1. Beyond VAP: Identifying areas for improvement to prevent ventilator-associated conditions Michael Klompas MD, MPH, FRCPC, FIDSA Harvard Medical School, Harvard Pilgrim Health Care Institute, and Brigham and Women’s Hospital, Boston, MA Partnership for Patients Quality and Patient Safety Conference April 30, 2013

2. Disclosures Honoraria from Premier Healthcare Alliance

3. Outline 1.Ventilator-associated events – a patient safety opportunity 2.Zero VAC – where do we start? 3.The problem with current ventilator bundles 4.The promise of better weaning & sedation strategies 5.The CDC Prevention Epicenters’ Wake Up & Breathe Collaborative 6.Lessons learned

4. VAP – subjective, inaccurate, and rare VAC – simple and objective – seeks all complications of mechanical ventilation, not just pneumonia. Most cases due to: Pneumonia Pulmonary edema ARDS Atelectasis VAC is a strong predictor of poor outcomes (increased ventilator days, hospital days, and mortality) Ventilator-associated events

5. Ventilator-associated event surveillance A patient safety opportunity Increase Awareness VAC surveillance provides hospitals with a fuller picture of complications in mechanically ventilated patients Catalyze Prevention A significant portion of VACs are likely preventable Reflect and Inform Progress VAC surveillance provides an efficient and objective yardstick to track one’s progress relative to oneself and to peers

6. Where do we start?

8. Image from http://img.ehowcdn.com/article-new/ehow/images/a07/86/tp/increase-torque-cars-rear-end-800x800.jpg

10. VAP Prevention Measures Impact on VAP Rates Head-of-bed elevation  78% Regular oral care with chlorhexidine  40-60% Daily interruption of sedation  64% Daily assessment of readiness to extubate  10% Continuous aspiration subglottic secretions  37-75% Silver coated endotracheal tubes  36% NEJM 2000;342:1471 Crit Care Med 2004;32:1272 Chest 2000;118:459 Ann Intern Med 1995;122:179 Am J Respir Crit Care Med 2006;174:894 Lancet 1999;354:1851 BMJ 2007;334:889 JAMA 2008;300:805

11. But VAP diagnoses are unreliable. Can we trust the VAP reduction rates reported in the literature?

12. Silver Coated Endotracheal Tubes VAP Rates and Outcomes VAP Incidence VAPs per 100 Patients 4.0 5.0 3.0 2.0 1.0 0 8.0 10.0 6.0 2.0 0 4.0 Conventional ETTsSilver coated ETTs Lengths of Stay (days) Vent days ICU days Hospital days 6.0 12.0 JAMA 2008;300:805-813

13. Oral antiseptics & outcomes Antiseptics protective Antiseptics harmful VAP Vent days ICU days Mortality Chan et al., BMJ 2007;334:889

14. The VAP Prevention Paradox VAP Rates Vent LOS ICU LOS Hospital LOS Death Head-of-bed elevation Regular oral care with chlorhexidine Silver-coated endotracheal tubes Klompas, Critical Care 2009;13:315

15. Why the Paradox? VAP as measured includes a multitude of conditions, ranging from benign to serious  Less serious: bacterial colonization superimposed upon atelectasis / CHF / barotrauma  More Serious: pneumonia, ARDS, pulmonary infarction, others Most prevention measures work by decreasing oral secretions or bacterial colonization  Circularity between mechanism of action and diagnostic criteria  Preferential impact on less serious events leading to lower perceived VAP rates, smaller impact on more serious events For any given intervention, difficult to know if primary impact is on less serious or more serious events since both count as “VAPs” Klompas, Critical Care 2009;13:315

16. What does work? Vent LOS ICU LOS Hospital LOS Mortality Sedative interruption Readiness to extubate Sedative interruption AND Readiness to extubate

17. Daily Interruption of Sedation Duration of Ventilation Days Kress, NEJM 2000:342:1471 Schweickert, Crit Care Med 2004;32:1272 8.0 10.0 6.0 4.0 2.0 0 4 5 3 1 0 2 Usual Care Daily interruption VAP Cases Cases of VAP ICU Stay * * NS N=128

18. Daily Interruption of Sedation & Daily Spontaneous Breathing Trials Daily sedative interruption AND spontaneous breathing trial N=168 Daily spontaneous breathing trial alone N=168 OutcomeImpactP Time on Ventilator  3.1 days.02 ICU Length of Stay  3.8 days.01 Hospital Length of Stay  4.3 days.04 Mortality at 1 year  32%.01 Girard, Lancet 2008;371:126

19. Patients Alive (%) 0 0 20 40 60 80 100 60120180240300360 Days Usual Care+SBT (n=168) SAT+SBT (n=167) p=.01 Girard TD, et al. Lancet 2008;371:126-34 One year survival Slide courtesy of Wes Ely

20. Improving Sedation Management A good strategy to prevent VACs? Sedation and prolonged mechanical ventilation are both important risk factors for multiple complications of intensive care Pneumonia ARDS Pneumothorax Pulmonary edema Delirium Kidney dysfunction GI bleeding Bacteremia Thromboembolic disease Cholestasis Sinusitis

21. Sedative interruption adherence poor Daily sedative interruptions are a component of most ventilator bundles but audits suggest that in practice interruptions are only done about 25-50% of the time e.g. Brigham and Women’s Hospital, Boston, 2011 Sedative interruption 54% of sedative-days Contraindication marked 31% of sedative-days List of contraindications liberal Included “high ventilator requirements” (40%), “weaning from high sedative dose” (16%), and “hemodynamic instability” (22%) Klompas, Unpublished Data

22. Are we unduly cautious with sedative interruptions? 140 patients randomized to routine sedation versus no sedation 70 prescribed routine sedation (propofol then midazolam) 70 prescribed no sedation Morphine boluses permitted for both groups PRN Unblinded Patients with no sedation Mean 4.2 (95% CI 0.3-8.1) fewer days on the vent Shorter ICU stay (HR 1.86, 95% CI 1.1-3.2) Shorter hospital stay (HR 3.6, 95% CI 1.5-9.1) More agitated delirium (20% versus 7%) but no difference in self-extubations Strøm et al. Lancet 2010;375:475

23. The CDC Prevention Epicenters’ Wake Up and Breathe Collaborative

24. 13 ICUs from 8 hospitals  Stroger Cook County Hospital  Missouri Baptist Medical Center  Duke University  Durham VA  Durham Regional Hospital  North Shore Union  North Shore Salem  Hospital of the University of Pennsylvania Goal: prevent ventilator associated complications through less sedation and earlier liberation from mechanical ventilation Mechanism: paired daily spontaneous awakening trials and breathing trials (SATs and SBTs)

25. Collaborative Components All Teach – All Learn Model Each participating unit has designated RN, RT, and MD champions Monthly written reports by each ICU –  Progress, challenges, successes, and failures from the preceding month  Goals for the forthcoming month Monthly collaborative phone calls for all champions Monthly data feedback and benchmarking Collaborative facilitated by a CDC “improvement advisor” Two in-person meetings at CDC for all champions held April 2012 (kick-off) and October 2012 (consolidation) Expert advice from CDC, Institute for Healthcare Improvement, and consulting faculty

26. Lessons Learned 1.Get the right people on the bus 2.Educate, educate, and re-educate 3.The spirit of the law matters more than the letter of the law 4.Assess performance not just documentation 5.It’s a marathon not a sprint 6.Choose the denominator that fits the intervention 7.Wake up and walk

27. Get the right people on the bus Image from http://www.kerrvilleisd.net/files/bus_cartoon_tilt.gif Chief Medical Officer Chief Nursing Officer ICU Medical Director ICU Nursing Director Chief Quality Officer Head of Respiratory Therapy Local Opinion Leaders Day Staff Night Staff Frontline Nurses Frontline Doctors Frontline RTs Pharmacists Night Staff Unit Clerk MD Champion RN Champion RT Champion

28. Educate, educate, & re-educate Never assume that everyone knows about the protocol Never assume that everyone understands the protocol Never assume everyone agrees with the protocol Use both formal and informal teaching methods In-services, postings, articles, lectures Ask colleagues for their impressions, seek hallway discussions, bring it up at morning rounds

29. The Spirit of the Law Matters More than the Letter of the La w Our goal is not to perform SATs per se but to minimize the use of sedatives and speed extubation SATs and SBTs are a means, not an end

30. “Conclusion: For mechanically ventilated adults managed with protocolized sedation, the addition of daily sedation interruption did not reduce the duration of mechanical ventilation or ICU stay.” Mehta et al. JAMA 2012;308(19):1985-92

31. Midazolam Equivalents

32. Fentanyl Equivalents

33. Boluses Per Day in Mehta et al.

34. Assess Performance as well as Documentation

36. It’s a marathon not a sprint Image from http://media.mediapost.com/images/inline_image/2012/01/27/Boston-Marathon-B.jpg

37. SAT Performance, ICU X, June 2012 – March 2013

38. SAT Performance, ICU Y, June 2012 – March 2013

39. Chose a denominator that fits the intervention The traditional metric for hospital-acquired infections is infections per 1000 device-days or patient days What if your intervention, however, is specifically designed to reduce device days?

40. Absolute Counts: VACs

41. Absolute Counts: VACs and Vent Days

42. VACs per 1000 Ventilator Days

43. VACs per 1000 Ventilator Days vs VACs per 100 Episodes of Mechanical Ventilation

44. Early mobility – Wake Up & Walk! Increasing evidence that early mobilization speeds extubation and decreases ICU length of stay May also help prevent atelectasis & delirium As with improved sedative management and weaning protocols, less time on vent means less time at risk for VACs http://69.36.35.38/images/CHESTPhysician/Crit CareCom0610Fig2.jpg Lord et al., Crit Care Med 2013;41:717 Schweickert et al., Lancet 2009;373:1874 Needham et al., Arch Phys Med Rehabil 2010;91:536

45. Summary VAE surveillance is a patient safety opportunity Spontaneous awakening trials and spontaneous breathing trials decrease ventilator days, hospital days, and mortality. Maybe SATs and SBTs can also lower VAC rates! Lessons learned from the CDC Prevention Epicenters’ Wake Up and Breathe Collaborative: Get the right people on the bus Educate, educate, and re-educate The spirit of the law matters more than the letter of the law Assess performance as well as documentation It’s a marathon not a sprint Choose a denominator that fits the intervention Wake up and walk!

46. Thank You! Michael Klompas (mklompas@partners.org)