1. How to Improve Patient Outcomes after Mechanical Ventilation
Essential Hospitals Engagement Network
October 1, 2013

2. Our new Name
We’ve rebranded! The National Association of Public Hospitals and Health Systems is now America’s Essential Hospitals.
Although we’ve changed our name, our mission is the same: to champion hospitals and health systems that provide the highest quality of service to all by achieving the best health outcomes for every patient, especially those in greatest need. The new name underscores our members’ continuing public commitment and the essential nature of our work to care for the most vulnerable and provide vital community services, such as trauma care and disaster response.
This is an exciting time for us and our members, as we lean forward into new care models, opportunities and challenges of reform, and quality and safety innovations that often take root in our member systems.
Our new website address:

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5. Speaker information Michele C. Balas, PhD, RN, APRN-NP, CCRN
Associate Professor
Center of Excellence in Critical and Complex Care
The Ohio State University College of Nursing
Alex Ramos, RN, MSN, CCRN
Trauma Operations Manager
Sandra Gonzalez RN, BSN
Director of Trauma, Neurosurgery and Adult Med/Surg Critical Care Services
Dustin Bierman, RN, MSN
ICU Med/Surg Clinical Coordinator
Luis Martinez, RN, BSN
ICU Med/Surg Manager
ABCDE Team
University Medical Center of
El Paso
John Young, RN, MBA
Improvement Coach EHEN
Michele C. Balas, Ph.D., RN, led work focused on the determining the prevalence and consequence of delirium in the critically-ill, older adult population. Her research evaluated the effects of a nurse-led intervention aimed at mitigating the effects of ICU-acquired delirium and weakness. Dr. Balas joined the Center of Excellence in Critical and Complex Care at The Ohio State University College of Nursing and plans to collaborate with researchers and clinicians in nursing, gerontology, and critical care medicine to continue her research trajectory aimed at improving the physical, functional, and neurocognitive outcomes of critically ill older adults.
Her complete biography is in the additional materials ed ahead, as are citations and abstracts for her peer-reviewed articles studying the ABCDE bundle. Also in the notes are links for additional delirium-related information and an article citation reviewing mobilizing mechanically ventilated trauma and burn patients from the University of Alabama, an America’s Essential Hospitals member.
Also joining us are frontline clinicians from the University Medical Center of El Paso in El Paso, TX. UMC El Paso is an EHEN member doing great work in reducing infections, pressure ulcers and readmissions. Alex Ramos, Sandra Gonzalez and Dustin Bierman, all nursing leaders, join us to talk about their ABCDE team. They’ll share their story planning and organizing to implement the bundle in their ICU.
And finally I’m John Young, EHEN Improvement coach. I’ll moderate today’s webinar.

6. Agenda VAP work in EHEN and Partnership for Patients
The ABCDE bundle   - Michele C. Balas, PhD, RN, APRN-NP, CCRN
An EHEN hospital’s story - UMC El Paso ABCDE team  
   
Q & A
Wrap-up and announcements
Review agenda

7. EHEN Vap Results (as of May, 2013)
Summary UHC-Defined VAP Outcome
Numerator: Adult discharges (age ≥ 18) with an ICU stay ≥ 1 day on an invasive mechanical ventilator (ICD-9-CM code ). Inclusions: Diagnosis code = , POA=N,U;
Denominator: Adult discharges (age ≥ 18) with an ICU stay ≥ 1 day on an invasive mechanical ventilator (ICD-9-CM code ).
Review measure, coach control chart and inspire to apply today’s material to further improve.

8. Improving Patient-Centered Outcomes in the ICU: The ABCDE Bundle
I’ll turn things over now to our featured presenter. Dr. Balas, the floor is yours.
Michele C. Balas PhD, RN, APRN-NP,CCRN
Associate Professor, The Ohio State University
College of Nursing, Center for Critical & Complex Care
Adjunct Professor , University of Nebraska Medical Center
College of Nursing, Department of Community Based Health

9. Disclosures
Dr. Balas is currently a Co-investigator on a grant supported by the Alzheimer’s Association and has received honoraria from ProCe, the France Foundation, Hospira, & Hillrom.
Images courtesy of Nancy Adams-
Research supported by RWJF-INQRI
For references regarding outcomes of delirium in the ICU setting and the ABCDE bundle please see:

10. The Issues- ICU Acquired Delirium & Weakness
Profound & emerging public health threat
Common
Lethal
Disabling
Persistent

11. The Issues- ICU Acquired Delirium & Weakness
33% Emergency Room
14-56% Medical/Surgical Units
20-50% Non-Mechanically Ventilated-ICU
50-80% Surgical/Trauma/ Burn ICU
70-87% Mechanically Ventilated-ICU
25-50% of patients who receive MV for 4-7 days
50-75% sepsis patients
80-95% of patients with ICU- AW have neuromuscular abnormalities 2-5 YEARS after hospital discharge
70% of MV patients have difficulty with ADLs 1 year after discharge

12. DELIRIUM AN INDEPENDENT PREDICTOR OF MORTALITY
ICU & hospital
Mortality rates ranging from %
6-month*
(3 fold ↑ risk)
1 year
Each day delirious ↑ 10% mortality!!!!!!
Lin (CCM, 2004); Inouye (NEJM, 2006); *Ely (JAMA, 2009); Pisani (AJRCC, 2009)

13. Outcomes Associated With Delirium
ICU & hospital LOS
↑ restraints & sedation
Poor functional recovery
New institutionalization
Multiple complications
Total 1-year US health-care costs $ billion dollars

14. Delirium & New Onset Cognitive Impairment
½ of all ICU survivors experience long-term cognitive impairment
Persistent
Associated with delirium duration
Older patients without dementia hospitalized for a non-critical illness have a 40% higher risk of dementia 10 20 30 40 50 60 5 15
Delirium Days
Cognitive Function at 12 months
(predicted mean T-score)
p=.03
Jackson et al., Anesthesiology Clinics, 2011; Ehlenbach, Jama, 2010

15. Other Outcomes Associated with Critical Care
10-50% of all ICU survivors experience
PTSD
Depression
Anxiety
Sleep disorders
Need for caregiver assistance

16. Patient Experience
“On Sunday, I was on the ICU, where a horror ceremony like in a concentration camp was going on. Four patients were executed. Laying in their beds, they received a death pill. I was one of them…The hangman gave us the pill, with a blank face. In the background were two ladies waiting to carry away our dead bodies…The torturers watched us all the time, they asked us: “Do you feel anything yet? How does your foot feel? How does your arm feel?”… The children of Satan were in command. They were dressed in green coats and had scary faces. They were waiting for our death. … Worst was, that I did not try to resist. How can a man throw away his life like that? Why me? Did they do a mistake during the surgery and try to cover it up by killing all of us? … The pills did not work. I did not die. So they tried it again with gas, pressing a mask on my face. …"- Male, 67 years old.

17. Precipitating Factors for ICU Acquired Delirium & Weakness
Potentially Modifiable
Sedative Medications
Mechanical Ventilation
Immobility/prolonged bed rest
Uncontrolled pain
Sleep deprivation
Non-Modifiable
Age
Severity of illness
Comorbidities
Pre-existing CI/dementia
Drug/ETOH withdrawal

19. Potential Solution- ABCDE Bundle
Awakening
Breathing
Coordination/Choice of sedation
Delirium monitoring/ management
Early exercise/mobility

20. What Does the Evidence Tell Us? Awakening Kress et al. (2000) NEJM
Pro-RCT, 128 MV, MICU
Treatment group-CI sedatives stopped 1Xday
(restarted at ½ rate if needed)
SS reduction in
MV days 4.9 vs. 7.3
ICU LOS 6.4 vs. 9.9

21. What Does the Evidence Tell Us? Awakening
Kress et al. (2000) NEJM
Fewer diagnostic tests
No difference in
Complications
Mortality
Hospital LOS
Kress et al. (2003) AJRCCM
32 patients 6 month FU
Results
Fewer symptoms PTSD vs (p=0.02)
Lower incidence of PTSD 0 vs. 32 (p=0.06)
Better psychosocial adjustment to illness

22. What Does the Evidence Tell Us? Awakening
Weinert et al. (2007) CCM
85% of 18,050 evals had sedation (N=274)
1 in 3 unarousable (32%)
1 in 5 no spontaneous motor activity (21%)
Only 2.6% of providers thought patients were “over-sedated”!!!!!!

23. What Does the Evidence Tell Us? Breathing
Spontaneous Breathing Trials (Ely et al NEJM)
RCT, single center, N=300
Respiratory care-driven weaning protocol using SBTs found to lead to statistically significant improvements
MV days 3 vs. 4.5 (p=0.003)
Reintubation 6 vs. 15 (p=0.04)
MV >21 days 9 vs. 20 (p=0.04)
ICU cost 15,740 vs. 20,890 (p=0.03)

24. What Does the Evidence Tell Us? Awakening & Breathing Coordination
Multicenter, RCT (N=336)
Intervention group protocolized SATs & SBTs; control group daily SBTs & “usual care” sedation
Results
Survival at 1 yr. 58% vs. 44% p=0.01

25. What Does the Evidence Tell Us
What Does the Evidence Tell Us? Awakening & Breathing Coordination Girard et al. (2008) Lancet
No difference in….
Self extubation with reintubation
Total re-intubations
Delirium
Tracheostomy
Long-term cognitive & psych. outcomes (Jackson et al.)
Stat. Significant Results…
32% less likely to die
NNT-7 to save a life at 1 year
VFDs (3 days)
Successful extubation (7 vs. 5)
ICU & hospital LOS (4 days)
Coma (1 day)
Self-extubation (3 vs. 5)

26. What Does the Evidence Tell Us? Choice of Sedation
Analgosedation (Strøm T, et al. Lancet. 2010;375: )
140 critically ill adult patients undergoing MV in single center
Randomized, open-label trial
Both groups received bolus morphine (2.5 or 5 mg)
Group 1: No sedation (n = 70 patients) - morphine prn
Group 2: Sedation (20 mg/mL propofol for 48 h, 1 mg/mL midazolam thereafter) with daily interruption until awake (n = 70, control group)

27. What Does the Evidence Tell Us? Choice of Sedation
Patients receiving no sedation had
More days without MV (13.8 vs 9.6 days, P = 0.02)
Shorter stay in ICU (HR 1.86, P = 0.03)
Shorter stay in hospital (HR 3.57, P = 0.004)
More agitated delirium (N = 11, 20% vs N = 4, 7%, P = 0.04)
No differences found in
Accidental extubations
Need for CT or MRI
Ventilator-associated pneumonia

28. What Does the Evidence Tell Us? Choice of Sedation
2013 SCCM Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU
Regular PAD screening using valid & reliable tools
Role of preemptive analgesia/importance of effectively managing pain
Maintaining light levels of sedation (DSI vs. light target level)
Nonbenzodiazepine sedative strategies
Potential role of Dexmedetomidine (MV at risk for delirium)
No prophylactic haloperidol or atypical antipsychotics
Atypical antipsychotics may reduce duration of delirium

29. What Does the Evidence Tell Us? Delirium Monitoring/Management
Morandi A, et al. Intensive Care Med. 2008;34:
CAM-ICU
ICDSC

30. What Does the Evidence Tell Us? Early Exercise/Mobility
Early PT and OT in Mechanically Ventilated ICU Patients
Schweickert WD, et al. Lancet. 2009;373(9678):

31. ABCDE Bundle Steps
ABCDE bundle is multicomponent, interdependent, & designed to:
Improve clinical team collaboration
Standardize care processes
Break the cycle of oversedation & prolonged mechanical ventilation
Opt-out method
Safety screen & self-guided ABCE’s

32. Awakening

33. Breathing SBT Failure Criteria SBT Safety Screen
Respiratory rate > 35/min
Respiratory rate < 8/min
Oxygen saturation < 88%
Respiratory distress
Mental status change
Acute cardiac arrhythmia
SBT Safety Screen
No agitation
Oxygen saturation ≥ 88%
FiO2 ≤ 50%
PEEP ≤ 7.5 cm H2O
No myocardial ischemia
No vasopressor use
Inspiratory efforts

34. Early Mobility Safety Screen
Patient responds to verbal stimulation (ie, RASS ≥ -3)*
FIO2 ≤ 0.6
PEEP ≤ 10 cmH2O
No  dose of any vasopressor infusion for at least 2 hours
No evidence of active myocardial ischemia (24 hrs)
No arrhythmia requiring the administration of new antiarrhythmic agent (24 hrs)

35. Early Mobility Progression
Walking A
Short Distance
Standing at bedside and
sitting in chair
Each eligible patient is encouraged to be mobile twice a day, with the specific level of activity geared to his or her readiness. Patients progress through a three-step process, embarking on the highest level of physical activity they can tolerate, as outlined below:
Sitting on edge of bed: As a first step, the PT & RN helps patients sit at the edge of the bed with their feet planted on the floor or on a platform. A caregiver may support the patient from behind, but the position is discontinued after a few minutes if the patient cannot hold his or her torso upright. The goal is to maintain this position for 10 minutes with minimal support. The patient moves to the second step after accomplishing this goal twice.
Standing at bedside and sitting in chair: As a next step, the PT & RN helps the patient stand at the bedside, bear some weight (by lifting each leg), and pivot into a chair by the bed. The patient is encouraged to sit in the chair for as long as he/she can tolerate it, up to 2 hours. The patient moves to the next step after accomplishing this step twice.
Walking a short distance: The final step is for the care team to help the patient walk, beginning with a few steps (e.g., to the doorway) and ultimately reaching 200 feet. The PT, RT and the RN will verify optimal time for ambulation.
Use of the protocol ends when the patient is discharged from the ICU. Readiness for ICU discharge depends on clinical considerations, not the patient's ability to walk 200 feet.
This step is appropriate for patients who are still on sedation and/or critically ill, and for others for whom it is risky to leave the bed. Care team members stay with patients for as long as they can tolerate the position, monitoring the patients for physiological signs and symptoms of distress such as fatigue and/or changes in blood pressure, heart rate, respiratory rate, and oxygen saturation level.
If the patient is stable and awake, the care team departs after approximately 15 minutes, but checks in periodically; equipment allows all patients to be monitored from a central station. If the patient becomes disconnected or declines physiologically, the care team returns immediately. If the care team is concerned about the patient’s ability to tolerate the sitting position, they remain with the patient.
PT and/or the RN will contact the RT to coordinate a time for the first ambulation session the following day. The RT will enter an order as “Patient Ambulation by RCS” in the Hospital Information System (HIS), including the frequency of ambulation.
The healthcare team will inform the patient (and family/caregivers) the ambulation schedule/activity for the day. The RT will assemble the equipment necessary for patient ambulation and ensure the patient’s artificial airway is secure throughout ambulation. The RT will adjust ventilator settings and/or provide manual resuscitation based on patient’s tolerance during ambulation and reconnect or return the patient to the ventilator at the previously ordered settings after completion of the activity. The RT will also document in the medical record: tolerance, complications, and adjustments in ventilator settings, etc. The RN will monitor the patient’s HR, RR, SpO2, ETCO2 etc. The RN and PT support the patient; canes and walkers may be used as needed. A patient care technician will follow the patient with a wheelchair in case of fatigue or medical need and assists with other equipment as needed. For ventilated patients in contact isolation caregivers will wear clean appropriate isolation barriers (gowns, gloves, etc.) when ambulating the patient in the hallway. The RN will ensure the patient’s drainage is contained. The team will dedicate the equipment for the activity whenever practical and if reusable equipment is used, clean with low level disinfectant solution after use. The team will maintain a “no-touch” technique of all environmental surfaces when outside of the patient’s room.
Sitting on edge of bed

36. Delirium Monitoring/Management
Routine Sedation & Delirium Assessment Using Standardized, Validated Assessment Tools
RN administers & records RASS/SAS results q2h
Team sets “target” RASS/SAS score for the patient to be maintained at for the following 24 hours
RN administers & records results of the CAM-ICU/ICDSC q8h & whenever a patient experiences a change in mental status

37. Delirium Monitoring/Management
Each day during interdisciplinary rounds, the RN will:
State the “TARGET” sedation score
State the patient’s ACTUAL sedation score
State the patient’s delirium status
State the sedative/analgesic medications the patient is currently receiving
Each day during interdisciplinary rounds, the team will use the acronym “THINK” if a patient is CAM positive (delirious)
The interdisciplinary team will employ the following non-pharmacologic interventions when treating a delirious patient:
Eliminate or minimize risk factors
Provide a therapeutic environment

38. Delirium Monitoring/Management
USE MEDICATIONS ONLY IF ABSOLUTELY NECESSARY!
Give “PEACE” a chance
Physiologic
Environmental
ADLs/Sleep
Communication
Education

39. So Easy- What Could Possibly Go Wrong?
Canada – 40% get SATs (273 physicians in )1
US – 40% get SATs ( )2
Germany – 34% get SATs (214 ICUs in )3
France – 40–50% deeply sedated with 90% on continuous infusion of sedative/opiate4
1. Mehta S, et al. Crit Care Med. 2006;34:
2. Devlin J. Crit Care Med. 2006;34:
3. Martin J, et al. Crit Care. 2007;11:R124.
4. Payen JF, et al. Anesthesiology. 2007;106:

40. Barriers to Daily Sedation Interruption
(Survey of 904 SCCM members)
Increased device removal
Poor nursing acceptance
Compromises patient comfort
Leads to respiratory compromise
Difficult to coordinate with nurse
No benefit
#1 Barrier
Leads to cardiac ischemia
#2 Barrier
#3 Barrier
Leads to PTSD 10 20 30 40 50 60 70
Number of respondents (%)
Clinicians preferring propofol were more likely use daily interruption
than those preferring benzodiazepines (55% vs 40%, P < )
Tanios MA, et al. J Crit Care. 2009;24:66-73. 40

41. Implementation Challenges
Facilitators:
Daily interdisciplinary rounds
Engagement of key implementation leaders
Sustained, diverse educational efforts
Bundle’s quality and strength
Barriers:
Intervention-related issues (e.g., timing of trials, fear of adverse events)
Communication and care coordination challenges
Knowledge deficits
Workload concerns
Documentation burden

42. Implementation Challenges
Structural characteristics of the ICU
Organization-wide patient safety culture
ICU culture of quality improvement
Implementation planning, training/support
Prompts/documentation
Excessive turnover (both in project and ICU leadership)
Staff morale issues
Lack of respect between disciplines
Knowledge deficits
Excessive use of registry staff

43. Is it Worth It? Absolutely

44. Q & A
Ask LA to unmute phones for questions. Can also submit thru chat box.
If not mentioned, what impact has she observed on VAP after implementing the bundle?
What are some countermeasures for staff turnover to hardwire the bundle?
Mute phones.

45. University medical center of el paso
Reintroduce Alex Ramos, Sandra Gonzalez and Dustin Bierman from the UMC El Paso ABCDE team
Can you tell us a bit about UMC El Paso and the patients you serve?
- ICU size, physician staffing (open/closed), staffing
What started you thinking about the ABCDE bundle?
AACN evidence
VAP in trauma patients
Next slide

46. Implementation Challenges
Facilitators:
Daily interdisciplinary rounds
Engagement of key implementation leaders
Sustained, diverse educational efforts
Bundle’s quality and strength
Barriers:
Intervention-related issues (e.g., timing of trials, fear of adverse events)
Communication and care coordination challenges
Knowledge deficits
Workload concerns
Documentation burden
Who is on the team working to implement the bundle?
What barriers have you run into? How have you handled them?
Physician champions, sedation guidelines and evidence IT
Is there anything you’d recommend to someone starting to think about the ABCDE bundle?
Next slide

47. Q & A Handle questions. Unmute phones. Mute when complete.
How would you describe the ICU’s culture in regards to quality improvement at UMC El Paso?

48. The patient’s voice
Dr. Needham: “What did you think when we discussed getting you out of bed while on a ventilator with a breathing tube in your mouth?”
Mr. E:”I thought it was wonderful. Anything to get me up and moving, and get me out of bed; anything to get me off my back and on my feet - that is what I really wanted.”
Dr. Needham: “How did it feel to be awake, with the breathing tube in your mouth, on a ventilator, and walking laps around the medical intensive care unit?”
Mr. E: “It was wonderful. It was nice to get up and walk around. It was not uncomfortable. I enjoyed it. I think it had a very positive effect on me.”
Close with this quote and picture of a patient’s impression of what’s possible.
Ask audience to do three things
Look at their hospital’s context for facilitators and barriers
Identify functional champions
Decide on and execute a plan
Hand back to Laura Anne to close us out. Laura Anne?
Needham DM. Mobilizing patients in the intensive care unit: Improving neuromuscular weakness and physical function. JAMA October. 300(14)

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