Reports: Daily Process, VAE, NHSN Armstrong Institute for Patient Safety and Quality Presented by: Kathleen Speck, MPH Linda Greene, RN, MPS, CIC

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality

I don’t get it. Lots of mumbo- jumbo if you ask me Surveillance Definition Change - VAP to VAE What’s with this VAE Stuff? I don’t get it. Lots of mumbo- jumbo if you ask me

http://www.cdc.gov/nhsn/VAE-calculator

NHSN Data Total VAE VAC Only IVAC Possible VAP Probable VAP

We have the VAE data; now what? Comparative Data from NHSN Other Changes ( Combine Possible and Probable VAP) Device Utilization Ratios

In the Meantime Review Outcome Data At the Bedside In Team Meetings

Patient Data Vent Day PEEP min FiO2 Temp WBC Polys Epis Organism 1 10 Anti-micro agent Micro source Polys Epis Organism 1 10 50 37.5 11.6 none 2 5 37.8 11.8 3 12.0 ETA 3+ s.aureus 4 8 70 38.2 15.0 PIPTAZ Vanco 60 38.5 14.2 6 38.0 12.9 7 40 37.6 1+ Oral flora Now we have data regarding use of antimicrobial agent, positive culture from endotracheal aspirate. Moving in to defining a possible or probably ventilator associated pneumonia. High lighted area provides information needed to complete the algorithm.: positive culture of endotracheal aspirate. . . .

Looking at the data My first quarter VAC is 15.38 per 1,000 vent days The average performance of the group is 5.5 per 1,000 vent days Do I have opportunities?

Looking Carefully at the Measures I notice that my SAT and SBT compliance is much lower than the cohort group. I also notice that subglottic suctioning is lower than the peer group .

Looking at Cases Ms. X is a 26 y.o. vent dependent patient . She has a history anoxic brain injury and is admitted with pneumonia from a long term care facility ( LTCF) She is placed on antibiotics and after 4 days has stabilized on the vent. She is improving clinically and the plan is to return to the LTCF On day 7 , she has a significant event and a sustained period of worsening oxygenation. She meets definition for VAE

Case Review The clinicians have identified that her event was caused by a mucus plug. What Next?

The Analysis Changes in Nurses and Respiratory Therapy staff- no documentation of secretions Failure to notice thickened secretions and change in color of secretions Although Patient was at baseline – did not get her up into a chair Patient was dehydrated

Opportunities Hardwire ambulation protocols Assure documentation of secretions Work collaboratively with respiratory therapy to identify subtle changes Daily huddle

Another Case Mrs. X is a 76 y.o woman admitted to the ICU with septic shock requiring large volume fluid resuscitation. She is intubated and placed on the ventilator She is stable on the ventilator until day 6 when she has progressing oxygenation demands She has developed a VAC

Case evaluation No fever No increased white count No new antibiotics Diagnosis: Pulmonary Edema Opportunities for improvement ?

Analysis In another ICU, a large proportion of VAC’s are possible or probable pneumonia Evaluation: HOB monitoring? Suctioning frequency? SATs? ET tubes with Subglottic suctioning?

Tools

The Change Model “If we could change ourselves, the tendencies in the world would also change. As a man changes his own nature, so does the attitude of the world change towards him. … We need not wait to see what others do” -Gandhi

Conclusion Analyzing both process and outcome data will lead to new opportunities for improvement VAE gives us an opportunity to take a broader view of patient safety. It’s not about the numbers, it’s about the Patient

Next Steps for CUSP Conduct a culture assessment (HSOPS) Establish an interdisciplinary CUSP team Partner with a Senior Executive Review the Science of Safety training Identify defects Download results from your culture assessment (HSOPS) and share with team Meet regularly with your CUSP team Use the Daily Goals tool in your ICU

Next Steps for Data Collection Unit Lead completes Structural Assessment Unit staff complete HSOPS Unit Lead/Data Facilitator enters Daily Process Measures Unit staff complete Exposure Receipt Assessment via survey link Unit Lead/Data Facilitator enters monthly VAE rates Unit Lead/Data Facilitator enters Early Mobility Measures Data Facilitator contemplates next steps for collecting Objective Outcomes Measures Unit Lead/Data Facilitator pulls data reports from the data portal and share the feedback with your frontline staff One person from unit (we recommend the Unit Lead) complete the Implementation Assessment.

Questions Contact the CUSP 4 MVP-VAP Help Desk at cusp4mvp@jhmi.edu for all questions!