1. ***Please note some slides have been removed since the webinar at the presenter’s request.
CUSP for VAP Revisiting Your Action Plan: Using Reports to Drive Change
Sara Cosgrove, MD, MS
Donna Fellerman, RN, CIC
Chelsea Lynch, RN, MSN, MPH, CIC
Elizabeth Zink, MS, RN, CCNS, CNRN
Polly Trexler, MS, CIC
July 10, 2014

2. Data Drives Outcomes
How to Present Your Data Effectively

3. Define the Audience Front-line clinicians
Clinical committees (e.g., critical care committee)
Hospital administration
Patients/families

4. Define the Purpose of Sharing the Data
Assessment of individual cases to determine areas for improvement
Trending of data over time to compare units to themselves or other units
Dashboards or other quality improvement documents
Usually red, yellow, green
Decide in advance how these will be defined

5. What do you want them to take away?
Define the Message
What do you want them to take away?
This is often in flux and needs to re-evaluated frequently
Rate trending upwards in a
clinically significant way
Needs to be addressed now
Rate is very low
Nothing to worry about
Keep up the good work

6. Address Concerns about Data Validity Upfront
Share the surveillance definitions and how you perform surveillance
Describe data sources
Repeat often
Point out limitations and definitional cases without negating the validity of the data
Distinguish between the surveillance definition and the clinical definition
Allow time for venting, but rally the team back
Complaining is not going to make the CDC change the definition!
Everyone follows the same rules

7. CDC VAE Surveillance

8. Determine How to Display the Data
Numbers (numerators) vs. rates
Time frames
Weekly, monthly, quarterly, etc.
Depends on how common the event is
Benchmarks
CDC or other
Process and outcome measures on the same graph?
Indicators of when interventions started
Annual goals/targets

9. Suggestions Based on Audience
Front-line clinicians
Numbers of cases
Weeks since last case
Process measures
Graphs with rates
Goals & benchmarks
Action plan
Administrators
Graphs with rates
High level process measure information
Goals & benchmarks
Action plan
Patients/families
Tailor message to request

10. Bundle Up! Be a VAP Prevention STAR! Head of Bed > 30⁰
Subglottic Suctioning
Oral Care with CHG
How are we doing?
Post the unit’s VAP graph or other information here
Daily Assessment for Readiness to Wean
Sedation Vacation

11. Change the Data Display When Necessary
Data display should be an iterative process
Base changes on questions from and interpretations of audience
Particularly difficult with VAC, IVAC, possible and probable VAP

12. Process Measures
Process measure data is only as good as the data collection
Need to have and apply a standard definition, which is challenging when numerous people are collecting
More appropriate for unit level trending and initiation of discussions regarding improvement than for reporting at high-level meetings

13. Keep it Visible Give internal access (such as an intranet source)
Post it where staff can see it
Personally take it to where
staff are working (on units)
A unit “huddle” – taking information to staff and gaining feedback/ideas rather than waiting for a formal group meeting

14. Stay on schedule with data reports to committees
Keep it Timely
Stay on schedule with data reports to committees
Distribute as soon as possible to stakeholders
Use multiple opportunities – staff meetings, provider meetings, QI meetings, rounds, “huddles”

15. Make it Meaningful WHO does this dot on a graph represent?
Tell the patient’s story. Use patients’ names for unit personnel. They will remember the patient and may have ideas for improvements in practice or products
Have an expectation that front line staff can answer how the unit is doing with VAP, CLABSI, CAUTI when asked

16. Make the data visible, interpretable, and timely
Conclusions
Manage the message
Make the data visible, interpretable, and timely
Solicit input from stakeholders about effective ways to do this
Make it meaningful—we are talking about patients

17. Project Updates and Next Steps

18. Next Steps
Collect Process Measure data (7 days of data per month collected during the 1st week of the month)
Collect Early Mobility data (7 days of data per month collected during the 2nd week of the month)
Complete Structural Assessment 3 (begins next week)
Data collection for Low Tidal Volume Ventilation measure (August)

19. Additional Resources
For questions regarding data collection, us at
Society for Critical Care Medicine ICU Liberation Group
AHRQ CUSP Toolkit
Armstrong Institute CUSP Tools
Armstrong Institute Training Opportunities

20. Thank You
A sincere THANK YOU for all of your effort and hard work to reduce the incidence of VAP in your units and prevent HAIs!