An Initiative of the Florida Hospital Association Hospital Improvement Innovation Network Infection Prevention and NHSN Webinar Series NHSN: Ventilator-Associated Events (VAE) Surveillance Identification and Analysis December 18, 2018
Agenda • Welcome & FHA Mission to Care HIIN Overview – Cheryl Love, RN, BSN, BS-HCA, MBA, LHRM, CPHRM, Director of Quality and Patient Safety and Improvement Advisor, FHA • NHSN: Ventilator-associated Events (VAE) Surveillance Identification and Analysis – 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
HIIN Core Topics – Aim is 20% reduction • 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
VAE Resources, Trainings and Tools Mission to Care Website FHA IVAC Call to Action Website HRET HIIN Website
UP Campaign: Spreading Cross Cutting Strategies 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 5
FHA Mission to Care Update: Ventilator-associated Condition Rate 7.0 6.5 6.0 5.5 5.0 4.5 Rate per 100 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 BL 10/16 11/16 12/16 1/17 2/17 3/17 4/17 5/17 6/17 7/17 8/17 9/17 10/17 11/17 12/17 1/18 2/18 3/18 4/18 5/18 6/18 7/18 8/18 9/18 FL Rate 6.5 5.3 6.4 6.3 5.0 5.5 5.6 6.6 5.5 6.0 5.8 6.1 5.0 6.0 3.3 5.7 4.3 6.2 4.0 5.9 6.2 6.3 5.1 5.3 4.7 HRET HIIN Rate 5.0 4.8 4.5 5.0 4.9 4.8 4.7 4.9 5.2 4.9 4.6 5.0 4.7 5.3 4.5 5.1 5.0 5.1 4.9 5.4 4.9 5.3 5.1 5.2 4.7 # FL Reporting 77 75 75 76 77 77 77 75 75 76 76 77 76 74 72 72 71 67 67 67 71 66 66 66 65 #HRET HIIN Reporting 921 917 908 898 895 888 887 882 874 873 875 867 871 876 863 865 857 846 845 838 849 835 812 800 771 Source: HRET Comprehensive Data System, December 17, 2018
FHA Mission to Care Update: Infection-related Ventilator-associated Condition Rate 4.0 3.5 3.0 Rate per 100 2.5 2.0 1.5 1.0 0.5 0.0 BL 10/16 11/16 12/16 1/17 2/17 3/17 4/17 5/17 6/17 7/17 8/17 9/17 10/17 11/17 12/17 1/18 2/18 3/18 4/18 5/18 6/18 7/18 8/18 9/18 FL Rate 2.2 1.8 1.9 2.5 2.4 2.3 2.6 2.3 2.4 1.9 1.5 2.4 2.9 2.4 0.9 1.8 1.3 2.0 0.9 1.9 1.9 1.6 1.1 1.3 0.8 HRET HIIN Rate 1.6 1.5 1.4 1.6 1.7 1.4 1.6 1.5 1.8 1.5 1.4 1.7 1.5 1.7 1.7 1.6 1.2 1.6 1.4 1.8 1.3 1.5 1.5 1.6 1.0 # FL Reporting 77 75 75 76 77 77 77 75 75 76 76 77 76 75 73 73 72 68 68 68 72 67 66 66 65 #HRET HIIN Reporting 920 921 910 897 896 888 887 883 876 872 874 870 873 878 866 864 857 846 844 838 848 835 812 799 771 Source: HRET Comprehensive Data System, December 17, 2018
FHA Mission to Care Update: Florida | Ventilator-associated Events
VAE Update and Review Linda R. Greene, RN, MPS,CIC, FAPIC Manager, Infection Prevention UR Highland Hospital Rochester, NY linda_greene@urmc.rochester.edu
Objectives 1. Review VAE definitions and updates 2. Discuss the rationale for the VAE definition 3. Identify strategies to prevent VAE
Polling Question 1 Please identify your background: 1. Nursing 2. Infection Prevention 3. Quality 4. Respiratory Care 5. Other
Let’s Review
Possible and Probable VAP are combined (PVAP) Provides simplification Consistent with original plan for analysis (PoVAP and PrVAP combined as 1 event )
Pathogen Exclusions Community associated fungal pathogens that are not known or rarely cause healthcare-associated infections: Cryptococcus Histoplasma Coccidiodes Paracoccidiodes Blastomuces Pneumocystis
Denominator Options Optional Field (Episodes of Mechanical Ventilation) Total number of episodes occurring during a month Evidence based practices focus on getting the patient off the ventilator First step in exploring other denominators Still require ventilator days and APRV days
VAE 2019
Test Your Knowledge Mrs. Jones has a blood stream infection with ecoli om 12/1 She has had a PICC line in place since 11/27 She is has been intubated since 11/27 and placed on a ventilator She also has a VAE onset 11/29
Polling Continued Can the blood stream infection be considered secondary? 1. No 2. Yes 3. If IVAC met 4. If PVAP met
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
Analysis
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
Why the Shift ? inter-rater reliability Variations in Chest X-Ray Interpretation Poor Inter-rater reliability
Why the Shift? 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.
Challenge: We don’t know much about prevention practices Strategy: Execute prevention practices that are evidence based. Standardize practices. 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.
Connect the Safety Dots Immobility Ventilator VAP VAC Harm Morbidity Pulmonary Mortality ARDS Edema IVAC Delays, LOS Atelectasis Antibiotic C Diff Cost$ infection Resistance
Get the patient off the ventilator sooner
Studies • 20 ICUs Nov 2011- May 2013 • Daily paired SATs and SBTs • SATs- stopped all sedatives and narcotics as indicated • SBTs- lower positive end-expiratory pressure support to 5-8 cm H2O for up to 2 hours • Encourage extubation of patients who passed SBTs
Findings Significant decreases in duration of mechanical ventilation Decrease in hospital and ICU LOS Decrease in VAE rate per episode of mechanical ventilation
CDC Prevention Epicenters’ Wake Up and Breathe Collaborative SATs & SBTs Increases 37% in VACs 63% in SATs 16% in SBTs 65% in IVACs 81% in SBTs done with VAE sedatives off Reductions
Basic bundle Sub Epiglottic Suctioning-Evidence supports HOB Monitoring- Low cost. Benefit unknown. Important with tube feeding Weaning, decreasing duration of ventilation-Suggestive evidence PUD Prophylaxis- not related to VAP DVT prophylaxis- not related to VAP Enhanced Bundle Mouth care- (chlorhexidine?) Education and Training Program- Ambulation- Evidence supports
What about Oral Care?
Challenge: This is not Infection Prevention Strategy: Look at this in the broader context of patient safety Need a team approach - opportunity to expand Partner with Respiratory Therapy Many infectious complications are associated with prolonged ventilator use
Reviewing Cases Patient who develops a VAC Chronic vent Ambulation protocols not implemented Dehydrated Sputum not documented Nursing and respiratory not communicating
Challenge: Not a CMS reportable event; I’ll wait until have to report Strategies: Related to morbidity and mortality Included in LTACH reporting Most likely not “if “ but “ when”
Determining VAE- Calculator
Polling Question 3 Is this a VAC? 1. Yes 2. No
The Calculator
Evaluate the Data eventType gender location patID patgname patsurname spcEvent VAE F ICU 1234 Mickey Mouse PVAP VAE F ICU 5678 Donald Duck PVAP 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
Data for Action Vent unit
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?
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