cusp for vap: evap project overview

CUSP for VAP: EVAPProject Overview Sean Berenholtz M.D., MHSKathleen Speck, MPH

August 7th - 1pm August 8th – 11 am

Learning Objectives

• Understand the magnitude of preventable harm

• Review CUSP for VAP:EVAP program– Project goals and interventions– Participation requirements and timeline

• Describe steps to enroll

3

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

1. http://oversight.house.gov/story.asp?id=1865

http://oversight.house.gov/story.asp?id=1865

Impact of VAP

• 10-20% of ventilated patients 2

• Common HAI 3

– Median rate 1-4.3 per 1000 vent day– 250,000 infections per year

• Most lethal HAI4– Mortality likely exceeds 10% 5

– Up to 36,000 deaths per year• Cost per episode: $23,000

2.Safdar CCM 2005, 3.Kollef Chest 2005,4.Perencevich ICHE 2007, 5. Klevens RM , Public Health Rep. 2007

CUSP for VAP: EVAPProject Overview

CUSP for VAP: EVAP 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

Armstrong Institute for Patient Safety and Quality6

Who can join CUSP for VAP: EVAP?

• Participation in the program is available to any facility with mechanically ventilated patients in Maryland and Pennsylvania.

• Hospital participation will be coordinated with state hospital association or hospital engagement network (HEN).


Project Goals

• To achieve significant reductions in VAP/VAE rates

• To achieve significant improvements in safety culture

How will we get there?

6. http://www.hopkinsmedicine.org/armstrong_institute

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

Translating Evidence Into

Practice(TRiP)

1. Summarize the evidence

2. Identify local barriers to implementation

3. Measure performance

4. Ensure all patients get the evidence

• Engage• Educate• Execute• Evaluate

Reducing Ventilator Associated Pneumonia

• HOB elevation

• SAT and SBT

• Oral Care with CHG

• CSS-ETT

• Structural measures

Technical Work Adaptive Work

Successful Efforts to Reduce Preventable Harm

• Michigan Keystone ICU program– Reductions in central line-associated blood

stream infections (CLABSI) 7,8

– Reductions in ventilator-associated pneumonias (VAP) 9

• National On the CUSP: Stop BSI program 10

7. Pronovost ,N Engl J Med 2006;355:2725-32. 8. Pronovost, N . BMJ 2010;340:c309. 9. Berenholtz ,Infect Control Hosp Epidemiol. 2011;32(4): 305-314. 10. www.onthecuspstophai.org

Percent of Units with Zero CLABSIs and Achieving Project Goal (<1/1000 CL days)

1111. www.onthecuspstophai.org

Lessons Learned

• Informed by science

• Led by clinicians and supported by management

• Guided by measures


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

Interventions

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 Epid of America

• ICHE 2008;29:S31-S40.

Armstrong Institute for Patient Safety and Quality

Process measures: Daily evaluation

• Use a semi-recumbent position ( ≥ 30 degrees).• Make a daily assessment of readiness to wean.• Use sedation protocol with sedation vacation and

validated sedation scale (i.e. RASS) at least daily. • Use chlorhexidine when performing oral care.• Use subglottic suctioning ETTs in patients expected

to be mechanically ventilated for >72 hours


Structural measures (examples): Quarterly evaluation

1. Use a closed ETT suctioning system2. Change close suctioning catheters only as needed3. Change ventilator circuits only if damaged or soiled4. Change HME every 5-7 days and as clinically

indicated5. Provide easy access to NIVV equipment and

institute protocols to promote use6. Periodically remove condensate from circuits,

keeping the circuit closed during the removal, taking precautions not to allow condensate to drain toward patient

17ETT endotrachael tube; HME heat moist exchanger; NIVV non-invasive ventilation

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

12. Schweickert Lancet 2009; 373: 1874–82


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 13. Timmel Jt Comm J Qual Patient Saf 2010;36:252-

60 14. Resources: www.safercare.net

Sample Daily Goals

Education

Decrease complexity and create redundancy

• Daily goals checklist• Standardized order

sets and protocols

Independent redundancies• Nursing, RT, families

15. Pronovost , J Crit Care. 2003;18(2):71-75

Benefits of Participation

Estimate of Preventable Harm and Costs

• Pennsylvania ( CY10- 11)– 1426 VAP Cases

• 319 Deaths • 10,000 LOS Days• $115 Million

• Maryland (FY11)– 583 VAP Cases

• 130 Deaths • 4,000 LOS Days• $47 Million


16.http://www.hopkinsmedicine.org/quality_safety_research_group/our_projects/ventilator_associated_pheumonias/estimator.html

Benefits to Participation

• Improve patient outcomes – Build upon and spread efforts to date– Focused specifically on VAP prevention, including

structural measures

• Get “a leg up” on the new CDC VAE definition– Predicted to increase current VAP rates– Aligned with public reporting of VAP


NHSN VAE reporting

• Starts Jan 2013• 2 webinar calls targeting IPs

– Over 200 participants• Ongoing training with CDC and experts from

Epicenters for Excellence group. • Explore resources to collect baseline data• Explore transferring data collected during

field testing and submit to NHSN


Maryland • Health Service Cost Review

Commission's quality initiatives including Maryland Hospital Acquired Conditions (MHACs) Initiatives

• Maryland Health Care Commission’s Healthcare-Associated Infections Prevention Plan

• MHA BOT three-year strategic plan that includes the goal of zero VAP

Pennsylvania • VAP Publicly Recorded • Part of the HAP Action Plan &

PA- HEN VAP Project



• Aligned with CMS led national initiatives to reduce harm via the Partnership for Patients Hospital Engagement Networks

• Inform future national VAP prevention efforts– Model similar to CLABSI and CAUTI

• Advancing science together



CECity Project Platform

• Data collection – Manual entry or electronic import

• Real time reporting• Learning management system

– Share slides, protocols, literature, videos, etc.• Social networking• Working on MOC credit, CMEs for

participation (in progress)

Armstrong Institute for Patient, Safety and Quality27

What do teams need to do?

– Assemble a multidisciplinary team• Including frontline unit staff

– Participate in 6 weekly on-boarding webinars followed by monthly content and coaching webinars• All webinars recorded and archived online

– Regularly meet as a team to implement interventions and monitor performance

– Participate in state–specific requirements


What data will teams need to collect?

• Monthly VAE data using new CDC NHSN definitions – Numerator and denominator– Will work with you to collect baseline ‘VAE’ data

• Daily process measure data• Quarterly structural measure and implementation data

– Brief survey and structured interview • Annual teamwork/culture data using the AHRQ Hospital

Survey of Patient Safety (HSOPS)• Will work with HENS to ensure data reporting meets their

needs


How do we enroll or learn more?

• Complete the commitment/enrollment form• To learn more or to receive the enrollment

packet contact:

– Karol G. Wicker, MHSSenior Director, Quality Policy & AdvocacyMaryland Hospital [email protected]

– Mary Catanzaro RN BSMT CIC Project Manager HAIs Hospital and Healthsystem Association of [email protected]

30

mailto:[email protected]

mailto:[email protected]

Questions or Comments?


References

Slide 31. http://oversight-archive.waxman.house.gov/story.asp?ID=1865 Accessed:

August 21, 2012.

Slide 4 2. Safdar N, Dezfullian 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.

3. 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.

4. Perencevich EN, Stone PW, Wright SB, Carmeli Y, Fisman 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.

5. 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.

Armstrong Institute for Patient Safety and Quality 32

http://oversight-archive.waxman.house.gov/story.asp?ID=1865

References

Slide 9 6. http://www.hopkinsmedicine.org/armstrong_institute. Accessed: August 21, 2012.

Slide 107. 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 cathere- related bloodstream infection in the ICU. N Engl J Med 2006;355:2725-32.

8. 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;340:c309.

9. 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;32(4): 305-314.

10 www.onthecuspstophai.org Accessed, August 21, 2012. 33

http://www.onthecuspstophai.org/

References

Slide 1111. www.onthecuspstophai.org Accessed: August, 21, 2012.

Slide 18 12. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook

CL, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman A, Barr R,McCallister KE, Hall JB, Kress JP. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet. 2009 May 30;373(9678):1874-82.

Slide 1913. Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Impact

of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf 2010;36:252-60

14. www.safercare.net Accessed: August 21, 20012.


http://www.onthecuspstophai.org/

http://www.safercare.net/

References

Slide 2015. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C.

Improving communication in the ICU using daily goals. J Crit Care. 2003;18(2):71-75

Slide2216.

http://www.hopkinsmedicine.org/quality_safety_research_group/our_projects/ventilator_associated_pheumonias/estimator.html Accessed: August 21, 2012.


http://www.hopkinsmedicine.org/quality_safety_research_group/our_projects/ventilator_associated_pheumonias/estimator.html



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