Am I right that ventilator patients can be audited multiple times and that central-line patients can only be counted once?
Yes. The denominator for VAP is number of patients sampled — because the elements of the bundle must be done every day, you can sample the same patient multiple times, and each time counts as one in the denominator. For the central-line bundle, the denominator is also patients sampled, but you should survey a patient only once per admission — four out of the five elements are one-time only processes. Both of these bundles are for ICU patients only, and you should count them in the month you sampled.
If the central line is inserted in Radiology (or anywhere other than the ICU), should that be counted in the population?
No, the specifications from NQF are that it must be inserted in the ICU. All lines are important though, so any monitoring of lines placed outside the ICU is encouraged.
What is the definition of ICU?
The CDC definition of ICU/ICU-Status is: a nursing care area that provides intensive observation and diagnostic and therapeutic procedures for adults who are critically ill. This excludes bone-marrow transplant units and nursing areas that provide step-down care, intermediate care or telemetry only.
What is the standard for collection on central-line bundle — femoral or jugular?
The inserter should avoid the femoral line. If there is reason that the femoral line is used (documented or per hospital protocol), give it a pass (count as compliant).
For the optimal site: Does the MD documentation of the site in his report constitute the optimal site or does the doctor need to explain why that site was chosen? At present we don't have a policy or guidelines for what is the optimal site.
If they choose femoral they should be asked to write why. Sometimes there is an obvious reason and if it is not obvious, the MD should be asked what the reason was. If he/she has one, then it should be a pass.
Should hand hygiene be both before and after insertion of the central line or just before?
It is good practice to do both, but the standard is only before.
When auditing for daily assessment, should we check for documentation every day or just for the day we audit?
Use only the day you audit. It is a snapshot of the practice of insertion elements and one day of daily assessment. Use a patient only once. All days are important though, so any monitoring beyond this required data collection is encouraged.
Can we use administrative codes to find central-line patients to audit?
There are no administrative codes to identify someone with a central line which is placed in the ICU.
What is a “large drape?”
IHI defines a large drape as, “a cover from head to toe.”
The instructions say a central-line patient should only be audited once. What if the patient was: a) discharged and readmitted and a new central line started, or, b) taken off a central line and put back on a central line later in the same admission?
In both scenarios, the old central line was discontinued and subsequently a new one was started. These can be counted twice. A more correct statement would be that a patient should be counted once per continuous time on a central line.
Some patients are put on central lines for long-term IV therapy — doing daily assessment on these patients seems pointless. Should we be excluding these patients?
IHI says this in their How-to Guide, October 2008: “Define an appropriate timeframe for regular review of necessity, such as weekly, when central lines are placed for long-term use (e.g., chemotherapy, extended antibiotic administration, etc.). Daily review was designed for the intensive care population and may not be appropriate when long-term use over weeks or months is planned.”
Therefore, you should exclude patients intended to have long-term use of central lines.
Are there exclusions for VAP for kinetic beds?
If someone is on a kinetic bed, give it a pass (count as compliant) for that element.
If my facility has a small volume of ventilator days, should I report on every day the patient is on the ventilator?
Yes. You can count the same patient. You should report at least 15 day audits or as many as you have (e.g. if you had one patient vented for 9 days you would report audits for 9 days).
Some of the elements of the ventilator bundle may be not applicable for medical reasons, but the data collection tool doesn’t let me change the denominator for the individual elements. What should I do?
If a bundle element is not applicable, it should be counted as met. Therefore, the denominator for individual elements will always be the same as the overall bundle volume. Remember to increase your numerator by the number of audits where the elements were not applicable.