SCCM Resource Library-20-Interdisciplinary, Synergistic, Multimodal Interventions Decrease Ventilator-Associated Events

Video Transcription

Good afternoon. I'm Christy Schwarzman. I'm a clinical nurse specialist at Orlando Health in Orlando, Florida, and I'm very honored to be here today to share with you the results  of our program entitled Interdisciplinary Synergistic Multimodal Interventions Decrease Ventilator Associated Events. So I'd like to start by thanking our team. We have an  amazing team of interdisciplinary folks from all different departments in our organization.  We have infection prevention. We have both our critical care medicine and surgical critical  care intensivist groups. We have four clinical nurse specialists from our various ICU populations,  our respiratory therapy department, our physical therapy department, our organizational director  of operational improvement, and our organization's director of nursing research. So I just want  a huge thank you to everybody. I don't have any disclosures. So we have learned from the literature that our ventilator associated events are associated with adverse outcomes  for our patients. Some of these include mortality, vent length of stay, ICU length of stay, and  increased antibiotic usage, among others. Certain conditions have been noted to be associated  with VAE in addition to pneumonia. These patients may also have fluid overload and pulmonary  edema, atelectasis, ARDS, and others. And there have been a number of different interventions  that have been discussed that could potentially decrease VAE, but there is still a good amount of controversy about what elements of event bundle do actually decrease VAE the best.  So there is some evidence for SAT and SBT for this purpose, and certainly we do use those as part of the ICU liberation bundle, which is recommended for its association with  decreased ventilator time, among other outcomes that it's been known to improve. Other things have been the head of the bed, subglottic suction endotracheal tubes, routine oral care  and tooth brushing, minimizing sedation and avoiding benzodiazepines, low tidal volume ventilation, conservative fluid management, and transfusion thresholds. So many of these  items were already in place at our facility, so we needed to be a little bit innovative with how we addressed our increased rates that we observed. So Orlando Regional Medical  Center is our 800-bed level one trauma center in downtown Orlando. We have four ICUs that have various specialties. You can see them there. And from June of 17 to May of 19, our  rates were 6.47 per 1,000 vent days for IVAC and PVAP combined. This was higher than other level one trauma centers, and it was also higher than our benchmark against our comparison  hospitals in our Florida HEN. And we also noticed that we just had some incorrect perceptions  among the team that VAE and VAP were synonymous and just a need for improved understanding  about the complex contributing factors to these events. So we hypothesized that an interdisciplinary  multimodal set of quality interventions over a two-year period would result in decreases  in our rates. Our sample were all of our patients in the ORMC ICUs who qualified via CDC NHSN  definitions for IVAC or PVAP during the period of June 2017 to May 2020. We performed a hospital-wide  observational and quality improvement with targeted interventions implemented at the unit level. Our pre-period was June of 17 to May of 19, and this was when we implemented  the various individual interventions in the units. And our post-intervention period was  June of 19 to May 2020. Our analysis included an independent samples t-test comparing the means.  So for our measures, we used the CDC NHSN definitions for IVAC and PVAP, which were validated by our infection preventionist using the CDC calculator for VAE. We also created an  medical review for one of our processes where we conducted in-depth chart reviews by our two  dedicated physician champions. The items for this were decided on by expert consensus from the team  or were available from existing literature. So a little bit about our corporate safe team structure. So we are very blessed to have corporate executive support for interdisciplinary  quality teams to decrease hospital-acquired complications and events, and this is one of them. It was reformed in early 2017, and you can see our interdisciplinary makeup here.  The IVAC medical reviews I mentioned, these began late in the pre-intervention period in  the spring of 2019. We looked at some of the items from the literature that had been suggested to be  associated with VAE to see if they were present in our patients at the time of qualification.  So some of these things included positive fluid balance, ARDS, adalectasis. We looked at sedation  practices and whether they were appropriate. We looked at whether there was a concern for any  other infection besides pneumonia and whether new antibiotic days were escalation or de-escalation  of therapy as well as the stewardship. We also have interdisciplinary intensive reviews for the  nursing units and respiratory therapy for them to look at for PVAP patients. These reviews are  primarily looking at elements of the VAP bundle and traditional vent bundles as well as the A to F  bundle and a few other items that we felt may be relevant, and these do generate unit action plans  for the units each time. Our trauma neuro ICUs noticed that they had a number of patients who were going for a high number of diagnostic procedures requiring supine positioning.  They instituted a transport care bundle where they check cuff pressure prior to transport. They also perform deep subglottic suction, endotracheal suction, and oral care immediately  prior to and following transport, and they transport with the head of the bed up.  Our multi-system ICU conducted an early mobility protocol in 2018 and 2019 that was built into our  EHR. In June of 2018, we created an electronic audit compliance report to push the bundle  compliance to administrative leadership for all the units. In August of 2018, we conducted VAE  education for our entire respiratory therapy department at ORMC by our infection prevention  team. In September of 2018, we took on our dedicated physician champions from each service,  and in January 2019, we started what we call at the elbow auditing of our daily spontaneous  awakening and breathing trial performance by our nursing leaders and nursing peers with real-time  feedback, and later in October of 2019, we did notice that the suction regulators were contaminated and we replaced them with a routine guideline for cleaning and maintenance.  So you can see our decreases here in our rates from 6.47 per 1,000 vent days to 3.79 per 1,000 vent days in the post-period. The P there is 0.004 with the 41 percent rate reduction.  The total number of events in the pre-period was 158, and that was 83 in the first year and 75 in  the second year. The third year, the post-period, there was only 51 events. There was not a difference  in our average ventilator length of stay. So you can see here on our control chart a little bit of  a timeline of the different events we did and when we performed them, and in April of 2019,  you can see that we had a decrease or we observed a special cause variation where we actually decreased our rates and we were able to change the control limits in the chart.  So this is just some data that we looked at that we felt was interesting to share. So this was 42 cases that we did our IVAC and PVAP medical reviews on. 18 of them were from our  surgical critical care service, 20 were from critical care medicine, and four were other surgeries. Our 78 percent of them qualified with increases in PEEP as opposed to FIO2,  and the majority of the patients were in our trauma ICU.  So interestingly here, 57 percent of our patients did have positive fluid balance, which we defined as five or more liters positive in the three days prior to the qualification of  the event. Almost 62 percent of the patients had atelectasis either on a chest x-ray or  documented by a physician. 23 percent, almost 24 percent, the reviewers were not able to determine  medical necessity for benzodiazepines. 19 percent of the patients, they weren't able to determine medical necessity for a RAS that was targeted deeper than zero to minus two.  24 percent of our cases actually did not, or excuse me, actually had concern for or evidence for another infection besides pneumonia. And 21 percent of the patients  actually had a de-escalation of their antibiotic as opposed to an escalation of therapy.  So in conclusion, we did have a synergistic effect of our quality interventions over time  that made a statistically significant difference. We're hoping to expand our IVAC medical review  process to be able to present opportunities for future targeted quality improvements or research. We do have improved and ongoing awareness of VAE among our team,  and our targeted interventions at the population level may have allowed for more effective efforts.  Next steps, we'll be transitioning to EPIC in the next few months, and we're very excited to  be able to use the pre-built ICU liberation bundle in the foundation system. We also built our transport bundle, and we'll be expanding that system-wide. We're going to be expanding  our IVAC medical reviews, as I mentioned, and we're going to be re-educating our frontline teams on the ICU liberation bundle. So limitations, this is a quality improvement design,  it is observational only. It was a little bit difficult to figure out the exact cause of the hospital-wide rate improvements because of the locally implemented interventions,  and we did have some data collection resource limitations. And of course, we did have COVID,  as everyone else, and we were very proud to say that our rates did sustain over 18 months  despite COVID. So again, we saw improvements in our IVAC and PVAP rates that were sustained over  18 months with no corresponding reduction in average vent length this day. Thank you so much, and I will be happy to take your questions.

Video Summary

Christy Schwarzman, a clinical nurse specialist at Orlando Health, presented the results of their program called Interdisciplinary Synergistic Multimodal Interventions Decrease Ventilator Associated Events. The program aimed to decrease rates of ventilator-associated events (VAE), which have adverse outcomes for patients. The team implemented various interventions in their ICUs, including the use of the ICU liberation bundle, head of bed elevation, subglottic suction endotracheal tubes, and others. Their analysis showed a significant decrease in VAE rates from 6.47 to 3.79 per 1,000 vent days. The team plans to expand their program and use the pre-built ICU liberation bundle in the future.

Asset Subtitle

Pulmonary, Quality and Patient Safety, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Christine Swartzman

Introduction/Hypothesis: Reducing ventilator-associated events (VAE) requires interventions to decrease ventilator time and prevent infections. Although an 800-bed Level I trauma center already used evidence based strategies, including the A2F bundle, head of bed elevation, subglottic suction endotracheal tubes, routine oral care and toothbrushing, and low tidal volume ventilation, rates for infection-related ventilator-associated complications (IVAC) and possible ventilator-associated pneumonia (PVAP) were high. The authors hypothesized that a synergistic, multimodal approach was needed to reduce IVAC and PVAP rates.

Methods: Combined rates for IVAC plus PVAP ('IVAC Plus') were compared for the periods from June 2017-May 2019 (pre) vs June 2019-May 2020 (post). In Fall 2018, a team of nurses, respiratory therapists (RT), clinical nurse specialists, infection preventionists, and intensivist leaders developed and implemented multiple interventions over a period of fourteen months. Daily awakening and breathing trials were audited 'at the elbow' each shift. An intensive review for nursing and RT was conducted on all PVAP cases. An intensivist review for potential causes of IVACs was instituted to determine if non-pulmonary, non-infectious, or non-preventable factors may have contributed. The multisystem ICU performed an improvement cycle for early mobility, for which the protocol was added to the electronic health record. Because many IVAC plus cases occurred in patients with frequent transports that required supine positioning, the trauma and neuro ICUs implemented a transport bundle which included oral care, deep subglottic suctioning, and cuff pressure monitoring just prior to and immediately following transports. Finally, contaminated suction regulators were replaced, thus a guideline for routine cleaning and maintenance was implemented.

Results: The mean 'IVAC Plus' rate was 6.47/1000 ventilator days in the pre-intervention and 3.79/1000 ventilator days in the post-intervention periods (p=0.004) with a 41% rate reduction and a corresponding decrease in monthly variability, but no difference in average ventilator length of stay.

Conclusions: An interdisciplinary, multimodal intervention to decrease IVAC Plus events achieved significant and sustained results over fourteen months.

Meta Tag

Content Type Presentation

Knowledge Area Pulmonary

Knowledge Area Quality and Patient Safety

Knowledge Level Advanced

Membership Level Select

Tag Ventilation

Tag Ventilator Associated Pneumonia VAP

Tag Length of Stay

Year 2021

Keywords

Ventilator-associated events

ICU liberation bundle

Head of bed elevation

Subglottic suction endotracheal tubes

Program expansion

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