© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

CUSP for VAP: EVAPProject Overview Sean Berenholtz M.D., MHSKathleen Speck, MPH

August 21,2012

Conference Number(s):800-779-9891 Participant Code:4757941

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On Boarding Call Schedule –Tuesdays 8/21–9/25 @ 2:00

Armstrong Institute for Patient Safety and Quality

Program Introduction August 21, 2012• Building CUSP team – August 28, 2012• Science of Safety –September 4, 2012• CUSP Part 2-September 11, 2012• VAP Evidence- September 18,2012• Daily Goals Review -September 25, 2012

• Early Ambulation -August /30/2012

CUSP Comprehensive Unit Based Safety Program; VAP Ventilator Associated Pneumonia

Learning Objectives

• Overview of CUSP for VAP:EVAP program– Project goals and interventions– Participation requirements and timeline

• Outline next steps

CUSP Comprehensive Unit Based Safety Program; VAP Ventilator Associated Pneumonia; EVAP Eliminate VAP 3

© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

CUSP for VAP: EVAPProject Overview

CUSP for VAP: EVAP Project Overview

• NIH/NHLBI and AHRQ funded project– Individual hospitals participate for 3 years,

including 2 year intervention period and 1 year evaluation of sustainability

• Leveraging leaders in field – Armstrong Institute for Patient Safety and

Quality, NIH/NHLBI, CDC, AHRQ, University of Pennsylvania, MHA and HAP

Armstrong Institute for Patient Safety and Quality5

NIH/NHLBI National Institutes of Health National Heart, Lung, and Blood Institute; AHRQ Agency for Healthcare Research and Quality

Who can join CUSP for VAP: EVAP?

• Participation in the program is available to any facility with mechanically ventilated patients in Maryland and Pennsylvania.

• Hospital participation will be coordinated with state hospital association or hospital engagement network (HEN).

Armstrong Institute for Patient Safety and Quality6

Project Goals

• To achieve significant reductions in VAP/VAE rates

• To achieve significant improvements in safety culture

7VAP Ventilator Associated Pneumonia; VAE Ventilator Associated Events

How will we get there?

http://www.hopkinsmedicine.org/armstrong_institute 8

Successful Efforts to Reduce Preventable Harm

• Michigan Keystone ICU program– Reductions in central line-associated blood

stream infections (CLABSI) 1,2

– Reductions in ventilator-associated pneumonias (VAP) 3

• National On the CUSP: Stop BSI program 4

N Engl J Med 2006;355:2725-32. BMJ 2010;340:c309. Infect Control Hosp Epidemiol. 2011;32(4): 305-314. www.onthecuspstophai.org

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Lessons Learned

• Informed by science

• Led by clinicians and supported by infection control staff and management

• Guided by measures

Armstrong Institute for Patient Safety and Quality10

Advancing the Science

• Development of a ‘VAP Prevention’ bundle– Updating the ‘Ventilator Bundle’ to focus on VAP– Advancing science of process measurement

• CDC NHSN VAP definition is changing– Ventilator-Associated Event (VAE) algorithm

• Identification of contextual variables– Ethnographic studies

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© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

Interventions

VAP Prevention Guidelines

• CDC Guidelines • MMWR Recomm Rep. 2004;53:1-36

• American Thoracic Society/ Infectious Diseases Society of America

• AJRCCM 2005;171(4):388-416.• Canadian VAP Prevention Guidelines

• J Crit Care 2008;23(1):138-147.• Society for Healthcare Epid of America

• ICHE 2008;29:S31-S40.

Armstrong Institute for Patient Safety and Quality 13

Process measures: Daily evaluation

1. Head of Bed Elevation (HOB)– Use of a semi-recumbent position ( ≥ 30 degrees).

2. Spontaneous Awakening and Breathing Trials (SAT & SBT)– Daily assessment of sedation and readiness to wean

3. Oral Care– At least 6 times per day

4. Oral Care with Chlorhexidine (CHG)– Should be included in the oral care regimen 2 times per day

5. Subglottic Suctioning ETTs– Use subglottic suctioning ETTs in patients expected to be mechanically ventilated for

>72 hoursArmstrong Institute for Patient Safety and Quality

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Policy Based Structural Measures :

1. Use a closed ETT suctioning system2. Change close suctioning catheters only as needed3. Change ventilator circuits only if damaged or soiled4. Change HME every 5-7 days and as clinically

indicated5. Provide easy access to NIVV equipment and

institute protocols to promote use6. Periodically remove condensate from circuits,

keeping the circuit closed during the removal, taking precautions not to allow condensate to drain toward patient

7. Use early mobility protocol15ETT endotrachael tube; HME heat moist exchanger; NIVV non-invasive ventilation

Policy Based Structural Measures :

8. Perform hand hygiene9. Avoid supine position10. Use standard precautions while suctioning respiratory

tract secretions11. Use orotracheal intubation instead of nasotracheal12. Avoid use of prophylactic systemic antimicrobials13. Avoid non-essential tracheal suctioning14. Avoid gastric over-distention

16ETT endotrachael tube; HME heat moist exchanger; NIVV non-invasive ventilation

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Invitation to Join Call :

• Early Ambulation – Dr. Dale Needham – Thursday, August 30th , 2012

Armstrong Institute for Patient Safety and Quality

Comprehensive Unit-based Safety Program (CUSP)

1. Educate staff on science of safety

2. Identify defects

3. Assign executive to adopt unit

4. Learn from one defect per quarter

5. Implement teamwork tools 5. Jt Comm J Qual Patient Saf

2010;36:252-60 Resources: www.safercare.net 18

Sample Daily Goals

J Crit Care 2003;18(2):71-75

Education

Decrease complexity and create redundancy

• Daily goals checklist• Standardized ordersets

and protocols

Independent redundancies• Nursing, RT, families

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Program Support

Armstrong Institute for Patient Safety and Quality

Education Materials • Toolkits, slides, factsheets etc..

Series of Follow Up Calls • On Boarding Calls

– Aug 21-Sep 25• Coaching & Content Calls

– Nov 1 – Feb 7• Hospital Interviews

– Schedule TBD

Ethnography site visits• Selected sites TBD

CECity Project Platform

• Data collection – Manual entry or electronic import

• Real time reporting• Learning management system

– Share slides, protocols, literature, videos, etc.• Social networking

– Provider specific communities• Working on Maintenance of Certification (MOC)

credit, CMEs for participation (in progress)Armstrong Institute for Patient, Safety and Quality

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© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

Participation Requirements

What do teams need to do?

– Assemble a multidisciplinary team• Including frontline unit staff

– Participate in 6 weekly on-boarding webinars followed by monthly content and coaching webinars• All webinars recorded and archived online

– Regularly meet as a team to implement interventions and monitor performance

– Participate in state–specific requirements

Armstrong Institute for Patient Safety and Quality23

What data will teams need to collect?

• Monthly VAE data using new CDC NHSN definitions – VAC, IVAC, PVAP 1, PVAP 2

• Daily process measure data• Quarterly structural measure and implementation data

– Brief survey and structured interview • Annual teamwork/culture data using the AHRQ Hospital

Survey of Patient Safety (HSOPS)• Will work with HENS to ensure data reporting meets their

needs

Armstrong Institute for Patient Safety and Quality24

NHSN National Healthcare Safety Network; VAE Ventilator Associated Event; VAC Ventilator Associated Condition; IVAC Infection Related Ventilator Associated Complications; PVAP1 Possible Ventilator Associated Pneumonia; PVAP2 Probable Ventilator Associated Pneumonia

© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

Next Steps

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On Boarding Call Schedule –Tuesdays 8/21–9/25 @ 2:00

Armstrong Institute for Patient Safety and Quality

• Program Introduction August 21, 2012• Building CUSP team – August 28, 2012• Science of Safety –September 4, 2012• CUSP Part 2-September 11, 2012• VAP Evidence- September 18,2012• Daily Goals Review -September 25, 2012

• Early Ambulation -August /30/2012

CUSP Comprehensive Unit Based Safety Program; VAP Ventilator Associated Pneumonia

All calls recorded: please make sure your CUSP team listens to call if they are unable to join

CUSP Team Composition• Size (not too small, not too large)

• Multidisciplinary representationPhysician championNurse championProject lead/ unit championRespiratory TherapistInfection ControlExecutive PartnerFrontline staff

Nurse EducatorICU Nurse ManagerPharmacistHospital Patient Safety Chief Quality OfficerStaff from Safety, Quality or Risk Mgmt Office

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Finalize enrollment

• Complete and submit the commitment/enrollment form

• Questions or comments:

– Karol G. Wicker, MHSSenior Director, Quality Policy & AdvocacyMaryland Hospital Associationkwicker@mhaonline.org

– Mary Catanzaro RN BSMT CIC Project Manager HAIs Hospital and Healthsystem Association of Pennsylvaniamcatanzaro@haponline.org

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References

Slide 9: Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welch R, Roth G, Bander J, Kepros J, Goeschel C. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2723-32.Pronovost PJ, Goeschel CA, Colantuoni E, Watson S, Lubomski LH, Berenholtz SM, Thompson DA, Sinopoli DJ, Cosgrove S, Sexton JB, Marsteller JA, Hyzy RC, Welsh R, Posa P, Schumacher K, Needham D. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ. 2010;340:c309.Berenholtz SM, Pham JC, Thompson DA, Needham DM, Lubomski LH, Hyzy RC, Welsh R, Cosgrove SE, Sexton JB, Colantuoni E, Watson SR, Goeschel CA, Pronovost PJ. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011;32:305-14.www.onthecuspstophai.org

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References

Slide 18: Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf. 2010;36:252-60.Slide 19:Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003;18:71-5.