Every Patient ★ Every Day

1. Every Patient ★ Every Day The CDC Epicenters’ Wake Up and Breathe Collaborative Michael Klompas MD, MPH Brigham and Women’s Hospital, Boston, USA March 18, 2014 CUSP for Mechanical Ventilation

2. Disclosures • Honoraria from Premier Healthcare Alliance for lectures on VAE surveillance

3. Critical Care Medicine 2013;41:2467-2475

4. Ventilator-associated conditions (VAC) Worsening ventilator settings after a period of stable or improving ventilator settings VAC

5. Attributable Mortality of VAC vs VAP PLoS ONE 2011;6: e18062 Crit Care Med 2012;40:3154-3161 Chest 2013;144:1453-1460 Am J RespCrit Care Med 2014; ePub ahead of print

6. Presumptive analysis of 147 VACsRoyal Brisbane & Women’s Hospital, Queensland, Australia Abx + Furosemide 6% Pneumonia 38% Edema 26% Atelectasis 15% Other 8% ARDS 6% Hayashi et al. Clin Infect Dis 2013;56:471-477

7. VAC = VAP + CHF + ARDS + Atelectasis + Others

8. Ventilator-associated event surveillanceA patient safety opportunity • Broaden Awareness • VAE surveillance provides hospitals with a fuller picture of patients suffering complications of mechanically ventilation • Catalyze Prevention • A significant portion of VAEs are likely preventable • Reflect and Inform Progress • VAE surveillance provides an efficient and objective yardstick to track one’s progress relative to oneself and to peers N Engl J Med 2013;368:1472

9. Zero VAC • How do we get there? http://www.macrobert.org/assets/images/Film/May%202013/WizardOfOz_214Pyxurz.jpg

10. Selecting an Intervention • Since VAEs are a global measure of serious complications in ventilated patients, the most logical way to prevent VAEs is to shorten the duration of mechanical ventilation • The most powerful and consistent strategy to speed liberation from mechanical ventilation is minimizing sedation and regularly testing readiness to extubate • Paired daily spontaneous awakening and breathing trials associated with 2-4 day decrease in ventilator days

11. The CDC Prevention Epicenters’Wake Up and BreatheCollaborative

12. Participants • 12 ICUs from 7 hospitals • Stroger Cook County Hospital • Missouri Baptist Medical Center • Duke University • Durham VA • Durham Regional Hospital • North Shore Union Hospital • North Shore Salem Hospital

13. The CDC Prevention Epicenters’Wake Up and Breathe Collaborative • Goal: prevent VAEs through less sedation and earlier liberation from mechanical ventilation • Mechanism: paired daily spontaneous awakening trials and breathing trials (SATs and SBTs)

14. Strategies • Opt-out protocol for paired daily SATs and SBTs • RNs and RTs initiate SATs/SBTs rather than MDs • Automatic for all patients unless MD actively “opts out” • Protocol developed by national experts • Narrow set of well-defined contraindications • CUSP 4MVP protocol is nearly identical • Multicenter learning collaborative to aid implementation

15. Collaborative Components • All Teach – All Learn Model • Each unit designated RN, RT, and MD champions • Two in-person meetings at CDC for all champions • Kick-off meeting to orient, educate, and motivate • Interim meeting to consolidate and re-motivate • Monthly written reports from all ICUs • Progress, challenges, successes, and failures • Goals for the forthcoming month • Monthly collaborative phone calls for all champions • Monthly data feedback of local and comparative SAT/SBT rates + outcomes • Expert advice from CDC and Institute for Healthcare Improvement • Consulting faculty: Wes Ely, Michele Balas, Terry Clemmer, John Jernigan, Shelley Magill, Ronda Sinkowitz-Cochran

16. Sample extract from a monthly report

17. Sample unit-specific monthly summary report

18. Results coming soon!

19. Lessons Learned • Get the right people on the bus • Educate, educate, and re-educate • The spirit of the law matters more than the letter of the law • Assess performance not just documentation • It’s a marathon not a sprint • Choose the denominator that fits the intervention • Wake Up and Breathe is a great start … but more we can do

20. Night Staff Get the right people on the bus Frontline Nurses Chief QualityOfficer Chief Nursing Officer MD Champion ICU NursingDirector RT Champion No VACs Frontline RTs Chief Medical Officer ICU Medical Director RN Champion Night Staff Head of Respiratory Therapy Day Staff Local Opinion Leaders Frontline Doctors Unit Clerk Pharmacists Image from http://www.kerrvilleisd.net/files/bus_cartoon_tilt.gif

21. Educate, educate, & re-educate • Never assume that everyone knows about the protocol • Never assume that everyone understands the protocol • Never assume everyone agrees with the protocol • Use both formal and informal teaching methods • In-services, postings, articles, lectures • Ask colleagues for their impressions, seek hallway discussions, bring it up at morning rounds

22. The Spirit of the Law Matters More than the Letter of the Law • Our goal is not to perform SATs per se but to minimize the use of sedatives and speed extubation • SATs and SBTs are a means, not an end

23. “Conclusion: For mechanically ventilated adults managed with protocolized sedation, the addition of daily sedation interruption did not reduce the duration of mechanicalventilation or ICU stay.” Mehta et al. JAMA 2012;308(19):1985-92

24. Midazolam Equivalents

25. Assess Performance as well as Documentation

26. Assess Performance as well as Documentation

27. It’s a marathon not a sprint Image from http://media.mediapost.com/images/inline_image/2012/01/27/Boston-Marathon-B.jpg

28. SAT Performance, ICU X, June 2012 – March 2013

29. SAT Performance, ICU Y, June 2012 – March 2013

30. Chose a denominator that fits the intervention • The traditional metric for hospital-acquired infections is infections per 1000 device-days or patient days • What if your intervention, however, is specifically designed to reduce device days?

31. Absolute Counts: VACs

32. Absolute Counts: VACs and Vent Days

33. VACs per 1000 Ventilator Days vsVACs per 100 Episodes of Mechanical Ventilation

34. VACs per 1000 Ventilator Days vsVACs per 100 Episodes of Mechanical Ventilation

35. Wake Up and Breathe:A great start but more we can do… Target the primary conditions associated with VAC Decrease duration of mechanical ventilation

36. Wake Up and Breathe:A great start but more we can do… Early mobility ETT with subglottic suction Low tidal volume ventilation Target the primary conditions associated with VAC Decrease duration of mechanical ventilation

37. Enhanced prevention of VAEs Strong evidence from RCTs and/or meta-analyses Probable but not proven

38. Early mobility – Wake Up & Walk! • Increasing evidence that early mobilization speeds extubation and decreases ICU length of stay • May also help prevent atelectasis & delirium • As with improved sedative management and weaning protocols, less time on vent means less time at risk for VACs Balas et al. Crit Care Med 2014;ePub Lord et al., Crit Care Med 2013;41:717 Schweickert et al., Lancet 2009;373:1874 Needham et al., Arch Phys Med Rehabil2010;91:536 http://69.36.35.38/images/CHESTPhysician/CritCareCom0610Fig2.jpg

39. Subglottic secretion drainage Meta-analysis of 13 studies of subglottic secretion drainage 45% reduction in VAP risk. Decrease in mean vent LOS by 1.1 days and ICU LOS by 1.5 days (Caveat: most studies only enrolled patients expected to be on vent for >48-72 hours) Hi-Lo® Evac tube (Mallinckrodt® Medical) Crit Care Med 2011;39:1985-1991

40. Low tidal volume ventilation • Higher tidal volumes associated with ARDS • RCT data showing lower tidal volumes protect against acute lung injury in patients without ARDS and lower mortality rates in patients with ARDS • Meta-analysis of 20 studies found lower rates of ARDS, pneumonia, and mortality in patients without ARDS SerpaNeto, JAMA 2012;308:1651 Determann, Critical care2010;14(1):R1 ARDSnet, NEJM 2000;342:1301-1308 http://page2anesthesiology.org/2012/less-rather-than-more-volume-is-better-when-ventilating-patients-after-cardiac-surgery/

41. Summary • Get the right people on the bus • Educate, educate, and re-educate • The spirit of the law matters more than the letter of the law • Assess performance not just documentation • It’s a marathon not a sprint • Choose the denominator that fits the intervention • Wake Up and Breathe is a great start … but more we can do • Early mobility • Endotracheal tubes with subglottic secretion drainage • Low tidal volume ventilation

42. Thank You! All RN, RT, and MD Champions and Frontline Providers • Dev Anderson • Ellen Arrington • Hilary Babcock • Michele Balas • Rosie Banks • Christina Bruce • Terry Clemmer • Chris Cox • Wes Ely • Vicky Fraser • Scott Fridkin • Tim Girard • Don Goldmann • Kareema Hunter • John Jernigan • MeetaKerlin-Prasad • Barry Kitch • Ken Kleinman • Julie Lankiewicz • Ebb Lautenbach • Lingling Li • Shelley Magill • Kelly McCutcheon-Adams • Michael Murphy • Carrie O’Neil • Rich Platt • Dan Sexton • Ronda Sinkowitz-Cochran • ManjuSrinivasan • William Trick • Bob Weinstein • Tiffanee Woodard • Michael Klompas (mklompas@partners.org)

43. CUSP4MVP-VAP Data CollectionSedation and Delirium • Percentage of RASS/SAS actual being {-1, 0, 1} or {4, 5} • Percentage of achieving RASS/SAS target • Distribution of RASS/SAS actual scores • Delirium assessment compliance rate • Percentage of incorrectly reporting CAM-ICU/ASE UTA (higher is worse) • Percentage of CAM-ICU negative or ASE <=2 (no delirium)

44. CUSP4MVP-VAP Data CollectionSAT/SBT (1) SAT compliance rate (2) SBT compliance rate (3) SAT contraindication rate (4) SBT contraindication rate (5) Percentage of ventilated ptdays w/o sedation (6) SBT with Sedation off compliance rate (7) SAT contraindication distribution plot and table (counts and percentages) (8) SBT contraindication distribution plot and table (counts and percentages)

45. Translating evidence into practice: a model for large scale knowledge translation • Summarize the evidence • Focus on CUSP4MVP-VAP prevention interventions • Identify local barriers to implementation • Observe staff performing the interventions • “Walk the process” to identify defects • Enlist all stakeholders to share concerns • Measure performance • Measure baseline performance • Focus on CUSP4MVP-VAP prevention measures • Ensure all patient receive the intervention • Engage, educate, execute, evaluate • Standardize, create redundancy, learn from defects • Couple ‘technical efforts’ with CUSP to address adaptive challenges BMJ 2008;337:963-965.

46. Gap Between Best Evidence and Practice • Knowledge • awareness or familiarity (n=77) • Attitudes • agreement (n=33) • self-efficacy (n=19) • outcome expectancy (n=8) • inertia of previous practice (n=14) • Behavior • external barriers (n=34) Cabana et al. JAMA 1999

47. Your Next Steps: • Investigate the current protocols and practices for Spontaneous Awakening and Spontaneous Breathing Trials (SAT/SBTs) in your unit and how they compare to protocols developed by national experts. • Create monthly collaborative components for team members to have discussions for improvement, innovations and to share data. • Please send us your team’s SAT/SBT protocols to CUSP4MVP@jhmi.edu so we can share with other teams.