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Sean Berenholtz, MD MHS FCCM September 20, 2011 at 2ET/1 CT/12 MT/11 PT

Sean Berenholtz, MD MHS FCCM September 20, 2011 at 2ET/1 CT/12 MT/11 PT. CLABSI Supplemental Call Series. Ventilator Associated Pneumonia Prevention. Your Feedback is Important. https://www.surveymonkey.com/s/Z6FJ28T. Learning Objectives.

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Sean Berenholtz, MD MHS FCCM September 20, 2011 at 2ET/1 CT/12 MT/11 PT

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  1. Sean Berenholtz, MD MHS FCCMSeptember 20, 2011 at 2ET/1 CT/12 MT/11 PT CLABSI Supplemental Call Series Ventilator Associated Pneumonia Prevention

  2. Your Feedback is Important https://www.surveymonkey.com/s/Z6FJ28T

  3. Learning Objectives • To describe the morbidity and mortality associated with Ventilator Associated Pneumonia • To understand the framework used to achieve substantial and sustained reductions in VAP as part of the Michigan Keystone ICU program • To outline next steps towards implementing VAP prevention efforts

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

  5. Healthcare Associated Pneumonia Prevention • CDC/HICPAC: Guidelines for the Prevention of Healthcare Associated Pneumonia; 2004. • Canadian Critical Care Trials Group1: Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Prevention. Journal of Critical Care; 2008. • SHEA/IDSA: Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals; 2008.

  6. How Can These Errors Happen? • People are fallible • Medicine is still treated as an art, not science • Need to view the delivery of healthcare as a science • Need systems that catch mistakes before they reach the patient

  7. To Improve Reliability • Standardize what is done, when it is done • Reduce complexity • Create independent checks for key processes • How often do we do what we should • Learn from defects • How often do we learn from defects Health Services Research 2006; Circulation 2009;119:330-337.

  8. Improving Care for Ventilated Patients • Semirecumbant positioning • Peptic ulcer disease and DVT prophylaxis • Appropriate sedation • Daily assessment of readiness to extubate • Oral care with antiseptics • Minimize contamination of equipment

  9. Translating Evidence into Practice Pronovost, Berenholtz, Needham. BMJ 2008

  10. Improving Care for Ventilated Patients • Engage • Partner with infection preventionists, • Post performance, • Tell stories of harm • Educate • Reviewed evidence on conference calls, • One-page fact sheets, • Slides for teams

  11. Improving Care for Ventilated Patients • Decrease complexity / create redundancy • Standardized order sets and protocols • Daily goals checklist • Other independent redundancies • Nursing and families • Are patients receiving the prevention they should?

  12. Sample Daily Goals J Crit Care 2003;18(2):71-75

  13. Improving Care for Ventilated Patients Evaluate • VAP • Standardized CDC NHSN definitions for VAP • VAP definition varies; Did not change definition • Ventilator Bundle Process Measures • Collected by the ICU teams; daily cross-sectional sample • Standardized definitions and data collection forms • Limited number of trained data collectors • After first quarter of daily data collection, teams were allowed to collect process measures one to two days/week (min of 15 vent pts/mo) to minimize burden.

  14. Results • 124 of 127 ICUs submitted VAP data • 12 ICUs started after funding ended • 112 ICUs, 72 hospitals included in analysis • 3228 ICU months and 550,800 vent days • 10% quarters without complete data • 4% missing data; 6% stopped submitting data • Sensitivity analysis yielded similar results • Results reported through 28-30 months post-implementation

  15. Michigan Keystone ICU Infect Control Hosp Epidemiol. 2011;32(4):305-314.

  16. Michigan Keystone ICU (n= Infect Control Hosp Epidemiol. 2011;32(4):305-314.

  17. Limitations • Lack of concurrent control group • Temporal changes, other interventions • Did not evaluate accuracy of VAP diagnosis • All hospitals reported using CDC definitions • Used existing hospital infrastructure • Can not evaluate importance of individual therapies in ventilator bundle • Can not evaluate importance of other intervention • Focus on ventilator care vs VAP prevention

  18. Strengths • Largest cohort to date • Significant and sustained VAP reductions • Focus on system of care • Engagement of local interdisciplinary teams to assume ownership • Centralized support for technical work • Local adaptation of intervention • Culture improvement and social networking among ICUs

  19. Summary • VAP is most lethal HAI; majority are preventable • Effective interventions to prevent VAP are known; patients are not receiving the care they should • Focus on systems to ensure patients receive the therapies they ought to

  20. Next Steps • Keystone ICU VAP project focused on ‘Ventilator Bundle’ • Developing ‘VAP prevention bundle’ • Funded by NIH/NHLBI • Delphi process led by RAND researcher

  21. European Care Bundle for VAP Prevention Intensive Care Med 2010;36:773-780

  22. Your Feedback is Important https://www.surveymonkey.com/s/Z6FJ28T

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