1. CUSP 4 MVP-VAP Data Facilitator Discussion – 1
February 12, 2014
Kathleen Speck, MPH
Nishi Rawat, MD
Program support provided by MHA Keystone Center.
Scientific expertise and educational presentations provided by Harvard Medical School.
December 6, 2018

2. Administrative announcements
Webinar information:
You can call in through the webinar or
Code:
Please contact your Coordinating Entity for a copy of these slides if you have not yet received them
We will make a recording of this webinar available to you

3. Objectives
Discuss the data elements needed to complete the Daily Process Measures Form
Review the definitions of those data elements
Consider and discuss strategies for finding the data elements.

4. Poll – Who is on the call? Ask questions! Make suggestions!
December 6, 2018

7. Track by bed, not patient Complete
Fill out for all beds
Track by bed, not patient
Complete
Bed number
Whether the patient in that bed was intubated or trached and was on mechanical ventilation at the time of observation
Y = Yes
N = No
E = Empty bed

9. Enter the date the patient was intubated
Date of Intubation
Enter the date the patient was intubated
If the date is not available*, enter admission date (either to the unit or to the hospital, as appropriate)
If the patient is extubated and re-intubated within 24 hours, use the original date
*i.e., when from an outside institution

10. Does the patient have a sub-glottic endotracheal tube?
Sub-G ETT
Does the patient have a sub-glottic endotracheal tube?
Y = Yes
N = No
If your unit doesn’t use Sub-G ETTs, enter N
C = Contraindicated
If C, fill in the reason sub-glottic endotracheal tubes are contraindicated for this patient in the next column

11. What is the reason the use of a Sub-G ETT is contraindicated?
*Remember, enter ‘N’ if your unit does not use Sub-G ETTs

12. Location of intubation
Enter the number corresponding to the location the patient was intubated (list on contraindications page)
If you are using Sub-G ETTs on your unit, but the patient is admitted with a different type of ETT, this allows you to track where the patient came from

13. Location of intubation
Where was the patient intubated?

14. Is the HOB elevated to an angle of ≥ 30 degrees from the horizontal?
≥ 30o
Is the HOB elevated to an angle of ≥ 30 degrees from the horizontal?
Y = Yes
N = No
C = Contraindicated
If contraindicated, choose the reason from the contraindications page

15. HOB Con
What is the reason placing the HOB at an angle of ≥ 30 degrees from the horizontal contraindicated?

16. 1st question – What sedation scale do you use on your unit?
This question refers to your unit, not to this specific patient.

17. R = Richmond Agitation Sedation Scale (RASS)
S = Riker Sedation-Agitation Scale (SAS)
NU = Unit uses neither RASS or SAS
If NU, skip to Delerium Assessment

18. Sedation Scale
Choose R or S, not both
Choose the value closest to 10:00 am
If equidistant, choose the earlier time

19. If you entered ‘R’ Target
What is the target RASS score for this patient?
Enter RASS sedation scale value (-5 to 4)
Enter ‘NS’ if target RASS was not set
Enter ‘NK’ if target RASS was set but is not known
Enter ‘NK’ if you don’t know whether a target RASS was actually set

20. If you entered ‘R’ Actual
What is the actual RASS score for this patient?
Enter RASS sedation scale value (-5 to 4)
Enter ‘X’ if an actual RASS sedation level was not scored
Enter ‘NK’ if target RASS was scored, but is not known
Enter ‘NK’ if you don’t know whether a target RASS was actually scored

21. If you entered ‘S’ Target
What is the target SAS score for this patient?
Enter SAS sedation scale value (1 to 7)
Enter ‘NS’ if target SAS was not set
Enter ‘NK’ if target SAS was set but is not known
Enter ‘NK’ if you don’t know whether a target SAS was actually set

22. If you entered ‘S’ Actual
What is the actual SAS score for this patient?
Enter SAS sedation scale value (1 to 7)
Enter ‘X’ if an actual SAS sedation level was not scored
Enter ‘NK’ if target SAS was scored, but is not known
Enter ‘NK’ if you don’t know whether a target SAS was actually scored

23. If you entered ‘NU’
Skip Target and Actual Sections and go to Delirium Assessment

24. C = Confusion Assessment Method for the ICU (CAM-ICU)
Delirium Assessment
C = Confusion Assessment Method for the ICU (CAM-ICU)
A = Attention Screening Exam (ASE)
NU = Unit uses neither CAM-ICU or ASE
If NU, skip to SAT

25. Attention Screening Exam (ASE)
If the CAM-ICU is not yet feasible in your unit, we recommend that patients at least undergo the ASE once per nursing shift.
The ASE is feature 2 of the CAM-ICU and this second test of attention is the cardinal feature of a delirium diagnosis.

26. Delerium Assessment
Choose CAM-ICU or ASE, not both
CAM-ICU incorporates the ASE
Choose the value closest to 10:00 am
If equidistant, choose the earlier time

27. CAM-ICU
The Society of Critical Care Medicine’s 2013 pain/agitation/delirium (PAD) clinical practice guidelines recommend the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) as the most valid and reliable delirium screening tools, and that moderate to high risk patients be screened at least once per nursing shift.

28. CAM-ICU – is the patient positive or negative for delirium
Enter ‘P’ if the patient is positive for delirium
Enter ‘N’ if the patient is negative for delirium
Enter ‘UTA’ if unable to assess (i.e.: RASS = -4 or -5 OR SAS = 1 or 2
Enter ‘X’ if CAM-ICU assessment was not completed
Enter ‘NK’ if CAM-ICU was completed, but results aren’t known
Enter ‘NK’ if you don’t know whether the exam was performed

29. Attention Screening Exam (ASE)
The goal of this second test is to determine if a patient can follow a simple command (pay attention) for that period of time.
Inattention is the cardinal feature of delirium and must be present to diagnose delirium.
For centers not using the full CAM-ICU, conducting the ASE is a good barometer of the presence or absence of delirium. This test may be abnormal due to disease, drugs or other causes.

30. Attention Screening Exam (ASE)
The exam consists of the provider reading the following sequence of letters:
‘S A V E A H A A R T’ or ‘C A S A B L A N C A’ or ‘A B A D B A D D A Y’
The patient is told to squeeze the provider’s hand when the letter ‘A’ is stated.
An error is defined as no squeeze with letter ‘A’ or a squeeze on a letter other than ‘A’. The number of errors is counted. Inattention is present if the patient commits more than 2 errors. If the patient squeezes on every letter or doesn’t squeeze on any letter, then assign an error count of 10.

31. ASE – What is the patient’s ability to pay attention?
Use only if CAM-ICU is not performed
Enter the number of errors, 0 to 10
Enter ‘UTA’ if unable to assess (i.e.: RASS = -4 or -5 OR SAS = 1 or 2
Enter ‘X’ if the exam was not performed
Enter ‘NK’ if the exam was performed, but number of errors is not known
Enter ‘NK’ if you don’t know whether the exam was performed

32. Spontaneous Awakening Trial (SAT)
Has the patient had a Spontaneous Awakening Trial today?

34. Enter ‘NS’ if the patient is not sedated
SAT
Enter ‘NS’ if the patient is not sedated
Enter ‘Y’ if medications for sedations have been held today
Enter ‘N’ if medications for sedation have not been held today
Enter ‘C/NI’ if holding medications for sedation is either contraindicated or not indicated today
If ‘C/NI’ go to Reason SAT Con

35. SAT Con
What is the reason an SAT is inappropriate for this patient?

36. Spontaneous Breathing Trial (SBT)
Has the patient had a spontaneous breathing trial today?

37. SBT
Ventilatory support is removed
The patient breathes through either a T-tube circuit or ventilatory circuit with low levels of PS (5–8 cm H2O in adults) with or without 5 cm H2O PEEP
No changes are required in FiO2 or the level of PEEP

38. Enter ‘Y’ if the patient had an SBT
Enter ‘N’ if the patient did not have an SBT
Enter ‘C/NI’ if the use of an SBT is contraindicated/not indicated
If ‘C/NI’, go to Reason SBT Con

39. Enter ‘Y’ if the patient had an SBT
Enter ‘N’ if the patient did not have an SBT
Enter ‘C/NI’ if the use of an SBT is contraindicated/not indicated
If ‘C/NI’, go to Reason SBT Con

40. SBT Con
What is the reason an SBT is inappropriate for this patient?

41. SBT with Seds off? Was the SBT performed with the sedatives off?
Sedatives are considered off:
During an SAT
If sedative infusion is stopped
If standing order for intermittent sedating meds is held or cancelled
If the interval between standing doses is extended

42. Data Collection Ideas Where can you find these data? Ideas?
Suggestions?
Barriers?
December 6, 2018

43. Next Steps Where will you find your data? Look for data sources
Make plans for data collection processes
Practice collecting data for next call
December 6, 2018

44. Going forward -
After you have found your data sources and data collection has officially started
Collect data daily
Enter the data at least weekly
December 6, 2018

45. Next Data Facilitator Call
March 12th at 2:00 EST
Discuss solutions, barriers and ideas for data collection
Explore the CECity data entry portal for Daily Process Measures
December 6, 2018