© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Providing Feedback: Structural Assessment 2 Results & Exposure Receipt Assessment 1 Results Kathleen Speck, MPH Nishi Rawat, MD The Armstrong Institute for Patient Safety and Quality April 3, 2014

© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Structural Assessment: Comparative Findings

Objectives To review the Structural or Policy-based Measures included in the VAP Prevention Bundle To assess improvements made in the implementation of the Policy-based Measures in your unit’s policies To identify opportunities to focus improvement efforts and facilitate horizontal learning 3

Structural Measures, Use a closed ETT suctioning system 2.Change closed suctioning catheters only as needed 3.Change ventilator circuits only if circuits become damaged or soiled 4.Change HME every 5-7 days and as clinically recommended 5.Provide easy access to NIVV equipment and institute protocols to promote use 4

Structural Measures, Periodically remove condensate from circuits, keeping the circuit closed during the removal, taking precautions not to allow the condensate to drain toward the patient 7.Use an early mobility protocol 8.Perform hand hygiene 9.Avoid supine position 10.Use standard precautions while suctioning respiratory tract secretions 5

Structural Measures, Use orotracheal intubation instead of nasotracheal 12.Avoid the use of prophylactic systemic antimicrobials 13.Avoid non-essential tracheal suctioning 14.Avoid gastric over-distention 6

The Structural Assessment Survey of Unit Leaders conducted at the baseline and in Dec – Jan Evaluates your implementation of the 14 Structural Measures included in the VAP Prevention Bundle 34 sites answered the assessment at baseline 22 sites answered the assessment during the second administration 7

How have the policies in your unit changed for the care of MVP? 8 Question % Best Response T1 (n=34) T2 (n=22) For intubated/trached patients, how often do you change the ventilator system? (Best response – Not routinely changed unless soiled or malfunctioning) 76%63% When used, how often do you change the closed endotracheal suction system? (Best response – Not routinely changed unless soiled or malfunctioning) 39%50%

How have the policy changes been implemented in your unit? 9 Question % Best Response T1 (n=34) T2 (n=22) In the absence of a difficult airway, how often is an orotracheal route used for elective intubation in your unit? (Positive) 82%81% For patients receiving mechanical ventilation via an endotracheal tube, how often is a closed endotracheal suction system used? (Positive) 94%100% When mechanical ventilation is required, how often are prophylactic intravenous antibiotics used to prevent ventilator-associated pneumonia? (Negative) 82%81%

How have the policy changes been implemented in your unit? Question % Best Response T1 (n=34) T2 (n=22) In your ICU, how often are patients placed in a supine position, when there is no contraindication? (Negative) 71%86% In your ICU, how often are standard precautions used while suctioning the respiratory tract? (Positive) 85%100% In your ICU, how often is tracheal suctioning performed when it is not clinically indicated? (Negative) 74%68% In your ICU, how often are mechanically ventilated patients experiencing g gastric over- distention? (Negative) 82%91% 10

How have the policy changes been implemented in your unit? Question % Best Response T1 (n=34) T2 (n=22) In your ICU, how often is condensate drained away from the patient while the circuit remains closed? (Positive) 47%50% In your ICU, how often do healthcare providers perform hand hygiene prior to contact with respiratory equipment? (Positive) 97%91% How often is non-invasive ventilation used in your ICU? (Positive) 76%59% In your ICU, how often is an early mobility protocol used for patients receiving mechanical ventilation? (Positive) 35%55% 11

In the policies for care of MVP in your unit, is there guidance to: Question % Yes T1 (n=34) T2 (n=22) Avoid supine (flat) patient positioning unless clinically indicated 91% Use standard precautions while suctioning respiratory tract secretions? 94%100% Avoid non-essential tracheal suctioning?59%77% Avoid gastric over-distention?59%77% Periodically remove condensate from circuits?56%77% Assure that circuits are closed during removal of condensate to assure that condensate doesn’t drain toward the patient? 62%77% Perform hand hygiene prior to contact with respiratory equipment? 88%100% 12

Does your ICU actively promote: Question% Yes T1 (n=34) T2 (n=22) Use of non-invasive ventilation protocol?47%68% Early mobility protocol in patients receiving mechanical ventilation? 41%64% 13

Summary More sites have changed policies to be in line with CUSP for VAP recommendations General improvement or consistency in the care of patients with MVP Paradoxical implementation in care vs changes in written policies and/or procedures –Tracheal suctioning performed without clinical indications –The use of non-invasive ventilation 14

Barriers? Protocols? Discussion What barriers have you faced in changing policies in your unit? Do you have policies regarding any of these measures that you would be willing to share? The Structural Assessment - –Do you have any suggestions for improving the survey? 15

© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Exposure Receipt Assessment Results

Exposure Receipt Assessment 17 Evaluates the penetration 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

Exposure Receipt Assessment Measures Results divided into 4 categories based on question type to allow similar components to be examined together. The categorical measures are as follows: –Response Rate on Assessment –Distribution of Participants –CUSP Components of the Intervention –VAP Components of the Intervention 18

Response Rate Administered 18 months into the pilot February - March 2014 Results from 11 sites 133 observations –103 observations from MD –30 observations from PA 19

Distribution of Participants 1: What is your role in the Unit? 20

CUSP Components of the Intervention 3. Have you watched a Science of Safety presentation 4. Have you completed a Staff Safety Assessment 21

CUSP Components of the Intervention 5. Have you used the Learning from Defects tool? 6. For how many patients has your unit used Daily Goals? 22

CUSP Components of the Intervention 7: How familiar are you with CUSP? 23

CUSP Components of the Intervention 8. Do you have a CUSP team on your unit? 9. Has CUSP been active at improving patient safety? 24

Summary CUSP Components of Intervention A high proportion of units have CUSP teams Providers believe that these teams are active at improving patient safety. Penetration CUSP toolkit tools appears low (Daily Goals, Staff Safety Assessment, Learning from a Defect, Science of Safety video) 25

VAP Components of Intervention 9. How many interventions are used in your unit? 26

VAP Components of Intervention 10. Do you believe these interventions will help prevent VAE? 27

VAP Components of Intervention 11. Which of the following interventions are most likely to prevent VAE? 28

VAP Components of Intervention 12. Where is the biggest opportunity to improve the care of ventilated patients? 29

VAP Components of Intervention 13. How much training have you been given on the VAP Prevention Toolkit? 30

Summary VAP Components of Intervention High proportion of front-line providers believe that the technical intervention prevents VAE Process measure implementation could be improved –50% of providers report using at least 4 Implementation not related to training –high proportion of providers received a significant amount of toolkit training Early mobility represents the biggest opportunity to improve care 31

Your Feedback is Important Was this ERA assessment helpful? –If yes, what was helpful? –If no, could we do anything differently so it would be helpful? Will anyone do anything different based on results? What do teams think about paper based distribution vs. survey monkey? How often do teams think these assessments should be completed? 32

© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Opportunities: CUSP4MVP-VAP National Project

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 34

CUSP4MVP-VAP: Join Content Calls 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/ 36

Reminder: Next Steps Complete 2 nd HSOPS (March-April) 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 needed information to your state leads. Forms will be provided: –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 your efforts to reduce ventilator-associated pneumonia? 39

Thank You THANK YOU for all of your effort and hard work. 40