Transcript streamlined versus conventional vap surveillance

CUSP 4 MVP – VAP
Improving Care for Mechanically Ventilated Patients
Data 3:
Introduction to Objective Outcome Measures
March 4, 2015
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
Johns Hopkins University
CUSP 4 MVP - VAP
Comprehensive Unit-based Safety Program
for Mechanically Ventilated Patients and
Ventilator-Associated Pneumonia
2
CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Data 3: Introduction to Objective Outcome Measures
Polling Question
Who is on the call?
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IP – infection preventionist
RN – registered nurse
RT – respiratory therapist
PT – physical therapist
OT – occupational therapist
MD – medical doctor
Quality improvement/ patient safety professional
Healthcare executive
Educator
National project team
Other
CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Data 3: Introduction to Objective Outcome Measures
Objective Outcomes
What are they?
Why do they matter?
CUSP for Mechanically Ventilated Patients
March 4, 2015
Michael Klompas MD, MPH, FRCPC, FIDSA
Harvard Medical School, Harvard Pilgrim Health Care Institute, and
Brigham and Women’s Hospital, Boston, USA
Disclosures
Grant funding from the US Centers for Disease Control and
Prevention
Honoraria from Premier Healthcare Alliance for lectures on
VAP surveillance
Ventilator-associated pneumonia
Affects ~5-10% of ventilated patients
Increases ICU length of stay by ~4-7 days
Increases hospital length of stay by ~14 days
Crude mortality rate 30-50%
Attributable mortality 8-12%
Adds ~$10-50,000 to cost of hospital stay
CMS 1533-P, 2007
Safdar et al, Crit Care Med 2005; 33:2184
Tejerina et al, J Crit Care 2006; 21:56
Muscedere et al, J Crit Care 2008;23:5-10
Eber et al, Arch Intern Med 2010;170:347-353
Nguile-Makao et al, Intensive Care Med 2010;36:781-9
Beyersmann et al, Infect Control Hosp Epidemiol 2006;27:493
Infiltrate
New Antibiotic
Start
Gram stain
neutrophils
Purulent
secretions
Increased vent
settings
Low P:F Ratio
Low WBC
High WBC
Low Temp
High Temp
Diagnostic Criteria for VAP
ACCP Criteria
✓✓✓✓ ✓
✓
✓
✓✓✓✓
✓
✓ ✓
✓ ✓
✓
✓
✓
✓ ✓✓
✓
✓
Clinical Pulmonary Infection
Score
✓✓✓✓ ✓
✓
✓
Johanson’s Criteria
✓
✓
✓
CDC Old Definition
CDC New Definition
HELICS Criteria
✓
Ego et al. Chest 2015;147:347-355
Impact of Diagnostic Criteria on VAP Prevalence
Prospective surveillance, 1824 patients, Tertiary Med-Surg Unit, Belgium
Number of VAPs
40
30
20
10
0
CDC Old
Criteria
CDC
New
Criteria
HELICS
ACCP
CPIS
Johanson
Ego et al. Chest 2014;ePub ahead of print
All VAP Signs Subjective, Non-Specific, or Both
The core clinical signs associated with VAP:
•
•
•
•
•
Radiographic opacities
Fever
Abnormal white blood cell count
Impaired oxygenation
Increased pulmonary secretions
Interobserver agreement in VAP surveillance
50 ventilated patients with respiratory deterioration
IP 1
(11 VAPs)
3
1
0
7
7
IP 2
(20 VAPs)
3
5
Kappa = 0.40
IP 3
(15 VAPs)
Klompas, AJIC 2010:38:237
6 Case Vignettes Presented to 43 Surveyors
6
Number of VAPs
5
4
3
2
1
0
Survey Respondents
Crit Care Med 2014;42:497
Physician Agreement Poor
Series of 84 ICU patients with abnormal chest x-rays and
purulent sputum
• Evaluated by 7 physicians for VAP
• “True diagnosis” established by histology or quantitative
bronchoscopy cultures
• 32% found to have VAP
Physicians disagreed on presence or absence of VAP in
35/84 (42%) of patients
• The “best” doc missed 28% of true VAP’s
• The “worst” doc missed 50% of true VAP’s
• Both labeled ~20% of patients without VAP as having VAP
Fagon et al, Chest 1993; 103:547-53
Accuracy of clinical diagnosis of VAP
Sensitivity /
Positive Predictive Value
Relative to 253 autopsies
100%
Loose definition:
Infiltrate and 2 of
temp / wbc / purulence
80%
60%
Strict definition:
Infiltrate and 3 of
temp / wbc / purulence
40%
20%
0%
Sensitivity
Positive
Predictive
Value
Tejerina et al., J Critical Care 2010;25:62
Accuracy of quantitative BAL cultures
Sensitivity /
Positive Predictive Value
Relative to histology
100%
80%
60%
40%
20%
0%
Sensitivity
Positive
Predictive
Value
Kirtland, Chest 1997;112:445
Fabregas, Thorax 1999;54:867
Chastre, Am Rev Respir Dis 1984;130:924
Torres, Am J Resp Crit Care Med 1994;149:324
Marquette, Am J Resp Crit Care Med 1995;151:1878
Papazian, Am J Resp Crit Care Med 1995;152:1982
Implications for prevention
from doctorrw.blogspot.com
The VAP Prevention Paradox
VAP Vent
Rates LOS
ICU
LOS
Hospital
Death
LOS
Regular oral care with
chlorhexidine
Silver-coated
endotracheal tubes
Head-of-bed elevation
Crit Care 2009;13:315
Silver-Coated Endotracheal Tubes
VAP Rates and Outcomes
Silver coated ETTs
6.0
12.0
5.0
10.0
4.0
8.0
3.0
6.0
2.0
4.0
1.0
2.0
0
VAP
Incidence
Vent
days
ICU
days
Hospital
days
Lengths of Stay (days)
VAPs per 100 Patients
Conventional ETTs
0
JAMA 2008;300:805
Routine Oral Care with Chlorhexidine
Meta-analysis suggests CHG lowers VAP rates
Risk Ratio 0.72 (0.55-0.94)
Lancet Infectious Dis 2011;11:845
Routine Oral Care with Chlorhexidine
Impact on mean duration of mechanical ventilation:
NONE!
Impact on ICU length-of-stay
NONE!
Impact on mortality
POSSIBLE INCREASE!!! RR 1.13 (0.99 to 1.28)
JAMA Internal Med 2014;174:751
Why the Paradox?
“VAP” as measured includes a multitude of conditions, ranging from
benign to serious
 Less serious: bacterial colonization superimposed upon
atelectasis / CHF / barotrauma
 More Serious: pneumonia, ARDS, pulmonary infarction, others
Most prevention measures work by decreasing oral secretions or
bacterial colonization
 Circularity between mechanism of action and diagnostic criteria
 Preferential impact on less serious events leading to lower
perceived VAP rates, smaller impact on more serious events
For any given intervention, difficult to know if primary impact is on
less serious or more serious events since both count as “VAPs”
Klompas, Critical Care 2009;13:315
Critical Care Medicine 2013;41:2467-2475
Ventilator-associated conditions (VAC)
Rise in daily minimum PEEP ≥3cm or FiO2 ≥20 sustained ≥2 days
after ≥2 days of stable or improving daily minimum PEEP or FiO2
Date
PEEP
(min)
FiO2
(min)
Jan 1
10
100
Jan 2
5
50
Jan 3
5
40
Jan 4
5
40
Jan 5
8
60
Jan 6
8
50
Jan 7
8
40
Jan 8
5
40
Jan 9
5
40
http://www.cdc.gov/nhsn/VAE-calculator
Impact of VAEs on length-of-stay
Controlled for time to VAE, age, sex, unit, comorbidities, severity
of illness. All comparisons are to patients without VAE (control).
Control
VAC ***
Ventilator Days
IVAC ***
Possible VAP ***
Probable VAP ***
Control
VAC ***
IVAC ***
Possible VAP ***
Probable VAP ***
Hospital Days
0
5
10
15
20
25
30
35
Days
Infect Control Hosp Epidemiol 2014;5:502-510
Impact of VAEs on mortality
VAE
VAP
USA – 3 centers
PLoS ONE 2011;6:e18062
USA – 8 centers
Crit Care Med 2012;40:3154
Canada – 11 centers
Chest 2013;144:1453
Netherlands – 2 centers
Am J Resp Crit Care Med 2014;189:947
USA – 2 centers
Crit Care Med 2014;ePub
USA – 1 center
Infect Control Hosp Epidemiol 2014;5:502
0.5
1
2
5
10
Odds Ratio or Hazard Ratio
The VAP Prevention Paradox
VAP Vent
Rates LOS
Regular oral care with
chlorhexidine
Silver-coated
endotracheal tubes
Head-of-bed elevation
ICU
LOS
Hospital
Death
LOS
VAEs
?
?
?
Crit Care 2009;13:315
The Upshot
VAP rates are unreliable outcomes
VAE rates likely reliable but still very new. Unclear how best
practices will impact them.
If we want to know whether a prevention measure really works or
not, we have to look at objective outcomes such as:
duration of mechanical ventilation
ICU length-of-stay
hospital length-of-stay
mortality
Summary
VAP diagnosis is subjective and non-specific
Inconsistent association between VAP and patient outcomes
Many interventions purportedly lower VAP rates but no impact on
patient outcomes: “the VAP Prevention Paradox”.
Makes VAP an unreliable outcome
VAEs more objective and consistently predict adverse outcomes… but
the definitions are still very new, very little data so far on how prevention
strategies impact VAE rates
Implication: need to look at objective outcomes if we want to be sure
that CUSP 4 MVP is helping our patients
Thank you!
Michael Klompas ([email protected])
CUSP4MVP – VAP
Comprehensive Unit-based Safety Program
for
Mechanically Ventilated Patients- Ventilator Associated Pneumonia
Objective Outcomes Registry
Objective Outcomes Registry – Training Overview
• Overview of the Objective Outcomes Data Entry and Data Upload
• Review of Objective Outcomes Performance Monitor
• Review of Network Performance and Reports Page
Home Page
Site can be accessed
directly at:
https://armstrongresearch.
hopkinsmedicine.org
Option to login on or
browse. Some pages only
available with log-in
The “Return to Armstrong
Institute – Home” will take
you back to the Armstrong
Institute’s homepage
Clicking on Project will
take you to the Project
Home Page
CUSP4MVP-VAP
Home Page
Tools that Focus on
Eliminating VentilatorAssociated Pneumonia
My Projects
• Shows all the available
projects and will highlight
the one(s) you are
participating in
• You will be prompted to login
before accessing this page
• Clicking on the project will
take you to the CUSPMVPVAP Project page
Mary Schmidt
CUSP4MVP-VAP
My Tools Page
Ability to Search by Tool
Mary Schmidt
Allows you to quickly access
various tools your network(s)
are registered for.
Tool
Name
CUSP4MVP-VAP Test Network
Coordinating Entities will
have the ability to view Tools
registered to their Children
networks.
Network which Data
will be Entered for
Search by Tool
Name or by
Network Name
CUSP4MVP-VAP
Project Page
Manage/View
Faith Memorial ICU as Jane Tester
Displays the
Network entering
data. Ability to click
on network name to
navigate to network
CUSP4MVP-VAP National Tools
• Displays your data entry tools
• Your access to a tool is
determined by your role whether you are a member or
an administrator. For
example, only administrators
will see the “Manage” button
for HSOPS.
Network Admins see
the Manage Button
My Networks
View Networks
Mary Schmidt
• Shows all the
Networks that
you are
associated with
• Ability to search
by name of
Network
Objective Outcomes
Add New Event
• Enter data by
accessing the
Events Tab
Faith Memorial ICU as Jane Tester
• Sort previous
entries by
Column Titles
• Sort by Filter
Criteria as well
• Ability to Edit or
Delete entries
Objective Outcomes – Data Entry
Objective Outcomes – Data Entry
Help icons available for each data entry field.
Data entry grid opens in modal overlay. Date validation enabled on form.
Objective Outcomes
Add New Event
• Enter data by
uploading a
spreadsheetvery
convenient!
Faith Memorial ICU as Jane Tester
Objective Outcomes
Add New Event via Upload
Faith Memorial ICU
Objective Outcomes
Add New Event via Upload
Objective Outcomes Reports
My Rate will show your performance rate as well
as an indicator of whether “Higher is Better” or
“Lower is Better”
Faith Memorial ICU as Jane Tester
Objective Outcomes Reports
Improvement Opportunities display the number
of events, which if eliminated improve your
measure value
Faith Memorial ICU as Jane Tester
Objective Outcomes Reports
View Chart
Interactive chart that allows selection of your
comparators and time periods
Ability to turn
comparators ON
and OFF
Ability to
download PDF
Hover over data
point to display
your rate and the
comparators
My Networks
My Network Performance
• Network Admins will see the
measures from the Tools for
each of the networks they
are associated with
Reports
available for
download
My Networks
My Reports
• Allows you to run all
reports from a single
interface. Reports are also
available within their
specific data entry tool.
• Tools, Networks and
Reports are displayed
based upon what you are
associated with
Recommended System Requirements
• Firefox 17.0+, Internet Explorer 8.0+, Safari 4.0+
• Adobe Acrobat 5.0+ (For downloading reports)
• Excel 2000 + (For downloading reports)
• Broadband connection with 500+ Kbps
Support
Technical Support
Contact Information:
[email protected]
Thank You!
Questions?
Next Steps
CUSP 4 MVP – VAP
Improving Care for Mechanically Ventilated Patients
Next Steps: Homework
• Determine information sources for the
Objective Outcome Measures
• Collect and enter Objective Outcome
Measures data into the data portal
• Continue collecting and entering VAE
Surveillance data
55
CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Data 3: Introduction to Objective Outcome Measures
Mark Your Calendar:
Upcoming Content Webinars
For current
schedule of
upcoming project
webinars, visit
https://armstrongres
earch.hopkinsmedi
cine.org/cusp4mvp/
schedules.aspx
56
CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Data 3: Introduction to Objective Outcome Measures
CUSP 4 MVP – VAP Website
Visit:
https://armstrongrese
arch.hopkinsmedicine
.org/cusp4mvp.aspx
57
CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Data 3: Introduction to Objective Outcome Measures
What Can I Find on the
CUSP 4 MVP – VAP Website?
• Education materials
–
–
–
–
Daily Care Toolkits
SAT/SBT Protocol
SAT/SBT Literature Review
SAT/SBT Fast Fact Sheet
• Exposure Receipt Assessment tool
• CUSP Tools and Guides
• Archive of webinars led by subject matter experts
https://armstrongresearch.hopkinsmedicine.org/cusp4mvp.aspx
58
CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Data 3: Introduction to Objective Outcome Measures
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Data 3: Introduction to Objective Outcome Measures