preventing icu complications - ucsf cme - chen... · preventing icu complications lee-lynn chen, md...
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Preventing ICU Complications
Lee-lynn Chen, MDAssistant Clinical Professor
UCSF Department of Anesthesia and Perioperative Care
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Overview
Catheter related bloodstream infectionVentilator associated pneumonia Pressure ulcers
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Catheter Related Blood Stream Infection
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Epidemiology of CRBSI
> 5 million central venous catheters inserted each year (15 million CVC days)CRBSI occurs with 3-5% of catheters and affects more than 250,000 patients per year in the US (5.3 per 1000 catheter days)Prolong hospitalization by 7 daysMortality: 5-35%
2500 to 20,000 deaths per yearUCSF cost $80,000/CRBSI
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CRBSI Prevention Bundle
Hand hygieneHand hygieneMaximal barrier precautions (mask, gown, gloves Maximal barrier precautions (mask, gown, gloves and full barrier drapes)and full barrier drapes)Chlorhexidine skin antisepsisChlorhexidine skin antisepsisOptimal catheter site selection, with subclavian Optimal catheter site selection, with subclavian vein as the preferred site for nonvein as the preferred site for non--tunneled tunneled catheters in adultscatheters in adultsUltrasound guidance Ultrasound guidance Daily review of line necessity with prompt Daily review of line necessity with prompt removal of unnecessary linesremoval of unnecessary lines
Institute for Healthcare Improvement
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108 ICU108 ICU’’s in Michigans in MichiganInterventions:Interventions:
Handwashing, full barrier precautions, chlorhexidine Handwashing, full barrier precautions, chlorhexidine prep, avoiding femoral lines, asking about removal on roundsprep, avoiding femoral lines, asking about removal on rounds
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CRBSI Prevention Pronovost et al, NEJM 2006
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Reduction in CRBSI Pronovost et al, NEJM 2006
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CRBSI Prevention at UCSF
CVC insertion checklistRoutine use of ultrasoundguidance
Daily antibiotic review by pharmacy teamDaily review of CVC necessity with prompt removal of unnecessary catheters (Daily Goals)
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Daily Screening for CVC Indications
Critical Care RNs are responsible for assessing. Indication for CVC:
Monitoring (i.e. hemodynamics)Therapies (i.e. medications requiring CVC or long term administration >14 days, TPN, dialysis/pheresis)Unable to obtain alternate IV access
If none of the above criteria are present, RN should contact team to discuss plan for central line removal
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CVC Rounds by ICU Leadership Teams
Patient care managers, clinical nurse specialists and educators conduct daily roundsReinforce CRBSI prevention strategies and current CVC maintenance proceduresVisually inspect CVC system with the nursesRounding template to engage nurses in dialogue about indications for CVC use and maintenance standards
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Maintaining a Closed CVC System Minimizing access to system
Manifold use based on experience from oncology populationIf central line is accessed more than 2x/day, set up a maintenance lineIf more than 2 intermittent infusions ordered, use upper manifold to avoid repeated entry into CVC system
IV bag
UpperManifold
IV tubing
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CRBSI Reduction at UCSF
In 2004: 19,536 patient days, 12,052 line daysIn 2004: 19,536 patient days, 12,052 line daysCRBSI rate = 3.7/1000 line days, 47 CRBSICRBSI rate = 3.7/1000 line days, 47 CRBSI’’s s Attributable deaths => 16Attributable deaths => 16
Program implemented in 2005 Program implemented in 2005 In 2006: 24,408 patient days, 12,769 line daysIn 2006: 24,408 patient days, 12,769 line days
CRBSI rate = 1.7/1000 line days, 22 CRBSICRBSI rate = 1.7/1000 line days, 22 CRBSI’’ssAttributable deaths => 8 Attributable deaths => 8
Estimated 8 lives savedEstimated 8 lives saved
2004: 47 CRBSI2004: 47 CRBSI’’s x $80K = $3,760,000s x $80K = $3,760,0002006: 22 CRBSI2006: 22 CRBSI’’s x $80K = s x $80K = $1,760,000$1,760,000
estimated savings = $2,000,000estimated savings = $2,000,000
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Ventilator Associated Pneumonia
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Ventilator Associated Pneumonia
A leading cause of death among hospital acquired infectionsIncreased length of time on ventilator, LOS in both the ICU and hospital.Mortality with VAP 46% versus 32%Estimated cost is > $40,000 (2004)
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Ventilator Bundle
Elevation of the Head of the Bed Daily "Sedation Vacations" and Assessment of Readiness to Extubate Peptic Ulcer Disease Prophylaxis Deep Venous Thrombosis Prophylaxis
Institute for Healthcare Improvement
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HOB Interventions Implemented
Made a “standing order” on ICU admissionIncorporated assessment of HOB and intervention into the Adult Critical Care Standards of CareUtilized data: HOB gauge vs. visual assessmentDocumentation/Flowsheet prompt addedSignage addedIntensivist, RCP & RN focus on ICU roundsMonitored compliance Reinforced practice
Helman et al Crit Care Med
2003 31(9):2285‐90
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Nurse/Therapist‐Driven Weaning Protocols
• Randomized, controlled
trial of 300 patients• Physician order versus RN
and RT driven weaning
trials• Duration of mechanical
ventilation and cost were
both lower• Less complications in
intervention group• Fewer reintubations
Ely, E. et al. NEJM 1996 335:1864-1869.
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Daily Interruption of Sedative Infusions
128 mechanically ventilated patientsIntervention: Daily interruption of sedative infusionsDuration of mechanical ventilation:4.9 days vs 7.3 days (p=0.004)ICU median LOS:6.4 days vs 9.9 days (p=0.02)
Kress, J et al. NEJM 2000 342: 1471-1477.
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Other components of the bundle
Peptic Ulcer ProphylaxisFive fold increase in mortality for patients with GI bleedAddress the subject
DVT prophylaxisHigher incidence of venous thrombosis in sedentary patients
When all four components of bundle implemented, demonstrated significant reduction in VAP rates.
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Oral decontamination
2007 meta-analysis11 trials, 3242 patients
VAP reduced by oral mouthwash onlyLess VAP, same mortality same length of ventilationChlorhexidine most extensively studied oral antisepticSafe, cheap and easy to apply
Chan, E et al. BMJ 2007 334: 889-900
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Micro-Aspiration
Aspiration still occurs despite having endotracheal tube, as secretions channel through folds in cuff.Experiments with cuff profileTaper shaped cuff Cuff material is minimizedLimited pathway for aspiration
Lorenteet al. AJRCCM Vol176 pp 1079 –1081, 2007
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Cuff Technology
Unique tapered shapeReduction in folds and channelsEven lower occlusive pressures (20% lower)Improvement in quality of seal (reducing microaspiration by 95%)Not 100% occlusive
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Subglottic space
Subglottic secretion drainage with integrated suction line
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Continuous aspiration of subglottic secretions
Continuous aspiration of subglottic secretions (CASS)5 studies, 896 patients intubated
Continuous aspirationHalved incidence VAPReduced length of ICU stayReduced antibiotic use
Dezfulian, C et al. Am J Med. 2005 118: 11-18
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Continuous Aspiration of Subglottic Secretions
Requires intubation with special tubeSeparate dorsal lumen that opens in to subglottic areaAspiration may be continuous or intermittentRequires frequent monitoringCost is approximately 25% higher than standard endotracheal tubes
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UCSF VAP Performance (80 ICU Beds)UCSF VAP Performance (80 ICU Beds)
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Pressure Ulcers
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Incidence and Cost
Incidence ranging from 0.4% to 38%2.5 million patients treated annually in US acute care facilities for pressure ulcers related complicationsOnce pressure ulcer develops, mortality is increased by 2-6 fold with 60,000 deaths Total annual cost $11 billion
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Pressure Ulcers
Definition: Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or in combination with shear or friction. Identifying patients at risk and identifying early skin changes can allow early intervention to prevent a pressure ulcer from developing
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Function of both time and pressure(hyperbolic curve)
32 mmHg sufficient to disrupt blood flow70mmHg pressure for two hours produces irreversible injury
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Staging
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Sites
Sacrum - most common site (30%)Slouching in bed or chairHigher risk in incontinent pts
Heels- 2nd most common (20%)Immobile or numb legsHigher risk with PVD & diabetes neuropathy
Trochanter Device related
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Pressure Ulcer Bundle
Conduct a pressure ulcer admission assessment for all patientsReassess risk for all patients dailyInspect skin of at-risk patients dailyManage MoistureOptimize nutrition/hydrationMinimize pressure
Institute for Healthcare Improvement
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Risk identification
Norton: 1-4 point scoring system rating patients (physical condition, mental status, activity, mobility, and incontinence) – score of 14 or less indicates risk of PU development.Braden: 1-4 point scoring system rating patients (sensory perception, moisture, activity, mobility, nutrition and friction/shear) – score of 18 or less indicates risk PU development.
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Braden
Scale
1 2 3 4Sensory
PerceptionCompletely
LimitedVery Limited Slightly
LimitedNo
ImpairmentMoisture Constantly
MoistVery Moist Occasionally
MoistRarely Moist
Activity Bedfast Chairfast Walks Occasionally
Walks Frequently
Mobility Completely immobile
Very Limited Slightly Limited
No Limitation
Nutrition Very Poor Probably Inadequate
Adequate Excellent
Friction & Shear
Problem Potential Problem
No Apparent Problem
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Braden
Scores:Scores:
< 9 indicates severe risk10-12 indicates high risk13-14 indicates moderate risk15-18 indicates mild risk
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Minimize pressure
Frequent small position changes (every 1.5 to 4 hrs)Keep reclining chair and bed below 30 degree angle to decrease pressure loadSitting: may need hourly position changesIncrease mobility/Consult PT/OT
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Minimize pressure (Support surfaces)
Order air mattress if turning protocols are ineffectiveReposition off of any know ulcersUse pillows to pad bony prominencesFloat heels with pillow lengthwise under calves
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Minimize friction and shear
Use draw sheet under patient to assist with movingDo not drag over mattress when lifting up in bedAvoid mechanical injury- use slide boards, turn sheet, trapeze, corn starch
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Manage Moisture
Cleanse skin at time of soiling and use absorbent Provide a non-irritating surfaceBarrier ointments and padsUtilize appropriate fecal/urinary collection devices
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Nutrition/hydration
Skin condition reflects overall body functionSkin breakdown may be evidence of general catabolic stateIncrease hydration & caloric needsNutritional goals: ↑ protein intake1.2-1.5 gm/kg body weight daily—unless contraindicatedConsider vitamin supplementation
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Education and Quality Initiatives
Prospective cohort studyImplemented prevention guidelinesEducate all playersMultidisciplinary approachTimely transfer to a specific pressure reducing device40% reduction in pressure ulcers
De Laat, E et al. Crit Care Medi. 2007 March; 35(3) :815-20.
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Pressure UlcersPressure Ulcers
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RN’s
MD’s Others
Patients
Prevention TeamworkPrevention Teamwork