October 4, 2010
Mayer Brezis, MD MPH
Professor of Medicine
Center for Clinical Quality & Safety

Ventilator-Associated Pneumonia
(VAP)
Project aim: reduce VAP incidence at Hadassah
Inna Apelbaum, Nurit Katz, Dr. Philip Levine, Dr. Shmulick Benenson,
Carmela Shwartz, Prof. Colin Block, Lois Gordon, Prof. Mayer Brezis
General Intensive Care, Unit for Infection Control and the Center for Clinical Quality and Safety

Recommendations Rated
With High Level of Evidence
ICHE 2008

1.
The incidence of VAP at Hadassah is higher than what is reported in the literature.
2.
The adherence to guidelines for VAP prevention is lower than desirable.
3.
How can adherence to guidelines be improved?

Elevating the head of the bed between 30 o - 45 o

Hand hygiene by staff before and after contact with ventilator, patient and patient ’s belongings

Oral hygiene including brushing

Discontinuation of sedation once a day

Intervention
Findings discussed with staff
• Review of guidelines at staff meetings
• Emails 30 o 45 o ןיב םרומ הטימה שאר לוהוכלא תסימתב וא ןובסו םימב םיידי תנייגיה עוציב
• Signs
• Posters
רישכמב םיעגונש ירחאו ינפל
ויצפחו לפוטמב , המשנהה
• Buttons
• Screensaver
ןיעל הארנה ךולכלו תושרפהמ הייקנ המשנהה תרנצ םייניש חוצחצ םע ןידיסקהרולכ תסימתב תרמשמ לכ הפ לופיט
Re-evaluation scheduled for early 2010

Periods of observation :
Pre Intervention:
February – March 2009
Post Intervention:
February – March 2010

2009
Department
ICU A
ICU B
Neurosurgical ICU
Medical ICU
Total
Intern. Medicine A
Intern. Medicine B
Intern. Medicine C
Neurology
Total
Mean ventilation days/pt.
12
11
16
10
12
Ventilation days during period
(observed for processes)
N of ventilated patients during observation period
449 (187)
175 (78)
195 (86)
220 (81)
1039 (432)
32
19
11
17
79
11
10
9
14
11
212 (79)
139 (55)
238 (106)
29 (13)
618 (253)
17
13
25
2
57

2010
Department
ICU A
ICU B
Neurosurgical ICU
Medical ICU
Total
Intern. Medicine A
Intern. Medicine B
Intern. Medicine C
Neurology
Total
Mean ventilation days/pt.
12
8
4
6
7
Ventilation days during period
(observed for processes)
N of ventilated patients during observation period
128 (58)
73 (34)
23 (11)
11
9
6
84 (41)
308 (144)
13
39
13
9
9
9
9
50 (23)
64 (29)
57 (25)
80 (33)
251 (110)
9
9
4
7
29

Adherence to VAP prevention guidelines
Department
ICU A
ICU B
Neuro ICU
Medical ICU
Total
% Head of bed ≥ 30 o % Ventilator tubing clean
2009 2010 (

) 2009
59 62 74
58 40 75
32
54
53%
91
41
*
55%
68
72
72%
Medicine A
Medicine B
Medicine C
Neurology
Total 39%
 for stable patients only
36
37
37
62
78 *
69 **
52
70
68% *
71
68
69
92
75%
* p<0.001 ** p<0.01

Adherence to hand hygiene (nurses)
Hands washed before contact (%)
Hands washed after contact (%)
Department 2009
ICU A 35
ICU B
Neuro ICU
33
30
Medical ICU
Total
35
33%
2010
86*
76*
55
85*
75%*
2009
54
52
39
47
47%
2010
91*
91*
82**
93*
91%*
Medicine A
Medicine B
Medicine C
Neurology
Total
29
27
26
23
28% 34%
* p<0.001 ** p<0.01
35
34
36
30
39
37
38
62
39%
57
62**
68**
48
58%*

Hand hygiene (respiratory technicians)
Hands washed before contact (%)
Hands washed after contact (%)
Department 2009
ICU A 12
ICU B
Neuro ICU
13
8
Medical ICU
Total
11
11%
2010
26
23
27
39
29%*
2009
58
59
45
55
54%
2010
58
62
63
71
63%**
Medicine A
Medicine B
Medicine C
Neurology
Total
10
9
9
15
26
34
32
27
10% 30%*
* p<0.001 ** p<0.05
48
46
47
38
47%
65
65
72
63
66%*

Diagnostic criteria for VAP

Department
Rates of VAP: 2009 & 2010
Patients observed
Ventilation days
Cases of VAP
Percent developing VAP
VAP cases/1000 ventilation days
ICUs
43
827
15
35%
18 ‰
Medicine
24
296
5
21%
17 ‰
Patients observed
Ventilation days
Cases of VAP
Percent developing VAP
VAP cases/1000 ventilation days
41
711
13
32%
18 ‰
19
383
7
37 %
18 ‰
60
1094
20
33%
18 ‰
Mean cases/1000 ventilation days in literature* 11 ‰
(95%CI, 10-13)
* Chest 2008 ( before interventions, down by 50% after interventions)
Total
67
1123
20
30%
18 ‰

Rate of VAP per 1000 ventilation days
Adherence to VAP Guidelines 2009
Department
ICU A
ICU B
Neuro ICU
Medical ICU
Total
Medicine A
Medicine B
Medicine C
% Head of bed ≥ 30
Department
2009 2010 (

) o N of days Rate of
VAP ‰
ICU A
ICU B
62
40
91 *
594 19
17
53% 55%
Medical ICU
Total
78 *
69 **
52
176
%
57
827
18
18 ‰
24

Neurology
Total 39% 68% *
Medicine B for stable patients only
Medicine C
5%
108
* p<0.001 ** p<0.01
104
9
19
Neurology
Total
0
296 17 ‰
2010
N of days observed
Rate of
VAP ‰
252
124
24
8
53
282
711
0
21
18 ‰
48
75
95
165
383
21
13
21
18
18 ‰

1.
Adherence to VAP prevention guidelines has somewhat improved but remains lower than desirable.
2.
The incidence of VAP remains higher than that reported in the literature.
3.
Reactions from teams:
• “We don’t believe your data”
• “You lie and mislead”
• “Our patients are sicker”
• “We need more staff”
• “We need more equipment”
• “We need to look into this issue”
• “We should have a checklist to increase adherence to guidelines”
• “We should introduce a protocol of daily sedation cessation”
• “We will build an algorithm for VAP diagnosis”

Ventilator-Associated Pneumonia
Last VAP
SICU: Jan. 1, 2008
CICU: January 15,
2010*
*Prior to 1/15/10, the last
CICU VAP was on 3/24/08, or
621 days

VAP: The Beginning (2001)
• Do we have a problem?
• IHI Conference: VAP Prevention Bundle
• BUDAS: B ed up, U lcer prophylaxis, D VT prophylaxis, A nemia, S edation wake-up
• VAP Workgroup: Critical Care Medical Director,
Infection Control, CNS, Respiratory Therapy
– Consistent definition for VAP
– Policies & procedures
– Equipment & supplies
– Intensivists
– Education of RNs & RTs

VAP Initiatives (2002-2004)
• BUDAS
• Intensivist Co-Attending Model
• Multidisciplinary Rounds
– Reviewed components of BUDAS
– Reinforced education
• Education of ICU RNs & RTs
• Hand cleanser dispensers
• Monthly compliance review by Critical Care
Medical Director
• Critical Care Committee
– Informed physicians of EBP changes

Compliance with BUDAS

Process Improvements (2004)
• Daily multidisciplinary rounds (7 days a week)
• Chart documentation
• Physician contracting
Multidisciplinary Rounds
Pt seen with:
{ }Nursing { }Pharmacy { }Rehab Services
{ }Resp Therapy { }Nutrition { }MSW
Pt summary:
PUD Y N NA DVT Y N
NA
HOB Y N NA Sed WU Y N
NA
New Findings:
Goals:
Recommendations:
Pharmacy
Nutrition
Other
Follow up:

Cycles of Improvement
2005 Reported BUDAS compliance by individual component
2006 Improved oral care, added chlorhexidine rinse
2007 Opened MCR with best practices from PVH
Switched to oral gastric tubes
2008 Reinforced standard procedure, chlorhexidine has to be after toothbrushing, storage of Yankauer, deep oralpharyngeal suctioning
2009 Introduced silver-coated endotracheal ETT (IHI 5
Million Lives Campaign)
New approach: Root cause analysis for each VAP

Lessons Learned
• Small incremental improvements based on audit data, literature & outcomes
• Education, education, education
– Posters, case studies, self-learning packets, face to face
• Physician engagement
– Partner with physician champion
• Staff engagement
– Engage staff in solving problem
– Post rates in each ICU
– Rates = reflection of THEIR practice

Roni Cohen, B.Sc., Inbal Yifrach-Damari, M.Sc.*
Dr. Meir Frankel, Prof. Mayer Brezis
Hadassah-Hebrew University Hospital, Jerusalem, Israel
* Clinical Pharmacist, Hadassah Pharmacy Services
PhD student, School of Pharmacy, Hebrew University
With Help From Joint Commission International


Medication errors are the fourth leading cause of death or major permanent loss of function in hospital patients.

The majority of problems with patient safety occur during the transition from one care setting to another.

Ambulatory-hospital lack of communication is responsible for
50 % of medical errors.

To improve patient safety, the Joint Commission on
Accreditation of Healthcare Organizations now recommends a procedure designed to minimize errors.

Obtaining a complete and accurate list of each patient ’s medications.
Documenting EVERY change:
Before the patient moves on, the physician must decide about each drug:
CONTINUE DISCONTINUE
This way, no drug is forgotten !
Drugs include: ‘over-the-counter’ medications, topical medications, eye drops, vitamins, herbal medications and ‘occasional’ medications.


Over 100 adult patients admitted to the ER, on at least
5 regular drugs, underwent medication reconciliation.

Review of medications with patient, family, primary physician and/or database of HMOs (sick funds).

After 24-48 hours, we checked the list of medications prescribed to the patient by the ward staff.

Our list was then compared with the list in the ward.

If any discrepancy was observed or an error was suspected, the staff was approached to clarify the reason for the change.

In 97% of our patients, an error / intervention was found on admission, during hospitalization or at discharge.
On average: 7 mistakes / interventions per patient
Pharmacological interventions in 85%
Med-Rec interventions in 87%
On average: ≈ 3 mistakes / interventions per patient, of any kind

At least one error was found in 73% of the patients
Enalapril and ramipril were both prescribed in the ward.
11%
5%
19%
5%
11%
19%
Antiepileptic drug, taken at home, was not continued in the ward.
65%
65%
Captopril was prescribed to a patient only once a day
(instead of 3 times a day).
Hydralazine was written for no reason.
Unexplained discrepancies in medication
Unexplained discrepancies in medication
Double treatment / contraindications
Wrong dosage /frequency /route
Wrong dosage /frequency /route
Medication put on hold - not in Hadassah pharmacy

At least one error was found in 65% of the patients
“Pain killers as needed”
11%
6%
Combination of nortriptyline
& citalopram
17% 6%
11%
Propafenone prescribed once a day
(instead of 3 times a day).
10%
Alendronate omitted from discharge letter.
56%
56%
Levothyroxine
(eltroxin) omitted from discharge letter.
Unexplained medication discrepancies
Medications on hold during hospitalization - not included in discharge letter
Wrong dosage /frequency /route
Unclear instructions on discharge letter
Double treatment / contraindications
Unclear instructions on discharge letter

On
Hospitalization
At
Discharge
39% 47%
46% 45%
13.5%
1.5%
7.5%
0.5

At least one error / problem was found in 23% of the patients!
● Nearly all patients had visited primary care physician after discharge.
● 25% of patients were not aware of a change in medication.
● On occasion, an error noted during admission was continued after discharge.

In 85% of patients:
•
Apply correct indications and contra-indications ( ≈ 18% ).
•
Adapt dosage to kidney or liver function ( ≈ 15% ).
•
Drug-Drug Interaction ( ≈ 37% ).
•
Correct administration: After discharge, over 50% of patients were not taking medications correctly.
Polypharmacy

Survey of 100 patients at the Mayo Clinic: Inpatient
Medication Reconciliation in an Academic Setting
American Journal of Health-System Pharmacy 2007
Number of medication discrepancies decreased from 3 per patient in phase 1 to 1.8 per patient in phase 2 (p = 0.003)
Survey of 180 patients at Brigham and Women’s
Hospital, in Boston: Classifying and Predicting Errors of Inpatient Medication Reconciliation. J Gen Intern
Med 2008. Average of 1.5 error per patient with potential for harm.
Solutions included development of special software for adapting prescription to the patient’s provider preferred medications outside hospital.

•
Avoidable mistakes in medications are very common.
About 1% can be life threatening.
•
Drug lists, in the community and in hospitals, are not updated and often fail to reflect the medications that the patient actually takes.
•
A correct medical history can identify errors and can sometimes even shed new light on the cause of hospitalization.
•
Critical changes in medications made during hospitalization are often not implemented after discharge.


At the individual level: have patient bring his/her bag of drugs and carefully review them with him/her.

A clinical pharmacist is very useful, as shown in literature: improvement in outcomes, ↓errors, cost of care & LOS.

Devise a computerized table for medication reconciliation for each patient at each transfer of care provider.
Medication Continue Discontinue Why?
Aspirin

Furosemide
 hypokalemia

Improve IT for transfer of information between Hadassah and outside providers on admission and on discharge.

Monitor quality for continuity of care by measuring quality of handovers within Hadassah wards and with outside.

(III) Follow Up on a Few Other Projects
 Involvement of family during physician’s rounds: conclusion
After discussion of survey findings, a new policy was enacted by the Division of
.

•
• support the idea
Checklist to reduce central lines infections think it improves communication
• and relieves family’s anxiety the use of a checklist (as shown by Pronovost et al, NEJM 2006). help overcome inertia, we proposed to the Ministry of Health to publish guidelines
Findings are consistent with literature with mandatory use and documentation of a checklist. The guidelines were

(III) Follow Up on a Few Other Projects
 Leadership for Quality & Safety
A survey on leadership at Hadassah,* showed that 70% of departments heads and 80% of head nurses, thought it would be appropriate to use as criteria for appointment
(or re- appointment) of a department head, presentation of initiatives on clinical quality & safety.
Such a policy is worthwhile to consider as it would enhance participation of clinical heads in quality & safety and facilitate implementation of improvement initiatives such as on VAP and central line infections.
* Dr. Nurit Porat. The Relationship between the Leadership Style of Hospital
Department Head, Cooperation with Head Nurse, and Climate of Quality and Patient
Safety in General Hospital. PhD thesis, BGU, 2010.

(III) Follow Up on a Few Other Projects
 Disruptive Behavior

Disruptive Behavior
“Do you have disruptive behavior at Hadassah?”
Mark Chassin, MD, MPP, MPH
Professor of Medicine & VP for Excellence
Mount Sinai School of Medicine
President of the Joint Commission
Joint Commission now requires hospitals to have a written code of conduct and a process for enforcing it

Last year exposure to intimidating behavior (%)
Refuses to answer questions/calls
Arrogant tone
Impatience to answer questions
Strong verbal insult
Threatening body language
“Just do it”
Physical violence
Frequently or
Very frequently
9
18
22
9
9
8
0
Sometimes
30
48
41
16
15
16
3
Rarely or Never
60
32
36
73
76
75
97
Didn’t answer
1
1
1
2
1
1
0
Data from 100 MDs & nurses, at Departments of Medicine & Surgery at Ein Kerem and Mt Scopus Hadassah Hospitals

(III) Follow Up on a Few Other Projects
 Disruptive Behavior
Hadassah Quality and Safety Committee has proposed to adopt a code of conduct and a policy for enforcing it with an institutional committee to handle disruptive behavior, using review of cases, sanction for recidivism and education.
Despite several reminders, our suggestion has not been followed.
 Rapid Response Teams (RRT’s)
RRT’s have been shown in some studies to reduce need for coding, morbidity and mortality. Efficacy may depend on local institutional culture. In a survey of intensive care experts and anesthesiologists (N=32), nearly half thought RRT’s might be efficacious at Hadassah. A working team from the Quality and Safety
Committee has proposed to run a pilot project with several departments.
Members of this Committee have commented that the death of a woman from bleeding after a C/S could have been averted by a RRT.
The suggestion to run a pilot has not been followed.

(III) Follow Up on a Few Other Projects
 Transparency
Recent studies suggest that an open disclosure policy after a medical error is useful to restore trust, reduce anger and liability costs and to enhance safety improvement efforts.

A Better Approach to Medical Malpractice Claims?
The University of Michigan Experience
“… an honest, principle-driven approach to claims is better for all those involved — the patient, the healthcare providers, the institution, future patients, and even the lawyers ”

 Survey of members of the Quality & Safety Committee:
9/10 senior clinicians and department heads responded yes, some reported they already work according to a policy of full disclosure. These were from pediatrics, medicine, obgyn and hemato-oncology.
 Survey of 43 department heads:
15 responded yes, 8 of them added they already work according to a policy of full disclosure. These were from pediatrics, pediatric surgery, medicine, and hematology.
2 responded no; 5 asked for more time; the remainder have not replied.
 Based on these preliminary observations, a policy of disclosure appears worthwhile to consider at least with some wards and with the development of a support team in collaboration with RM.