CUSP for VAP : Technical Sustainability It’s almost the last year. What now?

1. CUSP for VAP: Technical SustainabilityIt’s almost the last year. What now? Sean M. Berenholtz, MD MHS FCCM October 2, 2014

2. You might be asking yourself these questions: • What has changed in VAP prevention in the past year? • How can I keep my unit’s focus on VAP prevention and improving the care of mechanically ventilated patients? • What resources are available to me as I enter the last year? and beyond? • What does data collection look like for this final year? and beyond?

3. CUSP for VAP, Goals – Technical Interventions, Daily Process Measures • To prevent the development of ventilator-associated pneumonia (VAP) in mechanically ventilated patients • HOB - Maintain the patient’s head of the bed at 30o or more from the horizontal • Sub-G ETT - Use sub-glottic endotracheal tubes – for patients expected to be intubated for ≥72 hours • Oral Care - Perform oral care 6 times/day – 2 with CHG • SAT - Perform a spontaneous awakening trial (SAT) at least once/day • SBT - Perform a spontaneous breathing trial (SBT) at least once/day

4. National Focus, VAE Prevention – SHEA VAP Prevention Strategies (2014) • Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update1 • “The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates.” • http://www.jstor.org/stable/10.1086/677144

5. Changes in best practices – VAP Prevention to VAE Prevention

6. Oral care with or without CHG2 • Systematic review and meta-analysis of the effectiveness of CHG oral care for the prevention of VAP– 16 studies • No change in duration of mechanical ventilation or ICU or hospital LOS • Exception: cardiac surgery patients • SHEA VAP Prevention Strategies (2014) does not include oral care with CHG as a basic practice to prevent VAP • Many reasons for oral care other than VAP prevention

7. PAD Guidelines3 • Roadmap for developing integrated, evidence-based, patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients • Goals • Ensure that patients are free from pain, agitation, and delirium • Links with SAT/SBT, early mobility protocols and environmental management strategies (to maintain sleep cycle) • SCCM: New PAD Guidelineshttp://www.sccm.org/Communications/Critical-Connections/Archives/Pages/SCCM-Releases-New-Pain,-Agitation-and-Delirium-Clinical-Practice-Guidelines.aspx • AACN: PAD Guidelines: Tools for Implementationhttp://www.aacn.org/wd/cetests/media/Launching%20PAD/PAD%20Guidelines%20Toolkit.pdf

8. PAD Guidelines: Focus on Sedation • Assess or screen using RASS or SAS scales • Every 4 - 6 hours • Set target sedation level during rounds • Target light or no sedation (RASS = -2 to 0, SAS = 3 or 4) • Titrate sedative medications to achieve or maintain target • Use SAT or light sedation for titration • PAD guidelines – VAP Webinar by Dr. Wes Ely, 9/4/2014 https://armstrongresearch.hopkinsmedicine.org/vap/calls.aspx • AACN - PAD Implementation Worksheethttp://www.aacn.org/wd/cetests/media/Launching%20PAD/PAD%20Guidelines%20Toolkit.pdf

9. PAD Guidelines: Focus on Delirium • Assess your patient’s delirium level at least once per day • Use the CAM-ICU or ASE • Training manual and CAM-ICU worksheet located – http://www.icudelirium.org/delirium/monitoring.html • ASE evaluates inattention (the best gauge of delirium) and is Part II of CAM-ICU • Determine whether the patient is positive for delirium • If positive, determine cause – Delirium protocol located http://www.icudelirium.org/delirium/management.html • PAD guidelines – Webinar by Dr. Wes Ely, 9/4/2014 https://armstrongresearch.hopkinsmedicine.org/vap/calls.aspx

10. Pairing SAT with SBT • An SBT should be performed as the patient is undergoing the SAT • Patients can perform better on SBT if their sedation level is minimal • Shortens duration of mechanical ventilation • For a flow chart, see CUSP4MVP-VAP “SAT/SBT Education” https://armstrongresearch.hopkinsmedicine.org/cusp4mvp/processmeasures.aspx • Can be measured as how often SBT is performed off sedation

12. Reducing VAEs & VAPGetting Patients Off Ventilator Faster • Daily process measures • Preventing VAP • Early mobility • Mobilizing ICU patients earlier to reduce complications • Low tidal volume ventilation • Preventing acute lung injury • CUSP • Engaging frontline staff and tapping into their wisdom

13. Process Measures: Daily Evaluation • Use a semi-recumbent position (≥30 degrees) • Use subglottic suctioning endotracheal tube (ETTs) in patients expected to be ventilated for >72 hours • Assess readiness to wean daily with spontaneous breathing trial (SBT) • Use spontaneous awakening trial (SAT) with validated sedation scale daily • Richmond agitation sedation scale (RASS) • Riker sedation agitation scale (SAS)

14. Early Mobility: Daily Evaluation • Assess sedation level at least once/day using a validated sedation scale (RASS or SAS) • Assess delirium level at least once/day using the CAM-ICU or the Attention Screening Exam • Track patient’s highest daily level of mobility • Track perceived barriers to achieving a higher level of mobility daily • Track the involvement of PT or OT in the mobilization process • Track events daily (if needed)

15. Low Tidal Volume Ventilation: Daily Evaluation • Prevent acute respiratory distress syndrome (ARDS) • Use positive end-exploratory pressure ≥5 cm H2O, not ZEEP • Maintain plateau pressure at ≤30 cm H2O • Use tidal volume of 6–8 cc/kg PBW

16. How Can We Get PatientsOff the Ventilator Faster? 61%

17. Gap Between Best Evidence and Practice4 • Knowledge • awareness or familiarity (n=77) • Attitudes • agreement (n=33) • self-efficacy (n=19) • outcome expectancy (n=8) • inertia of previous practice (n=14) • Behavior • external barriers (n=34) 17

18. 4 Es Model for Implementation and Sustainability5

19. Engage: How will VAE prevention make the world a better place? • Need to change culture and practice by convincing staff and stakeholders about the value of VAP/VAE prevention in improving patient outcomes • Consistently message the impact of prevention: decreased duration of ventilation, ICU LOS, and hospital LOS • Recruit a champion to build support and anticipate barriers • Share patient anecdotes: successes and struggles • Invite guest speakers for fresh and outside perspectives • Get executive buy-in buy sharing research that supports hospital-level decision-making (e.g. cost-benefit analysis) • Make performance visible at all times

20. Educate: How will VAE prevention get patients off the ventilator faster? • Get the evidence to the frontline staff • Fastfact sheets • Literature reviews • CUSP for VAP content call webinars • Hands-on trainings • Conferences • Interactive discussions • VAP Process Measure and Early Mobility Toolkit education resource lists

21. Execute: How to implement VAE prevention interventions given local culture and resources? • Frame interventions to target system-level change – Do not target individuals • Standardize care • Daily multi-disciplinary rounds • Reduce complexity • Sedation, breathing trial, mobility protocols • Create independent checks • Daily Goals tool • Check and modify current policies

22. Evaluate: How will we know that our efforts make a difference? • Assess impact: are the interventions adding value for staff, patients and families? • Monitor and report process and outcome measures to staff at least once a month • Generate detailed reports with CECity platform • Identify gaps and iterate processes • Celebrate successes

23. CUSP 4 MVP – VAP Website https://armstrongresearch.hopkinsmedicine.org/cusp4mvp.aspx • Education materials • Toolkits • CUSP • Daily Process Measures • Early Mobility • Low Tidal Volume Ventilation (soon) • Literature Reviews • Fast Fact Sheets • Archive of past webinars led by subject matter experts

24. CUSP 4 MVP – VAP Website https://armstrongresearch.hopkinsmedicine.org/cusp4mvp.aspx Data Portal • Data collection tools • Manual entry or electronic import • Real time reporting • Monthly, quarterly, and yearly data reports • Benchmarks • Comparison to ICUs within your CE • Comparison to ICUs within your cohort • Detailed instructions

25. Opportunities to keep the ball rolling! • CUSP 4 MVP – VAP (National Project) • SCCM - ICU Liberation • Johns Hopkins Critical Care Rehabilitation Conference • ICU Delirium and Cognitive Impairment Study Group – Vanderbilt University • We would love to host teams here at AI for a 1-day Sustainability Kickoff Meeting and developing a “Learning Network”

26. Learning Network • Sustaining your CUSP efforts • Potential opportunity to launch a learning network to provide ongoing CUSP support after project ends: • Learning network members develop relationships integral to expanding and sustaining CUSP within their organizations and experience: • Consulting from peers • Working together to overcome challenges • Sharing best practices • Understanding how to better use and integrate CUSP Tools

27. Learning Network • What is the time commitment? • What you make of it! • Successful learning networks use a variety of methods for sharing and collaborating for example: • In-person meetings • Webinars • Listserv

28. CUSP 4 MVP – VAP (National Project) • Call in to National Project calls • We will send out information • Join Cohorts 2, 3 or 4 to sustain and/or enhance your VAE prevention program • Contact CUSP4MVP@jhmi.edu • Recruitment and registration are currently underway for Cohort 2

29. SCCM – ICU Liberation • Features • PAD Guidelines • Assessment tools • Information on getting your patients moving • Presentation on PAD by Julianna Barr • Presentations from SCCM 43rd Critical Care Conference • http://www.iculiberation.org/Pages/default.aspx

30. The Third Annual Johns Hopkins Critical Care Rehabilitation Conference Takes place October 24-25th in Baltimore. Join to experience more about why interdisciplinary collaboration and coordination is vital to facilitate early mobility and rehabilitation in the intensive care unit (ICU) setting. http://www.hopkinscme.edu/CourseDetail.aspx/80034272

31. ICU Delirium and Cognitive Impairment Study Group – Vanderbilt University • Extensive resource for prevention of delirium and its sequelae. • Site is for all patients, not specifically those on mechanical ventilation • Includes • ABCDEF Bundle (Originally the ABCDE Bundle, adding Family) • Resources • Implementation of delirium monitoring and management • Many, many others

32. CUSP for VAP Data collection – the final year and beyond! • Sustainability period Jan. 2015- Dec. 2015 • During the final year • VAE rates are “required” • The data portal will remain open for all other data collection • You can use it if and as you wish • If you enter data, the reports will be available • 4 sampling strategies are available

33. Next Steps – Data • Sustainability period Jan. 2015- Dec. 2015 • Data Collection Sampling Strategy began Oct. 2014 (continues through Dec. 2015) and includes: • Daily Process Measures • Early Mobility Data • Low Tidal Volume Ventilation Measure • Data collection for Low Tidal Volume Ventilation measure • Began Oct. 2014 • CECity portal ready for data entry/upload

34. Next Steps – Assessments • 2014 Assessment Schedule • Complete Structural Assessment 3 – if not already done • Exposure Receipt Assessment 2 – Nov 2014 • 2015 Assessment schedule: • Structural Assessment 4 – Dec. 2014 • Premortem for Sustainability – Feb. 2015 • VAP Quarterly Interview – Jun. and Dec. 2015 • All other assessments- Oct. – Dec 2015 • VAP tools/metrics for all measures will be posted with the recording to this webinar here: https://armstrongresearch.hopkinsmedicine.org/vap/calls.aspx

35. Your Input is Important • What do you need during sustainability • Calls? • Content? • Anything else? • We can explore this more during the face-to-face meeting, but we would really like to know any ideas you have now

36. References • Klompas M, Branson R,Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update.Infect Control Hosp Epidemiol. 2014; 35(8):915-36. • Klompas M, Speck K, Howell MD, et al. Reappraisal of routine oral care with chlorhexidinegluconate for patients receiving mechanical ventilation: systematic review and meta-analysis. JAMA Intern Med. 2014; 174(5):751-61.

37. References • Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013; 41(1):263-306. • Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA.1999; 282(15):1458-65. • Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008; 6:337:a1714.

38. 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!