1 © 2009 TMIT Safe Practice 23 Care of the Ventilated Patient NQF-endorsed™ Safe Practices for Better Healthcare Chapter 7: Improving Patient Safety Through Prevention of Healthcare-Associated Infections

© 2006 HCC, Inc. CD XX 2 © 2009 TMIT Slide Deck Overview Slide Set Includes:  Section 1: NQF-endorsed™ Safe Practices for Better Healthcare Overview  Section 2: Harmonization Partners  Section 3:The Problem  Section 4: Practice Specifications  Section 5: Example Implementation Approaches  Section 6: Front-line Success Stories

3 © 2009 TMIT NQF-endorsed™ Safe Practices for Better Healthcare Overview Safe Practice 23 Care of the Ventilated Patient Chapter 7: Improving Patient Safety Through Prevention of Healthcare-Associated Infections

4 © 2009 TMIT 2010 NQF Safe Practices for Better Healthcare: A Consensus Report 34 Safe Practices Criteria for Inclusion Specificity Benefit Evidence of Effectiveness Generalization Readiness

5 © 2009 TMIT Culture SP NQF Report

CHAPTER 7: Hospital-Associated Infections Hand Hygiene Influenza Prevention Central Venous Catheter-Related Blood Stream Infection Prevention Surgical-Site Infection Prevention Care of the Ventilated Patient and VAP MDRO Prevention UTI Prevention Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition-, Site-, and Risk-Specific Practices Consent & Disclosure Wrong-site Sx Prevention Press. Ulcer Prevention DVT/VTE Prevention Anticoag. Therapy VAP Prevention Central V. Cath. BSI Prevention Sx-Site Inf. Prevention Contrast Media Use Hand Hygiene Influenza Prevention Pharmacist Systems Leadership: High-Alert, Std. Labeling/Pkg., and Unit-Dose Med. Recon. Culture CPOE Read-Back & Abbrev. Discharge System Patient Care Info. Labeling Studies Culture Meas., FB., and Interv. Structures and Systems ID and Mitigation Risk and Hazards Team Training and Team Interv. Nursing Workforce ICU Care Direct Caregivers Workforce CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care CHAPTER 2: Creating and Sustaining a Culture of Patient Safety (Separated into Practices]  Leadership Structures and Systems  Culture Measurement, Feedback, and Interventions  Teamwork Training and Team Interventions  Identification and Mitigation of Risks and Hazards CHAPTER 5: Information Management and Continuity of Care  Patient Care Information  Order Read-Back and Abbreviations  Labeling Studies  Discharge Systems  Safe Adoption of Integrated Clinical Systems including CPOE CHAPTER 6: Medication Management  Medication Reconciliation  Pharmacist Leadership Role Including: High-Alert Med. and Unit-Dose Standardized Medication Labeling and Packaging CHAPTER 8: Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Prevention Pressure Ulcer Prevention DVT/VTE Prevention Anticoagulation Therapy Contrast Media-Induced Renal Failure Prevention Organ Donation Glycemic Control Falls Prevention Pediatric Imaging Informed Consent Life-Sustaining Treatment Disclosure CHAPTER 3: Informed Consent and Disclosure Informed Consent Life-Sustaining Treatment Disclosure Care of the Caregiver Consent and Disclosure Care of Caregiver MDRO Prevention UTI Prevention Falls Prevention Organ Donation Glycemic Control Pediatric Imaging

7 © 2009 TMIT Harmonization Partners Safe Practice 23 Care of the Ventilated Patient Chapter 7: Improving Patient Safety Through Prevention of Healthcare-Associated Infections

8 © 2009 TMIT Harmonization – The Quality Choir

9 © 2009 TMIT The Patient – Our Conductor

© 2006 HCC, Inc. CD XX 10 © 2009 TMIT The Objective Care of the Ventilated Patient  Prevent healthcare-associated complications in ventilated patients.

11 © 2009 TMIT The Problem Safe Practice 23 Care of the Ventilated Patient Chapter 7: Improving Patient Safety Through Prevention of Healthcare-Associated Infections

© 2006 HCC, Inc. CD XX 12 © 2009 TMIT The Problem

© 2006 HCC, Inc. CD XX 13 © 2009 TMIT The Problem Frequency  Reported to range from 1 to 4 cases per 1,000 ventilator days  May exceed 10 cases per 1,000 ventilator days in special populations, such as pediatric and surgical patients  VAP occurs in 8% to 28% of mechanically ventilated patients [Edwards, Am J Infect Control 2007 Jun;35(5): ; NNIS, Am J Infect Control 2004 Dec;32(8):470-85]

© 2006 HCC, Inc. CD XX 14 © 2009 TMIT The Problem Severity  Mortality rate of 14.4%  Presence of nosocomial pneumonia prolonged the length of mechanical ventilation by 10.3 days and mean ICU unit length of stay by 12.2 days [Klevens, Public Health Rep 2007 Mar-Apr;122(2):160-6; Levinson, Adverse events in hospitals: state reporting systems, 2008; Koulenti, Crit Care Med 2009 Aug;37(8):2360-8]

© 2006 HCC, Inc. CD XX 15 © 2009 TMIT The Problem Preventability  Reduce the duration of mechanical ventilation by assessing patients daily  Maintain patients in semi-recumbent position, with a 30°-45° of elevation of the head of the bed  To reduce bacterial colonization, provide oral care with an antiseptic agent [Tablan, MMWR Recomm Rep 2004 Mar 26;53(RR-3):1-36; ATS/IDSA, Am J Respir Crit Care Med 2005 Feb 15;171(4): ; Dellinger, Crit Care Med 2005;9(6):653-4; Resar, Jt Comm J Qual Patient Saf 2005 May;31(5):243-8; Panchabhi, Chest 2009 May;135(5):1150-6; Segers, JAMA 2006 Nov22;296(20):2460-6; Sona, J Intensive Care Med 2009 Jan-Feb;24(1):54-62]

© 2006 HCC, Inc. CD XX 16 © 2009 TMIT The Problem Cost Impact  Hospitalization costs were $48.9K higher in patients with VAP, and length of hospitalization 25 days longer  Hospital costs due to VAP range from $19.6K to $28.5K in 2007 dollars  Pediatric patients admitted to PICU had a mean additional hospitalization cost of $30.9K [Warren, Crit Care Med 2003; 31: ; Foglia, Clin Microbiol Rev 2007 Jul;20(3):409-25; Scott, The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention, 2009]

17 © 2009 TMIT Practice Specifications Safe Practice 23 Care of the Ventilated Patient Chapter 7: Improving Patient Safety Through Prevention of Healthcare-Associated Infections

© 2006 HCC, Inc. CD XX 18 © 2009 TMIT Additional Specifications

© 2006 HCC, Inc. CD XX 19 © 2009 TMIT Safe Practice Statement Care of the Ventilated Patient  Take actions to prevent complications associated with ventilated patients: specifically, ventilator- associated pneumonia, venous thrombo- embolism, peptic ulcer disease, dental complications, and pressure ulcers. [Institute for Healthcare Improvement, Ventilator Bundle: IHI Improvement Map, 2009]

© 2006 HCC, Inc. CD XX 20 © 2009 TMIT Additional Specifications  Educate healthcare workers about the daily care of ventilated patients  Implement policies and practices for disinfection, sterilization, and maintenance of respiratory equipment  Conduct active surveillance for VAP in units that care for ventilated patients at high risk for VAP based on risk assessment [Coffin, Infect Control Hosp Epidemiol Oct;29 Suppl 1:S31-40; Tablan, MMWR Recomm Rep 2004 Mar 26;53(RR-3):1-36; CDC, An Overview of Ventilator-Associated Pneumonia, 2005; Brito, Crit Care Med 2009 Jan;37(1):350-2; Hortal, Crit Care 2009;13(3):R80]

© 2006 HCC, Inc. CD XX 21 © 2009 TMIT Additional Specifications  Provide ventilated patient data to key stakeholders  Educate patients and their families about prevention measures involved in the care of ventilated patients  Institute a ventilated patient checklist and a standardized protocol

22 © 2009 TMIT Example Implementation Approaches Safe Practice 23 Care of the Ventilated Patient Chapter 7: Improving Patient Safety Through Prevention of Healthcare-Associated Infections

© 2006 HCC, Inc. CD XX 23 © 2009 TMIT Example Implementation Approaches

© 2006 HCC, Inc. CD XX 24 © 2009 TMIT Example Implementation Approaches  Incorporate range-of-motion as daily care for ventilated patients per the organization’s protocol  Consider the use of direct antibiogram using E- test strips  Utilize antibiotic de-escalation therapy with critically ill patients who acquire a VAP [ASHP, Am J Health-Syst Pharm 1998; 55:1724-6; Clavet, CMAJ 2008 Mar 11;178(6):691-7; Trudel, Clin Orthop Relat Res 2008 May;466(5): ; Bouza, Curr Opin Infect Dis 2009 Aug;22(4):345-51; Eachempati, J Trauma 2009 May;66(5):1343-8]

© 2006 HCC, Inc. CD XX 25 © 2009 TMIT Example Implementation Approaches  Perform regular oral care with an antiseptic solution, considering a chlorhexidine agent  Remove oral secretions before changing the patient’s position  Provide easy access to noninvasive ventilation equipment  Devise strategies to prevent aspiration  Devise strategies to reduce colonization of the aerodigestive tract  Devise strategies to minimize contamination of equipment [ Yoneyama, J Am Geriatr Soc 2002 Mar;50(3):430-3; Kollef, Crit Care Med 2004 Jun;32(6): ; Mori, Intensive Care Med 2006 Feb;32(2):230-6; Segers, JAMA 2006 Nov22;296(20):2460-6; Chan, BMJ 2007 Apr 28;334(7599):889; Silvestri, Crit Care Med 2007 Oct;35(10):2468; Chao, J Clin Nurs 2009 Jan;18(1):22-8]

© 2006 HCC, Inc. CD XX 26 © 2009 TMIT Example Implementation Approaches Strategies of Progressive Organizations  Set a goal of zero VAPS and visually display their successes in patient care areas

27 © 2009 TMIT Front-line Success Stories Safe Practice 23 Care of the Ventilated Patient Chapter 7: Improving Patient Safety Through Prevention of Healthcare-Associated Infections

© 2006 HCC, Inc. CD XX 28 © 2009 TMIT Title of Video Insert Video this size

29 © 2009 TMIT

30 © 2009 TMIT

© 2006 HCC, Inc. CD XX 31 © 2009 TMIT TMIT High Performer Webinar Safer Critical Care: Resources to Prevent Ventilator-Associated Pneumonia and Central Venous Catheter-Associated Bloodstream Infections  This program is a webinar presentation designed to help you and your hospital team understand and implement NQF-Endorsed TM Safe Practices 19 and 20*. Renowned educators in the field will guide you in a special informational session about the importance and implementation of these Safe Practices.  Go to: *NQF Safe Practices for Better Healthcare – 2006 Update

© 2006 HCC, Inc. CD XX 32 © 2009 TMIT TMIT High Performer Webinar Healthcare-Associated Infection and You: Cleaner, Safer Care (Safe Practices 19-25)  The National Quality Forum’s (NQF) 2009 Update of the Safe Practices for Better Healthcare and TMIT’s Webinar series provide tools to unite healthcare providers, purchasers, and consumers to more rapidly identify and adopt techniques that will reduce patient harm and improve care.  Go to: