PeaceHealth/St. Joseph Hospital
Bellingham, Washington, USA
PeaceHealth/St. Joseph Hospital is a participant in IHI’s Learning and Innovation Community on Improving Outcomes for Critically Ill and High-Risk Patients.
Margie Campbell, RN, BSN, ICU Manager
Sharon Rutherford, RN, BSN, ICU Director
Brad Diestelhorst, MD, ICU Medical Director
Gurpreet Dhillon, Quality Facilitator
Becky Stermer, RN, BSN, ICU Outcome Coordinator
Our aim was to decrease morbidity and mortality associated with nosocomial infections by doing the following by July 2007:
Ventilator-Associate Pneumonia (VAP)
In 1999, the Medical Director and Nurse Manager at St. Joseph Hospital (SJH) initiated efforts to reduce VAP in our hospital. A multidisciplinary team was formed to oversee improvement efforts. Interventions included the following:
We joined IHI’s 100,000 Lives Campaign in 2005. Working with IHI, we have used many small tests of change to continue improving the quality of care. For example, in the area of sedation, we have educated staff, included the Motor Activity Assessment Scale (MAAS) in our set of vital signs with a target sedation level of 2-3, implemented review of sedation vacation at daily multidisciplinary rounds, and shifted from a default of sedation drips to a default of bolus sedation.
In January 2007, we changed from having ICU techs enter Ventilator Bundle compliance data to an RN, who provided follow-up on non-compliant patients. Compliance improved markedly after this change. From September 2006 through July 2007, we had 305 days without a VAP! We have added mouth care back to the VAP checklist as a reminder; we do not count it as a compliance element. We are at 4+ months without a VAP.
Central Line Bloodstream Infections (CL-BSI)
Audits of our compliance with strict sterile technique revealed surprising lapses. We made several simple improvements.
- Created a Central Line Bundle Audit Tool for RNs to fill out each time a line was placed
- Copied the audit tool on bright fuchsia paper, and taped it to the top of every insertion kit in the ICU
- RNs were empowered to remind physicians by saying, “No, we can’t go any further until you put on these additional barriers.”
- Stocked the Central Line Insertion Cart and bedside Nurseserver carts with chlorhexidine and removed all Betadine from the carts and from the ICU Central Supply stock rooms
From May 2006 through April 2007, we had 334 days without a central line bloodstream infection. We had a particularly difficult fourth quarter of 2007, with one infection in each of the three months. We have renewed our emphasis on central line maintenance, as our insertion bundle compliance is consistently at 90 to 100 percent. We are currently at 3+ months without a central line infection.
Summary of Results / Lessons Learned / Next Steps
These small tests of change are not high-tech, high-dollar, or complicated interventions. They are basic health care practices that, when relentlessly implemented together in a bundle, prevent harm rather than causing it. We have learned to make best practice the default. We continue to foster a culture of zero tolerance for any hospital-acquired infection. We now drill down on a case-by-case basis when we see an infection, and look for something we may have missed or a process that needs to be corrected.
Becky Stermer, RN, BSN
ICU Outcome Coordinator
PeaceHealth/St. Joseph Hospital