1. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 How Your Unit’s Policies and Protocols Compare to Other’s Kathleen Speck, MPH

2. 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? Armstrong Institute for Patient Safety and Quality 2

3. 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? Armstrong Institute for Patient Safety and Quality 3

4. 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 Armstrong Institute for Patient Safety and Quality 4

5. How does my unit compare? Review the questions Discuss the best practice Discuss the results Group discussion of barriers Armstrong Institute for Patient Safety and Quality 5

6. 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! –Barriers can show you and everyone else who is having problems that you aren’t the only one! Armstrong Institute for Patient Safety and Quality 6

7. Change ventilator circuits only if circuits become damaged or soiled Question 1 – For intubated/trached patients how often do you change the ventilator circuit? n=28 Armstrong Institute for Patient Safety and Quality 7 Not routinely changed Routinely changed, interval = 1 day Routinely changed, interval = 30 days Routinely changed, interval = 7 days Routinely changed, interval = 7-30 days 85.7% (24)3.6% (1)

8. Why? Armstrong Institute for Patient Safety and Quality 8 3. 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.

9. 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 mortality directly attributed to ventilator-associated pneumonia –With/7 day changes had 247 circuit changes - total of $7410 –w/o routine changes had a total of 11 circuit changes costing $330. Armstrong Institute for Patient Safety and Quality 9 Kollef, et.al. 1995

10. Change closed suctioning circuits only as needed Question 2 – When used, how often do you change the closed suctioning endotracheal system? n=28 Armstrong Institute for Patient Safety and Quality 10 They are not used in this ICU Not routinely changed unless soiled or malfunctioning Routinely changed, interval = 1 day Routinely changed, interval = 2 days Routinely changed, interval = 3 days Routinely changed, interval = 7 days Routinely changed, interval = each shift 0% (0)35.7% (10)21.4% (6)14.3% (4)17.9% (3)7.1% (2)3.6% (1)

11. Why? Armstrong Institute for Patient Safety and Quality 11 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

12. Why? American Association for Respiratory Care Guidelines –When closed suction catheters are used, they do not need to be changed daily for infection control purposes Armstrong Institute for Patient Safety and Quality 12 Hess, et al, 2003

13. 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 Armstrong Institute for Patient Safety and Quality 13 Muscedere, et al, 2008

14. Use orotracheal, not nasotracheal for elective intubation Question 3 - In the absence of a difficult airway, how often is an orotracheal route used for elective intubation in your unit? n=29 Armstrong Institute for Patient Safety and Quality 14 Almost all the time Most of the time About 50% of the time InfrequentlyAlmost never 86.2 (25)0.0% (0) 3.4% (1)10.3% (3)

15. Why? 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. Armstrong Institute for Patient Safety and Quality 15

16. Does it really make a difference? Nasotracheal intubation increases the risk of sinusitis 1,2, which can increase the risk of VAP 3,4 Armstrong Institute for Patient Safety and Quality 16 1.Salord, et al, 1990 2.Rouby, et al, 1994 3.Holzapfel, et al, 1999 4.Saint, et al, 1998

17. Use a closed ETT suctioning system Question 4 – For patients receiving MV via an endotracheal tube, how often is a closed endotracheal system used in your unit? n=29 Armstrong Institute for Patient Safety and Quality 17 Almost all the time Most of the time About 50% of the time InfrequentlyAlmost never 100.0 (25)0.0% (0)

18. Why? Armstrong Institute for Patient Safety and Quality 18 1. 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

19. Avoid the use of prophylactic systemic antimicrobials Question 5 – When mechanical ventilation is required, how often are prophylactic IV antibiotics used to prevent VAP in your ICU? n=29 Armstrong Institute for Patient Safety and Quality 19 Almost all the time Most of the time About 50% of the time InfrequentlyAlmost never 6.9% (2)0.0% (0)3.4% (1)20.7% (6)69.0% (20)

20. Why? Armstrong Institute for Patient Safety and Quality 20 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

21. Does it really make a difference? For the patients who received prophylactic antibiotics –first pneumonia was diagnosed later –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 Armstrong Institute for Patient Safety and Quality 21 Hoth, et al, 2003

22. Avoid the supine position Question 6 – In your ICU, how often are patients placed in a supine position, when there is no contraindication? n=29 Armstrong Institute for Patient Safety and Quality 22 Almost all the time Most of the time About 50% of the time InfrequentlyAlmost never 0.0% (0)3.4% (1)13.8% (4)17.2% (5)65.5% (19)

23. In written ICU, Nursing, and/or RT policies and procedures for patients on MV, is there guidance to: Question 14a - Avoid supine (flat) patient positioning unless clinically indicated (i.e. hemodynamic instability, orthopedic injury, etc.)? n=29 Armstrong Institute for Patient Safety and Quality 23 YesNo 93.1% (27)6.9% (2)

24. Why? Armstrong Institute for Patient Safety and Quality 24 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 30-45 degrees rather than supine. CDC Pro- Recommends the elevation of head of the bed to an angle of 30-45 degrees.

25. Does it really 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 Armstrong Institute for Patient Safety and Quality 25 Drakulovic, et al, 1999

26. Use standard precautions while suctioning the respiratory tract Question 7 – In your ICU, how often are standard precautions used while suctioning the respiratory tract? n=29 Armstrong Institute for Patient Safety and Quality 26 Almost all the time Most of the time About 50% of the time InfrequentlyAlmost never 82.8% (24)3.4% (1)10.3% (3)0.0% (0)3.4% (1)

27. In written ICU, Nursing, and/or RT policies and procedures for patients on MV, is there guidance to: Question 14b - Use standard precautions while suctioning the respiratory tract secretions? n=29 Armstrong Institute for Patient Safety and Quality 27 YesNo 89.7% (26)10.3% (3)

28. Why? Armstrong Institute for Patient Safety and Quality 28 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

29. Avoid non-essential tracheal suctioning Question 8 – In your ICU, how often is tracheal suctioning performed when it is not clinically indicated? n=29 Armstrong Institute for Patient Safety and Quality 29 Almost all the time Most of the time About 50% of the time InfrequentlyAlmost never 3.4 (1)13.8% (4)3.4% (1)27.6% (8)51.7% (15)

30. In written ICU, Nursing, and/or RT policies and procedures for patients on MV, is there guidance to: Question 14c – Avoid non-essential tracheal suctioning? n=29 Armstrong Institute for Patient Safety and Quality 30 YesNo 64.5% (19)34.5% (10)

31. Why? Armstrong Institute for Patient Safety and Quality 31 13. 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.

32. Use standard precautions while suctioning the respiratory tract Question 9 – In your ICU, how often are mechanically ventilated patients experiencing gastric over-distention? n=29 Armstrong Institute for Patient Safety and Quality 32 Almost all the time Most of the time About 50% of the time InfrequentlyAlmost never 3.4% (1) 41.4% (12)48.3% (14)

33. In written ICU, Nursing, and/or RT policies and procedures for patients on MV, is there guidance to: Question 14d – Avoid gastric over-distention? n=29 Armstrong Institute for Patient Safety and Quality 33 YesNo 89.7% (26)10.3% (3)

34. Why? Armstrong Institute for Patient Safety and Quality 34 14. Avoid gastric over-distention. SHEA Pro- Recommends the avoidance of over distention. ZAPMakes No Recommendations ATSMakes No Recommendations CDCMakes No Recommendations

35. Periodically remove condensate from circuits, keeping the circuit drain closed during the removal, taking precautions not to allow condensate to drain towards patient Question 10 – In your ICU, how often is condensate drained away from the patient while the circuit remains closed? n=29 Armstrong Institute for Patient Safety and Quality 35 Almost all the time Most of the time About 50% of the time InfrequentlyAlmost never 48.3% (14)6.9% (2) 10.3% (3)27.6 (8)

36. In written ICU, Nursing, and/or RT policies and procedures for patients on MV, is there guidance to: Question 14e – Periodically remove condensate from circuits? n=29 Armstrong Institute for Patient Safety and Quality 36 YesNo 69.0% (20)31.0% (9)

37. In written ICU, Nursing, and/or RT policies and procedures for patients on MV, is there guidance to: Question 14f – Assure that the circuits are closed during removal of condensate to assure that condensate doesn’t drain toward the patient? n=29 Armstrong Institute for Patient Safety and Quality 37 YesNo 86.2% (25)13.8% (4)

38. Why? Armstrong Institute for Patient Safety and Quality 38 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

39. Does it really 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 Armstrong Institute for Patient Safety and Quality 39 Craven, et al, 1984

40. Perform hand hygiene Question 11 – In your ICU, how often do healthcare providers perform hand hygiene prior to contact with respiratory equipment? n=29 Armstrong Institute for Patient Safety and Quality 40 Almost all the time Most of the time About 50% of the time InfrequentlyAlmost never 89.7% (26)6.9% (2)3.4% (1)0.0% (0)

41. In written ICU, Nursing, and/or RT policies and procedures for patients on MV, is there guidance to: Question 14g – Perform hand hygiene prior to contact with respiratory equipment? n=29 Armstrong Institute for Patient Safety and Quality 41 YesNo 100.0% (29)0.0% (0)

42. Why? Armstrong Institute for Patient Safety and Quality 42 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.

43. Provide easy access to NIVV equipment and institute protocols to promote use Question 12 – How often is non-invasive ventilation used in your ICU? n=29 Armstrong Institute for Patient Safety and Quality 43 Almost all the time Most of the time About 50% of the time InfrequentlyAlmost never 20.7% (6)37.9% (11)20.7% (6) 0.0% (0)

44. Does your ICU actively promote: Question 15a – Use of non-invasive ventilation protocol? Armstrong Institute for Patient Safety and Quality 44 YesNo 72.4% (21)27.6% (8)

45. Why? Armstrong Institute for Patient Safety and Quality 45 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

46. Does it really 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 Armstrong Institute for Patient Safety and Quality 46

47. Use an early mobility program Question 13 – In your ICU, how often is an early mobility protocol used for patients receiving mechanical ventilation? n=29 Armstrong Institute for Patient Safety and Quality 47 Almost all the time Most of the time About 50% of the time InfrequentlyAlmost never 10.3% (3)17.2% (5)20.7% (6)37.9% (11)13.8% (4)

48. Does your ICU actively promote: Question 15b – Early mobility protocol for patients receiving mechanical ventilation? Armstrong Institute for Patient Safety and Quality 48 YesNo 75.9% (22)24.1% (7)

49. Why? Armstrong Institute for Patient Safety and Quality 49 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.

50. Does it really 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! Armstrong Institute for Patient Safety and Quality 50

51. 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 Armstrong Institute for Patient Safety and Quality 51

52. Questions? Comments? Let us know your –Concerns –Ideas –Anticipated barriers –Successes –Possible implementation techniques Armstrong Institute for Patient Safety and Quality 52

53. Next Steps for CUSP  Conduct a culture assessment (HSOPS)  Establish an interdisciplinary CUSP team  Partner with a Senior Executive  Review the Science of Safety training  Identify defects  Download results from your culture assessment (HSOPS) and share with team  Meet regularly with your CUSP team  Use the Daily Goals tool in your ICU Armstrong Institute for Patient Safety and Quality 53

54. Next Steps for Data Collection  Unit Lead completes Structural Assessment  Unit staff complete HSOPS  Unit Lead/Data Facilitator enters Daily Process Measures  Unit staff complete Exposure Receipt Assessment via survey link  One person from unit (we recommend the Unit Lead) complete the Implementation Assessment.  Unit Lead/Data Facilitator enters monthly VAE rates  Unit Lead/Data Facilitator enters Early Mobility Measures  Data Facilitator contemplates next steps for collecting Objective Outcomes Measures  Unit Lead/Data Facilitator pulls data reports from the data portal and share the feedback with your frontline staff Armstrong Institute for Patient Safety and Quality 54