Title: SICSAG VAP Prevention Bundle – does it work ?
1SICSAG VAP Prevention Bundle does it work ?
Malcolm Daniel, Andrew Longmate, Kevin Rooney
2Aims
- To review data from Scottish Centres
- To look at interpretation of run charts
- To look at ways of improving care
3- SICSAG VAP Prevention Bundle Jan 2008
- http//www.sicsag.scot.nhs.uk/SubGroup/HAI.htmlpu
b - Beard D, Booth M, Cook B, Cole S, Crofts S,
Curran S, Kellagher A, Longmate A, Swann D - Sedation to be reviewed and, if appropriate,
stopped each day - All patients will be assessed for weaning and
extubation each day - Avoid supine position, aiming to have the
patient at least 30 head up - Use Chlorhexidine as part of daily mouth care
- Use subglottic secretion drainage in patients
likely to be ventilated for more than 48 hours
4What is the variation in one system over time?
Walter A. Shewhart - early 1920s, Bell
Laboratories
Dynamic View
Static View
Static View
LCL
- Every process displays variation
- Controlled variation
- stable, consistent pattern of variation
- chance, constant causes
- Special cause variation
- assignable pattern changes over time
Static View
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6NHS Dumfries and Galloway Royal Infirmary VAP
Rate
Shift downward and sustained
7NHS Tayside Ninewells ICU VAP Rate
Shift downward and sustained
8Remember
- These are outcomes
- Are processes important ?
- Remember processes drive outcomes
- Structure Process Outcome
- (Avedis Donabedian 1966)
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13Repeated Use of the Cycle
Changes That Result in Improvement
DATA
Implementation of Change
Wide-Scale Tests of Change
Follow-up Tests
Hunches Theories Ideas
Very Small Scale Test
14Improvement vs. ResearchContrast of
Complementary Methods
- Improvement
- Aim
- Improve practice of health care
- Methods
- Test observable
- Stable bias
- Just enough data
- Adaptation of the changes
- Many sequential tests
- Assess by statistical significance
- Clinical Research
- Aim
- Create New clinical knowledge
- Methods
- Test blinded
- Eliminate bias
- Just in case data
- Fixed hypotheses
- One fixed test
- Assess by statistical significance
15National Results
16Conclusions
- SICSAG developed a VAP Prevention Bundle
- Key step is working on improvement in process
reliability - Improvement in process reliability is driving a
reduction in VAP rate
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20Sustainability Key Concepts
- Leadership Support
- Systems approach
- Interdisciplinary Teams
- Standardise and Simplify work
- Embed Measurement in Daily Work
- Real Time Process Measurement
- Real Time Outcome Measurement
- Transparency and Avoidance of Blame
21Blue to Yellow published
- Reduction of Ventilator Associated Pneumonia
Active versus Passive Guideline Implementation. - C Hawe, KS Ellis, CJS Cairns, A Longmate.
Intensive Care Medicine 2009 35 1180-1186
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23Unit 1
Unit 2
Unit 3
R Lloyd, Institute for Healthcare Improvement
24 Limitations and Strengths
- Non-controlled
- Non blinded
- Confounding variables
- Other changes
- VAP definition
- Hawthorne
- Continuous measurement
- Validated definitions
- Clear link between process and outcome
- Consistent with other studies
25Some u chart rules
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27Drawing new limits
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29Architecture of Quality Improvement Programmes
30Secondary DriverVAP prevention screening for
weaning
Cycle 1Econsolidation
Cycle 1D recording on WW at midnight
Cycle 1C daily prompt sheet charge
nurse-(police)
Cycle 1B 1-3-5 nurses. Recorded on 24hr chart
Cycle 1A Stickie developed (using existing
agreed work) trialled with one nurse several
times
Testing Trigger Screening for Weaning