VA Pittsburgh Healthcare System experienced a drop in MRSA infection rates with its "Perfecting Patient Care" program, based on the Toyota Production System

Preventing hospital-acquired infections (HAIs) is perhaps the best thing that could happen to a hospitalized patient, but it’s also good business practice for the organization. Preventing HAIs can put more cash in the coffers, and what organization couldn’t use that?

Ventilator-associated pneumonia
The second most common HAI, following UTI (urinary tract infection) in first place, is an HAI with great cost-saving potential: ventilator-associated pneumonia (VAP). In the "Guidelines for Preventing Health-care—Associated Pneumonia, 2003," the Centers for Disease Control and Prevention (CDC) noted that fatality rates for VAP account for 60 percent of all deaths due to HAI.1 The guidelines state that VAP can prolong ICU stay by an average of 4.3 to 6.1 days and hospitalization by 4 to 9 days. A study by Rello et al said, "VAP is a common nosocomial infection that is associated with poor clinical and economic outcomes," and it went on to illuminate the numbers: "The inpatient billed charges were also significantly higher among patients with VAP, averaging >$40,000 more compared to patients without VAP." 2 Clearly, it pays to attack VAP aggressively.

Kimberly-Clark’s BAL-Cath

St. Luke’s Regional Medical Center, Boise, ID, has seen reduction in VAP rates following implementation of a standardized oral-care program. St. Luke’s started reporting to VHA’s Transformation of the ICU (TICU) strategic initiative in October 2003, reporting on VAP and bloodstream infection (BSI) for adult critical care to the consortium of hospitals. "We had always been cognizant of VAP," said Rick Bassett, R.N., BSN, CCRN, TICU, project manager, Heart Institute Critical Care Services, "but it wasn’t until we started in the TICU initiative that we became more aggressive in our attack on VAP."

Bassett said, "The first year in TICU, we had a 10 percent improvement in our VAP rate. I reset the baseline to reflect the 10 percent improvement, and we’ve achieved a 19 percent reduction over that baseline. That’s not to say we’re at zero, but one of our units was able to go 12 months without a VAP. We’ve had a very impressive reduction of mortality; we started at 4.4%, and our aggregate mortality rate is 2.8% now."

Bassett believes that oral care with Sage products is an integral part of the reduction in cases and costs. "During 2004, we avoided three cases of VAP, so we had a cost avoidance of $120,000." St. Luke’s spends about $100 in Sage oral-care products per ventilator patient. "The investment is well worth it because of the potential cost avoidance of $40,000 per VAP case."

"Sage products are easy-to-use, packaged conveniently, and designed with the clinician and patient in mind. If you don’t design something for the clinician, the reality is it just won’t be used." Bassett appreciates Sage’s educational offering, too. "Sage has a user-friendly web site with research articles, clinical presentations, posters, and lots of different tools that can be used to help drive a change in clinical practice and standardization of care. If you need something not found on the web site, the rep will take care of it for you. In July, we had our Sage rep do 12 inservices to reorient staff to all elements of the Sage oral-care products and to tell those that are performing oral care at the bedside what kind of impact they can have, just how important their role is."

Oral care reduces the incidence of VAP by eliminating risk factors leading to VAP. "It all starts in the mouth," explained Bassett. "Oral secretions can be aspirated or can migrate down the trachea and colonize in the lungs, causing pneumonia. We try to decrease the bacterial load in the mouth; keep the head of the patient’s bed raised 30o, so that secretions will go down into the esophagus instead of the trachea; and use the Hi-Low Evac tube to extract secretions to decrease the incidence of aspiration."

Taking the patient off the ventilator as soon as possible also has helped St. Luke’s to reduce their VAP rate. "The shorter the time the patient is on the ventilator, the less opportunity for VAP. The opportunity is gone when the ventilator is gone." St. Luke’s has cut patient time on the ventilator by half, from just over 4 days to 2.3 days.

"All of these measures are important," observed Bassett. You can’t achieve your best level of success by implementing just one thing, but oral care is paramount to making a successful VAP-prevention program."

Tip: identifying pathogen reduces expenditures on VAP
Tool: Kimberly-Clark’s BAL-Cath
One of the problems in dealing with VAP is that it is difficult to diagnose. Gerry Arambula, senior trade marketer for medical devices, Kimberly-Clark, Roswell, GA, told HPN that "30 percent of diagnoses of VAP are wrong." That’s because its symptoms, typical responses to infection such as fever, cough, purulent sputum, elevated white blood count, could be caused by other conditions; the patient is already under critical care after all.

Central-line infections

The document opens by encouraging institutions to "prevent catheter-related bloodstream infections by implementing the five components of care called the ‘central line bundle’. . . .The central line bundle is a group of evidence-based interventions for patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually. The central line bundle has five key components: (1) hand hygiene; (2) maximal barrier precautions; (3) chlorhexidine skin antisepsis; (4) optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters; (5) daily review of line necessity, with prompt removal of unnecessary lines."

Because a CL is introduced to a major vessel, it represents a portal for infection to reach the bloodstream. Patty Bumgarner, director critical care, Centra Health, Lynchburg, VA, said, "A CL can have up to four ports, and, every time one of those is used, there’s more chance for infection, particularly if not handled properly."

Centra Health participates in IHI’s 100,000 Lives campaign. "The idea is to reach zero infections, so benchmarks are no longer needed," said Bumgarner. Centra Health also reports to TICU but had started concentrating on reducing their number of BSIs before joining the initiatives. A check list had already been developed as a reminder of correct procedure, and nurses were already empowered to stop doctors who weren’t following proper procedure.

At Centra Health, they use a CL bundle in the surgical and medical intensive care units. Bumgarner observed that, since institution of the bundle, they "can go up to 6 or 7 months without a BSI."

The CDC’s 2002 "Guidelines for the Prevention of Intravascular Catheter-Related Infections" states: "As knowledge, technology, and health-care settings change, infection control and prevention measures also should change."7 Making changes in routine isn’t always easy, but imparting knowledge about evidence-based practice and potential benefits can be the driving force. "Everyone has to be on board," declared Bumgarner. "Nurses want to do what’s best for the patient and understand what’s best when told why. Communicate, communicate, communicate to get buy-in from everyone." Bumgarner employed videotapes, articles, tests, and staff meetings to spread the word about the CL bundle and gave out awards to staff doing the right thing. "It’s part of orientation now, too," said Bumgarner.

Catheter securement
A report, by the Pennsylvania Health Care Cost Containment Council, an independent state agency, said catheter-associated urinary tract infections and catheter-related bloodstream infections accounted for most of the 1,510 unnecessary deaths from hospital-acquired infections reported in 2004 by the states’ hospitals. The report’s findings prompted comments from a developer of infection-control measures. "How many more patients have to die before hospitals and clinicians drop their archaic, discredited reliance on tape and suture for catheter securement?" said Steve Bierman, M.D., StatLock’s inventor and chief medical officer for Venetec International. "The new study confirms what we have been saying for years: Using tape and suture to secure urinary and central-line catheters places patients at serious risk. There is no justification for the failure to recognize tape-free and suture-free securement as the best, simplest, lowest-cost solution to a high-cost problem that kills patients and wastes millions of dollars." The company’s StatLock product replaces suture and tape securement of catheters, which can greatly reduce the danger of infection from the use of suture or tape to hold urinary tract and central venous catheters in place. StatLock devices are included in safety infusion systems made by Baxter Healthcare, B. Braun, Arrow International, BD (Becton Dickinson), C.R. Bard, Cook Inc., Kendall/Tyco, and others.

Again, the potential for cost saving is astounding. The CDC7 estimated that "approximately 80,000 CVC [central venous catheter]-associated BSIs occur in ICUs each year in the United States. . . . The attributable cost per infection is estimated $34,508-$56,0008,9, and the annual cost of caring for patients with CVC-associated BSIs ranges from $296 million to $2.3 billion."10 A total of 250,000 cases of CVC-associated BSIs have been estimated to occur annually if entire hospitals are assessed rather than ICUs exclusively.7,11 In this case, attributable mortality is an estimated 12%-25% for each infection, and the marginal cost to the health-care system is $25,000 per episode.11 . . . "Therefore," concludes the guideline, "by several analyses, the cost of CVC-associated BSI is substantial, both in terms of morbidity and in terms of financial resources expended. To improve patient outcome and reduce health-care costs, strategies should be implemented to reduce the incidence of these infections."

The CL bundle is a strategy to reduce the incidence of catheter-related BSI. One of the components of the CL bundle is chlorhexidine. IHI’s "Getting Started Kit"6 states: "Chlorhexidine skin antisepsis has been proven to provide better skin antisepsis than other antiseptic agents such as povidone-iodine solutions." Crosby cited a study by Maki et al comparing povidone-iodine, alcohol, and chlorhexidine for disinfection of patients’ central venous and arterial catheter insertion sites in a surgical intensive care unit.12 The authors concluded "that use of 2% chlorhexidine, rather than 10% povidone-iodine or 70% alcohol for cutaneous disinfection before insertion of an intravascular device and for post-insertion site care, can substantially reduce the incidence of device-related infection." Crosby also referred to the CDC’s "Guidelines for the Prevention of Intravascular Catheter-Related Infections": "The CDC prefers 2% chlorhexidine, based on strong clinical evidence."7,12 Medi-Flex’s ChloraPrep is 2% chlorhexidine and 70% isopropyl alcohol and is designed for hands-off application.

ChloraPrep is applied differently than the traditional method of concentric circles. IHI’s document instructs: "Apply chlorhexidine solution using a back-and-forth friction scrub for at least 30 seconds." Crosby explained, "There’s no [medical literature] support for applying antiseptics in concentric circles. With ChloraPrep you use a back-and-forth motion. The skin isn’t smooth; it has cracks and fissures, and the cells are in layers. If you move in one direction, as in concentric circles, the cell layers lay down, like the nap on velvet. Gentle friction, by scrubbing up and down, results in greater bacterial reduction because it penetrates into the first five cell layers of the epidermis, where 80 percent of the resident and transient bacteria reside."

Tip: single use only
Tool: BD’s single-use blood collection products
In a statement issued in July at the International Congress of Clinical Chemistry in Orlando, the NPA urged phlebotomists and other healthcare workers to stop reusing blood tube holders for patient blood collections. The statement cited a study completed by the NPA, which revealed that 99 percent of sampled reusable holders were contaminated with blood, creating an unnecessary risk of exposure to HIV, hepatitis C virus, hepatitis B virus and other bloodborne pathogens for healthcare workers and patients. According to NPA Chief Executive Officer Diane Crawford, the association has always supported single-use devices. However, the results of the NPA study, the rise in antibiotic resistant pathogens and the prevalence of healthcare associated infections prompted the association to strengthen its stance against reusing blood tube holders. "We’d like to see all phlebotomists, nurses and physicians use blood collection needles and holders that are designed for single use—preferably with pre-attached holders," Crawford said. "There is simply no reason to jeopardize the safety of healthcare workers or patients when devices that can virtually prevent reuse are readily available. Holders that are pre-attached to safety-engineered blood collection needles and sets may offer the highest level of infection prevention and control." BD offers several single-use blood collection needles and blood collection sets with pre-attached holders with its BD Vacutainer products. Each holder is engraved, "DO NOT REUSE" and "SINGLE USE ONLY" to encourage single-use compliance.

Tip: make use of cost-free resources
Tools: thinking caps, elbow grease, and teamwork
When healthcare workers on the inpatient surgery unit at the VA Pittsburgh Healthcare System wanted to reduce the number of their methicillin-resistant Staphylococcus aureus (MRSA) cases, they looked toward methods rather than products. In collaboration with the Pittsburgh Regional Healthcare Initiative (PRHI) and the CDC, the VA Pittsburgh Healthcare System developed its "Perfecting Patient Care" program, based on the Toyota Production System (TPS). The program started in November 2001 and is ongoing.

REFERENCES
1.Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care—associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004;53(RR-3):1-36.

2.Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large U.S. database. Chest 2002;122:2115-2121.

3.Schleder B, Stott K, Lloyd RC. The effect of a comprehensive oral care protocol on patients at risk for ventilator-associated pneumonia. J Advocate Health Care 2002;4:27-30.

4.Yoneyama T, Yoshida M, Ohrui T, Mukaiyama H, Okamoto H, Hoshiba K, et al. Oral care reduced pneumonia in older patients in nursing homes. J Am Geriatr Soc 2002;50:430-433.

5.Fagon JY, Chastre J, Wolff M, Gervais C, Parer-Aubas S, Stephan P, et al. Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia. A randomized trial. Ann Intern Med 2000;132:621-630.

6.Institute for Healthcare Improvement. Getting Started Kit: Prevent Central Line Infections, How-to Guide. http://www.ihi.org/NR/rdonlyres/BF4CC102-C564-4436-AC3A0C57B1202872/0/
CentralLinesHowtoGuideFINAL720.pdf.

7.O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-10):1-20.

8.Rello J, Ochagavia A, Sabanes E, Roque M, Mariscal D, Reynage E, et al. Evaluation of outcome of intravenous catheter-related infections in critically ill patients. Am J Respir Crit Care Med 2000;162:1027-1030.

9.Dimick JB, Pelz RK, Consunji R, Swoboda SM, Hendrix CW, Lipsett PA. Increased resource use associated with catheter-related bloodstream infection in the surgical intensive care unit. Arch Surg 2001;136:229-234.

10.Mermel LA. Correction: catheter-related bloodstream infections. Ann Intern Med 2000;133:395.

11.Kluger DM, Maki DG. The relative risk of intravascular device related bloodstream infections in adults. [Abstract]. In: Abstracts of the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy. San Francisco, CA: American Society for Microbiology, 1999:514.