1. CUSP for VAP: EVAP Project Overview Sean Berenholtz M.D., MHS Kathleen Speck, MPH August 7 th - 1pm August 8 th – 11 am

2. Learning Objectives Understand the magnitude of preventable harm Review CUSP for VAP:EVAP program –Project goals and interventions –Participation requirements and timeline Describe steps to enroll

3. 3 Healthcare-Associated Infections (HAI): A Preventable Epidemic Focus on 4 HAIs: –VAP, CLABSI, surgical site infections and catheter associated urinary tract infections $5 billion per year excess costs 1.7 million patients per year –1 out of 20 patients 98,000 deaths per year –As many deaths as breast cancer and HIV/AIDS –6th leading cause of preventable deaths 1. http://oversight.house.gov/story.asp?id=1865http://oversight.house.gov/story.asp?id=1865

4. Impact of VAP 10-20% of ventilated patients 2 Common HAI 3 –Median rate 1-4.3 per 1000 vent day –250,000 infections per year Most lethal HAI 4 –Mortality likely exceeds 10% 5 –Up to 36,000 deaths per year Cost per episode: $23,000 2.Safdar CCM 2005, 3.Kollef Chest 2005, 4.Perencevich ICHE 2007, 5. Klevens RM, Public Health Rep. 2007

5. CUSP for VAP: EVAP Project Overview

6. CUSP for VAP: EVAP Project Overview NIH/NHLBI and AHRQ funding project –Individual hospitals participate for 3 years, including 2 year intervention period and 1 year evaluation of sustainability Leveraging leaders in field –Armstrong Institute for Patient Safety and Quality, NIH/NHLBI, CDC, AHRQ, University of Pennsylvania, MHA and HAP Armstrong Institute for Patient Safety and Quality 6

7. Who can join CUSP for VAP: EVAP? Participation in the program is available to any facility with mechanically ventilated patients in Maryland and Pennsylvania. Hospital participation will be coordinated with state hospital association or hospital engagement network (HEN). Armstrong Institute for Patient Safety and Quality 7

8. Project Goals To achieve significant reductions in VAP/VAE rates To achieve significant improvements in safety culture

9. How will we get there? 6. http://www.hopkinsmedicine.org/armstrong_institute Comprehensive Unit based Safety Program (CUSP) 1.Educate staff on science of safety 2.Identify defects 3.Assign executive to adopt unit 4.Learn from one defect per quarter 5.Implement teamwork tools Translating Evidence Into Practice (TRiP) 1.Summarize the evidence 2.Identify local barriers to implementation 3.Measure performance 4.Ensure all patients get the evidence Engage Educate Execute Evaluate Reducing Ventilator Associated Pneumonia HOB elevation SAT and SBT Oral Care with CHG CSS-ETT Structural measures Technical Work Adaptive Work

10. Successful Efforts to Reduce Preventable Harm Michigan Keystone ICU program –Reductions in central line-associated blood stream infections (CLABSI) 7,8 –Reductions in ventilator-associated pneumonias (VAP) 9 National On the CUSP: Stop BSI program 10 7. Pronovost,N Engl J Med 2006;355:2725-32. 8. Pronovost, N. BMJ 2010;340:c309. 9. Berenholtz,Infect Control Hosp Epidemiol. 2011;32(4): 305-314. 10. www.onthecuspstophai.org

11. Percent of Units with Zero CLABSIs and Achieving Project Goal (<1/1000 CL days) 11 11. www.onthecuspstophai.org

12. Lessons Learned Informed by science Led by clinicians and supported by management Guided by measures Armstrong Institute for Patient Safety and Quality 12

13. Advancing the Science Development of a ‘VAP Prevention’ bundle –Updating the ‘Ventilator Bundle’ to focus on VAP –Advancing science of process measurement CDC NHSN VAP definition is changing –Ventilator-Associated Event (VAE) algorithm Identification of contextual variables –Ethnographic studies

14. Interventions

15. VAP Prevention Guidelines CDC Guidelines MMWR Recomm Rep. 2004;53:1-36 American Thoracic Society/ Infectious Diseases Society of America AJRCCM 2005;171(4):388-416. Canadian VAP Prevention Guidelines J Crit Care 2008;23(1):138-147. Society for Healthcare Epid of America ICHE 2008;29:S31-S40. Armstrong Institute for Patient Safety and Quality

16. Process measures: Daily evaluation Use a semi-recumbent position ( ≥ 30 degrees). Make a daily assessment of readiness to wean. Use sedation protocol with sedation vacation and validated sedation scale (i.e. RASS) at least daily. Use chlorhexidine when performing oral care. Use subglottic suctioning ETTs in patients expected to be mechanically ventilated for >72 hours Armstrong Institute for Patient Safety and Quality 16

17. Structural measures (examples): Quarterly evaluation 1.Use a closed ETT suctioning system 2.Change close suctioning catheters only as needed 3.Change ventilator circuits only if damaged or soiled 4.Change HME every 5-7 days and as clinically indicated 5.Provide easy access to NIVV equipment and institute protocols to promote use 6.Periodically remove condensate from circuits, keeping the circuit closed during the removal, taking precautions not to allow condensate to drain toward patient 17 ETT endotrachael tube; HME heat moist exchanger; NIVV non-invasive ventilation

18. Early Ambulation RCT, 104 MICU patients on ventilators PT/OT starting at day 1-2 vs ‘usual care’ –Passive range of motion to ambulation Improved return to independent functional status at hospital discharge Shorter duration of delirium Increased ventilator-free days 12. Schweickert Lancet 2009; 373: 1874–82 Armstrong Institute for Patient Safety and Quality 18

19. Comprehensive Unit-based Safety Program (CUSP) 1.Educate staff on science of safety 2.Identify defects 3.Assign executive to adopt unit 4.Learn from one defect per quarter 5.Implement teamwork tools 13. Timmel Jt Comm J Qual Patient Saf 2010;36:252-60 14. Resources: www.safercare.net

20. Sample Daily Goals Education Decrease complexity and create redundancy Daily goals checklist Standardized order sets and protocols Independent redundancies Nursing, RT, families 15. Pronovost, J Crit Care. 2003;18(2):71-75

21. Benefits of Participation

22. Estimate of Preventable Harm and Costs Pennsylvania ( CY10- 11) –1426 VAP Cases 319 Deaths 10,000 LOS Days $115 Million Maryland (FY11) – 583 VAP Cases 130 Deaths 4,000 LOS Days $47 Million Armstrong Institute for Patient Safety and Quality 22 16.http://www.hopkinsmedicine.org/quality_safety_research_group/ou r_projects/ventilator_associated_pheumonias/estimator.html

23. Benefits to Participation Improve patient outcomes –Build upon and spread efforts to date –Focused specifically on VAP prevention, including structural measures Get “a leg up” on the new CDC VAE definition –Predicted to increase current VAP rates –Aligned with public reporting of VAP Armstrong Institute for Patient Safety and Quality 23

24. NHSN VAE reporting Starts Jan 2013 2 webinar calls targeting IPs –Over 200 participants Ongoing training with CDC and experts from Epicenters for Excellence group. Explore resources to collect baseline data Explore transferring data collected during field testing and submit to NHSN Armstrong Institute for Patient Safety and Quality 24

25. Maryland Health Service Cost Review Commission's quality initiatives including Maryland Hospital Acquired Conditions (MHACs) Initiatives Maryland Health Care Commission’s Healthcare- Associated Infections Prevention Plan MHA BOT three-year strategic plan that includes the goal of zero VAP Pennsylvania VAP Publicly Recorded Part of the HAP Action Plan & PA- HEN VAP Project Armstrong Institute for Patient Safety and Quality 25 Benefits to Participation

26. Aligned with CMS led national initiatives to reduce harm via the Partnership for Patients Hospital Engagement Networks Inform future national VAP prevention efforts –Model similar to CLABSI and CAUTI Advancing science together Armstrong Institute for Patient Safety and Quality 26 Benefits to Participation

27. CECity Project Platform Data collection –Manual entry or electronic import Real time reporting Learning management system –Share slides, protocols, literature, videos, etc. Social networking Working on MOC credit, CMEs for participation (in progress) Armstrong Institute for Patient, Safety and Quality 27

28. What do teams need to do? –Assemble a multidisciplinary team Including frontline unit staff –Participate in 6 weekly on-boarding webinars followed by monthly content and coaching webinars All webinars recorded and archived online –Regularly meet as a team to implement interventions and monitor performance –Participate in state–specific requirements Armstrong Institute for Patient Safety and Quality 28

29. What data will teams need to collect? Monthly VAE data using new CDC NHSN definitions –Numerator and denominator –Will work with you to collect baseline ‘VAE’ data Daily process measure data Quarterly structural measure and implementation data –Brief survey and structured interview Annual teamwork/culture data using the AHRQ Hospital Survey of Patient Safety (HSOPS) Will work with HENS to ensure data reporting meets their needs Armstrong Institute for Patient Safety and Quality 29

30. How do we enroll or learn more? Complete the commitment/enrollment form To learn more or to receive the enrollment packet contact: – Karol G. Wicker, MHS Senior Director, Quality Policy & Advocacy Maryland Hospital Association kwicker@mhaonline.org –Mary Catanzaro RN BSMT CIC Project Manager HAIs Hospital and Healthsystem Association of Pennsylvania mcatanzaro@haponline.org 30

31. Questions or Comments? Armstrong Institute for Patient Safety and Quality 31

32. References Slide 3 1. http://oversight-archive.waxman.house.gov/story.asp?ID=1865 Accessed: August 21, 2012.http://oversight-archive.waxman.house.gov/story.asp?ID=1865 Slide 4 2.Safdar N, Dezfullian C, Collard HR, Saint S. Clinical and economic consequences of ventilator –associated pneumonia: a systematic review. Crit Care Med. 2005. Oct;33(10):2184-93. 3.Kollef MH, Shorr A, Tabak YP, Gupta V, Liu LZ, Johannes RS, Epidemiology and outcomes of health –care-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest 2005. Dec;128(6):3854-62. 4.Perencevich EN, Stone PW, Wright SB, Carmeli Y, Fisman DN, Cosgrove SE, Society for Healthcare Epidemiology of America. Raising standards while watching the bottom line:making a business case for infection control. Infect Control Hosp Epidemiol. 2007. Oct;28(10):1121-33. 5.Klevens RM, Edwards JR, Richards CL Jr, Horan TC, Gaynes RP, Pollock DA, Cardo DM. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007 Mar-Apr;122(2):160-6. Armstrong Institute for Patient Safety and Quality 32

33. References Slide 9 6.http://www.hopkinsmedicine.org/armstrong_institute. Accessed: August 21, 2012. Slide 10 7.Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J,Kepros J, Goeschel C,. An intervention to decrease cathere- related bloodstream infection in the ICU. N Engl J Med 2006;355:2725-32. 8.Pronovost PJ, Goeschel CA, Colantuoni E, Watson S, Lubomski LH, Berenholtz SM, Thompson DA, Sinopoli DJ, Cosgrove S, Sexton JB, Marsteller JA, Hyzy RC, Welsh R, Posa P, Schumacher K, Needham D. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ 2010;340:c309. 9.Berenholtz SM, Pham JC, Thompson DA, Needham DM, Lubomski LH, Hyzy RC, Welsh R, Cosgrove SE, Sexton JB, Colantuoni E, Watson SR, Goeschel CA, Pronovost PJ. Collaborative cohort study of an intervention to reduce ventilator associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011;32(4): 305-314. 10 www.onthecuspstophai.org Accessed, August 21, 2012.www.onthecuspstophai.org 33

34. References Slide 11 11. www.onthecuspstophai.org Accessed: August, 21, 2012.www.onthecuspstophai.org Slide 18 12.Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman A, Barr R,McCallister KE, Hall JB, Kress JP. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet. 2009 May 30;373(9678):1874-82. Slide 19 13.Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf 2010;36:252-60 14.www.safercare.net Accessed: August 21, 20012.www.safercare.net Armstrong Institute for Patient Safety and Quality 34

35. References Slide 20 15.Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003;18(2):71-75 Slide22 16. http://www.hopkinsmedicine.org/quality_safety_research_group/our_projects/vent ilator_associated_pheumonias/estimator.html Accessed: August 21, 2012. http://www.hopkinsmedicine.org/quality_safety_research_group/our_projects/vent ilator_associated_pheumonias/estimator.html Armstrong Institute for Patient Safety and Quality 35