CUSP for VAP: EVAP
Where are we going and How will we get there?
Sean Berenholtz M.D., MHS
© The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
3
Armstrong Institute for Patient Safety and Quality
Healthcare-Associated Infections (HAI):
A Preventable Epidemic
• Focus on 4 HAIs:
– VAP, CLABSI, surgical site infections and
catheter associated urinary tract infections
• $5 billion per year excess costs
• 1.7 million patients per year
– 1 out of 20 patients
• 98,000 deaths per year
– As many deaths as breast cancer and HIV/AIDS
– 6th leading cause of preventable deaths
Waxman HA. Hearing of April 16, 2008
4
Impact of VAP
• 10-20% of ventilated patients
• Common HAI
– Median rate 1-4.3 per 1000 vent day
– 250,000 infections per year
• Most lethal HAI
– Mortality likely exceeds 10%
– Up to 36,000 deaths per year
• Cost per episode: $23,000
Safdar CCM 2005, Kollef Chest 2005,
Perencevich ICHE 2007, Klevens Public Health Rep. 2007.
Project Overview
• NIH/NHLBI and AHRQ funding project
– Individual hospitals participate for 3 years,
including 2 year intervention period and 1
year evaluation of sustainability
• Leveraging leaders in field
– Armstrong Institute for Patient Safety and
Quality, NIH/NHLBI, CDC, AHRQ, University
of Pennsylvania, MHA and HAP
– MD and PA hospitals
6
Armstrong Institute for Patient Safety and Quality
Project Goals
• To achieve significant reductions in
VAP/VAE rates
• To achieve significant improvements in
safety culture
How will we get there?
http://www.hopkinsmedicine.org/armstrong_institute
Successful Efforts to Reduce
Preventable Harm
• Michigan Keystone ICU program
– Reductions in central line-associated
blood stream infections (CLABSI) 1,2
– Reductions in ventilator-associated
pneumonias (VAP) 3
• National On the CUSP: Stop BSI program 4
1.
2.
3.
4.
Pronovost P, N Engl J Med 2006;355:2725-32.
Pronovost P, BMJ 2010;340:c309.
Berenholtz S, Infect Control Hosp Epidemiol. 2011;32(4): 305-314.
www.onthecuspstophai.org
9
Percent of Units with Zero CLABSIs and
Achieving Project Goal (<1/1000 CL days)
*Data drawn from Interim Project Report – Figure 5 – Cohorts 1 through 3
www.onthecuspstophai.org
10
Ventilator Bundle
• Semirecumbant positioning
• Appropriate SUD prophylaxis
• Appropriate DVT prophylaxis
• Appropriate sedation
• Daily assessment of readiness to
extubate
Sample Daily
Goals
Education
Decrease complexity and
create redundancy
• Daily goals
checklist
• Standardized
ordersets and
protocols
Independent
redundancies
• Nursing, RT,
families
J Crit Care 2003;18(2):71-75
Ventilator Bundle Adherence Through
36-months Post-Intervention
Infect Control Hosp Epidemiol. 2011;32(4): 305-314.
Mean Quarterly VAP Rate Through
36-Months Post-Intervention
Infect Control Hosp Epidemiol. 2011;32(4): 305-314.
Lives and Dollars Saved
• 10% mortality reduction
– Michigan Medicare data compared to over
350 hospitals in surrounding states
• BMJ 2011;342:d219
• $1.1 million saved per year for average hospital
– 30 CLABSIs and 18 VAP cases averted
annually
– Financial benefits far exceed costs of
intervention
• Am J Med Qual. 2001;26:333-339
15
Lessons Learned
• Harm is preventable
– Many healthcare acquired infection are
preventable; should be viewed as defect
• Focus on systems; Not individuals
• Limitations of the ‘Ventilator Bundle’
Ventilator Bundle
• Developed to prevent complications for patients
requiring MV
– Not focused specifically on VAP prevention
– Not systematically updated
• VAP prevention guidelines conflicting and
outdated
• Need to develop a ‘VAP prevention’ bundle
– Pilot test before national dissemination
17
Armstrong Institute for Patient Safety and Quality
VAP Prevention Guidelines
• CDC Guidelines
• MMWR Recomm Rep. 2004;53:1-36
• American Thoracic Society/ Infectious
Diseases Society of America
• AJRCCM 2005;171(4):388-416.
• Canadian VAP Prevention Guidelines
• J Crit Care 2008;23(1):138-147.
• Society for Healthcare Epidemiology of
America
• ICHE 2008;29:S31-S40.
Armstrong Institute for Patient Safety and Quality
Process Measures: Daily Evaluation
1.
Head of Bed Elevation (HOB)
–
2.
Use of a semi-recumbent position (
≥ 30 degrees).
Spontaneous Awakening and
Breathing Trials (SAT & SBT)
– Make a daily assessment of
readiness to wean with the use of the
SAT and SBT.
3.
Oral Care
–
4.
Oral Care with Chlorhexidine
–
5.
At least 6 times per day
2 times per day
Subglottic Suctioning
–
Use CSS ETTs in patients expected
to be MV for >72 hours
Armstrong Institute for Patient Safety and Quality
19
Policy Based Structural Measures :
1.
2.
3.
4.
5.
6.
Use a closed ETT suctioning system
Change close suctioning catheters only as needed
Change ventilator circuits only if damaged or soiled
Change HME every 5-7 days and as clinically indicated
Provide easy access to NIVV equipment and institute protocols to promote use
Periodically remove condensate from circuits, keeping the circuit closed during
the removal, taking precautions not to allow condensate to drain toward patient
7.
Use early mobility protocol
8.
Perform hand hygiene
9.
Avoid supine position
10. Use standard precautions while suctioning respiratory tract secretions
11. Use orotracheal intubation instead of nasotracheal
12. Avoid use of prophylactic systemic antimicrobials
13. Avoid non-essential tracheal suctioning
14. Avoid gastric over-distention
ETT endotrachael tube; HME heat moist exchanger; NIVV non-invasive ventilation 20
Early Ambulation
• RCT, 104 MICU patients on ventilators
• PT/OT starting at day 1-2 vs ‘usual care’
– Passive range of motion to ambulation
• Improved return to independent functional
status at hospital discharge
• Shorter duration of delirium
• Increased ventilator-free days
Lancet 2009; 373: 1874–82
21
Armstrong Institute for Patient Safety and Quality
Far More Complex than
Implementing a Checklist
• Technical work
– ‘Things we have a solution to’
– Summarize the evidence and educate
providers
• Adaptive work
– Addressing values, attitudes and beliefs
that drive actions
– Teamwork and safety culture is important and
can be improved
22
Armstrong Institute for Patient Safety and Quality
L&D RN/MD
© The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
ICU RN/MD
OR RN/Surg
CRNA/Anesth
25
Teamwork and Safety Culture
• Linked to important clinical and
operational outcomes
• Predicts successful efforts to implement
safety programs
• Responsive to interventions like CUSP
26
Armstrong Institute for Patient Safety and Quality
"Needs Improvement” Statewide
Michigan CUSP ICU Results
• “Needs Improvement”: Less than
60% of respondents reporting good
safety or teamwork climate
• Statewide in 2004 82-84% needed
improvement, in 2007 22-23%
J Critical Care 2008;23:207-221
Crit Care Med 2011;39(5):1-6
27
Comprehensive Unit-based
Safety Program (CUSP)
1. Educate staff on science of safety
2. Identify defects
3. Assign executive to adopt unit
4. Learn from one defect per quarter
5. Implement teamwork tools
Jt Comm J Qual Patient Saf 2010;36:252-60
Resources: www.safercare.net
Sample Daily
Goals
Education
Decrease complexity and
create redundancy
• Daily goals
checklist
• Standardized
ordersets and
protocols
Independent
redundancies
• Nursing, RT,
families
J Crit Care 2003;18(2):71-75
Best Way Forward
• Informed by science
• Led by clinicians and supported by
management
• Guided by measures
30
Armstrong Institute for Patient Safety and Quality
Advancing the Science
• Development of a ‘VAP Prevention’ bundle
– Updating the ‘Ventilator Bundle’ to focus on VAP
– Advancing science of process measurement
• CDC NHSN VAP definition is changing
– Ventilator-Associated Event (VAE) algorithm
• Identification of contextual variables
– Ethnographic studies
Today is going to be a good
day: Overview
© The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
Overview of the Day
•
•
Details and requirements of the effort
Targeted topics to build unit plans
– Sr. Leader,
– Physician, and
– Patient and Family engagement
•
•
•
Networking and planning to develop a unit level
plan of action
Data Collection and Data Entry Requirements
Introduction of CECity Platform
– Real time reporting, LMS, Social networking
• Summary, Next Steps, and Adjourn
34
Armstrong Institute for Patient Safety and Quality
References-1
Slide 4
Waxman, HA. Healthcare-associated infections: A preventable
epidemic. Hearing, April 16, 2008; House of Representatives, Committee
on Oversight and Government Reform, Washington DC.
Slide 5
Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and economic
consequences of ventilator-associated pneumonia: a systematic review.
Crit Care Med. 2005 Oct;33(10):2184-93.
Kollef MH, Shorr A, Tabak YP, Gupta V, Liu LZ, Johannes RS.
Epidemiology and outcomes of health-care-associated pneumonia: results
from a large US database of culture-positive pneumonia. Chest. 2005
Dec;128(6):3854-62.
Perencevich EN, Stone PW, Wright SB, Carmeli Y, Fishman DN, Cosgrove
SE: Society for Healthcare Epidemiology of America. Raising standards
while watching the bottom line: making a business case for infection control.
Infect Control Hosp Epidemiol. 2007 Oct;28(10):1121-33.
35
Armstrong Institute for Patient Safety and Quality
References-2
Slide 5, continued
Klevens RM, Edwards JR, Richards CL Jr, Horan TC, Gaynes RP, Pollock
DA, Cardo DM. Estimating health care-associated infections and deaths in
U. S. hospitals, 2002. Public Health Rep. 2007 Mar-Apr;122(2):160-6.
Slide 8
http://www.hopkinsmedicine.org/armstrong_institute
Slide 9
Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S,
Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C. An
intervention to decrease catheter-related bloodstream infections in the ICU.
N Engl J Med. 2006 Dec 28;355(26):2725-32.
36
Armstrong Institute for Patient Safety and Quality
References-3
Slide 9, continued
Pronovost PJ, Goeschel CA, Colantuoni E, Watson S, Lubomski LH,
Berenholtz SM, Thompson DA, Sinopoli DJ, Cosgrove S, Sexton JB,
Marsteller JA, Hyzy RC, Welsh R, Posa P, Schumacher K, Needham D.
Sustaining reductions in catheter related bloodstream infections in
Michigan intensive care units: observational study. BMJ. 2010 Feb
4;340:c309.
Berenholtz SM, Pham JC, Thompson DA, Needham DM, Lubomski LH,
Hyzy RC, Welsh R, Cosgrove SE, Sexton JB, Colantuoni E, Watson SR,
Goeschel CA, Pronovost PJ. Collaborative cohort study of an intervention
to reduce ventilator-associated pneumonia in the intensive care unit. Infect
Control Hosp Epidemiol. 2011 Apr;32(4):305-14.
www.onthecuspstophai.org
37
Armstrong Institute for Patient Safety and Quality
References-4
Slide 10
www.onthecuspstophai.org
Slide 12
Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden
C. Improving communication in the ICU using daily goals. J Crit Care.
2003 Jun;18(2):71-5.
Slide 13
Berenholtz SM, Pham JC, Thompson DA, Needham DM, Lubomski LH,
Hyzy RC, Welsh R, Cosgrove SE, Sexton JB, Colantuoni E, Watson SR,
Goeschel CA, Pronovost PJ. Collaborative cohort study of an intervention
to reduce ventilator-associated pneumonia in the intensive care unit. Infect
Control Hosp Epidemiol. 2011 Apr;32(4):305-14.
38
Armstrong Institute for Patient Safety and Quality
References-5
Slide 14
Berenholtz SM, Pham JC, Thompson DA, Needham DM, Lubomski LH,
Hyzy RC, Welsh R, Cosgrove SE, Sexton JB, Colantuoni E, Watson SR,
Goeschel CA, Pronovost PJ. Collaborative cohort study of an intervention
to reduce ventilator-associated pneumonia in the intensive care unit. Infect
Control Hosp Epidemiol. 2011 Apr;32(4):305-14.
Slide 15
Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock
LL, Pronovost PJ. Impact of a statewide intensive care unit quality
improvement initiative on hospital mortality and length of stay: retrospective
comparative analysis. BMJ. 2011 Jan 28;342:d219.
Waters HR, Korn R Jr, Colantuoni E, Berenholtz SM, Goeschel CA,
Needham DM, Pham JC, Lipitz-Snyderman A, Watson SR, Posa P,
Pronovost PJ. The business case for quality: economic analysis of the
Michigan Keystone Patient Safety Program in ICUs. Am J Med Qual. 2011
Sep-Oct;26(5):333-9.
39
Armstrong Institute for Patient Safety and Quality
References-6
Slide 18
Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R; CDC; Healthcare
Infection Control Practices Advisory Committee. Guidelines for preventing
health-care-associated pneumonia, 2003: recommendations of CDC and
the Healthcare Infection Control Practices Advisory Committee. MMWR
Recomm Rep. 2004 Mar 26;53z(RR-3):1-36.
American Thoracic Society; Infectious Diseases Society of America.
Guidelines for the management of adults with hospital-acquired, ventilatorassociated, and healthcare associated pneumonia. Am J Respir Crit Care
Med. 2005 Feb 15;171(4):388-416.
Muscedere J, Dodek P, Keenan S, Fowler R, Cook D, Heyland D; VAP
Guidelines Committee and the Canadian Critical Care Trials Group. J Crit
Care. 2008 Mar;23(1):138-47.
40
Armstrong Institute for Patient Safety and Quality
References-7
Slide 18, continued
Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ,
Burstin H, Calfee DP, Dubberke ER, Fraser V, Gerding DN, Griffin FA,
Gross P, Kaye KS, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA,
Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS.
Strategies to prevent ventilator-associated pneumonia in acute care
hospitals. Infect Control Hosp Epidemiol. 2008 Oct;29 Suppl 1:S31-40.
Slide 19
Zolfaghari PS, Wyncoll DL. The tracheal tube: gateway to ventilatorassociated pneumonia. Crit Care. 2011;15(5):310. Epub 2011 Sep 29.
Speck K. Not published. The Johns Hopkins University School of
Medicine.
Calleamanecer (Own work) [CC-BY-SA-3.0
(http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
http://commons.wikimedia.org/wiki/File%3AClinicians_in_Intensive_Care_U
nit.jpg
41
Armstrong Institute for Patient Safety and Quality
References-8
Slide 20
ETT endotrachael tube; HME heat moist exchanger; NIVV noninvasive ventilation
Slide 21
Lancet 2009; 373: 1874–82
42
Armstrong Institute for Patient Safety and Quality
References-9
Slide 27
J Crit Care 2008;23:207-22; Crit Care Med 2011;39(5):1-6
Slide 28
Jt Comm J Qual Patient Saf 2010;36:252-60
Resources: www.safercare.net
Slide 29
J Crit Care 2003;18(2):71-75
43
Armstrong Institute for Patient Safety and Quality