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

Reports: Daily Process, VAE, NHSN

Armstrong Institute for Patient Safety and Quality

Presented by: Kathleen Speck, MPHLinda Greene, RN, MPS, CIC

Armstrong Institute for Patient Safety and Quality2

Armstrong Institute for Patient Safety and Quality3

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What’s with this VAE

Stuff?I don’t get it. Lots of

mumbo- jumbo if you ask me

Surveillance Definition Change - VAP to VAE

http://www.cdc.gov/nhsn/VAE-calculator

NHSN Data

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Total VAE

VAC Only

IVAC

Possible VAP

Probable VAP

We have the VAE data; now what?

• Comparative Data from NHSN• Other Changes ( Combine Possible and

Probable VAP)• Device Utilization Ratios

In the Meantime

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Review Outcome Data

At the Bedside In Team Meetings

Patient Data

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Vent Day

PEEP min

FiO2 Temp WBC Anti-microagent

Microsource

Polys Epis Organism

1 10 50 37.5 11.6 none

2 5 50 37.8 11.8 none

3 5 50 37.8 12.0 none ETA 3+ 0 s.aureus

4 8 70 38.2 15.0 PIPTAZVanco

5 8 60 38.5 14.2 PIPTAZVanco

6 6 50 38.0 12.9 PIPTAZVanco

7 5 40 37.5 11.8 PIPTAZVanco

8 5 40 37.6 11.6 none ETA 1+ 1+ Oral flora

Looking at the data

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My first quarter VAC is 15.38 per 1,000 vent days

The average performance of the group is 5.5 per 1,000 vent days

Do I have opportunities?

Looking Carefully at the Measures

I notice that my SAT and SBT compliance is much lower than the cohort group.

I also notice that subglottic suctioning is lower than the peer group .

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Looking at Cases

• Ms. X is a 26 y.o. vent dependent patient . She has a history anoxic brain injury and is admitted with pneumonia from a long term care facility ( LTCF)

• She is placed on antibiotics and after 4 days has stabilized on the vent. She is improving clinically and the plan is to return to the LTCF

• On day 7 , she has a significant event and a sustained period of worsening oxygenation.

• She meets definition for VAE

Case Review

• The clinicians have identified that her event was caused by a mucus plug.

• What Next?

The Analysis

Changes in Nurses and Respiratory Therapy staff- no documentation of secretions

Failure to notice thickened secretions and change in color of secretions

Although Patient was at baseline – did not get her up into a chair

Patient was dehydrated

Opportunities

• Hardwire ambulation protocols• Assure documentation of secretions• Work collaboratively with respiratory therapy to

identify subtle changes• Daily huddle

Another Case

Mrs. X is a 76 y.o woman admitted to the ICU with septic shock requiring large volume fluid resuscitation.

She is intubated and placed on the ventilator

She is stable on the ventilator until day 6 when she has progressing oxygenation demands

She has developed a VAC

Case evaluation

• No fever• No increased white count• No new antibiotics

Diagnosis: Pulmonary Edema Opportunities for improvement ?

Analysis

In another ICU, a large proportion of VAC’s are possible or probable pneumonia

Evaluation: HOB monitoring? Suctioning frequency? SATs? ET tubes with Subglottic suctioning?

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Tools

The Change Model

“If we could change ourselves, the tendencies in the world would also change. As a man changes

his own nature, so does the attitude of the world change towards him. … We need not wait

to see what others do”

-Gandhi

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Conclusion

Analyzing both process and outcome data will lead to new opportunities for improvement

VAE gives us an opportunity to take a broader view of patient safety.

It’s not about the numbers, it’s about the Patient

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Next Steps for CUSP Conduct a culture assessment (HSOPS) Establish an interdisciplinary CUSP team Partner with a Senior Executive Review the Science of Safety training Identify defects Download results from your culture assessment (HSOPS) and share with

team Meet regularly with your CUSP team Use the Daily Goals tool in your ICU

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Next Steps for Data Collection Unit Lead completes Structural Assessment Unit staff complete HSOPS Unit Lead/Data Facilitator enters Daily Process Measures Unit staff complete Exposure Receipt Assessment via survey link Unit Lead/Data Facilitator enters monthly VAE rates Unit Lead/Data Facilitator enters Early Mobility Measures Data Facilitator contemplates next steps for collecting Objective Outcomes

Measures Unit Lead/Data Facilitator pulls data reports from the data portal and

share the feedback with your frontline staff One person from unit (we recommend the Unit Lead) complete the

Implementation Assessment.

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Questions

Contact the CUSP 4 MVP-VAP Help Desk at cusp4mvp@jhmi.edu for all questions!