Nursing Staff Drives Dramatic Reduction in Ventilator Associated Pneumonia
One of the biggest challenges faced by critical care units is prevention of ventilator associated pneumonia (VAP). VAP prolongs the time that patients spend on the ventilator, the length of ICU stay, and the length of hospital stay after discharge from the ICU. It is the leading cause of death among hospital-acquired infections. In addition, VAP adds an estimated cost of $40,000 to a typical hospital admission.
Since 2005, Crozer-Keystone Health System has been participating in the VHA Transformation of the Intensive Care Unit (TICU) initiative. To prevent ventilator-associated pneumonia, the VHA developed a series of evidence-based interventions known as the ventilator bundle. The bundle’s key components are elevation of the head of the bed, appropriate sedation, daily weaning assessments, peptic ulcer prophylaxis, deep venous thrombosis prophylaxis, glycemic control and oral care measures. When implemented together, these interventions have been found to produce significantly better outcomes than when implemented individually.
In 2006, Crozer-Keystone set a goal of reducing the incidence of VAP by 10 percent system-wide. At that time, the average number of VAP cases among VHA East Coast PA member hospitals was 4 to 5 per 1,000 ventilator days, and Crozer-Keystone hospitals generally fell within this range.
Since 2006, multidisciplinary teams at each CKHS hospital have worked vigorously to implement and maintain the ventilator bundle. The teams include critical care unit nursing staffs, respiratory therapists, pulmonologists and pharmacists. An important new oral care measure was added to the ventilator bundle, and nurses across the system agree that this has contributed significantly to a dramatic improvement in preventing VAP.
As of May 2008, Springfield had no cases of VAP for 18 consecutive months. “The nursing staff has been the key driver of our success in preventing VAP,” says Lisa Schmidt, RN, nurse manager of the Acute Care Center at Springfield Hospital, which won the VHA Leadership Award for Clinical Excellence for exceeding national performance standards for clinical care in the prevention of VAP. “The commitment and diligence of the nurses in ensuring that all interventions in the VAP bundle are implemented every day on every ventilated patient has been exceptional.”
At Taylor Hospital, the Intensive Care Unit has had no VAP cases for 6 months, and the Telemetry Unit has been 100 percent VAP free for 12 months. “This achievement is particularly noteworthy when you consider that we have patients who stay on Telemetry for as long as 70 or even 100 days, pending placement, without developing VAP,” notes Kelly Dignazio, RN, co-nurse manager of Telemetry.
“We attribute our success to the care that the nursing staff provides,” says Theresa Sardella, RN, co-nurse manager of Telemetry. “The nurses make sure that the VAP bundle is maintained seamlessly when patients are transferred here from ICU, and they collaborate very effectively with the respiratory therapists.”
At Crozer-Chester Medical Center, all critical care units far exceeded the system’s 10 percent VAP reduction goal. As of the fourth quarter of 2007, the hospital-wide average was down to 1.3 cases per 1,000 ventilator days. Crozer’s Medical Intensive Care Unit has been 100 percent VAP-free for 12 months. “The oral care measures that are part of the VAP bundle have played a major role in our success,” says Jessica Wheaton, RN, a Crozer MICU staff nurse. “Our nurses are very diligent about providing oral care every two hours and using chlorhexidine mouthwash three times daily. This consistency has made a big difference.”
Over the last two years, Delaware County Memorial Hospital has decreased the number of VAP cases by 25 percent, and they continue to work toward a 10 percent decease over last year’s performance with intensive educational efforts. Currently, DCMH is running a comprehensive educational program on preventing hospital infections, focused primarily on VAP, for the entire critical care nursing staff as well as respiratory therapists. In addition to education, teamwork is key to their success. “Preventing VAP is a collaborative effort between the nursing staff, respiratory therapists, physicians and pharmacists” notes Patricia LaPorta, RN, BSN, MS, CCRN, BC, critical care clinical nurse educator at DCMH. In April 2008, 37 members of the nursing staff also attended a VHA satellite conference dedicated to VAP. As a result, DCMH is already experiencing marked improvement with zero cases of VAP for March and April 2008.
“There’s no question that our nursing staff is at the forefront of our success in preventing VAP,” says Nancy Bucher, RN, MSN, CNAA-BC, Vice President and Chief Nursing Officer, CKHS. “We are very proud of their commitment and dedication to meeting this challenge.”
Oral care measures are completed every two to four hours on all ventilated patients. Throughout CKHS, all critical care units have obtained 12-hour oral care kits that include toothbrushes, mouthwash, ointment for dry lips and membranes, suctioning and deep epiglotic suctioning equipment so the nursing staff has everything needed for patient care at their fingertips. “Education brought the importance of oral care to the forefront,” notes Sardella. “The nursing staff hadn’t thought about bacteria in the mouth going down the patient’s airway and causing VAP. Now we realize why it’s really important to suction regularly.”
Tight glycemic control measures in ICUs across the system have led to dramatic improvement in ventilated patient outcomes. (See March issue, “Best Practices: New Protocol Improves Glycemic Control.”)
The Springfield Acute Care Center nursing staff places a VAP checklist on the chart of every ventilated patient. Every morning, the nursing staff reviews the charts to ensure that each component of the VAP bundle has been completed. The nurses advise physicians of anything that requires their follow up.
At each CKHS hospital, multidisciplinary teams that include nursing staff, respiratory therapists, physicians and pharmacists and an evidence-based medicine (EBM) program coordinator work collaboratively to prevent VAP.
Education about preventing VAP is ongoing and timely. “Every time there’s been a new initiative, we’ve jumped on it right away, gotten the necessary education and gotten it up and running very quickly,” says Schmidt. Members of the critical care nursing staffs have attended the VHA national conference and satellite conferences as well as VAP education programs conducted by Crozer-Keystone.
Isolation carts are kept outside every critical care patient’s room throughout the system to reduce the risk of contamination.
Every patient room has hand sanitizer, and bleach wipettes are provided for cleaning common equipment.
Compliance monitoring for hand washing and other barriers to infection is conducted routinely at Crozer.
Spotlight On...Springfield Hospital
Congratulations to the 2008 Nursing Excellence Award Winners!
Excellence in Professional Nursing Practice
Mimi Arpa, RN, a staff nurse in Springfield’s Acute Care Center, is known as a great patient advocate and information resource for her colleagues. As the ACC’s representative on the Nurse Practice Council, she is diligent about sharing information from Council meetings with her coworkers. Arpa also serves as Magnet Ambassador for the unit, and was one of Crozer-Keystone’s representatives at the national Magnet conference held in Atlanta in 2007.
“Mimi works very well with all kinds of patients, no matter what their age or situation,” says Lisa Schmidt, Springfield ACC nurse manager. “She also spends a lot of energy with the patient’s families, taking time to educate them and help them get any assistance they need.”
Diane Neary, RN, BSN, played a very active role in the hospital’s recent Emergency Department expansion project, serving on the ED Expansion Task Force and helping to coordinate the employee fundraising campaign to support the expansion. A 21-year veteran of Springfield Hospital, Neary went above and beyond her job as staff nurse to help with the physical move of equipment and supplies to the new facilities, often doing it on her own time.
A team player who is well-liked by her co-workers, Neary is a member of the ED Unit Council. When she finds something in the unit that needs improvement, she takes the initiative to bring it to the Unit Council and figure out a way to solve it. A certified school nurse who serves in Springfield Township schools, she is an excellent clinician who is particularly gifted with comforting and reassuring children in the ED.
“Diane shows exceptional ownership of her job and puts a lot of thought and effort into everything she does,” says Amy Meehan, RN, Springfield ED nurse manager.
Mary Weldon, RN, is known throughout Springfield Hospital as a person who will go out of her way to help anyone with anything. A 30-year veteran of Springfield, she has been a certified diabetic educator in the Center for Diabetes for the past 18 years.
“There’s nothing Mary wouldn’t do for the Center for Diabetes,” says Mary Jane McDevitt, RN, nurse manager of the Center. “She gives of her own time, often coming in on weekends to put patients on continuous glucose monitoring if it’s more convenient for them. She goes out of her way to empathize with her patients and help them with whatever needs they have. She is very, very knowledgeable and shares that knowledge with her co-workers as well as patients.”
Weldon teaches classes on diabetes at the Center and often goes to community health fairs where she teaches about the disease and its complications. Many nurses who are pursuing a master’s degree and residents rotating through the Center attend her classes, and she is happy to spend time mentoring her diabetes skills with them. Currently pursuing a bachelor’s degree in nursing, Weldon is widely respected as a very talented and giving co-worker and clinician.
Outstanding Patient Support Staff Employee
Danielle Keller, patient care secretary in Springfield’s Acute Care Center, is a multi-talented multi-tasker who is always smiling, pleasant and calm no matter how hectic it gets in the unit. She is always willing to help the nursing staff, whether it’s answering a call light, taking water to a patient or making a phone call. She’s also very helpful to physicians on the floor, finding charts or calling for lab results. No matter how busy she is, she always takes the time to listen to people and does her best to help them with their needs. She’s especially empathetic and reassuring to the patients’ families when they call with concerns about the patient.
“Danielle is one of the calmest people working here, which is great because she’s one of the first people visitors see when they walk on the floor,” says Schmidt. “She’s very well organized and helps keep all of us organized!”
Amy Meehan, RN
Nurse Manager, Emergency Department
Joyce Sisson, RN
OR Scheduler, Surgical Services
Spotlight On...Crozer-Chester Medical Center
Congratulations to the Nightingale Award Nominees!
Nightingale Awards of Pennsylvania is a volunteer, non-profit organization dedicated to the support and recognition of the positive impact of nursing in health care lives within the Commonwealth. Nurses who are nominated for this award must exhibit excellence in nursing professional practice, achieve quality patient care outcomes, demonstrate intentional caring relationships and contribute to the profession or local community.
Marianne Kupchick, RN, MSN, CCRN, exhibits excellence in nursing every day in Crozer’s Cardiovascular Unit, keeping the needs of the patient and their families at the forefront. Recently the recipient of the Excellence in Professional Nursing Practice Award, Kupchick strives to keep current on the latest clinical procedures and techniques and shares that knowledge with others.
The staff often calls Kupchick the resident “PR person” because she always knows the right things to say to the patient and family. She shares information with them and is an advocate for the family, making sure that doctors are available to them.
As an adjunct faculty member at a local college, a preceptor for new employees and chairperson of the Nursing Education Council, Kupchick is committed to continuous clinical education and finds it very rewarding to educate others through the expertise she has developed over the years. A 27-year Crozer veteran, she has achieved a reputation for the highest quality patient care, serves as a professional role model for others and is recognized for her willingness to lend a hand as well as advice.
Kupchick contributes to the nursing profession and the local community through dedicated participation in veterans’ organizations and at church where she is known as the “nurse on site” and is recognized as the lead person for any medical needs or issues that arise.
Kathryn Miller, RN, BSN, is a 30-year nursing veteran with a gift for anticipating and addressing the thoughts and fears of patients and their families on Crozer’s Telemetry Unit. She can often be seen at the patient’s bedside, patiently explaining what’s going on around them, helping them understand their plan of care and how to achieve the best outcomes.
Miller is also dedicated to sharing her years of nursing experience with new nurses, interns and peers and is proud to be a lifelong learner, consistently keeping current on the latest clinical practices. She recently completed a two-year term as chairman of the Educational Council where she was instrumental in rolling out a new safety measures program. She is currently serving as a Magnet Ambassador for the hospital as it works to achieve its Magnet designation, and recently attended a Magnet retreat in Atlanta.
Miller contributes to the local community through many volunteer organizations. With a son currently serving our country in Afghanistan, she is an active member of a parents’ group that meets regularly to send care packages to the troops. She is also a member of the South Jersey Quilt Guild which, over the years, has sent quilts to soldiers, nursing homes, foster care babies, Habitat for Humanity families and others. As part of Catholic Charities, Miller visited New Orleans after Hurricane Katrina and served as the medical representative on the team.
Recently she received the Excellence in Professional Nursing Practice Award as well as a Bertram Speare “Spirit of Crozer” Award, a testament to the caliber of her dedication to the nursing profession.
Justine Voell, RN, RNC, has spent most of her 35 years of nursing in Labor and Delivery. During this time, she has seen countless changes in the Labor and Delivery arena and is often commended for her flexibility and adaptability to those changes. She knows the importance of keeping up-to-date on the latest clinical procedures and techniques, and sharing that knowledge with others. She is an enormously helpful resource, adept at mentoring and teaching younger nurses and residents while keeping abreast of the latest quality improvements, patient safety issues and standards of care.
Voell has a unique ability to provide a calm, reassuring atmosphere and develop a special rapport with patients through the process of childbirth. She is an advocate for the patients, both mother and child, consistently keeping their welfare a top priority.
With certification as an In-Patient Obstetric Nurse and many years of experience, Voell has the ability to react rapidly in emergency situations, quickly assess the situation, make appropriate decisions and provide the patient and family with reassuring information and advice. She also has a gift for compassionately helping patients through loss, such as miscarriages or birth anomalies. Her skill was recognized this year with an Excellence in Professional Nursing Practice Award.
Voell has contributed to the nursing profession and the local community through dedicated participation in Delaware Foundation of Retarded Citizens (DFRC) activities and through volunteer activities at local schools throughout the years. In addition, she has worked with her mother to crochet blanket squares that serve as keepsakes for patients who have lost their babies. This volunteer activity grew out of her experience with patients and a compassionate desire to give the patients something that will provide comfort after their children are gone.
Debra Lillback, RN, BSN, MSN is a 35-year veteran nurse who has embraced excellence in all aspects of the nursing profession. She has served as a staff nurse, clinical instructor, quality analyst, outreach educator, charge nurse, supervisor, nursing research instructor, QA coordinator, and currently, as trauma administrative manager. Her breadth of experience has been a major advantage as she engages other disciplines and team members to find the best plan of care for patients and their families.
Lillback serves as a mentor to other managers and has gained the respect of the clinical and administrative staffs through consistent hard work, competence, a willing spirit, and dedication to the nursing profession.
As an integral member of numerous trauma-related organizations and committees, Lillback participates in the development of trauma care systems at the community, local state, and regional levels and is responsible for stabilizing the complex network of disciplines that work in concert to provide high quality care. She serves as an internal resource for staff in all departments, and acts as an extended liaison for Emergency Medical Services locally and regionally. She also has been very active both on the state and national level lobbying for “designated” Trauma Center funding.
Lillback has spearheaded many programs that deal with the complicated issues caused by trauma. For the last two years, she has implemented “Second Trauma,” a program that deals with the secondary issues patients and families often face after the initial trauma has taken place. “Trauma takes all control away from people and causes interruption, inconvenience, and sometimes devastating life-changing events,” explains Lillback. “This program gives nurses and caregivers the tools and background they need to provide compassionate care for trauma patients and their families.”
Lillback also fulfills the role of community educator and outreach coordinator for programs such as CARAVN (Counter Act Random Acts of Violence Now), SMASH: Tales of Teens & Alcohol, Burn Prevention, and Fall Prevention. As a volunteer for the American Red Cross, she assisted in preparing the Langstuhl Regional Medical Center in Frankfurt, Germany for the American College of Surgeons trauma site survey visit in April 2007. The hospital received full accreditation in October 2007.
Last year, she was trauma site surveyor for the Pennsylvania Trauma Systems Foundation for level III accreditation, and in 2008, assisted with the educational consultative site survey visits for hospitals seeking level III accreditation.
Lillback actively serves the large community church where her husband is pastor, and she has served as president of a state-wide church organization. She also serves on the board of Melmark Inc., which provides services for children and adults with developmental disabilities.
Guard Against Identify Theft
Suppose one of your co-workers needs to access the Pixus system quickly and doesn’t remember her password. If she asked to use your password, what would you say?
It can be difficult to turn down a co-worker, especially in what seems like an emergency situation. But sharing your password is never wise. What seems like an innocent way to help a coworker could result in your identity being stolen, or worse, your implication in a drug diversion. It’s important to protect yourself from such a situation by protecting your password. Here are some ways to do it:
- Don’t give your password to anyone.
- If there is a true emergency and you feel you must give your password to someone, go back into the system and change it immediately.
- When going to the Pixus machine or a computer to log on, give each other space. Don’t feel silly about asking others to turn around or step back while you’re entering your password. Everyone should understand and respect that request.
- Don’t write down identification numbers or passwords, and then later throw the piece of paper in the trash. Identity thieves often go through the trash to find and use such information.
- Don’t write your password on the back of your ID badge. If you lose it or set it down and leave it somewhere unattended, anyone who finds it will have access to your password.
- The Pixus system requires you to change your password every 90 days. However, if you suspect that a coworker may be diverting, it may be wise to change your password more often.
- When you create passwords, use a combination of letters and numbers. If someone happens to be looking over your shoulder, it will be harder for them to figure out your password than when you’re typing only letters.
Your identity can easily be stolen if you log into Pixus and forget to log out. The system automatically logs you out within a minute after you’ve stopped using it. But if you don’t log out and someone comes up behind you to use the system, they can use your identity to complete transactions. This is what happened recently when a drug diversion occurred in a Crozer-Keystone unit.
“Just about everyone in the unit was affected,” says Nancy Bucher, RN, MSN, CNAA-BC, Crozer-Keystone Vice President and Chief Nursing Officer. “The administrative director had to do research and pull charts to be able to rule people out. But had she not done that or not had the documentation to prove that these other people weren’t involved, it could have been a really unpleasant situation for the nurses and techs on the unit. Nurses really need to protect themselves from such situations.”
Nurses need to be cognizant of how waste transactions are made in Pixus,” emphasizes Dave Showalter, PharmD , assistant director of Crozer-Keystone Pharmacy Services. “If one nurse is wasting medication, another nurse has to witness. It’s one thing to sign in and put your initials in the system as a witness. It’s another to actually wait and watch while the nurse physically dumps it down the drain. If you witness at a Pixus, you are expected to witness the actual waste going down the drain or in the Sharps container before you log out and leave. You will protect yourself and your identity by adhering to this practice.
Crozer STU Nurses Honored with U. S. Flag Flown in Iraq
A very special U.S. flag hangs in the Shock Trauma Unit at Crozer-Chester Medical Center. Early this year, Vince Moss, M.D., a trauma surgeon at Crozer and member of the U.S. Army Reserves, was deployed to Iraq for the third time along with his brother Vance Moss, M.D. a Crozer-Keystone urologic surgeon. During their deployment, the Moss brothers decided to find a way to show the utmost respect they have for the nurses of Crozer’s Shock Trauma Unit. They had a flag flown in the village where they are serving in Iraq and dedicated to the STU nurses.
“The nurses have worked with Vince Moss for the past two years, and they felt very honored and touched by this gesture of appreciation for the wonderful work they do,” says Liz Dougherty, RN, Crozer STU nurse manager. To show their gratitude, the STU nursing staff collected personal items such as toys, games, food and clothing, which they sent to the Moss brothers to give to the children of the Iraqi village.
In the May issue, we incorrectly printed Bill McCune’s title as Vice President of Operations, DCMH. Bill’s title is President, DCMH. We apologize for this error.
Jo-Zetta Shawl, RN, MHA, CNAA-BC
Director, Nursing and Clinical Support Services
Each May at Crozer-Keystone, we set aside time during Nurses’ Week to acknowledge the outstanding contributions of our nursing staff. However, I believe that nurses should be recognized 12 months out of the year for the wonderful work they do. In this issue, we spotlight individual nurses who have won awards for outstanding practice, as well as our award-winning work throughout the system to reduce the incidence of ventilator-acquired pneumonia. Many of the great outcomes we’re seeing in evidence based medicine initiatives such as VAP have a lot to do with the contributions of our nurses.
One way to highlight the good work our nurses are doing is by first measuring what we do, and I’m pleased that Crozer-Keystone has developed a nursing quality dashboard for this purpose. I like to call it an “award board” because it enables us to monitor our nursing sensitive performance so we know when we are successfully implementing the measures that we have determined are important to patient care, and we can congratulate our nurses.
Since I have been a nurse for a long time, I remember that in the past, we weren’t really encouraged to toot our own horns or reward ourselves for a job well done. I’m glad to see a change occurring now where we as a profession, along with our physician colleagues and support staff in ancillary departments, realize the extent of the contribution that nurses make and recognize its extraordinary value. Now more than ever, we are able to measure and report our nursing practices and I think that speaks volumes about the magnitude of their importance to patient care.
This year, we had the opportunity to go to the VHA leadership conference held in Philadelphia. We are very proud that Springfield Hospital received the VHA Leadership Award for Clinical Excellence for exceeding national performance standards for clinical care in the prevention of VAP. Receiving that award was especially gratifying because it was really won by the Acute Care Center nursing staff whose outstanding efforts and diligence made it possible.
Throughout our health system, the individuals who really make the difference in whether or not we achieve our patient care goals are our nurses. They deserve to be acknowledged and rewarded for their wonderful professional practice and for their efforts to keep patient safety and outstanding patient care foremost in everyone’s mind every day of the year.
Nursing Excellence: Influencing practice, quality of care and professional development through inquiry and innovation.