1. CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Onboarding 3: Introduction to Daily Care Process Measures ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY Johns Hopkins University

2. 2 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Housekeeping Notes Once you are on the webinar, choose the "Call Me" option and enter your phone number to be connected to audio. If you cannot join the webinar online, please call in with the information below: US Toll Free 1-855-797-9480 Access code: 669 227 342 Your phones are on mute, but we want to hear from you! Please use the chat box to ask questions or write comments during the call. The recording file and presentation slides will be uploaded to the project website in the next two weeks.

3. 3 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Polling Question Who is on the call? IP – infection preventionist RN – registered nurse RT – respiratory therapist PT – physical therapist OT – occupational therapist MD – physician Quality improvement professional Healthcare executive Educator Coordinating entity representative National project team Other 

4. 4 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes CUSP 4 MVP - VAP Comprehensive Unit-based Safety Program for Mechanically Ventilated Patients and Ventilator-Associated Pneumonia

5. 5 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Today’s Discussion Sean Berenholtz, MD, MHS, FCCM Principal Investigator Kathleen Speck, MPH Co-Investigator Brian Boyle Guest Speaker & International Patient Safety Advocate Mary Twomley, MS, PMP Senior Research Coordinator II

6. 6 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Objectives Introduce the Daily Care Process Measures Explain Daily Care Process Measures data elements and their definitions Identify strategies for finding the data elements Explain importance of spontaneous awakening trials and spontaneous breathing trials Define delirium List risks associated with delirium

7. Patient Experience Brian Boyle CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

8. 8 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

9. 9 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

10. 10 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

11. 11 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

12. 12 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

13. 13 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

14. 14 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

15. 15 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

16. 16 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

17. 17 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

18. 18 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

19. 19 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

20. 20 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

21. 21 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

22. 22 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

23. 23 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

24. 24 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

25. Introduction to Daily Care Process Measures Sean Berenholtz, MD, MHS, FCCM CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

26. 26 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

27. 27 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Cohort 3 Tracks CUSP Daily Care Processes Early Mobility LTVV optional OR CHOOSE ONE OR BOTH

28. 28 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes 2014 SHEA Compendium Update 1 Elevate the head of the bed 30-45° Provide endotracheal tubes with subglottic secretion drainage ports for patients likely to require more than 48 or 72 hours of intubation Manage ventilated patients without sedatives whenever possible

29. 29 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes 2014 SHEA Compendium Update 1 Interrupt sedation once a day (spontaneous awakening trials) Assess readiness to extubate once a day (spontaneous breathing trials) Pair spontaneous breathing trials with spontaneous awakening trials Employ early exercise and mobilization Use non-invasive positive pressure ventilation (NIPPV) whenever feasible

30. 30 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes 2013 Society of Critical Care Medicine PAD Guidelines 2 1.Establish an overarching protocolized approach to daily ICU patient management using 2013 Pain, Agitation, and Delirium (PAD) Guidelines 2.Assess and treat pain first (may be sufficient) 3.If patient remains agitated after adequately treating pain –Start with PRN bolus sedation (as needed) –Use continuous sedation if boluses exceed 3 per hour 4.Avoid benzodiazepines in most patients

31. 31 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes 2013 Society of Critical Care Medicine PAD Guidelines 2 5.Interrupt sedation daily –If necessary, restart at lowest dose to maintain chosen target level of consciousness 6.Avoid deep sedation (RASS -4/-5) as it appears harmful; instead, target awake or alert 7.Screen for delirium (CAM-ICU or ICDSC) –If delirious, first seek reversible causes and attempt non-pharmacologic management 8.Use the ABCDE’s to improve outcomes for your patients

32. 32 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Risks Associated with Delirium In ICU or hospital– Increased mortality Longer intubation time Average 10 additional days in hospital Higher costs of care After discharge– Increased mortality Development of dementia Long-term cognitive impairment Requirement for care in chronic care facility Decreased functional status at 6 months

33. 33 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes PAD Treatment of Delirium Recommendations 2 No published evidence that treatment with haloperidol reduces the duration of delirium in adult ICU patients (No Evidence) Atypical antipsychotics may reduce the duration of delirium in adult ICU patients (C) Rivastigmine NOT recommended to reduce the duration of delirium in ICU patients (–1B)

34. 34 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Effective Approach to Delirium Management Stop THINK Last – Medicate

35. 35 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes In God we trust. All others bring data. – W. E. Deming “ ”

36. 36 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes What Can You Achieve? SAT Compliance Rate High Performers – Cohort 1

37. 37 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Per 1000 ventilator days – Cohort 1 SAT Compliance Rate High Performers VAE Outcomes Incidence Rates

38. 38 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Daily Care Processes Compliance – Cohort 1

39. 39 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Daily Care Processes Compliance – Cohort 1

40. 40 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Daily Care Processes Compliance – Cohort 2

41. 41 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Daily Care Processes Compliance – Cohort 2

42. 42 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes VAE per 1000 Ventilator Days – Cohort 1

43. 43 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes SBT with Seds off Compliance Sampling

44. 44 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Delirium Assessment Compliance Rate Sampling

45. 45 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes % Ventilated Patient Days without Sedation Sampling

46. 46 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes % Achieve RASS/SAS Target Sampling

47. Daily Care Processes Data Collection Kathleen Speck, MPH CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

48. 48 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Daily Care Process Measures Data Collection Tool Contraindications & Location Codes Detailed Instructions Data Collection Tool

49. 49 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

50. 50 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Contraindications and Locations

51. 51 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Let’s Begin Fill Out For All Beds Track by bed, not by patient Include –Bed number –Was the patient in that bed intubated or trached AND on mechanical ventilation at the time of observation Y = Yes N = No E = Empty bed

52. 52 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

53. 53 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes 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

54. 54 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Sub-G ETT Does the patient have a subglottic endotracheal tube? Y = Yes N = No –If your unit doesn’t use Sub-G ETTs, enter N C = Contraindicated –If C, enter the contraindication code for this patient in the next column

55. 55 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Sub-G ETT Contraindications Why a Sub-G ETT is contraindicated? Find the contraindications on the back or on page 2 of the tool Remember, enter ‘N’ if your unit does not use Sub-G ETTs

56. 56 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Location of Intubation Enter the location code where the patient was intubated Find the locations on the back or on page 2 of the tool 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

57. 57 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Location of Intubation Where was the patient intubated? Find the locations on the back or on page 2 of the tool

58. 58 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Elevating the Head of Bed Is the HOB elevated to an angle of ≥ 30° from the horizontal? –Y = Yes –N = No –C = Contraindicated If contraindicated, choose the reason from the contraindications listed on page 2 of the tool

59. 59 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Head of Bed Contraindications Why was placing the HOB at an angle of ≥ 30° from the horizontal contraindicated? Find the contraindications on the back or on page 2 of the tool

60. 60 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Sedation Scale 1 st question What sedation scale do you use on your unit? This question refers to your unit, not to this specific patient

61. 61 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Sedation Scale R = Richmond Agitation Sedation Scale (RASS) S = Riker Sedation- Agitation Scale (SAS) NU = Unit uses neither RASS or SAS –If NU, skip to Delirium Assessment

62. 62 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Sedation Scale Choose either RASS or SAS, but not both Choose the value closest to 10:00 am If equidistant, choose the earlier time

63. 63 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Sedation Scale: Target RASS If you use ‘RASS’… Target: What is the target RASS score for this patient? –Enter RASS sedation scale value (-5 to 4) –‘NS’ means not set –‘NK’ means target RASS was set, but is not known –Enter ‘NK’ if you don’t know whether a target RASS was actually set

64. 64 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Sedation Scale: Actual RASS If you use ‘RASS’… 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

65. 65 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Sedation Scale: Target SAS If you use ‘SAS’… Target: What is the target SAS score for this patient? –Enter SAS sedation scale value (1 to 7) –Enter ‘NS’ if 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

66. 66 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Sedation Scale: Actual SAS If you use ‘SAS’… 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

67. 67 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Sedation Scale: NU If you entered ‘NU’ NU = Unit uses neither RASS or SAS –If NU, skip Target and Actual sections and go to Delirium Assessment

68. 68 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes 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

69. 69 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes 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 10-20 second test of attention is the cardinal feature of a delirium diagnosis

70. 70 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Delirium Assessment Choose either CAM- ICU or ASE, not both CAM-ICU incorporates the ASE Choose the value closest to 10:00 a.m. If equidistant, choose the earlier time

71. 71 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Confusion Assessment Method for the ICU (CAM-ICU) Society of Critical Care Medicine’s 2013 Pain, Agitation, and Delirium (PAD) clinical practice guidelines Recommends theses valid and reliable delirium screening tools –Confusion Assessment Method for the ICU (CAM-ICU) –Intensive Care Delirium Screening Checklist (ICDSC) Screen moderate to high risk patients at least once per nursing shift

72. 72 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Delirium Assessment 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 –Such as 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

73. 73 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Attention Screening Exam (ASE) Determine if patient can follow a simple command (pay attention) for 10-20 seconds Recognize inattention as the cardinal feature of delirium that must be present for diagnosis For centers not using the full CAM-ICU, conducting the ASE is a good barometer of the presence or absence of delirium May yield abnormal results due to disease, drugs or other causes

74. 74 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Attention Screening Exam (ASE) Provider reads one of the following sequences: –S A V E A H A A R T –C A S A B L A N C A –A B A D B A D D A Y Patient squeezes the provider’s hand when he hears the letter ‘A’ Error defined as –No squeeze with letter ‘A’ –A squeeze on a letter other than ‘A’

75. 75 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Attention Screening Exam (ASE) Count the number of errors Inattention is present if the patient commits more than 2 errors If the patient squeezes on every letter, assign an error count of 10 If the patient doesn’t squeeze on any letter, assign an error count of 10

76. 76 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Attention Screening Exam (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 –RASS = -4 or -5 –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

77. 77 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Spontaneous Awakening Trial (SAT) Has the patient had a Spontaneous Awakening Trial today?

78. 78 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Spontaneous Awakening Trial (SAT)

79. 79 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Spontaneous Awakening Trial (SAT) Enter ‘NS’ if the patient is not sedated Enter ‘Y’ if medications for sedation 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 next column labeled “Reason SAT Contraindic”

80. 80 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Spontaneous Awakening Trial (SAT) Contraindications Why is an SAT inappropriate for this patient? Find the contraindications on the back or on page 2 of the tool

81. 81 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Spontaneous Breathing Trial (SBT) Has the patient had a spontaneous breathing trial today?

82. 82 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Spontaneous Breathing Trial (SBT) Remove ventilator support Allow patient to breathe –With either a T-tube circuit –Or with a ventilator circuit –With low levels of PS (5–8 cm H 2 O in adults) –With or without 5 cm H 2 O PEEP No changes are required in FiO 2 or the level of PEEP

83. 83 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Spontaneous Breathing Trial (SBT) 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 contra- indicated/not indicated –If ‘C/NI’, go to Reason SBT Contraindic

84. 84 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Spontaneous Breathing Trials Contraindications (SBT) What is the reason an SBT is inappropriate for this patient? Find the contraindications on the back or on page 2 of the tool

85. 85 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Spontaneous Breathing Trial (SBT) with Sedatives 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

86. 86 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes VAE Affinity Group Tune in to the VAE Affinity Group webinars for Infection Prevention training on ventilator-associated event surveillance Webinars are 90 minutes and occur on the fourth Tuesday in September, October and November at 2:00 PM ET DATETOPIC Sept 22, 2015VAE Surveillance Training: An Overview Oct 27, 2015VAE: Infection-related Ventilator-associated Complication (IVAC) Nov 24, 2015VAE: Possible VAP (PVAP)

87. 87 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes References 1.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):915-936. PMID: 25026607. 2.Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BR, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Skrobik Y, Jaeschke R; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013 Jan;41(1):263- 306. PMID: 23269131.

88. 88 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes

89. Next Steps Mary Twomley, MS, PMP CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

90. 90 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Wednesday, October 14, 2015 2:00 PM – 3:00 PM ET Executive Engagement Join Peter J. Pronovost, MD, PhD, FCCM for a candid discussion on patient safety: Role of engaged executives and successful efforts to improve patient safety Business case for patient safety Creating an infrastructure to improve organizational quality A practicing anesthesiologist and critical care physician, Dr. Pronovost is the Senior Vice President for Patient Safety and Quality and Director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine. Invite Your Hospital Executives

91. 91 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Progress List Enrollment documents due dates Letter of CommitmentComplete! Data Use Agreement Due as soon as possible Online Registration Due by August 31 st Choose a track on the online registration form: Daily care processes Early mobility BOTH

92. 92 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Next Steps: Homework Determine where to find Daily Care Process data Determine data collection and upload method for your unit Determine who will collect the data

93. 93 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Next Steps: Homework to Date  Form a CUSP Team on your unit  Schedule meetings through August 2016  Draft a project mission statement  Complete your pre mortem exercise  Educate frontline staff and executive partners on the science of safety  Administer HSOPS to your unit staff OR Upload your pre-existing HSOPS data from the last 12 months into the project data portal

94. 94 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes Tune in to the content webinars for evidence supporting each intervention Content webinars are 90 minutes and occur at 2:00 PM ET DATETOPIC Aug 18, 2015Introduction to Early Mobility: A Protocol to Get Patients out of the Bed Faster Aug 25, 2015Value of Patient and Family Perspective Engaging Executives and a Business Case for ICU Quality Improvement Sept 8, 2015Project Kickoff! Mark Your Calendar: Upcoming Sessions

95. 95 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes CUSP 4 MVP – VAP Website Visit: https://armstrongr esearch.hopkinsm edicine.org/cusp4 mvp.aspx https://armstrongr esearch.hopkinsm edicine.org/cusp4 mvp.aspx Project site will be password protected on Aug 31 st, 2015.

96. 96 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes 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 Daily Care Process Data Collection tool CUSP Tools and Guides Archive of webinars led by subject matter experts https://armstrongresearch.hopkinsmedicine.org/cusp4mvp.aspx

97. 97 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Onboarding 3: Daily Care Processes