The Cardiac Surgery Translational Study (“CSTS”) The Quality And Safety Research Group

Ventilator Associated Pneumonia Prevention

Sean Berenholtz, MD MHS FCCMMarch 25, 2011 Immersion Call

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Immersion call ScheduleImmersion call ScheduleTitle Date /Time

13:00 ESTPresented by

Program Overview Feb 18, 2011 Peter Pronovost MD PhD

Science Of Safety February 25, 2011 Jill Marsteller, PhD, MPP

Comprehensive Unit-Based Safety Program CUSP

March 4, 2011 Christine Goeschel MPA MPS ScD RN

Central Line Blood Stream Infection Elimination

March 11, 2011 David Thompson DNSC, MS

Surgical Site Infection Elimination March 18, 2011 Elizabeth Martinez, MD, MHS

Ventilator-Associated Pneumonia Reduction

March 25, 2011 Sean Berenholtz, MD

Hand-Offs: Transitions in Care April 1, 2011 Ayse Gurses, PhD

Data we Can Count on April 8, 2011 Lisa Lubomski, PhD.

Team Building April 15, 2011 Jill Marsteller, PhD, MPP

Physician Engagement April 22, 2011 Peter Pronovost, MD, PhD

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CSTS TimelineCSTS Timeline• Planned Roll-out

– CLABSI Prevention interventions and monthly data collection: June, 2011

– SSI Prevention interventions and monthly data collection: Approximately September 2011

– VAP Prevention and monthly data collection: After December 2011

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Learning Objectives

•To describe the morbidity and mortality associated with Ventilator Associated Pneumonia

•To understand the framework used to achieve substantial and sustained reductions in VAP as part of the Michigan Keystone ICU program

•To outline next steps towards implementing VAP prevention efforts as part of CSTS

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Impact of VAP Impact of VAP

• 10-20% of ventilated patients• Common HAI

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

• Most lethal HAI– Mortality likely exceeds 10%– Up to 36,000 deaths per year

• Cost per episode: $23,000Safdar CCM 2005, Kollef Chest 2005,Perencevich ICHE 2007, Public Health Rep. 2007.

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Healthcare Associated Pneumonia Healthcare Associated Pneumonia PreventionPrevention

• CDC/HICPAC: Guidelines for the Prevention of Healthcare Associated Pneumonia; 2004.

• Canadian Critical Care Trials Group1: Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Prevention. Journal of Critical Care; 2008.

• SHEA/IDSA: Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals; 2008.

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How Can These Errors Happen?How Can These Errors Happen?

• People are fallible• Medicine is still treated as an art, not

science• Need to view the delivery of healthcare as

a science• Need systems that catch mistakes before

they reach the patient

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To Improve Reliability To Improve Reliability • Standardize what is done, when it is done

– Reduce complexity• Create independent checks for key processes

– How often do we do what we should• Learn from defects

– How often do we learn from defects

Health Services Research 2006; Circulation 2009;119:330-337.

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Improving Care for Improving Care for Ventilated PatientsVentilated Patients

• Semirecumbant positioning

• Peptic ulcer disease and DVT prophylaxis

• Appropriate sedation

• Daily assessment of readiness to extubate

• Oral care with antiseptics

• Minimize contamination of equipment

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Translating EvidenceTranslating Evidenceinto Practiceinto Practice

Pronovost, Berenholtz, Needham. BMJ 2008

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Improving Care for Ventilated Improving Care for Ventilated PatientsPatients

• Engage– Partner with infection preventionists– Post performance,– Tell stories of harm

• Educate– Reviewed evidence on conference calls, – One-page fact sheets, – Slides for teams

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Improving Care for Ventilated Improving Care for Ventilated PatientsPatients

• Decrease complexity / create redundancy: – Standardized ordersets and protocols– Daily goals checklist

• Other independent redundancies– Nursing and families– Are patients receiving the prevention they should?

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Sample Daily Goals

J Crit Care 2003;18(2):71-75

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Improving Care for Ventilated Improving Care for Ventilated PatientsPatients

Evaluate

• VAP– Standardized CDC NHSN definitions for VAP– VAP definition varies; Did not change definition

• Ventilator Bundle Process Measures– Collected by the ICU teams; daily cross-sectional sample– Standardized definitions and data collection forms – Limited number of trained data collectors– After first quarter of daily data collection, teams were

allowed to collect process measures one to two days/week (min of 15 vent pts/mo) to minimize burden.

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ResultsResults• 124 of 127 ICUs submitted VAP data

– 12 ICUs started after funding ended• 112 ICUs, 72 hospitals included in analysis• 3228 ICU months and 550,800 vent days• 10% quarters without complete data

– 4% missing data; 6% stopped submitting data• Sensitivity analysis yielded similar results• Results reported through 28-30 months post-

implementation

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Infect Control Hosp Epidemiol. 2011;32(4):305-314.

Michigan Keystone ICU

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Michigan Keystone ICUMichigan Keystone ICU

(n=

Infect Control Hosp Epidemiol. 2011;32(4):305-314.

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LimitationsLimitations• Lack of concurrent control group

– Temporal changes, other interventions• Did not evaluate accuracy of VAP diagnosis

– All hospitals reported using CDC definitions– Used existing hospital infrastructure

• Can not evaluate importance of individual therapies in ventilator bundle

• Can not evaluate importance of other intervention

• Focus on ventilator care vs VAP prevention

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StrengthsStrengths• Largest cohort to date • Significant and sustained VAP reductions• Focus on system of care• Engagement of local interdisciplinary teams to

assume ownership• Centralized support for technical work• Local adaptation of intervention• Culture improvement and social networking

among ICUs

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SummarySummary• VAP is most lethal HAI; majority are

preventable

• Effective interventions to prevent VAP are known; patients are not receiving the care they should

• Focus on systems to ensure patients receive the therapies they ought to

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Next StepsNext Steps

• Keystone ICU VAP project focused on ‘Ventilator Bundle’

• Need to develop ‘VAP prevention bundle’– Funded by NIH/NHLBI– Delphi process led by RAND researcher– Recruiting ICU physicians and nurses to gain broad

consensus– Send us an email if your interested in participating

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European Care Bundle for European Care Bundle for VAP PreventionVAP Prevention

Intensive Care Med 2010;36:773-780

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Next StepsNext Steps

• Develop ‘VAP prevention bundle’

• Revise process measures and data collection tools

• CSTS VAP prevention and monthly data collection: After December 2011