Children’s Participating in Campaign to End Preventable Deaths

from Caring For Our Future, Spring 2006

By Cindy McConnell, MS, RN, CPON

The Institute of Medicine shocked the nation in 1999 with a report on hospital errors. The report concluded that up to 98,000 Americans each year die in hospitals. The deaths are not from the diseases that brought them into the hospital but from injuries caused by their medical care: preventable bleeding or infection, a medication mix-up, a respirator tube put in the wrong way (Berwick, 2005). In December 2004, Dr. Donald Berwick and the Institute for Healthcare Improvement (IHI) launched the 100,000 Lives Campaign. The IHI is a not-for-profit organization focused on improving health by advancing the quality and value of healthcare.

The campaign’s main objectives are to save 100,000 lives across the country over 18 months (end date of June 14, 2006), to enroll as many as 2,000 hospitals to join the campaign, and to build a reusable national infrastructure for change. Currently there are 3,000 hospitals that have enrolled in the campaign across the country. In Colorado , 61 hospitals, including Children’s, have joined the campaign. The campaign has asked hospitals to implement some or all of the following six evidence-based interventions:

• Deployment of rapid response teams
• Delivery of reliable, evidence-based care for acute myocardial infarction
• Prevention of adverse drug events (ADEs)
• Prevention of central line infections
• Prevention of surgical site infections
• Prevention of ventilator-associated pneumonia.

The campaign is measuring the progress toward the goal of saving 100,000 lives by collecting mortality data from participating hospitals on a quarterly basis. In December 2005, Dr. Berwick announced that 14,679 deaths had been averted due to the efforts of the 3,000 hospitals involved with the 100K Lives campaign.

Though patients less than 18 years old are excluded from most of the IHI data collection, The Children’s Hospital is participating in five of the six interventions.

1. A Rapid Response Team (RRT), known by some as a Medical Emergency Team,  is a team of clinicians who bring critical care expertise to the patient bedside (or wherever it is needed). The goal of this intervention is to prevent deaths in patients who are failing outside of the intensive-care setting. A group of clinicians at Children’s is looking at how the COR Team functions and how the PICU/CICU teams participate in the assessment of the patients outside of the ICU.
2. Medication Reconciliation is a process of identifying the most accurate list of all medications a patient is taking, including name, dosage, frequency and route, and using this list to provide correct medications for patients anywhere within the healthcare system. This intervention also is a 2006 National Patient Safety Goal for JCAHO. Medication reconciliation will be completed at the time of admission, transfers and discharge. In addition, reconciliation in the ambulatory areas must be done when medications are administered or decisions about medications are made.

3. Prevention of Central Line Infection has been an initiative at Children’s since 2001. This project was spearheaded by Susan Dolan, Margaret Ferguson and Kathi Polage. A decrease in bacteremia in the PICU was noted after implementation of antibiotic impregnated central catheters, review and use of sterile barrier technique (sterile gloves, long-sleeved sterile gown, mask, cap and large sterile sheet drape) during line insertion, and staff education regarding management and care of existing intravascular access devices. Subsequently, the PICU and CICU implemented the use of a central line cart that houses the supplies necessary to perform the procedure.

   The use of sterile barrier technique during line insertion has been shown to reduce the incidence of catheter-related bloodstream infection compared with standard (sterile gloves and small drape) precautions (0.08/1000 and 0.5/1000 catheter-days, respectively; P = 0.02) (Raad, et al, 1997). These findings also are supported by the results of a prospective, observational study (Mermel , McCormick, Springman, Maki, 1991).

   Full barrier precautions are the standard of care during central venous catheter insertion. A central line task force regularly reviews hospital procedures related to the care of vascular access devices. In addition, surveillance activities for line-related bacteremia have been expanded to the home care population due to the significant number of high-risk patients who receive home-infusion therapies.

4. Postoperative surgical site infections (SSI) are a major source of morbidity in the U.S. Among the 27 million people who have surgery each year, approximately 500,000 will get a nosocomial surgical-site infection. Some patient characteristics put the individual at an increased risk for surgical-site infections. Other preoperative and intraoperative risk factors include the inappropriate use of antimicrobial prophylaxis, shaving vs. clipping, long duration of surgery, improper skin preparation, lack of asepsis and sterile surgical technique. Children’s currently is evaluating these processes in the perioperative area to define areas with opportunity for practice improvement.

5. The Adult Ventilator Associated Pneumonia (VAP) Prevention Bundle includes four components:

   • Elevate head of bed 30 degrees to 45 degrees

   • Daily sedation vacation

   • Peptic ulcer prophylaxis

   • Deep vein thrombosis prophylaxis.

Due to a lack of supporting evidence to justify a standard VAP Bundle in the pediatric population, IHI proposes that hospitals implement low-risk practice changes in relation to the care of pediatric ventilated children. The PICU Practice Council has done an extensive review of the literature related to the prevention of VAP in the pediatric population. This was a joint project with input from medical staff, nursing, respiratory and pharmacy staff. The goal is to decrease ventilator utilization (ventilator days/patient days). The proposed new guidelines include revisions to the standards of care in a number of areas, particularly oral care, sedation management and respiratory-care practices related to suctioning and equipment changes.

The champions for each of the IHI 100K Lives interventions are:

1. Rapid Response Team – Beth Wathen, MSN, RN, Rita Keuten, BSN, RN, Emily Dobyns, MD, and Desmond Henry, MD.
2. Medication Reconciliation – Cindy McConnell, MS, RN, CPON, Amy Poppy, RPh, and Chris Nyquist, MD.
3. Prevention of Central Line Infections – Susan Dolan, MS, RN, CIC, and Chris Nyquist, MD.
4. Prevention of Surgical Site Infections – Tammy Woolley, MS, RN, CNOR, and Mory Ziegler , MD.
5. Ventilator Associated Pneumonia Bundle –Beth Wathen, MSN, RN, and Emily Dobyns, MD.

References

Berwick, D. (2005, December 12). Keys to Safer Hospitals. Newsweek.

Raad, I.,  Darouiche, R., Dupuis, J., Abi-Said, D., Gabrielli, A., Hachem, R., Wall, M., Harris, R., Jones, J., Buzaid, A., Robertson, C., Shenaq, S., Curling, P., Burke, T., & Ericsson, C. (1997). Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections. Annals of Internal Medicine, 127 (4), 267-274.