Surgery News - February 2009 - (Page 15) FEBRUARY 2009 • SURGERY NEWS PRACTICE TRENDS Dashboard Drives Down VAP in Surgical ICU BY JANE SALODOF MACNEIL Else vier Global Medical Ne ws S A N TA F E , N . M . — Putting a screen saver “dashboard” with red alerts on computers in a surgical intensive care unit helped staff to increase compliance with measures to prevent ventilatorassociated pneumonia and to reduce the incidence of these potentially deadly infections. The rate of ventilator-associated pneumonia (VAP) fell from 15.2 cases per 1,000 ventilator days during the 18 months before the dashboard was introduced in July 2007 to 9.3 per 1,000 ventilator days during the following 12 months, Dr. Victor Zaydfudim reported at the annual meeting of the Western Surgical Association. Complete compliance with a bundle of six measures designed to prevent VAP rose from barely over 30% to around 90% during the same time frames, said Dr. Zaydfudim of the department of general surgery at Vanderbilt University, Nashville, Tenn. The bundle had been implemented in 2002, he noted, but compliance was low and VAP rates had not gone down prior to dashboard use. The bundle requires spontaneous breathing trials by respiratory therapists; administration of the Richmond Agitation Sedation Scale by physicians and registered nurses; and head of bed elevation, oral care, dental hygiene, and hypopharyngeal suction by registered nurses. “All critically ill patients received stress ulcer A sample screenshot of the dashboard shows the green, yellow, and red boxes that alert staff to each patient’s level of compliance with the VAP bundle. prophylaxis and deep venous thrombosis prophylaxis,” he added. As described by Dr. Zaydfudim, the dashboard tracks compliance in real time for every patient in the ICU. Each measure in the bundle corresponds on the dashboard to a colored box in a row assigned to each patient. Green means that the patient’s care is up to date with that item, yellow shows that compliance for that item is about to expire, and red means the patient’s care no longer meets the standard set forth in the bundle. All computers in the ICU are equipped with the screen saver, which appears for everyone to see whenever a computer is not being used. The closed, intensivist-run, 21-bed surgical ICU where the dashboard was tested is in a tertiary referral center that admits about 1,300 patients per year. Except for the average APACHE II score, which increased from 17.8 to 22, and a small rise in body mass index, Dr. Zaydfudim said patient case mix did not change significantly during the study. The rate of bloodstream infection was 4.5 per 1,000 catheter days before and 5 per 1,000 catheter days after the dashboard. VAP accounts for 60% of hospital-acquired pneumonia deaths, prolongs hospital stays by 4 days, and increases direct hospital costs by about $40,000 per patient, he said. The study defined VAP by the following criteria: mechanical ventilation lasting more than 48 hours; fever higher than 38.5 °C and/or leukocytosis greater than 12,000 cells per microliter, and/or infiltrate on chest radiograph; and positive bronchoalveolar lavage culture with greater than 104 cfu/mL. Despite the reduction in VAP, further efforts are needed to meet the goal of 4.1 cases or less per 1,000 ventilator days, based on data published by the Centers for Disease Control and Prevention (Am. J. Infect. Control 2007;35:290-301), he said. “I am not sure we are ready to accept those benchmarks as stated,” said Dr. Charles Wright Pinson, an ACS Fellow who is the H. William Scott Professor of Surgery at Vanderbilt and senior author of the study. “The presence of a complication is directly proportional to how hard you look VAP rates fell from 15.2 to 9.3 cases per 1,000 ventilator days after the dashboard was implemented. DR. ZAYDFUDIM for it. And so I would submit that people who report very low VAP rates, like zero VAP rates, are not looking for it very hard,” Dr. Pinson said, questioning whether generalized targets are realistic for specific subgroups of surgical ICU patients. The Vanderbilt surgical ICU was limited to general surgery, vascular surgery, and patients from surgical subspecialties such as thoracic, plastic, orthopedics, and otolaryngology, as well as transplant patients, he noted; it did not include cardiac and trauma patients. Asked how Vanderbilt kept staff motivated once the dashboard was no longer a novelty, he said, “We set this up as a management goal, so all personnel in this unit were responsible for the outcome.” He did not have cost data, but said that putting the dashboard on a screen saver, where it serves as a constant reminder, was helpful. Neither Dr. Zaydfudim nor Dr. Pinson disclosed any conflicts of interest. HHS Sets Goals to Reduce Health Care–Associated Infections B Y M A RY E L L E N S C H N E I D E R COURTESY DR. VICTOR ZAYDFUDIM Else vier Global Medical Ne ws officials some the most common health care–associated Federalofover theare seeking significant reductions in infections next 5 years. In a new “action plan” issued in January, officials at the Department of Health and Human Services outlined goals related to six categories of health care–associated infections: central line–associated bloodstream infections, Clostridium difficile infections, catheter-associated urinary tract infections, methicillin-resistant Staphylococcus aureus (MRSA) infections, surgical-site infections, and ventilator-associated pneumonia. The seven national prevention targets identified in the HHS action plan call for the following: Reducing the number of central line–associated bloodstream infections per 1,000 device days to below the current 25th percentile set by the National Healthcare Safety Network by location type. Achieving full compliance with the central line bundle in nonemergent insertions. Reducing by 30% the case rate per patient days and administrative/discharge data for ICD-9-CM–coded C. difficile infections. Reducing by 25% the number of symptomatic urinary tract infections per 1,000 urinary catheter days. Reducing by half the incidence rate of all health care–associated invasive MRSA infections. Reducing the median deep-incision and organ-space infection rate for each procedure/risk group to at or below the current National Healthcare Safety Network 25th percentile. Achieving 95% adherence rates for each Surgical Care Improvement Project/National Quality Forum infection process measure for surgical-site infections. “This plan will serve as our road map on how the department addresses this important public health and patient safety issue,” said Mike Leavitt, former HHS secretary. The goals outlined by HHS are “reasonable,” said Kathy Warye, CEO of the Association for Professionals in Infection Control and Epidemiology. The action plan targets the most costly infections, both in terms of dollars and harm to patients, she said. The 5-year timeline also gives hospitals time to achieve reductions. At first, many hospitals may see increases in these infections, because the more you look, the more you find, she said. The action plan may also play an important role by giving infection-control specialists more clout when they lobby their hospital administrators for resources for infection prevention, she said. “When the federal government gets into the act, it raises the stakes,” Ms. Warye added. The plan also addresses concerns that there has been a lack of coordination among the various federal agencies and departments that have some responsibility for health care–associated infections, said Dr. Patrick J. Brennan, chairman of the Healthcare Infection Control Practices Advisory Committee. Dr. Brennan, who served on the steering committee that prepared the report, said that improved coordination is especially important at a time when federal budget dollars are tight. For example, the HHS plan addresses the role of information technology as a way to improve coordination of federal departments with databases of infection information. The action plan also outlines a research agenda related to the prevention of health care–associated infections, notably research on the barriers to adherence of recommended infection-control practices, and strategies to overcome those barriers. HHS also calls for more basic, epidemiologic, and translational research into how health care–associated pathogens are acquired. Many current infection-control practices are based on empirical observation, according to HHS. The plan is available at the HHS Web site www.hhs.gov/ophs/initiatives/hai. http://www.hhs.gov/ophs/initiatives/hai
Table of Contents Feed for the Digital Edition of Surgery News - February 2009 Surgery News - February 2009 Contents The 20/20 Vision ICD-10 Looms News From the College: MedPAC Flak Oncology: Best for Breast General Surgery: Weighty Problem Surgery News - February 2009 Surgery News - February 2009 - Contents (Page 1) Surgery News - February 2009 - Contents (Page 2) Surgery News - February 2009 - Contents (Page 3) Surgery News - February 2009 - Contents (Page 4) Surgery News - February 2009 - The 20/20 Vision ICD-10 Looms (Page 5) Surgery News - February 2009 - The 20/20 Vision ICD-10 Looms (Page 6) Surgery News - February 2009 - The 20/20 Vision ICD-10 Looms (Page 7) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 8) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 9) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 10) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 11) Surgery News - February 2009 - Oncology: Best for Breast (Page 12) Surgery News - February 2009 - Oncology: Best for Breast (Page 13) Surgery News - February 2009 - Oncology: Best for Breast (Page 14) Surgery News - February 2009 - Oncology: Best for Breast (Page 15) Surgery News - February 2009 - Oncology: Best for Breast (Page 16) Surgery News - February 2009 - Oncology: Best for Breast (Page 17) Surgery News - February 2009 - Oncology: Best for Breast (Page 18) Surgery News - February 2009 - General Surgery: Weighty Problem (Page 19) Surgery News - February 2009 - General Surgery: Weighty Problem (Page 20)
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