Beyond VAP:
Identifying areas for improvement to prevent
ventilator-associated conditions
Partnership for Patients
Quality and Patient Safety Conference
April 30, 2013
Michael Klompas MD, MPH, FRCPC, FIDSA
Harvard Medical School, Harvard Pilgrim Health Care Institute, and
Brigham and Women’s Hospital, Boston, MA
Disclosures
Honoraria from Premier Healthcare Alliance
Outline
1. Ventilator-associated events – a patient safety opportunity
2. Zero VAC – where do we start?
3. The problem with current ventilator bundles
4. The promise of better weaning & sedation strategies
5. The CDC Prevention Epicenters’ Wake Up & Breathe Collaborative
6. Lessons learned
Ventilator-associated events
• VAP – subjective, inaccurate, and rare
• VAC – simple and objective – seeks all complications of
mechanical ventilation, not just pneumonia.
• Most cases due to:
•
•
•
•
Pneumonia
Pulmonary edema
ARDS
Atelectasis
• VAC is a strong predictor of poor outcomes (increased
ventilator days, hospital days, and mortality)
Ventilator-associated event surveillance
A patient safety opportunity
Increase Awareness
• VAC surveillance provides hospitals with a fuller picture of
complications in mechanically ventilated patients
Catalyze Prevention
• A significant portion of VACs are likely preventable
Reflect and Inform Progress
• VAC surveillance provides an efficient and objective yardstick
to track one’s progress relative to oneself and to peers
Where do we start?
Image from http://img.ehowcdn.com/article-new/ehow/images/a07/86/tp/increase-torque-cars-rear-end-800x800.jpg
VAP Prevention Measures
Impact on
VAP Rates
 78%
Head-of-bed elevation
Regular oral care with chlorhexidine
 40-60%
Daily interruption of sedation
 64%
Daily assessment of readiness to extubate
 10%
Continuous aspiration subglottic secretions
 37-75%
Silver coated endotracheal tubes
 36%
Am J Respir Crit Care Med 2006;174:894
Lancet 1999;354:1851
BMJ 2007;334:889
JAMA 2008;300:805
NEJM 2000;342:1471
Crit Care Med 2004;32:1272
Chest 2000;118:459
Ann Intern Med 1995;122:179
But VAP diagnoses are unreliable.
Can we trust the VAP reduction rates
reported in the literature?
Silver Coated Endotracheal Tubes
VAP Rates and Outcomes
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
0
JAMA 2008;300:805-813
Silver coated ETTs
Lengths of Stay (days)
VAPs per 100 Patients
Conventional ETTs
Oral antiseptics & outcomes
VAP
Vent days
ICU days
Mortality
Antiseptics
protective
Antiseptics
harmful
Chan et al., BMJ 2007;334:889
The VAP Prevention Paradox
VAP
Rates
Vent
LOS
ICU
LOS
Hospital
LOS
Death
Head-of-bed elevation
Regular oral care with
chlorhexidine
Silver-coated
endotracheal tubes
Klompas, Critical Care 2009;13:315
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
What does work?
Vent
LOS
Sedative interruption
Readiness to extubate
Sedative interruption
AND
Readiness to extubate
ICU
LOS
Hospital
LOS
Mortality
Daily Interruption of Sedation
*
10.0
8.0
Days
Daily interruption
Usual Care
NS
*
5
4
3
6.0
4.0
2
2.0
Cases of VAP
N=128
1
0
0
Duration of
Ventilation
ICU
Stay
VAP
Cases
Kress, NEJM 2000:342:1471
Schweickert, Crit Care Med 2004;32:1272
Daily Interruption of Sedation &
Daily Spontaneous Breathing Trials
Daily sedative interruption
AND
spontaneous breathing trial
N=168
Outcome
Daily
spontaneous breathing trial
alone
N=168
Impact
P
Time on Ventilator
3.1 days .02
ICU Length of Stay
3.8 days .01
Hospital Length of Stay 4.3 days .04
Mortality at 1 year
32%
.01
Girard, Lancet 2008;371:126
Slide courtesy of Wes Ely
One year survival
100
Patients Alive (%)
80
60
SAT+SBT (n=167)
40
Usual Care+SBT (n=168)
20
p=.01
0
0
60
120
180
Days
240
300
360
Girard TD, et al. Lancet 2008;371:126-34
Improving Sedation Management
A good strategy to prevent VACs?
Sedation and prolonged mechanical ventilation are both
important risk factors for multiple complications of intensive
care
•
•
•
•
•
•
Pneumonia
ARDS
Pneumothorax
Pulmonary edema
Delirium
Kidney dysfunction
• GI bleeding
• Bacteremia
• Thromboembolic
disease
• Cholestasis
• Sinusitis
Sedative interruption adherence poor
• Daily sedative interruptions are a component of most
ventilator bundles but audits suggest that in practice
interruptions are only done about 25-50% of the time
• e.g. Brigham and Women’s Hospital, Boston, 2011
• Sedative interruption 54% of sedative-days
• Contraindication marked 31% of sedative-days
• List of contraindications liberal
•
Included “high ventilator requirements” (40%),
“weaning from high sedative dose” (16%), and
“hemodynamic instability” (22%)
Klompas, Unpublished Data
Are we unduly cautious
with sedative interruptions?
• 140 patients randomized to routine sedation versus no sedation
•
•
•
•
70 prescribed routine sedation (propofol then midazolam)
70 prescribed no sedation
Morphine boluses permitted for both groups PRN
Unblinded
• Patients with no sedation
•
•
•
•
Mean 4.2 (95% CI 0.3-8.1) fewer days on the vent
Shorter ICU stay (HR 1.86, 95% CI 1.1-3.2)
Shorter hospital stay (HR 3.6, 95% CI 1.5-9.1)
More agitated delirium (20% versus 7%) but no difference in
self-extubations
Strøm et al. Lancet 2010;375:475
The CDC Prevention Epicenters’
Wake Up and Breathe
Collaborative
The CDC Prevention Epicenters’
Wake Up and Breathe Collaborative
13 ICUs from 8 hospitals








Stroger Cook County Hospital
Missouri Baptist Medical Center
Duke University
Durham VA
Durham Regional Hospital
North Shore Union
North Shore Salem
Hospital of the University of Pennsylvania
Goal: prevent ventilator associated complications through less
sedation and earlier liberation from mechanical ventilation
Mechanism: paired daily spontaneous awakening trials and
breathing trials (SATs and SBTs)
Collaborative Components
All Teach – All Learn Model
Each participating unit has designated RN, RT, and MD champions
Monthly written reports by each ICU –
 Progress, challenges, successes, and failures from the
preceding month
 Goals for the forthcoming month
Monthly collaborative phone calls for all champions
Monthly data feedback and benchmarking
Collaborative facilitated by a CDC “improvement advisor”
Two in-person meetings at CDC for all champions held April 2012
(kick-off) and October 2012 (consolidation)
Expert advice from CDC, Institute for Healthcare Improvement,
and consulting faculty
Lessons Learned
1. Get the right people on the bus
2. Educate, educate, and re-educate
3. The spirit of the law matters more than the letter of the law
4. Assess performance not just documentation
5. It’s a marathon not a sprint
6. Choose the denominator that fits the intervention
7. Wake up and walk
Get the right people on the bus
Chief Quality Officer
Chief
Nursing RT Champion
Officer
Frontline RTs
ICU
Medical
Director
Night Staff
Day Staff
Local
Opinion
Leaders
Pharmacists
Frontline Nurses
MD Champion ICU
Nursing
Director
Chief
Medical
Officer
RN Champion
Head of
Respiratory Therapy
Frontline Doctors
Unit Clerk
Image from http://www.kerrvilleisd.net/files/bus_cartoon_tilt.gif
Educate, educate, & re-educate
Never assume that everyone knows about the protocol
Never assume that everyone understands the protocol
Never assume everyone agrees with the protocol
Use both formal and informal teaching methods
• In-services, postings, articles, lectures
• Ask colleagues for their impressions, seek hallway
discussions, bring it up at morning rounds
The Spirit of the Law Matters
More than the Letter of the Law
Our goal is not to perform SATs per se but to minimize the
use of sedatives and speed extubation
SATs and SBTs are a means, not an end
“Conclusion: For mechanically ventilated adults
managed with protocolized sedation, the addition
of daily sedation interruption did not reduce the
duration of mechanical ventilation or ICU stay.”
Mehta et al. JAMA 2012;308(19):1985-92
Midazolam Equivalents
Total Midazolam (mg) per Patient
Control
SAT
20000
18000
16000
14000
12000
10000
8000
6000
4000
2000
0
Kress 2000
Girard 2008
Mehta 2012
Fentanyl Equivalents
Total Fentanyl (mg) per Patient
Control
SAT
20000
18000
16000
14000
12000
10000
8000
6000
4000
2000
0
Kress 2000
Girard 2008
Mehta 2012
Boluses Per Day in Mehta et al.
Control
SAT
2.5
2
1.5
1
0.5
0
Midazolam
Fentanyl
Assess Performance as well as Documentation
100%
80%
60%
40%
SATs (performed/indicated)
20%
0%
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Assess Performance as well as Documentation
100%
80%
60%
40%
SATs (performed/indicated)
20%
SATs (performed/sedative days)
0%
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
It’s a marathon not a sprint
Image from http://media.mediapost.com/images/inline_image/2012/01/27/Boston-Marathon-B.jpg
SAT Performance, ICU X, June 2012 – March 2013
100%
80%
60%
40%
20%
0%
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
SAT Performance, ICU Y, June 2012 – March 2013
100%
80%
60%
40%
20%
0%
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Chose a denominator
that fits the intervention
• The traditional metric for hospital-acquired infections is
infections per 1000 device-days or patient days
• What if your intervention, however, is specifically
designed to reduce device days?
Absolute Counts: VACs
Number of VACs per Month
14
12
10
8
6
VACs
4
2
0
Jun
Jul
Aug Sep
Oct
Nov Dec Jan
Feb Mar
Absolute Counts: VACs and Vent Days
1000
900
12
800
10
700
600
8
500
6
400
VACs
Vent Days
4
300
200
2
100
0
0
Jun
Jul
Aug Sep
Oct
Nov Dec Jan
Feb Mar
Number of Ventilator Days per Month
Number of VACs per Month
14
VACs per 1000 Ventilator Days
VACs per 1000 Ventilator Days
14
12
10
8
6
VACs per 1000 vent days
4
2
0
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
VACs per 1000 Ventilator Days vs
VACs per 100 Episodes of Mechanical Ventilation
VACs per 1000 Ventilator Days
14
12
10
8
6
VACs per 1000 Vent Days
4
VACs per 100 Episodes
2
0
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Early mobility – Wake Up & Walk!
Increasing evidence that
early mobilization speeds
extubation and decreases
ICU length of stay
May also help prevent
atelectasis & delirium
As with improved sedative
management and weaning
protocols, less time on vent
means less time at risk for
VACs
http://69.36.35.38/images/CHESTPhysician/Crit
CareCom0610Fig2.jpg
Lord et al., Crit Care Med 2013;41:717
Schweickert et al., Lancet 2009;373:1874
Needham et al., Arch Phys Med Rehabil 2010;91:536
Summary
VAE surveillance is a patient safety opportunity
Spontaneous awakening trials and spontaneous breathing trials
decrease ventilator days, hospital days, and mortality.
• Maybe SATs and SBTs can also lower VAC rates!
Lessons learned from the CDC Prevention Epicenters’
Wake Up and Breathe Collaborative:
•
•
•
•
•
•
•
Get the right people on the bus
Educate, educate, and re-educate
The spirit of the law matters more than the letter of the law
Assess performance as well as documentation
It’s a marathon not a sprint
Choose a denominator that fits the intervention
Wake up and walk!
Thank You!
Michael Klompas (mklompas@partners.org)