CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Onboarding: Introduction to Daily Care Process Measures & Structural Assessment ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY Johns Hopkins University November 12, 2014

CUSP 4 MVP - VAP Comprehensive Unit-based Safety Program for Mechanically Ventilated Patients and Ventilator-Associated Pneumonia

Introduction to Daily Care Process Measures Kathleen Speck, MPH CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

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Administrative Announcements Webinar access information: https://mhakeystonecenterevents.webex.com/mhakeystonecentere vents/onstage/g.php?t=a&d=669992364 Call in details Dial: 1-877-668-4493 Use code: 669 992 364 Contact your Coordinating Entity (CE) for the presentation slides, if necessary Recording will be available on the project website

Polling Question Who is on the call? IP – infection preventionist RN – registered nurse RT – respiratory therapist PT – physical therapist OT – occupational therapist Healthcare executive Educator National project team Other  

Objectives Introduce the Daily Care Process Measures Describe the required Daily Care Process Measures data elements and their definitions Identify strategies for finding the data elements Navigate the CUSP 4 MVP – VAP data portal Enter Daily Care Process Measures data in the data portal Show how to complete the Structural Assessment

2014 SHEA Compendium Update1 Elevate the head of the bed 30-45° Provide endotracheal tubes with subglottic secretion drainage ports for patients likely to require more than 48 or 72 hours of intubation Manage ventilated patients without sedatives whenever possible

2014 SHEA Compendium Update1 Interrupt sedation once a day (spontaneous awakening trials) Assess readiness to extubate once a day (spontaneous breathing trials) Pair spontaneous breathing trials with spontaneous awakening trials Employ early exercise and mobilization Use non-invasive positive pressure ventilation (NIPPV) whenever feasible

2013 Society of Critical Care Medicine PAD Guidelines2 Establish an overarching protocolized approach to daily ICU patient management using 2013 Pain, Agitation, and Delirium (PAD) Guidelines Assess and treat pain first (may be sufficient) If patient remains agitated after adequately treating pain Start with PRN bolus sedation (as needed) Use continuous sedation if boluses exceed 3 per hour Avoid benzodiazepines in most patients

2013 Society of Critical Care Medicine PAD Guidelines2 Interrupt sedation daily If necessary, restart at lowest dose to maintain chosen target level of consciousness Avoid deep sedation (RASS -4/-5) as it appears harmful; instead, target awake or alert Screen for delirium (CAM-ICU or ICDSC) If delirious, first seek reversible causes and attempt non-pharmacologic management Use the ABCDE’s to improve outcomes for your patients Turn off sedation daily and restart only if needed at lowest dose to maintain chosen target level of consciousness Deep sedation (RASS -4/-5) appears harmful; target awake/alert Screen for delirium (CAM-ICU or ICDSC); If delirious, first seek reversible causes and attempt non-pharmacologic management Use the ABCDEs to improve outcomes for your patients

What Is the Evidence? Tune in to the content webinars for evidence supporting each intervention Content webinars are 90 minutes and occur on the third Wednesday of each month from 11:00 am EST DATE TOPIC Jan 21, 2015 Science of Safety & Identifying Defects Pain, Agitation, and Delirium (PAD) and Sedation Management Feb 18, 2015 Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT) Utility of the Exposure Receipt Assessment Mar 18, 2015 Delirium Assessment Training Benefits of Subglottic Endotracheal Tubes

What Is the Evidence? Tune in to these Infection Prevention webinars for training on the importance and details of ventilator-associated events IP webinars are 60 minutes and occur on the fourth Wednesday in January, February and March at 11:00 am EST DATE TOPIC Jan 28, 2015 VAE Surveillance Training: An Overview Feb 25, 2015 VAE Surveillance Training: Infection-related Ventilator-associated Complication (IVAC) Mar 25, 2015 VAE Surveillance Training: Possible VAP (PoVAP) and Probably VAP (PrVAP)

“ In God we trust. All others bring data. – W. E. Deming ”

Daily Care Process Measures Data Collection Tool Detailed Instructions We like to call it the DCPMDCT. Just kidding. Contraindications & Location Codes

Contraindications and Locations

Let’s Begin Fill Out For All Beds Track by bed, not by patient Include Bed number Was the patient in that bed intubated or trached AND on mechanical ventilation at the time of observation Y = Yes N = No E = Empty bed

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

Sub-G ETT Y = Yes N = No C = Contraindicated Does the patient have a subglottic endotracheal tube? Y = Yes N = No If your unit doesn’t use Sub-G ETTs, enter N C = Contraindicated If C, enter the contraindication code for this patient in the next column

Sub-G ETT Contraindications Why a Sub-G ETT is contraindicated? Find the contraindications on the back or on page 2 of the tool Remember, enter ‘N’ if your unit does not use Sub-G ETTs

Location of Intubation Enter the location code where the patient was intubated Find the locations on the back or on page 2 of the tool 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? Find the locations on the back or on page 2 of the tool

Elevating the Head of Bed Is the HOB elevated to an angle of ≥ 30° from the horizontal? Y = Yes N = No C = Contraindicated If contraindicated, choose the reason from the contraindications listed on page 2 of the tool

Head of Bed Contraindications Why was placing the HOB at an angle of ≥ 30° from the horizontal contraindicated? Find the contraindications on the back or on page 2 of the tool

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

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

Sedation Scale Choose either RASS or SAS, but not both Choose the value closest to 10:00 am If equidistant, choose the earlier time

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

Sedation Scale: Actual RASS If you use ‘RASS’… 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

Sedation Scale: Target SAS If you use ‘SAS’… Target: What is the target SAS score for this patient? Enter SAS sedation scale value (1 to 7) Enter ‘NS’ if 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

Sedation Scale: Actual SAS If you use ‘SAS’… 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

Sedation Scale: NU NU = Unit uses neither RASS or SAS If you entered ‘NU’ NU = Unit uses neither RASS or SAS If NU, skip Target and Actual sections and go to Delirium Assessment

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

Delirium Assessment Choose either CAM- ICU or ASE, not both CAM-ICU incorporates the ASE Choose the value closest to 10:00 a.m. If equidistant, choose the earlier time

Confusion Assessment Method for the ICU (CAM-ICU) Society of Critical Care Medicine’s 2013 Pain, Agitation, and Delirium (PAD) clinical practice guidelines Recommends theses valid and reliable delirium screening tools Confusion Assessment Method for the ICU (CAM-ICU) Intensive Care Delirium Screening Checklist (ICDSC) Screen moderate to high risk patients at least once per nursing shift

Delirium Assessment 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 Such as 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) Determine if patient can follow a simple command (pay attention) for 10-20 seconds Recognize inattention as the cardinal feature of delirium that must be present for diagnosis For centers not using the full CAM-ICU, conducting the ASE is a good barometer of the presence or absence of delirium May yield abnormal results due to disease, drugs or other causes

Attention Screening Exam (ASE) Provider reads one of the following sequences: S A V E A H A A R T C A S A B L A N C A A B A D B A D D A Y Patient squeezes the provider’s hand when he hears the letter ‘A’ Error defined as No squeeze with letter ‘A’ A squeeze on a letter other than ‘A’

Attention Screening Exam (ASE) Count the number of errors Inattention is present if the patient commits more than 2 errors If the patient squeezes on every letter, assign an error count of 10 If the patient doesn’t squeeze on any letter, assign an error count of 10

Attention Screening Exam (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 RASS = -4 or -5 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?

Spontaneous Awakening Trial (SAT)

Spontaneous Awakening Trial (SAT) Enter ‘NS’ if the patient is not sedated Enter ‘Y’ if medications for sedation 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 next column labeled “Reason SAT Contraindic”

Spontaneous Awakening Trial (SAT) Contraindications Why is an SAT inappropriate for this patient? Find the contraindications on the back or on page 2 of the tool

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

Spontaneous Breathing Trial (SBT) Remove ventilator support Allow patient to breathe With either a T-tube circuit Or with a ventilator 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

Spontaneous Breathing Trial (SBT) 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 contra- indicated/not indicated If ‘C/NI’, go to Reason SBT Contraindic

Spontaneous Breathing Trials Contraindications (SBT) What is the reason an SBT is inappropriate for this patient? Find the contraindications on the back or on page 2 of the tool

Spontaneous Breathing Trial (SBT) with Sedatives 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 Scenarios CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

Collecting Daily Care Process Measures Who should collect this data? Nurse Nurse educator Respiratory therapist How often should this data be collected? Daily How often should this data be entered in the data portal? Weekly As with any new process, it takes some time to find where to extract the data for each field. Once the process is established, it becomes easier and takes less time.

Collecting Daily Care Process Measures 1st 2nd Data Source Data Entry Method Bedside Paper tool Direct Portal Entry Charts Spreadsheet Template Upload into Portal EMR Workstation or Mobile Device

Collecting Daily Care Process Measures Scenario 1: Bedside Observe the collected measures at the bedside Enter data directly into the project data entry portal via mobile computing device Bedside Mobile Device Direct Portal Entry

Collecting Daily Care Process Measures Scenario 2: Patient charts Review physical patient charts Identify the fields for each of the daily care process measures Record data on data collection tool Enter data into the project data portal Charts Paper Tool Direct Portal Entry

Collecting Daily Care Process Measures Scenario 3: Electronic medical records Access the electronic medical records Identify the fields for each of the daily care process measures Note data on a data collection tool Enter data into the spreadsheet template Upload spreadsheet into project data entry portal EMR Paper Tool Spreadsheet Template

Introduction to Structural Assessment CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

Structural Assessment Who should collect this data? Unit lead How often should this data be collected and entered into the data portal? Semi-annually How long does it take to complete? About ten minutes

Semi-Annual Structural Assessment Please answer the following questions regarding your ICU. For intubated/trached patients, how often do you change the ventilator circuit? Not routinely changed unless soiled or malfunctioning Routinely changed at regular interval; please specify in days ____ When used, how often do you change the closed endotracheal suction system? It is not used in this ICU

Semi-Annual Structural Assessment In the absence of a difficult airway, how often is an orotracheal route used for elective intubation in your ICU? For patients receiving mechanical ventilation via an endotracheal tube, how often is a closed endotracheal suction system used in your ICU? When mechanical ventilation is required, how often are prophylactic intravenous antibiotics used to prevent ventilator-associated pneumonia in your ICU? In your ICU, how often are patients placed in a supine (flat) position, when there is no contraindication? In your ICU, how often are standard precautions used while suctioning the respiratory tract?

Semi-Annual Structural Assessment In your ICU, how often is tracheal suctioning performed when it is not clinically indicated? In your ICU, how often are mechanically ventilated patients experiencing gastric over-distention? In your ICU, how often is condensate drained away from the patient while the circuit remains closed? In your ICU, how often do healthcare providers perform hand hygiene before contact with respiratory equipment? How often is noninvasive ventilation used in your ICU? In your ICU, how often is an early mobility protocol used for patients receiving mechanical ventilation?

Semi-Annual Structural Assessment Regarding your written ICU, nursing and/or respiratory therapy policies and procedures concerning patients receiving mechanical ventilation, is there guidance to: (YES/NO) Avoid supine (flat) patient positioning unless clinically indicated (i.e. hemodynamic instability, orthopedic injury, etc.)? Use standard precautions while suctioning the respiratory tract secretions? Avoid nonessential tracheal suctioning? Avoid gastric over distention? Periodically remove condensate from circuits? Assure that circuits are closed during removal of condensate to assure that condensate doesn’t drain toward the patient? Perform hand hygiene before contact with respiratory equipment?

Semi-Annual Structural Assessment Does your ICU actively promote: (YES/NO) Use of noninvasive ventilation protocol? Early mobility protocol for patients receiving mechanical ventilation?

Data Collection Ideas Where can you find these data? Ideas Suggestions Barriers

Next Steps Where will you find your data? Look for data sources Make plans for data collection processes Practice collecting data for next call After finding your data sources and starting data collection: Collect data daily Enter the data at least weekly

Discussion Question How will using the data portal benefit me?

CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Next Steps CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

Next Steps: Homework By January 1, 2015 Determine the location of information that is needed to complete the Daily Care Process Measures Determine who will gather the data for the Daily Care Process Measures.

Next Onboarding Call: VAE Overview November 19, 2014 1:00 – 2:00 PM EST Review the theory supporting the new NHSN VAE surveillance Review basic VAE surveillance techniques Apply techniques to determine whether patients on mechanical ventilation have acquired VAEs

Mark Your Calendar: Upcoming Onboarding Sessions ACTION DATE Orientation Webinars 3: Ventilator Associated Events (VAE) Overview Nov 19, 1–2 pm EST 4: Assessing Patient Safety Culture using the Hospital Survey on Patient Safety (HSOPS) Dec 3, 1–2 pm EST Project Kick-Off Dec 17, 1–3 pm EST Do not need all dates. Put first couple of calls…

CUSP 4 MVP – VAP Website Visit: https://armstrongresearch.hopkinsmedicine.org/cusp4mvp.aspx

What Can I Find on the CUSP 4 MVP – VAP Website? Education materials Toolkits CUSP Daily Process Measures Early Mobility Low Tidal Volume Ventilation (soon) Literature Reviews Fast Fact Sheets CUSP Tools and Guides Archive of webinars led by subject matter experts

References ARMSTRONG INSTITUTE Klompas M, Branson R, Eichenwald EC, Greene LR, Howell MD, Lee G, Magill SS, Maragakis LL, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35(8):915-936. PMID: 25026607. Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BR, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Skrobik Y, Jaeschke R; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013 Jan;41(1):263- 306. PMID: 23269131. ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY