How to Improve Patient Outcomes after Mechanical Ventilation Essential Hospitals Engagement Network October 1, 2013

Our new Name We’ve rebranded! The National Association of Public Hospitals and Health Systems is now America’s Essential Hospitals.   Although we’ve changed our name, our mission is the same: to champion hospitals and health systems that provide the highest quality of service to all by achieving the best health outcomes for every patient, especially those in greatest need. The new name underscores our members’ continuing public commitment and the essential nature of our work to care for the most vulnerable and provide vital community services, such as trauma care and disaster response. This is an exciting time for us and our members, as we lean forward into new care models, opportunities and challenges of reform, and quality and safety innovations that often take root in our member systems. Our new website address: www.EssentialHospitals.org

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Speaker information Michele C. Balas, PhD, RN, APRN-NP, CCRN Associate Professor Center of Excellence in Critical and Complex Care The Ohio State University College of Nursing Alex Ramos, RN, MSN, CCRN Trauma Operations Manager Sandra Gonzalez RN, BSN Director of Trauma, Neurosurgery and Adult Med/Surg Critical Care Services Dustin Bierman, RN, MSN ICU Med/Surg Clinical Coordinator Luis Martinez, RN, BSN ICU Med/Surg Manager ABCDE Team University Medical Center of El Paso John Young, RN, MBA Improvement Coach EHEN Michele C. Balas, Ph.D., RN, led work focused on the determining the prevalence and consequence of delirium in the critically-ill, older adult population. Her research evaluated the effects of a nurse-led intervention aimed at mitigating the effects of ICU-acquired delirium and weakness. Dr. Balas joined the Center of Excellence in Critical and Complex Care at The Ohio State University College of Nursing and plans to collaborate with researchers and clinicians in nursing, gerontology, and critical care medicine to continue her research trajectory aimed at improving the physical, functional, and neurocognitive outcomes of critically ill older adults. Her complete biography is in the additional materials emailed ahead, as are citations and abstracts for her peer-reviewed articles studying the ABCDE bundle. Also in the notes are links for additional delirium-related information and an article citation reviewing mobilizing mechanically ventilated trauma and burn patients from the University of Alabama, an America’s Essential Hospitals member. Also joining us are frontline clinicians from the University Medical Center of El Paso in El Paso, TX. UMC El Paso is an EHEN member doing great work in reducing infections, pressure ulcers and readmissions. Alex Ramos, Sandra Gonzalez and Dustin Bierman, all nursing leaders, join us to talk about their ABCDE team. They’ll share their story planning and organizing to implement the bundle in their ICU. And finally I’m John Young, EHEN Improvement coach. I’ll moderate today’s webinar.

Agenda VAP work in EHEN and Partnership for Patients The ABCDE bundle   - Michele C. Balas, PhD, RN, APRN-NP, CCRN An EHEN hospital’s story - UMC El Paso ABCDE team       Q & A Wrap-up and announcements Review agenda

EHEN Vap Results (as of May, 2013) Summary UHC-Defined VAP Outcome Numerator: Adult discharges (age ≥ 18) with an ICU stay ≥ 1 day on an invasive mechanical ventilator (ICD-9-CM code 96.70-96.72). Inclusions: Diagnosis code = 997.31, POA=N,U; Denominator: Adult discharges (age ≥ 18) with an ICU stay ≥ 1 day on an invasive mechanical ventilator (ICD-9-CM code 96.70-96.72). Review measure, coach control chart and inspire to apply today’s material to further improve.

Improving Patient-Centered Outcomes in the ICU: The ABCDE Bundle I’ll turn things over now to our featured presenter. Dr. Balas, the floor is yours. Michele C. Balas PhD, RN, APRN-NP,CCRN Associate Professor, The Ohio State University College of Nursing, Center for Critical & Complex Care Adjunct Professor , University of Nebraska Medical Center College of Nursing, Department of Community Based Health

Disclosures Dr. Balas is currently a Co-investigator on a grant supported by the Alzheimer’s Association and has received honoraria from ProCe, the France Foundation, Hospira, & Hillrom. Images courtesy of Nancy Adams- http://www.nancyandrews.net Research supported by RWJF-INQRI For references regarding outcomes of delirium in the ICU setting and the ABCDE bundle please see: www.icudelirium.org

The Issues- ICU Acquired Delirium & Weakness Profound & emerging public health threat Common Lethal Disabling Persistent

The Issues- ICU Acquired Delirium & Weakness 33% Emergency Room 14-56% Medical/Surgical Units 20-50% Non-Mechanically Ventilated-ICU 50-80% Surgical/Trauma/ Burn ICU 70-87% Mechanically Ventilated-ICU 25-50% of patients who receive MV for 4-7 days 50-75% sepsis patients 80-95% of patients with ICU- AW have neuromuscular abnormalities 2-5 YEARS after hospital discharge 70% of MV patients have difficulty with ADLs 1 year after discharge

DELIRIUM AN INDEPENDENT PREDICTOR OF MORTALITY ICU & hospital Mortality rates ranging from 22-76% 6-month* (3 fold ↑ risk) 1 year Each day delirious ↑ 10% mortality!!!!!! Lin (CCM, 2004); Inouye (NEJM, 2006); *Ely (JAMA, 2009); Pisani (AJRCC, 2009)

Outcomes Associated With Delirium ICU & hospital LOS ↑ restraints & sedation Poor functional recovery New institutionalization Multiple complications Total 1-year US health-care costs $38-152 billion dollars

Delirium & New Onset Cognitive Impairment ½ of all ICU survivors experience long-term cognitive impairment Persistent Associated with delirium duration Older patients without dementia hospitalized for a non-critical illness have a 40% higher risk of dementia 10 20 30 40 50 60 5 15 Delirium Days Cognitive Function at 12 months (predicted mean T-score) p=.03 Jackson et al., Anesthesiology Clinics, 2011; Ehlenbach, Jama, 2010

Other Outcomes Associated with Critical Care 10-50% of all ICU survivors experience PTSD Depression Anxiety Sleep disorders Need for caregiver assistance

Patient Experience “On Sunday, I was on the ICU, where a horror ceremony like in a concentration camp was going on. Four patients were executed. Laying in their beds, they received a death pill. I was one of them…The hangman gave us the pill, with a blank face. In the background were two ladies waiting to carry away our dead bodies…The torturers watched us all the time, they asked us: “Do you feel anything yet? How does your foot feel? How does your arm feel?”… The children of Satan were in command. They were dressed in green coats and had scary faces. They were waiting for our death. … Worst was, that I did not try to resist. How can a man throw away his life like that? Why me? Did they do a mistake during the surgery and try to cover it up by killing all of us? … The pills did not work. I did not die. So they tried it again with gas, pressing a mask on my face. …"- Male, 67 years old.

Precipitating Factors for ICU Acquired Delirium & Weakness Potentially Modifiable Sedative Medications Mechanical Ventilation Immobility/prolonged bed rest Uncontrolled pain Sleep deprivation Non-Modifiable Age Severity of illness Comorbidities Pre-existing CI/dementia Drug/ETOH withdrawal

Potential Solution- ABCDE Bundle Awakening Breathing Coordination/Choice of sedation Delirium monitoring/ management Early exercise/mobility

What Does the Evidence Tell Us? Awakening Kress et al. (2000) NEJM Pro-RCT, 128 MV, MICU Treatment group-CI sedatives stopped 1Xday (restarted at ½ rate if needed) SS reduction in MV days 4.9 vs. 7.3 ICU LOS 6.4 vs. 9.9

What Does the Evidence Tell Us? Awakening Kress et al. (2000) NEJM Fewer diagnostic tests No difference in Complications Mortality Hospital LOS Kress et al. (2003) AJRCCM 32 patients 6 month FU Results Fewer symptoms PTSD 11.2 vs. 27.3 (p=0.02) Lower incidence of PTSD 0 vs. 32 (p=0.06) Better psychosocial adjustment to illness

What Does the Evidence Tell Us? Awakening Weinert et al. (2007) CCM 85% of 18,050 evals had sedation (N=274) 1 in 3 unarousable (32%) 1 in 5 no spontaneous motor activity (21%) Only 2.6% of providers thought patients were “over-sedated”!!!!!!

What Does the Evidence Tell Us? Breathing Spontaneous Breathing Trials (Ely et al. 1996 NEJM) RCT, single center, N=300 Respiratory care-driven weaning protocol using SBTs found to lead to statistically significant improvements MV days 3 vs. 4.5 (p=0.003) Reintubation 6 vs. 15 (p=0.04) MV >21 days 9 vs. 20 (p=0.04) ICU cost 15,740 vs. 20,890 (p=0.03)

What Does the Evidence Tell Us? Awakening & Breathing Coordination Multicenter, RCT (N=336) Intervention group protocolized SATs & SBTs; control group daily SBTs & “usual care” sedation Results Survival at 1 yr. 58% vs. 44% p=0.01

What Does the Evidence Tell Us What Does the Evidence Tell Us? Awakening & Breathing Coordination Girard et al. (2008) Lancet No difference in…. Self extubation with reintubation Total re-intubations Delirium Tracheostomy Long-term cognitive & psych. outcomes (Jackson et al.) Stat. Significant Results… 32% less likely to die NNT-7 to save a life at 1 year VFDs (3 days) Successful extubation (7 vs. 5) ICU & hospital LOS (4 days) Coma (1 day) Self-extubation (3 vs. 5)

What Does the Evidence Tell Us? Choice of Sedation Analgosedation (Strøm T, et al. Lancet. 2010;375:475-480) 140 critically ill adult patients undergoing MV in single center Randomized, open-label trial Both groups received bolus morphine (2.5 or 5 mg) Group 1: No sedation (n = 70 patients) - morphine prn Group 2: Sedation (20 mg/mL propofol for 48 h, 1 mg/mL midazolam thereafter) with daily interruption until awake (n = 70, control group)

What Does the Evidence Tell Us? Choice of Sedation Patients receiving no sedation had More days without MV (13.8 vs 9.6 days, P = 0.02) Shorter stay in ICU (HR 1.86, P = 0.03) Shorter stay in hospital (HR 3.57, P = 0.004) More agitated delirium (N = 11, 20% vs N = 4, 7%, P = 0.04) No differences found in Accidental extubations Need for CT or MRI Ventilator-associated pneumonia

What Does the Evidence Tell Us? Choice of Sedation 2013 SCCM Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU Regular PAD screening using valid & reliable tools Role of preemptive analgesia/importance of effectively managing pain Maintaining light levels of sedation (DSI vs. light target level) Nonbenzodiazepine sedative strategies Potential role of Dexmedetomidine (MV at risk for delirium) No prophylactic haloperidol or atypical antipsychotics Atypical antipsychotics may reduce duration of delirium

What Does the Evidence Tell Us? Delirium Monitoring/Management Morandi A, et al. Intensive Care Med. 2008;34:1907-1915. CAM-ICU ICDSC

What Does the Evidence Tell Us? Early Exercise/Mobility Early PT and OT in Mechanically Ventilated ICU Patients Schweickert WD, et al. Lancet. 2009;373(9678):1874-1882.

ABCDE Bundle Steps ABCDE bundle is multicomponent, interdependent, & designed to: Improve clinical team collaboration Standardize care processes Break the cycle of oversedation & prolonged mechanical ventilation Opt-out method Safety screen & self-guided ABCE’s

Awakening

Breathing SBT Failure Criteria SBT Safety Screen Respiratory rate > 35/min Respiratory rate < 8/min Oxygen saturation < 88% Respiratory distress Mental status change Acute cardiac arrhythmia SBT Safety Screen No agitation Oxygen saturation ≥ 88% FiO2 ≤ 50% PEEP ≤ 7.5 cm H2O No myocardial ischemia No vasopressor use Inspiratory efforts

Early Mobility Safety Screen Patient responds to verbal stimulation (ie, RASS ≥ -3)* FIO2 ≤ 0.6 PEEP ≤ 10 cmH2O No  dose of any vasopressor infusion for at least 2 hours No evidence of active myocardial ischemia (24 hrs) No arrhythmia requiring the administration of new antiarrhythmic agent (24 hrs)

Early Mobility Progression Walking A Short Distance Standing at bedside and sitting in chair Each eligible patient is encouraged to be mobile twice a day, with the specific level of activity geared to his or her readiness. Patients progress through a three-step process, embarking on the highest level of physical activity they can tolerate, as outlined below: Sitting on edge of bed: As a first step, the PT & RN helps patients sit at the edge of the bed with their feet planted on the floor or on a platform. A caregiver may support the patient from behind, but the position is discontinued after a few minutes if the patient cannot hold his or her torso upright. The goal is to maintain this position for 10 minutes with minimal support. The patient moves to the second step after accomplishing this goal twice. Standing at bedside and sitting in chair: As a next step, the PT & RN helps the patient stand at the bedside, bear some weight (by lifting each leg), and pivot into a chair by the bed. The patient is encouraged to sit in the chair for as long as he/she can tolerate it, up to 2 hours. The patient moves to the next step after accomplishing this step twice. Walking a short distance: The final step is for the care team to help the patient walk, beginning with a few steps (e.g., to the doorway) and ultimately reaching 200 feet. The PT, RT and the RN will verify optimal time for ambulation. Use of the protocol ends when the patient is discharged from the ICU. Readiness for ICU discharge depends on clinical considerations, not the patient's ability to walk 200 feet. This step is appropriate for patients who are still on sedation and/or critically ill, and for others for whom it is risky to leave the bed. Care team members stay with patients for as long as they can tolerate the position, monitoring the patients for physiological signs and symptoms of distress such as fatigue and/or changes in blood pressure, heart rate, respiratory rate, and oxygen saturation level. If the patient is stable and awake, the care team departs after approximately 15 minutes, but checks in periodically; equipment allows all patients to be monitored from a central station. If the patient becomes disconnected or declines physiologically, the care team returns immediately. If the care team is concerned about the patient’s ability to tolerate the sitting position, they remain with the patient. PT and/or the RN will contact the RT to coordinate a time for the first ambulation session the following day. The RT will enter an order as “Patient Ambulation by RCS” in the Hospital Information System (HIS), including the frequency of ambulation. The healthcare team will inform the patient (and family/caregivers) the ambulation schedule/activity for the day. The RT will assemble the equipment necessary for patient ambulation and ensure the patient’s artificial airway is secure throughout ambulation. The RT will adjust ventilator settings and/or provide manual resuscitation based on patient’s tolerance during ambulation and reconnect or return the patient to the ventilator at the previously ordered settings after completion of the activity. The RT will also document in the medical record: tolerance, complications, and adjustments in ventilator settings, etc. The RN will monitor the patient’s HR, RR, SpO2, ETCO2 etc. The RN and PT support the patient; canes and walkers may be used as needed. A patient care technician will follow the patient with a wheelchair in case of fatigue or medical need and assists with other equipment as needed. For ventilated patients in contact isolation caregivers will wear clean appropriate isolation barriers (gowns, gloves, etc.) when ambulating the patient in the hallway. The RN will ensure the patient’s drainage is contained. The team will dedicate the equipment for the activity whenever practical and if reusable equipment is used, clean with low level disinfectant solution after use. The team will maintain a “no-touch” technique of all environmental surfaces when outside of the patient’s room. Sitting on edge of bed

Delirium Monitoring/Management Routine Sedation & Delirium Assessment Using Standardized, Validated Assessment Tools RN administers & records RASS/SAS results q2h Team sets “target” RASS/SAS score for the patient to be maintained at for the following 24 hours RN administers & records results of the CAM-ICU/ICDSC q8h & whenever a patient experiences a change in mental status

Delirium Monitoring/Management Each day during interdisciplinary rounds, the RN will: State the “TARGET” sedation score State the patient’s ACTUAL sedation score State the patient’s delirium status State the sedative/analgesic medications the patient is currently receiving Each day during interdisciplinary rounds, the team will use the acronym “THINK” if a patient is CAM positive (delirious) The interdisciplinary team will employ the following non-pharmacologic interventions when treating a delirious patient: Eliminate or minimize risk factors Provide a therapeutic environment

Delirium Monitoring/Management USE MEDICATIONS ONLY IF ABSOLUTELY NECESSARY! Give “PEACE” a chance Physiologic Environmental ADLs/Sleep Communication Education

So Easy- What Could Possibly Go Wrong? Canada – 40% get SATs (273 physicians in 2005)1 US – 40% get SATs (2004-05)2 Germany – 34% get SATs (214 ICUs in 2006)3 France – 40–50% deeply sedated with 90% on continuous infusion of sedative/opiate4 1. Mehta S, et al. Crit Care Med. 2006;34:374-380. 2. Devlin J. Crit Care Med. 2006;34:556-557. 3. Martin J, et al. Crit Care. 2007;11:R124. 4. Payen JF, et al. Anesthesiology. 2007;106:687-695.

Barriers to Daily Sedation Interruption (Survey of 904 SCCM members) Increased device removal Poor nursing acceptance Compromises patient comfort Leads to respiratory compromise Difficult to coordinate with nurse No benefit #1 Barrier Leads to cardiac ischemia #2 Barrier #3 Barrier Leads to PTSD 10 20 30 40 50 60 70 Number of respondents (%) Clinicians preferring propofol were more likely use daily interruption than those preferring benzodiazepines (55% vs 40%, P < 0.0001) Tanios MA, et al. J Crit Care. 2009;24:66-73. 40

Implementation Challenges Facilitators: Daily interdisciplinary rounds Engagement of key implementation leaders Sustained, diverse educational efforts Bundle’s quality and strength Barriers: Intervention-related issues (e.g., timing of trials, fear of adverse events) Communication and care coordination challenges Knowledge deficits Workload concerns Documentation burden

Implementation Challenges Structural characteristics of the ICU Organization-wide patient safety culture ICU culture of quality improvement Implementation planning, training/support Prompts/documentation Excessive turnover (both in project and ICU leadership) Staff morale issues Lack of respect between disciplines Knowledge deficits Excessive use of registry staff

Is it Worth It? Absolutely

Q & A Ask LA to unmute phones for questions. Can also submit thru chat box. If not mentioned, what impact has she observed on VAP after implementing the bundle? What are some countermeasures for staff turnover to hardwire the bundle? Mute phones.

University medical center of el paso Reintroduce Alex Ramos, Sandra Gonzalez and Dustin Bierman from the UMC El Paso ABCDE team Can you tell us a bit about UMC El Paso and the patients you serve? - ICU size, physician staffing (open/closed), staffing What started you thinking about the ABCDE bundle? AACN evidence VAP in trauma patients Next slide

Implementation Challenges Facilitators: Daily interdisciplinary rounds Engagement of key implementation leaders Sustained, diverse educational efforts Bundle’s quality and strength Barriers: Intervention-related issues (e.g., timing of trials, fear of adverse events) Communication and care coordination challenges Knowledge deficits Workload concerns Documentation burden Who is on the team working to implement the bundle? What barriers have you run into? How have you handled them? Physician champions, sedation guidelines and evidence IT Is there anything you’d recommend to someone starting to think about the ABCDE bundle? Next slide

Q & A Handle questions. Unmute phones. Mute when complete. How would you describe the ICU’s culture in regards to quality improvement at UMC El Paso?

The patient’s voice Dr. Needham: “What did you think when we discussed getting you out of bed while on a ventilator with a breathing tube in your mouth?” Mr. E:”I thought it was wonderful. Anything to get me up and moving, and get me out of bed; anything to get me off my back and on my feet - that is what I really wanted.” Dr. Needham: “How did it feel to be awake, with the breathing tube in your mouth, on a ventilator, and walking laps around the medical intensive care unit?” Mr. E: “It was wonderful. It was nice to get up and walk around. It was not uncomfortable. I enjoyed it. I think it had a very positive effect on me.” Close with this quote and picture of a patient’s impression of what’s possible. Ask audience to do three things Look at their hospital’s context for facilitators and barriers Identify functional champions Decide on and execute a plan Hand back to Laura Anne to close us out. Laura Anne? Needham DM. Mobilizing patients in the intensive care unit: Improving neuromuscular weakness and physical function. JAMA. 2008 October. 300(14). 1685-1690.

Thank you for attending! Equity Webinar – October 10 @ 2pm ET Building Health Literacy: Essential Steps and Practical Solutions Speakers: Dean Schillinger MD, Director, Health Communication Program, UCSF Center for Vulnerable Populations Michele Edwards , NP Grady Heart Failure Clinic Evaluation: When you close out of WebEx following the webinar a yellow evaluation will open in your browser. Please take a moment to complete. We greatly appreciate your feedback! Essential Hospitals Engagement Network website: http://tc.nphhi.org/Collaborate