How to Improve Patient Outcomes after Mechanical Ventilation

How to Improve Patient Outcomes after Mechanical VentilationEssential Hospitals Engagement Network

October 1, 2013

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OUR NEW NAME

We’ve rebranded! The National Association of Public Hospitals and Health Systems is now America’s Essential Hospitals. Although we’ve changed our name, our mission is the same: to champion hospitals and health systems that provide the highest quality of service to all by achieving the best health outcomes for every patient, especially those in greatest need. The new name underscores our members’ continuing public commitment and the essential nature of our work to care for the most vulnerable and provide vital community services, such as trauma care and disaster response.

This is an exciting time for us and our members, as we lean forward into new care models, opportunities and challenges of reform, and quality and safety innovations that often take root in our member systems. Our new website address: www.EssentialHospitals.org

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SPEAKER INFORMATION

Michele C. Balas, PhD, RN, APRN-NP, CCRNAssociate Professor

Center of Excellence in Critical and Complex CareThe Ohio State University

College of Nursing

Alex Ramos, RN, MSN, CCRNTrauma Operations Manager

Sandra Gonzalez RN, BSNDirector of Trauma, Neurosurgery and Adult Med/Surg Critical Care

Services Dustin Bierman, RN, MSN

ICU Med/Surg Clinical CoordinatorLuis Martinez, RN, BSNICU Med/Surg Manager

ABCDE TeamUniversity Medical Center of

El Paso

John Young, RN, MBAImprovement Coach

EHEN

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AGENDA

• VAP work in EHEN and Partnership for Patients

• The ABCDE bundle - Michele C. Balas, PhD, RN, APRN-NP, CCRN

• An EHEN hospital’s story - UMC El Paso ABCDE team • Q & A

• Wrap-up and announcements

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EHEN VAP RESULTS (AS OF MAY, 2013)

Summary UHC-Defined VAP OutcomeNumerator: Adult discharges (age ≥ 18) with an ICU stay ≥ 1 day on an invasive mechanical ventilator (ICD-9-CM code 96.70-96.72). Inclusions: Diagnosis code = 997.31, POA=N,U;Denominator: Adult discharges (age ≥ 18) with an ICU stay ≥ 1 day on an invasive mechanical ventilator (ICD-9-CM code 96.70-96.72).

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Subgroup

22.222222222222

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23.722627737226

3

23.734177215189

9

32.608695652173

9

36.220472440944

9

32.258064516129

33.057851239669

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29.310344827586

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54.750402576489

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42.721518987341

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35.087719298245

6

33.175355450237

36.253776435045

3

42.477876106194

7

27.070063694267

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37.931034482758

6

28.419182948490

2

46.511627906976

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39.451114922813

36.565977742448

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23.890784982935

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24.115755627009

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34.545454545454

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38.397328881469

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28.218694885361

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34.954407294832

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27.070063694267

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28.828828828828

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22.865853658536

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41.958041958042

33.546325878594

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32.478632478632

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34.482758620689

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Center

33.409982415798

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UCL

56.081544547108

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56.834416043325

7

55.222251120538

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55.018075625201

9

55.170665075821

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54.901589098922

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56.686225640051

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54.819528445370

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56.337728521932

3

55.326533477742

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56.081544547108

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56.770560130907

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LCL

10.738420284489

2

9.9855487882717

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11.597713711059

11.801889206395

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11.649299755775

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11.918375732674

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10.640907739289

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10.340643236637

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55 UCL

LCL

UHC-Defined VAP/1,000 DischargesU Chart

RateRate

Goal : 40% reduction (median = 20.04)

EHEN kickoff

VAEDef. change

Improving Patient-Centered Outcomes in the

ICU: The ABCDE Bundle

Michele C. Balas PhD, RN, APRN-NP,CCRN

Associate Professor, The Ohio State University

College of Nursing, Center for Critical & Complex Care

Adjunct Professor , University of Nebraska Medical Center

College of Nursing, Department of Community Based Health

Disclosures

• Dr. Balas is currently a Co-investigator on a grant supported by the Alzheimer’s Association and has received honoraria from ProCe, the France Foundation, Hospira, & Hillrom.

• Images courtesy of Nancy Adams-http://www.nancyandrews.net

• Research supported by RWJF-INQRI

• For references regarding outcomes of delirium in the ICU setting and the ABCDE bundle please see: www.icudelirium.org

The Issues-ICU Acquired Delirium &

Weakness

• Profound & emerging public health threat• Common

• Lethal

• Disabling

• Persistent

The Issues-ICU Acquired Delirium &

WeaknessDelirium

•33% Emergency Room

•14-56% Medical/Surgical Units

•20-50% Non-Mechanically Ventilated-ICU

•50-80% Surgical/Trauma/ Burn ICU

•70-87% Mechanically Ventilated-ICU

Weakness• 25-50% of patients who

receive MV for 4-7 days

• 50-75% sepsis patients

• 80-95% of patients with ICU-AW have neuromuscular abnormalities 2-5 YEARS after hospital discharge

• 70% of MV patients have difficulty with ADLs 1 year after discharge

DELIRIUM AN INDEPENDENT PREDICTOR

OF MORTALITY•ICU & hospital

• Mortality rates ranging from 22-76%

•6-month* • (3 fold ↑ risk)

•1 year• Each day delirious ↑

10% mortality!!!!!!

Lin (CCM, 2004); Inouye (NEJM, 2006); *Ely (JAMA, 2009); Pisani (AJRCC, 2009)

Outcomes Associated With Delirium•ICU & hospital LOS

•↑ restraints & sedation

•Poor functional recovery

•New institutionalization

•Multiple complications

•Total 1-year US health-care costs $38-152 billion dollars

Delirium & New Onset Cognitive Impairment

•½ of all ICU survivors experience long-term cognitive impairment

•Persistent

•Associated with delirium duration

•Older patients without dementia hospitalized for a non-critical illness have a 40% higher risk of dementia

0

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0 5 10

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Delirium Days

Cog

nitiv

e F

unct

ion

at 1

2 m

onth

s(p

red

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d m

ean

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)

p=.03

•Jackson et al., Anesthesiology Clinics, 2011; Ehlenbach, Jama, 2010

Other Outcomes Associated with Critical Care

•10-50% of all ICU survivors experience

• PTSD

• Depression

• Anxiety

• Sleep disorders

• Need for caregiver assistance

Patient Experience

“On Sunday, I was on the ICU, where a horror ceremony like in a concentration camp was going on. Four patients were executed. Laying in their beds, they received a death pill. I was one of them…The hangman gave us the pill, with a blank face. In the background were two ladies waiting to carry away our dead bodies…The torturers watched us all the time, they asked us: “Do you feel anything yet? How does your foot feel? How does your arm feel?”… The children of Satan were in command. They were dressed in green coats and had scary faces. They were waiting for our death. … Worst was, that I did not try to resist. How can a man throw away his life like that? Why me? Did they do a mistake during the surgery and try to cover it up by killing all of us? … The pills did not work. I did not die. So they tried it again with gas, pressing a mask on my face. …"- Male, 67 years old.

Precipitating Factors for ICU Acquired Delirium & Weakness

Potentially Modifiable• Sedative

Medications

• Mechanical Ventilation

• Immobility/prolonged bed rest

• Uncontrolled pain

• Sleep deprivation

Non-Modifiable

• Age

• Severity of illness

• Comorbidities

• Pre-existing CI/dementia

• Drug/ETOH withdrawal

Potential Solution-ABCDE Bundle

•Awakening

•Breathing

•Coordination/Choice of sedation

•Delirium monitoring/ management

•Early exercise/mobility

http://webmedia.unmc.edu/nursing/grants/abcde/videos/Main.html

What Does the Evidence Tell Us?Awakening

Kress et al. (2000) NEJM

•Pro-RCT, 128 MV, MICU

•Treatment group-CI sedatives stopped 1Xday

• (restarted at ½ rate if needed)

•SS reduction in• MV days 4.9 vs. 7.3

• ICU LOS 6.4 vs. 9.9

What Does the Evidence Tell Us?

Awakening• Kress et al. (2000) NEJM

• Fewer diagnostic tests

• No difference in• Complications

• Mortality

• Hospital LOS

•Kress et al. (2003) AJRCCM

•32 patients 6 month FU

•Results• Fewer symptoms PTSD

11.2 vs. 27.3 (p=0.02)

• Lower incidence of PTSD 0 vs. 32 (p=0.06)

• Better psychosocial adjustment to illness


Awakening•Weinert et al. (2007) CCM

• 85% of 18,050 evals had sedation (N=274)

• 1 in 3 unarousable (32%)

• 1 in 5 no spontaneous motor activity (21%)

•Only 2.6% of providers thought patients were “over-sedated”!!!!!!


Breathing• Spontaneous Breathing Trials (Ely et al.

1996 NEJM)

• RCT, single center, N=300

• Respiratory care-driven weaning protocol using SBTs found to lead to statistically significant improvements• MV days 3 vs. 4.5 (p=0.003)

• Reintubation 6 vs. 15 (p=0.04)

• MV >21 days 9 vs. 20 (p=0.04)

• ICU cost 15,740 vs. 20,890 (p=0.03)

What Does the Evidence Tell Us?Awakening & Breathing

Coordination

•Multicenter, RCT (N=336)

•Intervention group protocolized SATs & SBTs; control group daily SBTs & “usual care” sedation

•Results• Survival at 1 yr. 58% vs.

44% p=0.01

What Does the Evidence Tell Us?Awakening & Breathing

Coordination Girard et al. (2008) Lancet

Stat. Significant Results…

• 32% less likely to die

• NNT-7 to save a life at 1 year

• VFDs (3 days)

• Successful extubation (7 vs. 5)

• ICU & hospital LOS (4 days)

• Coma (1 day)

• Self-extubation (3 vs. 5)

No difference in….• Self extubation with

reintubation

• Total re-intubations

• Delirium

• Tracheostomy

• Long-term cognitive & psych. outcomes (Jackson et al.)


Choice of Sedation• Analgosedation (Strøm T, et al. Lancet.

2010;375:475-480)

• 140 critically ill adult patients undergoing MV in single center

• Randomized, open-label trialBoth groups received bolus morphine (2.5 or 5 mg)

Group 1: No sedation (n = 70 patients) - morphine prn

Group 2: Sedation (20 mg/mL propofol for 48 h, 1 mg/mL midazolam thereafter) with daily interruption until awake (n = 70, control group)


Choice of Sedation• Patients receiving no

sedation had • More days without MV (13.8 vs

9.6 days, P = 0.02)

• Shorter stay in ICU (HR 1.86, P = 0.03)

• Shorter stay in hospital (HR 3.57, P = 0.004)

• More agitated delirium (N = 11, 20% vs N = 4, 7%, P = 0.04)

• No differences found in• Accidental extubations

• Need for CT or MRI

• Ventilator-associated pneumonia


Choice of Sedation• 2013 SCCM Clinical Practice Guidelines for the

Management of Pain, Agitation, and Delirium in Adult Patients in the ICU• Regular PAD screening using valid & reliable tools

• Role of preemptive analgesia/importance of effectively managing pain

• Maintaining light levels of sedation (DSI vs. light target level)

• Nonbenzodiazepine sedative strategies

• Potential role of Dexmedetomidine (MV at risk for delirium)

• No prophylactic haloperidol or atypical antipsychotics

• Atypical antipsychotics may reduce duration of delirium

Morandi A, et al. Intensive Care Med. 2008;34:1907-1915.


Delirium Monitoring/Management

• CAM-ICU

• ICDSC


Early Exercise/Mobility

Duration of ICU Delirium

Mechanical Venti-lation

ICU LOS Hospital LOS0

2

4

6

8

10

12

14

16

2

3.4

5.9

13.5

4

6.1

7.9

12.9

PT/OT with DSI n = 49

DSI alone n = 55

Me

dia

n T

ime

(d

ay

s)

• Early PT and OT in Mechanically Ventilated ICU Patients

Schweickert WD, et al. Lancet. 2009;373(9678):1874-1882.

ABCDE Bundle Steps

• ABCDE bundle is multicomponent, interdependent, & designed to: • Improve clinical team collaboration

• Standardize care processes

• Break the cycle of oversedation & prolonged mechanical ventilation

• Opt-out method

• Safety screen & self-guided ABCE’s

Awakening

Breathing

SBT Failure Criteria• Respiratory rate > 35/min

• Respiratory rate < 8/min

• Oxygen saturation < 88%

• Respiratory distress

• Mental status change

• Acute cardiac arrhythmia

SBT Safety Screen• No agitation

• Oxygen saturation ≥ 88%

• FiO2 ≤ 50%

• PEEP ≤ 7.5 cm H2O

• No myocardial ischemia

• No vasopressor use

• Inspiratory efforts

Early Mobility Safety Screen• Patient responds to verbal

stimulation (ie, RASS -3)*

• FIO2 ≤ 0.6

• PEEP ≤ 10 cmH2O

• No dose of any vasopressor infusion for at least 2 hours

• No evidence of active myocardial ischemia (24 hrs)

• No arrhythmia requiring the administration of new antiarrhythmic agent (24 hrs)

Early Mobility Progression

WalkingA

Short Distance

Standing at bedside

andsitting in chair

Sitting on edge of bed


• Routine Sedation & Delirium Assessment Using Standardized, Validated Assessment Tools

• RN administers & records RASS/SAS results q2h

• Team sets “target” RASS/SAS score for the patient to be maintained at for the following 24 hours

• RN administers & records results of the CAM-ICU/ICDSC q8h & whenever a patient experiences a change in mental status


• Each day during interdisciplinary rounds, the RN will:• State the “TARGET” sedation score • State the patient’s ACTUAL sedation score• State the patient’s delirium status• State the sedative/analgesic medications the patient is currently

receiving

• Each day during interdisciplinary rounds, the team will use the acronym “THINK” if a patient is CAM positive (delirious)

• The interdisciplinary team will employ the following non-pharmacologic interventions when treating a delirious patient:• Eliminate or minimize risk factors • Provide a therapeutic environment


•USE MEDICATIONS ONLY IF ABSOLUTELY NECESSARY!

•Give “PEACE” a chance

• Physiologic• Environmental• ADLs/Sleep• Communication• Education

So Easy-What Could Possibly Go

Wrong?

• Canada – 40% get SATs (273 physicians in 2005)1

• US – 40% get SATs (2004-05)2

• Germany – 34% get SATs (214 ICUs in 2006)3

• France – 40–50% deeply sedated with 90% on continuous infusion of sedative/opiate4

1. Mehta S, et al. Crit Care Med. 2006;34:374-380.2. Devlin J. Crit Care Med. 2006;34:556-557.3. Martin J, et al. Crit Care. 2007;11:R124.4. Payen JF, et al. Anesthesiology. 2007;106:687-695.

Number of respondents (%)

Barriers to Daily Sedation Interruption

(Survey of 904 SCCM members)

Clinicians preferring propofol were more likely use daily interruption than those preferring benzodiazepines (55% vs 40%, P < 0.0001)

Tanios MA, et al. J Crit Care. 2009;24:66-73.

0 10 20 30 40 50 60 70

Leads to PTSD

Leads to cardiac ischemia

No benefit

Difficult to coordinate with nurse

Leads to respiratory compromise

Compromises patient comfort

Poor nursing acceptance

Increased device removal

#1 Barrier

#2 Barrier

#3 Barrier

Implementation Challenges

• Facilitators:• Daily interdisciplinary rounds

• Engagement of key implementation leaders

• Sustained, diverse educational efforts

• Bundle’s quality and strength

• Barriers: • Intervention-related issues (e.g., timing of trials,

fear of adverse events)

• Communication and care coordination challenges

• Knowledge deficits

• Workload concerns

• Documentation burden


• Structural characteristics of the ICU

• Organization-wide patient safety culture

• ICU culture of quality improvement

• Implementation planning, training/support

• Prompts/documentation

• Excessive turnover (both in project and ICU leadership)

• Staff morale issues

• Lack of respect between disciplines


• Excessive use of registry staff

Is it Worth It?Absolutely

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Q & A

45

UNIVERSITY MEDICAL CENTER OF EL PASO


• Facilitators:• Daily interdisciplinary rounds

• Engagement of key implementation leaders

• Sustained, diverse educational efforts

• Bundle’s quality and strength

• Barriers: • Intervention-related issues (e.g., timing of trials,

fear of adverse events)

• Communication and care coordination challenges


• Workload concerns

• Documentation burden

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Q & A

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THE PATIENT’S VOICE

Dr. Needham: “What did you think when we discussed getting you out of bed while on a ventilator with a breathing tube in your mouth?”

Mr. E:”I thought it was wonderful. Anything to get me up and moving, and get me out of bed; anything to get me off my back and on my feet - that is what I really wanted.”

Dr. Needham: “How did it feel to be awake, with the breathing tube in your mouth, on a ventilator, and walking laps around the medical intensive care unit?”

Mr. E: “It was wonderful. It was nice to get up and walk around. It was not uncomfortable. I enjoyed it. I think it had a very positive effect on me.”

Needham DM. Mobilizing patients in the intensive care unit: Improving neuromuscular weakness and physical function. JAMA. 2008 October. 300(14). 1685-1690.

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THANK YOU FOR ATTENDING!

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How to Improve Patient Outcomes after Mechanical Ventilation

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