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CUSP for VAP: Year in Review. Sean Berenholtz, MD, MHS Kathleen Speck, MPH The Armstrong Institute for Patient Safety and Quality February 6, 2014. CUSP for VAP: Project Review. NIH/NHLBI and AHRQ funded project

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CUSP for VAP: Year in Review


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    1. CUSP for VAP: Year in Review Sean Berenholtz, MD, MHS Kathleen Speck, MPH The Armstrong Institute for Patient Safety and Quality February 6, 2014

    2. CUSP for VAP: Project Review • NIH/NHLBI and AHRQ funded project • Individual hospitals participate for 3 years, including 2 year intervention period and 1 year sustainability period • Leveraging leaders in field • Armstrong Institute for Patient Safety and Quality, NIH/NHLBI, CDC, AHRQ, University of Pennsylvania • Maryland Hospital Association • Hospital and Healthsystem Association of Pennsylvania

    3. Project Goals • Our objectives were: • To achieve significant reductions in VAE rates • To achieve significant improvements in safety culture utilizing the components of CUSP • To advance the science of VAP prevention utilizing: • - Updated VAP prevention bundle • - New CDC NHSN VAP definition • - Identification of contextual variables that foster/impede the implementation of QI projects

    4. How Will We Get There? • Key concepts: Adaptive and Technical Work

    5. Why Safety Culture Matters? Safety culture is related to outcomes Patient outcomes Patient care experience Infection rates, sepsis Postop. hemorrhage, respiratory failure, accidental puncture/laceration Treatment errors Clinician outcomes Incident reporting, burnout, turnover Huang et al., 2010; Mardon et al., 2010; MacDavitt et al., 2007; Singer et al., 2009; Sorra et al., 2012; Weaver, 2011.

    6. Why Safety Culture Matters? Safety culture influences the effectiveness of other safety and quality interventions Can enhance or inhibit effects of other interventions Safety culture can change through intervention Best evidence so far for culture interventions that use multiple components Haynes et al., 2011; Morello et al., 2012; Van Nord et al., 2010; Weaver et al., in press

    7. Technical Work • Project currently in 2nd year of implementation phase • We have introduced the following VAP prevention measures to reduce VAE rates: • - Process Measures • HOB • Sub-G ETT • Oral care • Oral care with CHG • SAT • SBT • - Early Mobility

    8. Adaptive Work • We have introduced the following CUSP tools: • - CUSP Components • Science of Safety • Learning from Defects • Engaging Senior Executives & Leadership • Daily Goals • Culture Checkup • Shadowing • Daily Briefing • Barrier identification and Mitigation

    9. Project Resources • VAP Tools • https://armstrongresearch.hopkinsmedicine.org/vap/vap/resources.aspx • CUSP Tools • https://armstrongresearch.hopkinsmedicine.org/vap/cusp/resources.aspx • Recordings and Slide Presentations for CUSP and VAP Webinars • https://armstrongresearch.hopkinsmedicine.org/vap/calls.aspx

    10. MD and PA Teams Are Engaged: MedConcert Teams have shared tools and protocols via MedConcert: • Holy Cross Hospital MICU– Noon Charge Nurse Update Protocol • University of Maryland Shore Health Hospitals - ABCDE Protocol • Johns Hopkins Hospital WICU – VAP Family Involvement Sign-In Protocol • Western Maryland Health System – Vent Weaning Protocol • Meritus Medical Center – Vent Weaning Pocket Protocol • St. Agnes Hospital – Flow Sheet, Mechanical Vent Weaning Protocol, Mechanical Vent Management Protocol, Drug Administration Protocol • Maryland Hospital Association - VAP Talking Points Document MedConcert Link: • https://www.medconcert.com/

    11. MD and PA Teams Are Engaged:Content/Coaching Call Participation Teams have presented their experiences on CUSP/VAP content/coaching calls: • St. Agnes Hospital AICU - Early Mobility • Magee Rehabilitation Hospital SCI - Early Mobility • Troy Hospital ICU – Early Mobility • Johns Hopkins Hospital WICU – Learning from Defects • Prince George’s Hospital ICU – PreMortem • Johns Hopkins Bayview Medical Center MICU – PreMortem • Sinai Hospital of Baltimore ICU - PreMortem

    12. MD and PA Teams Are Engaged:Exposure Receipt Assessment Pilot Teams have helped to pilot the Exposure Receipt Assessment and provided feedback: • Western Maryland Health System CVU and ICU • MedStar St. Mary's Hospital ICU • Meritus Medical Center CCU • Doylestown Hospital ICU • St Joseph's Hospital ICU • Brandywine Hospital ICU

    13. MD and PA Teams Are Engaged:Early Mobility Helped to develop the Early Mobility Data Collection Instrument • St. Agnes Hospital AICU • Magee Rehabilitation Hospital SCI • Troy Hospital ICU Helped to pilot the Early Mobility Data Collection Instrument • Johns Hopkins Hospital WICU, SICU, CVSICU

    14. MD and PA Teams Are Engaged:Video Submissions • Teams have shared stories via video submissions:

    15. Reports: 2013 – A Year in Review

    16. REPORTS • Report highlights from of several assessments in 2013: • Summary Reports (Process Measure Data) • VAE Rates • Structural Assessment • Exposure Receipt Assessment – Pilot • Quarterly Interviews

    17. Compliance Reports: VAP Daily Process Measures (Q1-Q3 2013) * The P-value was obtained by performing a Fisher’s Exact Test. Table 1: Compliance Report for Daily Process Measures

    18. Completion Rates: VAP Daily Process Measures (Q1- Q3 2013) Break from data collection Table 2: Completion Rates on Daily Process Measure Data Entry

    19. VAE Rates: VAC (Q2-Q4 2013) Per 1000 Vent Days Figure 1 & Table 3: VAC Rate Per 1000 Ventilator Days

    20. VAE Rates: IVAC(Q2-Q4 2013) Figure 2 & Table 4: Total IVAC Rate Per 1000 Ventilator Days

    21. VAE Rates: VAP [PoVAP + PrVAP](Q2-Q4 2013) Figure 3 &Table 5: Total VAP Rate Per 1000 Ventilator Days

    22. Completion Rate: VAE Rate Registry Data (Q2–Q4 2013) Proportion of months with VAE data Figure 4 & Table 6: Total VAP Rate Per 1000 Ventilator Days

    23. Structural Assessment: Oct. 2012 – Jan. 2013 (n=36) Baseline • MD = 21 units (58.3%) • PA = 15 units (41.7%) Results Reported • 31.4% changing their ventilator circuits routinely • 60% changing their suctioning systems routinely • 85.3% used the orotracheal route for elective intubation in absence of difficult airway • 85.3% used a closed suction system with endotracheal tubes • 97.1% have policies for using precautions when suctioning, with 88.9% using these elements • 91.2% have policies for using hand hygiene, with 86.1% using these elements

    24. Structural Assessment: Oct. 2012 – Jan. 2013 (n=36) Results Reported • 13.9% used prophylactic IV antibiotics for VAP • 70.6% used policies against non-essential tracheal suctioning, with 16.7% using these elements • 94.1% used policies against supine positioning, with 16.7% using these elements • 67.7% have policies against gastric over-distention, with 0% occurrence • 71.9% had policies regarding performing condensate draining, with 41.7% using these elements • 57.1% used noninvasive ventilation, 44.1% had policies promoting its use • 33.3% used early mobility, 41.2% had policies promoting its use

    25. Exposure Receipt Assessment Pilot • Evaluates the penetrance of the CUSP and VAP interventions to front-line staff • Anonymous assessment • Completed by staff with direct patient care on the unit for only one shift • Piloted by 5 teams in MD and PA • Results divided into 4 domains: • Response Rate on Assessment • Distribution of Participants • CUSP Components • VAP Components

    26. Exposure Receipt Assessment Pilot: Familiarity with CUSP Components (Nov. 2013) Figure5: Reported Familiarity with CUSP Components of Intervention

    27. Exposure Receipt Assessment Pilot: Training on VAP Toolkit (Nov. 2013) Figure6: Reported Training on VAP Prevention Toolkit in Unit

    28. Quarterly Interviews:Frequent Barriers to Progress (Q1 2013) Table 7. Barriers Reported as Being Frequent or Always

    29. REPORTS SUMMARY 2013 • Highlights from of several assessments • including Summary Reports (Process Measure Data), VAE Rates, Structural Assessment, Exposure Receipt Assessment Pilot, Quarterly Interviews • Your Unit’s reports are available on CECity platform • Can be utilized for • Increasing communication with your team members and front-line staff • Illustrating your unit’s progress to your senior executive partner • Sharing your performance and progress on VAE prevention with your hospital administrators

    30. Your work makes a difference!CUSP4MVP-VAP National Project Overview

    31. MD and PA Work Influenced the CUSP4MVP-VAP National Project • Based on your feedback • Changing approach for incorporating CUSP into our QI project • Revising tools (i.e. quarterly interview, early mobility pilot, exposure receipt assessment pilot) • Including objective outcome measures • Focus on sedation and delirium management

    32. CUSP4MVP-VAP: Participating CEs • Coordinating Entities (CEs) for Cohort 1 of CUSP4MVP-VAP National Project • Iowa • Michigan • New Jersey • Oklahoma • Pennsylvania • South Carolina • Tennessee • Texas • UHC

    33. CUSP4MVP-VAP: MD and PA Opportunities • MD and PA opportunities with National Project: • - Joining National Project content calls for continued education on CUSP and VAE prevention • - Share your experience on content/coaching calls: • as implementation experts • to discuss implementation successes and barriers

    34. CUSP4MVP-VAP: Content Call Schedule Date: First Tuesday of every month (* Please note that this call does not follow the regular content call schedule) Time: 2pm EST Webinar Link: CUSP4MVP-VAP Content Calls Call-in Information: 1-877-668-4493; Access code: 667 844 665

    35. Additional Resources • Society for Critical Care Medicine ICU Liberation Group • http://www.iculiberation.org/Pages/default.aspx • AHRQ CUSP Toolkit • http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/ • Armstrong Institute CUSP Tools • http://www.hopkinsmedicine.org/armstrong_institute/training_services/cusp_offerings/cusp_guidance.html • Armstrong Institute Training Opportunities • http://www.hopkinsmedicine.org/armstrong_institute/training_services/cusp_offerings/

    36. Next Steps

    37. Next Steps • Collect Early Mobility data(January – March) • Complete Exposure Receipt Assessment (February) • Complete 2ndHSOPS (March) • Begin data collection sampling strategy between process measures and early mobility (April) • Begin data collection for Low Tidal Volume Ventilation measure (August)

    38. Data Collection Sampling Strategy: Begins April 1st

    39. Enhancing Support for MD and PA Teams • Objective Outcome Data - Armstrong will analyze your data for outcome measures if you provide it • decreasing duration of mechanical ventilation • decreasing hospital length of stay • decreasing mortality • How do we enhance horizontal learning? • What can the AI/MHA/HAP team do to better support you?

    40. 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!