CUSP for VAP: EVAP Project Overview

1. CUSP for VAP: EVAPProject Overview Sean Berenholtz M.D., MHS Kathleen Speck, MPH August 21,2012 Conference Number(s):800-779-9891 Participant Code:4757941

2. On Boarding Call Schedule –Tuesdays 8/21–9/25 @ 2:00 Program Introduction August 21, 2012 • Building CUSP team – August 28, 2012 • Science of Safety –September 4, 2012 • CUSP Part 2-September 11, 2012 • VAP Evidence- September 18,2012 • Daily Goals Review -September 25, 2012 • Early Ambulation -August /30/2012 CUSP Comprehensive Unit Based Safety Program; VAP Ventilator Associated Pneumonia Armstrong Institute for Patient Safety and Quality

3. Learning Objectives • Overview of CUSP for VAP:EVAP program • Project goals and interventions • Participation requirements and timeline • Outline next steps CUSP Comprehensive Unit Based Safety Program; VAP Ventilator Associated Pneumonia; EVAP Eliminate VAP

4. CUSP for VAP: EVAP Project Overview

5. CUSP for VAP: EVAP Project Overview • NIH/NHLBI and AHRQ funded 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 NIH/NHLBI National Institutes of Health National Heart, Lung, and Blood Institute; AHRQ Agency for Healthcare Research and Quality Armstrong Institute for Patient Safety and Quality

6. 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). Armstrong Institute for Patient Safety and Quality

7. Project Goals • To achieve significant reductions in VAP/VAE rates • To achieve significant improvements in safety culture VAP Ventilator Associated Pneumonia; VAE Ventilator Associated Events

8. How will we get there? http://www.hopkinsmedicine.org/armstrong_institute

9. Successful Efforts to Reduce Preventable Harm • Michigan Keystone ICU program • Reductions in central line-associated blood stream infections (CLABSI)1,2 • Reductions in ventilator-associated pneumonias (VAP) 3 • National On the CUSP: Stop BSI program 4 N Engl J Med 2006;355:2725-32. BMJ 2010;340:c309. Infect Control Hosp Epidemiol. 2011;32(4): 305-314. www.onthecuspstophai.org

10. Lessons Learned • Informed by science • Led by clinicians and supported by infection control staff and management • Guided by measures Armstrong Institute for Patient Safety and Quality

11. 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

12. Interventions

13. 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

14. Process measures: Daily evaluation • Head of Bed Elevation (HOB) • Use of a semi-recumbent position ( ≥ 30 degrees). • Spontaneous Awakening and Breathing Trials (SAT & SBT) • Daily assessment of sedation and readiness to wean • Oral Care • At least 6 times per day • Oral Care with Chlorhexidine (CHG) • Should be included in the oral care regimen 2 times per day • Subglottic Suctioning ETTs • Use subglottic suctioning ETTs in patients expected to be mechanically ventilated for >72 hours Armstrong Institute for Patient Safety and Quality

15. Policy Based Structural Measures : • Use a closed ETT suctioning system • Change close suctioning catheters only as needed • Change ventilator circuits only if damaged or soiled • Change HME every 5-7 days and as clinically indicated • Provide easy access to NIVV equipment and institute protocols to promote use • Periodically remove condensate from circuits, keeping the circuit closed during the removal, taking precautions not to allow condensate to drain toward patient • Use early mobility protocol ETT endotrachael tube; HME heat moist exchanger; NIVV non-invasive ventilation

16. Policy Based Structural Measures : • Perform hand hygiene • Avoid supine position • Use standard precautions while suctioning respiratory tract secretions • Use orotracheal intubation instead of nasotracheal • Avoid use of prophylactic systemic antimicrobials • Avoid non-essential tracheal suctioning • Avoid gastric over-distention ETT endotrachael tube; HME heat moist exchanger; NIVV non-invasive ventilation

17. Invitation to Join Call : • Early Ambulation • Dr. Dale Needham • Thursday, August 30th , 2012 Armstrong Institute for Patient Safety and Quality

18. Comprehensive Unit-based Safety Program (CUSP) • Educate staff on science of safety • Identify defects • Assign executive to adopt unit • Learn from one defect per quarter • Implement teamwork tools 5. JtComm J Qual Patient Saf 2010;36:252-60 Resources: www.safercare.net

19. Sample Daily Goals • Education • Decrease complexity and create redundancy • Daily goals checklist • Standardized ordersets and protocols • Independent redundancies • Nursing, RT, families J Crit Care 2003;18(2):71-75

20. Program Support Education Materials • Toolkits, slides, factsheets etc.. Series of Follow Up Calls • On Boarding Calls • Aug 21-Sep 25 • Coaching & Content Calls • Nov 1 – Feb 7 • Hospital Interviews • Schedule TBD Ethnography site visits • Selected sites TBD Armstrong Institute for Patient Safety and Quality

21. CECity Project Platform • Data collection • Manual entry or electronic import • Real time reporting • Learning management system • Share slides, protocols, literature, videos, etc. • Social networking • Provider specific communities • Working on Maintenance of Certification (MOC) credit, CMEs for participation (in progress) Armstrong Institute for Patient, Safety and Quality

22. Participation Requirements

23. 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 Armstrong Institute for Patient Safety and Quality

24. What data will teams need to collect? • Monthly VAE data using new CDC NHSN definitions • VAC, IVAC, PVAP 1, PVAP 2 • 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 NHSN National Healthcare Safety Network; VAE Ventilator Associated Event; VAC Ventilator Associated Condition; IVAC Infection Related Ventilator Associated Complications; PVAP1 Possible Ventilator Associated Pneumonia; PVAP2 Probable Ventilator Associated Pneumonia Armstrong Institute for Patient Safety and Quality

25. Next Steps

26. On Boarding Call Schedule –Tuesdays 8/21–9/25 @ 2:00 • Program Introduction August 21, 2012 • Building CUSP team – August 28, 2012 • Science of Safety –September 4, 2012 • CUSP Part 2-September 11, 2012 • VAP Evidence- September 18,2012 • Daily Goals Review -September 25, 2012 • Early Ambulation -August /30/2012 All calls recorded: please make sure your CUSP team listens to call if they are unable to join CUSP Comprehensive Unit Based Safety Program; VAP Ventilator Associated Pneumonia Armstrong Institute for Patient Safety and Quality

27. CUSP Team Composition • Size (not too small, not too large) • Multidisciplinary representation • Physician champion • Nurse champion • Project lead/ unit champion • Respiratory Therapist • Infection Control • Executive Partner • Frontline staff • Nurse Educator • ICU Nurse Manager • Pharmacist • Hospital Patient Safety • Chief Quality Officer • Staff from Safety, Quality or Risk Mgmt Office

28. Finalize enrollment • Complete and submit the commitment/enrollment form • Questions or comments: • Karol G. Wicker, MHS Senior Director, Quality Policy & Advocacy Maryland Hospital Association kwicker@mhaonline.org • Mary Catanzaro RN BSMT CIC Project Manager HAIs Hospital and Healthsystem Association of Pennsylvania mcatanzaro@haponline.org

29. References Slide 9: Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welch R, Roth G, Bander J, Kepros J, Goeschel C. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2723-32. 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. 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 HospEpidemiol. 2011;32:305-14. www.onthecuspstophai.org

30. References Slide 18: 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. JtComm J Qual Patient Saf. 2010;36:252-60. Slide 19: Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003;18:71-5.