Infection Prevention Webinar Series: Implementation of Best - - PowerPoint PPT Presentation

An Initiative of the Florida Hospital Association Hospital Improvement Innovation Network

Infection Prevention Webinar Series: Implementation of Best Practices for Ventilator-associated Events (VAE) Prevention

July 24, 2019

• Welcome & FHA Mission to Care HIIN Update

– Cheryl Love, RN, BSN, BS-HCA, MBA, LHRM, CPHRM, Director of Quality and Patient Safety and Improvement Advisor, FHA

• Infection Prevention Series: Implementation of “Best

Practices” for VAE Prevention

– Linda R. Greene, RN, MPS, CIC, FAPIC, Manager of Infection Prevention, UR Highland Hospital, Rochester, NY

• Q&A
• Upcoming HIIN Events and Opportunities
• Evaluation Survey & Continuing Nursing Education

Agenda

• Adverse Drug Events (ADE)
• Catheter-associated Urinary Tract Infections (CAUTI)
• Clostridium Difficile Infection (CDI)
• Central line-associated Blood Stream Infections (CLABSI)
• Hospital-onset MRSA Bacteremia
• Injuries from Falls and Immobility
• Pressure Ulcers (PrU)
• Sepsis
• Surgical Site Infections (SSI)
• Venous Thromboembolisms (VTE)
• Ventilator-Associated Events (VAE/IVAC/PVAP)
• Readmissions (12% reduction)
• Worker Safety

HIIN Core Topics – Aim is 20% reduction

VAE Resources, Trainings and Tools

 Mission to Care Website  FHA IVAC Call to Action Website  HRET HIIN Website

Designed to reduce multiple forms of harm with simple, easy-to-accomplish activities that cut across several topics to decrease harm. Focused on four components:

• SOAP UP: Hardwire Hand Hygiene
• GET UP: Mobilize Patients
• WAKE UP: Prevent Over-sedation
• SCRIPT UP: Optimize Inpatient

Medications

UP Campaign:

Spreading Cross Cutting Strategies

5

FHA Mission to Care Update: Ventilator-associated Condition Rate

Source: HRET Comprehensive Data System, July 23, 2019

BL O-16 N-16 D-16 J-17 F-17 M-17 A-17 M-17 J-17 J-17 A-17 S-17 O-17 N-17 D-17 J-18 F-18 M-18 A-18 M-18 J-18 J-18 A-18 S-18 O-18 N-18 D-18 J-19 F-19 M-19 A-19 M-19 FL Rate 6.58 5.21 6.29 6.37 4.99 5.41 5.52 6.55 5.44 6.09 5.82 6.11 5.05 6.03 3.34 5.66 4.27 5.71 3.85 5.61 5.74 6.08 4.99 5.77 4.97 4.44 5.20 5.38 6.31 7.12 6.33 7.38 6.10 HRET HIIN Rate 4.93 4.82 4.60 4.96 4.96 4.85 4.69 4.98 5.27 4.97 4.75 5.00 4.77 5.32 4.51 5.13 5.05 4.99 4.81 5.43 4.88 5.33 5.16 5.26 4.94 5.03 5.22 5.27 5.06 5.67 5.25 5.36 5.18 # FL Reporting 76 74 74 75 76 76 76 75 75 76 76 77 76 75 73 73 72 68 68 68 72 68 69 69 69 73 73 72 72 71 71 67 60 #HRET HIIN Reporting 913 910 904 895 891 884 883 876 874 871 874 868 867 871 864 863 860 850 849 845 853 845 842 839 839 836 836 832 814 798 788 727 584

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 Rate per 100

FHA Mission to Care Update: Infection-related Ventilator-associated Condition Rate

Source: HRET Comprehensive Data System, July 23, 2019

BL O-16 N-16 D-16 J-17 F-17 M-17 A-17 M-17 J-17 J-17 A-17 S-17 O-17 N-17 D-17 J-18 F-18 M-18 A-18 M-18 J-18 J-18 A-18 S-18 O-18 N-18 D-18 J-19 F-19 M-19 A-19 M-19 FL Rate 2.20 1.83 1.86 2.48 2.33 2.31 2.53 2.29 2.39 1.85 1.48 2.38 2.87 2.45 0.89 1.77 1.23 1.97 0.94 1.94 1.88 1.52 1.09 1.58 1.06 0.85 2.01 0.89 1.37 1.67 2.11 2.05 2.28 HRET HIIN Rate 1.60 1.54 1.44 1.62 1.71 1.44 1.63 1.53 1.81 1.52 1.48 1.71 1.52 1.69 1.67 1.68 1.27 1.63 1.46 1.84 1.43 1.50 1.56 1.66 1.19 1.49 1.76 1.53 1.60 1.66 1.67 1.61 1.57 # FL Reporting 76 74 74 75 76 76 76 75 76 77 77 78 77 76 74 74 73 69 69 69 73 69 70 70 70 74 74 74 74 73 72 68 61 #HRET HIIN Reporting 910 914 907 894 893 885 883 876 875 871 875 871 870 873 865 862 858 849 847 845 851 845 844 841 841 835 834 831 812 799 786 724 582

0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 Rate per 100

FHA Mission to Care Update: Possible Ventilator Association Pneumonia (PVAP)

Source: HRET Comprehensive Data System, July 23, 2019

BL O-16 N-16 D-16 J-17 F-17 M-17 A-17 M-17 J-17 J-17 A-17 S-17 O-17 N-17 D-17 J-18 F-18 M-18 A-18 M-18 J-18 J-18 A-18 S-18 O-18 N-18 D-18 J-19 F-19 M-19 A-19 M-19 FL Rate 0.68 0.60 0.12 0.22 0.68 0.34 0.66 0.25 0.76 0.96 0.85 0.48 0.37 1.09 0.34 0.73 0.41 0.71 0.46 0.89 1.53 0.50 1.29 0.59 1.26 0.69 0.90 0.73 1.64 0.76 1.07 0.51 0.41 HRET HIIN Rate 0.53 0.58 0.49 0.39 0.49 0.63 0.58 0.43 0.65 0.62 0.61 0.64 0.74 0.82 0.51 0.44 0.67 0.61 0.47 0.47 0.58 0.76 0.92 0.74 0.73 0.60 0.57 0.61 0.79 0.50 0.59 0.48 0.47 # FL Reporting 54 49 49 50 52 52 52 49 49 51 50 51 51 52 54 53 51 54 55 55 55 54 55 55 56 56 57 56 58 57 57 55 53 #HRET HIIN Reporting 605 669 671 659 687 683 681 679 683 683 687 686 689 693 698 692 694 695 693 692 698 699 701 701 704 705 712 708 697 688 684 619 496

0.0 0.5 1.0 1.5 2.0 2.5 3.0 Rate per 100

FHA Mission to Care Update: Florida | Ventilator-associated Events

Infection Prevention and NHSN Virtual Series

*Access Event Archives (Recordings | Slides) on the Mission to Care HIIN Website

10

Date Topic Register Online

• Oct. 23, 2018

NHSN: SSI Surveillance Identification and Analysis

Event archive*

• Nov. 20, 2018

SSI-Colon: How to Assess Root Cause and Prevention Strategies

Event archive*

• Dec. 18, 2018

NHSN: VAE Surveillance Identification and Analysis

Event archive*

• Jan. 22, 2019

VAE: How to Assess Root Cause and Prevention Strategies

Event archive*

• Feb. 19, 2019

NHSN: MRSA Bacteremia Surveillance Identification and Analysis

Event archive*

• Mar. 26, 2019

MRSA Bacteremia : How to Assess Root Cause and Prevention Strategies

Event archive*

Infection Prevention Boot Camp Resource Guide (May 30-31, 2019)

Surgical Infection Prevention (SIP) Webinar Series

*Access Event Archives (Recordings | Slides) on the Mission to Care HIIN Website

Date Topic Register Online

• Apr. 26, 2019

SIP Webinar Series #1: Pre-operative Strategies for Prevention of SSI

Event archive*

May 22, 2019 SIP Webinar Series #2: Intra-operative Strategies for Prevention of SSI

Event archive*

• Jun. 25, 2019

SIP Webinar Series #3: Post-operative Strategies for Prevention of SSI

Event archive will be posted online

11

Preventing Post-Surgical Harm Resource Guide (Jun. 5, 2019)

VAE

Assessment and Prevention Strategies

Linda R. Greene, RN, MPS, CIC, FAPIC Linda_Greene@urmc.rochester.edu

Objectives

 Review VAE definition  Discuss Current Literature related to VAE  Describe key prevention strategies to prevent VAE

Polling Question

What is your background?

• 1. IP
• 2. Respiratory Care
• 3. Quality
• 4. Nursing
• 5. Other

Background

 Estimate: 157,000 healthcare-associated

pneumonias occur in acute care hospitals in U.S. with 39% being ventilator-associated*

 Ventilator-associated pneumonia (VAP) is an

important complication of mechanical ventilation but other adverse events also happen to ventilated patients

*Magill SS., Edwards, JR., Bamberg, W., et al. “Multistate Point-Prevalence Survey of Health Care-

Associated Infections, 2011”. New England Journal of Medicine. 370: (2014): 1198-1208

Background

 Definition changed in 2013  Challenges with inter-rater reliability related to CXR  No major changes except:

Possible and Probable VAP- Now PVAP Pathogen updates

Let’s Review

Connect the Safety Dots

ARDS

Antibiotic Resistance

Atelectasis

C Diff infection

Ventilator Harm

IVAC VAC Pulmonary Edema

VAP

Morbidity Mortality

Delays, LOS Cost$

Immobility

Broadening the Surveillance

Intentional Associated Conditions:

• ARDS
• Pulmonary Edema
• Thromboembolic disease
• Sepsis

Respiratory deterioration in previously stable patients is a risk factor for increased morbidity and mortality

The Chest X-RAY

Goal

Get the patient off the ventilator sooner

Study

A retrospective cohort study examining 20,356 episodes of mechanical ventilation (MV)1 – VAEs

• 1,141 ventilator-associated conditions (VACs)
• 431 infection-related VACs (IVACs)
• 266 possible cases of ventilator-associated

pneumonia (PVAP) – Patients with a VAE have—

• More days to extubation
• More days to discharge
• Higher mortality rate
• Klompas M, Kleinman K, Murphy MV

. Descriptive epidemiology and attributable morbidity of

ventilator-associated events. Infect Control Hosp Epidemiol. 2014 May;35(5):502-10.

Risk Factors

Risk factors for ventilator-associated events: A prospective cohort study

Liu et al. / American Journal of Infection Control 47 (2019) 744−749

Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update

• The true incidence of VAP is difficult to determine since traditional surveillance definitions

are highly subjective.

• Historically, 10-20% of ventilated patients developed VAP.
• More recent reports suggest much lower rates but it is unclear to what extent these

lower rates reflect better care versus stricter application of subjective surveillance criteria

• r better care
• Until studies are published on best strategies to prevent all VAEs, the

existing VAP prevention literature is the best available guide to improving

• utcomes for ventilated patients

Prevention Strategies



Avoid intubation if possible



Minimize sedation:

Assess readiness to extubate once a day (spontaneous breathing trials) Interrupt sedation once a day (spontaneous awakening trials) Pair spontaneous breathing trials with spontaneous awakening trials Patients are more likely to pass a spontaneous breathing trial and get extubated if they are maximally awake at the time of the breathing trial

Physical Conditioning

Lack of physical conditioning can result In ICU related weakness ( presence of weakness with no other etiology

• ther than ICU)

Healthy adults can lose 5-9% of quadriceps muscle mass after 2 weeks In mechanically ventilated patients, skeletal muscle area can decrease as much as 12.5 % in the first week

Hashem et. Al Respir Care 2016;61(7): 971-979Early Mobilization and Rehab in the ICU

Importance of Nurse-led Mobilization

 Most ICU nurses know why Early Mobility in the

ICU is critically important

 Need to do root cause analysis of barriers and

address each through education, training, policies, equipment, communication

 Barriers found upon Beaumont survey:

 Safety is a high concern  Risk of injury to patient and self  Accurately dosing mobility, choosing equipment,

and communicating

Problems Associated with Critical Illness

 When deconditioning and muscle weakness occur the

course becomes complicated, the stay in the ICU is prolonged, and mortality increases

 Risk developing ICU-associated weakness due to

polyneuropathy, myopathy, or a combination of both

 The cumulative effect of the complications are

functional limitations that might or might not resolve.

Potential body/structure effects of critical illness

Nordon-Craft A, Moss M, Quan D, Schenkman M: Intensive care unit-acquired weakness: Implication for physical therapist management. Phys Ther. 2012; 92:1494-1506.

What Are Your Barriers?

Needham and Korpolu, Top Stroke Rehabil 2010;17(4):271–281

4E’s Early Mobility

Frontline Staff Early Mobility Engage Adaptive

Ask, how will Early Mobility make the world a better place?

• Help staff understand preventable harm
• Share stories about patients affected
• Develop a business care
• Include execute champion/physician leadership
• Define evidence related to preventing VAEs (short and

long term cognitive affects, and physical/psychological disabilities)

• Create business case related to the impact of early

mobility, including increased time off the ventilator, decreased hospital LOS and decreased ICU LOS

• Share business case with executive champion/ physician

leadership

Educate Technical

What do we need to mobilize critically ill patients?

• Convert evidence into behaviors
• Evaluate awareness and agreement
• Review the literature
• develop mobility criteria and progressive mobility

protocol/guideline

• Define your education plan (utilizing workshops, hands-
• n trainings, conferences, slides, presentations and

interactive discussions via multiple modalities to cater to different learning styles)

• Identify support through outreach to the leadership team

Execute Adaptive

How will we implement early mobility at our hospital give local culture and resources?

• Listen to resisters
• Standardize care and create independent checks
• Make it easy to do the right thing
• Learn from mistakes
• What is the process for mobilizing a patient?
• Is there a policy on the unit?
• Who should be involved?
• Do we have all the equipment?
• Discuss as part of interdisciplinary rounds/daily goals
• Learn from defects

Evaluate Technical

How will we know that our efforts to mobilize our patients made a difference?

• Define measures
• Regularly assess measures
• Provide feedback to staff and celebrate success
• Collect Early Mobility Daily Rounding measures and

review at CUSP 4 MVP-VAP meetings

• Use CECity to trend performance

Educate

Turn evidence into behaviors

 Define/Approve Mobilization readiness criteria  Develop early/progressive mobility

protocol/guideline

Polling Question

Our unit has protocol for early exercise and progressive mobility for ALL patients:

 Yes  No

Strategies

• Green- low risk of

adverse even

• Yellow – potential

risk ( weigh benefit/ Risk)

• Red Significant Risk

Other Strategies

Minimize pooling of secretions above the endotracheal tube cuff

 Provide endotracheal tubes with subglottic secretion

drainage ports for patients likely to require more than 48

• r 72 hours of intubation

(Extubating patients in order to place a subglottic

secretion drainage endotracheal tube is not recommended)

Head of Bed

Elevate the head of the bed to 30-45°



A trial in 86 patients showed that semi recumbent positioning reduced the rates of clinically suspected and microbiologically proven nosocomial pneumonia by 4-fold.

 A Cochrane literature review based on small and

potentially biased studies found an overall benefit in reducing VAP rates when patients were positioned at 30° to 60°

What about bundles?

ABCDE Awakening and Breathing Coordination, Delirium, and Early exercise/mobility bundle

Identifying Barriers to Delivering the Awakening and Breathing Coordination, Delirium, and Early Exercise/Mobility Bundle to Minimize Adverse Outcomes for Mechanically Ventilated Patients

A Systematic Review

Costa et. Al CHEST 2017; 152(2):304-311

Identified Barriers to ABCDE Delivery From the Literature

Patient-related barriers:

 Lack of patient cooperation 

Patient instability and patient safety concerns (hemodynamics, treatment-related adverse events, physiologic patient issues)

 Patient status issues (diarrhea, fatigue, leaking

wound, patient weight or size, confusion/agitation, imminent death)

Clinician-related barriers:

• Lack of knowledge and awareness about protocol
• Lack of conceptual agreement with guidelines
• Lack of self-efficacy and confidence in implementing protocol
• Clinician preference for autonomy (resistance to change,

expectation of nurse)

• Staff and patient safety concerns
• Perception that rest equals healing
• Lack of confidence that protocol will improve workflow or

improve patient outcomes

• Perceived workload (hard work)
• Staff attitude and lack of buy-in

Protocol-related barriers:

• Unavailable or cumbersome to use protocols
• Unclear protocol criteria and agreement or discomfort with

guidelines

• Protocol development cost (time and money to develop)
• Learning curve (possibility for clinician to test guideline and
• bserve other clinicians using the guideline easily)
• Lack of clarity as to who is responsible, steps needed to take,

and expected standards for protocol implementation

• Lack of confidence in evidence supporting protocol and

guideline developer

• Lack of confidence in reliability of screening tool

ICU Culture (safety culture)



Inter professional team care coordination, communication, and collaboration barriers



Lack of leadership/management



Inter professional clinician staffing, workload, and time



Lack of inter professional team support and training/expertise



Physical environment, equipment, and resources



Staff turnover



Low prioritization and perceived importance



Competing priorities and need for further planning



Scheduling conflicts (i.e., patient off unit, at dialysis, procedure) contextual barriers

What about Mouth Care?

Tooth brushing for critically ill mechanically ventilated patients: a systematic review and meta-analysis of randomized trials evaluating ventilator-associated pneumonia.

Six trials enrolling 1,408 patients, five of which compared tooth brushing to usual oral care and one of which compared electric with manual tooth brushing. Four trials, there was a trend toward lower ventilator-associated pneumonia rates (risk ratio, 0.77; 95% confidence interval, 0.50-1.21; p = 0.26). No impact on length of stay, morbidity or mortality

Alhazzani et. al Crit Care Med. 2013 Feb;41(2):646-55.

What About Oral Care With Chlorhexidine?

 Routine oral care with chlorhexidine

 Prevents nosocomial pneumonia in cardiac surgery

patients

 May not decrease VAP risk in noncardiac surgery

patients

 Does not affect—

 Mortality  Duration of MV  Intensive care unit (ICU) LOS

Klompas M, Speck K, Howell MD, Greene LR et al. Reappraisal

• f routine oral care with chlorhexidine gluconate for patients

receiving mechanical ventilation: systematic review and meta-

• analysis. JAMA Intern Med. 2014 May;174(5):751-61. PMID:

24663255.

IVAC

Review IVAC

Associated Strategies

 CHG bathing  Urinary catheter and central line usage  Central line care and maintenance

What about bundles?

Two-State Collaborative Study of a Multifaceted Intervention to Decrease Ventilator-Associated Events

Setting: Fifty-six ICUs at 38 hospitals in Maryland and Pennsylvania from October 2012 to March 2015. Evidence-based interventions promoted by the collaborative included head-of-bed elevation, use of subglottic secretion drainage endotracheal tubes, oral care, chlorhexidine mouth care, and daily spontaneous awakening and breathing trials Measurements and Results: ICUs reported 69,417 ventilated patient-days of intervention compliance observations and 1,022 unit-months of ventilator-associated event data. The quarterly mean ventilator-associated event rate significantly decreased from 7.34 to 4.58 cases per 1,000 ventilator-days after 24 months of implementation (p = 0.007). During the same time period, infection-related ventilator-associated complication and possible and probable ventilator-associated pneumonia rates decreased from 3.15 to 1.56 and 1.41 to 0.31 cases per 1,000 ventilator-days (p = 0.018, p = 0.012), respectively

Rawat et.al Critical

cal Car are Medici cine : Volume 45(7), July 2017, p 1208-1215

Best Practices for VAE Reduction

RECOMMENDATION INTERVENTION

Basic practice

• Use noninvasive positive pressure ventilation in

selected populations

• Manage patients without sedation whenever

possible

• Interrupt sedation daily
• Assess readiness to extubate daily
• Perform SATs with sedatives turned off
• Facilitate early mobility
• Use endotracheal tubes with subglottic secretion

drainage ports for patients expected to require greater than 48 or 72 hours of MV

• Change the ventilator circuit only if visibly soiled
• r malfunctioning
• Elevate HOB to 30– 45°

Special approaches

• Select oral or digestive decontamination
• Regular oral care with chlorhexidine
• Prophylactic probiotics
• Ultrathin polyurethane endotracheal tube cuffs
• Automated control of endotracheal tube cuff

pressure

• Saline instillation before tracheal suctioning
• Mechanical tooth brushing

Generally not recommended

• Silver-coated endotracheal tubes
• Kinetic beds
• Prone positioning

Final Information

2020- update to compendium Nutritional strategies Pediatrics Bundles Current public reporting More recent evidence

Final Thoughts

 Must Measure to manage  VAE surveillance takes a village  Bundle should be simple and measurable  Compliance is key

Questions?

• Jul. 25 – Sepsis Alliance | Sepsis: Across the Continuum of Care
• Jul. 30 – HRET HIIN | Hot Topic: Patient and Family Engagement
• Jul. 31 – HRET HIIN | Hot Topic: Falls
• Aug. 5 – FHA HIIN Lead Virtual Meeting (Registration Coming Soon)
• Aug. 7 – FHA | Monthly Quality Hot Topics Virtual Meeting #9
• Aug. 8 – FHA HIIN | What is Health Literacy, and Why is it Important?
• Aug. 12 – HRET HIIN | Alternatives to Opioids Webinar Series #4
• Aug. 14 – FHA HIIN | Enhanced Recovery After Surgery

Upcoming Virtual Events

Check the weekly MTC HIIN Upcoming Events for details and registration

Register today at www.FHAAnnualMeeting.com Early Bird – Register by Aug. 31

• Eligibility for Nursing CEU requires submission of an evaluation

survey for each participant requesting continuing education: https://www.surveymonkey.com/r/IP-VAE-072419

• Share this link with all of your participants if viewing today’s

webinar as a group (Survey closes Aug. 3, 2019)

• Be sure to include your contact information and Florida nursing

license number

• FHA will report 1.0 credit hour to CE Broker and a certificate will

be sent via e-mail (Please allow at least 2 weeks after the survey closes)

Evaluation Survey & Continuing Nursing Education

Cheryl D. Love, RN, BSN, BS-HCA, MBA, LHRM, CPHRM Florida Hospital Association cheryll@fha.org | 407-841-6230 Linda R. Greene, RN, MPS, CIC Manager of Infection Prevention UR Highland Hospital, Rochester, NY linda_greene@urmc.rochester.edu

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