© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

Providing Feedback: Structural Assessment 2 Results & Exposure Receipt Assessment 1 ResultsKathleen Speck, MPHNishi Rawat, MD

The Armstrong Institute for Patient Safety and QualityApril 3, 2014

© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

Structural Assessment: Comparative Findings

3

Objectives

• To review the Structural or Policy-based Measures included in the VAP Prevention Bundle

• To assess improvements made in the implementation of the Policy-based Measures in your unit’s policies

• To identify opportunities to focus improvement efforts and facilitate horizontal learning

4

Structural Measures, 1-5

1. Use a closed ETT suctioning system2. Change closed suctioning catheters only as

needed3. Change ventilator circuits only if circuits

become damaged or soiled4. Change HME every 5-7 days and as

clinically recommended5. Provide easy access to NIVV equipment and

institute protocols to promote use

5

Structural Measures, 6-10

6. Periodically remove condensate from circuits, keeping the circuit closed during the removal, taking precautions not to allow the condensate to drain toward the patient

7. Use an early mobility protocol8. Perform hand hygiene9. Avoid supine position10.Use standard precautions while suctioning

respiratory tract secretions

6

Structural Measures, 11-14

11.Use orotracheal intubation instead of nasotracheal

12.Avoid the use of prophylactic systemic antimicrobials

13.Avoid non-essential tracheal suctioning14.Avoid gastric over-distention

7

The Structural Assessment

• Survey of Unit Leaders conducted at the baseline and in Dec. 2013 – Jan. 2014

• Evaluates your implementation of the 14 Structural Measures included in the VAP Prevention Bundle

• 34 sites answered the assessment at baseline• 22 sites answered the assessment during the

second administration

8

How have the policies in your unit changed for the care of MVP?

Question % Best Response  T1

(n=34)T2

(n=22)For intubated/trached patients, how often do you change the ventilator system?(Best response – Not routinely changed unless soiled or malfunctioning)

76% 63%

When used, how often do you change the closed endotracheal suction system?(Best response – Not routinely changed unless soiled or malfunctioning)

39% 50%

9

How have the policy changes been implemented in your unit?

 Question % Best Response  T1

(n=34)T2

(n=22)In the absence of a difficult airway, how often is an orotracheal route used for elective intubation in your unit? (Positive)

82% 81%

For patients receiving mechanical ventilation via an endotracheal tube, how often is a closed endotracheal suction system used? (Positive)

94% 100%

When mechanical ventilation is required, how often are prophylactic intravenous antibiotics used to prevent ventilator-associated pneumonia? (Negative)

82% 81%

10

How have the policy changes been implemented in your unit?

Question % Best Response  T1

(n=34)T2

(n=22)In your ICU, how often are patients placed in a supine position, when there is no contraindication? (Negative)

71% 86%

In your ICU, how often are standard precautions used while suctioning the respiratory tract?(Positive)

85% 100%

In your ICU, how often is tracheal suctioning performed when it is not clinically indicated?(Negative)

74% 68%

In your ICU, how often are mechanically ventilated patients experiencing g gastric over-distention?(Negative)

82% 91%

11

How have the policy changes been implemented in your unit?

 Question % Best Response  T1

(n=34)T2

(n=22)In your ICU, how often is condensate drained away from the patient while the circuit remains closed?(Positive)

47% 50%

In your ICU, how often do healthcare providers perform hand hygiene prior to contact with respiratory equipment?(Positive)

97% 91%

How often is non-invasive ventilation used in your ICU?(Positive)

76% 59%

In your ICU, how often is an early mobility protocol used for patients receiving mechanical ventilation?(Positive)

35% 55%

12

In the policies for care of MVP in your unit, is there guidance to:

Question  % Yes  T1

(n=34)T2

(n=22)

Avoid supine (flat) patient positioning unless clinically indicated

91% 91%

Use standard precautions while suctioning respiratory tract secretions?

94% 100%

Avoid non-essential tracheal suctioning? 59% 77%Avoid gastric over-distention? 59% 77%Periodically remove condensate from circuits? 56% 77%Assure that circuits are closed during removal of condensate to assure that condensate doesn’t drain toward the patient?

62% 77%

Perform hand hygiene prior to contact with respiratory equipment?

88% 100%

13

Does your ICU actively promote:

 Question % Yes  T1

(n=34)T2

(n=22)

Use of non-invasive ventilation protocol? 47% 68%

Early mobility protocol in patients receiving mechanical ventilation?

41% 64%

14

Summary

• More sites have changed policies to be in line with CUSP for VAP recommendations

• General improvement or consistency in the care of patients with MVP

• Paradoxical implementation in care vs changes in written policies and/or procedures– Tracheal suctioning performed without clinical

indications– The use of non-invasive ventilation

15

Barriers? Protocols? Discussion

• What barriers have you faced in changing policies in your unit?

• Do you have policies regarding any of these measures that you would be willing to share?

• The Structural Assessment - – Do you have any suggestions for improving

the survey?

© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

Exposure Receipt Assessment Results

Exposure Receipt Assessment

17

• Evaluates the penetration of the CUSP and VAP interventions to front-line staff

• Anonymous assessment

• Completed by staff with direct patient care on the unit for only one shift

18

Exposure Receipt Assessment Measures

• Results divided into 4 categories based on question type to allow similar components to be examined together. The categorical measures are as follows: – Response Rate on Assessment– Distribution of Participants– CUSP Components of the Intervention– VAP Components of the Intervention

 

19

Response Rate

• Administered 18 months into the pilot February - March 2014

• Results from 11 sites• 133 observations

– 103 observations from MD – 30 observations from PA

Site 1 Site 2 Site 3 Site 4 Site 5 Site 6 Site 7 Site 8 Site 9 Site

10

Site

11

Total

Response

Rate

100% 100% 100% 100% 100% 61% 100% 85% 53% 76% 100% 85%

20

Distribution of Participants1: What is your role in the Unit?

Aggregate PA MD0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

70%

33%

81%

5% 7%4%3% 3% 3%

8% 7% 9%14%

50%

4%

Nurse Doctor Technician Respiratory Therapist Other

21

CUSP Components of the Intervention

3. Have you watched a Science of Safety presentation

4. Have you completed a Staff Safety Assessment

Aggregate MD PA0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

56%

62%

33%

44%

38%

67%

Yes No

Aggregate MD PA0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

46% 47%

20%

53% 53%

77%

0%3% 1%

Yes No Missing

22

CUSP Components of the Intervention

5. Have you used the Learning from Defects tool?

6. For how many patients has your unit used Daily Goals?

Aggregate MD PA0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

20%25%

0%

16% 18%

11%

61%55%

81%

3% 2%8%

Yes No, but am familiar with itNo, not heard of it Use different tool

Aggregate MD PA0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

42%

50%

17%

9% 9% 10%

4% 5%0%

17% 18%13%

21%16%

37%

7%2%

23%

All/almost all Over halfUnder half We don't use Daily GoalsUse different checklist Don't know

23

CUSP Components of the Intervention7: How familiar are you with CUSP?

Aggregate MD PA0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

32%

39%

7%

41%45%

30%27%

16%

63%

Very familiar Somewhat familiar Not familiar

24

CUSP Components of the Intervention

8. Do you have a CUSP team on your unit?

9. Has CUSP been active at improving patient safety?

Aggregate MD PA0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

59%

71%

17%12% 10%

20%

29%

19%

63%

Yes No Don't know

Aggregate MD PA0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

78% 80%

60%

18% 16%

40%

0% 0% 0%3% 3%

0%1% 1% 0%

Active Somewhat Active Not ActiveDon't know Missing

25

SummaryCUSP Components of Intervention

• A high proportion of units have CUSP teams• Providers believe that these teams are active

at improving patient safety. • Penetration CUSP toolkit tools appears low

(Daily Goals, Staff Safety Assessment, Learning from a Defect, Science of Safety video)

26

VAP Components of Intervention 9. How many interventions are used in your unit?

Aggregate MD PA0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

5% 6%3%5% 3%

13%13% 13% 13%

29% 27%

33%36%

40%

23%

10% 10% 10%

2% 2% 3%0% 0% 0%

0 1 2 3 4 5 6 Missing

27

VAP Components of Intervention10. Do you believe these interventions will help prevent VAE?

Aggregate MD PA0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

79% 79% 80%

15% 15% 13%

0% 0% 0%2% 0%

7%4% 6%

0%

Yes Maybe No Don't Know Missing

28

VAP Components of Intervention11. Which of the following interventions are most likely to prevent VAE?

Aggregate MD PA0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

25% 24%29%

17%14%

28%

16% 16% 17%15% 16%11%

8% 9%3%

10% 11%6%

1% 1% 2%1% 1%4%

Maintain elevation of the head of the bed to ≥ 30 degreesPerform oral care 6 times dailyUse Chlorhexidine 2 times daily while performing oral careUse of subglottic suctioning endotracheal tubes for patients ventilated > 72 hoursUse of spontaneous awakening trial (SAT) (sedation vacation)Use of spontaneous breathing trial (SBT)OtherMissing

29

VAP Components of Intervention12. Where is the biggest opportunity to improve the care of ventilated patients?

Aggregate MD PA0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

4% 3%7%

4% 4% 3%2% 2% 3%5% 7%0%

6% 7%3%2% 3%

0%

26% 24%

33%

3% 3% 3%1% 0%3%

47% 48%43%

Maintain elevation of the head of the bed ≥ 30 degrees

Perform oral care 6 times daily

Use chlorhexidine 2 times daily while performing oral care

Use of subglottic suctioning endotracheal tubes for atients ventilated > 72 hours

Use of spontaneous awakening trial (SAT) (sedation vacation)

Use of spontaneous breathing trial (SBT)

Mobilizing patients

Low tidal volume ventilation

Other

Missing

30

VAP Components of Intervention13. How much training have you been given on the VAP Prevention Toolkit?

Aggregate MD PA0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

41%45%

27%

36% 36%

43%

10% 10% 10%8%4%

20%

5% 6%

0%

A great deal Moderate Limited None Missing

31

SummaryVAP Components of Intervention

• High proportion of front-line providers believe that the technical intervention prevents VAE

• Process measure implementation could be improved – 50% of providers report using at least 4

• Implementation not related to training – high proportion of providers received a

significant amount of toolkit training• Early mobility represents the biggest

opportunity to improve care

32

Your Feedback is Important

• Was this ERA assessment helpful?– If yes, what was helpful? – If no, could we do anything differently so it

would be helpful?• Will anyone do anything different based on

results? • What do teams think about paper based

distribution vs. survey monkey?• How often do teams think these assessments

should be completed?

© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

Opportunities: CUSP4MVP-VAP National Project

CUSP4MVP-VAP: MD and PA Opportunities

• MD and PA opportunities with National Project:- Joining National Project content calls for continued

education on CUSP and VAE prevention

- Share your experience on content/coaching calls:

• as implementation experts

• to discuss implementation successes and barriers

34

35

CUSP4MVP-VAP: Join Content Calls

Date: First Tuesday of every month (* Please note that this call does not follow the regular content call schedule)Time: 2pm ESTWebinar Link: CUSP4MVP-VAP Content Calls Call-in Information: 1-877-668-4493; Access code: 667 844 665

Date Call Type and Module # Topic

February 5, 2014* Content Call, Module 1 CUSP 4 MVP-VAP Kickoff Webinar

February 18, 2014* Content Call, Module 2 Science of Safety & Identifying Defects

March 4, 2014 Content Call, Module 3

Pain, Agitation, and Delirium (PAD) - Delirium and Sedation Management

March 18, 2014* Content Call, Module 4

PAD – Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)

April 1, 2014 Content Call, Module 5 Daily Early Mobility Overview

May 6, 2014 Content Call, Module 6

How to run a CUSP Team (Engaging all members of the CUSP team)

June 3, 2014 Content Call, Module 7 Daily Goals Facilitates VAE Prevention

July 1, 2014 Content Call, Module 8 Learning from Defects

36

Additional Resources

• Society for Critical Care Medicine ICU Liberation Group– http://www.iculiberation.org/Pages/default.aspx

• AHRQ CUSP Toolkit– http://www.ahrq.gov/professionals/education/curriculum-tools/cuspt

oolkit/

• Armstrong Institute CUSP Tools– http://

www.hopkinsmedicine.org/armstrong_institute/training_services/cusp_offerings/cusp_guidance.html

• Armstrong Institute Training Opportunities– http://www.hopkinsmedicine.org/armstrong_institute/training_servic

es/cusp_offerings/

Reminder: Next Steps

• Complete 2nd HSOPS (March-April)

• Begin data collection sampling strategy between process

measures and early mobility (April)

• Begin data collection for Low Tidal Volume Ventilation

measure (August)

37

38

Data Collection Sampling Strategy: Begins April 1st

2014 CUSP for VAP Data Collection Calendar

January

February

March

April

S M T W T F S

S M T W T F S

S M T W T F S

S M T W T F S

1 2 3 4

1

1

1 2 3 4 5

5 6 7 8 9 10 11

2 3 4 5 6 7 8

2 3 4 5 6 7 8

6 7 8 9 10 11 12

12 13 14 15 16 17 18

9 10 11 12 13 14 15

9 10 11 12 13 14 15

13 14 15 16 17 18 19

19 20 21 22 23 24 25

16 17 18 19 20 21 22

16 17 18 19 20 21 22

20 21 22 23 24 25 26

26 27 28 29 30 31

23 24 25 26 27 28

23 24 25 26 27 28 29

27 28 29 30

30 31

May

June

July

August

S M T W T F S

S M T W T F S

S M T W T F S

S M T W T F S

1 2 3

1 2 3 4 5 6 7

1 2 3 4 5

1 2

4 5 6 7 8 9 10

8 9 10 11 12 13 14

6 7 8 9 10 11 12

3 4 5 6 7 8 9

11 12 13 14 15 16 17

15 16 17 18 19 20 21

13 14 15 16 17 18 19

10 11 12 13 14 15 16

18 19 20 21 22 23 24

22 23 24 25 26 27 28

20 21 22 23 24 25 26

17 18 19 20 21 22 23

25 26 27 28 29 30 31

29 30

27 28 29 30 31

24 25 26 27 28 29 30

31

September

October

November

December

S M T W T F S

S M T W T F S

S M T W T F S

S M T W T F S

1 2 3 4 5 6

1 2 3 4

1

1 2 3 4 5 6

7 8 9 10 11 12 13

5 6 7 8 9 10 11

2 3 4 5 6 7 8

7 8 9 10 11 12 13

14 15 16 17 18 19 20

12 13 14 15 16 17 18

9 10 11 12 13 14 15

14 15 16 17 18 19 20

21 22 23 24 25 26 27

19 20 21 22 23 24 25

16 17 18 19 20 21 22

21 22 23 24 25 26 27

28 29 30

26 27 28 29 30 31

23 24 25 26 27 28 29

28 29 30 31

Key: Process Measure data collection Early Mobility data collection No data collection; use this time to catch up on missing Process Measure and Early Mobility data

39

Enhancing Support for MD and PA Teams

• Objective Outcome Data - Armstrong will analyze your data for outcome measures if you provide needed information to your state leads. Forms will be provided:– decreasing duration of mechanical ventilation– decreasing hospital length of stay– decreasing mortality

• How do we enhance horizontal learning?• What can the AI/MHA/HAP team do to better support

your efforts to reduce ventilator-associated pneumonia?

40

Thank You

THANK YOU for all of your effort

and hard work.