Research Critique Paper

M u ltip le A p p ro a c h e s to P re v e n tin g V e n tila to r-a s s o c ia te d

Pneumonia R e c e n t d a ta p o in ts to a c r o s s - th e -b o a r d d e c lin e s in h o s p i ta l - a c q u ir e d

in fe c t io n s in A m e r ic a n h o s p ita ls — e x c e p t fo r v e n t i la to r -a s s o c ia te d

p n e u m o n ia , w h ic h r e m a in s a p e r s is te n t d a n g e r to p a t ie n ts .

BY PHYLLIS H A N LO N

www. rtmagazine. com

In 2007, the Institute for Healthcare Improvement (IHI) created the Triple Aim,1 which focused on “improving the experience of care, improving the health of populations and reducing per capita cost of healthcare.” Since that time, healthcare systems across the country have ramped up efforts to reduce the incidence of hospital-acquired conditions (HAC), which account for some readmissions, declining health, and rising costs. To some degree, those efforts are paying off. The Department of Health and Human Services (HHS) reported approximately 87,000 fewer inpatient deaths and a 17% decline in hospital-acquired conditions from 2010 to 2014, resulting in a reduction of almost $40 billion in healthcare costs.

Specifically, in its 2013 update on Annual Hospital-acquired Conditions Rate and Estimates of Cost Savings and Deaths Averted from 2010 to 2013, HHS cited a decrease in catheter- associated urinary tract infections (CAUTI) of 28%; central line associated blood stream infections (CLABSI) experienced an impressive 49% reduction. However, rates o f ventilator- associated pneumonia (VAP) and ventilator-associated events (VAE) failed to realize such reductions.

Reducing Infections Through Partnerships Nancy E. Foster, vice president of Quality and Patient Safety

Policy at the American Hospital Association (AHA), said, “W e are also making progress on surgical site infections, but there is more work to be done. W e haven’t seen as rapid a reduction with ventilator-associated pneumonia or ventilator- associated events for a wide variety of reasons.” She pointed out that “squishy” data leads to variations in interpretation. “Even though the CDC offered good definitions, people are still reading different things into what qualifies as pneumonia. W e need to get a consistent definition so we know the data collection changes reflect real changes in care.”

Working closely with the Association for Healthcare Research and Quality (AHRQ), the AHA is helping to promote efforts to implement successful strategies for reducing safety events, particularly infections. ‘W e are focused like a laser beam on reducing infections. Sharing these strategies with hospitals across the nation will help as they step through,” Foster said. “W e are bringing hospitals together to talk about what to do differently, what reminders they use. We are sharing in collaborative work.”

18 RT | For Decisioii Makers in Respiratory Care January 2016

Multiple Approaches to Preventing Ventilator-associated Pneumonia

T he Centers for M edicare and M edicaid Services (CM S) launched th e P artnersh ip for P atien ts in 2011, a public- private initiative tha t aims to reduce specific H A C s through “system atic q u a lity im provem en t w o rk .” T h e H o sp ita l Engagem ent N etworks (H E N S) are a central part in this in i­ tiative and include hospital systems at the state, regional and national levels, w hich focus on ten specific H A C s, including ventilator-associated events.

Creating Healthy States T h e V irg in ia H o sp ita l and H e a lth c a re A sso c ia tio n

(V H H A ), w hich includes 110 Virginia and N orth C arolina h osp ita ls , p a rtic ip a ted in the firs t round o f H E N S and was recently am ong a select group chosen to partic ipate in the second round , according to Julian W alker, V H H A ’s vice president o f com m unications. “O ne o f the formal goals of the V H H A is to make Virginia the health i­ est state in the nation by 2020. O ur active role in the H E N S process is one example o f V H H A and its m em bers’ p u rsu ing th a t goal. T hose efforts are facilita ted by V H H A ’s C en te r for H ealthcare Excellence, a newer division o f the Association launched in January 2015, charged w ith im proving the safety and quality o f hea lth care in V irg in ia by assisting V H H A m em bers in achieving to p - tie r perform ance in quality , safety and service,” he said.

“T he C en ter’s mission includes supporting and encourag­ ing adoption o f patien t care and service best practices at all V irginia hospitals and health systems; facilitating effective co llaborations am ong V irginia hosp ita ls, health systems, h ea lth care p roviders and key stakeho lders; and serving as a coordinator for efforts to seek, secure and adm inister funding th a t supports patien t safety and health care quality initiatives in V irginia.”

W alker added tha t these efforts focus on reducing H A Is, including VAP. “D uring the first round of H E N S, VAP rates at hospitals in V irginia and N orth Carolina declined 38%,

resulting in the prevention o f an estim ated 53 harm events,” he said, noting that VAP rates were already extremely low in both states. “V FIHA and its members are encouraged by these results, even though plenty o f work remains. Efforts in these areas will continue as a m atter o f course and will be aided during the second round o f H E N S .”

A n im portan t tool in cap tu ring im p o rtan t in fo rm ation th a t helps prevent V A Es is the electronic m edical record (E M R ), according to Kyle E nfield, M D , M S, d irector o f the m edical IC U and assistant hosp ita l epidem iologist at the University o f V irginia School o f M edicine, D ivision of Pulm onary and C ritical Care M edicine. For instance, when the facility paired spontaneous awake treatm en t (SA T) w ith

spon taneous b rea th in g tre a tm en ts (SB T ) last January and in p u t the data in to the E M R , the im p lem en ta tion rate increased from 70% to 90%.

T h e use o f con tinuous subg lo ttic suc­ tioning tubes in the IC U has been another im p o rtan t too l in reducing the incidence

o f VAEs. “E ighty percent o f patients have CSS in place,” Enfield said. V irginia has also im plem ented early mobility strategies. “W e are trying recum bent bikes tha t fit over the bed,” he said. “There are no results yet, but we expect to see big results in this area.”

Accessing National Resources T he C olorado H ospital Association (C H A ), a 31-hospital

network, was also a part o f H E N S , under the A H A ’s H ealth R esearch and E du ca tio n a l T ru s t (H R E T ). W h ile som e systems have their own H E N S , C H A decided to participate through A H A , according to N ancy G riffith , R N , director o f C H A ’s Q uality Im provem ent and P atien t Safety.

“W e would have national resources we could build ou t to local hospitals. T he benefit o f the H R E T is th a t you can partner w ith hospitals in o ther states. H R E T has a lot o f resources. T hey do a num ber o f webinars and share learning tools w ith the hospitals,” she said.

Editor's Note You can access

the references for this article in the online

editions of /?T Magazine.

Defining the Condition

Shelly Magill, MD, PhD, medical epidemiologist in the Division of Health Care Quality Promotion (DHQP) at the Centers for Disease Control and Prevention (CDC) reported that in 2009 the CDC convened a working group comprising representatives from organizations and associations with an interest in the topic, as well as federal partners, to began revising existing definitions for ventilator-associated pneumonia (VAP). “We wanted to move away from trying to define VAP. That definition was fraught with problems. We preferred to move toward a larger, more objective ventilator surveillance to capture many conditions for patients on ventilators,” she said.

In January 2013, those definitions became available for health care facility use. “We created objective criteria for any mechanical ventilator patient regardless of size of the hospital. We moved away from using chest x-ray as one of the identifiers. The interpretations vary from radiologist to radiologist and physician to physician,” Magill said. “ Rather, we focused on information pertinent to ventilator settings, specifically positive end expiratory pressure (PEEP) and fraction of inspired oxygen (Fi02).”

The team decided to use the term ventilator-associated condition (VAC), which identifies a period of worsening oxygenation in the patient who had been stable for two days. “This is the foundational tier,” said Magill. “ Patients who meet these criteria and have an abnormal temperature, white blood cell count or have been taking an antimicrobial drug for four calendar days would be identified as having an infection ventilator associated complication (IVAC).”

Patients who meet the criteria for a VAC and IVAC and also have microbiologic evidence of a respiratory infection could be identified as possible VAP (PVAP), Magill added.

Magill said the CDC expected initial rates to be substantially higher, since the new definitions capture more data. “We are in the process of looking at 2014 data now. After the first full year of implementation, we are seeing relative stable rates,” she said.

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T eri H u le tt, R N , program m anager for infection preven­ tion at C H A , noted th a t hospitals w ith in its system have been w orking on V AP since early 2000. She reported that the use o f a V AP bundle, w hich has evolved over tim e, is largely responsible for reducing incidence rates statew ide. “W e educated the staff at the bedside and w orked w ith the doctors. R Ts took the lead w orking in the intensive care u n it where they manage ventilator pa tien ts ,” she said. “I t is an evidence-based bundle. W e standardized how to measure every piece o f the bundle.”

C onsistent guidelines were created for head o f bed eleva­ tion, as well as suctioning before tu rn ing patients to prevent aspiration, prophylaxis for peptic ulcer disease and deep vein throm bosis (D V T ), and sedation vacations.

G riffith added th a t the success o f the C H A bundle can also be attributed to regular oral care and incorporating the bundle into multi-disciplinary rounds. “Patients get oral care every four hours. W ith in the system one or two hospitals first adopted oral care and go t g rea t results. W ord spread and other hospitals adopted [the p ra c t ic e ] ,” she said . “ [A n d ] IC U s ta f f , nurses, RTs, intensivists and pharm acists w ere in c lu d e d . P h y s ic ia n buy-in and leadership was key. T hey have to be champions.”

T he VAP bundle has been built into C H A ’s E M R system and issues red flags th a t help to reduce VAP. C H A also prom oted transparency by m o u n tin g h ig h ly visible boards on each u n it th a t tracks p rog­ ress. “Everyone can see them and get real-tim e feedback,” G riffith said. “W e built in goals for the units, the staff and the hospitals tha t are tied to a performance value system.”

Probably the m ost significant change for C H A has been a m ental sh ift in th in k in g , G riffith explained. A decade ago, hospitals were m ore com placent and settled for higher infection rates. O nce hospitals saw th a t it was possible to fix the problem s related to infections, they climbed on board, she reported, and now strive for 100% reductions.

Dashboard Data Capture In response to the benchmarks set by the C D C , Vanderbilt

University H ospital engaged operational leaders and frontline caregiving staff to create standards and develop a strategy to reduce the incidence o f V AP, according to T hom as R. T albo t, M D , M P H , ch ie f hosp ita l epidem iologist for the Vanderbilt M edical Center.

“W e w anted to do som ething innovative and w orked in close co llaboration w ith IT s ta ff to develop a dashboard designed to trigger conversations w ith providers and offer rem inders,” T alho t said.

T he result was a screensaver at all bedsides th a t captures data regarding head-o f-bed elevation, com pliance in five- m inute slices and o ther measures. Inform ation is tracked and fed back vigorously, making staff accountable and prom pting an 85%-plus reduction in V AP, w hich has been sustained over tim e, T albo t noted. “W e had already been docum enting [these measures] so they were hardw ired in to practice. I t was part o f the w ork flow,” he said. “[The system] is easy to use and doesn’t require a lo t to orient staff. I t brought about more awareness.”

V anderbilt continued to see good numbers after the C D C re tired its defin ition o f V A P in 2013. T h e hosp ita l now focuses on track ing ven tila to r-associa ted events (V A Es), including m ortality and length o f stay.

Device Improvements M an u fac tu re r im provem ents in v en tila to r equ ipm en t,

based on industry recom m endations and governm ent stan­ dards, are contributing to th e re d u c t io n in V A E s. F o r in s tan ce , th e use o f sub g lo ttic secretion drain ing has c o n s i s te n t ly sh o w n benefits, according to G ary M ilne, BS, R RT, d ir e c to r o f c l in ic a l m arketing, Respiratory Solutions, M edtronic.

H e explained th a t shorter time on mechan­ ical ven tila tion , daily assessments for readi­ ness to wean, the use of non-invasive ventilation, sedation vacations and appropriate sanita tion practices also help reduce the incidence o f VAP.

“A lthough we cannot say that one particular approach to ventilation will reduce the duration o f mechanical ventilation, we can look at problems and solutions that are associated. I t is well known that asyn­ chrony occurs in a large degree o f patients,” he said, noting that a 2013 study2 showed a 24% incidence.

M ilne added th a t certain types o f ven tila tion are more synchronous than others. For example, P roportional A ssist V entilation Plus (PAV+) mode has been shown to reduce asynchrony. “PA V mode is a type o f ventilation th a t enables th e p a tie n t to b rea the m ore na tu ra lly so th a t there is a reduced asynchrony betw een the ventilator and the p a tien t,” he said. Research published in 2006 determ ined th a t asyn­ chrony has been shown to increase the use o f sedation up to 42%.3

T h e In s titu te fo r H ea lth c a re Im p ro v em e n t hopes to achieve health ier populations, im proved care and a reduc­ tion in health care costs by 2020 as com m unities and hos­ pita l netw orks across the country adopt the T rip le A im . RT

Phyllis Hanlon is a contributing writer to RT. For further informa­ tion, contact RTmagazine@allied360.com.

20 RT | For Decision Makers in Respiratory Care January 2016

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