CUSP 4 MVP-VAP Data Facilitator Discussion – 1 February 12, 2014 Kathleen Speck, MPH Nishi Rawat, MD Program support provided by MHA Keystone Center. Scientific expertise and educational presentations provided by Harvard Medical School. December 6, 2018

Administrative announcements Webinar information: https://mhakeystonecenterevents.webex.com/mhakeystonecenterevents/onstage/g.php?t=a&d=669992364 You can call in through the webinar or 1-877-668-4493 Code: 669 992 364 Please contact your Coordinating Entity for a copy of these slides if you have not yet received them We will make a recording of this webinar available to you

Objectives Discuss the data elements needed to complete the Daily Process Measures Form Review the definitions of those data elements Consider and discuss strategies for finding the data elements.

Poll – Who is on the call? Ask questions! Make suggestions! December 6, 2018

Track by bed, not patient Complete Fill out for all beds Track by bed, not patient Complete Bed number Whether the patient in that bed was intubated or trached and was on mechanical ventilation at the time of observation Y = Yes N = No E = Empty bed

Enter the date the patient was intubated Date of Intubation Enter the date the patient was intubated If the date is not available*, enter admission date (either to the unit or to the hospital, as appropriate) If the patient is extubated and re-intubated within 24 hours, use the original date *i.e., when from an outside institution

Does the patient have a sub-glottic endotracheal tube? Sub-G ETT Does the patient have a sub-glottic endotracheal tube? Y = Yes N = No If your unit doesn’t use Sub-G ETTs, enter N C = Contraindicated If C, fill in the reason sub-glottic endotracheal tubes are contraindicated for this patient in the next column

What is the reason the use of a Sub-G ETT is contraindicated? *Remember, enter ‘N’ if your unit does not use Sub-G ETTs

Location of intubation Enter the number corresponding to the location the patient was intubated (list on contraindications page) If you are using Sub-G ETTs on your unit, but the patient is admitted with a different type of ETT, this allows you to track where the patient came from

Location of intubation Where was the patient intubated?

Is the HOB elevated to an angle of ≥ 30 degrees from the horizontal? HOB @ ≥ 30o Is the HOB elevated to an angle of ≥ 30 degrees from the horizontal? Y = Yes N = No C = Contraindicated If contraindicated, choose the reason from the contraindications page

HOB Con What is the reason placing the HOB at an angle of ≥ 30 degrees from the horizontal contraindicated?

1st question – What sedation scale do you use on your unit? This question refers to your unit, not to this specific patient.

R = Richmond Agitation Sedation Scale (RASS) S = Riker Sedation-Agitation Scale (SAS) NU = Unit uses neither RASS or SAS If NU, skip to Delerium Assessment

Sedation Scale Choose R or S, not both Choose the value closest to 10:00 am If equidistant, choose the earlier time

If you entered ‘R’ Target What is the target RASS score for this patient? Enter RASS sedation scale value (-5 to 4) Enter ‘NS’ if target RASS was not set Enter ‘NK’ if target RASS was set but is not known Enter ‘NK’ if you don’t know whether a target RASS was actually set

If you entered ‘R’ Actual What is the actual RASS score for this patient? Enter RASS sedation scale value (-5 to 4) Enter ‘X’ if an actual RASS sedation level was not scored Enter ‘NK’ if target RASS was scored, but is not known Enter ‘NK’ if you don’t know whether a target RASS was actually scored

If you entered ‘S’ Target What is the target SAS score for this patient? Enter SAS sedation scale value (1 to 7) Enter ‘NS’ if target SAS was not set Enter ‘NK’ if target SAS was set but is not known Enter ‘NK’ if you don’t know whether a target SAS was actually set

If you entered ‘S’ Actual What is the actual SAS score for this patient? Enter SAS sedation scale value (1 to 7) Enter ‘X’ if an actual SAS sedation level was not scored Enter ‘NK’ if target SAS was scored, but is not known Enter ‘NK’ if you don’t know whether a target SAS was actually scored

If you entered ‘NU’ Skip Target and Actual Sections and go to Delirium Assessment

C = Confusion Assessment Method for the ICU (CAM-ICU) Delirium Assessment C = Confusion Assessment Method for the ICU (CAM-ICU) A = Attention Screening Exam (ASE) NU = Unit uses neither CAM-ICU or ASE If NU, skip to SAT

Attention Screening Exam (ASE) If the CAM-ICU is not yet feasible in your unit, we recommend that patients at least undergo the ASE once per nursing shift. The ASE is feature 2 of the CAM-ICU and this 10-20 second test of attention is the cardinal feature of a delirium diagnosis.

Delerium Assessment Choose CAM-ICU or ASE, not both CAM-ICU incorporates the ASE Choose the value closest to 10:00 am If equidistant, choose the earlier time

CAM-ICU The Society of Critical Care Medicine’s 2013 pain/agitation/delirium (PAD) clinical practice guidelines recommend the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) as the most valid and reliable delirium screening tools, and that moderate to high risk patients be screened at least once per nursing shift.

CAM-ICU – is the patient positive or negative for delirium Enter ‘P’ if the patient is positive for delirium Enter ‘N’ if the patient is negative for delirium Enter ‘UTA’ if unable to assess (i.e.: RASS = -4 or -5 OR SAS = 1 or 2 Enter ‘X’ if CAM-ICU assessment was not completed Enter ‘NK’ if CAM-ICU was completed, but results aren’t known Enter ‘NK’ if you don’t know whether the exam was performed

Attention Screening Exam (ASE) The goal of this 10-20 second test is to determine if a patient can follow a simple command (pay attention) for that period of time. Inattention is the cardinal feature of delirium and must be present to diagnose delirium. For centers not using the full CAM-ICU, conducting the ASE is a good barometer of the presence or absence of delirium. This test may be abnormal due to disease, drugs or other causes.

Attention Screening Exam (ASE) The exam consists of the provider reading the following sequence of letters: ‘S A V E A H A A R T’ or ‘C A S A B L A N C A’ or ‘A B A D B A D D A Y’ The patient is told to squeeze the provider’s hand when the letter ‘A’ is stated. An error is defined as no squeeze with letter ‘A’ or a squeeze on a letter other than ‘A’. The number of errors is counted. Inattention is present if the patient commits more than 2 errors. If the patient squeezes on every letter or doesn’t squeeze on any letter, then assign an error count of 10.

ASE – What is the patient’s ability to pay attention? Use only if CAM-ICU is not performed Enter the number of errors, 0 to 10 Enter ‘UTA’ if unable to assess (i.e.: RASS = -4 or -5 OR SAS = 1 or 2 Enter ‘X’ if the exam was not performed Enter ‘NK’ if the exam was performed, but number of errors is not known Enter ‘NK’ if you don’t know whether the exam was performed

Spontaneous Awakening Trial (SAT) Has the patient had a Spontaneous Awakening Trial today?

Enter ‘NS’ if the patient is not sedated SAT Enter ‘NS’ if the patient is not sedated Enter ‘Y’ if medications for sedations have been held today Enter ‘N’ if medications for sedation have not been held today Enter ‘C/NI’ if holding medications for sedation is either contraindicated or not indicated today If ‘C/NI’ go to Reason SAT Con

SAT Con What is the reason an SAT is inappropriate for this patient?

Spontaneous Breathing Trial (SBT) Has the patient had a spontaneous breathing trial today?

SBT Ventilatory support is removed The patient breathes through either a T-tube circuit or ventilatory circuit with low levels of PS (5–8 cm H2O in adults) with or without 5 cm H2O PEEP No changes are required in FiO2 or the level of PEEP

Enter ‘Y’ if the patient had an SBT Enter ‘N’ if the patient did not have an SBT Enter ‘C/NI’ if the use of an SBT is contraindicated/not indicated If ‘C/NI’, go to Reason SBT Con

Enter ‘Y’ if the patient had an SBT Enter ‘N’ if the patient did not have an SBT Enter ‘C/NI’ if the use of an SBT is contraindicated/not indicated If ‘C/NI’, go to Reason SBT Con

SBT Con What is the reason an SBT is inappropriate for this patient?

SBT with Seds off? Was the SBT performed with the sedatives off? Sedatives are considered off: During an SAT If sedative infusion is stopped If standing order for intermittent sedating meds is held or cancelled If the interval between standing doses is extended

Data Collection Ideas Where can you find these data? Ideas? Suggestions? Barriers? December 6, 2018

Next Steps Where will you find your data? Look for data sources Make plans for data collection processes Practice collecting data for next call December 6, 2018

Going forward - After you have found your data sources and data collection has officially started Collect data daily Enter the data at least weekly December 6, 2018

Next Data Facilitator Call March 12th at 2:00 EST Discuss solutions, barriers and ideas for data collection Explore the CECity data entry portal for Daily Process Measures December 6, 2018