1. The CDC Prevention Epicenters’ Wake Up and Breathe Collaborative
CUSP for Mechanically Ventilated Patients
August 4, 2015
Michael Klompas MD, MPH, FIDSA, FSHEA
Harvard Medical School, Harvard Pilgrim Health Care Institute, and
Brigham and Women’s Hospital, Boston, USA

2. Disclosures
Grant funding from CDC Honoraria from the Hospital Association of New York State

3. Critical Care Medicine 2013;41:2467-2475
The group came up with VAE definitions.
Critical Care Medicine 2013;41:

4. Ventilator-Associated Events (VAE)
Sustained rise in daily minimum PEEP ≥3cm or FiO2 ≥20 points after a period of stable or improving daily minimum PEEP or FiO2
Date
PEEP (min)
FiO2
(min)
Jan 1 10
100
Jan 2 5 50
Jan 3 40
Jan 4
Jan 5 8 60
Jan 6
Jan 7
Jan 8
Jan 9
VAE
The core condition for VAE surveillance is a VAC, or ventilator-associated condition. Conceptually, it’s simply a patient who was stable or improving on a vent and then suffered a period of sustained deterioration. This is measured by looking at the vent settings. We look for increases in daily minimum PEEP and FiO2. We use the daily minimum in order to capture the patient’s best value of the day.

5. Canadian Critical Care Trials Group ABATE Study 11 ICUs, 1330 patients, VAE vs VAP Surveillance
9.9 events
per 1000 vent days
VAP
10.6 events
per 1000 vent days VS
100 39
109
What do we know then about VAEs? Well there are now almost a dozen studies of VAE epidemiology. This one is from the Canadian Critical Care Trials Group. They compared VAE vs VAP surveillance in 11 ICUs, more than 1300 patients. They found that VAE and VAP rates were very similar but they captured very different populations of patients. There was very little overlap between the two groups. It’s worth thinking for a moment about the 109 patients that were VAP positive but VAE negative. By definition, these were VAPs that did not require a sustained increase in ventilator support (if they had, they would have been VAEs). One wonders about the clinical significance of these physiologically more benign events.
Muscedere et al. Chest 2013;144:1453

6. Qualitative analysis of 153 VAEs Royal Brisbane & Women’s Hospital, Queensland, Australia
Abx + Furosemide 6%
Pneumonia
38%
Edema
26%
There are also now at least 5 studies assessing the clinical correlates of VAE. What sorts of clinical events tend to trigger VAEs? The results are consistent across all 5 studies. Almost all VAEs are triggered by 1 of 4 conditions: pneumonia, volume overload, atelectasis, or ARDS.
Atelectasis
15%
Other 8%
ARDS 6%
Hayashi et al. Clin Infect Dis 2013;56:

7. VAE = VAP + CHF + ARDS + Atelectasis
Rather, VAEs are a mix of pneumonias, volume, ARDS, and atelectasis.

8. Attributable Mortality of VAE versus VAP
USA – 3 centers
PLoS ONE 2011;6:e18062
USA – 8 centers
Crit Care Med 2012;40:3154
Canada – 11 centers
Chest 2013;144:1453
Netherlands – 2 centers
Am J Resp Crit Care Med 2014;189:947
USA – 2 centers
Crit Care Med 2014;ePub
USA – 1 center
Infect Control Hosp Epidemiol 2014;5:502
What is clear, though, is that VAEs are bad for patients. Here are findings from 6 studies estimating the attributable mortality of VAEs. The results are very consistent. VAEs appear to double the risk of dying compared to similar patients without VAEs. Four of the six studies also estimated the attributable mortality of VAP and we can see that in 3 out of 4 studies, the attributable mortality for VAE was higher.
0.5 1 2 5 10
Odds Ratio or Hazard Ratio 8

9. Fewer VAEs How do we get there?
How do we get there?

10. Minimize duration of mechanical ventilation

11. The CDC Prevention Epicenters’ Wake Up and Breathe Collaborative
Every Patient  Every Day

13. The downsides of sedation
Suppresses respiratory drive
Prolongs ventilator dependence
Increases risk for delirium
Impairs mobility
Increases risk for pneumonia,
atelectasis, ARDS,
deconditioning, etc.

14. 140 patients randomized to routine sedation versus no sedation
Lancet 2010;375:475-80
140 patients randomized to routine sedation versus no sedation
70 prescribed routine sedation (propofol then midazolam)
70 prescribed no sedation (morphine boluses PRN)
Patients with no sedation
Mean 4.2 (95% CI ) fewer days on the vent
Shorter ICU stay (HR 1.86, 95% CI )
Shorter hospital stay (HR 3.6, 95% CI )
More agitated delirium (20% versus 7%) but no difference in self-extubations
1:1 nursing

15. Spontaneous Awakening Trials (SATs)
Putting Our Patients to the Test
Spontaneous Awakening Trials (SATs)
We want to give our patient’s the minimum amount of sedation necessary for comfort
How do we know if we’ve reached the minimum or not?
Give them a challenge: stop all sedatives & observe
Spontaneous Breathing Trials (SBTs)
We want to extubate our patients as soon as it is safe to do so
How do we know if we’ve reached that point or not?
Give them a challenge: turn down the vent or give them a T-piece & observe

16. N=128
NEJM 2000;342:1471-7
Crit Care Med 2004;32:1272

17. Lancet 2008;371:126-34

18. Restart sedatives at ½ prior dose
No oscillator
No active seizures
No benzos for ETOH
No agitation
No paralytics
No active MI
Normal intracranial pressure
No planned surgery in 24hr
SAT Safety Screen
pass
Anxiety, agitation, or pain
Respiratory rate >35/min
SpO2 <88%
Respiratory distress
Acute cardiac dysrhythmia
Diaphoresis
Heart rates >130
Fail SAT
Perform SAT
pass
Screen for SBT
Restart sedatives at ½ prior dose

19. Perform SBT Extubate pass pass SBT Safety Screen Fail SBT Resume
Inspiratory efforts
Oxygen saturation 88%
FiO2 50%
PEEP 8-10cm H2O
No active MI
No paralytics
No agitation (RASS  +2)
Low or no vasopressors
SBT Safety Screen
pass
Agitation or diaphoresis
Respiratory rate >35/min
Respiratory rate <8/min
SpO2 <88%
Mental status change
Acute cardiac dysrhythmia
Fail SBT
Perform SBT
pass
Resume
Vent Support
Extubate

20. CDC Prevention Epicenters’ Wake Up and Breathe Collaborative
Goal: prevent VAEs through less sedation and earlier liberation from mechanical ventilation Mechanism: paired daily spontaneous awakening trials and breathing trials (SATs and SBTs)
Am J Resp Crit Care Med 2015;191:

21. CDC Prevention Epicenters’ Wake Up and Breathe Collaborative
Opt-out protocol for paired daily SATs and SBTs
RNs and RTs initiate SATs/SBTs rather than MDs
Automatic for all patients unless MD actively “opts out”
Protocol developed by national experts
Narrow set of well-defined contraindications
Multicenter learning collaborative to aid implementation
Am J Resp Crit Care Med 2015;191:

22. Participants 12 ICUs from 7 hospitals Stroger Cook County Hospital
Missouri Baptist Medical Center
Duke University
Durham VA
Durham Regional Hospital
North Shore Union Hospital
North Shore Salem Hospital
Am J Resp Crit Care Med 2015;191:

23. Collaborative Components
All Teach – All Learn Model
Each unit designated RN, RT, and MD champions
Improvement Advisor to co-ordinate and motivate the collaborative
Ronda Sinkowitz-Cochran
Two in-person meetings at CDC for all champions
Kick-off meeting to orient, educate, and motivate
Interim meeting to consolidate and re-motivate
Monthly written reports from all ICUs
Progress, challenges, successes, and failures
Goals for the forthcoming month
Monthly collaborative phone calls for all champions
Monthly feedback of local and comparative SAT/SBT rates + outcomes
Expert advice from CDC and Institute for Healthcare Improvement
Consulting faculty: Wes Ely, Terry Clemmer, John Jernigan, Shelley Magill, Michele Balas, Tim Girard, Don Goldmann

24. Sample extract from a monthly report

25. Sample unit-specific monthly summary report

26. Results

27. Enrollment 3,425 episodes of mechanical ventilation
22,991 days of mechanical ventilation
Ventilator-associated events
Events
per 100
Episodes
per Vent-Days
VAC
293
8.5
12.7
IVAC
100
2.9
4.3
Possible Pneumonia 33
1.0
1.4
Probable Pneumonia 17
0.5
0.7
Possible or Probable Pneumonia 50
1.5
2.2
Am J Resp Crit Care Med 2015;191:

28. Population Summary Episodes 3,425 Vent Days 22,991 Age (mean) 62.8
Male
57%
SOFA (mean)
9.3
Mean Vent Days
6.7 days
Mean ICU LOS
11.2 days
Mean Hospital LOS
21.7 days
Hospital Mortality
28%
Am J Resp Crit Care Med 2015;191:

29. Reasons for Intubation
Am J Resp Crit Care Med 2015;191:

30. Unadjusted Outcomes
Am J Resp Crit Care Med 2015;191:

31. SATs and SBTs SBTs: 40% increase SATs: 100% increase
Am J Resp Crit Care Med 2015;191:

32. SBTs Done with Sedatives Off
Am J Resp Crit Care Med 2015;191:

33. Ventilator-Associated Events CDC Prevention Epicenters Wake Up and Breathe Collaborative
VAEs: 37% decrease
IVAC: 65% decrease
Am J Resp Crit Care Med 2015;191:

34. Ventilator Days and ICU Days
ICU: 3 day decrease
Ventilator: 2.4 day decrease
Am J Resp Crit Care Med 2015;191:

35. Some Lessons Learned

36. Get the right people on the bus
Night
Staff
Get the right people on the bus
Chief Quality Officer
Frontline Nurses
Chief
Nursing
Officer
MD Champion
ICU Nursing Director
RT Champion
No VAEs
Frontline RTs
Chief
Medical
Officer
ICU Medical Director
RN Champion
Night Staff
Head of
Respiratory Therapy
Day Staff
Local Opinion Leaders
Frontline Doctors
Pharmacists
Unit Clerk
Image from

37. Educate, educate, & re-educate
Never assume that everyone–
KNOWS about the protocol
UNDERSTANDS the protocol
AGREES with the protocol
Use both formal and informal teaching methods
In-services
Postings
Articles
Lectures
Morning rounds
Hallway discussions

38. Distinguish between means vs ends
SATs are a means, not an end Merely doing SATs alone is insufficient  they’re a means to reduce sedative exposures If staff don’t buy into the idea of managing patients with less sedation, SATs can backfire

39. “Conclusion: For mechanically ventilated adults managed with protocolized sedation, the addition of daily sedation interruption did not reduce the duration of mechanical ventilation or ICU stay.”
SLEAP Study, JAMA 2012;308:

40. Midazolam Equivalents
JAMA 2012;308:

41. Boluses Per Day in the SLEAP Study
JAMA 2012;308:

42. It’s a marathon not a sprint
Image from

43. SAT Performance, ICU X, June 2012 – March 2013
BTRLW

44. Choose the right denominator
The traditional metric for VAP is events per 1000 vent days What if your intervention, however, is specifically designed to reduce vent days?

45. CDC Prevention Epicenters Wake Up and Breathe Collaborative
VAEs per 100 episodes
CDC Prevention Epicenters Wake Up and Breathe Collaborative
37% Decrease
Am J Resp Crit Care Med 2015;191:

46. VAEs per 1000 ventilator-days
CDC Prevention Epicenters Wake Up and Breathe Collaborative
No Change!
Am J Resp Crit Care Med 2015;191:

47. Summary
Hypothesis:
earlier liberation from mechanical ventilation will decrease VAE rates
Strategy: minimizing sedation, paired daily SATs and SBTs
Results
Large increase in SAT rates, marginal increase in SBT rates, large increase in SBTs done with sedatives off
37% decrease in VAEs, 65% decrease in IVACs, non-significant decrease in pneumonias
2.4 day decrease in mean vent days, 3.0 day decrease in ICU days, 6.3 day decrease in hospital days
Lessons:
Get everyone involved
Educate, educate, and re-educate
Prepare for the long-run
Choose the denominator that fits the intervention

48. Thank You! Michael Klompas (mklompas@partners.org)
All RN, RT, and MD Champions and Frontline Providers
Dev Anderson
Barry Kitch
Ellen Arrington
Ken Kleinman
Hilary Babcock
Julie Lankiewicz
Michele Balas
Ebb Lautenbach
Rosie Banks
Lingling Li
Christina Bruce
Shelley Magill
Terry Clemmer
Kelly McCutcheon-Adams
Chris Cox
Michael Murphy
Wes Ely
Carrie O’Neil
Vicky Fraser
Rich Platt
Scott Fridkin
Dan Sexton
Tim Girard
Ronda Sinkowitz-Cochran
Don Goldmann
Manju Srinivasan
Kareema Hunter
William Trick
John Jernigan
Bob Weinstein
Meeta Kerlin-Prasad
Tiffanee Woodard
Michael Klompas