of interaction. This was challenged when hospitalists, serving many locations, transition from one facility’s expectations to another. The hospitalist director has expressed firm commitment to our goals. The difficulty lies in communicating with individual hospitalists and receiving their buy-in to the process.

Each are provided with an educational folder and encouraged to interact with the ICP’s and staff. Building trust between the ICP’s and hospitalists is ongoing.

Current status:

Recently, our hospital added the role of physician extenders, (NP’s and PA’s ) to work with the hospitalists. This has afforded us an improved communication line and we believe the possiblity of greater success.

ICP’s use of time and resources to get issues addressed has moved into the limelight !!!!

History of Pneumonia/VAP at JMH

• We traditionally have had monthly ICC meetings and review all ICP prepared cases for consideration of HAI determination including pneumonia and VAP (using CDC Definitions of Nosocomial Infections as our tool).

• By the end of 2005, we began to gather our pneumonia data into something measurable to facilitate analysis and goal formation. The terminology of “VAP” was being heard more.

• In February 2006, we presented our rates of all HAI’s from 2005 and our 2006 Goals to the Infection Control Commitee. The occurrence of pneumonia was identified as an area needing attention.

•The following goals were set for the ICP’s:

* Review of ER/admission data for pneumonia occurrence * Develop program to inform staff of our pneumonia occurrences * Report annually to ICC on health-care acquired pneumonia statistics * * Educate all care-givers on the IHI pneumonia initiatives * Surveil for implementation of initiatives; exhaustive chart review for all

• More aggressive studies and surveillance occurred, as well as healthcare- acquired pneumonias statistics gathered.

• IHI Initiatives were being promoted

• Jones Memorial Hospital was approached to participate in the HANYS VAP Initiative. On 11/30/07, newly appointed ICU Coordinator, Scott Swift and this ICP attended the HANYS Ventilator-Associated Pneumonia Prevention Project held at ECMC. We were challenged to commit to a plan. We returned to Jones and presented the oral care and HOB steps to the Infection Control Committee and it was approved for initiation. (Of note, economics and the transition of LIP coverage from primary MD to hospitalist influenced this decision - these two steps are predominantly nurse-driven and added little to no additional expense) To: ICU staff/Respiratory Therapy staff/ Hospitalists and MD’s admitting to the ICU

–  –  –

At this time, we will be concentrating on compliance with the first 2 of these elements. Please find enclosed a copy of the protocols.

1. At JMH, we formed a task force: the ICU Coordinator, ICP’s and ICU staff.

2. A chart review was done to determine a baseline for documented measures to support the VAP initiatives; little discoverable data was found.

ICU Staff assured the ICP that HOB elevation and oral care were being done. However, when the ICP measured, documentation did not support staff observations.

This is a not an unusual finding in healthcare… and a challenge to use data to enable change.

3. We looked at existing forms for documentation (this being key to our ability to show the steps of oral care and HOB elevation were being done).

4. The current oral care products in stock were reviewed to determine if they were adequate for the study guidelines

5. Dialog was held with present ICU staff re: their current practice and the need for a culture change A target date of 2/1/08 was selected, recognizing that we were uncertain when our first patient would arrive who required a ventilator.

An educational folder was created and approved by the Infection Control Committee. It was given to the ICU Manager, with a list of all staff who needed to complete the review. The manager was to ensure all staff read the material and addressed questions/concerns to the ICP’s or himself. Any resistance issues were discussed and re-education given.

The folder included the following items:

We at JMH are participating in a HANYS VAP (Ventilator Associated Pneumonia) Project.

–  –  –

At this time, we will be concentrating on compliance with the first 2 of these elements.

Oral Care:

1. Suction toothbrush bid with Perox-A-Mint solution.

Chart as T=toothbrush, orange label

2. Suction swab every two (odd hours). Apply mouth moisturizer to oral mucosa.

Chart as G=toothette swab, green label

3. Oral swabs every two (even hours) to clean mouth and teeth.

Chart as P= pink swab

4. Replace Yankauer every 24 hours or use single use devices for mouth care.(Ready Care Oral Suction Kit from Kimberly Care seen on left below)

–  –  –

Mydoc/infecondoc/VAP/HOB↑ careprotocol JMH Oral Care Protocol for prevention of Ventilator Associated Pneumonia Introduction Most bacterial healthcare acquired pneumonias occur by aspiration of bacteria colonizing the oropharynx or upper gastrointestinal tract of the patient. Intubation and mechanical ventilation alter first-line patient defenses, thus greatly increasing the risk for healthcare acquired bacterial pneumonia. Frequent oral care can decrease the risk of acquiring ventilator acquired pneumonia (VAP).

–  –  –

Patient Teaching 4. Inform patient and family of rationale to decrease risk of complications.

Documentation 5. Insert a premade label (provided in the packet) in the oral care section on the “ventilation: area of the ICU Flow work sheet. All oral care is documented on the 24 hour flow sheet.

–  –  –

The staff have used the educational handbook, and have consistently documented the needed data.

Staff have also been in dialogue with each other and the ICP’s re: the additional indicators and are proactively working with the MD’s to accept/ enact them.

Documentation has been present 100% of the time to support HOB elevation and oral care; documentation review data is supporting our ability to report on additional indicators Lessons Learned

• As team leaders, we must facilitate a change of culture:

we must support initiatives to prevent infection.

• We needed accurate denominator data;

a new form was developed and implemented in the ICU.

# of Patients, Name, Central Line?, Urinary Catheter?, Vent?

–  –  –


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