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CUSP for VAP: Technical Sustainability
It’s almost the last year. What now?
Sean M. Berenholtz, MD MHS FCCM
October 2, 2014
© The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
You might be asking yourself these
questions:
• What has changed in VAP prevention in the past year?
• How can I keep my unit’s focus on VAP prevention and
improving the care of mechanically ventilated patients?
• What resources are available to me as I enter the last
year? and beyond?
• What does data collection look like for this final year? and
beyond?
2
CUSP for VAP, Goals –
Technical Interventions, Daily Process Measures
• To prevent the development of ventilator-associated
pneumonia (VAP) in mechanically ventilated patients
– HOB - Maintain the patient’s head of the bed at 30o or more
from the horizontal
– Sub-G ETT - Use sub-glottic endotracheal tubes – for
patients expected to be intubated for ≥72 hours
– Oral Care - Perform oral care 6 times/day – 2 with CHG
– SAT - Perform a spontaneous awakening trial (SAT) at least
once/day
– SBT - Perform a spontaneous breathing trial (SBT) at least
once/day
3
National Focus, VAE Prevention –
SHEA VAP Prevention Strategies (2014)
• Strategies to Prevent Ventilator-Associated Pneumonia
in Acute Care Hospitals: 2014 Update1
– “The intent of this document is to highlight practical
recommendations in a concise format to assist acute
care hospitals in implementing and prioritizing strategies
to prevent ventilator-associated pneumonia (VAP) and
other ventilator-associated events (VAEs) and to improve
outcomes for mechanically ventilated adults, children,
and neonates.”
• http://www.jstor.org/stable/10.1086/677144
4
Changes in best practices –
VAP Prevention to VAE Prevention
Dropped Interventions
Added Interventions
Oral care
Sedation Management
Oral care with CHG
Delirium Management
Pair SAT and SBT
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Oral care with or without CHG2
• Systematic review and meta-analysis of the effectiveness
of CHG oral care for the prevention of VAP– 16 studies
– No change in duration of mechanical ventilation or ICU or
hospital LOS
– Exception: cardiac surgery patients
• SHEA VAP Prevention Strategies (2014) does not include
oral care with CHG as a basic practice to prevent VAP
• Many reasons for oral care other than VAP prevention
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PAD Guidelines3
• Roadmap for developing integrated, evidence-based,
patient-centered protocols for preventing and treating pain,
agitation, and delirium in critically ill patients
• Goals
– Ensure that patients are free from pain, agitation, and delirium
– Links with SAT/SBT, early mobility protocols and
environmental management strategies (to maintain sleep
cycle)
• SCCM: New PAD Guidelineshttp://www.sccm.org/Communications/CriticalConnections/Archives/Pages/SCCM-Releases-New-Pain,-Agitation-and-Delirium-ClinicalPractice-Guidelines.aspx
• AACN: PAD Guidelines: Tools for
Implementationhttp://www.aacn.org/wd/cetests/media/Launching%20PAD/PAD%20Gui
delines%20Toolkit.pdf
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PAD Guidelines: Focus on Sedation
• Assess or screen using RASS or SAS scales
– Every 4 - 6 hours
• Set target sedation level during rounds
– Target light or no sedation (RASS = -2 to 0, SAS = 3 or 4)
• Titrate sedative medications to achieve or maintain target
– Use SAT or light sedation for titration
– PAD guidelines – VAP Webinar by Dr. Wes Ely, 9/4/2014
https://armstrongresearch.hopkinsmedicine.org/vap/calls.aspx
– AACN - PAD Implementation
Worksheethttp://www.aacn.org/wd/cetests/media/Launching%20PAD/PAD%20G
uidelines%20Toolkit.pdf
8
PAD Guidelines: Focus on Delirium
• Assess your patient’s delirium level at least once per day
– Use the CAM-ICU or ASE
• Training manual and CAM-ICU worksheet located –
http://www.icudelirium.org/delirium/monitoring.html
• ASE evaluates inattention (the best gauge of delirium) and is
Part II of CAM-ICU
• Determine whether the patient is positive for delirium
• If positive, determine cause – Delirium protocol located
http://www.icudelirium.org/delirium/management.html
• PAD guidelines – Webinar by Dr. Wes Ely, 9/4/2014
https://armstrongresearch.hopkinsmedicine.org/vap/calls.aspx
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Pairing SAT with SBT
• An SBT should be performed as the patient is
undergoing the SAT
– Patients can perform better on SBT if their
sedation level is minimal
• Shortens duration of mechanical ventilation
• For a flow chart, see CUSP4MVP-VAP “SAT/SBT
Education”
https://armstrongresearch.hopkinsmedicine.org/cusp4mvp/processmeasures.aspx
• Can be measured as how often SBT is
performed off sedation
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Reducing VAEs & VAP
Getting Patients Off Ventilator Faster
• Daily process measures
– Preventing VAP
• Early mobility
– Mobilizing ICU patients earlier to reduce
complications
• Low tidal volume ventilation
– Preventing acute lung injury
• CUSP
– Engaging frontline staff and tapping into their
wisdom
Process Measures: Daily Evaluation
• Use a semi-recumbent position (≥30 degrees)
• Use subglottic suctioning endotracheal tube (ETTs) in
patients expected to be ventilated for >72 hours
• Assess readiness to wean daily with spontaneous
breathing trial (SBT)
• Use spontaneous awakening trial (SAT) with validated
sedation scale daily
– Richmond agitation sedation scale (RASS)
– Riker sedation agitation scale (SAS)
Early Mobility: Daily Evaluation
• Assess sedation level at least once/day using a
validated sedation scale (RASS or SAS)
• Assess delirium level at least once/day using the
CAM-ICU or the Attention Screening Exam
• Track patient’s highest daily level of mobility
• Track perceived barriers to achieving a higher level of
mobility daily
• Track the involvement of PT or OT in the mobilization
process
• Track events daily (if needed)
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Low Tidal Volume Ventilation:
Daily Evaluation
• Prevent acute respiratory distress syndrome
(ARDS)
• Use positive end-exploratory pressure ≥5 cm
H2O, not ZEEP
• Maintain plateau pressure at ≤30 cm H2O
• Use tidal volume of 6–8 cc/kg PBW
How Can We Get Patients
Off the Ventilator Faster?
44 Responses from 19 ICU Staff Members
61%
Daily Care
Provider Preferences
Communication/Trust
LTVV
Structural Measures
Early Mobility
0
10
Number of responses
20
30
Gap Between Best Evidence
and Practice4
• Knowledge
– awareness or familiarity (n=77)
• Attitudes
– agreement (n=33)
– self-efficacy (n=19)
– outcome expectancy (n=8)
– inertia of previous practice (n=14)
• Behavior
– external barriers (n=34)
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4 Es Model for Implementation and
Sustainability5
Engage
Win the hearts and
minds of your teams
Educate
Teach your teams about
your intervention
Execute
Implement your plan with
purposeful team
participation
Evaluate
Determine how well your
intervention has been
embedded in care
processes
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Engage: How will VAE prevention
make the world a better place?
• Need to change culture and practice by convincing
staff and stakeholders about the value of VAP/VAE
prevention in improving patient outcomes
– Consistently message the impact of prevention: decreased
duration of ventilation, ICU LOS, and hospital LOS
– Recruit a champion to build support and anticipate barriers
– Share patient anecdotes: successes and struggles
– Invite guest speakers for fresh and outside perspectives
– Get executive buy-in buy sharing research that supports
hospital-level decision-making (e.g. cost-benefit analysis)
– Make performance visible at all times
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Educate: How will VAE prevention
get patients off the ventilator faster?
• Get the evidence to the frontline staff
– Fastfact sheets
– Literature reviews
– CUSP for VAP content call webinars
– Hands-on trainings
– Conferences
– Interactive discussions
– VAP Process Measure and Early Mobility Toolkit
education resource lists
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Execute: How to implement VAE
prevention interventions given local
culture and resources?
• Frame interventions to target system-level change
– Do not target individuals
• Standardize care
– Daily multi-disciplinary rounds
• Reduce complexity
– Sedation, breathing trial, mobility protocols
• Create independent checks
– Daily Goals tool
• Check and modify current policies
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Evaluate: How will we know that our
efforts make a difference?
• Assess impact: are the
interventions adding value
for staff, patients and
families?
• Monitor and report process
and outcome measures to
staff at least once a month
– Generate detailed reports with
CECity platform
• Identify gaps and iterate
processes
• Celebrate successes
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CUSP 4 MVP – VAP Website
https://armstrongresearch.hopkinsmedicine.org/cusp4mvp.aspx
• Education materials
– Toolkits
•
•
•
•
CUSP
Daily Process Measures
Early Mobility
Low Tidal Volume Ventilation (soon)
– Literature Reviews
– Fast Fact Sheets
• Archive of past webinars led by subject
matter experts
CUSP 4 MVP – VAP Website
https://armstrongresearch.hopkinsmedicine.org/cusp4mvp.aspx
Data Portal
• Data collection tools
– Manual entry or electronic import
• Real time reporting
– Monthly, quarterly, and yearly data reports
• Benchmarks
– Comparison to ICUs within your CE
– Comparison to ICUs within your cohort
• Detailed instructions
Opportunities to keep the ball rolling!
• CUSP 4 MVP – VAP (National Project)
• SCCM - ICU Liberation
• Johns Hopkins Critical Care Rehabilitation
Conference
• ICU Delirium and Cognitive Impairment Study Group
– Vanderbilt University
• We would love to host teams here at AI for a 1-day
Sustainability Kickoff Meeting and developing a
“Learning Network”
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Learning Network
• Sustaining your CUSP efforts
• Potential opportunity to launch a learning network to
provide ongoing CUSP support after project ends:
• Learning network members develop relationships
integral to expanding and sustaining CUSP within
their organizations and experience:
–
–
–
–
Consulting from peers
Working together to overcome challenges
Sharing best practices
Understanding how to better use and integrate CUSP Tools
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Learning Network
• What is the time commitment?
– What you make of it!
• Successful learning networks use a variety of
methods for sharing and collaborating for
example:
– In-person meetings
– Webinars
– Listserv
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CUSP 4 MVP – VAP (National Project)
• Call in to National Project calls
– We will send out information
• Join Cohorts 2, 3 or 4 to sustain and/or enhance
your VAE prevention program
– Contact [email protected]
• Recruitment and registration are currently
underway for Cohort 2
28
SCCM – ICU Liberation
• Features
– PAD Guidelines
– Assessment tools
– Information on getting your patients moving
– Presentation on PAD by Julianna Barr
– Presentations from SCCM 43rd Critical Care
Conference
– http://www.iculiberation.org/Pages/default.aspx
29
The Third Annual Johns Hopkins
Critical Care Rehabilitation Conference
Takes place October 24-25th
in Baltimore. Join to
experience more about why
interdisciplinary collaboration
and coordination is vital to
facilitate early mobility and
rehabilitation in the intensive
care unit (ICU) setting.
http://www.hopkinscme.edu/Cou
rseDetail.aspx/80034272
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ICU Delirium and Cognitive Impairment
Study Group – Vanderbilt University
• Extensive resource for prevention of delirium
and its sequelae.
• Site is for all patients, not specifically those on
mechanical ventilation
– Includes
• ABCDEF Bundle (Originally the ABCDE Bundle,
adding Family)
• Resources
– Implementation of delirium monitoring and management
– Many, many others
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CUSP for VAP Data collection – the
final year and beyond!
• Sustainability period Jan. 2015- Dec. 2015
• During the final year
– VAE rates are “required”
– The data portal will remain open for all other
data collection
• You can use it if and as you wish
• If you enter data, the reports will be available
• 4 sampling strategies are available
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Next Steps – Data
• Sustainability period Jan. 2015- Dec. 2015
• Data Collection Sampling Strategy began Oct. 2014
(continues through Dec. 2015) and includes:
– Daily Process Measures
– Early Mobility Data
– Low Tidal Volume Ventilation Measure
• Data collection for Low Tidal Volume Ventilation
measure
– Began Oct. 2014
– CECity portal ready for data entry/upload
33
Next Steps – Assessments
• 2014 Assessment Schedule
– Complete Structural Assessment 3 – if not already done
– Exposure Receipt Assessment 2 – Nov 2014
• 2015 Assessment schedule:
–
–
–
–
Structural Assessment 4 – Dec. 2014
Premortem for Sustainability – Feb. 2015
VAP Quarterly Interview – Jun. and Dec. 2015
All other assessments- Oct. – Dec 2015
• VAP tools/metrics for all measures will be posted with
the recording to this webinar here:
https://armstrongresearch.hopkinsmedicine.org/vap/calls.aspx
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Your Input is Important
• What do you need during sustainability
– Calls?
– Content?
– Anything else?
• We can explore this more during the face-to-face
meeting, but we would really like to know any
ideas you have now
35
References
1. Klompas M, Branson R,Eichenwald EC, et al. Strategies
to prevent ventilator-associated pneumonia in acute
care hospitals: 2014 update.Infect Control Hosp
Epidemiol. 2014; 35(8):915-36.
2. Klompas M, Speck K, Howell MD, et al. Reappraisal of
routine oral care with chlorhexidine gluconate for
patients receiving mechanical ventilation: systematic
review and meta-analysis. JAMA Intern Med. 2014;
174(5):751-61.
36
References
3. Barr J, Fraser GL, Puntillo K, et al. Clinical practice
guidelines for the management of pain, agitation, and
delirium in adult patients in the intensive care unit. Crit
Care Med. 2013; 41(1):263-306.
4. Cabana MD, Rand CS, Powe NR, et al. Why don't
physicians follow clinical practice guidelines? A
framework for improvement. JAMA.1999; 282(15):145865.
5. Pronovost PJ, Berenholtz SM, Needham DM. Translating
evidence into practice: a model for large scale knowledge
translation. BMJ. 2008; 6:337:a1714.
37
Thank You
A sincere
THANK YOU
for all of your effort
and hard work to
reduce the incidence of VAP
in your units
and prevent HAIs!
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