1. 1 © 2010 TMIT NQF-Endorsed ® Safe Practices for Better Healthcare Safe Practice 23 Daily Care of the Ventilated Patient Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections

2. © 2006 HCC, Inc. CD000000-0000XX 2 © 2010 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 Resources

3. 3 © 2010 TMIT Safe Practice 23 Daily Care of the Ventilated Patient Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections NQF-Endorsed ® Safe Practices for Better Healthcare Overview

4. 4 © 2010 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. 5 © 2010 TMIT Culture SP 1 2010 NQF Report

6. CHAPTER 7: Healthcare-Associated Infections Hand Hygiene Influenza Prevention Central Line-Associated Blood Stream Infection Prevention Surgical-Site Infection Prevention Daily Care of the Ventilated Patient MDRO Prevention Catheter-Associated UTI Prevention Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition- and Site-Specific Practices Consent & Disclosure Wrong-site Sx Prevention Press. Ulcer Prevention VTE Prevention Anticoag. Therapy VAP Prevention Central Line-Assoc. BSI Prevention Sx-Site Inf. Prevention Contrast Media Use Hand Hygiene Influenza Prevention Pharmacist Leadership Structures and Systems Med. Recon. Culture CPOE Read-Back & Abbrev. Discharge Systems Patient Care Info. Labeling Diag. Studies Culture Meas., FB., and Interv. Structures and Systems Risk and Hazards Team Training and Skill Bldg. Nursing Workforce ICU Care Direct Caregivers Workforce CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care CHAPTER 2: Creating and Sustaining a Culture of Safety (Separated into Practices]  Culture of Safety Leadership Structures and Systems  Culture Measurement, Feedback, and Intervention  Teamwork Training and Skill Building  Risks and Hazards CHAPTER 5: Information Management and Continuity of Care  Patient Care Information  Order Read-Back and Abbreviations  Labeling Diagnostic Studies  Discharge Systems  Safe Adoption of Computerized Prescriber Order Entry CHAPTER 6: Medication Management  Medication Reconciliation  Pharmacist Leadership Structures and Systems CHAPTER 8: Condition- and Site-Specific Practices Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Prevention Pressure Ulcer Prevention 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: 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. 7 © 2010 TMIT Safe Practice 23 Daily Care of the Ventilated Patient Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections Harmonization Partners

8. 8 © 2010 TMIT Harmonization – The Quality Choir

9. 9 © 2010 TMIT The Patient – Our Conductor

10. © 2006 HCC, Inc. CD000000-0000XX 10 © 2010 TMIT The Objective Daily Care of the Ventilated Patient  Prevent healthcare-associated complications in ventilated patients

11. 11 © 2010 TMIT Safe Practice 23 Daily Care of the Ventilated Patient Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections The Problem

12. © 2006 HCC, Inc. CD000000-0000XX 12 © 2010 TMIT The Problem

13. 13 © 2010 TMIT [http://online.wsj.com/article/SB121867229022038907.html]

14. 14 © 2010 TMIT [http://online.wsj.com/article/SB10001424052970204488304574428950126681432.html]

15. © 2006 HCC, Inc. CD000000-0000XX 15 © 2010 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):290-301; NNIS, Am J Infect Control 2004 Dec;32(8):470-85]

16. © 2006 HCC, Inc. CD000000-0000XX 16 © 2010 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]

17. © 2006 HCC, Inc. CD000000-0000XX 17 © 2010 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 [ATS/IDSA, Am J Respir Crit Care Med 2005 Feb 15;171(4):388-416; Resar, Jt Comm J Qual Patient Saf 2005 May;31(5):243- 8; Dellinger, Crit Care Med 2005;9(6):653-4; Tablan, MMWR Recomm Rep 2004 Mar 26;53(RR-3):1-36; 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]

18. © 2006 HCC, Inc. CD000000-0000XX 18 © 2010 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: 1312-7; Scott, The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention, 2009 ; Foglia, Clin Microbiol Rev 2007 Jul;20(3):409-25]

19. 19 © 2010 TMIT Safe Practice 23 Daily Care of the Ventilated Patient Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections Practice Specifications

20. © 2006 HCC, Inc. CD000000-0000XX 20 © 2010 TMIT Additional Specifications

21. © 2006 HCC, Inc. CD000000-0000XX 21 © 2010 TMIT Safe Practice Statement Daily Care of the Ventilated Patient  Take actions to prevent complications associated with ventilated patients: specifically, ventilator-associated pneumonia, venous thromboembolism, peptic ulcer disease, dental complications, and pressure ulcers [Institute for Healthcare Improvement, Ventilator Bundle: IHI Improvement Map, 2009]

22. © 2006 HCC, Inc. CD000000-0000XX 22 © 2010 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. 2008 Oct;29 Suppl 1:S31-40; Tablan, MMWR Recomm Rep 2004 Mar 26;53(RR-3):1- 36; Centers for Disease Control and Prevention, An Overview of Ventilator-Associated Pneumonia, 2005; Brito, Crit Care Med 2009 Jan;37(1):350-2; Hortal, Crit Care 2009;13(3):R80]

23. © 2006 HCC, Inc. CD000000-0000XX 23 © 2010 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  For pediatric patients, institute a ventilated patient checklist and a standardized protocol

24. 24 © 2010 TMIT Safe Practice 23 Daily Care of the Ventilated Patient Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections Example Implementation Approaches

25. © 2006 HCC, Inc. CD000000-0000XX 25 © 2010 TMIT Example Implementation Approaches

26. © 2006 HCC, Inc. CD000000-0000XX 26 © 2010 TMIT Example Implementation Approaches  Incorporate range-of-motion as daily care for ventilated patients per the organization’s protocol  Utilize antibiotic de-escalation therapy with critically ill patients who acquire a VAP  Perform regular oral care with an antiseptic solution, considering a chlorhexidine agent  Remove oral secretions before changing the patient’s position [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):1239-44; Eachempati, J Trauma 2009 May;66(5):1343-8; Yoneyama, J Am Geriatr Soc 2002 Mar;50(3):430-3; Kollef, Crit Care Med 2004 Jun;32(6):1396-405; 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]

27. © 2006 HCC, Inc. CD000000-0000XX 27 © 2010 TMIT Example Implementation Approaches  Consider the use of direct antibiogram using E- test strips  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 [Bouza, Curr Opin Infect Dis 2009 Aug;22(4):345-51; Kollef, Crit Care Med 2004 Jun;32(6):1396-405]

28. © 2006 HCC, Inc. CD000000-0000XX 28 © 2010 TMIT Example Implementation Approaches Strategies of Progressive Organizations  Set a goal of zero VAPS and visually display their successes in patient care areas

29. 29 © 2010 TMIT Safe Practice 23 Daily Care of the Ventilated Patient Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections Front-line Resources

30. 30 © 2010 TMIT [http://www.shea-online.org/about/compendium.cfm; http://www.ncbi.nlm.nih.gov/pubmed/18840087]

31. 31 © 2010 TMIT [http://www.cdc.gov/media/pressrel/2010/s100202.htm]

32. 32 © 2010 TMIT [http://www.shea-online.org/Assets/files/patient%20guides/NNL_VAP.pdf]

33. 33 © 2010 TMIT [http://www.jointcommission.org/PatientSafety/SpeakUp/]Poster available in Spanish

34. 34 © 2010 TMIT [http://www.ihi.org/imap/tool/#Process=0f029d21-a307-4663-9d64-07da43f3f857]

35. © 2006 HCC, Inc. CD000000-0000XX 35 © 2010 TMIT TMIT National Webinar Series Healthcare-Associated Infection and You: Cleaner, Safer Care (Safe Practices 19-25)  Kathy Warye – Topic: Perspective on the Development of the Implementation Examples of the NQF Safe Practices  Peter Angood, MD – Topic: HAI National Attention and Harmonization  David Classen, MD – Topic: HAI Compendium Harmonization with the Safe Practices  Julianne Morath, RN – Topic: Implementation  Jennifer Dingman – Topic: Call to Action  Go to: http://www.safetyleaders.org/pages/idPage.jsp?ID=4932 (May 14, 2009)

36. © 2006 HCC, Inc. CD000000-0000XX 36 © 2010 TMIT TMIT National Webinar Series Safer Critical Care: Resources to Prevent VAP & CVC-BSI (SPs 19-20)  Joan Reischel, RN, BSN, CCRN – Clinical Coordinator, Critical Care, The Medical Center of Aurora  Tom Talbot, MD – Assistant Professor of Medicine and Preventive Medicine, Chief Hospital Epidemiologist, Vanderbilt University School of Medicine  Richard J. Wall, MD, MPH – Pulmonary, Critical Care, & Sleep Medicine, Southlake Clinic, Valley Medical Center  Mary E. Foley, MS, RN – Associate Director, Center for Research and Nursing Innovation, University of California, San Francisco  Go to: http://www.safetyleaders.org/pages/idPage.jsp?ID=4878 (May 14, 2008)