1. Sean Berenholtz, MD MHS FCCM September 20, 2011 at 2ET/1 CT/12 MT/11 PT Ventilator Associated Pneumonia Prevention CLABSI Supplemental Call Series

2. Slide 2 Your Feedback is Important https://www.surveymonkey.com/s/Z6FJ28T

3. Slide 3 Learning Objectives To describe the morbidity and mortality associated with Ventilator Associated Pneumonia To understand the framework used to achieve substantial and sustained reductions in VAP as part of the Michigan Keystone ICU program To outline next steps towards implementing VAP prevention efforts

4. Slide 4 Impact of VAP 10-20% of ventilated patients Common HAI – Median rate 1-4.3 per 1000 vent day – 250,000 infections per year Most lethal HAI – Mortality likely exceeds 10% – Up to 36,000 deaths per year Cost per episode: $23,000 Safdar CCM 2005, Kollef Chest 2005, Perencevich ICHE 2007, Public Health Rep. 2007.

5. Slide 5 Healthcare Associated Pneumonia Prevention CDC/HICPAC: Guidelines for the Prevention of Healthcare Associated Pneumonia; 2004. Canadian Critical Care Trials Group1: Comprehensive evidence-based clinical practice guidelines for ventilator- associated pneumonia: Prevention. Journal of Critical Care; 2008. SHEA/IDSA: Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals; 2008.

6. Slide 6 How Can These Errors Happen? People are fallible Medicine is still treated as an art, not science Need to view the delivery of healthcare as a science Need systems that catch mistakes before they reach the patient

7. Slide 7 To Improve Reliability Standardize what is done, when it is done – Reduce complexity Create independent checks for key processes – How often do we do what we should Learn from defects – How often do we learn from defects Health Services Research 2006; Circulation 2009;119:330-337.

8. Slide 8 Improving Care for Ventilated Patients Semirecumbant positioning Peptic ulcer disease and DVT prophylaxis Appropriate sedation Daily assessment of readiness to extubate Oral care with antiseptics Minimize contamination of equipment

9. Slide 9 Translating Evidence into Practice Pronovost, Berenholtz, Needham. BMJ 2008

10. Slide 10 Engage – Partner with infection preventionists, – Post performance, – Tell stories of harm Educate – Reviewed evidence on conference calls, – One-page fact sheets, – Slides for teams Improving Care for Ventilated Patients

11. Slide 11 Improving Care for Ventilated Patients Decrease complexity / create redundancy – Standardized order sets and protocols – Daily goals checklist Other independent redundancies – Nursing and families – Are patients receiving the prevention they should?

12. Slide 12 Sample Daily Goals J Crit Care 2003;18(2):71-75

13. Slide 13 Evaluate VAP – Standardized CDC NHSN definitions for VAP – VAP definition varies; Did not change definition Ventilator Bundle Process Measures – Collected by the ICU teams; daily cross-sectional sample – Standardized definitions and data collection forms – Limited number of trained data collectors – After first quarter of daily data collection, teams were allowed to collect process measures one to two days/week (min of 15 vent pts/mo) to minimize burden. Improving Care for Ventilated Patients

14. Slide 14 Results 124 of 127 ICUs submitted VAP data – 12 ICUs started after funding ended 112 ICUs, 72 hospitals included in analysis 3228 ICU months and 550,800 vent days 10% quarters without complete data – 4% missing data; 6% stopped submitting data Sensitivity analysis yielded similar results Results reported through 28-30 months post- implementation

15. Slide 15 Infect Control Hosp Epidemiol. 2011;32(4):305-314. Michigan Keystone ICU

16. Slide 16 Michigan Keystone ICU (n= Infect Control Hosp Epidemiol. 2011;32(4):305-314.

17. Slide 17 Limitations Lack of concurrent control group – Temporal changes, other interventions Did not evaluate accuracy of VAP diagnosis – All hospitals reported using CDC definitions – Used existing hospital infrastructure Can not evaluate importance of individual therapies in ventilator bundle Can not evaluate importance of other intervention Focus on ventilator care vs VAP prevention

18. Slide 18 Strengths Largest cohort to date Significant and sustained VAP reductions Focus on system of care Engagement of local interdisciplinary teams to assume ownership Centralized support for technical work Local adaptation of intervention Culture improvement and social networking among ICUs

19. Slide 19 Summary VAP is most lethal HAI; majority are preventable Effective interventions to prevent VAP are known; patients are not receiving the care they should Focus on systems to ensure patients receive the therapies they ought to

20. Slide 20 Next Steps Keystone ICU VAP project focused on ‘Ventilator Bundle’ Developing ‘VAP prevention bundle ’ – Funded by NIH/NHLBI – Delphi process led by RAND researcher

21. Slide 21 European Care Bundle for VAP Prevention Intensive Care Med 2010;36:773-780

22. Slide 22 Your Feedback is Important https://www.surveymonkey.com/s/Z6FJ28T