© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 CUSP for VAP: Year in Review Sean Berenholtz, MD, MHS Kathleen Speck, MPH The Armstrong Institute for Patient Safety and Quality February 6, 2014

CUSP for VAP: Project Review NIH/NHLBI and AHRQ funded project –Individual hospitals participate for 3 years, including 2 year intervention period and 1 year sustainability period Leveraging leaders in field –Armstrong Institute for Patient Safety and Quality, NIH/NHLBI, CDC, AHRQ, University of Pennsylvania –Maryland Hospital Association –Hospital and Healthsystem Association of Pennsylvania 2

Project Goals Our objectives were: –To achieve significant reductions in VAE rates –To achieve significant improvements in safety culture utilizing the components of CUSP –To advance the science of VAP prevention utilizing: - Updated VAP prevention bundle - New CDC NHSN VAP definition - Identification of contextual variables that foster/impede the implementation of QI projects 3

Key concepts: Adaptive and Technical Work How Will We Get There? Technical Work Adaptive Work 4

Why Safety Culture Matters? 1.Safety culture is related to outcomes –Patient outcomes Patient care experience Infection rates, sepsis Postop. hemorrhage, respiratory failure, accidental puncture/laceration Treatment errors –Clinician outcomes Incident reporting, burnout, turnover 5 Huang et al., 2010; Mardon et al., 2010; MacDavitt et al., 2007; Singer et al., 2009; Sorra et al., 2012; Weaver, 2011.

Why Safety Culture Matters? 2.Safety culture influences the effectiveness of other safety and quality interventions –Can enhance or inhibit effects of other interventions 3.Safety culture can change through intervention –Best evidence so far for culture interventions that use multiple components 6 Haynes et al., 2011; Morello et al., 2012; Van Nord et al., 2010; Weaver et al., in press

Technical Work Project currently in 2 nd year of implementation phase We have introduced the following VAP prevention measures to reduce VAE rates: - Process Measures HOB Sub-G ETT Oral care Oral care with CHG SAT SBT - Early Mobility 7

Adaptive Work We have introduced the following CUSP tools: - CUSP Components Science of Safety Learning from Defects Engaging Senior Executives & Leadership Daily Goals Culture Checkup Shadowing Daily Briefing Barrier identification and Mitigation 8

Project Resources VAP Tools – p/resources.aspxhttps://armstrongresearch.hopkinsmedicine.org/vap/va p/resources.aspx CUSP Tools – sp/resources.aspxhttps://armstrongresearch.hopkinsmedicine.org/vap/cu sp/resources.aspx Recordings and Slide Presentations for CUSP and VAP Webinars – ls.aspxhttps://armstrongresearch.hopkinsmedicine.org/vap/cal ls.aspx 9

MD and PA Teams Are Engaged: MedConcert Teams have shared tools and protocols via MedConcert: Holy Cross Hospital MICU – Noon Charge Nurse Update Protocol University of Maryland Shore Health Hospitals - ABCDE Protocol Johns Hopkins Hospital WICU – VAP Family Involvement Sign-In Protocol Western Maryland Health System – Vent Weaning Protocol Meritus Medical Center – Vent Weaning Pocket Protocol St. Agnes Hospital – Flow Sheet, Mechanical Vent Weaning Protocol, Mechanical Vent Management Protocol, Drug Administration Protocol Maryland Hospital Association - VAP Talking Points Document MedConcert Link: 10

MD and PA Teams Are Engaged: Content/Coaching Call Participation Teams have presented their experiences on CUSP/VAP content/coaching calls: St. Agnes Hospital AICU - Early Mobility Magee Rehabilitation Hospital SCI - Early Mobility Troy Hospital ICU – Early Mobility Johns Hopkins Hospital WICU – Learning from Defects Prince George’s Hospital ICU – PreMortem Johns Hopkins Bayview Medical Center MICU – PreMortem Sinai Hospital of Baltimore ICU - PreMortem 11

MD and PA Teams Are Engaged: Exposure Receipt Assessment Pilot Teams have helped to pilot the Exposure Receipt Assessment and provided feedback: Western Maryland Health System CVU and ICU MedStar St. Mary's Hospital ICU Meritus Medical Center CCU Doylestown Hospital ICU St Joseph's Hospital ICU Brandywine Hospital ICU 12

MD and PA Teams Are Engaged: Early Mobility Helped to develop the Early Mobility Data Collection Instrument St. Agnes Hospital AICU Magee Rehabilitation Hospital SCI Troy Hospital ICU Helped to pilot the Early Mobility Data Collection Instrument Johns Hopkins Hospital WICU, SICU, CVSICU 13

MD and PA Teams Are Engaged: Video Submissions Teams have shared stories via video submissions: 14

© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Reports: 2013 – A Year in Review

REPORTS Report highlights from of several assessments in 2013: i.Summary Reports (Process Measure Data) ii.VAE Rates iii.Structural Assessment iv.Exposure Receipt Assessment – Pilot v.Quarterly Interviews 16

Compliance Reports: VAP Daily Process Measures (Q1-Q3 2013) Compliance Rates - Aggregated Q1 2013Q2 2013Q3 2013P-value* (Q1 vs. Q3) Data Entry Completion Rate 70%71%70%- HOB 97% (13783/14201) 98% (12569/12834) 99% (7615/7711) <0.001 Sub-G ETT 30% (527/1762) 39% (624/1604) 38% (320/845) <0.001 Oral Care 67% (9352/14006) 71% (8774/12388) 76% (5076/6664) <0.001 Oral Care with CHG 81% (10623/13097) 86% (10109/11720) 83% (5306/6398) SAT 74% (6566/8815) 76% (6287/8227) 78% (3467/4436) <0.001 SBT 67% (6227/9243) 74% (5690/8067) 70% (3056/4341) < * The P-value was obtained by performing a Fisher’s Exact Test. Table 1: Compliance Report for Daily Process Measures

Completion Rates: VAP Daily Process Measures (Q1- Q3 2013) 18 Table 2: Completion Rates on Daily Process Measure Data Entry Break from data collection

VAE Rates: VAC (Q2-Q4 2013) 19 Figure 1 & Table 3: VAC Rate Per 1000 Ventilator Days Q2 2013Q3 2013Q4 2013P-value* (Q2 vs. Q4) Aggregate4.26 (77/18077) 4.74 (61/12871) 2.72 (16/5890) MD3.51 (40/11387) 5.56 (49/8810) 2.85 (12/4208) PA5.53 (37/6690) 2.95 (12/4061) 2.38 (4/1682) Per 1000 Vent Days

VAE Rates: IVAC (Q2-Q4 2013) 20 Figure 2 & Table 4: Total IVAC Rate Per 1000 Ventilator Days Q2 2013Q3 2013Q4 2013P-value* (Q2 vs. Q4) Aggregate3.04 (55/18077) 3.26 (42/12871) 1.53 (9/5890) MD3.25 (37/11387) 3.18 (28/8810) 1.19 (5/4208) PA2.69 (18/6690) 3.45 (14/4061) 2.38 (4/1682) 1.000

VAE Rates: VAP [PoVAP + PrVAP] (Q2-Q4 2013) 21 Figure 3 &Table 5: Total VAP Rate Per 1000 Ventilator Days Q2 2013Q3 2013Q4 2013P-value* (Q2 vs. Q4) Aggregate1.38 (25/18077) 1.40 (18/12871) 0.68 (4/5890) MD1.49 (17/11387) 1.36 (12/8810) 0.48 (2/4208) PA1.20 (8/6690) 1.48 (6/4061) 1.19 (2/1682) 1.000

Completion Rate: VAE Rate Registry Data (Q2–Q4 2013) 22 Q2 2013Q3 2013Q Aggregate100%88%53% MD100%86%54% PA100%90%51% Proportion of months with VAE data Figure 4 & Table 6 : Total VAP Rate Per 1000 Ventilator Days

Structural Assessment: Oct – Jan (n=36) Baseline MD = 21 units (58.3%) PA = 15 units (41.7%) Results Reported 31.4% changing their ventilator circuits routinely 60% changing their suctioning systems routinely 85.3% used the orotracheal route for elective intubation in absence of difficult airway 85.3% used a closed suction system with endotracheal tubes 97.1% have policies for using precautions when suctioning, with 88.9% using these elements 91.2% have policies for using hand hygiene, with 86.1% using these elements 23

Structural Assessment: Oct – Jan (n=36) Results Reported 13.9% used prophylactic IV antibiotics for VAP 70.6% used policies against non-essential tracheal suctioning, with 16.7% using these elements 94.1% used policies against supine positioning, with 16.7% using these elements 67.7% have policies against gastric over-distention, with 0% occurrence 71.9% had policies regarding performing condensate draining, with 41.7% using these elements 57.1% used noninvasive ventilation, 44.1% had policies promoting its use 33.3% used early mobility, 41.2% had policies promoting its use 24

Exposure Receipt Assessment Pilot 25 Evaluates the penetrance of the CUSP and VAP interventions to front-line staff Anonymous assessment Completed by staff with direct patient care on the unit for only one shift Piloted by 5 teams in MD and PA Results divided into 4 domains: 1.Response Rate on Assessment 2.Distribution of Participants 3.CUSP Components 4.VAP Components

Exposure Receipt Assessment Pilot: Familiarity with CUSP Components (Nov. 2013) 26 Figure 5: Reported Familiarity with CUSP Components of Intervention

Exposure Receipt Assessment Pilot: Training on VAP Toolkit (Nov. 2013) 27 Figure 6: Reported Training on VAP Prevention Toolkit in Unit

Quarterly Interviews: Frequent Barriers to Progress (Q1 2013) 28 Table 7. Barriers Reported as Being Frequent or Always All units (N=43)MD units (N=23)PA units (N=20) Barrier Percent of Units Barrier Percent of Units Barrier Percent of Units Competing priorities58.1Competing priorities47.8Competing priorities70.0 Data collection burden48.8Data collection burden43.5Data collection burden55.0 Not enough time39.5Not enough time39.1Staff turnover on unit45.0 Data system problems32.6Data system problems26.1Confusion on CUSP40.0 Staff turnover on unit27.9Leader support - exec13.0Not enough time40.0 Leader support - MDs18.6Leader support - MDs13.0Data system problems40.0 Confusion on CUSP18.6Staff turnover on unit13.0Leader support - MDs25.0 Poor buy-in - MD staff16.3Knowledge of evidence8.7Turnover CUSP team25.0 Turnover CUSP team14.0Poor buy-in - MD staff8.7Poor buy-in - MD staff25.0

REPORTS SUMMARY 2013 Highlights from of several assessments –including Summary Reports (Process Measure Data), VAE Rates, Structural Assessment, Exposure Receipt Assessment Pilot, Quarterly Interviews Your Unit’s reports are available on CECity platform Can be utilized for -Increasing communication with your team members and front- line staff -Illustrating your unit’s progress to your senior executive partner -Sharing your performance and progress on VAE prevention with your hospital administrators 29

© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Your work makes a difference! CUSP4MVP-VAP National Project Overview

MD and PA Work Influenced the CUSP4MVP-VAP National Project Based on your feedback –Changing approach for incorporating CUSP into our QI project –Revising tools (i.e. quarterly interview, early mobility pilot, exposure receipt assessment pilot) –Including objective outcome measures –Focus on sedation and delirium management 31

CUSP4MVP-VAP: Participating CEs Coordinating Entities (CEs) for Cohort 1 of CUSP4MVP-VAP National Project Iowa Michigan New Jersey Oklahoma Pennsylvania South Carolina Tennessee Texas UHC 32

CUSP4MVP-VAP: MD and PA Opportunities MD and PA opportunities with National Project: - Joining National Project content calls for continued education on CUSP and VAE prevention - Share your experience on content/coaching calls: as implementation experts to discuss implementation successes and barriers 33

CUSP4MVP-VAP: Content Call Schedule Date: First Tuesday of every month (* Please note that this call does not follow the regular content call schedule) Time: 2pm EST Webinar Link: CUSP4MVP-VAP Content CallsCUSP4MVP-VAP Content Calls Call-in Information: ; Access code:

Additional Resources Society for Critical Care Medicine ICU Liberation Group – AHRQ CUSP Toolkit – tools/cusptoolkit/ tools/cusptoolkit/ Armstrong Institute CUSP Tools – _services/cusp_offerings/cusp_guidance.htmlhttp:// _services/cusp_offerings/cusp_guidance.html Armstrong Institute Training Opportunities – _services/cusp_offerings/ _services/cusp_offerings/ 35

© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Next Steps

Collect Early Mobility data (January – March) Complete Exposure Receipt Assessment (February) Complete 2 nd HSOPS (March) Begin data collection sampling strategy between process measures and early mobility (April) Begin data collection for Low Tidal Volume Ventilation measure (August) 37

Data Collection Sampling Strategy: Begins April 1st 38

Enhancing Support for MD and PA Teams Objective Outcome Data - Armstrong will analyze your data for outcome measures if you provide it –decreasing duration of mechanical ventilation –decreasing hospital length of stay –decreasing mortality How do we enhance horizontal learning? What can the AI/MHA/HAP team do to better support you? 39

Thank You A sincere THANK YOU for all of your effort and hard work to reduce the incidence of VAP in your units and prevent HAIs! 40