CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Content 2: Spontaneous Awakening Trials (SAT), Spontaneous Breathing Trials (SBT) , and The Utility of the Exposure Receipt Assessment February 18, 2015 ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY Johns Hopkins University

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

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

Learning Objectives Define and explain the importance of spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) Implement the process measure used to assess SAT and SBT compliance Assess barriers to implementing SATs and SBTs Describe value to your team of the Exposure Receipt Assessment

Agenda Introduction of guidelines Define SAT/SBT protocols Daily Care Process Measures tool Sample reports Identify barriers to implementation Resources Overview of Exposure Receipt Assessment Next Steps

CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Spontaneous Awakening and Breathing Trials (SAT & SBT) Bradford Winters, MD, PhD with Keith Lamb and Carl Hinkson CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

SAT & SBT Specific VAP Prevention Guidelines Society for Healthcare Epidemiology of America1 Recommends simultaneous use of daily sedation interruption (SAT) and daily assessment of readiness wean (SBT) Recommends management of ventilated patients with minimal sedation whenever possible and avoidance of benzodiazepines

SAT & SBT Specific VAP Prevention Guidelines Centers for Disease Control and Prevention2 Does not specifically address SAT and SBT, however supports weaning American Thoracic Society3 Recommends use of daily interruption or lightening of sedation to avoid constant heavy sedation and to facilitate and accelerate weaning Does not specifically address SBT

Spontaneous Awakening Trials (SATs) Protocol4,5 SAT consists of two parts: safety screen and trial Safety screen checks for contraindications Patient passes the screen unless following factors are present Receiving a sedative infusion for active seizures or alcohol withdrawal Receiving escalating doses of sedative for agitation Receiving neuromuscular blockers Evidence of active myocardial ischemia in prior 24 hours Evidence of increased intracranial pressure

Spontaneous Awakening Trials (SATs) Protocol4,5 If patient passes the safety screen, Stop all sedatives and analgesics used for sedation Continue analgesics used for pain

Spontaneous Awakening Trials (SATs) Protocol4,5 Passes the SAT if can do 3 out of 4 task on request Open their eyes Look at their caregiver Squeeze the hand Put out their tongue OR can go without sedation for 4 hours without new symptoms or complications

Spontaneous Awakening Trials (SATs) Protocol4,5 Passes the SAT if without sedation for 4 hours without the following: Sustained anxiety Agitation Pain Respiratory rate of 35 breaths/minute for ≥ 5 minutes SpO2 of less than 88% for ≥ 5 minutes Acute cardiac dysrhythmia Two or more signs of respiratory distress Tachycardia Bradycardia Use of accessory muscles Marked dyspnea Abdominal paradox Diaphoresis

Spontaneous Awakening Trials (SATs) Protocol4,5 If patient fails the SAT, Sedatives are started at one half the prior dosage Then titrated up as needed

Spontaneous Breathing Trials (SBTs) Protocol4,5 If passes the SAT, assessed for the SBT safety screen Passes the SBT screening if achieve: Adequate oxygenation (SpO2 ≥ 88% or an FiO2 of ≤ 50% and a PEEP ≤ 8 cm H2O) Any spontaneous inspiratory effort in a 5-minute period No agitation No significant use of vasopressors or inotropes No evidence of increased intracranial pressure

Spontaneous Breathing Trials (SBTs) Protocol4,5 If fails the safety screen, reassess for SAT the following day If passes the safety screen, undergo the SBT Ventilator support is removed Patient is allowed to breathe through either T-tube circuit of a ventilator circuit with CPAP of 5cm H2O OR Pressure support ventilation of less than 7cm H2O

Spontaneous Breathing Trials (SBTs) Protocol4,5 Patient passes the trial if they avoid developing any of the following failure criteria within 120 minutes: Respiratory rate of either < 8 breaths per minute (bpm) or > 35 bpm for 5 min or longer Hypoxemia (SpO2 < 88% for ≥ 5 min) Abrupt change in mental status Acute cardiac arrhythmia Two or more signs of respiratory distress Tachycardia Bradycardia Use of accessory muscles Abdominal paradox Diaphoresis Marked dyspnea

Spontaneous Breathing Trials (SBTs) Protocol4,5 If fails the SBT, reassess for SAT the following day If passes the SBT, physician(s) are notified for possible extubation

SAT & SBT Protocol4,5 Is the patient responsive to verbal stimuli? Rescreen tomorrow SAT Safety Screen Rescreen tomorrow Rescreen tomorrow SAT: Can patient go w/o sedation and complications for 4 hours? SBT Safety Screen Restart sedation at half dosage, then titrate for pain/sedation SBT: Does patient breathe w/o complications for 2 hours? Notify physician to consider extubation Rescreen tomorrow

Polling Question What action should be taken if the patient becomes agitated during SAT/SBT? Restart heavy sedation Restart sedation to RASS of -3 Restart sedation at one-half the previous dose and titrate up as needed Continue SAT/SBT

CDC Prevention Epicenters’ Wake Up and Breathe Collaborative6 What: Prospective quality improvement collaborative Who: 12 ICUs affiliated with 7 hospitals Why: prevent VAEs through less sedation and earlier liberation from mechanical ventilation How: increase performance of paired daily spontaneous awakening trials and breathing trials (SATs and SBTs) Prospective quality improvement collaborative 12 ICUs affiliated with 7 hospitals Prevent VAEs through less sedation and earlier liberation from mechanical ventilation Increase performance of paired daily spontaneous awakening trials and breathing trials (SATs and SBTs) The CDC Prevention Epicenters just recently presented the results of their VAE prevention collaborative. 12 ICUs affiliated with 7 hospitals sought to decrease VAEs by decreasing duration of mechanical ventilation. They focused on enhancing the performance of paired daily SATs and SBTs.

CDC Prevention Epicenters’ Wake Up and Breathe Collaborative6 SATs & SBTs Increases 63% in SATs 16% in SBTs 81% in SBTs done with sedatives off 37% in VACs 65% in IVACs Over a 19 month period they observed a substantial increase in SATs and SBTs which in turn was mirrored by substantial decreases in VACs and IVACs. VAE Reductions

CDC Prevention Epicenters’ Wake Up and Breathe Collaborative6 SATs & SBTs Increases 2.4 vent days 3.0 ICU days 6.3 LOS days 63% in SATs 16% in SBTs 81% in SBTs done with sedatives off Over a 19 month period they observed a substantial increase in SATs and SBTs which in turn was mirrored by substantial decreases in VACs and IVACs. Vent Days & LOS Reductions

Daily Interruption of Sedatives Less than half of practitioners worldwide have implemented daily interruption of sedatives7,8 Germany 34% Canada 40% USA 40%

Perceived Barriers to Sedation Protocols and SATs7 Multidisciplinary web-based survey (n=904) Reasons for lack of protocol use No physician order, 35% Lack of nursing support, 11% Fear of over sedation, 7% Barriers for daily sedation interruption Nursing acceptance, 22% Risk of device removal, 19% Respiratory compromise, 26% Patient discomfort, 13%

ICU Barriers to SATs View SATs as unnecessary, and light sedation as more appropriate and safer Claim no physician orders Maintain inadequate staff to undertake protocols Unconvinced lowering sedation will benefit patients

ICU Barriers to SATs9 Nursing attitudes account for one-third of variance in number of patients who received sedatives Only 17.7% of respondents thought it was easier to care for an awake and alert patient receiving mechanical ventilation than to care for a similar patient more sedated

Data Collection Drives quality improvement efforts Is NOT for research Provides quantifiable measures of care practices Guides patient safety conversations Justifies resource allocations Human resources (time) Financial resources (money) Supplies and equipment (stuff)

SAT & SBT Daily Care Process Measures SAT Contraindication SBT SBT Contraindication SBT with Sedatives Off

SAT Contraindications 0. Other Sedatives for active seizures or objective evidence of active alcohol withdrawal Escalating sedative doses due to ongoing agitation Neuromuscular blockers Active myocardial ischemia in the previous 24 hours Increased intracranial pressure in the previous 24 hours High frequency oscillation ventilation

SBT Contraindications 0. Other No adequate oxygenation [SpO2 < 88% on an FiO2 of ≥ 50% and a PEEP of ≥3 cm H2O] No spontaneous inspiratory effort in a 5-minute period Acute agitation requiring escalating sedative doses Significant vasopressors or inotropes Increased intracranial pressure in the previous 24 hours

Accessing SAT & SBT Reports SAT and SBT reports are part of the Daily Process Measures data collection tool. Login at http://armstrongresearch.hopkinsmedicine.org

Daily Care Process Measures Compliance Reports Download and Print reports You can view your Compliance reports for 1) SAT Compliance Rate; 2) SBT Compliance Rate; and 3) SBT with Seds off Compliance Rate. Improvement Opportunities display the number of events, which if eliminated improve your measure value

Daily Care Process Measures Reports: View Chart Ability to download PDF Turn comparators ON and OFF This brings up an interactive chart with customizable options. This is available for all three compliance reports. Interactive chart that allows selection of your comparators and time periods

Daily Care Process Measures Contraindication Reports You can view your Contraindication reports. Average Performance displays the mean for all the other participants in VAP. My Percentile shows what percentile your rate is versus all other participants in VAP

Daily Care Process Measures Distribution Reports Scroll down to view SAT/SBT information The Distribution tab will provide more information. Scroll down to view SAT/SBT information.

Daily Care Process Measures Distribution Reports You can find the distribution reports for 1) SAT Contraindications and 2) SBT Contraindications. An example of SAT Contraindications is shown on this slide.

Resources: Fast Facts Ready to post in the unit Provides quick reference to latest evidence-based protocols Summarizes position of four leaders in the VAP field

Resources: SAT & SBT Protocol

Resources: Literature Synopsis Summarizes guidelines in the VAP field SHEA: Society for Healthcare Epidemiology of America American Thoracic Society ZAP the VAP: Ventilator-associated Pneumonia Center for Disease Control and Prevention Includes details of literature published post- guidelines, both positive and negative Annotated bibliography Updated with the latest SHEA guidelines published in 2014

References SHEA; 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):915-36. PMID: 25026607. CDC; Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing healthcare- associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53:1-36. PMID: 15048056. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416. PMID: 15699079. Kress J, Pohlman A, O'Connor M, Hall JB. Daily interruption of sedative infusion in critically ill undergoing mechanical ventilation. N.Engl.J.Med. 2000;342(20):1471-7. PMID: 10816184. Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, Taichman DB, Dunn JG, Pohlman AS, Kinniry PA, Jackson JC, Canonico AE, Light RW, Shintani AK, Thompson JL, Gordon SM, Hall JB, Dittus RS, Bernard GR, Ely EW. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): A randomised controlled trial. Lancet. 2008;371(9607):126-134. PMID: 18191684.

References Klompas M, Anderson D, Trick W, Babcock H, Kerlin MP, Li L, Sinkowitz-Cochran R, Ely EW, Jernigan J, Magill S, Lyles R, O'Neil C, Kitch BT, Arrington E, Balas MC, Kleinman K, Bruce C, Lankiewicz J, Murphy MV, Cox C, Lautenbach E, Sexton D, Fraser V, Weinstein RA, Platt R; for the CDC Prevention Epicenters. The Preventability of Ventilator-Associated Events: The CDC Prevention Epicenters' Wake Up and Breathe Collaborative. Am J Respir Crit Care Med. 2014 Nov 4. PMID: 25369558. Tanios MA, de Wit M, Epstein SK, Devlin JW. Perceived barriers to the use of sedation protocols and daily sedation interruption: a multidisciplinary survey. J Crit Care. 2009; 24(1):66-73. PMID: 19272541. Devlin JW, Tanios MA, Epstein SK. Intensive care unit sedation: waking up clinicians to the gap between research and practice. Crit Care Med 2006; 34(2):556-7. PMID: 16424748. Guttormson JL, Chlan L, Weinert C, Savik K. Factors influencing nurse sedation practices with mechanically ventilated patients: a U.S. national survey. Intensive Crit Care Nurs. 2010;26(1):44-50. PMID: 19945879.

Utility of the Exposure Receipt Assessment Nishi Rawat, MD CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

Exposure Receipt Assessment (ERA) Goals Measures awareness and involvement of frontline staff Helps you understand what information your staff actually receives National Project Team Resources (webinars, coaching) Team Lead Dissemination of Information Frontline Provider Knowledge

Exposure Receipt Assessment (ERA) Goals Addresses technical interventions and techniques Addresses adaptive CUSP initiatives designed to improve your unit safety culture Like every collaborative risk reduction initiative, CUSP 4 MVP – VAP can only achieve success if the frontline staff is involved.

Exposure Receipt Assessment (ERA) Goals Assess your unit’s use of VAE prevention interventions Identify best practices for disseminating these interventions Generate lessons for peer to peer learning

Exposure Receipt Assessment (ERA) Details Who completes the survey? All frontline staff How long does it take? About 5 minutes How often? Twice a year For Cohort 2 teams, ERA surveys occur during these timeframes Feb/Mar 2015 Sept/Oct 2015 Apr/May 2016

Exposure Receipt Assessment (ERA) FAQ’s Who sees the results? Anonymous No identifiers on responses Supervisors will not see responses

Exposure Receipt Assessment (ERA) FAQ’s Who does see the results? Subset of the national project team What do they do with the results? Collate and report results back to you Improve education materials to increase penetration Why should I ask my busy staff take this survey? Learn the extent to which the interventions are reaching your frontline providers Interventions cannot be effective without provider awareness of intervention

Where Can I Find the ERA? Project website: https://armstrongresearch. hopkinsmedicine.org/cusp4mvp.aspx Select Data Collection Tools and Tutorials Select Exposure Receipt Assessment

Exposure Receipt Assessment (ERA) Survey What is your role in the unit? Nurse Technician Doctor Do you know your unit’s ventilator-associated pneumonia (VAP) or ventilator-associated event (VAE) rate(s)? YES / NO Have you watched the Science of Safety presentation? YES / NO Respiratory therapist Other ____________

Exposure Receipt Assessment (ERA) Survey Have you completed a Staff Safety Assessment? YES / NO  Have you used the Learning From Defects tool in the past three months? Yes, I have used it No, I have not used it; I have not heard of it No, I have not used it, but I am familiar with it We use a different kind of defect tool The Staff Safety Assessment is a two-question tool about how the next patient may be harmed. Learning From Defects is a tool that helps teams to prioritize safety issues, develop plans to address the issues, and evaluate if the issues are less likely to occur.

Exposure Receipt Assessment (ERA) Survey Over the past three months, for how many patients has your unit used the Daily Goals checklist? All / Almost all We don’t use the Daily Goals Over half We use a different kind of checklist Under half Don’t know The Staff Safety Assessment is a two-question tool about how the next patient may be harmed. Learning From Defects is a tool that helps teams to prioritize safety issues, develop plans to address the issues, and evaluate if the issues are less likely to occur.

Exposure Receipt Assessment (ERA) Survey How familiar are you with the Comprehensive Unit-based Safety Program (CUSP)? Very familiar Somewhat familiar Not at all familiar Do you have a CUSP team on your unit? YES / NO / DON’T KNOW  If yes, has the CUSP team on your unit been active in improving patient safety? The Staff Safety Assessment is a two-question tool about how the next patient may be harmed. Learning From Defects is a tool that helps teams to prioritize safety issues, develop plans to address the issues, and evaluate if the issues are less likely to occur.

Exposure Receipt Assessment (ERA) Survey Which of these interventions are being used by your unit and how often? Maintain elevation of the head of the bed to ≥ 30° Mobilizing patients Low tidal volume strategy for the prevention of acute lung injury Subglottic suctioning endotracheal tubes Spontaneous awakening trial (SAT) (sedation vacation) Spontaneous breathing trial (SBT) Do you believe that the interventions above will help to prevent VAE on your unit? The Staff Safety Assessment is a two-question tool about how the next patient may be harmed. Learning From Defects is a tool that helps teams to prioritize safety issues, develop plans to address the issues, and evaluate if the issues are less likely to occur.

Exposure Receipt Assessment (ERA) Survey In your opinion, which of the following interventions are most likely to prevent VAE? To the best of your ability, please select the three most important interventions. Maintain elevation of the head of the bed to ≥30° Mobilize patients Low tidal volume ventilation Subglottic suctioning endotracheal tubes Spontaneous awakening trial (SAT) (sedation vacation) Spontaneous breathing trial (SBT) Perform oral care 6 times daily Use chlorhexidine 2 times daily while performing oral care

Exposure Receipt Assessment (ERA) Survey In your opinion, where is the biggest opportunity to improve the care of mechanically ventilated patients in your unit? Maintain elevation of the head of the bed to ≥30° Mobilize patients Low tidal volume ventilation Subglottic suctioning endotracheal tubes for patients ventilated >72 hours Spontaneous awakening trial (SAT) (sedation vacation) Spontaneous breathing trial (SBT)

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 March 18, 2015 Audit SAT/SBTs for 10 patients to assess barriers Report barriers in next coaching call

Mark Your Calendar: Upcoming Content Webinars ACTION DATE Delirium Assessment Training Mar 18, 11-12:30pm EST Daily Goals Facilitates VAE Prevention Implementation Assessment Overview Apr 15, 11-12:30pm EST Early Mobility: A Practical Approach May 20, 11-12:30 pm EST Learning From Defects Jun 17, 11-12:30 pm EST For current schedule of upcoming project webinars, visit https://armstrongresearch.hopkinsmedicine.org/cusp4mvp/schedules.aspx

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 Daily Care Toolkits SAT/SBT Protocol SAT/SBT Literature Review SAT/SBT Fast Fact Sheet Exposure Receipt Assessment tool CUSP Tools and Guides Archive of webinars led by subject matter experts https://armstrongresearch.hopkinsmedicine.org/cusp4mvp.aspx

Additional Resources ICU Delirium at http://www.icudelirium.org/ ICU Liberation at http://www.iculiberation.org/