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Beyond VAP: Identifying areas for improvement to prevent ventilator-associated conditions

Beyond VAP: Identifying areas for improvement to prevent ventilator-associated conditions. Partnership for Patients Quality and Patient Safety Conference April 30, 2013. Michael Klompas MD, MPH, FRCPC, FIDSA Harvard Medical School, Harvard Pilgrim Health Care Institute, and

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Beyond VAP: Identifying areas for improvement to prevent ventilator-associated conditions

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  1. Beyond VAP: Identifying areas for improvement to prevent ventilator-associated conditions Partnership for Patients Quality and Patient Safety Conference April 30, 2013 Michael Klompas MD, MPH, FRCPC, FIDSA Harvard Medical School, Harvard Pilgrim Health Care Institute, and Brigham and Women’s Hospital, Boston, MA

  2. Disclosures • Honoraria from Premier Healthcare Alliance

  3. Outline • Ventilator-associated events – a patient safety opportunity • Zero VAC – where do we start? • The problem with current ventilator bundles • The promise of better weaning & sedation strategies • The CDC Prevention Epicenters’ Wake Up & Breathe Collaborative • Lessons learned

  4. Ventilator-associated events • VAP – subjective, inaccurate, and rare • VAC – simple and objective – seeks all complications of mechanical ventilation, not just pneumonia. • Most cases due to: • Pneumonia • Pulmonary edema • ARDS • Atelectasis • VAC is a strong predictor of poor outcomes (increased ventilator days, hospital days, and mortality)

  5. Ventilator-associated event surveillanceA patient safety opportunity • Increase Awareness • VAC surveillance provides hospitals with a fuller picture of complications in mechanically ventilated patients • Catalyze Prevention • A significant portion of VACs are likely preventable • Reflect and Inform Progress • VAC surveillance provides an efficient and objective yardstick to track one’s progress relative to oneself and to peers

  6. Zero VAC • Where do we start?

  7. VAP Bundle?

  8. VAC ≠ VAP Image from http://img.ehowcdn.com/article-new/ehow/images/a07/86/tp/increase-torque-cars-rear-end-800x800.jpg

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

  10. VAP Prevention Measures NEJM 2000;342:1471 Crit Care Med 2004;32:1272Chest 2000;118:459Ann Intern Med 1995;122:179 Am J RespirCrit Care Med 2006;174:894Lancet 1999;354:1851BMJ 2007;334:889JAMA 2008;300:805

  11. But VAP diagnoses are unreliable. Can we trust the VAP reduction rates reported in the literature? Need to look at outcomes…

  12. Silver Coated Endotracheal TubesVAP Rates and Outcomes Conventional ETTs Silver coated ETTs 12.0 6.0 5.0 10.0 4.0 8.0 VAPs per 100 Patients Lengths of Stay (days) 6.0 3.0 2.0 4.0 1.0 2.0 JAMA 2008;300:805-813 0 0 Hospitaldays ICUdays Ventdays VAP Incidence

  13. Oral antiseptics & outcomes VAP Vent days ICU days Mortality Antiseptics harmful Antiseptics protective Chan et al., BMJ 2007;334:889

  14. The VAP Prevention Paradox Klompas, Critical Care 2009;13:315

  15. Why the Paradox? • VAP as measured includes a multitude of conditions, ranging from benign to serious • Less serious: bacterial colonization superimposed upon atelectasis / CHF / barotrauma • More Serious: pneumonia, ARDS, pulmonary infarction, others • Most prevention measures work by decreasing oral secretions or bacterial colonization • Circularity between mechanism of action and diagnostic criteria • Preferential impact on less serious events leading to lower perceived VAP rates, smaller impact on more serious events • For any given intervention, difficult to know if primary impact is on less serious or more serious events since both count as “VAPs” Klompas, Critical Care 2009;13:315

  16. What does work?

  17. Daily Interruption of Sedation N=128 Daily interruption Usual Care NS * 5 10.0 * 8.0 4 3 6.0 Days Cases of VAP 4.0 2 2.0 1 0 0 Duration ofVentilation ICUStay VAPCases Kress, NEJM 2000:342:1471Schweickert, Crit Care Med 2004;32:1272

  18. Daily Interruption of Sedation &Daily Spontaneous Breathing Trials Daily sedative interruption ANDspontaneous breathing trialN=168 Dailyspontaneous breathing trialaloneN=168 vs Girard, Lancet 2008;371:126

  19. One year survival 100 Slide courtesy of Wes Ely 80 60 Patients Alive (%) SAT+SBT (n=167) 40 Usual Care+SBT (n=168) 20 p=.01 0 60 120 180 240 300 360 0 Days Girard TD, et al. Lancet 2008;371:126-34

  20. Improving Sedation ManagementA good strategy to prevent VACs? • Sedation and prolonged mechanical ventilation are both important risk factors for multiple complications of intensive care • Pneumonia • ARDS • Pneumothorax • Pulmonary edema • Delirium • Kidney dysfunction • GI bleeding • Bacteremia • Thromboembolic disease • Cholestasis • Sinusitis

  21. Sedative interruption adherence poor • Daily sedative interruptions are a component of most ventilator bundles but audits suggest that in practice interruptions are only done about 25-50% of the time • e.g. Brigham and Women’s Hospital, Boston, 2011 • Sedative interruption 54% of sedative-days • Contraindication marked 31% of sedative-days • List of contraindications liberal • Included “high ventilator requirements” (40%),“weaning from high sedative dose” (16%), and “hemodynamic instability” (22%) Klompas, Unpublished Data

  22. Are we unduly cautious with sedative interruptions? • 140 patients randomized to routine sedation versus no sedation • 70 prescribed routine sedation (propofol then midazolam) • 70 prescribed no sedation • Morphine boluses permitted for both groups PRN • Unblinded • Patients with no sedation • Mean 4.2 (95% CI 0.3-8.1) fewer days on the vent • Shorter ICU stay (HR 1.86, 95% CI 1.1-3.2) • Shorter hospital stay (HR 3.6, 95% CI 1.5-9.1) • More agitated delirium (20% versus 7%) but no difference in self-extubations Strøm et al. Lancet 2010;375:475

  23. The CDC Prevention Epicenters’Wake Up and Breathe Collaborative

  24. The CDC Prevention Epicenters’Wake Up and Breathe Collaborative • 13 ICUs from 8 hospitals • StrogerCook County Hospital • Missouri Baptist Medical Center • Duke University • Durham VA • Durham Regional Hospital • North Shore Union • North Shore Salem • Hospital of the University of Pennsylvania • Goal: prevent ventilator associated complications through less sedation and earlier liberation from mechanical ventilation • Mechanism: paired daily spontaneous awakening trials and breathing trials (SATs and SBTs)

  25. Collaborative Components • All Teach – All Learn Model • Each participating unit has designated RN, RT, and MD champions • Monthly written reports by each ICU – • Progress, challenges, successes, and failures from the preceding month • Goals for the forthcoming month • Monthly collaborative phone calls for all champions • Monthly data feedback and benchmarking • Collaborative facilitated by a CDC “improvement advisor” • Two in-person meetings at CDC for all champions held April 2012 (kick-off) and October 2012 (consolidation) Expert advice from CDC, Institute for Healthcare Improvement, and consulting faculty

  26. 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 walk

  27. 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

  28. 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

  29. 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

  30. “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

  31. Midazolam Equivalents

  32. Fentanyl Equivalents

  33. Boluses Per Day in Mehta et al.

  34. Assess Performance as well as Documentation

  35. Assess Performance as well as Documentation

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

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

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

  39. 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?

  40. Absolute Counts: VACs

  41. Absolute Counts: VACs and Vent Days

  42. VACs per 1000 Ventilator Days

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

  44. 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 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

  45. Summary • VAE surveillance is a patient safety opportunity • Spontaneous awakening trials and spontaneous breathing trials decrease ventilator days, hospital days, and mortality. • Maybe SATs and SBTs can also lower VAC rates! • Lessons learned from the CDC Prevention Epicenters’ Wake Up and Breathe Collaborative: • 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 as well as documentation • It’s a marathon not a sprint • Choose a denominator that fits the intervention • Wake up and walk!

  46. Thank You! • Michael Klompas (mklompas@partners.org)

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