An Initiative of the Florida Hospital AssociationHospital Improvement Innovation Network

Infection Prevention Webinar Series:Implementation of Best Practices forVentilator-associated Events (VAE) PreventionJuly 24, 2019

• Welcome & FHA Mission to Care HIIN Update– Cheryl Love, RN, BSN, BS-HCA, MBA, LHRM, CPHRM, Director of

Quality and Patient Safety and Improvement Advisor, FHA

• Infection Prevention Series: Implementation of “Best Practices” for VAE Prevention– Linda R. Greene, RN, MPS, CIC, FAPIC, Manager of Infection

Prevention, UR Highland Hospital, Rochester, NY

• Q&A• Upcoming HIIN Events and Opportunities• Evaluation Survey & Continuing Nursing Education

Agenda

• Adverse Drug Events (ADE)• Catheter-associated Urinary Tract Infections (CAUTI)• Clostridium Difficile Infection (CDI)• Central line-associated Blood Stream Infections (CLABSI)• Hospital-onset MRSA Bacteremia• Injuries from Falls and Immobility• Pressure Ulcers (PrU)• Sepsis• Surgical Site Infections (SSI)• Venous Thromboembolisms (VTE)• Ventilator-Associated Events (VAE/IVAC/PVAP)• Readmissions (12% reduction)• Worker Safety

HIIN Core Topics – Aim is 20% reduction

VAE Resources, Trainings and Tools

Mission to Care Website FHA IVAC Call to Action Website HRET HIIN Website

Designed to reduce multiple forms of harm with simple, easy-to-accomplish activities that cut across several topics to decrease harm.

Focused on four components:

• SOAP UP: Hardwire Hand Hygiene• GET UP: Mobilize Patients• WAKE UP: Prevent Over-sedation• SCRIPT UP: Optimize Inpatient

Medications

UP Campaign: Spreading Cross Cutting Strategies

5

FHA Mission to Care Update: Ventilator-associated Condition Rate

Source: HRET Comprehensive Data System, July 23, 2019

BL O-16 N-16 D-16 J-17 F-17 M-17 A-17 M-17 J-17 J-17 A-17 S-17 O-17 N-17 D-17 J-18 F-18 M-18 A-18 M-18 J-18 J-18 A-18 S-18 O-18 N-18 D-18 J-19 F-19 M-19 A-19 M-19

FL Rate 6.58 5.21 6.29 6.37 4.99 5.41 5.52 6.55 5.44 6.09 5.82 6.11 5.05 6.03 3.34 5.66 4.27 5.71 3.85 5.61 5.74 6.08 4.99 5.77 4.97 4.44 5.20 5.38 6.31 7.12 6.33 7.38 6.10

HRET HIIN Rate 4.93 4.82 4.60 4.96 4.96 4.85 4.69 4.98 5.27 4.97 4.75 5.00 4.77 5.32 4.51 5.13 5.05 4.99 4.81 5.43 4.88 5.33 5.16 5.26 4.94 5.03 5.22 5.27 5.06 5.67 5.25 5.36 5.18

# FL Reporting 76 74 74 75 76 76 76 75 75 76 76 77 76 75 73 73 72 68 68 68 72 68 69 69 69 73 73 72 72 71 71 67 60

#HRET HIIN Reporting 913 910 904 895 891 884 883 876 874 871 874 868 867 871 864 863 860 850 849 845 853 845 842 839 839 836 836 832 814 798 788 727 584

0.00.51.01.52.02.53.03.54.04.55.05.56.06.57.07.58.0

Rate

per

100

FHA Mission to Care Update: Infection-related Ventilator-associated Condition Rate

Source: HRET Comprehensive Data System, July 23, 2019

BL O-16 N-16 D-16 J-17 F-17 M-17 A-17 M-17 J-17 J-17 A-17 S-17 O-17 N-17 D-17 J-18 F-18 M-18 A-18 M-18 J-18 J-18 A-18 S-18 O-18 N-18 D-18 J-19 F-19 M-19 A-19 M-19

FL Rate 2.20 1.83 1.86 2.48 2.33 2.31 2.53 2.29 2.39 1.85 1.48 2.38 2.87 2.45 0.89 1.77 1.23 1.97 0.94 1.94 1.88 1.52 1.09 1.58 1.06 0.85 2.01 0.89 1.37 1.67 2.11 2.05 2.28

HRET HIIN Rate 1.60 1.54 1.44 1.62 1.71 1.44 1.63 1.53 1.81 1.52 1.48 1.71 1.52 1.69 1.67 1.68 1.27 1.63 1.46 1.84 1.43 1.50 1.56 1.66 1.19 1.49 1.76 1.53 1.60 1.66 1.67 1.61 1.57

# FL Reporting 76 74 74 75 76 76 76 75 76 77 77 78 77 76 74 74 73 69 69 69 73 69 70 70 70 74 74 74 74 73 72 68 61

#HRET HIIN Reporting 910 914 907 894 893 885 883 876 875 871 875 871 870 873 865 862 858 849 847 845 851 845 844 841 841 835 834 831 812 799 786 724 582

0.00

0.50

1.00

1.50

2.00

2.50

3.00

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00

FHA Mission to Care Update: Possible Ventilator Association Pneumonia (PVAP)

Source: HRET Comprehensive Data System, July 23, 2019

BL O-16 N-16 D-16 J-17 F-17 M-17 A-17 M-17 J-17 J-17 A-17 S-17 O-17 N-17 D-17 J-18 F-18 M-18 A-18 M-18 J-18 J-18 A-18 S-18 O-18 N-18 D-18 J-19 F-19 M-19 A-19 M-19

FL Rate 0.68 0.60 0.12 0.22 0.68 0.34 0.66 0.25 0.76 0.96 0.85 0.48 0.37 1.09 0.34 0.73 0.41 0.71 0.46 0.89 1.53 0.50 1.29 0.59 1.26 0.69 0.90 0.73 1.64 0.76 1.07 0.51 0.41

HRET HIIN Rate 0.53 0.58 0.49 0.39 0.49 0.63 0.58 0.43 0.65 0.62 0.61 0.64 0.74 0.82 0.51 0.44 0.67 0.61 0.47 0.47 0.58 0.76 0.92 0.74 0.73 0.60 0.57 0.61 0.79 0.50 0.59 0.48 0.47

# FL Reporting 54 49 49 50 52 52 52 49 49 51 50 51 51 52 54 53 51 54 55 55 55 54 55 55 56 56 57 56 58 57 57 55 53

#HRET HIIN Reporting 605 669 671 659 687 683 681 679 683 683 687 686 689 693 698 692 694 695 693 692 698 699 701 701 704 705 712 708 697 688 684 619 496

0.0

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1.5

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2.5

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00

FHA Mission to Care Update:Florida | Ventilator-associated Events

Infection Prevention and NHSN Virtual Series

*Access Event Archives (Recordings | Slides) on the Mission to Care HIIN Website10

Date Topic Register Online

Oct. 23, 2018 NHSN: SSI Surveillance Identification and Analysis

Event archive*

Nov. 20, 2018 SSI-Colon: How to Assess Root Cause and Prevention Strategies

Event archive*

Dec. 18, 2018 NHSN: VAE Surveillance Identification and Analysis

Event archive*

Jan. 22, 2019 VAE: How to Assess Root Cause and Prevention Strategies

Event archive*

Feb. 19, 2019 NHSN: MRSA Bacteremia Surveillance Identification and Analysis

Event archive*

Mar. 26, 2019 MRSA Bacteremia : How to Assess Root Cause and Prevention Strategies

Event archive*

Infection Prevention Boot Camp Resource Guide (May 30-31, 2019)

Surgical Infection Prevention (SIP) Webinar Series

*Access Event Archives (Recordings | Slides) on the Mission to Care HIIN Website

Date Topic Register Online

Apr. 26, 2019 SIP Webinar Series #1:Pre-operative Strategies for Prevention of SSI

Event archive*

May 22, 2019 SIP Webinar Series #2:Intra-operative Strategies for Prevention of SSI

Event archive*

Jun. 25, 2019 SIP Webinar Series #3:Post-operative Strategies for Prevention of SSI

Event archive will be posted online

11

Preventing Post-Surgical Harm Resource Guide (Jun. 5, 2019)

VAEAssessment and

Prevention Strategies

Linda R. Greene, RN, MPS, CIC, FAPICLinda_Greene@urmc.rochester.edu

Objectives

Review VAE definition

Discuss Current Literature related to VAE

Describe key prevention strategies to prevent VAE

Polling QuestionWhat is your background?

1. IP

2. Respiratory Care

3. Quality

4. Nursing

5. Other

Background Estimate: 157,000 healthcare-associated

pneumonias occur in acute care hospitals in U.S. with 39% being ventilator-associated*

Ventilator-associated pneumonia (VAP) is an important complication of mechanical ventilation but other adverse events also happen to ventilated patients

*Magill SS., Edwards, JR., Bamberg, W., et al. “Multistate Point-Prevalence Survey of Health Care-Associated Infections, 2011”. New England Journal of Medicine. 370: (2014): 1198-1208

Background Definition changed in 2013

Challenges with inter-rater reliability related to CXR

No major changes except:

Possible and Probable VAP- Now PVAP

Pathogen updates

Let’s Review

Connect the Safety Dots

ARDS

AntibioticResistance

Atelectasis

C Diff infection

Ventilator Harm

IVAC

VAC

Pulmonary Edema

VAP

Morbidity Mortality

Delays,LOS

Cost$

Immobility

Broadening the SurveillanceIntentional

Associated Conditions: • ARDS

• Pulmonary Edema

• Thromboembolic disease

• Sepsis

Respiratory deterioration in previously stable patients is a risk factor for increased morbidity and mortality

The Chest X-RAY

GoalGet the patient off the ventilator sooner

Study A retrospective cohort study examining 20,356 episodes of mechanical ventilation (MV)1

– VAEs• 1,141 ventilator-associated conditions (VACs)• 431 infection-related VACs (IVACs)• 266 possible cases of ventilator-associated

pneumonia (PVAP)– Patients with a VAE have—

• More days to extubation• More days to discharge• Higher mortality rate

• Klompas M, Kleinman K, Murphy MV. Descriptive epidemiology and attributable morbidity of ventilator-associated events. Infect Control Hosp Epidemiol. 2014 May;35(5):502-10.

Risk FactorsRisk factors for ventilator-associated events:

A prospective cohort study

Liu et al. / American Journal of Infection Control 47 (2019) 744−749

Strategies to Prevent Ventilator-Associated Pneumonia

in Acute Care Hospitals: 2014 Update

• The true incidence of VAP is difficult to determine since traditional surveillance definitions are highly subjective.

• Historically, 10-20% of ventilated patients developed VAP.

• More recent reports suggest much lower rates but it is unclear to what extent these lower rates reflect better care versus stricter application of subjective surveillance criteria or better care

• Until studies are published on best strategies to prevent all VAEs, the existing VAP prevention literature is the best available guide to improving outcomes for ventilated patients

Prevention Strategies Avoid intubation if possible

Minimize sedation:

Assess readiness to extubate once a day (spontaneous breathing trials)

Interrupt sedation once a day (spontaneous awakening trials)

Pair spontaneous breathing trials with spontaneous awakening trials

Patients are more likely to pass a spontaneous breathing trial and get extubated if they are maximally awake at the time of the breathing trial

Physical Conditioning

Lack of physical conditioning can result In ICU related weakness ( presence of weakness with no other etiology other than ICU)

Healthy adults can lose 5-9% of quadriceps muscle mass after 2 weeks

In mechanically ventilated patients, skeletal muscle area can decrease as much as 12.5 % in the first week

Hashem et. Al Respir Care 2016;61(7): 971-979Early Mobilization and Rehab in the ICU

Importance of Nurse-led Mobilization

Most ICU nurses know why Early Mobility in the ICU is critically important

Need to do root cause analysis of barriers and address each through education, training, policies, equipment, communication

Barriers found upon Beaumont survey: Safety is a high concern Risk of injury to patient and self Accurately dosing mobility, choosing equipment,

and communicating

Problems Associated withCritical Illness

When deconditioning and muscle weakness occur the course becomes complicated, the stay in the ICU is prolonged, and mortality increases

Risk developing ICU-associated weakness due to polyneuropathy, myopathy, or a combination of both

The cumulative effect of the complications are functional limitations that might or might not resolve.

Potential body/structure effects of critical illness

Nordon-Craft A, Moss M, Quan D, Schenkman M: Intensive care unit-acquired weakness: Implication for physical therapist management. Phys Ther. 2012; 92:1494-1506.

What Are Your Barriers?

Needham and Korpolu, Top Stroke Rehabil 2010;17(4):271–281

4E’s Early MobilityFrontline Staff Early Mobility

Engage

Adap

tive

Ask, how will Early Mobility make the world a better place?-Help staff understand preventable harm-Share stories about patients affected-Develop a business care-Include execute champion/physician leadership

-Define evidence related to preventing VAEs (short and long term cognitive affects, and physical/psychological disabilities)-Create business case related to the impact of early mobility, including increased time off the ventilator, decreased hospital LOS and decreased ICU LOS-Share business case with executive champion/ physician leadership

Educate

Tec

hnic

al What do we need to mobilize critically ill patients?-Convert evidence into behaviors-Evaluate awareness and agreement

-Review the literature-develop mobility criteria and progressive mobility protocol/guideline-Define your education plan (utilizing workshops, hands-on trainings, conferences, slides, presentations and interactive discussions via multiple modalities to cater to different learning styles)-Identify support through outreach to the leadership team

Execute

Adap

tive

How will we implement early mobility at our hospital give local culture and resources?-Listen to resisters-Standardize care and create independent checks-Make it easy to do the right thing-Learn from mistakes

-What is the process for mobilizing a patient?-Is there a policy on the unit?-Who should be involved?-Do we have all the equipment?-Discuss as part of interdisciplinary rounds/daily goals-Learn from defects

Evaluate

Tec

hnic

al

How will we know that our efforts to mobilize our patients made a difference?-Define measures-Regularly assess measures-Provide feedback to staff and celebrate success

-Collect Early Mobility Daily Rounding measures and review at CUSP 4 MVP-VAP meetings-Use CECity to trend performance

EducateTurn evidence into behaviors

Define/Approve Mobilization readiness criteria

Develop early/progressive mobility protocol/guideline

Polling Question

Our unit has protocol for early exercise and progressive mobility for ALL patients:

Yes

No

Strategies

• Green- low risk of adverse even

• Yellow – potential risk( weigh benefit/ Risk)

• Red Significant Risk

Other StrategiesMinimize pooling of secretions above the endotracheal tube cuff

Provide endotracheal tubes with subglottic secretion drainage ports for patients likely to require more than 48 or 72 hours of intubation

(Extubating patients in order to place a subglottic secretion drainage endotracheal tube is not recommended)

Head of Bed

Elevate the head of the bed to 30-45°

A trial in 86 patients showed that semi recumbent positioning reduced the rates of clinically suspected and microbiologically proven nosocomial pneumonia by 4-fold.

A Cochrane literature review based on small and potentially biased studies found an overall benefit in reducing VAP rates when patients were positioned at 30° to 60°

What about bundles?ABCDE Awakening and Breathing Coordination, Delirium, and Early exercise/mobility bundle

Identifying Barriers to Delivering theAwakening and Breathing Coordination,Delirium, and Early Exercise/MobilityBundle to Minimize Adverse Outcomes forMechanically Ventilated PatientsA Systematic Review

Costa et. Al CHEST 2017; 152(2):304-311

Identified Barriers to ABCDE Delivery From the Literature

Patient-related barriers:

Lack of patient cooperation

Patient instability and patient safety concerns (hemodynamics, treatment-related adverse events, physiologic patient issues)

Patient status issues (diarrhea, fatigue, leaking wound, patient weight or size, confusion/agitation, imminent death)

Clinician-related barriers:

• Lack of knowledge and awareness about protocol

• Lack of conceptual agreement with guidelines

• Lack of self-efficacy and confidence in implementing protocol

• Clinician preference for autonomy (resistance to change, expectation of nurse)

• Staff and patient safety concerns

• Perception that rest equals healing

• Lack of confidence that protocol will improve workflow or improve patient outcomes

• Perceived workload (hard work)

• Staff attitude and lack of buy-in

Protocol-related barriers:

• Unavailable or cumbersome to use protocols

• Unclear protocol criteria and agreement or discomfort with guidelines

• Protocol development cost (time and money to develop)

• Learning curve (possibility for clinician to test guideline and observe other clinicians using the guideline easily)

• Lack of clarity as to who is responsible, steps needed to take, and expected standards for protocol implementation

• Lack of confidence in evidence supporting protocol and guideline developer

• Lack of confidence in reliability of screening tool

ICU Culture (safety culture)

Inter professional team care coordination, communication, and collaboration barriers

Lack of leadership/management

Inter professional clinician staffing, workload, and time

Lack of inter professional team support and training/expertise

Physical environment, equipment, and resources

Staff turnover

Low prioritization and perceived importance

Competing priorities and need for further planning

Scheduling conflicts (i.e., patient off unit, at dialysis, procedure) contextual barriers

What about Mouth Care?Tooth brushing for critically ill mechanically ventilated patients: a systematic review and meta-analysis of randomized trials evaluating ventilator-associated pneumonia.

Six trials enrolling 1,408 patients, five of which compared tooth brushing to usual oral care and one of which compared electric with manual tooth brushing.

Four trials, there was a trend toward lower ventilator-associated pneumonia rates (risk ratio, 0.77; 95% confidence interval, 0.50-1.21; p = 0.26).

No impact on length of stay, morbidity or mortality

Alhazzani et. al Crit Care Med. 2013 Feb;41(2):646-55.

What About Oral Care With Chlorhexidine?

Routine oral care with chlorhexidine

Prevents nosocomial pneumonia in cardiac surgery patients May not decrease VAP risk in noncardiac surgery

patients Does not affect— Mortality

Duration of MV

Intensive care unit (ICU) LOSKlompas M, Speck K, Howell MD, Greene LR et al. Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis. JAMA Intern Med. 2014 May;174(5):751-61. PMID: 24663255.

IVAC

Review IVAC

Associated Strategies

CHG bathing

Urinary catheter and central line usage

Central line care and maintenance

What about bundles?Two-State Collaborative Study of a Multifaceted Intervention to Decrease Ventilator-Associated Events

Setting: Fifty-six ICUs at 38 hospitals in Maryland and Pennsylvania from October 2012 to March 2015.

Evidence-based interventions promoted by the collaborative included head-of-bed elevation, use of subglottic secretion drainage endotracheal tubes, oral care, chlorhexidine mouth care, and daily spontaneous awakening and breathing trials

Measurements and Results: ICUs reported 69,417 ventilated patient-days of intervention compliance observations and 1,022 unit-months of ventilator-associated event data.

The quarterly mean ventilator-associated event rate significantly decreased from 7.34 to 4.58 cases per 1,000 ventilator-days after 24 months of implementation (p = 0.007).

During the same time period, infection-related ventilator-associated complication and possible and probable ventilator-associated pneumonia rates decreased from 3.15 to 1.56 and 1.41 to 0.31 cases per 1,000 ventilator-days (p = 0.018, p = 0.012), respectively

Rawat et.al Critical Care Medicine : Volume 45(7), July 2017, p 1208-1215

Best Practices for VAE Reduction

RECOMMENDATION INTERVENTION

Basic practice • Use noninvasive positive pressure ventilation in selected populations

• Manage patients without sedation whenever possible

• Interrupt sedation daily• Assess readiness to extubate daily• Perform SATs with sedatives turned off• Facilitate early mobility• Use endotracheal tubes with subglottic secretion

drainage ports for patients expected to require greater than 48 or 72 hours of MV

• Change the ventilator circuit only if visibly soiled or malfunctioning

• Elevate HOB to 30– 45°

Special approaches • Select oral or digestive decontamination• Regular oral care with chlorhexidine• Prophylactic probiotics• Ultrathin polyurethane endotracheal tube cuffs• Automated control of endotracheal tube cuff

pressure• Saline instillation before tracheal suctioning• Mechanical tooth brushing

Generally not recommended • Silver-coated endotracheal tubes• Kinetic beds• Prone positioning

Final Information2020- update to compendium

Nutritional strategies

Pediatrics

Bundles

Current public reporting

More recent evidence

Final Thoughts Must Measure to manage

VAE surveillance takes a village

Bundle should be simple and measurable

Compliance is key

Questions?

Jul. 25 – Sepsis Alliance | Sepsis: Across the Continuum of Care

Jul. 30 – HRET HIIN | Hot Topic: Patient and Family Engagement

Jul. 31 – HRET HIIN | Hot Topic: Falls

Aug. 5 – FHA HIIN Lead Virtual Meeting (Registration Coming Soon)

Aug. 7 – FHA | Monthly Quality Hot Topics Virtual Meeting #9

Aug. 8 – FHA HIIN | What is Health Literacy, and Why is it Important?

Aug. 12 – HRET HIIN | Alternatives to Opioids Webinar Series #4

Aug. 14 – FHA HIIN | Enhanced Recovery After Surgery

Upcoming Virtual Events

Check the weekly MTC HIIN Upcoming Events for details and registration

Register today at www.FHAAnnualMeeting.comEarly Bird – Register by Aug. 31

• Eligibility for Nursing CEU requires submission of an evaluation survey for each participant requesting continuing education:https://www.surveymonkey.com/r/IP-VAE-072419

• Share this link with all of your participants if viewing today’s webinar as a group (Survey closes Aug. 3, 2019)

• Be sure to include your contact information and Florida nursing license number

• FHA will report 1.0 credit hour to CE Broker and a certificate will be sent via e-mail (Please allow at least 2 weeks after the survey closes)

Evaluation Survey & Continuing Nursing Education

Cheryl D. Love, RN, BSN, BS-HCA, MBA, LHRM, CPHRMFlorida Hospital Associationcheryll@fha.org | 407-841-6230

Linda R. Greene, RN, MPS, CICManager of Infection PreventionUR Highland Hospital, Rochester, NYlinda_greene@urmc.rochester.edu

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