1. The Cardiac Surgery Translational Study (“CSTS”) The Quality And Safety Research Group Ventilator Associated Pneumonia Prevention Sean Berenholtz, MD MHS FCCM March 25, 2011 Immersion Call

2. Slide 2 Immersion call Schedule TitleDate /Time 13:00 EST Presented by Program Overview Feb 18, 2011Peter Pronovost MD PhD Science Of Safety February 25, 2011Jill Marsteller, PhD, MPP Comprehensive Unit-Based Safety Program CUSP March 4, 2011Christine Goeschel MPA MPS ScD RN Central Line Blood Stream Infection Elimination March 11, 2011David Thompson DNSC, MS Surgical Site Infection Elimination March 18, 2011Elizabeth Martinez, MD, MHS Ventilator-Associated Pneumonia Reduction March 25, 2011Sean Berenholtz, MD Hand-Offs: Transitions in Care April 1, 2011Ayse Gurses, PhD Data we Can Count on April 8, 2011Lisa Lubomski, PhD. Team Building April 15, 2011Jill Marsteller, PhD, MPP Physician Engagement April 22, 2011Peter Pronovost, MD, PhD

3. Slide 3 CSTS Timeline Planned Roll-out – CLABSI Prevention interventions and monthly data collection: June, 2011 – SSI Prevention interventions and monthly data collection: Approximately September 2011 – VAP Prevention and monthly data collection: After December 2011

4. Slide 4 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 as part of CSTS

5. Slide 5 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.

6. Slide 6 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.

7. Slide 7 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

8. Slide 8 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.

9. Slide 9 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

10. Slide 10 Translating Evidence into Practice Pronovost, Berenholtz, Needham. BMJ 2008

11. Slide 11 Improving Care for Ventilated Patients Engage – Partner with infection preventionists – Post performance, – Tell stories of harm Educate – Reviewed evidence on conference calls, – One-page fact sheets, – Slides for teams

12. Slide 12 Improving Care for Ventilated Patients Decrease complexity / create redundancy: – Standardized ordersets and protocols – Daily goals checklist Other independent redundancies – Nursing and families – Are patients receiving the prevention they should?

13. Slide 13 Sample Daily Goals J Crit Care 2003;18(2):71-75

14. Slide 14 Improving Care for Ventilated Patients 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.

15. Slide 15 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

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

17. Slide 17 Michigan Keystone ICU (n= Infect Control Hosp Epidemiol. 2011;32(4):305-314.

18. Slide 18 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

19. Slide 19 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

20. Slide 20 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

21. Slide 21 Next Steps Keystone ICU VAP project focused on ‘Ventilator Bundle’ Need to develop ‘VAP prevention bundle’ – Funded by NIH/NHLBI – Delphi process led by RAND researcher – Recruiting ICU physicians and nurses to gain broad consensus – Send us an email if your interested in participating

22. Slide 22 European Care Bundle for VAP Prevention Intensive Care Med 2010;36:773-780

23. Slide 23 Next Steps Develop ‘VAP prevention bundle’ Revise process measures and data collection tools CSTS VAP prevention and monthly data collection: After December 2011