The ‘How to Guide’ for
Improving
Critical Care
Main contacts for Improving Critical Care
Campaign Director leading on the content area: Alan Willson
Faculty member for this content area: Mark Smithies, Dave Hope
Content Specialist: Chris Hancock
IA/Senior IA: Mike Davidge
Other (as determined by Director)
Improving Critical Care
Contents
Improving Critical Care Getting Started List 4
Improving Critical Care 5
Drivers, Interventions and Measures 6
Goal: Reduce mortality and harm from mechanical ventilation 6
Goal: Reduce mortality and harm due to complications of using central venous catheters 9
Goal: Reduce mortality and harm due to severe sepsis 12
Goal: Reduce mortality and harm due to transmission of infection in critical care 15
Goal: Reduce mortality and harm by the creation in critical care of an environment of collaboration and a culture of safety 17
Making it Happen 18
Goal: Reduce mortality and harm from mechanical ventilation 18
Defining the Problem 18
The Ventilator Bundle 19
Goal: Reduce mortality and harm due to complications of using central venous catheters 21
The Central Line Bundle 22
Preventing Catheter-Related Bloodstream Infections – Components of Care 23
Goal: Reduce mortality and harm due to severe sepsis 25
Surviving Sepsis Campaign 25
27
Goal: Reduce mortality and harm due to transmission of infection in critical care 28
What changes can we make that will result in improvement? 29
Goal: Reduce mortality and harm by the creation in critical care of an environment of collaboration and a culture of safety 31
Leadership and Organisational Culture 31
Getting Started 32
Using the Model for Improvement 32
Forming the Team 33
Setting Aims 34
First Test of Change 34
Barriers That May Be Encountered 34
Measurement 35
Track Measures over Time 37
Tips for Gathering Data 37
Critical Success Factors 38
Programme managers 38
Local Champions 38
Patient involvement 38
Ownership of change 38
Links 39
Improving Critical Care Getting Started List
Prior to testing and implementation of improving critical care, organisations may wish to consider the following:
· Engage senior leadership support
· Appoint a multi-disciplinary implementation team to: -
o Steer and co-ordinate the interventions
o Review process and outcome data
· Appoint individual or team as ‘process owner’.
This ‘local content specialist’ will have well developed links with both critical and acute care and will co-ordinate implementation of the interventions.
· Appoint clinical champions
· Provide education and training
· Establish quantitative and qualitative feedback mechanisms
· Measure effectiveness
Improving Critical Care
The aim of the Improving Critical Care work area within the 1000 Lives Campaign is to build upon the achievements of the Welsh Critical Care Improvement Programme (WCCIP) and spread service improvement work to operational areas that also treat critically ill patients beyond the intensive care unit
During the years 2006 - 2008 the WCCIP has enabled the introduction of care bundles and change methodologies in Welsh adult critical care units. In collaboration with the Welsh Critical Care Advisory Group, Critical Care Networks and other stakeholders, the 1000 Lives Campaign will aim to further reduce the incidence of adverse events in critical care.
As part of the 1000 Lives Campaign, participating NHS Trusts will improve care of the critically Ill by improving communication, handwashing and patient involvement in the ICU and implementing the ventilator, central line and sepsis bundles in the wider hospital environs.
This booklet is adapted from the Safer Patient Initiative ‘how to kits’ and intended as a toolkit for the Trust Critical Care Team to use to introduce the various interventions within this work area. The interventions and measures are outlined and change methodology tools are introduced.
Drivers, Interventions and Measures
Goal: Reduce mortality and harm from mechanical ventilation
Intervention level: All level 3 and 3T critical care units
Reliable Processes:
Welsh ventilator care bundle elements:
· Elevation of head of the bed to between 30 and 45 degrees
· Daily “sedation vacation” and daily assessment of readiness to wean
· Peptic Ulcer (PU) Prophylaxis
· Deep Venous Thrombosis (DVT) Prophylaxis
Implement non-physician driven weaning protocol
Formal swallow evaluations for long term ventilated patients
Endotracheal tube cuff inflation via minimal pressure technique
Use protocols and auto-stop points for antibiotics
Measures
Measure / Operational Definition / Data Collection Guidance / Data Collection SourceVAP Rate
Code: CC01 / 1. Determine the numerator: The total number of ventilator acquired pneumonia cases in the month Use definition agreed between the WCCIP and the WHAI Programme.
2. Determine the denominator: the total ventilator days in the month
The VAP rate is calculated by dividing the total number of VAPs occurring in the month by the total number of ventilator days in the month and then multiplying the result by 1000 to create a VAP rate for 1000 ventilator days / Report monthly infection rate for the months of April 08 through March 09. This serves as your baseline. Continue to report monthly data over the life of the initiative into the Extranet. Provide numerators and denominators when entering the data. The annotation section should be used to reflect any interventions that were made to reduce the VAP rate.
There should be no sampling for this measure. / VAP surveillance in Wales is due to be piloted from January / February 2008, with a view to the surveillance scheme being added to the mandatory CVC infection surveillance on ICU from September 2008. Data on all ventilated patients will be collected plus information on any VAP infections identified according to HELICS definitions. The data will be presented as a VAP rate per 1000 ventilator days and will be reported back to units on a monthly basis similar to the Central line infection surveillance see below.
Percent compliance with ventilator bundle
Code: CCP2 / 1. Determine the numerator: the number of vented patients in the sample receiving all 4 components of the ventilator bundle.
2. Determine the denominator: the total number of patients reviewed
3. Calculate the percent compliance with the ventilator bundle by dividing the numerator by the denominator and multiplying the result by 100
Note: The ventilator bundle components include: HOB, PUD prophylaxis, DVT prophylaxis, daily sedation vacation. / Ventilator compliance is measured by selecting all patients in the unit(s) on a randomly selected day each week and determining ventilator bundle compliance. Use daily goal sheet or consultant order sheet as the primary data source or direct observation. Review each sheet for implementation of the vent bundle. This is a sample Yes/No outcome. If the patient did not have ALL 4 components then they are considered not in compliance with the ventilator bundle.
Sample should include all vented patients. Only patients with all 4 aspects of vent bundle in place are recorded as compliant.
Conduct sample one day each week, this is a weekly prevalence measure. Rotate days of the week and shifts. All vented patients on the day of the sample are examined for evidence of bundle compliance. Report the 4 prevalence data points (the 4 days selected) for the month as an aggregated numerator and denominator each month on the Extranet. / This figure is at present collected on the WCCIP database and reports are generated as required.
ALOS on mechanical ventilation
Code: CCP1 / 1. Determine the numerator: the total number of ICU mechanical ventilator days during the month.
2. Determine the denominator: The total number of ICU patients on a mechanical ventilator during the month.
3. Calculate the ALOS on mechanical ventilator by dividing the numerator (total number of vent days) by the denominator (total vent patients) / This measure should not be based on a sample. Instead it should include all the vent days and patients in the ICU(s) being studied. / A monthly report on this measure is generated from the Welsh Critical Care Minimum Dataset (CCMDS).
ICU ALOS (balancing measure)
Code: CCB1 / 1. Determine the numerator: ICU monthly patient days
2. Determine the denominator: total number of patients discharged from the ICU in the month.
3. Calculate the ICU ALOS. All patients discharged in a given month should have their length of stays summed up and divided by the number of patients. This is the average for the month. / Collect and report this measure monthly for patients admitted to ICU. / A monthly report on this measure is generated from the Welsh Critical Care Minimum Dataset (CCMDS).
Monthly rate of delayed transfers of care / A patient who is identified as fit for discharge when the time between requesting a Ward bed and discharge from the Critical Care unit exceeds 4 hours / Check against the definition in the CCMDS of “fit for discharge” and the time the discharge was initiated but it was considered that the “clock starts” around the time the ward level bed was requested.
Goal: Reduce mortality and harm due to complications of using central venous catheters
Intervention level: All level 1, 2, 3 and 3T units in which CVCs are used
Reliable Processes:
Elements of the Welsh Central Line Insertion Bundle
· Wash hands before and after procedure: soap and water or alcohol-based agents.
· Use barrier precautions: gown and gloves must be worn; as much as possible of the patient should be covered with sterile drapes.
· Sterilise skin with 2% chlorhexidine in alcohol and wait until the skin is dry.
· Avoid the femoral site unless it is the last resort.
Elements of the Welsh Central Line Maintenance Bundle
· Review necessity of central line every day - and remove promptly if it is not needed.
· TPN should be given via a separate line or a dedicated lumen.
· Access to line must be made using a clean technique.
· Entry site to be checked every day for signs of leakage or inflammation and line removed promptly if these signs are present.
Implement preparation and dressing protocols for management of lines
Use line trolleys and dressing change kits
Measures
Measure / OperationalDefinition / Data Collection
Guidance / Data Collection
Source
Central line catheter-Related bloodstream infection rate
Code: CC02 / 1. Determine the numerator: The total number of central line catheter-related infections for the month
2. Determine the denominator: the total number of central line days for the month
The CLC BSI rate is calculated by dividing the total numerator by the denominator and multiplying the result by 1000 to get the CLC BSI rate per 1000 catheter days / Report the numerator and denominator monthly to the Extranet. Provide annotations as appropriate to reflect any interventions you made during the month. / In Wales CVC infections on ICU are collected within a mandatory surveillance scheme (Mandatory since September 2007). Data is submitted to the WHAIP team centrally and reported back on a monthly basis in the form of central line infections per 1000 catheter days.
Days between a CLC bloodstream infections
Code: CC03 / This measure is a cumulative count of the number of days that have gone by with no CLC bloodstream infections being reported. Every time a CLC infection occurs the count is started over again. In this case, we are plotting successes between failures. The longer the run of cumulative successes (days with no CLC BSIs occurring) the better o
utcome. / Whenever events occur that are relatively rare in nature or when a ward or pilot area has sufficiently small numbers of events, the preferred way to go about analysing the data is to plot: (1) successes between failures, or (2) time between failures. Both of these techniques have being used in the SPI work.
For events, 150 days or more between CL infections is the target. If an intervention is initiated, however, and the period between events is greater than two times the baseline period average this is also significant. In this case, it may be possible to show a true improvement before going 150 days without a CLC BSI. / Days between infections can be calculated locally, but may become part of the report sent out by the WHAIP team in due course
.
Percentage compliance with CVC insertion
bundle / 1. Determine the numerator: the total number of patients who have all 4 elements of the bundle in place
2. Determine the denominator: the total number of inserted lines.
3. Calculate the percent compliance with the central line bundle by dividing the numerator by the denominator and then multiplying the resulting proportion by 100 / A report on this
measure is currently
generated by the
WCCIP database.
Percentage compliance with central line bundle
Code: CCP3 / 1. Determine the numerator: the total number of patients who have all 4 elements of the bundle in place
2. Determine the denominator: the total number of patients reviewed
3.Calculate the percent compliance with the central line bundle by dividing the numerator by the denominator and then multiplying the resulting proportion by 100 / Use daily goal sheet or consultant order sheet as the primary data source. Review each sheet for implementation of the CL bundle.
Rotate the days of the week and shifts within a day. On the randomly selected days, all patients with CLs should be examined for evidence of CL bundle compliance. There is no sampling with this measure; include all patients with CLs, you could select a random sample of 5 patients with CLs on the day you select for the study.
Only patients with all 4 aspects of CL bundle in place are recorded as being in compliance.
Report monthly to the
Extranet but report each
week’s prevalence. This
means that there should
be 4 data points for each
month unless the volume
is low (e.g. some weeks
there are no CLs in place)
in which case the results
for all CLs for the month
will need to be aggregated. / A report on this
measure is currently
generated by the
WCCIP database.
Goal: Reduce mortality and harm due to severe sepsis
Intervention level: All level 0,1,2,3 and 3T units