1. CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Content 2: Spontaneous Awakening Trials (SAT), Spontaneous Breathing Trials (SBT) , and The Utility of the Exposure Receipt Assessment
February 18, 2015
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
Johns Hopkins University

2. CUSP 4 MVP - VAP
Comprehensive Unit-based Safety Program for Mechanically Ventilated Patients and Ventilator-Associated Pneumonia

3. Polling Question Who is on the call? IP – infection preventionist
RN – registered nurse
RT – respiratory therapist
PT – physical therapist
OT – occupational therapist
MD – medical doctor
Healthcare executive
Educator
National project team
Other  

4. Learning Objectives
Define and explain the importance of spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT)
Implement the process measure used to assess SAT and SBT compliance
Assess barriers to implementing SATs and SBTs
Describe value to your team of the Exposure Receipt Assessment

5. Agenda Introduction of guidelines Define SAT/SBT protocols
Daily Care Process Measures tool
Sample reports
Identify barriers to implementation
Resources
Overview of Exposure Receipt Assessment
Next Steps

6. CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients
Spontaneous Awakening and Breathing Trials (SAT & SBT) Bradford Winters, MD, PhD with Keith Lamb and Carl Hinkson
CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

8. SAT & SBT Specific VAP Prevention Guidelines
Society for Healthcare Epidemiology of America1
Recommends simultaneous use of daily sedation interruption (SAT) and daily assessment of readiness wean (SBT)
Recommends management of ventilated patients with minimal sedation whenever possible and avoidance of benzodiazepines

9. SAT & SBT Specific VAP Prevention Guidelines
Centers for Disease Control and Prevention2
Does not specifically address SAT and SBT, however supports weaning
American Thoracic Society3
Recommends use of daily interruption or lightening of sedation to avoid constant heavy sedation and to facilitate and accelerate weaning
Does not specifically address SBT

10. Spontaneous Awakening Trials (SATs) Protocol4,5
SAT consists of two parts: safety screen and trial
Safety screen checks for contraindications
Patient passes the screen unless following factors are present
Receiving a sedative infusion for active seizures or alcohol withdrawal
Receiving escalating doses of sedative for agitation
Receiving neuromuscular blockers
Evidence of active myocardial ischemia in prior 24 hours
Evidence of increased intracranial pressure

11. Spontaneous Awakening Trials (SATs) Protocol4,5
If patient passes the safety screen,
Stop all sedatives and analgesics used for sedation
Continue analgesics used for pain

12. Spontaneous Awakening Trials (SATs) Protocol4,5
Passes the SAT if can do 3 out of 4 task on request
Open their eyes
Look at their caregiver
Squeeze the hand
Put out their tongue
OR can go without sedation for 4 hours without new symptoms or complications

13. Spontaneous Awakening Trials (SATs) Protocol4,5
Passes the SAT if without sedation for 4 hours without the following:
Sustained anxiety
Agitation
Pain
Respiratory rate of 35 breaths/minute for ≥ 5 minutes
SpO2 of less than 88% for ≥ 5 minutes
Acute cardiac dysrhythmia
Two or more signs of respiratory distress
Tachycardia
Bradycardia
Use of accessory muscles
Marked dyspnea
Abdominal paradox
Diaphoresis

14. Spontaneous Awakening Trials (SATs) Protocol4,5
If patient fails the SAT,
Sedatives are started at one half the prior dosage
Then titrated up as needed

15. Spontaneous Breathing Trials (SBTs) Protocol4,5
If passes the SAT, assessed for the SBT safety screen
Passes the SBT screening if achieve:
Adequate oxygenation (SpO2 ≥ 88% or an FiO2 of ≤ 50% and a PEEP ≤ 8 cm H2O)
Any spontaneous inspiratory effort in a 5-minute period
No agitation
No significant use of vasopressors or inotropes
No evidence of increased intracranial pressure

16. Spontaneous Breathing Trials (SBTs) Protocol4,5
If fails the safety screen, reassess for SAT the following day
If passes the safety screen, undergo the SBT
Ventilator support is removed
Patient is allowed to breathe through either
T-tube circuit of a ventilator circuit with CPAP of 5cm H2O OR
Pressure support ventilation of less than 7cm H2O

17. Spontaneous Breathing Trials (SBTs) Protocol4,5
Patient passes the trial if they avoid developing any of the following failure criteria within 120 minutes:
Respiratory rate of either < 8 breaths per minute (bpm) or > 35 bpm for 5 min or longer
Hypoxemia (SpO2 < 88% for ≥ 5 min)
Abrupt change in mental status
Acute cardiac arrhythmia
Two or more signs of respiratory distress
Tachycardia
Bradycardia
Use of accessory muscles
Abdominal paradox
Diaphoresis
Marked dyspnea

18. Spontaneous Breathing Trials (SBTs) Protocol4,5
If fails the SBT, reassess for SAT the following day
If passes the SBT, physician(s) are notified for possible extubation

19. SAT & SBT Protocol4,5 Is the patient responsive to verbal stimuli?
Rescreen tomorrow
SAT Safety Screen
Rescreen tomorrow
Rescreen tomorrow
SAT: Can patient go w/o sedation and complications for 4 hours?
SBT Safety Screen
Restart sedation at half dosage, then titrate for pain/sedation
SBT: Does patient breathe w/o complications for 2 hours?
Notify physician to consider extubation
Rescreen tomorrow

20. Polling Question
What action should be taken if the patient becomes agitated during SAT/SBT?
Restart heavy sedation
Restart sedation to RASS of -3
Restart sedation at one-half the previous dose and titrate up as needed
Continue SAT/SBT

21. CDC Prevention Epicenters’ Wake Up and Breathe Collaborative6
What: Prospective quality improvement collaborative
Who: 12 ICUs affiliated with 7 hospitals
Why: prevent VAEs through less sedation and earlier liberation from mechanical ventilation
How: increase performance of paired daily spontaneous awakening trials and breathing trials (SATs and SBTs)
Prospective quality improvement collaborative 12 ICUs affiliated with 7 hospitals Prevent VAEs through less sedation and earlier liberation from mechanical ventilation Increase performance of paired daily spontaneous awakening trials and breathing trials (SATs and SBTs)
The CDC Prevention Epicenters just recently presented the results of their VAE prevention collaborative. 12 ICUs affiliated with 7 hospitals sought to decrease VAEs by decreasing duration of mechanical ventilation. They focused on enhancing the performance of paired daily SATs and SBTs.

22. CDC Prevention Epicenters’ Wake Up and Breathe Collaborative6
SATs & SBTs
Increases
63% in SATs
16% in SBTs
81% in SBTs done with sedatives off
37% in VACs 65% in IVACs
Over a 19 month period they observed a substantial increase in SATs and SBTs which in turn was mirrored by substantial decreases in VACs and IVACs.
VAE Reductions

23. CDC Prevention Epicenters’ Wake Up and Breathe Collaborative6
SATs & SBTs
Increases
2.4 vent days 3.0 ICU days 6.3 LOS days
63% in SATs
16% in SBTs
81% in SBTs done with sedatives off
Over a 19 month period they observed a substantial increase in SATs and SBTs which in turn was mirrored by substantial decreases in VACs and IVACs.
Vent Days & LOS Reductions

24. Daily Interruption of Sedatives
Less than half of practitioners worldwide have implemented daily interruption of sedatives7,8
Germany 34%
Canada 40%
USA 40%

25. Perceived Barriers to Sedation Protocols and SATs7
Multidisciplinary web-based survey (n=904)
Reasons for lack of protocol use
No physician order, 35%
Lack of nursing support, 11%
Fear of over sedation, 7%
Barriers for daily sedation interruption
Nursing acceptance, 22%
Risk of device removal, 19%
Respiratory compromise, 26%
Patient discomfort, 13%

26. ICU Barriers to SATs
View SATs as unnecessary, and light sedation as more appropriate and safer
Claim no physician orders
Maintain inadequate staff to undertake protocols
Unconvinced lowering sedation will benefit patients

27. ICU Barriers to SATs9
Nursing attitudes account for one-third of variance in number of patients who received sedatives
Only 17.7% of respondents thought it was easier to care for an awake and alert patient receiving mechanical ventilation than to care for a similar patient more sedated

28. Data Collection Drives quality improvement efforts Is NOT for research
Provides quantifiable measures of care practices
Guides patient safety conversations
Justifies resource allocations
Human resources (time)
Financial resources (money)
Supplies and equipment (stuff)

30. SAT & SBT Daily Care Process Measures
SAT Contraindication
SBT
SBT Contraindication
SBT with Sedatives Off

31. SAT Contraindications0.
Other
Sedatives for active seizures or objective evidence of active alcohol withdrawal
Escalating sedative doses due to ongoing agitation
Neuromuscular blockers
Active myocardial ischemia in the previous 24 hours
Increased intracranial pressure in the previous 24 hours
High frequency oscillation ventilation

32. SBT Contraindications0.
Other
No adequate oxygenation [SpO2 < 88% on an FiO2 of ≥ 50% and a PEEP of ≥3 cm H2O]
No spontaneous inspiratory effort in a 5-minute period
Acute agitation requiring escalating sedative doses
Significant vasopressors or inotropes
Increased intracranial pressure in the previous 24 hours

33. Accessing SAT & SBT Reports
SAT and SBT reports are part of the Daily Process Measures data collection tool.
Login at

34. Daily Care Process Measures Compliance Reports
Download and
Print reports
You can view your Compliance reports for 1) SAT Compliance Rate; 2) SBT Compliance Rate; and 3) SBT with Seds off Compliance Rate.
Improvement Opportunities display the number of events, which if eliminated improve your measure value

35. Daily Care Process Measures Reports: View Chart
Ability to download PDF
Turn comparators ON and OFF
This brings up an interactive chart with customizable options. This is available for all three compliance reports.
Interactive chart that allows selection of your comparators and time periods

36. Daily Care Process Measures Contraindication Reports
You can view your Contraindication reports. Average Performance displays the mean for all the other participants in VAP.
My Percentile shows what percentile your rate is versus all other participants in VAP

37. Daily Care Process Measures Distribution Reports
Scroll down to view SAT/SBT information
The Distribution tab will provide more information. Scroll down to view SAT/SBT information.

38. Daily Care Process Measures Distribution Reports
You can find the distribution reports for 1) SAT Contraindications and 2) SBT Contraindications. An example of SAT Contraindications is shown on this slide.

39. Resources: Fast Facts Ready to post in the unit
Provides quick reference to latest evidence-based protocols
Summarizes position of four leaders in the VAP field

40. Resources: SAT & SBT Protocol

41. Resources: Literature Synopsis
Summarizes guidelines in the VAP field
SHEA: Society for Healthcare Epidemiology of America
American Thoracic Society
ZAP the VAP: Ventilator-associated Pneumonia
Center for Disease Control and Prevention
Includes details of literature published post- guidelines, both positive and negative
Annotated bibliography
Updated with the latest SHEA guidelines published in 2014

42. References
SHEA; Klompas M, Branson R, Eichenwald EC, Greene LR, Howell MD, Lee G, Magill SS, Maragakis LL, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(8): PMID:
CDC; Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing healthcare- associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53:1-36. PMID:
American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4): PMID:
Kress J, Pohlman A, O'Connor M, Hall JB. Daily interruption of sedative infusion in critically ill undergoing mechanical ventilation. N.Engl.J.Med. 2000;342(20): PMID:
Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, Taichman DB, Dunn JG, Pohlman AS, Kinniry PA, Jackson JC, Canonico AE, Light RW, Shintani AK, Thompson JL, Gordon SM, Hall JB, Dittus RS, Bernard GR, Ely EW. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): A randomised controlled trial. Lancet. 2008;371(9607): PMID:

43. References
Klompas M, Anderson D, Trick W, Babcock H, Kerlin MP, Li L, Sinkowitz-Cochran R, Ely EW, Jernigan J, Magill S, Lyles R, O'Neil C, Kitch BT, Arrington E, Balas MC, Kleinman K, Bruce C, Lankiewicz J, Murphy MV, Cox C, Lautenbach E, Sexton D, Fraser V, Weinstein RA, Platt R; for the CDC Prevention Epicenters. The Preventability of Ventilator-Associated Events: The CDC Prevention Epicenters' Wake Up and Breathe Collaborative. Am J Respir Crit Care Med Nov 4. PMID:
Tanios MA, de Wit M, Epstein SK, Devlin JW. Perceived barriers to the use of sedation protocols and daily sedation interruption: a multidisciplinary survey. J Crit Care. 2009; 24(1): PMID:
Devlin JW, Tanios MA, Epstein SK. Intensive care unit sedation: waking up clinicians to the gap between research and practice. Crit Care Med 2006; 34(2): PMID:
Guttormson JL, Chlan L, Weinert C, Savik K. Factors influencing nurse sedation practices with mechanically ventilated patients: a U.S. national survey. Intensive Crit Care Nurs. 2010;26(1): PMID:

44. Utility of the Exposure Receipt Assessment Nishi Rawat, MD
CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

45. Exposure Receipt Assessment (ERA) Goals
Measures awareness and involvement of frontline staff
Helps you understand what information your staff actually receives
National Project Team Resources
(webinars, coaching)
Team Lead Dissemination of Information
Frontline Provider
Knowledge

46. Exposure Receipt Assessment (ERA) Goals
Addresses technical interventions and techniques
Addresses adaptive CUSP initiatives designed to improve your unit safety culture
Like every collaborative risk reduction initiative, CUSP 4 MVP – VAP can only achieve success if the frontline staff is involved.

47. Exposure Receipt Assessment (ERA) Goals
Assess your unit’s use of VAE prevention interventions
Identify best practices for disseminating these interventions
Generate lessons for peer to peer learning

48. Exposure Receipt Assessment (ERA) Details
Who completes the survey? All frontline staff
How long does it take? About 5 minutes
How often? Twice a year
For Cohort 2 teams, ERA surveys occur during these timeframes
Feb/Mar 2015
Sept/Oct 2015
Apr/May 2016

49. Exposure Receipt Assessment (ERA) FAQ’s
Who sees the results?
Anonymous
No identifiers on responses
Supervisors will not see responses

50. Exposure Receipt Assessment (ERA) FAQ’s
Who does see the results?
Subset of the national project team
What do they do with the results?
Collate and report results back to you
Improve education materials to increase penetration
Why should I ask my busy staff take this survey?
Learn the extent to which the interventions are reaching your frontline providers
Interventions cannot be effective without provider awareness of intervention

51. Where Can I Find the ERA? Project website:
hopkinsmedicine.org/cusp4mvp.aspx
Select Data Collection Tools and Tutorials
Select Exposure Receipt Assessment

52. Exposure Receipt Assessment (ERA) Survey
What is your role in the unit?
Nurse
Technician
Doctor
Do you know your unit’s ventilator-associated pneumonia (VAP) or ventilator-associated event (VAE) rate(s)? YES / NO
Have you watched the Science of Safety presentation? YES / NO
Respiratory therapist
Other ____________

53. Exposure Receipt Assessment (ERA) Survey
Have you completed a Staff Safety Assessment? YES / NO 
Have you used the Learning From Defects tool in the past three months?
Yes, I have used it
No, I have not used it; I have not heard of it
No, I have not used it, but I am familiar with it
We use a different kind of defect tool
The Staff Safety Assessment is a two-question tool about how the next patient may be harmed.
Learning From Defects is a tool that helps teams to prioritize safety issues, develop plans to address the issues, and evaluate if the issues are less likely to occur.

54. Exposure Receipt Assessment (ERA) Survey
Over the past three months, for how many patients has your unit used the Daily Goals checklist?
All / Almost all
We don’t use the Daily Goals
Over half
We use a different kind of checklist
Under half
Don’t know
The Staff Safety Assessment is a two-question tool about how the next patient may be harmed.
Learning From Defects is a tool that helps teams to prioritize safety issues, develop plans to address the issues, and evaluate if the issues are less likely to occur.

55. Exposure Receipt Assessment (ERA) Survey
How familiar are you with the Comprehensive Unit-based Safety Program (CUSP)?
Very familiar
Somewhat familiar
Not at all familiar
Do you have a CUSP team on your unit?
YES / NO / DON’T KNOW 
If yes, has the CUSP team on your unit been active in improving patient safety?
The Staff Safety Assessment is a two-question tool about how the next patient may be harmed.
Learning From Defects is a tool that helps teams to prioritize safety issues, develop plans to address the issues, and evaluate if the issues are less likely to occur.

56. Exposure Receipt Assessment (ERA) Survey
Which of these interventions are being used by your unit and how often?
Maintain elevation of the head of the bed to ≥ 30°
Mobilizing patients
Low tidal volume strategy for the prevention of acute lung injury
Subglottic suctioning endotracheal tubes
Spontaneous awakening trial (SAT) (sedation vacation)
Spontaneous breathing trial (SBT)
Do you believe that the interventions above will help to prevent VAE on your unit?
The Staff Safety Assessment is a two-question tool about how the next patient may be harmed.
Learning From Defects is a tool that helps teams to prioritize safety issues, develop plans to address the issues, and evaluate if the issues are less likely to occur.

57. Exposure Receipt Assessment (ERA) Survey
In your opinion, which of the following interventions are most likely to prevent VAE? To the best of your ability, please select the three most important interventions.
Maintain elevation of the head of the bed to ≥30°
Mobilize patients
Low tidal volume ventilation
Subglottic suctioning endotracheal tubes
Spontaneous awakening trial (SAT) (sedation vacation)
Spontaneous breathing trial (SBT)
Perform oral care 6 times daily
Use chlorhexidine 2 times daily while performing oral care

58. Exposure Receipt Assessment (ERA) Survey
In your opinion, where is the biggest opportunity to improve the care of mechanically ventilated patients in your unit?
Maintain elevation of the head of the bed to ≥30°
Mobilize patients
Low tidal volume ventilation
Subglottic suctioning endotracheal tubes for patients ventilated >72 hours
Spontaneous awakening trial (SAT) (sedation vacation)
Spontaneous breathing trial (SBT)

60. CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients
Next Steps
CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

61. Next Steps: Homework By March 18, 2015
Audit SAT/SBTs for 10 patients to assess barriers
Report barriers in next coaching call

62. Mark Your Calendar: Upcoming Content Webinars
ACTION
DATE
Delirium Assessment Training
Mar 18, 11-12:30pm EST
Daily Goals Facilitates VAE Prevention
Implementation Assessment Overview
Apr 15, 11-12:30pm EST
Early Mobility: A Practical Approach
May 20, 11-12:30 pm EST
Learning From Defects
Jun 17, 11-12:30 pm EST
For current schedule of upcoming project webinars, visit

63. CUSP 4 MVP – VAP Website
Visit:

64. What Can I Find on the CUSP 4 MVP – VAP Website?
Education materials
Daily Care Toolkits
SAT/SBT Protocol
SAT/SBT Literature Review
SAT/SBT Fast Fact Sheet
Exposure Receipt Assessment tool
CUSP Tools and Guides
Archive of webinars led by subject matter experts

65. Additional Resources ICU Delirium at http://www.icudelirium.org/
ICU Liberation at