10/13/2017. The Christiana Care Way Awards PDCA Template Title goes here 1. Opportunity for Improvement. Team Members

Transcription

1 A Comparative Pilot Study of Supply Tray Management in the Medical Intensive Care Unit: Repeated use Versus Exchanged Supply Tray and Tray Contents Jill Kane MSN, RN, CCRN Lynn Bayne PhD, APRN, NNP-BC Carol Ritter MSN, RN, CCRN-K, CNML Kristen Hover BSN, RN, CCRN Shawna Varichak BSN, RN, CCRN 1 Opportunity for Improvement Opportunity Statement: Determine the presence of microbial contamination and impact on supply costs for repeated use versus exchanged use in-room supply trays and tray contents Desired Outcomes: Statistical microbial disparity between repeated use versus exchanged in-room supply trays Determine correlation between methods of supply tray management and healthcare-associated infections (HAIs) Impact on inventory supply cost Future direction for supply tray management 2 Team Members Principal Investigator: Jill Kane, MSN, RNIII, CCRN Co-Principal Investigator: Lynn Bayne, PhD, APRN, NNP-BC Co-Investigators: Carol Ritter, MSN, RN, CCRN-K, CNML, MICU Nurse Manager Kristen Hover, BSN, RNIII, CCRN Shawna Varichak, BSN, RN, CCRN Key Stakeholders: Dr. Michael Benninghoff, DO, MA, MICU Medical Director Donna Casey, DNP, MA, RN, Vice President, Patient Care Services Michelle Power, BSMT, CIC, Infection Prevention Lorraine Adkins, RN, Infection Prevention Terry Messick, MLS(ASCP) Microbiology Supervisor Wayne Stephens, Critical Care Project Manager 3 Title goes here 1

2 Background/Current Knowledge Each patient care room in Medical ICU has a locked drawer containing a supply tray with 19 packaged items, such as syringes, flushes, needles, etc. Traditional Clinical Practice: Reuse in room supply trays and contents from patient-to-patient without disinfection between patients Supplies restocked on an as needed basis Supply Tray Brainstorming: Inciting the Change Supply trays and contents are frequently touched inanimate objects Belief that trays and tray supplies are contaminated with pathogens Belief that contaminated supplies can directly or indirectly be transferred by the hands of healthcare workers to patients Surgical Critical Care Complex exchanges tray supplies for patients in isolation precautions and based on nursing judgement 4 Background/Current Knowledge Alternative Supply Tray Practice: Initiated 3/15/16 Supply trays redesigned Type and quantity of supplies were reorganized Every patient with length of stay (LOS) >24hrs regardless of isolation, trays and supplies were exchanged Every patient with LOS <24hrs and no isolation, trays and supplies were not exchanged. If + for isolation, trays and supplies were exchanged Alternative Practice Cyclical Process Flow: 1) Each tray is stocked with specific type and quantity of supplies, sealed inside a clear trash bag, and remains located in unit s supply room 2) Patient posted to MICU: obtain sealed supply tray, open supply tray, and place into room drawer 3) Depending on MICU LOS, once patient is discharged, supplies are disposed into trash and supply tray is placed in soiled utility room 4) Equipment personnel disinfect tray and return tray to supply room 5 Baseline Data & Literature Review Baseline Data: No quantifiable microbial data from supply trays prior to practice change Three months following practice implementation, nursing staff expressed dissatisfaction in throwing supplies away and creating waste unnecessarily Literature Review: High-touch surfaces, such as bed rails, IV pumps, have potential to be a reservoir for nosocomial pathogens and play a role in cross-contamination Contaminated environmental surfaces, equipment, and hands of healthcare workers all have been linked to transmission of various pathogens, which has led to individual cases and multiple outbreaks of HAIs No supportive evidence on whether methods of supply tray practices have variable microbial contamination nor was a causal relationship with HAIs identified 6 Title goes here 2

3 Key Outcomes/Goals Research Questions: What is the microbial burden of repeated use and exchanged supply trays and contents? Is there a difference in microbial contamination between repeated use versus exchanged supply trays and tray contents? Is there a difference in MICU-acquired infection rates among contaminated repeated-use versus exchanged supply trays and tray contents? What is the cost-effectiveness of repeated-use versus exchanged supply tray and tray contents? Key Data Measures: Ruhof Adenosine Triphosphate (ATP) Complete : Rapidly measures bioburden Blood Agar Plate Analysis: Microbial quantification of growth and broad classification of microorganisms Incidences of MICU-acquired infections Monthly analysis of expenditures of supply inventory and supply disposal 7 Action Plan: Solutions Implemented Quasi-experimental study for tray microbial load comparisons and a performance improvement initiative for cost analyses Timeline: October 11 th, 2016-Approval to use incubator space in microbiology lab October 28 th, 2016-Letters of endorsement from Donna Casey and Carol Ritter November 1 st, 2016: Research members recruited among MICU staff November 2 nd, 2016-DDD #603388, Expedited Review per 45 CFR (f)(7) Waiver of Consent 45 CFR (d) received from IRB November th, 2016-Live education and return demonstration on data collection procedures (i.e. ATP testing, 4-quadrant streaking of blood agar plates) from all thirty research members Study Go-Live: Control Group- December 2 nd, 2016 Experimental Group-December 12 th, Action Plan: Solutions Implemented Control Group, N=173: Traditional Practice-Repeated Use Trays & Contents Experimental Group, N=144: Alternative Practice-Exchanged Use Trays & Contents MICU District 1, patient rooms 1-8 MICU District 3, patient rooms December 2 nd, 2016-all 8 room December 12 th, 2016-all 8 rooms received new disinfected/stocked received new disinfected/stocked supply tray supply tray and same pre-test Pre-Test: Tray corners and 2 supplies procedure occurred (10ml NSS flush, Site Scrub ) All supply trays and contents were received ATP testing and sampling for patient specific and individualized inoculation of blood agar plates Throughout duration, tray supplies Each patient admit to district 3, had could be replenished and authenticity same pre-test procedure as control of control group trays verified daily group. Every patient discharge, had by investigators same post-test procedure. Study concluded March 29 th, 2017: If specific patient did not receive both pre-test and post-test data points, Post-Test: Tray corners and 2 supplies (10ml NSS flush, Site Scrub ) received information was discarded ATP testing and sampling for Study concluded April 13 th, 2017 inoculation of blood agar plates 9 Title goes here 3

4 Control Group/ Repeated Use District 1 Room 3E01-3E08 N=173 Average age = Gender 57.2%, Male 42.8%, Female Race 71.7%, Caucasian 24.3%, African American 4%, Other Experimental Group/ Exchanged Use District 3 Room 3E20-3E27 N=144 Average age = Gender 46.5%, Male 53.5%, Female Race 71.5%, Caucasian 24.3%, African American 4.2%, Other 10 Control Group/ Repeated Use, N-173 # Patient Turnover 3E0 30 3E E03 7 3E04 tray handling error 3E E E E08 31 Experimental Group/ Exchanged Use, N=144 # Patient Turnover 3E E E E E E E E Research Question: What is the microbial burden of repeated-use and exchanged supply trays and contents? Interpretation: No statistical difference in ATP RLUs between two styles of trays when comparing tray bioburden at all 6 points. ATP Test Location Repeated Use Tray Exchanged Use Tray Data Mean + Std Data Mean + Std Dev Dev Reactive Light Reactive Light Units Units (RLUs) (RLUs) ATP Pre Left Corner * ATP Post Left Corner * ATP Pre Saline ATP Post Saline * ATP Pre Scrub Hub ATP Post Scrub Hub * Recommended Pass/Fail Criteria PASS (RLU) 0-45 Fail (RLU) 46 and over * t-test unpaired samples, p< Title goes here 4

5 100% Research Question: Is there a difference in microbial contamination between repeated-use versus exchanged supply trays and tray contents? Interpretation: No statistical difference in % total positive (no growth vs. commensals + pathogens) on blood agar cultures between two styles of trays when comparing tray bioburden at all 6 points. Some individual site differences existed. Repeated Use Trays 100% Exchanged Use Trays 80% 60% 40% 20% 0% 80% 60% 40% 20% 0% No Growth Growth No Growth Growth * t-test unpaired samples, p < Research Question: Is there a difference in microbial contamination between repeated-use versus exchanged supply trays and tray contents? Interpretation: No statistical difference in % total positive (No Growth Vs. Commensals Vs. Pathogens) blood agar cultures between two styles of trays when comparing tray bioburden at all 6 points. Some individual site differences existed % 80.0% 60.0% 40.0% 20.0% 0.0% Repeated Use Trays 100% 80% 60% 40% 20% 0% Exchanged Use Trays * t-test unpaired samples, p < N=173 Patients Repeated Use N=144 Patients 69.2 Exchanged Use Pre, (Any Site, %) Post, (Any Site, %) Site, %) Pre, (Any Post, (Any Site, %) 15 Title goes here 5

6 RESULTS Blood Agar Plate Growth: Broad Classification Commensal versus Pathogenic Organisms Commensal Pathogenic Diptheroids- type of gram positive rod Gamma Strep- type of Enterococcus, potentially be VRE Bacillus- type of gram positive rod Mold Micrococcus Proteus-type of gram negative rod (GNR) Alpha Strep Mucoid Gram Negative Rod- examples: Klebsiella, Pseudomonas, Burkholderia Beta strep- group A or B Strep Gram Negative Rod- examples: Klebsiella, E- Coli, Pseudomonas, Acinerobacter Yellow, Flat yellow, Yellow GN ENV, STAPH (beta hemo), STAPH SPS GNR ENV, dry yellow ENV GNR- All gram (hemo), rare STAPH SPS hemopotentially be MSSA or MRSA negative rods (GNR), which are common environmental organisms Gram Positive Organisms/Mixed Organisms- example: Diptheroids, Staph STAPH SPS, STAPH SPS (white), staph SPS (CNS)- potentially be coagulase negative staph, which could be opportunistic versus common flora depending on patient factors (i.e. immunosuppression) 16 RESULTS Research Question: Is there a difference in MICU-acquired infection rates among contaminated repeated-use versus exchanged supply trays and tray contents? Interpretation: No statistical difference in rates of hospital acquired infections between the two groups. Hospital Acquired Infection? Yes No Repeated Use Tray (N=173) Exchanged Use Tray (N=144) 4 * χ2 = 1.31, p =.2522, not statistically significant *2 IVACs, 1 PVAP, 1 CLABSI 1 CDIFF 17 Research Question: What is the cost-effectiveness of repeated-use versus exchanged supply tray and tray contents? Interpretation: A statistical difference exists in cost between the two groups, favoring the traditional tray practices. 90, , Comparing Tray Practices: Inventory Cost for Supplies Alternative Practice C O S T 70, , , , , Traditional Practice $54, $76, , , TIME Feb 2015-Feb Mar 2016-Mar Supply Tray Items (same for both practices): 2x2 gauze, 10ml NSS flush, 3ml NSS flush, 6ml syringe, 12ml syringe, insulin pen needles, heart monitor stickers, sterile lubricant packs, filter needles, red caps, TB syringe, 18g needle, 25g needle, scrub hub, clave caps, paper tape, 3ml syringe * t-test unpaired samples, p< Title goes here 6

7 Cost of Disposing Tray Items (WASTE): An initial stocked, sealed supply tray costs $24.99 Calculating total cost of disposed items is predicated on that tray was stocked at baseline quantities March 15 th, 2016-March 31 st, 2017: 1,590 patient turnovers each with used supply tray items disposed into trash and/or sharps container $39, for disposed supply items Unknown Supply Disposal Cost Variables: If tray had supply items overstocked prior to disposal If tray had supply items understocked prior to disposal 19 Path Forward/ Next Steps Short-Term Solution: Following statistical analysis, the MICU returned to traditional/repeated use supply tray practice in mid September Next Steps: Unit education on microbial burden and transfer upon direct and indirect hand manipulation of patient and surrounding in-room environment Unit education on World Health Organization s 5 Moments for Hand Hygiene Unit education of appropriate utilization of gloves and glove exchange Further research to compare microbial burden between supply trays and other high touch surfaces (i.e. bed rails, cardiac monitors, ventilators) Further research to contrast microbial burden between in-room supply trays versus supply trays located outside of patient rooms 20 Lessons Learned Staff concerns or ideas sparks the research question Research process is a marathon not a sprint Collaborate with stakeholders Break out of the comfort zone; Reach out across disciplines Team members enjoyed interacting with microbiology personnel Engage and empower staff members to be part of the research process Be an excited motivator; it is infectious for staff involvement Unit leadership is extremely willing to support new ideas and initiatives 21 Title goes here 7