1. CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Year In Review
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
Johns Hopkins University
November 12, 2014

2. CUSP 4 MVP - VAP
Comprehensive Unit-based Safety Program for Mechanically Ventilated Patients and Ventilator-Associated Pneumonia

4. Polling Question Who is on the call? IP – infection preventionist
RN – registered nurse
RT – respiratory therapist
PT – physical therapist
OT – occupational therapist
Healthcare executive
Educator
National project team
Other  

5. The Adaptive Work: CUSP David Thompson, DNSc, MS, RN
CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

7. Key Concepts: Technical and Adaptive Work
TECHNICAL WORK
ADAPTIVE WORK
Procedural components of work, like elevating the head of bed and using subglottic suctioning endotracheal tubes (ETTs)
The intangible components of work, like ensuring ICU team members speak up with concerns and hold each other accountable
Work that lends itself to standardization (e.g., checklists and protocols)
Work that shapes the attitudes, beliefs, and values of clinicians, so they consistently perform tasks the way they know they should
Evidence-based interventions
Local culture

8. What Have We Learned in Project Year 1?
The steps of CUSP and their importance
How to form a CUSP team
How to assess patient safety culture with the Hospital Survey on Patient Safety (HSOPS)
How to learn from defects
The importance of using Daily Goals during interdisciplinary rounds

9. Steps of CUSP Educate staff on the science of safety Identify defects
How can we get patients off the ventilator faster?
How will your next ventilated patient be harmed?
Partner with a senior executive
Learn from defects
Improve teamwork and communication

10. Why CUSP? Designed to improve safety culture and learn form mistakes
Values the wisdom of frontline staff
Empowers staff to be actively engaged in safety improvements
Linked with improvements in clinical outcomes and human resources outcomes
Helps eliminate barriers between staff and senior leadership
How did priorities, beliefs, habits, and loyalties (i.e., adaptive issues) impact your efforts?
An adaptive intervention to:
Identify and learn from mistakes
Improve safety culture
Improve teamwork

11. Successful CUSP Teams
Are composed of engaged frontline clinicians who take ownership of patient safety
Include staff members who have different levels of experience and perspectives
Represent all stakeholders by bringing multiple disciplines together

12. Successful CUSP Teams Meet regularly
Have adequate resources including protected time
Between 2–4 hours per week for a CUSP champion
Share leadership
Work together to make decisions
Avoid preconceived notions
Engage in breaking down silos within unit

13. Measuring Safety Culture
Measure safety culture “Pre-CUSP,” or pre- interventions
Provides a baseline status
Identifies assets and barriers that impact improvement efforts
Reassess months into improvement efforts
Use reliable and valid survey instrument
Hospital Survey on Patient Safety (HSOPS)
Implement CUSP to improve safety culture results

14. What Is HSOPS? Hospital Survey On Patient Safety Culture (HSOPS)
Measures safety culture within the clinical units of hospital
Part of a suite of survey tools (SOPS) for hospitals, medical offices, and nursing homes
Sponsored by Agency for Healthcare Research & Quality (AHRQ)
HSOPS App: online survey tool
Developed by the Armstrong Institute in partnership with CeCity
Allows participants to complete the HSOPS survey online
Provides detailed reports for survey coordinators to debrief clinical areas

15. HSOPS Dimensions
Supervisor / manager expectations and actions promoting patient safety
Nonpunitive response to error
Staffing
Organizational learning- continuous improvement
Hospital management support for patient safety
Teamwork within unit
Teamwork across hospital units
Communication openness
Feedback and communication about error
Hospital handoffs and transitions

16. Anything you do not want to happen again.
What Is a Defect?
Anything you do not want to happen again.
Anything you do not want to happen again – an unsafe condition, a patient fall, a venous thromboembolism, a medication error, a surgical site infection, wrong-site surgery, missing equipment, nursing time spent away from the bedside–anything that might lead to preventable patient harm.

17. How Has CUSP Improved Safety on Our Unit During the First Year?
Team 1 Experience
Team 2 Experience

18. Next Steps Celebrate Year 1 progress with your CUSP teams
Prepare to administer the next cycle of HSOPS
Start date: Monday, Feb 16, 2015
Closing date: Friday, April 10, 2015

20. CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients
Technical Work: Daily Care Processes Measures Sean Berenholtz, MD, MHS, FCCM
CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

21. Data Collection Drives quality improvement efforts Is NOT for research
Provides quantifiable measures of care practices
Guides patient safety conversations
Justifies resource allocations
Human resources (time)
Financial resources (money)
Supplies and equipment (stuff)

22. Unleash the power of your data
Sample reports
Unleash the power of your data

23. Daily Care Process Measures Compliance Report
Improvement Opportunities display the number of events, which if eliminated improve your measure value.

24. Sample SBT Compliance Report
What if your SBT compliance rates went from 100% to the lowest in your CE and cohort in four months and continued dropping?
THEM
YOU

25. Sample HSOPS Report

26. Sample HSOPS Report
Data Available in Variety of Aggregate Reports in PDF Format

28. 2014 SHEA Compendium Update1
Elevate the head of the bed 30-45°
Provide endotracheal tubes with subglottic secretion drainage ports for patients likely to require more than 48 or 72 hours of intubation
Manage ventilated patients without sedatives whenever possible

29. 2014 SHEA Compendium Update1
Interrupt sedation once a day (spontaneous awakening trials)
Assess readiness to extubate once a day (spontaneous breathing trials)
Pair spontaneous breathing trials with spontaneous awakening trials
Employ early exercise and mobilization
Use non-invasive positive pressure ventilation (NIPPV) whenever feasible

30. 2013 Society of Critical Care Medicine PAD Guidelines2
Establish an overarching protocolized approach to daily ICU patient management using Pain, Agitation, and Delirium (PAD) Guidelines
Assess and treat pain first (may be sufficient)
If patient remains agitated after adequately treating pain
Start with PRN bolus sedation (as needed)
Use continuous sedation if boluses exceed 3 per hour
Avoid benzodiazepines in most patients

31. 2013 Society of Critical Care Medicine PAD Guidelines2
Interrupt sedation daily
If necessary, restart at lowest dose to maintain chosen target level of consciousness
Avoid deep sedation (RASS -4/-5) as it appears harmful; instead, target awake or alert
Screen for delirium (CAM-ICU or ICDSC)
If delirious, first seek reversible causes and attempt non-pharmacologic management
Use the ABCDE’s to improve outcomes for your patients
Turn off sedation daily and restart only if needed at lowest dose to maintain chosen target level of consciousness
Deep sedation (RASS -4/-5) appears harmful; target awake/alert
Screen for delirium (CAM-ICU or ICDSC); If delirious, first seek reversible causes and attempt non-pharmacologic management
Use the ABCDEs to improve outcomes for your patients

32. “
In God we trust.
All others bring data.
– W. E. Deming ”

34. Daily Care Processes Data Collection Progress
Yes
At least 7 consecutive days of data was submitted for the assigned month No
7 consecutive days of data was not submitted for the assigned month
N/A
Indicates no Daily Care Process Measures data collection assignment for the month

35. Daily Care Processes Data Collection Progress

36. Daily Care Processes Data Collection Progress

37. Keep Up the Good Work!!! Teams with Four YES’s
Teams that submitted data for at least 4 months
Hendrick Medical Center - CCU
Scott & White Memorial – Cardio Thoracic ICU
Henry Ford Hospital - SICU
St. Joseph Mercy Hospital Ann Arbor – CICU
Inspira Medical Center Elmer - EICU
Inspira Medical Center Vineland - MICU
St. Joseph Mercy Hospital Ann Arbor – MICU
Mary Washington Hospital – MICU
St. Mary Mercy - ICU
Mary Washington Hospital –SICU
Tampa General Hospital - TICU and SICU
McLaren Bay Region - CCU
McLaren Oakland - ICU
The Valley Hospital - ICU
Medical Center Hospital – ICU2
Truman Medical Centers - ICU
Medical Center Hospital - ICU4
Williamsburg Regional - ICU
Mercy Memorial Hospital System – ICU

38. Experiences with Daily Care Processes
Team 1 Experience
Team 2 Experience

39. Technical Work: Daily Early Mobility Measures Nishi Rawat, MD
CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

41. Daily Early Mobility: Key Interventions
Use multi-disciplinary and coordinated approach
Interrupt daily sedation and minimize sedative use
Assess sedation and delirium with structured scales
Screen for highest level of mobilization
Employ a nurse-driven protocol to achieve highest level of mobility  

43. Daily Early Mobility Data Collection Progress
Yes
At least 7 consecutive days of data was submitted for the assigned month No
7 consecutive days of data was not submitted for the assigned month
N/A
Indicates no Daily Early Mobility data collection assignment for the month

44. Daily Early Mobility Data Collection Progress

45. Daily Early Mobility Data Collection Progress

46. Keep Up the Good Work!!! Teams with Four YES’s
Teams that submitted data for at least 4 months
Centrastate Medical Center – CCU
McLaren Bay Region - CCU
Medical Center Hospital - ICU2
Henry Ford Hospital - SICU
Mercy Memorial Hospital System - ICU
Inspira Medical Center Elmer - EICU
St Luke's Warren Campus - ICCU
Inspira Medical Center Vineland - MICU
St. Mary Mercy – ICU
The Valley Hospital - ICU
Mary Washington Hospital – MICU
Williamsburg Regional - ICU
Mary Washington Hospital - SICU

47. Experiences Using Daily Early Mobility Measures
Team 1 Experience
Team 2 Experience

48. Technical Work: Ventilator Associated Events (VAE) Kathleen Speck, MPH
CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

49. VAE: Data Collection Progress

50. VAE: Data Collection Progress

51. VAE: 2015 Update What are the changes?
The third tier of the VAE algorithm will be consolidated
Possible VAP and Probable VAP will be combined: PVAP
PVAP defined as IVAC + one of the following:
Positive quantitative or semi-quantitative culture above threshold
Culture (any quantity) with purulent secretions
Positive pleural fluid culture, lung histology, diagnostic test for Legionella, or diagnostic test for a respiratory virus

52. VAE: 2015 Update What are the changes?
Community-acquired fungal pathogens will be excluded
Cryptococcus
Histoplasma
Coccidioides
Paracoccidioides
Blastomyces
Pneumocystis

53. VAE: 2015 Update What are the changes?
Option to collect and report a new denominator
Episodes of mechanical ventilation
Rationale
Many best practices in critical care are designed to decrease duration of mechanical ventilation
Decreasing average duration of mechanical ventilation means fewer total ventilator days and a paradoxical increase in the VAE rate per 1000 vent-days
Compare:
3 VAEs / 1000 vent days  3 VAEs per 1000 vent-days
3 VAEs / 900 vent days  3.3 VAEs per 1000 vent-days

54. VAE: 2015 Update For additional information
CDC’s VAE definitions change in 2015
Details will be presented in the upcoming Cohort 2 Infection Prevention webinars:
January 28, 2015 from 11:00 to 12:00 PM EST:
VAE Surveillance Training: An Overview
February 25, 2015 from 11:00 to 12:00 PM EST:
VAE Surveillance Training: Infection-related Ventilator-Associated Complication (IVAC)
March 25, 2015 from 11:00 to 12:00 PM EDT
VAE Surveillance Training: VAP (PVAP)

56. Cohort 1, Year 2: Upcoming Activities Sean Berenholtz, MD, MHS, FCCM
CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

57. Evaluating Objective Outcome Measures
To evaluate the effectiveness of prevention measures, look at objective outcomes, such as:
Duration of mechanical ventilation
ICU length-of-stay
Hospital length-of-stay
Mortality rates

58. Objective Outcome Measures Data Collection Progress

59. Objective Outcome Measures Data Collection Progress

60. Keep Up the Good Work!!! Teams with Data
Teams that submitted data
Centrastate Medical Center – CCU
Inspira Medical Center Vineland - MICU
St Luke's Warren Campus - ICCU
St. Mary Mercy - ICU
Trinitas Regional Medical Center – ICU
The Valley Hospital - ICU
Williamsburg Regional - ICU

61. Low Tidal Volume Ventilation

62. Low Tidal Volume Ventilation
Introduced to Cohort 1 on Dec 10th
What is Low Tidal Volume Ventilation?
Target a Tidal volume of 4-6 ml/kg of predicted body weight
Not ideal body weight
Not actual body weight
Predicted body weight based on height
Avoid the use of Zero Positive End-expiratory Pressure (ZEEP)
Use PEEP settings ≥ 5 cm H20

63. Next Steps: Low Tidal Volume Ventilation
Jan 14, 2015
Tune into the next webinar, titled “How to Enter Low Tidal Volume Ventilation Data”
Feb 1, 2015
Begin collecting and entering Low Tidal Volume Ventilation data

64. Special Thanks to 2014 Presenting Teams
Baylor Scott and White, Texas
Centrastate, New Jersey
Hendrick Medical, Texas
Inspira Medical Vineland, New Jersey
Medical Center Hospital, Texas
Oakwood Hospital Dearborn, Michigan
St. Joseph Mercy Ann Arbor ICU, Michigan
St. Mary Mercy ICU, Michigan
Tampa General Hospital, Florida
Truman Medical Center, Missouri
Williamsburg Regional Hospital, South Carolina

65. CUSP 4 MVP – VAP Website
Visit:

66. What Can I Find on the CUSP 4 MVP – VAP Website?
Education materials
Toolkits
CUSP
Daily Process Measures
Early Mobility
Low Tidal Volume Ventilation (soon)
Literature Reviews
Fast Fact Sheets
CUSP Tools and Guides
Archive of webinars led by subject matter experts