How to Improve Patient Outcomes after Mechanical Ventilation

1. How to Improve Patient Outcomes after Mechanical Ventilation Essential Hospitals Engagement Network October 1, 2013

2. Our new Name We’ve rebranded! The National Association of Public Hospitals and Health Systems is now America’s Essential Hospitals. Although we’ve changed our name, our mission is the same: to champion hospitals and health systems that provide the highest quality of service to all by achieving the best health outcomes for every patient, especially those in greatest need. The new name underscores our members’ continuing public commitment and the essential nature of our work to care for the most vulnerable and provide vital community services, such as trauma care and disaster response. This is an exciting time for us and our members, as we lean forward into new care models, opportunities and challenges of reform, and quality and safety innovations that often take root in our member systems. Our new website address: www.EssentialHospitals.org

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5. Speaker information Michele C. Balas, PhD, RN, APRN-NP, CCRN Associate Professor Center of Excellence in Critical and Complex Care The Ohio State University College of Nursing Alex Ramos, RN, MSN, CCRN Trauma Operations Manager Sandra Gonzalez RN, BSN Director of Trauma, Neurosurgery and Adult Med/Surg Critical Care Services Dustin Bierman, RN, MSN ICU Med/Surg Clinical Coordinator Luis Martinez, RN, BSN ICU Med/Surg Manager ABCDE Team University Medical Center of El Paso John Young, RN, MBA Improvement Coach EHEN

6. Agenda • VAP work in EHEN and Partnership for Patients • The ABCDE bundle - Michele C. Balas, PhD, RN, APRN-NP, CCRN • An EHEN hospital’s story- UMC El Paso ABCDE team • Q & A • Wrap-up and announcements

7. EHEN Vap Results (as of May, 2013) Summary UHC-Defined VAP Outcome Numerator: Adult discharges (age ≥ 18) with an ICU stay ≥ 1 day on an invasive mechanical ventilator (ICD-9-CM code 96.70-96.72). Inclusions: Diagnosis code = 997.31, POA=N,U; Denominator: Adult discharges (age ≥ 18) with an ICU stay ≥ 1 day on an invasive mechanical ventilator (ICD-9-CM code 96.70-96.72).

8. Improving Patient-Centered Outcomes in the ICU: The ABCDE Bundle Michele C. Balas PhD, RN, APRN-NP,CCRN Associate Professor, The Ohio State University College of Nursing, Center for Critical & Complex Care Adjunct Professor , University of Nebraska Medical Center College of Nursing, Department of Community Based Health

9. Disclosures Dr. Balas is currently a Co-investigator on a grant supported by the Alzheimer’s Association and has received honoraria from ProCe, the France Foundation, Hospira, &Hillrom. Images courtesy of Nancy Adams-http://www.nancyandrews.net Research supported by RWJF-INQRI For references regarding outcomes of delirium in the ICU setting and the ABCDE bundle please see: www.icudelirium.org

10. The Issues-ICU Acquired Delirium & Weakness • Profound & emerging public health threat • Common • Lethal • Disabling • Persistent

11. The Issues-ICU Acquired Delirium & Weakness Delirium Weakness 25-50% of patients who receive MV for 4-7 days 50-75% sepsis patients 80-95% of patients with ICU-AW have neuromuscular abnormalities 2-5 YEARS after hospital discharge 70% of MV patients have difficulty with ADLs 1 year after discharge • 33% Emergency Room • 14-56% Medical/Surgical Units • 20-50% Non-Mechanically Ventilated-ICU • 50-80% Surgical/Trauma/ Burn ICU • 70-87% Mechanically Ventilated-ICU

12. DELIRIUM AN INDEPENDENT PREDICTOR OF MORTALITY • ICU & hospital • Mortality rates ranging from 22-76% • 6-month* • (3 fold ↑ risk) • 1 year • Each day delirious ↑ 10% mortality!!!!!! Lin (CCM, 2004); Inouye (NEJM, 2006); *Ely (JAMA, 2009); Pisani (AJRCC, 2009)

13. Outcomes Associated With Delirium • ICU & hospital LOS • ↑ restraints & sedation • Poor functional recovery • New institutionalization • Multiple complications • Total 1-year US health-care costs $38-152 billion dollars

14. 60 p=.03 50 40 30 Cognitive Function at 12 months (predicted mean T-score) 20 10 0 0 5 10 15 20 Delirium Days Delirium & New Onset Cognitive Impairment • ½ of all ICU survivors experience long-term cognitive impairment • Persistent • Associated with delirium duration • Older patients without dementia hospitalized for a non-critical illness have a 40% higher risk of dementia • Jackson et al., Anesthesiology Clinics, 2011; Ehlenbach, Jama, 2010

15. Other Outcomes Associated with Critical Care • 10-50% of all ICU survivors experience • PTSD • Depression • Anxiety • Sleep disorders • Need for caregiver assistance

16. Patient Experience “On Sunday, I was on the ICU, where a horror ceremony like in a concentration camp was going on. Four patients were executed. Laying in their beds, they received a death pill. I was one of them…The hangman gave us the pill, with a blank face. In the background were two ladies waiting to carry away our dead bodies…The torturers watched us all the time, they asked us: “Do you feel anything yet? How does your foot feel? How does your arm feel?”… The children of Satan were in command. They were dressed in green coats and had scary faces. They were waiting for our death. … Worst was, that I did not try to resist. How can a man throw away his life like that? Why me? Did they do a mistake during the surgery and try to cover it up by killing all of us? … The pills did not work. I did not die. So they tried it again with gas, pressing a mask on my face. …"-Male, 67 years old.

17. Precipitating Factors for ICU Acquired Delirium & Weakness Potentially Modifiable • Sedative Medications • Mechanical Ventilation • Immobility/prolonged bed rest • Uncontrolled pain • Sleep deprivation Non-Modifiable • Age • Severity of illness • Comorbidities • Pre-existing CI/dementia • Drug/ETOH withdrawal

19. Potential Solution-ABCDE Bundle • Awakening • Breathing • Coordination/Choice of sedation • Delirium monitoring/ management • Early exercise/mobility

20. What Does the Evidence Tell Us?AwakeningKress et al. (2000) NEJM • Pro-RCT, 128 MV, MICU • Treatment group-CI sedatives stopped 1Xday • (restarted at ½ rate if needed) • SS reduction in • MV days 4.9 vs. 7.3 • ICU LOS 6.4 vs. 9.9

21. What Does the Evidence Tell Us?Awakening • Kress et al. (2000) NEJM • Fewer diagnostic tests • No difference in • Complications • Mortality • Hospital LOS • Kress et al. (2003) AJRCCM • 32 patients 6 month FU • Results • Fewer symptoms PTSD 11.2 vs. 27.3 (p=0.02) • Lower incidence of PTSD 0 vs. 32 (p=0.06) • Better psychosocial adjustment to illness

22. What Does the Evidence Tell Us?Awakening • Weinert et al. (2007) CCM • 85% of 18,050 evals had sedation (N=274) • 1 in 3 unarousable (32%) • 1 in 5 no spontaneous motor activity (21%) • Only 2.6% of providers thought patients were “over-sedated”!!!!!!

23. What Does the Evidence Tell Us?Breathing • Spontaneous Breathing Trials (Ely et al. 1996 NEJM) • RCT, single center, N=300 • Respiratory care-driven weaning protocol using SBTs found to lead to statistically significant improvements • MV days 3 vs. 4.5 (p=0.003) • Reintubation 6 vs. 15 (p=0.04) • MV >21 days 9 vs. 20 (p=0.04) • ICU cost 15,740 vs. 20,890 (p=0.03)

24. What Does the Evidence Tell Us?Awakening & Breathing Coordination • Multicenter, RCT (N=336) • Intervention group protocolized SATs & SBTs; control group daily SBTs & “usual care” sedation • Results • Survival at 1 yr. 58% vs. 44% p=0.01

25. What Does the Evidence Tell Us?Awakening & Breathing Coordination Girard et al. (2008) Lancet Stat. Significant Results… • 32% less likely to die • NNT-7 to save a life at 1 year • VFDs (3 days) • Successful extubation (7 vs. 5) • ICU & hospital LOS (4 days) • Coma (1 day) • Self-extubation (3 vs. 5) No difference in…. • Self extubation with reintubation • Total re-intubations • Delirium • Tracheostomy • Long-term cognitive & psych. outcomes (Jackson et al.)

26. What Does the Evidence Tell Us?Choice of Sedation • Analgosedation(StrømT, et al. Lancet. 2010;375:475-480) • 140 critically ill adult patients undergoing MV in single center • Randomized, open-label trial • Both groups received bolus morphine (2.5 or 5 mg) • Group 1: No sedation (n = 70 patients) - morphine prn • Group 2: Sedation (20 mg/mL propofol for 48 h, 1 mg/mL midazolam thereafter) with daily interruption until awake (n = 70, control group)

27. What Does the Evidence Tell Us?Choice of Sedation • Patients receiving no sedation had • More days without MV (13.8 vs 9.6 days, P = 0.02) • Shorter stay in ICU (HR 1.86, P = 0.03) • Shorter stay in hospital (HR 3.57, P = 0.004) • More agitated delirium (N = 11, 20% vs N = 4, 7%, P = 0.04) • No differences found in • Accidental extubations • Need for CT or MRI • Ventilator-associated pneumonia

28. What Does the Evidence Tell Us?Choice of Sedation • 2013 SCCM Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU • Regular PAD screening using valid & reliable tools • Role of preemptive analgesia/importance of effectively managing pain • Maintaining light levels of sedation (DSI vs. light target level) • Nonbenzodiazepine sedative strategies • Potential role of Dexmedetomidine (MV at risk for delirium) • No prophylactic haloperidol or atypical antipsychotics • Atypical antipsychotics may reduce duration of delirium

29. What Does the Evidence Tell Us? Delirium Monitoring/Management Morandi A, et al. Intensive Care Med. 2008;34:1907-1915. • CAM-ICU • ICDSC

30. What Does the Evidence Tell Us?Early Exercise/Mobility Schweickert WD, et al. Lancet. 2009;373(9678):1874-1882. Early PT and OT in Mechanically Ventilated ICU Patients

31. ABCDE Bundle Steps • ABCDE bundle is multicomponent, interdependent, &designed to: • Improve clinical team collaboration • Standardize care processes • Break the cycle of oversedation &prolonged mechanical ventilation • Opt-out method • Safety screen & self-guided ABCE’s

32. Awakening

33. Breathing SBT Failure Criteria • Respiratory rate > 35/min • Respiratory rate < 8/min • Oxygen saturation < 88% • Respiratory distress • Mental status change • Acute cardiac arrhythmia SBT Safety Screen • No agitation • Oxygen saturation ≥ 88% • FiO2 ≤ 50% • PEEP ≤ 7.5 cm H2O • No myocardial ischemia • No vasopressor use • Inspiratory efforts

34. Early Mobility Safety Screen Patient responds to verbal stimulation (ie, RASS -3)* FIO2 ≤ 0.6 PEEP≤ 10 cmH2O No  dose of any vasopressor infusion for at least 2 hours No evidence of active myocardial ischemia (24 hrs) No arrhythmia requiring the administration of new antiarrhythmic agent (24 hrs)

35. Early Mobility Progression Walking A Short Distance Standing at bedsideand sitting in chair Sitting on edge of bed

36. Delirium Monitoring/Management • Routine Sedation & Delirium Assessment Using Standardized, Validated Assessment Tools • RN administers & records RASS/SAS results q2h • Team sets “target” RASS/SAS score for the patient to be maintained at for the following 24 hours • RN administers & records results of the CAM-ICU/ICDSC q8h & whenever a patient experiences a change in mental status

37. Delirium Monitoring/Management • Each day during interdisciplinary rounds, the RN will: • State the “TARGET” sedation score • State the patient’s ACTUALsedation score • State the patient’s delirium status • State the sedative/analgesic medications the patient is currently receiving • Each day during interdisciplinary rounds, the team will use the acronym “THINK” if a patient is CAM positive (delirious) • The interdisciplinary team will employ the following non-pharmacologic interventions when treating a delirious patient: • Eliminate or minimize risk factors • Provide a therapeutic environment

38. Delirium Monitoring/Management • USE MEDICATIONS ONLY IF ABSOLUTELY NECESSARY! • Give “PEACE” a chance • Physiologic • Environmental • ADLs/Sleep • Communication • Education

39. So Easy-What Could Possibly Go Wrong? 1. Mehta S, et al. Crit Care Med. 2006;34:374-380. 2. Devlin J. Crit Care Med. 2006;34:556-557. 3. Martin J, et al. Crit Care. 2007;11:R124. 4. Payen JF, et al. Anesthesiology. 2007;106:687-695. • Canada – 40% get SATs (273 physicians in 2005)1 • US – 40% get SATs (2004-05)2 • Germany – 34% get SATs (214 ICUs in 2006)3 • France – 40–50% deeply sedated with 90% on continuous infusion of sedative/opiate4

40. Barriers to Daily Sedation Interruption (Survey of 904 SCCM members) Increased device removal Poor nursing acceptance Compromises patient comfort Leads to respiratory compromise Difficult to coordinate with nurse No benefit #1 Barrier Leads to cardiac ischemia #2 Barrier #3 Barrier Leads to PTSD 0 10 20 30 40 50 60 70 Number of respondents (%) Clinicians preferring propofol were more likely use daily interruption than those preferring benzodiazepines (55% vs 40%, P < 0.0001) Tanios MA, et al. J Crit Care. 2009;24:66-73.

41. Implementation Challenges • Facilitators: • Daily interdisciplinary rounds • Engagement of key implementation leaders • Sustained, diverse educational efforts • Bundle’s quality and strength • Barriers: • Intervention-related issues (e.g., timing of trials, fear of adverse events) • Communication and care coordination challenges • Knowledge deficits • Workload concerns • Documentation burden

42. Implementation Challenges Structural characteristics of the ICU Organization-wide patient safety culture ICU culture of quality improvement Implementation planning, training/support Prompts/documentation Excessive turnover (both in project and ICU leadership) Staff morale issues Lack of respect between disciplines Knowledge deficits Excessive use of registry staff

43. Is it Worth It?Absolutely

44. Q & A

45. University medical center of el paso

46. Implementation Challenges • Facilitators: • Daily interdisciplinary rounds • Engagement of key implementation leaders • Sustained, diverse educational efforts • Bundle’s quality and strength • Barriers: • Intervention-related issues (e.g., timing of trials, fear of adverse events) • Communication and care coordination challenges • Knowledge deficits • Workload concerns • Documentation burden

47. Q & A

48. The patient’s voice Dr. Needham: “What did you think when we discussed getting you out of bed while on a ventilator with a breathing tube in your mouth?” Mr. E:”I thought it was wonderful. Anything to get me up and moving, and get me out of bed; anything to get me off my back and on my feet - that is what I really wanted.” Dr. Needham: “How did it feel to be awake, with the breathing tube in your mouth, on a ventilator, and walking laps around the medical intensive care unit?” Mr. E: “It was wonderful. It was nice to get up and walk around. It was not uncomfortable. I enjoyed it. I think it had a very positive effect on me.” Needham DM. Mobilizing patients in the intensive care unit: Improving neuromuscular weakness and physical function. JAMA. 2008 October. 300(14). 1685-1690.

49. Thank you for attending! • Equity Webinar – October 10 @ 2pm ET Building Health Literacy: Essential Steps and Practical Solutions Speakers: • Dean Schillinger MD, Director, Health Communication Program, UCSF Center for Vulnerable Populations • Michele Edwards , NP Grady Heart Failure Clinic • Evaluation: When you close out of WebEx following the webinar a yellow evaluation will open in your browser. Please take a moment to complete. We greatly appreciate your feedback! • Essential Hospitals Engagement Network website: http://tc.nphhi.org/Collaborate