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
3.50
4.00Ra
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er 1
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
0.5
1.0
1.5
2.0
2.5
3.0Ra
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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)
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 [email protected] | 407-841-6230
Linda R. Greene, RN, MPS, CICManager of Infection PreventionUR Highland Hospital, Rochester, [email protected]
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