Linda R.Greene,RN,MPS,CIC Manager of Infection Prevention Highland Hospital Rochester, NY Affiliate of University of Rochester Medical Center [email protected].

Linda R.Greene,RN,MPS,CICManager of Infection PreventionHighland Hospital Rochester, NY

Affiliate of University of Rochester Medical [email protected]

Clinical Uses and Ramifications of VAE Data

ObjectivesDiscuss the ramifications of VAE

Describe methods to evaluate VAE

Identify ways to use data to drive improvement

Why Collect VAE Data ?

Infection Prevention efforts may fail due to silo mentality

Need to view interventions under the larger context of patient safety

Connect the dots to harm

Multicenter Evaluation of a Novel Surveillance Paradigmfor Complications of Mechanical Ventilation

PLoS ONE | www.plosone.org 5 March 2011 | Volume 6 | Issue 3 | e18062

Analysis

Outcomes of VAE

Conclusions: Objective surveillance definitions that include quantitative evidence of respiratory deterioration after a period of stability strongly predict increased length of stay and hospital mortality

Connect the Safety Dots

ARDS

AntibioticResistance

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

Why the Shift ?

Variations in Chest X-Ray Interpretation Poor Inter-rater reliability

1. inter-rater reliability

Why the Shift?

2. Broaden the Focus

Shifting the focus of surveillance from pneumonia alone to complications in general emphasizes the importance of preventing all complications of mechanical ventilation, not just pneumonia.

When definitions are objective, care givers can focus on what went wrong rather than debate the definition.

Retrospective Cohort Study 2006-2011

20,356 episodes of mechanical ventilation

1,141 VACs 431 IVACs 266 Combined Pneumonias

VAEsMore days to extubationMore days to dischargeHigher Mortality Rate

ConclusionPrevention Strategies are needed

.

Magill et.al 2014 ID Week : approximately 79% of VAEs were in patients who were either on MV for ≥5 days or in the hospital for ≥5 days at the time of VAE onset.

Conclusion: Characteristics of patients with VAEs in 2013 differ from those with tVAP in 2012. Time to onset data suggest that the majority of VAEs are likely hospital-associated.

Is VAC Preventable ?

What Else do we Know About VAE Prevention?

.

The existing VAP prevention literature is the best available guide to improving outcomes for ventilated patients.

VAP interventions that have been shown to improve objective outcomes, such as duration of mechanical ventilation, intensive care or hospital length of stay, mortality, and/or costs in randomized controlled trials.

Getting Started

Where to Start ?

1. Look at both process and outcome measures

2. Do we see improvements?

3. Important to track you own performance over

time

How can we Evaluate the Data?

eventType gender location patID patgname patsurname spcEvent

VAE F ICU

1234

Mickey Mouse POVAP

VAE F ICU 5678 Donald Duck POVAP

VAE F ICU 2222 Charlie Brown VAC

VAE F ICU 1333 Minnie Mouse VAC

VAE M ICU 4444 Bugs Bunny VAC

VAE M ICU 5555 Super Man VAC

VAE F ICU 6666 Spider Woman VAC

Bundle Process Measure Date Y/N CommentsContinuous Subglottic Suctioning

Assess readiness to extubate ( Spontaneous breathing trials)

Paired SBT’s and SATs

Interrupt sedation daily( Spontaneous awakening trials)

If contraindications – note here

Ambulate according to protocol*

Note level

Regular Mouth care (without chlorhexidine )*

Elevate HOB 35-400

Conservative fluid management

Blood Transfusions Given Rationale:

Low Tidal Volume Identify:

What about Oral Care?

Findings Randomized clinical trials comparing

chlorhexidine vs placebo in adults receiving mechanical ventilation.

16 studies meeting criteria – 3,630 patients

There were fewer lower respiratory tract infections in cardiac surgery patients randomized to chlorhexidine

No significant difference in ventilator-associated pneumonia risk in double-blind studies of non–cardiac surgery patients

Your VAC Rates

Early Comparison DataComparative data should be available early next year

Incidence rates of ventilator-associated events and ventilator-associated pneumonia in the National Healthcare Safety Network, 2012-2013

VAE Rates in Published Studies

How will I use my data to drive improvement?

Review both individual cases and system level issues

Do we have policies and procedures in place ?

Do we follow evidence based guidelines?

Are we consistent with our practices?

Reviewing Cases

Patient who develops a VAC

Chronic vent

Ambulation protocols not implemented

Dehydrated

Sputum not documented

Nursing and respiratory not communicating

Opportunities

• Hardwire ambulation protocols

• Ensure documentation of secretions

• Work collaboratively with respiratory therapy to identify subtle changes

• Daily huddle

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Another Case Mrs. X is a 76 y.o. woman admitted to the ICU with septic shock requiring large volume fluid resuscitation.

She is intubated and placed on the ventilator

She is stable on the ventilator until day 6 when she has

progressing oxygenation demands

She has developed a VAC

Case evaluationNo fever

No increased white count

No new antibiotics

Diagnosis: Pulmonary Edema

Opportunities for improvement ?

Another oneIn another ICU, a large proportion of VAC’s are possible or probable pneumonia

Evaluation:

HOB monitoring?

Suctioning frequency?

SATs?

ET tubes with Subglottic suctioning?

Analysis of Data

The team analyzes their data

During the first quarter they had 20 VAC’s

16 of these meet criteria for IVAC

They recognize that the usual ratio for ICU’s is 1/3 to 1/2

IVAC Analysis Not PVAPS

Most are other HAIs

Considerations?

Prevention Thoughts

Prevention of Pneumonia- HOB

Pulmonary- fluid conservation

Atelectasis – manage sedation

Acute lung injury-low tidal volume

Execute- Applying the NHSN Definition

“If we could change ourselves, the tendencies in the world would also change. As a man changes his own nature, so does the attitude of the world change towards him. … We

need not wait to see what others do”

-Gandhi

36

Know your Data

Surveillance is a critical component of every quality improvement effort; you cannot prevent it if you cannot measure it.

The Bottom Line

VAE associated with mortality and LOS (my experience supports this)

Continue to monitor processes of care and outcomes

Give feedback to providers and assess potential for preventable events