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APIC 2019 (Riffat)

This document describes a Six Sigma project to reduce ventilator-associated pneumonia (VAP) rates at a tertiary care hospital. The current VAP rate was 61.2 cases per 1000 ventilated days, with patients staying on ventilators for an average of 8 days. The project aims to reduce the VAP rate by 50% and reduce ventilator time to 5 days by December 2017 through implementing surveillance, identifying gaps, training staff, and monitoring compliance with bundles and control measures. Methodology includes observation, identifying issues, and implementing strategies like monitoring hand hygiene and personal protective equipment use.

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riffat shaheen
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0% found this document useful (0 votes)
79 views19 pages

APIC 2019 (Riffat)

This document describes a Six Sigma project to reduce ventilator-associated pneumonia (VAP) rates at a tertiary care hospital. The current VAP rate was 61.2 cases per 1000 ventilated days, with patients staying on ventilators for an average of 8 days. The project aims to reduce the VAP rate by 50% and reduce ventilator time to 5 days by December 2017 through implementing surveillance, identifying gaps, training staff, and monitoring compliance with bundles and control measures. Methodology includes observation, identifying issues, and implementing strategies like monitoring hand hygiene and personal protective equipment use.

Uploaded by

riffat shaheen
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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You are on page 1/ 19

SIX SIGMA PROJECT ON

Hospital Acquired Ventilator Associated


Pneumonia (VAP) at Tertiary Care Hospital

Ms. Riffat Shaheen


IPC, QA, ESH, ISO Certification and SHCC Consultant with
1. National Institute of Blood Diseases (NIBD)
2. Children Hospital Karachi (CHK),
3. Khairunnisa Eye Hospital (KEH)
4. Sindh Healthcare Commission’s (SHCC)
5. Sindh Nursing Examination Board (SNEB)
Learning Objectives

1. Learners will be able to identify actual issues in their system when they

are not getting their desire result in reduction of infection

2. Learner will be able to discussed the important elements to reduce

VAP rate in their setting

3. Learner will be able to explain the importance of actual surveillance

system and VAP bundles


BACKGROUND

Ventilator associated pneumonia (VAP) is the most common hospital


acquired infection among patient in intensive care unit and is associated
with significant mortality rate and rising the cost of care by increasing a
patient’s stay (Babcock, 2004).

Problem Statement
In the month of August 2017 at Tertiary Care Hospital, HAI surveillance
system was modified to see that how many patients received hospital
acquired pneumonia from ventilator and it was identified that 61.2 cases
per 1000 ventilated days got VAP which was a leading cause to increase a
patient’s stay with ventilator that was almost 8 days.
Several standards of care have been developed in attempt to reduce the
occurrence of VAP rate and patient stay with ventilator
PURPOSE

1. To implement a HAI surveillance system in a right manner.

2. 50% reduction of hospital acquired VAP rate and patient stay with
ventilator from 8 to 5 by the end of December 2017.

3 . To observe current practices of nursing staff and doctors

4. To identify the gape for improvement

5. To see the benefit of supply chain and biomedical managers’ inclusion


in VAP committee to reduce a VAP rate.

6. To train all concern people who can participate directly or indirectly in


reduction of hospital acquired infection in a future by putting their right
efforts
METHODOLOGY

Observation was conducted in all intensive care units including


medical, surgical and pediatric, consist of 51 beds, at tertiary care
hospital.

Population Inclusion Criteria: All patients who developed a VAP


Patients

All nurses and doctor Process start Process End

Purchase Department • Who are connected to • Within 48 hours after


a ventilator for more disconnection of
than 48hours ventilator
Biomedical Engineering
Exclusion Criteria: NIL
IPC Team
METHODOLOGY : Daily Round

Start
SWIM LANE MAP End

Need MV Healthy patient


Patient (Can breath)

Connect to MV ATB Prophylaxis

Doctor Yes
Daily Peptic ulcer Deep vein
sedation diseases thrombosis
interruption prophylaxis prophylaxis
NO Extubate
Oral Care +- Use of filter Suctioning with
with normal without describe no decribe
Nurse MW time frame method

IPC Sputum C/S positive after


Team 48hours of admission in VAP
hospital
METHODOLOGY : Daily Round

More Issues were Identified


Issues Details Defect Category

Oxygen therapy Tap water was using in O2 humidifier Therapy related

One staff was handling more than 1


Lack of staff Staffing plan
ventilated patient which lead to poor care

Staff with respiratory symptoms were


Health assessment Health assessment
assigned on patient with ventilator
It was observed that external surfaces of
Ventilators Environmental
ventilators were not cleaned on regular
cleaning hygiene
basis
Shortage of the resources at the time of Supply Chain
Lack of Resources
need such as hand rub, PPE or Filters Management
METHODOLOGY :Control Measures

Control Measures

Method of Data Checking Person


Name of Measure Target Strategies
Capture Frequency Responsible

1. Number of HH 80% HH compliance Monthly TL & IPC Training, observation and


compliance monitoring sheet compliance monitoring

2. # of 80% Daily Daily TL & IPC Training, observation and


compliance of observation in compliance monitoring
PPE round
Daily TL, &IPC Training, observation and
3. Monitor VAP 70% Record of VAP compliance monitoring
Bundle Bundle sheet
Weekly TL & IPC Training, observation and
4. Use of HMF 100% (Record) # of compliance monitoring
filter & change filter on each Reassure the availability in
after 48houes patient ‘s IPR store
book
METHODOLOGY :Control Measures

Control Measures

Method of Data Checking Person


Name of Measure Target Strategies
Capture Frequency Responsible

5. SC will not dip 100% Daily round Daily TL Training, observation and
in whole N/S report compliance monitoring

6. Use of sterile 100% Physical Daily TL Observation, and


water for O2 availability of compliance monitoring and
therapy Pyrex bottle and corrective action
record of CSSD

7. Maintain 1:1 100% Daily Daily TL & Observation and compliance


staff and observation HOD monitoring and corrective
ventilated Unit’s Shift action
patient ratio Report

8. Resource 80% Check the PAR Monthly TL & Observation and compliance
Management level and Items HOD monitoring and corrective
request sheet of action
unit
METHODOLOGY :Control Measures

End
Start
(Improved) SWIM LANE MAP
Healthy patient
Patient Need MV (Can breath)

Connect to MV ATB Prophylaxis Extubate

Peptic ulcer Deep vein 10


Doctor Daily
sedation diseases thrombosis NO
interruption prophylaxis prophylaxis
Hand Hygiene & Change of gloves SC will not dip Monitor
Need
between 2 pts & 2 procedures on same in whole N/S VAP
2 for MV?
patient, 1 Bundle
Nurse Head 7 11
Oral Care Use of HMF Close 6
elevate 3 with CH filter & change5 suctioning
0.12% 4 after 48houes technique
Yes
IPC
Assess a patient for developing
Team VAP NO
(based on criteria)
8 9
RESULT : Practices

Value Stream Map of August 17


   

Use of RO water Suctioning Change of gloves Hand Hygiene


for oxygen
5 8 8
5
Total observation 20 observation 20 observation 20
observation 20
observation compliance 7 compliance 6 compliance 11
compliance 9
Per day 4 %C&A 45% %C&A 35% %C&A 30% %C&A 55%
5 days 20
20 times   20 times   20 times   20 times
9times   7times   6times   11times
Humidifier
Disinfectant Head Elevated Oral Hygiene Humidifier
After 72 hours Disinfectant Total
5 5
5
observation 20 observation 20 Observation 140
observation 20
compliance 5 compliance 7 Compliance 55
compliance 10
%C&A 25% %C&A 35%
%C&A 50% % C&A 39.2%
20 times   20 times   20 times (1.1)
5 times   11times   10times
RESULT : : Practices Improved

Value Stream Map of December 17


   
Use of RO water Suctioning Change of gloves Hand Hygiene
for oxygen
5 8 8
5
Observatio observation 20
Total observation 20 n
20 observation 20
observation compliance 17
compliance 17 Compliance 16 compliance 18
Per day 4
%C&A 85% %C&A 85% %C&A 90%
%C&A 80%
5 days 20
20 times   20 times   20 times   20 times
17times   16times   17times   18times
Humidifier
Disinfectant Head Elevated Oral Hygiene Humidifier
Disinfectant
5 5 Total
After 72 hours 5
observation 20
observation 20 Observation 140
observation 20
compliance 20
compliance 18 compliance 17
Compliance 123
%C&A 90% %C&A 100% % C&A 87.8%
%C&A 85%
20 times   20 times   20 times (3.7)
18times   20times   17times
RESULT: VAP Rate

Month Aug Sept Oct Nov Dec

Numerator 15 8 7 3 8

Denominator 245 140 174 187 334

VAP Rate 61.2 57.1 40.2 16.0 24.0

70.0
VAP Rate
61.2
60.0 57.1
50.0
40.2
40.0
VAP
30.0 24.0 Rate
20.0 16.0
10.0
0.0
Aug Sept Oct Nov Dec
RESULT: Data of Patient’s stay
with ventilator
StayStay
#
G1 G2
1 6.5 3.5
2 6.5 4.8
3 7.5 3.6
4 6.0 4.6
5 6.9 5.0
6 7.18 3.9
7 7.11 3.7
8 5.9 4.2
9 5.7 4.3
10 6.2 3.4
11 6.44.18
12 8.04.21
13 5.5 4.00
14 5.2 3.7
15 5.14 3.2
CONCLUSION

1. HAI surveillance system is a first necessary step


2. Hand hygiene practices, and changing of PPE are vital step
3. Implementation of VAP bundle has a key value
4. Using of RO water for oxygen therapy can help to reduce 1 % risk of
infection
5. Avoiding contamination during suction must be focus

6. Cleaning and disinfection of oxygen can play a major role.


7. Identified that people who can have indirect relation with less
percentage can play a major role to achieve big percentage of
compliance.

8. Preparation on monthly VAP indicator will capture the attention of


concern stakeholders for continuity of improvement
LIMITATIONS

Details Category
Initially, implementation of surveillance system
IPC team
with modification was very tough

VAP bundle’s implementation HealthCare Workers

changing of gloves from one use to another HealthCare Workers


use and hand hygiene practices IPC team
No need to discuss with IPC team and VAP Supply Chain
committee before purchasing any item Department
Bio-medical
PPM and calibration schedule of ventilator
department
REFERENCES
1. https://www.hpsc.ie/az/microbiologyantimicrobialresistance/infectioncontrolandhai/
guidelines/File,12530,en.pdf. Accessed October 25, 2018.
2. Elmansoury A, Said H. Closed suction system versus open suction.Egyptian Journal of Chest
Diseases and Tuberculosis. 2017; 66(3): 509–515.
3. Hussein B, Hassan MH.Integration of Monte Carlo simulation tool for forecasting medical
equipment risks in HIQMA system. 2016.doi:10.1109/MECBME.2016.7745397.
4. Sezdi M.Two different maintenance strategies in the hospital environment: preventive
maintenance for older technology devices and predictive maintenance for newer high-tech
devices. Journal of Healthcare Engineering. 2016:Article ID 7267983: 16
pages.doi:org/10.1155/2016/7267983.
5. Shi Z, Xie H, Wang P, et al. Oral hygiene care for critically ill patients to prevent ventilator-
associated pneumonia.Cochrane Database of Systematic Reviews. 2013;(8).Art. No.
CD008367.doi: 10.1002/14651858.CD008367.pub2.
6. Stu¨bner SS,, WarneckeAS, Hwang HJ. VRE transmission via the reusable breathing circuit of a
transport ventilator: outbreak analysis and experimental study of surface disinfection. 2013;
39:975–976. doi: 10.1007/s00134-013-2842-y.
7. Gunasekera P,GratrixA.Ventilator-associated pneumonia. BJA Education. 2016; 16 (6): 198–
202.doi: 10.1093/bjaed/mkv046.
8. SARI Working Group. Health Protection Surveillance Centre. Guidelines for the prevention of
ventilator-associated pneumonia in adults in Ireland.2011.
Thank You
For
Your Attention
Contact # 0092-3362823262
thegreatriffat@gmail.com

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