AHRQ Safety Program for Mechanically Ventilated Patients AHRQ Pub No 1617001841EF January 2017 Learning Objectives After this session you will be able to Discuss the ramifications ID: 695465
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Slide1
Ventilator-Associated Event Surveillance
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No.
16(17)-0018-41-EF
January
2017Slide2
Learning ObjectivesAfter this session, you will be able
to—Discuss the ramifications of ventilator-associated events (VAEs)Describe methods to evaluate
VAEs
Understand the implications of objective VAE surveillance
Identify ways to use data to drive improvementSlide3
Why Collect VAE Data?Collecting VAE data can be used to—Connect the dots to harmAvoid failure of infection prevention efforts due to “silo mentality”
View interventions under the larger context of patient safetySlide4
Why Do I Want To Know About VACs and IVACs?A retrospective cohort study examining 20,356 episodes of mechanical ventilation (MV)
1VAEs1,141 ventilator-associated conditions (VACs)431 infection-related VACs (IVACs)266 possible cases of ventilator-associated pneumonia (PVAP)Patients with a VAE have—
More days to extubation
More days to discharge
Higher mortality rate
1. Klompas
M, Kleinman K, Murphy MV. Descriptive epidemiology and attributable morbidity of ventilator-associated events. Infect Control Hosp Epidemiol. 2014 May;35(5):502-10. PMID: 24709718.Slide5
Connect the Safety Dots
Ventilator Harm
Immobility
Atelectasis
Pulmonary edema (PE)
VAP
Mortality
Cost
IVAC
Clostridium difficile
c
olitis
Antibiotic resistance
VAC
Morbidity
Increased length of stay (LOS)
Acute
respiratory
d
istress
s
yndrome
(ARDS)Slide6
Why Use the New VAE Surveillance Definitions?Screening ventilator settings for VAC captures a similar set of complications to traditional VAP surveillance but is faster, more objective, and a superior predictor of outcomes.
2Objective surveillance definitions that include quantitative evidence of respiratory deterioration after a period of stability strongly predict increased LOS and hospital mortality.
3
2. Klompas
M, Khan Y, Kleinman K, et al. Multicenter evaluation of a novel paradigm for complications of mechanical ventilation. PLoS One. 2011 Mar 22;6(3):e18062. PMID: 21445364.
3. Klompas
M, Magill S, Robicsek A, et al. Objective surveillance definitions for ventilator-associated pneumonia. Crit Care Med. 2012 Dec;40(12):3154-61. PMID: 22990454.Slide7
Why the Change?
3
7
0
3
IP 1
(11 VAPs)
IP 2
(20 VAPs)
IP 3
(15 VAPs)
Results from a study on inter-rater
reliability among infection preventionists (
IP)
4
50 ventilated patients with respiratory deterioration
Kappa = 0.40
Criteria are subjective, leading to disagreement between reviewers
4. Klompas
M. Interobserver variability in ventilator-associated pneumonia surveillance. Am J Infect
Control
. 2010 Apr;38(3):237-9. PMID: 20171757.Slide8
Why the Shift?Broaden the focus
Shifting focus of surveillance from pneumonia alone to complications in general emphasizes the importance of preventing all complications of MV, not just pneumonia
When definitions are objective, caregivers can focus on what went wrong rather than debate the definitionSlide9
Applying the National Healthcare Safety Network Definition5
Image designed by Wikipedia user “
pnautilus
” and used with permission
5. Rogers
E. Diffusion of innovation, 5
th
ed. New York, NY: Simon and Schuster; 2003.Slide10
Broadening the SurveillanceThe definition of VAE is intentionally broader than traditional VAP surveillanceCommon VACs:
ARDSPEThromboembolic diseaseSepsisClinical ramifications?Respiratory deterioration in previously stable patients is a risk factor for increased morbidity and mortalitySlide11
Analysis of VAC vs. VAP2Multicenter, retrospective studyEvaluated a novel surveillance paradigm for VACs: screening ventilator settings
Blinded critical care physician reviewed 52 randomly selected patients with VAC (defined by protocol) or VAP (determined by IPs based on VAP definition)Screening ventilator settings for VAC captures a similar set of complications to traditional VAP surveillance
2. Klompas
M, Khan Y, Kleinman K, et al. Multicenter evaluation of a novel paradigm for complications of mechanical ventilation. PLoS One. 2011 Mar 22;6(3):e18062. PMID: 21445364.Slide12
Analysis of VAC vs. VAP2
CONDITIONETIOLOGY OF VAC (N=44)
ETIOLOGY OF VAP (N=18)
Any pulmonary complication
26 (59%)
11 (61%)
Pneumonia
10 (23%)
6 (33%)
Pulmonary edema
8 (18%)
4 (22%)
Acute respiratory distress syndrome
7 (16%)
2 (11%)
Atelectasis
5 (11%)
2 (11%)
Mucous plugging
1 (2%)
0
Abdominal
compartment syndrome
1 (2%)
0Pulmonary embolus1 (2%)0Radiation pneumonitis1 (2%)0Sepsis syndrome1 (2%)0Poor pulmonary toilet1 (2%)02. Klompas M, Khan Y, Kleinman K, et al. Multicenter evaluation of a novel paradigm for complications of mechanical ventilation. PLoS One. 2011 Mar 22;6(3):e18062. PMID: 21445364.Slide13
Are VAEs Preventable?Many providers feel some of the conditions associated with VAEs are pre-existing
Preliminary data from the first year of VAE data collection showed approximately 79 percent of VAEs were in patients who were either on MV for ≥5 days or in the hospital for ≥5 days at the time of VAE onset6 Time to onset data suggest
that the majority of VAEs are likely
hospital-associated based on previous criteria
7,8
6. Magill
S,
Gross C, Edwards JR. Incidence and characteristics
of ventilator-associated events reported to the National Healthcare Safety Network in
2013. Oral abstract presented at the meeting of IDWeek, Philadelphia, PA, October 2014.
7. Klompas M. Complications of mechanical ventilation – the CDC’s new surveillance paradigm. N Engl J Med. 2013 Apr 18;368(16):1472-5. PMID: 23594002.
8. Muscedere
J, Sinuff T, Heyland DK, et al. The clinical impact and preventability of ventilator-associated conditions in critically ill patients who are mechanically ventilated. Chest. 2013 Nov;144(5):1453-60. PMID: 24030318.Slide14
Prevention StrategiesStrategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update9
Contributions from—Society of Healthcare Epidemiology of AmericaInfectious Diseases Society of AmericaAmerican Hospital AssociationAssociation for Professionals in Infection Control and EpidemiologyThe Joint Commission
9. Klompas
M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Aug;35(8):915-36. PMID: 25026607.Slide15
Intervention Bundle Checklist
PROCESS MEASURE
DATE
Y/N
COMMENTS
Continuous
subglottic suctioning
Assess
readiness to extubate with
spontaneous breathing trials (SBTs)
Paired SBTs
and SATs
Interrupt sedation daily with
spontaneous awakening trials (SATs)
Note contradictions here
Ambulate
according to protocol
Note
level here
Regular mouth care
(without chlorhexidine)
Elevate
head of bed (HOB) 30–45
0Conservative fluid managementBlood transfusions givenRationale: Low tidal volume Identify:Slide16
Best Practices for VAE Reduction
RECOMMENDATIONINTERVENTION
Basic practice
Use noninvasive positive pressure ventilation in selected populations
Manage patients without sedation whenever possible
Interrupt sedation daily
Assess readiness to extubate daily
Perform SATs with sedatives turned off
Facilitate early mobility
Use endotracheal tubes with subglottic secretion drainage ports for patients expected to require greater than 48 or 72 hours of MV
Change the ventilator circuit only if visibly soiled or malfunctioning
Elevate HOB to 30– 45°
Special
approaches
Select oral or digestive decontamination
Regular oral care with chlorhexidine
Prophylactic probiotics
Ultrathin polyurethane endotracheal tube cuffs
Automated control of endotracheal tube cuff pressure
Saline instillation before tracheal suctioning
Mechanical tooth brushing
Generally not recommended
Silver-coated endotracheal tubes
Kinetic beds
Prone positioningSlide17
What About Oral Care With Chlorhexidine?Routine oral care with chlorhexidine
10Prevents nosocomial pneumonia in cardiac surgery patientsMay not decrease VAP risk in noncardiac surgery patientsDoes not affect—Mortality
Duration of MV
Intensive care unit (ICU) LOS
10. Klompas
M, Speck K, Howell MD, et al. Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis. JAMA Intern Med. 2014 May;174(5):751-61. PMID: 24663255.Slide18
VAE Prevention TechniquesPrevent pneumonia by implementing HOB elevationAvoid pulmonary complications through fluid conservationProtect against atelectasis by managing sedation
Combat acute lung injury by following a low tidal volume ventilation strategySlide19
Getting Started on PreventionWhere to start?
Look at both process and outcome measuresTrack your own performance over time
Do we see improvements?Slide20
How Can We Evaluate the Data?
EVENT TYPE
GENDER
LOCATION
PATIENT ID
FIRST
NAME
LAST
NAME
EVENT
VAE
M
ICU
1234
M
ickey
Mouse
PVAP
VAE
M
ICU
5678
Donald
Duck
PVAP
VAE
M
ICU
2222
Charlie
Brown
VAC
VAE
F
ICU1333
Minnie
Mouse
VAC
VAEM
ICU
4444
Bugs
Bunny
VAC
VAE
M
ICU
5555
Super
Man
VAC
VAE
F
ICU
6666
Spider
Woman
VACSlide21
How Will I Use My Data To Drive Improvement?
Review both individual cases and system level issuesDevelop a form to help analyze individual casesDo we have policies and procedures in place?Do we follow evidence-based guidelines?Are we consistent with our practices?Slide22
Review All VAC Cases–Case Review 1Patient develops a VACChronic ventilator dependencyAmbulation protocols were not implemented
Not monitored for dehydrationPresence of sputum not documentedLack of communication between nursing and respiratory groupsSlide23
Case Review 2Ms. X is a 76-year-old woman, admitted to the ICU with septic shock requiring large volume fluid resuscitationIntubated and placed on ventilatorStable until day 6 when she has progressive oxygenation demands
Increased demands last for 72 hoursSlide24
Case Review 2 – OutcomesPatient has a VACNo feverNo increased white blood cell countNo new antibiotics
Diagnosis: Pulmonary edemaOpportunities for improvement?Slide25
Case Review 3In an example ICU, many VAEs are PVAPsEvaluationHead of bed monitoringSuctioning frequency
SATsEndotracheal tubes with subglottic suctioningSlide26
Case Review 3 – OutcomesAnalysisQuarter 1: 20 VACs4 VACs
16 IVACs0 PVAPsMost are other healthcare-acquired infectionsSlide27
Opportunities for Improvement
Hardwire ambulation protocolsEnsure documentation of secretions
Work collaboratively with respiratory
therapists
to identify subtle changes
Daily
huddlesSlide28
Know Your DataSurveillance is a critical component of every quality improvement effort; you cannot prevent it if you cannot measure it.
Linda Greene, R.N., M.P.S., CIC
Infection Prevention Manager
University of Rochester Medical Center, Highland Hospital
“
”Slide29
The Bottom LineVAEs are associated with increased mortality and ICU and hospital LOS
In randomized controlled trials, VAP interventions have been shown to improve objective outcomes, such as duration of MV, ICU or hospital LOS, mortality, and costsThe existing VAP prevention literature is the best available guide to improving outcomes for ventilated
patients
It is important to continue monitoring the processes of care and the outcomes for mechanically ventilated patients
Always give feedback to providers and assess the potential for preventable events
Slide30
Questions?Slide31
ReferencesKlompas M, Kleinman K, Murphy MV. Descriptive epidemiology and attributable morbidity of ventilator-associated events. Infect Control Hosp Epidemiol. 2014 May;35(5):502-10. PMID: 24709718.
Klompas M, Khan Y, Kleinman K, et al. Multicenter evaluation of a novel paradigm for complications of mechanical ventilation. PLoS One. 2011 Mar 22;6(3):e18062. PMID: 21445364.Klompas M, Magill S, Robicsek A, et al. Objective surveillance definitions for ventilator-associated pneumonia. Crit Care Med. 2012 Dec;40(12):3154-61. PMID: 22990454.
Klompas M. Interobserver variability in ventilator-associated pneumonia surveillance. Am J Infect Control. 2010 Apr;38(3):237-9. PMID: 20171757.
Rogers E. Diffusion of innovation, 5
th ed. New York, NY: Simon and Schuster; 2003.Slide32
ReferencesMagill S, Gross C, Edwards JR. Characteristics of ventilator-associated events reported to the National Healthcare Safety Network in 2013. Oral abstract presented at the meeting of IDWeek, Philadelphia,
PA, October 2014. Klompas M. Complications of mechanical ventilation – the CDC’s new surveillance paradigm. N Engl J Med. 2013 Apr 18;368(16):1472-5. PMID: 23594002.
Muscedere J, Sinuff T, Heyland DK, et al. The clinical impact and preventability of ventilator-associated conditions in critically ill patients who are mechanically ventilated. Chest. 2013 Nov;144(5):1453-60. PMID: 24030318.
Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Aug;35(8):915-36. PMID: 25026607.
Klompas M, Speck K, Howell MD, et al. Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis. JAMA Intern Med. 2014 May;174(5):751-61. PMID: 24663255.