ICU diligence reduces number of infections
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BY MARK ANDERSEN / Lincoln Journal Star
Small changes in intensive care unit routines at Lincoln hospitals have quietly saved lives and small fortunes.
The intensive care unit at Saint Elizabeth Regional Medical Center recently marked its 700th straight day without a case of ventilator-associated pneumonia, known as VAP in hospital jargon.
Ventilator associated pneumonias (VAPs) and central line infections (CLIs) have dropped at Lincoln hospital intensive care units (ICUs) and neonatal ICUs (NICUs). These are late-February numbers:
* ICU at BryanLGH East 6 North: one VAP in three years, 64 days since a central line infection.
* Cardio-vascular ICU at BryanLGH East 2 North, one VAP in 28 months, 450 days since a central line infection.
* ICU at BryanLGH West, home to Lincoln’s trauma center, 90 days VAP free and 78 days since a central line infection.
* Saint Elizabeth ICU — 700 days without a VAP and 390 days without a central line infection.
* Saint Elizabeth NICU — 142 days without a VAP and 705 days without a central line infection.
VAPs kill in about 30 percent to 40 percent of cases, said intensivist Ellen Miller. (An intensivist is a physician specially trained to care for the critically ill.)
VAPs also add six to 10 days to hospital stays — and between $40,000 and $100,000 in costs.
Miller’s physician group serves both Saint Elizabeth and BryanLGH Medical Center East. A similar group serves BryanLGH West. The methods saving lives and money at Saint Elizabeth, she said, have become the standard of care at all of Lincoln’s general hospitals.
After VAPs, the main infection risk comes from central lines, fatal in nearly 20 percent of cases. Infections in a central line can increase hospital stays by three to eight days and increase costs by $15,000 to $40,000.
Central lines are used when there’s a need to deliver lots of fluids and medications.
Not long ago, and not just in Lincoln, an occasional infection of either type was the norm, believed to be an unavoidable hazard of hospital care.
It still is in some places.
Not here, Miller said.
“Now, if we have a central line infection or pneumonia, it’s almost a sentinel event,” she said.
An investigation ensues. What went wrong? Can a recurrence be prevented?
Ventilator tubes and central lines create paths for aggressive bacteria that hang out in all hospitals to enter weakened patients, and yet they’re often necessary.
In the intensive care unit, said Barb George, nurse director of Saint Elizabeth’s 16-bed intensive care unit, 80 percent to 85 percent of patients will be on ventilators at some point in their stays, and 90 percent to 95 percent of patients will have central lines.
Diligence is the price of preventing either infection.
About 10 years ago, VAPs and central line infections emerged from the background noise of hospital care to gain prominence. These were the lead killers among preventable errors sending 100,000 patients per year to early graves.
Nurses were key players in taking that research and moving it onto the front lines of patient care.
“The nurses make it happen,” Miller said.
The solution turned out to be about as exciting as a grocery list.
Like pilots with pre-flight checklists, multidisciplinary teams meet daily at the hospitals to check standardized criteria for each patient:
* Is the head of the patient’s bed up 30 degrees?
* Are blood sugars carefully controlled?
* If on a ventilator, has the patient received oral care and suction?
* Is the patient’s stomach protected against ulcers?
* Have anticoagulants been given to suppress blood clots?
Sometimes, Miller said, there are reasons not to do something on the list. Anticoagulants could be a bad idea following a stroke, for example.
But the questions need to be asked, and asked again tomorrow.
And that doesn’t happen unless it’s institutionalized into the nurses’ routines. Nurses typically spend the most time with each patient.
An analogy might be a business executive taking a spouse along on a trip. As they leave home, the executive re-checks reports, charts and the list of key contacts. That would be the doctor assessing the interaction of complex biological systems.
The spouse checks the coffee pot so the house doesn’t burn, locks the back door and sets out cat food. That’s the nurse asking: Does this patient need a central line? If not, get it out rather than leave it just in case it’s handy later.
In addition to nurses, the patient teams include respiratory therapists, pharmacists, social workers, physical therapists, spiritual counselors and doctors.
It took the weight of research, Miller said, to convince doctors the team approach was the way to go. Doctors like to take charge, she said.
The research landed about the same time Lincoln hospitals began using hospitalists — doctors specialized in treating hospitalized patients. A hospitalists typically replace a patient’s family doctor or specialist during the stay. Patients don’t always like it, but hospitalists have more experience with hospitalized patients, and they ease the burden on family doctors.
Intensivists entered the Lincoln scene in 2004, extending the hospitalist concept to the ICU.
Dr. Bill Johnson, a pulmonologist intensivist, was a primary leader in bringing the concept to Saint Elizabeth. Nancy Exstrom, clinical nurse educator, made it a reality. The protocols mean extra work for nurses.
“It’s hard to check (blood) glucose every hour,” George said. But once nurses noted better patient outcomes, she said, they needed no further persuasion.
Similar changes are occurring in Saint Elizabeth’s neonatal intensive care unit. In terms of nursing care, infants and adults might as well be different species, but the hospital’s NICU recently went 705 days without a central line infection.
With success in central lines behind it, said nurse practitioner Lorri Niemeyer, they’re working out procedures to reduce VAPs.
“You can’t introduce a lot of changes all at once,” she said. “Do one part and get it right.”
There are fewer proven rules for NICUs than for ICUs, Niemeyer said, but there are ideas, and Saint Elizabeth participates in a multihospital effort to address the issue.
One thing that’s changed is the lack of wedding rings, watches and other hand jewelry on NICU nurses.
All bacteria can’t be removed from them, so nobody wears them.
Of the 500 babies who come through the NICU each year, about 70 weigh less than 1,500 grams, or 3.3 pounds. This group typically needs central lines because their guts haven’t developed to extract sufficient nutrients.
Among this group at Saint Elizabeth, central line infections used to hover around 30 percent.
Here, the significance of 705 days infection free becomes apparent.
Reach Mark Andersen at 473-7238 or mandersen@journalstar.com.
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