Broad­en­ing ven­ti­la­tor sur­veil­lance mea­sures im­proves care

Modern Healthcare - - BEST PRACTICES - By Mau­reen McKin­ney

Scott & White Health­care in­fec­tion preven­tion spe­cial­ists used to de­bate at length whether in­ten­sive-care pa­tients had ven­ti­la­tor-as­so­ci­ated pneu­mo­nia.

There was good rea­son to put ven­ti­la­tor-as­so­ci­ated pneu­mo­nia, or VAP, on the watch list at the Tem­ple, Texas, hospi­tal. The dan­ger­ous lung in­fec­tion hits an es­ti­mated 1 in 11 crit­i­cally ill pa­tients on ven­ti­la­tors na­tion­wide. VAP is as­so­ci­ated with longer hospi­tal stays, higher mor­tal­ity rates and steeper health­care costs.

Over the past decade, hos­pi­tals have fo­cused in­creased at­ten­tion on VAP. The Cen­ters for Dis­ease Con­trol and Preven­tion added sur­veil­lance pro­to­cols for VAP in its Na­tional Health­care Safety Net­work, an on­line health­car­e­as­so­ci­ated in­fec­tion reporting sys­tem.

But the def­i­ni­tion for VAP was no­to­ri­ously sub­jec­tive. It re­quired, for in­stance, in­ter­pre­ta­tion of a chest X-ray. Just get­ting in­fec­tion-preven­tion staff and clin­i­cians to agree that a pa­tient ac­tu­ally had VAP was very dif­fi­cult, said Bill Schreier, an in­fec­tion preven­tion prac­ti­tioner at Scott & White.

The strug­gle to cor­rectly iden­tify pneu­mo­nia cases took time away from med­i­cal staff’s abil­ity to main­tain sur­veil­lance of other com­pli­ca­tions re­lated to ven­ti­la­tor care, such as edema, blood clots and ad­verse drug re­ac­tions. Clin­i­cal ex­perts be­gan ar­gu­ing for pro­to­cols that looked more broadly at all ven­ti­la­tor-re­lated ad­verse events.

“Con­ven­tional VAP sur­veil­lance could take as long as 30 to 40 min­utes per case,” said Dr. Michael Klom­pas, an in­fec­tious-dis­ease physi­cian and as­so­ciate hospi­tal epi­demi­ol­o­gist at Brigham and Women’s Hospi­tal in Bos­ton. “It was a para­dox: It took an enor­mous amount of time to see if a pa­tient had pneu­mo­nia, and then that de­ter­mi­na­tion was still sub­jec­tive.”

In 2011, the CDC con­vened a work group to de­velop an eas­ier-to-use al­go­rithm for a broader cat­e­gory: ven­ti­la­tor-as­so­ci­ated events, or VAEs. Hos­pi­tals across the coun­try wel­comed the new cri­te­ria as a way to more ac­cu­rately mea­sure ad­verse ven­ti­la­tor events, gauge ICU qual­ity and im­prove pa­tient care.

Schreier and his col­leagues were pleased with the cri­te­ria, but un­sure what changes the new VAE sur­veil­lance meth­ods re­quired. They were anx­ious to move be­yond mea­sure­ment and adopt new ev­i­dence-based ven­ti­la­tion prac­tices.

So in June 2012, six months be­fore the CDC’s new VAE sur­veil­lance def­i­ni­tions were sched­uled to take ef­fect, Scott & White Health­care joined the Texas Wake Up and Breathe Im­prove­ment Col­lab­o­ra­tive, an ini­tia­tive led by the Texas Cen­ter for Qual­ity and Pa­tient Safety, part of the state’s hospi­tal as­so­ci­a­tion.

The col­lab­o­ra­tive’s 19 mem­ber hos­pi­tals shared ev­i­dence-based prac­tices for ven­ti­lated ICU pa­tients, while also pre­par­ing to im­ple­ment the CDC’s new reporting pro­to­cols, said Rachel Harde­gree, a re­s­pi­ra­tory ther­a­pist and the qual­ity cen­ter’s di­rec­tor of pro­gram man­age­ment.

The two-prong ini­tia­tive fo­cuses on wak­ing ICU pa­tients up daily, and then test­ing whether they can breathe on their own. This paired, co­or­di­nated in­ter­ven­tion has been shown to sig­nif­i­cantly re­duce lengths of stay and im­prove out­comes for ven­ti­lated pa­tients.

Bol­stered by its work with the col­lab­o­ra­tive, Scott & White also markedly re­duced the amount of se­da­tion drugs given to its ven­ti­lated pa­tients. Heavy se­da­tion is not only as­so­ci­ated with ad­verse events such as delir­ium, but makes it more dif­fi­cult to wake pa­tients and test in­de­pen­dent breath­ing, Schreier said.

“Many of us were afraid that by re­duc­ing se­da­tion, we would have pa­tients wak­ing up and tak­ing their breath­ing tubes out,” Schreier said. “We learned from the suc­cess other hos­pi­tals had that that didn’t re­ally hap­pen.”

Scott & White also charged a phys­i­cal ther­apy team with get­ting hospi­tal ICU pa­tients up and walk­ing around far sooner, an­other in­ter­ven­tion linked to shorter lengths of stay and fewer com­pli­ca­tions.

Through the Wake Up and Breathe col­lab­o­ra­tive, Scott & White ad­justed its data-collection pro­cesses to align with the CDC’s new ven­ti­la­tor-as­so­ci­ated event re­quire­ments.

Those VAE pro­to­cols and def­i­ni­tions, which went into ef­fect in Jan­uary 2013, use a clearly de­fined, tiered al­go­rithm to iden­tify all ven­ti­la­tor-as­so­ci­ated con­di­tions—not just VAP—and to de­ter­mine whether those con­di­tions are in­fec­tion-re­lated.

Klom­pas, who pro­vided pro­fes­sional guid­ance for the Texas Wake Up and Breathe col­lab­o­ra­tive, de­vel­oped a re­lated cal­cu­la­tor that hos­pi­tals can use to en­ter data—such as the per­cent­age of oxy­gen a pa­tient is in­hal­ing—that pro­vide spe­cific mea­sures for mak­ing a VAE de­ter­mi­na­tion. “With the new def­i­ni­tions, there’s no room to ar­gue about whether some­thing is a VAE or not,” Schreier said. “It just is what it is.”

As of Feb. 1, roughly 1,500 hos­pi­tals are now vol­un­tar­ily reporting VAEs to the CDC’s Na­tional Health­care Safety Net­work, federal of­fi­cials said.

Al­though the new VAE def­i­ni­tion makes it hard to com­pare data from be­fore and af­ter Scott & White’s im­prove­ment ef­forts, Harde­gree iden­ti­fied Scott & White as a stand­out among the col­lab­o­ra­tive’s hos­pi­tals, and said the hospi­tal did see fewer VAEs than it ex­pected.

“We have been very pleased with the re­sults of this project,” said Char­lotte Wheeler, Scott & White’s di­rec­tor of in­fec­tion preven­tion. “It has re­ally helped us make im­prove­ments to pa­tient care.”

The Arm­strong In­sti­tute for Pa­tient Safety and Qual­ity at Johns Hop­kins Univer­sity, Bal­ti­more, has in­vited Scott & White to par­tic­i­pate in a fed­er­ally funded project that will study and mea­sure early adopters’ VAE in­ter­ven­tions. They plan to de­velop ven­ti­la­tor-care so­lu­tions that can be im­ple­mented at the na­tional level.

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