1. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 CUSP for VAP: Year in Review 2014 Sean Berenholtz, MD, MHS Kathleen Speck, MPH Kisha Ali, MS The Armstrong Institute for Patient Safety and Quality January 8, 2015

2. CUSP for VAP: Project Review NIH/NHLBI and AHRQ funded project –Individual hospitals participate for 3 years, including 2 year intervention period and 1 year sustainability period –2015 begins the sustainability period Leveraging leaders in field –Armstrong Institute for Patient Safety and Quality (AI), NIH/NHLBI, CDC, AHRQ, University of Pennsylvania –Maryland Hospital Association (MHA) –Hospital and Healthsystem Association of Pennsylvania (HAP) 2

3. Project Goals Our objectives were: To achieve significant reductions in VAE rates To achieve significant improvements in safety culture utilizing the components of CUSP To advance the science of VAP prevention utilizing: - Updated VAP prevention bundle - Newest CDC NHSN VAP definition - Identification of contextual variables that foster/impede the implementation of QI projects 3

4. Key Concepts: Technical and Adaptive Work TECHNICAL WORKADAPTIVE WORK Procedural components of work, like elevating the head of bed and using subglottic suctioning endotracheal tubes (ETTs) The intangible components of work, like ensuring ICU team members speak up with concerns and hold each other accountable Work that lends itself to standardization (e.g., checklists and protocols) Work that shapes the attitudes, beliefs, and values of clinicians, so they consistently perform tasks the way they know they should Evidence-based interventionsLocal culture

5. Key concepts: Adaptive and Technical Work Combining Concepts Technical Work Adaptive Work 5

6. Why Safety Culture Matters? 1.Safety culture is related to outcomes –Patient outcomes Patient care experience Infection rates, sepsis Postop. hemorrhage, respiratory failure, accidental puncture/laceration Treatment errors –Clinician outcomes Incident reporting, burnout, turnover 6 Huang et al., 2010; Mardon et al., 2010; MacDavitt et al., 2007; Singer et al., 2009; Sorra et al., 2012; Weaver, 2011.

7. Why Safety Culture Matters? 2.Safety culture influences the effectiveness of other safety and quality interventions –Can enhance or inhibit effects of other interventions 3.Safety culture can change through intervention –Best evidence so far for culture interventions that use multiple components 7 Haynes et al., 2011; Morello et al., 2012; Van Nord et al., 2010; Weaver et al., in press

8. Adaptive Work We have introduced the following CUSP tools: - CUSP Components Science of Safety Learning from Defects Engaging Senior Executives & Leadership Daily Goals Culture Checkup Shadowing Daily Briefing Barrier identification and Mitigation 8

9. Technical Work Project just completed it’s 2 nd year of the implementation phase and now enters the sustainability phase During implementation we introduced the following VAP prevention measures to reduce VAE rates: - Process Measures - Early Mobility Measures - Low Tidal Volume Ventilation Measures 9

11. Project Resources VAP Prevention Toolkit and Resources –https://armstrongresearch.hopkinsmedicine.org/vap/vap/resourc es.aspxhttps://armstrongresearch.hopkinsmedicine.org/vap/vap/resourc es.aspx –Literature reviews, factsheets, data collection tools CUSP Toolkit and Resources –https://armstrongresearch.hopkinsmedicine.org/vap/cusp/resources.as pxhttps://armstrongresearch.hopkinsmedicine.org/vap/cusp/resources.as px –Tools and templates that can be adapted for local use Recordings and Slide Presentations for CUSP and VAP Webinars –https://armstrongresearch.hopkinsmedicine.org/vap/calls.aspxhttps://armstrongresearch.hopkinsmedicine.org/vap/calls.aspx –Slides can be modified for local use 11

12. MD and PA Teams Are Engaged: 2014 Team Participation Teams have presented their experiences on CUSP/VAP content/coaching calls: NPHS St. Joseph ICU and PICU Abington Memorial 3T1&2 and 3T3&4 Troy Hospital ICU St. Agnes ICU Magee Rehabilitation SCI Johns Hopkins Bayview MICU Teams have helped to pilot the Low Tidal Volume Ventilation Tool and provide feedback: Johns Hopkins Hospital WICU 12

13. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Reports: 2014 – A Year in Review

14. REPORTS These are report highlights from in 2014 on: i.Process Measure Compliance Rates ii.Process Measure Missing Data Report iii.VAE Rates iv.Structural Assessment v.Exposure Receipt Assessment vi.Implementation Assessment Interviews Your Unit’s full reports are available on: - CECity platform for VAE Rates, Structural Assessment, Exposure Receipt Assessment Reports https://armstrongresearch.hopkinsmedicine.org/Apps/11921/1141680/Project.aspx - MedConcert for Implementation Assessment Report https://www.medconcert.com/Network/12120/5D8E5AFE-CA11-4450-910A- 94141926733F/View.aspx 14

15. 15 Oct – Dec 2012Jan – Mar 2013Apr – Jun 2013Jul – Sept 2013Oct – Dec 2013Jan – Mar 2014Apr – Jun 2014 Quarter 1Quarter 2Quarter 3Quarter 4Quarter 5Quarter 6Quarter 7 Sub G ETT 24% (114/477) 30% (575/1888) 39% (704/1799) 37% (464/1261) 37% (297/806) 31% (228/728) 36% (173/475) HOB 96% (3692/3864) 97% (13870/14290) 98% (12747/13012) 99% (9589/9718) 99% (5718/5791) 99% (5562/5591) 97% (3788/3907) Oral Care 49% (1822/3724) 67% (9355/14064) 71% (8851/12541) 76% (6897/9097) 80% (4281/5382) 81% (4510/5580) 79% (3050/3883) CHG 72% (2541/3527) 81% (10635/13174) 86% (10183/11831) 85% (7163/8398) 89% (3971/4465) 90% (4180/4636) 88% (2827/3204) SAT 63% (1665/2626) 74% (6543/8794) 77% (6380/8324) 79% (4907/6239) 83% (3327/4010) 89% (3453/3878) 90% (2338/2590) SBT 66% (1837/2772) 67% (6218/9234) 74% (6036/8148) 71% (4155/5815) 74% (2615/3555) 82% (2594/3159) 83% (2008/2422) Network Months50136131119706156 Networks25504643282123 Data – July 30, 2014

16. 16 State Network Oct 2012Nov 2012Dec 2012Jan 2013Feb 2013Mar 2013Apr 2013May 2013Jun 2013Jul 2013Aug 2013Sep 2013Oct 2013Nov 2013Dec 2013Jan 2014Feb 2014Mar 2014Apr 2014May 2014Jun 2014Jul 2014Aug 2014Sep 2014Oct 2014Nov 2014Dec 2014Jan 2015 MDSibley Memorial Hospital - Intensive Care Unit -- 68%58%54%61%80%61%43%29%16%47%29%43%26%16%25%32%3% 0% MDAnne Arundel Medical Center - Critical Care Unit -- 0% MDBon Secours Baltimore Health System - ICU -- 67%77%65%39%81%80%90%100%84%74%93%94%87%84%71%57%29%60%74%77%71%97%100%97%93%94%0% MDDorchester General Hospital - ICU -- 0% MDHoly Cross Hospital - CCU -- 84%89%97% 100% 97%94%53%0% MDHoly Cross Hospital - ICU -- 71%86%87%80%81%100%94% 53%0% MDHoly Cross Hospital - SICU -- 7%0%6%96%94%83%81%87%81%77%83%0% 53%6%0% MDHoward County General Hospital - Intensive Care Unit -- 63%68%65%64%71%93%87%77%74%61%83%87%83%81%71%79%90%63%55%57%87%84%63%0% MDJohns Hopkins Bayview Medical Center - CICU -- 87%100%84%100% 90%100%90%100%27%0% MDJohns Hopkins Bayview Medical Center - MICU -- 83%55%100% 90%97%90%100%84%100%17%0% 20%0% 23%0% MDJohns Hopkins Hospital & Health System - CVSICU -- 33%45%100%89%87%100% 97%100% 90%53%52%48%57%39%53%26%53%29%32%33%23%0% MDJohns Hopkins Hospital & Health System - NCCU -- 67%3%10%43%10%0% 17%13%16%37%0% 29%35%0% MDJohns Hopkins Hospital & Health System - SICU -- 57%45%48%54%45%43%68%63%71%39%53%45%33%32%48%50%45%37%0%3% 0% 10%0% MDJohns Hopkins Hospital & Health System - WICU 6%73%84% 86%90%93%90%87%90%94%80%35%0% 7%10%0% 35%0% MDLaurel Regional Hospital - 4B Spellman Specialty -- 0%65%68%55%13%6%3%10%16%30%0% MDLaurel Regional Hospital - Intensive Care Unit -- 77%84%90%96%42%0% 19%100%0% MDMedStar Franklin Square Medical Center - ICU -- 10%46%23%0% MDMedStar St. Mary's Hospital - ICU -- 100% 23% 27%23% 0% MDMedStar Union Memorial Hospital - CCU 10%100% 97%100% 77%83%100% 50%100% 97%100% 0% MDMeritus Medical Center - 4 West Critical Care -- 6%100% 97%100% 97%61%0% MDPrince George's Hospital Center - ICU -- 100% 63%32%100% 29%0% MDSaint Agnes Hospital - AICU -- 100% 0% 23% 0% MDSinai Hospital of Baltimore - 4th Floor ICU -- 87%100% 93%100% 97% 100% 94%97%94%80%81%0% MDSuburban Hospital - ICU 3400 10%97% 96%100%80%87%100%97%100% 68%0%3%0% MDSuburban Hospital - ICUA 3100 10%87%6%81%100%42%30%77%43%97%94%97%23%0% MDUniversity of Maryland Medical Center - CCU -- 3%35%65%57%52%97% 87%39%35%87%0% 3% 0% MDWestern Maryland Health System - CVU -- 100% 87%100%97% 100% 97%100% 0% MDWestern Maryland Health System - ICU -- 90%96%94%97%94%93%68%84%83%94%87%94%87%89%90%97%90%83%87% 90%94%0% PAAbington Memorial Hospital - 3T1&2 -- 0%100% 93%100% 94%100%65%20%23% 27%26%23% 0% PAAbington Memorial Hospital - 3T3&4 -- 0% 93%97%93%100% 97%100%65%20%23% 0% PAAbington Memorial Hospital - MICU -- 0%96%97%80%100% 97%100% 65%20%23% 0% PAAbington Memorial Hospital - WPCU/1W -- 0%96%100%93%100% 90%100% 90%100%93%94%83%65%23%19%23% 0% PABrandywine Hospital - ICU -- 18%52%0% PADoylestown Hospital - ICU -- 3%32%35%10%0% 3%0%19%3%0% 40%45%47%55%100%0%100%0% PALower Bucks Hospital - ICU -- 100% 97%100% 87%100%0% PAMagee Rehabilitation - SCI -- 100%0%100% 39%100%84%93%94%100% 0% 100% 29%23% 0% 23% 0% PANPHS- St Josephs- ICU 65%100% 97% 100% 29%0% PANPHS- St Josephs- PICU 65%100% 27%100% 96%100% 94%100% 0% PATroy - ICU Med/surg -- 0% 65%63%68%80%100% 90%100%90%87%89%74%53%100%90%94%100% 55%0% VAP Process Measures – Missing Data Report Jan 8, 2015

17. VAE Rates: Aggregated MD & PA Jan 2013 - Jul 2014 17

18. VAE Rates: Aggregated MD & PA Jan 2013 - Jul 2014 18 Jan – Mar 2013 Apr – Jun 2013 Jul – Sept 2013 Oct – Dec 2013 Jan – Mar 2014 Apr – Jun 2014 July – Sept 2014 Quarter 1Quarter 2Quarter 3Quarter 4Quarter 5Quarter 6 Quarter 7 VAE Rate (per 1000 ventilator days) 6.14 (106/17274) 7.52 (136/18077) 7.95 (106/13327) 8.48 (110/12967) 7.82 (111/14195) 6.14 (72/11727) 5.65 (44/7789) Total IVAC Rate (per 1000 ventilator days) 2.03 (35/17274) 3.21 (58/18077) 3.3 (44/13327) 3.32 (43/12967) 2.32 (33/14195) 1.88 (22/11727) 1.67 (13/7789) Total VAP Rate (per 1000 ventilator days) 0.75 (13/17274) 1.44 (26/18077) 1.35 (18/13327) 1.39 (18/12967) 0.92 (13/14195) 0.6 (7/11727) 0.39 (3/7789) VAC Rate (per 1000 ventilator days) 4.11 (71/17274) 4.31 (78/18077) 4.65 (62/13327) 5.17 (67/12967) 5.49 (78/14195) 4.26 (50/11727) 3.98 (31/7789) IVAC Rate (per 1000 ventilator days) 1.27 (22/17274) 1.77 (32/18077) 1.95 (26/13327) 1.93 (25/12967) 1.41 (20/14195) 1.28 (15/11727) 1.28 (10/7789) Possible VAP Rate (per 1000 ventilator days) 0.69 (12/17274) 1.16 (21/18077) 0.98 (13/13327) 1.31 (17/12967) 0.85 (12/14195) 0.34 (4/11727) 0.39 (3/7789) Probable VAP Rate (per 1000 ventilator days) 0.06 (1/17274) 0.28 (5/18077) 0.38 (5/13327) 0.08 (1/12967) 0.07 (1/14195) 0.26 (3/11727) 0 (0/7789) Total Number of Unit- Months125146127104105 76 Total Number of Units50 4735 34

19. Structural Assessment Baseline vs. Jan. – June 2014 19 Helps teams track progress toward implementation of the recommended policies for VAP reduction on their unit Assessment completed by units lead semi-annually 2 administration cycles in 2014: Jan - Jun & Jul - Dec 4 administration cycles thus far Cycle 1: Jan - Jun 2013 (baseline) Cycle 2: Jun – Dec 2013 Cycle 3: Jan – Jun 2014 Cycle 4: Jun – Dec 2014 (closes Jan 15, 2015)

20. Structural Assessment: Baseline vs. Jan-Jun 2014 20 Distribution Baseline n=36Jan. – June 2014 n=18 MD21 units (58%)12 units (67%) PA15 units (42%) 6 units (33%) Results Reported Changed vent circuits regularly31%44% Changed suctioning systems regularly 60%44% Used orotracheal route85%90% Used closed suctioning system85%94% Have policies for standard precautions 97%100% Follow policy89%100%

21. Structural Assessment: Baseline vs. Jan-Jun 2014 21 Results Reported Baseline n=36Jan. – June 2014 n=18 Policies for hand hygiene prior to contact with resp. equip 91%100% Follow policy86%100% Use prophylactic antimicrobials14%11% Policies against non-essential suctioning 71%89% Follow policy17%72% Policy against supine position94% Follow policy17%78% Have policies against gastric over-distention 68%78% Follow policy100%89%

22. Structural Assessment: Baseline vs. Jan-Jun 2014 22 Results Reported Baseline n=36Jan. – June 2014 n=18 Policies for appropriate condensate draining 72%89% Follow policy42%33% Policies for promoting non- invasive ventilation 44%78% Follow policy57%61% Policy promoting use of early mobility 41%78% Follow policy33%61%

23. Exposure Receipt Assessment Mar-Jun 2014 & Oct-Dec 2014 23 Helps teams understand how well they are engaging front-line staff in the CUSP and VAP interventions Anonymous assessment completed by front-line staff with direct patient care on the unit during one shift 2 administration cycles in 2014 Cycle 1: Mar – Jun 2014 Cycle 2: Oct - Dec 2014 Results divided into 4 domains: 1.Response Rate on Assessment 2.Distribution of Participants 3.CUSP Components 4.VAP Components Reports available here at the end of January: https://armstrongresearch.hopkinsmedicine.org/Apps/11921/1141680/Project.a spx https://armstrongresearch.hopkinsmedicine.org/Apps/11921/1141680/Project.a spx

24. Exposure Receipt Assessment Compliance Cycle 2: Oct-Dec 2014 24 Maryland and Pennsylvania ERA Cycle 2 176 observations in total from both Maryland and Pennsylvania 123 observations come from MD 53 come from PA 12 units Exposure Receipt Reports unit- level reports will be available on the CECity Platform at the end of January

25. Exposure Receipt Assessment: Training on VAP Prevention Toolkit Mar-Jun 2014 & Oct-Dec 2014 25 Percentage

26. Exposure Receipt Assessment: Familiarity with CUSP Components Mar-Jun 2014 & Oct-Dec 2014 26

27. Exposure Receipt Assessment: Know Unit’s VAE Rate Mar-Jun 2014 & Oct-Dec 2014 27

28. 28 Evaluates the implementation of the CUSP components and VAP interventions on the unit Measures implementation components and contextual factors that presents barriers to progress on your units 4 administration cycles thus far: Interview Cycle 1: Feb - Jun 2013 Interview Cycle 2: Sept – Dec 2013 Interview Cycle 3: Apr – Aug 2014 Interview Cycle 4: Oct – Dec 2014 (results available soon) Results divided into 4 domains: 1.Number of safety training actions taken 2.Leadership support 3.CUSP tools used 4.Barriers to progress Implementation Assessment Interviews

29. Implementation Assessment Interviews: Number of Patient Safety Training Actions Taken (Q3 May-Jul 2014) 29

30. Implementation Assessment Interviews: Number of Leadership Support Actions Taken (Q3 May-Jul 2014) 30

31. Implementation Assessment Interviews: Number of CUSP Tools Used (Q3 May-Jul 2014) 31

32. Implementation Assessment Interviews: Frequent Barriers to Progress (Q3 May-Jul 2014) 32

33. REPORTS SUMMARY 2014 Highlights from of several assessments –Including VAE Rates, Structural Assessment, Exposure Receipt Assessment, Your Unit’s reports are available on –CECity platform for VAE Rates, Structural Assessment, Exposure Receipt Assessment Reports https://armstrongresearch.hopkinsmedicine.org/Apps/11921/1141680/Project.aspx - MedConcert for Implementation Assessment Report https://www.medconcert.com/Network/12120/5D8E5AFE-CA11-4450-910A- 94141926733F/View.aspx Reports can be utilized for -Increasing communication with your team members and front-line staff -Illustrating your unit’s progress to your senior executive partner -Sharing your performance and progress on VAE prevention with your hospital administrators -Supporting / sustaining your CUSP and VAP improvement efforts 33

34. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Next Steps

35. Complete one more round of Assessments to show your unit’s improvement trend over time (Aug - Nov 2015) Exposure Receipt Assessment Structural Assessment HSOPS Implementation Assessment Interview Collect Process Measure Data (30 mechanically ventilated patient days per quarter for 4 quarters in 2015) Collect Early Mobility and Low Tidal Volume Ventilation data as you are able to per the data collection sampling strategy Link to data collection sampling strategy: https://armstrongresearch.hopkinsmedicine.org/vap/calls.aspx https://armstrongresearch.hopkinsmedicine.org/vap/calls.aspx 35

36. Data Collection Sampling Strategy 36 Focus on VAP Daily Rounding Process Measure Data Collection This will quantifiably measure your improvement efforts during this collaborative This will illustrate your hard work over the past 2 years to your staff and executive leaders Webinar data training date options will be available and emailed to you Link to 7 minute online VAP Daily Rounding Process Measure Data Collection training video: https://www.youtube.com/watch?v=x-0n5_JpUlE https://www.youtube.com/watch?v=x-0n5_JpUlE

37. Enhancing Support for MD and PA Teams Objective Outcome Data –Duration of ventilation, hospital length of stay, mortality –Supports the business case for resources –Link to enter data on CECity: https://armstrongresearch.hopkinsmedicine.org/Apps/11921/1 141680/Project.aspx https://armstrongresearch.hopkinsmedicine.org/Apps/11921/1 141680/Project.aspx Armstrong will analyze your data for outcome measures if helpful Sustaining and spreading CUSP for VAP work What can the AI/MHA/HAP team do to better support you during sustainability 37

38. CUSP4MVP-VAP: MD and PA Opportunities MD and PA opportunities with National Project - Joining National Project content calls for continued education on CUSP and VAE prevention - Share your experience on content/coaching calls: as implementation experts to discuss implementation successes and barriers 38

39. CUSP4MVP-VAP: Cohort 2 Call Schedule Date: 3 rd Wednesday of every month Call Type: Content Webinar Time: 11am-12:30pm EST For call-in information and webinar link go here and select “Cohort 2 webinar call and log- in information”: https://armstrongresea rch.hopkinsmedicine.o rg/cusp4mvp/schedule s.aspx 39

40. Additional Resources SCCM PAD Guidelines –http://www.learnicu.org/SiteCollectionDocuments/Pain,%20A gitation,%20Delirium.pdfhttp://www.learnicu.org/SiteCollectionDocuments/Pain,%20A gitation,%20Delirium.pdf SHEA Strategies to Prevent VAP –http://www.shea- online.org/PriorityTopics/CompendiumofStrategiestoPr eventHAIs.aspxhttp://www.shea- online.org/PriorityTopics/CompendiumofStrategiestoPr eventHAIs.aspx Society for Critical Care Medicine ICU Liberation Group –http://www.iculiberation.org/Pages/default.aspxhttp://www.iculiberation.org/Pages/default.aspx Armstrong Institute Training Opportunities –http://www.hopkinsmedicine.org/armstrong_institute/tra ining_services/cusp_offerings/http://www.hopkinsmedicine.org/armstrong_institute/tra ining_services/cusp_offerings/ 40

41. Questions

42. 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! 42