CUSP 4 MVP – VAP Cohort 2 Data Webinar 2 How to Complete the Exposure Receipt Assessment | Preliminary Structural Assessment Data Reports Wednesday, February 4, 2015, 11:00 a.m. - 12:30 p.m. EST Kisha Ali, MS Tara McFarlin Kathleen Speck, MPH  Your phone lines are automatically set to mute.  Use the Chat Panel on the right of your screen if you have questions during the webinar.  if you have additional questions and comments after the  The webinar recording will be posted once it become available.

2 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment CUSP 4 MVP - VAP Comprehensive Unit-based Safety Program for Mechanically Ventilated Patients and Ventilator-Associated Pneumonia

3 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment

4 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment 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 

5 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment jhmi-events.webex.com

Introducing the Exposure Receipt Assessment CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

7 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Exposure Receipt Assessment Exposure Receipt Assessment Metric allows the implementation components of the project to be quantified Data provided directly by front-line staff with direct- patient care Utilized in congruence with the Implementation Assessment – both tools are complementary ERA Assessment –consist of solely quantitative questions –Anonymous –Semi-annual Supports improvement efforts of individual units

8 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Exposure Receipt Assessment Exposure Receipt Assessment Using the ERA results, units will be able to track their specific implementation successes and barriers over time via the CECity platform, as well as view peer-comparators First ERA assessment for Cohort 2 will be administered Feb 9th to Mar 31st 2015 This assessment helps identify –Additional opportunities for education and training on the unit –Bridges the gap in information –Areas of success Involves your font-line staff in the CUSP4MVP-VAP project

Exposure Receipt Assessment Review CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

10 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment

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13 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment

14 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Recipients receive from Recipients click link to access Assessment

15 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Recipients complete assessment

16 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment

17 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment

18 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Reports

19 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Reports

20 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Reports

21 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Reports

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CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Preliminary Structural Assessment Data Reports ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY Johns Hopkins University February 4, 2015

About the Structural Assessment

25 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment What is the Structural Assessment? 22-item survey Conducted semi- annually Completed by one person in the hospital unit (e.g. Unit Lead)

26 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Policy-based or Structural Measures What are your unit’s policies and/or protocols for the care of mechanically ventilated patients? –Official or un-official –Are they in line with best practices? Do staff on your unit really follow your current policies and procedures?

27 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Best Practices and Change Are you implementing best practices as stated in the CUSP 4 MVP-VAP Prevention Guidelines? –Why should I do this? –Changing policies can be a lot of work. Is it worth it?

28 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Why are we focusing on these policies? Our goals are: –To reduce the duration of mechanical ventilation –To reduce patients’ length of stay in the unit and hospital –To reduce mortality related to mechanical ventilation –To prevent all VAEs, including VAP

29 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment How does my unit compare? Review the questions Discuss the best practice Discuss the results Group discussion of barriers

30 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Please chime in! Share your patient stories with our group! –They can inspire Share your successes! –Let us know how you did it –What barriers did you face? Share your barriers! –Shared barriers can show you and everyone else who is having problems that you aren’t the only one!

Preliminary Results and Best Practices

32 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Who is included in the results? 24 of 67 (35.8%) Cohort 2 hospital units responded Response period: Dec 2014 to Jan 2015

33 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Changing Ventilator Circuits

34 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Changing Ventilator Circuits only if Damaged or Soiled Change ventilator circuits only if circuits become damaged or soiled. SHEA Pro- Recommends the change of ventilator circuit only when visibly soiled or malfunctioning. ZAP Pro-Recommends the use of new circuits for each patient, and changes if the circuits become soiled or damaged, but no scheduled ventilator circuit changes. ATSMakes No Recommendations CDC Pro- Recommends the change of circuit when it is visibly soiled or mechanically malfunctioning.

35 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Changing Ventilator Circuits – Does it really make a difference? RCT – Mechanical ventilation with or without 7-day circuit changes. –No difference in mortality between 2 groups hospital mortality intensive care unit mortality death during mechanical ventilation death in patients with ventilator-associated pneumonia –With 7 day changes had 247 circuit changes - total of $7410 –Without routine changes had a total of 11 circuit changes costing $330. Kollef, et.al. 1995

36 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Changing the Closed Endotracheal Suction Systems

37 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Avoid Routine Changing of Closed Endotracheal Suction Systems Change closed suctioning catheters only as needed. All GuidelinesMake No Recommendations American Association of Respiratory Care - Evidence-Based Guidelines Pro- Recommends that ventilator circuits should not be changed routinely for infection control purposes. Also, notes that the use of closed suction catheters should be considered part of a VAP prevention strategy. When closed suction catheters are used, they do not need to be changed daily for infection control purposes. Hess, et. al., 2003

38 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Does it really make a difference? Scheduled daily changes and unscheduled changes –Have no effect on the incidence of VAP –Cost considerations favor less changes Muscedere, et al, 2008

39 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Use of Orotracheal Intubation

40 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Avoid Use of Orotracheal Intubation Use orotracheal intubation instead of nasotracheal. SHEA Pro- Recommends orotracheal intubation over nasotracheal intubation based on the increased risk of sinusitis. ZAP Pro- Recommends the use of the orotracheal route for intubation when intubation is necessary. ATS Pro- Recommends orotracheal intubation over nasotracheal intubation based on a trend toward reduction in VAP rates and sinusitis. CDC Pro- Recommends the use of orotracheal intubation over nasotracheal intubation unless contraindicated.

41 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Avoiding Use of Orotracheal Intubation - Does it really make a difference? Nasotracheal intubation increases the risk of sinusitis 1,2, which can increase the risk of VAP 3,4 1.Salord, et al, Rouby, et al, Holzapfel, et al, Saint, et al, 1998

42 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Use of Closed Endotracheal Suction Systems

43 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Use of Closed Endotracheal Suction Systems Use a closed ETT suctioning system. SHEA 1 Pro- Recommends the use a cuffed endotracheal tube with in-line or subglottic suctioning. ZAP 2 Pro- Recommends the use of closed endotracheal suctioning system. ATS 3 Makes No Recommendations CDC 4 Makes No Recommendations

44 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Use of Prophylactic Intravenous Antibiotics

45 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Avoid the Use of Prophylactic Intravenous Antibiotics Avoid the use of prophylactic systemic antimicrobials. SHEA Pro- Recommends prophylactic aerosolized or systemic antimicrobials should not be used for routine VAP prevention. ZAPMakes No Recommendations ATSMakes No Recommendations CDCMakes No Recommendations

46 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Does it make a difference? For the patients who received prophylactic antibiotics –first pneumonia was diagnosed later in the ICU stay –causative organisms were more likely to be resistant or Gram-negative bacteria –incidence of antibiotic complications were two times greater than for patients who did not receive extended antibiotic prophylaxis Use is associated with –significant clinical complications –increased patient resources, –lengthened hospital stay –higher cost Hoth, et al, 2003

47 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Placing Patients in a Supine Position

48 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Avoid Placing Patients in a Supine Position Avoid supine position. SHEA Pro- Recommends the maintenance of patients in the semirecumbent position (30-45 degrees) unless medically contraindicated. ZAPMakes No Recommendation ATS Pro – Recommends that patients should be kept in the semirecumbent position degrees rather than supine. CDC Pro- Recommends the elevation of head of the bed to an angle of degrees.

49 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Does it make a difference? RCT - Semirecumbent vs supine for VAP prevention –Semirecumbent – 3/39 (8%) VAP incidence –Supine – 16/47 (34%) VAP incidence Supine position is an independent risk factor for nosocomial pneumonia Drakulovic, et al, 1999

50 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Use of Standard Precautions while Suctioning the Respiratory Tract

51 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Use of Standard Precautions while Suctioning the Respiratory Tract Use standard precautions while suctioning respiratory tract secretions. SHEA Pro - Recommends appropriate infection prevention and control practices are used at all times, including aseptic techniques when suctioning secretions and handling respiratory therapy equipment. ZAPMakes No Recommendations ATSMakes No Recommendations CDCMakes No Recommendations

52 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Frequency of Tracheal Suctioning Performance

53 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Frequency of Tracheal Suctioning Performance Avoid non-essential tracheal suctioning. All GuidelinesMake No Recommendations New South Wales Statewide Guideline for Intensive Care (Rolls, 2009) 9 Pro – Recommends that tracheal tube suctioning should not be carried out on a routine basis, but rather out of clinical need to maintain the patency of the tracheobronchial tree.

54 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Frequency of Gastric Over- distention

55 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Frequency of Gastric Over- distention Avoid gastric over-distention. SHEA Pro- Recommends the avoidance of over distention. ZAPMakes No Recommendations ATSMakes No Recommendations CDCMakes No Recommendations

56 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Condensate Draining from Circuits

57 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Condensate Draining from Circuits Periodically remove condensate from circuits, keeping the circuit closed during the removal, taking precautions not to allow condensate to drain toward patient. SHEA Pro- Recommends the removal of condensate from ventilator circuits while keeping the ventilator circuit closed during condensate removal. ZAPMakes No Recommendation ATS Pro – Recommends that contaminated condensate should be carefully emptied from ventilator circuits and condensate should be prevented from entering either the endotracheal tube or inline medication nebulizers. CDCMakes No Recommendation

58 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Proper Condensate Draining from Circuits – Does it make a difference? Condensate study –80% of samples were contaminated at a median level of 2 X 10 5 organisms/ml at 24 hours –Empty regularly –Considered to be infectious waste –Prevent contaminated condensate from inadvertently washing into the patient’s tracheobronchial tree Craven, et al, 1984

59 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Frequency of Hand Hygiene Precautions with Equipment

60 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Frequency of Hand Hygiene Precautions with Equipment Perform hand hygiene. SHEA Pro- Recommends the adherence to hand-hygiene guidelines published by the Centers for Disease Control and Prevention / World Health Organization. ZAPMakes No Recommendations ATS Pro- Recommends the use of effective infection control measures: staff education, compliance with alcohol-based hand disinfection, and isolation to reduce cross-infection with MDR pathogens. CDC Pro- Recommends the decontamination of hands by washing them with either antimicrobial soap and water or with nonantimicrobial soap and water or by using an alcohol-based waterless antiseptic agent.

61 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Use of Noninvasive Ventilation

62 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Use of Noninvasive Ventilation Provide easy access to NIVV equipment and institute protocols to promote use. SHEA Pro-Recommends the use of noninvasive ventilation whenever possible. ZAPMakes No Recommendations ATS Pro-Recommends that noninvasive ventilation should be used whenever possible in selected patients with respiratory failure. CDCMakes No Recommendations

63 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Use of Noninvasive Ventilation – Does it make a difference? Patients receiving non-invasive ventilation cannot have a VAE –Ease of access can allow caregivers the option to choose –Protocols to promote use assure that everyone knows the equipment is available

64 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Use of Early Mobility Protocols

65 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Use of Early Mobility Protocols Use early mobility protocol. All GuidelinesMakes No Recommendations Early ICU Mobility Therapy (Morris, 2008) 6 Pro- Findings of this study showed that mechanically ventilated acute respiratory failure patients who underwent early intensive mobility therapy had a shorter ICU and hospital stay than similar patients who received standard physical therapy. Receiving Early Mobility in ICU (Morris, 2011) 7 Pro-The aim of this study was to determine the post hospital outcomes of implementing early mobility protocol. This study finding showed that patients who received early ICU mobility therapy had fewer hospital readmissions and deaths in 12 months post discharge period. Early Physical Medicine and Rehabilitation (Needham, 2010) 8 Pro- This quality improvement program found that the incorporation of early mobility into the daily care of ICU patients substantially reduced length of stay.

66 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Use of Early Mobility Protocols- Does it make a difference Decreased length of stay Decreased duration of mechanical ventilation* Decreased mortality Decreased readmissions Decreased time for rehab and recovery after discharge To the patient? –Yes!

67 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Written ICU, nursing, and RT Policies and Procedures

68 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment ICU Protocols

69 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Can the CUSP 4 MVP-VAP program make a difference? Our goals are to: –Get the patients off mechanical ventilation faster –Discharge patients from both the ICU and the hospital faster –Decrease mortality rate –Decrease rates of all VAEs, including VAP

70 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Questions? Comments? Let us know your –Concerns –Ideas –Anticipated barriers –Successes –Possible implementation techniques

71 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment

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

73 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Next Steps  Conduct a culture assessment (HSOPS)  Establish an interdisciplinary CUSP team  Partner with a Senior Executive  Review the Science of Safety training

74 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment Homework Continue to collect data for: 1.Exposure Receipt Assessment 2.Structural Assessment

75 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment DATETOPIC Feb 18, 2015–Spontaneous Awakening and Breathing Trials –Utility of the Exposure Receipt Assessment Mar 18, 2015–Delirium Assessment Training –Benefits of Subglottic Endotracheal Tubes Apr 15, 2015–Daily Goals Facilitates VAE Prevention –Implementation Assessment Overview May 20, 2015–Early Mobility: A Practical Approach June 17, 2015–Learning from Defects Upcoming Content Sessions Third Wednesday of each month from 11:00 am – 12:30 pm EST

76 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment DATETOPIC Mar 4, 2015–Intro to Objective Outcome Measures Mar 11, 2015*–Understanding Your HSOPS Data & Reports –Debrief Your Safety Culture Results Apr 1, 2015–Defining the Daily Early Mobility Measures May 6, 2015–Strategies for Collecting and Entering Early Mobility Measures June 3, 2015–Assessing Your Exposure Receipt Assessment Data Reports Upcoming Data Sessions First Wednesday of each month from 11:00 – 12:00 pm EST *Mar 11, 2015 session will be from 3:00-4:00pm EDT

77 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment DATETOPIC Feb 25, 2015–VAE Surveillance Training: Infection-related Ventilator- associated Complication (IVAC) Mar 25, 2015–VAE Surveillance Training: VAP (PVAP) Upcoming IP Sessions Fourth Wednesday of Jan, Feb and March from 11:00 am – 12:00 pm EST

78 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment CUSP 4 MVP – VAP Website Visit: esearch.hopkinsm edicine.org/cusp4 mvp.aspx esearch.hopkinsm edicine.org/cusp4 mvp.aspx

79 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment What Can I Find on the CUSP 4 MVP – VAP Website? CUSP Tools and Guides HSOPS Resources Data Collection Tools Educational Materials –Toolkits –Literature Reviews –Fast Fact Sheets Archive of webinars led by subject matter experts

80 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Structural Assessment